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RECEIVED
f'C)Wry ,lf�lli..�� DEC 0
U -A I't SY9rsm PIJMPJNU R
t?C,on 6 2005
J y S 0 _ TOWN OF NORTH ANDOVER
9A 4 �inpR.$35 " — ________ _ HEALTH DEPARTMENT
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�ocroc^ ONER-EXPLAIN
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TYPE OF SE\k .%RGE DISPOS.%L
Public Sewer
i ri�;tte iseptic tank, e c.
Tannin- Massae Bode Art
! Tobacco Sales
I PCI'lllanenl Dunlpster on Sitc
Swimming" Pools
- Food Packaging Sales
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`OTE: Per.�r►«.v cv�n/rurli«;; ►� ilh « e�, 's/c�r'd un/rticlurN (hp «W huve crccecs lu lite l; «tire t «r►r/ - —
5111ature of
---- Signature of"
Contractor
PlanS Submitted % = Plans Waivcd Certified Plot Plan
-_ . Stamped Plans _.
THE FOLLOWING SECTIONS FOR OFFICE USE ONLY
INTERDEPARTMENTAL SIC:N OFF - L' FORM
PLANING & DEVELOPMENT
COMMENTS
CONSERVATION
y
COMMENTS )�U (rr1��(�
HEALTH
COtil;v1ENTS
Lorin Board uf.Xppcals: Variance, Prtition \u
ionint, Decision riceeipt submittal es
Planuinu, Board Decision:
DATE REJECTED
J
E]Water Shed Special Permit
-J Site Plan Special Permit
Li Other
DATE APPROVED
I�,kTE REJECTED DATE ,APPROVED
I:
------------------
DATE REJECTED DA PPROVED
('ons(:nation Decision: ---- ----- Conuncnts
S"C'. C01111CCt1011 SI`-IlatU1-L & elate — —
T-mp Dunlpster on 110_ Fire Department signature date (J.. ------------
Buildillp I'cl-1111t Apprm ed and ISSLIed by:
TONA N OF NORT14 ANDOVER
-
FOR PLA\
EXA: N,,11\ U ION N
Dat;' R c c� i d:
0:
IMPORTANT: Applicant Illust colliplete-all-Itellis oil this jxwk2
TION -
R rN, o\\ N LR--
�T — PARCEL ZONING DISTRICT:
7
AND USE OF BUILDING HISTORIC DIS ; TRICT YES 0
OF IMPROVEMENT PROPOSED USE
N\ Building
difioll
teration
pair. replacement
'1110 1 1 t ioll
—.;n:, I rNlnrntii)ll I
it One family
Two or more family
No. off -units:
Assessor), Bldg
1 Other
-: - IndUstrial
Commercial
- Others:
undation 0.111v — i — — I
�kj—PTIOI, OF WORK TO BE PREFORMED
Identification Please Type or Print Clearly)
P11011C.
;ER: Nan -le: a,�
Signature
2, s S: 11; -1 a -
,f-R,,\CTOR Name:
CSS:3.2-
p,ist)r's construction License* 1. 7 4/ __E\p. Date: 21
-2 C)
Fop. D.,,Atc:
;CHEDI LE: HI'LDI.\G PER 111T:.S10.00 PER Sl000.00 OF ME TOTAL EST12.1 D COST B.4SED O -N
12- j-
10 PER S. F. j� x
\I'tM 0 FLET
I Project C,,)St:S
-k No.: Receipt No.:—
j
FROM : FAX NO. : Oct. 11 2006 03:03PM P1
.AA
!R %"-EW N
10 industrial Way, Amesbury MA 01913
Receptionist: (978) 7921000
Sales: (888) 839-5551
FAX COVER SHEET
This fax was sent from;
0 Sales/Tech Support: (978) 792-1091 0 Administration/Production (978) 792-1095
Editorial (978) 792-1093 ElExecutive (978) 797-1094
To: 5. ..1
J1' �F's�.. fax:
From: Date: ZW11411106,
M
Number of pages including cover sheet:
Message:
FROM FAX NO. Oct. 11 2006 03:03PM P2
10/1112006 14:54 9736BOB476 HEALTH PAGE 01!01
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TO: NORTH ANDOVER, MASS 19 7F
BOARD OF HEALTH
FROM: DESIGN ENGINEER Re: Soil Absorption Sewage
System Inspection
This is to certify that I have inspected the construction of the said disposal system at
Z c % 17 1-4 CY' North Andover, Mass.
SITE LOCATION
The grades and construction are as specified in my plans and specifications dated
19
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0
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MOR115H APWI7 POkRD OF TF LTH
C:I,rK UST
APPRGV DISAP"RG''-,.D rXCAVATTn� OK
Date: 1 Al Dates - . �����' /09_`'t —
b Reason:
7�i
1 s Built Submitte
ec Lot location, dimensions, of system, location in regard to
percolation tests, depth of system, grater table
2. Distance to V,etland Areas, Drains, Street & House, Drainage Easement and Wells.
3. Water Line Location
4. No C Pipe
5. Septic Tank - Is. ement-Pipe Tank -Joints on both side of Tank.
6. Distribution Box - No cracks insbox or cover,_1 1Snes ow ec~ually from boxi a
7. Leach Fields - Dime s9.ens, Stone epths, C app�nds, Clean doubler ed stone
1
8. Leach Pits - Dimensions, Depth of Stone, Splash pads tees, Coment-pipe to tank -
joints on both sides of tank, Clean double -washed stone
9. No Garbag 'sposals
10. ILnal Grading �',barricading of sub -surface system)
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SOIL PROFILE & PERCOLATION TEST DATA
Town/City No.&Street Lot No. / %
Loc./Subdiv. Plan Owner
Investigator Observer
�1 SOIL PROFILES -DATE
5 /f� Elev. �� Elev. 3' Elev.. !—'Elev.
p
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14
31 1 3
4 4
L
5 5
6 6
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8 L 8
1
2
3
4
5
6
7
8
9
1
2
3
4
5
6
7
8
9
101 10 10 10
Benchmark Location
Elevation Datum
Percolation Tests -Date
s/6>17 7
Pit Number// 2 3 4 S
Start Saturation 1-f1v
Soak-Mins.—
Start
oak-Mins.Start Test -Time
Drop of 3" -Time
Drop of 6" -Time
Mins.lst 3"Dro
Mins.2nd 3"Dro
,VU LC5 « z)Kezcnes on bacK
Frank C. Gelinas & Associates, North And.
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WELL DAT_AJBASE
ADDRESS: _/o
AGE OF 7A/7Lr : ? WELL DRILLF�Z:
PLRIYE i ,T.
WELL LGCA,TiON:
- _W= PERM? DATL:- DEPT7� OF WELL:
-TYPE:OF W'r.� - a_ DRILLED b. Z b. DUG C. LN���i WN
TYPEOFWATER EEARING ROCK_ I
WATT ANALYaS DATE HIGHLN�i'ESE: Y N
MCE.IRCN: Y :.N OTS CO A T: y' N
rF:C��
W"r7 T. DATA.EAsE
f
ADDRESS:
AGE OF 'W=. ? WELL DRILLED
WELL PEI�tiffT T: LL L O.CATiZ4_:
WELL PERi�T DATE: DEPTOF WELL: Z
TYPE OF WELL: a.. DRILLED b. DUG c. Ut FKNL C WN
TYPE OF WATER BEARaiG ROCK: ;>
WATER ANALYSIS DATE.: Z HIGH NIANGA.NTESE: Y N
HIGH IRON: Y N CTI-= CONTANE [NiANTS: Y N
TO: NORTH ANDOVER, MASS 19 77
BOARD OF HEALTH
FROM: DESIGN ENGINEER Re: Soil Absorption Sewage
System Inspection
This is to certify that I have inspected the construction of the said disposal system at
L o T 7 4,1 C y 577- ' North Andover, Mass.
SITE LOCATION
The grades and construction are as specified in my plans and spej' s dated
19 �a��\11�3 a N
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TO: NORTH ANDOVER, MASS 19 27
BOARD OF HEALTH
FROM: DESIGN ENGINEER Re: Soil Absorption Sewage
System Inspection
This is to certify that I have inspected the construction of the said disposal system at
North Andover, Mass.
S UR LOCATION
The gradesand cons ruction are as specified in my plans and specifications dated
19
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SOIL PROFILE & PERCOLATION TEST DATA
Town Cit5�� U1, No.&Stree
---.------,. t Lot No.
Loc./Subdiv. Plan 49c,�� Owner,AJC
Investigator Cc �U Observer
dall 17/ SOIL PROFILES -DATE
O
1. Elev.2.
Elev. 3' Elev. !—Elev.
� oZ 77
0
d
2 1 L of 2
5 I 1 5
6
6
7
7
8
8
2
3!
4
5
6
7
8
9
10 10 10 1---- 10
Benchmark Location
Elevation Datum
Percolation Tests Date
.
z2- 7/_ z�77
P.i_t Number �l� 2 r 3 4 5
Start Saturation
Soak -Mins. ,
Start Test -Time
Dro of 3" -Time
Drop of 6" -Time
Mins.lst 3"Dro
Mins . 2nd 3 "Dro
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