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HomeMy WebLinkAboutMiscellaneous - 1493 Forest Street 14:3 FmE:.swuT_ gcf304es> �' MAP # LOT it o�- PARCEL # _ STF2EET._.___. ._....._..........._.........._.. __ ._ '... . CONSTRUCTION APPRO HAS PLAN REVIEW FEE BEEN PAID? YES NO PLAN APPROVAL: DATE GZ --- APP. BY .. ..........................................._......... DESIGNER: �o' �/1/CG �/� - PLAN DA fE. 711 z CONDITIONS WATER SUPPLY: TOWN WELL WELL PERMIT 3F DRILLER"- j VIM, ......._..._.. ...__ WELL TESTS: CHEMICAL DA I E f PiROVE=D,. BACTERIA I Df-HE f1F-'I�F2UVED cJ/1�5 BACTERIA II DA I E APPNUVE.D&�"//. COMMENTS: FORM U APPROVAL: APPROVAL 1-0 ISSUE _(YES NU i DATE ISSUED �� � ./ _ BY CONDITIONS: FINAL APPROVAL: . - ALL PERMITS RAID tlU WELL CONSTRUCTION APPROVAL Z\ ^YEE5 NO SEPTIC SYSTEM CONSTRUCTION APPROVAL � ES -'t NO OTHER YES Nu ANY VARIANCE NEEDED YES NU` FINAL BOARD OF HEALTH .APPROVAL: DAIS: BY: . . SEPTIC �_Y_SZE(�__LNa.T8.4.L.A.�CL.QN. IS THE INSTALLER LICENSED? YG NO _._. TYPE. OF CONSTRUCTION: NLW ftEl?n 111 NEW CONSTRUCTION: CERTIFIED PLOT PLnN REVIL=W Yt=s NO CONDITIONS OF APPROVAL YES 14U (FROM FORM U) ISSUANCE OF DWC PERMIT YES NO DWC PERMIT N0. C:�6� INSTALLER: M �EG — BEGIN .INSPECTION EXCAVATION . INSPECTION: NEEDED: PASSED v HY CONSTRUCTION INSPECTION: NEEDED: AS BUILT PLAN SATISFACTORY: APPROVAL TO BACKFILL: DATE: h3 FINAL GRADING APPROVAL: DATE Z 93 _HY—�_5 - ----- I FINAL CONSTRUCTION APPROVAL: DATE:__�__.______�Y___._ } Of NORT:,� 7064 : .,001 ia Town of North Andover HEALTH DEPARTMENT ,SSAC MU`+t� CHECK#: c 1 TE: LOCATIO • H/O NAME: tpW CONTRACTOR NAME: ape of Permit or License: (Check box) ❑ Animal $ ❑ Body Art Establishment $ ❑ Body Art Practitioner $ ❑ Dumpster $ ❑ Food Service-Type: $ ❑ Funeral Directors $ ❑ Massage Establishment $ ❑ Massage Practice $ ❑ Offal(Septic)Hauler $ ❑ Recreational Camp $ ❑ Sun tanning $ ❑ Swimming Pool $ ❑ Tobacco $ ❑ TrashlSolid Waste Hauler $ ❑ Well Construction $ SEPTIC Systems: ❑ Septic-Soil Testing $ ❑ Septic-Design Approval $ ❑ Septic Disposal Works Construction(DWC) $ ❑ Septic Disposal Works Installers(DWI) $ ❑ Title 5 Inspector $�T "16Title 5 Report �� $ ,4 ❑ Other. (Indicate) $ Health Agent Initials White-Applicant Yellow-Health Pink-Treasurer 7 { Commonwealth of Massachusetts Title 5 Official Inspection form � t V g Subsurface Sewage Disposal System Form-Not for Voluntary Assessments r�a C�,FA /' M 1493 Forest Street Extersion Property Address Scott Rushford Owner Owner's Name information is North Andover MA 01845 3/30/2015 required for every page. City/Town State Zip Code Date of Inspection Inspection results must be submitted on this form.Inspection forms may not be altered in any way. Please see completeness checklist at the end of the form. Important: When filling out A. General Information forms on the computer,use 1. Inspector: only the tab key to move your Neil J. Bateson cursor-do not Name of Inspector use the return key. Bateson Enterprises Inc. Company Name 111 Argilla Road +� Company Address Andover MA 01810 _ City/Town State -Zip-Code 978-475-4786 S115 ' - Telephone Number License Number rrt 062015 B. Certification H ht. - - 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 the inspection. The inspection was performed based on my training and experience in the proper function and maintenance.of on site sewage disposal systems. I am a DEP approved system inspector pursuant to Section 15.340 of Title 5(310 CMR 15.000).The system: ® Passes ❑ Conditionally Passes ❑ Fails i ❑ Needst Further Evaluation by the Local Approving Authority I t i 3/30/2015 Inspector's ignature V Date The system inspector shall submit a copy of this inspection report to the Approving Authority(Board of Health or DEP)within 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 DEP. The original should be sent to the system owner and copies sent to the buyer, if applicable, and the approving authority. ****This report only describes conditions at the time of inspection and under the conditions of use at that time.This inspection does not address how the system will perform in the future under the same or different conditions of use. t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 1 of 17 r 4X Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 1493 Forest Street Extersion Property Address Scott Rushford Owner Owner's Name information is required for North Andover MA 01845 3/30/2015 every page. City/Town State Zip Code Date of Inspection B. Certification (cont.) Inspection Summary: Check A,B,C,D or E/always complete all of Section D A) System Passes: ® 1 have not found any information which indicates that any of the failure criteria described in 310 CMR 15.303 or in 310 CMR 15.304 exist. Any failure criteria not evaluated are indicated below. Comments: B) 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. Check the box for"yes", s yesn a, non "not not determinedn a(Y, N, ND)for the following statements. If not determined," please explain. The septic tank is metal and over 20 years old*or the septic tank(whether metal or not) is structurally unsound, exhibits substantial infiltration or exfiltration or tank failure is imminent. System will pass inspection if the existing tank is replaced with a complying septic tank as approved by the Board of Health. *A metal septic tank will pass inspection if it is structurally sound, not leaking and if a Certificate of Compliance indicating that the tank is less than 20 years old is available. ❑ Y ❑ N ❑ ND(Explain below): t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 2 of 17 <L\, Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 1493 Forest Street Extension Property Address Scott Rushford Owner Owner's Name information is required for North Andover MA 01845 3/30/2015 every page. City/rown State Zip Code Date of Inspection B. Certification (cont.) ❑ Pump Chamber pumps/alarms not operational. System will pass with Board of Health approval if pumps/alarms are repaired. B) System Conditionally Passes(cont.): ❑ Observation of sewage backup or break out or high static water level in the distribution box due to broken or obstructed pipe(s)or due to a broken, settled or uneven distribution box. System will pass inspection if(with approval of Board of Health): ❑ broken pipe(s) are replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below): ❑ distribution box is leveled or replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ The system required pumping more than 4 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 ❑ Y ❑ N ❑ ND (Explain below): ❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below): C) Further Evaluation is Required by the Board of Health: ❑ Conditions exist which require further evaluation by the Board of Health in order to determine if the system is failing to protect public health, safety or the environment. 1. System will pass unless Board of Health determines in accordance with 310 CMR 15.303(1)(b)that the system is not functioning in a manner which will protect public health, 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 t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 3 of 17 F Commonwealth of Massachusetts i Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 1493 Forest Street Extersion Property Address Scott Rushford Owner Owners Name information is required for North Andover MA 01845 3/30/2015 . every page. Citylrown State Zip Code Date of Inspection B. Certification (cont.) 2. System will fail unless the Board of Health(and Public Water Supplier, if any) determines that the system is functioning in a manner that protects the public health, safety and environment: ❑ The system has a septic tank and soil absorption system (SAS)and the SAS is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ The.system has a septic tank and SAS and the SAS is within a Zone 1 of a public water supply. El The system has a septic tank and SAS and the SAS is within 50 feet of a private water supply well. ❑ ,The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or more from a private water supply well**. Method used to determine distance: **This system passes if the well water analysis, performed at a DEP certified laboratory, for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered.A copy of the analysis must be attached to this form. 3. Other: D) System Failure Criteria Applicable to All Systems: You must indicate"Yes"or"No"to each of the following for all inspections: Yes No ❑ ® Backup of sewage into facility or system component due to 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 '/day flow t5ins•3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 4 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 1493 Forest Street Extersion Property Address Scott Rushford Owner Owner's Name information is North Andover MA 01845 3/30/2015 required for every page. Cityrrown State Zip Code Date of Inspection B. Certification (cont.) Yes No E] ® 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 SAS, cesspool or privy is below high ground water elevation. El ® Any portion of 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 1 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. [This system passes if the well water analysis, performed at a DEP certified laboratory,for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered.A copy of the analysis and chain of custody must be attached to this form.] ❑ ® The system is a cesspool serving a facility with a design flow of 2000gpd- 10,000gpd. ❑ ® The system fails. I have determined that one or more of the above failure criteria exist as described in 310 CMR 15.303, therefore the system fails. The system owner should contact the Board of Health to determine what will be necessary to correct the failure. E) Large Systems: To be considered a large system the system must serve a facility with a design flow of 10,000 gpd to 15,000 gpd. For large systems, you must indicate either"yes"or"no"to each of the following, in addition to the questions in Section D. 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 If you have answered "yes"to any question in Section E the system is considered a significant threat, or answered"yes" in Section D above the large system has failed. The owner or operator of any large system considered a significant threat under Section E or failed under Section D shall upgrade the system in accordance with 310 CMR 15.304. The system owner should contact the appropriate regional office of the Department. t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal system•Page 5 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form a Subsurface Sewage Disposal System Form-Not for Voluntary Assessments ° 1493 Forest Street Extersion Property Address Scott Rushford Owner Owner's Name information is required for North Andover MA 01845 3/30/2015 every page. City/Town State Zip Code Date of Inspection C. Checklist Check if the following have been done. You must indicate"yes"or"no"as to each of the following: Yes No ® ❑ Pumping.information was provided by the owner, occupant, or Board of Health ❑ ® Were any of the system components pumped out in the previous two weeks? ® ❑ Has the system received normal flows in the previous two week period? ❑ ® Have large volumes of water been introduced to the system recently or as part of this inspection? ® ❑ Were as built plans of the system obtained and examined? (If they were not available note as N/A) ® ❑ Was the facility or dwelling inspected for signs of sewage back up? ® ❑ Was the site inspected for signs of break out? ® ❑ Were all system components, excluding the SAS, located on site? ® ❑ Were the septic tank manholes uncovered, opened, and the interior of the tank inspected for the condition of the baffles or tees, material of construction, dimensions, depth of liquid, depth of sludge and depth of scum? ® ❑ Was the facility owner(and occupants if different from owner) provided with information on the proper maintenance of subsurface sewage disposal systems? The size and location of the Soil Absorption System (SAS)on the site has been determined based on: ® ❑ Existing information. For example, a plan at the Board of Health. ® ❑ Determined in the field (if any of the failure criteria related to Part C is at issue approximation of distance is unacceptable) [310 CMR 15.302(5)] D. System Information Residential Flow Conditions: Number of bedrooms(design): 4 Number of bedrooms(actual): 4 DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): 600 t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 6 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments r 1493 Forest Street Extersion Property Address Scott Rushford Owner Owner's Name iequiredfo is North Andover MA 01845 3/30/2015 required for every page. City/Town State Zip Code Date of Inspection D. System Information Description: Number of current residents: 2 Does residence have a garbage grinder? ❑ Yes ® No Is laundry on a separate sewage system? (Include laundry system inspection information in this report.) El Yes ® No Laundry system inspected? ❑ Yes ❑ No Seasonal use? ❑ Yes ® No Water meter readings, if available(last 2 years usage (gpd)): On well water Detail: Sump pump? ❑ Yes ® No Last date of occupancy: Current Date Commercial/Industrial Flow Conditions: Type of Establishment: Design flow(based on 310 CMR 15.203): Gallons per day(gpd) Basis of design flow(seats/persons/sq.ft., etc.): Grease trap present? ❑ Yes ❑ No Industrial waste holding tank present? ❑ Yes ❑ No Non-sanitary waste discharged to the Title 5 system? ❑ Yes ❑ No Water meter readings, if available: t5ins•3113 Title 5 Official Inspection Forth:Subsurface Sewage Disposal System•Page 7 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 1493 Forest Street Extersion Property Address Scott Rushford Owner Owner's Name information is required for North Andover MA 01845 3/30/2015 every page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Last date of occupancy/use: Date Other(describe below): General Information Pumping Records: Source of information: Pumped 2012, owner Was system pumped as part of the inspection? ® Yes ❑ No If yes, volume pumped: 1500 gallons How was quantity pumped determined? Measured tank Reason for pumping: Inspect tank&tees Type of System: ® Septic tank, distribution box, soil absorption stem p Y Single cesspool ❑ Overflow cesspool ❑ Privy ❑ Shared system (yes or no) (if yes, attach previous inspection records, if any) ❑ Innovative/Alternative technology. Attach a copy of the current operation and maintenance contract(to be obtained from system owner) and a copy of latest inspection of the I/A system by system operator under contract ❑ Tight tank. Attach a copy of the DEP approval. ❑ Other(describe): t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 8 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments re 1493 Forest Street Extersion Property Address Scott Rushford Owner Owner's Name information is required for North Andover MA 01845 3/30/2015 every page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Approximate age of all components, date installed (if known)and source of information: 22 years old, 7/8/1993, as built plan Were sewage odors detected when arriving at the site? ❑ Yes ® No ! Building Sewer(locate on site plan): I Depth below grade: 2 feet Material of construction: ❑ cast iron ® 40 PVC ❑ other(explain): Distance from private water supply well or suction line: feet Comments(on condition of joints, venting, evidence of leakage, etc.): 4" PVC through wall, 3" PVC in house, no leaks visible Septic Tank(locate on site plan): Depth below grade: 1 feet Material of construction: ® concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain) If tank is metal, list age: years Is age confirmed by a Certificate of Compliance? (attach a copy of certificate) ❑ Yes ❑ No Dimensions: 10'x 5'x 4' Sludge depth: 4" t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 9 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 1493 Forest Street Extersion Property Address Scott Rushford Owner Owner's Name information is North Andover required for MA 01845 3/30/2015 every page. Cityfrown State Zip Code Date of Inspection D. System Information (cont.) Septic Tank(cont.) Distance from top of sludge to bottom of outlet tee or baffle 29" Scum thickness 4., Distance from top of scum to top of outlet tee or baffle 8" Distance from bottom of scum to bottom of outlet tee or baffle 11" How were dimensions determined? Tape Measure Comments(on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): Pumped septic tank. Inlet tee ok. Outlet tee ok. Depth of liquid at outlet invert. No evidence of leakage. Grease Trap(locate on site plan): Depth below grade: feet 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: Date t5ins•3/13 Title 5 Official Inspection Forth:Subsurface Sewage Disposal System-Page 10 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 1493 Forest Street Extersion Property Address Scott Rushford Owner Owner's Name required for is North Andover required for MA 01845 3/30/2015 every page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Comments(on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): Tight or Holding Tank(tank must be pumped 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 per day Alarm present: ❑ Yes ❑ No Alarm level: Alarm in working order: ❑ Yes ❑ No Date of last pumping: Date Comments(condition of alarm and float switches, etc.): *Attach copy of current pumping contract(required). Is copy attached? ❑ Yes ❑ No t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 11 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 1493 Forest Street Extersion Property Address Scott Rushford Owner Owner's Name information is required for North Andover MA 01845' every page. Cltyrrown 015 State Zip Code Date ate ooff Inspection D. System Information (cont.) Distribution Box(If present must be opened) (locate on site plan): Depth of liquid level above outlet invert 0 Comments(note if box is level and distribution to outlets equal, any evidence of solids carryover, any evidence of leakage into or out of box, etc.): D-box cover broken, replaced it. D-box level&distribution equal. Evidence of carryover, pumped d-box to clean. No evidence of leakage. Pump Chamber(locate on site plan): Pumps in working order: ❑ Yes ❑ No' Alarms in working order: ❑ Yes ❑ No* Comments(note condition of pump chamber, condition of pumps and appurtenances, etc.): *If pumps or alarms are not in working order, system is a conditional pass. Soil Absorption System (SAS) (locate on site plan, excavation not required): If SAS not located, explain why: t5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 12 of 17 Commonwealth of Massachusetts v 'Title 5 Official Inspection Form J Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 1493 Forest Street E tersion Property Address Scott Rushford Owner Owner's Name information is North Andover required for MA 01845 3/30/2015 every page. Cltyfrown State Zip Code Date of Inspection D. System Information (cont.) Type: ® leaching pits number: 5 ❑ leaching chambers number: ❑ leaching galleries number: ❑ leaching trenches number, length: ❑ leaching fields number, dimensions: ❑ overflow cesspool number: ❑ innovative/alternative system Type/name of technology: Comments(note condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of vegetation, etc.): Lawn covered in snow. 5 leach pits on a bed of stone 18'x 54'. Camera pits thru outlets in d-box, no liquid to inverts.No sign of ponding to surface i I i Cesspools (cesspool must be pumped as part of inspection) (locate on site plan): I 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 ❑ Yes ❑ No t5ins•3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 13 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments °< 1493 Forest Street Extersion Property Address Scott Rushford Owner Owner's Name information is required for North Andover MA 01845 3/30/2015 every page. Cityfrown State Zip Code Date of Inspection D. System Information (cont.) Comments(note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): I 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.): t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 14 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 1493 Forest Street Extersion Property Address Scott Rushford Owner Owner's Name information is required for North Andover MA 01845 3/30/2015 every page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Sketch Of Sewage Disposal System: Provide a view of the sewage disposal system, including ties to at least two permanent reference landmarks or benchmarks. Locate all wells within 100 feet. Locate where public water supply enters the building. Check one of the boxes below: ® hand-sketch in the area below ❑ drawing attached separately Td we\1 R o I t5ins•3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 15 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments r 1493 Forest Street Extersion Property Address Scott Rushford Owner Owner's Name information is required for North Andover MA 01845 3/30/2015 every page. City town State Zip Code Date of Inspection D. System Information (cont.) Site Exam: ® Check Slope ® Surface water ® Check cellar ® Shallow wells Estimated depth to high ground water: 4 feet Please indicate all methods used to determine the high ground water elevation: ® Obtained from system design plans on record If checked, date of design plan reviewed: 8/19/1992 Date ❑ Observed site(abutting property/observation hole within 150 feet of SAS) Checked with local Board of Health -explain: Design plan ❑ Checked with local excavators, installers-(attach documentation) ❑ Accessed USGS database-explain: You must describe how you established the high ground water elevation: As per test pit data on design plan. Before filing this Inspection Report, please see Report Completeness Checklist on next page. t5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 16 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System f=orm-Not for Voluntary Assessments 1493 Forest Street Extersion Property Address Scott Rushford Owner Owner's Name information is required for North Andover MA 01845 3/30/2015 every page. City/Town State Zip Code Date of Inspection E. Report Completeness Checklist ® Inspection Summary: A, B, C, D, or E checked ® Inspection Summary D (System Failure Criteria Applicable to All Systems) completed ® System Information—Estimated depth to high groundwater ® Sketch of Sewage Disposal System either drawn on page 15 or attached in separate file t5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 17 of 17 a ' rt ( . NEW ENGLAND RADON, LTD. 603-89.34UO 21f1 Industrial Way, Unif 3 Fax: 6031893-8163 Salem,New Hampshire 03079 Email:�es}�:na�<n?neti+en�IandxadD}Cts'ii� Website: www.nevvenglandradon,con! WATER ANALYSIS RESULTS DATE: 18 Mar 2015 NAME: MAIDA SERVICES P.O. BOX 15 PLAISTOW, NH 03865 Date & time Sampled: 03/16/2015, 1330 Date Received: 03/16/2015 LAB.# 69377 TEST(SITE: --1493 FOREST STREET, NO ANDOVER, MA (524835) -----�------ ---------------------------------------------------------------------------- PARAMETERS RESULTS REQUIREMENTS ANALYTICAL DATE OF TIME OF MCL/SMCL METHOD ANALYSIS ANALYSIS HARDNESS *# 90.0 NO LIMIT SM2340C 20150318 IRON * 0.17 0.3 mg/l EPA 200.8 20150317 1926 MANGANESE *# 0.051 0.05 mg/l EPA 200.8 20150317 1926 PA *# 7.8 6.5 - 8.5 EPA 150.1 20150316 1905 CHLORIDE *# 7.2. 250 mg/l EPA 300.0 20150316 1745 TURBIDITY **# 1.3 1 NTU*** EPA 180.1 20150316 COPPER **# <0.5 1.3 mg/l EPA 200..8 20150317 1926 SODIUM *# <20.0 250 mg/l EPA 200.8 20150317 1926 NITRATE *'*# <0.5 10 mg/l EPA 300.0 20150316 1745 COLIFORM **# A ABSENCE/100 ml P/A COLI'SURE 20150316 1515 E-COIN **# A ABSENCE/100 ml P/A COLISURE 20150316 1515 COLOR * 0 1.5 C.U. HACH 8025 20150316 ODOR * ND 3 O.U. SM2150B 20150316 LEAD **# <0.005 0.015 mg/l EPA 200.8 20150317 1926 ARSENIC **# <0.005 0.010 mg/1 EPA 200.8 20150317 1926 FLUORIDE **# <0.5 4.0 mg/l EPA 300.0 20150316 1745 CALCIUM *# 17.2 100.0 mg/l EPA 200.8 20150317 1926 NITRITE **# <0.5 1.0 mg/l EPA 300.0 20150316 1745 URANIUM **# <0.005 0.030 mg/l EPA 200.8 2015031.7 1926 MAGNESIUM *# 4.1 ---- EPA 200.8 20150317 1926 POTASSIUM *# <0.5 ---- EPA 200.8 20150317 1926 *** 5 NTU is allowed for well water. THIS SAMPLE MEETS EPA PRIMARY STANDARDS FOR THE PARAMETERS TESTED. These parameters exceed the MCL* or are out of range: Manganese. =::K. r•, -+u 10 WY.1.�Fl_ .',^Z�>."".i 4�} 1 T.�K f � +-3,"�- •� t v�,l. i'i _ S- '�' l 'r.Tir:�^..`� � �.-. �'C�,> '>r- --1• xi P. =Cir`. a 1 .? t.- r - :S iL>, �'. "�:, r ..m-� _ ti< �'�":�' 7 .n. n +•Y a_ e",*' ;,-' t.;�-:- .oF�, :�' K 1 M- •.sm.[,=. t,�?`.. ..,2. '.h>_..,.':::.ae .n,iY.-t:Y ..s'>,•s�., _is!+ t - SC t-.+. _i S:.' 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Lw R v ..},t3�,k.� ,�- "G�:s''..•" az5a i'w ..Y:..>..-:�h>c�;S-';F<. :.2. 'v'"::z fir.�S� :x -3 3 fgr�axt '�F49x r�.=L:{:�•:> \v�kCiro � ;L., rs �' .1 -tJ-, cti x d-i+ - .:� ,.,t"L•li....'�y Stir Wiz)-r>. �'A. '�i�-s i`}a,. T�. 4s .� .. r' .-a f-�` v -`:, �. r' .:'x t - S -'\ \ .. �- - ,�- - + o : \ L;ommonweann oT massacnuser[s UWTown d System Pumping.Record 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 forrh they use.The System Pumping Record must be submitted to the local Board of Health or other approving authority. A. Facility. Information 1. System Location: Left/ fight front ofd s Left/Right rear of house, Left/right side of house, Left/ Right side of building, Left/Right front of building, Left/Right rear of building, Under deck Adder --- City/Town state Zip Code 2. System Owner. Name' Address(if different from locafion) city/Town state �,_ Zip Code ; � l fe i Telephone Number ; B. Pumping Record f 1. Date of Pumping gate 2. Quantity Pumped: Gallons , 3. Type of system: ❑ Cesspool(s) eptic Tank ❑ Tight Tank Other(describe): 4. Effluent Tee Filter present? ❑ Yes No If yes, was it cleaned? ❑ Yes ❑ No . 5. Condition stem: l v 6. System Pumped By. Neil.Bateson F5821 Name Vehicle License Number Bateson Enterprises Inc Company 7. Location where contents-were disposed: Q- S Lowell Waste Water Sig HauleV Date t5form4.docr 06103 system Pumping Record•Page 1 of 1 f • f Department of Environmental Management/Division of Water Resources �e WELL GOMPEE44GN REPORT y'MAt nn�o WELL LOCATION GEOGRAPHIC GEOGRAPHIC DESCRIPTION � Address�- N SW of eet) c1 e) City/Town Well owner // /. /��edr/� (Za) r Address f 3 I N W of tenths) Q— (circis) Board of Health permit obtained: yes kIA no ❑ intersect. w/ WELL USE WELL DATA _ Domestic Public EJ Industrial El Total well depth ft. Monitoring Other Depth to bed.Lock ft. Water-bearing rock/ onsolidated material: Method drilled Description Date drilled Water-bearing zones: CASING / 1) From --_— o Typed l 2) From To Length ft. Dia(I.D.) in. 3) From A To Length into bedrock ft. Gravel pack,well ,r1 Eu.Sa n Protective well seal: Screen: dia. CI - -- - Grout Othe Slot# length from to STATIC WATER LEVEL(all wells) - Static water level below land surface - ft. Date WELL TEST(production wells) Drawdown -ft----,affe,L um�pingr min. at gpm How measured Reppu"e"ry�, t_ after_ hr. min. LOG of FORMAT ONS /COMMENTS Materials From To Driller �P,-,2 `7` fir Firm -f' Address City/Town � 0,76, 'J Supervising Driller Reg.# OF Signal s er6sing regi re ,,slydn11er t Please print firmly BOARD OF HEALTH COPY f assachusetts J'r MASSACHUSETTS FIRE INCI ` Fire f 'ilia Incident DEPARTMENT OF PUBLIC SAFETY OFFICE OFT ST E MARS \�gJ � � IL1 I porti 1010 Commonwealth Avenue Boston,Mas Chu US 02215 System Oq 10 FDID#' QC7 ED Department ,/iD/T� A v�' eport FOP 3n2 If Exposure `� DATE Day Of 1 Sun 2 Mon 3 e Flit Time Arrival Time -Back in Service Incident# �S%j Fire only: !/-!3 7 ',S Week 4 Wed 5 Thu 6 * 7 Sat /.z 3 i' I?;J/ / • f a Z 0 11 I I Structure fire 17 17 Outside spill with fire SEE MANUAL 0 13 I I Vehicle fire 18 17 Other fires not classified FOR OTHER Z Z 1 ❑ Extinguish is 5 f 1 Stand by MUTUAL AID N Z CALLS P W 2 ❑Rescue or Assistance G i l Salvage 1 Recd Q� 14 1 1 Brush,grass,leaves 47 n Chemical spill D F-Y 3 n Investigation only 7 [-1 Ambulance 2 Given 0 to;1 Trash,rubbish 44 F] Power line down � tJ Q ka.. 4(1 Remove Hazard 8 Cl Fill in.Move up N A 1n 16; Explosion.No after fire 45 17 Arcing electric equipment — ':3 - © FIXED PROPERTY USE(Occupancy) IGNITION FACTOR WIN _1 -` CORRECT ADDRESS(Up to maximum of 21 characters) ZIP CODE CENSUS TRACT 1 TOCCUPANT NAAMEFIR } (LAST ST,MI) TEL_EPyHsONE ROOM or APT OWNER NAME (LAST,FIRST,MI) ADDRESS TELEPHONE (I Vl/1 e- sa n'4 'e. LC'rlc`Yl w _ _ �- MEI HOD OF ALARM Co.wsPECTiON NO.FIRE SERVICE PERSONNEL N0.ENGINES - NO.AERIAL APPARATUS ((�) 13 1 r le homeduect DISTRICT O RESPONDED RESPONDED I j� RESPONDED 2 Mumapal alarm L sy tem I__�J ,, - I 3 Pt iv.to alarm system --- - 4 Rad o SHIFT HAZARDOUS MATERIAL PRESENT? NO.TANKERS NO.OTHER VEHICLES 5 Verbal L YES(=1 NO X RESPONDED ��1� RESPONDED '- 6 No alarm recd. SC% 7 Tiu line 19111 — SUBSTANCE 8 Voce signal municipal alarm NO.ALARMS USE FP 33 signal j — ---- — FOR ALL 9 Not classified above /" 0 undetermined or not reported Special Equipment Used? _ CASUALTIES (I ) 20 FIRE NUMBER OF NUMBER OF NUMBER OF 1 - j NUMBER OF RESCUES r- �-- SERVICE INJURIES FATALITIES INJURIES Il �� II FATALITIES _.�- --- OTHER -- O MOBILE PROPERTY TYPE VEHICLE STOLEN? Yes❑ No❑ 11 AUTO,VAN 22 TRUCK UNDER 1 TON ESTIMATED TOTAL Insurance Co. 12 BUS 41 BOAT,UNDER 65' DOLLAR LOSS ___ 13 MOTORCYCLE Total Insurance $ Claim Paid $ 21 TRUCK OVER 1 TON 08 NONE ` YEAR MAKE MODEL COLOR LICENSE NO. VIN# 30 40 IF EQUIPMENT INVOLVED YEAR' MAKE MODEL SERIAL NO. IN IGNITION ---P I IMeRi cjigp) -ZUO O COMPLEX A A-EA-0-FT EQUIPMENT INVOLVED IN IGNITION ORIGIN / l © FORM OF HEAT IGNITION MATERIAL IGNITED FORM TYPE W00D _ METHOD OF LEVEL OF FIRE ORIGIN Number of Stories CONSTRUCTION TYPE OEXTINGUISHMENT 1 Grade level to 9 ft. 1 F. 1 story 1 ' i Fire resistive i Self extinguished 2 I 1 10 to 19 feet 2 `i 2 story 2 Heavy timber 2 !1 Make shift aids 3 1 20 to 29 feet 3 l; 3 to 4 stories 3 Protected noncombustible 3 f I Ponable extinguisher 4 I l 30 to 49 feet 4;15 to 6 stories 4 i Unprotected noncombustible 4 f_i Automatic Ding system 5(; 50 to 70 feet 5�_ 7 to 12 stories 5 1 1 Protected ordinary 6 i i Pre e-connect hose lank only 6 F1 Over 70 feet 6 i . 13 to 24 stories 6 i Unprotected ordinary 6 1l Pre-connect hose'hydranl draft standpipe 7 F'Objects to flight 7(i 25 to 49 stories 7 '-' Protected wood frame 7 ! I Hand-laid hose,hydrant draft standpipe 8 i7 Below ground level 8 r 50 stories or more 8 'i Unprotected wood frame 8 f I Master stream device 9:1 Not classified above 9;1 Not classified above 0:1 Undetermined 0;1 Undetermined or not reported O EXTENT OF DAMAGE DETECTOR PERFORMANCE SPRINKLER PERFORMANCE 1 Confined to the object of origin Flame Smoke 1 F7) Det.in room or space of fire origin—oper. 1 i. 1 Equipment operated 2 Confined to part of room or area of origin t. 2 F1 Det not in rm.or space of fire origin—oper. 2 i 1 Equipment should have operated- 3 Conti ed to room of origin 3 F1 Det in rm or space of origin—no oper, did not 4 Confined to the fire-rated comp.of origin © 4 i 1. Det not in rm or space of origin—no oper. 3 Equipment pre.but fire too small 5 Confined to floor of origin n 5 I.Det lin lint or space of fire origin but to oper. — 6 Confined to structure of origin fire too small to oper 9 i Not classified above 7 Extended beyond structure of origin 9 Not classified above 0 i 1 Undetermined or not reported 9 No damage of this type IN AI 0 I_-1 Undetermined or not reported [i 8 ... No equipment present(N AI ^ 9 YP 8 i No detectors present IN AI 0' IF SMOKE SPREAD MATERIAL GENERATING MOST SMOKE FORM TYPE BEYOND ROOM CF ORIGnN ooL _ C L eQ-a AVENUE OF SMOKE TRAVEL 7 t j Utility opening in floor ® 1 n Air handling duct 4 !--, Stairwell 9 Not classified above 2❑Corridor 5 F1 Opening in construction 0! Undetermined or not reported WEATHER _ _ 3❑ Elevator shaft 6 i] Utility opening in wall 8 i 1 No avenue of smoke travel IN AI CONDITIONS Entries contained in this report are intended for the sole 7j O El use of the State Fire Marshal Estimations and evaluations made herein represent"most likely"and 'most probable" cause and effect.Any representation as to the validity or MEMBER MMING REPORT DATE accuracy of reported conditions outside the State Fire Marshal's office,is neither intenoed nor implied FIRE IMARSHAL F.M. _._N� r }age 3- SOP CHECKLIST FOR CARBON MONOXIDE Location of Incident: 7 9,� } G��C�5 T S7 x Date of incident QUICK CHECKLIST OF OCCUPANTS Headache yes nom/ Fatigue yes no Nausea yes no ✓ Dizziness yes no Confusion yes no Are any members of the household feeling ill? yes no✓ Do the residents feel better away from the house?yes no Since the detector's alarm went off,what have you done? Shut- off carbon monoxide sources yes no If yes which sources Let in fresh air? yes no / If yes how did you let the air in How long did you let the air in PPM reading ambient outside the dwelling f 11 Highest PPM reading in jhe dwelling a 7 l p/'1 Carbon monoxide detector present? yes no If yes list the number of detetors locations and make, and serial number of each below. 1. W/ tc,hell LveA) -- ,yly'P'fle"gy sEA)SaeS F-r3 6)3y 2. _ -v►c�nE� - cis -z�v 3. 4. Which detector(s)by number above activated? / SOURCE CHECKLIST . LOCATION PPM READING Chimney clogged flue,blocked opening celled- j�5- Jif-/'f Fireplace(s) Natural gas,LPG,Wood(indicate type for each fireplace) 1. De rl P?/Y) 3. 2. ce 11 c.tie P)9tyI 4. Gas Appliance (if Gas Company on Scene they can perform this check) (IF MORE THAN 1 OF THE FOLLOWING APPLIANCES LIST EACH ADDITIONAL ON THE COMMENTS PAGE WITH ITS LOCATION, AND PPM READING) refrigerator stove vent over stove clothes dryer water heater (chimney pipe) furnace (gas,oil;leaking flue/chimney pipe barbacue grill (in eclosed or semi enclosed area Oil burner car garage Entranceway from garage to house Name of individual operating the CO monitor Person completing the Checklisto HANCOCK SURVEY ASSOCIATES O x#3290 July 8, 1993 North Andover Board of Health Town Hall North Andover, MA 01845 Attn: Sandy Starr RE: Subsurface Sewage Disposal System Lot 2 - Forest Street Extension Dear Cindy: I hereby certify that the subject system was installed as shown on the enclosed as-built sketch. Plea e call if you have any questions. V AQ,@ ter' ss CAV V: Y 1 Vaclav \ y �� c\I0h—A VVTlnmp a acv vim° VTJBS 235 Newbury Street•Route 1 North•Danvers,MA 01923•(508)777-3050•(508)352-7590•(508)283-2200•(617)662-9659•FAX(508)774-7816 HANCOOK SURVEY A$80CIA'FM, INC. JOB 236 Newbury Street (Route 1 North) SHEET NO. / of DANVERS-. MASSACHUSETTS 01923 - f 1. 17 777*3050 . 6.171 66�--•9659' CALCULATED BY_ 1 GATE r? 617 332-7890 1617 283.2200 CHECKED BY DATE '-- _... SCALE_ \ ;... ........ I i ...... I Ei ........._ .�... ; : : € t .........;.............i...._ { LL 1 t t : { ......_ PIRA-i� rr` , - j//•• , �1LI ........................_..............:........... 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E ..... ....... i i i ....:......................_...{.............a._.._. ..........................�...__;..............�......... .— ...-- _........ ...... _..'..__:_.. ..................' ' { { ..... ... _.....-f..—.....'......................_«..«_..._....._......................�..........................:............�.... __.:._— 1 __............ .. i ........«. ..�.................. i I : — j......... �. —_ _..«............T........ . .. ..... .... .........i.....................—...�..— i I { —r j I • N1 .... i...._ _M......._.. ... Z' _ . Q 1... ........ ._. ..........................._..._.' .... o�RS © cdIN ► E ' ,gin .. �.... k �..«.- : -- .. Hoatir�i®�•ate.wa nal. � ' _ 8fJ R'YIY ASSOCIATE$, W. Joe -, 235 Newbury Street (Route 1 North) . SHEET NO. Z of 2 DANVERS, MASSACHUSETTS 01923 (617) 777.3050 (617) 662-9659 CALCULATED BY r � DATES z ' (617) 392-7590 (617) 2832200 CHECKED BY DATE SCALE ..........i..........................................s............ ........ ......... ..... ...... ...... ...... ...... ..... ...... ..... ...... ..... .... i .. ... i ! y .. ... .. :.... O f3M.; ......... G _ .. TAZ�'_L: Or A� �J S Fj r�� ....... .. = . . 1 . 4 fT . ...... .......... ... .. . .. ...... ..... .. ................... ... .... ............ -T 5 . !... ...._......_'............. _ . ................ ...... .......... J...'.............'_'.... ..........:1.. �_ ..... Z„ ....................... � . L 1 ki .........................:.......... .....1 ........... s ......... ..... ...... ...... .......... ...... ...... ... ... :, _.__. __: i... . 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COMMONWEALTH OF MASSACHUSETTS �/ln^�1Vrh ^• EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS'pF�q�yL� DEPARTMENT OF ENVIRONMENTAL PROTECTION TITLE 5 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM-FORM PART A CERTIFICATION Property Address:_1493 Forest Street Extension_ —North Andover— Owner's Name:_David Deacon_ Owner's Address:_1493 Forest Street Extension_ _North Andover,MA 01845_ Date of Inspection:_4/16/2004_ Name of Inspector: Neil J.Bateson Company Name: Bateson Enterprises Inc._ Mailing Address:_111 Argilla Road_ _Andover,Ma.01810_ Telephone Number: (978)4754786_ 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 the inspection.The inspection was performed based on my training and experience in the proper function and maintenance of on site sewage disposal systems.I am a DEP approved system inspector pursuant to Section 15340 of Title 5(310 CMR 15.000). The system: X Passes Conditionally Passes Needs FAther Evaluation by the Local Approving Authority ' s Inspector's Signature: Date: _4/16/2004_ The system inspector shall submit a copy of this inspection report to the Approving Authority(Board of Health or DEP)within 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 DEP.The original should be sent to the system owner and copies sent to the buyer,if applicable,and the approving authority. Notes and Comments: ****This report only describes conditions at the time of inspection and under the conditions of use at that time.This inspection does not address how the system will perform in the future under the same or different conditions of use. Page 2 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address:_1493 Forest Street Extension_ _North Andover— Owner:_Deacon_ Date of Inspection:_4/16/2004_ Inspection Summary: Check A,B,C,D or E/ALWAYS complete all of Section D A. System Passes: X I have not found any information which indicates that any of the failure criteria described in 310 CMR 15.303 or in 310 CMR 15.304 exist.Any failure criteria not evaluated are indicated below. Comments: B. System Conditionally Passes: in the"Conditional Pass"section need to be One or more system components as described replaced or Y P repaired.The system,upon completion of the replacement or repair,as approved by the Board of Health,will pass.. Answer yes,no or not determined(Y,N,ND)in the for the following statements.If"not determined"please explain. _The septic tank is metal and over 20 years old*or the septic tank(whether metal or not)is structurally unsound,exhibits substantial infiltration or exfiltration or tank failure is imminent.System will pass inspection if the existing tank is replaced with a complying septic tank as approved by the Board of Health. *A metal septic tank will pass inspection if it is structurally sound,not leaking and if a Certificate of Compliance indicating that the tank is less than 20 years old is available. ND explain: Observation of sewage backup or break out or high static water level in the distribution box due to broken or obstructed pipe(s)or due to a broken,settled or uneven distribution box. System will pass inspection if(with approval of Board of Health): broken pipe(s)are replaced obstruction is removed distribution box is leveled or replaced ND explain: The system required pumping more than 4 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 ND explain: I Page 3 of 11 OFFICIAL INSPECTION FORM -NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address:_1493 Forest Street Extension_ _North Andover_ Owner:_Deacon_ Date of Inspection:_4/16/2004 C. Further Evaluation is Required by the Board of Health: Conditions exist which require further evaluation by the Board of Health in order to determine if the system is failing to protect public health,safety or the environment. 1. System will pass unless Board of Health determines in accordance with 310 CMR 15.303(1)(b)that the system is not functioning in a manner which will protect public health,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 any)determines that the tem is functioning in a manner that protects the public health,safety and environment: system g _ The system has a septic tank and soil absorption system(SAS)and the SAS is within 100 feet of a surface water supply or tributary to a surface water supply. _ The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water supply. _ The system has a septic tank and SAS and the SAS is within 50 feet of a private water supply well. The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or more from a private water supply well".Method used to determine distance__ "This system passes if the well water analysis,performed at a DEP certified laboratory,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,provided that no other failure criteria are triggered.A copy of the analysi§must be attached to this form. 3. Ot NF1'•• Page 4 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address:_1493 Forest Street Extension_ _North Andover— Owner:_Deacon_ Date of Inspection:_4/16/2004_ D. System Failure Criteria applicable to all systems: You must indicate"yes"or"no"to each of the following for all inspections: Yes No _ No Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool —No Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool No Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool _No Liquid depth in cesspool is less than 6"below invert or available volume is'/i day flow. No Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number of times pumped No Any portion of the SAS,cesspool or privy is below high ground water elevation. No Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. _No Any portion of a cesspool or privy is within a Zone 1 of a public well. _ —No_ Any portion of a cesspool or privy is within 50 feet of a private water supply well. No— 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. [This system passes if the well water analysis, performed at a DEP certified laboratory,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,provided that no other failure criteria are triggered.A copy of the analysis must be attached to this form.] No (Yes/No)The system fails.I have determined that one or more of the above failure criteria exist as described stem owner should contact the Board of Health to fails.The s in 310 CMR 15.303,therefore the system y determine what will be necessary to correct the failure. E. Large Systems: To be considered a large system the system must serve a facility with a design flow of 10,000 gpd to 15,000 gpd. You must indicate either"yes"or"no?'to each of the following: (The following criteria apply to large systems in addition to the criteria above) 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 Y _ 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 If you have answered"yes"to any question in Section E the system is considered a significant threat,or answered "yes"in Section D above the large system has failed.The owner or operator of any large system considered a significant threat under Section E or failed under Section D shall upgrade the system in accordance with 310 CMR 15.304.The system owner should contact the appropriate regional office of the Department. Page 5 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST Property Address:_1493 Forest Street Extension_ _North Andover— Owner:_Deacon_ Date of Inspection:_4/16/2004_ Check if the following have been done.You must indicate"yes"or"no"as to each of the following: Yes No Yes_ _ Pumping information was provided by the owner,occupant,or Board of Health No Were any of the system components pumped out in the previous two weeks? _Yes_ — Has the system received normal flows in the previous two week period? No Have large volumes of water been introduced to the system recently or as part of this inspection? Yes _ Were as built plans of the system obtained and examined?(If they were not available note as N/A) Yes _ Was the facility or dwelling inspected for signs of sewage back up? Yes Was the site inspected for signs of break out? Yes_ _ Were all system components,excluding the SAS,located on site? _Yes_ _ Were the septic tank manholes uncovered,opened,and the interior of the tank inspected for the condition of the baffles or tees,material of construction,dimensions,depth of liquid,depth of sludge and depth of scum? _Yes_ _ Was the facility owner(and occupants if different from owner)provided with information on the proper maintenance of subsurface sewage disposal systems? The size and location of the Soil Absorption System(SAS)on the site has been determined based on: Yes no _Yes_ _ Existing information. _NoDetermined in the field(if any of the failure criteria related to Part C is at issue approximation of distance is_unacceptable)[3 10 CMR 15.302(3)(b)] Page 6 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION Property Address:_1493 Forest Street Extension_ _North Andover_ Owner:_Deacon_ Date of inspection: 4/16/2004 FLOW CONDITIONS RESIDENTIAL Number of bedrooms(design):_4_ Number of bedrooms(actual):_4 DESIGN flow based on 310 CMR 15.203(for example: 110 gpd x#of bedrooms):_600_ Number of current residents: Does residence have a garbage grinder(yes or no): No Is laundry on a separate sewage system(yes or no):_No_ Laundry system inspected(yes or no): Seasonal use:(yes or no):_No Water meter readings: No,on well water_ Sump pump(yes or no):_No Last date of occupancy: — Current—COMMERCIAL/MISTRIAL Type of establishment: Design flow(based on 310 CMR 15.203): gpd Basis of design flow(seats/persons/sgft,etc.): 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 of occupancy/use: OTHER(describe): GENERAL INFORMATION Pumping Records Source of information: Pumped 2002,owner_ Was system pumped as part of the inspection(yes or no): Yes_ If yes,volume pumped:_1500__Vallons—How was quantity pumped determined?_Measured tank Reason for pumping: Inspect tank&tees_ TYPE OF SYSTEM X 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) Innovative/Alternative technology.Attach a copy of the current operation and maintenance contract(to be ob_tained from system owner) _Tight tank —Attach a copy of the DEP approval Other(describe):_ Approximate age of all components,date installed(if known)and source of information:_11 Years old,7/8/1993, As built plan_ Were sewage odors detected when arriving at the site(yes or no): No Page 7 of 1 I OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) _1493 Forest Street Extension Property Address: _ _North Andover_ Owner:_Deacon_ Date of Inspection: 4/16/2004_ BUILDING SEWER_X_ (locate on site plan) Depth below grade:_24"_ Materials of construction: _X cast iron 40 PVC other Distance from private water supply well or suction line: Comments(on condition of joints,venting,evidence of leakage,etc.):_4" PVC thru wall& 3"PVC in house,no leaks visible SEPTIC TANK: X_(locate on site plan) Depth below grade:_12"_ Material of construction: X concrete metal_fiberglass__polyethylene _other(explain) If tank is metal list age:____ Is age confirmed by a Certificate of Compliance(yes or no): (attach a copy of ccrtificate) Dimensions: 10'x 5'x 4' Sludge depth 6"_ Distance from top of sludge to bottom of outlet tee or baffle: 21"_ Scum thickness:_6"_ Distance from top of scum to top of outlet tee or baffle:_8" Distance from bottom of scum to bottom of outlet tee or baffle:_15"_ How were dimensions determined: _ Comments(on pumping recommendations,inlet and outlet tee or baffle condition,structural integrity,liquid levels as related to outlet invert,evidence of leakage,etc.):_Pumped septic tank.Inlet tee ok.Outlet tee ok. No evidence of septic tank leaking. Depth of liquid at outlet invert. _ GREASE TRAP: (locate on site plan) Depth below grade: ade:_ 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(on pumping recommendations,inlet and outlet tee or baffle condition,structural integrity,liquid levels as related to outlet invert,evidence of leakage,etc.): Page 8 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address:_1493 Forest Street Extension_ _North Andover- Owner:_Deacon_ Date of Inspection:_4/16/2004 TIGHT or HOLDING TANK: (tank must be pumped 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 present(yes or no): Alarm level: Alarm in working order(yes or no): Date of last pumping: Comments(condition of alarm and float switches,etc.): DISTRIBUTION BOX: X (if present must be opened)(locate on site plan) Depth of liquid level above outlet invert: _0"_ Comments(note if box is level and distribution to outlets equal,any evidence of solids carryover,any evidence of leakage into or out of box,etc.):_D-box level& distribution equal No evidence of leakage out of d-box. Evidence of solid carryover,pumped d-box to clean_ PUMP CHAMBER:_(locate on site plan) Pump in working order(yes or no): Alarm in working order(yes or no): Comments(note condition of pump chamber,condition of pumps and appurtenances,etc.): Page 9 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address:_1493 Forest Street extension- -North Andover_ Owner:_Deacon_ Date of Inspection: 4/16/2004 SOIL ABSORPTION SYSTEM(SAS): X (locate on site plan,excavation not required) If SAS not located explain why: Type X leaching pits,munber:_5 leach pits on bed of stone 18'x 54'_ leaching chambers,number: leaching galleries,number: _ leaching trenches,number,length: _ leaching fields,number,dimensions: overflow cesspool,number: innovativelaltemative system Type/name of technology: Comments(note condition of soil,signs of hydraulic failure,level of ponding,damp soil,condition of vegetation, etc.):_Soil ok.Vegetation ok.No sign of ponding to surface_ CESSPOOLS: (cesspool must be pumped as part of inspectionxlocate 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(yes or no): Comments(note condition of soil,signs of hydraulic failure,level of ponding,condition of vegetation,etc.): PRIVY: (locate on site plan) Materials of construction: Dimensions: Depth of solids: Comments(note condition of soil,signs of hydraulic failure,level of ponding,condition of vegetation,etc.): Page 10 of 11 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address:_1493 Forest Street Extension_ _North Andover Owner: Deacon_ Date of inspection:_4/16/2004 SKETCH OF SEWAGE DISPOSAL SYSTEM Provide a sketch of the sewage disposal system including ties to at least two permanent reference landmarks or benchmarks.Locate all wells within 100 feet.Locate where public water supply enters the building. ♦— To Well House Driveway Garage A B A to Tank=3512" Septic Tank A to D-Box=7819" B to Tank=27' B to D-Box=8614" I Pit#1 Pit#2 D- Box Pit#3 Pit#4 Pit#5 Page 11 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address:_1493 Forest Street Extension_ _North Andover_ Owner:_Deacon_ Date of Inspection:_4/16/2004_ SITE EXAM Slope Surface water Check cellar Shallow wells Estimated depth to ground water –49 _ Please indicate(check)all methods used to determine the high ground water elevation: X Obtained from system design plans on record-If checked,date of design plan reviewed: 8/19/1992_ — _ Y �P – Observed site(abutting property/observation hole within 150 feet of SAS) Checked with local Board of Health-explain:_ Checked with local excavators,installers-(attach documentation) Accessed USGS database-explain: _ You must describe how you established the high ground water elevation:–Design Plan_ Tel: (978) 475-4786 Fax: (978) 475-5451 BATESON ENTERPRISES, INC. Excavating-Water.& Sewer Lines-Septic Systems&Pumping Service 1 I 1 Argilla Road Andover, Mass. 01810 Title 5 Inspection Report Property t Address: 1493 Forest Street Extension North Andover er P Owner: Deacon Date of Inspection: 4/16/2004 My report contained herein does not constitute a guarantee of future usage and the functionality of the existing septic system. Such report issued herewith is merely based upon my observations, and I hereby disclaim any further operation of your current septic system. 41ateson Nei Bateson Enterprises, Inc. i 0 I'C=) M a r�n(3 16 EAST MAIN STREET, P.O. BOX 1153, GLOUCESTER, MA 01931-1153 TELEPHONE: (978)281-0222 FAX: (978)283-3374 CERTIFICATE OF ANALYSIS Mr.David Deacon Report No.: 91645 1493 S August 26, 1999 N.Andover MA Re: ANALYSES OF DRINKING WATER QUALITY SOURCE INFORMATION: In-use well,�-3 years old and 280 feet in depth,located at the above address. SAMPLE COLLECTION: Sample taken by George Rollins on August 13, 1999. Coliform sample taken August 17, 1999. FINDINGS: ,44' ', VIE R RESULT t�RE�VTE�aD NALYSI 3 . Gi7IDEL DATE; , A .. To(al C 08/17/ P11 o /J 00,M 99 0 \C alcium Cont t(mg/I) 82.6 08/24!99 7hJ6x1d94 nt nt�(1rngn) ' 13.1 ��50 08/16799 It ffv / J ia` 3 rn Conduct>vity(}mhos/crn: y 08/18/99 419 -ice n Contgn`t �-, �0 Q4 , :art 0$/23199 IVlagfneslulrcxaoxqng/l 5 76 08/24/99 4N s� ManganeseContent(mg/l�) 08/23/99 Nitrate r g n n ent( 7.55 08/16%99 alae(s ) �� 662(slightly acidic) 5 . 08/14199 oc`�u stent(mg/1 f12:2, w <� 28 08/23/99 F Hatdness( g/1 (assCaCO3)� 179(hard) calculation ,� 1 ...waual4Yr �` .,, .,,.�,�. of L '�, '1L ,,.., METHODS: Analyses performed in accordance with Standard Methods for the Examination of Water & Wastewater, 19th Edition, 1995. Guidelines are based on the maximum contaminant levels recommended by the Massachusetts Department of Environmental Protection for drinking water. Analyses performed by Massachusetts certified laboratory MA123. REMARKS:Although the Nitrate Nitrogen level detected does not exceed the EPA recommended maximum,it is elevated in comparison to most area wells tested. Care should be taken to avoid the use of fertilizer compounds in the runoff area of the well. Nitrate may enter water systems via runoff from heavily fertilized areas,septic contamination,or from degraded vegetative material. Excessive levels of nitrate in drinking water have caused serious illness and sometimes death in infants under 6 months of age. Nitrate is converted to nitrite in the body which interferes with the oxygen carrying capacity of a child's blood.Nitrite,of itself, Page 1 of 2 0 [$SOomamrino Report No.: 91645 August 26, 1999 can react with organic material in water to produce cancer-causing compounds. Nitrate/Nitrite may be removed by reverse osmosis filtration. Retesting of the nitrate level is recommended. n.MaxluutWLab DkOcLor Cc: N.Andover Board of Health Page 2 of 2 North Andover Health Dept. • 27 Charles Street North Andover,MA 01845 in To: Dave Deacon Fax: 887-3235 From: Sandy Starr Date: 09/03/99 Re: Well water report Pages: 2 CC: [Click here and type name] ❑ Urgent ❑For Review ❑ Please Comment ❑ Please Reply ❑ Please Recycle n Notes Select this text and delete it or replace it with your own. To save changes to this template t i.4 y t for future use,choose Save As from the File menu. In the Save As Type box, choose Document Template""Next time you want to use it,choose New from the File menu,and then double-click your template. r.l 0 O f . 16 EAST MAIN STREET, P.O. BOX 1153,GLOUCESTER, MASS.01930 TELEPHONE: (508)281-0222 FAX: (508)283-3374 CERTIFICATE OF ANALYSIS MR DON ROBINSON REPORT NO.: 30470 9 OLD ESSEX STREET APRIL 29, 1993 MIDDLETON MA 01949 RE: WELL WATER ANALYSIS �sS Well nescription: New !ucll deet deep, located on-,Lot-2,-Fd-rest-Street, N. And- -Ver, "J!^. Ex7; Sampling: Samples taken by customer on April 26, 1993. Findings: Parameter Results Guideline' Total Coliform Bacterial Count/100 mL . . . . . . 0 0 pH Value . . . . . . . . . . . . . . . . . . 7.57 Slightly Alkaline Hardness(CaCO3, mg/L) . . . . . . . . . . . . 98.6 Moderate. Nitrate Nitrogen Content (mg/L) . . . . . . . . . 1.22 10 Sodium Content (mg/L) . . . . . . . . . . . . 15.2 20 Copper Content (mg/L) . . . . . . . . . . . . . <0.01 1.3 Iron Content (mg/L) . . . . . . . . . . . . . . 0.14 0.3 Manganese Content (mg/L) . . . . . . . . . . . 0.02 0.05 Specific Conductance (umhos/cm) . . . . . . . . 250 - Methods: Analyses performed in accordance with Standard Methods for the Examination of Water & Wastewater, 17th Edition, 1989. 'Guidelines are based on the recommended levels of the Mass Department of Environmental Protection Agency's 310 CMR 22.00, "Drinking Water Regulations"and the "Safe Drinking Water Act"of the United States Environmental Protection Agency. By: J o hn Marl etta Lab Director JM/dn MASS CERTIFIED LABS#MA026&MA123 I Town of North Andover f NORTH 1 OFFICE OF 3�O t,,go ,e. hOOL COMMUNITY DEVELOPMENT AND SERVICES p 27 Charles Street North Andover, Massachusetts 01845 WILLIAM J. SCOTT 9SSACHUS�� Director (978)688-9531 Fax(978)688-9542 August 4, 1999 Arthur M. Rollins Charles M. Rollins Co.,Inc. 129 Depot Road Boxford, MA 01921 Dear Mr. Rollins: This letter is in regards to the drinking water well servicing 1493 Forest Street Extension. The North Andover Health Department has recently received information that your company repaired/replaced a well pump which was damaged in a lightning strike. The homeowner inquired at our office about water testing after your repair. We advised him that he should be boiling the water until it is tested for contaminants or not consume it at all. It is for reasons such as this that it is vitally important that you contact the Health Department and receive a permit for any and all work done on the well system, not just the initial construction. Understanding that this was a catastrophic repair, we agree that prior notice would have been difficult, however, in regards to public health you must apprise this office of the situation as soon as possible. Having very sketchy information on the repair, I have attached a blank form for any applicable information. Please fill out any necessary sections. In addition, please submit a detailed description of any work that pertains to the proper function of the well. Thank you for your anticipated cooperation in this matter. If you have any questions please feel free to call this office at(978) 688-9540. Sincerely, 'r su,San Ford Health Inspector BOARD OF APPEALS 688-9541 BUILDING 688-9545 CONSERVATION 688-9530 HEALTH 688-9540 PLANNING 688-9535 G✓CLL ti./'(j 3 l711- I L�L,--D F 102 1•G•e arra t, co Fz P c {� v'A2 cc i4 .4 S-e-o L o•T- /} nl D o! %ORTN I C fi t v o-t ,e D • p 00 . � A # i • • i BOARD OF HEALTH Z 7 G SSA US%' NORTH ANDOVER, MASS. p pti S APPLICATION FOR WELL AND PUMP PERMIT Permit # Date7 . 7 O A permit is requested to: eedr.ill a well install a pump LOCATION: Lor i �dZeS-r tet-- C?cr�NS'�2)�J Lot # t KeQ- iet, co2P. a- Nd— d- Swkc- N Owner"�Avi V Mwco rJnn Address 14G 3 S-ro ue cc,eA-le 4. Tel Well ContrctrO4 M. aw-i,",;S CO , 'zNc, Add. 12A V4ec�•r tom• wxF'OtZTel f7?-Fa' -7 ._Z37-O Pump Contrctr S Ayvl p- Add. Tel WELLS (To be completed at time of pump test. ) Type of well Use �vl-\•e STkC Diameter of well C1 Size of casing b If Depth of bed rock Depth casing into bedrock Seal been tested? Yes O No (_) Date of test 9? Depth of well 3 45S water-bearing rock '354 3S7 A-1I Depth to water :2-q Delivers Ifl\D GPM for (how long?) Drawdown feet after pumping hon at GPM .7 Date of completion �� J Signature of well contractor PUMPS (To be filled in before installation. ) Name & size of pump �J�JI'�S Type �j0P/ZSfO'CG WY, - Size of tank . tAT9-oL Via?- Pump delivers ( 0 GPM Pipe used in well: Cast iron (_) Galvanized (_) Plastic Sleeve used to protect pipe? Yves (_) No ( `!c) Type w 11 seal Date Signature of pump installer Date water analysis report submitted to Board of Health Plumbing inspector Wiring inspector Board of Health 1 TOWN OF F APR SYSTEM PUMPING RECORD --� 6, DATE: SYSTEM OWNER& ADDRESS SYSTEM LOCATION (example:left front of house) C)c DATE OF PUMPING: �C QUANTITY PUMPED : S GALLONS i CESSPOOL: NO� YES SEPTIC TANK: NO YES NATURE OF SERVICE: ROUTINE EMERGENCY OBSERVATIONS: GOOD CONDITION FULL TO COVER HEAVY GREASE BAFFLES IN PLACE ROOTS LEACIFIELD RUNBACK EXCESSIVE SOLIDS FLOODED SOLIDS CARRYOVER OTHER(EXPLAIN) SYSTEM PUMPED BY: Bateson Enterprises, Inc. COMMENTS: coNTENTs TRANSFERRED To: G.L.S.D Lowell Waste NUMBER FEE THE COMMONWEALTH OF MASSACHUSETTS jFE ; owtj.... of ........4"-- S� This is to Certify that . — ._-•---... - NAME ADDRESS HER GRANTED A LICENSE — ��C� «✓��� For ......:....... .d4. ...... ...UL ..... _.. .._ ..._--_----------------------------------------------------- ............................ = .._�..>n - ax -.....y ......._ .........- . ...................•---.---.........---••--••-----------....--•------------...---••--•--•-----------•••-----------•_---•-- This license ' granrd in conformity With the Statutes and ordinances relating thereto, and p expires---------- a .3.t._ .� -- , - • -••------ ••-----••-----•----......unless sooner suspended-or revoked. ...............- qc . .......... ...............................- . .................•-- FORM 488 ..... • H&W HOBBS 8 WARREN TM r O l r /U�Jj l BOARD OF HE'ALT}l Town of North Andover ,t1ass i'ermit ' Date �� 3 r APPLICATION FOR WELL & PUMP PERMIT p(u�.'Ication .is hereby made for permit to T a well ( Application is i,nade to install (–) a pump system. V<-__3TAa t '.ocation : Address' ve Lot It �)wner j��_ Oras Address Tel . 'aell Contractor-f't �pRr Address ,-t �• �. sr c1 • � ,?ump Contractor Address re (,TELL CONTRACTOR (To be completed at Lime of pump test ) jrype of Well el-11e Well used for �ie_r207C (Diameter of Well Size of Casi.ng 'Depth of Bed Rock Depth casing ^- .Was Seal Tested? Yes (`) No (_) Date. of Testing ` 7 Depth ••oWell Ended in What. Material I'Dn_nrh to Water_ �'g��� r ll� �� Delivrrs Gals . Per Min . for 4 hours Drawdown feet after pumping _hours0 at Date of' Completion Si at eI on actor S� urr✓ ¢-PIC ( :.; . ..-X0. 0 .::. .. .. .. � � ; taIl.ation ) PUMP INSTALLER (To be'• filled i.n' before i n s S*i ze & Name Pump Pump TyOe Used ('Water Pump Delivers CPM Size of Tank— Pipe ank _Pipe Material Used in Well : Cast Iron ( _) Galv;inized ( _) Plastic (_1 Well Pit (_) or Pitless Adapter (_) Was sleeve used to protect pipe? Yes (_) 110(_) 1'ype or Pdamc Well Seal ' Date _ �'c�`t�tl4itith��t�rtt���"ct����Yi4i4t`t�'c�41�ti414t'r�c1't�4�4�t�4t4t'ttY�tiY �r���`r�'t�4�kti'rti'��'r►'r�`r,`: 5: I I;C! �).,'S:DC r;:�IC if , rYrhdv�t P� t.'e Water analysi's . repor-t submitted to hoard of He* al'th Do _e .release given w owner of record & 111clg . Insp llealtll Inspector '� , ,., :,'•. ', �� "� .��> lJ 1�4OeRoTFJ TOWN OF NORTH ANDOVER .e 6"eL o HEAL'T'H DEPARTMENT -14 27 CHARLES STREET NORTH ANDOVER, MASSACHUSETTS 01845 S = �t SACHUS Sandra Starr Telephone(978)688-9540 Public Health Director FAX(978)688-9542 March 5, 2003 Mr. David Deacon 1493 Stonecleave Road Boxford, MA 01921 Dear Mr. Deacon: This letter is being sent per your request to verify that there were no notifications received by the North Andover Health Department about dangerous levels of pollutants in the well that supplies drinking water to your home. F. We now do have copies of tests performed on January 6, 2000 and March 15, 2000 at the address of 1493 Forest Street North Andover, as well as the letter you received from Downeast Adjusters. However, this information was hand delivered by you on February 7, 2003. Therefore, we had no prior notifications from Merrimack Mutual Fire Insurance Company, Exeter Evironmental Associates or Downeast Adjusters. Please call if you need further verification of this. Sincerely, Sandra Starr, R.S., C.H.O. Health Director /pd ! A V I ! ! E A C • 1493 Stonecleave Road Boxford, Ma. 01921 978-887-3232 Town of North Andover February 28,2003 Sandra Starr •Health Director 27 Charles Street E North Andover, Ma. 01845 LIAR - 4 2003 I k Dear Sandra; � �---. -_.. - ------�-- I would like to request a letter from the North Andover Board of Health/Building Department verifying that at no time did your departments receive any notification(s)about dangerous levels of pollutants in the well that supplies drinking water to my home in regards to the two water tests listed below. These two water tests were conducted by my homeowners insurance company and their agents on January 6, 2000,and then again on March 15,2000. These Companies are: 1) Merrimack Mutual Fire Insurance Company 2) Exeter Environmental Associates 3) Downeast Adjusters The pollutants in those water tests that exceeded the maximum contaminant levels established by the Massachusetts Department of Environmental Protection for drinking water are: 1) E-coli Bacteria 2) Fecal Coliform Bacteria 3) Nitrate Nitrogen 4) Nitrite Nitrogen 5) Alkalinity As always, thank you so very much for your assistance in this matter; / kAi 1 David C.Deacon 1493 Forest Street Extension North Andover,Ma 01845 1493 Stonecleave Road Boxford,Ma 01921 (mailing address) `1 1 FOP---(Gr2 �Au-S DOWNEAST N f � �. .�. .,.-fix March 2, 2000 M� f 11J David & Claire Deacon 7 1492 Stonecleave Road Boxford MA 01921 - - RE: Lichtniniz Strike, 7/23/99 Location: 1492 Stonecleave Road, Boxford, MA —m/9'ikl%Y-0 Policy #: HP 166-26-52 Our File #: DE 99344-GC Dear Mr. & Mrs. Deacon: As you are aware. we have been assimilating data which has been provided through your agent. Mr. Peter Sennott, regarding your well water. First, let me state that we have approached this matter with an open mind and carefully presented all the data submitted regarding your well to a licensed hydrogeologist for his review and opinion. The material you forwarded suggested that the lightning strike somehow caused the well to tap into a new fracture in the bedrock, which contains a concentration of nitrates. A review of the ` material forwarded to us shows that when the well was first.tested in April 1993, it showed the . nitrate concentration to be in the area of 1.22 mg/L. Recent water testing from neighboring resident wells showed nitrate concentrations ranging from less than 0.1 to 0.26 mg/L. It is the hydrogeologist's opinion that the water result from these neighboring wells are representative of background nitrate concentration. This indicates that in 1993 the water quality in your well was above the established background level and was already impacted. try a source of nitrate, such as a nearby septic system. It is the opinion of the hydrogeologist that the lightning strike is not responsible for the elevated concentrations in your well. Your most recent statement you indicated that it would seem logical that the well was damaged beyond repair. However, since the well is functioning properly after the installation of a new pump, we are unable to provide any further payment with regard to your well. We do agree that the pump and well cap were damaged by lightning and payment was made for these damaged items. But as concluded by the hydrogeologist, there is no correlation between the poor water quality and the lightning strike. I P.O. Box 116♦ 7 Elm Street Boxford Massachusetts 01921 ♦ Tel(978)887-8766 Fax(978)887-0660 .,-, i David'& Clare Deacon Page 2 Should you have any questions or concerns, please feel free to contact the undersigned at (978) 887-8766. Very truly yours, Gary J. C h General Adjuster CC: Sennott Insurance Merrimack Mutual Fire Insurance r From Donna Saunders Biornarine Inc. (781) 846-4698 Tue, Apr 18, 2000 1 V:I r rMn 7o Gary Church powneast Adjusters978887323 5 Page 1 of 2 Blomadne Inc., 16 E.Main Street/PO Boa 1153,Glouccster.MA 01931.1153 Phone(978)281-0222 * Fax(761)846-4698 or(978)283-6296 * riom rim nHi t net CERTIFICATE OF ANALYSIS Mr.Gary Church Report No.: 20006 Downeast adjusters April 18,2000 PO Box 116 Boxford,MA 01921 Re: ANALYSES OF DRINKINO WATER QUALITY ac,3ii-RcE 1tvr i1 : In-use well located at the Deacon residence, 1493 Stonecleave Road, Boxford, MA. rA_ rF-E 11ECTI,;N: Samples taken before the water filtration system by John Slarletta of Biomarine Inc. on January 6,2000 at 11:00 a.m. FII?�INy S Total Coliform Count'100 m 1 2 0 Presence of Fecai Coliform Positive Negative O1Jo7 00 i Presence ofE. :oli Negative Negative 01/07/00 :alkalinity(mgIM as Ca(7113 134 ' 100 0li07'00 Calcium Content(mg;l) 57.1 5C• 0,111,00 ChlondeContent(mg'1) 15.6 250 U;Iit7rU0 Conductiv ity 4unhos.icm) 438 01,107,'00 Fluoride Content(mg,'1) <U.15 2.0 01/117!00 1mn Content(mail) -.o.0 C.3 )1!07.110 Magnesium Content(mg/1) 6.4 G':.11100 Manganese Content(mgil) C.04 (t 05 Nitrate Nitrogen Content;tr.gll's 8.59 10.0 ' 01%o7%too Nitrite Nitrogen Content(mg/1) 0.09 f 1 Oo O1U07 Orthophosphate(mg.'l) 0, 01'0'7;00 pH(s.u.) 677(si;ghtlyacid.6 6.5-S.5 01'07/00 Potassium(mgil) 1.85 O1%1 l:oo Sodium Content(mg!l) 15.5 28 OI.,I II 0 Sulfate Contem(mg,l) 35.2 01/071%/X( Hardness(mgrs as CaCO3) 169(hard) calc::lauon Corrosion I Slightly Corrosive estimate METHOD : Analyses performed in accordance wirh Stanclural,llethods for the tt minarcon of H ater ct` fVastewater. 19th Edition, 1995. Guidelines are based on the maximum contaminant Page 1 tit'2 rrum Uonna Saunders Biormrine Inc. "(781) 846-4698 Tue, Apr 18, 2000 1017 AM To Gary Church Downeast Adjusters 9788873235 Page 2 of p Report No.: 2WO6 BdonnaCdne Inc. April 141, 2000 levels recommended by the Massachusetts Department of 1 nN ironmental Protection for drinking water. Analyses performed by Massachusetts certified laboratories it .1'1AU26 and MA 123, REM,ARK S: Coliform bacteria are an indicator of possible contamination from the intestinal J wastes of people,domestic animals,birds,or other wildlife.;Coliforms are ofconcern ifthere are E.coli present, which are of fecal origin. The presence of fecal coliforms which are not confirmed as E. coli, indicates the water is momentarily sate for consumption;however;there ) should be no coliforms of any kind in drinking water for guaranteed potabilit-*.,'Barring sampling errors, such contamination may arise from (1)a contaminated source. t2)inadequate well disinfection after installation or repair,(3)defective well construction.(4)water treatment system problems, (5)contaminated pipes such as from a water line break or pinholes from corrosion,or(6)a decaying animal or bird carcass in the well or open storage tank. Alkalinity describes the capacity,of a water to r:act with strong acid to a designated pH—in the case of total alkalinity. to a pH 4.5. Excessi%e concentrations may give the water an objectionable taste and cause undue drying of hair and skin. High alkalinity combined with soma dishwasher and laundry detergents may lead to white film tbrmation. 11 can also react with calcium and magnesium (hardness)to form scale when heated. ,although the Nitrate and Nitrite Nitrogen levels detected do not exceed the E1'A recommended maximum,they are elevated in comparison to most area wells tested. Care should be taken to avoid the use of fertilizer compounds in the runoff area of the well. Nitrate may enter water systems via runoff from heavily fertilized areas, septic contamination,or from degraded vegetative material. Excessive levels of nitrate in drinking water have caused serious illness and J sometimes death in infants under 6 months of age. Nitrate is converted to nitrite in the body which interferes with the oxygen carrying capacity of a child's blood. Nitrite, of itself, can react; with organic material in water to produce cancer-causing compounds. Nitrate/Nitrite may be removed by reverse osmosis filtration. Corrosion is commonly defined as an electrochemical reaction in which metal deteriorates or is destroyed tivhen in contact with elements of its environment such as air, water, or soil. :any characteristic of the water which tends to increase or allow this electrical current A,I!l increase the rate of corrosion. The important characteristics of water that affect its corrosiveness include the following: (1)acidity, (2)conductivity, (3)oxygen content(amount dissolved in water promotes corrosion),(4)carbon dioxide(forms carbonic acid which tends to attack metallic surfaces), and(5)water temperatures(corrosion rate increases with water temperature). rhn hlaxkt 't.alY D:'<+"fur Page 2 of 2 EXETER ENVIRONMENTAL r` , A890CIATES. INC. P.O.Box 451 Exeter,NN 03833.0e51 Td: 7MON FAX MEMORANDUM Fax, �eec°, 77"104 i Date: April 12,2000 , i To. Dave Deacon fax: 978-81373235 i From. Steven Shope.P.HG. page 1 of 4 Re: Deacon Property,1493 Stoneclem Road, Boxford, MA (If HP 186 2S 52) i i David: Attached is a fax copy of our lab results from your well (nitrate,bacteria) and from the pond(nitrate only). i ' We did receive your estimates from Charles Rollins drilling and Picariello Construction. ! We have a call into Rollins to inquire as to the breakdown of the installation of the pumping equipment. We have no problem with a footage rate of$8,as that is the going rate. Would you please contact Picariello and get a time & materials breakdown of the$4,600 estimate for trenching? As we mentioned on the phone,it is our opinion that this bid is high. A second estimate would be helpful for comparison, E Sincerely yours, I I i I I { i r i s i Please call If all of the pages were not received,or if they are illegible. 04/12/00 —09:21 $'603 778 0104 EXETER ENVIRON Q003/004 �H LABORATORY REPORT Eastern Analytical, Inc. ID#: 20622 Client: Exeter Environmental Assoc., Inc. Client Designation: Deacon/Boxford 1039.192 Sample ID: DW-1 Analytical Type: Sample Matrix: aqueous Date Sampled: 3/15/00 i Date of Date Received: 3/16/00 ? Units Analysis Method Analyst Nitrate 10 -T mg/I 3117/00 353.2 LO Total Coliform Present ' = No Units 3116/00 92238 KL E Coli Present ;/ No Units 3116!00 522.38 KL Sample ID: Fond-1 Analytical Type: Sample Matrix: aqueous Date Sampled: 3115/00 Date of Date Received: 3/16/00 Units Analysis Method Analyst Nitrate <0.5 mg/1 3/17/00 353.2 LO T.Coli/E.Ccli analyzed 28 hours after collection. www.eailabs.com TFL 611) 2S-05'j I-����}-' r•ii.. F:a.\i,`i "��?'I l II t 04/1.2/00 09:20 '&603 778 0104 EXETER ENVIRON Q002/004 eastern analytical professional laboratory services Steve Shope Exeter Environmental Assoc., Inc. P.O. Sox 451 Exeter , NH 03833 Subject: Laboratory Report Eastern Analytical, Inc. ID: 20622 Client Identification: Deacon/Boxford 1039.192 Date Received: 3/16/2000 Dear Mr. Shope Enclosed please find the laboratory report for the above identified project. All analyses were subjected to rigorous quality control measures to assure data accuracy. Unless otherwise stated, all holding times, preservation techniques, container types, and sample conditions adhered to EPA Protocol. The following standard abbreviations and conventions apply to all EAI reports: Solid samples are reported on a dry weight basis, unless otherwise noted < = "less than" followed by the reporting limit TNR =Testing Not Requested ND = None Detected, no established detection limit RL = Reporting Limits If you have any questions regarding the results contained within, please feel free to directly contact me, the department supervisor, or the analytical chemist who performed the testing in question. Unless otherwise requested, we will dispose of the sample(s) 30 days from the sample receipt date. We appreciate this opportunity to be of service and look forward to your continued patronage. Sincerely, usan C. Uhler, Lab Director Date Fastern An;&,,0rai. %'WN.eaitabs.coal �Lh!i '_ l'; j-1�0•=�, h)'> F,;\(�13_"_�-- al f 1 eastern anaftr cal Inc. as ch'•N ad.a C...L m rano$a tRL N"2204=5 114KW=:•0525-El � PAX COM 220•4wl a I-NMR:ffo11LaMftft09 4s.ecm 20622 i CHAIN-OF-CUSTODY RECORD r REQ0ESEED ANALYSES ry ITEM 7;mg SAMPLE SAMPLIi G MATRIX �for LD. DATEITIME A•A1Ia tabao 0 0 0 Wr only r c, offi ®� 8a d� Q a o o o ;13o z � � � al, ao 1,5 00 06 ®ma oa oo no 0o an � a o 0 0 0 0 o a 'k �w-t �•esoo it s: 10 )L X R W Sw r 0 r 0 '-3 70 Cr' Z PRE tNAflY6:WHCJ;N•HNO3; 9412M;iVofhW p E I 1 9 1 1 —1 — z PROJECT MANAMR: Steven Shope NOTES:(.e.Special Dekcflolt Llrnik,Ming lnlo.if different) RESULTS NEEDED BY FOR LAB USE ONLY COMPANY: Exeter Environmental (ems preferred dals)= S Adhered to EPA Pra oug ADDRESS: p-O.-Box 4 51 (C*wwftd vqW wm&w W trees pwwfrmr l 0 Yea O No(m m *dtm i CITY: Exeter STATE NH DP 03833 GA OC Papwdq Leel R"n9Options: 0Yes 0N O A ®8 0C O Hard Copy O Pax Electronic: PHONE:(6 03 )__7.71-3SA R_EXT: O E4kl O Disk Quots/ FAX: 603-778-'0109 P.O./ E-MAIL: f3a s}: - PROJECT NAME: ^rce,� Box F®R e -(6 eb PROJECT• !03$. HL — Dais Time Received by o STATE:,O NH KMA U ME Cl VT 07MR � ReffaQulAed by Oak ' Tlaaa Reoelved bV 0 0 Site histadcaly eomeminated O Compliance Testing Regnqutshed by Date Time Received by /M/R11Ye./i.:..:....• Irm 1 two. 1—6.tl... muw.. 1I------1 NUMBER FEE 6 t THE COMMONWEALTH OF MASSACHUSETTS J .�.. of ..` .:.. ---- This is to Certify that ` t"l �......................... NAME -•-•-••••--....•---•------•--•---....---•-------------•..........--•---......---------------•--•----•--------------....---•--•---••------............_._....•-------•------ ADDRESS IS HEREBY GRANTED A LICENSE For ` .. .........r--................................. -----....... --- ------------------------------------------- ....------•••-•------•-----•---•--.....•-•-------•-•-•-------•----••--------••----••--••--••--••----------•-••------•---•-•----•------•---------•••-••---•--••---------•---. ..-------•-•--••--------••-•-•----••-•••--------------------•----••----•---•--•------••-•------------••---•---•--------------••-•-••-••-------•-------•---------------••---- This license is granted in conformity with the Statutes and ordinances relating thereto, and expires.......I.t ,- I�4?.......................................unless sooner suspended or revoked. - ----------- ---- ................... �Od ....... r .•... ....... .................. � -------- .........................-----..... �.--.. ............. -------------- _. -.------ � FORM 488 H&W HOB..&WAFREN rM ........ i HSA HANCOCK SURVEY ASSOCIATES #3290 August 25, 1992 Heritage Bank 71 Washington Street Salem, MA 01970 Attn: Mr. Peter Copelas Re: Forest street Extension Lots 1, 2 & 3 Dear Mr. Copelas: On August 19, 1992, Hancock Survey Associates, Inc. conducted deep soil observation testing on Lots 1, 2, & 3 of Forest Street Extension. This testing was a re-testing of test holes conducted by Hancock Survey Associates in April 1987. The re-testing was r the North Andover Ap ting required by Board of Health as the original testing results expire after two years. The,retesting was successful and confirmed the original test data. We have enclosed a copy of the Soil Test Field Report for your, files. We will also forward a copy of this testing information to the North Andover Board of Health. Sincerely, HANCOC'K SURVEY ASSOCIATES, INC. William J. uell Project Engineer WJM:jpo enclosure cc: Sandy Starr, North Andover, B.O.H. George Belleau wjmhb 2 Electronics Avenue•Danvers Industrial Park• Danvers, MA 01923•(508)777-3050•(508) 283-2200•(617) 662-9659•FAX (508)774-7816 139 Beach Road•Salisbury, MA 01952•(508)462-3036•(508) 352-7590•FAX (508)462-5547 P.O. Box 587•Haverhill, MA 01830•(508)521-5515 i HANCOCK SURVEY ASSOCIATES, INC. SOIL TESTING FIELD REPORT 2 Electronics Ave. Danvers Industrial Park HSA JOB NO. 3 Z9v SHEET NO. / OF DANVERS, MASSACHUSETTS 01923 (508) 777-3050 DATE g /9 9 Z. CONTRACTOR Ph./ to"",-,c//o WEATHER Oat CLIE[TT oat PM LOCATION � NAMEfjcri �-f e can .3, ADDRESS 7/ GrJcS�iinyl�a.� s�' - 74�Siavi /�� A✓o�u✓�� s'4/emq ln.� PWNE _OWNER (if different) SPECIAL NOTES, REMARKS & REC©� IJENDATIONS; PRESENT AT SITE �� a^ s14' 1*4t 1 5' fon. lYe4/T//+ }M=-- die/NU� ENGINEER 4441114-1 1;7417al// HEALTH AGENT -S .S 7�,r/ rda nv/S� (.SUM ( 74 1-7" 7' h<'� O'I�S Be//<44 /�iC�' {PS/� C2' I'P7�--sZe QPX�i/i p� Gi�iSPiva7��r Llo%S PERCOLATION TEST RESULTS SITE SKETCH (not to scale) NO. ane erklmec/ t� . EADE GRTO 12.. PRESOAK @ 12" o 12" ( �eN,c �o r 30 .t 9" .✓ �' �o lot 25' po �� 2.5 LO ISo,04 6" 73R TZA TIA T7A1"l nee t4A 9„ to 6„ TIME Lo+ ( _ ( T /S DESIGN RATE —-" -- - - 3 7�A Lo-r t �vlcgf 5� £X� T- /A SOIL LOG T-qA SOIL LOG GRADE (TYP.)ZN 6O. ® ( w' scoff, G w e. fev Bb 94 fV0 G w 04 Z T-2A T-5A Zit - �s zy Q . . Fr r, S•. S. F, T-3A _ T- &A T 7a Z�{ 160 g,!!<d rOG� Sf, Fro3 d. rac 4 rxk G=Gravel s--sand Si=Silty M=Medium 0�0;oarse G.W.=Groundwater Barb (No refusal) �— T/S=Top & Subsoil Tr--Trace C/S=Clean/Sharp F=Fine B---Bony REFUSAL/LEDGE 71.155,1 . Note: Test results shown hereon should in no Way be construed as a representation that the land tested is suitable for subsurface sewage disposal. �ORT/y OSs.eb •�'Tj. TOWN OF NORTH ANDOVER HEALTH DEPARTMENT * � 27 CHARLES STREET NORTH ANDOVER,MASSACHUSETTS 01845 CWS' . . Sandra Starr R.S.,C.H.O. (978)688-9540-Telephone Public Health Director (978)688-9542-Fax 1T-Y1 TO: From: Fax: Pages: Phone: Date: Re: CC: ❑ Urgent ❑ For Review ❑Please Comment ❑Please Reply ❑Please Recycle G��v�. LP�i.��, rice.� S✓�� Please call 978-688-9540 for assistance with any questions. Thank you. xc: Address File Chrono File Name Associatio Address Olaf Weeks Mark Angelos 343 Montague Rd. Amherst �Town State Zi Pcode Phone Number Kenneth G.Barnhill 25 Enfield Dr. Andover MA 01002- 413-549-0406 Todd Bateson �/ 28 Wolcott Ave. MA 01810- 978-475-0436 Bateson Enterprises 111 Argilla Rd. Andover MA - 01810- 978-475-2376 Neil J.Bateson✓ Bateson Enterprises Andover Clarence D.Beatty EMCON 111 Argilla Rd. MA 01.810- 978-475-4786 _ Andover MA 01810- 978-475-4786 Robert Blanchette,Jr. Diversified Civil Engineering 6 Riverside Dr.,Suite 101 Andover Stephen M.Boudreau 65 Andover St MA 01810-1121 978-682-1980 9 Crescent Dr.,#8 Andover MA 01810- 978-692-0939 John Chongris Haggetts Pond Development Andover MA 01810- William Crowley Watson cc 129 Haggetts pond rd Andover 978-475-8197 Robert C.Dale 43 Lowell Jct Rd MA 01810- 978-475-1228 Daley Merrimack Engineering Services 66 Park St. Andover MA 01810- 978-475-3262 William R.Dufresne I/ Merrimack Engineering Services Andover MA 01810- Don Erb 66 Park St. Andover 978-475-3555 New england Inspection 4 Sandalwood Ln MA 01810- 978-475-3555 Alexander D.Gibson,Jr. Andover MA 01810- Leslie P.Godin 47 Old County Rd 978-659-2248 Merrimack Engineering Services 66 Park St. Andover MA 01810- 978-475-2496 William R.Hickey,Jr. AB Septic Andover MA 01810 Robert Katz PO Box 4082 978-475-3555 16 Kathleen Dr. Andover MA 01810- 978-470-0760 Kurt L.Kefferstan Andover MA 01810- Robert D.Murgia,Jr. 115 Haverhill St. 978-475-0205 8 Canterbury St Andover MA 01810- 978-475-3925 Michael Reilly ,/ R.P.Reilly&Sons Inc. Andover MA 01810- 206 Andover St. 978-475-8666 David Shaw Wildwood Nurseries 34 Wildwood Rd Andover MA 01810- 978-475-1237 John T.Shaw,III Wildwood Nurseries Andover MA 01810- Benjamin G.Siebecker 34 Wildwood Rd 978-475-2264 EMCON Andover MA 01810- 978-475-2264 Merrimac Steven Stapinski 6 Riverside Dr. Suite 101 Andover mac Engineering 66 Park St Gregory Tomaszewski Andover MA 01810- 978-682-1980 Joseph R.Watson MA 01810- 144 Lovejoy Rd 978-475-3555 James M.Watson Watson CO JW Watson Co. 43 Lowell Junction Rd Andover MA 01810- 978-932-7747 Andover Bassem M.Bandar 43 Lowell Jct Rd MA 01810- 978-475-1237 88 Ronald Rd. Andover MA 01810- 978-475-3262 Werner A.Carlson Carlson Inspection Associates Inc. Arlington MA 02174-2051 781-646-4056 John Finlayson 51 Dudley St.Rear Arlington MA 02174- Todd Moline 53 Nicod St. 781-641-0600 GEI Consultants Arlington MA 02174- 781-643-3314 Joseph Reynolds Mass Highway Dept 260 Massachusetts Ave.#8 Arlington MA 02174- Kevin A.Lashua 141 Park Ave Extension 781-721-4028 Bill'Sewer Service Inc. 79 Fitchburg Rd. Arlington MA 02174- 781-643-7339 Angela M.Lehtonen Northland Engineers Ashbumham MA 01430- Dave Perry Dave Perry Construction P.O.Box 1018 Ashbumham 978-827-5520 Jeffrey Raskett P.O.Box 1059(149 Center St. MA 01430- 978-827-5944 Bill's Sewer Service j Ashbumham MA 01430- Beatrice B.Reynolds 79 Fitchburg Rd. Ashbumham 978-827 6259 Granville N.Rideout P.O.Box 85 MA 01430- 978-827-5520 G.N.Rideout&Co. 171 Packard Hill Rd. Ashbumham MA 01430- 978-397-2918 Valorle J.Sibley Northland Engineers Ashbumham MA 01430- Bruce Adams Adams Construction 184 Damon 6 Central n Ashbumham 978-827-4355 Rd. MA 01430-0514 978-827-5944 Keith B.Maynard Maynard Exc Co Ashby MA 01431-1978 978-386-5850 Stanley W.Deck 446 Bennett Rd Ashb Stonewall Dr.,PO Box 57 y MA 01431- 978-386-7214 William Turner Harris&Gray contractors Ashfield 21 Main St - PO Box 300 MA 01330- 413-628-3853 Wednesday,January 08,2003 Ashfield MA 01330- 413-628-4771 Page 3 of 80 Name- Robert A.Alukonis Associatio Sunspace Inspection Services Address Psul P.Avery Ransom Environmental Consultants,Inc. 126 Merrdmac St.#33 Town State Zi code Carlton A.Brown Browns Wharf Newburyport MA o1950- Phone Number Port Engineering Assoc.,Inc. Newburyport 978-628-4437 Raymond F.Fitzmaurice 1 Harris St. MA 01950• �-' Christopher J.Groth P.O.Box 849 Newburyport MA 01950- 978.465-1822 Wendy A.Kimball-Murray 25 Columbus Ave. Newburyport MA 01950-5549 978-465-8594 Paul D.Turbide 7B Christie Dr. Newburyport MA 01950- 978-465-8340 Port Engineering Assoc.,Inc. Newbu 978-465-8648 Raymond Ball Environmental Risk Management,Inc. 1 Hams St. ryport MA 01950 Robert R.DeLuca 119 Oakdale Rd. Newburyport MA 01950 978-462-3430 Henry K.FitzGerald,III Newton Health Dept. Newton. 978-465-8594 HK FitzGerald-Archit.and Engin. 1294 Centra St. MA 02161-1812 617-965-6478 Henry K.FitzGerald,Jr. 171 Upland Ave. Newton MA 02159- HK FitzGerald•Arohitects and Engin. Newton 617-552-7058 Tracey A.Garan Newton Health Dept. 31 Channing St MA 02461 617-527-5029 Pio Lombardo 1294 Centre St. Newton MA 02158- Stephen W.Smith 49 Edgehill Rd. Newton MA 02159- 617-527-5029 GeoHydroCycle,Inc. Newton 617-552-7058 ew Henry Welsgold PO Box 650043 Newton MA 02160.1904 Ronald S.Cucchi Garden City Inspection Co. 5 Madison Ave. MA 02167- 617-964-2924 David Manugfan Newton(West) MA 02185- 617.527-8074 426 Ward St. 617-965-2746 Daniel R.Brag 709 Boylston St. Newton Centre MA 02159- Newton Highlands MA 02161 508-394-7060 Brian Baker Army Corps of Engineers 110 Washington Park,#2 617-647-0809 Michael Kane 365 Metcalf Rd. Ne.Attleboro MA 02460 James B.Lanagan,III Seekonk Supply No.Attleboro 617-266-6035 g J B Lanagan&Co.Inc. 550 Old Post Rd, MA 02760 617-253-4471 Sean B.Skehili 21 E.River Dr. No.Attleboro MA 02760 Tomily Corp. No.Dartmouth 508-316-2220 Judy Curini The Chase/Harris Corp. PO Box 699 MA 02747 508-992-3240 Tamela LeBlanc 108 No,Main St. No.Falmouth MA 02556 The Chase/Harris Corp. No.Grafton 508-563-5421 Michael O'Neill 108 No.Main St. MA 01536 508-839-6500 Paul H.Blinco 6 North Hill Dr. No.Grafton MA 01536 508-839-6500 Paul N.Cutler Landmark Engineering gentlle and sons ineering of N.E. 11 MasConemet Ave. No.Reading MA 01864 508-664-0254 Lee G.Gentile 224 Dedham St. Norfolk MA 02056- Norfolk 508-528-5343 No Clifton D.Holman Jr. 228 Dedham St MA 02056- 508-384-3064 Paul R.KnowlesKing Philip Trail Norfolk MA 02056- Knowles Const. N 508-384-5156 Edward L.Lyons Callahan const. 20 Dean St Norfolk MA 02056- 508-528-9772, Pfisch Fred L.Pfischner,Jr. PO Box 423 44 Lake Norfolk MA 02056 ner Engineering Co. e St 508-376-8602 Richard H.Whelan 5 Cleveland St. Norfolk MA 02056- 508-520-7170 William P.Foie 46 Noon Hill Ave. Norfolk MA Foley Environmental Controls,Ltd, Norfolk 02036- 508-520-1431 Scott D.Kelloway Mass Highway 16 Rand St. MA 02056- 508-541-8738 James T.Melvin687 Salem St North Adams A 01247- Big Rocks North Andover 413-663-3672 Thomas J.Murphy 296 Middlesex St MA 01845- 978-662-5449 Keith Nilzsche 22 Beacon Hill Blvd. North Andover MA 01845- Benjamin C.Osgood,Jr.✓ 1084 Johnson St. North Andover 978-685-8289 9 New England Engineering Services MA 978-470-2496 Kenneth W.Rea 60 Beechwood Dr. North Andover MA 01845- Maureen W.Sakakeeny Rea Construction North Andover 978-664-3603 44 Rea St. MA 01845- 978.686-1768 Robert Scherpf 89 Hickory Hill Rd. North Andover MA 01845- John F.Torrey 11 Stonecleave Rd. North Andover 978-68 01845- 978-688-08-0445 MA 437 110 Abbott St. North Andover MA 01845 Wednesday,January 08,2003 North Andover MA 01845- 978 794-0111 978-686-3030 Page 48 of 80 FULL / ACCESS MANHOLE RlSEP, SEE SPEC. MOi7TAR REQ!/IRED 'k..F4.r; /"5'� , BEDS _._-_ J" VENT ------INSP£C'770/✓60J V!— t4, .• Cj/jr 'v�//d 7"/•"/ 2"-0" M/N (TYP.) .\ FULL M.H. TO GRADE d !Cr G!f'^"'�•„/tA/ y",�,�j�:,��/er 'X! /F OVER 2000 CAI,. lwf.%F�'L"<'/ 7`/!Iv'it/C,//.fi.�t L9/G CAPACITY \ NLET — _MAX L/0_U/D_ _ '� d OUTLET/N VERT ��T `—PRECAST BACFLf'O!t /c5• f1L/��-,fl Plg bs v RPE 7L£OP£/✓AT INSPECT TANK k. TDP(r P,)/N/FT AND - ANUALL Y" PUMP OUT OU7LET. r AS REQU/RED —OUTLET KORTH AKDOVE�- ° OF WN 10 6"OEP7H OF 3 4"— a roved — / PP -- 3 1 7/2"STD/✓£ • TANK N W1D TH �P Date C TA( �yp�g n nature SEPT! slg MJ NOT TO SCALE SFP nC TANK TABLE OF DIMENS1lo,; CAPACITY(CAL.) . /// O. D 5'-1" 5-8 7'-8 4'-0 --- 7.5017 /n=0" 6=n 5-10 TD _--OUTLET(TYP.) 1'-G"M/N. COVER r /NLET 2' OUTLET /MET -_ L° DE� CR/TER/A ------ -TEz�� 5„ NO. READ - ° BU/LD/NG USE, .SINGLE /AM/L Y DWELLING NE 7' e" (/F REQ IJ) I'-e' 6"DEPTH NO. OF BEDROOMS SOUR• • • • •DES/GN NO. OF PEOPL PLAN 3/4"-1 1/2" DESIGN FLOW.B?•• C P.CD. TOTAL DA/LY FLOW 6.• SECT/ON GARBAGE GRINDER - NO . ?r.YES . . (INCREASE LEAC STONE S - OUTLET D/.SMIBUT7ON BOX NOT TO SCALE SPECIAL GOND/170NS . r? ;5;F: ,.�1�,• Fa>z T_>zEN DES/GN PERCOLA 7701V RA TE. .F/' -' . MINUTES PER Io'_o" LEACH AREA REQU/REMENTS (SQ.FT./GALLON) - BOTTO e .r TOTAL AREA REQD-40CAL COOS>3�&p FT. - T/7LF FINISH sursFacE PRO VIDED-TOTAL �3 A MArnoLE-- - ANO/oN .f °•FT.-BOTTOM�TTZSQ.FT.-S/DE. Q2 I/2" PAVEMENT } (TYP) u L PLAN 0 STONE—SEE 6'.0. 'VFWIDTH pL SPCC. D 44 EFf1r ECTIVE N LET _ 2"DEPTH- SECTION Is, y r+W v -^ SEE NOTE T Ve"70 I/4" STONE-SEE TABLE of DIMESIONS 0 10'.O" SPEC 0 EFFECTIVE LENGTH•B• NO.AEOT -SECTION 'A' CH IT, 51� LOCUS MAP ' JUMBO ALSH LEAC�II�1G_ CHAMBER o�L SCALE I" r,DT re L 0.4,f>1Y j �"" '►3 IEFr��nv� L1EVF{T Lo4oirvc, ADQEn LEACH p/7's S'O/L TEST DA TA g"7 y� bl7��gZ' LTESTSBY. < 7 NO DA 7E REIi1S/ON � WITNESS•_ M/KF r'RAF OBSERVA77ON PIT _ PROPOSED SUBSURFA CE DATE ] _ a 9g9L "Z - SEWAGE DISPOSAL SYST_Ei GRADE EL. z. 4-L 4., l43. r /y o GROUND WATER EL. -- - - I- S.o BOTTOM EL ;•"j�, •3 — 13� SITE PLAN. PROF/LES & DE7 "tiP/SWISS G1t. - zy` LO T is c j FU QST— .S;+' I 77 . - c z. (rYr?) PREPARED fW. 4. SCALE AS NOTED �A KEY VERT/CA!_ SCALE.' 1" - •!�" DATE.• ✓UL Y 75, 1892 DESIGNED BY. W✓•M. GRADE --_ CHECKED BY V.V. BOTTOM (NO REFUSAL) -�- OBSERVED GROUND WATER p HANG®C!( SUR PEr ASSOC/A; REFUSAL/LEDGE -�� ("J0^F U6.S FPVE p j HSA 2 ELECTRON/CS AVENUE, DANVERS, SHEET 1 OF 1 ✓OB NO. i I i PLAIN SCA4E: I 14j() E.A sT•I A P 12,U P F- L I M C -L_Ir.1C G �T y a �� - Nb [ r If- Ra1VI'E- f, �tA . _...� �� � �- •\ _ fes_ •� ., p - 1�''f?3�, ��• ( NF:"(21 7"A i FLOW PP�OFILE G' .tirr 4T ! l"r I .'�r•r � -f L,. r.c.yrrn .yncry UN NH/: l07 ���p ✓ w/l/�ll. N/ �7%iYl11-0411' l D �(�' / SHALL 9E CONSTRUCTED IN ACCORDANCE WITH L/NES, GRADES Al�l7 W/Tl'l T77JAL A ChIl7Fc (/RAl I//1/ly"`/I)�ji IJIIW° DETAILS SHOWN ALL TOPSOIL, ORGANICAND OTHER UNSUITABLE PRIOR TO CON.010(' OY,, MATERIAL SHALL BE REMOVED AND REPLACED AS SPECIFIED ON U. THIS PLAN IS IV07 IN71;h/ D 71 4/tow AIV I;W,ffj//Efl PLAN"" AND "PROFILE CONCRETE STRUCTURES SHALL BE AS FOUNDATION OF,lIG (' ((1Vt/�/��/t OX l',14/1`+ MANUFAC7URF.D BY SHEA CONCRETE PRODUCTS OR EQUAL. L'LFVARONS OT 1'd I l !� l'. (�lrl/1 �/ �. 7' 7 1/0-1- D. dl/ W/ `� O STONE DI?AINAG� Mr A UP:dA��` Y f1i�Flyllri rlI STONE USED IN LEACH AREA SHALL BE OF SIZES AND AMOUNTS A0 AS l0 // /' ly l/j �((�11(JjJy.l1 /lj JAI;17//µ RAID W177/ANO SHOWN IN DETAILS, WASHED FREE OF ALL FOREIGN MA TTER PRIOR TO PLACEMENT. BOTTOM OF EXCAVATION SHALL BE 10. 1OCA 770N5 0/" CXl,'77N((:' IIA lCf� �f✓�l,11/1/jl7/C'�' l[ SCARIFIED PRIOR TO PLACEMENT OF STONE. STADIA SURVEY AND ,51•I (l, � Ijtl1/L/a Ij5 ljl i!3/d' PRIOR TO CON S%RUC7/O/d. E. SAND & GRA VEL 11. 711E CON IRACTOR �R-14/1 NO RFY SHALL BE COMPOSED OF HARD, DURABLE STONE AND MEDIUM TO AT LEAST 72 l-IOUR9 P1 O1 /0 C M1d1. C�rf//11 j COARSE SAND FREE OF FOREIGN MAIER/AL (LOAM, CLAY, ETC) W7H NO STONE OVER 12" ANY DIMENSION, COMPAC7ED /N 72""LAYERS 12. ALL t`E4/ORES AND 5TY71/ClUlZL'a ARl r1feOIrL7V,%7 6/m// BY APPROVED MECHANICAL MEANS OR ALLOWED TO SET7LL_ IN AS EY,/S7/1V/. PLACE, FOR TWEL VE (12) MONTHS OR AS OIRECTED. FILL SHALL ; HAVE A PERCOLA77ON RATE OF TWO (2) MIN. PER INCH OR FASTER S. /�c_L_ si %I t_ , �'%15sc,rr, /)//p AFTER COMPAC7701V ANDIOR SETTLEMENT IN PLACE BOTTOM OF nn,gT P'R ISG EXCA VA 7/ON SHALL BE SCARIFIED PRIOR TO PLACEMENT OF FILL PLACE FILL AS SHOWN ON 'PLAN"AND "PROFILE" T<F'=�'u`/C'' i3/L✓=q _�//q 1.7-. /d /�C'rq�y,7/�/j t A/ C./. FRAME&COVFR/F r<E'F'L. q G!'/� ,..//i// J/"/"C. / '' r,,grA�ejE 'If-0 FULL ACCESS MANHOLE RISER SEE SPEC B /_G-'v /'Y MORTAR REQUIRED - REDS --- J" VENT INSPEC770N CObER- - - r4. /o :.lFr�1a�I/� 2•_p" MIN. (7YP.)- FULL M.H. TO CRAOE IF OVER 2000 GAL. ;NLET —j �` CAPACITY MAXLIQUID_ L = ET INVERT �� PRECAST BAFFLE OR PIPE TEE OPEN AT NKTOP(T'YP)INLET AND PUMP OUTOUTLET.ED OU7L£T OF NORTH ANDOVER �" TOWN 6-DEPTH OF 3/4"- Approved 3 A -- 1 7/2'STONE 4 . TANK WDTH Date Signature _ SEPTIC TANK n"rAL =7701V NOT TO SCALL / SEP77C TANK ` TABLE OF DIMENSIOA / CAPACITY(GAL.) A B' C -D `" E — ApN 1000 8"-1 5"-1" 5"-8 7"-8" 4"-0_i F _2 -- _ , 1500 10-0" 6'-05=10 9=5" _OUTLET(TYP.) 1'-0"MIN. COVER S'� $/pEC B ---- INLET 2 �OU7LET A/ LOADING DES/G/V INLET _ CR%TER/A - NO. REO D T NGLE FAM/L Y,OWELL7NG ' 3fE� BUILDING USE SI 64<FEL=, ONE . N0. OF 9E9ROOMS FOUR --j - 6"DEPTH .DESIGN NO. OF PEOPLE° .314"-1 1 2" DESIGN FLOW.B�l6., TOTAL DAILY FLIOW •GP PLAN SECTION GARBAGE GRINDER - NO .'X.YES. (INCREASE LEACH A STONE SPECIAL COND177ONS ,. rxe 6;it,^3l/J. ,>r cit '. -12 f niy�1 E 6 — OUTLET D/S7R/BU770N BOX NOT TO SCALE DESIGN PERCOLA I70N RATE .P/F,7EEN. MINUTES PER INCA LEACH AREA REQUIREMENTS (Sq.--r/GALLON) = BOTTOM , TOTAL AREA REOY?_t )CAL COD,, 134, iOFT 777LE 5 �' —� FINISH SVRFACE PROVIDED-TOTAL T�3t'O.F7:-BOTT•OM.q,fr2S'0•FT-SIDE';. ------- -0 --__-_ FILL - N€ . _ -- IS"0 A AND/OR MANHOLE PAVEMENT. ' b �p 2 1/2" b • { a �M �jI t6 (TYP.) 1 3/4"701 1/2".. 6 0 PLAN 8 STONE-SEE EFLr (TIN /her 4+� t f -0" Ttwinr SPEC.D WIDTH 'A' V Cn..rp .j INLET 2" DEPTH- SECTION T' y�1 A`.a I/sVa '- "TO " TABLE of OIMESIONS J/ "-0 W M1n SEE NOTE 7 STONE-SEE l. uSV f/j��ly'' 10O" SPEC.D a b ` ��•, \ ' J I ci - i C c �+ NO.REO'D r s e.l EFFECTIVE LENGTH'S' S!' l8-Q'"Z=G LOCUS SECTION 'A' EACH PIT,- `S MAP SCALE 1" eso GAL.�' '^ JUMBO SHALLOW LEACHING CHAMBER "o-t---TQs-Ay - ?c 6 15/93° AcpE0[EACH P/75 So/LL 7 q3, bl �ETIOEEJ.1 77CEAr'�Nl�s��oF�� l TEST ®A TA PERC RATE MlN /N. DA lE A zS t slnolrrovac. Sores 7'f5T- /.vF'aRirAT7 wl P-4 15 MIN. /N 7 27 V NO. DA IE TESTS BY. ✓. AMATO P-5 6 MIN. 7 REVISION WTNESS. MIKE GRAF _ PROPOSED SUBSURFA CE OBSERVA7)ON PIT - DATE %''? - 1A 7 �7 /SEWAGE DISPOSAL STEM, -2.�1�- G-zL/->✓-1 6 19.41. A 4z GRADE EL. !N.3 r 1 �l 3. C, r y 4 0 GROUND WATER EL. - - SITE PLAIN, PROF/LES & ®ETA 80770"EL. 3 .3 ::i5. r_r 1.3h.1t (3rr•Z L0 T [ T {TR EIE zy 0.-� �'� NORTH ANDOI/ R MASS__ 411.7 Y SAf�r1Y lrv.�.a ,,,-��._— -, �� I 9r# --- Address Title of File Page of Date File Open: Date file closed: Doc Document/Action Title Date of Refer to other Purpose of Document/Action and notes, action Document/ document/ filum• Action Department Board of Appeals — Board of Health — Planniing Board — Conservation Commission — Building Department Gt Hancock Survey Assoclates Inc. LACE-'-TCEG3 OF -TRUSOMOUTU 2 Electronics Avenue Danvers Industrial Park DANVERS, MASSACHUSETTS 01923 DATE ' JOB NO. ��6 (508) 777-3050 (617) 662-9659 (508) 352-7590 (508) 283-2200 ATTENTIO RE: TO �t/o,&n A n c,�av e r' 3. o. i7' 7_0"J n `� Lo 2 =cres S1L .�x7L AA > WE ARE SENDING YOU Attached ❑ Under separate cover via re, Moi the following items: ❑ Shop drawings ❑ Prints ❑ Plans ❑ Samples ❑ Specifications ❑ Copy of letter ❑ Change order ❑ COPIES DATE NO. DESCRIPTION Z- hC_ eff THESE ARE TRANSMITTED as checked below: or approval ❑ Approved as submitted ❑ Resubmit copies for approval ❑ For your use ❑ Approved as noted ❑ Submit copies for distribution > ❑ As requested ❑ Returned for corrections ❑ Return corrected prints ❑ For review and comment ❑ ❑ FOR BIDS DUE 19 ❑ PRINTS RETURNED AFTER LOAN TO US REMARKS :5a'l C 41 rc I/ccT raw, zle 41a ,yc COPY TO SIGNED: 8/J/ �Cj,•�ti{�� PRODUCT 240 EBS Inc,Gromn,Mass 01471. If enclosures are not as noted, kindly notify us at once. I PITS �+ f I MIN 660 LEACHING GW MIN 41 BELOW BOTTOM MANHOLE/PIT ,I I EXCAV 2x EFF W OR D 12"-48" STONE SURROUNDING BOT + SIDE x LOAD = TOTAL (L x W x #) (2 x (L+W) x D x #) , CHAMBERS MIN 660 LEACHING GW MIN 4" BELOW COVER >3 FT - VENT MANHOLES 12"-48" STONE SPLASH PADS SLOPE . 005 BED/TRENCH (Bed max. 60' X 601 ) BOT417% + SIDE Z 461 X LOAEP6'7"¢ TOTAL (L x W x #) (2 x (L+W) A D x #) 5e: FIELDS MIN 900 ft2 LEACHING PERC RATE FASTER THAN 20M/IN GW MIN 41 BELOW BOTTOM OF FIELD PIPE ENDS JOINED W/NON-PERF. PIPE. 4" PEA STONE? DIST LINE SLOPE .005? >3' COVER - VENT SCH 40 MIN 12" COVER L x W = T x LDNG > DESIGN FLOW? DOSING TANKS AND PUMPS DIMENSIONS X X = PUMP CAPACITY gpm L W D Vol. DISCHARGE SIZE DISCHARGE RATE DISCHARGE TIME gpm MANHOLES TO GRADE ALARM SEP. CIRC. GW (Min. 1' below inlet) HWL LWL CHECK VALVE BLEEDER HOLE MANUAL OP. SWITCH PLAN REVIEW CHECKLIST ADDRESS e /�I� ENGINEER A41 no C GENERAL 3 COPIES STAMP ��~ LOCUS C.- '"' SCALE CONTOURS PROFILE L/' SECTION BENCHMARK c,--' ELEVATIONS SOIL & PERC INFO n/ WETS. DISCLAIMER Lam—. WELLS & WETLANDS !1'" w WATERSHED? b DRIVEWAY Elevations) WATER LINE ,�--- DRAINS t/ SCH40 SLOPE TESTS CURRENT? SEPTIC TANK / MIN 1500G. C/ . 17 INVERT DROP GARB. GRINDER(+200% EDF) . 25' TO CELLAR V MANHOLE TO GRADE `S ELEVGW 0 D-BOX SIZE '7J8'S # LINES FIRST 2' LEVEL STATEMENT INLET 4 ,a - OUTLET /47-9/ (2" OR . 17 FT) LEACHING RESERVE AREA L/� 4' FROM PRIMARY? 100' TO WETLANDS "" 2% SLOPE 100' TO WELLS �-X 325' TO SURFACE H2O SUPP 35' TO FND & INTRCPTR DRAINS VZ 4' TO S.H.GW 4' PERM. SOIL BELOW FACILITY MIN 12" COVER L-- �FILL? x(25' if above natural elevation; 101if below) 7-0 TRENCHES 'M UND8K DPW&1019y MIN 660 gpd SLOPE (min . 005 or 6"/100' ) >3 ' COVER? - VENT v SIDEWALL DIST. 2X EFF. W, OR D (MIN 6' ) r✓ IS RESERVE BETWEEN TRENCHES? V, IN FILL? MUST BE 10' MIN. 4" PEA STONE? BOT X LDNG•)q7ll+ SIDE �/�� X LDNG-= TOT 9() 7. 8-:5 >��0 (L x W x #) (G/ft2) (DxLx2x#) PLAN REVIEW CHECKLIST ADDRESS �OI�EST JcT. ENGINEER . ANcocxE GENERAL 3 COPIES STAMP LOCUS NORTH ARROW c_ SCALE CONTOURS f PROFILE ' SECTION BENCHMARK SOIL & PERC INFO ELEVATIONS WETS. DISCLAIMER WELLS & WETLANDS WATERSHED? DRIVEWAY (Eley) WATER LINE FDN DRAIN SCH40 TESTS CURRENT? SEPTIC TANK MIN 1500G. . 17 INVERT DROP GARB. GRINDER (+200% EDF) 25' TO CELLAR MANHOLE TO GRADE ELEV GW D-BOX SIZE # LINES FIRST 2' LEVEL STATEMENT INLET - OUTLET = (2" OR . 17 FT) TEE REQ'D? LEACHING RESERVE AREA 4' FROM PRIMARY? I,--' 100' TO WETLANDSy 2% SLOPE 100' TO WELLS 35' TO FND' & INTRCPTR DRAINS ✓ 4' TO S.H.GW 325' TO SURFACE H2O SUPP ", 4' PERM. SOIL BELOW FACILITY MIN 12" COVER FILL? (25' if above natural elev; 101if below) BREAKOUT MET? TRENCHES MIN 660 gpd SLOPE (min . 005 or 6"/1001 ) >3 ' COVER? - VENT SIDEWALL DIST. 2X EFF. W OR D (MIN 61 ) IS RESERVE BETWEEN TRENCHES? IN FILL? MUST BE 10' MIN. 4" PEA STONE? BOT X LDNG + SIDE X LDNG = TOT 2 (L x W x #) (G/ft ) (DxLx2x#) i Form No.3 Town of North Andover, Massachusetts BOARD OF HEALTH MORTM T3 19�— 0t4���D iy,tiO J �NA - 3? OC .��-D,,,,o .•s,� DISPOSAL WORKS CONSTRUCTION PERMIT SgACHUSE Applicant � U ADDRESS TELEPHONE NAME Site Location �—' �O Permission is hereby granted to Construct. ()Q or Repair ( ) an Individual Soil Absorption Sewage Disposal System as shown on the Design Approval S.S. No. CHAIRMAN,BOARD OF HEALTH D.W.C. No. L 3 � Fee ' i FORM U - IAT RELEASE FORM INSTRUCTIONS: This form is used to verify that all necessary approvals/permits from Boards and Departments having jurisdiction have been obtained. This does not relieve the applicant and/or landowner from compliance with any applicable local or state law, regulations or requirements. ****************Applicant fills out this section********t******** APPLICANT: /� �`�r ,r/ �ca� -1Je1l,,Phone S LOCATION: Assessor's Map Number Parcel Subdivision �Pk/ "t/¢/�i �/�o� ��,- Lot(s) �. -. Street ly t-�S SI �X I St. Number j¢ ***********.*************Official Use Only************************ RECOMMENDATIONS OF TOWN AGENTS: F Date Approved Conservation Administrator Date Rejected Comments Date Approved Town Planner Date Rejected Comments Date Approved Food ,I/nspector-Health Date Rejected -tel � /1/L� Date Approved V-% Septic Inspector-Health Date Rejected Comments Public Works - sewer/water connections - driveway permit Fire Department R F@cli$eW l ill ing Inspector Date � ��u 5 GM Y "DING aEPAR i 1/-N �1. Town of North Andover, Massachusetts F°""No. ., f MOR„ BOARD OF HEALTH ° ,...o 9 / Y p r• ---�-• - • DESIGN APPROVAL FOR sSACH ES SOIL ABSORPTION SEWAGE DISPOSAL SYSTEM f� rk Applicant0j..0e%cTest No. �. Site Location a' y� o L3 . . Reference Plans and Specs. ENGINEER DESIGN DATE Permission is granted for an individual soil absorption sewage disposal system to be installed in accordance with regulations of Board of Health.. ' AIRMAN,BOARD OF HEALTH •.f Fee Site System Permit No. I No......................... Fss.............................. THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH "' .... .............OF...........�U� .....I..`��c&/e►/ Appliratiou for Uhipoii al Workii Tunitrurtiun tIrrutit Application is hereby made for a Permit to Construct ( ) or Repair ( ) an Individual Sewage Disposal System at / Location-Address r ,q 7/ nA Co70 ................................. ..Owner Address W -----•-•.............................................•-----....---•--............................. ................•--••••-•-------------.......------------......-----•---••-•--•-••---......_..-•- Installer Address16,ee'-s PQ Type of Building Size Lot.--/.� ...............-Sq--feet Dwelling—No. of Bedrooms.------C v.........................Expansion Attic ( ) Garbage Grinder ( ) Other—Type of Building ............................ No. of persons-_---..-.--.---.--.------- Showers ( ) — Cafeteria ( ) fz4 Other fixtures ------------------------------- -- ----•-•-------------•---•-------... W Design Flow.......`----------------_----u�gallons per person per day. Total daily flow..----.�v�--------.-..-------------gallons. WSeptic Tank—Liquid capacity.�.s.-....gallons Length.... ......... Width.------....... Diameter......--.--.---. Depth.y.......... x Disposal Trench—No. .....3........... Width......3. ...... Total Length..... 3.t....... Total leaching area...1.k e_7._---sq. ft. Seepage Pit No--------------------- Diameter.---..-----------.-- Depth below inlet.................... Total leaching area..................sq. ft. Z Other Distribution box (C ) Dosing tank ( ) Percolation Test Results Performed by....p-�ir)_ � ..�� 'r ��f ^,r C UL............ Date.-V/.. ......7` ' � 7 aT_44'Test Pit No. l.--I.$.......minutes per inch Depth of Test Pit...?A-- ..... Depth to ground water..------"""-.-.-.--. 7`!; Test Pit No. 2....4........minutes per inch Depth of Test Pit----- ........ Depth to ground water..------"""­--------- .............................................-•••••-•--••......•-•••--•-•--•---•-------------•-•--------------------------------------•--------------------- O Description of Soil.................. '�'------ Gco, ,Jcn{t!' ......f��itz'1-------_//I ......`�`�= 1------ � t W ---------------------------------------------------------•-•--------------••.......-•-••--••------•---•----------•----------------•---•-----•--------------•-------•-•--•--••----•---•--•------------••- UNature of Repairs or Alterations—Answer when applicable.-.--------------------------------------------------------------------------------------------- --------•---------------------•---•--•----------•---------•-•---•-------•-----------•--------------------•--••------------•-----•--•--•...-••••....-•--•----•--•-------............................ Agreement: The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of TITLE 5 of the State Environmental Code—The undersigned further agrees not to place the system in operation until a Certificate of Compliance has been issued by the board of health. Signed . . .. .................. ..... ... . . .......... .... ............ ................ ........................................ Date ApplicationApproved By ---------------------------------------------------------------------------------------------------------------------------------------------- --------------------------------------- Date Application Disapproved for the following reasons: ...... ................. ... . ...................... . .---- .---..........---............................... ---------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------- ---.... ----------............. Date PermitNo- -------------------------------------------------------------------- Issued ....--------------.------------- ------------------ Date THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH ---------------------------------------------- OF ...---------------------...--------------------------------------------------------------------- %Cex.tifira e of C�ampltttrtce THIS IS TO CERTIFY, That the Individual Sewage Disposal System constructed ( ) or Repaired ( ) by ----------------------------------------------------------- --------------------------------------------...-.......-.....-------------------------...----.-....-...-....-..............-.--...........------------------------------- Installer ............. .........----..--...-.......-...------------......--...............------------------------------------------------------------------------------- . has been installed in accordance with the provisions of TITLE 5 of The State Environmental Code as described in the application for Disposal Works Construction Permit No- ------------------------------------------------ dated ----------------------------------------------- THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE SYSTEM WILL FUNCTION SATISFACTORY. DATE.......................................................... ...........---------------_--- Inspector -------------------------------------------------------.....----------------------------------- THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH ...........................................O F............---------...........................................................---.. No......................... FEE........................ RaVosal Works Tunitr ilan "permit Permissionis hereby granted......-••-•------••---------------------------•---•--------------•---------------------------------•-•------••-•••.................-------- to Construct ( ) or Repair ( ) an Individual Sewage Disposal System atNo----------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------- Street as shown on the application for Disposal Works Construction Permit No..................... Dated.......................................... Board of Health DATE------------------------•-------•---------•-----•------------------------------- FORM 1255 HOBBS & WARREN. INC.. PUBLISHERS No......................... FEB.............................. THE COMMONWEALTH OF MASSACHUSETTS, BOARD OF HEALTH ,\ f-/ AA.O elope v' - .ix .............OF..........!."......... .-- . . . . ----•------------- Appliration for Uhipati al Workii Tomitrnrtiun Frrmit Application is hereby made for a Permit to Construct ( ) or Repair ( ) an Individual Sewage Disposal System at: - J Location-Address or o. f T.CrI-�lu C... t✓1.1c.............. 7� a,�hl IA Owner Address W Installer Address 44rs Type of Building Size Lot.../:_0............._Sq—fm Dwelling—No. of Bedrooms.._.... ` .....................Expansion Attic ( ) Garbage Grinder ( ) aOther—Type of Building ---------------------------- No. of persons............................ Showers ( ) — Cafeteria ( ) a' Other fixtures ------------------------------------------------------ W ��---- r ----------------------•------ ------- x Desi n Flow...... -----•-----------.._..._._ allons Per_ erson er ay Total dail..flow........ff�(..____..__--------------gallons. 1:4SepticTank—Liquid capacity 9gallons Length__-_ Width.....Z ,..-- Diameter--._.-._-__--. Depth`4i._....... Disposal Trench—No......:_.......... Width......3. ....... Total Length----- ..`... Total leaching area.../. i_%....sq. ft. Seepage Pit No--------------------- Diameter_._--__-_------.-. Depth below inlet.................... Total leaching area..................sq. ft. Z Other Distribution box (f ) Dosing tank ( ) `� '-' Percolation Test Results Performed by.--- t:r.t fi , c: ale _ �-___.-._-_. Date__fl_q_b'3_,__.-_ -�� .- .. •� ,�- •_ 1. "4 / W Test Pit No. LIS.-_-_-._minutes per inch Depth of Test Pit__. ._. Depth to ground water........................ Test Pit No. 2..... _t........ per inch Depth of Test Pit-_...e........ Depth to ground water............. ........ f� O Description of Soil------------------. ------..Ca '. + '' t�Itt!t'=---. ,,qA------- '�� 'X� S_ __ '�),Ce� �G�Ly 7 f 1 x ------------------------------•----•---------.......--------------•--------•--••••••••-••--•---••---------------------------------••----------------•-------•----------------------•--••--------------- !, V Nature of Repairs or Alterations—Answer when applicable............................................................................................... ------------------------------------7...........................................•---------------•------••---------•---•---•------•-•----•--•----...----------------••-•-•-•-•---------•----------------- Agreement: The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of TITLE 5 of the State Environmental Code—The undersigned further agrees not to place the system in operation until a Certificate of Compliance has been issued by the board of health. Signed -------------- --- -- - ---- ---- --------------------------------------------------- -- -- --- ----------- ----- Dace ApplicationApproved By ----------------------------------------------------------------------------------------------------------------- ----------- ...---..------------------------------- Date Application Disapproved for the following reasons: ............................... .. ........ ..................................................... .. .................. - ----------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------- . ----........--......... ---. Date PermitNo. --------------_--------------------------------------------------- Issued ------.............................................................. Dace THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH ------------------------------------(--�--------- OF .-------------------------------......------------------------------------------------------------ Q'Lrrtifi ate of 011ompli2 nre THIS IS TO CERTIFY, That the Individual Sewage Disposal System constructed ( ) or Repaired ( ) by--------------------------------------------------------------------------------------------------------------------�------.-........---....--..-----------------------..--------------------...-...----..........-...------------------------------- staller at ---- -- ----------------------------------------------------------------------------------------------------------------------------------------------------- has been installed in accordance with the provisions of TITLE 5 of The State Environmental Code as described in the application for Disposal Works Construction Permit No- ------------------------------------------------ dated --.....-...-.---------------------..------------ THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE SYSTEM WILL FUNCTION SATISFACTORY. DATE--------------------------- --- - ---_.....---....--...-- .-- -- ---................-- Inspector ---- ... ...................---------•-------._.... ........----------- THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH ..........................................OF..................................................................................... No......................... FEE........................ Diopasa1 Works TAImitrudion rrmit Permission is hereby granted.............................................................................................................................................. to Construct ( ) or Repair ( ) an Individual Sewage Disposal System atNo............................................................................................................................................................................................... Street as shown on the application for Disposal Works Construction Permit No------------_------- Dated.......................................... -•--...----•------•-•----•-------•----•-•---•---•------•-----•••-••••---•.............................- Board of Health DATE............... --------•-----------------------------........................ FORM 1255 HOBBS & WARREN, INC.. PUBLISHERS Hancock Survey Associates Inc. LREME D OF V D QRZE DUT'Q 2 Electronics Avenue Danvers Industrial Park DANVERS, MASSACHUSETTS 01923 DATE ��—� JOB NO. (508) 777-3050 (617) 662-9659 .96 (508) 352-7590 (508) 283-2200 ATTENTION 13Vr-a/ ay'r �9 � RE- TO %Dw� 0 o f7� A� c;jvve✓ �c n A a I v v > WE ARE SENDING YOU Attached El Under separate cover via Ce- the following items: i ❑ Shop drawings ❑ Prints ❑ Plans ❑ Samples ❑ Specifications ❑ Copy of letter ❑ Change order ❑ COPIES DATE NO. DESCRIPTION Des 1 THESE ARE TRANSMITTED as checked below: or approval ❑ Approved as submitted ❑ Resubmit copies for approval ❑ For your use ❑ Approved as noted ❑ Submit copies for distribution > ❑ As requested ❑ Returned for corrections ❑ Return corrected prints ❑ For review and comment ❑ ❑ FOR BIDS DUE 19 ❑ PRINTS RETURNED AFTER LOAN TO US REMARKS /�� 040 e43c /c i lec !,ODS -.c.z G COPY TO SIGNED: !-��� �yJC�✓�C��-�/ PRODUCT 240-2 ees Inn,Crohn,Mass 01471. If enclosures are not as noted, kindly notify us at once. pORTF� of 3� BOARD OF HEALTH N p 120 MAIN STREET TEL. 682-6483 CHUSE�ty NORTH ANDOVER, MASS. 01845 Ext. 32 TO: Hanrnnk surue , Associates . Inc- DATE: Sept. 9 , 19.92 2 Electronics Ave. Danvers, MA 01923 FROM: Sandy Starr RE: Lot 2 Forest Street Dear Bill: This is to inform you that the proposed septic design plans for the above site dated 8/25/92 have been APPROVED. If you have any questions about the next step in the process, please call the Board of Health office. APPROVED WITH THE FOLLOWING CONDITIONS: 1 DISAPPROVED FOR THE FOLLOWING REASONS: A minimum of 10 ' is required between trenches when the reserve is proposed in fill or between trenches. (N.A 17 . 03) 4" of pea stone is required - OR 2" of stone and filter fabric. (N.A. 17 . 07) NORTH °t' BOARD OF HEALTH °c F p a + �, '% 120 MAIN STREET TEL. 682=6483 �,SS4CMUSEtty NORTH ANDOVER, MASS. 01845 Ext. 32 TO: Hannnnk srnrvey Associates . Inc. DATE: Sept. 9, 19.92 2 Electronics Ave. i Danvers, MA 01923 FROM: Sandy Starr , r RE: Lot 2 Forest Street Dear Bill: This is to inform you that the proposed septic design plans for the above site dated 8/25/92 have been -A-PPRO=VEDA. If you have any questions about the next step in the process, please call the Board of Health office. -APP-ROVED W3�H=THE-FOL-L-OWING—CONDIT-IONS: DISAPPROVED FOR THE FOLLOWING REASONS: A minimum of 10 ' is required between trenches when the reserve is proposed in fill or between trenches. 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OF 3 235 Newbury Street (Route 1, North)` HSA JOB NO. 3 Z DANVER'S MASSACHUSETTS 01923 ACTOR KILL�M (617)777-3050 (617) 662-9659 DATE q p g� (617) 352-7590 (617) 283-2200 •gyp, oat 13 WEATHER C Lv uD Y 50p oat PM CLIENT ST ST.��T E,�E,,vsroa LOCATION sT Pi E �05 NAME ADDRESS S 2 0 7 k7 f NE D S SPECIAL NOTES 0 ARKS & RECOMMENDATIONS 04RdERif different PRESENT AT SITE ENGINEER HEALTH AGENT OTHERS ort GRS DRV(D SMR ! SITE SKETCH (not to scale) L,Mrr or PERCOLATION TESL' RESULTS su.TRSL_ LOT N0. GRADE ro 12" IfoEFTH- " 3S" yy'l o��Pa100JFi 26 1=27 ® ®® I�® PRESOAK @ 12" ; I2 P-3® P-2 Big l%(6 ---- — --- 35 56'tir T3�T. Conk. gip. �j9 VEL DP'- 7" ! 27 — mow. — — — �.�� — — I4,U -- 6.9 f:37 s. 9" to 6" TIME �'� h+1//j 2U Mie✓ 'S, DESIGN RATE yL) Min! l/J /S M/J//Ij 7 H/"j SAIL 1J SOIL LOG T-2- " TO Zlo'� 7V- 511^j yTlS TY . 2FrG,�"cTrov �'D G�G1.1Y s/EP ACK?EUDLpE:RS T-o° ol4GRADE 7/GyT l9 „ � 93 W/ (TYP. dD1Y1� D 7/LND 6,/,V,Miq cH/N� .o r FFA cTv�r n Le vG G Pv `` GD . rf • a BUUG,0ERS Ton �oK gp .;,�- BovGtJ�%25 7b0 L, XGt 130 T- T-O" D 83 " 76f�)e P"cKE '- 9 5?nNDY SI l7Y '77 Wl L/tKGC = gov�DE� � �RAc%vCcl? =:r .b ' No G rel•� R�=r � �� u 6 i T- T- W groundwater BOTfOt•� (No refusal) �— Cr-Coarse G. . G=Gravel S=Sand Si=Silty M=Medium F=Fine B=Bon REFUSAL/ T/S=Top'& Subsoil Tr=Trace C/S�l�/ `� Note: Test results shown hereon should in no way be construed as a representation that the land tested is suitable for subsurface sewage disposal. HANCOCK SURVEY ASSOCIATES, INC., - SOLL:TESTING FIELD REPORT 235 Newbury Street .(Route 1 North) HSA JOB NO. 3 SHEET No. 2 OF 3 OANVERS, MASSACHUSETTS 01923 2 9 O (617 777.3050 617 662-9659 CONTRACTOR (617; 352-7590 (617) 283-2200 DATE 24 APR S7 {G/LLgM WEATHER TEMP SS° Oat 8 PM CLIENT FOREST ST�ZEET �,,���-�JSio^/ oat OVE�C�IST //�� S. F�/�,��g LOCATION `/ NAME G��p VCOR-6a = �/� 44-0-) f TE/Z�Y T -1- .S' 14—it- f /D"' ADDRESS SW-F6 Zo - b N ✓C n/E /OOn110 /o Co`oN1AL '5'xLE1%1 , MA PHONENE different)n(( OT D�✓�� — SPECIAL NES REMARKS & RECO"'IENDATIONS• OWNER /S" l� PRESENT AT SITE s �O T ENGINEER JOHN J. AMATO PA Orr .5'01LffC ED W / TE Lo N � EKE CT .QfD yr K HEALTH AGENT MIKE 6lrt F � MME 3OA/ U6� 75 OTHERS �.IGK OPERA �p�C'� PERCOLATION TEST RESULTS ''r` ' SITE SKETCH (not to scale) OT 3or NO. P' '(c�3{ �o KE -r DEPTH- GRADE TO 12" 3(0" \ _ _ o PRESOAK @ 12" 101140 12" 10: 56 9" 1.1 ;36 ��T � ®T-y T 5 ��T 1 811 oil 9" to 6" TIME 4f6" m1tj TWNE DESIGN RATE T- SOIL LOG T- -7SQIL " ' GRADE J Q" To 30ry T�5 /� �Z" T�5 MT.) 30" To 88 SILTI' 51fn►DY 77LL v 32 ` Tv /?O" 514:TY/Goff R 5E T° Mt=p W1t_,gR(,6 8006-DERS 4 F'�oTiJeED J /bf£O• 17ovr.DE�,s _ 6. o. �o RocK• No �W• , k�f, (P83" „ 71GH*LY PfJc,t'�v. ( t./ 7Z ge/ a /2v ,tlo ,er"F. %1 T- o To 32 Ti`L d V,//LAS -4GTtJ�'E'D a ROCK. NO O 1 L T-6 T- � •o.'Ta 32 T�5 32p /2v o SILTY/ CoRFcS£ T° LQ%o MEp 5/,.jvy vL.L L✓/ MED ,'' BovGptKs W6Nr6y Pf�cf«D. cr• G✓. 4� @ 7:2 No RAF Si=Silty M=Medium Coarse G.W.�roundwater BarTOM (No refusal) G=Gravel S=Sand �— T/S=Top & Subsoil Tr=Trace C/S=Clean/Sharp F=Fine B---Bony P.EFUSAL/LEDGE Note: Test results shown hereon should in no way be construed as a representation that the land tested is suitable for subsurface sewage disposal. HANCOCK SURVEY ASSOCIATES, INC. , _ SOIL TESTING FIELD REPORT 235 Newbury Street (Route 1.North), DANVERS, MASSACHUSETTS 01923 HSA JOB NO. # 32 90 SHEET NO. 3 OF (617 777-3050 617) 662-9659 (617; 352-7590 617) 283-2200 DATE27 JLi-'( 57C MA�RTM oM PSo1✓ CLIENT -:vRgFsT STame-T e5e7z-_/s10AJ WEATHER C46-,49 , bvA RM TII�P B v°oat PM NAME e o F._49 A1 i T699'r ST P/F,eCr' LOCATION o ST ST EST X7�Tn/s/aV ADDRESS SviTC Zo`Z AlakTH 1qNvoVER, TC1kV.-1e 1001JD PHONE OWNER (if different) SPECIAL NOTES, REMARKS & RECOMMENDATIONS- PRESENT AT SITE ENGINEER HN MA_F0 HEALTH AGENT M/Kr< 612 A r OTHERS PERCOLATION TEST RESULTS SITE SK= (not to scale) F4.� GRADE TO 12 52 52 52 � PRESOAK @ 12" 12;50 1.'43 12" 1;05 /1,613 9 , 3S 1. �9 2:07 =2 T-7 Lo-7 Z 811 P- � 7 711 �V LST 3 9" to 6" TIMEN J /U iylnl, me'E To c.i rJ L .7 M, id ! Po M D DESIGN RATE 6 m 1 tj b t1j M1/J,/MN /yudI/// T- SOIL LOG T- SOIL LOG GRADE (TYP.) T- T- T- T- G=Gravel S=Sand Si=Silty M---Medium Coarse G.W.=Groundwater BOTTOM (No refusal) �— T/S=Top & Subsoil Tr=Trace C/S=Clean/Sharp F=Fine B--Bon P.EFUSAL/LEDGE Note: Test results shown hereon should in no way be construed as a representation that the land tested is suitable for subsurface sewage disposal. EXT -710 _ AS-BUILT CHECK LIST and FINAL INSPECTION Proposed Elevations As-Built Elevation House 41, Tank IN /Cf3, �, j /43. 77 Tank OUT D-box IN D-box OUT 49 Trench Inverts Line 1 Line 2 Line 3 19 Z 79 Line 4 Bottom of Exc. l Stone OK? V/ D-box checked?___,4L'� Pipes cemented? `� BOARD OF HE-ALTH Town of North Andover ,Mass . D a t e ' -- =19 rmity APPLICATION FOR WELL & PUMP PERMIT well Application plication is hereby made for permit to drill a (_) • de to install ( ) a pump system. -' . . Lot # cation: Address Gam, ner /� Jr �}-S/ � _Address /�� ,4 11 Contractor dress-� 1Z Address tel . mp Contractor • LL CONTRACTOR (To be completed at time of pump test ) 1 ���.�- Well used for pe of Wel `r .1 Size of Casing ' _ameter of Well f Depth casing into Bed Rock 2pth Bed Rock is Seal Tested? Yes ( No (-) Date. .of Testing t Well T:ndcd in Wha-t. Material f c- D '� Delivers —Gals . Per 2pth to Water_ tlin . for 4 hours rawdown Z&feet after pumping_ hours at -&-LG I'M ate of Completion -A' — i�nature We Contractor UMP INSTALLER (To be~ f-illcd in before insta].].ati.On ) Pump Type Used — ize & Name Pump GPM Size of Tank-_ ,ater Pump Delivers ip e MaCerial Used in Well : Cast Iron ( _) C-nly.-inized ( _) Plastic ( _1 'ell Pit (_) or Pitless ,Adapter (_) leeve used to protect pipe? Yes (_) NO(_) Fype or Name Well Seal____ as s , )ate Pn '�;.nc S� m99991. I `r�4it11r�'r�4�ti'ci4�M�4►t�F�'��M�4�M���4��C�Mt4�"ti41k�'t�'rtkt4i4�4�'��4�Y�4�'��4�4�4i'rti'r�'��'rti'rti`r,::':'.:•.:;;,,,c,r,-,:,t:: ::,.: )ate Water analysis repor-t 'submitted to Board of liealth_ Date release given LD owner of record & Bldg • InsP 0K }Health Inspector NUMBER FEE 3-71 THE COMMONWEALTH OF MASSACHUSETTS $25 . 00 ...T.QWN....... of ......ND1:UJ:L-=.O.VER................................. Robinson Aresian Well Thisis to Certify that ....................................................................................................................... NAME P.O. ..1.2.3.. Lypafi.e.1 .d......MA...0.1.9.4.9.............................................. ADDRESS IS HEREBY GRANTED A LICENSE For ..........Mel 2-J?-P-XM-.t--- ....#2...F.o.r.e.%9t... A...... ............................................................I............................................................................................................... ........................................................................................................................................................................... ............................................................................................................................................................................ This license is granted in conformity with the Statutes and ordinances relating thereto, and expires......December 3l........1.9.9.3..... unless sooner suspw oked. ....... .. ................. Ir v or 14;-(y--- ------------------ ---- --------------------- --- ...... . ....................... ....Ma r c;h...3-0...................••-------19---9L.3 .................. .. ............... ............ .... ... .7 . . .......... ....... ............. .................. - ------ - ------------------- FORM 433 HOBBS & WARREN. INC. 7� WELL DATABASE ADDRESS: l 't f 3 4:19- AGE OF W-ELL: WELL DRILLER.- WELL RILLER:WELL PER-NET WELL LOCATION: a. - WELL PERMIT DATE: 3 `3 0 —� ,,• DEPTH OF WELL: TYPE OF WELL: b. DUGS c. UpWN TYPE OF WATER BEARING ROCK: .2-c WATER ANALYSIS DATE: 4 ' �j— 3 HIGEL GANESE: Y N HIGH IRON: Y ( N/ GT=CONTA�NfINAlNI TS. Y N WELL DATABASE ADDRESS: AGE OF WELL: WELL DRILLER: V SAA WELL PERMIT,4: ? WELL L�CATION: �• � (� '� . Y WELL:PERNET DATE. 4-2-96 DEATH OF WELL: � TYPE OF WELL: a.. DRILLED b. DUG- C. je, -01WIN TYPE OF WATER BEARING ROCK: 0-4 WATER ANALYSIS DATE: 3 HIGH NLkNZ GANESE: N HIGH IRON: Dy N OTHER CONTAMNANTS: Y N