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HomeMy WebLinkAboutMiscellaneous - 1100 SALEM STREET 4/30/2018 (3) 1100 SALEM STREET i210/106.A-0056-0000.0 J TOWN OF NORTH ANDOVER SEWAGE DISPOSAL SYSTEM INSTALLATION CERTIFICATION The undersigned hereby certify that the Sewage Disposal System (A) constructed; ( ) repaired; by located at o(D was installed in conformance with the North Andover Board of Health approved plan, System Design Permit# dated , with an approved design flow of gallons per day. The materials used were in conformance with those specified on the approved plan; the system was installed in accordance with the provisions of 310 CMR 15.000, Title 5 and local regulations, and the final grading agrees substantially with the approved plan. All work is accurately represented on the As-built which has been submitted to the Board of Health.. Bed inspection date: C Engi er Represe ave Final inspection date: 3a 9 ngi er RepresenVtWe Installer: #: Date: Design Engineer• ��I� Date: RICIIARD 4// /�� `a RECEIVED -'L\ Commonwealth of Massachusetts City/Town of North Andover ,,L 07 2014 Sys-.tem pumping Record TOWN OF NORTH ANDOVER HEALTH DEPARTMENT ;w4 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 forms 1. System Location: on the computer, Q use only the tab 1160 -�1 (� Y� key to move your Address cursor-do not North Andover Ma 01886 use the return City/Town State Zip Code key. 2. System Owner: Name mnun Address(if different from location) City/Town State Zip Code Telephone Number B. Pumping Record 1. Date of Pumping Date p / 2. Quantity Pumped: Gallons 3. Type of system: ❑ Cesspool(s) [ Septic Tank ❑ Tight Tank ❑ Grease Trap ❑ Other(describe): \ 4. Effluent Tee Filter present? ❑ Yes ❑ No If.yes, was it cleaned? ❑ Yes ❑ No 5. Condition of System: 6. System Pumped By: l Name Vehicle License Number Stewart's Septic Service Company w 7. Location where contents were disposed: Stewart's Pre-treatment Plant, 20 So. Mill Bradford, Ma 01835 Signature of Hauler Date Signature of Receiving Facility Date t5form4.doc•03/06 System Pumping Record•Page 1 of 1 Af"v•RECEIVEb OR 1, J, y S ?_000. h1 A ��VE M�qso ��. �{I Recoca ' US T �) \, TOWN OF NOR ,ll�ll•�1J' .{�tQlr I1I'irt�;v�':IR d��`4 ,111!'1' „C HEALTH DEPARTMENT ul'' rl�j•I'y!1' �O�P.hll plOYldld > ,"vi•'�1 Oo 1• Intl IQlln lol :vmlllod 10 thi loch 8cr'rc c•I „ , pl °I ^Ue�: ''1 OJiln Q/ Cl/l0/ ' ..• .. Ip?l.or'rr,� 1•.InQrlry A' Faculty In(orm�llon w rI e_ ^�,^ zo W 1 1 I . v',�{ .I(',•,,';1:•l,rl. 1:1/'J1�1' r•1,.,` ,1,.•N�.,'u.,' .. ,, ,, i.:�ll.�,`h J'��''rl j/nl:•' i��,•-+1•,tY�yl,�r(r: ' r _ l�drµ� (Il4 (rinl r '�• Afi bu Vvnl i l l9�pn1 n,mp,1 _ e • P,umA�Ilg;RapOrd , r I y, Ito ; L, I. Oalo of Pu'mDlnq � D ,• J. ,Type of ryalem;`:• � Ca>>9ool�, :, +1. ;,.''s ►'c;.a :' . SOD(!c Ten, , .IS. T e ?;r;1/ tyuon)ITeo Fllle(;' LR,aonr? n Ypl Q No u y e r..,; c r ':!tr ;'6r••m(°,c:';. I•� "I:'1• X11: • ,1"1 •!i ql l't�.•'nl,,IItir;6'1'1,�" • ti ed8 • 'v,s''�fli ,f t 'll' '1• I VIAIc11 'Jcenll n. . . 1 .�Jh'/������ir r /•'t(f�i'1 ' � ,�I',�u�Iy��+,�rr ,/t l4k .,.�...', .., r,'1•�loc� on,wher9 'roAlenla;�ero P iYr l\'hl.J r�,1�iJd1'� lul;„„° ;• dl� OSBQ. ` .; . .�; ,,;.y.,,�•,�Y:�rr•, S�nl,�l olNlv4((�,�y,l,,.-•,.,,1, � y m • 84. OYl ,. q da , alar/e ' . P'�' PDroYelallblorm�,n.�,ainT t •.• ,',• • . 9001 �'A11D0 SRT ISE Reccrd � 1 'rA> ,.,fig, �r)�,,.��; ,.,�, AUG r l 4 2008 P.hai provided 1hliloan for .ao Uy local BoarCy of((�� ba + brr!I}od to Gia local E�carc; hoa!,n or oTrAa rtF(C�LPA $N4Q��f, L TMENT Faculty Inforrrlatlon -- V>4 nwm 17...QK _._ LO `° Addre+l (I(dlNonn! turn bc.4Uon) -- 7 — \.� ��;'�{ ����`Z,�`d'i:..r,.;r,,,,,rJ:•/'�,{fry,.�:{:.,�,� / ,Q(',,' In n,, 3, Typo p( ayalam; C699pool(9J SOPOC Tank T19h1 TenK 4, Effluent Tee FUIe ,. r n (.P 9.sent? 1'09 no !I ya9, n'89 'eana�? Yes reCn. PVMP0 'BY. �'G wnvr 'a,�,�. .�Ir i�r� � 11�(,f� 1\�r,{Y\ •}f���.;f�•J,��,�'r;'':,� f �j/.//�/��/,vim/ye/�h/�lGe Uca�e r�uT.�er ---- 4w�r�,�,.,� '�/ ��7,.Ay�r � r4/t.f �I',• '. j ;. 7. . on wna(e conlenls'ware ^fs�csee: ! �":^fvrr�.m•aS3.Sow/da��vralef/epprovaJs/l6lorms.r;�T;;, ��s�ac� -- ,. 74 { °' 'tet- I Y del s Ir yr o: �, � chusetts r A�l[� ER` MA$SAC US OVTT + : i system PumPlt�g - o Record FEB ti 2. I4 TI.1lr ��' t i t P (•f Nl ` Y ifs;�Oxi1] 4�.,�•Fia i t -t I t Y iy+Yi fai•s 7 - •. .6. �. . ,,c t. . HE-A�rFNORT gnfr^1 DEP has provided this form for use by local Boards of Health. The Syste`tn=Puir�ti,p�n &ord must be submitted.to the local'Board of Health or other approving authority. 5 s . A Facility Information .. -tmAortant. ,z,Wrier,filling out 1 : System.Location n forjna on the �/D 'computer,use` ����' • only the tab key AddressQt� to move your':.' cursor do not . use the return City/rown : State Zip Code" key ; .,. ... : f System Owner Name r Address(If different from location) ° 1 Cityrrown State '' Telephone Number P << , 6.:Pumping Record a r • Date of Pumping Date 2. Quantity Pumped: Ga . ,• ons Type of system ❑ .. Cesspools) Septic Tank ❑ Ti ht Tank ❑ Other(describe), 4 Effluent Tee Filter present? ❑ Yes.❑ No' If yes, was It cleaned? ❑ Yes ❑ No S Condition of Sy`st m•` . �. - iV Y� •fir j: ... . ... 1t ._, t . .. i l;Y `t i.}{'..c a •,.i tfr tt-:' - r g• $y en1 Pumped By N �•`• ,., , . 1 Name Vehicle UCen t a 5 }I ��r , , +r•tF :: .,;,, "/I� a *e Number t. -_ t iwti„th ir•:1fr�r'y1 L�15� "/Iht- I(Y 5' "•�lr1Vf '• w` • . �Q/�7p��y ! Iy1(AY••C tt 1 1 Y l t r� r ` �r..t t�"•T a'I I,d lY J B4Gr �S. yYl tir.t. 7, l.`ocatipn where contents yirere dleposed; r a � t.• Data httpa/www mass.gov/deplwafer/approvais/t5forms,htm#inspect � Y t5fomA.doC 06/03 System Pumping Record Page 1 of t Lot & Street GALC—rn J j Map/Parcel CONSTRUCTION APPROVAL Has plan review fee been paid: YES NO Permit# 99 Plan Approval: Date: _� :Z4L9,,y Approved by: Designer: /VEW C—/1,6,eA 6—,(�� _ Plan Date:- AI,a3 9r Conditions:O 'DL'&D Water Supply: T n Well Well Permit: Driller: Well Tests: Chemical Date Approved Bacteria I Date Approved Bacteria II Date Approved Plumbing g Si n-Off: Wiring Sign-Off: � Comments: Form"U" Approval: Approval to Issue: YES NO Date Issued By: Conditions: Final Approval: All Permits Paid? YES NO ' Well Construction Approval? YES NO Septic System Construction Approval? YES NO Certification? YES NO Other YES NO Any Variance Needed? YES NO FINAL BOARD OF HEALTH APPROVAL: DATE: APPROVED BY: ,s SEPTIC SYSTEM INSTALLATION Is the installer licensed? YES NO - Type of Construction: NEW REPS New Construction: - Certified Plot Plan Review YES NO Floor Plan Review YES NO Conditions of Approval from Form U YES NO Issuance of DWC permit: YES NO --- DWC Permit Paid? �i NO DWC Permit # Installer: ; Begin Inspection: NO Excavation Inspection: Needed: i Passed: By: (j Construction Inspection: Needed: As Built Plan Satisfactory: YES: y � ��i l'°LCr '�S�7 f/�'�.�j // f/`�'�� ���f�Pi' !. ✓J /r'dl��O/� Imo'�'/O 1���' Approval of Backfill: Date: By: Final Grading Approval: Date: / By: Final Construction Approval: Date: By: Certificate of Compliance: Approval: Date: itK tti ,;�ir Ik r.irlb 1. tit s T ` La r ,rtri .S r< p (jYtY Atte' • k�,. trGi of • 4 � iP 3�stk4 S 1* `yrj {i �L f fL to t (i'1 3 is 4 �ttP+Yt 3 tr it r x s Y fi as{{ s �I���� +itP't Cfy��ia•,tt�jr ?I�''t�ftrr �p r�i�Y 4,5tt-Y Yv i ) �✓ f � y �1 }Sh"a0, r i1t ay 5✓I l 4" r /{t 7 t c:4,!, "TOWN OF NORTH ANDOVER r t; a SYSTEM PUMPING RECORD t* � $i '� �t k,z rk, 1D 'y i it 1R s " � " !Yr x ✓.y "k 'q'�'' i( i� t x r • b,Yr' 2 {`� '��h�It Zs✓ i a r 6Y r7 '1! 1 a C�sY i {v!' a {t�} r nri.r yu s $ »g{ i t rtR ''j 1, )h 7 1 P d6 t e tx 1 't{ €tt t,� if l i it y , f �. ; f7 t"'Y$( C '` } r �I ��d6 l?Y f� lw' p t , J. � ,} y '3 q r "j�tpr+ tF I I tti�} t E r d , ✓ Y u... �,v,�'� ia: P �:• r I ' �.t Y;Tt ilI "SYSTErM OWNER&ADDRESS ' z* ;SYSTEM LOCATION (example: left front of house) Ft2rs+yYdI' ( ti` e +rF'�' { :•'ytJ 7� t},r - .� r� t. a 7 'sj b rrr i� rid k t f6 p?' ltr,�a�y� n i i b {7,{���i}���• ,y.ili � ��r� 4; s'�J � m "� tI Y ..,a t i.j ",�y� , 1r tdYr} Y�''qy. r ♦ Y i 6'r.+`,i s ^ r .Y, .. ;F; i ' r h .seft iP Ib3 ej Ei 1y. �7iky�;vaf2�i'.sf a r Qtik.y y,t�g>, 'i 5 t St.t.... a i. i k , :� Y ' '� x`-� � rj '+ •h p 4 kFay71`rji(S�^ s tYr s 11 QF PUMPING. 7 C�I QUANTITY PUMPED GALLONS R. W CESS ',(IOL:'NO ,YES SEPTIC TANK: NO YES ✓� '.; ti F• °` "r• Y p' ,P'�f16'�}'abgC � � 't TMOF • O SERVICE, , ROUTINE EMERGENCY x° y�� y ri'L�N•r, �rSat,'�tt ti,S -:�ko +a y % 4 l l J[qii 4 t �� IG`;'f`p ktlrf h✓ ! d �w �� ,l 1� �'1 )1'` ?k��§2�' ���t� y 7 i JI•r ,r -. ! aY �. Y y.r' �2 .�l. �'� 'r��I��># �x`T��� �d"vI`lei4'Mt rry.�Jr 3;a I >-�Y;�s�.; r� r ta,♦` ., ..- •.. - ,Y W +�GOOD CONDITION . `;FULL TO COVER Yrt ?�wd�� Fwd wyYHEAVY GREASE S .BAFFLES IN PLACE " »0.kali ROOTS' LEACHFIELD R �E EXCESSIVE SOLIDS FLOODED RUNBACK C ARR�}�YO• OTHER(EXPLAIN) �]ER��i F r 'P✓'ry r�k a li r.�i •,� ti �4�2 r t y : ' r S- 4 ti$S +5 _7EM°PUMPED BY• t F r ; k a ri ' "i.e"r;�o-y'yi Ot YsmS"* jt }s d r5k r ! .p'in f i Y Lc R 01 (, �ESF��{� .tritlF Y�' kn•st Fr M F Y /Y t Mt+ § , _ i �'t dtWyilr� wd ,��<fj,�411 it ;« r y rs r s Y 1 7 4 1M' Y}Yy tM a}pr y�#Y d+y.�y?-2t 4� YJ� � 1,p.,✓ {� gr t� F ,..,.... .�� pts� iiD{9j _,3� 77i y t. xF1Yl,S p iY 1, yt {'dIY�Rd f t yr°rkY6 r ' lr L t t VVI 0 NO �d A.€8L� 1 �r�iYlk ! ld� ■/�■ NT(� ,I t JIr 1 .-,t t 9 i .� �� tilP I a�.Y ' �1�r�`t4'M1t ,�.�1'4`/•I.l•. ' f o r ` � ���` t-.. t�4ilj�.��a t � • �n ! ttSf t4'S3' r,�F Iy,(G��1wgrt P�✓�'S,r�r;) y �i ' a�. e = dr 11IS 1{ �` 'a'4 ��Y � j�,g�yY�i+ra,'I�'�;ff 3'2 ttib I• tr. � Yc [r hs F �, 1. I rrdAi � ' P {{ 1' , .y 'r< ai t Yom,,.,.--•'.""`°`_.- ',{ a� t)��r{ , �, k}:+�• �S'}rtkPayr�i'dv�s4`1.,�ll•�i S r i�I 5. � 3 t ,': '1 t ,� � :� +� tl°H I }' o 'M � >, s,p a. 7 t Rp Y {k ;� r r a i t 4 Y. t • ; �r''�a �YYz ��I. 'yet d.�titT r`:�Ist'`i!�;"�����fi',Y 1 r; x �.,t v ' t Y 1i i+ r`k �� .— -_ �..1 f� '•, Igg t d9, YTf'� IYT! S TRANSFEIREI� TQ:, N4 � � �,P't'i.'�� I'=�i �'T�4i 4 tau,t,y '+�i�rf y- � q '• � a P � <lt dt„'F h7 Itl� -�{�I(��, tMe#y�{,��ri ` 1. � e l�; f ' ✓ ' /�t.1 �� r lJ• ;p } 1rr YaLt Y ..��. .W w Y �¢ (, tt3 9 J 13 fpiPdi�, r r✓I I4 b r. i4 1,(h 7 '�� �. ,� �+'y +� -M1r J �✓ A Ai',� IY>hf � �'a ear .t [�t[_ &MR..' d tib! 2 �, rT sa 5 r it N 1, 1�t RE,° �yaaa�cf7s �'i, o �•`I r t a13 r .� "a �+.`C "`.,.. r Yqw1)6vcr i2-4o. i+o 1�b AIO#n St 47 RAIIRAADC A8ffitVItE l,d�4 A n®4v®r &ri=r u I c I GJ-C]614 Bp4DFM• Mh 01835 Lich 978-372.7472 Pan 0rDIM FJPMM FOR Tom Cp ADEREss F/ 7 - /7 S . 16 / 7_ )S� 7- 1 16 � Sao 7^ Psi /c?,)c IQav taop v�hn,san �� 1 ✓ �'/9 I/art Sc�dem �-� � 5-Q 15bp 16 00lip a ( O )00<). I9�c 15 0 073 LJ)1Ilow �'�� 10 t Ervin // , 5 • RECEIVED V14 SEP 7 2005 UA I kSYTTTkl PUI'v pj?,4U RP-,C`17k ... . ... TOWN OF NORTH ANDOVER �YSrEM �WHEALTH DEPARTMENT AA & Ana _..__.._ _.,__._.-.__ - - Ile c5� !� 104r or- �, V 7 .,.�,._ . IANTITY PL.!MPrr - �Z)0 _.... sPOOL: Nq__Le Yn J"UKE OF' 9 Rvrc. KUV'f"trr u ry"A Y A ► flUNJ. 0000 com)� RAVY C)Rl.A38 OXCUSIYE SOLIDS __.. M40DJrD EXP L TOWN OF NORTH ANDOVER SEWAGE DISPOSAL SYSTEM INSTALLATION CERTIFICATION The undersigned hereby certify that the Sewage Disposal System ( 'constructed; ( ) repaired; by LJrIA located at CC) -f, CbV_ was installed in conformance with the Northover Board of Health approved.plan, System Design Permit#( l>3bdated with an approved design flow of 4110 gallons per day. The materi is used were in conformance with those specified on the approved plan; the system was installed in accordance with the provisions of 310 CMR 15.000, Title 5 and local regulations, and the final grading agrees substantially with the approved plan. All work is accurately represented on the As-built which has been submitted to the Board of Health. Bed inspection date: Engineer Representative Final inspection date: Engineer Representative Installer: Lic.#: Date: 9121. Design Engin r. Date: Address ltcso SA4.,P c Title of File Page of Date File Open Date file closed: Doc Document/Action Title Date of Refer to other Purpose of Document/Action and notes T action Document/ document/ Num. Action Department Board of Appeals — Board of Health — Planning Board — Conservatiion Commission — Building Departrnent f � � BOR f F'.NEr. : 'I 1264 Commonwealth of MassachusettsA an "�J Executive Office of Environmental Affairs ®apartment of Environmental Protection William F.Weld Trudy Coxe Gooemor secretary Argeo Paul Ceiluccl David B.StruhS U.G mnror Commissioner SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A '`CERTIFICATION Property Address: I 100 Qv�8�-• e�O��6'Address of Owner. Date of Inspection: 3 (If different) Name of inepcctor. Q t` "A-950 Company Name,Address and Telephone Number. "BATESON ENTERPRISES, INC. TEL:(508)475-1474 Excavating-Water&Sewer lines-Septic Systems&Pumping Service FAX:(508)475-5451 111 Argilla Road Andover,Mass.01810 CERTIFICATION STATEMENT I certify that I have personally inspected the sewage disposal system at this address and that the information reported below is true,accurate and complete as of the time of inspection. The inspection was performed based on my training and experience in the proper function and maintenance of on-site sewage disposal systems. The system: _ Passes Conditionally Passes ' Nher Evaluation By the Local Approving Authority _ ails Inspector's Signature: t Date: The System Inspector.shall submit a copy of this inspection report to theApproving Authority within thirty(30)days of completing this inspection: If the system isfa 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 Department of Environmental Protection. The original should be sent to the system owner and copies sent to the buyer, if applicable and the approving authority. 0 INSPECTION SUMMARY: CheckAB , , C, or D: Al SYSTEM PASSES: { I have not found any information which indicates that the system violates any of the failure criteria as defined in 310 CMR, 15.303. Any failure criteria not evaluated are indicated below. Bl SYSTEM CONDITIONALLY PASSES: One or more system components need to be replaced or repaired. The system,upon completion of the replacement or repair,passes inspection. Indicate yes, no, or not determined(Y,N,"or ND). Describe basis of determination in all instances. If"not determined",explain why not) The septic,tank is metal, cracked,structurally unsound,shows substantial infiltration or exfiltration,.or.tank.failure is imminent., The system will pass inspection'if the existing septic tank is replaced with a Fonforming septic tank as approved by the Board of Health. (revised 11/03/95) 1 r. One Winter Street • Boston,Massachusetts 02108 a FAX(617)556-1049 a Telephone(617)292-5500 B ice.Printed on Recycled Paper 1 a SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: t l cosck'\avkA-�� W6 q1 • �x�\ Owner. FA J QS "iC4 a yrs Date of Inspection: vV 'B)SYSTEM CONDITIONALLY PASSES (continued) Sewage backup or breakout or high static water level observed in the distribution box is due to broken or obstructed pipe(s) or due to a broken,settled or uneven distribution box. The system will pass inspection if(with approval of the Board of Health): broken pipe(s)are replaced obstruction is removed distribution box is levelled or replaced _ The system required pumping more than four times a year due to broken or obstructed pipe(s). The system will pass inspection if(with approval of the Board of Health): btoken pipe(a)we replaced obstruction is removed 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 the public health, safety and the environment. 1) SYSTEM WILL PASS UNLESS BOARD OF HEALTH DETERMINES THAT THE SYSTEM IS NOT FUNCTIONING IN A MANNER WHICH WILL PROTECT THE PUBLIC HEALTH AND SAFETY AND THE ENVIRONMENT: Cesspool or privy is within 50 feet of a surface water Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh. 2) SYSTEM WILL FAIL UNLESS THE BOARD OF HEALTH (AND PUBLIC WATER SUPPLIER.IF APPROPRIATE) DETERMINES THAT THE SYSTEM IS FUNCTIONING IN A MANNER THAT PROTECT THE PUBLIC HEALTH AND SAFETY AND THE ENVIRONMENT: The system has a septic tank and soil absorption system and is within 100 feet to a surface water supply or tributary to a surface water supply. The system has a septic tank and soil absorption system and is within a Zone I of a public water supply well. The system has a septic tank and soil absorption system and is within 50 feet of a private water supply well. The system has a septic tank and soil absorption system and is less than 100 feet but 50 feet or more from a private water supply well,unless a well water analysis for coliform bacteria and volatile organic compounds indicates that the well is free from pollution from that facility and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm. 3) OTHER (revised 11/03/95) 2 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address: 00 sc ,ems Owner. d s Date of Inspection.- H� S D] SYSTEM FAILS: LI--<,W determined that the system violates one or more of the following failure criteria as defined in 310 CMR 15.303. The basis for this determination is identified below. The Board of Health should be contacted to determine what will be necessary to correct the failure. Backup of sewage into facility or qMtem com one due to an overloaded or clogged SAS or cesspool. ox .t ,}mak Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool. V 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 1/2 day flow. 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 Soil Absorption System, cesspool or privy is below'the high groundwater elevation. Any portion of a 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 I 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 60 feet from a private water supply well with ao acceptable water quality analysis. If the well has been analyzed to be acceptable,attach copy of well water analysis for coliform bacteria,volatile organic compounds,ammonia nitrogen and nitrate nitrogen. E] LARGE SYSTEM FAILS: The following criteria apply to large systems in addition to the criteria above: The system serves a facility with a design flow of 10,000 gpd or greater(Large System)and the system is a significant threat to public health and safety and the environment because one or more of the following conditions exist: _ 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) The owner or operator of any such system shall bring the system and facility into full compliance with the groundwater treatment program requirements of 314 CMR 5.00 and 6.00. Please consult the local regional office of the Department for further information.. (revised 11/03/95) 3 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST Property Address: Dante of Inspection" `K- � �� ,� �G vs�S 6- camti Check if the�fo]Ulohave been done:nformation was requested of the owner, occupant, and Board of Health. req Pan he 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 system recently or as part of this inspection. NAs plans have been obtained and examined. Note if they are not available with N/A. �The fhai'ty or dwelling was inspected for sign's of sewage back-up. The m does not receive non-sanitary or industrial waste flow _The�s' -was inspected for signs of breakout. r!/�The m components, excluding the Soil Absorption System, have been located on the site. _ ic tank manholes were uncovered,opened, and the interior of the septic tank was inspected for condition of baffles or tees terial of construction,dimensions,depth of liquid,depth of sludge, depth of scum. VThe size and location of the Soil Absorption System on the site has been determined based on existing information or epp ted by non-intrusive methods.. _The facility owner(and occupants, if different from owner)were provided with information on the proper maintenance of Sub- Surface Disposal System. (revised 11/03/95) 4 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C tt SYSTEM INF�O�R�M�ATIO Property Address: Owner. Date of Inspection: FLOW CONDITIONS RESIDENTIAL• Design flow: (7 ons Number of bedrooms: S Number of current residents: W l- Garbage grinder(yea or no): L � Laundry connected to (yes or no). Ivo Seasonal use(yes or no): 1 D �.�Ol ` `fir `^` V AL Water meter readings, if available: Last date ��ff�� ��C of occu LJ�7 ` �' P�cY COMMERCIAL/INDUSTRIAL: Type of establishment: Design flow:_ gallons/day Grease trap present: (yes or no)_ Industrial Waste Holding Tank resent: (yes or no) Non-sanitary waste discharged to the Title 5 system: (yes or no) Water meter readings,V available: Last date of occu Pancy: OTHER(Describe) Last date of occupancy: GENERAL INFORMATION PUMPING RECORDS and source of information: 1 System pumped as part of inspection: (yes or no)_�� t If yes,volume pumped: gallons Reason for pumping: TYPE OP SYSTEM L/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)and source of information: Sewage odors detected when arriving at the site: (yes or no) � (revised 11/03/95) b a SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM�INlFORMATION/(continued) Property Addresx Owner. Date of Inspection: SEPTIC TANIC (locate on site plan) �p Depth below grade: Material of construction:_concrete_metal FRPat _other(eaplaia) Dimensions: 4 .3 J~0�al Q S Sludge depth: If Ainttvtce from top of sludge to bottom of outlet tee or baffle: � m Ae Scum thickness:'_ Distance from top of scum to top of outlet tee or baffle: JV- V � _ CON Distance from bottom of scum to bottom of outlet tee or baffle: g � C Comments: (recommendation for pumpi:q,..cgndi ion oil t and outlet tees or baffles, de th of li d level in relation to outlet invert,A ty evidence of 1 ,etc.) Q ���- �"��--- eb Wo CG GC�uQ�C' 1 V GREASE TRAP.%4-SD re_ (lceoto an sit*. p)an) Depth below grade: Material of construction:_concrete_metal_FRP_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: -r Comments: (recommendation for pumping, condition of inlet and outlet tees or bafflei,depth of liquid level in relation to outlet invert,structural integrity, evidence of leakage,etc.) (revised 11/03/95) 6 a s SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTIOd FORM PART C �l�t SYSTEM INFORMATION(continued) Property Address: 1 (3© r-�`'l.`'QJ`N`_ 2 ` T ` Owner. �,C_ �atMF S ���` IPl g Date of Inspection: TIGHT OR HOLDING TANK_ (locate on site plan) Depth below grade: Material of construction:_concrete_metal FRP—other(explain) Dimensions: l;p }}y� ap110ns Design flow: _ Gallons/day Alarm level: Comments: (condition of inlet tee,condition of alarm and float switches,etc.) DISTRIBUTION BOX: (locate on site plan) Depth of liquid level above outlet invert: Lf � ue— Comments: (note if leve and diptribu ' n i� ual, 'dente of solids carryover• widen of lea�cagerinto or out of box, _ Llk Cl l� PUMP CHAMBEIL.Y\0 e (locate on site plan) v Pumps in working order:(yes or no) Comments: (note condition of pump chamber,condition of pumps and appurtenances,etc.) . (revised 11/03/95) 7 i SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTI&FORM PART C SYSTEM INFORMATION(oontinued) Property Addreae: j UQ4A/`. lv &WADL 9/� Owner �. ����`IVIQ- ` Date of Inspection:/cn C3— SOIL ABSORPTION(SYSTEM SYYSSTEMM (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 pits,number:_ leaching chambers, number:_ leaching galleries,number: Teaching trenches, number,length:— leaching fields, number, dimensions: -1 -0 overflow cesspool,number: �1 l Comments: (note con 'tion o s ', signs of hydraulic failure, lev 1 of nding,co ion of vegetat' C. f�� ` V ' CESSPOOLS:11bv�;e (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: Mow(cesspool must be pumped as part of inspection) r 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.) (revised 11/03/95) 8 r Y a SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C `,- SYSTEM INN AMu-ex Property Address: t Q(O S1t � Owner. ( AQa 4,cb� �S DRf�sf IwrfRiA�u y '� -� � Dn Ut SKETCH OF SEWAGE DISPOSAL SYSTEM: include ties to at least two permanent references landmarks or benchmarks locate all wells within 100' (W li V - `a31 I oil i `NG fi � ag DEPTH TO GROUNDWATER Depth to groundwater: feet method of determination or approximation: rC1l/�Se QS�-�C' VQ" I a&Z� (revised 11/03/95) 9 a' : Town of North Andover, Massachusetts Form No.3 t NORTH BOARD OF HEALTH A 19 bs+ DISPOSAL WORKS CONSTRUCTION PERMIT S�CHUSE : Applicant NAME ADDRESS TELEPHONE Site Location Permission is hereby granted to Construct ( ) or Repairman Individual Soil Absorption Sewage Disposal System as shown on the Design Approval S.S. No. /CHAI AN, BOARD OF HEALTH Fee D.W.C. No. l0 3.0 I, APPLICATION FOR DISPOSAL WORKS CONSTRUCTION PERMIT DATE: CURRENT INSTALLER'S LICENSE# LOCATION: LICENSED INST R: . SIGNATURE TELEPHONE# - 7/ / CHECK ONE: REPAIR: NEW CONSTRUCTION: IF NEW CONSTUCTION, PLEASE ATTACH FOUNDATION AS-BUILT. Administrative Use Only $75.00 Fee Attached? Yes No Foundation As-Built? Yes No Floor Plans? Yes No Approval Date: i ! ,. Town of North Andover a NORTH OFFICE OF ?c�`t`a °O COMMUNITY DEVELOPMENT AND SERVICES A 30 School Street 9 ^; WILLIAM J. SCOTT North Andover,Massachusetts 01845 sgc,Hus�t�y Director December 31, 1997 Ben Osgood Jr. New England Engineering 33 Walker Road - North Andover, MA 01845 Re: 1100 Salem Street Dear Mr. Osgood : - This is to inform you that the proposed plans for the site referenced above have been disapproved for the following reasons: 1. No perc test in system area. 2. Less than 100' and 50' to wetlands (3 10 CMR 15.211). 3. Note 12 should be deleted. 4. Groundwater elevation on profile and T.P. #2 disagree. If a groundwater gradient is held throughout leach area, elevation should be higher relative to existing elevation of 102. Please correct. 5. System less than 50' from open drain/culvert (3 10 CMR 15.211). 6. Barrier for breakout should be poured concrete. 7. Signed agreement for grading easement required before plan approval. Variance for deed restriction and proof of filing for 3 bedrooms will also be required. 8. Deep hole required at location of tanks to determine groundwater elevation. Groundwater must be a minimum of 1 foot below inlets. 9. Please provide buoyancy calculations. 10. Please note that abutters must be notified in accordance with (3 10 CMR 15.405 (2) ). If you have any further questions, please do not hesitate to call the Board of Health Office at the number listed below. Sincerely, Sandra Starr, R.S. Health Administrator \ BOARD OF APPEALS 688-9541 BUILDING 688-9545 CONSERVATION 688-9530 HEALTH 688-9540 PLANNING 688-9535 cc: James Higgins William J. Scott, Director, MCD File Town of North Andover f NORTR 14 OFFICE OF p 3? *,,a o •'�ppL COMMUNITY DEVELOPMENT AND SERVICES ° . A 30 School Street L �' WILLIAM J.SCOTT North Andover,Massachusetts 01845 �,ss';�H�SE``� Director May 29, 1998 Ben Osgood, Jr. New England Engineering 33 Walker Road North Andover, MA 01845 RE: 1100 Salem Street Dear Mr. Osgood: This letter is a confirmation that on May 28, 1998, the North Andover Board of Health granted the following variances: a) 8 feet to property line b) 11 feet to foundation c) 3 feet to groundwater instead of 4 feet d) 50 feet to wetlands instead of 100 feet Please call the Board of Health Office if you have any questions. Sincerely, Sandra Starr, R.S. Health Administrator Cc: Wm. Scott, Director, CD&S J. Higgins File CONSERVATION-(978)688 9530 • HEALTH-(978)688-9540 • PLANNING-(978)688-9535 *BUILDINGOFFICE-(978)688-9545 0 *ZONING BOARD OF APPEALS-(978)688-9541 • *146 MAIN STREET Town of North Andover HORT►y OFFICE OF 3i `"` 6 CO MMUNITY DEVELOPMENT AND SERVICES p 30 School Street North Andover Massachusetts 01845 '� "°�,.4°�^'`<y WILLIAM J.SCOTT 9SS�CHU Director June 1, 1998 Ben Osgood, Jr. New England Engineering 33 Walker Road North Andover, MA 01845 RE: 1100 Salem Street Dear Ben: This is to notify you that the proposed septic plans for the repair of the system at 1100 Salem Street, dated 4/23/98 have been approved. If you have any questions, please do not hesitate to call the office. Sincerely, Sandra Starr, R.S. Health Administrator cc: Wm. Scott, Dir. CD&S J. Higgins File CONSERVATION-(978)688 9530 .• HEALTH-(978)688-9540 PLANNING-(978)688-9535 *BUILDINGOFFICE-(978)688-9545 • *ZONING BOARD OF APPEALS-(978)688-9541 • *146 MAIN STREET Town of North Andover, Massachusetts Form No. 1 NORTH BOARD OF HEALTH (� 3�°y t1�ED /6 6 0 / • LJ�e �/_ 7 17 //yyVyyy � O �. 'oti0# o., E-«,� APPLICATION FOR SITE TESTING/INSPECTION SSACHUs���y Applicant NAME ADDRESS TELEPHONE Site Location lleo z:5/9L Cc/V Engineerj NAME ADD__REES/SS �g TELEPHONE Test/Inspection Date and Time Q40,47 2dRtta-e:i�a� CHAIR AN,BOARD OF HEALTH©©/ Fee Test No. O/� S.S. Permit No. D.W.C. No. C.C. Date Plbg. Permit No. Town of North Andover, Massachusetts Form No. 1 NORT)q BOARD OF HEALTH 3? 5� Q� 19 * - 07 * c ' °� APPLICATION FOR SITE TESTING/INSPECTION ��SSaCHus���y 17 Applicant NAME / ADDRESS TELEPHONE Site Location .r. Engineer-- NAME rADDRESS TELEPHONE Test/Inspection Date and Time CHAIRMAN,BOARD OF HEALTH Fee Test No. ' S.S. Permit No. D.W.C. No. C.C. Date Plbg. Permit No. Town of North Andover, Massachusetts Form No.2 f NORTq BOARD OF HEALTH o � � S « 3 DESIGN APPROVAL FOR b�Ano SSACMUSOIL ABSORPTION SEWAGE DISPOSAL SYSTEM Applicant" + S Test No. Site Location Reference Plans and Specs. �w ENGINEER DESIGN DATE Permission is granted for an individual soil absorption sewage disposal system to be installed in accordance with regulations of Board of Health. CH70R ,BOARD OF HEALTH : Fee— �� Site System Permit No. / �_ Town of North Andover t NORTH ti OFFICE OF COMMUNITY DEVELOPMENT AND SERVICES A « . • t .^ i 30 School Street North Andover, Massachusetts 01845 '°•, ° "ey WILLIAM J. SCOTT 9SSAcHuses Director May 29, 1998 Ben Osgood, Jr. New England Engineering 33 Walker Road North Andover, MA 01845 RE: 1100 Salem Street Dear Mr. Osgood: This letter is a confirmation that on May 28, 1998, the North Andover Board of Health granted the following variances: a) 8 feet to property line b) 11 feet to foundation c) 3 feet to groundwater instead of 4 feet d) 50 feet to wetlands instead of 100 feet Please call the Board of Health Office if you have any questions. Sincerely, ��; etla� Sandra Starr, R.S. Health Administrator Cc: Wm. Scott, Director, CD&S J. Higgins File CONSERVATION-(978)688 9530 • HEALTH-(978)688-9540 PLANNING-(978)688-9535 *BUILDINGOFFICE-(978)688-9545 • *ZONING BOARD OF APPEALS-(978)688-9541 • *146 MAIN STREET �... I� ,VrION rOR DISE. �4�;::MORKS. -(XN .2UCT10N-:EER�Y DATE: . C� _ CURRENT INSTALLER'S LICENSE# ..F LA ; P7 CHE Ck `y " NEW CONSTRUCTION: tiw,'r• a 7Fyr y �a �r .� - Yibru ea p w�cR;j y�r^F v _ .'�'�•,.r °'�...it:ii.Pu..i�-.�..w..Ca�i7.•�}�.±,i��".st.1t:..1�VF .�e. t }t.At��.d:.�.Ki.A fc^,«ia:;LS�r.LGt a ,.,. 'f�'. .. Administrative Use Only $75.0 :Fee,:-AuacdedZ Yes... No Town of North AndoverNORTh OFFICE OF .��c e �4, 3?O•� c.�� OL COMMUNITY DEVELOPMENT AND SERVICES p 30 School Street WILLIAM J. SCOTT North Andover,Massachusetts 01845 "SsgcNust`�y Director December 31, 1997 Ben Osgood Jr. New England Engineering 33 Walker Road North Andover, MA 01845 Re: 1100 Salem Street Dear Mr. Osgood : This is to inform you that the proposed plans for the site referenced above have been disapproved for the following reasons: 6�-1. No perc test in system area. .f-2. Less than 100' and 50' to wetlands (310 CMR 15.211). Note 12 should be deleted. __­!r.-_Groundwater elevation on profile and T.P. #2 disagree. If a groundwater gradient is held throughout leach area, elevation should be higher relative to existing elevation of 102. Please correct. .t-5. System less than 50' from open drain/culvert (3 10 CMR 15.211). 6. Barrier for breakout should be poured concrete. 7. Signed agreement for grading easement required before plan approval. Variance for deed o8restrictionand proof of filing for 3 bedrooms will also be required. 88,� Deep hole required at location of tanks to determine groundwater elevation. Groundwater must be a minimum of 1 foot below inlets. -4,-- 9. Please provide buoyancy calculations. �1"Please note that abutters must be notified in accordance with (3 10 CMR 15.405 (2) ). If you have any further questions, please do not hesitate to call the Board of Health Office at the number listed below. Sincerely,` .. k'X&'12 Sandra Starr, R.S. Health Administrator BOARD OF APPEALS 688-9541 BUILDING 688-9545 CONSERVATION 688-9530 HEALTH 688-9540 PLANNING 688-9535 s NEW ENGLAND ENGNIC EERING SERVICES wl May 2, 1998 Sandra Starr, Health Administrator North Andover Board of Health 30 School Street North Andover, MA 01845 Re: 1100 Salem Street Dear Sandra: Enclosed are three copies of a revised plan for the above referenced property. The plan has been revised to reflect the concerns of your letter dated December 31, 1997. The changes made are as follows: 1- A perc test has been done in the area of the system. The rate that was obtained is much lower than the rate originally used for design, which has caused the system design to be much smaller. 2. The soil absorption system is now designed to be 50 feet from the wetlands. A variance to the local bylaw will be needed to allow the system to be closer than 100 feet to the wetlands. This has been noted on the plans. 3. Note 12 has been revised to reflect the design condition. 4. The existing grade at the highest point in the proposed soil absorption system location is in an area where a large amount of fill was deposited to facilitate construction of the existing house. It can be said with reasonable certainty that the water table is no higher at that point than in test pit#2. If you do not agree with this statement then an additional test pit can be done at your convenience. 5. The system is currently designed with the soil absorption system 33 feet from a corrugated metal culvert that drains water from one side of Salem Street to the other. This drain is not a drain that intercepts groundwater so a local upgrade of title 5 is not required, however under the local bylaw the offset requirement is 50 feet. A note has been added to the plan requesting a local bylaw variance to reduce the distance from the required 50 feet to 33 feet. 6. The new design does not have a barrier. 33 WALKER ROAD-SUITE 23-NORTH ANDOVER, MA 01845-(978)686-1768-(888)359-7645-FAX(978)685-1099 7. The new design does not show filling on the adjacent property so no easement is needed. Since the leaching facility meets the 900 sq. ft. minimum required by the Town of North Andover local bylaw the system meets the size requirement for a four bedroom house. 8. This office has never seen the requirement that inlet inverts be one foot above the groundwater in the area of the tanks. If the groundwater gradient follows the ground, then based upon test pits one and three the tanks will be almost totally under water. However, the inlet grade exists and can not be changed without major renovation to the interior of the home. If this is a requirement(this office would like to be shown where it exists) a variance to this requirement will be needed. 9. Bouyancy calculations have been provided. H2O tanks have been specified to overcome buoyancy. 10. This revised plan does not require any DEP variances so the abutters do not need to be notified. I feel that it would be appropriate to sit and discuss this plan and any concerns you may continue to have prior to you sending out an additional formal letter and prior to the Board of Health meeting for the variances. The purpose of this meeting would be to try and streamline the process of approval so the owners can have this system constructed in the next few months. If you have any other questions or concerns please do not hesitate to contact this office. Yours truly, Benjamin C. Osgodd, Jr., EIT President SEPTIC PLAN SUBMITTALS LOCATION:--//(90 NEW PLANS: YES $60.00/Plan C) REVISED PLANS: YES $25.00/Plan DATE: '5-h-3 DESIGN ENGINEER:/61, -••s14,� ��x•��;r ����ceJ-1�L When the submission is all in place, route to the Health Secretary 70�14H 5LS Nor/ �r�v . r PLAN REVIEW CHECKLIST ADDRESS 5 A,/-C/t f S/- ENGINEER GENERAL 3 COPIES&Z STAMP LOCUS. NORTH ARROW 1/ SCALE CONTOURS'`' PROFILE t;-' (Sc) - SECTION `�� BENCHMARK SOIL & PERCS ELEVATIONS WETS. DISCLAIMER v "WELLS & WETS - �R- WATERSHED? IVV DRIVEWAY �! WATER LINE �� FDN DRAIN `- M&P SCH40 t,-� TESTS CURRENT? SOIL EVAL T-19 A)6 A) [� SEPTIC TANK - . MIN 150OG .1.7 INVERT DROP.__ GARB. GRINDER:- (2 comps +200) _ 10 ' TO FDN MANHOLEL ELEV GW #---COMPS. GB D-BOX _ SIZE - --- # LINES FLRST 2 ' LEVEL STATEMENT INLET/&Z. 33 OUTLET 17 (2." OR . 17 FT) - TEE REQ'D?y4e� LEACHING - - MIN 440 GPD?Z RESERVE ARE_ Az 4' FROM PRIMARY?— 20 SLOPE � 1 / 100 ' TO WETLANDS, 100 ' TO WELLS 4 ' TO S.H.GWJ-_ (5 ' >2M/IN) 20 ' TO FND & INTRCPTR..DRAI.NS, 400 ' TO SURFACE H2O SUPP 4 ' PERM. SOIL BELOW FACILITY MIN 12" COVER FILL? (15 ' ) BREAKOUT MET? � v �° 92k TRENCHES MIN 440 gpd SLOPE (min .005 or 6"/1001 ) SIDEWALL DIST. 3X EFF. W OR D (MIN 6 ' ) RESERVE BETWEEN TRENCHES? IN FILL? MUST BE 10 ' MIN. 4" PEA STONE? VENT? ( >3 ' COVER; LINES >501 ) BOT + SIDE = X LDNG = TOT (L x W x #) (DxLx2x#) (G/ft2) Copyright © 1996 by S.L. Starr PITS MIN 440 LEACHING MIN 1 ( 13 'x16 ' ) PIT MANHOLE/PIT GW MIN 4 ' BELOW BOTTOM EXC 2x EFF W OR D 12"-48" STONE BOT + SIDE x LOAD =TOTAL (L x W x #) -(2x(L+W)xD x #) (G/ft2) CHAMBERS= MIN." 440' LEACHING GW MIN 4" BELOW COVER >3 FT - VENT MANHOLES. 12"-48" STONE SPLASH PADS SLOPE .005 - BED./TRENCH. (Bed max:_--60 ' X 601 ) MIN 13 ' -X -16 ' PIT BOT ' + SIDE - X' LOAD = TOTAL (L x W x # ) (2—x- (L+W)xD x #) (G/ft2) - FIELDS. MIN 440 GPD 900 ft2 BEDy GW MIN 4' BELOW BOTTOM OF FIELD J`T L PIPE ENDS JOINED? / 4" PEA STONE? Lf"� DIST. LINE SLOPE . 005? >3 'COVER=VENT` SCH 40 '1> MIN 12" COVER RATE kQ MPI X 30 X ' 16 = TOTAL L W LDG -IqL DOSING TANKS AND PUMPS DIMENSIONS_X_ X = PUMP CAPACITY gpm L W D Vol. DISCHARGE SIZE DISCHARGE RATE DISCHARGE TIME 9Pm MANHOLES TO GRADE �� ALARM SEP . CIRC. GW- (Min. 1 ' below inlet) HWL.��,`iI LWL CHECK VALVE BLEEDER HOLE MANUAL OP. SWITCH ✓ ENUF STORAGE? . �� Copyright Q 1996 by S.L. Starr ISI • o , FORM 11 - SOIL EVALUATOR FORM Page 1 of 3 • ���ms's : No. f� - Date �e ,?7 Commonwealt of Massachusetts Massachusetts .Soil Suitability Assessment,dor On-site Sewage Dis nosal Performed By:`,1c7� ....... ...... , ... Date: ���. ._....... WitnessedBy: .....:7 .?,P ......... .2 .................................................................................................. _................... Location Adonis or � �-A�f �—, owners Num, � �5 W/e,-a Lo`I ,/n4 i T� , /��o ��i,and «sem 7 i ew Construction ❑ Repair Office Review Published Soil Survey Available: No ❑ Yes Z Year Published ....... Publication Scale I Z.Si. Soil Map Unit .. Drainage Class -2� .:........ Soil Limitations e4�/....... '' -r .!L'T ................._......._......_. Surficial Geologic Report Available: No I Yes ❑ Year Published _..... ... Publication Scale ..._... GeologicMaterial (Map Unit) ......................................................................................................................._............,.�........._..._ Landform .............................................................................................................-----.._.-------..-...._..__.... Flood Insurance Rate Map: 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) .......................................................................................... ......... a Current Water Resource Conditions(USGS): Month v........ .. Range :Above Normal ❑Normal ❑Belcw Normal 91 Other References Reviewed: DEP APPROVED FORM-12/07/95 FORM 11 - SOIL EVALUATOR FORM t� Page 1 of 3 No. �� Dater o �7 Commonwealt of Massachusetts A/0.� Massachusetts .Soil Suitability Assessgnt for On-site Sewage pgSaj Performed By:`>1 �lll�....... ...... ,�x�•��,��... Date: /��.1 ._....... WitnessedBy: .... ,� 4. �P ......... .2 ........................................................................................................................_................... Lxation Address or /1�l�jT, Owntti Nemo. ��HJ ,j /�o�o/�.s Lot r Addms,and ' 14 relepl M I pew construction ❑ Repair Office Review Published Soil Survey Available: No ❑ Yes S Year Published /q �....... Publication Scale � ..i. Soil Map Unit 6 .. Drainage Class �� '�.:........ Soil Limitations /....... '' .r !L'T _ .......__...._. Surficial Geologic Report Available: No [ Yes ❑ i Year Published _.......,...... Publication Scale x..........._.. GeologicMaterial (Map Unit) ..................................................................................................................._........... ...._.... Landform ....................................... ......... . .......... .................. Flood Insurance Rate Map: Above 500 year flood boundary No ❑Yes ❑ Within 500 year flood boundary No El Yes ❑ ' Within 100 year flood boundary No F-1 Yes ❑ Wetland Area: National Wetland Inventory Map (map unit) .....................:......................................................................... ..._. .._... Wetlands Conservancy Program Map (map unit) ............................................................................................. Current Water Resource Conditions(USGS): Month v .. ..... .. Range :Above Normal []Normal ❑Belcw Normal Other References Reviewed: DEP APPROVED FORM-12/07/95 FORM 11 - SOIL EVALUATOR FORM Page 2 or 3 Location Address or Lot No. 1/�o On-site Review Deep Hole Number ..:r.. Date:�e��/l' Time. '?C) '� Weather/1Z�F �L� Location (Identify on site plan) ���:.:...::::.:::::::..::....:: . ....::.:...- ..:...:..:::..::.:... . ...:...:.::::. ......... ..:...... . ..::::.. . .. Land Use . Slope M . Z . . Surface Stones . -:..:.. . Vegetation Landform Position on landscape (sketch on the back) .. .:.. :.:..... Distances from: Open Water Body Zmmo feet Drainage way feet Possible Wet Area . 36- feet Property Line :.. . `— feet Drinking Water Well 7i oo feet Other . DEEP OBSERVATION HOLE LOG' Depth from Soil Horizon Soil Texture Soil Color Soil Other Surface(Inches) (USDA) (MunselO Mottling (Structure,Stones, Boulders, Consistency, % Gravel) 3/z oel � � m Q� � s Z.S <#Z 11 r s e C 5 �7A Parent Material(geologic) OC C-L _ci�%��5' DepthtoSedrock: Depth to Groundwater: Standing Water in the Hole: Weeping from Pit Face: Estimated Seasonal High Ground Water: DEP APPROVED FORM-12/07/95 FORM 11 - SOIL EVALUATOR FORM Page 2of3 Location Address or Lot iso. On-site Review Deep Hole Number ..../ Date:���/l' Time:'�� Weather//Z'J F —1 ..Si .� Location (identify on site plan) ��' :.:::..:.::.:.:.: :..:...... . . .. .-�. .. . ... Land Use . i ,c Slope M . Z. . Surface Stones .. .....: . .... Vegetation .CEJ v:..::.: :.. . . . . ..:...:..... ..:.:...:..:........::.:.:.::...::.::::.........:. .. Landform Position on landscape (sketch on the back) :.:..... Distances from: Open Water Body Zomo feet Drainage way . .60 feet Possible Wet Area . �S feet Property Line :.. ` feet _ t Drinking Water Wellfeet Other . DEEP OBSERVATION HOLE LOG! Depth from Soil Horizon Soil Texture Soil Color Soil Other Surface(inches) (USDA) (Munsell) Mottling (Structure,Stones, Boulders, Consistency, % Gravel) eye Oe �rr � j m �kl MINIMUM OF 2 HOLES REQUIRED AT EVERY PROPOSED DISPOSAL AREA Parent Material(geologic) ���/�CG�fL _�s� � t DepthtoBedrock: .1 '/ Depth to Groundwater: Standing Water in the Hole: �7 Weeping from Pit Face: Estimated Seasonal High Ground Water; DEP APPROVED FORM-12/07/95 FORM 11 - SOIL EVALUATOR FORM Page 2 of 3 Location Address or Lot No. 77- On-site ,Review / � 'a Deep Hole Number � ..:: Date: �l.��9� Time:. .o.• .: Weather�ljL Location (identify on site plan) Yd>�tt7 ..::7i: E7.:..:.:::.::.:..:::.:.. . ...:..:..::::. ......:::.....:..... . Land Use Slope M Surface Stones . .: . .... Vegetation . i¢55.... ... : :.. . . . ....:...:..... ..: :. ....:... ..:,.:.:.::...::.:.:...:.....: Landform Position on landscape (sketch on the back) .. .:.. . Distances from: Open Water Body Z�5 feet Drainage way . . feet Possible VYet Area . feet Property Line :.�z��.. feet Drinking Water Well feet Other .. DEEP OBSERVATION HOLE LOG' Depth from Soil Horizon Soil Texture Soil Color Soil Other Surface(inches) (USDA) (Munsell) Mottling (Structure, Stones, Boulders, Consistency, % Gravel) 3/Z lee 41 0VIC MOP v-2 p �v IOLES REQUIRED AT EVERY PROPOSED DISPOSAL AREA Parent Material(geologic) DepthtoBedrock: Death to Groundwater_: Standing Water in the Hole: Weeping from Pit Face: Estimated Seasonal High Ground Water: DEP APPROVED FORM- 12/97/95 FORM 11 - SOIL EVALUATOR FORM Page 2of3 Location Address or Lot No. On-site Review / 8 01 ra Deep Hole Number � ::: Date: �lTime:. . � Weather� /lL—,6� 5 Location (identify on site plan) jC 7E ...::Ji, r \i'" ' .:..:.::::.:::..:::.:.. . ...:...:.:::.:.......:..::..:..... . Land Use ..... / TGA Slope M Surface Stones . _:........: . .... Vegetation . 55.... :, ... . . . .............. ..:.:..:...:... ..::.:.:.:.:..::.::::.........: Landform .... ..G�X7`�� /Z /.�..... Position on landscape (sketch on the back) .. .:.. ....:.. Distances from: Open Water Body 2�� feet Drainage way feet Possible Wet Area ifeet Property Line :.'%��.. feet Drinking Water Well ..:.: feet Other . DEEP OBSERVATION HOLE LOG* Depth from Soil Horizon Soil Texture Soil Color Soil Other Surface(Inches) (USDA) (Munsell) Mottling (Structure,Stones, Boulders, Consistency, % Gravel) �2 AI MINIMUM OF 2 HOLES REQUIREL POSED DISPOSAL AREA Parent Material(geologic) � � DepthtoSedrock: Death to Groundwater: Standing Water in the Hole: � Weeping from Pit Face:_ Esjimated Seasonal High Ground Water: 'q�y�� DEP APPROVED FORM-1210719S FORM 11 - SOIL EVALUATOR FORM Page 2of3 Location Address or Lot No. %/�� CG �7` AXD L ,� On-site Review Deep Hole Number .`� ... Date: jet. /9/ Time:. ���' Weather 1917 67� Location (identify on site plan) ,�� / ! % /,¢,PL7...:.:::.::::..::..:.. . ...:...:.:.:...:......:,._::..:..... . Land Use eT.... �►' ^n'� � Slope M Z Surface Stones _:........: . ... Vegetation . >�S .... :.:.:.:,...::.:..:.........: Landform Position on landscape (sketch on the back) ..'.:.. Distances from: Open Water Body Zmoo feet Drainage way feet Possible Wet Area feet Property Line :. .3`J.. feet Drinking Water Well feet Other .. DEEP OBSERVATION HOLE LOG* Depth from Soil Horizon Soil Texture Soil Color Soil Other Surface(Inches) (USDA) (Munsell) Mottling (Structure,Stones, Boulders, Consistency, % Gravel) L4. 3/Z� 4/�- lo% T q�J � Peel MINIMUM OF 2 HOLES REQUIREU AT EVERY PROPOSED DISPOSAL AREA Parent Material(geologic) OepthtoBedrock: Death to Groundwater: Standing Water in the Hole: Weeping from Pit Face; Estimated Seasonal High Ground Water; DEP APPROVED FORM.12/07/95 J FORM 11 - SOIL EVALUATOR FORA? Page 2 of 3 Location Address or Lot No. --:77`i /A/D, On-site Review Deep Hole Number .J� Dater.""/9/ Time:. ���' Weather 7j� g /�l�f'%. ,¢,�1� ... .Location (identify on site plan) ,��.....:.::.::.::... .�... : .....:..:.::::.:::..:::.:.. . .......::::.,:... ..:..: ..... Land Use Slope M -2—. Surface Stones . .l....:........: . .... Vegetation . .... : :.. . . . ....:...:..... .:..:. ...:..:.:..:,.:...:.:..::.::::.........: Landform .... .QUA �" "'� ..... . Position on landscape (sketch on the back) Distances from: Open Water Body Zmoo feet Drainage way feet Possible Wet Area feet Property Line :. . .. feet Drinking Water Well feet Other . DEEP OBSERVATION HOLE LOG" Depth from Soil Horizon Soil Texture Soil Color Soil Other Surface(Inches) (USDA) (Munsell) Mottling (Structure,Stones,Boulders, Consistency, % Gravel) 4i�- /D�l� — /J/ �j/i' / Uzi o/p, l 141<0 5 MINIMUM OF 2 HOLES REQUIRED AT EVERY PROPOSED DISPOSTL AREA Parent Material lgeo(ogic) ` ���'�"Y''C DepthtoBedrock: Depth to Groundwater: Standing Water in the Hole: Weeping from Pit Face:_ Esjimated Seasonal High Ground Water: DEP APPROVED FORM-12/07/95 FORM 11 - SOIL LVALUATOR FORM . Page 3 of 3 Location Address or Lot No. Determination for Seasonal High Water Table Method Used: ❑ Depth observed standing in observation hole................... inches El Depth weeping from side of observation hole................. inches Depth to soil mottles inches 'N4 / ` 4Z -7— El Ground water adjustment ................... feet � ,i 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 II areas observed throughout the area proposed for the soil absorption system? If not, what is the depth of naturally occurring pervious material? _ Certification I certify that on �O (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 • ate _ Al DEP APPROVED FORM-12/07/95 Y c . FORM 11 - SOIL LSVALUATOR FORM Page 3 of 3 Location Address or Lot No. f/rte Determination for Seasonal High Water Table Method Used: ❑ Depth observed standing in observation hole................... inches El Depth weeping from side of observation hole................. inches Depth to soil mottles 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 p1l areas observed throughout the area proposed for the soil absorption system? If not, what is the depth of naturally occurring pervious material? _ Certification I certify that on (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 ��Oate DEP APPROVED FORM-12/0719S NEW ENGLAND ENGINEERING ICUMN SERVICES, INC. 33 Walker Rd. Suite 23 NORTH ANDOVER, MA 01845 DATE JOB N0. Id 61f 7 PHONE (508) 686-1768 FAX (508) 685-1099 ATTENT'o RE: WE ARE SENDING YOU XAttached ❑ Under separate cover via the following items: ❑ Shop drawings EAC-Prints ❑ Plans ❑ Samples ❑ Specifications ❑ Copy of letter ❑ Change order ❑ i COPIES DATE NO. DESCRIPTION ff // 00 A10 THESE ARE TRANSMITTED as checked below: X For approval ❑ Approved as submitted ❑ Resubmit copies for approval ❑ For your use ❑ Approved as noted ❑ Submit copies for distribution ❑ As requested ❑ Returned for corrections ❑ Return corrected prints ❑ For review and comment ❑ ❑ FORBIDS DUE 19 ❑ PRINTS RETURNED AFTER LOAN TO US REMARKS Grr)VL _rs elec• CS tJL�a� /�4d�% .-ir� �sc�ry✓P/,� C/C'^ aa.eets COPY TO ��ri,�3 �s9���"3 SIGNED: - M enclosures are not as noted,kindly notify us at ce. SEPTIC PLAN SUBMITTALS LOCATION: ZD NEW PLANS: CYES� $60.00/PIan REVISED PLANS: YES $25.00/Plan A DATE: 7 DESIGN ENGINEER. When the submission is all in place, route to the Health Secretary i SEPTIC PLAN SUBMITTALS LOCATION: �- NEW PLANS: YE $60.00/Plan REVISED PLANS: YES $25.00/Plan DATE: DESIGN ENGINEER: �' / �' «cP.- SP/? mer v J When the submission is all in place, route to the Health Secretary ' 3 � �7 I b DATE: " c' / LOCATION: art _ ENGINEER: 8 194 BOH WITNESS: PERCOLATION TEST# _ BOTTOM DEPTH OF PERC TEST: TIME OF SOAK: - � (At least 15 minutes long) TIME AT 12" TIME AT 9" _ g0 TIME AT 6" OVERNIGHT SOAK TIME STARTED NEXT DAY SOAK: (At least 15 minutes) TIME AT 12" TIME AT 9" TIME AT 6" W Town of North Andover f HORTIy , OFFICE OF �2°�'' '°•,tib COMMUNITY DEVELOPMENT AND SERVICES A 30 School Street North Andover,Massachusetts 01845 sgc.NUs���y WILLIAM J.SCOTT Director December 31, 1997 Ben Osgood Jr. New England Engineering 33 Walker-Road North Andover, MA 01845 Re: 1100 Salem Street -- Dear Mr. Osgood : — This is to inform you that the proposed plans for the site referenced above have been disapproved for the following reasons: 1. No perc test in system area. 2. Less than 100' and 50' to wetlands (3 10 CMR 15.211). 3. Note 12 should be deleted. 4. Groundwater elevation on profile and T.P. #2 disagree. If a groundwater gradient is held throughout leach area, elevation should be higher relative to existing elevation of 102. Please correct. 5. System less than 50' from open drain/culvert (3 10 CMR 15.211). 6. Barrier for breakout should be poured concrete. 7. Signed agreement for grading easement required before plan approval. Variance for deed restriction and proof of filing for 3 bedrooms will also be required. 8. Deep hole required at location of tanks to determine groundwater elevation. Groundwater must be a minimum of 1 foot below inlets. 9. Please provide buoyancy calculations. 10. Please note that abutters must be notified in accordance with (3 10 CMR 15.405 (2) ). If you have any further questions, please do not hesitate to call the Board of Health Office at the number listed below. Sincerely, Sandra Starr, R.S. Health Administrator BOARD OF APPEALS 688-9541 BUILDING 688-9545 CONSERVATION 688-9530 HEALTH 688-9540 PLANNING 688-9535 cc: James Higgins William J. Scott, Director, MCD File NORTH ANDOVER BOARD OF HEALTH DESIGN REVIEW REPORT DATE_ %J FEE: *Q PERMIT # / DATE RECEIVED l`� APPLICANT J,QM6s )gt6-6/A3,5 MAP PARCEL ADDRESS //4O cJ/�LG� 51r LOT # STREET # ✓/6d ENG. 56cpS - A). Cf(16, CA)e,1 ,mac-*STREET- ENGINEER' S ADD. ,3 3 P LAN DATE DG/ -- off/, /CI 7 REV. DATE CONDITIONS OF APPROVAL - APPROVED DISAPPROVED ^ REASONS FOR DISAPPROVAL: - �. /UO `�E,�G i�ST /� 5��TES 19, /�•- -_-- -- a To GUc2`1 'Ud.S 6/6 C A4 R 1,5- Z /I A)GTG /L 5/ DUG D 6v --Pko�/cam (rg L) i&�T �5 /1EcD 7/�,�Ot�G/ DST ,9 /2 E� acv s/ ovc / T"D �.Y b /`r A) G -= it,' O f -%D7�1 D��/U 17�'�/i11/�'UG VU'•�y', vim, v 5 7TE/�l L C ,5.5 T/-�� T ca v J' f o v � J REVIEW CONTINUED SHEET ';L- OF ST/2lcl716/v ob A-(.s G )I l-6. 196 5 1/ C 19 rf9iv�S 7-6 ��T�, /�v Q��U . /v6 u>XI T � UO A/V G iU f GLA 5AJ OTC /tJOTI�i�lj /!v 19cco/leb 14 6- LVl7hV P/0 DATE: LOCATION. ENGINEER: ae tl BOH WITNESS: PERCOLATION TEST # TIME OF SOAK: L( _ (At least 15 m nutes long) a� TIME AT 12" 10 TIME AT d , TIME AT 6" ' OVERNIGHT SOAK TIME STARTED � -�� � (� . �• � C�- �.���c�Q ��� /2,'u. +�" NEXT DAY SOAK: ED 7 (At least 15 minutes) " TIME AT 12" _50.. �L-�t- /4v /5 TIME AT 9" /1 0 r �6 eI TIME AT'6" 0 ,plTly ° ,"`o '•,hyo Qhr ° BOARD OF HEALTH � i a ' 146 MAIN STREET TEL. 688-9540 'SSA Si NORTH ANDOVER, MASS. 01845 APPLICATION FOR SOIL TESTS DATE: dZ71,�-7 LOCATION Ot SOIL TESTS: /1P0 Assessor's map & parcel number: OWNER: ��tn�tc� �r(� �,,1s TEL. NO.: �v ADDRESS://00 � S7� ENGINEER: TEL. NO.: -/76 0 CERTIFIED SOIL EVALUATOR: Intended use of land: residential subdivision, single family home, commercial 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 $175.00 per lot for new construction. This covers the two deep holes and two percolation tests required for each lot. Fee of $75.00 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. 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. Y tJ5 NO ; rJ• �+µ'� r la�1.'i', t v iY 7 vrt 5+,7w b+�'la.l >'tl y,'.�r �Ir� � Jt 1. v 'J".1J+ ' + a' 7�`! 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't,,.�, r w17 r �.-r�c�ur�:iso'r�:,�.'�'w�;i;�AN��c�;i���a•��•r.,vl r . tl t �7�,1 ,r,. . :. �r,'i''r•'.>i�1�+7 ')rll�l 'SdihfJJtitr+1!u3�rl��lr a5'Ir11•'�d;.(�Jrr�)iu ----------------------------- •• ,; ;,,Ly1,,f• ',t.i:biia'jr',l)(i J1fr�rn•+,r•;4r.'r,. )': �Y r-,om:soucy's Sewer Service Inc. Month. ` Date Address Owners Name Gallons um d ' H,G,C,D,S Contents tranfered to Condition of s 2 _3 � Te �-�r:. _ hn � _3 � GoU S i $ 9 as 1goChrcL�i 1G s5SS 10 S 11 12 13 14 15 16 17 JUL 2 1$ TOWN OF NORT i ANDOVER )EP R T NIENT 19 20 w Cesspool, D= Drywell, S= Septic, G=Greasetra p, H= Holding Tank -C\ Commonwealth of Massachusetts w"Olm City/Town of NORTH ANDOVER MASSA -S o System Pumping Record Form 4 MAY 19 2008 DEP has provided this form for use by local Boards of Health. Thp System Pumping Re o d must be submitted to the local Board of Health or other approving authl pity. ,r,-1,t�RTMENT A. Facility Information Important: When filling out 1. System Location: forms on the computer,use only the tab key Address: to move your r1 ! A s,-• cursor-do not use the return City/Town State Zip Codes e key. 2. System Owner: 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 I . Type of system: ❑ Cesspool(s) [ Septic Tank ❑ Tight Tank ❑ Other(describe): 4. Effluent Tee Filter present? ❑ Yes [JNo If yes,was it cleaned? ❑ Yes ❑ No 5. Condition of System: 6. Sy em Pumped By: Name Vehicle License Number Company �- 7. Location where contents were disposed: r 6�,/P�I Y A Signature 0,Hauler I Date r http://www.mass,gov/dep/water/approvals/t5forms.htm#inspect t5form4.doc•06/03 System Pumping Record•Page 1 of 1 x` Commonwealth of Massachusetts City/Town of NORTH ANDOVER, MASSACHUSETTS System Pumping Record= Form 4 , DEP has provided this form for use by local Boards of Health. The System Pumping Record must be submitted to the local Board of Health or other approving authority. A. Facility Information Important: When filling out 1. System Location- forms forma on the . computer,use only the tab key Address to move your L I cursor-do not use the return Cit'Rown State Zip Code key. 2. System Owner. Name Address(if different from location) l Cityrrown State Zip Code Telephone Number B. Pumping Record , 1. Date of Pumping We 2. Quantity Pumped: Gallons 3. Type of system: ❑ Cesspool(s) Septic Tank ❑ Tight Tank ❑ Other(describe): 4. Effluent Tee Filter present? ❑ Yes ❑ No If yes,was it cleaned? ❑ Yes ❑ No 5. Condition of System: qo0d 6. stem Pumped By: rpt - ` ma � Vehicle License Number company 7. Location#4ere contents were disposed:00 C9 '1490 , 1cJy�-;G Signature of Hauler Date http:/twww.mass.gov/depANater/approvalstt5forrns.htm#inr)pect t5form4.doca 0=3 System Pumping Record•Page 1 of 1 f Commonwealth of Massachusetts W City/Town of No.Andover System Pumping, Record M SV a e 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 Pumpir]g Record�n.use be- ubmitted to the local Board of Health or other approving authority within 14 d i ate accordance with 310 CMR 15.351. A. Facility Information .£ r , Important: TOWN OF NORTH,ANOCAR When filling out 1. System Location: HEALTH DEpARt"TC��NT forms on the / //o (. "�/ k /�/� computer, use J / �./ �(JI' .( / I � only the tab key Address to move your- - cursor-do not +NO.Andoyer- Ma -C 845 use the return City/Town State Zip Code key. 2. System Owner: Name Address(if different from location) City/Town State Zip Code Telephone Number B. Pumping Record 1. Date of Pumping Date(� 2. Quantity Pumped: G�lon � 3. Type of system: ❑ Cesspool(s) /11 Septic Tank ❑ Tight Tank ❑ Grease Trap ❑ Other(describe): 4. Effluent Tee Filter present? .❑ Yes��] No If yes, was it cleaned? ❑ Yes ❑ No 5. Condition of System: 6 Syst um ed By: Na Vehicle License Number tewart's Septic Service Company 7. Location where contents were disposed: Stewart's Pre-treatment Plant, 20 So. Mill Bradford, Ma 01835 i � ­ / Sir7e o er Date g Si natur ceiving Facility Date / t5form4.doce 03/06 System Pumping Record a Page 1 of 1 �L\ Commonwealth of Massachusetts �� �`-~� W City/Town of North Andover a W° System Pumping Record Form 4 TVNN OFNORTH ANDOVER " t t c ALTH DEPAPTMEW 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. System Location: � y on the computer, ���1 i �� use only the tab I 1 key to move your Address cursor-do not North Andover Ma 01845 use the return . City/Town State Zip Code key. 2. System Owner: reb AA Name Address(if different from location) City/Town State Zip Code Telephone Number B. Pumping Record 1. Date of Pumping Ida, �)a Date 2. Quantity Pumped: Gallons 3. Type of system: ❑ Cesspool(s) Septic Tank ❑ Tight Tank ❑ Grease Trap ❑ Other(describe): 4. Effluent Tee Filter present? ❑ Yes [/No If yes, was it cleaned? ❑ Yes ❑ No 5. Condition of System: 6. stem Pumped B me Vehicle License Number Stewart's Septic Service Company 7. Location where contents were disposed: Stewart's Pre-treatment Plant, 20 So. Mill Bradford, Ma 01835 Sign of Ha er Date Signature of Wceiving Facility Date t5form4.doc•03/06 System Pumping Record•Page 1 of 1