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Miscellaneous - 100 LACONIA CIRCLE 4/30/2018 (2)
obi 0 0' 00 0 U W � W L5W uK Q U , U ti < Q Q O U d U W O £ o za�a ° ° Q�0 ~ C w a ° O t U O O v a C O � O v � !0 3AB ' cC o cu 8 a z mow° `"U nki O U p p p p i C N p p a U ti ti U ,on •o - � ti � _� � A ♦+ O 6� 6> C O 'aAv�3aa` � �� d� a i ❑ 8 b a o cw o � �`r° � �•G w � O � 0=_ O �� Q �•C vCi G O o0 O bW vi O O Q ti N N y o,C, obi 0 i O V 0 A U W O £ o ° ° E C w d O ° O t ' cC o cu 8 a z mow° `"U nki a U E U ,on •o - � ti _� N C O � �� d� a 'o ❑ 8 b a cw o � �`r° � �•G w O � 0=_ O �� Q �•C vCi 00 .D o0 O bW vi O O Q ti N N y o,C, i O V CN qb k1 cb N ti ct t Z N y O Q O D O Q IV n v� Zn vz Commonwealth of Massachusetts W City/Town of NORTH ANDOVER LTOVVN ,�, X02014 System Pumping Record rN,Kt�Ai ��R Form 4 'M 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. A. Facility Information Important: When filling out forms 1 on the computer, use only the tab key to move your cursor - do not use the return System Location: 100 LACONIA CIRCLE Address NORTH ANDOVER MA 01845 key. Cityrrown State Zip Code 2. System Owner: JEFF CONTI ensn Name Address (if different from location) City/Town State Zip Code Telephone Number B. Pumping Record 1. Date of Pumping 11/12/14 2. Quantity Pumped: 1500 Date Gallons 3. Component: ❑ Cesspool(s) ® Septic Tank ❑ Tight Tank ❑ Grease Trap ❑ Other (describe): 4. Effluent Tee Filter present? ❑ Yes ❑ No 5. Observed condition of component pumped: GOOD CONDITION 6. System Pumped By: JAMES H CURRIER II Name X SEPTIC & DRAIN Company 7. Location where contents were disposed: GLSD Signature of Hauler If yes, was it cleaned? ❑ Yes ❑ No H79 406 Vehicle License Number 14, 11/12/14 Date Signature of Receiving Facility (or attach facility receipt) Date t5form4.doc• 11/12 System Pumping Record • Page 1 of 1 Commonwealth of Massachusetts City/Town of NO. ANDOVER W� System Pumping Record Form 4 M Important: When filling out forms on the computer, use only the tab key to move your cursor - do not use the return key. VQ reagin MAY 10 200 TOWN OF t HEALTH 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: 100 LACONIA CIR. Address NO.ANDOVER City/Town 2. System Owner: JEFF CONTI Name Address (if different from location) City/Town B. Pumping Record 1. Date of Pumping 4/25/07 Date 3. Type of system: ❑ Cesspool(s) ❑ Other (describe): 4. Effluent Tee Filter present? ❑ Yes 5Q No 5. Condition of System: 6. System Pumped By: Benjamin Shute Name J's Septic & Drain Company 7. Location where contents were disposed: GLSD MA State State Telephone Number 01845 Zip Code Zip Code — 2. Quantity Pumped: 1500 Gallons Septic Tank ❑ Tight Tank If yes, was it cleaned? ❑ Yes ❑ No H79 406 Vehicle License Number 4/25/07 Date t5form4.doc• 06/03 System Pumping Record • Page 1 of 1 G o -100 Town of North Andover Office of the Health Department Community Development and Services Division 27 Charles Street North Andover, Massachusetts 01845 Susan Y. Sawyer, REHS/RS Public Health Director 978.688.9540 - Phone 978.688.9542 - Fax C��zr�rCA� o� Co�t�LrANCE As of: October 13, 2004 'This is to cert that the individua(su6surface disposalsystem was rep aired(f� by ,john Soucy at 100 Laconia CircCe North Andover, 31,4 01845 has been installed in accordance with the provisions of litre V of the State Sanitary Code and with the ,North Andover 0oard of Yfealth regulations. The Issuance of this certificate shall not be construed as a guarantee that the system will function satisfactorily. o,XSusa 2'. Sawyer, REWS/& Pu6Cc Yfealth Director BOARD OF APPEALS 688-9541 BUILDING 688-9545 CONSERVATION 688-9530 HEALTH 688-9540 PLANNING 688-9535 TOWN -OF NORTH ANDOVER SEWAGE DISPOSAL SYSTEM INSTALLATION CERTIFICATION The undersigned hereby certify that the Sewage Disposal System () constructed; Crepaired; :b o ll/ c located at /oc� G-�cv �t/io4 C'rrzC�� was installed in conformance with the North Andover B. and of ealth approved plan, Sy Design Permit.# ae_6plan dated 00 with a design flow of gallons per day. The materials used were in conformance with those specified on the approved pian; the system was iunstalled in accordance with. the provisions of 3 10 .04k. 1-5-000. Title 5 and local re gulations,. and the final grading agrees -substantially with the. approved plan. All work isaccurately represented on the As built which has been submitted to the Board of Health.. Bed inspection date: _ 1 Z 2 - Engineer Representative Final inspection date: / o Installer Engine Engineer Representative Date: /G^Gq—!!(- Date: RECEIVED OCT 0 8 2004 H �TH DEPARTM TER FINAL GRADE INSPE TION Date: p D�oGr�'L Address trco VLOAMED? W/ SEEDED? VCOVER PER PLAN? Other: fv t7 , Office of C TOWN OF NORTH AND COMMUNITY DEVELOPMENT AND SERVICES HEALTH DEPARTMENT NORTy 3�6t4TlP �hd 27 CHARLES STREET O� Susan Y• NORTH ANDOVF " < `^ Sa«'j'er, R.EHS/RS R, MASSACHUSETTS 0].845 3 .-J"".1.1 Public- *` + Health Director �SN4 iID r"•ygf'J SCNUSEt 978.688.9540 — Phone 978.688.9542—FAX SEPTIC SYSTEM CONSTRUCTION NOTES ADDRESS:1.*o Zz INSTALLER: °-�- ` MAP: S d t> V. —LOT: DESIGNER: PLAN DATE: s4n� BOH APPROVAL DATE( DATE OF BED BOTTOM INSPECTION DATE OF FINAL CONSTRUCTION INSPE DATE OF FINAL G RADE INSPECTION: CTION: SELECT SYSTEM TYPE GRAVITY DISTRIBUTION PRESSURE DISTRIBUTION X PRESSURE DOSING HOLDING TANK ADVANCED TREATMENT OTHER COMPONENT SUMMARY FROM PLAN GALLON TANK = _45_,,oLOADING OF SEPTIC TANK = GALLON PUMP CHAMBER = LOADING OF PUMP CHAMBER TYPE OF SAS = �� DIMENSIONS AND DETAILS FSA c SITE CONDITIONS El Existing septic tankro El Internal Plumbing Properly abandoned Comments: � Topogra h gall to one building sealer p y not appreciably altered Page 1 Of 2 TOWN OF NORTH ANDOVER NORTH of q Office of COMMUNITY DEVELOPMENT AND SERVICES 4`� .o °•a"°L HEALTH DEPARTMENT 3r 27 CHARLES STREET `► �,� <h „� NORTH ANDOVER, MASSACHUSETTS 01845S "^;SC'°''''tty Susan Y. Sawyer, REHYRS Public Health Director NUS£ 978.688.9540 — Phone 978.688.9542 — FAX SEPTIC TANK ❑ Bottom of tank hole has 6" stone base ❑ Weep hole plugged ❑ gallon tank has been installed (H-10 or H-20) (monolithic or 2 piece) ❑ Water tightness of tank has been achieved (Visual or Vacuum Test or Water held for 24hrs) ❑ Inlet tee installed, under access port ❑ Outlet tee (gas baffle or effluent filter) installed, under access port ❑ inch cover to within 6" of final grade installed over one access port, must be over outlet of tank if effluent filter is present ❑ Hydraulic cement around inlet & outlet Comments: PUMP CHAMBER ❑ Bottom of tank hole has 6" stone base ❑ Weep hole plugged ❑ gallon Pump Chamber installed (H-10 or H-20) (monolithic or 2 piece) ❑ Inlet tee installed, under access port ❑ Pump(s) installed on stable base ❑ Alarm float working ❑ Pump On/Off float working ❑ Drain hole in pressure line ❑ inch cover to within 6" of final grade installed over one access port ❑ Water tightness of tank has been achieved Visual or Vacuum Test or Water held for 24 hrs ❑ Hydraulic cement around inlet & outlet Comments: Page 2 of 2 TOWN OF NORTH ANDOVER ES Office of COMMUNITY DEVELOPMENT AND SERVICES aF �� pTH � yt't �`�T.� 6'°y4CT HEALTH DEPARTMENT 27 CHARLES STREET NORTH ANDOVER, MASSACHUSETTS 01845 Susan. Y. Sawyer, REHS/RS SS�CHUSE< Public Health Director 978.688.9540 — Phone 978.688.9542 — FAX D -BOX Comments: SOIL ABSORPTION SYS E 11 El Comments: PRESSURE DISTRIBUTION 11 El El 11 Comments: Installed on stable stone base Inlet tee (if pumped or >0.087foot) Hydraulic cement around inlet & outlets Observed even distribution Speed levelers provided (not required) Bottom of SAS excavated down to Csoil layer, as provided on plan Size of SAS excavated as per plan Title 5 sand installed, if specified on plan 3/4-1 %2" double washed stone installed 1/8-1/2" (peastone) double washed stone installed laterals installed and ends connected to header (and vented if impervious material above) Orifices @ 5 & 7 o'clock positions Gravelless disposal systems: type, number and location as per plan Elevations of laterals installed as on approved plan 40 Mil HDPE barrier installed Retaining wall (boulder / concrete / timber/ block) Final cover as per plan inch manifold laterals installed with end sweeps size: material: Squirt test ft in height Equal distribution to all laterals orifice size inch as per plan Page 3 of 3 TOWN OF NORTH ANDOVER Office of COMMUNITY DEVELOPMENT AND SERVICES ar°9 �N° aT ° 4"°L HEALTH DEPARTMENT 0 A 27 CHARLES STREET NORTH ANDOVER., MASSACHUSETTS 01845 .: t Susan Y. Sawyer, RENS/RS SS CHUSE� Public Health Director 978.688.9540 — Phone 978.688.9542 — FAX CONTROLPANEL ❑ Alarm & Pump are on separate circuits ❑ Alarm sounds when float is tripped ❑ Location of control panel: Comments: 11Rated for exterior if placed outside SYSTEM ELEVATIONS Benchmark: Rod at Benchmark: Height of Instrument: Page 4 of 4 Commonwealth of Massachusetts Board Of Health North Andover P.I. F.I. Disposal Works Construction Permit Permission is hereby granted John_ Soucy------ - --__ to (Repair) an Individual Sewage Disposal System. at No 100 LACONIA CIRCLE Map -Block -Lot 105.D- 0157 - Permit No BHP -2004-0635 ----------------------- FEE $250.00 ----------------------- - ----------------------------------------------------------------------------- as shown on the application for Disposal Works Construction Permit No. BHP-20� Dated September 09, 2004 --------------------------------------- rd Of Health Commonwealth of Massachusetts Map -Block -Lot 105.D- 0157 - Board Of Health -------------------- North Andover Certificate of Compli nee,-- THIS ee - THIS IS TO CERTIFY That the Individual Se a Disposal System (Repair) by John Soucy--- - -----............................. ----------------------------------------------------------------------------------- i Installer at No 100 LACONIA CIRCL -------------------------------------- ------------------------------------------------------------------------------------------ has been installed in accord with the provisions of TITLE 5 of the State Environmental Code as described in the application for Dis orks Construction Permit No. BHP -2004-063 Dated September 09, 2004 --------- -- ------------------------Printed On: Sep -09-2004 Board Of Health - - - -- n Town'of North Andover Health Department Date: /le,17 e Location: G/ ; , _ (Indicate Address, if esi tial, or Name of Business) Check Type of Permit o` r LLse"rcle) ➢ Animal $ ➢ Dumpster $ ➢ Food Service - Type: $ ➢ Funeral Directors $ ➢ Massage Establishment $ ➢ Massage Practice $ ➢ Offal (Septic) Hauler $ ➢ Recreational Camp $ ➢ SEPTIC PERMITS: ❑ Septic - Soil Testing $ ❑Sep 'c'- Design Approval $ ® Septic Disposal Works Construction (DWC) $ f5V61e ❑ Septic Disposal Works Installers (DWI) $ ➢ Sun tanning $ ➢ Swimming Pool $ ➢ Tobacco $ ➢ Trash/Solid Waste Hauler $ ➢ Well Construction $ ➢ OTHER: (Indicate) 201 Health Agent Initials White - Applicant Yellow - Health Pink - Treasurer 0 Q TOWN OF NORTH: ANDOVER Office of COMMUNITY DEVELOPMENT AND SERVICES HEALTH DEPARTMENT 27 CHARLES STREET `� o NORTH ANDOVER, MASSACHUSETTS 01845 sAC U Susan Y. Sawyer, R.EHS/RS Public Health Director 978.688.9540 — Phone 978.688.9542 — FAX h_ .. dept ,-toWnQfnorthandover.com www.towno.fnorthandover.com APPLICATION FOR DISPOSAL WORKS CONSTRUCTION PERMIT DATE: 9— 1�-- O l( LOCATION: % 60 L'0 -W- c a G[' 2.. LICENSED INSTALLER NAME: 0 -LC A/ PLEASE PRINT SIGNATURE: TELEPHONE# q7�- (per aq � CHECK ONE: FULL SYSTEM REPAIR: V r($50) COMPONENT REPAIR (indicate what parts): ($125) * NEW CONSTRUCTION: * If NEW CONSTRUCTION, please attach the Foundation As -Built Plan. $250.00or $125 Fee Attached? Project Manager Obligation From Attached? Foundation As -Built? Floor Plans? Yes No Yes No Yes No Yes No Approval of Health Agent Date: `� o INSTALLER PROJECT MANAGEMENT OBLIGATIONS As the North Andover licensed installer for the construction of the septic system for the property at—L22— (�6t)k t eC relative to the application of dk- �c ated `T--�--o�� for plans by and 44 1 dated 7y' '7 –c� with revisions dated I understand the .following obligations for management of this project: 1.. As the installer I am obligated to obtain all permits and Board of Health approved plans prior to performing any work on a site. I must have the approved plans and the permit on site when any work is being done. 2. As the installer I must call for any and all inspections. If homeowner, contractor, project manger, or any other person not associated with my company schedules an inspection and the system is not ready then item three shall be applicable. 3. As the installer I am required to have the necessary work completed prior to the applicable inspections as indicated below. I understand that requesting an inspection, without completion of the items in accordance with Tile 5 and the Board of Health Regulations may result in a $50.00 fine being levied against my company. a) Bottom of Bed - generally first inspection unless there is a retaining wall which should be done first. Installer must request the inspection but does not have to be present. b) Final inspection — Engineer must first do their inspection for elevations, ties, etc. As -built or verbal OK from engineer must be submitted to Board of Health, after which installer calls for inspection time. Installer must be present for this inspection. With pump system all electrical work must be ready and able to cause pump to work and alarm to function. c) Final Grade — Installer must request inspection when all grading is complete. Does not have to be on site. 4. As the installer I understand that only I may perform the work (other than simple excavation) required to complete the installation of the system identified in the attached application for installation. I further understand that work by others unlicensed to install septic systems in North Andover can constitute reasons for denial of the system, and/or revocation or suspension of my license to operate in the Town of North Andover; significant fines to all persons involved are also possible. 5. As the Installer I understand that I must be on site during the performance of the following construction steps: a) Determination that the proper elevation of the excavation has been reached. b) Inspection of the sand and stone to be used. c) Final inspection by Board of Health staff or consultant. (1) Installation of tank, D -box, pipes, stone, vent, pump chamber, retaining wall and other components. 6. As the installer I understand that I am solely responsible for the installation of the system as per the approved plans. No instructions by the homeowner, general contractor, or any other persons shall absolve me of this obligation. UnderXn�d Licensed Septic j;nstaller Date: ?^ Works Construction Permit # CERTiF/ED FOUNDATYclN PLAN LOCATED /N—.a��-�-t Aaao . SCALE. I' _ 4-ol DATE' Z �� S.L.GILES R.L.S. L AWRENCE a NORTH ANDOVER r C � GAS �....WE150,00 .• t .a�3 �5 d- L S .i t+G,S I 1 i�yl� t9 r or N a `n4 E Cr a�orrx� Co -a p .13A.4 i rJ A. • sIe e6 / CERrrFY rHAr rHE OFFSETS SHOWN ARE FOR THE USE OF°':a,._. OFFSETS SHOWN THE BUIL DING INSPECTOR ONL Y, B SUCH1-4 CONFORMG r0 rHE USE /S FOR DETERMINATION OFZON/NG ZON/NG S Y L AW OF CONFORM/TY OR NON CONFORM/TY A►j � O WHEN TAKEN.rt FORM U - IAT RELEASE FORM INSTRUCTIONS: This form is used to verify that all necessary approvals/permits from Boards and Departments having jurisdiction have been obtained. This does not relieve the applicant and/or landowner from compliance with any applicable local or state law, regulations or requirements. ****************Applicant fills out this section***************** APPLICANT: ea a ne, Ll) rl) Phone IACATION: Assessor's Map Number Parcel Subdivision Lot(s) A Street kit C 0 n) a C 12 St. Number /00 ************************Official Use Only************************ ^� RECOMMENDATI NS OF TOWN AGENTS: servation Administrator Comments Date Approved q5 Date Rejected Date Approved Town Planner Date Rejected Comments Date Approved Food. Inspector -Health Date Rejected Date Approved ZI,01,5 v Septic Inspector -Health Date Rejected Comments CSW v Public Works - sewer/water connections. - driveway permit Fire Department Received by Building Inppector Date P-ul3b of N -� No�TM ,�tiDovEi�, ti1,4, SS 4P�{ovED p r�' CDNIPiTVJ5 DI S,�PPKvVED IA -16 R�SoNS DwC. 4-:'X4V4Tto/lJ ,�QP�� CAti I_ JN�IS WPIC SYS TEAj vEs�(-,/J A03�0vIN6 AuToi�rry Stp,r(C Sy sTENI 1 j 51;0 u -AT l o kj F41 L- TO Cc) � o �TH -PFSO 1L �wA� (tiSPF�TIon� ,bPPRdOEP �4�1�ITjp1�,QL, I�5�.1 (ONS (11-- h'y) DISk PMo\j6D RczSo NS FML APPi()VAL DAT -5 d BOARD OF HEALTH No.Andover; Mass. AFFROVh DATLS/_I Z• _U5 Provided: Title V Reg 2.5 1. SUBSURFACE DISPOSAL DESIGN CHECK LIST DISAPPROV DATE, _ Reasons: 4f -A LOT # 1,�6001 I CIS, The submitted plan must show as a mi.r, .w a) the lot to be served -area dimensions 1( #,abutters blocation and log deep observation Men-aistance to ties c location and results percolation testas- li.st.ance to ties d design calculations & calculations showing required leaching area ,e) location and dimensions of system -including reserve area .f) existing and proposed contours ,g) location any wet areas within 1001 of sewage dispopal system or disclaimer -check wetlands mapping h) surface and subsurface drains within 1001 of sewage disposal system or disclaimer i) location any drainage easements within 3.001 of sewage disposal system or disclaimer -Planning Hoard files J) known sources of water supply within 2001 of sewage disposal a system or disclaimer k) location of any proposed well to serve lot -1001 from leaching facility 1) location of water lines on property -10) from leaching facility m) location of benchmark n) driveways o) garbage disposals P) no PVC to be used in construction q) profile of system -elevations of basemv.,t, plumb, pipe, septic tank, distribution box inlets and outlets, d stribution field piping and Other elevations r) maximum ground water elevation in .,ea sewage disposal system s) plan must be prepared by a Professional .7ngineer or other professional authorized by law to prepare such plans Reg 6 Septic Tanks (a) capacities -150% of flown water table., tees] depth of tees access, pumping (b) cleanout (c) 101 from cellar wall or inground swimming pool (d) �5, from subsurface drains Reg 10.2 Distribution Boxes I(a) slope greater than 0.08 Reg 10.1 b} sump September 2, 2004 Susan Y. Sawyer Town of North Andover Office of Community Development & Services Health Department 27 Charles Street North Andover, MA 01845 Dear Ms. Sawyer, 100 Laconia Circle North Andover, MA 01845 -1D SEp 1ZZ4 �rN PN��VER TO NEP�T 1�.y UrP �q�;JnFN� I am enclosing a copy of Variance/Deed Restriction and the receipt from the Registry of Deeds that you requested in your letter of August 27, 2004. I went to the Registry on September 2, 2002 and recorded the variance. It will take a year for me to get the original copy, but it should be recorded in about 1 month and be listed on www.lawrencedeeds.com If you have any questions or need further information feel free to contact me at 978-722- 7076(work) or 978-794-1972. Thank you. Sincerely, Jeanne D'Angelo E;sex W F 1, i •tr- v o D e e 3 LO; I COWIF,10r: sb�C.. Lawrenc c- —4, jr. Q RECEIVED EOTVARIANCE IDEED RESTRIMOf SEP - 7 2004 90 Iritle 5, and as a condition ofseptic plan ajrr= notice is here6y given that reafestate located North Andover, Wassachusetts, (aka /Lot ), as descri6edin a deed from to J? -4,q n e- M , / O'Any=10 A lq'"and recorded in the Essex County ftistry of Deeds in 2 01 and Document # fe 3 3 9 from the Town of North -Andover Minimum Requirements for the • zitary Sewage Al. 05 and C9.01(4). Said variance limits the )ms at this dwelTing to 41 bedrooms. 9his variance YO -11U! T� f the North Andover 0oardofiTeafth. day of ry\ � D'A 2:qP min Pr*erty Owner(s)Si�natures f"a COWWONWEALW OT 9W ASSAC7f1VSETrS CA Esse,-,G s.s. Date: � ")" , 20 6'4 c::) Then personally appeared the above-named and Or j acknowledged the foregoing instrument to 6e hislherltheirftee act and deed before me. - LORI BERMAN Notary Public My !Commission Expires March 24, 2006 L-�- /V"CW Name Notary (N61ic o � TOWN OF NORTH ANDOVER HEALTH DEPARTMENT `'' CHARLES STREET NORTH ANDOVER, MASSACHUSETTS 01.845 Susan Y. Sawyer, REHS/RS Public Health Director I AM Benjamin C. Osgood, Jr., EIT To: NEW ENGLAND ENGINEERING SERVICES, INC. 60 Beechwood Drive North Andover, MA 01845 978.688.9540 - Phone 978.688.9542 - Fax healthdei)t@townofnorthandover.com www.towno.fnorthandover.com From: Pamela Fax: 978-685-1099 Pages: 978-686-1768 Date: Phone: Septic Plan Response CC: File Re: ❑ Urgent x For Review ❑ Please Comment ❑ Please Reply ❑ Please Recycle • Comments: Attached is the response from the Health Agent regarding Septic Plans for the following property: A� A copy has also been mailed to the homeowner. Please call 978-688-9540 for assistance with any questions. Thank you. Cc: File - / o � HP Fax K 1220xi Log for NORTH ANDOVER 9786889542 Aug 27 2004 4:02pm Last Transaction Date Time Type Identification Duration Pages Result Aug 27 3:57pm Fax Sent 89786851099 4:11 6 OK TOWNO RT OF NORTH ANDOVER No w Office of COMMUNITY DEVELOPMENT AND SERVICES o: •; ° � HEALTH DEPARTMENT 27 CHARLES STREET NORTH ANDOVER, MASSACHUSETTS 01845 Susan Y. Sawyer 978.688.9540 — Phone Public Health Director 978.688.9542 — FAX August 27, 2004 Jeanne D'Angelo 100 Laconia Circle North Andover, MA 01845 RE: Subsurface Sewage Disposal System Plan for 100 Laconia Circle, Map 105D, Parcel 157, North Andover, Massachusetts Dear Ms. D'Angelo, The North Andover Board of Health has completed the review of the septic system design plans, for the above referenced property, submitted on your behalf by New England Engineering Services dated July 27, 2004. The design has been approved for use in the construction of a replacement onsite septic system. This approval is valid for three years from the date of this letter and during this time a licensed septic system installer must obtain a permit and complete this work, and a Certificate of Compliance must be endorsed by the installer, designer and the Town of North Andover. The time period for which this plan is valid is reduced to two years from the date of a septic system inspection which did not meet the acceptable criteria in the state regulations. In the event an imminent. health problem such as sewage backup into the dwelling is occurring, the time period for which this plan is valid may be reduced by the North Andover Board of Health. The following requests were approved at the Board of Health meeting. 1. To allow the application for a Local Upgrade as requested, for a reduction in the separation between the soil absorption system and the high groundwater from the required four feet to three feet. With the granting of this reduction, a deed restriction must be placed on the property, which limits the maximum number of bedrooms of this dwelling to four bedrooms (a nine -room house). The applicant must submit proof of recording, prior to the issuance of a Certificate of Compliance by the health department. This restriction shall remain on the property until such time that the dwelling is connected to a municipal sanitary sewer system and the soil absorption system is properly abandoned. This approval is subject to the following conditions: 1. The attached DEP Form 9b must be submitted to the appropriate Regional Office of the Department of Environmental Protection at One Winter Street, Boston MA by the property owner 2. If site conditions are found in the field to be different from those indicated on the design plan and/or soil evaluation, the originally issued Disposal System Construction Permit is void, installation shall stop, and the applicant shall reapply for a new Disposal Systems Construction Permit (3 10 CMR 15.020(1)). 3. It is the responsibility of the applicant and/or the applicant's septic system designer, septic system installer or other representative to ensure that all other state and municipal requirements are met. These may include review by the Conservation Commission, Zoning Board, Planning Board, Building Inspector, Plumbing Inspector and/or Electrical Inspector. The issuance of a Disposal System Construction Permit shall not construe and/or imply compliance with any of the aforementioned requirements. Your effort to provide a properly functioning septic system for your dwelling is greatly appreciated. The Health Department may be reached at 978-688-9540 with any questions you might have. Sincerely, Susan Y. Sawyer, REHS/RS Public Health Director cc: New England Engineering Services file It is the responsi6igty of the appficant to record the required deed restriction per 310 CW R15. 000 T tfe 5. The foff4 w ng is a s ested ormat, 6ut the finafdocument should 6e approved b yourattomey prior to recording. NOTICE 0T VARIANCE / DEED REST<iZIC9705V ftrsuant to 310 CMR,15.000 Title S, and as a condition of septic plan approvarby the North Andover 0oard of ifeafth, notice is hereby given that reafestate Located at: , North Andover, Massachusetts, (aka Assessor's Map /.Got ), as described in a deed from to dated , 20 and recorded in the Essex County ftistry of Deeds in Book andEage , andas Document # is the su6ject of a variance from the Town of North Andover Minimum Requirements for the Su6surface Disposal of Sanitary Sewage,41.05 and C9.01(4). Said variance Limits the maximum number of bedrooms at this dweLLing to bedrooms. This variance is within the jurisdiction of the North Andover 0oard of Wealth. Signedandseafed this day of . 20 ftoperty Owners) Signatures COWWOYWEAL2ff Off' MASS 4CifVSEgtlS Essex s. s. Date: , 20 Then personally appeared the above-named and acknowledged the foregoing instrument to be his/her/their free act and deed, before me. Name Notary 1t 6f c Y i' Commonwealth04i Massachusetts City/Town of Local Upgrade Approval Fonn 9B rnporbM: when filling out forms on Hie campuber. use o* Hre tab My to move your cursor - do not use Me return WY. VQ 0 DEP has provided this form for use by local Boards of Health if they choose to do so. The Local Upgrade Approval is to be completed by the local Board of Health and a signed copy provided to the system owner. The system owner shall provide a copy of the Local Upgrade Approval to the appropriate Regional Office of the Department of Environmental Protection, Bureau of Resource Protection, Title 5 Permitting Program, upon issuance by the local approving authority and before commencement of construction. A. Facility Information 1. Facility Name and Address Jeanne D'Anaelo Name 100 Laconia Circle Street Address North Andover MA Cihdrown State 2. Owner Name and Address (if different from above): Name Cityrrawn Zip Code 3. Type of Facility (check all that apply): x Residential ❑ Institutional 4. Design flow per 310 CMR 15.203: 5. System Designer. 60 Beechwood Drive Address Street Address State Telephone Number ❑ Commercial ❑ School 440 go Ben Osgood Jr. Name NorthAndover 01845 Cityrrown B. Approval 1. Local Upgrade Approval is granted for: ❑ Reduction in setback(s) — specify: ❑ Reduction in SAS area of up to 25%: 100 Lacon Circle 9b prop • rev. 5102 State, ZIP 01845 Zip Code x PE El. RS SAS size, sq. R. % reductio, Local Upgrade Approval- Page 1 of 2 ,r n Commonwealth of Massachusetts City/Town of Local Upgrade Approval Fonrn 9B B. Approval (continued) x Reduction in separation between the SAS and high groundwater. Separation reduction 1 ft. 48 Percolation into Depth to groundwater ❑ Relocation of water supply well (explain): minJmch 3 ft. List local variances granted not requiring DEP approval per 310 CMR 15.412(4): List variances granted requiring DEP approval: North Andover Board of Health jb,yA yov mke(eti Print or Type Name and Trde gate tQA8OH C-1711AIrzdMrS� 100 Laconia circle 9b prop • rev. 5/02 Local Upgrade Approval• Page 2 of 2 NEW ENGLAND ENGINEERING SERVICES INC August 17, 2004 Susan Sawyer North Andover Board of Health 27 Charles Street North Andover, MA 01845 Re: 100 Laconia Circle, North Andover Dear Susan: Please accept this letter as a request to appear before the North Andover board of Health in regards to granting the local variance or upgrade for the above referenced property. The requests are as follows. 1. Allow the construction of a leach field with a separation to ground water of 3 feet in lieu of 4 feet as required by Title 5. If you have any questions please do not hesitate to contact this office. Sincerely, C�� Benjamin C. Osgo , Jr., EIT President 60 BEECHWOOD DRIVE -NORTH ANDOVER, MA 01845 -(978) 686-1768 - (888) 359-7645- FAX (978) 685-1099 n � Page 1 of 1 Dellechiaie, Pamela From: Dan Ottenheimer [info@millriverconsulting.com] Sent: Wednesday, August 11, 2004 8:41 PM To: Susan Sawyer; amcbrearty@millriverconsulting.com; 'Pamela Dellechiaie' Subject: Plans Sue and Pam, Attached please find the plan revie s for 100 Laconia Circle and 1094 Salem Street. On both designs they are requesting a reduction in ground w offset. I am hard- to see why the Laconia site would need such a reduction as it appears to be a very largo-area.w raised system could be well designed and look ok. The Salem Street site is pretty tight for space. Most communities around here would not approve the local upgrade approval for either site and would look for the designer to achieve full compliance with a conventional system and a wall (if needed) or a treatment unit. One item for you and/or the Board to considerwould be requiring pressure distribution of the wastewater in the event a pump is needed and the LUA for only 3' to ground water is requested. This would provide some improved wastewater treatment to counterbalance the lack of 4' separation to groundwater. Dan Mill River consulting Daniel Ottenheimer, President Mill River Consulting Septic System Management Services 2 Blackburn Center Gloucester, MA 01930-2259 978-282-0014 or 1-800-377-3044 fax: 978-282-0012 www.millriverconsulting.com info a�millriverconsulting.com 8/30/2004 Town of North Andover �f Health Department Date: / 0 Location: /zo /(g�Q/'�1;7 � (Indicate Address, if Residential, or Name of Business) Check #: z; Type of Permit or License: (Circle) ➢ Animal $ ➢ Dumpster $ ➢ Food Service - Type: $ ➢ Funeral Directors $ ➢ Massage Establishment $ ➢ Massage Practice $ ➢ Offal (Septic) Hauler $ ➢ Recreational Camp $ ➢ SEPTIC PERMITS: ❑ Septic - Soil Testing eptic - Design Approval $ X $ ❑ Septic Disposal Works Construction (DWC) $ ❑ Septic Disposal Works Installers (DWI) $ ➢ Sun tanning $ ➢ Swimming Pool $ ➢ Tobacco $ ➢ TrashlSolid Waste Hauler $ ➢ Well Construction $ ➢ OTHER: (Indicate) 167 Health Agent Initials White - Applicant Yellow - Health Pink - Treasurer NEW ENGLAND ENGINEERING INC July 30, 2004 Susan Sawyer North Andover Board of Health 27 Charles Street North Andover, MA 01845 Re: 100 Laconia Circle, Septic System Design Dear Susan: SERVICES RE E1VED jUL 3 0 2004 TDHEgLTH DEPARTANDOVER Enclosed are the following documents concerning the above referenced property. 1. 5 Copies of septic system design plans. 2. Copy of Form 11 -Soil Evaluator Form. 3. Copy of Form 12 -Percolation Test Form. 4. Pressure Distribution Calculations. 5. Copy of Form 9A -Application for Local Upgrade Approval. 6. Application for approval plans. 7. Check to cover the approval fee. These plans are being submitted for approval. Please contact this office with any questions or concerns at (978)-686-1768. Sincerely, Thomas Hector Project Engineer 60 BEECHWOOD DRIVE - NORTH ANDOVER, MA 01845 - (978) 686-1768 - (888) 359-7645 - FAX (978) 685-1099 -1 - O Town of North Andover HEALTH DEPARTMENT 27 Charles Street North Andover, MA 01845 978.688.9540 healthdepWownofnorthandover. com SEPTIC PLAN SUBMITTAL FORM DATE OF SUBMISSION: SITE LOCATION: f DD L-ar an i o. C rc.�e I ENGINEER: Ae GJ Cptal. &J NEW PLANS: YES $225.00/Plan '� o Check #: (c 808 (Includes 1 Ew and one Re -Review Only) REVISED PLANS: YES $ 75.00/Plan Check #: SITE EVALUATION FORMS INCLUDED: YE NO LOCAL UPGRADE FORM INCLUDED: YES NO Telephone #:6 7 86 -17 6 a Fax #: 8) 1611 E-mail: HOMEOWNER NAME: l OFFICE USE ONLY When the submission is complete (including check): L f'-'�' e stamp plans and letter 2. `� C�rkplete and attach Receipt 3. 'y File; Forward to Consultant 4. Enter on Log Sheet and Database .. RECEIVED JUL 3 0 2004 TOWN OF NORTH ANUUVER HEALTH DEPARTMENT :1 • 11 I No. l � TP z 0 FORM 11 - SOIL EVALUATOR FORM Page 1 of 3 Commonwealth of Massachusetts Date: 71z Massachusetts Soil Suitability Assessment for On-site Sewage Disposal Performed By:..��. r.��+.��..I,�...... G......... Date: 7131 �. ��............... . nA�2k,.v /v�.1�.............................................. _............._ Witnessed By: ............................................. `.. owner's !lame. Location Address or � I � O � �„/�%Cd Al /Iit Cr/ZC LC Address, and �� J ��Ge�n/ 14 C'<2GL� Telephone I �i7 /Ll}l �N,p !�v �' yam: !l rel lhNJ7 UcI'P/L , �a4 ew Construction Repair Office Review Published Soil Survey Available: No ❑ Yes Year Published 1 q.( ............. Publication Scale yo Soil Map Unit /�s-- -- Drainage Class W El- ........... Soil Limitations ........... .�. ..........�5. .,v r.,v.. ss ...... .................... _....... .._ Surficial Geologic Report Available: No �Q Yes ❑ Year Published Publication Scale Geologic Material (Map Unit) Landform ................................................................................................................................. Flood Insurance Rate Map: r� 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) WA .......... Current Water Resource Conditions (USGS): Month ................. . Range :Above Normal Normal ❑Belcw Normal ❑ Other References Reviewed: RECEIVED DEP APPROVED FORM - 12107/95 JUL 3 4 2004 TOWN OF NOK I H HivL.)vFR HEALTH OEPA 3TMENT o o ` FORM 11 - SOIL EVALUATOR FORM Page 2of3 Location Address or Lot No. On-site Review Deep Hole Number .::.:,::.�Date:..::.-7..1.Time::....:/.z..0 Weather 0v&2cczS % Location (identify on site Ian) Land Use Slope (%) ola Surface Stones l/w. Vegetation., G:�ss..:.....:... ............:...:....:,...:.:::..::.. .::::.: . Landform ......:....::...:... Position on landscape Distances from: Open Water Body Z,>-22. feet Drainage way. 2� feet Possible Wet Area 0:. feet Property Line ........�.. feet Drinking Water Wellfeet. Other :...v.. :'....v:::.... DEEP OBSERVATION HOLE LOG Depth from Soil Horizon Surface (Inches) Soil Texture (USDA) '—Soil Color (Munsell) Soil Mottling Other (Structure, Stones, Boulders, Consistency, °/, o--7 A Gravel) -7—L! O 11 \j Gv1 e.5 vaY-�eS y�-5c� lvw S- l,- 10jJ2 � @55� � G-, u5 Parent Material (geologic) %/ 1, L DepthtoBedrock: Depth to Groundwater: Standing Water in the Hole: %l �o it/t% Weeping from Pit Face: Estimated Seasonal High Ground Water: " DEP APPROVED FORM • 12/07/95 o - � ' FORM 11 - SOIL EVALUATOR FORM Page 2 of 3 Location Address or Lot No. LAI n Y)') G On-site Review Deep Hole Number .::1.:.: Dater..;:. �:..:.:.3 Time:.:...:. /2 : o O Weather D ✓C,2 c,15 i Location (identify on site plan) s..:..:..:.....:_/L ©N j..:n....c..::'7% .:..:.:.:.,.:...:.... Land Use ,..,:...:...s::c�?.:t �vi�..L... Slope Sti'rface Stones N....:J...N .. Vegetation ............:...:....:::.::::::..:... .:::.::. . Landform .....:::.......:,:,M..D'2 Fk.I..N.. . . ...:: :..:.::... ......:....::...:........: Position on landscape Distances from: Open Water Body Z -5D. feet Drainage way..`. feet Possible Wet Area /60:. feet Property Line .'.....,5v. feet Drinking Water Well :ls� . feet Other DEEP OBSERVATION HOLE LOG Depth from Surface (Inches) Soil Horizon Soil Texture Soil Color (USDA) (Munsell) Soil Other Mottling (Structure, Stones, Boulders, Consistency, 0-- S A Gravel 2 �i1 vaM5 k_)ayies 25 - 37 2 14a Parent Material (geologic) / i L' LL DepthtoBedrock: A/ Depth to Groundwater: Standing Water in the Hole: A/ Weeping from Pit Face: /1f 0 ,v Estimated Seasonal High Ground Water:_ , 3 7 " _ DEP APPROVED FORM - 12/07/95 o _ o FORM 11 - SOIL EVALUATOR FORM Page 3 of 3 Location Address or Lot No. 100 1-19Cv,Jlr9- C112-CC,L Determination for Seasonal High Water Table Method Used: ❑ Depth observed standing in observation hole ................... inches ❑ Depth weeping from side of observation hole ................... inches M Depth to soil mottles V1 inches ❑ Ground water adjustment ................... feet Index Well Number .................. Reading Date ................... Index well level .......... Adjustment factor ................... Adjusted ground water level ........................................................ Depth of Naturally Occurring Pervious Material Does at least four feet of naturally occurring pervious material exist in all areas observed throughout the area proposed for the soil absorption system? w� s If not, what is the depth of naturally occurring pervious material? Certification I certify that on NO U l ggS- (date) I have passed the soil evaluator examination approved by the 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. Signature f �� Date -712-8113 `f DEP APPROVED FORM - 12/07/95 0 Commonwealth of Massac usetts City/Town of Nor+ k 4 ofeI- • Percolation Test Form 12 M yv Important: When filling out forms on the computer, use only the tab key to move your cursor - do not use the return key. rub ieban 0 Percolation test results must be submitted with the Soil Suitability Assessment for On-site Sewage Disposal. 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 the local Board of Health to determine the form they use. A. Site Information Jeanne D'Angelo Owner Name 100 Laconia Circle Street Address or Lot # North Andover MA 01845 City/Town State Zip Code 978-794-1972 Contact Person (if different from Owner) B. Test Results Telephone Number t5form12.doc• 06/03 Perc Test - Page 1 of 1 PT1 PT1 (after soak) Observation Hole # 78" 78" Depth of Perc Start Pre -Soak 12:54 9:01 End Pre -Soak 1:09 9:16 Time at 12" 1:09 9:16 Time at 9" - 11:19 Time at 6" - 1:41 Time (9"-6") - 142 min. Four Hour Soak Req'd 48 min./inch Rate (Min./Inch) Test Passed: ❑ Test Passed: Test Failed: ® Test Failed: ❑ Benjamin C. Osgood, Jr. Test Performed By: Andrew McBrearty, Mill River Consultants Witnessed By: Comments: t5form12.doc• 06/03 Perc Test - Page 1 of 1 NEW ENGLAND ENGINEERING INC DESIGN FLOW (in gallons/day)? Elevation of the PUMP OFF SWITCH, in feet? Elevation of the upper LATERAL, in feet? DELIVERY PIPE distance, from pump to manifold, in feet? DELIVERY PIPE diameter, in inches (if not 2" -use 2" min)? Design DISTAL PRESSURE, in feet (if not 2.5)? (hd) IS MANIFOLD CENTER -FED & SYMETRICAL (yes or no)? yes How many orifices in the MANIFOLD? MANIFOLD ORIFICE diameter, in inches (if not 5116") MANIFOLD DIAMETER (if not 2" -use 2" min)? TOTAL LENGTH OF MANIFOLD Does MANIFOLD drain to FIELD after dose (yes or no)? no How many LATERALS? Pumping chamber weep hole size (usually .25') PROGRAM WILL CALCULATE UP TO 26 LATERALS AND UP TO 50 Your HIGHEST elevation lateral MUST be LATERAL 1: (first orifice from lateral 1/2 of orifice spacing) Length of each LATERAL, in feet? Diameter of each LATERAL, in inches (1.5' min)? Elevation of each LATERAL, in feet? Number of ORIFICES per lateral Distance from Manifold to closest Orifice, in feet ORIFICE SPACING, in feet Diameter of ORIFICES, in inches? (D) Square feet of leachfield per laterals (can ignore) Maximum number of orifices in any one lateral Minimum lateral diameter 0.25 4 USE 0 IF FORCE MAIN DOES NOT DRAIN PER LATERAL Lateral 1: Lateral 2: Lateral 3: Lateral 4: "46 di5 46.875 46 875 _ 46.87 1.51 1.5€ 1.5 1. 100.971 100.971 100.97 100.9 7{ 7) 7- 7 3.35` 3.351 3.351 3.3 6.7' 6.7 6.7 6. 0.25: 0.25) 0.25; 0.2 2481 248- 2481 y-- 1.5 2ESiJLT FRICTION CALCULATIONS (using Hazen Williams friction ft= Ld((3.55Qm/Ch(Dd^2.63)))^1.85) PRESSURE CALCULATIONS (using orifice dischage equation Q=11.79 D^2 hd^.5 Lateral l: Lateral 2: LATERAL DISCHAGE (first approximation) 8.93 8.93 MANIFOLD ORIFICE DISCHARGE 0.00 TOTAL SYSTEM DISCHAGE (first approximation) 71.47 TOTAL DISCHARGE PER LATERAL DISCHARGE PER SQUARE FOOT OF LEACHFIELD ORIFICE MAXIMUM DISCHARGE BY LATERAL ORIFICE MINIMUM DISCHARGE BY LATERAL ORIFICE % DIFFERENCE DISCHARGE within LATERAL MAXIMUM DISCHARGE LATERAL MINIMUM DISCHARGE LATERAL MAXIMUM DISCHARGE PER SQUARE FOOT MINIMUM DISCHARGE PER SQUARE FOOT • DIFFERENCE DISCHARGE for SYSTEM by orifice % DIFFERENCE DISCHARGE for SYSTEM by laterals % DIFFERENCE DISCHARGE for SYSTEM by square feet WEEP HOLE DISCHARGE (usually a 1/4" weep hole) VOID VOLUME IN DELIVERY PIPE VOID VOLUME IN MANIFOLD VOID VOLUME IN EACH LATERAL TOTAL LATERAL VOID VOLUME SERVICES Lateral 5: Lateral 6: Lateral 7: Lateral 8: 46.875 _46 . ii5} 46.8751 '-4-6 8-75 1.5 1.51 1.5 1.5 100.97 100.971 100.971 100.97 7 71 71 7 3.35 3.35? 3.35; 3.35 6.7 6.71 6.7€ 6.7 0.251 0.251 0.251 0.25 Lateral 6 Lateral 7 Lateral 8 Hole Spacing Hole Spacing Hole Spacing Error Error Error Lateral 3: Lateral 4: Lateral 5: Lateral 6: Lateral 7: Lateral 8: 8.93 8.93 8.93 8.93 8.93 8.93 8.96 8.96 8.96 8.96 8.96 0.03611395 0.03611395 0.036114 #DIV/0! #DIV/0! 1.28 1.28 1.28 1.28 1.28 1.28 1.28 1.28 1.28 1.28 0.7% 0.7% 0.7% 0.7% 0.7% 8.96 8.96 #DIV/0! #DIV/0! 0.7% as percent of maximum orifice in system 0.0% as percent of maximum lateral in system as percent of maximum square foot in system 4.53 weep hole= 0.375 inch 5.87 15.24 4.30 4.30 4.30 4.30 4.30 21.51 8.96 8.96 8.96 #DIV/0! #DIV/0! #DIV/0! 1.28 1.28 1.28 1.28 1.28 1.28 MINIMUM DOSE VOLUME (based on void volume) 107.57 to 215.14 MIN ACTUAL MINIMUM IS BASED ON DAILY DESIGN FLOW (weep hole, usually 1/4", not counted for dose, effluent is repumped during process and not counted for friction, except as fitting headloss) TOTAL HEAD LOSS IN EACH LATERAL MAXIMUM TOTAL LATERAL HEADLOSS IN SYSTEM MANIFOLD HEADLOSS (center -fed unless manifold design) DELIVERY PIPE HEADLOSS FITTING LOSS (headloss'.15) DISTAL PRESSURE HEAD STATIC HEAD (OFF -SWITCH TO HIGH LATERAL/MANIFOLD) HEADLOSS PUMP TO WEEPHOLE (assume T run) 0.18 0.18 0.18 0.18 0.18 0.18 0.18 0.02 0.20 w/ delivery 3 inch diameter 0.45 add extra head if fittings are more than absolute minimum 3.00 6.62 0.04 PUMP MUST BE ABLE TO PASS SOLIDS AT 76.18 G.P.M 10.52 FEET OF HEAD or After OTIS (network losses=1.3'distal head) 76.18 G.P.M. 13.80 FEET OF HEAD 0.18 0.18 60 BEECHWOOD DRIVE - NORTH ANDOVER, MA 01845 - (978) 686-1768 - (888) 359-7645 - FAX (978) 685-1099 0 0 Commonwealth of Massachusetts City/Town of Aar+ Arrdolei Form 9A - Application for Local Upgrade Approval 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. Form 9A is to be submitted to the Local Board of Health for the upgrade of a failed or nonconforming septic system with a design flow of less than 10,000 gpd, where full compliance, as defined in 310 CMR 5.404(1), is not feasible. 310 CMR 15.403(4) requires the system owner to provide a copy of the local upgrade approval to the appropriate Regional Office of the Department of Environmental Protection, Bureau of Resource Protection, Title 5 Permitting Program, upon issuance by the local approving authority and before commencement of construction. System upgrades that cannot be performed in accordance with 310 CMR 15.404 and 15.405, or in full compliance with the requirements of 310 CMR 15.000, require a variance pursuant to 310 CMR 15.410 through 15.417. NOTE: Local upgrade approval shall not be granted for an upgrade proposal that includes the addition of a new design flow to a cesspool or privy, or the addition of a new design flow above the existing approved capacity of an on-site system constructed in accordance with either the 1978 Code or 310 CMR 15.000. Zip Code 3. Type of Facility (check all that apply): ® Residential ❑ Institutional 4. Describe Facility: Residential Sinole Familv Home 5. T p RECEIVED JUL 3 0 200 TOWN OF NORTH ANDOVER TiMA1Fr(AIO QT*&AAur..ir . of Existing System: 5/02 ❑ Cesspool(s) State Street Address State Telephone Number ❑ Commercial ❑ School 01845 Zip Code ® Conventional ❑ Other (describe below): Application for Local Upgrade Approval* Page 1 of 4 A. Facility Information Important: When filling out 1. Facility Name and Address: forms on the computer, use Jeanne D'Angelo only the tab key Name to move your 100 Laconia Circle cursor - do not Street Address use the return key. North Andover Q City/Town 2. Owner Name and Address (if different from above): Same as above P7p� Name Cityrrown Zip Code 3. Type of Facility (check all that apply): ® Residential ❑ Institutional 4. Describe Facility: Residential Sinole Familv Home 5. T p RECEIVED JUL 3 0 200 TOWN OF NORTH ANDOVER TiMA1Fr(AIO QT*&AAur..ir . of Existing System: 5/02 ❑ Cesspool(s) State Street Address State Telephone Number ❑ Commercial ❑ School 01845 Zip Code ® Conventional ❑ Other (describe below): Application for Local Upgrade Approval* Page 1 of 4 a o CommonwealthT04�\ Massachu�s efts City/Town of Ahdover w Form 9A - Application for Local Upgrade Approval wM 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. A. Facility Information (continued) 6. Type of soil absorption system (trenches, chambers, leach field, pits, etc): Leach Bed 7. Design Flow per 310 CMR 15.203: Design flow of existing system: Design flow of proposed upgraded system Design flow of facility: B. Proposed Upgrade of System 1. Proposed upgrade is (check one): 440 gpd 440 gpd 440 gpd ❑ Voluntary ❑ Required by order, letter, etc. (attach copy) ® Required following inspection pursuant to 310 CMR 15.301: 2. Describe the proposed upgrade to the system: Install new pump chamber and leach field. Existina septic tank to remain. 3. Local Upgrade Approval is requested for (check all that apply): ❑ Reduction in setback(s) — describe reductions: ❑ Reduction in SAS area of up to 25%: SAS size, sq. ft. ® Reduction in separation between the SAS and high groundwater: Separation reduction 1 ft. Percolation rate 50 min./inch Depth to groundwater min./inch 37" TP2 ft. date of inspection % reduction T5Form9A 100 Laconia Cir • rev. 5/02 Application for Local Upgrade Approval* Page 2 of 4 oM 0 Commonwealth of Massachusetts City/Town of /IJ04LX A n4over Form 9A - Application 101 for Local Upgrade Approval 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. B. Proposed Upgrade of System (continued) ❑ Relocation of water supply well (explain): ❑ Other requirements of 310 CMR 15.000 that cannot be met— describe and specify sections of the Code: If the proposed upgrade involves a reduction in the required separation between the bottom of the soil absorption system and the high groundwater elevation, an Approved Soil Evaluator must determine the high groundwater elevation pursuant to 310 CMR 15.405(1)(i)(1). The soil evaluatormust be a member or agent of the local approving authority. High groundwater evaluation determined by: Andrew McBrearty Evaluator's Name (type or print) Signature C. Explanation 7/13/04 Date of evaluation Explain why full compliance, as defined in 310 CMR 15.404(1), is not feasible. (Each section must be completed) 1. An upgraded system in full compliance with 310 CMR 15.000 is not feasible: Due to high ground water, a four foot separation would place the finish grade of the system 1.5' above the sill of the dwelling creating a potential drainage problem at the front of the dwelling. 2. An alternative system approved pursuant to 310 CMR 15.283 to 15.288 is not feasible: Due to large size, cost is prohibitive. T5Form9A 100 Laconia Cir • rev. 5/02 Application for Local Upgrade Approval* Page 3 of 4 Commonwealth f Massachusetts City/Town of ,�orer Form 9A - Application M for Local Upgrade Approval 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. C. Explanation (continued) 3. A shared system is not feasible: No land available on adjacent lots. 4. Connection to a public sewer is not feasible: No public sewer in this area of town. 5. The Application for Local Upgrade Approval must be accompanied by all of the following (check the appropriate boxes): ® Application for Disposal System Construction Permit ® Complete plans and specifications ® Site evaluation forms ❑ A list of abutters affected by reduced setbacks to private water supply wells or property lines. Provide proof that affected abutters have been notified pursuant to 310 CMR 15.405(2). ❑ Other (List): D. Certification "I, the facility owner, certify under penalty of law that this document and all attachments, to the best of my knowledge and belief, are true, accurate, and complete. I am aware that there may be significant consequences for submitting false information, including, but not limited to, penalties or fine and/or imprisonment for deliberate violations." Facility wner's Signature Benjamin C. Osgood, Jr. Agent Print Name Benjamin C. Osgood, Jr. Name of Preparer 60 Beechwood Drive Preparer's address MA 01845 State/ZIP Code 7/29/04 Date 7/29/04 Date North Andover City/Town (978) 696-1768 Telephone T5Form9A 100 Laconia Cir • rev. 5/02 Application for Local Upgrade Approval* Page 4 of 4 s01 C TOWN OF NORTH ANDOVER HEALTH DEPARTMENT 27 CHARLES STREET NORTH ANDOVER, MASSACHUSETTS 01845 Susan Y. Sawyer, REHS/RS Public Health Director FAX 978.688.9540 - Phone 978.688.9542 - Fax RECEIVED JUL 16 2004 TOWN OF NOR`I H ANDOVER , HEALTH DEPARTMENT Q J ❑ Urgent x For Review ❑ Please Comment ❑ Please Reply ❑ Please Recycle • Comments: Septic Plan Review Soil Test •./OTHER Note: For plan reviews, this is notification only. Plans will be mailed or arrangements made to pick them up as requested. Please call 978-688-9540 for assistance with any questions. Thank you. Cc: File - Address DanielOttenheimer From: Pa To: Mill River Consulting Fax: 978.282.0012 Pages: LJ 1.800.377.3044 or Date: Phone: 978.282.0014 Request for Soil Testing or CC: Re: Septic Plan Review 978.688.9540 - Phone 978.688.9542 - Fax RECEIVED JUL 16 2004 TOWN OF NOR`I H ANDOVER , HEALTH DEPARTMENT Q J ❑ Urgent x For Review ❑ Please Comment ❑ Please Reply ❑ Please Recycle • Comments: Septic Plan Review Soil Test •./OTHER Note: For plan reviews, this is notification only. Plans will be mailed or arrangements made to pick them up as requested. Please call 978-688-9540 for assistance with any questions. Thank you. Cc: File - Address BOARD OF HEAL'1 NORTH ANDOVER, MASS. 01845 978-688-9540 APPLICATION FOR SOIL TESTS DATE: 61Z} MAP & PARCEL: _ AAA Parcel W7 LOCATION OF SOIL TESTS: 100 Circle OWNER:- .J p n,y,y► c �+� p m TEL. NO.: ADDRESS: I o c) 0. ' 0n 1 ; r- rA ENGINEER: 1t,V_ ca - ` I , rinqeryt , LL. NO.: 9 6 CERTIFIED SOIL EVALUATOR: Intended use of land: Residential Subdivision(--Singemily Home N Commercial Is This: Repair testing_ Undeveloped lot testing In the Lake Cochichewick Watershed? Yes Upgrade for addition No I THE FOLLOWING MUST BE INCLUDED WITH THIS FORM: 1. Proof of land ownership (Tax bill, deed, or letter from owner permitting tests) 2. Plot plan 3. Fee of $425.00 per lot for new construction. This covers the minimum two deep holes and two percolation tests required for each disposal area. Fee of $360.00 per lot for repairs or upgrades. GENERAL INFORMATION 1. Only Certified Soil Evaluators may perform deep hole inspections. 2. Only Mass. Registered Sanitarians and Professional Engineers can design septic plans. 3. At least two deep holes and two percolation tests are required for each septic system disposal area. 4: Repairs require at least two deep holes and at least one percolation test, at the discretion of the BOH representative. 5. Full payment will be required for all additional tests within two weeks of testing. 6. Within 45 days of testing, a scaled plan (no smaller than 1"-100') shall be submitted to the Board of Health showing the location of all tests (including aborted tests). 7. Within 60 days of testing soil evaluation forms shall be submitted. Please Do Not Write Below This Line N.A. Conservation Commission Approval: S, ,a{% l't N4 Date Received: Check Amount: Check Date: 7RE.—CEI'VEnL 1 6 —A TOW CERTIFIED FOUNDAT%ON PLAN LOCATED /N SCALE./"= ' DATE" Z s� S.L.G/LES R.L.S. LAWRENCE Q NORTH.ANDOVER Lo -r- AA -se--, 46) 2-95 5Q:p- ", 1,0(0-5 ACfZC-'5 /) / �J � / CERT/FY THAT TH OFFSETS SHOWN ARE FOR THE USE OF OFFSETS SHOWN THE BUILDING INSPECTOR ONL Y, S SUCH CONFORM TO THE USE /S FOR DETERMINATION OFZON/NG t ZON/NG B Y L AW OF CONFORM/ TY OR NON CONFORM/TY WHEN TAKEN. z.l a► (gam N Lo -r 3 3g � �.e 40� oo" '� . N h .p 11 �T 5a {/1 lll..Gr�vl ug 1 Ill. 1 (Iq.51 '' IIG SI I u` 33 u7.o2 4auzr Ir./ Areas -ia -rk E Co •oP I Av.J EASErtis'�� � T1415 Lcrr- 1 g h..)oT IIJ 1 �J � / CERT/FY THAT TH OFFSETS SHOWN ARE FOR THE USE OF OFFSETS SHOWN THE BUILDING INSPECTOR ONL Y, S SUCH CONFORM TO THE USE /S FOR DETERMINATION OFZON/NG t ZON/NG B Y L AW OF CONFORM/ TY OR NON CONFORM/TY WHEN TAKEN. z.l a► (gam Page 1 of 1 Dellechiaie, Pam From: Andrew McBrearty [amcbrearty@millriverconsulting.com] Sent: Monday, July 12, 2004 11:46 AM To: pdellechiaie@townofnorthandover.com; Sawyer, Susan Cc: 'Daniel Oftenheimer (E-mail)' Subject: Re: 191 Granville Lane - Final Inspection Request Hi Pam & Sue, I have setup for a Final for Granville for 7:00 tomorrow es Uay ning. I also have two soil tests that NEES will be performing on 69 Oakes &�Lac�oniait tomorrow as well. After the Laconia test, we will be heading to 338 BerryBenchmark elevation. We have also scheduled a perc test with Joe Fuchs(sp?) for 70 Wesley St on Aug 5th. Hope you had a good weekend. -andy Pamela DelleChiaie wrote: Please schedule a Final Inspection for above and arrange with John Soucy: 603.216.7175 or 978.683.5709. Steve from NEES also called and said that the As Built is okay. Any questions, call NEES at 978.686.1768. Thank you! Pamela DelleChiaie, Health Dept. Assistant Town of North Andover Community Development & Services 27 Charles Street North Andover, MA 09845 pdellechiaie@townofnorthandover. com Tel. 978-688-9540 Fax 978-688-9542 PW 7/12/2004 1 Town of North Andover _ Health Department Date: 0 Location• (Indicate Address, if Residential, or Name of Business) Check #: d VCA Type of Permit or License: (Circle) ➢ Animal $ ➢ Dumpster $ ➢ Food Service - Type: $ ➢ Funeral Directors $ ➢ Massage Establishment $ ➢ Massage Practice $ ➢ Offal (Septic) Hauler $ ➢ Recreational Camp $ ➢ SEPTIC PERMITS: t Soil Testing - $ ❑ Septic - Design Approval $ ❑ Septic Disposal Works Construction (DWC) $ ❑ Septic Disposal Works Installers (DWI) $ ➢ Sun tanning $ ➢ Swimming Pool $ ➢ Tobacco $ ➢ TrashlSolid Waste Hauler $ ➢ Well Construction $ ➢ OTHER: (Indicate) 113 Health Agent Initials White - Applicant Yellow - Health Pink - Treasurer TOWN OF NORTH ANDOVER HEALTH DEPARTMENT 27 CHARLES STREET NORTH ANDOVER, MASSACHUSETTS 01845 Susan Y. Sawyer, REHS/RS Public Health Director II Daniel Ottenheimer From: Pamela To: Mill River Consulting Fax: 978.282.0012 Pages: 1.800.377.3044 or Date: Phone: 978.282.0014 Request for Soil Testing or CC: Re: Septic Plan Review 978.688.9540 - Phone 978.688.9542 - Fax ❑ Urgent x For Review ❑ Please Comment ❑ Please Reply ❑ Please Recycle • Comments: Se tic Plan Review Soil Test �./ OTHER p Note: For plan reviews, this is notification only. Plans will be mailed or arrangements made to pick them up as requested. /OD Please call 978-688-9540 for assistance with any questions. Thank you. Cc: File - Address 0 HP Fax'K1220xi 1101 Log for NORTH ANDOVER 9786889542 Jun 28 2004 4:22pm Last Transaction Date Time Twe Identification Duration Pages Result Jun 28 4:19pm Fax Sent 819782820012 2:22 3 OK 0 0 BOARD OF HEALTFf NORTH ANDOVER, MASS. 01845 978-688-9540 APPLICATION FOR SOIL TESTS DATE: LI)MAP & PARCEL: � arcs ( h7 7 LOCATION OF SOIL TESTS:A (7D L a n o (AC%C-le- OWNER: ,�P_aMye nip{D TEL.NO.:*7, V�% ADDRESS: IDB La mic irc 1 ENGINEERWOI= I r�-1 2r'yt`e EL. NO.: 6— 1 768 CERTIFIED SOIL EVALUATOR: _8e jn I m� n _ , v — Intended use of land: Residential Subdivision Sing aFamilyHome Commercial r Is This: Repair testing_ Undeveloped lot testing Upgrade for addition In the Lake Cochichewick Watershed? Yes No. X THE FOLLOWING MUST BE INCLUDED WITH THIS FORM: 1. Proof of land ownership (Tax bill, deed, or letter from owner permitting tests) 2. Plot plan 3. Fee of $425.00 per lot for new construction. This covers the minimum two deep holes and two percolation tests required for each disposal area. Fee of $360.00 per lot for repairs or upgrades. GENERAL INFORMATION 1. Only Certified Soil Evaluators may perform deep hole inspections. 2. Only Mass. Registered Sanitarians and Professional Engineers can design septic plans. 3. At least two deep holes and two percolation tests are required for each septic system disposal area. 4. Repairs require at least two deep holes and at least one percolation test, at the discretion of the BOH representative. 5. Full payment will be required for all additional tests within two weeks of testing. 6. Within 45 days of testing, a scaled plan (no smaller than 1"-100') shall be submitted to the Board of Health showing the location of all tests (including aborted tests). 7. Within 60 days of testing soil evaluation forms shall be submitted. Please Do Not Write Below This Line N.A. Conservation Commission Approval: Date Received: Check Amount: Check Date: CERTIFIED FOUNDAT %-e PL AN LOCATED /N klat,-K SCALE. -I"'= ' DATE.-_j� %, S.L.G/LES R.L.S. LAWRENCE a NORTH.ANOOVER III L.cr 4Pll 4611 Z5 1,06-5 "41 3¢ 3 i .g M , �- i tv. -T f- ` T �1 D, N 3.I. -d. �•eq,�` .+i ` 38{0 4'! h 1►.l� . ll uB I �Ic�3 u�.o2 r�rec�s 1 EaSEh�eTl� � 1---AGa N 1 A�, Cj R,G, VGA 0 Z Gawr (r-./ --� -n4E Coacolz.�s Itil A. F'L-o 01> O AZ Azx. / CERT/FY THAT TH OFFSETS SHOWN ARE FOR THE USE OF ; OFFSETS SHOWN THE BUILDING INSPECTOR ONL Y,a SUCH CONFORM TO THE USE /S FOR DETER4,1//VA7-I0N OFZONING / t ZON/NG B Y L A W OF CONFORM/T Y OR NON CONFORMITY a uailg-H A,a M>,o o WHEN TAKEN. , Dellechiaie, Pamela From: Andrew McBrearty[amcbrearty@millriverconsulting.com] Sent: Thursday, September 23, 2004 10:21 AM To: pdellechiaie@townofnorthandover.com Cc: 'Daniel Ottenheimer (E-mail)'; Sawyer, Susan Subject: Final Inspection - 100 Laconia Circle, 292 Granville Hi Pam, We have set up inspections for 292 GranvilC d 100 LacoDfor tomorrow morning (9/24). thanks, -andy ti 0 7 0 0 z N x w m ti a O W) 0000 O W U � W u U > U ti Q Q Q O U Q U zaa i U o E�. b o = O U V E V v = O U � s 3 � x � o � L bU � 40 L 3 �o L 3AB �+ 0 U °q £ O .3 r o � 1 i ii I o I U^ t` O O O to G Y p O O N O N O (U = c U-0 cn� ti q v a� �� o titin QC c a E o o p, 3 r Lt. _ O C LYO . E n n� a oQ o,irn U •-� w � L CL CL aA�3aw O O O E � O O L 0 7 0 0 z N x w m ti a O U o E�. o = O U V E v = O U O O s 3 � � L bU � �o z U °q £ O .3 r o � o� o w „ o to G Y p 3 (U = c U-0 cn� ti q v a� �� o i. QC c a E o o p, 3 r Lt. vimy} O C LYO . E n n� a oQ o,irn U 0 7 0 0 z N x w m ti a O O Page 1 of 1 Dellechiaie, Pamela From: Dan Ottenheimer [info@millriverconsulting.com] Sent: Monday, September 27, 2004 11:49 AM To: amcbrearty@millriverconsulting.com; 'Pamela Dellechiaie'; Susan Sawyer Subject: construction inspections Sue and Pam, Attached please find construction inspection forms for 292 Granville Lanend 100 Laconia Circ . No problems found at either site. L— Dan Daniel Ottenheimer, President Mill River Consulting Septic System Management Services 2 Blackburn Center Gloucester, MA 01930-2259 978-282-0014 or 1-800-377-3044 fax: 978-282-0012 www.millriverconsulting.co info@millriverconsulting.com 9/27/2004 TOWN OF NORTH ANDOVER E pORTh Office of COMMUNITY DEVELOPMENT AND SERVICES HEALTH DEPARTMENT 27 CHARLES STREET NORTH ANDOVER' MASSACHUSETTS 01845 s t� � S�CNua t Susan Y. Sawyer, REHS/RS 978.688.9540 — Phone Public Health Director 978.688.9542 — FAX ADDRESS: 100 Laconia Circle MAP:105D INSTALLER: John Soucy DESIGNER: NEES PLAN DATE: 7/27/2004 BOH APPROVAL DATE ON PLAN: 8/20/2004 DATE OF BED BOTTOM INSPECTION: 9/17/2004 DATE OF FINAL CONSTRUCTION INSPECTION: 9/24/2004 DATE OF FINAL GRADE INSPECTION: SELECT SYSTEM TYPE Pressure Distribution COMPONENT SUMMARY FROM PLAN GALLON TANK = 1500 LOADING OF SEPTIC TANK = GALLON PUMP CHAMBER = 1000 LOADING OF PUMP CHAMBER = H-10 TYPE OF SAS = Infiltrator field DIMENSIONS AND DETAILS OF SAS: 8x8 chambers SITE CONDITIONS Comments: Existing tank reused. LOT: 157 ❑Existing septic tank properly abandoned ❑Internal plumbing all to one building sewer ®Topography not appreciably altered Page 1 of 1 o TOWN OF NORTH ANDOVER t NORTa Office of COMMUNITY DEVELOPMENT AND SERVICES HEALTH DEPARTMENT 41 27 CHARLES STREET NORTH ANDOVER, MASSACHUSETTS 01845 Susan Y. Sawyer, REHS/RS 978.688.9540 — Phone Public Health Director 978.688.9542 — FAX SEPTIC TANK ❑ Bottom of tank hole has 6" stone base ❑ Weep hole plugged ❑ 1500 gallon tank has been installed H-10 loading 2 -Piece construction ❑ Water tightness of tank has been achieved (Visual or Vacuum Test or Water held for 24hrs) ® Inlet tee installed, centered under access port ® Outlet tee (gas baffle or effluent filter) installed, centered under access port ® 24" inch cover to within 6" of final grade installed over one access port, must be over outlet of tank if effluent filter is present ® Hydraulic cement around inlet & outlet Comments: 1500 gallon tank reused. Tee placed inside existing baffle, which was not used in original tank setup. C. I. Pipe originally from house, spliced to PVC into Tank. PUMP CHAMBER Comments: ❑ Bottom of tank hole has 6" stone base ® Weep hole plugged ® 1000 gallon Pump Chamber installed H-10 loading 2 -Piece construction) ® Inlet tee installed, centered under access.port ® Pump(s) installed on stable base ® Alarm float working ® Pump On/Off float working ® Drain hole in pressure line ® 24" inch cover to within 6" of final grade installed over pump access port ® Water tightness of tank has been achieved Visual testing ® Hydraulic cement around inlet & outlet Page 2 of 2 O .O TOWN OF NORTH ANDOVER f NORTH Office of COMMUNITY DEVELOPMENT AND SERVICES �r �'aP`.o "to HEALTH DEPARTMENT 27 CHARLES STREET NORTH ANDOVER MASSACHUSETTS 01845 �9S •inn ' S�cHus Susan Y. Sawyer, REHS/RS 978.688.9540 — Phone Public Health Director 978.688.9542 — FAX SOIL ABSORPTION SYSTEM 103 Comments: Bottom of SAS excavated down to soil layer, as provided on plan Size of SAS excavated as per plan Title 5 sand installed, if specified on plan 3/4-1 Y2" double washed stone installed 1/8-1/2" (peastone) double washed stone installed laterals installed and ends connected to header (and vented if impervious material above) Orifices @ 5 & 7 o'clock positions Gravelless disposal systems: type, number and location as per plan Elevations of laterals installed as on approved plan 40 Mil HDPE barrier installed Retaining wall (boulder / concrete / timber/ block) Final cover as per plan PRESSURE DISTRIBUTION ® 4" inch manifold ® 8 laterals installed with end sweeps size: 1.5" material: PVC ® Squirt test 2.5 ft in height ® Equal distribution to all laterals ® orifice size 1/4" inch as per plan Comments: Squirt design is 3' CONTROL PANEL ® Alarm & Pump are on separate circuits ® Alarm sounds when float is tripped ® Location of control panel: Basement ❑ Rated for exterior if placed outside Comments: Page 3 of 3 TOWN OF NORTH ANDOVER t°RTN Office of COMMUNITY DEVELOPMENT AND SERVICES HEALTH DEPARTMENT 27 CHARLES STREET NORTH ANDOVER MASSACHUSETTS 01845 ss'„°' tt� �cMus Susan Y. Sawyer, REHS/RS 978.688.9540 - Phone Public Health Director 978.688.9542 - FAX SYSTEM ELEVATIONS Benchmark: 100.00 Rod at Benchmark: 6.26 Height of Instrument: 106.26 INVERT ON DESIGN PLAN INVERT ELEVATION Building Sewer OUT Septic Tank IN 97.65 97.71 Septic Tank OUT 9740 97.33 Pump Chamber IN 97.35 97.25 Pump Chamber OUT 97.10 97.10 Infiltrator Chamber 101.43 101.45 Top (average) 1.5" Lateral Invert 100.97 101.06 Page 4 of 4 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 NO. ANDOVER System Pumping Record JUN - 9 zolp Form 4 TOWN OF NORTH ANDOVER DEP has provided this form for use by local Boards of Healt . , 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: 100 LACONIA CIR. Address NO.ANDOVER City/Town 2. System Owner: JEFF CONTI Name Aaaress pt aitterent from location) City/Town B. Pumping Record MA State State Telephone Number 01845 Zip Code Zip Code 1. Date of Pumping Date 2. Quantity Pumped: 1500 Gallons 3. Type of system: ❑ Cesspool(s) �ptic Tank ❑ Tight Tank ❑ Other (describe): 4. Effluent Tee Filter present? ❑ Yes No If yes, was it cleaned? ❑ Yes ❑ No 5. Condition of System: 6. System Pumped By: James H. Currier Name J's Septic & Drain Company 7. Location where contents were disposed: GLSD H79 406 Vehicle License Number 7F- L 5/3/10 Signature ofHauler Date t5form4.doc• 06/03 System Pumping Record • Page 1 of 1