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Commonwealth of Massachusetts -33V \
Title 5 Official Inspection Form DEC 112017
Subsurface Sewage Disposal System Form -Not for Voluntary AssessmentsTOWN OF NORTH ANDOVER
HEALTH DEPARTMENT
2001 Salem Street
Property Address
Isaac Blanchard
Owner's Name
North Andover
City/Town
Ma 01845
State Zip Code
11/15/2017
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. 11
A. General Information
1. Inspector:
Dean Dynan
Name of Inspector
Company Name
2 Suntau4 Street
Company Address
Lynnfield
City/Town
508-726-9935
Telephone Number
B. Certification
Ma
State
S112837
License Number
01940
Zip Code
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
❑ Needs Further Evaluation by the Local Approving Authority
PD
I ector's Signature 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
Owner
information is
required for
every page.
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
2001 Salem Street
Property Address
Isaac Blanchard
Owner's Name
North Andover Ma 01845 11/15/2017
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:
® 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:
4 bed single family dwelling with system in working order
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", "no" or "not determined" (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
Owner
information is
required for
every page.
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
2001 Salem Street
Property Address
Isaac Blanchard
Owner's Name
North Andover Ma 01845 11/15/2017
City/Town 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
Owner
information is
required for
every page.
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
2001 Salem Street
Property Address
Isaac Blanchard
Owner's Name
North Andover Ma 01845 11/15/2017
Cityrrown 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.
❑ 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 '/z day flow
t5ins - 3/13
Title 5 Official Inspection Form: Subsurface Sewage Disposal System • Page 4 of 17
❑ ® 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
W
Title 5
Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
wM
2001 Salem Street
Property Address
Isaac Blanchard
Owner
information is
Owner's Name
required for
North Andover
Ma 01845 11/15/2017
every page.
City/Town
State Zip Code Date of Inspection
B. Certification (cont.)
Yes
No
❑
® 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.
❑
® 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
Owner
information is
required for
every page.
Commonwealth of Massachusetts
W Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
2001 Salem Street
Property Address
Isaac Blanchard
Owner's Name
North Andover
City/Town
C. Checklist
01845
Zip Code
11/15/2017
Date of Inspection
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):
DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x # of bedrooms):
440 GPD
t5ins - 3/13 Title 5 Official Inspection Form: Subsurface Sewage Disposal System - Page 6 of 17
Commonwealth of Massachusetts
W Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
;M 2001 Salem Street
Owner
information is
required for
every page.
Property Address
Isaac Blanchard
Owner's Name
North Andover
City/Town
D. System Information
Description:
4 bedroom single familv dwell
Ma
State
01845 11/15/2017
Zip Code Date of Inspection
1500 gallon tank with infiltrator field 14.2'X 48'
Number of current residents: 3
Does residence have a garbage grinder? ❑ Yes ® No
Is laundry on a separate sewage system? (Include laundry system inspection ❑ Yes ® No
information in ffs report.)
Laundry system inspected? ❑ Yes ❑ No
Seasonaluse? ❑ Yes ® No
Water meter readings, if available (last 2 years usage (gPd))� well water
Detail:
well water
Sump pump?
Last date of occupancy:
Commercial/industrial Flow Conditions:
Type of Establishment:
Design flow (based on 310 CMR 15.203):
Basis of design flow (seats/persons/sq.ft., etc.):
Grease trap present?
Industrial was' � hc!ding tank present?
Non -sanitary �,Jste discharged to the Title 5 system?
Water meter readings, if available:
❑ Yes ® No
occupied
Date
Gallons per day (gpd)
❑ Yes ❑ No
❑ Yes ❑ No
❑ Yes ❑ No
t5ins - 3/13 Title 5 Official Inspection Form: Subsurface Sewage Disposal System • Page 7 of 17
Commonweal,h of Massachusetts
W Title 5 ( Jicial Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
ww 2001 Salem Street
Owner
information is
required for
every page.
Property Address
Isaac Blanchard
Owner's Naic,a
North Angio\ -r Ma 01845 11/15/2017
City/Town State Zip Code Date of Inspection
D. System l;, urmation (cont.)
Last date of occupancy/use: Date
Other ; ser "., ''elow):
General Information
Pumping Records:
Homeowner/ Board of Health
Source of information: tank pumped after inspection / regular service
Was system pumped as part of the inspection? ❑ Yes ® No
If yes, v: 'ume mped:
How ; .a, ''y pumped determined?
Reason f.x p..:,nping:
gallons
Type o s:�-.o:
❑ 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 obtained from system owner) and a copy of latest
spc-cl, on of the I/A system by system operator under contract
❑ i-i;ht tank. Attach a copy of the DEP approval.
Other (describe):
t5ins • 3113 Title 5 Official Inspection Form: Subsurface Sewage Disposal System • Page 8 of 17
Owner
information is
required for
every page.
Commonwealth of Massachusetts
W Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
2001 Salem Street
Property Address
Isaac Blanchard
Owner's Name
North Andover Ma 01845 11/15/2017
Cityrrown State Zip Code Date of Inspection
D. System Information (cont.)
Approximate age of all components, date installed (if known) and source of information:
installed Der plan 2012
Were sewage odors detected when arriving at the site?
Building Sewer (locate on site plan):
Depth below grade: 18
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.):
buildino sewer in good condition no evidence of leaks
Septic Tank (locate on site plan):
Depth below grade:
Material of construction:
® concrete ❑ metal
1500 gallon concrete septic tank
26"
feet
❑ 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
11'X5'8"X5'8"
Dimensions:
6"
Sludge depth:
t5ins - 3/13 Title 5 Official Inspection Form: Subsurface Sewage Disposal System - Page 9 of 17
Owner
information is
required for
every page.
t5ins • 3113
Commonwealth of Massachusetts
W Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
2001 Salem Street
Property Address
Isaac Blanchard
Owner's Name
North Andover
City/Town
D. System Information (cont.)
Septic Tank (cont.)
Ma 01845
State Zip Code
Distance from top of sludge to bottom of outlet tee or baffle
Scum thickness
Distance from top of scum to top of outlet tee or baffle
11/15/2017
Date of Inspection
25"
211-31-
6"
"-3"6"
Distance from bottom of scum to bottom of outlet tee or baffle
16"
How were dimensions determined? infield with measure stick and tape
Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity,
liquid levels as related to outlet invert, evidence of leakage, etc.):
Septic tank should be pumped every 2-3 years depending on number of occupants and usage
Septic tank is in working order inlet and outlet PVC T in good cond
Liquid is at bottom of pipe on outlet line with separation from inlet and outlet
Tank shows no evidence of leakage
Zable filter in tank/ filter was cleaned during inspection
Grease Trap (locate on site plan):
Depth below grade:
Material of construction:
❑ concrete ❑ metal
Dimensions:
Scum thickness
❑ fiberglass
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:
feet
❑ polyethylene ❑ other (explain):
Date
Title 5 Official Inspection Form: Subsurface Sewage Disposal System - Page 10 of 17
Commonwealth of Massachusetts
W Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
2001 Salem Street
Property Address
Isaac Blanchard
Owner
information is
required for
every page.
Owner's Name
North Andover
Ma 01845 11/15/2017
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
D FI
eslgn ow.
gallons per day
Alarm present: El Yes E-1No
Alarm level: Alarm in working order: E-1Yes El 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
�w 2001 Salem Street
Property Address
Isaac Blanchard
Owner Owner's Name
information is
required for North Andover Ma 01845 11/15/2017
every page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
Distribution Box (if present must be opened) (locate on site plan):
Depth of liquid level above outlet invert liquid is at bottom of outlet lines
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.):
Concrete d box / box is level with equal distribution / no evidence of carryover / no evidence of
leakage into or out of box / speed levelers in box
D box is 20" below arade / d box in aood condition
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
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
2001 Salem Street
�M
Property Address
Isaac Blanchard
Owner Owner's Name
information is
required for North Andover Ma 01845 11/15/2017
every page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
Type:
❑ leaching pits
number:
❑ leaching chambers
number:
❑ leaching galleries
number:
❑ leaching trenches
number, length:
® leaching fields
1 @ 48' X 14.2'
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.):
SAS in working condition / no evidence of breakout /
no ponding
SAS located in green grass area with no damp soil and vegitation in good condition
located in sloping lawn area
chambers have a loop vent
Cesspools (cesspool must be pumped as part of inspection) (locate on site plan):
Number and configuration
Depth — top of liquid to inlet invert
Depth of solids layer
Depth of scum layer
Dimensions of cesspool
Materials of construction
Indication of groundwater inflow ❑ Yes ❑ No
l5ins • 3l13 Title 5 Official Inspection Form: Subsurface Sewage Disposal System - Page 13 of 17
Owner
information is
required for
every page.
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
2001 Salem Street
Property Address
Isaac Blanchard
Owner's Name
North Andover
City/Town
D. System Information (cont.)
Ma 01845 11/15/2017
State Zip Code Date of Inspection
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.):
t5ins - 3/13 Title 5 Official Inspection Form: Subsurface Sewage Disposal System • Page 14 of 17
Commonwealth of Massachusetts
W Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
2001 Salem Street
Property Address
Isaac Blanchard
Owner Owner's Name
information is
required for North Andover Ma 01845 11/15/2017
every page. Citylrown 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
t5ins • 3/13 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
;M 2001 Salem Street
Property Address
Isaac Blanchard
Owner Owner's Name
information is
required for North Andover Ma 01845 11/15/2017
every page. CityTTown 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: 60" as per plan on file _
feet
Please indicate all methods used to determine the high ground water elevation:
® Obtained from system design plans on record
If h k d date f Ansi n Ian reviewed
2012
c ec e o g p Date
❑ 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:
checked with health dept plans on file dated 2012
System is a gravity mound
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 Form - Not for Voluntary Assessments
2001 Salem Street
Owner
information is
required for
every page.
Property Address
Isaac Blanchard
Owner's Name
North Andover
City/Town State Zip Code
E. Report Completeness Checklist
11/15/2017
Date of Inspection
® 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
koil
'
H ) 27
O, NORT :1y
•O
Town of North Andover
` ''' ''•'' HEALTH DEPARTMENT
,sSACMU5�4
CHECK #: ; oQ O S DATE:
LOCATION: 2-001
H/O NAME:
CONTRACTOR NAME: Amo-/)
Type of Permit or License: (Check box)
0 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
$
❑ Trash/Solid 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
$
Title 5 Report Q.
$ ��
❑ Other. (Indicate) $
HeaM Agent Initials
White - Applicant Yellow - Health Pink - Treasurer
PUBLIC HEALTH DEPARTMENT
Town of North Andover
Community Development Division
CERTIFICATE OF
COMPLIANCE
As of: 02/26/2013
This is to certify that the individual subsurface disposal system received a
SATISFACTORY INSPECTION of the:
Complete Repair and Construction of an
On -Site Sewage Disposal System
By: Tom Sawyer
At:
2001 Salem Street
Map 34 Lot 2
North Andover, MA 01845
The Issuance of this certificate shall not be construed as a guarantee that the system will function satisfactorily.
Michele Grant
Public Health Agent
y
1600 Osgood Street, North Andover, Massachusetts 01845
Phone 978.688.9540 Fax 978.688.8476 Web www.townofnorthandover.com
WML*
THIS PLAN & CERTIFICATION IS NOT
A WARRANTY OF THE SUBSURFACE DISPOSAL
SYSTEM. IT IS A RECORD OF THE LOCATION
AND ELEVATION OF THE EXISTING SYSTEM
COMPONENTS.
"I HEREBY CERTIFY THE LOCATIONS, ELEVATIONS, TIES, COVER MATERIAL;
EXPOSED COMPONENT COVERS ETC., SHOWN ON THIS AS -BUILT SUBSTANTIALLY
AGREE WITH THE APPROVED PLAN AND HAVE DETERMINED THAT THE BREAK
OUT ELEVATIONS, IF APPLICABLE, HAVE BEEN : MET."
APPROVED DESIGNS PLANS.
�,uGh�i1/r�c—
SIGNATURE OF DESIGNER
LOT 2
(220.498 S.F.)
Ae
0
TZ AS BUILT PLAN
RECEIVED
F Eta 25 2013
TOWN OF NORTH ANDOVER
HEALTH DEPARTMENT
O 30 ee
DA E
I
OF
SUBSURFACE DISPOSAL SYSTEM
LOCATED IN
xoKrx nrmovEx, Mass.
AS PREPARED FOR
GEORGE HASELTINE TM: ioa
DATE: 8-30-12 TL: 2
SCALE: 1"=40'
0 20 ao eo
�'RRIMACK ENGINEERING SERVICES
66 PARK STREET
ANDOVER, MASSACHUSETTS 01810
I
r�.
NOR7M
0�,�.�an �•1ti0
t �wNaYy��ti� s
��aS�cHus t�'
PUBLIC HEALTH DEPARTMENT
Community Development Division
TOWN OF NORTH ANDOVER
SEPTIC DISPOSAL SYSTEM — INSTALLATION CERTIFICATION
The undersigned hereby certify that the Sewage Disposal System (, constructed; ( ) repaired;
By: !haw �( E&2f
(Print Name)
Located at: G% f✓j 6TE-zp'�r
(Installation Address)
REC1§ EV p
Ed 25 2013
TOWN OF NORTH ANDOVER
HEALTH DEPARTMENT
Was installed in conformance with the North Andover Board of Health approved plan, originally dated
1Z and last revised on , with a design flow of
gallons per day. The materials used were in conformance with those specified on the
approved plan; the system was installed in accordance with the provisions of 310. CMR 15.000, Title 5 and local
regulations, and the final grading agrees substantially with the approved plan. All work is accurately represented on
the As -built which has been submitted to the Board of Health.
Bottom of Bed Inspection Date: 6--7;7_ j -,7-
P%
-,7-
P%ILli PaFIZE-�Pue�
And — Print Name �}
Final Construction Inspection
&'L" 994_ t"3-vE
And — Print Name
Installer: / (Signature)
Enginer: (1401a AG/%r 4(MV (Signature)
Engineer Representative (Signature)
Engineer Representative (Signature)
Date: 9 /a 6113
And — Print Name
Date: M
And — Print Name
1600 Osgood Street, North Andover, Massachusetts 01845
Phone 978.688.9540 Fax 978.688.8476 Web http://www.townofnorthandover.com
North Andover Health Department
Community Development Division
ONSITE WASTEWATER SYSTEM CONSTRUCTION NOTES
LOCATION INFORMATION
ADDRESS: 2001 Salem Street MAP: 34 LOT: 2
INSTALLER: Tom Sawyer
DESIGNER: Merrimack Engineering Services
PLAN DATE: 3/26/12
REVISED DATE: 8/8/12
BOH APPROVAL DATE ON PLAN: 5/1/12
INSPECTIONS
TANK INSPECTION: 8/15/12
DATE OF BED BOTTOM INSPECTION:
DATE OF FINAL CONSTRUCTION INSPECTION:
DATE OF FINAL GRADE INSPECTION:
SITE CONDITIONS
Comments:
SEPTIC TANK
❑ Contractor reports any changes to design plan
❑ Existing septic tank properly abandoned
❑ Internal plumbing all to one building sewer
❑ Topography not appreciably altered
❑ Building sewer in continuous grade, on
compacted firm base
❑ Cleanouts per plan
X Bottom of tank hole has 6" stone base
Weep hole plugged
❑ 1500 gallon tank has been installed
loading
X Monolithic tank construction (tank 16' from
house)
❑ Water tightness of tank has been achieved by
f
Comments:
PUMP CHAMBER
Comments:
CONTROL PANEL
Comments:
DISTRIBUTION -BOX
Comments:
❑ Inlet tee installed, centered under access port
❑ Outlet tee installed, centered under access port
(gas baffle/effluent filter)
❑ inch cover to within 6" of final grade
installed over one access port
❑ Hydraulic cement around inlet & outlet
❑ Bottom of tank hole has 6" stone base
❑ Weep hole plugged
❑ 1500 gallon Pump Chamber installed
❑ loading
❑ Monolithic tank construction
❑ Inlet tee installed, centered under access port
❑ Pump(s) installed on stable base
❑ Alarm float working
❑ Pump On/Off floats working
❑ Separate on/off floats
❑ Drain hole in pressure line
❑ cover at final grade installed over pump
access port
❑ Water tightness of tank has been achieved by
testing
❑ Hydraulic cement around inlet & outlet
❑ Alarm & Pump are on separate circuits
❑ Alarm sounds when float is tripped
❑ Location of control panel: basement
❑ Alarm signal located inside: basement
❑ Installed on stable stone base
❑ H-20 D -Box
❑ Inlet tee (if pumped or >0.08'/foot)
❑ Hydraulic cement around inlet & outlets
❑ Observed even distribution
❑ Speed levelers provided (not required)
SOIL ABSORPTION SYSTEM (General)
X Bottom of SAS excavated down to C soil layer,
as provided on plan
X Size of SAS excavated as per plan 58'x25'
❑ Title 5 sand installed, if specified on plan
❑ 40 Mil HDPE barrier installed
❑ Laterals installed and ends connected to
header (and vented if impervious material
above)
❑ Elevations of laterals and chambers installed as on
approved plan
❑ Retaining wall (boulder / concrete / timber/ block)
❑ Final cover as per plan
Comments:
SOIL ABSORPTION SYSTEM (Gravel -less Chambers)
❑ Brand and Model of Chamber: Standard Quick
4 Infiltrator Chambers
❑ Number of chambers per row:
❑ Number of rows (trenches):
Comments: Total Chambers =
FINAL GRADE
x Loamed?
x Seeded?
❑ Cover per plan?
Comments:
DOCUMENTS NEEDED
Certification of Installation Form submitted
By engineer and signed and dated by
Engineer and installer
A As -Built Plan
BM =
HR=
HI =
SYSTEM ELEVATIONS
ROD AS -BLT INVERT DESIGN INVERT
ELEVATION ELEV ELEV
Benchmark
Building Sewer OUT
Septic Tank IN
Septic Tank OUT
Pump Chamber IN
Pump Chamber OUT
Distribution Box IN
Distribution Box OUT
Lateral 1 TOP
Lateral 1 INVERT
Lateral 2 TOP
Lateral 2 INVERT
Lateral 3 TOP
Lateral 3 INVERT
Lateral 4 TOP
Lateral 4 INVERT
Lateral 5 TOP
Lateral 5 INVERT
Lateral 6 TOP
Lateral 6 INVERT
Top of Chamber
Bottom of Bed/Chamber
SKETCH PLAN
CRITICAL SETBACK DISTANCES
Mark those distances checked in the field against the design plan and regulatory
setback
1 Suction line 222(2)
2 100 feet is a minimum acceptable distance and no variance is allowed for a lesser distance (NA 5.02).
3 As defined in 310 CMR 10.55, 10.32, 10.54, and 10.30, respectively, pursuant to 15.211(3), also by NA
wetland bylaws
Tank
SAS Sewer
®
Property line
10
10 --
®
Cellar wall
10
20 --
®
Inground pool
10
20 --
®
Slab foundation
10
10 --
®
Deck, on footings, etc
5
10 --
Waterline
10
10 101
®
Private drinking well
75
1002 50
®
Irrigation well
75
100
®
Surface Water
25
50
®
Bordering Vegetated Wetland ,
Salt Marsh, Inland / Coastal Banka
75
100
®
Wetlands bordering surface
water supply or trib. (in Watershed)
150
150
®
Trib. to surface water supply
325
325
®
Public well
400
400
®
Interim Wellhead Prot. Area
®
Reservoirs
400
400
®
Drains (wat. supply/trib.)
50
100
®
Drains (intercept g.w.)
25
50
®
Drains (Other) Foundation
10 (5)
20 (10)
®
Drywells
20
25
1 Suction line 222(2)
2 100 feet is a minimum acceptable distance and no variance is allowed for a lesser distance (NA 5.02).
3 As defined in 310 CMR 10.55, 10.32, 10.54, and 10.30, respectively, pursuant to 15.211(3), also by NA
wetland bylaws
Commonwealth of Massachusetts Map -Block -Lot
BOARD OF HEALTH ---------------------
Permit No
North Andover BHP -2012-0707
-----------------------
FEE
$250.00
-----------------------
DISPOSAL WORKS CONSTRUCTION PERMIT
Permission is hereby granted William T. Sawyer
to (Construct) an Individual Sewage Disposal System.
at No 2001 SALEM STREET
as shown on the application for Disposal Works Construction Permit No. BHP -2012-070 Date_ ugust 14, 2012
Issued On: Aug -14-2012
----------- BOARD OF HEALTH
:+ r
Important:
When filling out
forms on the
computer, use
only the tab key
to move your
cursor - do not
use the return
key.
rd
1�1
- Application for Septic Disposal System
rConstruction Permit — TOWN OF
ORTH ANDO
Applicalign is hereby made fora permit to:
Construct a new on-site sewage disposal system*
❑ Repair or replace an existing on-site sewage disposal system*
❑ Repair or replace an existing system component — What?
A. Facility Information
Address or Lot # JbQL Z6r 0, ;Q U I o ani S f `
City/Town Q JQr
2.- *TYPE OF SEPTIC SYSTEM*:
❑ Pump [Gravity (choose one)
***If pump system, attach copy of electrical permit to application***
TODAY'S DATE
$ 250.00 — Full Repair
$125.00 - Component
❑ Conventional System (pipe and stone system)
❑ Infiltrator or Biodiffuser (Gravel -Less) (Attach a copy of your certification to install this type of system.
❑ Pressure Distribution S.A.S. (No D -Box) (Attach Draft Maintenance Agreement)
❑ Pressure Dosed (D -Box Present) S.A.S.
2. owner Information
Name
Address (if different from above)
City/Town State Zip Code
Telephone Number
3. Installer Information
Name Name of Company
Pd.
Address
City/Town State Zip Code
.0/?!? - 3 i(,D - 7 g 3 a
Telephone Number (Cell Phone # if possible please)
4. Desi ner Information
4 /, �/
Ine l'l yi4d
Name Name of Company
Address
City/Town State Zip Code
Telephone Number (Best # to Reach)
Application for Disposal System Construction Permit • Page 1 of 2
C
J�
N�T� 'Application for Septic Disposal System
�TODAY'S DATE
$ 250.00 — Full Repair
$125.00 - Component
PAGE 2OF2
A. Facility Information continued....
5. Type of Building: ['Residential Dwelling or ❑Commercial
B. Agreement
The undersigned agrees to ensure the construction and maintenance of the afore -described
on-site sewage disposal system in accordance with the provisions of Title 5 of the
Environmental Code, as well as the Local Subsurface Disposal Regulations for the Town of
North Andover, and not to place the system in operation until a Certificate of Compliance has
been issued by this Board of Health.
Name Date
Application Approved By: (Board of Health Representative)
Name Date
Application Disapproved for the following reasons:
For Office Use Only:
Z Fee Attached.
2. Project Manager Obligation Form Attached?
3. Pump System? If so, Attach copy ofElectrical Permit
4. Foundation As -Built? (new construction ronly).
(Same scale as approved plan)
5. Floor Plans? (new construction only):
Yes
Yes
Yes
No
No
No
No
No
Application for Disposal System Construction Permit • Page 2 of 2
'SEPTIC SYSTEM INSTALLER PROJECT MANAGEMENT OBLIGATIONS
As the North Andover licensed installer for the construction for the septic system for the property at:
4'0r a gag/ le S r /�
(Address of septic system) For plans by r (Engineer) neer) L.�
/�&*V -&Wder
Relative to the application of 1 `
(Installer's name) �- And dated
(Original ate
Dated
(I o ay sdate) /
With revisions dated
I understand the following obligations for management of this project:
(Last revised date)
1. As the installer, I am obligated to obtain all permits and Board of Health approved plansrp for 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 manager, 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 Title 5 and the Board of Health Regulations may result in a $50.00 fine being levied against me and/or
my company.
a. Bottom of Bed — Generally, this is the first (1'� inspection unless there is a retaining wall, which
should be done first. The installer must request the inspection but does not have to be present.
b. Final Construction Inspection — Engineer must first do their inspection for elevations, ties, etc.
As -built of verbal OK (or e-mail to: healthdept a&townofnorthandover.com) from the engineer must
be submitted to the Board of Health, after which installer calls for an inspection time. Installer must
be present for this inspection. With a 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. Installer does not
have to be on-site.
4. As the installer, I understand that only I may perform the work (other than simple excavation) and I am required
to complete the installation of the system identified in the attached application for installation. I further
understand that work done by others unlicensed to install seltic systems in 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, p pes, stone, vent, pump chamber, retaining wall and other
components.
As the installer, I understand that I am solely responsible for the installation of the system as per the
approved No instructions by the homeowner, general contractor, or any other persons shall absolve
me of this obligation.
Undersigned Licensed Septic Installer:
(Today's Date) 0/9/19,
ame —Print) (Name — igneq
TOWN OF NORTH ANDOVER
N°R Tot
f
Office of COMMUNITY DEVELOPMENT AND SERVICES 3r -`' '• °��
HEALTH DEPARTMENT
1600 OSGOOD STREET; BUILDING 20; SUITE 2-36
NORTH ANDOVER, MASSACHUSETTS 01845
978.688.9540 — Phone
Susan Y. Sawyer, REHS/RS
978.688.8476— FAX
Public Health Director E-MAIL: healthdevtatownofnorthandover.com
WEBSITE: http://www.townofnorthandover.com
SEPTIC PLAN SUBMITTAL FORM
Date of Submission: j— �-' -- 12' -
Site
?j
Site Location: -&00 1 � l�( y` el j
New Plans? Yes V / $225/Plan Check # Z (includes I't submission and one re-
review only)
Revised Plans?Yes $75/Plan Check #/
Site Evaluation Forms Included? Yes V No
Local Upgrade Form Included? /USA Yes No
Telephone #:h:70 7G Fax #: l cl 0
E-mail:
Homeowner
Name:
OFFICE USE ONLY
When the submission is complete (including check):
➢/ Date stamp plans and letter
➢ l/ Complete and attach Receipt
➢ Copy File; Forward to Consultant
➢ Enter on Log Sheet and Database
7� r/ N t"C/
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Commonwealth of Massachusetts'
City/Town of North Andover
- Percolation Test
Form 12
Observation Hole #
Depth of Perc
Start Pre -Soak
End Pre -Soak
Time at 12"
Time at 9"
Time at 6"
Time (9"-6")
Rate (Min./Inch)
William Dufresne
Test Performed By:
Isaac Rowe Mill River
Witnessed By:
Comments:
7-8-11
Date
P-3
Percolation test results must be submitted with the Soil Suitability Assessment for On-site Sewage
45"
Disposal. DEP has provided this form for use by local Boards of Health. Other forms may be used, but
9:53
the information must be substantially the same as that provided here. Before using this form, check with
10:10
the local Board of Health to determine the form they use.
Important:
A. Site Information
When filling out
forms on the
computer, use
George Haseltine
only the tab key
Owner Name
to move your
2001 Salem Street
cursor - do not
Street Address or Lot #
use the return
key.
-
North Andover MA 01845
City/Town State Zip Code
(603) 785-8768
Contact Person (if different from Owner) Telephone Number
B. Test Results
Observation Hole #
Depth of Perc
Start Pre -Soak
End Pre -Soak
Time at 12"
Time at 9"
Time at 6"
Time (9"-6")
Rate (Min./Inch)
William Dufresne
Test Performed By:
Isaac Rowe Mill River
Witnessed By:
Comments:
7-8-11
Date
P-3
10 am
Time
45"
9:53
10:10
10:10
11:03
12:11
68
23
Test Passed:
Test Failed:
❑
7-8-11 10 am
Date Time
P-4
45"
9:51
10:08
10:08
10:31
10:56
25
9
Test Passed:
Test Failed: ❑
t5fonn12.doc• 06/03 Perc Test • Page 1 of 1
OF NORT/� qti
m
o �
5
q& CH13
North Andover Health Department
Community Development Division
April 2, 2012
Vladimir Nemchenok
Merrimack Engineering Services
66 Park Street
Andover, MA 01810
Re: Subsurface Sewage Disposal System Plan for 2001 Salem Street, Man 108A, Lot 2, Sub Lot 2
Dear Mr. Nemchenok:
The proposed wastewater system design plan for the above site dated February 17, 2012 and
received on March 14, 2012 has been reviewed. Unfortunately, the plan cannot be approved
until the following items are corrected. The specific section in Title 5: 310 CMR 15.000, or
tNorth Andover regulation that is not met by this design follows each item.
1. Please provide the location of the abutting property wells and wastewater systems to
confirm adequate setbacks distances have been met — 310CMR15.211
,,""'2. Please depict the waterline location between the proposed dwelling and proposed well —
310CMR15.211
3 Please provide the location of benchmarks within 50'-75' of the proposed wastewater
system. It is understood that this is proposed new construction and true benchmarks
might have not yet been set, but please provide at the least elevations of an existing fixed
location on the site plan — 310CMRI5.220(4)(q)
4. Please provide a riser over the distribution box to within 6" of final grade —
310CMR15.221(13), 228(l),232(3)
Please specify the placement of washed pea stone and double washed stone, respectively,
below and above the distribution piping in the leach trenches — 310CMR15.247(1) and
(2)
6. Specify the removal of the B soil horizon and replacement with appropriate sand fill or
please perform a percolation test in the B soil horizon as it is more restrictive than the C
soil horizon where the percolation tests were performed, 310CMR15.104(2)
Page 1 of 2
North Andover Health Department, 1600 Osgood Street, Building 20, Suite 2-36,
North Andover, MA 01845 Phone: 978.688.9540 Fax: 978.688.8476
Ip
Please feel free to contact the office with any questions you may have. We look forward to
working with you to obtain a wastewater treatment and dispersal system which will be in
compliance with all regulations and assure protection of public health and the environment of
North Andover.
Sincerely,
Susan Y. SawyeZ,S
Public Health Director
cc: File
Page 2 of 2
North Andover Health Department, 1600 Osgood Street, Building 20, Suite 2-36,
North Andover, MA 01845 Phone: 978.688.9540 Fax: 978.688.8476
MERRIMACK ENGINEERING SERVICES, INC.
PROFESSIONAL ENGINEERS LAND SURVEYORS PLANNERS
66 PARK STREET • ANDOVER, MA 01810 • (978) 475-3555, 373-5721 • FAX (978) 475-1448 • E-MAIL info@merrimackengineering.com
Susan Sawyer
Director of Public Health
1600 Osgood Street
Building 20, Suite 2-36
North Andover, MA 01845
RE: 2001 & 2005 Salem Street.
Dear Ms. Sawyer,
The plans submitted and reviewed for the above referenced sites were done so as a
"PROOF" plan and for the purpose of demonstrating that a conventional system could be
constructed in accordance with the requirements of Title 5. Although your final
comments have not been addressed, we feel that this requirement has been met and we
are submitting new design plans utilizing Infiltrator Chambers as an alternative design
and as the systems intended to be installed.
Please review these designs as the final designs for construction approval. Any comments
that were made as part of the original review, which are pertinent to this design, have
been made.
We appreciate your prompt attention to this matter.
Yours truly,
I
Bill Dufresne, Pa4:r
ager
MERRIMACK ENGINEERING SERVICES
ashoba Analyti
31A Willow Road, Ayer MA 01432
Client:
Skillings and Sons, Inc.
9 Columbia Drive
Amherst, NH 03031
LLC Tel: 978-391-4428 Fax: 978-391-4643 LabNumber: 127878
Website: http:Uwww.NashobaAnalytical.eom
Certificate of Analysis
22134-Haseltine, George 001 Salem Street . Andover, MA 01845
Parameter Method Result MCL
- At Wellhead
Sampled: 4/1812012 2:00.00 PM by John Gove
Total Coliform Bacteria,/100ML MF-SM9222B
Arsenic, Total, MG/L
SM 3113B
Calcium, MG/L
EPA 200.7
Copper, MG/L
EPA 200.7
Iron, MG/L
EPA 200.7
Lead, MG/L
SM 31138
Magnesium, MG/L
EPA 200.7
Manganese, MG/L
EPA 200.7
Potassium, MG/L
EPA 200.7
Sodium, MG/L
EPA 200.7
Alkalinity, MG/L
SM 2320B
Ammonia, MG/L
SM 4500-NH3-D
Chloride, MG/L
EPA 300.0
Chlorine, Free Residual, MG/L
SM 4500 -CL -G
Color Apparent, CU
SM 21208
Conductivity, UMHOS/CM
SM 251 OB
Fluoride, MG/L
EPA 300.0
Hardness, Total, MG/L
SM 2340B
Nitrate as N, MG/L
EPA 300.0
Nitrite as N, MG/L
EPA 300.0
Odor, TON
SM 2150B
pH, PH AT 25C
SM 4500 -H -B
Sediment, pos/neg
--- -`
Sulfate, MG/L
EPA 300.0
Total Dissolved Solids, MG/L
SM 2540C
Turbidity, NTU
EPA 180.1
Use this number with ail correspondence
ReportDate: 4/26/2012
MRL Date of Analysis Analyst
0
0/Absent
0
4/20/2012 1:00:00 PM
M-MAI118
0.002
0.01
0.001
4/23/2012
M-MAI118
33.8
Not Spec
1
4/23/2012
M-MA1118
ND
1.3
0.01
4/23/2012
M-MA1118
0.08
0.3
0.01
4/23/2012
M-MA1118
ND
0.015
0.001
4/23/2012
M-MAI118
5.5
Not Spec
1
4/23/2012
M-MA1118
# 0.056
0.05
0.005
4/23/2012
M-MA4118
ND
-Not Spec
1
4/23/2012
M-MAI118
6.4
See Note
1
4/23/2012
M-MA1118
115
Not Spec
1
4/20/2012
M' -MAI 118
ND
Not Spec
0.1
4/20/2012
M-MA1118
2.5
250
1
4/20/2012
M-MAI118
ND
Not Spec
0.02
4/20/2012
M-MAI118
2
15
1
4/20/2012
M-MAI118
260
Not Spec
1
4/20/2012
M-MA1118
0.2
4
0.1
4/20/2012
M-MA1118
107
Not Spec
2
4/23/2012
M-MA1118
ND
10
0.05
4/20/2012
M-MA1118
ND
1
0.01
4/20/2012
M-MA1118
0
3
0
4/20/2012
DLK
7.6
6.5-8.5
NA
4/20/2012
M-MA1118
NEG
---
NEG
4/20/2012
DLK
11.5
250
1
4/20/2012
M-MAI118
158
500
1
4/24/2012
M-MA1118
1.9
Not Spec
0.1
4/20/2012
M-MA1118
MCL=Maximum Contaminant Level (EPA Limit), MRL = Minimum Reporting Level
Sodium Guidelines- Mass 20, EPA 250, # = Result Exceeds Limit or Guideline
ND = None Detected (<MRL), * = Background Bacteria Noted
Massachusetts Certified
Laboratory #MA1118
David L. Knowlton
Laboratory Director Page 1 of 1
`DelleChiaie, Pamela
From: DelleChiaie, Pamela
Sent: Wednesday, May 02, 2012 1:24 PM
To: Sawyer, Susan
Subject: FW: Well Applications - 2001 and 2005 Salem Street, North Andover
From: Brian Castora jmailto:bcastora@)skillingsandsons.com)
Sent: Wednesday, May 02, 2012 1:18 PM
To: DelleChiaie, Pamela
Subject: Re: Well Applications - 2001 and 2005 Salem Street, North Andover
I'll get that to you when I get back into the office this afternoon
----- Original Message -----
From: DelleChiaie, Pamela<pdellechp_townofnorthandover.com>
To: Brian Castora
Cc: Sawyer, Susan <ssawyer ,townofnorthandover.com>
Sent: Wed May 02 13:15:03 2012
Subject: FW: Well Applications - 2001 and 2005 Salem Street, North Andover
Hi Brian,
Just following up to see if you have the well testing results and the completed applications for 2001 and 2005 Salem Street. The
owner wants to acquire the building permit, and needs to have this information in order to do so. Your soonest response is
appreciated. If you could scan and send the information back to me via email, that would be great. Thank you for your assistance.
Pamela DelleChiaie
Health Department
Town of North Andover
1600 Osgood Street I Bldg. 20 1 Suite 2-36
North Andover, MA 01845
Phone 978.688.9540
Fax 978.688.8476
Email pdellechiaiektownofnorthandover.com <mailto:pdellechiaie@townofnorthandover.com>
Web www.TownofNorthAndover.com <hqp://www.TownofNorthAndover.com>
From: q)elleChiaie, Pamela
,Sent: Monday, April 09, 2012 2:02 PM
To: 'bcastora@skillingsandsons.com'
Cc: 'GEORGE.HASELTINE@GMAIL.COM; Bill Dufresne (wrdufresne@comcast.net)
Subject: Well Applications - 2001 and 2005 Salem Street, North Andover
Importance: High
Hello Brian,
Attached are the well applications signed off by Susan. Please fill in the remaining information required when complete, and submit a
copy back to us. Thank you.
Pamela DelleChiaie
Health Department
Town of North Andover
1600 Osgood Street I Bldg. 20 1 Suite 2-36
North Andover, MA 01845
Phone 978.688.9540
Fax 978.688.8476
Email pdellechiaie@townofnorthandover.com <mailto:cbellavance@townofnorthandover.com>
Web www.TownofNorthAndover.com<hqp://www.TownofNorthAndover.com>
Please note the Massachusetts Secretary of State's office has determined that most emails to and from municipal offices and officials
are public records. For more information please refer to: hn://www.sec.state.ma.us/pre/preidx.htm.
Please consider the environment before printing this email.
,DelleChiaie, Pamela
From: DelleChiaie, Pamela
Sent: Wednesday, May 02, 2012 1:24 PM
To: Sawyer, Susan
Subject: Riemitis Radio - 1140 Osgood Street
http://riemitisradio.com/
Looks like a cool store - they have quite a variety of products.
Edward J Riemitis Inc
Tweet 1148 Osgood St
North Andover, MA 01845
(978)682-3572
View Website»
See More: CitySearch
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Phone Service I Telephone Companies I Directory &z Guide Advertising
12
North Andover Health Department
Community Development Division
May 2, 2012
George Hazeltine
66 Gilcrest Rd.
Londonderry, NA03053
RE: Subsurface Sewage Disposal System Plan for 2001 Salem Street Map 108A lot 2
subdivision lot 2, North Andover Massachusetts
Dear Property Owner,
The North Andover Board of Health has completed the review of the septic system design plans,
for the above referenced property, submitted on your behalf by Merrimack Engineering Services,
dated March 26, 2012. The design has been approved for use in the construction of a new onsite
septic system for a four bedroom design at 440 gallons per day. This plan is good for 3 -years
from the date of approval.
During this time, a licensed septic system installer must obtain a permit and complete this work,
and a Certificate of Compliance be endorsed by the installer, designer and the Town of North
Andover.
This approval is also subject to the following conditions:
1. Prior to the issuance of the building permit the potable well reports must be
submitted.
2. Prior to the issuance of the Disposal Works Installers Permit, the applicant must
submit a foundation as -built at the same scale as the approved plan.
3. Prior to the issuance of the Disposal Works Installer's Permit, the applicant must
submit the floor plans of the home showing no greater than four bedrooms or a total
of nine rooms.
Page 1 of 2
North Andover Health Department, 1600 Osgood Street, Building 20, Suite 2-36,
North Andover, MA 01845 Phone: 978.688.9540 Fax: 978.688.8476
: 2001 Salem Street May 2, 2012
4. If site conditions are found in the field to be different from those indicated on the
design plan and/or soil evaluation, the originally issued Disposal System Construction
Permit is void, installation shall stop, and the applicant shall reapply for a new
Disposal Systems Construction Permit (3 10 CMR 15.020(1)).
5. It is the responsibility of the applicant and/or the applicant's septic system designer,
septic system installer or other representative to ensure that all other state and
municipal requirements are met. These may include review by the Conservation
Commission, Zoning Board, Planning Board, Building Inspector, Plumbing Inspector
and/or Electrical Inspector. The issuance of a Disposal System Construction Permit
shall not construe and/or imply compliance with any of the aforementioned
requirements.
Your effort to provide a properly functioning septic system for your dwelling is greatly
appreciated. The Health Department may be reached at 978-688-9540 with any questions you
might have.
Sincere' ,
l
Su Y. Sawy ` , REHS/
Pu 6c Healti irector
cc: Vladimir Nemchenok, Merrimack Engineering
file
Page 2 of 2
North Andover Health Department, 1600 Osgood Street, Building 20, Suite 2-36,
North Andover, MA 01845 Phone: 978.688.9540 Fax: 978.688.8476
BUILDING PERMIT
TOWN OF NORTH ANDOVER
APPLICATION FOR PLAN EXAMINATION
Permit NO: Date Received
TYPE OF IMPROVEMENT
PROPOSED USE
Residential
Non- Residential
ew Building
;B ne family
El Addition
El Two or more family.
❑Industrial
❑ Alteration
No. of units:
Q Commercial
❑ Repair, replacement
❑ Assessory Bldg
❑ Others:
❑ Demolition
❑ Other
'Septic =,iVeli t
Flobdplain ; `> Ul/etlands f
`Watershed District
f
rnMQf1010T1nM nG WnRK TO RF PREFORMED.
Please Type or Print Clearly)
OWNER: Name:
e: 6019 766- ee
Address: 46 Gi�CPPG�T R �a� �%- 6�0
t Y
CONTRACTOR Name
assh
` ? 4 i r
SuP�ruisor.'s Construction L�censexp f
f l F
5 E L Date
S.
Home 1r p,mvement License,
ARCHITECT/ENGINEER Pa -F RnS� �i?ns� �r�trr�� 'hone: �OO
Address:
Reg. No
FEE SCHEDULE: BOLDING PERMIT: $12.00 PER $9000.00 OF THE TOTAL ESTIMATED COST BASED ON $125.00 PER S.F.
Total Project Cost: $ FEE: $
Check No.: Receipt No.:
NOTE: Persons contracting with agegistered contractors do not have access to the
fund
Plans Submitted ❑ Plans Waived ❑ Certified Plot Plan ❑ Stamped Plans ❑
TYPE OF SEWERAGE DISPOSAL
Public Sewer ❑
Tanning/Massage/Body Art ❑
Swimming Pools 0
Well
Tobacco Sales ❑
Food Packaging/Sales ❑
Private (septic tank, etc.
Permanent Dumpster on Site ❑
THE FOLLOWING SECTIONS FOR OFFICE USE ONLY
INTERDEPARTMENTAL SIGN OFF --U FORM
PLANNING & DEVELOPMENT ❑
COMMENTS
CONSERVATION
COMMENTS
DATE REJECTED
DATE APPROVED
DATE REJECTED DATE APPROVED
IN
DATE REJECTED DATE APP OVED
HEALTH ❑ ����� z -
COMMENTS „ /� _ %.�_ �� _ 1
Zoning Board of Appeals: Variance, Petition No: Zoning Decision/receipt submitted yes
Planning Board Decision:
Conservation Decision:
Comments
Comme
Water & Sewer Connection Driveway Permit
Located at 384 Osgood Street
FIRS; DEPI�RTMENT Temp Durnpste on site des
..no
Located at 124 Mam Street -
Ftre Department signature/date F,
A
.n
DelleChiaie, Pamela
From: Sawyer, Susan
Sent: Tuesday, August 14, 2012 3:34 PM
To: Grant, Michele; DelleChiaie, Pamela/
Subject: 7'
bottom of bed request 4,vaemtr—eet
Mr. Sawyer is ready with a BOB and has requested an inspection for Hazeltine's Sa for Wed AM ... I think.
He has requested sand for Wed AM, however please ck with Tom before you go way out there to be sure the sand has
arrived... It is way too far to go and waste time.
thx
978 360-7832
Susan
Susan Sawyer
Public Health Director
Town of North Andover
1600 Osgood Street
Bldg. 20, Unit 2035
North Andover, MA 01845
Phone 978.688.9540
Fax 978.688.8476
Email mailto:ssawver@townofnorthandover.com
Web www.TownofNorthAndover.com
Please note the Massachusetts Secretary of State's office has determined that most emails to and from municipal offices and officials are public records. For more
information please refer to: htto://www.sec.state.ma.us/ore/i)reidx.htm.
Please consider the environment before printing this email.
Grant, Michele
From: Grant, Michele
Sent: Wednesday, August 29, 2012 9:43 AM
To: 'plally@millriverconsulting.com'; 'Isaac Rowe'; 'Randy Burley'; 'dano@millriverconsulting.c(
Subject: 2001 Salem Str Lot 1
Hi All,
FYI .... 2OO1 Salem Lot 1, is ready for Final Construction Inspection.
Thank you
Michele E. Grant
Public Health Agent
Town of North Andover
1600 Osgood St I Suite 2035
North Andover, MA 01845
Phone 978.688.9540
Fax 978.688.8476
Email mgrant0townofnorthandover.com
Web www.TownofNorthAndover.com
Blackburn, Lisa
From: Sawyer, Susan
Sent: Tuesday, November 06, 2012 11:32 AM
To: Blackburn, Lisa
Cc: Kellett, Jim; 'JoAnn'; Lee, Joyce; Keane-Dowley, Lauren; wrdufresne@comcast.net
Subject: RE: Request for Placement on Docket for Next Meeting
Lisa,
Could you please add 554 Foster Street to the agenda for the BOH meeting to be held on November 15, 2012; Hall, 120
Main Street.
Thank you
Susan
JoAnn Runions will be representing the owner.
the meeting begins at 7PM on the second Floor of the Town Hall
From: JoAnn [mailto:jmrunionsO)comcast.net]
Sent: Monday, November 05, 2012 5:12 PM
To: Sawyer, Susan
Cc: Kellett, Jim; Lee, Joyce; Keane-Dowley, Lauren; wrdufresne(a)comcast.net
Subject: Request for Placement on Docket for Next Meeting
Hello Susan,
As a follow up to a conversation with Jim Kellett today, I am requesting to be added to the docket for the next meeting
with the conservation board.
We are requesting permission for an out of season permit, weather permitting, to install a new septic system at 554 Foster
Street, North Andover.
I am speaking on behalf of my mother, Elizabeth Andrukaitis, for whom I have Power of Attorney. Since my father had
passed, my mother had been maintaining her home but she is no longer able to do so. She is now a resident at Academy
Manor in Andover with dementia. Unfortunately, in order to maintain her medical bills for long term care expenses due to
Alzheimer's, we are forced to sell the property. The house currently has a failed septic system and I have contracted with
Jim Kellett to install a new system which would enable us to sell the home and generate the revenue that is now needed
for my mother's continued care.
Your attention to my request would be greatly appreciated.
Kind regards,
JoAnn Runions POA for Elizabeth Andrukaitis
H: 978-688-2342
W: 978-975-9135
Please note the Massachusetts Secretary of State's office has determined that most emails to and from municipal offices and officials are public records. For more
information please refer to: htto://www.sec.state.ma.us/ore/oreidx.htm.
Please consider the environment before printing this email.
EIVED
hAY — 4 LG12
71u 1'5.
TOWN OF NOR$tMM
HEALTH D,EFpQRWdR
TOWN OF NORTH ANDOVER
01, fl ,YI, Ak
ffice of COMMUNITY DEVELOPMENTAND SERVICES
HEALTH DEPARTMENT
1.600 OSGOOD STREET; BUILDING 20; SUITE 2-36
•�q ~ iia++°
NORTH ANDOVER, MASSACHUSETTS 01845
IIEIIS/RS 978.688.9540 – Phone
•ector 978.688.8476 – FAX
healthcleptgto«ntofn orthandover, com
n,Nvkv.townof iiortllandover, corn
Well and/or Pmun ) Application
(Please—print)
DANT:
LOCATION t Drill Wcll a�• install a plunp:t
Licensed Well Contractor Name and Company Name:
r"
Homeowner:_
Address:
O ,36,E
Contact Phone Numbers:
WELLS (to be completed at time of pump test) r f, ,
Type ofwcll: Use:
Diameter of well:___ Size of Casing; �_
r /
Depth of bedrocic:...._.__.1.. _ _... —_ ..._...._._..._____....... ..... Depilr of casing into bedrock:_ 12 — .
.......
sent bceu tesled? Yes ( ) No ( ) Date of test:..,__ � 2
Depth of well: � yQ \vatcr-bearing rock;_ZZ • �� yQ `yZ� �� �e��
/ // -7—`_
Depth of water: _-� Delivers: GPtl for:_EAbi'e S
Z 31'1' �/ / �,
(11011' 1011g)
Drawdown feet after pumping: 271 1 "V hours at:—�—>__GPii
Date of Completion;__ Z l f
Sig�."Weil Contractor
PUMPS (To be filled ire beef�o�re�instnlintion)
Name & size of Pump: (!(.d1lL�_3/y Type:
Size of Tank: -_3S` ,��� Pump delivers:_ _- 7—__GPM
Pipe used ill Weil; Cast Iron__ Galvanized Plastic
Sleeve used to protect pipe? Yes_ No Type of well scRi jbi/e
Date: V_��r? f c��a�f
Signature of Pump (nstailer _-� --
Date watel analysis repo"( submitted to Health Department: L(p-% f
-
g 1Yirin Inspector --
$ l Health Departmr,zt"Representative
C:A.Documeuts and Set619s\pdellecl1Wy Documents\COMMERCIAL PERml TS\Per'mit\Permit Applications\Well
Application.doc
DelleChiaie, Pamela
From: Brian Castora [bcastora@skillingsandsons.com]
Sent: Wednesday, May 02, 2012 3:39 PM
To: DelleChiaie, Pamela
Cc: Sawyer, Susan
Subject: RE: Well Applications - 2001 ad 2005 alem Street, North Andover
Attachments: 4120_001.pdf; 127878-2001 S orth Andover MA.pdf; 127880-2005 Salem St North
Andover MA.pdf
Pam,
Please find attached well application and water test results for Salem St. I also mailed in a copy of each well application. If you need anything
further please let me know.
Thanks,
Brian Castora
Project Manager
Skillings & Sons Inc.
9 Columbia Dr.
Amherst NH 03031
local # (603)-459-2600
toll free 1-800-441-6281
cell# (603)-235-7646
e-mail bcastoraCcD-skillingsandsons.com
website www.skillinasandsons.com
Bringing water well technology to a whole new level
From: DelleChiaie, Pamela jmailto:pdellech@townofnorthandover.com]
Sent: Wednesday, May 02, 2012 1:15 PM
To: Brian Castora
Cc: Sawyer, Susan
Subject: FW: Well Applications - 2001 and 2005 Salem Street, North Andover
Importance: High
Hi Brian,
Just following up to see if you have the well testing results and the completed applications for 2001 and 2005
Salem Street. The owner wants to acquire the building permit, and needs to have this information in order to
do so. Your soonest response is appreciated. If you could scan and send the information back to me via email,
that would be great. Thank you for your assistance.
Pamela DelleChiaie
Health Department
Town of North Andover
1600 Osgood Street I Bldg. 20 I Suite 2-36
North Andover, MA 01845
Phone 978.688.9540
Fax 978.688.8476
Email Pdellechiaie@townofnorthandover.com
Wer www.TownofNorthAndover.com
From: DelleChiaie, Pamela
Sent: Monday, April 09, 2012 2:02 PM
To: 'bcastora@skillingsandsons.com'
Cc: 'GEORGE. HASELTINE@GMAIL.COM'; Bill Dufresne (wrdufresne(a comcast.net)
Subject: Well Applications - 2001 and 2005 Salem Street, North Andover
Importance: High
Hello Brian,
Attached are the well applications signed off by Susan.
complete, and submit a copy back to us. Thank you.
Pamela DelleChiaie
Health Department
Town of North Andover
1600 Osgood Street I Bldg. 20 1 Suite 2-36
North Andover, MA 01845
Phone 978.688.9540
Fax 978.688.8476
Email pdellechiaiePtownofnorthandover.com
Web www.TownofNorthAndover.com
Please fill in the remaining information required when
Please note the Massachusetts Secretary of State's office has determined that most emails to and from municipal offices and officials are public records. For more
information please refer to: http://www.sec.state.ma.us/pre/preidx.htm.
Please consider the environment before printing this email.
'R I Massachusetts Department of Environmental Protection
Bureau of Resource Protection
I
WELL DRILLER
Please specify work performed: st+ca'�vi�V Address at well location:
—�� 2001__.__. �
Please specify well type: Building Lot#:
--� TOWN OF NORTH ANDOVER �
Domestic HEALTH DEPARTMENT
Assessor's Lot#:
New Well
GPS
Street Number:
Street Name:
North:
MAiL�, LU1Z
SALEM ST
71.05071
Subdivision/Property/Description:
Assessor's Map #:
Mailing Address:
r click here if same as well location address
Property Owner:
Street Number:
Street Name:
GEORGE HASELTINE66
GILCREAST RD
ZIP Code:
Number Of Wells:
State:
I
01845
MASSACHUSETTS
ZIP Code:
03053 j
City/Town:
Well Location
NORTH ANDOVER
In public right-of-way:
GPS
i
Yes ��
North:
West:
12.63680
71.05071
Subdivision/Property/Description:
Mailing Address:
r click here if same as well location address
Property Owner:
Street Number:
Street Name:
GEORGE HASELTINE66
GILCREAST RD
City/Town:
State:
Engineering Firm:
LONDONDERRY
MASSACHUSETTS
ZIP Code:
03053 j
Board of health permit obtained:
Yes (' Not Required
Permit Number: J
Date Issued:
_....._____ ___.1
i
4/5/2012 �.......��
.f A4
Massachusetts Department of Environmental Protection
Bureau of Resource Protection —Well Driller Program
Well Completion Reports (General)
Well Driller - General Well Form
DRILLING METHOD
Overburden Bedrock
!Air Hammer ;Air Hammer
WELL LOG OVERBURDEN LITHOLOGY
From To(ft) Code Color Comment Drop in Extra fast or slow Loss or addition of
(ft) drill stem drill rate fluid
Boulders ;Brown Yes r Fast i Siova �� Loss (_ Addition
WELL LOG BEDROCK LITHOLOGY
From
(ft) To(ft) Code
Granite —m
Z iti Granite
Granite
s v 167 Gneiss
its LO j (Granite
ADDITIONAL WELL INFORMATION
Developed % Yes No
Comment Drop in Extra fast or slow Loss or addition of
drill stem drill rate fluid
............
r �
t- Y
Ye
�4 GPM
j r Ye
2 GPM
Disinfected
Total Well Depth X440 Depth to Bedrock
Fracture
Surface Seal Tyre 'None Enhancement
Fast (` Slow f Loss f Additionl
( {` Fast r slow ( Lcss Addition.
c _
r Fast —r Siow r Loss r Addition
r Fast C slow f Loss r Addition
r Fust C Slow L f ILoss Addition
rr..Yes...... No
r Yes No
Visible
Rust
Staining
E Ye
—, ,
Iff Ye.
F Yesj
Ye
[E;]
CASING IS Casing above ground?) From: 1.5 To: F0
From To Type Thickness Diameter Driveshoe
Steep
SCREENNo Scree
From To Type Slot Size Diameter
- Choose Screen Type --- E::---
_.. _.._...............
L
WATER -BEARING ZONES DRY WELD
From To j �Y;ield (gpm)
_-
' 322 i._.._ _._....._-- .l
PERMANENT PUMP (IF AVAILABLE)
Extra
Large
Chips
r Ye.
r Yes
EE,
r Ye
Ye.
Massachusetts Department of Environmental Protection
Bureau of Resource Protection — Well Driller Program
Well Completion Reports(General)
'i
i
12 Wire Constant Speed
Pump Description { Horsepower
Submersible _ 3/4 � T
Pump Intake Depth (ft) 400 Nominal Pump Capacity (gpm)
ANNULAR SEAL / FILTER PACK
Water
From To Material 1 Weight Material 2 Weight(gal)
Batches Method Of Placement
jNative Material ? Choose Material —� Gravity
WELL TEST DATA
Time
Pumping
Time To
Recovery (ft
Date Method Yield (gpm) Pumped
Level (ft
Recover
BGS)
(HH:MM)
BGS)
(HH:MM)
c3; � I :Air Blow With Drill Stem (E7C):30
i4i 00
?G:{'O j
20.f3
WATER LEVEL
Date Measured Static Depth BGS (ft) Flowing Rate (gpm)
-+i20;i2t `.2
COMMENTS
WELL DRILLERS STATEMENT
This well was drilled or altered under my direct supervision, according to the applicable rules and regulations, and this report is complete a
knowledge.
Driller ';JUSTINSKILLINGS-- Registration # 546 Monitoring [M] i Supervising Drill
Firm SKILLINGS & SONS, IN! Rig Permit # 006 Date Job Compl
NOTE: Well Completion Reports must be filed by the registered well driller within 30 days of well completion.
'moo
03)
D7
7 5,, \3
4
95,,,61'
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