HomeMy WebLinkAboutMiscellaneous - 140 COLONIAL AVENUE 4/30/2018 140 COLONIAL AVENUE 'r ive
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PARCEL # STREET - •
�ON5�RUCTIO.N A.PPROVAL�
HAS PLAN REVIEW FEE .DEEN PAID? 1 YES NO
PLAN APPROVAL: DATE ¢/� '/QRZ APP. BY
DESIGNER: PLAN DwE.
CONDITIONS
WATER SUPPLY: TOWN :�)WELL
WELL PERMIT DRILLER.__.______._._._._..__.
a
WELL TESTS: CHEMICAL UA1E APPRUVEU
RC TERIA I Ufa 1 E f)PPRUVEU
BACTER II DAi•E APPROVED
COMMENTS:
r�
ti
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
OTHER YES NU
ANY VARIANCE NEEDED YES NO
FINAL BOARD OF HEALTH APPROVAL: DATE:.412A8 •__BY: ..'IC1V
K
t°
IS"THE' INSTALLER LICENSED? :: + ^, �� ->, - NO
T N- REPAIR
-TYPE
OF CONSTRUC ION:
NEW CONSTRUCTION: : CERTIFIED PLOT PLAN REVIEW NO
CONDITIONS OF:.APPROVAL YES NO
(FROM .FORM U) !:
ISSUANCE •OF DWC PERMIT r _ + NO
DWC PERMIT NO'. INSTALLER: R
BEGIN INSPECTIONES 0:
EXCAVATION INSPECTION: ; NEEDED:
.` _
PASSED Y` ' H1( ��
. .•CO.NSTR
UCTION. INSPECTIONs
NE
EDEDZ
AS BUILT " PLAN SATISFACTORY. ;.. YESs
APPROVAL TO BACKFILL. DATE: ` /' �� BY
" FINAL . GRADING APPROVAL: DATE ��/fir BY
FINAL CONSTRUCTION APPROVAL: DATEi/� � '`
l ,l
Add ress d e.o l,.o k((14'-- AV Title of Fide
Page of
Date File Open:
Gate file closed: _
Docacts Document/Action Title Date of Refer to other Purpose of Document A
action Document/ doeurnent/
Rum. / coon and -
Action De artment
------------
Board of Appeals — Board of Heal h Planniin Board
9. ConsIeruaton Commission - Building Departme
nfi �--
T40Rrti L_ 116
Town of _ jAndover
No.
* s dover, Mass.,— -1996
OLAKE
_C.CH CHEWICK
rEb
S E BOARD OF HEALTH
PERMIT T D Food/Kitchen n
Septic System 1-f�
BUILDING INSPECTOR
THIS CERTIFIES THAT.............................................l..0..............
............:.�......0........ .....�.............. ..........:............ Foundation
has permission to erect......................................_buildings on ....�..(. .......... d../��.l.. '. .......... -(�.Lc. Rough
to be occupied as................................................ j../ /.. .�. ............... ........................... Chimney
provided that the person accepting this permit shall in every respect conform to the terms of the plication on file in
Final
this office, and to the provisions of the Codes and By-Laws relating to the Inspection, Alteration and Construction of
Buildings in the Town of North Andover. PLUMB GSPECTOR
VIOLATION of the Zoning or Building Regulations Voids this Permit. 4 a Cl/ k 4 L-_Q_
An
r��0 W�,�!
PERMIT EXPIRES IN 6 MONTHS
UNLESS CONSTRUCTION gh I EC
Rough '
... ................. . . ...... ..............................
BUILD INSPECTOR _
in�
Occupancy Permit Required to Occupy Building GAS INSPECT R
Display in a Conspicuous Place on the Premises — Do Not Remove Rough
Final
No Lathing or Dry Wall To Be Done FIRE DEPARTMENT
Until Inspected and Approved by the Building Inspector. Burner — orc .q• '4 W.-
Street No. a r �' 4
f r'h .
Smoke Det.
TOWN OF NORTH ANDOVER
SEWAGE DISPOSAL SYSTEM
INSTALLATION CERTIFICATION
The undersigned hereby certify that the Sewage Disposal System(}constructed; ( )repaired;
by ''��
located at ��� l Co �-
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 materiarsused 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-dgrees substantially with the approved plan. All work is
-accurately represented on the As-built which has been submitted to the Board of Health.
Installer: Li c. #: Date:
Design Engineer: Date:
TOWN OF NORTH ANDOVER
SEWAGE DISPOSAL SYSTEM
INSTALLATION CERTIFICATION
The undersigned hereby certify
Ythat the Sewage Disposal System(constructed; ( )repaired;
by �.��-a-Y-�e_ S
located at f�� l�, Gc[ e;;� a,
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 material's used were in conformance with those specified on the approved
plan;the system was installed irraccordance 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.
* Endorsement is to as-built grades on the septic system plan revised 10/29/97.
Installer: Lic. #: Date:
Design Engineer: O S Date: P�Pe t l_ 211�
FEMUL
Qffim
CNL
W 2n45
AL E��'
Commonwealth of Massachusetts RECEIV'
r ..
City/Town of
System Pumping Record OR 24
Form 4 TOWN' =R
HE w r
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. Syst m LoC tion:
forms on the Ii�
P 6 `�1 _. C1,~)-
p
computer,use � `-J�-
only the tab key Address +
to move your
cursor-do not Ci !town �Y
use the:retum ty St Zip Code
key.
2. System Owner:
�•V �
Name
Address(if different from location)
Citylrown
State Zip Zip Code
N/ J —
Telephone Number
B. Pumping Record
1. Date of Pumping
2.
p g Pate Quantity Pumped:
Gallons
.3. Type of system: ❑ Cesspool(s) eptic Tank ❑ Tight Tank
❑ Other(describe)`
4: Effluent Tee Filter present? ❑ Yes D_N If yes, was it cleaned? ❑ Yes ❑ No
6. Condition f System:
6. Sysm Fu ped B
P' ��
cs -a
Name Vehicle,License Number
Company -- .
7. Locaf he conte were disposed:fill
,
Sig at a auler Date
http://www.mass.gov/dep/waler/approvals-/`t5forms.htrn#inspect
t5form4.doc•06103 System Pumping Record•Page 1 of 1
.WN G URT-I AND. iER/
BC ' )OF HEALT
TOWN OF NORTH ANDOVER NOV - 4 2002
SYSTEM. PUMPING RECORD --�
OWNER & ADDRESS SYSTEM LOCATION - --
/��z�� (ezamPle: left from c;f hou�ej
L) E OF PUMPING; 10 (� (QUANTITY PUMPED G,z L „� �
NO 4_ YES SEPTICTANK : NO YES l/
� ATUREOFSERVICE: ROUTINE EMERGENCY
ffl>FRV:\TIONS:
GOOD CONDITION t/ FULL TO COVEiz _
HEAVY CREASE BAFFLE'S IN PLACE
ROOTS LEACHFIELD RLNBACK. .
EXCESSIVE SOLIDS FLOODED
SOLIDS CARRYOVER Oj�HER (EXPLAIN.)
> 1 I LM PUMPED BY: �� Y� �%� ,
� u�Iti1FNTS: COC�� � �/i��f
u1 I I:N I`J TIZANSFEIZIZED TO:
i01 AY/97
++ + �•'
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ttli
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tii it°,.J,ri.accixf i.s•, +fi '.. [ur f! !r�'f{i.ya ,
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Form No.4
Town of North Andover, Massachusetts
BOARD OF HEALTH
December 10 ,,19_97
CERTIFICATE OF COMPLIANCE
This is to certify that
the Individual Soil Absorption Sewage Disposal System constructed ( X) or repaired ( ; )
by Charles Zaher
INSTALLER
at Lot 16 Colonial Ave . , North Andover, MA 01845
SITE LOCATION
has been installed in accordance with Board of Health Regulations as described in the Design
Approval Site System Permit No. 850 dated A;,rii .23 , 19 9-7
The issuance of this certificate shall not be construed as a guarantee that the system will
function satisfactorily.
0-4
a{
I
:i
APPLICATION FOR DISPOSAL WORKS CONSTRUCTION PERMIT
DATE: l7 e� ") CURRENT INSTALLER'S LICENSE#
LOCATION: Lo e cc-) (0"J' ('01.
LICENSED INSTALLER:
SIGNATURE: TELEPHONE# ,- �'w
CHECK ONE:
REPAIR: NEW CONSTRUCTION:
IF NEW CONSTRUCTION, PLEASE ATTACH FOUNDATION AS-BUILT.
�2&a
Administrative Use Only
$75.00 Fee Attached? Yes L____ No 3 1,
Foundation As-built? Yes 16— No
Floor plans on file? Yes L---- No
Appr val zd Z 7z�_I/� Date: Q /vim
J )
b�
a.
Town of North Andover, Massachusetts Form No.3
• t NORTH, BOARD OF HEALTH
19 /
• 3? e,T.-.. ..e OL �,�
• � P
} ' o'� �• DISPOSAL WORKS CONSTRUCTION PERMIT
... ,SS^CHuSEt
Applicant
NAME ADDRESS TELEPHONE
Site LocationT �� �DLO�/�1 ���•
Permission is hereby granted to Construct ( or Repair ( ) an Individual Soil Absorption `-
C�u ....
.;• Sewage Disposal System as shown on the Design Approval S.S. No. �_:•^_..;��
CHAIRMAN,BOARD OF HEALTH
r
:.. • Fee Y7I
D.W.C. No.
y
A
tif AM,
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w l k� �s�rr c§' n' Z+x•ie''C7:"rtiiuN
x8LS7�S9 FORK
N,.l,r . •,, of
INSTRUCTIONS: This ''fora is used to `verify that all necessary
approvals/permits from Boards and Departments having jurisdiction
have been obtained. This does. not relieve the applicant and/or
landowner from compliance with any applicable local or state law,
,requlati„Ons Or=reef re�tS��r w
****************Applicant fills out this section**********.*******
APPLICANT: _t� • C. Uul ��L►'S nC Phone ��5-835a
LOCATION:' ' 'As's,Iess jot's `Map NumbllerParcel
Subdivision WOOD 'I f1 aT�S Lots �D
Street St. Number
Use only*****************.*******
TIONS OF
. •TOWN AGEn1TS.:.
v L s � Date Approved
Conservation Administrator Date Rejected
Comments �,.a„� .�'L.�1�..L_L _..f l) 0
Date Approved
Town Planner Date Rejected
Comments
Date Approved
Food Inspector-Health Date Rejected
Date Approved �7
Septic Inspector-Health Date Rejected
Comments
Public Works - sewer./water connections
- driveway permit --
Fire Department
Received by Building Inspector Date
eo /d
Ib P4' 20,242' -
i
2V To. WV
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FAMILY BRKFST KITCWEN � � STUDY
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DINING FOYER LIVING
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4'6' l'0'16'01 4'O' b'6' 3'6' 3'6' 6'6' 4'O'
FIRST FLOOR PLAN gyp' 1240'0"p. �'p'
11418 - 3 V4'`1'0'
To"
1'0" 1TV 5'44" 5'2° 2'10• 5'6"
= O Os
BEDROOM #4
u GL, o WALK-IN
CLOSET s
2'0'
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2'6' 214'
2-30' �I� lbl/i' �If 30'
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4 closet floor elopes 24'
to malntah headroom p
BEDROOM #3 foretatwaybelow M BEDROOM 01
8'2t 3'6 n
BED #2
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4'0' b'6' 3'b' 6'0' 6101 316' 6'6' 4'0'
1410' 1210' 14'0'
40'0'
1,4'-10' 11418 - 41
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i
3'0' 2'6' 5,0' 1 2'6' 3'14 3'104• 9,61
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FAMILY BRKFST KITCHEN
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-- ----- ----- - -- -- ----- 2a
AIWA r�tisc layout 2b' 36 2-26
3 ' ' AO
4'0' 344
,
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DINING �OiOOn
osO
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FOYER LIVING
Y
2'0' 3'0' 2'0'
CL CL,
4'6' 1'O' 4'b'
16'O' 4'0' b'b' 3'b' 3'O" 1 3'0' 3'0' J.
3-0- 3'6' b'6' 4'O'
FIRST FLOOR PLAN �° p°• "°
11418 - 3 1/4'•1,01
40'0'
M
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14'i�i" lO bpi" 3'4' 1'0"
1,01 1'134' 5'4�4" 5 2' 2,10" 5 6"
= O O =
BEDROOM #4 Y
_ 17 WALK-IN
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GL. ° CLOSET
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2,6" 2'4' 2 4"
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n CLOSET
2-3'0'
2�6
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$ I
b+ I 9 v t CL.
sa Cloeet Moor elopes 24'
to maNtlalm headroom
BEDROOM #3 For eta"below � M BEDROOM #1
8,2t§ 3 6
BED #2
o
cn
4'0' 6'b' 3'6" 6 0" 6'O' 3,61 6'6' 4'0"
14'0' 1210' 14,0'
40,0.
SECOND FLOOR PLAN
L/4'-1'0' 11418 — 4
RE
R E E:E
C
IV
D
TOWN OFN TH ANDOVER NOV - 3 20F04j�
SYSTEM F,u PINQ RECORI.) TOWN OF NORTH AND v,
10
DA I HEALTH DEPARTrVIE
E TME -
iYSTb4—oWNF,R & ADDRESS SYSTM LOCATION
DATE OF pUMpjNo:_
CLSSPOOL: Np YES
S00c Tank: No- YES
NA rUKE ()F SERVICE: KOU rIN bMER0EN(,)-
0bShRVA'rl0NS
GOOD CONDITION FULL -Ty)COVER
HEAVY ORYLASE EMIFFLES IN PLACL
,ROOT'S LEA-CKIFIELD RUNBACK
BXCF,SSIVE SOLIDSFLOODED
SOLID CARRYOVER,.......... OTHER EXPLAIN
rrla.
CUMMENTS,
....................
'UN I LN i's rKANsybRUL) I-L)
Form No.2
• Town of North Andover, Massachusetts
„oRTM BOARD OF HEALTH
Cl
19 �.
o w
...�•.:.. 4 DESIGN APPROVAL FOR
• Ss�CHUSOIL ABSORPTION SEWAGE DISPOSAL SYSTEM
Applicant eic, Test No.
Site Location
AA J2
Reference Plans and Specs. ENGINEER DESIGN DA
Permission is granted for an individual soil absorption sewage disposal system to be installed
• in accordance with regulations of Board of Health.
CHAIRMAN,BOARD OF HEALTH
Fee U Site System Permit No.
f
Town of North Andover ct NORTil ,
OFFICE OF 3� ,.0 V6aoo`
COMMUNITY DEVELOPMENT AND SERVICES A
30 School Street
North Andover,Massachusetts 01845 �q`° •° ''qty
WILLIAM J.SCOTT SSACHUS�
Director
August 25, 1997
TO',vT4 C
Mr. Aurele Cormier -
2 Evergreen Lane
Andover, MA 01810
Re: Woodland Estates �'""`�
Dear Mr. Cormier:
This letter is in reference to Lot 16 Woodland Estates. As you are aware on
Thursday August 21 1 visited the lot as a result of a complaint that work was in
the process in the 50 foot buffer zone. As a result of the visit, I discovered an
employee burying boulders within the 50' buffer. On Friday August 22, you
visited the Planning Office to explain that ; "there were no trees there (in the
buffer) it was just a pile of dirt" .
First you violated the zoning ordinance by conducting work in the 50' buffer
established through an approved PRD pursuant to a special permit.
Second you have been aware of the above infraction as early as October 18,
1996 when Kathleen Colwell indicated that you must remove the pile of dirt and
replant the area. If you had a concern regarding replanting then you should
have responded accordingly to Mrs. Colwell's request in 1996. Because you
acquiesced to her request I am requiring the following:
As I indicated to you on Friday you have ten days from the date of this letter to
restore all areas which are not 50' in width along the buffer zone between lot 16
and the adjacent lot. You will plant a buffer of Canadian Hemlock trees six feet
high and greater in a staggered.overlapping row with a 2 foot gap between the
plants. The buffer shall create a complete visual buffer for the distance planted.
The distance shall be all areas where the 50' bufferdoes not exist whether it was
disturbed by you or others. This means that if there is a buffer of 49 feet you
will plant at least a grouping of three trees to serve as a buffer.
CONSERVATION 688-953P HEALTH 688-9540 PLANNING 688-9535
i
You will complete this planting within 10 business days of receipt of this letter.
The planting will be warranted in writing to the next property owner for
replacement within two years of installation.
On the 10th day from receipt of this letter if the planting is not complete the Town
will begin levying fines, in accordance with the Zoning By-Law, of $300.00 per
day with each day constituting a violation.
You will also provide an as-built survey of the planting to show the location of
the buffer and the edge of the planted and wooded areas. The survey will be
used to confirm that every foot of the buffer is either left in its natural state or
planted. The survey will be completed and in the Planning Office within five
days of completing the buffer planting.
Failure to provide the survey will constitute a violation of the zoning By-law and
subject you to the $300.00 fine. I will be entering the property of lot 15 to tape
measure the buffer on that lot. If I discover the same violations then from the
date of my notification the above remedy and penalties apply. Further, I have
asked that all of the departments in Community Development review the files
and site to determine if there are further violations.
A very simple and polite request was made of you in October of 1996. Your
inaction has made your circumstance far more severe than the opportunity that
was presented to you in October of 1996. Your continued inaction will only
make your situation worse.
Sincerel
William J. Sc
CC: e Howard. Conservation Administrator
Sandra Starr, Health Sanitarian
Robert Nicetta, Building Inspector
Planning Board
Conservation Commission
Return Receipt# - P 205 969 147
Town of North Andover t NORTH ,
OFFICE OF 3�o�`"e ,�°c
COMMUNITY DEVELOPMENT AND SERVICES A
146 Main Street • t
North Andover, Massachusetts 01845
WILLIAM J.SCOTT SSACHUSE
Director
October 31, 1996
Mr. Aurele Cormier
AC Builders
33 Walker Road
North Andover, MA 01845
Re: Lots 27, 28, & 29 Colonial Ave.
Dear Aurele:
This is to notify you that the septic plans for Lots 27, 28, & 29 Colonial Ave. have been
approved.
The system for Lot 15 Puritan Ave and Lot 16 Colonial Ave. cannot be approved until
waivers from the Planning Board for the 50 foot buffer zone have been granted.
Lot 17 Colonial Ave. needs additional soil testing at the South end of the system.
Any questions, please do not hesitate to call me at the number below.
Sincerely,
..............
Sandra Starr, R.S.
Health Administrator
SS/cjp
cc: Ed Stearns, Hayes Engineering
BOARD OF APPEALS 688-9541 BUILDING 688-9545 CONSERVATION 688-9530 HEALTH 688-9540 PLANNING 688-9535
i
( ORM I 1 S011, FIVALLATOR l OIt;11
l'a�c 2 of t
1,oc ttlon Address or 1.wr �CQ (�G'1 - 'LE
On-site Review
Deep Hole Number (.�o. ..... Date:..�'.`.SC _ T rne: lV; a(Itct
Location (identify on site plan) ... _. ...
Land Use _. .... . .__.-..-- . . Slope (°o).._. __ Surface Stones.
Vegetation..._._ .. . .. .. . ... .. _.. ... .. . . _
Landform ................... ........ _ .. _. - . .
Position on landscape (sketch on the back)
Distances from:
Open Water Body .. . . . ..-. .. feet Drainage way .. _:. .feet
Possible Wet Area. .. feet Property Line . . .. feet
Drinking Water Well. .- . - . feet Other
DEEP OBSERVATION HOLE LOG*
i
i
Depth from Soil Horizon Soil Texture Soil Color Soil Other
Surface (Inches) (USDA) (Munsell) Mottling (Structure, Stones, Boulders, Consistency, %
Gravel)
6� �t
C 1s Z y ssy�s ���
I
i
I
I
I
Zo
MINIMUM OF 2
L t
Parent Material (geologic) _ _ DepthtoBedrock_
Depth to Groundwater: Standing Water in the`lose Weeping from Pit Face.
Estimated Seasonal High Ground Water
Ut:P APPRMT,l)FOR-t 12"07:9;
HAYESENGINEERING, INC. )�AIs
603 SALEM STREET T0�BOARn OF EALTH I',t C
WAKEFIELD, MA 01880
(617)246-2800
FAX(617)246-7596 JUN L 1 1996
No. 16
JOB FILE
Commonwealth of Massachusetts
----- North Andover Massachusetts
Soil Suitability Assessment for On-site Sewage My sal
Performed By: .._Gordon ,Rogerson__. "- __ __ .. . ............ ...
Witnessed By:y --Susan Ford--- ---
I.a 1.0.Add—,11 A.C. BUILDERS
L.o:r nGdfcss.,2i
No. Andover, Mass.
ew Construction Repair l❑
Office Review
Published Soil Survey Available: No ❑ Yes l❑
Year Published __________________._.. Publication Scale_._.._.__.__________ Soil Map Unit
Drainage Class______________... ..__.. Soil Limitations
Surficial Geologic Report Available: No ❑ Yes ❑
Year Published Publication Scale
Geologic Material (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)
Current Water Resource Conditions (USGS): Month
Range :Above Normal ❑Norma! ❑Bel; Normal
Other References Reviewed:
DF:1' nPl'ROvFn PUH>1 1"07!95
1 .
1
uy-
i�
X3-
11Z
-
1
- -----------------
��
77
i
Town of North Andover, Massachusetts Form No. 1
I
N ORT" BOARD OF HEALTH
W
3� yE s O -19L
O
AR °°•°°w°•�"
DTED APPLICATION FOR SITE TESTING/INSPECTION
7�AgAA ,�5
C
SS
Applicant 4-
NAME ADDRESS TELEPHONE
Site Location
Engineer
NAME ADDRESS TELEPHONE
Test/Inspection Date and Time
CHAIRMAN,BOARD OF HEALTH
Fee 5 Test No. � �J
f:
S.S. Permit No. D.W.C. No. C.C. Date Plbg. Permit No.
Town of North Andover, Massachusetts Form No. 1
NORTH BOARD OF HEALTH j /-
3?Oy`t`EO 6`b�OpL� �I'k
o m
APPLICATION FOR SITE TESTING/INSPECTION
��SSACHUS����
i
i
Applicant A 4- C,
NAME ADDRESS TELEPHONE
Site Location
Engineer
NAME ADDRESS TELEPHONE
Test/Inspection Date and Time
CHAIRMAN,BOARD OF HEALTH
Fee Test No. 4
S.S. Permit No. D.W.C. No. C.C. Date Plbg. Permit No.
Town of North Andover, Massachusetts Form No. 1
NORTH BOARD OF HEALTH
3���ASLED ib�AOL t 19 OI L
E
Q �
~ A
41 X
/°R APPLICATION FOR SITE TESTING/INSPECTION
7 ADRATED PPp`y��J
9SSACHUS��
Applicant
NAME ADDRESS TELEPHONE
Site Location
Engineer �� lye
NA ADDRESS TELEPHONE
Test/Inspection Date and Time
CHAIRMAN,BOARD OF HEALTH
Fee Test No. 2e�X
S.S. Permit No. D.W.C. No. C.C. Date Plbg. Permit No.
Town of North Andover, Massachusetts Form No. 1
NORTIy BOARD OF HEALTH
,6�6N�L - 19
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APPLICATION FOR SITE TESTING/INSPECTION
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NAME ADDRESS TELEPHONE
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Engineer
NAME ADDRESS \ TELEPHONE
Test/Inspection Date and Time
CHAIRMAN,BOARD OF HEALTH
Fee I Test No. /
S.S. Permit No. D.W.C. No. C.C. Date Plbg. Permit No.
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Commonwealth of MassachusettsIED
City/Town of ,
System Pumping Record OCT 15 2007
IV
;DEOForm 4 tTH ANDOVER
TER
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.
A. Facility Information
Important:
When filling out 1. SySt
forms on the �sC;���
computer,use
only the tab key Address t i
to move your
cursor-do not Citylrown State Zip Code
use the return
key. 2. System Owner: /��/� !
VQ1��V 1� \ ( K
Name
rim Address(if different from location)
City(fown State ^ ` Zip��
Telephone Number
B. Pumping Record
1. Date of Pumping Date 2. Quantity Pumped: Gallons
3. Type of system: ❑ Cesspool(s) Septic Tank ❑ Tight Tank
❑ Other(describe):
4. Effluent Tee Filter present? ❑ Yes to If yes,was it cleaned? ❑ Yes ❑ No
5. Condition of System: �
6. System�—UjAA,(
mpec�By: esc>'�Cw\
Name Vesicle License Number
Company
7. Location contents werej),osed:
a`7
Signature ul Date
t5form4.doc•06/03 System Pumping Record•Page 1 of 1
Commonwealth of Massachusetts RECEIVED
City/Town of JUL 2 2 2009
a` System Pumping Record
Form 4 TOWN OF NORTH ANDOVER
HEALTH DEPARTMENT
DEP has provided this form for use by local Boards of Health. Other forms may be used, but the
information must be substantially the same as that provided here. Before using this form, check with your
local Board of Health to determine the form they use. The System Pumping Record must be submitted to
the local Board of Health or other approving authority.
A. Facility Information
Important:
When filling out 1. System Location: Left fro , left Sipe o ouse ight front, right rear, right side of house.
forms on the
computer, use
only the tab key Address
to move your
cursor-do not City/Town State Zip Code
use the return
key. 2. System Owner:
Name
Address(if different from location)
City/Town �Sta Zip Code
co's-5 -- 7
Telephone Number
B. Pumping Record
1. Date of Pumping Date 2. Quantity Pumped: Gallons
3. Type of system: Cesspool(s) eptic Tank Tight Tank
Q Other(describe):
4. Effluent Tee Filter present? 0 Yes __ No If yes, was it cleaned? p Yes No
5. Condition Qf System:
6. System Pumped By:
Neil Bateson F 5821
Name Vehicle License Number
Bateson Enterprises Inc
Company
7. Location where contents were disposed:
.L.S. Lowell Waste Water
igna ure of H u r Date
t5form4.doc•06/03 System Pumping Record•Page 1 of 1
Commonwealth of Massachusetts
City/Town of — -
W° System Pumping Record
Form 4 QEQ 14 2010
i b svey`'
DEP has provided this form for use by local Boards of Health. Ot the
information must be substantially the same as that provided here - ck with your
local Board of Health to determine the form they use. The System - submitted to
the local Board of Health or other approving authority.
A. Facility Information
1. System Location: Left front of house, right front of house, left side of house, right side of hous Left
r rear of house, left side of building, right rear of building, under deck.
(D
City/Town State Zip Code
2. System Owner:
inn a ��
Name
Address(if different from location)
City/Town State& Zip Code
7
Telephone Number
B. Pumping Record
1. Date of Pumping Date 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:
6. System Pumped By:
Neil J. Bateson F5821
Name Vehicle License Number
Bateson Enterprises Inc.
Company
7. Lo ere contents were disposed:
6L.S.D. LovAIIAaste W
Signature of H&UW Date
t5form4.doc•06/03 System Pumping Record•Page 1 of 1