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Town Of North Andover
OHealth Department Attn: Susan Sawyer
1600 Osgood Street
North Andover, Massachusetts 01845
Dear Susan Sawyer;
Tuesday, January 23, 2007
I enjoyed meeting with you in your office some months back at this point about my
up coming building project and the impact upon my existing septic system. Thank you for
taking that time to meet with me, you were very knowledgeable.
As a result of that conversation I have enclosed a separate section in the application
package for you to review. The pages I have enclosed of existing conditions at # 10 Lacy St.
include the correct assessors page. First floor existing floor plan with notes marked AA. ,
First floor proposed floor plan with notes marked BB, first floor proposed addition floor
plan with notes marked. First floor proposed addition floor plan with notes marked B0.
I also talked with Mr. Osgood who was aware of the system from a recent inspection
for the previous owner before the sale in August 2005. I did query him about an upgrade
O and his opinion seemed to lean towards not needing one at this time feeling the system was
of adequate size and the additional work would not exceed the ability of the present system.
We have not had a problem with the system to date and is functioning correctly.
Again thank you for meeting with me, and if any additional information is necessary
that I can obtain to help you, please call me.
William Pogor
10 Lacy Street
North Andover, Massachusetts 01845
978-376-1875
wpogor@comcast.net
101
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DEC 0 6 2005
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TOWN OF NORTH ANDOVER
N 0 R 'I [HEALTH DEPARTMENT
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y NEW ENGLAND ENGINEERING SERVICES
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�EI'�EDMay 20, 2005 ��05NORTH ANDOVER DEPARTMENT
North Andover Board of Health
400 Osgood Street ,
North Andover, MA 01845
RE: TITLE V REPORT: RE: 10 Lal Street North Andover, MA
Dear Sir or Madam:
Enclosed is a copy of the Title V report for the above referenced property. The system
PASSED our inspection.
If there are any questions please call me at my office, 686-1768.
Sincerely,
Ben anfin C. Os ood 9 r.
J g
Certified Title 5 inspector
60 BEECHWOOD DRIVE - NORTH ANDOVER, MA 01845 - (978) 686-1768 - (888) 359-7645 - FAX (978) 685-1099
Property Address: 10 Lacy Street North Andover, MA 01810
Owner's Name: V. Scott Follanssbee
Owner's Address: 10 Lacy Street North Andover, MA 01810
Date of Inspection: 5/19/05
Name of Inspector; (please print) Benjamin C. Osgood Jr., Certified Title 5 Inspector
Company Name: New England Engineering Services Inc.
Mailing Address: 60 Beechwood Drive North Andover, MA 01845
Telephone Number: (978) 686-1768
CERTIFICATION STATEMENT
I certify that I have personally inspected the sewage disposal system at this address and that the information
reported below is true, accurate and complete as of the time of the inspection. The inspection was performed
based on my training and experience in the proper function and maintenance of on site sewage disposal
systems. I am a DEP approved system inspector pursuant to Section 15340 of Title 5 (3 10 CMR 15.000).
The system:
_IZ—Passes
Conditionally Passes
Needs Further Evaluation by the Local Approving Authority
Fails
Inspector's Signature. ( �" Date: s-AY/v
The system inspector shall submit a copy of this inspection report to the Approving Authority (Board of
Health or DEP) within 30 days of completing this inspection If the system is a shared system or has a design
flow of 10,000 gpd or greater, the inspector and the system owner shall submit the report to the appropriate
regional office of the DEP. The original should be sent to the system owner and copies sent to the buyer, if
applicable, and the approving authority.
Notes and Comments
****This report only describes conditions at the time of inspection and under The conditions of use at
that time. This inspection does not address how the system will perform in the future under the same or
different conditions of use.
L_0 _ - _ _ __
OFFICIAL INSPECTION FORM -NOT FOR VOLUNTARYASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIIHICATION (m6nxdJ
Property Address: 10 Lacy Street North Andover, MA 01810
Owner's Name: V. Scott Follanssbee
Owner's Address: 10 Lacy Street North Andover, MA 01810
Date of Inspection: 5/19/05
Inspection Summa y: Check A, BCD or E / ALWAYS complete all US of Section D
A. System Passes:
cy �'c I have not found any information which indicates that any ofthe failure criteria described in 310 CMR 15.303
or in 310 CMR 15.304 exist . Any f dare criteria not evahkated are indicated below.
Comments
B. System Conditionafly Passes:
NOne or more system components as described in the "Conditional Pass" section need to be replaced or repaired.
The system upon c nvIetion ofdic replacement or repair, as approved by the Board ofHealtl>, will pass.
Answer yes, no or not determined (Y,N,ND) inthe =for the following statements. If "not determined" please explain.
The septic tank is metal and over 20 years old* or the septic tank (whether metal or not) is structurally
unsound, exhibits substantial infiltration or adiltration or tank failure is imminent. System will pass inspection if the
existing tank is replaced with a complying septic tank as approved by the Board ofHeahh
*A metal septic tank will pass inspection if it is structurally sound, not leaking and if a Certificate of Compliance
indicating that the tank is less than 20 years old is available.
ND explain:
mon of sewage backup or break out or high static water level in the distnb mon box due to broken or
obstructed pipe(s) or due to a broken, settled or uneven distribution box System will pass inspection if (with
approval of Board of Health):
broken pipe(s) are replaced
obstruction is removed
distribution box is leveled or replaced
ND explain:
The system required pumping nm than 4 times a year due to broken or obstructed pipe(s). The system will
pass inspection if(with approval ofthe Board ofHealth):
broken pipe(s) are replaced
obstruction is removed
Page 3 of 11
OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE
SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION (continued)
Property Address: 10 Lacy Street North Andover, MA 01810
Owner's Name: V. Scott Follanssbee
Owner's Address: 10 Lacy Street North Andover, MA 01810
Date of Inspection: 5/19/05
C. Further Evaluation is Required by the Board of Health:
D. W 0 Conditions east which require further evaluation by the Board of Health in order to &wnme if the system is
failing to protect public health, safety or the cevironmat
1. System will pass unless Board of Health determines in accordance with 310 CMR 1530300) that the
system is not functioning in a manner which w ill protect public health, safety and the environment:
Cesspool or privy is within 50 feet of a surface water
Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh
2. System will fail unless the Board of Health (and Public Water Supplier, if any) determines that the system
is functioning in a manner that protects the public health, safety and environment:
The system has a septic tank and soil absod on system (SAS) and the SAS is within 100 feet of a surface
water supply or tributary to a surface water supply.
The system has a septic tank and SAS and the SAS is within a Zane 1 of a public water supply.
The system has a septic tank and SAS and the SAS is within 50 feet of a private water supply well
The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or more from a private
water supply well**. Method used to determine distance
**Ibis system passes ifthe well water analysis, performed at aDEP certified laboratory, for coliformbacteria and
volatile organic compourxis indicates that the well is free firm pollution fran that facility and the presence of
amrnonra nitrogen and nitrate nitrogen is equal to or less man 5 ppin, provided that no other failure criteria are
triggered, A copy of the analysis must be attached to this form
3. Other:
Page 4of 11
OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTSSUBSURFACE SEWAGE
DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION (continued)
Property Address: 10 Lacy Street North Andover, MA 01810
Owners Name: Helen Weitzler
Owner's Address: 10 Lacy Street North Andover, MA 01810
Date of Inspection: 5/19/05
D. System Failure Criteria applicable to all systems:
You must indicate "yes" or "no" to each of the following for all inspections;
Yes No
1� Backup of sewage into facility or system component due to overloaded or clogged S AS or cesspool
u/ 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 man 6" below invert or available volume bless than 1/2 day flow
Required pumping more man 4 times in the last year NOT due to clogged or obstructed pipe(s). Number
of times pumped _ .
Any portion of me SAS, cesspool or privy is below high ground water elevation
Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply.
Any portion of a cesspool or privy is within a Zone 1 of a public well.
-- % Any portion of a cesspool or privy is within 50 feet of a private water supply well.
Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water
supply well with no acceptable water quality analysis• [This system passes if the well water analysis, performed
at a DEP certified laboratory, for 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, provided that no other failure criteria are triggered. A copy of the analysis
must be attached to this form.]
(Yes/No) The system fails. I have determined that one or more ofthe above failure criteria exist as
described in 310 CMR 15.303, tl>erefore the system fails. The systetn owner should contact the Board oflleatth to determine what
will be necessary to correct the Mire.
E. Large Systems:
To be considered a large system the system must serve a facility with a design flow of 10,000 gpd to
15,000 gpd
You must indicate ' " or "no" to each ofthe following
(Tike following criteria apply systems in addition to the crit ove)
Yes No
the system is within o drinking water supply
the 200 feet of a in to a surface drinking water supply of public water supply well
is located ibb a nitrogen sensitive Interim Wellhead Protection Area IWPA)
or a map Zone 11 of public water supply well
1f you have answered "yes" to any question in SectionE the system is consdered a sign ficant hot, or answered "y" in Sectionl) above the
large system has failed The owner or Terata of arty large system considered a significant threat under Sermon E or failed under SectionD
shallunerade the system in accordance with 310 OAR 15.304. The system owner should contact the mmmriate reeional office ofthe
Page 5 of 11
OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY SSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PARTB
CHECKLIST
Property Address: 10 Lacy Street North Andover, MA 01810
Owner's Name: V. Scott Follanssbee
Owner's Address: 10 Lacy Street North Andover, MA 01810
Date of Inspection: 5/19/05
Check if the following have been done. You must indicate "yes" or "no" as to each of the following:
Yes No
yrs Pumping information was provided by the owner, occupant, or Board of Health
/ Were any of the system components pumped out in the previous two weeks ?
Has the system received normal flows in the previous two week period?
Have large volumes of water been introduced to the system recently or as part of this inspection?
—Z— Were as built plans of the system obtained and examined? (If they were not available note as N/ A)
V Was the facility or dwelling inspected for signs of sewage back up?
Was the site inspected for signs of break out?
J Were all system components, excluding the SAS, located on site ?
Were the septic tank manholes uncovered, opened, and the interior of the tank inspected for the
condition of the baffles or tees, material of construction, dimensions, depth of liquid, depth of sludge and
depth of scum ?
Was the facility owner (and occupants if different from owner) provided with information on the proper
maintenance of subsurface sewage disposal systems ?
The size and location of the Soil Absorption System (SAS) on the site has been determined based on:
Yes No
y1 Existing information. For example, a plan at theme Board of Health.
Determined in the field (if any of the failure criteria related to Part C is at issue approximation of
distance is unacceptable) [310 CMR 15.302(3)(b)]
Page 6 of 11
OFFICIAL INSPECTION FORM -NOTFORVOLUNTARY ASSESSMENTS SUBSURFACESEWAGEDISPOSAL
SYSTEMINSPECTIONFORM
PARTC
SYSTEM INFORMATION
Property Address: 10 Lacy Street North Andover, MA 01810
Owner's Name: V. Scott Follanssbee
OwneesAddress: 10 Lacy Street North Andover, MA 01810
Dateofh : 5/19/05
FLOW CONDITIONS
RESIDENTIAL
Number of bedrooms (design): Number of bedrooms (actual)- - —
DESIGN flow based on 310 CMR 15.203 (for example:110 gpdx # of bedrooms): X060
Number of current residents: I
Does residence have a garbage grinder (yes or no): --Al^�
Is laundry on a separate sewage system (yes or no): Al 0 (if yes separate inspection required )
Laundry system inspected (yes or no):
Seasonal use: (yes or no): O
Water meter readings, if available ale (last 2 years usage (gpd) w c>
Sump pump (yes or no)
Last date of occupancy. e v r r& N r
COMNIERCIALA NDUSTRIAL
Type of establishment:
Design flow (based on 310 CMR 15.203): {bpd
Basis of design flow (seats/persons/sq ft,etc.):
Grease trap present (yes or no):
Industrial waste holding tank present (yes or no):
Non -sanitary waste discharged to the Title 5 system (yes or no):
Water meter readings, if available:
Last date of occupancy/use:
OTHER(describe):
[l;�I►I�I; : hl�l ; u : 11 ►I
PumpingRecords
Source of information: Q /i Ktv z ,„ j
Was system pumped as part of the inspection (yes or no): A-1 0
If yes, volume pumped: _____gallons How was quantity pumped determined?
Reason for pumping:
TYPE OF SYSTEM
_Septic Tank, distribution box, soil absorption system
Single cesspool
Overflow cesspool
Privy
Shared system ( yes or no) ( if yes, attach previous inspection records, if any
Innovative/Alternative technology. Attach a copy of the current operation and maintenance contract (to
be obtained from system owner)
Tight Tank Attach a copy of the DEP approval
Other ( describe ):
Approximate age of all components, date installed (if known) and source of information:
Were sewage odors detected when arriving at the site (yes or no) -14/ 0—
Page 7 of l 1
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY
SURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Property Address: 10 Lacy Street North Andover, MA 01810
Owner's Name: V. Scott Follanssbee
Owner's Address: 10 Lacy Street North Andover, MA 01810
Date of Inspection: 5/19/05
BUILDING SEWER (locate on site plan)
Depth below grade
Materials of construction ✓ cast iron 40 PVC other (explain)
Distance from private water supply well or suction line: 3
Comments (on Condition of jests, venting, evideme of leakage, etc.):
SEPTIC TANK _ (locate on site plan)
Depth below grade:_
Material of construction: . Z coricrete, metal fiberglass polyethylene
o"explain)
If tank is meal list age: is age confirmed by a Certificate of Compliance (yes or no): _ (attach a copy of
certificate)
Dimensions: /S-00 6-e" iy s
Sludge Z- 1 �.
Dista= from top of sludge to bottom of outlet tee or baffie:
Scum thickness. t Z
Distance fiiom top of Scum to top ofoutlet tee or bate:
Distance from bottom of scum to bottom of outlet tee or baffle-- !i1 "
How were dimensions determined: 44 e j s s i 2C tc_
Commerrts (on punping rec oni mmdatioru, inlet and outlet tee or bade bion, structural urtegrid , liquid levels as related
to outlet invet, evidence of leakagr, etc.):
GREASE TRAP: IrA pocate on site plan)
Depth below grade:
Material of construction: concrete metal fiberglass polyethylene other
(explain):
Dimensions:
Scum thickness:
Distance from top of scum to top of outlet tee or baffle:
Distance from bottom of scum to bottom of outlet tee or baffle
Date of last pumping:
Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels
as related to outlet invert, evidence of leakage, etc.):
Page 8 of 11
OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE
SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Property Address: 10 Lacy Street North Andover, MA 01810
Owner's Name: V. Scott Follanssbee
Owner's Address: 10 Lacy Street North Andover, MA 01810
Date of Inspection: 5/19/05
TIGHT or HOLDING TANK: V R (tank must be pumped at time of inspection) (locate on site plan)
Depth below grade: _
Material of construction: concrete metal _ fiberglass polyethylene
other(explain):
Dimensions:
Capacity:
gallons
Design Flow gallons/day
Alarm present (yes or no):
Alarm level: Alarm in working order (yes or no):
Date of last pumping:
Comments (condition of alarm and float switches, etc.):
DISTRIBUTION BOX: (if present must be opened) (locate on site plan)
Depth of liquid level above outlet invert -
Comments (note if box is level and distribution to outlets equal, any evidence of solids carryover, any evidence of
leakage into or out of box, etc.): d x o c,),4, D ,,, f3 0x s 77Z 0
PA./I>� /L �p 7V P�F Z'� e6orle INJe21 S �cJT S NS
w As o¢y F s ex 'R415CD io 1"UtIe '/Oso
PUMP CHAMBER:7q(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.):
Page9of ll
OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE
DISPOSAL SYSTEM INSPECTION FORM
PART C SYSTEM INFORMATION (continued)
Property Address: 10 Lacy Street North Andover, MA 01810
Owner's Name: V. Scott Follanssbee
Owner's Address: 10 Lacy Street North Andover, MA 01810
Date of Inspection: 5/19/05
SOIL ABSORPTION SYSTEM (SAS): _ (locate on site plan, excavation not required)
If SAS not located explain why.
Type
leaching pits, number
leaching chambers, number:
leaching galleries, number
leaching trenches, number length:
✓ leaching fields, number, dimensions: _I Ifie LD 20 X 115 �
overflow cesspool, number:
innovative/ahmative system Type/name oftecimlogy:
Comments (note condition of soil, signs of hydraulic failures level of ponding, damp soil, condition of vegetation ,
etc.):
1�ifJ Of" e/EG GJvKs rvciQ.vt/IL �'� 7c .�/C �.t/S? i /`SND �cJJ�p
1 ?� R.F L464rt/ AN %i c7l��1
CESSPOO]AW(cesspool must be pumped as part of inspection) (locate on site plan)
Number and configuration:
Depth - top of liquid to inlet invert
Depth of solids layer:
Depth of scum layer:
Dimensions of cesspool:
Materials of construction:
Indication of groundwater inflow (yes or no):
Comments (note condition of soil, signs of hydraulic & ur, level of poking condition of vegetation, etc.):
PRIVY: k6 (locate on site plan)
Materials of construction:
Dimensions:
Depth of solids
Canrrients (note condition of soil, signs ofhydraulic failure, level of ponding, condition of vegetatiM etc.):
Page 10 of 11
OFFICIAL INSPECTION FORM -NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PARTC
SYSTEM INFORMATION (oon inued)
Property Address: 10 Lacy Street North Andover, MA 01810
Owner's Name: V. Scott Follanssbee
Owner's Address: 10 Lacy Street North Andover, MA 01810
Date of Inspection: 5/19/05
SKETCH OF SEWAGE DISPOSAL SYSTEM
Provide a sketch of the sewage disposal system including ties to at least two permanent reference
landmarks or benchmarks. Locate all wells within 100 feet. Locate where public water supply enters the
building.
Page 11 of 11
OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PARTC
SYSTEM INFORMATION (continued)
Property Address: 10 Lacy Street North Andover, MA 01810
Owner's Name: V. Scott Follanssbee
Owner's Address: 10 Lacy Street North Andover, MA 01810
Date of Inspection: 5/19/05
STTE EXAM
Slope
Surface water
Check cellar fl �� / NO S0M �
Shallow wells N ,�
Estimated depth to ground water _q_ feet
Please indicate (check) all methods used to determine the high ground water elevation:
Obtained from system design plans on record - If checked, date of design plan reviewed
_Observed site (abutting property/observation hole within 150 feet of SAS)
Checked with local Board of Health -explain:
Checked with local excavators, installs sr- (attach doc urnartation)
Accessed USGS database -explain:
You must describe how you established the high ground water elevation:
SATE �fl �sC�� 3 Aal)ye /LCA H20v.,p S�1rTe.v?
N 1c, 0 1 -F2U,L/ i �4 6(a D
4
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PATRICK J. DONOVAN ASSOCIATES, INC.
claim and Foss ✓adjustments
P. O. BOX 110
WAKEFIELD, MA 01880
TEL. (781) 245-5540 — FAX (781) 245-7016
January 8, 2002
Building Commissioner
City or Town Hall
North Andover, MA 01845
Insured
Property Address
Insurer
Policy Number
Type of Loss
Date of Loss
Our File #
OF t?C;P7'ii�I
POARrJ OF 1?L_C Ili
FEB 4 2oo?
V Scott Follansbee
10 Lacey Street, North Andover
Merrimack Mutual Insurance Company
: FP1879344
Puffback/Soot Damage
1 /4/02
WAP33246
Claim has been made involving loss, damage or destruction of the above -captioned
property, which may either exceed $1,000 or cause Mass. Gen. Laws, Chapter 143,
Section 6, to be applicable. If any notice under Mass. Gen. Laws, Chapter 139, Section
3B is appropriate, please direct it to the attention of the writer and include a reference to
the captioned Insured, location, policy number, date of loss and file number.
On this date, I caused copies of this notice to be sent to the persons named above at
the addresses indicated above by first class mail.
` Vern Laws, Adjuster
VL/so
INDEPENDENT INSURINC6 MUSTERS
Massachusetts
wl��r�ln (Ot Wceco-rl��, a
e
Stevens Water Analysis
38 Montvale Avenue * Stoneham, MA 02180 • Mass. (617) 438-6114 • Salem, N.H. (603) 893-3106
LABORATORY NUMBER: 171781
SUBMITTED BY: S.B. HOMES
33 WALI:ER ROAD
N. ANDOVER MA 01845
ATTN: GREG FOLLANSBEE
SAMPLE DATE: 7/5/89
SAMPLE SOURCE:L OLLECTED FROM PUMP `�` "
10 LACY STREET N ANDOVER, MA
ANALYSIS: According to Standard Methods of Water and Wastewater Analysis,
16th Ed. .
Total Coliform .......................0 per 100 ml
Chlorides ............................10 mg/l
pH...................................7.65
Hardness .............................36 mg/l
Manganese............................0.06 mg/l
Sodium...............................32 mg/l
Iron...............................'..0.34 mg/l
Nitrate..............................0.25 mg/l
Nitrite..............................less than 0.10 mg/l
COMMENT: The results of these analyses meet the required federal
and state standards for drinking water. However, the iron,
manganese and sodium concentrations exceed the recommended
.standards.
Although iron and manganese are not harmful to your health,
they can affect the taste, color and odor of your water.
Iron, manganese and sodium are frequently found at elevated
levels in new wells; however, it is likely that these con-
centrations will decrease when the well is put into regular
use.
In Massachusetts the recommended sodium standard is 20
mg/L.
?,c,
��4Cht/Miobiologist
WELL DATABASE
ADDRESS:
AGE OF W—ELLI.WELL r DFILLE
WELL. PERLti , T: � WELL LOCATION.:
- =PPLRLti' DATE: oZ -� �- �� DEP-m- OF WE L: I
=E OF WELL: D b. DUG Uiv-1�iOWN
TYPEOFWA,r BFARING ROCK-
WAIMANAT-Y9 ' DAANCAL`�ESE:
=C,HIRCN. o :.N OT=CON7ANlTYi ANTS. y
-1 L DATABASE r
t
3
N
ADDRESS:
AGE OF W=r : L DRLLLE
WlIqELL PERI T: � LO� /M /V.
WELL PER,\/9TDATE: DEPTH OF R�ELL: 3 o O
TYPE OF WELL: QZD:RLLLED b. DUG' c. tTNi�'vOWN
TYPE OF WA i iR BEARING ROCK: -
A
WATER ANALYSIS DATE: P2GH ?' ANGA.NESE. Y N
HIGH IRON: Y OTI= CONT u'vf CANTS: Y N
13D op � I
TM 4tiPOVEP�, MA.
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FUAL AMP OVAL
DAT -C-"
ort�Ii Aiivc1-
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APPLT, ,ATION FOR W];AA, & -1'U111' I'l_Ithti_l r
Application is hereby made for permit to drill a well V). Application
e to install (e() a pump system.
location: Address pie S7� r Lot /)
U0d,C11lt;hiOAddress_ J� �/� Tcl. _
t•Jcl.1 Contractor /��/) �yE�,� �'� Address A .RyT'GE��P��C
ctor
Contra
i-arn1 � If Add
res /L�/ /(T�)��) {�� Tel
l'
h6 jjA1G (�,
V)FI,1, CONTRACTOR (To be completed at time of pump test)
-- - /
of Well
l'ype ��4;1
Well used for ococ/d�/yc --
Diameter of Well �A Size of Casing ��----i
r �
Depth of Bed Rock_ Depth casing into Bed Rock
t':zs Seal Tested? Yes (V) No (_) Date of Testing_
I) (z p t h o f—W e-1-1 _-------
�'� We11 Ended in What. Mater. i-a1�C,�,-- --.i
-- — -
Depth to Water ��n� Delivers Gals.Per Min. for 4 hour, :.
1)z wdowr-1 feet after pumping; --hours. at --- GPM
P(i(i e of Completion,
SI nit u r e Wel Contractor
PUMP INS'IALLhR (Tobe' f-i.11ed in -before i.nstal.lati.on)
i. ze & Name Pum li/' 43''K K�l`� Pump Type Used
p /v --'-------. --- — --
t,Jat_er Pump Delivers S GP11 Size of Tank if IdT—t
1'i.pe Material Used in Well: Cast iron (_) Ga)v,inized (—) Plastic (�
urJ1 Pit (_) or Pitless .Adapter
lJas sleeve used to protect pipe? Yes (—) NO(4 Type or Name Well Seal/i1<_4',_
S1
".."75!
Date •later analysis repbr-t •submitted to I;orird of lleal'th _---
Date release given tD owner of record & Bldg, Insp
Health Inspector
s
n
Stevens Water Analysi's
38 Montvale Avenue • Stoneham, MA 02180 • Mass. (617) 438-6114 0 Salem, N.H. (603) 893-3106
LABORATORY NUMBER: 169953 SAMPLE DATE: 2/22/88
SUBMITTED BY: WILMINGTON PUMP SUPPLY
639 Woburn Street
Wilmington, MA 01887
SAMPLE SOURCE: New artesian well/collected from pump
Lacey Street, No. Andover, MA
ANALYSIS: According to Standard Methods of Water and Wastewater Analysis,
16th Ed.
Total Coliform ....................... 0 per 100 ml
Chlorides ............................ 12 mg/L
PH....................................
Hardness .............................
Manganese ............................
Sodium ...............................
Iron.................................
Nitrate ..............................
Nitrite..............................
8.4
24 mg/L
less than 0.005 mg/L
104 mg/L
0.12 mg/L
less than 0.10 mg/L
less than 0.10 mg/L
COMMENT: The results of these analyses meet the required federal
and state standards for drinking water. However, the
sodium concentrations exceeds the recommended Massachusetts
standard of 20 mg/L.
Water quality can vary significantly from time to time due
to various local conditions. It is advisable to have your
water tested in approximately six to twelve months to
determine any change in water quality.
Chemis
*The sodium concentration will likely decrease when
use.
obiologist
11 is put into regular
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WN OF rAo ....�, .
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SYSTEM PUMPING RECO, '
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i„
SYSTEM OWNER & ADDRESS
- F
LID
DATE OF PUMPING: 'O
CESSPOOL: NO YES_
NATURE OF SERVICE: ROUTINE
OBSERVATIONS:
GOOD CONDITION
HEAVY GREASE
ROOTS
EXCESSIVE SOLIDS
SOLIDS CARRYOVER
SYSTEM LOCATION
(example: left front of house)
QUANTITY
PUMPED: GALLONS
EPTIC TANK: NO YES
EMERGENCY
FULL TO COVER
BAFFLES IN PLACE
LEACHFIELD RUNBACK
FLOODED
OTHER (EXPLAIN)
SYSTEM PUMPED $Y: Bateson Enterprises, Inc.
COMMENTS:
CONTENTS TRANSFERRED TO:
G.L.S.D
Lowell Waste
Commonwealth of Massachusetts RECEIVER
City/Town of
System Pumping Record APR 0 92008
g Form 4
TOWN OF NORTH ANDC
Important:
When filling out
forms on the
computer, use
only the tab key
to move your
cursor - do not
use the return
key.
DEP has provided this form for use by local Boards of Health. Other fo I "".L "'
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. SysterLo�(Dq-�
Address /u - A -v
City/Town C State
2. System Owner:
Address (if different from location)
City/Town
Zip Code
Stat 7� f<S rz�� Code
Telephone Number
B. Pumping Record 'j
1. Date of Pumping at Date 2. Quantity Pumped:
Gallons
3. Type of system: ❑ Cesspool(s) rr---',-8eptic-Tank ❑ Tight Tank
❑ Other (describe):
4. Effluent Tee Filter present? ❑ Yes Q -1q -o- If yes, was it cleaned? ❑ Yes ❑ No
5. Condition of S (-A0
tem: ���� � `A-
6. System Pumtt,�
Name R4!4�
License Number
Company
7. Locationa ntents were posed:
"Sd. o ,
Date
1
t5form4.doc- 06/03 System Pumping Record . Page 1 of 1
Commonwealth of Massachusetts
City/Town of NORTH ANDOVER, MASS]
System Pumping Record
r Form 4 ,
DEP has provided this form for use by local Boards of Health.
be submitted to the local Board of Health or other approving
Important:
When filling out
forms on the
computer, use
only the tab key
to move your
cursor - do not
use the return
key.
http://www
t5form4.doca 06/03
A. Facility Information
1. System Location:
) 0
Address
Cityrrown
2. System Owner: ,
Name
Address (if different from location)
Cityrrown
OCT - 5 U10
State
Telephone Number
Zip Code
Zip Code
ust
B. Pumping Record —/ /A -
Q/6 / U
1. Date of Pumping zrrj e 2. Quantity Pumped: Gallons
ons
3. Type of system: ❑ Cesspool(s) Septic Tank ❑ Tight Tank
❑ Other (describe):
4. Effluent Tee Filter present? ❑ Yes ❑ No If yes, was it cleaned? ❑ Yes ❑ No
5. Condition of System: n.._ — /—\ h
6.em Pumped
y t
I Fvk---) nnuuj .—
me fis Vehicle License Number
l
-Company
7.
of
were disposed:
In MW
s.htm#inspect
a
ma.
x'5110
System Pumping Record • Page 1 of 1