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Miscellaneous - 10 DEER MEADOW ROAD 4/30/2018
N O o O m m W ;u o D m 4 � 60 O � O� O 0 0 O �L ,�a r 6 e- a � erto I INh 0. Of ADb 6 8-er-Olno - us q7X 171 �89 (Blue Cross Blue Shield of IVIA�-, Fallon Senior Plan (FAilon Community Health Plan) First Seniority Freedom (Harvard Pilgrim Health Care) Senior Whole Health Tufts Health Plan Medicare Preferred (Tufts Health Plan) Medicare Card Number I # I give permission to bill my insurance ci (Signature of person to receive vaccine or that x For Clinic/Office Use: Vaccine name. Injection site: K Date VIS giver Vaccine manufacturer: Name and title of vaccine administrator: Clinic/office address: Influenza Forms — MAHPIMasspro Plan Reimbursement Prograi __C_\ Commonwealth of Massachusetts City/Town of System Pumping Record NORTH ANDOVER .y Form 4 DEP has provided this form for use by local Boards of Health. Other forms may be used, but the information must be substantially the same as that provided here. Before using this form, check with your local Board of Health to determine the form they use. The System P mping-Record must be submitted to the local Board of Health or other approving authority within 14 day fromBe umptngate in accordance with 310 CMR 15.351. rlt { M vrt Important: When filling out forms on the computer, use Orly the tab key to move your cursor - do not use the return keys A. Facility Information TOWN Of, NOR`rN ANDOVER 1. System Location:r'h�-- h(eG HEALTH DEPARTMENT -- --1�--eek-_--- - Address City Town -_ - - State Zip Code 2. System Owner: Name Address (if different from location) City/Town State Zip Code 3,713- 691- 11 --------- - — - Telephone Number B. Pumping Record L4/1f_/11 — 2. Quantity p Pum ed: 1. Date of Pumping Oat 3. Type of system: ❑ Cesspool(s) ❑ Septic Tank ❑ Tight Tank ❑ Other (describe): - --- -- —— ---- -- ___ Gallons �!_��- -- ❑ Grease Trap 4. Effluent Tee Filter present? ❑ Yes Y/No If yes, was it cleaned? ❑ Yes [0"*No 5. Condition of System: --- -- - -- G0C_J __ 6. System Pumped By: i m _G_ c l I an � ---- — _ �Z � —_ — -- --- -- Nam Vehicle License Number !,�v��ny�ronlm�,r�� aI Company 7. Location where contents were disposed: Signature of Hauler Signature of Receiving Facility pate t5form4.doc• 03106 System Pumping Record • Page 1 of 1 s Lot &Street /Q _,Iae, 04L) Map/Parcel CONSTRUCTION APPROVAL Has plan review fee been paid: NO Permit# Plan Approval: Date: 10IF1,597 Approved by: Designer: J . Plan Date: Conditions: Water Supply: Town Well Permit: Well Tests: Chemical Bacteria I Bacteria II Well Driller: Date Approved Date Approved Date Approved Plumbing Sign -Off: Wiring Sign -Off: Comments.- Form omments:Form "U" Approval: Approval to Issue: YES NO Date Issued By: Conditions: Final Approval: All Permits Paid? � NO Well Construction Approval?NO Septic System Construction Approval? � NO Certification? YES NO Other YES NO Any Variance Needed? YES NO FINAL BOARD OFHEALTH APPROVAL: DATE: %b 13/ 161 APPROVED BY: Is the installer licensed? Type of Construction: SEPTIC SYSTEM INSTALLATION C� NO NEW REPAIIZ New Construction: - Certified Plot Plan Review YES NO Floor Plan Review YES NO Conditions of Approval from Form U YES NO Issuance of DWC permit: S NO DWC Permit Paid? S NO DWC Permit # q63 Installer: .Ac/JA) Sooc�c Begin Inspection: Excavation Inspection: Needed: YES NO Construction Inspection: Needed: As Built Plan Satisfactory: YES: 1 Approval of Backfill: Date: 16130 By: ,(J Final Grading Approval: Date: X61,31l9 By: ��yO Final Construction Approval: Date: lb ,3b/-! %�By: G/�! G' Certificate of Compliance: Approval :,019//?'% Date: Commonwealth of Massachusetts . City/Town of _ System Pumping Record NORTH ANDQ1/ER Form 4 y DEP has provided this form for use by local Boards of Health. Other forms may be used, but the information must be substantially the same as that provided here. Before using this form, check with your local Board of Health to determine the form they use. The System Pumping Record must be submitted to the local Board of Health or other approving authority within 14 days from the pumping date in accordance with 310 CMR 15.351. RECEIVED JI I'19 2013 UL TOWN OF NORTH ANDOVER HEALTH DEPARTMENT 6. System Pumped By. tYY, Go lam ---- --- -- - Vehicle License Plumber Name } t1 j - _i' Vj'�- Ef1V I �QY1 YYl �,i'1%C� l Company 7. Location where contents were disposed: Signature of Hauler Signalufe of Receiving Facility 15form4.doc• 03/06 Date N Andom M& Date System Pumping Record • Page 1 of 1 A. Facility Information Important: When filling out 1. System Location.- ocation:forms formson the - computer, use only the tab key to move Address 1 N©�•kvi-1(1�0�/C.i:.._ your cursor . do not--- Cityffo - Slate Zip Code use the return key. 2 System Owner: a/Slm i1 - _Bob �^ Narne-- Address_(if_di_fferent from location) - - ..._.. - ---- - ------ - - _ City/T—own State Zip Code Telephone Number _ B. Pumping Record b 1- 1. -- — Date of Pumping Date 2 Quantity Pumped: Gallons 3. Type of system: ❑ Cesspool(s) [Septic Tank ❑ Tight Tank ❑ Grease Trap ❑ Other (describe):_ --- 4. Effluent Tee Filter present? ❑ Yes v No if yes, was it cleaned? ❑ Yes U No 5. Condition of System: Gan 6. System Pumped By. tYY, Go lam ---- --- -- - Vehicle License Plumber Name } t1 j - _i' Vj'�- Ef1V I �QY1 YYl �,i'1%C� l Company 7. Location where contents were disposed: Signature of Hauler Signalufe of Receiving Facility 15form4.doc• 03/06 Date N Andom M& Date System Pumping Record • Page 1 of 1 Commonwealth of Massachusetts City/Town of System Pumping Record NORTH ANDOVER Form 4 DEP has provided this form for use by local Boards of Health. Other Farms may be used. but the information must be sutiatantiatly the same as that provided here. fore using this mging Record must be ubm, Check iitted to your local Board of Health to determine the form they use. The y pumping date in the local Board of Health or other approving authority Within 14 days from the accordance with. 310 CMR 15.3:1 A. Facility information important: 1. System Location: when Ming out forms on the IIII��aa t /4 I t d *i� /� oomputet, use 4Jlf only the lob key Address /j �) / to move your ��Afl4LICG! Stale ZipCodc cursor - do not Cityliown use the return ken 2. System Owner: NOW n,n Address (if different lrom tocation)_ sit Zip Code CitylTown �C j'7Q 1pt5 j l �f _ Telephone Number B. pumping Record 61224AP _�Qo �� 2. Quantity Pumped= ran s1. Date of Pumping 3. Type of system: ❑cesspool(s) Septic; Tank Q Tight Tank © Grease Trap [] other (describe): - - - Yes No if yes, was it cteaned? El Yes E] No 4. Effluent Tae Filter present.. Q �- 5. Condition of System: (� � ' ly"t is ef` ML -F • rl L . _ — _� ---- - - P ..- _ �y. 6. System Pumped By: Vehicle License Number — - Name Company 7. Location where contents were disposed: signature of Havier signature of Receiving FaciUty I9farrM:d6a 03106 system Pumping Record • Page t of 1 DelleChiaie, Pamela From: Bob Bertolino [bob@bertolino.us] Sent: Wednesday, April 20, 20115:05 PM To: DelleChiaie, Pamela Subject: Re: I. R. - Septic File -10 Deermeadow Road - Remaining scanned file Thank you From: "DelleChiaie, Pamela" <Pdellech aatownofnorthandover.com> To: "'Bob@Bertolino.us"' <Bob(o),Bertolino.us> Sent: Wednesday, April 20, 20112:21 PM Subject: I.R. - Septic File -10 Deermeadow Road - Remaining scanned file Reference: Bob Bertolino 978.681.8119 Re: Soil Test information/water table Dear Mr. Bertolino, Here is the second email referencing the additional information regarding the soils. Please call the office if you have any further questions. Best Regards, Pamela DelleChiaie Departmental Assistant lCommunity Development I Health Department Town of North Andover 1600 Osgood Street I Bldg 20 1 Suite 2-36 North Andover, MA 01845 2 Office - 978-688-9540 Fax - 978-688-8476 0 Email - pdellechiaie@townofnorthandover.com Website htti)://www.townofnorthandover.com/Pages/index "We can never see the path of our life if we are too busy focusing on the pebbles under our feet. "~ Anonymous Please note the Massachusetts Secretary of State's office has determined that most emails to and from municipal offices and officials are public records. For more information please refer to: http://www.sec.state.ma.us/pre/preidx.htm. Please consider the environment before printing this email. DelleChiEie, Pamela From: DelleChiaie, Pamela Sent: Wednesday, April 20, 20112:19 PM To: 'Bob@Bertolino.us' Subject: 1. R. - Septic File - 10 Deermeadow Road - As Built Plan Attachments: 20110420134430396 Reference: Bob Bertolino 978.681.8119 Re: Soil Test information/water table Dear Mr. Bertolino, I have attached scanned copies of the information in your file for 10 Deermeadow Road. This is the septic As Built Plan. The following email will be the additional information regarding the soils. Please call the office if you have any further questions. Brrc Ref a44, Pamela DelleChiaie Departmental Assistant I Community Development I Health Department Town of North Andover 1600 Osgood Street I Bldg 20 1 Suite 2-36 North Andover, MA 01845 2 Office - 978-688-9540 2 Fax - 978-688-8476 0 Email - pdellechiaieotownofnorthandover.com -16 Website hM://www.townofnorthandover.com/Pages/index "We can never see the path of our life if we are too busy focusing on the pebbles under our feet. "— Anonymous ca ,V_EE ss z 5? 3 £E-45 -:10 t M-,FrdT7;ZM /jN"ZLaLNI �3dl,6 AM -% OPI-L-VA3-1-a f r 0= cn - - m r' -.._........_ CA S ! : N m D .... r N p 5. 00 a Z. �p „ m 00- < m 3 0 U) • O ol r m un Z w0rrl �I a x 90 n 4 O m Ln O Z Q I i • D y e �RI�L''opl\f� Qj�O!� o .w 91 �D Z Co �0 I �• ,�i `v o � � y IPA z 11 fq l DelleChiaie, Pamela From: DelleChiaie, Pamela Sent: Wednesday, April 20, 20112:21 PM To: 'Bob@Bertolino.us' Subject: 1. R. - Septic File -10 Deermeadow Road - Remaining scanned file Attachments: 20110420134541242 Reference: Bob Bertolino 978.681.8119 Re: Soil Test information/water table Dear Mr. Bertolino, Here is the second email referencing the additional information regarding the soils. Please call the office if you have any further questions. 2rec Re94V4. Pamela DelleChiaie Departmental Assistant I Community Development I Health Department Town of North Andover 1600 Osgood Street I Bldg 20 I Suite 2-36 North Andover, MA o1845 2 Office - 978-688-9540 Fax - 978-688-8476 Email - pdellechiaie(&townofnorthandover.com Website http://www.townofnorthandover.com/Pages/index "We can never see the path of our life if we are too busy focusing on the pebbles under our feet. "--Anonymous Important: When filling out forms on the computer, use only the tab key to move your cursor - do not use the return key. Commonwealth of Massachusetts City/Town of System Pumping Record Form 4 RECEIVED JUN 3 0 2009 TOWN OF'NORTH ANDOVER HEALTH DEPARTMENT DEP has provided this form for use by local Boards of Health. Other forms may be used, but the information must be substantially the same as that provided here. Before using this form, check with your local Board of Health to determine the form they use. The System Pumping Record must be submitted to the local Board of Health or other approving authority. A. Facility Information 1. System Location: Left frorE froleft (e -W, left sif hoti . Right front, right rear, right side of house. Address d Cityfrown 2. System Owner: Name Address ('d different from location) Cityrrown State Zip Code Vim Stat � ` & C qfip Code Telephone Number B. Pumping Record `� Com.• 1. Date of Pumping bate 2. Quantity Pumped: Gallons 3. Type of system: [3 Cesspool(s) eptic Tank ® Tight Tank ® Other (describe): 4. Effluent Tee Filter present? ® Yes E'lqo-' If yes, was it cleaned? ® Yes ® No 5. Conditi n of Syste 6. System Pumped By: Nell Bateson F 5821 Name Vehicle License Number Bateson Enterprises Inc Company 7. Locado h contents were disposed: L.S. Lowell Waste Water A t5form4.doc- 06103 System Pumping Record • Page 1 of 1 " 41; Xe if it fit TOWN OF NORTH ANDOVER SYSTEM PUMPING RECORD I m t TlYi INOWNE SYSTEM LOCATION. (.example; left front of house) W). '11 14 ....... {.1 It 4j,J,; 'k Opt UMPING0 :,QUANTITY PUMPED GALLONS i '4.e, 001o';:: NO"•' SEPTIC TANK: NO •, YES YES WOVIC ROUTINE.; tEVIG: EMERGENCY' oa, NDITION.:.' 1,.,.,FULL TO COVER HEAVY. GREASE .-BAFFLES IN PLACE' 'LEACHFIELD RUNBACK _.""YLOODED "WHER (EXPLAIN) CARRYOVER 4,5! 41. 'Fitlrt iei;i Xii N Ak k Form No. 4 Town of North Andover, Massachusetts BOARD OF HEALTH T. 3 19 Q 11 CERTIFICATEOF COMPLIANCE This is to certify that the Individual Soil Absorption Sewage Disposal System constructed ( ) or repaired (L --K by_ �(OM)1 Sove.Y INSTALLER at SITE LOCATION has been installed in accordance with Board of Health Regulations as described in the Design Approval Site System Permit No. 9' 7% dated ---/,Oz _199. The issuance of this certificate shall not be construed as a guarantee that the system will function satisfactorily. BOARD OF HEkL rH NaRrp �O A s�CHU Applican Town of North Andover, Massachusetts BOARD OF HEALTH DISPOSAL WORKS CONSTRUCTION PERMIT Site Location / ,, 1112e J,6 u- j Form No. 3 19`�� Permission is hereby granted to Construct ( Y or Repair (jw) an Individual Soil Absorption Sewage Disposal System as shown on the Design Approval S.S. No. 1 ? 7 N CHAIRMAN, BOARD OF HEALTH Fee D,W.C. No, 9' t4. .. STEVEN J. D'URSO Environmental Designs 22 Lilly Pond Road W. Boxford, MA 01921. WE ARE SENDING YOU dIEVVIEM ®F Attached ❑ Under separate cover via the following Items: a ❑ Shop drawings OKPrints ❑ Plans ❑ Samples ~„ P ❑Specifications ❑ Copy of letter ❑ Change order ❑ THESE ARE TRANSMITTED as checked below: 011For approval ❑ Approved as submitted ❑ For your use ❑ Approved as noted ❑ As requested ❑ Returned for corrections ❑ For review and comment ❑ ❑ FOR BIDS DUE REMARKS ❑ Resubmit copies for approval ❑ Submit copies for distribution O Return corrected prints 19 ❑ PRINTS RETURNED AFTER LOAN TO US COPY TO SIGNED: %�l� 10! NO. 1 /j ATTENTION RE. i Attached ❑ Under separate cover via the following Items: a ❑ Shop drawings OKPrints ❑ Plans ❑ Samples ~„ P ❑Specifications ❑ Copy of letter ❑ Change order ❑ THESE ARE TRANSMITTED as checked below: 011For approval ❑ Approved as submitted ❑ For your use ❑ Approved as noted ❑ As requested ❑ Returned for corrections ❑ For review and comment ❑ ❑ FOR BIDS DUE REMARKS ❑ Resubmit copies for approval ❑ Submit copies for distribution O Return corrected prints 19 ❑ PRINTS RETURNED AFTER LOAN TO US COPY TO SIGNED: %�l� MAP AND PARCEL 337 A ADDRESS (0 6too i6fjf� 4 j) OQ J tA OWNER-_, ___.....____. SIZE OF LOT-. N SQUARE FEET r S # BEDROOMS SEPTIC SYSTEM LOCA? (For example, FRONT YA FINAL GRADING DATE AS BUILT PLAN IN FILE? ^ '' INSTALLER C a: ----- `7 DWC PERMIT DATE Z % CERTIFICATE OF COMPLIANCE DATE ENGINEER No. FORM I I -SOIL EVALUATOR FORM Page 1 of 3 Date: Commonwealth of Massachusetts /V, ,qA&J O /fie , Massachusetts Performed By:_ "62 Date: Witnessed By. IttorfAdd= or 7419 �7 11 1 Owner's Name 4G.CAj 7)20 COP Address and Telephone # New Construction Repair Otfice Review Published Soil Survey Available: No a Yes a Year Published /1�� - Publication Scale ��" BGG y Soil Map Unit ,���} til Drainage Class kJ j Soil Limitations 6),v Surficial Geologic Report Available: No Q Yes Q YearPublished_ Publication Scale Geologic Material (Map Unit) Landform/CL- �4�t17�CX Cil}7Lcl5// " Flood insurance Rate Map: Above 50o year flood boundary No Yes within 500 yearflood boundary NoYes Within 100 year flood boundary No Yes Wetland Area: National Wetland inventory Map (map unit) Wetlands Conservancy Program Map (map unit) Current Water Resource Conditions (USGS): Month Range: Above Normal Normal Below Normal Other -References Reviewed: DEP APPROVED FORM - =195 fail ausm FORM 11 -SOIL EVALUATOR FORM Page 2 of 3 Location Address orLotNo.:,-A/, DQE Deep Holablumber Date Time 9/p d Weather Location (identify on site plan) LandUsej Jj-e : 0 Slope (%) Surface Stones `a vegetation Landform. �Tzl, four Position on. landscape.(sketch on the back) SSC Distances. from: Open WaterBody �j/QQ feet Possible.WgArea. feet Dunking **rWell feet Drainage.way ILA feet Property Line- feet Other DEEP OBSERVATION HOLE. LOG* Depth from Surface (Inches) Soil Horizon Soil Texture- (USDA) Soil Color (Munsell) Soil Mottling Other (Structure, Stones, Boulders, Consistency, % Gravel) o� I t=ire- -120 Y� *MINIMUM OF 2HOLES REQUIRED AT EVERY PROPOSED DISPOSAL AREA Parent Material (geologic) I�-�,,IAV- l -.-ICI Depth to Bedrock: ////A. th to Groundwater-, Standing. Water in the Hole: pl(e5_ Weeping from Pit -Face: Estimated Seasonal High Ground Water: j),V e -y /,>) f' DEP'APMVWFDRM-1210 M: FORM 11 - SOIL. EVALUATOR FORM Page 3: of I Location Address orLotNo._ EDDepth. observed standing in, observation hole epth_weeping.from side ofobservation hole Depth.to•soiLmottles- , f/`% inches: Groundwater adjustment feet Index-WelLNumber Reading Date Index well level Adjustment factor Adjusted ground water level inches inches Does at least four feet of naturally occurring pervious material exist in all areas observedthroughoutthe- area. proposed.forthesoil- absorptibmsystem? I �S If not;. what: is the depth of naturally occuring pervious material? Certificalin I certify that. on (date) I have: passed. the, soil evaluator examination. approved by a Department of 'Environmental Protection and that. the. above. analysis- was performed by me. consistent with the required training, expertise and. experience described in 310 CMR 15.017. t Signature Date: r�197 DRpMMOMFORM-42W BS aau fflu m FORM 12 - PERCOLATION TEST Location Address or Lot No. �Q 3 �/�- /)-, r- 0, �A) COMMONWEALTH OF MASSACHUSETTS Wo A�j Massachusetts Percolation Test* Date:Time: r b Observation Hole# / Depth of Perc rb Start Pre-soak `>S End Pre-soak Time at 12" ;. Time at 9" Time at 6" p Time (9"-6") Rate Min./Inch *Minimum of 1 percolation test must be performed in both the primary area AND reserve area. Site Passed Site Failed Performed By: Witnessed By: Comments: DEP APPROVED FORM - IV0719S PaftekSAM PITS MIN 440 LEACHING MIN 1 (131x16') PIT MANHOLE/PIT GW MIN 4' BELOW BOTTOM EXC 2x EFF W OR D 12"-48" STONE BOT + SIDE x LOAD = TOTAL (L x W x #) (2x(L+W)xD x #) (G/f t2) QMBBRS MIN 440 LEACHING GW MIN 4" BELOW COVER >3 FT - VENT MANHOLES 12"-48" STONE SPLASH PADS SLOPE .005 BED/TRENCH (Bed max. 60' X 601) MIN 13' X 16' PIT BOT + SIDE X LOAD = TOTAL (L x W x #) (2 x (L+W)xD x #) (G/ft2) FIELDS / / MIN 440 GPD" 900 ft2 BEDv GW MIN 4' B �-� , ELOW BOTTOM OF FIELD PIPE ENDS JOINED?_ y/ 4" PEA STONE? ()J-' DIST LINE SLOPE .005? G--- >3'COVER-VENT 4-� SCH 40 MIN 12" COVER RATE X ) X = TOTAL L W LDG DOSING TANKS AND PUMPS DIMENSIONS X X�-= PUMP CAPACITY gpm L W D Vol. DISCHARGE SIZE DISCHARGE RATE DISCHARGE TIME gpm MANHOLES TO GRADE ALARM SEP. CIRC. GW (Min. 1' below inlet) HWL LWL CHECK VALVE BLEEDER HOLE MANUAL OP. SWITCH ENUF STORAGE? n Copyright 0 1996 by S.G. Starr PLAN REVIEW CHECKLIST ADDRESS_ 2 P4-awi ENGINEER GENERAL / 3 COPIES ?� STAMP�� LOCUS L --'NORTH ARROW �/ SCALE CONTOURS PROFILE—L(SC) SECTION1.� BENCHMARK ----- SOIL & PERCS ELEVATIONSETS. DISCLAIMER �" WELLS &.WETS WATERSHED? DRIVEWAY WATER LINE FDN DRAIN M&P SCH40 � TESTS CURRENT? " SOIL EVAL sPTIC TANK MIN 1500G .17 INVERT DROP GARB. GRINDER_4(2 comps +200) 10' TO FDN -- MANHOLE ELEV GW # COMPS. GB D -BOX SIZE # LINES FIRST 2' LEVEL STATEMENT INLET1 .Se -- OUTLET %651. jV = ( 2" OR .17 FT) TEE REQ' D? LEACHING MIN 440 GPD? RESERVE AREA 4' FROM PRIMARY?�— 2% SLOPE 100'. TO WETLANDS x`100' TO WELLS Lr---- 4' TO S . H. GW L----"(5'>2M/IN) 20' TO.FND & INTRCPTR DRAINS 400' TO SURFACE H2O SUPP L,_� 4' PERM. SOIL BELOW FACILITY MIN 12" COVER 6`_ FILL? (151) BREAKOUT MET? TRENCHES MIN 440 gpd SLOPE (min .005 or 6"/100')SIDEWALL DIST. 3X EFF. W OR D (MIN 6') RESERVE BETWEEN TRENCHER?' IN FILL? MUST BE 10' MIN. 4" PEA STONE? VENT? (>3' COVER; LINES >501) BOT + SIDE X LDNG = TOT (L x W x #) (DxLx2x#) (G/ft2) Copyright 0 1996 by S.L. Starr 0 i .PPROV ED DIVPE PROVIDED 71161 , Title 5 Reg. 2.5 1 'ail Reg. 6 NORTH Air DTIV ER BOARD OF HEALTH T DISAPPROVED DATE TIME REASON . )K The submitted plan must show as a minumum: (a) the lot to be served (area,dimensions ,lot #,abutters (Planning Board 'files) M. location and log of deep observation holes -distance to ties (c), location and results of percolation tests• -distance to ties (d) design calculations'& calculations showing required leaching area reserve (e) location and dimensions of system .(including area)' (f) existing and proposed contours (g) location of any wet areas within 100' of the sewage disposal system ot.,disclaimer (check wetlands mappin (h) surface and subsurface drai ris within 100' of sewage disposal system of disclaimer (i) location of any drainage easements within 100 of sei-;age disposal system or disclaimer (planning board files) ' t,,,(j ). Y .known:' sources_ of-- �v&ter_ supply withi*n.:. 200'. of sewage disposal -.system, or :disclaimer (k) -=''location- of any proposed well t'o serve the lot {100' from leaching faci-lity) {1) location of water .lines on property (10' from. leachi facilities) M location of benchmark Po driveways k o garbage disposers p no PVC is to be used in construction q a profile of the system (elevations of basement, ply pipe septic tank, distribution box inlets and outle� distribution. -field piping and any other elevations) (r) maximum ground water elevation in area of sewage di; .system P (s) plan must be prepared by a Professional Engiarersor. other professional authorized by law to prep ue plans Septic Tanks ( Capacities -.150 of flow, water table, tees, depth • of tees, access, pumping, - b Cleanout 10, 'from cellar wall 'or inground swimming pool d 25' . from subsurface drains 9.1 9.6 K Distribution Boxes a Slope greater than �b� Sump Leaching Pits Leaching pits ar preferred where the a nstallation $,s possible a Calc tions of leaching area (minimum 500 S.F.) b Sp' ng c rface drainage 2% d peer material e 24'4"5p1,sk ��A Leaching Fields %Greater than 20 minutes/inch Vd- Area'.(minimum...900 S.F.) Construction of field Surface . drainage 2% - 20'from cellar wall or inground swimming pool Le"adhing Trenche a Calculat'ons of leaching area (min. 500 S.F.) b/Dime (4 ft. min. 6 ft. with reserve between): cnsdtioefdrainage 2% = Downhill Slope , (a) Slope y/x = to be shown b y/x X 150 = to be shown P_ umfle �a Approval b Stand --by power Board Of HBalth North An�_o ver X"54 ffW_E_D_ DATE 9 BEMO SISTM INSrALLATICK CMK LT -8f FiM OK Distanoe Tot a. Vetlmds b. Drains 0. 'Won 2, WAer TAne Location LOT ; 414011 XCAVATION OK FAIL 3. No M Pipe Septic Tank a* -Tess _Length & 'TO Clegm'Dut 60TOr8• b. Cement pipe to Tank — On Both Sides of Ta* Distribution Box a. Covers & Box - No Cracks b. A3.1 Lines Flowing Equal )mounto o. No Back 'Flow 6. Leach Field or Trench a. Dimensions b. Stone Depth o: Capped 3nds d. Clean Double"Washed Stone 7- Leach Pits a. io Dimensi0i ' s D b. Stone depth h Pads d Tess �'Cment Pipe to pit Both Sides f, Clem DoubIle washed Stone S. No Garbage MSPOSA -7inal grading :Inspection 100 'Barricading Covered System 3.1. As Built Submitted.. a. lot Location*. b. Dimensions Of System c. Location with Regard_to Pare Test d. FlovatiOnO Water Table DelleChlale. Pamela From: DelleChiaie, Pamela Sent: Monday, July 13, 200912:28 PM To: 'Carrie@Bertolino.us; 'Bob@Bertolino.us' Subject: Information Request - Septic File -10 Deermeadow Road Attachments: 10 Deermeadow Road - Septic As Built Plan; Septic As Built Plan - 2 -10 Deermeadow Road; Septic -10 Deermeadow Road - Title 5 Report; Pumping Records; Installation Paperwork from 1997 Dear Carrie, Attached Is the information you requested from you Health Dept. file a short while ago. Please call the office with any questions. Reference: Phone number — 978.681.8119 Pamela DelleChlale Health Department Assistant TOWN OF NORTH ANDOVER Health Department 1600 Osgood Street Building 20; Suite 2.36 North Andover, MA 01845 978.688.9540 - Phone 978.688.8476 - Fax pdelleehiaie@townofnorthanclover.com - E-mail http://www.towiiofiiortliandover.com - Website Notes - If copied to BOHMemhets - Reference Copy Only - no response requested at this time ' IC-\ Commonwealth of RECEIVED City/Town of System Pumping Record JUL 2 2 2008 Form 4 TOWN OF NORTH ANDOVER 9 HE H DEP TMENT DEP has provided this form for use by local Boards of Health. herfic>fmIrm the information must be substantially the same as that provided here. Before using this form, check with your local Board of Health to determine the fort they use. The System Pumping Record must be submitted to the local Board of Health or other approving authority. A. Facility Information Important: When filling out forms on the computer, use only the tab key to move your cursor - do not use the return key. 1. Syst m L n' s�-Q Ka -Z. -e ( 0 L, � ?-4 �-,) (� - Cityrrown 2. System Owner: Name Address (if different from location) Cityrrown B. Pumping Record 1. Date of Pumping 3. 4. raw W w. MA k�'�7 St^on8 t _a r ( --Zlo Code Telephone Number 7 pate 2. Quantity Pumped Type of system: ❑ Cesspool(s) Septic Tank ❑ Other (�scrtbe): Effluent TO -e Filter present? ❑ Yes Cd o 5. ConditiRn of System: tak ,,., Q Gallons ❑ Tight Tank if yes, was it cleaned? ❑ Yes ❑ No v e. Syste Pu By� Name Vehicle License Number Company 7. Location ere contents disposed: NL _�• SigrifftPauller Date t5fonM.doo• 08103 System Pumping Record • Page 1 of 1 COMMONWEALTH OF MASSACHUSETTS EXECUTIVE OFFICE OF ENVIRONMENTAL AFF ;iRsDEPARTMENT OF ENVIRONMENTAL PROTECTONE WINTER STREET, BOSTON MA 02108 (61?) 292.6600 TRUDY COXE Secretary ARGEO PAUL CELLUCCI DAVID B. STRUH3 - Oovarnor . ' - •� � Commissioner SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION Property Address: 1 ��' Name of 0w Dat. of Inspection: r g Uhl e �j0 Auloo- .r,M A 0!8V.Addraas of Owner: ( �% � ....— Name of Inspector: I I em a DEP approved system inspector pu to Section 16.340 of Tide 6 (310 CMR 16,0001 Company Nems: t S �r } MaSiny Address: Telepfp w Number: _ n-1 �- I- T 8 �'9 Le m 6 l 1 7 FICA ON 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: �Paasea Conditionally Passes _ Nee urther E alustion By the Local Approving Authority Fail Inspectors Signature: Data: m The System Inspector shal ubmit a py of this nspection report to the Approving A thority 18oard of Health or DEP}within thirty (30) days of completing this Inspection f the sya m 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 t e appropriate regional office of the Department of Environmental Protection. The original should be sant to the system owner and copies sent to the buyer, If applicable, and the approving authority. NOTES AND COMMENTS revised 9/2/98 Page 1 of 11 ^ PemrA nn R,v-•1a 1 n SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) '�----Property address: 1 a. U�Prt'T1 k esti b w .'QOr j -!j h d 0 0 er, 414 N 5 Owner: �a_meSbj D.te of Inspection: 1/ a- 1 B p INSPECTION SUMMARY: l Check B, C, of D: .A. SYSTEM PASSES:' I have not found any information which indicates that any of the failure conditions described in 310 CMR 15.303 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. Indicate yes; no, or not determined (Y, N, or ND). Describe basis of determination in all instances. If "not datermined", explain why not. The septic tank Is metal, unless the owner or operator has provided the system Inspector with a copy of a Certificate 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 exfiltradon, or tank failure is imminent. The system will pass inspection If the existing septic tank is replaced with a complying septic tank as approved by the Board of Health. ,^ Sewage backup or breakout or high static water level observed in the distribution box Is due to broken or obstructed pipe(s) or due to a broken, settled or uneven distribution box. The system will pass inspection if (with approval of the Board of 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 Iwlth approval of the Board of Health):_ broken pipe(al are replaced obstruction Is removed i . r *Note: THE TITLE 5 INSPDGTION IS NOT A GUARANTEE/WARRANTY OF THE P TIURE FONCTION OF THE SEPTIC SYSTEM. revised 9/2/98 Page 2of11 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (oontinued) Property Address: lD)bees'me-AA60-1kA, Nor' -h 4no(oVtr'r MA 6l$05 Owm: —73—"e-3 ICoblt L Dew of rrspeatieon: i (2'7 % 6 0 C. FURTHER EYALUA=N IS REaUIRED 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 IN ACCORDANCE WITH 310 CMR 16.303 (11(b) THAT THE SYSTEM IS NOT FUNCTIONING IN A MANNER WHICH WILL PROTECT THE PUBLIC HEALTH AND SAFETY AND THE ENVIRONMENT: Cesspool or privy is within 60 feet of surface water Cesspool or privy is within 60 feet of a bordering vegetated wetland or a salt marsh. 2) SYSTEM WILL FAIL UNLESS THE BOARD OF HEALTH (AND PUBLIC WATER SUPPLIER, IF ANY) DETERMINES THAT THE SYSTEM IS FUNCTIONING IN A MANNER THAT PROTECTS THE PUBLIC HEALTH AND SAFETY AND THE 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 soil absorption system and the SAS is within a Zone I of a public water supply well. The system has a septic tank and soil absorption system and the SAS is within 60 feet of a private water supply wall. The system has a septic tank and soil absorption system and the SAS is less than 100 feet but 60 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 lase then 6 ppm.. Method used to determine distance (approximation not valid). 3) OTHER revised 9/2/98 Page 3of11 N SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION Icontinued) Properly Add(ess: p'bee rn•:e&A*6:..� N o r4 -h A nd o o-cr, MA 0194's Ownse: s� o bl e t^ -Daft of lospection: D. SYSTEM FAILS: You must Indicate either "Yes" or "No" to each of the following: CMR 15.303 I have determined the flone or more of the ed beons exist 85 low. The Board lof Health owing f ishould beure ticontacted to determine haed In t will be nece sary to Correct the fallure. determination Is Idents Yes No _ due to an overloaded or clogged SAS or Cesspool. Backup of sewage into facility or system component 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. w Liquid depth in cesspool is less than 6" below Invert or available volume is less than 112 day flow. Required pumping more then A times In the last year K01 due to clogged or obstructed pipets). Number of times pumped Any portion of the Sall 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. Any portion of a cesspool or privy is within a Zone 1 of a public well. _ Any portion of a cesspool ar privy is within 60 feet of a private water supply well. ~ w _ Any portion of a cesspool or privy is less -than 100 feet but greater than 60 feet from a private water supply well with no acceptable water quality analysis- alyss-if the wellcompounds has been a nitrogen ento b nitrate able, attach copy of well water analysis for conform bacteria, volaorganic E. • LARGE SYS'i'E11 FAiLS:. You must Indicate either "Yes" or "No" 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 greeter (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 r, the system is within 400 teat of a surface drinking water supply the system is within 200 feet of a tributary to a surface drinking wets' supply the system is located in a nitrogen sensitive area flnterim Wellhead Protection Area='IWPA) or a mapped Zone 11 of a public water supply well) �. The owner or operator of any such system shall upgrade the system in accordance with 310 CMR 16.304121. Please consult the local regional office of the Department for further information. revised 9/2/98 Pose 4of11 SUBSURFACE SEWAGE DISPOSRAL SYSTEM INSPECTION FORM PAB CHECKLIST property Address: 10 1�e�rrYl ex& ow �` • 10,D ri-}1 �i nd ( J�.r, owner: �ctme_5 �R ob1 c c_ Dau of Inspection: Check If the following have been done: You must indicate either "Yea" or "No" as to each of the following: . Yes ' No� . pumping information was provided by the owner, occupant, or Board of Health. as mal None of the system period. p Lprgs voleve been umes of warter haveped not been at tintroduced Into o weeks and tthe ssyst mystorn l recently ar as part of this Sow . rates during that inspection, _ As built plans have been obtained and examined. Note if they are not available with NIA. The facility or dwelling was inspected for signs of sewage backup. The system does not receive non•sonitary or industrial waste flow. The site was Inspected for signs of breakout. _ All system components, excluding the Soil Absorption System, have been located an 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: tzExisting information. For example, 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) J1 6.304311b)) The facility owner (and occupants, if different from owner) were provided with information on the proper maintenance of SubSurface Disposal Systems. revised 9/2/98 page s or it SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION --Property Address:. i D deer e doW� U orth A r►d' b d -p:, tYl A Owe: Sarney h oblee , Date of inspection: FLOW CONDITIONS Design flow;, fit /�a.p.d.lbota m. Number of b—ad come (da n): Number of bedrooms (actual): , Total DESIGN flow— Number low j_^ d Number of current real eMs:Q Garbage grinder (Yale or no): Laundry {separate system) yea or nIf yes, separate inspection required Laundry system Inspected (ILes or no) Seasonal use (yes or no): Water motor readings, if available (last two year's usage (gpd)t 'PIE � Sump Pump {yas or no):60 -��'Y•'°'"'� Last date.of .occupancy: 'r CO MM GIAnNDUSTRWL: Type of estebiishment: AM Design flow:{Based on 16.303} Basis of design flow Grease trap present: (yes or no)— Industrial Waste Holding Tank present: {Yes or h0,,. Won•sanitary waste ditcharged to the Title S system: (yes or no)— Water motor readings, if available: Last date of occupancy: ' OTHER: {Describe) '.*at date of occupancy:GENERAL INFORMATION pUMP00 RECORDS and source of information: System pumped as pert of Inspection: a or nor u if yes, volume pumped: ^9011 I U, 04; Reason for pumping: 01AW, all T _ r YPE F SEM Septic tank/distribution box/soil absorption system Single cesspool Overflow cesspool. Privy Shared system (Yes or nal lit yes, attach previous inspection records, if any) IIA Technology ata. Attach copy of up to date operation and maintenance contract Tight Tank � -Copy of DEP Approval Other f" . - APPROWMATAGtcof all components, date installed (If known) and source of information: IE Sewage odors detected when arriving at the efts: (yes or no) revised 9/2/98 Page 6of11 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) �.- Property Address:. to �eerr�►ea�oi,J � • Not -4-h -Anc-b vtr, Yn A 011q-:; Owner:-10-mts'-RoUte- Dow of Impaction: 1 an j 0 D BUILDING SEWER: ((.ovate on Oto plan) Depth below grade: ` Material of construction; 44 coat Iron 40 PVC other (explain) Distance from�rivate water supply well or auction line Diameter -^ Comments: (condition of Joints, venting, evldenoe of Igo, etc.) SEPTIC TANK: (locate on site pian) Depth beiow grade� • Material of construction: concrete „matai _Fiberglass _Polyethylene ,,,_other(axplaln) If tank is metal, list age ^ is age confirmed by Certificate of Compliance — (Yes/No) Dimensions: ! c"k ?� of Sludge depth.,Distance from top o s)ydge to bottom of outlet tee or baffler Scum thioknessi= u Distance from top of Boum to top of outlet tee or baffle:_„Lm r �r Distance from bottom of scum to bottom of outlet to or baffle: Now dimensions were determined: Comments: (recommendation for pumping, cos Itton of info end outlet tees or baffles, depth of liquid level in relation to outlet Invert, structural integrlty, evidence of leakage, etc.) j .� `�� Stir t rcQ t„ "V2>/ E� GREASETRAP: (locate on site plan) ` Depth below grade: Materiel of contra 1 n: concrete metal _Fiberglass _Polyethylene _ other(explain) Dimensions: Scum thickness: Distance from top of scum WWI) of outlet toe 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.) .i revised -9/2/98" Page 7 of 11 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) `Properly Address: : O-be e r• m eadpl,) Rk N oro h fl nd ovu-, Yn A ht -,L15' Owner: 1--1Rme5-7R0blee. Date of lnspeatrar: (jai % 0 0 TIGHT OR HOLDING TANK:*Tank must be pumped prior to. or at time of, Inspection) (locate on site plan) —( Depth below gredet_ Material of construction. _concrete ,_.,metal Plberglase ,_Polyethylene _other(explain) Dimenslonst Capacity: gallons Design flow:gallonsfday Alarm present • Alarm level:_ Alarm In working order: Yes No Data of previous pumping: Comments: (condition of Inlet too, condition of alarm and float switches, eto.) DISTRIBUTION 80X• (locate on site pian) 4 lepth of liquid level above outlet Invert: Comments: (note If level and distr)b)igon is equal. 9yldenye of solids carry5qer, evidence of PUMP CHAMBER -J& {locate on site plan) Pumps In working order: (Yes or No) Alarms in working order (Yes or No) Comments: _ (note condition of pump *bomber, condition of pumps and appurtenances, etc.) . revised 9/2/98 Page 8of11 or out of box, oto.) SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) -�'propertyAddraaa: I D�eerrr1Cac(oiv^h�. Nor•lh'Andode r)IA 018'415" Owner: �A rrie �R obi t Dane 01 k*pWdM: SOIL. ABSORPTION SYSTEM (SAS):,, {locate on site plan, if possible; excavation not required, location may be approximated by non•intrusive methods) if not located, explain:. Typst leaching pits, number:, teaching chambers, number*._ leaching galleries, number,. _ leaching trenches, number, length: leaching fields, number, dimensions: overflow cesspool, number:_ Alternative system: Name of Technology: Comments: (note condition of soil, erns oUydraulic failure, level of po�ng, damp soil, c�ndition of vagMtatlon tc.) (locate on site Number and configuration: "Depth -top of liquid to inlet Invert: Depth of solids layer: `— Depth of scum layer: Dimensions of cesspool: Materials of conNruotion: 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: (locate on lte plan) Materials of construction: Dimensions: Depth of solids:_ Comments, ,Rot& condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation; etc.) revised 9/2/98 Pagc9orlt SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued} --�rowrty Addrge: 1' o 1 eermc4do0 r91) dooer) n7I 4/ IN6 0W1W** -ZmCs--4�0"ee- . O+�e �t Inspection: a-7) o 0 SKETCH OF SEWAGE DISPOSAL SYSTEM: . Include ties to at least two permanent reference landmarks or benchmarks iocate all wells within 100' (Locate where public water supply comes Into house) ' ' TICS .......�...J�.. 8-E 53, go, 5 F G - i8-(r o; C-� 33. 20 ?� , , xr 0 rrIdi 2 , r V •D ,vx,.,yipvd, , xrf.pv ..�-f:..:.r•., . ,. , . ... ���- � �.�(i/V f • •i J revised •9/2/98 Po�eloorll SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (ccrrdnued) %'' PMPKW Address: Owner: Das of Inspoe t: NRCS Report name Soil Type_' Typical depth to groundwater USGS Date website visited - Observstlon Wells checked Groundwater depth; Shallow Moderate Deep SITE EXAM Slope Surface water ..Check Celle Shallow wells Estimated Depth to Groundwater Feet Please ndioate all the methods used to determine High Groundwater Elevation: -4 0 tained from Design Pians on fsoord Observed Site (Abuttin Property, observation g P. P ert Y. hofs, basement sump eta.) / — Determined -from local conditions J Checked with local Board of health Checked FEMA.Maps Checked pumping records Checked local excavators, Installers Used U$GS Data Describe how you established the Nigh Groundwater Elevation. (Moat be completed) cher rc-� 0 >e�., ��l^ll 1�.,�� (� � ,�� S' {((/+� ( Rie.2C f- C _ " .1 ' ' r donc /0*TIg ,e 11' t revised 9/2/98 Page 11 of 11 Z00(� Ada 2THAO(INV HZlTON -4 1 MM m � .ml w� VM PZQR RRA RJR VV4 Pt*AT vera AAIT-+:rn M Na�a�Ia rho obi o �a C4 C7 \\\\\\ I I X O O i.1JJ i.& V mQ �o G .3 G 10 n I i 'r�i C� we �O �O �O b v W, I Ii 0. H H c � n m tr! I ca a n, z Ja .. o a © A rt ,. R 1 `� \ ` so 1 �i .4 i1o� ca cm c N N 1 \ -J s m 'S ao i ©o :: d I1. Cc CO l n oo -q " I -I cc c s NW.oW.o&P.!C7 .Mm»toMas� =oc 6uu�m i 144 I ..'c .. •'xta�Kr�ro CS C 40 �D N I C7 .. N Er•1O Z ID O • e 111P? ¢g M 3 Z VO 43 Ff! 4 46 cVS r8 ID V f' � Q to is as rn I CAO, V-4%4 V 1A\ C7 ..1q CL N a C- M 1 \t -4 L 0 ,IJ o@ � 1. a 40 b� � (A w to :D tib pJy © L7 O b ro s•+ W W N Ch �c , 0 =,I ro IT„�. aa��aa M u I �. ►� R7 R h 1✓� I B��N$& o O o °gym i .ii..►ii� I a 'al �� A R,G 3 1 V1 V1 cknn 0 % 6% r- )J, .Nf � F� � Fy+, lu0 x 0 EC 0 � ` •. %is a O i o w IV c.0N 11 m 1 A M n led I 1 �' i t "V v �M p C I� =MOMS iwe I ro . pr N��0 o -+42©b-110 1 C ;i 0 40NwCn.0N 1 \\\\\\� I 0 2 .. A i.ii.i.4 o, J p.. QRS CP �D •O .O +0 �b :O ,O M I Z 0 b W cd�lt �r U ” NVN1 \ TI ,• I 1 ElEVo�= Q i Mc C7 ro I rtQ.. 4- W 1R N" I N r1 © m V O L I u A, b S? 0 ai a 8 1 6wub juu Ada 2THAO(INV HZlTON -4 1 MM m � .ml w� VM PZQR RRA RJR VV4 Pt*AT vera AAIT-+:rn m m c rri M m m I rri rn C2 r" rri ryl M:'M rn x) w n mnGi brri r -o \/":v co I CD (Z) cz Ul I CD VD (4 C4 xi. m .Z ,co 4.m� Q m M P4: 0 ci w C -i W. -C S1 Z4 0, _q M mT> M* ni rr% c"). m m mM ZD, 0 4n 0 Ul cn co tn 117 .. .... ... . En ro, rt w 0 H a� Y Al tri tzj 1-3 :5 H(Znz .r o�� cg c� z 0 En o K z moo H 'tJ H O z V. b 0 ro c 1 0 to r ooz (P LP d �o 1-3 :5 H(Znz .r o�� cg c� z 0 En o K z moo H 'tJ H O z V. b 0 Important: When filling out forms on the computer, use only the tab key to move your. cursor - do not use the return key. Commonwealth of Massachusetts City/Town of System Pumping Record Form 4 RECEIVED JUN 3 0 20og TOWN OF NORTH AND :AVER HEALTH DEPARTMEAT DEP has provided this form for use by local Boards of Health. Other forms may be used, but the information must be substantially the same as that provided here. Before using this form, check with your local Board of Health to determine the form they use. The System Pumping Record must be submitted to the local Board of Health or other approving authority. A. Facility Information 1. System Location: Left fror(, left re , left sif hou . Right front, right rear, right side of house. Address V Citylrown 2. System Owner: Name Address (if different from location) City/Town v) State 0 Vve Zip Code i Stat p Code -Ss r - � Telephone Number B. Pumping Record 6 1. Date of Pumping Date `2. Quantity Pumped: Gallons 3. Type of system: 0 Cesspool(s) eptic Tank [j Tight Tank Other (describe): 4. Effluent Tee Filter present? E] Yes ErNo If yes, was it cleaned? Yes No 5. Conditi n of Syste p: 6. System Pumped By: Neil Bateson F 5821 Name Vehicle License Number Bateson Enterprises Inc Company 7. Looc�atiown contents were disposed: Lowell Waste Water igna ure of Hduthr Date t5form4.doc• 06/03 System Pumping Record • Page 1 of 1 . y r t r a j ri khFlf:� ot � �l ir(i a �� t a L'•.i r si ' , s �► , , � ,, ,:..� � �� � � TOWN� . OF NORTH ANDOVER { ` ' SYSTEM PTmPTN(: ,pvrn1Dn ti, j�rY'ts.i(�r'y t°it�r;14aF: +ul,��• IIx r. t 1 i j' zf t'� .3�1. .�',; }' . ;t{+{' s t • L .3A. + �{ Tgv f .lei } SYSTEM OWNER t& ADDRESS SYSTEM LOCATION (eumPle: left front of house) K it �4r4'?dat` �Y A AMM �rvt} 1 '3• t s C i 1.. ��Yk��ir'4 ��•#i d�j)'S�}Y �E� �PV�. j � y� • l j �, '.yam, � V IT.�, � t{'" s � i' 3 r s {•: .s s�.. �} tn14 �,E,n;vpt� DATE OF PUMPING: o I QUAxTITY PUMPED GALLONS �c ,. � ��}CA JIN� f, q,, il a r: CESSPOOL:: NO ; YES ,�SEPTIC TANK: NO YES �i� p. ; f '� �ijx� �"li"��d�lR�� �^{ ,Id`*•`{} ! `� �� I i :� I , �3 1 i 3 .. 4 F�I ,r ,., JY. �iN%� tATy t l.>R"1 .«.� Of F� SERVICE: ERVICE: ,may >Ra Or UTINE EMERGENCY' 'C. Z+ N } �`+'ei :•I rA {t'�: ;'�,$It ay`C�� 5 °tr 1 j ie �r Y`I?iSF�VTI4/NSRr4'}a / I 7 l� GOOD CONDITION 4�1 •. 6 �r; ,: 3 FULL TO COVER _ HEAVY GREASE„ . BAFFLES IN PLACE ROOTS LEACHFIELD RUNBACK --- G� i �� ! �3 t` jG� • ,...�w�. , {�, t ;.f:, ` EXCESSIVE SOLIDS ��; FLOODED r. SOLIDS CARRYOVER OTHER (EXPLAIN) i •5� ^w#:91 i S'�vr11 �t tlYt' � .1 1- ,r, j�((sr•,C ff 11,is Sr ,t,�aN4 3 �isl { e:.� �3; 3-t �3� �•�t ;" I f a . , t }h� zI SYSTEM PUMPED BY: �y„ 7{��tL����{'I iV4{'A'r,1�-At ! .I e� R t• k , yt 1 1�4 is W1k f 7�tiii '� i'A ri�s�J�� .ii" Y �"��� � ����Nt ," i r S:�• `# f,w t � s r - t dirl'i +S r_ �R}� sy��... 'WWI XMITS TRANSFERREITO tHnX y.at/,�f� "ff s"d err al; vw Y e 73 • sit 9° �1w{ i0 �°w �jT i hy�'n i r t 'EYJA/t1CJ.1 �J' 'y )Qn 11Y C 1 1'ck g�rt 6yr, i 1 i 0 Form No. 4 Town of North Andover, Massachusetts BOARD OF HEALTH 7 CERTIFICATE OF COMPLIANCE This is to certify that the Individual Soil Absorption Sewage Disposal System constructed ( ) or repaired (� by - n N AJ JD UCS INSTALLER at _ %O �CE2/�%Ei9l�Gy .L.4iU� SITE LOCATION has been installed in accordance with Board of Health Regulations as described in the Design Approval Site System Permit No. 9 ZZ dated /,0 9 19 97 The issuance of this certificate shall not be construed as a guarantee that the system will function satisfactorily. BOARD OF HEAL FH b e NORTH 0 �t�ao is 1.t. 3? e.�T, •�a O O L . ,SSACHUSEt Town of North Andover, Massachusetts BOARD OF HEALTH Form No. 3 �G� 7 19 -2 -2 - LA STEVEN J. WURSO Environmental Designs 22 Lilly Pond Road W. Boxford, MA 01921 (508) 352-9872 TO > WE ARE SENDING YOU /Attached ❑ Under separate cover via the following items: DATE � n� JOe No. ATTENTION P(7� RE 90 .'J ❑ Shop drawings Prints ❑ Plans ❑ Samples ❑ Specifications ❑ Copy of letter ❑ Change order ❑ COPIES DATE NO. DESCRIPTION 90 rr� THESE ARE TRANSMITTED as checked below: For approval ❑ Approved as submitted ❑ For your use ❑ Approved as noted ❑ As requested ❑ Returned for corrections ❑ For review and comment ❑ ❑ FOR BIDS DUE 19 REMARKS ❑ Resubmit copies for approval ❑ Submit copies for distribution ❑ Return corrected prints ❑ PRINTS RETURNED AFTER LOAN TO US COPY TO SIGNED: j 1/ �nnln.r.r�• ire nn1 �. nn1�A 41n A1� -00l ... .I ...... MAP AND PARCEL � q A - ADDRESS —/Q 10t1, -"j /'iG4b QUQ OWNER SIZEFLOT1N SQUARE FEET �c # BEDROOMS SEPTIC SYSTEM LOCAT (For example, FRONT YA FINAL GRADING DATE AS BUILT PLAN IN FILE? y INSTALLERj,� G� DWC PERMIT DATE U 2% e CERTIFICATE OF COMPLIANCE DATE ENGINEER No. FORM 11 -SOIL EVALUATOR FORM Page 1 of 3 Date: Commonwealth of Massachusetts Massachusetts Performed By: ��� o Date: Witnessed By: Address or 10731 -IA Owner's Name y, COP Address and �b=�--�;2f �/Ll Lc� Telephone # New Construction FlRepair FT Office Review Published Soil Survey Available: No Year Published Publication Scale Drainage Class Soil Limitations Yes 71 Soil Map Unit (A'N-1D A) IiCi,AjL Surficial Geologic Report Available: No Q Yes Year Published. Publication Scale Geologic. Material (Map Unit) Landform /C6:-- COAj�-4G7--— Flood Insurance Rate Map: Above 500 year flood boundary No Yes Within 500 year flood boundary No:�; Yes Within 100 year flood boundary No Yes Wetland Area: National Wetland Inventory Map (map unit) Wetlands Conservancy Program Map (map unit) Current Water Resource Conditions (USGS): Month Range: Above Normal Normal Below Normal Other- References Reviewed: DFP APPROVED FORM -12/07!95 SoilevaLsam i FORM 11- SOIL EVALUATOR FORM. Page 2 of 3 Location Address orLotNo. Deep HoleNumber _Date 7419 7Time Location (identify on site plan) Lanct Use, 2- } (A_W Slope(%} f } Surface Stones Vegetation: Landform. Position on. landscape (sketch on the back) Distances from- Open WaterBody �j /QQ feet Possible. Wet.Area. � !Q C) feet Drinking WaterWell feet Weather e Drainagtway �t feet Property Line- feet Other DEEP OBSERVATION HOLE LOG* Depth from Soil Horizon Soil Texture Soil Color Soil Other Surface (Inches) (USDA) (Munsell) Mottling (Structure, Stones, Boulders, Consistency, % Gravel) O-lZ �/GL ,r 12- / L /Ofe3% — v��e 30-120 C ,L - LS9ti , zs G � ,y v'',el *MM MUM OF 2.HOLES REQUIRED AT EVERY PROPOSED DISPOSAL AREA Parent Material (geologic) /1&7ZA/A_Qq —/C L Depth to Bedrock Deoth to Groundwater-- Standing. Water in the Hole: Weeping from PitFace-- Estimmated Seasonal High Ground Water A j /20 DFP APPROVED FORM -12VI" FORM 12 - PERCOLATION TEST Location Address or Lot No. 40 COMMONWEALTH OF MASSACHUSETTS W'D &_c> , Massachusetts Percolation Test* Date: Time: C� Observation Hole# / Depth of Perc Start Pre-soak End Pre-soak S Time at 12" 17 Time at 9" Time at 6" Time (9"-6") Rate Min./Inch Ov/ *Minimum of 1 percolation test must be performed in both the primary area AND reserve area. Site Passed EZSite Failed a Performed By: Witnessed By: Comments: DEP APPROVED FORM - 12/07/95 PerctatSAM PITS MIN 440 LEACHING MIN 1 (13'x16') PIT MANHOLE/PIT GW MIN 4' BELOW BOTTOM EXC 2x EFF W OR D 12"-48" STONE BOT + SIDE x LOAD = TOTAL (L x W x #) (Zx(L+W)xD x #) (G/ft2) CHAMBERS MIN 440 LEACHING GW MIN 4" BELOW COVER >3 FT - VENT MANHOLES . 12"-48" STONE SPLASH PADS SLOPE .005 BED/TRENCH (Bed max. 60' X 601) MIN 13' X 16' PIT BOT + SIDE X LOAD = TOTAL (L x W x #) (2 x (L+W)xD x #) (G/ft2) FIELDS / MIN 440 GPD r 900 ft2 BED GW MIN 4' BELOW BOTTOMFIELD 0 F �—� PIPE ENDS JOINED?--L_� 4" PEA STONE? OA-' DIST LINE SLOPE .005? >3 -COVER -VENT SCH 40 MIN 12" COVER RATE X zb ) X = TOTAL L W LDG DOSING TANKS AND PUMPS DIMENSIONS X X = PUMP CAPACITY gpm L W D Vol. DISCHARGE SIZE DISCHARGE RATE DISCHARGE TIME gpm MANHOLES TO GRADE ALARM SEP. CIRC. GW (Min. 1' below inlet) HWL LWL CHECK VALVE BLEEDER HOLE MANUAL OP. SWITCH ENUF STORAGE? Copyright 0 1996 by S.L. Starr PLAN REVIEW CHECKLIST ADDRESS—, � %�/ti% ENGINEER GENERAL / 3 COPIES STAMPy/ LOCUS L -- NORTH ARROW/ SCALE CONTOURS PROFILE-_L. ROFILEL (Sc) SECTION BENCHMARK ---- SOIL & PERCS ELEVATIONS WETS. DISCLAIMER L-� WELLS & WETS' WATERSHED?,L/a DRIVEWAY WATER LINE v� FDN DRAIN — M&P SCH40 � TESTS CURRENT? SOIL EVAL SEPTIC TANK MIN 150OG .17 INVERT DROP -- GARB. GRINDER4(2 comps +200) 10' TO FDN MANHOLE ELEV GW ## COMPS. GB D -BOX SIZE ## LINES FIRST 2' LEVEL STATEMENT �--� INLET /0,1_5* - OUTLET ( 2" OR .17 FT) TEE REQ' D? LEACHING MIN 440 GPD? RESERVE AREA 4' FROM PRIMARY?— 20 SLOPE 100'. TO WETLANDS 7100' TO WELLS Z— 4' TO S.H.GW L–f(5'>2M/IN) 20' TO FND & INTRCPTR DRAINS 400' TO SURFACE H2O SUPP L''___�I 4' PERM. SOIL BELOW FACILITY MIN 12" COVER 6`– FILL? (15') BREAKOUT MET? TRENCHES MIN 440 gpd SLOPE (min .005 or 6"/100') SIDEWALL DIST. 3X EFF. W OR D (MIN 6') RESERVE BETWEEN TRENCHEL IN FILL? MUST BE 10' MIN. 4" PEA STONE? VENT? (>3' COVER; LINES >501) BOT + SIDE _ ( L x W x #) ( DxLx2x## ) Copyright 0 1996 by S.L. Starr X LDNG = TOT (G/ft2) PPROVED DWPE PROVIDED 711617 Title 5 Reg. 2.5 IF Reg. 6 1,10RIPH A;11 E'ER n0:� ;D Of HEALTH DISAPPROVED DATE TIME REASON ')'J�� ij )K The submitted plan must show as a minumum: (a) the lot to be served (area, dimensions, lot //,abutters) (Planning Board files) (b) location and log of deep observation holes -distance to ties (c). location and results of percolation tests- distance to ties (d) design calculations & calculations showing required leaching area (e) location and dimensions sf system (including reserve area)" f existing and proposed contours ewag location of any wet areas wihin 101 of teOCk nsi disposal system ot- disclaimer(chewetladsmappn (h) surface and subsurface drains within '100' of sewage disposal system or disclaimer I-olo(i) location of any drainage easements within 100' of sewage disposal system or disclaimer (planning board files) t-o(j ) known.-- sou-rces_ of _-crater- supply within: 200' of sewage disposal --system_ ar- _disclaimer , . (k)- - )_ocation- of any proposed well t'6 serve the lot ('100 from leaching facility) (1) location of water lines on property (10' from.leachi facilities) (m) location of benchmark In) driveways o) garbage disposers p no PVC is to be used in construction a profile of the system (elevations of basement, p1L pipe septic tank, distribution box inlets and outlet: distribution -field piping and any other elevations) (r) maximum ground water elevation in area of sewage di: system Engineer or (s) plan must be prepared by a Professional g other professional authorized by law to prepare suci plans Septic Tanks ( Capacities - 150% of flow, water of tees, access, pumping, „(b Cleanout -. - �10' from cellar wall or inground la 25' from subsurface drains table, tees, depth swimming pool failiOd Distribution Boxes {a Slope greater than. (b) Sump - Leachin-_ Pits Leaching pits ar preferred where the installation is possible (a Calc tions of leaching area (minimum 500 S.F.) (b Sp-. ing c rface drainage 2% d fiver material' ev 7 �Z Cr-C e c �,Io sa ` eaching Fields % Greater than 20 minutes/inch b Area -(minimum -.900 S.F.) Construction of field d Surface drainage 2% (e 20' from cellar wall or inground swimming pool Leaching Trenche (a) CalculaU ons of leaching area (min. 500 S.F.) (b) /Dime (4 ft. min. 6 ft. with reserve between),. (cons (dctioe(fdrainage 2% - Downhill Slope �a� Slope y/x to be shownby/x X 150 = (to be shown Pum -Pe (a) - Approval .(b Stand-by power Board of Health North An ver Nass. WED DATB_ DI SAFF UV NU /* FMOK BEMC SISTEK INSTALLATION CHECK LIST C LCYT � J AVATIC�I Og FAIL 1. Distance Tot a. Wetlands b. Drains c. Well 2. Water Line Location 3. No PPC Pipe 4. Septic Tank a. _Tees --Length & To Clean Oat Gowers. b. Cement Pipe to Tank Ola Both Sides of Tank 5. Distribution Box a. Covers & Box - No Cracks b. All Lines Flowing Equal Amounts c. No Back Flow 69. Leach Field or Trench a. Dimensions b. Stone Depth c. Capped lhds d. Clean Double Washed Stone 7. Leach Pits a. Dimensio b. Stmne c. Sp Pads d. Tees g�Ceaaent Pipe to Pit - Both Sides. /f. Clean Double Washed Stone 8, No Garbage Disposal 9. Anal Grading Inspection 10. Barricading Covered System 11. As Built Sabmitted.. a. Lot Location'- b. ocation'.b. Dimensions of System C* Location 14th Regard -to Perc Test d. Elevations e; Water Table 0 DelleChiaie, Pamela From: DelleChiaie, Pamela Sent: Monday, July 13, 2009 12:28 PM To: 'Carrie@Bertolino.us'; 'Bob@Bertolino.us' Subject: Information Request - Septic File -10 Deermeadow Road Attachments: 10 Deermeadow Road - Septic As Built Plan; Septic As Built Plan - 2 -10 Deermeadow Road; Septic -10 Deermeadow Road - Title 5 Report; Pumping Records; Installation Paperwork from 1997 Dear Carrie, Attached is the information you requested from you Health Dept. file a short while ago. Please call the office with any questions. Reference: Phone number -978.681.8119 Pamela DelleChiaie Health Department Assistant TOWN OF NORTH ANDOVER Health Department 1600 Osgood Street Building 20; Suite 2-36 North Andover, MA 01845 978.688.9540 - Phone 978.688.8476 - Fax pdellechiaie@townofnorthandover.com - E-mail http://www.townofnorthandover.com - Website Nnrec- If copied to BOH Memhers - Reference Copy Only - no response requested at this time Commonwealth of Massachusetts RECEIVED City/Town of �System Pumping Record JUL 2 2 2008 Form 4 TOWN OF NORTH ANDOVER DEP RTMENTut the DEP has provided this form for use by local Boards of Health. HEALTH -m information must be substantially the same as that provided here. Before using this form, check with your local Board of Health to determine the form they use. The System Pumping Record must be submitted to the local Board of Health or other approving authority. A. Facility Information Important: When filling out forms on the computer, use only the tab key to move your cursor - do not use the rum key. re6m 1. Syst m Lo rr Q -�: Kct-� Address - el�z- City./Town C J 2. System Owner. Name Address (I different from location) City/Town B. Pumping Record 1. Date of Pumping 3. Type of system: ❑ ❑ Other (d6scribe): St e VkA Zip Code State p Code rob � �« Telephone Number I JIV-08� Date 2. Quantity Pumped Cesspool(s) Septic Tank Gallons ❑ Tight Tank 4. Effluent Tee Filter present? ❑ Yes Flo If yes, was it cleaned? ❑ Yes ❑ No 5. Condition of Sczt� � f 6. System Pu. � ( Name Company 7. Locationere contents disposed: t5form4.doc• 06/03 Vehicle License Number 71- /(/-, -0� Date System Pumping Record • Page 1 or 1 I COMMONWEALTH OF MASSACHUSETTS EXECUTIVE OFFICE OF ENVIRONMENTAL AFF DEPARTMENT OF ENVIRONMENTAL PROTECT ONE WINTER STREET, BOSTON MA 02108 (617) 292-5500 ARGEO PAUL CELLUCCI Governor SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION Property Address: Im ecce o 0_R d . Name of Ow S� v bl e NIS AY&oo•e fY�1 018'fJAddress ofOwner:_ ign/GDateof Inspection: Name of Inspector: ( S I am a DEP approved system inspectorPun=16tto Section 15.340 of rude 5 (310 CMR 15.000) Company Name: S ' S S (cS Zi i11c,. Mairg Address: i 61 g 7 t Telephone Number: g ' FEB 112000 OARD OF HEALTH TRUDY CORE Secretary DAVID B. STRUHS Commissioner 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: IZPasses Conditionally Passes Nee Further E aluation By the Local Approving Authority Fail Inspector's Signature: Date: �p The System Inspector shall ubmit a py of this nspection report to the Approving A thority (Board of Health or DEP)within thirty 1301 days of completing this inspection f the nor m 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 t e 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. NOTES AND COMMENTS revised 9/2/98 Page 1 of 11 ~i Pr t,d nn Pr -1, �. P SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) `— *oparty address: I b l e e -r -m -t oA b.� o �J 2r 11 D I y 5 Owner: ---7a---nes'�obl�� Date of Inspection: INSPECTION SUMMARY: lCheckC; B, C, or A A. SYSTEM PASSES: I have not found any information which Indicates that any of the failure conditions described in 310 CMR 15.303 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. Indicate yea, no, or not determined IY, N, or NO). 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 Certificate 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 complying septic tank as approved by the Board of Health. Sewage backup or breakout or high static water level observed in the distribution box is due to broken or obstructed pipe(s) or due to a broken, settled or uneven distribution box. The system will pass inspection if (with approval of the Board of Health). T 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 pips(s). The system will pass inspection if (with approval of the Board of Health): broken pipe(s) are replaced obstruction is removed r *Note: THE TITLE 5 INSPECTION IS NOT A GUARANTEE/WARRANTY OF THE F(flURE FUNCTION OF THE SEPTIC SYSTEM. revised 9/2/98 Page 2of11 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: I D r Y� l eC�i 6 a, o r�41� 4 rVA& U L r, Yn g Q l S u 5 Owner. �Gc Me5 �d4Jl2.e Date of Nspection: ►, a -r o D 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. 1) SYSTEM WILL PASS UNLESS BOARD OF HEALTH DETERMINES W ACCORDANCE WITH 310 CMR 15.303 (1)(b) THAT THE SYSTEM IS NOT FUNCTIONING IN A MANNER WHICH WILL PROTECT THE PUBLIC HEALTH AND SAFETY AND THE ENVIRONMENT: Cesspool or privy is within 50 feet of surface water Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh. 2) SYSTEM WILL FAIL UNLESS THE BOARD OF HEALTH (AND PUBLIC WATER SUPPLIER, IF ANY) DETERMINES THAT THE SYSTEM IS FUNCTIONING IN A MANNER THAT PROTECTS THE PUBLIC HEALTH AND SAFETY AND THE 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 soil absorption system and the SAS is within a Zone I of a public water supply well. The system has a septic tank and soil absorption system and the SAS is within 50 feet of a private water supply well. The system has a septic tank and soil absorption system and the SAS 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. Method used to determine distance (approximation not valid). 3) OTHER r M revised 9/2/98 Page 3 of 11 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: I D ear rn ea�0 i,J Nor A n of o J -e - r, VYl H o I g `I 5 Owner: warn 2 s�' p 4j l e f^ Date of Yrspec6orc 'Z-7 It, p D. SYSTEM FAILS: You must indicate either "Yes" or "No" to each of the following: I have determined that one or more of the following failure conditions exist as described 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 112 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. 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" 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 =1WPA) or a mapped Zone II of a public water supply well) The owner or operator of any such system shall upgrade the system in accordance with 310 CMR 15.304(2). Please consult the local regional office of the Department for further information. revised 9/2/98 Page 4 of 11 r SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST Property Address: I D l�e�m eA-dof ,� i� �.. �j nd p oma( $ LI S Owner: ,aMe_-s obi eC_ Daft of inspection: I Iate) o 0 Check if the following have been done: You must indicate either "Yes" or "No" as to each of the following: Yey No 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 Teceiving 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 NIA. _ The facility or dwelling was inspected for signs of sewage back-up. _ The system does not receive non -sanitary or industrial waste flow. _ 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: _ Existing information. For example, Pian 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) 115.302(3)(b)1 _ The facility owner (and occupants, if different from owner) were provided with information on the proper maintenance of SubSurface Disposal Systems. revised 9/2/98 Page 5orn SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION -Pr�yA�m; Io�eermeadow��. North Anr ��e�� h'1(� b1s45 Owner: Sa.m e s 1� ol�l e e Dame of Inspection: FLOW CONDITIONS RESIDENTIAL- ,` Design flo11- c. p.d./bedropm. Number of bedrooms (de ign): Number of bedrooms (actual): F Total DESIGN flow i' '�' Number of current residents:�Q Garbage grinder (yes or no): -40 Laundry (separate system) yes or no):If yes, separate inspection required Laundry system inspected (yes or no) Seasonal use (yes or no) --_w Water meter readings, if available (last two year's usage (gpd): /r%%fllGfrtpCJ Sump Pump lyes or no):-Ido- Lost o):-�� Last date. of .occupancy: COMMERCIALIINDUSTRIAL: Type of establishment: Design flow: oad ( Based on 15.203) Basis of design flow Grease trap present: lyes 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) '.ast date of occupancy: PUMPING RECORDS and source of information: System pumped as part of inspection: a or If yes, volume pumped: 'ai gat) ns Reason for pumping: �t &ZZ:�E . Va-h < GENERAL INFORMATION I� TYPE F SYSTEM ' G V Septic tank/distribution box/soil absorption system Single cesspool Overflow cesspool Privy Shared system lyes or no) (if yes, attach previous inspection records, if any) 1/A Technology etc. Attach copy of up to date operation and maintenance contract Tight Tank Copy of DEP Approval Other APPROXIMATE AGE of all components, date installed (if known) and source of information: Qea,'t 8 O Sewage odors detected when arriving at the site: (yes or no) L &J revised 9/2/98 Page 6of11 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) `--- Property Address: 01)1eerm e 4-doo-i�A. N D rV-h -Arid d U -Lr, NA 0 (8 y� Owner: �c.rnts�obleL Date of Inspection: k f Z-) / o 0 BUILDING SEWER: (Locate on site plan) . Depth below grade: y /- Material of construction: Veast iron _ 40 PVC _ other (explain) Distance from frivate water supply well or suction line Diameter _Er_ -014 Comments: (condition of joints, venting, evidence of lege, etc.) SEPTIC TANK•_✓ (locate on site plan) . . Depth below grade:Ile— Yconcrete Material of construction: _metal _Fiberglass _Polyethylene _other(explain) If tank is metal, list age _ Is age confirmed by Certificate of Compliance _ (Yes/No) Dimensions: • SAY . I d .��$'�� Sludge depth:!�4' Distance from top o s�, dge to bottom of outlet tee or baffle: Scum thickness: Distance from top of :cum to top of outlet tee or baffle:. 91 Distance from bottom of scum to bottom of outlet tog or baffle: How dimensions were determined:rfroe Comments: (recommendation for pumping, evidence of leakage, etc.) _ of inlet and outlet tees or baffles, depth of li uid level in relation to outlet invert, structural integrity, GREASE TRAP: (locate on site plan) Depth below grade: Material of construc'tidn: con r _ c ete _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.) revised 9/2/98 Page 7of11 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: 101 e e r Me&d pA) ): d. Owner: ern e s, 06) e e - Date of Inspection: 1 a D D TIGHT OR HOLDING TANK:_O(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/day Alarm present - Alarm level: Alarm in working order: Yes _ No Data of previous pumping: — Comments: (condition of inlet tee, condition of alarm and float switches, etc.) DISTRIBUTION BOX - (locate on site plan) . lepth of liquid level above outlet invert:_ Comments: (note if level and distrib 'on is equal, a idenge of solids carryoker, evidence of leakage'nto or out of box etc.) D - PUMP CHAAABEA:�1/�!�- (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.) revised 9/2/98 Page8of11 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) `-- Property Address: 16 11 e e.r m e &cC o u, R J, N o r� h n d o d c.r, rYl A O I if ti 5 - Owner: Owner: SGCrneS`R obl f Dab of Inspection: 1 a7•1 o 0 SOIL ABSORPTION SYSTEM (SAS) (locate on site plan, if possible; excavation not required, location may be approximated by non -intrusive methods) If not located, explain: Type: leaching pits, number:_ leaching chambers, number:_ leaching galleries, number:_ leaching trenches, number, length: leaching fields, number, dimensions: overflow cesspool, number: Alternative system: Name of Technology: Comments: (note condition of soil, signs of ydraulic failure, level of ponding, damp soil, cgndition of vegetation, etc.) ave to44r (locate on site Number and configuration: Depth -top of liquid to inlet invert: Depth of solids layer: v 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: �� (locate on lite plan) Materials of construction: Dimensions: Depth of solids: Comments: (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.) J revised 9/2/98 Page 9of11 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) --�t Address: 10)�eerrneadoto-Rd �ar�{����do�er yh� D�Sj-iS Owner: -rn e s7� bbl if e Due of bwpscdon: i/ a� J o 0 SKETCH OF SEWAGE DISPOSAL SYSTEM: . Include ties to at least two permanent reference landmarks or benchmarks locate all wells within 100' (Locate where public water Supply comes into house) Tc s �g-E s3, 113-F $D,j L CT C-� 20Xs LEA0.4 D ..0 -E 3s4 C -F X4.4 ' I.C- 70, t 1 90°� � • . Pale 10 of 11 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) -� Property Address: Owner. Date at Inspectkm: NRCS Report name Soil Type_ I ypicai depth to groundwater USGS Date website visited Observation Wells checked Groundwater depth: Shallow Moderate Deep SITE EXAM Slope Surface water Check Cellaq/ Shallow wells Estimated Depth to Groundwater Feet I ease ndicato all the methods used to determine High Groundwater Elevation: 700 tained from Design Plans on record V Observod Site (Abutting property, observation hole, basement sump etc.) Determined from local conditions Chocked with local Board of health Chocked FEMA, Maps Checked pumping records Checked local excavators, installers Used USGS Data Describe how you established the High Groundwater Elevation. (Must be completed) ZDA revised 9/2/98 Page 11 of 11 OOa- =O I 1 z-r!m 80••0Nw0• I I R ITla \ \ \ \ \ \ 1 1 x 0 �• •w= R R 3c I%ato-n 1 .... •x040 abeNO•olaid 1 .o arrZ© n O•g o o s r- ZD r? No. I p i C2 (Ato O I NI\\ \ c ■ o a pO w 1 �o I-+ 1 40 til til In w V N I-+ ! r �N w40rj.0Z- p O MM=M A --I C3 IO I N o C �NwC7. N3 ad I C7•• ad %bN m M .. .► �► .► &.A .► rz` -1 a u a �D�b�o�k7�o3 I \ oOm _ G w to n n N o 1 O N N CL c I � I N -4 a i3 = 3 �~ ma o rrr•c m Boa r;R .� Ili �1 U1J.lN wwggc� uO !"FG 'Z t�wVO.4Oc O ?Z rD aaaaaa M @� M M 1 7 W ppoo pp p .. 40 G t r"+Jh O r O taJ .i -L I a p Qv •o �O •O �o �O �o I 'LI p 40 40 •O 40 %o WO rt CA) N ' vl �n to 1n (T tT r T+• V n, c r Ul 7 W I rr Mr- o .. A I a I s i O Z rp N I C V" s % C12 1 R R n IN�O� •i�i.lOV'O� NNI�i1 I 40 W 04 C2 N aaaaaaK■ I >9 o I e l 010©p -LID I ■. �ONco ON 40N I r a •a a �o s .L 1 -►s j -►O I M' 4 . • L N •o coo oo �o c rr 1 t.t wcarrri-= 1 OA i SA 1 N ii rrw �I'1Nr; r =,L- m V O r vamaaau I u tT 1 r� I � I m' P-91 N u ES o n M n3, my3 v rx-C o = n MC �• •w= R R 3c In I>1iis ..m a e7 n .o arrZ© n O•g o o s r- ZD C2 (Ato O © Qw \ c ■ o a pO p a p vl D 1? G O R r u uu C p O a to I."IC T m nrrrrw.\r Q, .. In .. m M .. ..\ rz` -1 a u a 9 O a C2 \ oOm _ G w to n 6." 0 9 m o a o I=y� no CL c 3 mx R a rr n u = 3 r���� ma o rrr•c m -.Iz .� Ili •'� W. d ' \ Id load eb r� ,o @� M M j ` It —. r a p .. 40 O r O taJ p Qv 1 Om 0 C2 I In t� m Mr- o .. A O Z rp 0 cM s % F 7 u 0 Sk Z -40 s p .. ., a C2 N mm a -d um r a •a a �o s M' 4 . • L N t.t v w No, OA uuuuu V 1'J` z00Qj Mda HgAOQNV HINON fjC9 PQa 91 9 VVJ Of -'()T „nTJ nn /T-- ;Tn 0 V_ CTI 671 � 3 91 CII Ir , I j „q s y n n ,yJFSI.n t Jl�r,Y1r{�4) I lv{�Pi FIII d r ,it ui{ ill til . ... ....'I tr 1 ' r {,;}}In, .. illli, '}r Il{} ,•`; i+r .�.1?.r i I +S �,.,. ;r r . - r. 7115 a3uj � _�El;�l! .JLll.. .u'uGcrt>... •. o- � ,+ ,ti � i •a,.y�hnl, Lll:h,... 9+SLJ.�w,•x,: pngr.�r i r.. _....... ...... ._. - .. _.. o O l i i z © m. Q 1 zt ;D cz, 0. - I _ Zn 5I "• O c: CA mm r. r t } cnrth r ro z73 i -1 0m m z _... a .. . .. • Q: a:;l.::a,:.,,. :;.::,;:.;:`.; ,:.:. � -,..:; !tom<:, :.,.', :. .,':,.•..• . N Q: �:, PJ: 21•. vTJ ? 1 .... r....,,.., . ......�.i::�:::.. .... 4: is r.: tn ;`CFS ..... ................ .........:;;� !T'I rtiR3 .: .......... . I : .. 'i • tD 1 W I�. !1 IN cm ,.... -•,f-•... ...... .. �:.. .� ,, .,:-:::,, ;.,... . 1 rt yf} I� . „+ ly l , �r' , I v y � • , 0 V_ CTI 671 � 3 91 CII Ir , I j „q s y n n ,yJFSI.n t Jl�r,Y1r{�4) I lv{�Pi FIII d r ,it ui{ ill til . ... ....'I tr 1 ' r {,;}}In, .. illli, '}r Il{} ,•`; i+r .�.1?.r i I +S �,.,. ;r r . - r. 7115 a3uj � _�El;�l! .JLll.. .u'uGcrt>... •. o- � ,+ ,ti � i •a,.y�hnl, Lll:h,... 9+SLJ.�w,•x,: pngr.�r i r.. _....... ...... ._. - .. _.. FORM I1- SOIL. EVALUATOR FORM Location Address orLotNo.. aDepth. observed standing in observation hole Depth weeping from side of observation hole Depth_to-soiLmottles ,�/� inches - Ground -water adjustment Index Well.Number, Adjustmentfactor feet Reading Date Index well level Adjusted ground water level inches Page 3 of 3, inches Does at least four -feet of naturally occurring pervious material exist in all areas observed throughout the area proposed forthe soil absorption. system? If. not, what is the depth of naturally occuring pervious material? I certify that. on.1 Cl� (date) I have: passed_ the. soil evaluator examination approved by &. Department of Environmental Protection and that the. above. analysis was performed by me consistent with the required training, expertise and- experience ndexperience described in 310 CMR -15'.017. t Signature DFP APPROVED FORM --11!07/95 Date. � /d 9 % J 'VII -. --a- - ill, I- - 141 - --II -L 1. 1-1, ,11 --17 L i Ld ,AORTN 0 HUS Town of North Andover, Massachusetts Form No.2 BOARD OF HEALTH 911-5- -19 q7 DESIGN APPROVAL FOR SOIL ABSORPTION SEWAGE DISPOSAL SYSTEM Applicant 4L-ZC/-C-/0 -Peozf6)p Test No. Site Location Reference Plans and Specs. V ENGINEER Permission is granted for an individual soil absorption sewage disposal system to be installed in accordance with regulations of Board of Health. Fee- 942�2 - CK-AIRM-AN, BOARD OF HEALTH Site System Permit No. q —) ") THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH Tatifiratr of Tomphatirr THIS IS TO CERTIFY That the On -Site Sewage Disposal System installed ( ) or Repaired/Replaced ( ) on Dy for at has been constructed in accordance with the provisions of TITLE 5 of The State Environmental Code as described in the application for Disposal System Construction Permit No. dated Use of this system is conditioned on compliance with the provisions set forth below: THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE SYSTEM WILL FUNCTION AS DESIGNED. This Certificate expires on DATE Inspector No. THE COMMONWEALTH OF MASSACHUSETTS FEE BOARD OF HEALTH Disposal lftstrm Tonarurtion Vrrmit Permission is hereby granted to to Construct ( ) or Repair/Replace ( ) an On -Site Sewage Disposal System located at Street as described on the application for Disposal System Construction Permit. The Applicant recognizes his/her duty to comply with Title 5 and the following local provisions or special conditions. All construction must be completed within three years of the date below. DATE FORM 1255 (REV. 4/95) H&W HOBBS& WARREN TM PUBLISHERS - BOSTON Hoard of Health THIS FORM APPROVED BY THE MASSACHUSETTS DEPARTMENT OF ENVIRONMENTAL PROTECTION aleu ponssl a)eQ 'ON Iiw.tad :suostia.1 SuiM0jj0Jay1.10fpanoiddesia uo!Ieogddd a)eQ Aq panoiddd uo!leoilddd geQ 616 x pau2!S gil�aH 3o pi og aql Xq ponssi uaaq seg aoueildwoD 10 aiea13ivaD e i pun uolieiado ui waisXs ayi weld oI lou saa.r�e .iagiin3 pau&saapun oql •opoD le>uau Ui0llnu3 01eIS aqI 3o S H1111 3o suoisinoid aqi yi!M aauepioaae ui uzalsXS Iesodsia a�umoS lenpinipul p gyosopaio3e aqi lleisui of saaAe pau$isnpun aqs — :Iuawaz0v popodsuj Ise -1 aleQ algeoildde uogm iaMsud — suoileialld to siiedo d 3o ainleN N poS 3o uo►IduosaQ ialeM punoiO of yldaQ lid Isol, 3o ylda4 youi iod sainu!w Z •oN I!d IsU, �� >a1eM punor� oI ylda4 1!d is -31 3o y1da4 you! gad salnu►w I ON lid IsaZ aieQ Xq paw.�o3aad sllnsag Isa,L uoilelooaad duel $u!soa ( ) xoq uoilnq!lls!Q .iaylp i3 bs ease �u.goeal lelo.L Iglu► Molaq gldaa aalawe!Q oN IM 3�ud33S .13 •bs e2o eon, �uryoeal Ielol, z gl�ua I leloL — ylpiM ON — lesods►Q yl a4 J;)13we!Q 41p!M i2u;) OOiOF2 Xiloedeo p!nbrj — juel o!IdaS suolle2 Mo(3 Cl!ep palelnoleD (eosaad rad suolle2 Mold u21saQ s3anlx!3 aaylp ( ) e!npjuD — ( ) saaMoyS suosnd 3o -ON �ulppng 3o AXI — iaylp npupq a&eqjeq ( ) ollld uoisuedxg swooapag 30 o[q — Ou!IIaMQ 1903 -us 5AZSh 10.1 az!S 2u!pl!ng 3o adXL ssaippv aalleisul .lo.Iau7uaCl ssai pp V ()Nl� �T N )07 0 1aUM() JhPV - Ilo . (V _ :1e wa1sXS lesods!Q oBeMaS lenp!n!pul ue X aoeldmd/1!eda) io ( ) Isul 01 )lQQd pew �q;)ns! uo!Ieo!Iddd ��ux,ta� uui�lua��uv� u�a��h� j��a��i� zap uvi��si1d�� ��A001V �O �►' H1lV3H A CIUVOe 33,q S113snH0b'SS` V4 30 Hl_lV3MN0WW00 3H1 ON SOIL PROFILE & PERCOLATION TEST DATA Benchmark Elevation Location Datum Percolation Tests -Date 15dah9 tra uv ----- Pit Number North Andwer,l:�ss. No.&Street peer e 'AnC 1 Lot No. 3� S Start Saturation Loc./Subdiv. c►�k w,P�, r1n�. r �rn Plan Soak -Mins. Owner_ _S��;� Start Test -Time L'-07 Investigator :Joe Rr�n-or. hIfn Observer_ Dry of 311 -Time - "-Time-Dro Drop of 6" -Time V _ SOIL PROFILES -DATE Mins.lst. 3"Dro 1. — Elev. _ 2. ---- Elev. 3 -= Elev. 4. --Elev. 0 0 0 0 Percolation Rate L -roP 1 Y 1 1 1 j Ties to Test fits 2 I 2 2 2 3 3 3 3 ---- 4 i 4 - 4 4 5 �� 5 o 5 5 ' 6 6 6 6 7 i 716 7 _ 7 — 7_ 8 8 8 8 9 _ 9 9 9 10 10 10 10 ' Benchmark Elevation Location Datum Percolation Tests -Date 15dah9 tra uv ----- Pit Number 1 2 3 4 S Start Saturation Soak -Mins. Start Test -Time L'-07 _ Dry of 311 -Time - "-Time-Dro Drop of 6" -Time Z7 _ Mins.lst. 3"Dro Mins . 2nd 3"Dro - Percolation Rate Notes & Sketches on Back n 11 0 0 0 0 0 J20 0 CO 11 0 b t7 U/ YJ 0 CA P 0 a M' cp m Lo L .EVA -r a ®NS. I -My• • `- I KI V Pi I. /t )Te-,*- " _ . ct 1 iwvPl' a. OLJT• �• 60.0 yo 7 N E5 - =A-5. U I L—T 5u�'SUI��,c�E �ISPO L. IN r La I"= 40DgTE6, 1 1 �,z f �D FRA' NK GGELINL*S �= /�SSUGI�.TES �NC�1NEEjZS� ARL.4-tIT�GTS J� I d L o T j 45,785. S7 S. F YI un Iz r i 20 z p Ln JI� a i 507 �ar� i L .EVA -r a ®NS. I -My• • `- I KI V Pi I. /t )Te-,*- " _ . ct 1 iwvPl' a. OLJT• �• 60.0 yo 7 N E5 - =A-5. U I L—T 5u�'SUI��,c�E �ISPO L. IN r La I"= 40DgTE6, 1 1 �,z f �D FRA' NK GGELINL*S �= /�SSUGI�.TES �NC�1NEEjZS� ARL.4-tIT�GTS -- 101 12 Date.............................. TOWN OF NORTH ANDOVER PERMIT FOR WIRING This certifies that 49 : ........... ........................... has permission to pe orm. ...................................................... . ...................... 7d wiring in the building of ............................................................................. at ...,* ...... /I. kr ................. /.r...: ......... . NorthyAndo -.er. Ma4.. .. . ..... ... . . -- .�. i� ........... Lic. No. Y-5 r . . . Fee ... Y�.. ............. ..... /4//" .17. AL IN E R Check# "/,? 74�— 'A (fomm.onwea& of Ma-4iac4u.4etts e. pad. t of ire Services BOARD OF FIRE PREVENTION REGULATIONS Official Use Only Permit No. LO 0 2 Occupancy and Fee Checked [Rev. 1/07] (leave blank APPLICATION FOR PERMIT TO PERFORM ELECTRICAL WORK All work to be performed in accordance with the Massachusetts Electrical Code(MEC), 5' 7 CMR 12.00 (PLEASE PRINT OR TYPE ALL INFORMATI019 Date: _ 5 01 City oTownyygY>�pV To the Insp ctor of Wires: By this applicatio e rsigned gives notice of his or her intention to perform the electrical work described below. Location (Street & Owner or Tenant Owner's Address -)am - Is this permit in conjunction with a building permit? Yes ❑ No (Check Appropriate Box) Purpose of Building Existing Service Amps / Volts New Service Amps / Volts Number of Feeders and Ampacity Location and Nature of Proposed Electrical Work: r Utility Authorization No. Overhead ❑ Undgrd ❑ Overhead ❑ Undgrd ❑ No. of Meters No. of Meters ` 1 Cormtion oPthe following, table may he waived by the Incnertnr of Wire.c No. of Recessed Luminaires No. of Ceil.-Susp. (Paddle) Fans No. of Total Transformers KVA No. of Luminaire Outlets No. of Hot Tubs Generators KVA No. of Luminaires Swimming Pool Above ❑In- El rnd. arnd. o Emergency Lighting Battery Units No. of Receptacle Outlets No. of Oil Burners FIRE ALARMS No. of Zones No. of Switches No. of Gas Burners No. of Detection and Initiating Devices No. of Ranges No. of Air Cond. Total Tons No. of Alerting Devices g No. of Waste Disposers HeatPump Totals: Num_ ber T_ ons - KW " No. of Self -Contained Detection/AlertingDevices No. of Dishwashers Space/Area Heating KW Local ❑ Municipal Other No. of Dryers Heating Appliances KW Security Systems:* No. of Devices or Equivalent No. of Water Heaters KW No. of No. of Signs Ballasts No. of Devices or Equivalent No. Hydromassage Bathtubs No. of Motors Total HP Telecommunications Wiring: No. of Devices or Equivalent OTHER: Attach additional detail if desired, or as required by the Inspector of Wires. Estimated Value of Electrical Work: �. (When required by municipal policy.) Work to Start: Inspections to be requested in accordance with MEC Rule 10, and upon completion. INSURANCE COVERAGE: Unless waived by the owner, no permit for the performance of electrical work may issue unless the licensee provides proof of liability insurance including "completed operation" coverage or its substantial equivalent. The undersigned certifies that such coverage is in force, and has exhibited proof of same to the permit issuing office. CHECK ONE: INSURANCE ® BOND ❑ OTHER ❑ (Specify:) Self Insured I certify, under the pains and penalties of perjury, that the information on this application is true and complete. FIRMNAME: ADT 5ecurity Services Inc. LIC. NO.: C-45 Licensee: Mark A. Brophy Signature LIC. NO.: C-45 (If applicable, enter -exempt" in the license number line.) Bus. Tel. No.: 978-657-0443 Address: _155 West Street, Suite 6 Wilmington, Imington, MA 0 87 Alt. Tel. No.: *Per M.G.L. c. 147, s. 57-61, security work requires Department of Public Safety "S" License: Lic. No. 00953 OWNER'S INSURANCE WAIVER: I am aware that the Licensee does not have the liability insurance coverage normally required by law. By my signature below, I hereby waive this requirement. I am the (check one) ❑ owner ❑ owner's agent. Owner/Agent Signature Telephone No. PERMIT FEE. $ ,d`�-, a-) Date/—, -Z/- 09 ..x .......... 0.4 TOWN OF�NriTH ANDOVER PERMIT FOR PLUMBING A ACHUS cmus This certifies that ............................ has permission to perform ..... ..................... lumbing in the buildings of ............ at ......... North Andover, Mass. Fee-. Lic, No.A. ................ Check # 2 PLUMBING INSPECTOR M9 0 0 rt co (P rt 0 Lo co C) -j < 00 0 00 rt 0 ul ul (D rt (D (p Z 0 rt (D h rt (D U) (D (t (D 0 (D U) 0 (t alum Date ...... t -..l ... �..-07. TOWN OF NORTH ANDOVER PERMIT FOR WIRING j . .... / F -D I-VAIII) Thiscertifies that .............. .... ... . . ....................................................... has permission to perform ..... . . . .............................. wiring in the building of .......... Z.'Pt�r .................................. at ....... ....... ..... . North Andover, Mass. Fee—;r�� Lic.No��9.Q.7.& ............... . W ........ .. .. . ..... Check# EL�91 ALINSPECTOR 71,60.1 .W c1ur>llnlrla,tai,aaloltia of Massa all "Safts Locclullpanozy X111 tfallentOfpian ,�etvielm ant! peer,017 PREvENTi{JNRIEWLATiONS 91 lerembtantt �- /�Pi�'I., CATIOM FOR PERMIT,,,,, iI����ll�c�� ��� I���7 CUR 12,00 All Wnvkt to 11R q ibnnad rn ACKK)I d.t+ .t: Date; L/ L INFO Af. TION! r �. SE PRINT Dv1NI� OR TYPE AIr To rile Irtspector af'Wires: 1ta, Pr 'lrst>,wWk ,ill;: / �_5 Qi itcatio11 the undersigtle ygl11�1tIG�' �' hiti ar�� hel ,ntetlticln 1.0 J)DI fol", ate ical wont dasartbAd balaw. 9v ttat at1p 1 /,PC' I- m K'4 G� d j T.,AantAaa, {�trraat � 1VutttiAntr} 'rejapbolle No. firwttar or Ttrsafkat . iL� C_ ate. •a,c .-u- '— / - OWlllrr's A,ddl'0111 (CllAlclt /ApPA0priate saw} 1 1.t o I_t Is gilts Penni' Ill +^ottjnt+atiotl 1,11th n building pet•tldt . RR utility r' lithorRza'1ion No Ptlt paatt Af I�ulldlt*g -_ , -i -- -r '_ ttA rtl (� No, of "009's0,� co-head Ri tthtt ng Sill) AV, AMPS Utill t rl No. of mat;erg , Amps _ _ 1'alt� ffveal►anRlQ f!' t- t NwItMU� aodam11a d Ad,rtapaalty �. �.... c l.oeatlo RAW Nature of Iti,oposed l;ieetel al Wprll: j• C'ant tltc�o)l q rlts 0114win t big It he wn the 1 ee � r of Wad+as IN— "" """ """� No, of Cai.1.•`1+�sp, (Paddle) l++sns INo• Of Rttl�-524 � a?11lAltt^as `_'— - - -� -^-^—^ nunwneM•D RVA No, of 1l,Igbmw Wells No. of U101101tg IF1>Rt e No• OfRijapttaele Outlets No. of switches No, Of 1(a.atll�AB No• of Waste D1111110fic 9 No, of 018111wilish are No, of Dryers KIN NO. pt' "al I'llho 9wltlstxdttd No• o�et'a INo. of All. C;and. ornd. l_ l spav*'Arce 11e801% !CW Haating Appliances i<W ��,..,� ilallltata ALARMS MS I, NA, 0f Zo1A41 of A101111116 940465 Data 1VIulAlaA�alaA Otltsl CnnnAe IAII No. "Vdyol>laaggage Dattlit abs r+lo�ot A101ol's �Tnt ttl 1 t N iP Hca r tt t lnnchnAdkiatulldrrrttarsmetf,Rraerrrgnira�h,IrlhahtRlrRslnro/WJi-4A. flA z� INSURANCE COVERAGE; 1.1111006 Wsiv0d t,y the ""C', 1I0 11ci n't fortile perfort'nmice of electrical work play issue ttnl006 the licollSop, provides proni'of liability imwenre including "coinl-119opmatlon" Coverage or ita substantial equivalent. 711C undmipIW4 001- 03 that Sigh OW -age is in force, AM hay erhlltited lr.'oof O1 satlmc to tits: pt:t•t•nit tssuitl afl"tca. ' CHECK ONE; INSURANCE OTRf;R l5i)t:Cilyj u� - . rataatt etc) Fat mated Value✓ laarical Work. � f 1�'h�n rt�tautrcci lty ttt�ultcipal lapliey y Worlt to Start:^ k ll._ 0A 6 lnspecticnls to be ' eclucsted in ucaordancc with MEC Rule 10, And upon aampletian. I,c�re�l , ts►tatet ilia pastas nittrl /1+�1�oltict o1 p�I;jtljrl, titer Clic ll �nrHtrif Pit ml dOx tapplientipio k trite and Gonlildatlar FIRM NAME: � � �_,�) KO L—La _h,Ct LIC, NO.;— I,Icall,tte: _ iRaHture .11� LAC. NO.. j fn !+l?Ifhrnn/n, mnrar "aQ �.n . " Irr rbv !� arc •,.,, �` % �i tJ / T 7 fl1lt. Tel. No : Addd'ossl��� 9 A1C. TaI• NA.:?..2% QWN 1�AN . WAIVER, etr. su 0i a Chat the I i ctnsee rinc'.► not hen 0 the baUdht� insursanCe cal erap nat'tnally req» lyed by law By my signature below. i hereaby waive I Ucnrcrl'ent. 18111 tele tctllcclt one ownt:rowner's Agent ownerrA9109t ,i''FR'MI7',F,F.F� $ { Tclepbotie No..� I Ll MASSACHUSETTS UNIFORM APPLICATION FOR PERMIT TO DO PLUMBING (Print or Type) �_Y �r%Mass. Date f13 L17 Permit # ' Building Location 16 6to d rrnn dol L, i wner's NamesJ3f' 1^:" O LYl 4_ 9 Type of Occupancy Residential New Q Renovation ❑ Replacement N Plans Submitted: Yes ❑ No ❑ FIXTURES Installing Company. Name Heritage Htg. &Plg. Co. Inc. Check one: Certificate Address 35 Pleasant Street IXCorporation 714 Stoneham, Ma 02180 ❑ Partnership Business Telephone •. 781 —43:8-77 7 6 M Firm/Co. Name of Licensed Plumber Gordon Switzer INSURANCE COVERAGE: I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL Ch. 142. Yes ® No ❑ If you have checkedrtes, please indicate the type coverage by checking the appropriate box. A liability insurance policy L Other type of indemnity ❑ Bond O OWNER'S INSURANCE WAIVER: I am aware that the licensee does not have the insurance coverage required by Chapter 142 of the Mass. General Laws, and that my signature on this permit application waives this requirement. Check one: Owner ❑ Agent ❑ I hereby certify that all of the details and information I have submitted (or entered) in above application are true and accurate to the best of my knowledge and that all plumbing work and installations performed under the permit issued for this application will be in compliance with all pertinent provisions of the Massachusetts State Plumbing Code and Chapter P2 of -the General Laws. By Si ature of License Plum er Title City/Town Type of License: Master [X Journeyman E]APPROVED OFFICE USE ONLY) License Number 8 3 2 2 ''/z" Watts 9D Up on waterline to water boiler -- N I fj) o Z :: OLn W b LU x -aUj J W U Q �� Z (7 [C �4 �4 i4 (V) Z N 4 _~ 0 Z ` a Q� N I4 o N W N �" 0a. W N '.� F U W N x Q rn U. Q W o 7 W d ¢ 3 W N x (/) z 0 Q r> o N N N .Q~ ►- z 0 0 w__ c •S 3 x J < rA p J Q O _ Q ,- J �, Q LL rC CL 4'. Q C Q V-� -i SUB—BSMT. I BASEMENT, 1ST FLOOR 2ND FLOOR 3RD FLOOR 4TH FLOOR 5TH FLOOR 6TH FLOOR 7TH FLOOR ! , STH FLOOR Installing Company. Name Heritage Htg. &Plg. Co. Inc. Check one: Certificate Address 35 Pleasant Street IXCorporation 714 Stoneham, Ma 02180 ❑ Partnership Business Telephone •. 781 —43:8-77 7 6 M Firm/Co. Name of Licensed Plumber Gordon Switzer INSURANCE COVERAGE: I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL Ch. 142. Yes ® No ❑ If you have checkedrtes, please indicate the type coverage by checking the appropriate box. A liability insurance policy L Other type of indemnity ❑ Bond O OWNER'S INSURANCE WAIVER: I am aware that the licensee does not have the insurance coverage required by Chapter 142 of the Mass. General Laws, and that my signature on this permit application waives this requirement. Check one: Owner ❑ Agent ❑ I hereby certify that all of the details and information I have submitted (or entered) in above application are true and accurate to the best of my knowledge and that all plumbing work and installations performed under the permit issued for this application will be in compliance with all pertinent provisions of the Massachusetts State Plumbing Code and Chapter P2 of -the General Laws. By Si ature of License Plum er Title City/Town Type of License: Master [X Journeyman E]APPROVED OFFICE USE ONLY) License Number 8 3 2 2 ''/z" Watts 9D Up on waterline to water boiler -- } J Z O W W 3 W U LL O cc O LL 3 O J W m N W U W Y N N Z O Y v W CL N z z J Q LL W W LL 0 Z m s 7 J a O O O fH i ~ o m Z a 2 O LL Z _O H U J IL a Q Q W m J IL Ol v - O W F - Z a t7 W � O cc W . a %"`VVatts 9D Up on water line to water.boiler - - 9X0 O r - U W a N Z 0 Y4 Location 0 Y A 64 No. 419 91 Date TOWN OF NORTH ANDOVER Certificate Occupancy $ of Building/Frame Permit Fee $ '.50 Foundation Permit Fee $ Other Permit Fee $ 50 TOTAL $ -?zPI3 Check# @'I V Building Inspector TOWN OF NORTH ANDOVER BUILDING DEPARTMENT APPLICATION TO CONSTRUCT REPAIR, RENOVATE, OR DEMOLISH A ONE OR TWO FAMILY DWELLING BUILDING PERMIT NUMBER: / % DATE ISSUED: / S� SIGNATURE: Building Commissioner/Inspector of Buildings Date SECTION 1- SITE INFORMATION 1.1 Prmerty Address: f ka%% 1.2 Assessors Map and Parcel 10 hot -l• 9- Map Number Number: 0067 Parcel Number 1.3 Zoning Information: Zoning District Proposed Use 1.4 Property Dimensions: Lot Area (so Frontage ft 1.6 BUILDING SETBACKS ft Front Yard Side Yard Rear Yard Required Provide Required Provided R "red Provided 1.7 Water Supply M.GL.C.40. 54) Public ❑ Private 0 1.5. Flood Zone Information:1.8 Zone Outside Flood Zone ❑ Municipal Sewerage Disposal System: 0 On Site Disposal System 0 I SECTION 2- PROPERTY OWNERSHIP/AUTHORIZED AGENT I r l iz� l v i i u u i s u i c L: res iv o 2.1 Owner of Record 2-1,Cr-} 9Fier (i nv a l(,) e-,- �# ac oma- Name (Print) �-- Address for Service: Signature 2.2 Owner of Record: Name Print Telephone Address for Service: SECTION 3 - CONSTRUCTION SERVICES 3.1 Licensed Construction Supervisor: Not Applicable ❑ Licensed Construction Supervisor: P.O. Box 637 1pl4-1—h Remd—ino MA Address 01864 Signature -1 ' Telephone 3.2 Registered Home Improvement Contractor Company Name DQW RDD P.O. Box 637 Address 01864 nv� 0-5-8414-4 3 License Number /P/S---,� Expiration Date Not Applicable ,❑ Registration Number 0/ /& Expiration Date O Z M 90 O Mn ic r M r _r ^Z YI SECTION 4 - WORKERS COMPENSATION (M.G.L C 152 § 25c(6) Workers Compensation Insurance affidavit must be completed and submitted with this application. Failure to provide this affidavit will result in the denial of the issuance of the buildigg permit. Signed affidavit Attached Yes ....... V No ....... 0 SECTION 5 Descri tion of Proposed Work check all applicable) New Construction ❑ Existing Building ❑ Repair(s) ❑ Alterations(s) ❑ Addition ❑ Accessory Bldg. ❑ Demolition ❑ Other ❑ Specify Brief Description of Proposed Work: SECTION 6 - ESTIMATED CONSTRUCTION COSTS Item Estimated Cost (Dollar) to be Completed by permit applicant OFFICIAL USE ONLY 1. Building (a) Building Permit Fee Multiplier 2 Electrical (b) Estimated Total Cost of Construction 3 Plumbing Building Permit fee (e) X (b) ^ 4 Mechanical HVAC 5 Fire Protection 6 Total 1+2+3+4+5) Check Number SECTION 7a OWNER AUTHORIZATION TO BE COMPLETED WHEN OWNERS AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT 1, as Owner/Authorized Agent of subject property Hereby authorize ( to act on My -behalf, in all mattersrelative to work authoriz�ythisuilding permit application. Signature of Owner �„� _ Date Y rld-cc-�r SECTION 7b OWNER/AUTHORIZED AGENT DECLARATION 1, as Owner/Authorized Agent of subject property _ Hereby declare that the statements and information on the foregoing application arepw4gooffie, to the best of my knowledge and belief P.O. Box 637 North Reading, MA 01864 Print N e 8— iiiii of Owner/Agent Date NO. OF STORIES SIZE BASEMENT OR SLAB SIZE OF FLOOR TIMBERS 1ST 2 No3 RD SPAN DIMENSIONS OF SILLS DIMENSIONS OF POSTS DIMENSIONS OF GIRDERS HEIGHT OF FOUNDATION THICKNESS SIZE OF FOOTING X MATERIAL OF CHIMNEY IS BUILDING ON SOLID OR FILLED LAND IS BUILDING CONNECTED TO NATURAL GAS LINE North Andover Building Department Tel: 978-688-9545 DEBRIS DISPOSAL FORM In accordance with the provision of MGL c 40 S 54, a condition of Building Permit Number is that the debris resulting from this work shall be disposed of in a properly licensed solid waste disposal facility as defined by MGL c11,S150A. The debr's will be disposed of in: Lir 1A1G (Location of Signature of Permit Applicant Date NOTE: Demolition permit from the Town of North Andover must be obtained for this project through the Office of the Building Inspector The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations Boston, Mass. 02111 Workers' Compensaam Insurance Atifdavit Name Pleas Print Name: Locati9n: City _ Phone 0 I am a homeowner pedomiing all work myself. 0 I am a sole proprietor and have no one working in any capacity I am an employer providng workers' compensation for my employees working on this job. �I •- _. -1 V47, l Co. PokV ! Facture to seem coverage • required under Section 25A or MOL 152 can lead to the imposition of chnh al panaltlM d.a tine up to $1,500.01) wrdlor one yeah' Imprbamrant.as nrel.as.dd panattteslo]balomt>,fi STaP ViIDRK ORGER.aoda.fkre d.(,f1IID.Oq)�dq agair>•t ma 1 wxk ntand that a copy of this stdonwd may be forwarded to the Office of Inveadgedorn of the DIA for coverage verification. I db hereby tartly under the pafnb and penalties of perjury that Nte i *MWtlon providad above Is true and coned Print Offbbl use only do not write in this area to be completed by city or town dWer City or Town P censina []Check X immediate response to requied ❑ Building Dept ❑ Lrcensmy Board C] Selectman's Office Contact person: Phone * ❑ Health Department ❑ Other Page No. of Pages Builders License # 58443 Home Construction Reg. # 109288 , I i Duva Roofing,LLC (781) 944-1994 (978) 664-2557 ` "The Areas Oldest Roofing Company" P.O. Box 637, North Reading, MA 01864 PR A S MITTED TOw" PHONE DATE — 0� �t. a a l • l T . STREET/ L - / I JNA / 5 q — 1 –3r I CITY, STATYNO ZIP CO[ I JOB LOCATION We hereby submit specifications and estimates for: Recommended (Included in price) Rip & Remove all shingle debris from roof & job site: d1 layer 0 2 layers 0 3 layers or more t✓ Repair/or Replace any roof decking; not to exceed 50sq. ft. •� Install 8" aluminum drip-edge/and rake -edge along entire perimeter. Choice of mill, white or brown or ✓ Install ICE & WATER underlayment along horizontal eaves, valleys, sidewalls and sky -lights & chimneys - J Install premium base sheet underlayment between roof deck and roofing shingles II • Install 25yr CertainTeed/GAF/Tamko or Owens & Corning traditional 3 -tab roof shingles 0 30 year ✓ Install 30yr CertainTeed/GAF/Tamko or Owens & Corning architectural roof shingles ---- I 040year --- --------050 year------- 0 Lifetime See manufacturer warranty policy for more details ✓ Install new aluminum vent -pipe flange (s) r/ Chimney (s) -counter-flash and re -step existing flashing r 0 Cut & Install new lead flashing I Ridge-vent/exhaust vent with low profile design, hidden by shingle caps psi Soffit -ventilation 0 Roof louver -vents • Seamless style aluminum gutters --custom fabricated at job site 0 downspouts s/ Other -- -I,._--- - IA}-`---=...� �-} ��,`�� °`'I`2- -- --- 4 -1-- �'J' o -- ----- --- --.. -----___— ---------- Optional (Not included in price) I i II I I I I I , I I I I i `Please Note: All items in roof attic should be removed or covered due to falling roof particles, at time of roof tear -off l Price includes all items above that are checked only / others may be priced separately upon request. u We Propose hereby to furnish material and labor - complete in accordance with above specifications, for the sum of: �I it 4500 Total price not including options. dollars ($ .-J Payment to be made as follows: - --- - - --- - ---- - - -- -- - - --- - - - - -- - ---- ------ - - - - - - 30% deposit required before ordering materials. Balance due in full upon day of completion. Please make all payments out to Kenneth Duval, mailed to: P.O. Box 637, No. Reading, MA 01864 Late charges of $50 per week for all outstanding bills due upon day of Authorized completion. Signature - Accepting proposal means agreeing to the terms of the enclosed binder Note: This proposal may be co, ntract. Please sign contract & return top copy (white) with deposit. withdrawn by us if not accepted within days ;) a 1 W h 9 w O F=4 bI0 v v o1 z o S E y hoc E Is O NMA ?A;E3�p C_ O J h zip Go CIO O • 'COL Ci i m �: s �•� cc a :zs o cl, Ot L C :mom O h O O O 'Z : CO O d c Q m C Q o CL z � WLU c ++ H M C= W Z E SOM O V d O��C H w 0 5 C3 I- z s ce m zip M 09-61, N LSI c r' CO) O ■� w± Q IDca 0 - m m & �� �3 CDCD cc O d ir cma Co O= = C ev 'v O 61 C Z CL V CO) c C C C c CO2 W N 19 W LU C9 LLIW U) o a a o w° c� w a c w° wo' U w w w z cn E cn O F=4 bI0 v v o1 z o S E y hoc E Is O NMA ?A;E3�p C_ O J h zip Go CIO O • 'COL Ci i m �: s �•� cc a :zs o cl, Ot L C :mom O h O O O 'Z : CO O d c Q m C Q o CL z � WLU c ++ H M C= W Z E SOM O V d O��C H w 0 5 C3 I- z s ce m zip M 09-61, N LSI c r' CO) O ■� w± Q IDca 0 - m m & �� �3 CDCD cc O d ir cma Co O= = C ev 'v O 61 C Z CL V CO) c C C C c CO2 W N 19 W LU C9 LLIW U)