HomeMy WebLinkAboutMiscellaneous - 21 APPLETON STREET 4/30/2018 (2)Lot & Street A/ ji. Map/Parcel
11471
CONSTRUCT104 APPROVAL
Has plan review fee been paid
Plan Approval: Date:
Designer: 9 • R • R
Conditions:
NO Permit# %/
Approved by: A, F04,
Plan Date:
Water Sup 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? (:Y3Eb NO
Well Construction Approval? YES NO
Septic System Construction Approval? <�O; NO
Certification? YES NO
Other? YES NO
Any Variance Needed? YES NO
FINAL BOARD OF HEALTH APPROVAL:
DATE:
APPROVED BY:
SEPTIC SYSTEM INSTALLATION
CONDITIONS:
Is the installer licensed? Gz-) NO
Type of Construction: NEW REPAIR
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:
DWC Permit Paid?
DWC Permit # i a
Begin Inspection:
Excavation Inspection:
Needed: X
YES NO
ES NO
Installer:
YES NO
Passed: 6,& D/ By:
Construction Inspection: 1 C
Needed:
As Built Plan Satisfactory:
YES:
Approval of Backfill: Date: g:� Z11L By:/Gf/�LJ
d
Final Grading Approval: Date: By:
Final Construction Approval: Date:. By:
Certificate of Compliance: Approval: Date:
Commonwealth of Massachusetts
u W City/Town of No andover
System Pumping Record
Form 4
�M
City/Town State
Telephone Number
B. Pumping Record
1. Date of Pumping F�7 Date 2. Quantity Pumped:
3. Type of system: ❑ Cesspool(s) Septic Tank ❑ Tight Tank
❑ Other (describe):
4. Effluent Tee Filter present? ❑ Yes Q Nb If yes, was it cleaned? ❑ Yes ❑ No
5. Condition of System:
Zip Code
Gallons
❑ Grease Trap
6. System Pumped By:
Name
Stewart's Septic Service
Company
7. Location where contents were disposed:
Stewart'diP e -treatment Plant. 20 So. Mill Bradfoi
of abler—�
of Receiving Facility
t5form4.doc• 03106
Vehicle License Number
Ma 01835
Date
Date
System Pumping Record • Page 1 of 1
0 CEi'I
SAF .i L t
DEP has provided this form for use by local Boards
T W c�F' NORTH ANDOVER
f �e ,r tba fornsjma be used, but the
information must be substantially the same as that p
ft1ff ere. a ore using, this form, check with your
local Board of Health to determine the form they use.
The System Pumping Record must be submitted to
the local Board of Health or other approving authority within 14 days from the pumping date in
accordance with 310 CMR 15.351.
A. Facility Information
Important: When
filling out forms
1. System Location:
on the computer,
21 Rplleton-&
use only the tab
key to move your
Address
cursor - do not
use the return
No Andover
Ma
key.
City/Town
State Zip Code
2. System Owner:
McClean
Name
'
ream
Address (if different from location)
City/Town State
Telephone Number
B. Pumping Record
1. Date of Pumping F�7 Date 2. Quantity Pumped:
3. Type of system: ❑ Cesspool(s) Septic Tank ❑ Tight Tank
❑ Other (describe):
4. Effluent Tee Filter present? ❑ Yes Q Nb If yes, was it cleaned? ❑ Yes ❑ No
5. Condition of System:
Zip Code
Gallons
❑ Grease Trap
6. System Pumped By:
Name
Stewart's Septic Service
Company
7. Location where contents were disposed:
Stewart'diP e -treatment Plant. 20 So. Mill Bradfoi
of abler—�
of Receiving Facility
t5form4.doc• 03106
Vehicle License Number
Ma 01835
Date
Date
System Pumping Record • Page 1 of 1
Commonwealth of Massachusetts
City/Town of No.Andover
m System Pumping Record
a
1. SVS J
Form 4
DEP has provided this form for use by local Boards of Health. Other forms may' be used, but the
information must be substantially the same as that provided here. Before using this form, check with your
local Board of Health to determine the form they use. The System Pumping Record must be submitted to
the local Board of Health or other approving authority within 14 days from t
accordance with 310 CMR 15.351. 1
A. Facility Information
Important:
When filling out 1. System Location:
forms on the
computer, use
only the tab key
Address
to move your
No.Andover
cursor - do not
_
City/Town
use the return
key.
2. System OW r:
tab
If r
A 10
Name
Gc,/
Address (if different from location)
City/Town
TOWN OF NORTH ANDOVER
#igALTH DEPARTMENT
_ Ma _ 018_4_5
State Zip Code
State
Zip Code
Telephone Number
B. Pumping Record
f
1. Date of Pumping Date 2. Quantity Pumped: G Ions
3. Type of system: ❑ Cesspool(s) Septic Tank ❑ Tight Tank i Grease Trap
❑ Other (describe):
4. Effluent Tee Filter resent? ❑ Yes No If es, was it cleaned? ❑ Yes ❑ No_
p Y
5. Condition of System: �
t Vy 5b
6. Sy u ped By: �-
Na Vehicle License Number
Ste a 's Septic Service
7. Location where contents were disposed:
Stewart's Pre-treatment Plant, 20 So. Mill
Sig
Sig
t5form4.doc• 03/06
iving Facility
Ma 01835
Date
Date
System Pumping Record • Page 1 of 1
ORT.
b i
,,e ; •�, !1'1 Record• 2008
,AUL Q 7
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D�F,has provldad s 14 form for uea by local Boards of apWEArLTMOR7HANp0TER
ba +ubml(led to. tha.local Board of Health or other a ro d =
,';; PP authority,
A. Facility .lntoft'atIon
.1,,rY'rrd11 �9 out • 1..: System Location,
Gi:1ia( po (1PI Gf�"O�.
Slate
j. .l„ r m Owner �� .,_;:'•;..; • • �'.
Ili.4 _14,,00
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' Tolophonv NumOer -
5"Pur ping,Re�ord, ---
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-� � Dah of Pumpin9 '
t ooln Quanury Pumped: —
C IIon)
f Y (] Cesspool(s) eptic 'Tank ❑ TI9
ht Tank
' /Other(descrlbe�
Effl W Tee Fllle ' y'.. •r' , y
(.p(�•sent7 C] Ye o It es
was J 41 J I, Y I cleaned? Yes i nlfa'W�'!}!'•r./}'�`I,rllA.c� sl
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I
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t'.
TOWN OFORTH ANDA
{ t
SYSTEM OVER
VER
3 WING RECORD
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Ate.
.�y
.t �1 lila•'- r'}r,'�#'7rrf! ',
!! +fig �
Vr �
1
e%,q ,►, r 1 � $X$�'EM OWNER & ADD t ..,. , � .. .. ' .. .. . .
' KESS
K' SYSTEM I:,QCATIO
J( �� /(gip /•y/�� � P�� kAlrout of house
pC
•i�iy11j'yT?f ifa yh�'r. rt {f: f: ..•-Tr'. "'�
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y�ry�,lryyr,�p .�� +� rM 1 r {tl �.. .. -
1.ft
F--�nr4 �r„�r•`#• r r
+
r f
y UAN
r � f r ' TITY PUMPED Q� . GALLONS
m R*,;,Y $CC
�► {, $IpN ii�j .�l,�; I h '. it
3 .yr. t i}35 lrt', ,i.
SEPTIC TANK: NO YE
•.t� i µl 1 ra, ', �.�r S
-ibiir. r-SfTLR'r•�r rye{`.by ,I u' 1 e • - �r� A7
r ,�� (,f� I R' r : ,A' 1, i• t .t, .°t ti' t ,_ '' ,
41 + t TIRE OF SERVICE: ROUTINE' rs: ,
r
s i _ INERGENCY
}} ;
�m
r olkl�
OD � CONDITION FULL TO CO
HEAVY GREASE VER
��� ,►�; ; ,+; ;��' Sri` j,�'+ 1 '' •BAFFLES • --�_ ,
ROOTS IN PLACE
t j f
".EXCESSIVE SOLIDS LEACHJULD RUNBACK`SO FLOODED UNBA
SOLID CARRYOVER—•
OTHERNsaa4aN' V` (ExPT . A il►T)
•i }, + �y. a014Ff,**�L��T-ir�`��Zr
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"OWN OF NORTH
UA SYSTEM PUMPING:
SYSTEM OWN ER & ADDRESS
7 -
DATE OFiIJ-Mppqo,
0 0
WSTEM LOCATTOi4
I
-QUANTITY PUMPED:
T NU_
NAWRE OF SERVICE:
YES
0133ERVA'rIONS
GOOD CONDITIONZ--FU TV
LLTOCOVER
HEAVY ORF -ASE BAM13S IN PLACE,
ROOTS LEACHFIELD RUNBACK
EXCESSIVE SOLIDS FLOODED
SOLID CARRYOVER"'7- OTHER EXPLAIN
5yawm Pumped
by ..... .
6.. -LS- v,Af (
.�rlQ.
COMMhNTS.
CUN FEN I'S I"KANSFERUD J�c)
1 'i �' i ? l t 1. ,..•,
• 4 �Nul3 - . •+✓ xy�-,Kts f 7ta'�M�YAi ' 'a h Y � •wn...■u - - - —. � � � ........ w w rr'1 w � ti. V'�'���i-V
'�+bt..+d .; }r� 9!twF� • r� I•�.�.•�r^moi ■ ""�°^-,..
.T,S5rlsYstem
A Pumping R�/1�]
! pp • �Vcbrd '
a
prat: A
JAN 21.2007
DEP has provided this form for use by local Boards of Health t t_he System Pumping Record must
be submitted to the local Board of Health or other, approving auTt�ority: _
r trr ORTH ANDOVF.
, , + OLPARTMENT- ;1
A Facility.,inforniation .
Important -
"n'
n filling out', :;1.::; System location:
forma on the
computer, use
only the tab.key Address
Io move your""
• cunwr - do not •. 1
use the return City/Town State Zip Code'
key :,i, ,.,.., ..,r
2 System Owner
v
NameJI
1 . S i J I'
Address (if different from location)
Citylrown State
f M, a
�• Telephone Number
6. P..umping
Jd + J • 1 Dat@;of Pumping oats 2. Quantity Pumped:
Gallons
3 pe of.system: ❑ cesspool(s) Septic Tank ❑Tight Tank
❑ Other (describe):
Effluent Tee Filter present? El Yes No If yes, was it'cleaned? ❑ Yes 1 ❑ No
5 Condition of:Systgm
em Pumped By
A
-'Name.:tx Vehicle Ucen$e Number
! r4 ynN r+ t�`,�7Q,► t�<LII�/.IWLIl� �J/ /'Yl�/lT/J(/7 i{i//
+ r F.. 1 y�..h rngiYF,iq,vy ! r! •1 � r, 4 ,,. i. ...
7• Locat(onwhere con tentswere. di;3posed:
j
kl Signature of
SystemPumping Record • Page 1 of 1
Date
SystemPumping Record • Page 1 of 1
Town of North Andover, Massachusetts
BOARD OF HEALTH
,ED
A
e° 0APPLICATION FOR SITE TESTING INSPECTION
�q
Applican
Site Locz
Engineer
Form No. 1
19
Test/Inspection Date and Time
s
Fee
—�76
CHAIRMAN, BOARD OF HEALTH
Test No. f -r
S.S. Permit No. D.W.C. No. C.C. Date Plbg. Permit No.
Town of North Andover, Massachusetts
p10RTH Q BOARD OF HEALTH
m
\Ao^ w.oa APPLICATION FOR SITE TESTING/INSPECTION
Form No. 1
19
Applicant'
NAME ADDRESS TELEPHONE
Site Location r�-=;'r���� �• �,
Engineer
NAME iADDRESS TELEPHONE
Test/Inspection Date and Time
i
i
Fee '
CHAIRMAN, BOARD OF HEALTH
S.S. Permit No. D.W.C. No. C.C. Date
Test No
Plbg. Permit No.
f NORTH
O �
A
t
L
Ss�CHU
Town of North Andover, Massachusetts
BOARD OF HEALTH
19
DESIGN APPROVAL FOR
SOIL ABSORPTION SEWAGE DISPOSAL SYSTEM
Applicant—""71
�
Site Location
Reference Pla
Test No.
Form No. 2
Permission is granted for an individual soil absorption sewage disposal system to be installed
in accordance with regulations of Board of Health.
Fee
CHAIRMAN, BOARD OF HEALTH
Site System Permit No. 1 I.
TOWN OF NORTH ANDOVER
HEALTH DEPARTMENT
27 CHARLES STREET
NORTH ANDOVER, MASSACHUSETTS 01845
Sandra Starr
Public Health Director
June 14, 2001
Bob Masys
R.A.M. Engineering
160 Main Street
Haverhill, MA 01830
Re: As -built plan for 21 Appleton Street
Dear Mr. Masys:
Telephone (978) 688-9540
FAX (978) 688-9542
The as -built plan for the above referenced site dated June 12, 2001 has been reviewed and found
to have deficiencies. Please review the attached form, revise your as -built accordingly, and re-
submit it to the Health Department. A complete as -built plan is required before a Certificate of
Compliance from the Health Department can be issued.
Should you have any questions, please feel free to call the office at 978-688-9540.
Sincerely,
Sandra Starr, R.S., C.H.O.
Public Health Director
Cc: Homeowner
Engineer
File
TOWN OF NORTH ANDOVER
HEALTH DEPARTMENT .PAR'TMENT
27 CHARLES STREET
NORTH ANDOVER, MASSACHUSETTS 01845
Sandra Starr
Public Health Director
June 14, 2001
Bob Masys
R.A.M. Engineering
160 Main Street
Haverhill, MA 01830
Re: As -built plan for 21 Appleton Street
Dear Mr. Masys:
Telephone (978) 688-9540
FAX (978) 688-9542
The as -built plan for the above referenced site dated June 12, 2001 has been reviewed and found
to have deficiencies. Please review the attached form, revise your as -built accordingly, and re-
submit it to the Health Department. A complete as -built plan is required before a Certificate of
Compliance from the Health Department can be issued.
Should you have any questions, please feel free to call the office at 978-688-9540.
Sincerely,
I I _', al� �11_121�
Sandra Starr, R.S., C.H.O.
Public Health Director
Cc: Homeowner
Engineer
File