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HomeMy WebLinkAboutMiscellaneous - 190 FARNUM STREET 4/30/2018 190 FARNUM STREET 1 210/107.A-0103-0000.0 -� i _ I I I r Lot & Street Map/Parcel 0" /L CONSTRUCTION APPROVAL Has plan review fee been paid: YES NO Permit# 1� Plan Approval: Date: 0 (� Approved by: Designer: (3_566!b //V� Plan Date;, 1 0l2,1l�J Conditions: X0 Q rW i bb/)5- /eGc� a rtta, _si ze Water Supply: Town Well Well Permit: Driller: Well Tests: Chemical Date Approved Bacteria I Date Approved Bacteria II Date Approved Plumbing Sign-Off: Wiring Sign-off: Comments: Form "U" Approval: Approval to Issue: YES NO Date Issued By: Conditions: Final Approval: All Permits Paid? ESS` NO Well Construction Approval? YES NO Septic System Construction Approval? Y NO Certification? YES NO Other? YES NO Any Variance Needed? YES NO FINAL BOARD OF HEALTH APPROVAL: DATE: APPROVED BY: 1 ' SEPTIC SYSTEM INSTALLATION CONDITIONS: Is the installer licensed? ., .YES N Type of Construction: NEW REP New Construction: Certified Plot Plan Review YES NO Floor Plan Review YES NO Conditions of Approval from Form U YES NO Issuance of DWC permit: NO DWC Permit Paid? NO DWC Permit# /A 6 7 Installer: Begin Inspection: ES NO Excavation Inspection: Needed: Passed: 9 Aq6�D 7i By:_��v Construction Inspection: Needed: As Built Plan ati factory: YES: 'y 10 0 Approval of Backfill: Date: ti By: Final Grading Approval: Date: � O By: Final Construction Approval: Date: '614 01,- By:_ ` 2 Certificate.of Compliance: Approval: t Date: Commonwealth of Massachusetts RECEIVED ED IM City/Town of . System Pumping Record JUN 3 0 2014 Fortin 4 TOWN OF NORTH ANDOVER HEALTH DEPARTMENT DEP has provided this form for use by local Boards of Health. Other rms may , but the information must be substantially the same as that provided here. Before using.this form,check with your local Board of Health to determine the form they use.The System Pumping Record must be submitted to the local Board of Health or other approving authority. A. Facility. Information 1. System Locatio . Le Rig"; o 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 Address � c�vA� City/Town State Trp Code 2. System Owner. Name Address(d different from location) City/Town States + p de Telephone Number B. Pumping Record ` 1. Date of Pumping Date 2. Quantity Pumped: canons 3. Type of system- ❑ Cesspool(s) eptic Tank ❑ Tight Tank ❑ Other(describe): 4. Effluent Tee Filter present? ❑ Yes Lam'No If yes, was it cleaned? ❑ Yes ❑ No: ' 5. Condition of S©m: 6. System Pumped By: Neil.Bateson F5821 Name Vehicle License Number Bateson Enterprises Inc- Company 7. Location where contents were disposed: G.L S. � Lowell Waste Water Sigr4fitufe 9t Hau Date t5form4.doc-06/03 System Pumping Record•Page 1 of 1 Commonwealth of Massachusetts RECEIVE W City/Town of NO. ANDOVER System Pumping Record C -� 2010 Form 4 TOWN OF NORTH ANDOV R DEP has provided this form for use by local Boards of Health. Other fo Iid)lesa4T� tie information must be substantially the same as that provided here. Before using this form, c ith your local Board of Health to determine the form they use. The System Pumping Record must be submitted to the local Board of Health or other approving authority. A. Facility Information Important: When filling out 1. System Location: forms on the computer,use 190 FARNUM ST. only the tab key Address to move your NO. ANDOVER MA 01845 cursor-do not City/Town State Zip Code use the return key. 2. System Owner: SVETTA SMIRNOV Name Address(if different from location) City/Town State Zip Code Telephone Number B. Pumping Record 1. Date of Pumping 11/10/10 2 Quantity Pumped: 1500 Date Gallons 3. Type of system: ❑ Cesspool(s) Septic Tank ❑ Tight Tank ❑ Other(describe): 4. Effluent Tee Filter present? ❑ Yes No If yes, was it cleaned? ❑ Yes ❑ No 5. Condition of System: 6. System Pumped By: James H. Currier H79 406 Name Vehicle License Number J's Septic& Drain Company 7. Location where contents were disposed: GLSD 11/10/10 Signature Hauler Date t5form4.doc•06/03 System Pumping Record•Page 1 of 1 NvnIry BUILDING PERMIT o�st��° �bgti OC TOWN OF NORTH ANDOVER APPLICATION FOR PLAN EXAMINATION � o a I Permit NO: Date Received �SSACHUS�� Date Issued: IMPORTANT:Applicant must complete all items on this page �4IE�:� ,.z, ,,-a. a •n.. - ,y ! } ate:,«"g& ,. . -19J0 �"i` 3` ```� �-;b d'''"-a+` °"c-: .�,n' ,"E `v MRS> c ,nPt NE �r0�'Y2.;Fr"rC '�r ,.,�..€r �.',e, ::�x � :4� �' �'k. `�_•.:��x'-�, `",�.� '�� �`"' �'� Ye r.vy�.a„ "`tx+ -�. l^ .;�t� ��z�;tt� � s{p �' , TYPE OF IMPROVEMENT PROPOSED USE Residential Non- Residential New Building One family!--' Addition Two or more family Industrial Alteration c.1� No. of units: Commercial Repair, replacement Assessory Bldg Others: Demolition Other _a� �+ �- � a• .�.. z- � -". .�:k, tea,. ;�' �W� and � rcl ,?>,�. r �.... � 1Z DESCRIPTION OF WORK TO BE PREFORMED: O� Identification Please Type or Print Clearly) OWNER: Name: SE"12 ns — Phone: Address: '&" -.::''- -.c '. ' "" : :+� z-1� g T^sus x v �.'t' d Y`c R t S'•u. zYs .t', r n k {�1AGT ��aae x CT/ /� ' sa Jill i' 5' - "s .D >re #. xf, �5. . -r--" " ... r- .,a a .z7A AdTeSS 1 . �x Safer/ts©rte �n tr�cti as cease Amp sem'"=r s '4,Y1'- �," a 11-1 � 1r+� s ARCHITECT/ENGINEERLQwre-hceQ4��n Phone: q 72- 35-?- - 9313 Address: /'�'F s/ Reg. No. 2 7 705 FEE SCHEDULE:BULDING PERMIT:$12.00 PER$1000.00 OF THE TOTAL ESTIMATED COST BASED ON$125.00 PER S.F. Total Project Cost: $ 25 0� FEE: $ Check No.: Receipt No.: NOTE: Persons contracting wit egistered.contractors�do not have access to the guaranty fund Signature of Agent/Owr'' _ igr�atue of c©ntractor- -- Plans Submitted Plans Waived Certified Plot Plan Stamped Plans t TYPE OF SEWERAGE DISPOSAL Public Sewer Tanning/Massage/Body Art Swimming Pools Well Tobacco Sales Food Packaging/Sales Private(septic tank,etc. Permanent Dumpster on Site FICE USE ONLY I FORM DATE APPROVED PLANNIN COMMEN' DATE APPROVED CONSERV. COMMENTS DATE REJECTED DATE APPROVED HEALTH ` 4 OMMENTS 4jl2h Zoning Board of Appeals: Variance, Petition No: Zoning Decision/receipt submitted yes Planning Board Decision: Comments Conservation Decision: Comments Water & Sewer Connection/Signature &Date Drivewav Permit Located at 384 Osgood Street t=�FE DEPARTMENT 1'ernp Dempster on-site des `" nor a Located a# 14 /laln Street �, �reepartrnent sl!gnat�reldate w 4 f Z pORTN ,• /6 q� o * O � t � o c cx.«c.n— A `y �9SSACHLIs�i PUBLIC HEALTH DEPARTMENT Community Development Division Sergey Smimov 190 Farnum Street North Andover, MA 01845 Date: October 22,2007 Re: 190 Farnum Street Re: Application for raising roof that will provide living spaces on 2f loor:dormers, windows eta Dear: Mr. Smimov, Your application for the addition at has been reviewed by the Health Department. Unfortunately this application cannot be approved and was denied on, October 22, 2007, for the following reasons: The Board of Health file shows that a full septic repair was completed in 2002. The Board of Health approval of the septic system included a variance to the required size of the leaching field reducing it from 900 sq. ft.to 600 sq. ft.. The approved septic system plan dated October 12. 2001, refers to 190 Farnum Street, as an existing 9-room home. In addition, the drawing submitted with this application shows an existing 9-room home. This property cannot be increased in the number of rooms because the septic system is undersized for an increase in flow. Ffor any reason you believe that the information listed above is incorrect,you may request an onsite inspection by the Health Department personnel. Please contact the Health Department at 978 490-6678 with any questions or requests. Sincerely / XuAn Sawyer b is HeaA Director Cc: Building Department File 1600 Osgood Street,North Andover,Massachusetts 01845 Phone 918.688.9540 Fax 918.688.8416 Web www.towoofnorthandover.com RECEIV D Commonwealth of Massachusetts City/Town of I OCT 2 4 2006 System Pumping Record TOWN OF NORTH ANDOVER iv,y Form 4 HEALTH DEPARTMENT DEP has provided this form for use by local Boards of Health. The System Pumping Record must be submitted to the local Board of Health or other approving authority. . A. Facility Information Important: When filling out 1. Syst�m Loca forms on the computer,use only the tab key Address ���V �, to move your r 4 •� cursor-do not / w use the return Cityfrown State Zip Code key. 2. System Owner: Name Address(if different from•tocation) Cityrrown State C Telephone Number B. Pumping Record 1. Date.of Pumping Date 2. QuantityPumped: Gallons 3. Type of system: ❑ Cesspool(s) eptic Tank ❑ Tight.Tank ❑ Other(describe): 4. Effluent Tee Filter present? ❑ Yes 0'146 If yes, was it cleaned? ❑ Yes ❑ No 5. Condition of System: : 6. System Pumped By" Name -k Vehicle License Number - �� Company 7. Location where content',s^^were disposed:, Sig:—eatof auler Date http://www.mass.gov/dep/water/approvals/t5forms.htm#inspect t5form4.doc•06/03 System-Pumping Record•Page 1 of 1 I TOWN OF NORTH ANDOV SYSTEM PUMPING RECO RECEIVED � NOV - 92005� DATE: TOWN OF NORTH ANDOVER HEALTH DEPARTMENT SYSTEM OWNER &ADDRESS SYSTEM LOCATION Koi (example: left front of house) f DATE OF PUMPING: (07�-, UANTITY PUMPED C 6�GALLONS CESSPOOL: NO `� YES SEPTIC TANK: NO YES NATURE OF SERVICE: ROUTINE `EMERGENCY OBSERVATIONS: GOOD CONDITION FULL TO COVER HEAVY GREASE BAFFLES IN PLACE ROOTS LEACHFIELD RUNBACK EXCESSIVE SOLIDS FLOODED SOLIDS CARRYOVER OTHER (EXPLAIN) SYSTEM PUMPED BY: COMMENTS: i CONTENTS TRANSFERRED TO: V jVL AS-BUILT CBECKLIST [/ LOT NUMBER STREET NAME ASSESSORS MAP & PARCEL NUMBER LOT LINES &LOCATION OF DWELLINGS LOCATIONS &DIMENSIONS OF SYSTEM, / II�7�I, ING E TIES TO LOT LINES & DWELLING, WELLS a. FROM SEPTIC TANK / b. FROM LEACH AREA c./ LOCATIONS OF DEEP HOLES &PERC TESTS ELEVATIONS OF DISPOSAL SYSTEMx 7 TOP OF FDN ELEVATION LOCATIONS OF WELLS, DRAINS, WATERCOURSES WITHIN 150' OF SYSTEM _ LOCATION OF WATER, GAS, ELECTRIC LINES, CABLE -�� DISTANCES FROM CORNERS OF HOUSE TO CENTER OF TANK &D-BOX ORIGINAL STAMP & SIGNATURE IMPERVIOUS AREAS -DRIVEWAYS, ETC. NORTH ARROW LOCATION &ELEVATIONS OF BENCHMARK USED Town of North Andover f °RTM j Office of the Health Department Community Development and Services Division 27 Charles Street 4 -�• " North Andover,Massachusetts 01845 �ss;;Cs Sandra Starr Telephone(978)688-9540 Public Health Director Fax(978)688-9542 December 3, 2001 Sergey Smirnov 190 Farnum Street North Andover, MA 01845 RE: Proposed Subsurface Sewage Disposal System Dear Sergey: I am sending you this correspondence subsequent to our conversation last week along with enclosed excerpts of the North Andover Board of Health Regulations regarding the proposed septic system upgrade for the aforementioned property. The plans for the system upgrade entitled"Plan Showing Subsurface Sewage Disposal System, 190 Farmun St., N.Andover, MA" dated"Revised 10/12/01"were submitted and approved on October 15,2001. The plans were essentially submitted in time for fall construction and system completion by the end of the approved Disposal Works construction period as stated in Section 2.03 and 3.05 of the N. Andover Regulations. No request has been made by the system installer for issuance of the Disposal Works construction permit as of this date. According to Section 3.05 of the Regulations,all applications must be submitted prior to November 15 and all construction must be completed by no later than December 1. No permits will be issued for septic system installations until the upcoming spring. Septic system installations will commence on March 1, 2002 weather permitting. You may request a waiver in regard to the mandated system completion date of December 1,2001 from the Board of Health,but due to the uncertainty of the upcoming weather,it is not recommended. If you have any further questions or comments,feel free to contact me at any time. Sincerely, Brian J.LaGrasse Health Inspector BOARD OF APPEALS 688-9541 BUILDING 688-9545 CONSERVATION 688-9530 HEALTH 688-9540 PLANNING 688-9535 I tw I . TOWN OF NORTH ?ANDOVER 'MINIMUM REQUIREMENTS FOR THE SUBSURFACE DISPOSAL OF SANITARY SEWAGE 1 i f REVISED JUNE. 1997 E i a � i SECTION 2 .00 PROCESS TO OBTAIN A SITE SYSTEM PERMIT I . 2 . 01 Site Testing: Prior to application for soils testing with the Board of Health, . the applicant shall have a wetlands delineation done. Applicant ' s Designer then makes application to the Board of Health to perform and - have nd - have witnessed percolation tests and deep holes . This application shall be made an a form obtained from the Health Department and shall be accompanied with the following: ' a) Appropriate fee for each lot according to the current fee schedule. This fee it non-refundable and shall be valid for two years. b) Scaled site plan with wetlands delineations and Assessor ' s Map and Parcel referenced. c) Proof of ownership or "permission to test" letter fromowner of record. Once a complete application is • received, a date to conduct such tests will be assigned by the Board o Health... Percolation . and deep observation hole 'testing shall.. be witnessed by. te Board of Health. Soil testing I shall be performed from..March Ist through November. 20th unless soli conditions, such as extreme wetness or drought, preclude testing. This determination 'shall be at the . discretion of the Town Health Agent/soil evaluator. 2. 02 Site Evaluation Forms: Within 60 days of soil testing, the soil evaluator shall .submit. Sail Evaluation Forms with certifications to the Board of Health, These forms must be received by the Board of Health before or .with the fsling of the definitive subdivision plan. Under M.G.L. Ch.- 41, S . 81-U of the Subdivision Control Law, Boards of. Health must make recommendations to the Planning Board within 45 days of the filing date. If the Certified Soil Evaluator Forms have not been submi..tted as noted above, the Board of Health shall deny the plan. .2. f�3 ^ Plan Submittal : A subsurface disposal system plan is -_ - submitted. to . the Board -of Health for design approval along with a Pian- Review fee. The plan shall be subject to a review to determine -.if the plain is in conformance with local and state regulations and also subject to a site inspection to determine if conditions appear to be represented correctly on the plans . Minimum plan requirements are listed in Section 8 . 01 through 8 . 04 . Acceptable plans and any variances shall expire two years Page 7 I from the date approved unless construction .on the lot has begun. Expired plans shall be reviewed prior to the issuance of a new design approval, to insure conformance with changes in local or state -regulations. If changes . i in regulations have occurred, expired plans shall comply with new regulations . A fee in accordance with the current fee schedule shall be submitted prior to reviewing expired _ _pians for- conformance to current j regulations._ I Plans shall_be submitted by October . lst if ,system construction is planned for the fall . All systems- ;shall be installed. by December Ist of each year, unless a waiver is granted by the Board of Health. 2.04 Review Letters: Approval or disapproval letters will be sent to the designer upon completion of the pian review. A resubmittal fee in accordance with the current fee schedule will be .required for, resubmission of plans disapproved because. of plan requirement deficiencies . 2. 05 Well Construction: A well permit is applied for pursuant to the Town of North Andover Well Regulations (only when applicable). and the well is constructed and the water tested. Results . .of the. water analysis are to be . submitted to the Board of Health for review. (For further information, see North Andover Regulations for the drilling of wells) 2 . 06 Building Permit: An application fo.r a building permit (Form U) is applied for after septic _system plan and well (where applicable) approval by the Board of Health has been granted. Actual. floor plans of the proposed dwelling shall. be submitted, .prior to Form U approval . 2 -07 Found°ation As-Built.: Upon :completion of the foundation, a cert1f i ed. copy of the foundation pian is .submitted to the Board of health .prior .to .the_ recniest, for a Disposal Works Construction .perm t._ . The Board of 'Health shall review the plan as to the location and elevation of the foundation. No Disposal Works Construction_ Permit (Installer' s Permit) will be issued until. such plan is approved by the Board of Health or if not ace ceptabl , until septic system plans have been revised to address the inconsistencies 2 . 08 Construction Permit: A Disposal Warks_ Construction. Permit is issued to a licensed installer after Board of Health approval of 'the foundation plan. A non-refundable fee shall be paid to the Town of North Andover pursuant to the current fee schedule_ ? . 09 Inspections: Requests for appointments are made by the Page 8 .Board of Health approval has first beep obtained, unless {l. 'the Board of Health determines that the proposed design flow or existing sewage disposal system is adequate for the dwelling, including any proposed new construction, alteration of or an addition to an existing dwelling, and a system inspection shows that any existing septic system is functioning as designed. Any alteration of the footprint of an existing dwelling, other than. that caused i by open decks, or increase in design flow shall require an investigation into the condition and capacity of the existing septic system. 3. 05Disposal Works Const ruction• Permit : No person shall engage- in the construction, alteration, installation or repair of any individual disposal system without first- obtaining a Disposal Works Construction Permit from the Board of Health. Such permits shall be valid for 2 years and construction shall begin within. the 2-year period or the permit shall expire along with all approvals and variances. The North Andover Board- of- Health may issue -a one-year extension to the Disposal Works. Construction permit upon the written requestof the original applicant if such request is.filed for Board of Health adjudication prior to the expiration date. Documerittati on showing facts as to why completion, of the approved system was l prevented within the time . rame of the permit shall be submitted with .the ;letter of request. Onty one, one-year extension shall be granted. If during construction it . is discovered that site conditions differ from those stated on the approved plans, the installer shall cease work and i notify the Board of Health. If conditions awe significantly different from those on the approved plan, the Disposal: Works Construction Perm t and the design approval shall become void. Installation of septic systems shall take . place between March Ist and December Ist, weather permitting, ' with erm tting, ' with all systems. completed :by December Ist of each year., ;All applications for septic installations in .any given year shall" be made. prior- to November 15th of that year. . 06 Certificate of Compliance: No person .shall discharge sewage to a new, upgraded or expanded system without first obtaining . a Certificate of Compliance from the North Andover Board oaf Health in accordance with these regulations. and with 310 CMR 1.5.000. Prior to the issuance of a Certificate of Compliance., the Licensed System Installer and the Design Engineer shall certify in writing on. -a form provided by the Board of Health that "the system has been constructed in compliance with the approved p 1 ans, the North Andover Board of Health .regulations and 310 CMR . 15 . 000, that the materials used Page 12 I N&M Job number 1770/ TOWN OF NORTH ANDOVER INSPECTION CHECKLIST FOR SEPTIC SYSTEMS Site: 7L� i'C1 /''� �7� �_/J Final Date: Installer: a C/p �C� Tel: Date Yes No Initials A. Bottom of BedU 1. Excavation to proper depthy 2. With trenches,sides of excavation are beneath B horizon 3. Edge of excavation specified distance from foundation,etc. L-- Comments: (Use back of sheet for diagrams.) B. Retaining Wall 7/'- 1. 1. Wall height and width as specified r/ 2. Waterproofed 3. Wall minimum 10'to leaching facility ,�- 4. Wall meets specifications of plan —�– Comments: C. Building Sewer (o 1. Pipe diameter minimum 4" 2. Schedule 40 pipe >� 3. Inlet to tank cemented 4. Slope minimum 0.01 or 1/8"per foot minimum 5. Pipe properly set on compact firm base v 6. Pipe laid on continuous grade in straight line - 7. Cleanouts precede all change in alignment and grade – -- 8. Manholes at any 90°change — 9. 10'minimum offset to waterline Comments: D. Septic Tank 1. Level 2. 1,500 gal minimum y� 3. Gas baffle present on outlet 4. Manhole to w/in 6"of grade ✓` 5. Manholes over center and each tee �- 6. 3-20"manholes �- 7. Outlet line cemented . 8. 2"–3"drop from inlet to outlet t/ 9. Pipe set 10. Compact base with 6"of V crushed stone under tank 11. Tank is watertight 12. -Tees 12"off side of tank _ N&M Job number 1770/ Date Yes No Initials Comments: E. Pump Chamber = 1 1. If separate from tank,compact base with 6"of V stone underneath 2. Minimum 2"pipe to d-box if gravity system 3. 20"access manhole _ 4. Tank level 5. Watertight �- 6. Tank size agrees with plan specification e/ 7. Manhole to grade 8. Check valve and bleeder hole present 9. Alarm in building on separate circuit 10. Alarm functions 11. Manual operating switch 12. Pump delivers liquid to d-box Comments: F. Distribution Box 1. D-box level 2. Minimum 0.1 T'(2")drop from inlet to outlet 3. Minimum 6"sump 4. Outlet pipes show equal distribution 5. Compact base with 6"of stone beneath box t/ 6. Box is watertight 7. All lines cemented with hydraulic cement 8. Schedule 40 pipe 9. First 2'from box laid level Comments: G. Soil Absorption system 1. All stone double-washed—V— 1 '/" -pea stone Bucket test done? 2. Minimum 2"of pea stone above distribution lines 3. Minimum 6"stone beneath pipe 4. Distribution lines capped or connected together V 5. Toe of slope stops minimum 5' from edge of property; 5a. if not,then swale. Comments: N&M Job number 1770/ k i Date Yes No Initials H. Leach Trenches 1. Minimum 2 trenches 2. Length of trenches agrees with plan. (Max. length 100') 3. Width of trenches agrees with plan-Minimum 2';maximum-4'. 4. Vent present if>50 feet or specified 5. Minimum distance between trenches 10' 6. Pipe slope minimum 0.005 or 6"per 100' 7. Depth of trenches below outlet invert minimum of 6". 8. Pipes set on stable base. Comments: I. Leach Field 1. Maximum length of field 100' 2. Pipe slope minimum 0.005 or 6"per 100' 3. Separation between pipes 6'maximum 4. Pipes connected at end&vent end raised 5. Separation between adjacent fields 10'minimum 6. Pipes set on stable base V' 7. Maximum 4' separation from edge of field to first line 8. Minimum two distribution lines Comments: J. Leaching Pits 1. Minimum inlet pipe 4" 2. Pits of concrete 3. Sidewall between 12"and 48"wide 4. Access manholes on each pit 5. Pipes cemented with hydraulic cement 6. Comments: K. Final Grade 1. Slope over soil absorption system minimum 0.02 z--� 2. All system components covered by at least 9"soil t . 3. Cover soil free of stones larger than 6" c._.- 4. Grading slopes away from dwelling 5. No areas over system that may pond 6. Grading meets 3:1 slope t. r 7. Minimum of 9"of fill graded over system L.� } Town of North Andover, Massachusetts Form No.3 NORTH BOARD OF HEALTH t � 2 _ O tt� o y 7.0 �v 3? L 'h7 s -�.,,,o.•�"� DISPOSAL WORKS CONSTRUCTION PERMIT SS us Applicant NAME ADDRESS y� TELEPHONE Site Location ��� ��0X4 �/ ` Permission is hereby granted to Construct ( ) or Repair ( an Individual Soil Absorption Sewage Disposal System as shown on the Design Approval S.S. No. CHAIRMAN,WARD OF HEALTH r Fee � D.W.C. No. NEW ENGLAND ENGIIC EERING SERVICES r r kQ nrc December 4, 2002 Sandra Starr, Administrator North Andover Health Department Town Hall Annex 27 Charles Street North Andover, MA 01845 Re: 190 Farnum Street,North Andover, Septic system design Dear Sandra: Enclosed are revised as built plans for the above referenced property. If you have any questions regarding the information submitted, please do not hesitate to contact this office. Sincerely, "3, ' Cv Benjamin C. Osgo4 Jr.,EIT President 60 BEECHWOOD DRIVE-NORTH ANDOVER, MA 01845-(978)686-1768-(888)359-7645-FAX(978)685-1099 Town of North Andover a� ao D , , Office of the Health Department OLD , • Community Development and Services Division bb 27 Charles Street .North Andover,Massachusetts 01845 CMus�t Sandra Starr Telephone(978)688-9540 Public Health Director Fax(978)68&9542 TOWN OF NORTH ANDOVER BOARD OF HEALTH CERTIFICATE OF COMPLIANCE DATE OF COMPLIANCE 12/10/02 This is to certify that the individual subsurface disposal system constructed () or repaired (X) by Todd Bateson at 190 Farnum Street has been installed in accordance with the provisions of Title V of the State Sanitary Code and with the North Andover Board of Health regulations. The Issuance of this certificate shall not be construed as a guarantee that the system will function satisfactorily. f .l ria j. LaGrasse Board of Health Inspector BOARD OF APPEALS 688-9541 BUILDING 688-9545 CONSERVATION 688-9530 HEALTH 688-9540 PLANNING 688-9535 :i S`?.• > Y r�:sem: n ti: -�o. SEEM 60ARD OF P+ , \ h�S 2 0 2002 'x'0� Or NORrfH ANDOVER SF�V:�Crr DISPOS:�I: S S"S'�'Ei1t I\STALL.-t'rl0�t CERTIFICATION The undersismed sere' v certiiv that the 'e:vage Disposal Syste-a (><1 consu-uct d- ( ) re-aired: located at 1 a 0 1=. Pf(anu vv\, g;�T2ci T was installed in cOnfermance with the N %.th Andover Board of He:ith :!`proved plan. System Design Pe::rit = , dated: With an approved design clow of gailons per day The mate: als_usea; were in cotuormar._e :vi-`t those specined on the app-roved- plan; the system was installed in accordar:ce �,.ith the provisions of 3110 CNIR 15.000, Title 5 and local re-.ilations, and the final eradira aLrees substantially vAth the approved plan. :til work is accurate:Y represented or the As-bUilt which has been submitted to the Board e:Health. Bed inspection date- 8,t 0Z Enp-ineer R:arzst ::hive. Final inspecuon date: -- Enciree- Represent-1t:--.:e Installer: — _ L.C. Date: Cesi<_Tn Engineer: Date: RRHARD C. TANGARD �F�rE�•.` SS�ONAL EAG C' .4, BOARD OF HEALTH NORTH ANDOVER, MA 01845 978-688-9540 APPLICATION FOR DISPOSAL WORKS CONSTRUCTION PERMIT DATE: /—1 —�°� CURRENT INSTALLER'S LICENSE# LOCATION: LICENSED INSTA SIGNATURE: TELEPHONE# CHECK ONE: REPAIR: � NEW CONSTRUCTION: IF NEW CONSTUCTION, PLEASE ATTACH FOUNDATION AS-BUILT. Administrative Use Only 160.00 Fee Attached? Yes V/ No Project Manager Ob. Yes No Foundation As-Built? Yes No Floor Plans? Yes No Approval Date: �� I I INSTALLER PROJECT MANAGEMENT OBLIGATIONS I As the North Andover licensed installer for the construction of the septic system for the property at ��� i9�. J 4 '� relative to the application of dated o OL- for plans by t✓ C)S,co �*4 and dated with revisions dated I understand the following obligations for management of this project: 1. As the installer I am obligated to obtain all permits and Board of Health approved plans prior to performing any work on a site. I must have the approved plans and the permit on site when any work is being done. 2. As the installer I must call for any and all inspections. If homeowner, contractor, project manger, or any other person not associated with my company schedules an inspection and the system is not ready then item three shall be applicable. 3. As the installer I am required to have the necessary work completed prior to the applicable inspections as indicated below. I understand that requesting an inspection, without completion of the items in accordance with Tile 5 and the Board of Health Regulations may result in a$50.00 fine being levied against my company. a) Bottom of Bed- generally first inspection unless there is a retaining wall which should be done first. Installer must request the inspection but does not have to be present. b) Final inspection — Engineer must first do their inspection for elevations, ties, etc. As-built or verbal OK from engineer must be submitted to Board of Health, after which installer calls for inspection time. Installer must be present for this inspection. With pump system all electrical work must be ready and able to cause pump to work and alarm to function. c) Final Grade=Installer must request inspection when all grading is complete. Does not have to be on site. 4. As the installer I understand that only I may perform the work(other than simple excavation) required to complete the installation of the system identified in the attached application for installation. I further understand that work by others unlicensed to install septic systems in i North Andover can constitute reasons for denial of the system, and/or revocation or suspension of my license to operate in the Town of North Andover; significant fines to all persons involved are also possible. 5. As the Installer I understand that I must be on site during the performance of the following construction steps: a) Determination that the proper elevation of the excavation has been reached. b) Inspection of the sand and stone to be used. c) Final inspection by Board of Health staff or consultant. ! d) Installation of tank, D-box, pipes, stone, vent, pump chamber, retaining wall and other components. 6. As the installer I understand that I am solely responsible for the installation of the system as per the approved plans. No instructions by the homeowner, general contractor, or any other Persons shall absolve me of this obligation. Unders' icensed Septic Installer J o`er' Date: Disposal Works Construction Permit# o i Town of North Andover ,�No p*a i Office of the Health Department Community Development and Services Division • s ;� ' 27 Charles Street j North Andover, Massachusetts 01845 S^«Sti Sandra Starr Telephone(978)688-9540 Health Director Fax(978)688-9542 October 17, 2001 FILE Ben Osgood New England Engineering Services, Inc. 60 Beechwood Drive North Andover, MA 01845 Re: 190 Farnum Street, North Andover, MA 01845 Dear Ben: This is to notify you that the revised plans dated 10/12/01 for 190 Farnum Street have been approved. If you have any questions, please do not hesitate to call the Board of Health Office at 978-688-9540. Sincerely, Sandra Starr, R.S., C.H.O. Health Director cc: Battalagine File S S/aem BOARD OF APPEALS 688-9541 BUILDING 688-9545 CONSERVATION 688-9530 NURSE 688-9543 PLANNING 688-9535 NEW ENGLAND ENGNIC EERING SERVICES October 15, 2001 Sandra Starr,Administrator North Andover Health DepartmentTGov-- , QF , Town Hall Annex _ 20.:.?R0 C=_FEo'. A 27 Charles Street - North Andover, MA 01845 OCT 15 2001 I � 1 Re: 190 Farnum Street,North Andover, Septic system design ---- - ; Dear Sandra: Enclosed are revised plans for the above referenced property. The following changes have been made. 1. Spot grades have been provided over the system. 2. The test pits have been labeled correctly. 3. The depth of test pit#2 has been changed to 80"to match the Board of Health logs. It should be noted that our records indicate the pit was excavated to a depth of 100". 4. The use of a EPDM barrier and a stackable block retaining wall has been used before and the design still reflects this condition. 5. The impermeable barrier is 5 feet from the system. This has been acceptable with DEP so the plan is the same. Also enclosed is a check to cover the review fee. If you have any questions regarding the information submitted,please do not hesitate to contact this office. Sincerely, �- e- 0'J7Benjamin C. OsgJr.,EIT President 60 BEECHWOOD DRIVE-NORTH ANDOVER, MA 01845-(978)686-1768-(888)359-7645-FAX(978)685-1099 ,. m...�..�-m,�.+,.�+.�N,�� 3'a . . BOARD OF HEALTH .7 h OF i�OR��,��,,������s������ ; BOARD OF HEALTH . NORTH ANDOVER, MA 01845 978-688-9540 ICY 1'7 2001 APPLICATION FOR SOIL TESTS DATE: MAP &PARCEL: LOCATION OF SOIL TESTS: aAa v►� , OWNER: TEL.NO.: 17 5 ADDRESS: laic �2Y1vwr1 1 - V+V\.o ENGINEER: New England Engineering Services TEL.NO.: 978-686-1768 CERTIFIED SOIL EVALUATOR: Benjamin C. Osgood. Jr. and Richard C. Tangard Intended Use of Land: Residential SubdivisionSingle Family Home Commercial Is This: Repair Testing: Undeveloped lot testing: In'the Lake Cochichewick Watershed? Yes No X THE FOLLOWING MUST BE INCLUDED WITH THIS FORM 1. Proof of land ownership (Tax bill, or letter from owner permitting test) 2. Plot plan & Location of Testing 3. Fee of$275.00 per lot for new construction. This covers the minimum two deep holes and E two percolation tests required for each disposal area. Fee of$75.00 per lot for repairs or upgrades. GENERAL INFORMATION 1. Only Certified Soil Evaluators may perform deep hole inspections. 2. Only Mass. Registered Sanitarians and Professional Engineers can design septic plans. 3. At least two deep holes and two percolation tests are required for each septic system disposal area. 4. Repairs require at least two deep holes and at least one percolation test, at the discretion of the BOH representative. 5. Full payment will be required for all additional tests within two weeks of testing. 6. Within 45 days of testing, a scaled plan(no smaller than 1"-100') shall be submitted to the Board of Health showing the location of all tests (including aborted tests). 7. Within 60 days of testing soil evaluation forms shall be submitted. Please Do Not Write Bel This Line -TOWN of tvQRTti ANDOV- i BOARD OF HEALi H NA. 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C r IIt It 7• ;�`� j,?. rtet 4r � .. 5 s. ,ye. w ?. u}It IMli+x�7:.•� ":;� t+ 0,JV.Aak'yrt` ti x73 FN.�iPy r` .:' j Y; y PL_ + IsY- 1- :0�QriY --ei t za.,f 1 f :� Q ". v t+v L>' t; rkZd r - Y s 'a t �r 7.:tiM rf}�'"' ,1� ,y n:- 1. ?+•r.�R«a..s<rF a;.:.�+.... :•+r:.k; ,-<qes rr�x.,+.a .s..;:�� ,�t '% .1 ....+.�; ? y.,; fi''»'t';:..:+h�+`tads +"s :4`w� srt+ r:-. m: ',{ !T;�I�z' f-�Lf> •� '�'{ k BOARD OF HEALTH ' " TO1fUiV OF NORT�i A `GO BOARD_ HEALTH NORTH ANDOVER, MA 01845 978-688-9540 MAY Q 7 2001 a APPLICATION FOR SOIL TESTS f --------------- DATE: . ; 1-4c,( MAP &PARCEL: LOCATION OF SOIL TESTS: I q 0 ice(Zvi o m OWNER: Rao hoe 4n I e;t.q i V'-e, TEL.NO.: 6�8?' ADDRESS: jefo r-?i 5'F: ENGINEER: New England Engineering Services TEL. NO.: 978-686-1768 CERTIFIED SOIL EVALUATOR: Benjamin C. Osgood, Jr. and Richard C. Tangard Intended Use of Land: Residential SubdivisionSingleFamily Home Commercial Is This: Repair Testing: Undeveloped lot testing: In the Lake Cochichewick Watershed? Yes No jC THE FOLLOWING MUST BE INCLUDED WITH THIS FORM 1. Proof of land ownership (Tax bill, or letter from owner permitting test) 2. Plot plan & Location of Testing 3. Fee of$275.00 per lot for new construction. This covers the minimum two deep holes and two percolation tests required for each disposal area. Fee of$75.00 per lot for repairs or upg ades. GENERAL INFORMATION 1.; Only Certified Soil Evaluators may perform deep hole inspections. 2. Only Mass. Registered Sanitarians and Professional Engineers can design septic plans. 3. At least two deep holes and two percolation tests are required for each septic system disposal area. 4. Repairs require at least two deep holes and at least one percolation test, at the discretion of the BOH representative. 5. Full payment will be required for all additional tests within two weeks of testing. 6. Within 45 days of testing, a scaled plan(no smaller than 1"-100') shall be submitted to the Board of Health showing the location of all tests (including aborted tests). 7. Within 60 days of testing soil evaluation forms shall be submitted. Please Do Not Write Below This Line N:A. Conservation Commission Approval: Date Received: Check Amount: Check Date: Address ALO P IVO A, '�`7�-- � 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/ Num. Action Department _ S��"r"7G -i�'G¢� � -"7�r� �� i�G'/` ✓'�7J�r� u � ;,e �5 '//V 6 Board of Appeals - Board of Health - PlannMg Board - Conservation Commission - Building Departrment .No. Fee THE COMMONWEALTH OF MASSACHUSETTS —OF56,,6 _ BOARD OF HEALTH 0,4W is to TertifU t4at-_is hereby granted permission to install C SSPOO1,7SEPTIC TANK l d on the premises at — -- in accordance with an application on file at this office. Said work must be done in strict conformity with the requirements of the regulations of the Board of Health relating the to. AMA`N OF THE BOARD F HEALTH Violation of any of the requirements or conditiontit cause Immediate revocation of this permit. APPLICATION FOR SEWAGE DISPOSAL INSTALLATION HEALTH DEPARTMENT - NORTH ANDOVER, MASS. I hereby make applica ,on for a permit for a sewage disposal installation at cup Y i Tom. . I will install this system in ac- cordance with all the laws of t e Commonwealth of Massachusetts and regulations of the Board of Health of the Town of North Andover. Further, I will construct the house sewer of bell and spigot pipe, the minimum diameter being 4 inches, and will maintain a minimum grade of 1% until 10 feet pre- ceding the septic tank, where the grade shall not exceed 2%. I will install a con- crete septic tank of lg-� in size. A manhole (s) permitting easy cleaning will be provided with removable cover (s) of iron or concrete within 12 inches of the ground surface. I will provide subsurface disposal field with 4 inch perforated or open jointed pipe and laid in a series of trenches, the bottom of which will pro- vide a minimum of lineal (square) feet of effective absorption area. The pipes will be laid on a 6 inch layer of washed gravel or crushed stone ranging in size from 3/4 to 1-1/2 inches (dia.) and the pipes will be surrounded by similar material to a height of 2 inches above the crown of the pipe. The joints of these pipes will be protected from clogging and before filling the trench, 2 inches of gravel or stone 1/8" to 1/4" (dia.) will be placed over the course gravel or stone. The disposal field will be installed at a grade of 4 to 6 inches/100 feet. No single the line will exceed 100 feet in length and in any case, two lines of tile will be installed. A minimum of 6 feet will be maintained between the center lines of the disposal field trenches and the average depth of trench shall not exceed 36 inches. No part of the installation will be less than 100 feet from any private water supply, 25 feet from any stream, 20 feet from any dwelling or 10 feet from any property line. I further agree not to cover any portion of this installation until approved by the inspection officer, as provided below, and to incorporate any additional requirements that may be attached to the perm't. Plot Plans must be submitted with aVlic�tion. DATE S'_. Signature of Applicant I hereby issue the above permit for the Board of Health of the Town of North Andover, Massachusetts. DATE // G Signat e o Health Agent I have inspected the uncovered system indicated above and find everything done as describe . DATE 0A) .2 J1 Signature of specting Offic Percolation Test .7n-i . r e Garbage Grinder a 4. k. e- APPLICATION FOR SEWAGE DISPOSAL INSTALLATION HEALTH DEPARTMENT - NORTH ANDOVER, MASS. I hereby .make applicat/ r a permit for a sewage disposal installation at n fo 3� C� Ger I will install this system in ac- cordance with all the laws of the Commonwealth of Massachusetts and regulations of the Board of Health of the Town of North Andover. Further, I will construct the house sewer of bell and spigot pipe, the minimum diameter being 4 inches, and will maintain a minimum grade of 1% until 10 feet pre- ceding the septic tank, where the grade shall not exceed 2%. I will install a con- crete septic tank of /moi in size. A manhole (s) permitting easy cleaning will be provided with removable cover (s) of iron or concrete within 12 inches of the ground surface. I will provide subsurface disposal field with 4 inch perforated or open jointed pipe and laid in a series of trenches, the bottom of which will pro- vide a minimum of c5P lineal (square) feet of effective absorption area. The pipes will be laid on a 6 inch layer of washed gravel or crushed stone ranging in size from 3/4 to 1-1/2 inches (dia.) and the pipes will be surrounded by similar material to a height of 2 inches above the crown of the pipe. The joints of these pipes will be protected from clogging and before filling the trench, 2 inches of gravel or stone 1/8" to 1/4" (dia.) will be placed over the course gravel or stone. The disposal field will be installed at a grade of 4 to 6 inches/100 feet. No single tile line will exceed 100 feet in length and in any case, two lines of tile will be installed. A minimum of 6 feet will be maintained between the center lines of the disposal field trenches and the average depth of trench shall not exceed 36 inches. No part of the installation will be less than 100 feet from any private water supply, 25 feet from any stream, 20 feet from any dwelling or 10 feet from any property line. I further agree not to cover any portion of this installation until approved by the inspection officer, as provided below, and to incorporate any additional requirements that may be attached to the permit. Plot Plans must be submitted with application. DATE Signature of Applicant I hereby issue the above permit for the Board of Health of the Town of North Andover, Massachusetts. DATE Signat e o Health Agent I have inspected the uncovered system indicated above and find everything done as described. DATE Signature of Inspecting Officer Percolation Test_ � Garbage Grinder h •i sr BOARD OF HEALTH TOWN OF NORTH ANDOVER, MASS. 1. NAME DATE S 2. ADDRESS LOT NO. TEL. 3. NO. OF BEDROOMS -y DEN YES 1,1d NO 4. GARBAGE GRINDER YES NO 5. SHOW DIMENSIONS OF HOUSE 6. SHOW DISTANCES OF HOUSE TO ALL PROPERTY LINES 7. SHOW DIMENSIONS OF LOT 8. SHOW LOCATION AND SIZE OF SEPTIC TANK OR CESSPOOL 9. NOTE LOCATION AND DISTANCE OF WELL FROM SEWERAGE SYSTEM 10. SHOW LOCATION OF BROOKS, STREAMS, DITCHES, LEDGE OUTCROP, ETC. 11. SHOW DISTANCE OF SEPTIC TANK OR CESSPOOL FROM HOUSE NOTE: LOCAL REGULATIONS SHOULD BE READ CAREFULLY. BOARD OF HEALTH TOWN OF NORTH ANDOVER, MASS. 1. NAME ,r' DATE S 2. ADDRESSLOT NO. `/ TEL 3. NO. OF BEDROOMS DEN YES NO 4. GARBAGE GRINDER YES NO 5. SHOW DIMENSIONS OF HOUSE 6. SHOW DISTANCES OF HOUSE TO ALL PROPERTY LINES 7. SHOW DIMENSIONS OF LOT 8. SHOW LOCATION AND SIZE OF SEPTIC TANK OR CESSPOOL 9. NOTE LOCATION AND DISTANCE OF WELL FROM SEWERAGE SYSTEM 10. SHOW LOCATION OF BROOKS, STREAMS, DITCHES, LEDGE OUTCROP, ETC. 11. SHOW DISTANCE OF SEPTIC TANK OR CESSPOOL FROM HOUSE NOTE: LOCAL REGULATIONS SHOULD BE READ CAREFULLY. BOARD OF HEALTH TOWN OF NORTH ANDOVER, MASS. s � fi s ,l- 1. NAME /�Xel'C(,.e'®-r e-.. DATE 2. ADDRESS g -,ate, LOT NO. 9 TEL. 3. NO. OF BEDROOMS DEN YES `— NO 4. GARBAGE GRINDER YES NO 5. SHOW DIMENSIONS OF HOUSE 6. SHOW DISTANCES OF HOUSE TO ALL PROPERTY LINES 7. SHOW DIMENSIONS OF LOT 8. SHOW LOCATION AND SIZE OF SEPTIC TANK OR CESSPOOL 9. NOTE LOCATION AND DISTANCE OF WELL FROM SEWERAGE SYSTEM 10. SHOW LOCATION OF BROOKS, STREAMS, DITCHES, LEDGE OUTCROP, ETC. 11. SHOW DISTANCE OF SEPTIC TANK OR CESSPOOL FROM HOUSE NOTE: LOCAL REGULATIONS SHOULD BE READ CAREFULLY. BOARD OF HEALTH OF NORTH ANDOVER , MASSACHUSETTS SEWAGE DISPOSAL DATE $Z2l Z69 NAME OF APPLICANT Mr. Osgood LOCATION Lot 19 Raleigh Tavern Address of lot no. BUILDING: Dwelling X Other SYSTEM: New X Repair GENERAL DESCRIPTION OF LAND high SUBSOIL: Clay__K_ Gravel Sand PERCOLATION TEST 7 minutes per inch. MINIMUM INSTALLATION RECOMMENDATIONS CONCRETE SEPTIC TANK ] 000 gallon capacity. LEACH FIELD 225 lineal feet of drain pipe. It gravel under bed illiam J. O iscoll , Engin er Board of He th SEPTIC PLAN SUBMITTAL FORM i LOCATION:_ 1-70 NEW PLANS: YES $160.00/Plan REVISED PLANS: YES $ 60.00/Plan t� SITE EVALUATION FORMS INCLUDED: YES DATE: DESIGN ENGINEER:' DATE TO CONSULTANT: When the submission is all in place, route to the Health Secretary. OF NORTH ANIDG%'zR/ eo:%ARD OF HEALTH , i OCT 15 2001 NOONAN & Mc DOWELL, INC. 25 Bridge Street, Suite 6, Billerica, MA 01821-1023 Voice (978) 667-9736 Fax(978) 671-9565 Email: nm@ en twa com Date October 10, 2001 Town of North Andover Office of the Health Department Community Development and Services Division 27 Charles Street North Andover, MA 01845 RE: Subsurface Sewage Disposal System Plan Review, 1770/052 ,zSm&R,6ad 19,6 Assessors Map 107A, Lot 103 Dear Members of the Board, Please be advised that Noonan&McDowell, Inc. has reviewed the plan dated September 27, 2001, by New England Engineering Services, Inc. It is our opinion that the proposed design will meet the requirements of Title 5 and the North Andover Board of Health`By-Laws"if the following is addressed: 1) Provide proposed spot grade over leaching area for 2%slope 220(4)(g) 2) Relable soil log TPI to TP2 (second one) 220(4)(h) 3) Depth of testpit 2 should be 80 inches 4) Impermeable barrier should be concrete NA 9.02 5) Impermeable barrier should be 10 ft off leaching area 255(2)(g) Respectfully, John L.Noonan, P.L.S.-P.E. G:office/forms/smillrd.doc Town of North Andover, Massachusetts Form No.2 MORTh BOARD OF HEALTH 19 ' • s DESIGN APPROVAL FOR SSACmuSEt SOIL ABSORPTION SEWAGE DISPOSAL SYSTEM Applicant C1 U Test No. 1,666 Site Location 9,40 Reference Plans and Specs. -S 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. • CHAIRMAN,BOARD OF HEALTH Fee Site System Permit No. �f Town of North Andover, Massachusetts Form No. 1 NORTH A BOARD OF HEALTH "'E. /6�tiO 6 0� 19 o APPLICATION FOR SITE TESTING/INSPECTION 7 A°RATED PPP .�5 . �SSACHUS�� Applicant la3 — �lra NAME AO RESS TELEPHONE Site Location �d t Engineer NAME ADDRESS // TELEPHONE Test/Inspection Date and Time�&.2 r��. d��An, 7.4.41 �jJ CHAIRMAN,BOARD OF HEALTH Fee � Test No. lzrAewl S.S. Permit No. D.W.C. No. C.C. Date Plbg. Permit No. Town of North Andover, Massachusetts Form No. 1 NORTH • BOARD OF HEALTH SLED 1 6 '9'OL - 19 *A QA�gATEOWPPp`y^`y* APPLICATION FOR SITE TESTING/INSPECTION �SSACHUS�� Applicant-,--- NAME ADDRESS TELEPHONE Site Location - Engineer " _r • '. NAME ADDRESS •i' TELEPHONE Test/Inspection Date and Time CHAIRMAN,BOARD OF HEALTH Fee Test No. S.S. Permit No. D.W.C. No. C.C. Date Plbg. Permit No. NEW ENGLAND ENGINEERING SERVICES INC October 2, 2001 Sandra Starr,Administrator North Andover Health Department Town Hall Annex 27 Charles Street North Andover, MA 01845 Re: 190 Farnum Street,North Andover, Septic system design Dear Sandra: Enclosed are the following documents regarding the above referenced property. 1. 5 Sets of septic system design plans, 2 sets with original signatures. 2. Soil evaluator sheets. 3. Application for approval. 4. Check to cover the approval fee. If you have any questions regarding the information submitted, please do not hesitate to contact this office. Sincerely, Beri afhin Osgo IT J Jr.,� . President TOVkIN OF NORTH ANDC3k ---R/ BOARD OF HEALTH4 Ua22MI f iI 60 BEECHWOOD DRIVE-NORTH ANDOVER,MA 01845-(978)686-1768-(888)359-7645-FAX(978)685-1099 SEPTIC PLAN SUBMITTAL FORM LOCATION: NEW PLANS: 6E) $160.00/Plan REVISED PLANS: YES $ 60.00/Plan SITE EVALUATION FORMS INCLUDED: (ZS NO DATE:-- 1012-101 DESIGN ENGINEER: DATE TO CONSULTANT: When the submission is all in place, route to the Health Secretary. 2 2001 z ': 111111®IIIIIIIII��IG3�IIIIIIAa 111.... 11�In111111111111111111e11 n■� 111 eeeelln e1e� e��eelE�leee �, '� �- �-- IIIIIIIIIIIIIIIIIIIIIIIIIIIIIII�w IIIIIIIIIIIIIIIIi1��G�iflli�i;�le�i r ; ���� T - IIIIIIIIIIIIIIIIIi�i11�i1f1.11 lull ® 111GIIIIIIIIINIli�11f�%111f iGl- - - - s T 1 11111111111111111111111111Old,:1 111111111 IIIIIIIIIIIII1111i111111 �i111�111�11 ��111111i11ll�E113 11111111111. 11111111��111111111111 ��� 1111111iGri11i1Cii111%IIil1 IN IIIIIIIIeN1111111111 � '� 111N11111�'11e111 Gr111dIG�1 ��1 IINIIIIIN NI 11111111111.111 � � - 1 1111All 15i11 NIIIIIn1111111111�1111111111111 1111111 IIIIIIIi�i11G�i�11�111111111 ®� 11111111 e111�1�111111111A1111111 � � � .� 111��l1�11111i�1���i�I(111 G�IIL�IIi11�1 �'�II111���N11 11111!1l1�J11 III�i1G1�. IIIIINIfI�N��11111111111i1rG�i1 x Commonwealth of Massachusetts RECEIVED City/Town of W� System Pumping Record JAN 10 2007 y` Form 4 TOWN OF NORTH ANDOVER HEALTH DEPARTMENT DEP has provided this form for use by local Boards of Health. Other fo y-be-used,but-th information must be substantially the same as that provided here. Before using this form, check with your local Board of Health to determine the form they use. The System Pumping Record must be submitted to the local Board of Health or other approving authority. A. Facility Information Important: When fining out 1. System P ocati� forms on the computer,use only the tab key Address 1�� T�� (\kj� S+ �. to move your V cursor-do not Cityfrown I State Zip Code use the return key. 2. System Owner: Name Address(if different from location) Cityfrown State Zip Code 97 C"=�8 Z Telephone Number B. Pumping Record 1 -3-07 1. Date of Pumping Date 2. Quantity Pumped: Gallons 3. Type of system: ❑ Cesspool(s) peptic Tank ❑ Tight Tank ❑ Other(describe): 4. Effluent Tee Filter present? ❑ Yes No If yes,was it cleaned? ❑ Yes ❑ No 5. Conditi of S a� C r-c rem 6. System Pu d y: l U S;5 — Name ��— � n Vehicle License Number Company 7. Location%/ry1' ere contents we�r(&,��'Jsposed: Sign ureEMuler Date t5form4.doc•06/03 System Pumping Record•Page 1 of 1 l: 1„ Ql l: �J I. • nl Ill ^ 111 v Ill <I- ci << C � - 111 ILJ I11 t') 01 I L1 <( Z > > O (� t <f1- _ _ ll l lIJ U.1 - U FORM 11 - SOIL EVALUATOR FORM Page 1 of 3 No. Date:� � / 0 commonwealth of Massachusetts Massachusetts Soil Suitabilitv Assessment for On-site Sewage Disposal . rtes Performed By ...... , .1............... ..................... .. Date: / WitnessedBy: ....... ............ ...................................................... ..... L.6.,Aea.u, LIN. roe«,,,and Tdcpho- J New Construction ElRepair E -3 Office Review Published Soil Survey Available: No ❑ Yes Year Published �9>��................ Publication Scale .��8� .......... Cnil Man IIRII � v Drainage Class .............. Soil Limitations ��mav7z� Surficial Geologic Report Available: No ® Yes ❑ Year Published — Publication Scale Geologic Material (Map Unit) .............................................. Landform ..................�........................................................... Flood Insurance Rate Map: Above 500 year flood boundary No []Yes Within 500 year flood boundary No ❑Yes ❑ Within 100 year flood boundary No ❑Yes ❑ `--- Wetland Area: National Wetland Inventory Map (map unit) .............. Wetlands Conservancy Program Map (map unit) Q, ._ .. i 2 7nrn Current Water Resource Conditions (USGS): Month Range :Above Normal ❑Normal N Belc iv Normal ❑ Other References Reviewed: DEP APPROVED FORM-12/07/95 r� 1 _. I FORM 11 - SOIL EVALUATOR F0101 Page 2 of 3 Location Address or Lot leo. Xla �� ✓�'����' � On-site Review Deep Hole Number / Date: 1111 Time: / Weather Location (identify on site plan) '.,....CT Land Use � `�:��L- Slope (%) Surface Stones Vegetation � s__-:5 Landform �vT��r� Position on landscape (sketch on the back) Distances from: Open Water Body� feet Drainage way 4� feet Possible Wet Area 20 feet Property Line feet Drinking Water Well feet Other .. :. 777 DEEP OBSERVATION HOLE LOG* Depth from Soil Horizon Soil Texture Soil Color Soil Other Surface (Inches) (USDA) (Munsell) Mottling (Structure, Stones, Boulders, Consistency, Gravel) MINIMUM OF 2 H0LES REQUIRED AT EVERY-PROPOSED DISPOSAL AREA Parent Material (geologic) — 1172Z'_ ,W _ _ DepthtoBedrock: Depth to Groundwater: Standing Water in the Hole: '�/�"� Weeping from Pit Face: _- Estimated Seasonal High Ground Water: --- DEP APPROVED FORM- 12/07/95 , r FORM 11 - SOIL EVALUATOR FORIM Page 2 Of 3 o Location Address or Lot No. On-site Review 2 _/�/�1 Time: �, 25 Deep Hole Number Date:.. -. Weath `' Location (identify on site plan) � �` T..,...: /� G > T Land Use Slope (%) -- Surface Stones Vegetation Landform Position on landscape (sketch on the back) Distances from: Open Water Body feet Drainage way 4� feet Possible Wet Area feet Property Line l0 feet Drinking Water Well 7� feet Other DEEP OBSERVATION HOLE LOG* Depth from Soil Horizon Soil Texture Soil Color Soil Other Surface (Inches) (USDA) (Munsell) Mottling (Structure, Stones, Boulders, Consistency, o Gravel) �1 S _zj L `7 4 _ SDS �/� 4A, MUM OF 2 Hi5LES REQUIRED AT EVERY PROPOSED DISPOSAL AREA Parent Material (geologic) ��—f�/�?7` _ DepthtoBedrock: r Depth to Groundwater: Standing Water in the Hole: �� Weeping from Pit Face: ��0 i Estimated Seasonal High Ground Water. DEP APPROVED FORM• 12/07/95 r FORM 11 - SOIL EVALUATOR FORNI Page ? of 3 Location Address or Lot leo. On-site Review Deep Hole Number Date: /�/�/ Time: ��' Weather��/, Location (identify on site plan) Land Use ; l1� x��¢L Slope (%) Surface Stones Vegetation Landform Position on landscape (sketch on the back) Distances from: Open Water Body /�� feet Drainage way 46;' feet Possible Wet Area 45 feet Property Line _ 115> . feet Drinking Water Well 0 feet Other DEEP OBSERVATION HOLE LOG* Depth from Soil Horizon Soil Texture Soil Color Soil Other Surface (Inches) (USDA) (Munsell) Mottling (Structure, Stones, Boulders, Consistency. Gravel) d �L dy/e 11 CZ-- I L �Z �4OYO M-I NIMUM 01� 2 HOLES REQUIRED TT EVERY PROPOSED DISPO AREA r,NGr Parent Material (geologic) �/� _ DepthtoBedrock: Depth to Groundwater: Standing Water in the Hole: Weeping from Pit Face: Estimated Seasonal High Ground Water. -- DEP APPROVED FORTE• 12/07/95 FORM 11 - SOIL L VALUATOR TOR FpRq Pa3 fi of 3 Location Address or Lot No. )C,& Determinatr'on for Seasonal Hiph Water Table Method Used: ❑ Depth observed standing in observation hole ................ inches ❑ Depth weeping from side of observation hole........ . inches QDepth to soil mottles .........,:,1--�inches -""'e-/ ❑ Ground water adjustment ................... feet Index Well Number .................. Reading Date .................. Index well level ........._ Adjustment factor ................... Adjusted ground water level ..................................... ........ Depth of Naturally. Occurring Pervious Material Does at least four feet of naturally occurring pervious material exist in al ar as observed throughout the area proposed for the soil absorption system? If not, what is the depth of naturally occurring pervious material? — Certification I certify that one I date) I have passed the soil evaluator examination approved by the Department of Environmental Protection and that the above analysis was performed by me consistent with the re raining, expertise and experience described in 310 CMR 15. 17. Signature �� Date DEP APPROVED FORM•12/07/95 l NOONAN & Mc DOWELL, INC. 25 Bridge Street, Suite 6, Billerica, MA 01821-1023 Voice (978) 667-9736 Fax (978) 671-9565 Email: nmAnetway.com Date October 10, 2001 Town of North Andover Office of the Health Department Community Development and Services Division 27 Charles Street North Andover, MA 01845 RE: Subsurface Sewage Disposal System Plan Review, 1770/052 4"** a /96 1%qr,0hqerj Assessors Map 107A, Lot 103 Dear Members of the Board, Please be advised that Noonan&McDowell, Inc. has reviewed the plan dated September 27, 2001,by New England Engineering Services, Inc. It is our opinion that the proposed design will meet the requirements of Title 5 and the North Andover Board of Health`By-Laws" if the following is addressed: 1) Provide proposed spot grade over leaching area for 2% slope 220(4)(g) 2) Relable soil log TP 1 to TP2 (second one) 220(4)(h) 3) Depth of testpit 2 should be 80 inches 4) Impermeable barrier should be concrete NA 9.02 5) Impermeable barrier should be 10 ft off leaching area 255(2)(g) Respectfully, 2 John L. Noonan, P.L.S.-P.E. G:office/forms/smillyd.doc Land Surveyors Civil Engineers Environmental Planners NOONAN & Mc DOWELL, INC. 25 Bridge Street, Suite 6, Billerica, MA 01821-1023 Voice (978) 667-9736 Fax (978) 671-9565 Email: nm@netway.com Date 0 c71,57 Town of North Andover Office of the Health Department Community Development and Services Division 27 Charles Street North Andover, MA 01845 RE: Subsurface Y Sewage Disposal System P Plan Review, 1770/ 0 5 '�-- �' Assessors Map o7,4-,Lot /03 Dear Members of the Board, Please be advised that Noonan &McDowell, Inc. has reviewed the plan dated by Nc-�V �✓G c-�n� �GiNi•�•� fir/G G s �<v c It is our opinion that the proposed design will meet the requirements of Title 5 and the North Andover Board of Health `By-Laws"if the following is addressed: 01 lc� yv�c�®o s,G-� r P i �•a-!>-� ¢V cx L //���t 3r F-- 7` T' -�-) ee 1(2 Rectfully, '4es John L. Noonan, P.L.S.-P.E. G:office/forms/tonarev Land Surveyors Civil Engineers Environmental Planners 0 ' r i CHECKLIST FOR NORTH ANDOVER SEPTIC SYSTEM PLANS N&M Job 1770/ ,� Z The following is a checklist that incorporates all Title 5 and local regulations for septic plans. Name of Applicant: %' i=.>� jr-of Name of Designer: Ay S Plan Date: 7 7/67/' Revision Date: Date of Review: C? P Property Address: 3 c"7 I L— �-0 Map: (2 ;7,4 Lot: /(1 BOH Reviewer: Type of Plan(new or upgrade): Number of Bedrooms in Asszasb;%s'Records: gpd)Garbage Disposal Allowed: General Information: N.A.=North Andover Septic Regulations Other numbers refer to Title 5 OK Problem N/A Street number and map/lot-220(4)(u) Maximum scale of 1 "=40'for plot plan-220(4) Maximum scale of 1 "=20'for profile and component details-220(4) �— Legal boundaries of the facility being served-220(4)(a) Names of abutters from recent tax map- NA 8.02j �^ Number of bedrooms,design.calcs.,-NA 8.02i Name&address of record owner&applicant- NA 8.02k Name&address of designer-NA 8.021 Holder and location of all easements-220(4)(b) Date plan drawn&any revision date- NA 8.02m All dwellings and buildings,existing and proposed-220(4)(c) Location of all existing or proposed impervious areas-220(4)(d) !� All distances on site plan–NA 8.03a-c �-' Elevation of proposed driveway-NA 8.02t Location and elevation of foundation drain-NA 8.02y Location and dimensions of the system incl.reserve(new const.)-220(4)(e) Limits of excavation of leach area on site plan.,-NA 8.02z Locus plan-220(4)(t) (Not to scale) North arrow-220(4)(g) Existing and proposed contours-220(4)(g) dee s of Locations and to 4 ""ate g P holes-220( )(h) .� Locations and s to of percolation tests-220 4 i g P O() Date(s)of soil testing-220(4)(h)&(i) Existing grade elevation of each deep hole-220(4)(h) Elevation of percolation tests–N.A. 8.02n Name of approving authority representative-220(4)(h)&(i) Name of soil evaluator-220 4 0 3I —� Soil logs and perc test logs match BOH records Locations of waterlines,drains,and subsurface utilities-220(4)(m) Observed and adjusted g.w.elevation in the vicinity of the system-220(4)(n) Complete profile of the system to scale-220(4)(o),NA 8.02c — Cross section of leaching facility-NA .02w (Not to scale) Location of benchmark(s)within 50-75 feet of facility-220(4)(q) Note listing all variance requests with proper citations-220(4)(p) –�` Local upgrade approval request form submitted-403(1) C7 Original R.S./P.E.stamp,signature&date-220(l)&(2) If P.E.,discipline specified within stamp. MGL C. 112 s. 81M sfc.supplies(w/in 400'),pub.wells(w/in 250'),pvt.wells(w/in 150')-220(4)( Location of watercourses,wetlands,wells,etc. Win 150'of system–NA 8.02r Wetland disclaimer–NA 8.02s RLS plan reference&certification required(prop line setbacks)-220(3) �� Use approvals/standards checked for UA system-DEP docs., a 2 " Perc rate>30 MPI-not allowed for new,LUA for upgrade-245(1)&('3) Perc rate>60 MPI-must use modified tight tank or UA technology-245(4) Proposed system qualifies as"shared"system-002(definitions) Flow is over 2,000 gpd-No R.S.allowed-220(1) Design flow was set in accordance with code-203 Existing system location and note on proper abandonment-354 Leaching facility at least 1' above Base Flood elevation–NA 9.05 All piping Sch 40 minimum–NA 10.01 Basement floor minimum 1' above groundwater elevation–NA 5.04 Foundation drain present with elevation–NA 8.02y On-site Soil and Groundwater Review OK Problem N/A Proper deep observation hole logs on plan-220(4)(h) All deep holes and peres shown,including aborted tests–NA 8.02n �— Soil evaluation forms submitted within 60 days of field work-018(2) �^ Proper percolation test log-220(4)(i) Ample deep observation holes in primary disposal area(minimum 2)- 102(2) Ample deep observation holes in secondary disposal area(minimum 2)- 102(2) Ample perc testing(one in each disposal area,3 in prim.>2,000 gpd)- 104(4) Deep hole testing conducted within two years-NA 7.05 Hole Identification Numbers: ground elevation el. acceptable soil el. Leach facilitv invert el. ground water el. refusal el. bottom of leach facility el. thickness of acceptable soil before&after soil R&R separation to groundwater separation to refusal All, soil class perc rate r/ loading rate / septic tank below g.w. table V, (yes or no) pump tank below g.w.table ✓ (yes or no) l.f in fill -255(l) Setback Distances(Given in feet) 15.21 1 YES NO Is the lot in the Lake Cochiewick Watershed? NA 6.00&5.02 OK Problem N/A Septic Tank Leach Facility Property line 10 10 Cellar wall 10 20 2 3 f Inground pool 10 20 G� Slab foundation 10 10 Deck,on footings,etc. 5 10 Waterline 10 10 Private drinking well 75 100 - I Irrigation well / 75 100 Wetlands �"'@�Zr 1,6 / 75 100 Public well 400 400 Wetlands bordering surface 150 150 water Supply or trib. (in Watershed) Trib.To Surface Water supply 325 325 Reservoirs 400 400 Tributaries to reservoirs 200 200 C, Drains(wat.supply/trib.) 50 100 Drains(intercept g.w.) 25 50 Foundation drains 10 20 Drains(Other) 5 10 Drywells 20 25 f Downhill slope 15'to 3:1 slope w/o barrier Building Sewer OK Problem N/A Grease trap required for certain uses(check 230 for details) Pipe diameter listed(4"minimum)-222(1) Pipe schedule listed-222(3) Pipe cast iron or Sch 40 PVC–NA 11.02 Watertight joints specified-222(3)&(4) Pipe laid on compact,fin base-222(5) Pipe laid on continuous grade in straight line-222(7)@ Cleanouts precede all changes in alignment and grade-222(8) - Cleanout provided every 100 feet-222(8) Manhole at any 90 degree alignment change-222(8) Invert elevation at building: 'r Invert elevation at septic tank: Length of run: �-- Slope: (minimum of 0.01 -0.02 desired)-222(6) �— 10'offset to private well or suction line-222(2) 3 e 4 ti Septic Tank OK Problem N/A Tank is accessible-228(3) No structures above tank—(228(3) Tank can accommodate both primary&reserve—NA 9.04 200%of flow(required&provided given. 1500 min.)-220(4)(f)&223)(1)(a) 2-3"drop from inlet to outlet-227(5) Minimum of 4'liquid depth-223(2) 3"air space above tees/baffles(minimum)-227(4) 9"air space above flow line(minimum)-227(4) Tees are not to be replaced by baffles-227(1) Tees extend 6"above flow line-227(1) Inlet tee extends 10"below flow line(minimum)-227(6) Outlet tee extends 14"below flow line(more for deeper tanks)-227(6) Gas baffle installed on outlet-227(4) Access manhole cover above center of tank&each tee(except 2 compart)228(2) 3-20"manholes-228(2) 1 childproof,24"riser/manhole w/in 6"of final grade if<1000gpd-228(2) Inlet and outlet tees on center line-227(1) Soil compaction below tank specified(if soil is non-native)-221(2) 6"of<=3/4"stone beneath tank specified-221(2)&22 8(1) If> 1,000 gpd AND not a single fam.dwell.must be 2 tks or 2 comp.-223(1)(b) If plan specifies disposal must be 2 tanks in series or 2 compart.tank-223(1)(c) Buoyancy calcs.required if tank at or below water table-221(8) Tank is watertight-221 (1) 9"of cover over tank(minimum)-228(1) f H- 10 loading(min.)-H-20 if traffic-226(3) Top of tank<=36"below grade-221(7) All pumping to tank(if applies)in accordance with-229 Tank is set to keep old system in service during install if possible Distribution Box(Check here if not present: 1 OK Problem N/A d Inlet elevation: Outlet elevation: 0.17'drop from inlet to outlet(minimum)-232(3)(b) `— 6" sump(minimum)-232(3)(e) All outlets at same elevation-232(3)(b) Outlet pipes laid level for first 2 ft.-232(3)(c) f Pipe Sch 40-NA 10.01 Number of outlets: Number of laterals: Size of outlets: Inlet baffle/tee min. 1"over outlet invert for all d-boxes-232(3)(a), Soil compaction below distribution box specified(if soil is non-native)-221(2) 6"of stone beneath distribution box specified-221(2) Box is watertight-221 (1) T Top of box<=36"below grade-221(7) Buoyancy calculations required if box is at or below water table-221(8) Pump Chamber(Check here if not present: ) OK Problem N/A G, Volume specified: 220(4)(r) Pump on elevation- 220(4)(r) Pump off elevation: 220(4)(r) Alarm on elevation: 220(4)(r) Number of cycles per day-220(4)(r)(also 254(l)(d)if gravity from d-box) —�� Minimum 2"delivery line to d-box if gravity-254(1)(c) 4 >r 5 �— Pressure dosed It if flow>=2,000 gpd-254(1)(a)&254(2)(a) Cycles per day is consistent with chamber volume-23 1 Volume calculations include flowback volume-2') 1(2) cir 24 hour storage capacity above pump on elevation-231(2) Number of pumps: 2 if system serves>2 dwelling units-231(6) Capacity of pump(s)- gpm @ 'TDH-220(4)(r) Pump can pass 1 1/4"solids(minimum)-231(7) L' Pump controls specified-220(4)(r) `—' Alarm equipment specified-231(2) `— Alarm is in building and powered on separate circuit from pump-2') 1(9) Pump sequence correct(off-lead on-lag on-alan-n on)-231(8) �-- Pump performance curves included-220(4)(r) G-- Manual operating switch-NA 12.01 L Check valve,bleeder hole NA 12.01 6— 1 childproof,24"riser/manhole to final grade-2'31(5), Soil compaction beneath pump chamber specified(if soil is non-native)-221(2) G— 6"of<=3/4"stone beneath chmbr.specified-221(2)&228(l), �-- Buoyancy calculations if chamber is at or below water table-221(8)@ i 9"of cover over chamber(minimum)-228(1) H- 10 loading(min.)-H-20 if traffic-226(')), Chamber is watertight-221 (1) Top of chamber<=36"below grade-221(7) Leaching Facility(general-complete for all designs) OK Problem N/A 50%larger if garbage disposal-240(4) Trenches to be used whenever possible-240(6) No vehicle or imperv.area above It unless unavoidable-240(7);NA 13.02 Vented if under impervious cover-241 (1) ✓�—. Vented through same pipes as distribution system-241 (1)(a) Vent protected from precipitation/animal entry-241 (1)(b) Vent is placed beyond traffic or impervious area-24 1 (1)(c) �— All lines connected to vent if bed or trenches-241(1)(d) c 9"cover over peastone-240(9) �---" Reserve area provided(new construction)-248(1) Reserve 4' from primary leach area—NA 9.04 4'(5'if perc rate<=2 MPI)separation to g.w.-212(a)&(b) 4'(down to 2'with variance or UA-upgrades only)of natural soil under It GW separation is adjusted to highest existing grade if facility cuts into a hillside Pipe slope minimum of 0.005-251(9) v Require 5'removal and replacement if in fill-255(5) Top of leach facility<=36"below grade-221(7) Final grade over l.f.minimum 0.02 ft/ft-240(10) `^ Surface&subsurface drainage away from It -240(1 1)&245(5) -J Minimum design flow 440 gpd without deed restriction—NA 13.01 3:1 slope where grading required-255(2) �- Toe of fill slope stops 5'from property line or swale installed-255(2) Impermeable barrier if<3:1 slope or< 15 feet to—3:1slope-255(2) Impermeable barrier/retaining wall poured concrete—NA 9.02 Retaining wall stamped by P.E.-255(2)(b) Top of retaining wall>=top of peastone elevation-255(2)(f) / 10'offset from edge of leach facility to edge of ret.wall-255(2)(g) `—� Perc test(s)done in most restrictive layer- 104(2) Perc test 4' below leaching elevation—NA 7.06 Design flow listed and required/provided leach area given-220(4)(f) Leach pipes SCH40 PVC—NA 10.01 Leach pipes minimum 4"diameter except for dosed system—NA 14.04 Leach lines capped,vented,or connected together-251(9) ----rte Pressure dosing guidance followed if pressure distribution-254(2)(c), Pressure dosing required over 2,000 gpd or with I/A remedial use-231(1) 5 6 t Leaching Trenches(C here if not present: OK Problem Number of trenches: Minimum of 2 trenches-NA 9.01(2) Depth of trenches(max eff.2'): -247(1) Width of trenches(2'min.,4'max.). -251 (1)(b) Length of trenches(100'max)/ -25 1 (1)(a) Trenches are vented(whe�50')-251 (11) Trenches follow con lines-251(2) Trench spacm tunes effective width or dep nimum-251 (1)(d) In fill or re rve between trenches, 10' -NA 14.01& 14.03 Availa a leach area given(Min.50 )-NA 9.01(2) ottom=L x x# — s.f. Sidewall=L x# x2= s.f. Effective leach area give Loading factor: Effective are —total area s.£ x LTAR = g/day Effective area i =design flow of facility,being served 2"of 1/8"- l/ "2x washed peastone.-247(2) Trench depth of 3/4"to 1 1/2"double washed stone-247(1) Leach Fields(Check here if not present: 1 OK Problem N/A Number of fields: (need dosing chamber if> 1,231 (1)) Length(100'max.): -252(2)(b) Width: Total area:L x W = s.f. tl / lC Minimum 900 square feet-NA 9.01(1) Distribution lines connected with solid pipe—NA 15.01 !� Effective leach area given Loading factor: Effective area=total area s.f x LTAR = g/dav Effective area is>=design flow of facility being served Minimum of two distribution lines-252(2)(a) 6'line separation(max.)-252(2)(d) 4'maximum separation from edge of field to line-252(2)(e) 10'minimum separation between adjacent leach fields-252(2)(f) Between 6"and 12"of 3/4- 1 1/2"stone beneath field-252(2)(g)&247(2) G� 2"of 1/8"-1/2"2x washed peastone.-247(2) Final Grading OK Problem N/A Slope over leach area minimum of 0.02 feet/foot—240(10) Grading shall divert drainage away from leach area—240(l 1) Grading slopes away from dwelling 5/24/01 f:/office/forms/tonackltr.doc 6 t ti III/IIIMors // 1111!1111 IIIIIII41G3Zi11/If�� 1 � -- x�- r5 f v, 1®1��1111111�11111111!l11111111 11 eee�lleN 111'1' II�i �l 11 e1111111111111�1111111111111�w - � IIIIIIel11111111i1�G�iifili�i%' � � �Y IIIIIIIIIIIIIIIIIi��i11��i1111 Iii 1 II�i1G111111111Nili�elf���11`iG� _ � � ! . 1 IIIIIIIIIIIIIIIIIIIIIIIIIGp�: 1 1111111// 111111111 � f IIIIIIIii111111 � 111111 ,IIIIIIIIJIpi�Ir�l�i�li�lli 1 ilEll�IliG1 X11111 � , �. ,�, �� • . 11111�1�11T 111111�1���11111111111 � IIi111i11111e111111111111111111 11 --_ = - IIIIIWIIiiil�'1111 iliG1i11d1`�1 11 l 111111111111 No ® 1111�11111111Aw 11111 1'�I�i�i111i1�11�i1i1 ®� 1111111 IIIIIIil111111i1111111 1 � `� 1111111 IIIIIIIIIIfG1111�11r'ellll III Ilw - IIIIIIIIAIIIIIIWN 111 .1�I�IIIli�11��i�if111 G�ill�llll MISSION IIIGI�I� IIi11G1 t . —® _INTI 1111! 1!l�1 �� IIIIIIIG�/l��1111111111111rGii • � i FORM 11 - SOIL EVALUATOR FOIZM Page 1 of 3 No. Datc: /� �'/ ommomyealth of-Massachusetts Massachusetts Soil Suitability Assessinent for Oil-site Seiva�e Disposal Performed By: ......................�7��.1�....... ... ......... Date: WitnessedBy: .... �� ................................................ . .._......... .... L�oon ndd.us a —JT Aae«,s•and • Tcicphonc/ New construction ❑ Repair 0 Office Review Published Soil Survey Available: No ❑ Yes Year Published ................ Publication Scale �.��g� .......... Cnil Man Unit Drainage Class .................. Soil Limitations Surficial Geologic Report Available: No ® Yes ❑ Year Published — _...._...... Publication Scale Geologic Material (Map Unit) .........-................. Landform ............................................................................... Flood Insurance Rate Map: Above 500 year flood boundary No ❑Yes `� Within 500 year flood boundary No ❑Yes ❑ Within 100 year flood boundary No ❑Yes ❑ Wetland Area: National Wetland Inventory Map (map unit) Wetlands Conservancy Program Map (map unit) Current Water Resource Conditions (USGS): Month Range :Above Normal ❑Normal NBelc-i Normal ❑ Other References Reviewed: DEP APPROVED FORM-12/07/95 t I t FORM 11 -SOIL EVALUATOR FOR11 Page 2 or 3 Location Address or Lot No. �'�'�� �7 On-site Review Deep Hole Number / Date:.� �� Time: / Weather Location (identify on site plan) / ��. ..0 T Land Use Slope M f Surface Stones Vegetation Landform Position on landscape (sketch on the back) Distances from: Open Water Body 1""o feet Drainage way feet Possible Wet Area 20 feet Property Line _ feet Drinking Water Well ..../5-0 feet Other . ,. 777. DEEP OBSERVATION HOLE LOG* Depth from Soil Horizon Soil Texture Soil Color Soil Other Surface (Inches) (USDA) (Munsell) Mottling (Structure, Stones, Boulders, Consistency, So Gravel) �z 'MINIMUM OF 2 HrjLES REQUIRED T EVERY PROPOSED MPOSAL AREA _ Parent Material (geologic) DepthtoBedrock:— �G%J71 _ _ Depth to Groundwater: Standing Water in the Hole: Weeping from Pit Face: Estimated Seasonal High Ground Water: ------ DEP APPROVED FORnt- 12/07/95 FORM ll SOIL EVALUATOR FOIni Page 2 of 3 Location Address or Lot IJo. On-site Review e Deep Hole Number Date: Time:. �,2� Weathe�//':-:7-- / Location (identify on site plan) Land UseSlope (%) Surface Stones Vegetation ��'� - Landform - Position on landscape (sketch on the back) Distances from: Open Water Body feet Drainage way 4a feet Possible Wet Area feet Property Line �� feet Drinking Water Well 7150 feet Other DEEP OBSERVATION HOLE LOG' Depth from Soil Horizon Soil Texture Soil Color Soil Other Surface (inches) (USDA) (Munsell) Mottling (Structure, Stones, Boulders, Consistency, o Gravel) 71 Li MINIMUM OF 2 HOUS REQUIRED TT-EVr1TVTRMSED DISPOSAL AREA 5 Parent Material (geologic) m�—f��?7` DepthtoBedrock: Depth to Groundwater: Standing Water in the Hole: Weeping from Pit Face:_--- Estimated Seasonal High Ground Water: DEP APPROVED F0101- 12/07795 FORM 11 SOIL EVALUATOIZ F0101 Page 2 of 3 Location Address or Lot Ido. i On-site Review Deep Hole Number Date: Time: f Weatht T G> 7- Location (identify on site plan) Land Use Slope i%) Surface Stones Vegetation Landform Position on landscape (sketch on the back) . Distances from: Open Water Body /5�1r'e-' feet Drainage way 4� feet Possible Wet Area 4S feet Property Line feet Drinking Water Well 7�s� feet Other DEEP OBSERVATION HOLE LOG* i Depth from Soil Horizon Soil Texture Soil Color Soil Other Surface (Inches) (USDA) (Munsell) Mottling (Structure, Stones, Boulders, Consistency. `o Gravel) �L 33 r/ /* rN�r k d B h �4l/ %7`- Depttoeroc : � Parent Material (geologic) � _ — _ — Depth to Groundwater: Standing Water in the Hole: �/ Weeping from Pit Facer Estimated Seasonal High Ground Water. � __ _ ------- — DEP APPROVED FO"I• 12/07/95 ' , I • I FORM 11 - SOIL EVALUATOR FORM I'age 3 of 3 Location Address or Lot No. 9� ��T��v�/� �i� )C/a Determination for Seasonal Hieh Water Table Method Used: ❑ Depth observed standing in observation hole................. inches ❑ Depth weeping from side of observation hole................. inches QDepth to soil mottles -....::�nches �/ _- ❑ Ground water adjustment ................... feet Index Well Number .................. Reading Date .................. Index well level ....._ ... ... Adjustment factor ................... Adjusted ground water level ........................... . . ........................ Depth of Naturally Occurring Pervious Material Does at least four feet of naturally occurring pervious material exist in al ar as observed throughout the area proposed for the soil absorption system? If not, what Is the depth of naturally occurring pervious material? — Certification I certify that on r/ X?date) I have passed the soil evaluator examination approved by the Department of Environmental Protection and that the above analysis was performed by me consistent with there raining, expertise and experience described in 310 CMR 15. 17. Signature Date DEP APPR 0�'ED FOR11! 12/07/95 Y Project Request Record Town of North Andover Date: 4 Client Id:ToNA Card Id:ToNA Client/Company Name:43oard of Health j {7, t�Card(fT,yueLet entr:. ,rl�rt;e) tt,,`J! �t tr,itlrj`'ir!11,1rtrrJ`)li,tl,rirll�t��'rf�' r f( r E, r „ /� Contact)Name Ms Sandra'tStarr! Phorie 978 688 35 01<r rrltlt 'rd/t)J!'la,r a ) , •�) , , t r /,Title Dtrector ,rl) )1 r Fax.: 97;8 688-9542 ()'Address 271 Charles Streetr Email sstarr@townofnorthandover �lr tr)-1),! f ,!,t -t. ril r r.� 15 ,i! t7 .. rj7 1 t r!))rJj)Jt kt f t fl t Notes:• t,tr , •if t,tr%,IflfrJJ t;� .i )t ti-, 4 �1ToWri r NorthrAndover r) r !r f): � r,t/i f�'t�itll �))S;tate t MAS f'ttJ1iutJ''()1 �1 j r! r 1 1 t! t<-Il t! rfrt)jljt711 ', ,i tl r Ii t, r �r,r , ,t r,l rt-FrrjrJf,jr'r1 (f1,�JI}ft! �rrr, ,r; �It , " En) 'e staller frfOther,contacts�ifla�pLc�aliile r, ' m W. Ehone. � /,Tlt1e: F3X J/fJ /�, Address !' Email: Notes.: t `;','t�rtl"f�1ii1'J(1'�frl�t, �1 Town /yrti9iC+(i'r.��- j// t Jf i ( ;State Zip C6d rt�, � "W r-:;�.,, .., - �-, ..r,.;)tr.•ft�il tJt:un.tJ�l(1).l Project: Project Id: 1770 Project Title: Town of North Andover Board of Health (JOB NO) (PROJECT NAME&STREET ADDRESS) /a 5"Q e �✓ Manager:NOW Billing Group: � Billing Cod :Fixed Fee Contract"Iifo ProjectrDescnptiori,for each billing,.group. t ), ,,;,lt),°i,),?lirrtrl{°);f t j BG/ Applicant .�y� Assessors M'ap �Q 7 Lot /0"3 Street;.. _ .0�i 4 L 4,ZJ;7..7® t')t,ftl�lJr` ],,T.ype.of service " S l));! Tia F t 't) 1 f , I Office/forms/jbrqutona McDowell, File Edit Tools Data Maintain Process View Report (&M Windows Help Lid I ii -Billing Groups _ x Project: 1770 ,t Office of Health Department 27 Charles Street,No.Andover, Billing Group ID: � Billing Type: Fixed Fee Billing Fee:1 150.00 Card ID: To NA Mgin Billinglnfo J Contractlnfo I Classification �' GLAccounts Billing Messa esAlerts E Staffing Activities Assign To Proposal Number: Department: Contract Number: Contract Date: Work Start Date: 912 512 0 0 1 Expected Finish Date: 10/5/2001 Use Government Invoice Style Description: Engineering services required for septic system plan review Engineer:NEES,Phone-978-686-1768 60 Beechwood Dr,N.Andover MA 01845 Applicant:Paul&Josephine Battalagine _ 5 Mill Road,Assessors Map 107A,Lot 103 Vi,µ � $ave � Close Plates... d m -I ` ' r ci el It •1. UL j �YJ Q III _ c(' fl (�� (•1 _ I— I— v) 111 I I 01 (D •l �1• cl, ilJ LIJ U.) (IJ UJ U.1 Q 11 I O Z Z Z U I UJ �� l L1 l l 1 l IJ 11.1 — _ _ _ U trl UJ Commonwealth of Massac usetts ' UIOva- assachusetts . RECEIVED OCT 19 2004 TOHEDEPARTMENT ER ALLTH DEPARTM ANDOVER System Pu ZlngRecord System Owner System Location Z5VLAj,rv/ D U vvt q0 ca �- S-� 40 Date of Pumping: (® ' cs-(�`f Quantity Pumped: '5a 6 gallons Cesspool: No [iij Yes [) Septic Tank: No [I Yes [ System Pumped by: VatP.d" License# Contents transferred to: Greater Lawrence Sanitary District Date: dq Inspector: pORTH Q��TLtD 6 1 L `O ' f� r C'0 O10COC�C.H WKY 1' V0 TED PUBLIC HEALTH DEPARTMENT Community Development Division Sergey Smirnov 190 Farnum Street North Andover, MA 01845 Date: October 22,2007 Re: 190 Farnum Street Re: Appficadon for raising roof that will provide living spaces on 2"dfloor.-dormers, windows eta Dear: Mr. Smirnov, Your application for the addition at has been reviewed by the Health Department. Unfortunately this application cannot be approved and was denied on, October 22, 2007,for the following reasons: The Board of Health file shows that a full septic repair was completed in 2002. The Board of Health approval of the septic system included a variance to the required size of the leaching field reducing it from 900 sq. ft. to 600 sq. ft.. The approved septic system plan dated October 12. 2001, refers to 190 Farnum Street, as an existing 9-room home. In addition, the drawing submitted with this application shows an existing 9-room home. This property cannot be increased in the number of rooms because the septic system is undersized for an increase in flow. If for any reason you believe that the information listed above is incorrect,you may request an onsite inspection by the Health Department personnel. Please contact the Health Department at 978 490-6678 with any questions or requests. Sincerely XuAn Sawyer b is HealA Director Cc: Building Department .1'elle 1600 Osgood Street,North Andover,Massachusetts 01845 Phone 978.688.9540 Fax 978.688.8476 Web www.townofnorthandover.com ORT BUILDING PERMIT f " " TOWN OF NORTH ANDOVER 3 C APPLICATION FOR PLAN EXAMINATION Permit NO: _ e� Date Received �� �� ��'' 4q��=� -�• �' a Date Issued: �9SSACHUS IMPORTANT Applicant must complete all items on this page J to , a F a ..y-- a - .4t LacAloi�I s it rr yp x� . y 't^c,* ' r� x rel n x*5 - 'Ys e ,u' r �t 5 { n k^� �'4krY "Y u r fTx txv. �.xF ti P} t r t� :�.�. x �4d^ . .�., rar ^taV^-u s'Y rx. Pnrat' w PRC3PERTY OW N ERS: 6­. z z"#r�r A - C' AP"IzY�t c��� v'� �"�,, t x� •-. �a� � -- �l�k�' ��. '�4�` fit Kf n� r � '.'� �r w ' - r'<= �yr.k 7��` �- � ...:^•'�i5i4^�rasSt��:r- �� '�-+:-�.� �.. '��'4' :..� *�3�ta 1# � t- �y` r r5 �„� , �p e�-�,,, �ury0 �'� TYPE OF IMPROVEMENT PROPOSED USE Residential Non- Residential New • , Building .One family"' Addition Two or more family Industrial Alteration�' ' No. of units: Commercial Repair, replacement Assessory Bldg Others: Demolition Other , ept � � l/eII � 4� Watesed�b�sfnct rVaterSewer S" crl 4 `i r�- DESCRIPTION OF WORK TO BE PREFORMED: y 1ST/ 2Iden ( 2- Identification tification Please Type or Print Clearly) OWNER: Name: �E i2 �r� � gM t CZ I!� � c.i Phone' 417 7.3t`� Address: { ',z= o }CO'N'T ACTOR �„y,A_ Iv:dz-rraey,asge-r:,r�s,:.Y::..-€ma3uk. .wa'`isSrF,#ia,x fiF'E `YRy,dsyy'3t5.�r ♦A;..�u+.Ye�4k' 'i"s ''r t^te-Lr�, '',_ rYkstlrUr'�'Fx.,s..- ra ., '"'G*,$,'r�` p'n°d,.rh-�t .5fi•"t sx u.�'x.:a+� �"k�t EJ ” Mimi y: -- a �3g'7 a.;,y,,e 2�'�'t E .y,,:•ry"x� /'� t'ti=i,. �✓"t�. d,�f�.�:.� � 'YIc'- >*. t '�` J�, '"�� �.z ��- 4� ��`i i ",.� r- { �.�i f:,';f: �'?yr�'�•, ` � N a+L3�a�.,, , !- Ff"` F C h" `ai 7mE -"" ;S1Tin .zs Yy, ry rhq>C ^�s ie"q'} �* .„ SC1per1/J; Or S CCOn'SIMUCt1013 LlCer Se x � Y]�+� is //4 " R } 3k µ7. b .''. ':1 •�u - ' ,Air—".-,✓ .. �a. ..,, -.:;z.. ,sem r�, z r� m`"" „ `x,' ARCHITECT/ENGINEER Lawv�hce /f Q4��h Phone: Q 72- 36-2 - 6313 Address: /rIP Reg. No. 2 7 76'5- FEE SCHEDULE:BOLDING PERMIT:$12.00 PER$1000.00 OF THE TOTAL ESTIMATED COST BASED ON$125.00 PER S.F. Total Project Cost: $ 25� o� FEE: $ Check No.: NOTE: Persons contracReceipt No.: ting wit egistered contractors 4o not have access to the guarantyfund i nature o21 f Agent/Own _ - -- g-, .. . = Signature ofi co7ltractor - Plans Submitted Plans Waived Certified Plot Plan Stamped Plans TYPE OF SEWERAGE DISPOSAL Public Sewer Tanning/Massage/Body Art Swimming Pools Well Tobacco Sales Food Packaging/Sales,- Private ackaging/Sales;Private(septic tank,etc. Permanent Dumpster on Site THE FOLLOWING SECTIONS FOR OFFICE USE-ONLY INTERDEPARTMENTAL SIGN OFF - U FORM DATE REJECTED DATE APPROVED PLANNING & DEVELOPMENT COMMENTS DATE REJECTED DATE APPROVED CONSERVATION COMMENTS ATE REJECTEb REJECTDATE APPROVED 7 HEALTH OMMENTS j . Zoning Board of Appeals: Variance, Petition No: Zoning Decision/receipt submitted yes Planning Board Decision: Comments Conservation Decision: Comments Water & Sewer Connection/Signature & Date Driveway Permit Located at 384 Osgood Street FAREOEP1.0_7ART1. ME`l T hemp Durnpster on Atte. des k r o i ; Located #x��4rtMain Stree# r Fare a artnita. jna ureldate i.. is r Y Y } a 4 s may, n • >... .r:..<. fid, ,,. ....: !'-'.i "}T` . ._..'�.,_.,;. c NORTH -TOLD "/6 q-rO 6 O` yO Y T 0 T O COCwic Mtwrt• 7 ��SSACHUS���� PUBLIC HEALTH DEPARTMENT Community Development Division Sergey Smirnov 190 Farnum Street North Andover, MA 01845 f Date: November 5,2007 Re: 190 Farnum Street" Re: Application to raise the roof that will provide living spaces on 2"d,floor:dormers, windows etc- Dear: tcDear: Mr. Smirnov, The Health Department has received the revised plan of the addition for the property listed above. In addition, Health Department personnel conducted an on-site visit to your home on November 1, 2007. With this new information, your application for the addition has been approved.Please note that this addition is with the following agreed upon conditions. 1) The new 2'd floor area is approved as one entire living space 2) Various sections of wall in the lower level are being removed, resulting in only 2 rooms in the basement. 3) The septic system is at maximum capacity. Any future proposals will result in a zero net increase in room number. For example;to make the single room on the second floor two rooms, the wall between the two small bedrooms may be proposed to be eliminated. A reinspection of the basement area must be requested prior to obtaining a building occupancy approval for the use of the second floor. Thank you for your cooperation in this matter. Please contact the Health Department at 978 490-6678 with any questions. Sincerely, san Sawyer, KbWc Heal irector Cc: Building Department File 1600 Osgood Street,North Andover,Massachusetts 01845 Phone 978.688.9540 Fax 978.688.8476 Web www.townofnorthandover.com a EXISTING BULKHEAD NOV 0 5 2007 TOI EAL�1rl, T��I� E�7EFt O UTILITIES CE , 1 , LL -- II II BASEMENT/FOUNDATION FLAN I/�/ I I t l Q-, REMOVE EXISTING PARTITIONS A5 SHOWN BY DOTTED LINES - LEAVE EXI5TIN6 LALLY COL. IN PLACE =T li II II II II II I II POST EITHER 5IDE FOR NEW HEADER ABOVE I---6'--1 VERIFY ALL DIMENSIONS IN THE FIELD FIRST I L.00R PLAN POST EITHER SIDE FOR NEW HEADER ABOVE P05T EITHER 5IDE ,TYPICA FOR NEW HEADER ABOVE 10't MARTHA MAOINNI5 FROF05EI7) NEW ATTI G FLOOR ENOI NEER: LAWRENCE H. OC DEN PE 58 REGENT AVE. SMIRNOVA RESIDENCE 1ct8 EAST MAIN STREET BRADFORD, MA. 01835 ( 78)3-14-8�I q I cI`O FARNUM STREET O EORO ETOWN, MA. 01555 NORTH ANDOVER, MA. Q'78-352-8318, cell q-78-502-5821 11 Commonwealth of Massachusetts = City/Town of NO. ANDOVER System Pumping Record Form 4 �M DEP has provided this form for use by local Boards of Health. Other forms may be used, but the information must be substantially the same as that provided here. Before using this form, check with your local Board of Health to determine the form they use. The System Pumping Record must be submitted to the local Board of Health or other approving authority. RECEIVED A. Facility Information DEC 0 9 2008 Important: When filling out 1. System Location: forms on the TOWN OF NORTH ANDOVER computer,use 190 FARNUM ST. HEALTH DEPARTMENT only the tab key Address to move your NO. ANDOVER MA 01845 cursor-do not City/Town State Zip Code use the return key. 2. System Owner: SVETTA SMIRNOV Name Address(if different from location) City/Town State Zip Code Telephone Number B. Pumping Record 1. Date of Pumping 11/25/08 2. Quantity Pumped: 1500 Date Gallons 3. Type of system: ❑ Cesspool(s) R/Septic Tank ❑ Tight Tank ❑ Other(describe): 4. Effluent Tee Filter present? ❑ Yes No If yes, was it cleaned? ❑ Yes ❑ No 5. Condition of System: 6. System Pumped By: Benjamin Shute H79 406 Name Vehicle License Number J's Septic& Drain Company 7. Location where contents were disposed: GLSD z. f 11/25/08 e a r Date t5form4.doc-06/03 System Pumping Record•Page 1 of 1 Commonwealth of Massachusetts w City/Town of NO. ANDOVER RECEIVED a System Pumping Record DEC 0 8 2009 Form 4 TOWN OF NORTH ANDOVER DEP has provided this form for use by local Boards of Health. Other for.ns b 898QR6 l- information must be substantially the same as that provided here. Before using this form, check with your local Board of Health to determine the form they use. The System Pumping Record must be submitted to the local Board of Health or other approving authority. A. Facility Information Important: When filling out 1. System Location: forms on the computer,use 190 FARNUM ST. only the tab key Address to move your NO.ANDOVER MA 01845 cursor-do not City/Town state Zip Code use the return key. 2. System Owner: t� SVETTA SMIRNOV Name Address(if different from location) City/Town State Zip Code Telephone Number B. Pumping Record 1. Date of Pumping 11/6/09 2Date . Q antity Pumped: 150Gallo0s 3 .Type of system: El Cesspool(s) Septic Tank ❑ Tight Tank ❑ Other(describe): 4. Effluent Tee Filter present? ❑ Yes No if yes, was it cleaned? ❑ Yes ❑ No 5. Condition of System: 6. System Pumped By: Benjamin Shute H79 406 Name Vehicle License Number J's Septic& Drain Company 7. Location where contents were disposed: GLSD 0 11/6/09 Anarr'e -i6i6r Date t5form4.doc•06/03 System Pumping Record•Page 1 of 1 -C-N Commonwealth of Massachusetts w City/Town of NO. ANDOVER 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 form they use. The System Pumping Reco' -:iMN- ubmitted to the local Board of Health or other approving authority. A. Facility Information ► ta Important: TIS WNIr .'/ When filling out 1. System Location: f ,.h% },M lqR forms on the NT computer,use 190 FARNUM ST. only the tab key Address to move your NO.ANDOVER MA 01845 cursor-do not City/Town State Zip Code use the return key. 2. System Owner: �n SVETTA SMIRNOV Name Address(if different from location) 6' City/Town State Zip Code Telephone Number B. Pumping Record 1. Date of Pumping 10/24/11 2. Quantity Pumped: 1500 Date Gallons 3. Type of system: ❑ Cesspool(s) Septic Tank E3 Tight Tank ❑ Other(describe): 4. Effluent Tee Filter present? ❑ Yes /No If yes,was it cleaned? ❑ Yes ❑ No 5. Condition of System: 6. System Pumped By: James H. Currier H79 406 Name Vehicle License Number J's Septic&Drain Company 7. Location where contents were disposed: GLSD �flts-ems ii 10/24/11 Signature 6f Hauler Date t5form4.doc•06/03 System Pumping Record.Page 1 of 1