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uardian
Date:
.ccine administered:
n: Date on VIS:
Vaccine lot number:
(8/24/99)
FORM U - IAT RELEASE FORM
INSTRUCTIONS: This form is used to verify that all necessary
approvals/permits from Boards and Departments having jurisdiction
have been obtained. This does not relieve the applicant and/or
landowner from compliance with any applicable local or state law,
regulations or requirements.
****************Applicant.fills out this section*****************
APPLICANT: (-C L <Y_n: Phone LI i'Z_ 4 7Y
LOCATION: Assessor's Map Number (�p( Parcel ` -1
Subdivision
e- Street
Lots)
T-) 'n, no i�J%-;,) St. Number
,- / C
RECOMMN AION OFJq!
AGENTS:
ConservationI ministrator
Comments - A? AAi'��x 5
Town Planner
Comments
Food Inspector -Health
Septic Inspector -Health
Use Only************************
Date Approved
Date Rejected
o4 1/-,P Rep
Date Approved
Date Rejected
Date Approved
Date Rejected
Date Approved
Date Rejected
Comments ��'f� y C'�'.�'i �/? )� T/oiU'
Public Works - sewer/water connections
- driveway permit
(Fire Department
Received by Building Inspector Date
.R aio
APPLICATION FOR S WAGE DISPOSAL INSTALLATION
HEALTH DEPARTMENT - NORTH ANDOVER, MASS.
hereby m applic tion or a permit for a sewage disposal installation at
. I will install this system in ac-
cordance ith all the X6wr, 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 29D. I will install a con-
crete septic tank of /&*-- 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 -;�' 00 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 permit. Plot Plans must be submitted with application.
DATE % - 2-- 7
i - � - a
gnature o Applicant
I hereby issue the above permit for the Board of Health of the Town of North
Andover, Massachusetts.
DATE
Signature ot,'-ftegiih Agent
I have inspected the uncovered system indicated above and find everything done
as describe �
DATE %. %
Percolation
Test C/ e')O�e� '), L��_4 &_X
Garbage Grinder
•
BOARD OF HEALTH
TOWN OF NORTH ANDOVER, MASS.
r- call
'D -150k
I 000
4 -
so
1.
NAME A ���_
�d 1Q f
DATE_ 3 ZgZ7
2.
ADDRESS /—o7- -7
AZ FO A-
5 % LOT NO. 7 TEL . GG
3.
NO. OF BEDROOMS
q
DEN YES NO
4.
GARBAGE GRINDER
YES
NO L_._—
5. SHOW DIMENSIONS OF HOUSE 4---
6. SHOW DISTANCES OF HOUSE TO ALL PROPERTY LINES L_
7. SHOW DIMENSIONS OF LOT e--
8. SHOW LOCATION AND SIZE OF SEPTIC TANK OR CESSPOOL Lam,
9. NOTE LOCATION AND DISTANCE OF WELL FROM SEWERAGE SYSTEM
10. SHOW LOCATION OF BROOKS, STREAMS, DITCHES, LEDGE OUTCROP, ETC, iq& M C
11. SHOW DISTANCE OF SEPTIC TANK OR CESSPOOL FROM HOUSE L,
NOTE: LOCAL REGULATIONS SHOULD BE READ CAREFULLY.
R E E-1 V—E-D—
TOWN 0, NORTH ANDOVE�, NOV .2 2004
1 4-� L
SYSTE7 PUMPINQ RF.CopL) F01 VN,
DA I C0FN
T TH
�i
DJEPA�
SYSTEM OWNER & ADDRESS,
DATE
00 ,
a T Z5 I tM LOCATION
v
PUMPED:
NO--... , SOPOC funk: NO YES \/7
"A PURE OF SERVICE: KOU'rINE..,XEMERUEN(•)-
013SERVATIONS:
GOOD CONDYFI�
FULL
'TC)COVER
HEAVY GREASE BAFFLES IN PLACE.
ROOTS LEA.CKPIP-LDRUNBACK
BXCUSIVE SOLIDS FLOODED
SOLID CARRYOVER, ............ OTHER EXPLAIN . ......
systcm Pumpcd by
5
-7
(,:UMMENTS.
LN I'S f'KANSI`tRUD I'L) 5
9
m
im
V
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BOARD OF HEALTH OF NORTH ANDOVER, MASSACHUSETTS
SEWAGE DISPOSAL
DATE p /�71
NAME OF APPLICANT Barco Ccrporati on
LOCATION Lot#? Bradford at.
Address of lot no.
BUILDING: Dwelling X Other
SYSTEM: New Z Repair
GENERAL DESCRIPTION OF LAND high
SUBSOIL: Clay Gravel Sand C___jA"
PERCOLATION TEST q minutes per inch.
MINIMUM INSTALLATION RECOMMENDATIONS
CONCRETE SEPTIC TANK 10000 gallon capacity.
LEACH FIELDpQ lineal feet of drain pipe.
William J. Dri c 11, Engineer
Board of Healt
_I the undersigned agree to all terms and conditions.
Customer Signature Serviceman (��`
tureof Service
e
ASP Reg. Maint.
❑ N/C - �
� KOEmeMency
ANDOVER SEPTIC PUMPERS ❑ Night
/ ° Se" ��-
PAY FROM THIS SILL -
Customer Name:
f' `�-�`�' ��'� `
P.O. Box 4173 B Station
%' Andover, MA 01810
(508) 475-2593
Professional Septic & Drain
"ice Location:
Phone:`
!' ?` ,/
Contact:
Locally Owned and Operated
Emergency 24 Hr. Svc. — 7 Days
Billing Address:
City:
zip:
Special Instructions
Per:
'.: kcompleted
❑ Incomplete Reason:
AM/PM
Services Rendered
Vacuum Pumping
Observations
Drain Cleaning
d Septic Tank
❑, Good Condition
❑ Main Line
` ❑ Drywell
❑ Leech Pit/ Overflow
1:1 D -Box
- " D Leechfield Runback
❑ Riding High
( h .4 ) v
(liquid level
❑ Toilet Bowl
❑ Kitchen Sink
El Bathtub /Shower
❑ Pump Chamber
El Grease Trap
ElCatch Basin
❑ Portable Toilet
❑ Other
Oty:
Size:
❑ Under 1000 gallonsb�1000 gallons ❑ 1500 gallons
❑ 2000 gallons 0,..3000 gallons ❑ 4000 gallons
❑ 5000 gallons ❑ other
❑ Full to Cover
❑ Excessive Soiids
..
Top / Bottom, j
1:1 Use No Powdered Soap
❑ Heavy Grease
❑ Roots
❑ Suggest Electric
Rootering
❑ Van Called
❑ Other
O Vanity
❑Floor Drain
❑ Yard Drain
[I Vent
❑ Sewer Jet
❑ Other
Footage:
Misc.
❑ Digging Charge
❑ Location An.
❑ Backhoe ❑ Inspection
❑ Consultation hrs.
❑ Certification: P/F
`
r
❑ Service Call
❑ Labor
❑ Estimate Reason:
❑ Portable Toilet Rental ❑ Pump—Repair.-
------------
❑ Waiting Time
E-1Re air
El Baffle p — -_
' Digging Charge Is Per Driver
_____
❑ Chemical Treatment
Discretion
❑ Other
Description of Work"
Recommendations
4. r7., 1
Vacuum Pumping :� Dein Cleanin
P g�
Month Yr. Month
--
Terms of Payment
t q, r.
Parts
Tax
Discount
Terms & Conditions
.JX _
❑ Cash Check ( Credit -
Total
Not responsible for damage beyond curb line. 3. 1.5%per month will be charged to accounts past due.
2. All comDlants shail be reoorted within 48 hours. 4. The purchaser agrees to pay all cost of -collection.
_I the undersigned agree to all terms and conditions.
Customer Signature Serviceman (��`
HUSETTS '`
a%t:?c;���_c4/�n f�•V,(li �i�S�r'+�'.ry*� t: 1'yr;Yli�«,•yy:;;���ii;• . .., v
DER ,has provided thI* 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. lnforntlon
• s rY+!t enrt tant: f4TU: oh
out 1 System•Locatlon:.� .
C tar
ony the tab key Address
to move your :
,.cursor.• do not --'---. ��
.'use the return';;;; CltyRown State
p Code
Y stem Ow r
r
' ' t' + �:, + P/• Name
Address (If different from location) •
Ctty/rown.. State /}
Telephone Number
} B:P,um.ping .Rekord: r.
ljti HGylr+it +fit t Jul,, ry J o -
r«� 1; :Date' of Pum In
P % Date 2. Qu
antJty Pumped:
Gallons
3,!'TYpe qt system . ❑ Cesspools) a tic Tank
-� ❑ Tight Tank
Q'.Other (describe);
4 Effluent Tea Fl,
ter present? ❑ Yes[o\ Ifyes, was It cleaned? ❑ Yesb
Conditlon`of S st
M. ::'•
.Ir •I/ 1.+, T •..rl�lt In J
�. . � .r -�, v j r:6r ++ c!�� t r t r r,.,j,i:i: f�Pt�r,.%;y, ' • � � G')
Pumped By;..
u �i ��=1�k"!•JnF.fea'�f/�¢'�F '}J :11���'j, i, ''t�j�. r,�� •trig'•:• �W�.
.96
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.: '� �} �' 7, Location where contents Were d1oposed:
`.,,:; :•::,.r..,sa'::,.K-:,�,+:;.;.:$IpnatuleOlHaUlef;.�'r,';;,;t.•,,�,,.1 ..,:
httpJ/www.mass.gov/dei 4ii4r/tpp.rovals/tSforms,htm#inspect
t5form4.doa� OQl03 .
)Vehlcle Ucenge Number
Date � `3
System Pumping Record • Page 1 of i