HomeMy WebLinkAboutMiscellaneous - 1248 SALEM STREET 4/30/2018 (2) 1248 SALEM STREET
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North Andover MIMAP February 16,2012
106.A-0050 106..4-0121
106.A-0181 106..4-0182 ......:7 106-4-0175
106-4-008
8
. ...... ...
106-11-0043
106-4-0183 .......
-0176
106A-0041
--- - --- ---
W-
106.A-0118
7
106A-0184
4
106.A-01 19
106.A-0185
R1
106A-0186
R2 106A-0133
106-4-0187
-U6A-0134 106-4-0046
7'M,6�
AA-0143 106.A-0188
106.11C-0050
106.A-0160
106.C-0051
106.A-0122
106-4-0159
106.GO067 10640123
I CIO 8 4 106.A-0161
—Rail Line Exempt Lands
Interstates Zoning
Interstate Business 1(RA) Horizontal Datum:MA Stale lane Coordinate System,Datum NADB3.
Major Roads C Business 2(R-2) Meters Data Sources:The data for his map was produced by Merrimack
M Business 3�R-3) Valley Planning Commission(MVPCt)using data provided by the Town of
Roads .
Business 4 R-4) North Andover,Additional data provided by the Executive Office of
L7,Easements 13 General Business(G-B) Environmental Affairs/MassGIS.The information depicted on this map is
C3 MVPC Boundary 13 Planned Commercial Dev for planning purposes only.It may not be adequate for legal boundary
,,:ndus;(,.:1 0 definition or regulatory interpretation.THE TOWN OF NORTH ANDOVER
E3 Municipal Boundary Industrial 2 2 16. MAKES NO WARRANTIES,EXPRESSED OR IMPLIED,CONCERNING
- a
Zoning Overlay 13 Industrial 3(13) 41 4WI ♦ THE ACCURACY,COMPLETENESS,RELIABILITY,OR SUITABILITY
E3 Adult Entertainment 0 Industrial S(I-S) ilt. I. OF THESE DATA.THE TOWN OF NORTH ANDOVER DOES NOT
Historic District Residence I(R-1) r '0 0 ASSUME ANY LIABILITY ASSOCIATED WITH THE USE OR MISUSE OF
Water Protection Residence 2(R-2) THIS INFORMATION
0 Parcels
"Residence 3�R-3)
a
Re d nce 4 R4) A
Hydrographic Features C,Residence 5(R-5)
Streams Re &,g(R ),(VR)
ct.r�711TJ 'Is
Wetlands 0 Village Commercial(VC)
x - �
FORM - U - LOT RELEASE FORM
INSTRUCTIONS: This form is used to verify that all-necessary a 'royal
Boards and Departments having jurisdiction have been obtained. This does not relieve the ts from
applicant and or landowner from compliance with any applicable requirements.
APPLICANT_�/o �, ��(� l � � / PHONE 0 S ��
ASSESSORS MAP NUMBER O LOT NUMBER z
SUBDIVISION LOT NUMBER
STREET ��/�64, S'-/--
�............................................STREET NUMBER.... :...:...
.......................... OFFICIAL USE ONLY . �
RECOMMENDATIONS OF TOWN AGENTS i
.......................................... Z A-
..
CONSERVATION ADMINISTRATOR DATE APPROVED
DATE REJECTED
COMMEN'T'S
TOWN PLANNER DATE APPROVED
DATE REJECTED
COMMENTS
DATE APPROVED
FOOD INSPECTOR-HEALTH
DATE REJECTED
SEPTIC INSPECTOR-HHALTH DATE APPROVED
DATE REJECTED
COMMENTS L�� �l;�7�� �
AJ11vA9 770
PUBLIC WORKS-SEWER/WATER CONNECTIONS
DRIVEWAY PERMIT
FIRE DEPARTMENT DATE APPROVED
DATE REJECTED
COMMENTS
RECEIVED BY BUILDING INSPECTOR
DATE
a
R91 QQ
l
ls�
� r
(VA
(DO^
F
BOARp OF BUILDING
License: CONSTRUC77O REGULAT ONS
I Number: CS N 005743 SUPERVISOR
Birthdate: 03/26/1954
F-xPires:03/26/2002
Restricted To: 00 Tr.no: 23343
DAVID J DEVELLIS
198 MAIN ST
SANDOWN, NH 03873 !
Administrator
' COMMONA-TALTH OF MASSACHUSETTS
EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS
.`�
DEPARTMENT OF ENVIRONMENTAL PROTECTION
ONE WINTER STREET. BOSTON. MA 02108 617-292-5500
t'
WILLIAM F.WELD TRUDY COXE
Governo:
Secretary
ARGEO PAUL CELLUCCI DAVID B.STRUHS
Lt.Governor SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM Commissioner
�N`-� PART A
CERTIFICATION Xq�o 67
Property Address: i
Ct f Address of Owner:
Date of Inspection: 3- ,-Ll- (if different)
Name of Inspector: d{M g(J,5ilL
I am a DEP appr ved system inspector pursu nt to Section 15.340 of Title 5 (310 CMR 15.000)
Company Name: U P✓ e nth
Mailing Address:
Telephone Number:
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
Needs Further Evaluation By the Local Approving Authority
Fails
Inspector's Signature: Date:
The System Inspector shall submit a copy of this inspection report to the Approving Authority within thirty(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 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.
INSPECTION SUMMARY: Check A, B, C, or D:
A] SYSTEM PASSES:
1 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.
COMMENTS:
BI 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.
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, unless the owner or operator has provided the system inspector with a copy of a Certificate of
Compliance (attached) indicating that the tank was installed within twenty(20) years prior to the date of the inspection; or
the septic tank, whether or not metal, is 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 conforming septic tank
as approved by the Board of Health.
(revised 04/25/97) 'Paye 1 of 10
DEP on the Worid Wide Web* http://www.rnagnet.state.ma.us/dep
0 Printed on Recycled Paper
5
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION (continued)
Property Address: /� �• P� 5-1— /1/ 11-:;410
Owner: _
Date of Inspection: 3 a7. q9
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). Describe observations:
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):
broken pipe(s).are replaced
obstruction is removed
C) FURTHER EVALUATION IS REQUIRED BY THE BOARD OF HEALTH: Aid,
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 PROTECTS THE PUBLIC HEALTH AND SAFETY AND THE
ENVIRONMENT:
The system has a septic tank and soil absorption system (SAS)and the SAS 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 the SAS is within a Zone I of a public water supply well.
The system'has a septic tank and soil absorption system and the SAS is within 50 feet of a private water supply well.
The system has a septic tank and soil absorption system and the SAS 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. Method used to determine distance (approximation not valid).
3) OTHER
(revised 04/25/97) Page 2 of 10
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
> 4CERTIFICATION (continued)
Property Address: / / ;/Cew 5%""- �'� AxV 0 U C/ -0
Owner: L= e,</ e
Date of Inspection:
D) SYSTEM FAILS: -
You must indicate either "Yes" or No" as to each of the following:
I have 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.
Yes No
Backup of sewage into facility or system component due.to an 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 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 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 analysis for
coliform bacteria, volatile organic compounds, ammonia nitrogen and nitrate nitrogen.
El LARGE SYSTEM FAILS: ?o'
�J
You must indicate either "Yes"or " s to each of the following:
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:
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)
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 04/25/97) Raga 3 of 10
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART B
CHECKLIST
Property Address: .7/raj /�f/ p tI v
Owner: . Zj JE 1)
Date of Inspection: //
Check if the following have been done: You must indicate either "Yes" or"No"as to each of the following:
Yep No
✓/� _ Pumping information was provided by the owner, occupant, or Board of Health.
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 system recently or
as part of this inspection.
As built plans have been obtained and examined. Note if they are not available with N/A.
_ The facility or dwelling was inspected for signs of sewage back-up.
The system does not receive non-sanitary or industrial waste flow.
_ The site was inspected for signs of breakout.
_ All system components, excluding the Soil Absorption System, have been located on the site.
1 _ The septic tank manholes were uncovered, opened, and the interior of the septic tank was inspected for condition of
baffles or tees, material of construction, dimensions, depth of liquid, depth of sludge, depth of scum.
The size and location of the Soil Absorption System on the site has been determined based on:
The facility owner land occupants, if different from owner) were provided with information on the proper maintenance of
Sub-Surface Disposal System.
_ Existing information. Ex. Plan at B.O.H.
Determined in the field (if any of the failure criteria related to Part C is at issue, approximation of distance is
unacceptable) 115.302(3)(b)j
(revised 04/25/97) Page 4 of 10
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION
Property Address:
Owner:
Date of Inspection:
FLOW CONDITIONS
RESIDENTIAL:
Design flow: g.p.d. room for S.A.S.
Number of bedrooms.
cr
Number of current residents: -
Garbage grir:der(yes or no): /y
Laundry connected to systeln yes or no): QS
Seasonal use (yes or no): 6
Water meter readings, if available (last two(2)year usage (gpd):/,'-
Sump Pump(yes or no): Vt)
Last date of occupancy:(Ir( e
COMMERCI ALII N DUSTRIAL:
Type of establishment:
Design flow: gallonstday
Grease trap present: (yes or no)_
Industrial Waste Holding Tank present: (ves or no)_
Non-sanitary waste discharged to the Title 5 system: (yes or no)_
Water meter readings, if available:
Last date of occupancy:
OTHER: (Describe)
Last date of occupancy.
GENERAL INFORMATION
PUMPING RECORDS and source of information:
2 Com/
System pumped as part of inspection: (yes or 4
If yes, volume pumped: / y gallons
Reason for pumping
TYPE YSTEM
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)
VA Technology etc. Copy of up to date contract?
Other
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 04/2S/97) Paye 5 of 10
• • t t
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Property Address:
Owner: ggyni
Date of Inspection:
47
BUILDING SEWER: ^�
(Locate on site plan)
Depth below grade:
Material of construction: _cast iron _40 PVC_other(explain)
Distance from private water supply well or suction I,r-f-
Diameter
Comments: (condition of joints, venting, evidence of leakage, etc.)
SEPTIC TANKY05
(locate on site plan)
`'
Depth below grade: 30 A 7y-0 T�
Material of construction: _concrete _metal ,_Fiberglass _Polyethylene —other(explain)
If tank is metal, list age_ Is age confirmed by Certificate of Compliance _(Yes/No)
Dimensions: 0 /, �S- X S
Sludge depth:_'
n
Distance from top of slydge to bottom of outlet tee or baffle:.3 /
Scum thickness: // z--
Distance from top of scum to top of outlet tee or baffle: 7 �v
Distance from bottom of scum to bottom of outlet tee or baffler
How dimensions were determined: S'/TC
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, etc.)
GREASE TRAP: fy,
(locate on site plan)
Depth below grade:
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:
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, etc.)
(revised 04/25/97) Pago 6 of 10
1
I
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Property Address: �-C f D In.-, 571—
Owner:
1-Owner: x v N P
Date of Inspection:
Lf
TIGHT OR HOLDING TANK: (Tank must be pumped prior to,or at time, of inspection)
(locate on site plan)
Depth below grade:
Material of construction: _concrete _metal _Fiberglass_Polyethylene —other(explain)
Dimensions:
Capacity: gallons
Design flow: gallons/day
Alarm level: Alarm in working order_Yes; _ No
Date of previous pumping:
Comments:
(condition of inlet tee, condition of alarm and float switches, etc.)
DISTRIBUTION BOX:�PS
(locate on site plan)
Depth of liquid level above outlet invert:
Comments:
(note if level and distribution is equal, evidence of solids carryover, evidence of leakage into or out of box, etc.)
dx moo .
PUMP CHAMBER:_
(locate on site plan)
Pumps in working order: (Yes or No) Y�s
Alarms in working order(Yes or No)—T2
Comments:
(note condition of pump chamber, condition of pumps and appurtenances, etc.)
(ravinad 04/25/47) Paye 7 of 10
9
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Property Address: p- YJAW 5v- v Q4,--,
Owner. L'#go IV e yL
Date of Inspection: }-7- 97
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 pits, number:_
leaching chambers, number:_
leaching galleries, number:
leaching trenches, number,length:
leaching fields, number, dimensions: Pcc ,t� /Ifo—t Aldoel" 4X0
overflow cesspool, number:
Alternative system:
Name of Technology:
Comments:
(note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.)
c a ai-1 0 Z
CESSPOOLS:
(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 (cesspool must be pumped as part of inspection)
Comments:
(note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.)
PRIVY:_
(locate on site plan) /N
Materials of construction: Dimensions:
Depth of solids:
Comments:
(note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.)
(revised 04/25/97) Page 8 of 10
i SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Property Address: /,_re�? JoZlle"e4l
Owner: �/de p y p�
Date of Inspection:
3-
SKETCH OF SEWAGE DISPOSAL SYSTEM:
include ties to at least two permanent references landmarks or benchmarks
locate all wells within 100' (Locate where public water supply comes into house)
ZVOS
V Q
(revised 04/25/97) Page 9 of 10
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Property Address: , �-/ Ya
Owner:
Date of Inspection:
Depth to Groundwater Feet
Please indicate all the methods used to determine High Groundwater Elevation:
Obtained from Design Plans on record
Observation of Site(Abutting property, observation hole, basement sump etc.)
Determine it from local conditions
Check with local Board of health
Check FEMA Maps
Check pumping records
Check local excavators, installers
Use USGS Data
Describe in your own words how ,you established the High Groundwater Elevation. Must be completed)
�v"t,P S S 7/e'Kq
(revised 0{/7S/97) Page 10 of 10
ANDOVER SEPTIC 47 Railroad Street ROTO-RAM
Reg re of Service
O N/C (978) 475-2593 Bradford,MA 01835 (978) 452-9022 Ile Mi
❑, E ay
Z ❑ Night
-- PAY FROM THIS BILL
Customer Name:
Service Location:
Phone: / Septic Tank Pumping and Cleaning
Contact: "Done the Right Way"
Emergency 24 Hour Service - 7 Days a Week
Billing Address-
City-N,
ddressCiry: *WtICI
Zip: �.
Special Instructions
❑ Completed
❑ Incomplete Reason:
Pg.
A M ^
Services Rendered
Vacuu umping Obsa Ions Drain Cleaning
Septic Tank Good Condition ❑ Main Line
Drywall ❑ Leechfield Runback ❑ Toilet Bowl
❑ Leech Pit/Overflow ❑ Riding High ❑ Kitchen Sink
❑ D-Box (liquid level) ❑ Bathtub/Shower
❑ Pump Chamber ❑ Full to Cover ❑ Vanity
❑ Grease Trap ❑ Excessive Solids ❑ Floor Drain
❑ Catch Basin Top/Bottom ❑ Yard Drain
❑ Use No Powdered Soap
❑ Portable Toilet ❑ Vent
❑ Other ❑ Heavy Grease ❑ Sewer Jet
ally: ❑ Roots ❑ Other
Size: i ❑ Suggest Electric
Rooteri Footage:
El Under 1000 gallons CJ 1000 gallons /1500gallc n "9
❑ 2000 gallons ❑ 3000 gallons ❑ 4000 gallons ❑ Van Called
❑ 5000 gallons ❑ other ❑ Other
M'sc. ! I��� &0
Digging Charge ❑ Backhoe ❑ Inspection
Nlin. hra.
Location ❑ Consultation ❑ Certification: P/F
❑ Service Call ❑ Estimate Reason:
Labor ❑ Portable Toilet Rental ❑ Pump Repair
❑ Waiting Time ❑ Baffle ❑ Repair
Digging Charge Is Per Driver ❑ Chemical Treatment
Discretion ❑ Other
Description of Work
V 1 �
Recommendations Terms If Payment
Parts
Vacuum Pumping Drain Cleaning NET 15 DAYS
Tax
Yr. Month Yr. Month
Discount
Terms & Conditions ❑ Cash ❑ Check ❑ Credit
�j�
1 Not responsible for damage beyond curb line. 3. 1.59E per month will be charged to accounts past due. Total (J1(
2. All complaints shall be reported within 48 hours. 4. The purchaser agrees to pay all cost of collection.
Customer Signature Serviceman �� ��
Address: 1248 Salem Street , North Andover, Massa
1Registr of Deeds . County : Essex North
Book: 5a81 Pae: 255
Plan by : Christiansen Engineering. Inc.
Dated: Nov- 20, 1985
Plan Pio. 10110
I hereby certify that the structures shown on
this pian are located on the ground as shown,
t _ r and that they conformed to the horizontal
' ' dimensional requirements of the zoning laws of
the Town of North Andover when constructed , or
exist in accordance with Mass. General Laws
Ic I Chapter 40A, Section 7.
'Aray F hereby certify that the structures do not lie
within the Special Flood Hazard Zone as shown
,tiSi on the Federal Emergency ManagementAgency
\. Flood Insurance Rate Map of North Andover, Mass.
Community Panel No. : 250095 0009 C
Effective Date : June 2, 1993.
Registered Professional Land Surveyor
X
This mortgage inspection plan was not made from
l� w_£`MA- I an instrument survey and is intended for the
use of the mortgagee for mortgage purposes only.
Under no. circumstances is this elan to be used
\< for determining the location of property lines,
for special permits or variances, or to be used
tc establish the location of fences, walls,
hedges, or additions.
SALEM STREET MORTGAGE INSPECT .1ON PLAN
l z-t a Sale Sfre e
NORTH .4NDOVER HAAS.
;cafe: 1"=s 0' Date: April 24, ZOOO
METRO SUI ,i EYS
50 WORCESTER LANE
WALTHAM, MASS.
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(150) X = 150 . .. .. ... ... . . ..... .. .. .... .
DES/�N EL EV,4TION 47.. ...... .(TOP OF STONE) _ At
EY/5T/N6 ECEt/ ROAl 4T.. . .. .. . . .eEQU/,PFD F&C
•...... ... ..... .. . . .. .. ......
ELE!/.4TIOA15
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DES/�N <1S BU/CT 45 AY14
INI!P/PF OUT OF /OUSE lYy /4
/NV PIPE INTO T4NK i E a�sPosQ� .
/NV PIPE OUT Of 74- NA' y
INV PIPE INTO D. BOX !5'7. /' / Z
INV PIPE OUT OF D. BOX l y 7• j?. _s)/ IN
V. END OF PIPE V/ ' A l �f 'f `� !f
INf= '`
r PIPE /Y7,-rg f
FOR
ry
,4VE,e40E STONE 5"L E: �` DATE.•
DEPTI-1 ,47 RCO E CA01671ANSEN ENgINLCEEIN6, 11W.
NOTE.- 711/5 PZ,4N /S NOT ,4 R14,ee.41VTY 1/4 �ENOZ,4 .41/E., N,4v4EcA1LL, /Yl4.
OF T1/E SYSTEM BUT ,4 k1Ce1F/C.4TION "
Of Tf1E LOC.4TION OF TWE EY15TING
S7-,eOC7Z1,PE5.
Commonwealth of Massachusetts
,r City/Town of NORTH ANDOVER, MASSACHUSETTS
till
System Pumping Record
Form 4
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 aut-hor ty.... .w-
. .
A. Facility Information
Important: MAR 2 0 L�'
6
When filling out 1. System Location: c
forms on the i ( l T TO`�NN Of-Nu c
computer, use S r4 f� S. HEALTH DEPAENT
only the tab key Address L.
to move your 0-fl, A 0 C)0 i(z_ M 14- G `'3- V"S
cursor•do not City/Town State Zip Code
use the return
key. 2. System Owner: t
D i t --
Name
f0f"' Address(if different from location)
City/Town State Zi Code
US��
Telephone Number
B. Pumping Record
1. Date of PumpingDate t � 2. Quantity Pumped: Gallons �
3. Type of system: ❑ Cesspool(s) 0,b4e^ptic Tank ❑ Tight Tank
❑ Other(describe): --
4. Effluent Tee'1`iltgr present? Yes ❑ No If yes, was it cleaned? ❑ Yes ❑ No
5. Condition of System:
Goo
6. System F
_ jok H <b
Name Vehicle License Number
Company
7. Location where contents were Isposed:
Signature of Hauer Date
http://www.mass.gov/dep/water/approvals/t5forms.htm#inspect
t5form4.doc•06/03 System Pumping Record•Page 1 of 1
r
FORM U - LOT RELEASE FORM s
D>EcK
INSTRUCTIONS: This form Is used to verify that all necessary approvals/permits from
B dards 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
APPLICANT - `�SeW�` 'S' PHONE 3- `�q 5
LOCATION: Assessor's Map Number PARCEL 1 s h- o e��5
SUBDIVISION LOT (S)
STREET 5���"^ S�Ge� ST. NUMBER
OFFICIAL USE ONLY
R N TOWN A N :
COSERVATION ADMINISTRATOR DATE APPROVED
DATE REJECTED
COMMENTS Vit G�
�rINWS
TOWN PLANNER DATE APPROVED
DATE REJECTED
COMMENTS
FOOD INSPECTOR-HEAL H DATE APPROVED
ATE REJECTED
EPTI
INSPECTOR-HEALTH(/ DA APPROVED ,/ D
DATE REJECTED /r"5�r D_S"
COMMENTS 0 - d
PUBLIC WORKS-SEWERMATER CONNECTIONS
DRIVEWAY PERMIT
FIRE DEPARTMENT
DUMPSTER PERMIT
RECEIVED BY BUILDING INSPECTOR DATE
FORM U-Revised 6.05 JMC
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LOT 11?44r 5th f
.QREyf= ��2/5—3.F Petr
�- LOT 1/AA
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Town of North Andover °F NORTH
Community Development and Services Division
Office of the Health Department
400 OSGOOD STREET
North Andover,Massachusetts 01845 �9SS,Argo cry
Michele E.Grant
Public Health Inspector (978)688-9540-Phone
(978)688-8476-Fax
Date:July 15,2005
Address: 1248 Salem Street
Re: Application for: Enclose Existing Deck
Dear: Mr.DiBlasi,
Your application for a deck at has been reviewed by the Health Department. The application was denied on July 15,
2005 for the following reasons:
1. X Missing information
2. X Passing Title 5 inspection of septic system required Possibly-see below
3.' ❑ Location of structure not acceptable
4. ❑ Undersized septic system
To address the pmblem(s):
If#1 is checked, please supply:
a. Floor Plan of exhdne and proposed addition-all rooms
b. Certified plot plan showing house,septic system and proposed proiect in scale
If#2 is checked:
a. Have the septic system inspected by a certified Title 5 inspector to determine the size of the system and
whether it is operating properly: If this is just a bump out-No Title S is necessary
b. Tie-in to municipal sewer
If#3 is checked:
a. Relocate the project
If#4 is checked:
a. Provide additional information proving that the existing septic system meets current capacity
requirements. Please consult an engineer to determine the flow capacity of the septic system.
Please feel free to call the Health Office at 978-688-9540 with any questions you may have.
Sincerely,
Michele E.Grant
A
Cc: Building Department
File
BOARD OF APPEALS 688-9541 BUILDING 688-9545 CONSERVATION 688-9530 NURSE 688-9543 PLANNING 688-9535
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FORM - U - LOT RELEASE FORM
INSTRUCTIONS: This form is used to verify that all-necessary approval/permits from
Boards and Departments having jurisdiction have been obtained. This does not relieve the
applicant and or landowner from compliance with any applicable requirements.
APPLICANT -�Zo e. _ ))( l A c� / PHONE g 7` 7S—
ASSESSORS MAP NUMBERC2� LOT NUMBER
SUBDIVISION LOT NUMBER
STREET �-/`� STREET NUMBER o2-
OFFICIAL USE ONLY
RECOMA4ENDATIONS OF TOWN AGENTS ..7
Z
DATE APPROVED
CONSERVATION ADMINISTRATOR
DATE REJECTED
CONDO
DATE APPROVED
TOWN PLANNER
DATE REJECTED
COMMENTS
DATE APPROVED
FOOD INSPECTOR—HEALTH DATE REJECTED
DATE APPROVED
SEPTIC INSPECTOR-HEALTH
DAT�E1 REJECTED
COMMENTS
PUBLIC WORKS-SEWER/WATER CONNECTIONS
DRIVEWAY PERMIT
DATE APPROVED
FIRE DEPARTMENT
DATE REJECTED
COMMENTS
RECEIVED BY BUILDING INSPECTOR DATE
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COMMONWEALTH OF MASSACHUSETTS
1- EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS
DEPARTMENT OF ENVIRONMENTAL PROTECTION
ONE WINTER STREET. BOSTON, MA 02108 617
V
WILLIAM F.WELD TRUDY COXE
Governo: Secretan.
ARGEO PAUL CELLUCCI DAVID B.STRUHS
Lt.Governor SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM Commissioner
PART A
CERTIFICATION N�
/ �/-fcl57.
Property Address: / ?_ .� Address of Owner:
Date of Inspection- � a (If different)
Name of Inspector: 4444 dUsp
I am a DEP appy ved system inspector pursuant to Section 15.340 of Title 5 (310 CMR 15.000)
Company Name: #"O Q u ✓ P h
Mailing Address:
Telephone Number:
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
Needs Further Evaluation By the Local Approving Authority
_ Fails
Inspector's Signature: Date: 3 -)-7 9
The System Inspector shall submit a copy of this inspection report to the Approving Authority within thirty (30) days of completing this
inspection. If the system is a shared system or has a design flow of 10,000 god 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.
INSPECTION SUMMARY: Check A, B, C, or D:
AI SYSTEM PASSES:
L<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.
COMMENTS:
BI 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.
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, unless the owner or operator has provided the system inspector with a copy of a Certificate of
Compliance (attached) indicating that the tank was installed within twenty (20) years prior to the date of the inspection; or
the septic tank, whether or not metal, is cracked, structurally unsound, sho o-�Iirat'� or-exfiltration, or tank
PT
failure is imminent. The system will pass inspection if the existing septic tank is rep�_+a t a�`" , `stVseptic tank
as approved by the Board of Health. nLR"
.t
"/(�/ 1999
(revised 04/25/97) Page 1 of 10 i'�ttl
DEP on the World Wide Web http:awww.magnet.state.ma.us/dep v
Printed on Recyded Paper 4 a
r SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
r PART A
CERTIFICATION (continued)
Property Address: 1 Q 0 f
Owner: ;?_ gL7—
Date of Inspection:
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 sy`em will pass inspection if(with approval of the
Board of Health). Describe observations:
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):
broken pipe(s) are replaced a
obstruction is removed'
Cl FURTHER EVALUATION IS REQUIRED BY THE BOARD OF HEALTH:
l � fff
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 PROTECTS THE PUBLIC HEALTH AND SAFETY AND THE
ENVIRONMENT:
The system has a septic tank and soil absorption system (SAS) and the SAS 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 the SAS is within a Zone I of a public water supply well.
The system has a septic tank and soil absorption system and the SAS is within 50 feet of a private water supply well.
The system has a septic tank and soil absorption system and the SAS 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
n _ 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. Method used to determine distance (approximation not valid).
3) OTHER
(revised 04/25/97) Page 2 of 10 )
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION (continued)
Property Address: I
Owner: 1--11"44
Date of Inspection:
D] SYSTEM FAILS:
You must indicate either "Yes or No" as to each of the following:
I have 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.
Yes No
Backup of sewage into facility or system component due to an 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.
a . 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 porton 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 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 analysis for
coliform bacteria, volatile organic compounds, ammonia nitrogen and nitrate nitrogen.
E] LARGE SYSTEM FAILS: P A.
You must indicate either "Yes" or "No" as to each of the following:
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 coAditions exist:
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)
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 04/25/97) Page 3 of 10
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART B
CHECKLIST
Property Address:
Owner:
Date of Inspection: /e
3 -7
Check if the following have been done: You must indicate either "Yes" or "No" as to each of the following:
Yes. No
_ Pumping information was provided by the owner, occupant, or Board of Health.
f _ 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 system recently or
as part of this inspection.
L - - Y1
` {
_ -As built-plans have be6h obtained aA8 examined. Note if they are not.available'with N/A.
The facility or dwelling was inspected for signs of sewage back-up.
The system does not receive non-sanitary or industrial waste flow.
_ The site was inspected for signs of breakout.
_ All system components, excluding the Soil Absorption System, have been located on the site.
The septic tank manholes were uncovered, opened, and the interior of the septic tank was inspected for condition of
baffles or tees, material of construction, dimensions, depth of liquid, depth of sludge, depth of scum.
The size and location of the Soil Absorption System on the site has been determined based on:
The facility owner (and occupants, if different from owner) were provided with information on the proper maintenance of
Sub-Surface Disposal System.
Existing information. Ex. Plan at B.O.H.
Determined in the field (if any of the failure criteria related to Part C is at issue, approximation of distance is
unacceptable) [15.302(3)(b)J
k
(revised 04/25/97) Page 4 of 10
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION �1
Property Address: l d 5� �1' /A-/
Owner:
Date of Inspection:
FLOW CONDITIONS
RESIDENTIAL:
Design flow: e.p.d./bedroom for S.A.S.
Number of bedrooms:-
Number of current residents:_
Garbage grr-der (yes or no): /-/
Laundry connected to systejnjyes or no):,lf S
Seasonal use (yes or no): 6
Water meter readings, if avail ble (last two (2)year usage (gpd):/ r-
Sump Pump (yes or no): �
Last date pf occupancy: G� l , ' , E•r t i s +
COMMERNDUSTRIA /
Type of establishment: r
Design flow:_gallons/day
Grease trap present: (yes or no)_
Industrial Waste Holding Tank present: (yes or no)_
Non-sanitary waste discharged to the Title 5 system: (yes or no)_
Water meter readings, if available:
Last,date or occupancy:
OTHER: (Describe)
Last date of occupancy:
GENERAL INFORMATION
PUMPING RECORDS and source of information:
System pumped as part of inspection: (yes or n -xes
If yes, volume pumped: /, O gallons
Reason for pumping
TYPE YSTEM
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)
I/A Technology etc. Copy of up to date contract?
Other
APPROXIMATE AGE of all components, date installed (if known) and source of information:
Sewage odors detected when arriving at the site: (yes or no)'—yo
(revised 04/25/97) Page S of 10
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Property Address:
Owner:
Date of Inspection:
BUILDING SEWER:
(Locate on site plan)
Depth below grade:
Material of construction: _cast iron _40 PVC_other (explain)
Distance from private water supply well or suction hr(-
Diameter
reDiameter
Comments: (condition of joints, venting, evidence of leakage, etc.)
SEPTIC T-ANK:_Ju- r u s
(locate on site plan) �'i
j-.t 5T14 12
Depth below grade: -341 � T�� -r/V ter'
Material of construction: _concrete _metal _Fiberglass _Polyethylene _other(explain)
If tank is metal, list age _ Is age confirmed by Certificate of Compliance _(Yes/No)
r '
Dimensions: J 0 k J { X
Sludge depth:_'
Distance from top of sludge to bottom of outlet tee or baffler
Scum thickness: //I,
Distance from top of scum to top of outlet tee or baffle: 7' lv
Distance from bottom of scum to bottom of outlet tee or baffle: f
How dimensions were determined: /)
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, etc.)
CO1-�t121 71 y`i
GREASE TRAP: x
(locate on site plan) /
Depth below grade:
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:
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, etc.)
(revised 04/25/97) L _ Paye 6 of 10
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Property Address: .� wt �✓
Owner:
Date of Inspection:
TIGHT OR HOLDING TANK: (Tank must be pumped prior to, or at time, of inspection)
(locate on site plan)
Depth below grade:
Material of construction: _concrete _metal _Fiberglass _Polyethylene —other(explain)
Dimensions:
Capacity: gallons
Design flow:( gallons/day
Alarm level: Alarm in wAirg order Ye3; No
Date of previous pumping:
Comments:
(condition of inlet tee, condition of alarm and float switches, etc.)
�O S
DISTRIBUTION BOX:_
(locate on site plan)
Depth of liquid level above outlet invert: ' /
Comments:
(note if level and distribution is equal, evidence of solids carryover, evidence of leakage into or out of box, etc.)
jX ('e14r h ON /Ot TGiI
PUMP CHAMBER:_
' (locate on site plan)
Pumps in working order: (Yes or No)
YP
f Alarms in working order (Yes or No)�V
Comments:
(note condition of pump chamber, condition of pumps and appurtenances, etc.)
(revised 04/4S/97) Page 7 of 10
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Property Address: p y / Id //W,, s{ '.'Al /' '���(I v AZ,-
Owner: L�J�-� f'}2,
Date of Inspection:
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 pits, number:_
leaching chambers, number:
leaching galleries, number:
leaching trenches, number,lepgth:.
IeatfSing fields,number, dimensions: ortt'4 ,+ 't ,r p.4 A/''d6'� t
a overflow cesspool, number:
Alternative system:
Name of Technology:
Comments:
(note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.)
CESSPOOLS:
(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 (cesspool must be pumped as part of inspection)
I
w 1 Comments
(note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.)
f
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 04/23/97) Papa 8 of 10
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
r rf SYSTEM INFORMATION (continued)
Property Address: /�� r 1 '5
Owner: / Pk/Gv**'
Date of Inspection:
SKETCH OF SEWAGE DISPOSAL SYSTEM:
include ties to at least two permanent references landmarks or benchmarks
locate all wells within 100' (Locate where public water supply comes into house)
00
I`l
nil - 73
' V @ 1t
Q
` 1
(revised 04/25/97) Page 9 of 10
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Property Address: N �'" 5�,1 041 A/ v -A
Owner:
Date of Inspection:
� '-y
Depth to Groundwater Feet
Please indicate all the methods used to determine High Groundwater Elevation:
Obtained from Design Plans on record
Observation of Site (Abutting property, observation hole, basement sump etc.)
WOOODetermine it from local conditions f
Checklwit local Board of health , �.
Check FEMA Maps
Check pumping records
Check local excavators, installers
Use USGS Data
Describe in your own words how you established the High Groundwater Elevation. Must be completed)
w IA(C7P"4--e d/ To
lep e r) e ouu r �,.- twos'-r'tea.- %r� •
r
(revised 04/75/97) Page 10 of 10
t r �
CERT/FIED PLOT PLAN
AS-BUiL T AUG 12 2005
IN TOWN OF WIRTH ANDOVER
NORTH ANDOVER, MASS. HEALTH DEPARTMENT
MIDDLESEX SURVEY INC. LAND SURVEYORS
131 PARK STREET NORTH READING, MA. 01864
SCALE.- 1�-100' DA TE.• AUG. 11, 2005
GRAPHIC SCALE
100 0 50 100 200 400
( IN FEET )
1 inch = 100 ft.
34.47
� '� 184.15'
LOT 11AA
8 MONESETBACKS
50,588fsf 1. 30' FRONT
x.15' 27.41' 30' SIDE
30' REAR
?�. \ EXISTING BUILDING
COVERAGE= 2%
NOTE: �_ �, EXISTING OPEN
1) SUBSURFACE DISPOSAL \ z \ p��• SPACE= 92%
SYSTEM TAKEN FROM SKETCH
PROVIDED BY HOMEOWNER. 27� DECK 's}
`17• ( DFRAM
2) EXISTING 12' X 24' DECK $ a (Zeye
LOCATION FROM FOOTPRINT. w z
o �
o.
30'MIN.SETBACK v
\ � 12150.00'
SALEM STREET
H OF Mgssgc5G
ALPHONSE m
l CERTIFY THA T THE EXISTIN WELLING HALOEY N
LOCA TED AS SHOWN. NO. 31312
DA TE.' 8/11/05 FSS�Fci s1 �5
Registe LonL LAW
urtor SA
NO. 1289
�pD
7
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSP TION
Address of property Jr-) (48 C__,r1Cv,,,'&A , 0(OL/S"
owner's name
Date of Inspection
PART A
CHECKLIST
Check
if the following have been done:
V Pumping information was requested of the owner, .occupant, and Board of
Health.
None of the system components have beenum ed for at least two weeks
P P
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.
As built plans have been obtained and examined. Note if they are not
available with N/A.
The facility or dwelling was inspected for signs of sewage back-up.
� The site was inspected for signs of breakout.
All system components, excluding the SAS, have been located on the
site.
� The septic tank manholes were uncovered, opened, and the interior of
the septic tank was inspected for condition of baffles or tees,
material of construction, dimensions, depth of liquid, depth of
sl ge, depth of scum.
The size and location of the SAS on the site has been determined based
on e isting information or approximated by non-intrusive methods.
Thhee facility owner (and occupants, if different from owner) were
provided with information on the proper maintenance of SSDS.
r �� �
�"�; �' ; `r't',�j
� '
�,
�� �
8
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART B
SYSTEM INFORMATION
FLOW CONDITIONS
If residential
"1 number of bedrooms
number of current residents
WO garbage grinder, yes or no
e_s laundry connected to system, yes or no
NO seasonal use, yes or no
If nonresidential, calculated flow:
ltd gOLD"3 �"(.S= ��',oco5c��s
d U25 13�` s (317,1,-,L/a<
Water meter readings, if available: 7 v x `?.5= � ,
Last date of occupancy
GENERAL INFORMATION
Pumping records and source of information:
-k-
ND System pumped as part of inspection, yes or no
if yes, volume pumped
Reason for pumping:
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:
���' Sewage odors detected when arriving at the site, yes or no
9
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART B
SYSTEM INFORMATION continued
SEPTIC TANK:
(locate on site plan)
depth below grade• �} t ,` X-J-eT t
material of construction: concrete metal FRP other(explain)
dimensions: lq k Jc-X L{ JS
sludge depth
r distance from top of sludge to bottom of outlet tee or baffle
scum thickness
jL' distance from top of scum to top of outlet tee or baffle
• oll 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, recommendations for repairs etc. )
�. � �_ k , Uc � leue t �� �
xvll5-kq-l l �S',\c)VI\
DISTRIBUTION BOX:
(locate on site plan)
depth of liquid level above outlet invert
Comments:
(note if level and distribution is equal, evidence of solids carryover,
evidence of leakage into or out of bQx�, recommendation for repairs, /et . )
PUMP CHAMBER: `.'ice a � ��QA- io C-le-C`-
(locate on site plan)
le_,5 pumps in working order, yes or no
Comments:
(note condition of pump chamber, condition of pumps and appurtenances,
recnmendatio1n- s for maintenance or repairs,etc. /
o r"
10,rcu� v\ l (" -z��� ��'� els:�2?S
C � :,<'2
10
SUBSURFACE SEEPAGE DISPOSAL SYSTEM INSPECTION FORM
PART B
SYSTEM INFOORMATION 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 pits and number
leaching chambers and number
leaching galleries and number
leaching trenches, number, length
leaching fields, number, dimensions
overflow cesspool, number
Comments:
(note condition of soil, signs of hydraulic failure, level of ponding,
condition of vegetation, recommen ations fori maintenance or rep irs,etc. )
-PJB-'�C.� R %
CESSPOOLS (10 ate on site plan) : C� , D7 C �Q�ql(
number and con-figuration ��, ��`�`O � SSE
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:
(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. )
11
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
oda.66 all wells within 100 '
1
1Jrl�l�(/y
4S,
Ne �kv-bA-
br `c
I.Gz e_ 0 -ti�� CS �YX.7S 2X d��tSvs eu�.w O �-Q x
DEPTH TO GROUNDWATER
depth to
p groundwater
method of determination or approximation: �� bo" (-v Slk ,-V\ V) 0
12
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
FAILURE CRITERIA
Indicate yes, no, or not determined (Y, N, or ND) . Describe basis of
determination in all instances. If "not determined", explain why not)
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?
�V Liquid depth in cesspool <6" below invert or available volume< 1/2 day
Y
Required pumping 4 times or more in the last year?
number of times pumped
Y Septic tank is metal? cracked? structu ally unsound? substantial
infiltration? substantial exfiltration. tank failure imminent?
N Is any portion of the SAS, cesspool or privy:
below the high groundwater elevation?
within 50 feet of a surface water?
Iy within 100 feet of a surface water supply or tributary to a surface
water supply?
'V 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) ?
�vr within 50 feet of a private water supply 1 well?
� U 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 ac--eptable, attach copy of well water analyst
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
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 one:
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.
L/ I have determined that the system fails to protectP ublic health and
the environment as defined in 310 CMR 15. 303 . The basis for this
determination is provid d in he F LURE CRITERIA section of this
form.
Inspector' s Signature Q,,��
Date3�4�f
Original to system owner
Copies to:
Buyer (if applicable)
Approving authority
'q,`� c'�1 \�l>it �•� h• tl �t \'T'k� �`;s°r2.i fit•^^'�;•
-e t ♦`iE.l ) rR i-t f.; �1f t 'Si"t'�� ♦ t 1
• \,'+< <t�`t
-LA 1.
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1'. i•` i , r'�x \ +` �`a L.i; C + r y�`�. ."ay
� tL x i 1 + '� `it >•,'t i'1�
i`. �` ; '' 't :� 1 n:t i ,x n+` : \ ♦♦� t `' —' l.l�`�
:tl1�l\ lt4 �w�11y;�dx \�.i
' 1 't �7 tti T`A Zix4 i Tl"�yat `'tee t�
�!} t 4 1 • 'r. ,_ ,t + i�` � r,'+, L)+ ..x, a'�j! 1 •1 It (":+' Sx � i`1,� � `•
.
V. . . .. -
Town of North Andover, Massachusetts Form No.3
BOARD OF HEALTH
• HORTM 19 - —
A
O 9
DISPOSAL WORKS CONSTRUCTION PERMIT
,S'4cmusEt
Applicant ��f�
NAME ADDRESS TELEPHONE
Site Location
Permission is hereby granted to Construct ( ) or RepairKan Individual Soil Absorption
Sewage Disposal System as shown on the Design Approval S.S. No.
CKAIRMAN,BOARD OF HEALTH
Fee D.W.C. No. �.�
Board Or lle:i1th -
North �;_� -:Y:�j Y�9s• SEPA IC STSTF'
INST _M. ION CR 40K MST I.JT
�Pk G1'r
—DATE, Sk t�FilCt EB IL�'I` ,KCAVATI ON OK iA i,L
1 �0
�.
PIOK
1. Distance Tot
a. Wetlands
b. Drains
i c. Wall
3
2. Water Line Location
3• No PVC Pipe
± 4. Septic Tank----
a. Tees --Length & To Clean Out Covers
b. Cement Pipe to Tank - On Both Sides of Tank -
Distribution Box
a. Covers & Box - No Cracks
b. All Lines Flo;dng Equal Amounts
c- No Back Flow
a b. Leach Field or Trench
a. Dimensions
i b. Stone Depth
} ; e. Capped ids
d. Clean Double Washed Stone
7. Leach Pits
a. Dimensi s
b. Stoepth
c. ash Pads
Teas
e. Ct Pipe to Pit - Both Sides
f. Clean Double Washed Stone
v'
8. No Garbage Disposal
9. Final Grading Inspection
t J 10. Barricading Covered System
/ 11. As Built Submitted
a. Lot Location-
b. Dimensions of System
c. Location with Regard_to Perc Test
d. Elevations
ee Water Table
U _j: ._:.'i�:'�CE DISPOSAL SYSTEM CHECK LIST
d 'NORTH Ai4DOVER BOARD"OF HEALTH Y ' r
c
W
OVER DATE PROVIDED DISAPPROVED DATE TIME REASON
Title r ��y
Reg. 2. 5 Fail OK The submitted plan must show as a minumum:
�(a) the lot to be served (area,dimensions,lot //,abutters)
(Planning Board files)
L_-jb) location and log of deep observation holes-distance
to ties
(c) location and results of percolation tests-distance
f to ties
�(d) design calculations & calculations showing required
leaching area
(e) location and dimensions sf system (including reserve
f area)
k/ existing and proposed contours
g location of any wet areas within 1001 -of the sewage
disposal system or disclaimer (check wetlands mapping)
(h) surface and subsurface drains within 11001 of sewage
disposal system or disclaimer
(i) location of any drainage easements within 100' of
sewage disposal system or disclaimer--(planning board
files)
(j ) known sources of water- -supply--wi-thin -_200'_ of sewage
disposal system or disclaimer--
(k) location of any proposed well "to `serve the lot_ -(100'
from leaching facility)
�(1) location of water lines on property (101 from. leaching
facilities)
�(m) location of benchmark
j(ri) driveways
o) garbage disposers
� _p) no PVC is to be used in construction
�(q) a profile of the system (elevations of basement, plumb(
pipe septic tank, distribution box inlets and outle:-s ,
distribution field piping and any other elevations)
maximum ground water elevation in area of sewage dispo:
system
(s) plan must be prepared by a Professional Engineer or
other professional authorized by law to prepare such
plans
Septic Tanks
Reg. 6 (a) Capacities - 150° of flow, water table, tees , depth
of tees , access , pumping,
Cleanout
c) 101 from cellar wall or inground swimming pool
(d) 25' from subsurface drains
North 4Andover Subsurface disposal system check list - Page 2
r
' fail OK Distribution Boxes
Rrjg.'10. 2 (a Slope greater than 9.08
Reg.10.4 (b� Sump
Leaching Pits
Leaching pits are preferred where the installation -is
possible
Reg.11 .2 (a) Calculations of leaching area (minimum 500 S.F. )
Reg.11 .4 (b Spacing
Reg.11 .1 (c . Surface drainage 2%
Reg.11 .11 d /Cover material
e- 2'12'14" Splash pd A
fee er e;lbo to
Leaching Fields
Reg.15.1 (a N?Greater than 20 minutes/inch
Reg.15.1 G--'(b)-- Area (minimum 900 S.F.)
Reg.15.4 /(�c�' Construction of field
Reg.15.8 Surface drainage 2%
Reg. 3.7 --"(e) 20' from cellar wall or inground swimming pool
Leaching Trenches
Reg.14.1 (a Calculations of 1� ' ng area (min. 500 S.F.)
Reg.14. 3 (b Spacing (4 ft.,m� n. 6 ft. with reserve between)
Reg.14.4 (c Dimensions
14. 5 /
Reg 14.6- (d) Construction
Reg.14.7 (e)/8tone
Reg.14.1 .(-f) Surface drainage 2%
Downhill Slope
(a) Slope y/x = Ro
o be shown
V(b) y/x X 150 = be shown
Pump a
Reg. 9.1 (a) Approval
Reg. 9.6 (b) Stand-by power
Form 4 -- System Pumping Record
Commonwealth of Massachusetss
: Massachusetts
System Pumping Record
System Owner System Location
Type: Emergency Routine
Cesspool: No ✓ Yes Septic tank: No Yes �✓
Date of Pumping: / `2 m - 67 Quantity Pumped: 1 S( — Gallons
System Pumped By: Wind River Environmental, LLC Permit#:
Contents transferred to:
Contents Disposed
Po at: Sb
IZ-
Date: Pumper Signature:
Condition of System/Other Comments
Dnp Approved from - 12/07/95 r,3WQF RI Vi ANDD
BOARD OF HEALTH
,�=!2n:
Form 4 -- System Pumping Record
Commomvealth of Mossachusetss-- ------- ---
{ OF NOM14 ANU ��v
Massachusem gQAR4)OF�HEI.T ��.
System Pumaing Record
System Owner System Location
Type: Emergency Routine
Cesspool: Yes Septic tame: No ElYes
Cate of Pumping: Fj
�(�y Quantity Pumped: ($ O d Gallons
System Pumped By: Wind Riney Envir"renta/, LLC Permit#:
Contents transferred to:
Contents Disposed at:
r�
Date: L Pumper Signature:
Condition of System/Other Comments
Dep Approved Form - 12/07/95
n mn v vnnn i7; �rr7�u
Commonwealth of Massachusetts Form 4--System Pumping Record
Massachusetts
System Pumping Record
AUG - 7 2007
F NPRTH n°t.11) v,'�.
System Owner System Location HEALTH DE,AR i i-,. V(
:ICT+] Hi"lrvt✓PT� :'ta�� U�7' ir:rir;•rr .. .r
iW!F {.tip t',ti + a
Type: Emergency Routine
Cesspool: No Yes Septic Tank: No Yes
Date of Pumping: 6. �O Quantity Pumped: Gallons
System Pumped By: Wind River Environmental,LLC Permit#:
Contents Transferred to:
Contents Disposed at:
tz�/2;!��—�
Date: Pumper Signature:
Condition of System/Other Comments
Dep Approved Form-12/07/95
Commonwealthof assac usetts
City/Town of
System Pumping Recor JUL 2008
Form 4 TOWN OF NORTH ANDOVER
HEALTH DEPAR'''T FNT
DEP has provided this form for use by local Boards of Health. Other forms may a 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. Syste1mf Location:
forms on the
computer,use `f u dal em s�
only the tab key Address
to move your Nh o(- An�ove—f
cursor-do not Cit /Town State Zip Code
use the return City
/Town
2. System Owner:
'3ost h '► 1�10,S
Name
nem Address(if different from location)
City/Town State Zip Code
q-118- g355
Telephone Number
B. Pumping Record
1. Date of Pumping ` °Q� 013 2. Quantity Pumped:
Date Gallons n�3. Type of system: ElCesspool(s) [Z
Septic Tank ❑ Tight Tank ❑ Grease Trap
❑ Other(describe):
4. Effluent Tee Filter present? ❑ Yes [/No If yes, was it cleaned? ❑ Yes ❑ No
5. Conditiono System:
�'1,O d
6. System Pumped By:
r. �,rn Ga11 an b`?C)3 I
Name {� 1 Vehicle License Number 10j VeX
Company
41E swich ater
7. Location where contents disposed:
reatment Plant
Wswich, MA 0108
Signature of Hauler Date
Signature of Receiving Facility Date
t5form4.doc•03/06' System Pumping Record•Page 1 of 1
i
Carney Investigative Services
James R. Carney- President
MA P.I. License P-1672
Bonded & Insured
Comprehensive, Confidential, & Discrete PI Services
(781) 844-4713
carneyinvestigations@gmail.com
q+eua*'eaaw � �
• DE VELLIS CARPENTRY
QUALITY WORKMANSHIP
RESIDENTIAL z COMMERCOIAL
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QUALITY WORKMANSHIP
RESIDENTIAL•COMMERCIAL
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RESIDENTIAL•COMMERCIAL
Residential Property Record Card
PARCEL ID:210/106.A-0185-0000.0 MAP:106.A BLOCK:0185 LOT:0000.0 PARCEL ADDRESS:1248 SALEM STREET FY:2008
PARCEL INFORMATION Use-Cotler 101 Sale Price; 386,900 Book; 05734 Road Type: T Inspect.Date: 10/17/2006
Tax Class: T Sale Date: 04/27/00 Page: 0253 Rd Condition: PMeas Date: 06/22/2001
Owner: Tot Fin Area: 2464 Sale Type: P Cert/Doc: Traffic. M " Entrance:' X
DI BLASI,JOSEPH P Tot Land Area: 1.18 Sale Valid: Y Water: Collect Id: SGC
LAURA DI BLASI Grantor: DANNIEL NEAMTU Sewer: Inspect Reas: M
Address:
1248 SALEM STREET Exempt-B/L% / Resid-B/L% 100/100 Comm-B/LP/o Indust-B/L% / Open Sp-B/L% /
NORTH ANDOVER MA 01845
RESIDENCE INFORMATION LAND INFORMATION
Style: CL Tot Rooms: 7 Main Fn Area: 1232 Attic: N NBHD CODE: 6 NBHD CLASS: 6 ZONE: R1
T e
Story Height: 2.00 Bedrooms: 4 Up Fn Area: 1232 Bsmt Area: 1232 Seg Type Code Method Sq-Ft Acres Influ-YIN Value Glass
Roof: G Full Baths: 2 Add Fn Area: Fn Bsmt Area: 1 P 101 S 43560 1.000 208,652
Ext Wall: FB Half Baths: 1 Unfin Area: Bsmt Grade: 2 R 101 A 0 0.180 .1,368
Masonry Trim: Ext Bath Fix: 0 To Fin Area: 2464 . VALUATION INFORMATION
Foundation: CN Bath Qual: T RCNLD: 303266 Current Total: 513,300 Bldg: 303,300 Land: 210,000 MktLnd: 210,000
Kxt tch:QuaT Ye r Built: 1987 Mkt n dj: Prior Total: 547,300 Bldg: 315,000 Land: 232,300 MktLnd: 232,300
Heat Type: HW Ext Kitch: Year Built: 1985_ _ Sound Value:
Fuel Type: O Grade: G Cost Bldg: 303,300
Fireplace: 1 Bsmt Gar Cap: 2 Condition: A Aft Str Val1:
Central AC: N Bsmt Gar SF: Pct Complete: Aft Str Val2:
Att Gar SF: %Good P/F/E/R: /100/100/90
Porch Type Porch Area Porch Grade Factor
W 240
SKETCH PHOTO
W
12 240 Sq.Ft 12 !
4 20
} s
FU/FM/B
1262 Sq.Ft
28 28
1248 L-11 SALEM STREET r;
44
Parcel ID:210/106.A-0185-0000.0 as of 7/8/08 Page 1 of 1
�_L\ Commonwealth of Massachusetts. DEC ,; ,fi i
City/Town of
System Pumping Record NORTH ANDOVER d Tr, .,
ri� NT
Form 4
h DEP has provided this form fqr 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
�Z y
-------------
computer,use _ -- _----- ----- - - -- -
only the tab key Address
to move your _a/jh �,��v�/ `�
cursor-do not Zip Code
Cily(iovrrl " - — Slate
use the return
key. 2 System Owner:
Name---- ——
�^ Address(if different from location) —
—--- —
— State Zip Code
City/Town
Teiephone Number
B. Pumping Record
1. Date of PumpingDat
----e ----- — 2. Quantity Pumped: Gallons
3. Type of system: ❑ Cesspool(s) ptic.Tank ❑ Tight Tank ❑ Grease Trap
❑ Other(describe): ---
4. Effluent Tee Filter present? ❑ Yes [1 '— o If yes, was it cleaned? ❑ Yes ❑ No
5. Condition of System:
6. System Pumped By.
S/�'
Name vehicle License Number
Company
7. Location where contents were disposed:
---- --- - -----. ..- OV�1rY lYl k(e
Signature of Hauler
Signature of Receiving Facility Date
15form4.doc•03106 System Pumping Record•Page 1 of 1
Commonwealth of Massachusettsl74U11
City/Town of
System Pumping Record NORTH ANDOVER Ari
Form 4 TOWN OF NORTH ANDOVER
HEALTH DEPARTMENT
DEP has provided this form for use by local Boards of Health. Other forms may be MCI, not tile
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 O
computer,useonly the tab key Address
to move your
cursor-do not � ------- ----------- ��� ---------- --����.�_—_---
-���- State Zip Code
use the return City(Town
key. 2 System Owner:
Name
Address(if different from location) -----.--- - - — --- - -- ----------
CityfTown --- -— --- State -- - Zip Code
ci7Y'6,5'/ � ------
Telephone Number
B. Pumping Record
1. Date of Pumping Z Z—L� 2. Quantity Pumped:
Gallons -- -
Date
3. Type of system: ❑ Cesspool(s) K4'S p is Tank ❑ Tight Tank ❑ Grease Trap
❑ Other(describe): -----— --- — ------ ------------ -..
4. Effluent Tee Filter present? ❑ Yes ❑ No If yes, was it cleaned? ❑ Yes ❑ No
5. Condition of S tem:
6. System Pumped By:
Name Vehicle License Number
Company 00
7. Location where contents were disposed: co
L C
-- — — 0
Signature of Hauler Da
Signature of Receiving Facility
{..
Qt5form4.doc•03/06 . ?J System Pumping Record•Page 1 of 1
C
1
-\\\\j
�L\ Commonwealth of Massachusetts
City/Town of NORTH ANDOVER
System Pumping Kecora
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. rRECEIVEDA. Facility InformationB -- 4 2010
Important:
When filling out 1. System Location:
forms on theO �Q 1�rn 5 1 TOWN OF NORTH ANDOVER
computer,use I I l� —only the tab key Address \,,
to move your % y\ An d oy cA _ _ M//�t
cursor-do not City/Town State Zip Code
use the return
key.�---� 2. System Owner:
Name
Address(if different from location) -- --
City/Town State Zip Code
__-R7S- bS9 - 355 --
Telephone Number
B. Pumping Record
1. Date of PumpingDate— 1'�- 09 2. Quantity Pumped: G 11500
3. Type of system: ❑ Cesspool(s) VSeptic Tank ❑ Tight Tank ❑ Grease Trap
❑ Other(describe):
4. Effluent Tee Filter present? ❑ Yes E/�No If yes, was it cleaned? ❑ Yes [?/No
5. Condition of S stem:
6. System Pumped By:
76(D
—7
— \ — — (D l
Name vehicle License Number
�( Enyi rQhm �a
Company
7. Location where contents were disposed:
Signature of Hauler Date
Signature of Receiving Facility Date
t5form4.doc•03/06 System Pumping Record•Page 1 of 1