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Home My WebLink AboutMiscellaneous - 101 BRUIN HILL ROAD 4/30/2018., i LOT # - - r M- RCE! # S p REETi_& `d Ili '`''''I; � ---- ` 4 .__ - , __...�._,• .. , _.._...._. _.... _._..._._......_.._ ....... - t ',.- ,... .. % :. ��li:l�fif; A.'i-R.T d6_�� E'i-�Ci i.►V ��;,2 P' AN - REVIEta ESE :BEEN PA�YES NO -PLAN, APPROVA _ � •- 'SATE � / �+ - AP'Po DY.-_ , AM --- — DES16NER. PLAN DATE._—. __. � " -- i -- __.___ CONDITIONS );A_ _ _ Z�l.__-__— WRIER' SUPPLY:' T lW WELL WELL PERMIT'I1REL.t.E -- — — --- _._._._.________._._.__.._..... ..... __._._ ;< WELL B'E'STS �. SHEnsiCA DATE APPROVED._-----.___�... TEPIA I DATE APPROVED, RIA II DA•rE APPROVED.___-. C` M, MENTS.: & Rini U A AR SVA m k APPROVAL TO ISSUE YES NO DA TC TSSO°ED— COND a T I ONS 3 F l NflL APPROlVAL 3 RLL PERMITS PAID ES NO Wt --L CONSTRUCTION APPROVAL. YES NO SEPTIC SYSTEM CONSTRUCTION APPROVAL YES . NO f . :.OTHER YES NO ANY, 'VARIPNCE NEEDED YES NO 1': FINAL BOARD OF HEALTH PPPROVAL 3 DATE: BY: r IS THE INSTALLER LICENSED? YES NO ;r TYPE OF-CONSTRUCTION: NEW REPAIR NEW CONSTRUCTION: CERTIFIED PLOT PLAN REVIEW NO CONDITIONS OF APPROVAL YES NO (FROM FORM U) ISSUANCE OF DWC PERMIT YES NO DWC PERMITNO. _ _ INSTALLER: -._T 144-1- Yom_.____ BEGIN INSPECTION EXCAVATION INSPECTION: NEEDED: PASSED BY CONSTRUCTION INSPECTION: NEEDED: AS BUILT PLAN SATISFACTORY: � ?-- APPROVAL TO BACKFILL: DATE:�f _._�.�_BY_______._, FINAL GRADING APPROVAL: DATE BY ' FINAL CONSTRUCTION APPROVAL: DATE:____ _ _BY PUBLIC HEALTH DEPARTMENT Town of North Andover Community Development Division CERTIFICATE OF COMPLIANCE As of: 7/22/13 This is to certify that the replacement of T -baffle outlet has been installed in accordance with the provisions of Title 5 of the State Environmental Code: Replacement of T -Baffle outlet By: John DiVencenzo At: 101 Bruin Hill Rd. Map 104A Lot 0099 North Andover, MA 01845 The Issuar�Jof this certificate #'ll not be construed as a guarantee that the system will function satisfactorily. Susd' Sawyer Nb is Health gent MCOPY 1600 Osgood Street, North Andover, Massachusetts 01845 Phone 978.688.9540 Fax 978.688.8476 Web www.townofnorthandover.com f AORTh 5, 5 5 V o t, V V tiVj F w 9 Town of North Andover �� ` HEALTH DEPARTMENT SACHUst f q CHECK #: DATE: LOCATION: 1)1A MA H/O NAME: CONTRACTOR NAME:b 6, J 11 d C- 1 ON1, / Type of Permit or License: (Check box) 1:1Septic -Design Approval ❑ Animal $ ❑ Body Art Establishment $ ❑ Body Art Practitioner $ ❑ Dumpster $ ❑ Food Service - Type: $ ❑ Funeral Directors $ ❑ Massage Establishment $ ❑ Massage Practice $ ❑ Offal (Septic) Hauler $ ❑ Recreational Camp $ ❑ Sun tanning $ ❑ Swimming Pool $ ❑ Tobacco $ ❑ Trash/Solid Waste Hauler $ ❑ Well Construction $ SEPTIC Sustems: 11 Septic - Soil Testing '*"@�itle $ 1:1Septic -Design Approval $ ❑ Septic Disposal Works Construction (DWC) $ 13Septic Disposal Works Installers (DWI) $ 5 Inspector"j7'US (a� f�L Title 5 Report tt"" �%�-- ❑ Other: (Indicate) $� --L6- Health Agent Initials White - Applicant Yellow - Health Pink - Treasurer Owner information is required for every page. Important: When filling out forms on the computer, use only the tab key to move your cursor - do not use the return. key. _ II �I Commonwealth of Massachusetts Title 5 official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 101 Bruin Hill Rd Property Address William Thoden Owner's Name N Andover Ma 01745 7/17/13 City/Town State Zip Code Date of Inspection Inspection results must be submitted on this form. Inspection forms may not be altered in any way. Please see completeness checklist at the end of the form. A. General Information RECEIVED 1. Inspector: JUL 29 2013 David Chandler Name of Inspector TOWN OF NORTH A14DOVLK HEALTH DEPARTMENT Sewer Works Company Name 26 Hillside Ave Company Address Westford City/Town 9786924410 Telephone Number B. Certification Ma State S137 License Number 01886 Zip Code 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 15.340 of Title 5 (310 CMR 15.000). The system: ❑ Passes ® Conditionally Passes ❑ Fails ❑ Needs Further Evaluation by the Local Approving Authority I - i,� a,� Inspector Ignature 7/17/13 Date The system inspector shall submit a copy of this inspection report to the Approving Authority (Board of Health or DEP) within 30 days of completing this inspection. If the system is a shared system or has a design flow of 10,000 gpd or greater, the inspector and the system owner shall submit the report to the appropriate regional office of the DEP. The original should be sent to the system owner and copies sent to the buyer, if applicable, and the approving authority. ****This report only describes conditions at the time of inspection and under the conditions of use at that time. This inspection does not address how the system will perform in the future under the same or different conditions of use. t5ins • 3113 Title 5 Official Inspection Form: Subsurface Sewage Disposal System • Page 1 of 17 ma Owner information is required for every page. Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 101 Bruin Hill Rd Property Address William Thoden Owner's Name N Andover Ma 01745 7/17/13 City/Town State Zip Code Date of Inspection B. Certification (cont.) Inspection Summary: Check A,B,C,D or E / always complete all of Section D A) System Passes: ❑ I have not found any information which indicates that any of the failure criteria described in 310 CMR 15.303 or in 310 CMR 15.304 exist. Any failure criteria not evaluated are indicated below. Comments: B) System Conditionally Passes: ® One or more system components as described in the "Conditional Pass" section need to be replaced or repaired. The system, upon completion of the replacement or repair, as approved by the Board of Health, will pass. Check the box for "yes", "no" or "not determined" (Y, N, ND) for the following statements. If "not determined," please explain. The septic tank is metal and over 20 years old* or the septic tank (whether metal or not) is structurally unsound, exhibits substantial infiltration or exfiltration or tank failure is imminent. System will pass inspection if the existing tank is replaced.with a complying septic tank as approved by the Board of Health. * A metal septic tank will pass inspection if it is structurally sound, not leaking and if a Certificate of Compliance indicating that the tank is less than 20 years old is available. ❑ Y ❑ N ❑ ND (Explain below): t5ins • 3/13 Title 5 Official Inspection Form: Subsurface Sewage Disposal System • Page 2 of 17 Owner information is required for every page. Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 101 Bruin Hill Rd Property Address William Thoden Owner's Name N Andover Cityfrown B. Certification (cont.) Ma 017dF 7/17/13 State Zip Code Date of Inspection ❑ Pump Chamber pumps/alarms not operational. System will pass with Board of Health approval if pumps/alarms are repaired. B) System Conditionally Passes (cont.): ® Observation of sewage backup or break out or high static water level in the distribution box due to broken or obstructed pipe(s) or due to a broken, settled or uneven distribution box. System will pass inspection if (with approval of Board of Health): ❑ broken pipe(s) are replaced ❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below): ❑ Y ❑ N ❑ ND (Explain below): ❑ distribution box is leveled or replaced ❑ Y ❑ N ❑ ND (Explain below): outlet baffle requires replacement ❑ The system required pumping more than 4 times a year due to broken or obstructed pipe(s). The system will pass inspection if (with approval of the Board of Health): ❑ broken pipe(s) are replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below): C) Further Evaluation is Required by the Board of Health: ❑ Conditions exist which require further evaluation by the Board of Health in order to determine if the system is failing to protect public health, safety or the environment. 1. System will pass unless Board of Health determines in accordance with 310 CMR 15.303(1)(b) that the system is not functioning in a manner which will protect public health, safety and the environment: ❑ Cesspool or privy is within 50 feet of a surface water ❑ Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh t5ins • 3/13 Title 5 Official Inspection Form: Subsurface Sewage Disposal System • Page 3 of 17 Owner information is required for every page. Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 101 Bruin Hill Rd Property Address William Thoden Owner's Name N Andover Ma 01745 7/17/13 City/Town State Zip Code Date of Inspection B. Certification (cont.) 2. System will fail unless the Board of Health (and Public Water Supplier, if any) determines that the system is functioning in a manner that protects the public health, safety and environment: ❑ The system has a septic tank and soil absorption system (SAS) and the SAS is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ The system has a septic tank and SAS and the SAS is within a Zone 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: ** This system passes if the well water analysis, performed at a DEP certified laboratory, for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis must be attached to this form. 3. Other: D) System Failure Criteria Applicable to All Systems: You must indicate "Yes" or "No" to each of the following for all inspections: Yes No ❑ ® Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool ❑ ® Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool ❑ ® Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool ❑ ® Liquid depth in cesspool is less than 6" below invert or available volume is less than '/2 day flow t5ins • 3/13 Title 5 Official Inspection Form: Subsurface Sewage Disposal System • Page 4 of 17 E) Large Systems: To be considered a large system the system must serve a facility with a design flow of 10,000 gpd to 15,000 gpd. For large systems, you must indicate either "yes" or "no" to each of the following, in addition to the questions in Section D. Yes No ❑ ❑ the system is within 400 feet of a surface drinking water supply ❑ ❑ the system is within 200 feet of a tributary to a surface drinking water supply ❑ ❑ the system is located in a nitrogen sensitive area (Interim Wellhead Protection Area — IWPA) or a mapped Zone II of a public water supply well If you have answered "yes" to any question in Section E the system is considered a significant threat, or answered "yes" in Section D above the large system has failed. The owner or operator of any large system considered a significant threat under Section E or failed under Section D shall upgrade the system in accordance with 310 CMR 15.304. The system owner should contact the appropriate regional office of the Department. t5ins - 3/13 Title 5 Official inspection Forth: Subsurface Sewage Disposal System • Page 5 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 101 Bruin Hill Rd Property Address William Thoden Owner Owner's Name information is required for every N Andover Ma 01745 7/17/13 page. Cityrrown State Zip Code Date of Inspection B. Certification (cont.) Yes No ❑ ® Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number of times pumped: ❑ ® Any portion of the SAS, cesspool or privy is below high ground water elevation. ❑ ® 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 fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis and chain of custody must be attached to this form.] ❑ N The system is a cesspool serving a facility with a design flow of 2000gpd- 10,000gpd. ❑ ® The system fails. I have determined that one or more of the above failure criteria exist as described in 310 CMR 15.303, therefore the system fails. The system owner should contact the Board of Health to determine what will be necessary to correct the failure. E) Large Systems: To be considered a large system the system must serve a facility with a design flow of 10,000 gpd to 15,000 gpd. For large systems, you must indicate either "yes" or "no" to each of the following, in addition to the questions in Section D. Yes No ❑ ❑ the system is within 400 feet of a surface drinking water supply ❑ ❑ the system is within 200 feet of a tributary to a surface drinking water supply ❑ ❑ the system is located in a nitrogen sensitive area (Interim Wellhead Protection Area — IWPA) or a mapped Zone II of a public water supply well If you have answered "yes" to any question in Section E the system is considered a significant threat, or answered "yes" in Section D above the large system has failed. The owner or operator of any large system considered a significant threat under Section E or failed under Section D shall upgrade the system in accordance with 310 CMR 15.304. The system owner should contact the appropriate regional office of the Department. t5ins - 3/13 Title 5 Official inspection Forth: Subsurface Sewage Disposal System • Page 5 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 101 Bruin Hill Rd Property Address William Thoden Owner Owner's Name information is required for every N Andover page. . Cityfrown C. Checklist Ma 01745 State Zip Code 7/17/13 Date of Inspection Check if the following have been done. You must indicate "yes" or "no" as to each of the following: Yes No ® ❑ 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? ® ❑ Were as built plans of the system obtained and examined? (If they were not available note as N/A) ® ❑ Was the facility or dwelling inspected for signs of sewage back up? ® ❑ Was the site inspected for signs of break out? ® ❑ 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: ® ❑ Existing information. For example, a plan at the 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(5)] D. System Information Residential Flow Conditions: Number of bedrooms (design): 4 Number of bedrooms (actual): 3 DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x # of bedrooms): 440 gpd t5ins - 3113 Title 5 Official Inspection Form: Subsurface Sewage Disposal System • Page 6 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments wM ,.•''p 101 Bruin Hill Rd Property Address William Thoden Owner Owner's Name information is required for every N Andover page. Cityfrown D. System Information Description: Number of current residents: Ma 01745 State Zip Code 7/17/13 Date of Inspection Does residence have a garbage grinder? ❑ Yes ® No Is laundry on a separate sewage system? (Include laundry system inspection ❑ Yes ® No information in this report.) Industrial waste holding tank present? ❑ Yes Laundry system inspected? ❑ Yes ® No Seasonaluse? ❑ Yes ® No Water meter readings, if available (last 2 years usage (gpd)): 78 gpd Detail: Sump pump? ❑ Yes ® No Last date of occupancy: na Date Commercial/Industrial Flow Conditions: Type of Establishment: Design flow (based on 310 CMR 15.203): Gallons per day (gpd) Basis of design flow (seats/persons/sq.ft., etc.): Grease trap present? ❑ Yes ❑ No Industrial waste holding tank present? ❑ Yes ❑ No Non -sanitary waste discharged to the Title 5 system? ❑ Yes ❑ No Water meter readings, if available t5ins • 3/13 Title 5 Official Inspection Form: Subsurface Sewage Disposal System • Page 7 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments D. System Information (cont.) Last date of occupancy/use: Other (describe below): Pumping Records: Source of information: Ma 01745 State Zip Code General Information Was system pumped as part of the inspection? If yes, volume pumped: How was quantity pumped determined? Reason for pumping: Type of System: from owner gallons Date ® Septic tank, distribution box, soil absorption system ❑ Single cesspool ❑ Overflow cesspool ❑ Privy 7/17/13 Date of Inspection [M01111►=41111 W ❑ Shared system (yes or no) (if yes, attach previous inspection records, if any) ❑ Innovative/Alternative technology. Attach a copy of the current operation and maintenance contract (to be obtained from system owner) and a copy of latest inspection of the I/A system by system operator under contract ❑ Tight tank. Attach a copy of the DEP approval. ❑ Other (describe): t5ins • 3/13 Title 5 Official Inspection Form: Subsurface Sewage Disposal System - Page 8 of 17 101 Bruin Hill Rd Property Address William Thoden Owner Owner's Name information is required for every N Andover page. Cityrrown D. System Information (cont.) Last date of occupancy/use: Other (describe below): Pumping Records: Source of information: Ma 01745 State Zip Code General Information Was system pumped as part of the inspection? If yes, volume pumped: How was quantity pumped determined? Reason for pumping: Type of System: from owner gallons Date ® Septic tank, distribution box, soil absorption system ❑ Single cesspool ❑ Overflow cesspool ❑ Privy 7/17/13 Date of Inspection [M01111►=41111 W ❑ Shared system (yes or no) (if yes, attach previous inspection records, if any) ❑ Innovative/Alternative technology. Attach a copy of the current operation and maintenance contract (to be obtained from system owner) and a copy of latest inspection of the I/A system by system operator under contract ❑ Tight tank. Attach a copy of the DEP approval. ❑ Other (describe): t5ins • 3/13 Title 5 Official Inspection Form: Subsurface Sewage Disposal System - Page 8 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 101 Bruin Hill Rd Property Address William Thoden Owner Owner's Name information is N required for every Andover Ma 01745 page. City/Town State Zip Code D. System Information (cont.) 7/17/13 Date of Inspection Approximate age of all components, date installed (if known) and source of information: 1992 Were sewage odors detected when arriving at the site? Building Sewer (locate on site plan): Depth below grade: 24 11 feet Material of construction: ❑ cast iron ® 40 PVC ❑ other (explain): Distance from private water supply well or suction line: feet Comments (on condition of joints, venting, evidence of leakage, etc.): ❑ Yes ® No Septic Tank (locate on site plan): Depth below grade: 14"feet Material of construction: ® concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other (explain) If tank is metal, list age: years Is age confirmed by a Certificate of Compliance? (attach a copy of certificate) Dimensions: 5.5'x10.5' Sludge depth: 10" ❑ Yes ❑ No t5ins • 3/13 Title 5 Official Inspection Form: Subsurface Sewage Disposal System • Page 9 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 101 Bruin Hill Rd Property Address William Thoden Owner Owner's Name information is required for every N Andover Ma 01745 7/17/13 page. Citylrown State Zip Code Date of Inspection D. System Information (cont.) Septic Tank (cont.) Distance from top of sludge to bottom of outlet tee or baffle 24" Scum thickness 31- Distance "Distance from top of scum to top of outlet tee or baffle 6" Distance from bottom of scum to bottom of outlet tee or baffle 14" How were dimensions determined? measured Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): outlet baffle requires replacement, inlet baffle intact, liquid level at outlet invert, no signs of any leaks or cracks Grease Trap (locate on site plan): Depth below grade: feet 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: t5ins • 3/13 Date Title 5 Official Inspection Form: Subsurface Sewage Disposal System • Page 10 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 101 Bruin Hill Rd Property Address William Thoden Owner Owner's Name information is required for every N Andover Ma 01745 7/17/13 page. Cityfrown State Zip Code Date of Inspection D. System Information (cont.) Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): Tight or Holding Tank (tank must be pumped at time of inspection) (locate on site plan): Depth below grade: Material of construction: ❑ concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other (explain): Dimensions: Capacity: Design Flow: Alarm present: Alarm level: D t fl t gallons gallons per day ❑ Yes ❑ No Alarm in working order: ❑ Yes ❑ No a e o as pumping. Date Comments (condition of alarm and float switches, etc.): * Attach copy of current pumping contract (required). Is copy attached? ❑ Yes ❑ No t5ins • 3113 Title 5 official Inspection Forth: Subsurface Sewage Disposal System - Page 11 of 17 Owner information is required for every page.. Commonwealth of Massachusetts Title 5 official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 101 Bruin Hill Rd Property Address William Thoden Owner's Name N Andover Ma 01745 7/17/13 City/Town State Zip Code Date of Inspection D. System Information (cont.) Distribution Box (if present must be opened) (locate on site plan): Depth of liquid level above outlet invert 21" 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.): solids observed in box due to broken baffle, removed solids and added water via garden hose for 20 min. observed all 4 leach lines accepted flow, when stopped water two lines had slight backflow to box, no signs of any cracks or leaks Pump Chamber (locate on site plan): Pumps in working order: ❑ Yes ❑ No" Alarms in working order: ❑ Yes ❑ No* Comments (note condition of pump chamber, condition of pumps and appurtenances, etc.): * If pumps or alarms are not in working order, system is a conditional pass. Soil Absorption System (SAS) (locate on site plan, excavation not required): If SAS not located, explain why: t5ins - 3/13 Title 5 Official Inspection Form: Subsurface Sewage Disposal System - Page 12 of 17 N Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments wM 101 Bruin Hill Rd Property Address William Thoden Owner Owner's Name information is required for every N Andover page. City/Town Ma 01745 7/17/13 State Zip Code Date of Inspection D. System Information (cont.) Type: ❑ leaching pits number: ❑ leaching chambers number: ❑ leaching galleries number: ❑ leaching trenches number, length: ® leaching fields 1 at 20'x40' number, dimensions: ❑ overflow cesspool number: ❑ innovative/alternative system Type/name of technology: Comments (note condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of vegetation, etc.): grass over leach area, no signs of any hydraulic failure; no ponding no damp soil Cesspools (cesspool must be pumped as part of inspection) (locate on site plan): Number and configuration Depth — top of liquid to inlet invert Depth of solids layer Depth of scum layer Dimensions of cesspool Materials of construction Indication of groundwater inflow ❑ Yes ❑ No t5ins • 3/13 Title 5 Official Inspection Form: Subsurface Sewage Disposal System - Page 13 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 101 Bruin Hill Rd Property Address William Thoden Owner Owner's Name information is required for every N Andover Ma 01745 7/17/13 page. Citylrown State Zip Code Date of Inspection D. System Information (cont.) Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): Privy (locate on site plan): Materials of construction: Dimensions Depth of solids Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): t5ins • 3/13 Title 5 Official Inspection Form: Subsurface Sewage Disposal System • Page 14 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 101 Bruin Hill Rd Property Address William Thoden Owner Owner's Name information is required for every N Andover Ma 01745 7/17/13 page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Sketch Of Sewage Disposal System: Provide a view of the sewage disposal system, including ties to at least two permanent reference landmarks or benchmarks. Locate all wells within 100 feet. Locate where public water supply enters the building. Check one of the boxes below: ❑ hand -sketch in the area below ® drawing attached separately t5ins • 3/13 Title 5 Official Inspection Form: Subsurface Sewage Disposal System • Page 15 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 101 Bruin Hill Rd Property Address William Thoden Owner Owner's Name information is N required for every Andover Ma 01745 page. CityrFown State Zip Code D. System Information (cont.) Site Exam: ® Check Slope "t`GS ® Surface water 0+-R- ® Check cellar Yt S ® Shallow wells"`-� Et' tdd fin #^ hh d t ' 4' 7/17/13 Date of Inspection s Ima a ep o ig group wa er. feet Please indicate all methods used to determine the high ground water elevation: e Obtained from system design plans on record Ifh kddt fd I d 11/92 c ec e, a e o esign pan reviewe Date Observed site (abutting property/observation hole within 150 feet of SAS) Checked with local Board of Health - explain: Checked with local excavators, installers - (attach documentation) Accessed USGS database - explain: You must describe how you established the high ground water elevation: Review of engineered plans by Norse Environmental indicates leach field designed 4' above ground water. Review of property indicates leach area constructed above natural grade. Before filing this Inspection Report, please see Report Completeness Checklist on next page. t5ins • 3/13 Title 5 Official Inspection Form: Subsurface Sewage Disposal System • Page 16 of 17 Commonwealth of Massachusetts . Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments M 101 Bruin Hill Rd Property Address William Thoden Owner Owner's Name information is N required for every Andover Ma 01745 page. City/Town State Zip Code E. Report Completeness Checklist 7/17/13 Date of Inspection ❑ Inspection Summary: A, B, C, D, or E checked ❑ Inspection Summary D (System Failure Criteria Applicable to All Systems) completed ❑ System Information — Estimated depth to high groundwater ❑ Sketch of Sewage Disposal System either drawn on page 15 or attached in separate file t5ins - 3/13 Title 5 Official Inspection Form: Subsurface Sewage Disposal System • Page 17 of 17 CL Y C OL o 7u- m CD Cl k I- d — 0- Kr x 0 -a Commonwealth of Massachusetts W City/Town of NORTH 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. _ IA RECEIVED AUG 16 2013 TOWN OF NORTH ANDOVER HEALTH DEPARTMENT DEP has provided this form for use by local Boards of Health. Other forms may be used, but the information must be substantially the same as that provided here. Before using this form, check with your local Board of Health to determine the form they use. The System Pumping Record must be submitted to the local Board of Health or other approving authority within 14 days from the pumping date in accordance with 310 CMR 15.351. A. Facility Information 1. System Location: 161 Address NORTH ANDOVER Ma City/Town 2. System Owner: Name Address (if different from location) City/Town State State Telephone Number Zip Code Zip Code B. Pumping Record X 1. Date of Pumping mate Gallons Quantity Pumped: Gallons 3. Type of system: ❑ Cesspool(s) Septic Tank ❑ Tight Tank ❑ Grease Trap ❑ Other (describe): 4. Effluent Tee Filter present? ❑ Yes No 5. Condition of System: 6. System Pumped By: Name Stewart's Septic Service Company 7. Location where contents were disposed: vart's Pre-treatment Pla Signature of Hauler Signature of Receiving Facility 20 So. Mill If yes, was it cleaned? ❑ Yes ❑ No Vehicle License Number Ma 01835 Date t5form4.doc• 03/06 System Pumping Record • Page 1 of 1 h k North Andover Health Department Community Development Division ONSITE WASTEWATER SYSTEM CONSTRUCTION NOTES LOCATION INFORMATION ADDRESS: 101 Bruin Hill Rd. INSTALLER: John DiVencenzo DESIGNER: PLAN DATE: BOH APPROVAL DATE ON PLAN: INSPECTIONS MAP: 104A LOT: 0099 z, TANK INSPECTION: 8/22/13 Outlet Baffle DATE OF BED BOT -TOM INSPECTION: DATE OF FINAL CONS TION INSPECTION: DATE OF FINAL GRADE INSP ON: SITE CONDITIONS ❑ Contractor reports any changes to design plan ❑ Existing septic tank properly abandoned ❑ Internal plumbing all to one building sewer i ❑ Topography not appreciably altered Comments: SEPTIC TANK ❑ Building sewer in continuous grade, on compacted firm base ❑ Cleanouts per plan ❑ Bottom of tank hole has 6" stone base ❑ Weep hole plugged ❑ 1500 gallon tank has been installed H-10 loading ❑ Monolithic tank construction ❑ Water tightness of tank has been achieved by visual testing ❑ Inlet tee installed, centered under access port Comments: PUMP CHAMBER Comments: CONTROL PANEL Comments: DISTRIBUTION -BOX Comments: ❑ Outlet tee installed, centered under access.port (gas baffle/effluent filter) ❑ inch cover to within 6" of finish grade installed over one access port ❑ Hydraulic cement around inlet & outlet ❑ Bottom of tank hole has 6" stone base ❑ Weep hole plugged ❑ 1500 gallon Pump Chamber installed ❑ H-10 loading ❑ Monolithic tank construction ❑ Inlet tee installed, centered under access port \El Pump(s) installed on stable base ❑ Alarm float working Pump On/Off floats working ❑ Separate on/off floats ❑ Drain hole in pressure line ❑ �� cover at final grade installed over pump access port ❑Water tightness of tank has been achieved by testing ❑ Hydraulic cement around inlet & outlet ❑ Alarm $Pump are on separate circuits ❑ Alarm sounds when float is tripped ❑ Location �f control panel: basement ❑ Alarm sign�l located inside: basement ❑ Installed on st ble stone base ❑ H-20 D -Box ❑ Inlet tee (if pum ed or >0.08'/foot) ❑ Hydraulic cemen around inlet & outlets ❑ Observed even di tribution ❑ Speed levelers pro ided (not required) �l'.. Commonwealth of Massachusetts Map -Block -Lot _' .,• 104.A0099 BOARD OF HEALTH ------------------------ North -- ------ --------- North Andover CERTIFICATE OF COMPLIANCE THIS IS TO CERTIFY,That the Individual Sewage D' osal Sy em (Repair) by ---John DiVincenzo / at No 191BRUDMILL ROAD has be in accordance with the provisions o ITLE 5 of the State Environmental Code as described in the application for Disposal Works Construction Permit No. BHP -2013-081 Dated ... July_19Z - 2013-----_--_ ----------------------- Printed On: Jul -19-2013 - - ----------------------------- BOARD OF HEALTH Commonwealth of Massachusetts Map -Block -Lot 104.A0099 BOARD OF HEALTH ----------------------- Permit No North Andover BHP -2013-0817 ----------------------- FEE $125.00 ----------------------- DISPOSAL WORKS CONSTRUCTION PERMIT Permission is hereby granted John -DiVincenz0 -------------------------------------------------------------------------------------------------------- to (Repair) an Individual Sewage Disposal System. at No 101 BRUIN HILL ROAD ��` ------------------------------------------------------------ as shown on the application for Disposal Works Construction Permit No. BHP -2013-081 Dated July 19, 2013 ------------------------ Issued -On: -------Jul-19-2013 ------------------ ------------ -- BOARD OF HEALTH ,✓ Cf NORT H,ti 6549 0 p Town of North Andover HEALTH DEPARTMENT ,SSACHUSt� CHECK #: �3 d� DATE: _qk9_3 LOCATION: 101Y H/O NAME: Aii CONTRACTOR NAME .T_q Sbug 1�� Type of Permit or License: (Check box) ❑ Animal $ ❑ Body Art Establishment $ ❑ Body Art Practitioner $ ❑ Dumpster $ ❑ Food Service - Type: $ ❑ Funeral Directors $ ❑ Massage Establishment $ ❑ Massage Practice $ ❑ Offal (Septic) Hauler $ ❑ Recreational Camp $ ❑ Sun tanning $ ❑ Swimming Pool $ ❑ Tobacco $ ❑ Trash/Solid Waste Hauler $ ❑ Well Construction $ SEPTIC Systems: ❑ Septic - Soil Testing $ a ❑ Septic - Design Approval Septic Disposal Works ConsM(D4Aj $ r $ :.a ❑ Septic Disposal Works Installers (DWI) $ ❑ Title 5 Inspector $ ❑ Title 5 Report $ ❑ Other: (Indicate) $ Alr Health Agent Initials . White - Applicant Yellow - Health Pink - Treasurer Important: When filling out forms on the computer, use only the tab key to move your cursor - do not use the return key. r� Application for Septic Disposal System Construction Permit — TOWN OF ORTH Application is hereby made for a permit to: ❑ Construct a new on-site sewage disposal system* r) Iig1) TODAY'S DATE $ 250.00 – Full Repair $125.00 - Component Repair or replace an existing on-site sewage disposal system* /� Repair or replace an existing system component – What? tut 6-r eQ Ecce A. Facility Information Address or Lot # City/Town 2.- *TYPE OF SEPTIC SYSTEM*: ❑ Pump ❑ Gravity (choose one) ***If pump system, attach copy of electrical permit to application*** ❑ Conventional System (pipe and stone system) ❑ Infiltrator or Biodiffuser (Gravel -Less) (Attach a copy of your certification to install this type of system. ❑ Pressure Distribution S.A.S. (No D -Box) (Attach Draft Maintenance Agreement) . ❑ Pressure Dosed (D -Box Present) S.A.S. 2. bte City/Town State Zip Code Telephone Number 3. Installer Information �6 � 'j [ V N GC Name of Company City/Town 4. Designer Information Name Address City/Town V2 LIA11- o c r3;, Sty a Zip Code Telephone Number (Cell Phone # if possible please) Name of Company State Zip Code Telephone Number (Best # to Reach) Application for Disposal System Construction Permit - Page 1 of 2 "Y OR7h _Application for Septic Disposal Svstem w mqN �.��b�`pConstruction Permit — TO`iUN OF TODAY'S DATE H ANDOVER, MA 01845 $ 250.00 - Full Repair $125.00 - Component PAGE 2OF2 A. Facility Information continued.... 5. Type of Building: Residential Dwelling or ❑Commercial B. Agreement The undersigned agrees to ensure the construction and maintenance of the afore -described on-site sewage disposal system in accordance with the provisions of Title 5 of the Environmental Cod swell as the ocal Subsurface Disposal Regulations for the Town of North n over an n to place a system in operation until a Certificate of Compliance has been s ed thi rd of ealth. � NatDate Application roved By: I'd of Health Representative) 7A x,//., Name /' Date Application Disapproved for the following reasons: For Office Use Only: L Fee Attached. 2. Project Manager Obligation Form Attached? I Pump Svstem? If so, Attach copy of Electrical Permit 4. Foundation As -Built? (new construction ronly): (Same scale as approved plan) 5. Floor Plans? (new construction only): Yes No Yes No No Yes `\ \NQ__ Yes No Application for Disposal System Construction Permit • Page 2 of 2 0 13IgUIN HILL ROAD AS -BUILT SURVEY Lot 44 BRUIN HILL ROAD NO . ANDOVER. . h'1ASS . 01845 11 1 _ 2'J. L 11 -12 -'?L Owner: JAMES GRAPHOt,J I Installer•: TIM MELVIN Location Elevation Tap Foundation...... 156.'3 Foundation Outlet... 154.76. Tank Inlet.......... 154.21-1 Tank Outlet......... 154.00 D -Bax Inlet......... .153.x:.1 D -Box Outlet ......... 15.5.32 Bea. Pipe #1........ 153.3 11 II #i . . . . . . . . 153.32 11 11 #3 . . . . . . . . 153.32 11 II #4........ 153.342 End Pipe #1........ 153.06 It 11 # ' L ....... 153-06' 11 It #3....... 153.06 It it #4. . . . . . . . 153.06 Bottom Bed.......... 152.0 - jW . r � 9� a ►tSEiu ,�, Commonwealth of Massachusetts a City, own of NORTH ANDOVER MASSAC - System Pumping Record Form 4 Important: When filling out forms on the . computer, use only the tab key to move your cursor - do not use the return key. w� DEP has provided this form for use by local Boards of Health, be submitted to the local Board of Health or other approving a A. Facility Information 1. System Location: Address Clty/Town t, US;E�S9ED .AUG 0 4 2006 .SS5-.�y,,ste-PumipirH%,F'evW mu; rtiy;EALTH DEPARTIVEiNJT State -- —_ Zip Code 2. System Owner: Name Address(ifdifferentfromlocation) City/Town-.'--------- - ------ State _ _ �.--- -- Zip Co Telephone Number --' ----'- - B. Pumping Record1. z� Date of Pumping - -- 2. Quantity�S ®C� Date Pumped: Gallons 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: _ X< - _ - C-` - -- -- - - 6, Sy em Pumped By: Name Vehicle License Number -- --" c5t a ��• Company' - 7. Location where contents were disposed: _... _... ........ _.._. _ Sistore of Hau _- Date_ ..------------- -- -.. http:l/www.mas$,gov/dep/water/ proyals/t5forms.htm#inspect t5form4.doc- 06/03 System Pumping Record • Page 1 of � - y __ yy(( pyyy7,,, r y I `-i IYy la )I . r��'1''t�'ji �yi l� {�iiah;rrclV tl��d,yl4 rya �.. �. ,'IIS `a '. — _—. _.._ _ *' yr��i11 r4ir rajl rSPri IAV �'¢Ii1i1 a r�lrSl )Jr wl7 �r a`i�ra.l1G � 1 .i, la r 'r I. -lr�ll .}T1�1 1r�V. !! AI/7r{ IIYM I!•r �ti�`,I 1It i V � r r� 5 J' I 1. rel 7 .. .... .. I , .. , .. � ...... r � .... ..!` . .... ..I r � r �a. r+ (D O -h h Z v i 0. v 0 n m o n. O � U] � O Q 0 n o rt) v I ate, n rat S 7 O . (D ..,, D m L � 3 3 j+ lD O (DD r+ (D O -h h Yqtvlzve,r Q.a i+. M4sn Cf, A now.,, - -C)b 4 Lie - SrENUTIS SWMC TANK SEWCE 47 RAIIpAo MUM 54OFM,l Mh 01835 978-372-7471 13 LQ cir -Zj-6-Q- )s6e) /2L6 1560 IQov lDoo 166c) )SIM 1500 1600 loco )566 FORM. U -LOT RELEASE FORM INS TRU C T IONS: 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 or requirements. APPLICANT FILLS OUT THIS APPLICANT )/� �/i,�i� !/�'��y iy I PHONE c"G LOCATION: Assessors Map Number /PARCEL SUEDIVISION LOT (S) ST. NUMEER OFFICIAL USE ONLY RECOMMENDA T IONS OF TOWN AGENTS: WCC 6 `F I '-�- '?-NC-I ds -ea POrt 1/1 1 CONSERVATION ADMINISTRATOR DATE APPROVED CATE REJECTED CO MMENTS TOWN PLANNER COMMENTS DATE APPROVED GATE REJECTED. FOOD INSPECTOR -HEALTH CATF APPROVED A DATE REJECTED SE.'�T1C INSPECTOR -HEALTH i DATE APPROVED DATE REJECTED ' COMMENTS -Z:!i L)IPIV Gam- V7T /" & 5 T 09 C e2&65 /7, PUELIC WORKS-SEWERPNATER CONNECTIONS CRIVE'NAY PERMIT 'FIRE DEPARTNIENT. RECEIVED EY EUILDING iNSPECTOR Revised 9�9; im DATE PLOT PLAN OF LOT Scale: �'` �,,,,�v'��(.�y� l� I•`��j2- /y DANA: F PERKINS CIVIL ENGINEERS and SURVEYORS READING MASS. A/ ,� I 2997. � ti H FOIA_ 1 14�- o � e tc n3J rw - FIC (R:�. 11f7CLy 'Comily. ►nal 0w. 6 !d(h4 0 b4va o, m shgvin T}t�r -�)A and E11a1 it t tofm! jj --_Th'o v,EAI t.; t!�c; tt•�:{•�•'`',r„�t;;c,ttir,,!'iCntS q;' 'Ch .....,u nw .�i ' N 1-na RcJI��• r )ioivcl`7d9�� urYArr,r � ' •':,{ems. � r'rEli FOIA_ 1 FORM U - LOT RELEASE FORM INSTRUCTIONS: This form is used to verify that all necessary approvals/permits from Boards and Departments having jurisdiction have been obtained. This does not relieve the applicant and/or landowner from compliance with any applicable or requirements. APPLICANT FILLS OUT THIS SECTION �G APPLICANT C-e>%GL/�� /QJ��/ X P H 0 N E LOCATION: AsseS�s Map Number_PARCEL 9 t9 SUEDIViSION LOT (S) STREET :BPUlA) Lt ST. NUMEE,R�( OFFICIAL USE ONLY" 020 )6 3;Q_ Q ova RECOM>ti1cNDATIONS OF TOWN AGENTS: Sw�tlIA Cj II A ( v UL CO S�RVATION AOMINISTRA R COMMENTS TOWN PLANNER 1 1� COMMENTS FOOD INSPECTOR -HEALTH DATE APPROVED DATE -REJECTED Ld DATE APPROVED DATE REJECTED - DATE APPROVED DATE REJECTED _ cwu - SEPTIC INSPECTOR -HEALTH DATE APPROVED711,3192 DATE REJECTED COMMENTS / &y( 5- �rOU/Up �O®G 4 1. -1 PUELIC WORKS - SEWER/WATER CONNECTIONS DRIVEWAY PERMIT FIRE DEPARTMENT RECEIVED EY EUILDING INSPECTOR DATE n PLOT PLAN OF LOT � Scale: DANA: E PERKINS ��• CIVIL ENGINEERS, dna SURVEYORS READING�t?�1us�S�i��,I� � ,MASS. �Q F 6�� .1 ti q N i T o. L \ ' 1 F 27 fy.`''• dry 3� � // Lv I ItiE,�Ly �prtiir 1�ia► tltc ��i!rINtJ �n 1` Pc\o�ob,eA 40' 33 lo► �.:`.,._._,.ix I�rnicel �lrrrp:vir,{ditlji �A-Ioov�. G.,,.,.Q �o°''` ' ir ��s sh��r;n hara�tn ahci ►h,,1 i► t~rn1'�rn{� f;r,na 'N �- 0 fzc� ,?reluc17.t9�1 u� A ' 2 v:1,r b FORM U - LOT RELEASE FORM INSTRUCTIONS: This form is used to verify that all necessary approvals/permits from Boards and Departments having jurisdiction have been obtained. This does not relieve the applicant and/or landowner from compliance with any applicable local or state law, regulations or requirements. ****************Applicant fills out this section***************** APPLICANT: �u/% ��✓�� Phone LOCATION: Assessor's Map Number Parcel Subdivision Street Lots) St. Number ************************Official use Only************************ RECOMMENDATIO S OF TOWN AGENTS: Date Approved Conservation Administrator Date Rejected Comments Town Planner Comments Food Inspector -Health Septic Inspector -Health Comments Public Works - sewer/water connections - driveway permit Fire Department Date Approved Date Rejected Date Approved Date Rejected Date Approved Date Rejected Received by Building Inspector Date ... y ° Q H O ro S CL INC d, F �o S y w "ll�. � r*i V� �• � C o0 0 o A o cr tv C6cn r eD Q C rt� fl. OM A eb 0 O C u f� X C rA �a :z 3• A O r to s A � w zm C7 5-4 :r• b _ C, 0 plb T 3 !� C m m c° w rw m ? rl T o °c A 0 Cc 73 n mo Si 4 • v 0 c c� Town of North Andover, Massachusetts Form No. 3 of,.pRTH BOARD OF HEALT p 19�� '...... DISPOSAL WORKS CONSTRUCTION PERMIT SACMUSE Applicant Site Locat Permission is hereby granted to Construct( or Repair ( ) an Individual Soil Absorption Sewage Disposal System as shown on the Design Approval S.S. No. CH RMAN, BOARD OF HEALTH Fee D.W.C. No. `y' � Q �. NORSE ENVIRONMENTAL SERVICES, INC. - .o tx 3 Pondvlew Place TynOsboro, Mass. 01879 TEL. 649-9932 e CERTIFICATION OF SUBSURFACE' S1 WAG1: DISPOSAL -•SYSTEM INSTALLATION STEVEN PETESPN _ A Registered anitari:=I. dLlI licensed by the Commonwealth of Massachusetts, I.lcian"E rl�►n�l��-r ►lug., and working as an employee -for Norse Env i rorune"L,11 :��=► v i < c:: , certify that I have visually inspected the const c:t►ction ui c_►�: individual subsurface sewage disposal system at ti►e r::tt:r4.11CL:,t location and hereby certify that to the 1:,E:st: of lily belief all work has been performE:d and cou"i.lc:t" in ��:_ _► compliance with the terms" of the permit and in (Jel"ral u`=i-OL 1'"C with the plans approved by the local Board of ilc:altl►. t'urti�<<:: i1 all construction appears to comply with the provisiolls c,i '1 > t.►:: of the Massachusetts Environmental Code ( 3.10 CMR 15.00) applicable local regulations. LAT NUMBER: 4 STREET ADDRESS: BRUIN HILL ROAD t' TOWN: NO. ANDOVER, MASS., 0184504 DATE: 11-12-9 �/ s►tvFrr ell SIGNATURE: . ,. _'e //y 1,1/GG AS -BUILT CHECK LIST and FINAL INSPECTION Proposed Elevations House Tank IN Tank OUT D -box IN D -box OUT Trench Inverts Line 1 /40 Line 2 Line 3 Line 4 Bottom of Exc . Stone OK? D -box checked? As -Built Elevation /L5'y, :7G/ /J7 -Y, a d ,may -o 0 3a M Pipes cemented? PLOT PLAN OF LOT 4 N o Aid 904, �A�,, Scale: Al DANA: F PERKINS CIVIL ENGINEERS, and SURVEYORS READING E�til�.sl+�I1�'I', MASS. Z 7N N � r z ' �U X13, 1G .5. L • CJCS7 Top t.tt✓, : lel Q lx I�r,n}eel �ir�rq.ri!ildltl�6 tis sh orn Wrwi and 4im it tcnlomii Iii lfs �+i IC•�'J�^AtUfi: c�llfCil!!1Cf11� �i�G� i4Yu�r.+wv �3 Fcl �'?iof�D�1'i.t4�� ulYbr�F' s��IP, 1 s•lw��s��—' . .--4 .rA. Now OT- 4 uj> Sca T /y �/Cf tRS IN v N 1 -1 A n l yy.v� Tor ELC✓ : I `1 .tea! , ; f I irer(A)y reri;ty 11N.60'Mo im as "shown horfilo 1 and that it etntofmi Ih•��oi_ �,�1�., rein.* i�Y°��tW UU _ of Dana N0kOVA9:1 .r ury y�r 1 TE41 e vz 5 0 tv of 'PLOT PLAN OF LOT 4 NA4 Scale-. 11, DANA F PERKINS CIVIL ENGINEERS and SURVEYORS � READING I-, MASS. x. M�111 ill M I- 4 �b 5. -Tor is lccmqki ).r XiW,M,21� as tkown km and tai it ttnlowi II of 7 by TE44 V, o I PLOT PLAN -OF LOT 4 - Scale11� DANA F. PERKINS � CIVIL ENGINEERS ano-SURVEYORS-- s _ READING jiJ�sis0,7,(, MASS. 17N 4 _ z.G, C �.y �r•� o � 0 1 i*reby cenh Ow the buUing *ft m Lot 4— is Mcatod 4trmxinwelt as shown heron and that it iwnf"s 10� to !::e se.'b4;k requIr.e,Menls of th-- 40, 41OLwed- Zoning ay -law V of � ✓ Dana �EtW Mq f N By R o Bron �W1►IyM J DUPREE N .o No. 30747 �fGISiERi�P, IST �tr, 0 DATE L Sheet of BOARD OF HEALTH TOWN OF NORTH ANDOVER SUBSURFACE DISPOSAL DESIGN REVIEW FEE_0 PERMIT # DATE RECEIVED APPLICANT J0141 Cpa .-2 ASSESSOR'S MAP ADDRESS ENGINEER /u , Vl ►2�u ADDRESS 3 i�ourl �� P�A cF PLAN DATE CONDITIONS OF APPROVAL: APPROVED DISAPPROVED x PARCEL # LOT # STREET Tyug KA. REVISION DATE P1 awns 54013 (0 TSE -DE-S L r -"GD rot �(a5 4� / T3o�� (G�o H ta) i�o1E f-1A-�SA �E 'pErt.Fore►-coo �� -_a.�,D.c.T� �E �� z) _°I! GO t'• (,� . CoUTvo K .: �IhoJ i0 '�� ` � �-( i � �;� 131.1 iaotL-� sto & oc (ugelUjEr*j ISZ F4. C0llr*0+L < lltr-1 5tVeCLl.C--) SY 5Tt-t---A / (ar, ISO, 5 µ�Nl "V �wl-TTL J Sb,,r oY 5� �I � arz- f look- SI�� sc-r� so Int .� 6rN� G. �► . D��4r•� -7) 5t7& -k h/ .4 ?6.s rz)me oj62.. tiPE s SY 5Tt-t---A / (ar, ISO, 5 µ�Nl • :•IY•�..,. a �. �• �. 00.lr.�,0,.0 a ,I. � if � -:VVED • ((' • �� 1 QeAh#• . 19 6T19WIN • •�ANDOVER ART •. • • If • r �•• !, ' 1 •;'111.1, I' / � �/ / Oe1@ oI PVMPIA9,•; i L57c)o Emyen Tee Fill f,�,aonR n Yoj p • .;•j1 j 4.':�i1'1{i?�I�yf,�'�t1I��,Y��'t/��"��i�'Ir�li1'iY•''';'�• n'0 'r' •�5' �yV'f/�%��,1%I♦L l�' waw�'t I{1111 t�� ,. 61 I 11 WI I°I • �'�' '.�',',;;�;�jt�' 'i 1, ' �'� • • .'''�,:1.�/,�i,,,✓Vlv I , y�ti�(,�� , , Phi�,,yy�� 'lir' / 9/h'iY4(��ir�f.�.•',,,, 1 -'•mesa,porldep�y;%sl'eilipp�gYaJylb/orm It rim � Y�nlui 'Jc4nl i n'rTvi/ 1. 4v 'Ma sachusetts Commonwealth of. s Q ...,City/Town 'of No.Andover., as System Pum oing Record Form 4, DEP has provided this form for use by local Boards of Health. Other forms- may be used, but the information must be substantially the same as that provided here. Before using this form, check with your local Board of Health to determine the form they use. The System 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 1. System Location: forms on the, & hruen FhO computer, use0 only the tab key 6, 4— 6 _L1 ' Address to move your No Andover Ma cursor - do not use the return State e % Q SO' Ild *�e key. 2. System Owner: A P 00'4� 0 Of tAo 0EPA Name Address (if different from location) City/Town State � Zip Code Telephone Number .B. Pumping Record 1. Date of Pumping 2. Quantity Pumped: Date Gallons 3. Type of system: ❑ Cesspool(s) Septic Tank El Tight Tank [I Grease Trap El.'Other (describe): 4. Effluent Tee Filter present? ❑ Yes M No 5. Condition of System: 6. System Pumped By: Name Stewart's Septic Service Company T Location where contents were disposed: Stmart's Pre-treatment Plant, 20 So. Mill Bradfor Signature Maujer Signature 'Ziffteceivin_g Facility t5form4.doc- 03106 If yes, was it cleaned? [] Yes El No Vehicle License Number Ma 01835 Date Date System Pumping Record - Page 1 of 1