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HomeMy WebLinkAboutMiscellaneous - 102 SOUTH BRADFORD STREET 4/30/2018Mr En ft' ft' �i 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 andlor landowner from compliance with any applicable or requirements. APPLICANT FILLS OUT THIS SECTION APPLICANT�c '2� ��.�a't-S PHONE aN° P Flo 0 LOCATION: Assessors Map Number %3 PARCEL SUBDIVISION LOT (S) 32 STREET �d�.'1 �t`Q�9.�o�. ST. NUMBER OFFICIAL USE ONLY' RECOMMENDATIONS OF TOWN AGENTS: - CONSERVATION ADMINI-ITRATOR DATE APPROVED DATE REJECTED COMMENTS TOWN PLANNER DATE APPROVED DATE REJECTED COMMENTS FOOD INSPECTOR -HEALTH DATE APPROVED n.T- rr �rrr_n DATE REJECTED COMMENTS PUBLIC WORKS WORKS - SEWERIWATI;R CONNECTIONS DRIVEWAY PERMIT FIRE DEPARTMENT RECEIVED BY BUILDING INSPECTOR DATE_______ 9�,:0T 66, ET ddW 2_00-d LLI-1 90�-d 11f1- oorrac--r BOARD OF HEALTH 146 MAIN STREET TELEPHONE# (508) 688-9540 APPLICATION FOR ABANDO,1v1ENT OF SUBSURFACE DISPOSAL SYSTEM (SEPTIC SYSTEM) Pursuant to Section 310 CMR 15.354 of the State Environmental Code, Title V Name vLI&4 Phone Address i o Z -BrG. P r�-V Contractor Hired for work: Ell �L+���1ID 4�1 WN of NORTH AMDOVE' BOARD of Y' ,%' TA 6 1995 Name ('u ,r tb �o } Phone - zZ3� Address 54 a liter g�- . K f kZVel- Date for scheduled abandonment 9 The septic system at the above address has been doned according to Title V specifications. e of Contractor 1 Method of septic tank abandonment (check one). () removal () sandfill (�() crush.- () other' Name of Offal Hauler Tc44e!!5a� This form must be returned to the North Andover Board of Health. PLEASE DO NOT WRITE IN THE SPACE,BELOW FOR HEALTH REPRESENTATIVE'S USX ONLY.-*' Inspecting Agent Date J�ju.H �/C�� �// I NPZ��'� �Py�i/� f '?ease forward us as much of the following information that is possibl.e, 1.. Type of system L e L' AIIA16t IC / E C.P SYS TEM Soo Gr,�}C, `eme&7T SEPTIC To4/vit F/P au E TFu7') NE P/ PE IN Pu r TuuIN)DIsTRrBureo,v BoX��cE A�ee4e e, F& r) 2. A geBOEAc///�/Gi arp FT 23 YjPS1TH S�p`cs OF D/STK T o McHES 3 Location. $Aek YA,rP) 1 ox S, SRAvpoep Sr,, C�C�JC 4- Maintenance records and date of Last pumping; out /T /s pump p ouT EVERY MAY 10-WeMF9 /7- NEEP; TNEEAS /r oR Nor, pvMJp01q; Z7 MAY Iq 78 TlqNk house PRA�Nfe�Bfl � 4 DSA, I- ". u --U--- L— , 5. Documentation of repairs and reconstruction p(EI/49-e RECdIVSTA UdT-ED, HAD A CZ44AI -� cv7- „ y�, INSTAGLEp e -.4s r JANE /978 6. Site conditions SMALG. AOeK f G°GAY g IS -E So/ - 7. Builder of system AI E �LA,�E,Ve,E W, SpENC E,` 8. Engineer who approved; - Site BRAO EAv� FAME FRoM H4vER��LC..� Buz- wd�lCEv �� N• AN�vER S -y s t em f;+M E HIS �vGL K.4NrE 1 S }�EeaI� ft T THE Tvai/Va 6 U/ep jNG , 9, Installat ion Procedure 10. Problems NEPE9 HAP ANY. - a ��Dt1I�4D L6vEL a PIPE 1 �CGEAN-ouT Y eovse 9 INSIDE DIA, PIPE cAs r IRON ?/PE CquCKED �%INTT F— POST, POST, ��.,► r To 8mX� HouSE vT_ I ` 5EPrrc �N PrP 3 PrPE¢ 4N c'AST /RaN PIPE 0-4vt,kED Jo/NiS BErW EN 7.4el k 47 Box. - 7.0 $'� of 1-0,4Nj 41 QRAS's '4�,...._ T -we 4AYE.fS Op Ty4� pAI��R ¢y P/PF oRAk4E_ 190RC,7 o Ross w S ecr IPF 6# mF t 11jEH S7-01yE 1 Foo -r- of ..INCH WATER WAsf ev $rove ro4Nk Fr. OF SMALL ° ONS INCA cr»NE a •pm Cd Bds�e`�"' co a»o�,oa�aan mm000 00cpea&*o 0 ©�(63 4 (� O 0 C> (:D eD 4)0 .1, FoeT o F SMALC, FIELD STe /VES , FI r, A WN OF NORTH ANDOVER/ BOApr `•r ;�l 4TH 111AI C 1995 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPEC IJOM FORM Address of property J Oa, SOUS 6C-�-QDCA. Owner's name HC 00_ce,�AC o. Date of Inspection 9 5 - PART A CHECKLIST 7 Check�if,:the following have been done: t//Pumping information was requested of the owner, occupant, and'Board of ealth. None of the system components have been pumped for at least two weeks and the system has been receiving normal flow rates during that period. Large volumes of water have not been introduced into the ystem recently or as part of this inspection. As built plans have been obtained and examined. Note if they are not _1" ailable with N/A. facility or dwelling was inspected for signs of sewage back-up. :,,TP4 T site was inspected for signs of breakout. All system components, excluding the SAS, have been located on the se. The septic tank manholes were uncovered, opened, and the interior of �theptic tank was inspected for condition of baffles or tees, al of construction, dimensions, depth of liquid, depth of sludge, depth of scum. Theze and location of the SAS on the site has been determined based o existing information or approximated by non -intrusive methods. The facility owner (and occupants, if different from owner) were provided with information on the proper maintenance of SSDS. SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B SYSTEM INFORMATION FLOW CONDITIONS If residential 5 number of bedrooms number of current residents No garbage grinder, yes or no Lau,"`S !1 V\ �- �U,, laundry connected to system, yes or no �(� "o seasonal use, yes or no If nonresidential, calculated flow: �C c Water meter readings, if available: ol50o'E3�c , 5 =a low Oda-, 'Q�ln Last date of occupancy GENERAL INFORMATION Pumping records and source of information: �� \ l ats� uP mx- — owAe-.5- System pumped as part of inspection, yes or no if yes, volume pumped 55n Reason for pumping: t" ttike>� A-ee5 Typesystem , Septic tank/distribution box/soil absorption system Single cesspool Overflow cesspool Privy Shared system (yes or no) (if yes, attach previous inspection records, if.any) other (explain) Approximate age of all components. Date installed, if known. Source of information: 40 (AaaA-S A( � i I owvwp N� sewage odors detected when arriving at the site, yes or no SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B SYSTEM INFORMATION continued SEPTIC TANK: - (locate on site plan) depth below grade: material of constryction__co 9 1 FRP other(explain) a / va lei, p5 x 3.5=Co8.6�75'x'7,5- 500q -Q dimensions • S X 3. S � � I R 3 � y(a. S � = U" 4 i sludge depth ,pn it distance from top of sludge to bottom of outlet tee or baffle cl scum thickness IA distance from top of scum to top of outlet tee or baffle distance from bottom of scum to bottom of outlet tee or baffle Comments: (recommendation for pumping, condition of inlet and outlet tees or baffles, depth of liquid level in relation to outlet invert, structural integrity, evidence of leakage, reqommendatiorls for repairs etc.) e tt DISTRIBUTION BOX: � U AAvd (locate on site plan) `JJ depth of liquid level above outlet invert Comments: (note if level and distribution is equal, evidence of solids carryover, e id ce of 1 aka int o o t of box recommend ti o re airs, a .,, til 4�x 'e cjo� A c�� ,T t ��. `S v �cp�. D'� f 1 PUMP CHAMBER: (locate on site plan) pumps in working order, yes or no Comments: (note condition of pump chamber, condition of pumps and appurtenances, recommendations for maintenance or repairs,etc.) SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORDS PART B SYSTEM INFORMATION continued SOIL ABSORPTION SYSTEM (SAS): (locate on site plan, if possible; excavation not required, but may be approximated by non -intrusive methods) If not determined to be present, explain: Type . leaching leaching leaching leaching leaching overflow pits and number chambers and number galleries and number trenches, number, length fields, number, dimensions 10 cesspool, number i 3 g ao X0"9 A- a- Q 10-x " Comments: ► 1'a' 10�'j (note condition of soil, signs of hydraulic failure, level of ponding, condition of''veggetati n, recommendations for maintenance o repairs,etc. c� n.-9- f - 1' CESSPOOLS (locate on site plan): f\DAe 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 (cesspool must be pumped as part of inspection) Comments: (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, recommendations for maintenance or repairs,etc.) PRIVY: oov\ej (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, recommendations for maintenance or repairs,etc.) SUBSURFACE SEWAGE DISPOSAL'SYSTEM INSPECTION FORM PART B SYSTEM INFORMATION continued SKETCH OF SEWAGE DISPOSAL SYSTEM: include ties to at least two permanent references landmarks or benchmarks locate all wells within 100' DEPTH TO GROUNDWATER �- depth to groundwater method of determination or approximation: ;C.) G- 11 �V\ QJ4�k f i2 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C FAILURECRITERIA Indichte yes, no, or not determined (Y, N, or ND). Describe basis of determination in all instances. If "not determined", explain why not) �j Backup of sewage into facility? Discharge or ponding of effluent to the surface of the ground or surface waters? � Static liquid level in the distribution box above outlet invert? Liquid depth in cesspool <611,below invert or available volume< 1/2 day flow? Required pumping 4 times or more in the last Year? number of times pumped Septic tank is metal? cracked? structurally unsound? substantial infiltration? substantial exfiltration? tank failure imminent? Is any portion of the SAS, cesspool or privy: below the high groundwater elevation? I" within 50 feet of a surface water? Nwithin 100 feet of a surface water supply or tributary to a surface water supply? 0 within a Zone I of a public well? within 50 feet of a bordering vegetated wetland or salt marsh (cesspools and privies only, not the SAS)? I" within 50 feet of a rivate water supplywell? P less than 100 feet but greater than 50 feet from a private water 'supply well with no acceptable water quality analysis? If the well has been analyzed to be acceptable, attach copy of well water analysi ,for coliform bacteria, volatile organic compounds, ammonia nitrogen and nitrate nitrogen. 13 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART D CERTIFICATION Name of Inspector Company Name `N Company Address Certification Statement I certify that I have personally inspected the sewage disposal system at this address and that the information reported is true, accurate and complete as of the time of inspection. The inspection was performed and any recommendations regarding upgrade, maintenance and repair are consistent with my training and experience in the proper function and manitenance of on-site sewage disposal systems. Check ne: I have not found any information which indicates that the system fails to adequately protect public health or the environment as defined in 310 CMR 15.303. Any failure criteria not evaluated are as stated in the FAILURE CRITERIA section of this form. I have determined that the system fails to protect the environment as defined in 310 CMR 15.303. The determination is pr v ded the FAILURE CRITERIA form. Inspector's Signature 1 Date Original to system owner Copies to: Buyer (if applicable) Approving authority public health and basis for this section of this Z hereby rr►ay9 tj.0pl.:tc,.at.:� on. :for F It once ra3 t$1 hF,, � !' --�-�' I will of the Board t off' avis 01 the �;o oncrcul Lh Health of �:he 'i'c�tJ'a of ,dorth 4 A •• ') + t/ Of Af�a�i:3FJG�1�1SG rr �, k J -,n i0'7er. L•?.%1(� �'c:�_il.:.i �rS, ti`s ? Further, 1 will construct the r rr�in'iznum diameter bean .a inch ho��se seg exr o boll and :��� of :tQ feet Preceding i.��hes: sxad txJi1 ; rr iz.,tf,.--,n r rr ; the cess c� c3l L sz r!zt m ;r a r ,3 O exceed 2%. 1 ��J:t:r.:d 'ii� p i c�G septic tank., k., ivhex°e ,.',le r z's.cze sh:�l:: size. �► 1. c•€ SSPOO). or se,,d manhole s pea�mitfi, ting ,. :i� s. +�r. s , c« Soo Dover s } g .easy cleaxzi ` ��. ��. p_ �. ♦��I y �! �(y �•, { (o� z iron or c onc::c�i; '-p t r �- �f 1y •� �'j y� .Q� v1. the :r�ora• CEO c I�� 17, .'T YN .G. .L p Wide 7- `" fdV S. �Ah.d.S.'1 .R.( "chez lchCe p Of Lhe �T •� •� V� sub�nxtEace d'"08&1• f:iGld with r '�c�2Z�c� �Li��r;�•c� Alpe -'` ` £� € �'s � , I2�� ki . C .n'bo �, cbe].l Of L`2'011claea the boot' 4 �..2'zc�:. d�.is��3tG-V :�3:i r•i � r ,fora Of Which will provide s zlin:s.z:zu;U ca�Y�.�zi, L:in�a�:�l (square) �'Qet of F;;,���' . on a e sib s G Crich layer of clean o�° vet oraption a�"a�'•. `.e,,ja.e pipes C3 inches (die ) and the p:ipos t�j, 1�+����U'C�i :�'f�OK.� �'�'��.'3•i�•,n, » A� b a height Der. 2 Inches above -, e re, surrounded ia;LOX be protected a.rozr: c�.o ,� fl e j ��`�� Thcs JO-'ntsr of gravel or stone 1/81, to 2 � �n� and �, G OrO � a ins; th:. tx'a3�'at; :e., 2 stone, The (dia..) field FJ ia.. ) jvlll be Placed , , �., ill be inai led "aced ovc3� ��c� c:��'u?'sc� seta T�It3 single tls line vas17 exceed 1a0 �.t'a.,a k,r rx �:, ,, buts lin l fd;, o . �a es O the will be installed, � mi"a muln C)fl�32� gib. czn�i between the cent -or lines Of .,e.t will be de th o ., the c�ispr�sal field tren,01--14 aIz��, p-•r'cz�ih .sTaa.13 now emceed 36 nc:lios» 6, t1ho a�es"; , off' a cosspocI into a sizbeux' 'ace ,jis os� � �" �yhe case :: inlet and orzt:let conr:1ec;tior?.s. 'to thc�pc��s field �7 0 f another 7y l �` ��ze �:� tE:0, Itsan Lar •�oewsu» a h � *.�sn1�}l}�� ���«rh Of li�?e role -U i �.�. riaeasu•:['emalits OJ Cessp001 s�:;Q�.,�.�?�����Ci����r3t'� iJ' i6 r'noa n P pea No part of `thy iras�.�lt��t�c�za r,.b. o t�Tsen at tb any prxvr�te watot suppl.ya 25 Feet fro: any z tr�a �� � e:s.: c r���ra 1N��a dwelling om 1Q A"vet: "-"A � x�� �, � � , 20 feet :f7z• ,. ©Tg�t on of tYi.s �.� , property !..nen cap.. 1•... as pr cav �edYi cad .runt 1 s �o�red'°"� �"•�•.y....._ _: �3_ 'cr (� ,{}/� �']( �I- fin -6-- 0 o �.r1'p 6- L:'Yi.c'� �•� ��.? `'.Q.'.'."`"y /-••ry�`' ( a � ° ��'E�Er w,a.C��:r. C'1: l;`;d. �"iJ,'.' '.+� Att4WWhVr4 .m{ I. '. `.� t/.ka \d'J.A�.,[,�, _ y4 ♦.. r,v.rgF+e.«.. to he per t, DA TE, 1 kzr3l�eb;� issuo the above �q!� �;TUYO X . ,. z , - C13'ti7t +�il7d4iTQg'o r''t f3c,C'h'k!�3y? v'�'e"flt� \/4 the soar �f .i:i0altill L�f '�t�.;� .'r'i'.'i1 tit' � 4�s pia . _1 Val, 1(m+uT ht'a ixspected 'she tancoti"c�s'ed �'�atc-��3 rzaics.t��d .bc:+v�; :►�zr�. .. • dOnG as described, sifind ev��r,� t,T�ir.•c� : Date 1P Fc o atton Test i Iti 0 250 � n ` n 0 In n 0 rj 2� O O 214 / Ln Nb North Andover Clarence W. Spencer Board of Health P.O. Box 204 North Andover, MA 01845 Francis P. MacMillan, M.D. Chairman of the Board September 18, 1993 Dear Doctor MacMillan, Enclosed please find a copy of my cancelled check paid to Bateson Enterprises, Inc. for the pumping of my septic tank on June 17, 1993. I have had my tank pumped out every year, as a preventive maintenance measure, since we moved in here back in 1955. It's been pumped out 37 times since we've lived at 102 South Bradford street. I plan to continue this procedure until we sell the house, hopefully, in 1995. Respectfully submitted, Clarence W. Spencer r► f/ v CLARENCE W. SPENCER N0, 2250 CARLOTTA SPENCER PO BOX 204 NORTH ANDOVER,- MA 01845 19%3- 53-7047/2113 -- PAY ER THE Q _ ^fes . �_ .I ^ 4^ L 2 r� 0 ' O 0 ORDER OF � Ja/�.�IA P�y�j,� e�LY'1�(s s L f�ff DOLLARS ® Andover Savings Bank Andover, MA 01810 GROUP FIFTY PLUS Member FDIC/DIFM Anda6wBar* MEMO 'Z1�_ _3��(,1L2JL�Yjt�L.,,�+� 1:2l ? ?i: 6 5 L 2 500 L 38 211' 2 2 s0 1'0000 10000-1' 9 i I SEPTIC SYSTEM INSPECTION FORM I ADDRESS DATE INSPECTED PROPERLY FUNCTIONING? Y N WEATHER CONDITIONS COMMENTS: @, L. � o v � Co S �r-dv►� DYE TEST PERFORMED? Y N DATE? SKETCH: 0 WATERSHED RESIDENTS QUESTIONNAIRE 1. Name (-..LAReacE w. 5reyese 2. Street Address 149, S m u TH .5 9,4-P P S77 3. How many members are in your household? T w O 4. What type of sewage disposal system do you have? ❑ cesspool N"'septic tank and leaching area ❑ connection to municipal sewer ❑ other (describe) ❑ do not know 5. Are the plans (drawings) for your sewage disposal system on file with the Board of Health? Oyes ❑ no ❑ do not know'-_ - 6. How old is your sewage disposal system? ❑ 0-5 years ❑ 6-10 years ❑ 11-20 years"=' Lel' over 20 years ❑ do not know 7. Has your sewage disposal system been rebuilt or repaired? ❑ yes [4;'*"no ❑ do not know If yes, approximately how long ago? years. What was done? 8. How frequently is your sewage disposal system pumped out? E!� annually ❑ every 2-4 years ❑ every 5-10 years .. ❑ over 10 years ❑ never 9. Have you had any problems with your sewage disposal system? ❑ yes 21�no _ If yes, what problems? ❑ repeated pump -outs needed ❑ system clogs, backs up, or drains slowly ❑ odors ❑ sewage surfaces through ground 10. How many of each appliance are connected to your sewage disposal system? washing machine dishwasher garbage disposal dehumidifier drain sump pump toilet �� roof/pavement drains shower/bathtub &/DIVE 11. Please state the brand and type (liquid or powder) of detergent you use for: dishwasher DoyVr /4.4&16 o KE clotheswasher 72eN+T- "Avf OMS 12. Does your property have a lawn? 2 yes ❑ no If yes, approximately what size? ❑ less than 1/4 acre ❑ 1/4 acre [9 '/z acre ❑ 3/4 acre ❑ 1 acre ❑ , more than 1 acre (Specify) acres 13. How often do you fertilize your lawn? No. of applications per year ON E Season(s) of the year S.r+R /'VQ 14. Please state the brand and type (liquid or granular) of lawn fertilizer you use: Sea T7'3 -- f C uS (6,xA,yv4-+A! ) ❑ Check here if your lawn is maintained by a professional landscape contractor. FOR 14 - SYSTEM PUN PLUG RECORD Commonwealth of Massachusetts , Massachusetts System Pumping Record }stem Owner System Location OaAOV� SDAt-,k R4�'A Date of Pumping: Quantity Pumped: gallons Cesspool: No ;0— System Pumped by: Contents transferred to Yes ❑ Septic Tank: No ❑ Yes License #: Date Inspector Town of North Andover, MA Watershed Septic System r e h Servicing Report 3 Date:�� Homeowner: 0CL&QAACR Pumper Street �ov �3��s�- Address: Phone ja-~ Li 70 L4 Phone Nature of Service: Routine Emergency Observations: Good Condition Full to Cover Baffles in Place Leachfield Runback Excessive Solids Heavy Grease Roots Other (Explain) Description of Work: Comments: