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HomeMy WebLinkAboutMiscellaneous - 2163 TURNPIKE STREET 4/30/2018` ' rx ~ ~~ ' ^/� M�� / LOT # ' �.4-^/ ` PARCEL STREET __... ........ ... _ J»Z/ . C_.-T.-_�-_^�APPROVAL /q� HAS PLAN REVIEW FEE BEEN PAID? PLAN APPROVAL: DATE�PP. BY .. . `^ DESIGNER: PLAN DATE .' CONDITIONS ' ` __... ... .......... .... ........... .. . WATER SUPPLY: TOWN ^ ' WELL PERMIT ����/ ^x DRILLER .` ........ --_--_-__--- .......... ... ... ...... - ' ' WELL TESTS: CHEMICAL DAlE APPRUVED . ' ` . BACTERIA I DA�E APPRUVEQ . BACTERIA II DAlE APPROVED _.... ----------- ------ _ COMMENTS: ' - F[JRM U APPROVAL: APPROVAL TO ISSUE NO DATE ISSUED CONDITIONS: FINAL APPROVAL: ALL PERMITS PAID NO WELL CONSTRUCTION APPROVAL YES NO SEPTIC SYSTEM CONSTRUCTION APPROVALNO ___ OTHER YES NO ANY VARIANCE NEEDED YES NO FINAL BOARD OF HEALTH APPROVAL: DAlE: __ _ _BY: ° I ,� :• SEPTI.G.__�YS�EM__�.NS..T._9.4.h.A-Z�..QN. IS THE•INSTALLER LICENSED? YES NO ;._. TYPE. OF CONSTRUCTION: NEW REPAIR NEW CONSTRUCTION: CERTIFIED PLOT PLnN REVIEW YES 1,10 CONDITIONS OF APPROVAL YES NU -(FROM FORM U) ISSUANCE OF DWC PERMIT YES NO DWC PERMIT N0. 6X-1 INSTALLER:_/ %M BEGIN .INSPECTION _ YES 0: EXCAVATION ..INSPECTION : NEEDED: PASSED. if L7_�zBY -----------� ----�__------- CONSTRUCTION INSPECTION: NEEDED: L/NZu , fJY -D-BQX AS BUILT PLAN SATISFACTORY: YES: APPROVAL TO BACKFILL: DATE: FINAL GRADING APPROVAL: DATE BY FINAL CONSTRUCTION APPROVAL: DATE:_____.___.©Y___.______ I 77b -G77 Town of North Andover o, NORTH i*6D " Community Development and Services Division o? •" < -Office of the Health Department ` .� 400 OSGOOD STREET • °, ,�;,�,�. `,s" North Andover, Massachusetts 01845 Susan Y. Sawyer, REHS/RS Public Health Director Date: (978) 688-9540 - Phone (978) 688-9542 - Fax Address: , North Andover, MA 01845 Re: Application for: Dear: Your application for at has been reviewed by the Health Department. The application was denied on, 2004 for the following reasons: 1. ❑ Missing information 2. ❑ Passing Title 5 inspection of septic system required 3. ❑ Location of structure not acceptable 4. ❑ Undersized septic system To address the problem(s): If #1 Is checked, please supply: a. Floor plan of existing and proposed addition - all rooms b. Certified plot plan showing house, septic system and proposed project in scale If #2 is checked: a. Have the septic system inspected by a certified Title 5 inspector to determine the size of the system and whether it is operating properly: OR b. Tie-in to municipal sewer If #3 is checked: a. Relocate the project If #4 is checked: a. Provide additional information proving that the existing septic system meets current capacity requirements. Please consult an engineer to determine the flow capacity of the septic system. Please feel free to call the Health Office at 978-688-9540 with any questions you may have. Sincerely, Reviewer Cc: Building Department File BOARD OF APPEALS 688-9541 BUILDING 688-9545 CONSERVATION 688-9530 NURSE 688-9543 PLANNING 688-9535 AS -BUILT CHECK LIST and FINAL INSPECTION Proposed Elevations House 9,0 ` Tank IN a q ' 8� Tank OUT '69 , �D D -box IN 89I J-9- D -box OUT 511, 3,::57 - Trench ,::57 - Trench Inverts Line 1 8 C/ Line 2 Line 3 Line 4 Bottom of Exc. Stone OK? D -box checked? As -Built Elevation Pipes cemented? ,.r ,. -RIF t �- -8 ,. FORM_ U LOT 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:f��s� �`e� Phone 696-7,2-6F LOCATION: Assessor's Map Number Parcel 7 Subdivision , Lot(s) 7 Street .211&3�7 1&3 /u r•1P%fie 5'� St. Number 2/63 Use Only************************ RECO TIO S F AGENTS: Date Approved 20 7 ConservatioA Admi istrator Date Rejected Comments 01"..; 1280 ` iA qi, W r Date Approved Town Planner Date Rejected Comments Date Approved Food r -Health Date Rejected Date Approved ptic Inspector -Health Date Rejected Comments Public Works - sewer/water connections - driveway permit Fire Department Received by Building Inspector. Date COMMONWEALTH OF MASSACHUSETTS EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS DEPARTMENT OF ENVIRONMENTAL PROTECTION TITLE 5 OFFICIAL INSPECTION FORM — NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM PART A CERTIFICATION Property Address: Jr Owner's Name: Owner's Address: Date of Inspection: Name of Inspector: (please print 111 I U/ V t nG Company Name:C� Mailing Address: S • S _• .tea /93,S - 7W 93 ,-- Telephone Number:g 7 - 3"��— r%V? CERTIFICATION STATEMENT I certify that I have personally inspected the sewage disposal system at this address and that the information reported below is true, accurate and complete as of the time of the inspection. The inspection was performed based on my training and experience in the proper function and maintenance of on site sewage disposal systems. I am a DEP approved system inspector pursuant to7Se ion 15.340 of Title 5 (310 CMR 15.000). The system: i/ Passes Inspector's Signa Approving Authority The system inspector shalysubmit a copy of this inspection report to the Approving Authority (Board of Health or DEP) within 30 days of &mpleting this inspection. If the system is a shared system or has a design flow of 10,000 gpd or greater, the inspector and the system owner shall submit the report to the appropriate regional office of the DEP. The original should be sent to the system owner and copies sent to the buyer, if applicable, and the approving authority. Notes and Comments ****This report only describes conditions at the time of inspection and under the conditions of use at that time. This inspection does not address how the system will perform in the future under the same or different conditions of use. Title 5 Inspection Form 6/15/2000 page I Page 2 of 11 �`. OFFICIAL INSPECTION FORM — NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM w PART A CERTIFICATION (continued) Property Address: (l) / rn . ,� , Owner(' -1 b )1 J'11�.r Date of Inspection: Inspection Summary: Check A,B,C,D or E / ALWAYS complete all of Section D A. System Passes: _ZI have not found any information which indicates that any of the failure criteria described in 310 CMR 15.303 or in 310 CMR 15.304 exist. Any failure criteria not evaluated are indicated below. Comments: B. System Conditionally Passes: One or more system components as described in the "Conditional Pass" section need to be replaced or repaired: The system, upon completion of the replacement or repair, as approved by the Board of Health; will pass. Answer yes, no or not determined (Y,N,ND) in the for the following statements. If "not determined" please explain. The septic tank is metal and over 20 years old* or the septic tank (whether metal or not) is structurally unsound, exhibits substantial infiltration or exfiltration or tank failure is imminent. System will pass inspection if the existing tank is replaced with a complying septic tank as approved by the Board of Health. *A metal septic tank will pass inspection if it is structurally sound, not leaking and if a Certificate of Compliance indicating that the tank is less than 20 years old is available. ND explain: Observation of sewage backup or break out or high static water level in the distribution box due to broken or obstructed pipe(s) or due to a broken, settled or uneven distribution box. System will pass inspection if (with approval of Board of Health):., broken pipe(s) are replaced obstruction is removed distribution box is leveled or replaced ND explain: The system required pumping more than 4 times a year due to broken or obstructed pipe(s). The system will pass inspection if (with approval of the. Board of Health): ND explain: broken pipe(s) are replaced obstruction is removed 2 all Page 3 of 11 OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address-cLz - 70, -?,7 OwnerL2QQ / Date of Inspection: , z C. Further Evaluation is Required by the Board of Health: Conditions exist which require further evaluation by the Board of Health in order to determine if the system is failing to protect public health, safety or the environment. 1. System will pass unless Board of Health determines in accordance with 310 CMR 15.303(1)(b) that the system is not functioning in a manner which will protect public health, safety and the environment: _ Cesspool or privy is within 50 feet of a surface water Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh 2. System will fail unless the Board of Health (and Public Water Supplier, if any) determines that the 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 coliform bacteria and volatile organic compounds indicates that the well is free from pollution from that facility and the presence of ammonia nitrogen. and nitrate nitrogen is equal to or less than 5 ppm, providedthatno other failure criteria are triggered. A copy of the analysis must be attached to this form. , 3. Other: 3 Page 4 of l I OFFICIAL INSPECTION FORINT — NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: C-2/ 6 3 OwneL-:706 .)1A Date of Inspection: 4-::0 D. System Failure Criteria applicable to all systems: You must indicate "yes" or "no" to each of the following for all inspections: Yes Z.Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool iDischarge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool ,4t �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''/2 day flow equired 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. -Ze Any portion of cesspool or privy is within 100 feet of.a surface water supply or tributary to a surface water supply. f -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. -i Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality analysis. [This system passes if the well water analysis, performed at a DEP certified laboratory, for coliform bacteria and volatile organic compounds indicates that the well is free from pollution from that facility and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis must be attached to this form.] / V w�0 (Yes/No) 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: Tolbe considered a large system the-syste i must serve a facility with a design flow of 10,000 gpd to 15,000 gpd• You must indicate either "yes" or "no" to -each of the following: (The following criteria apply to large systems in addition to the criteria above) yes no the system is within 400 feet of a surface drinking water supply _ ^ the system is within 200. feet of a tributary to a surface drinking water supply the system is located in a nitrogen sensitive area (Interim Wellhead Protection Area - IWPA) or a napped 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. 4 : Page 5 of 11 OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST Property Address='Wa Iff1' Owne : 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 J%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 ? _ZHave 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) Y Was the facility or dwelling inspected for signs of sewage back up ? Was the site inspected for signs of break out _(Z Were all system components, excluding the SAS, located on site ? f 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 ? _Aeo' Was the facility owner (and occupants if different from owner) provided with information on the proper maintenance of subsurface sewage disposal systems? The size and location of the Soil Absorption System (SAS) on the site has been determined based on: Yes no _+/r_ 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) [3 10 CMR 15.302(3)(b)] 5 i Page 6 of I 1 OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION Property 1AddresstJ �I/�%i%) ��-�✓J Ownet• /V Date of Inspection: LOW CONDITIONS RESIDENTIAL Number. of bedrooms (design): Number of bedrooms (actual)_ S DESIGN flow based on 310 CMS 15.203 (for example: 110 gpd x # of bedrooms): Number of current residents: pC. Does residence have a garbage grinder (yes or no): N Is laundry on a separate sewage system (yes or no)V_o [if yes separate inspection required] Laundry system inspected (yes or no): Seasonal use: (yes or no)H o Water meter readings, if available (last 2 years usage (gpd)): Sump pump (yes or no): 4,�_Q Last date of occupancy:0r 6 j a t C COMMERCIAL/INDUSTRIAL Type of establishment: Design flow (based on 310 CMR 15.203): gpd Basis of design flow (seats/persons/sgft,etc.): Grease trap present (yes or no): _ Industrial waste holding tank present (yes or no): _ Non -sanitary waste discharged to the Title 5 system (yes or no): — Water meter readings, if available: Last date of occupancy/use: OTHER (describe): GENERAL INFORMATION Pumping Records Source of information: �,%5/ � VS Was system pumped as part of a inspection (yes or no)Ve If yes, volume pumpedj%�gallons -- How was uan rty pumped determined? Reason for pumping: f /J 5 00 r T Ir p.: s r TYP F SYSTEM Septic tank, distribution box, soil absmtptiam 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) Tight tank , Attach a copy of the. DEP approval _ Other (describe): Appro ate age of all comp9nents, date installed (if known) and source of information: Were sewage odors detected when arriving at the site (yes or no)A&) Page 7 of 11 x OFFICIAL INSPECTION FORM — NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: Gi/ /r/7 Owner Date of Inspection: f BUILDING SEWER (locate on site plan) q ti Depth below grade: / p _ Materials of construction:L.-fast iron _40 PVC _other (explain):. Distance from private water supply well or suction line: Comments (on condition of joints, venting, evidence of leakage, etc.): SEPTIC TANK:ocate on site plan) Depth below grade-&L— Material of construction: _concrete _metal _fiberglass polyethylene _other(explain) If tank is metal list age: _ Is age confirmed by a Certificate of Compliance (yes or no): _ (attach a copy of certificate) Dimensions: 5 x- – SC X /G Sludge depth: _�F_'(' n Distance from top of sledge to bottom of outlet tee or baffle: Scum thickness: 3 41 rr Distance from top of scum to top of outlet tee or baffle: Distance from bottom of scum to bottom of outlet tee or baffle: How were dimensions determined: r p,0 122ea 5-,l r Comments (on pumping recommendations, ml�outlet tee or baffle condition, structural integrity, liquid levels as r1jaWd to outlet invert, evid-11, a of leakage, etc.): Z2 ,v nj / GREASE TRAP: _(locate on site plan) Depth below grade: Material of construction: _concrete metal'_ fiberglass __polyethylene _other (explain): Dimensions: Scum thickness: Distance from top of scum to top of outlet tee or baffle: Distance from bottom of scum to bottom of outlet tee or baffle: Date of last pumping: Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): 7 Page 8 of 11 OFFICIAL INSPECTION FORM — NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C // SYSTEM INFORMATION (continued) Property Address• /z4G!/r7/9//6 S/— Owner . . Date of Inspection: Z TIGHT or HOLDING TANK: (tank must be pumped at time of inspection)(locate on site plan) Depth below grade: Material of construction: concrete metal fiberglass _polyethylene other(explain): Dimensions: Capacity: gallons Design Flow: gallons/day Alarm present (yes or no): Alarm level: Alarm in working order (yes or no): Date of last pumping: Comments (condition of alarm and float switches, etc.): DISTRIBUTION BOX: V(if present must be opened)(locate on site plan) Depth of liquid level above outlet invert: JQ_ 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.): 0 6 �! N 6 -sol i d Lya f t' r01 PUMP CHAMBER: (locate on site plan) Pumps in working order (yes or no): Alarms in working order (yes or no): Comments (note condition of pump chamber, condition of pumps and appurtenances, etc.): 8 Page 9 of 11 OFFICIAL INSPECTION FORM — NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C �j /G / �j SYSTEM INFORMATION (continued) Property Address: O` �oJ7a—ff19 Nitl/_.tJUr" Date of Inspection: , SOIL ABSORPTION SYSTEM (SAS): (locate on site plan, excavation not required) If SAS not located explain why: Type leaching pits, number: leaching chambers, number: eaching galleries, number: , leaching trenches, number, length: I AJ leaching fields, number, dimensions: overflow cesspool, number: innovative/alternative system Type/name of technology: Comments (note condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of vegetation, 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 or no): Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): PRIVY: (locate on site plan) Materials of construction: Dimensions: Depth of solids: Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): 1 9 Page 10 of 11 OFFICIAL INSPECTION FORINT — NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM'INFORMATION (continued) Property Address: r !� 1 •�/ Owner: Date of Inspection: — d SKETCH OF SEWAGE DISPOSAL SYSTEM Provide a sketch of the sewage disposal system including ties to at least two permanent reference landmarks or benchmarks. Locate all wells within 100 feet. Locate where public water supply enters the building. f �cve�l 10 ... .. � .i. ♦...,yam-"�-i... :��,_�. Y ..rte "`.---` .., .4.. �. -.w.N ._.. _.`.__i_ -. � ,...�-. ,,Y. v .__.. , ` .. _ ._. __. r i^+ * Page i l of 1 I OFFICIAL INSPECTION FORM — NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM .� PART C SYSTEM INFORMATION (continued) Property Address:c;� Owner Date of Inspection: SITE EXAM Slope Surface water Check cellar Shallow wells Estimated depth to ground water 2 feet 5\ Please indicate (check) all methods used to determine the high ground water elevation: Obtained from system design plans on record - If checked, date of design plan reviewed:0 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: Yog.4must describe ho!g you established the high ground water _ S 7' e rk /Z4a G( 2_1 f c r a , L WILLIANI F. WELD Goyerrno: ARGEO PAUL CELLUCCI Lt. Govemor COMMONWEALTH OF MASSACHUSETTS EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS DEPARTMENT OF ENVIRONMENTAL PROTECTION ONE WINTER STREET. BOSTON. AIA 02108 617-292-5500 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION Property Address: c� f �3 Q�'.AlLAddress of Owner: Date of Inspection: c��— ab— (If different) Name of Inspector: Ne " 15- rues 1 am a DEP appy ved system ins ectgr pursuant tom Section 15.340 of Title S (310 CMR. 15.000) Company Name: Y, -k A Mailing Address: t t; t - Telephone Number: TRUDY COXE Sccrctary DAVID B. STRUHS Commissioner CERTIFICATION STATEMENT I certify that I have personally inspected the sewage disposal system at this address and that the information reported below is true, accurate and complete'as of the time of inspection. The inspection was performed based on my training and experience in the proper function and maintenance of on-site. sewage disposal systems. The system: _ Passes _ Conditionally Passes Needs F rther Evaluation By the Local Approving Authority Fai Q P� /^ O!F Inspector's Signature: �'t'— Date: (� The System Inspector shall submit a cop f this inspection report to the Approving Authority within thirty (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 Department of Environmental Protection. The original should be sent to the system owner and copies sent to the buyer, if applicable, and the approving authority. INSPECTION SUMMARY: Check A, B, C, or D: A] SYSTEM PASSES: ave not found any information which indicates that the system violates any of the failure criteria as defined in 310 CMR 15.303. Any failure criteria not evaluated are indicated below. COMMENTS: r BI 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. Indicate yes, no, or not determined (Y, N, or ND). Describe basis of determination in all instances. If "not determined", explain why not. _ The septic tank is metal, unless the owner or operator has provided the system inspector with a copy of a Certificate of Compliance (attached) indicating that the tank was installed within twenty (20) years prior to the date of the inspection; or the septic tank, whether or not metal, is cracked, structurally unsound, shows substantial infiltration or exfiltration, or tank failure is imminent. The system will pass inspection if the existing septic tank is replaced with a conforming septic tank as approved by the Board of Health. (rovived 04/25/97) Pago 1 of 20 DEP on the World Wide Web: Attp:/M vAv.magnetstate.ma.usidep {fj Pnnted on Recycled Paper SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: Owner: a1 n n Date of Inspection. 6 B] SYSTEM CONDITIONALLY PASSES (continued) Sewage backup or breakout or high static water level observed in the distribution box is due to broken or obstructed pipe(s) or due to a broken, settled or uneven distribution box. The system will pass inspection if (with approval of the Board of Health). Describe observations: broken pipe(s) are replaced - obstruction is removed distribution box is levelled or replaced . The system required pumping more than four times a year due to broken or obstructed pipe(s). The system will pass inspection if (with approval of the Board of Health): . broken pipe(s) are replaced obstruction is removed Cl 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 the public health, safety and the environment. 1) SYSTEM WILL PASS UNLESS BOARD OF HEALTH DETERMINES THAT THE SYSTEM IS NOT FUNCTIONING IN A MANNER • WHICH WILL PROTECT THE PUBLIC HEALTH AND SAFETY AND THE ENVIRONMENT: Cesspool or privy Is within 50 feet of a surface water Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh. 2) SYSTEM WILL FAIL UNLESS THE BOARD -Of HEALTH (AND PUBLIC WATER SUPPLIER, IF APPROPRIATE) DETERMINES THAT THE SYSTEM IS FUNCTIONING IN A MANNER THAT PROTECTS THE PUBLIC HEALTH AND SAFETY AND THE ENVIRONMENT: _ The system has aseptic tank and soil absorption system (SAS) and the SAS is within 100 feet to a surface water supply or tributary to a surface water supply. _ The system has a septic tank and soil absorption system and the SAS is within a Zone 1 of a public water supply well. The system has a septic tank and soil absorption system and the SAS is within 50 feet of a private water supply well. The system has a septic tank and soil absorption system and the SAS is less than 100 feet but 50 feet or more from a _.._ private water supply well, unless a well water analysis for coliform bacteria and volatile organic eompowh(js indiciAtes that the well is free from pollution from that facility and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm. Method used to determine distance (approximation not valid). 3) OTHER (revised 04/25/97) fa94! 2 of 10 7 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address:_ Ov, OUIL(_ Owner: �j' Date of Inspection: V D] SYSTEM FAILS: You must indicate either "Yes" or "No" as to each of the following: I have determined that the system violates one or more of the following failure criteria as defined in 310 CMR 15.303. The basis for this determination is identified below. The Board of Health should be contacted to determine what will be necessary to correct the failure. Yes No Backup of sewage into facility or system component due to an 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 1/2 day flow. 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 Soil Absorption System, cesspool or privy is below the high groundwater elevation. .Any portion of a 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 I 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. If the well has been analyzed to be acceptable, attach copy of well water analysis for coliform bacteria, volatile organic compounds, ammonia nitrogen and nitrate nitrogen. E] LARGE SYSTEM FAILS: You must indicate either "Yes" or "No" as to each of the following: The following criteria apply to large systems in addition to the criteria above: The system serves a facility with a design flow of 10,000 gpd or greater (large System) and the system Is a significant threw to public health and safety and the environment because one or more of the following conditions exist: 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 11 of a public water supply well) The owner or operator of any such system shall bring the system and facility into full compliance with the groundwater treatment program requirements of 314 CMR 5.00 and 6.00. Please consult the local regional office of the Department for further information. (revisod 0{/25/97) Faye 1 of 10 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST Property Address: p((�`j Owner:. cam% Cr Date of Inspection: Check if the following have been done: You must indicate either "Yes" or "No" as to each of the following: Yes umping information was provided by the owner, occupant, or Board of Health. None of the system components have been pumped for at least two weeks and the system has been receiving normal flow rates during that period. Large volumes of water have not been introduced into the system recently or s p3?f of this inspection. Wit plans have been obtained and examined. Note if they are not available with N/A. T facility or dwelling was inspected for signs of sewage back-up. e system does not receive non -sanitary or industrial waste flow. e sl a was inspected for signs of breakout. �it system components, excluding the Soil Absorption System, have been located on the site. --The septic tank manholes were uncovered, opened, and the interior of the septic tank was inspected for condition of ba es -or tees, material of construction, dimensions, depth of liquid, depth of sludge, depth of scum. The. size and location of the Soil Absorption System on the site has been determined based on: _ e facility owner (and occupants, if different from owner) were provided with information on the proper maintenance of Sub•Surface Disposal System. Existing information. Ex. Plan at B.O.H. Determined in the field (if any of the failure criteria related to Part C is at issue, approximation of distance is unacceptable) (15.302(3)(b)) (revised 04/25/97) Page 4 of 20 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION Property Address: Owner. Date of Inspection:��n FLOW CONDITIONS RESIDENTIAL Design flow: p.d./bedroorn for S.A.S. Number of bedrooms: Number of current residents: GarWge pipor (yes or no): Laundry connected to system (yes or no): Yes Seasonal use lyes or no): Water meter readings if iyailable (last two (2) year usage (gpd): Sump Pump (yes or no):� Last date 'of Yoccu occupancy: cy: COMMERCI AAI NDUSTRIAL: Type`of establishment: Design pow: aallons/day Grease trap present: (yes or no)_ Industrial Waste Holding Tank present: (yes or no)_ Non -sanitary waste discharged to the Title 5 system: lyes or no)_ Water meter readings, if available: Last late of occupancy: OTHER: (Describe) Last date of occupancy: GENERAL INFORMATION PUMPING RECORDS and source of information: System pumped as part of inspection: (yes or no)25� If yes, volume pumped;, 1STgaLlIons Reason for pumping: tt V tSQ c # l h� TYPE OF SYSTE tic tank/distribution box/soil absorption system Single cesspool Overflow cesspool Privy Shared system (yes or no) (if yes, attach previous inspection records, if any) 1/A Technology etc. Copy of up to date contract? Other APPROXI TE AGfEAof all cimponents, date installed (if known) and source of information: lot p, Sewage odors detected when arriving at the site: (yes or no) /0 (zevipod 04/25/87) Fagg S of 10 r SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C . SYSTEM INFORMATION (continued) Property Address;. Owner; `Cu" Date of inspection,`'9 ^ ` BUILDING SEWER: / (Locate on site plan) ft / Depth below grade !// Material of constructpn: cast iron 40 PVC other (explai t f �4 ve e -kv �� C- 3 PV LPA F-- Distance froln,pGvate water supply Well or suction lire Diameter Commert)s:_lcondition gf joints, venting, evidence of leakage, etc.) SEPTIC TANK: (locate on site plan) t( . Depth b"croncrete __,meta grade: 0 Material of construction: metal _Fiberglass _Polyethylene _other(explain) If tank is metal, list'age Is age confirmed by Certificate of Compliance _ (Yes/No) Dimensions: 1 �t K s ,x r x i Sludge depth: I �! Disiance from to of sludge to bottom of outlet tee or baffle: Scum thickness: tl rr Distance from top of scum to top of outlet tee or baffler 3 l Distance from bottom of scum to bolt flm 9qf,��o 4tle-t _tee or baffle: How dimensions were determined: JUYJ�(�tG� SC.v -"k 51u�� �� Comments: (recommendation for v GREASE TRAP: (locate on site plan) of,liquid4eve+ in rielatiQn to outlet Depth below grade: Material of construction: _concrete _metal _Fiberglass _Polyethylene other(explain) Dimensions: Scum thickness: Distance from top of scum to top of outlet tee or baffle: Distance from bottom of scum to bottom of outlet tee or baffle: Date of last pumping: Comments: (recommendation for pumping, condition of inlet and outlet tees or baffles, depth of liquid level in relation to outlet invert, structural integrity, evidence of leakage, etc.) (zw#rad 04/25/97) Page 6 of 10 Property Address: Owner:, Date of Inspection: SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) C TIGHT OR HOLDING TANK: (Tank must be pumped prior to, or at time, of inspection) (locate on plan) Depth below grade: Mdteria) of construction: _concrete _metal _Fiberglass _Polyethylene ­other(explain) Dimensions: Capacity; gallons Design flow:- gallons/day Alarm level:, ^ Alarm in working order _ Yes; _ No Date of previous pumping: Comments; (condition of inlet tee, condition of alarm and float switches, etc.) DISTRIBUTION BOX: (locate on site plan) Depth of liquid level above outlet invert: Q Comments: , (not if leve] and istri ution (s equal evidence of solids carp(over evidence of leakage into or PUMP CHAMBER:UV-Q,. (locate on site plan) Pumps in working order: (Yes or No) Alarms in working order (Yes or No) Comments: (note condition of pump chamber, condition of pumps and appurtenances, etc.) . (sevippd 0{/35/97) F.q. 7 of 10 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: a '3 TvrnQ Owner Pate of Inspection; " n SOIL .ABSORPTION SYSTEM (SAS):_J--�— .(locate on site plan, if possible; excavation phot required, but may be approximated by non -intrusive methods) if not determined to be present, explain: Type: leaching pits, number: leaching chambers, number:_ leaching galleries, number: P +V -e ^ �u"` , _ ,( � leaching trenches, number,length: GJ leaching fields, number, dimensions: overflow cesspool, number: Alternative system: Name of Technology: tents:'. co4ditintof soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.) CESSPOOLS: _h01e (locate on site plan) Number and configuration: Depth -top of liquid to inlet invert: Depth pf solids layer: Depth of scum layer: Dimensions of cesspool: Materials of construction: Indication of groundwater: inflow (cesspool must be pumped as pan of inspection) Comments: (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.) PRIVY: WV'e, (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.) (royiped 04/25/97) Page $ of 10 c., SUBSURFACE SEWAGE DISPOSAL SYSTEM INSI PART C SYSTEM INFORMATION (continue POwnerty Address: Cx ll Date of Inspection: `-t V �q*'s i C9 -2o6 9� SKETCH OF SEWAGE DISPOSAL SYSTEM: include ties to at least two permanent references landmarks or benchmarks locate all wells within 1,00' (Locate where public water supply corms into hot A4� t -_ ( (C�'tL, II a::; ` �0 3 , I (o C'C-g0T :D t-( 'a t I 3 (revised 01/15/97) wA3 Page 9 of 10 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C �(^ SYSTEM INFORMATION (co tinued Property Address: �7 1 v'r� ` tz. 'v Owner: Date of Inspection: Qv v Vi Depth'to Groundwater Feet Please indicate all the methods used to determine High Groundwater Elevation: O bta ined from Design Plans on record Observation of Site (Abutting property, observation hole, basement sump etc.) e�-^�'D [ermine it from local .conditions eck with local Board of health Check FEMA Maps Check pumping records Check local excavators, installers Use USGS Data Describe in your own words how you established the High Groundwater Elevation. (Must be completed) �S &ISA (revised 04/25/97) Page 20 of 20 } TEL: (508) 475-1474 FAX: (508) 475-5451 BA'ECaN ENTERPRISES, INC, Excavating a Water & Sewer Lines - Septic Systems & Pumping Service 11 i Arglila Road Andover, Mass. 01810 Title 5 Inspection Report Property Address:---------------- Y-lv wnpr;----------------------------- 6 _ ao-963 Pate Of Inspection; ---------------- My report contained herein does not constitute a guarantee of future usage and the functionality of the existing septic system.. Such report issued herewith is merely based upon my observations, and I hereby disclaim any further operation of your current septic system. Neil J. Bateson Bateson Enterprises Inc. Page 11 of 11 Town of North Andover, Massachusetts Form N0. s pORTh BOARD OF HEALTH �3� e•r 0 14 19 9. Z L R A i s �`�"-'-~--�'•` ` DESIGN APPROVAL FOR as"C""S`` SOIL ABSORPTION SEWAGE DISPOSAL.SYSTEM Applicant _ Test No. Site Locatio .�. _LA JZ Reference Plans and Spec 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.Z. WELL DATABASE ADDRESS: L tiLti� AGE OFN=? r ��''L-� WELL D. .E?: TELL LOCATION: ZOO - r r per: Ls"ii DAT-: DEPTIE OF W-,--T-L: -=EOFWr.: L_ Drrr. b. DLIC c. liN iOlN�( - WA=ABY?-Li DAA - / " l ., 1 �- IGH ELLE acy =- W7? T DATA fir F, ADDRESS: OF 'W= DR=L=L- AGE _ _ x WELL PEl��,ffT T: WELL LOCATION: J � C 0 '��-i� -71 WELL PFR -'YL T DA �: P'I? OF ELL: r TYPE OF WELL: a-• DP, L.ED . b. Du L"Ni�iiO�NN TYPE OF WATER BE? -RING ROCK: ^ ^ WATER A- ALYSIS DATE: YEGH tiL= GaNESE: Y N F-DGH IRON: Y N OTH R CONTA� -ACTS: Y N j t 0� uj O z m � cm r W )p � �¢ � 0 w o cmc •C LLJ 06. a z �' W W o o � � A g O Lij w Q as -- w . 0 w a w w c� w � w v z o A cn cn uj O z m � cm r W )p � m CD � �m VA cmc •C LLJ 06. N z M W W o o � � g O Lij 0 T y LA .E c O O Q 4-1 _R y O O V h C 0 C-7 cc CLCO3 r�=-7 0 w co Q. CO) C C3 CD �a �co o O O CL O. cma C 4-0 C O !d O O Z co CLCOO c J Q z LL - W } z z O W a > Q u W CJS > Z "J Q z_ J LL. Q z W Z E cr: Z W W CL CJS FORM U - LOT 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***************** Daniel J. Brown, Jane A. Quinn (508) 657-6520 APPLICANT. Phone ( 508) 658-4107 LOCATION: Assessor's Map Number /oec -.37o Parcel Subdivision Lot 1B of Map loy, C, Parcel Lot (s) Street Turnpike Street (Rte. 114) $t. Number e'_ ************************Official Use Only************************ RECOMMENDATIONS OF TOWN AGENTS: Conservation Administrator Date Approved Date Rejected Comments Date Approved 2 T nm-Aanr�ar Date Rejected Comments Date Approved _1%/A1319-2 Health Agent Date Rejected Comments / Public Works - sewer/water connections n/a vvvV 30y (' p()A�driveway permit r t e� ' 2 >PC 41 Fire Department , Received by Building Inspector Date BOARD OF HEALTH 120 MAIN STREET NORTH ANDOVER, MASS. 01845 • / • ZZ A TEL. 682-6483 Ext. 32 DATE: e4'146 h:�4.. Dear This is to inform you that the proposed septic design plans for the above site dated have been APPROVED. If you have any questions about the next step in the process, please call the Board of Health office. APPROVED WITH THE FOLLOWING CONDITIONS: Cj_�� �•� DISAPPROVED FOR THE FOLLOWING REASONS: t Department of Environmental ManagWsources 4, WATER WELL COM LE 0 WELL LOCATION Address f? City/Town NOS Tii 1 i%Dn Well owner f ( l e. �T 72-y_5 71, Address P 0. %a x G1/, /,,7&!n o Board of Health permit: yes Er no GEOGRAPHIC DESCRIPTION A00 N la W of (feet) -(circle)',: (road) 7/D N S &)W of circle) ." (mi. in tenths) 1902),-1 intersect. w/ © 2) . (road) WELL USE WELL DATA Domestic [Public ❑ Industrial Q Total well depth s�© it. Monitoring ❑ Other Depth to bedrock Method drilled Date drilled ZZ1��1'2 CASING Type J T ! e Length ;2-6 ft. Dia (.I.D.) � in. Length into bedrock /0 ft. meter -bearing ro �kfunc nsolidated material: c Description Water -bearing zones: 1) From�To 2) From To 3) From To Gravel pack well: dia. Protective well seal: / Screen: Grout.[]Otherk; v e ✓`five Slot at STATIC WATER LEVEL Static water level below land surface_ ft. dia. length from_ to Date WELL TESTI_,�� Drawdown ft. after pumping hr. - min. at O- gpm How measured _&2Recovery_ l�d ft. afterehr. min. LOG of FORMATIONS COMMENTS I Materials From To Driller /111*-' A/ Mass. Registrations S. V b Firm Address��� City T0.,A _, 30 Y14 BOARV OF HEALTH CO ;.� NOV 20 '92 15:01 ••• ae i Department of Enuironmental Managemerit/Division of Water Resources WATER WELL COMPLETION REPORT WELL LOCATION Address A p City/Town&('? rr'�i //� sF/. '.."4- Well owner g y� " ;R�� Address f 0 4!54x ?.....LIF Board of Health permit'. yes no (] GEOGRAPHIC DESCRIPTION A010. NOW Of rr�a, rcVaa: N 5 VW of (tnr. in last kkclal intersect. w/ e • d !raid) WELL USE LWELL DATA Domestic 2`Pubiic Q Industrial 0 weft depth —Al 47 it Martitoring ❑ Other h to bedrock J O ft, r -bearing ro /tu►cgnsolidated Method drilled 4141 /' 4 Date driiied 4 CASING Type S re e l Length -2-1 ft. Dial.l_D.)in. Length into bedrock /b . Tft, Description A &2=6C " t 2ff^" Water -bearing zones: 1) From To�CL .� 2) From—To 3) FromTo Gravel pack well: dia. Protective well seal: Screen: Ilia. Groat.❑ Other 1104- Slat" lengde from—to— STATIC WATER LEVEL Static watae level below land sue face ,,��,, �ft. Data__.�� WELL TEST Z r Drawdown.:Wh. attar pumpingZ11r. min. at 4,2' gpin How measured Racovery ft. afterp'lir, min• LOG of FORMATIONS 1 COMM 4 Driller ;&k ' //-r-; Mass. Registration* ,!ry 6 Firm. ! /. c ty- j;ag S X c_ Address �-b�i CitY/Tow � ti _MpIflatulf M "sn r 4 rddlrer D ILLER COPY P.1/1 OVIPP yhozatemiem .eabratory, Am 66 LITTLETON ROAD WESTFORD, MA 01886 (508) 692.8395 FAX (508) 692-0023 1 -800 -649 -TEST Report Number: C-sks-7265 Report Date: November 1.0,1992 Client: Sample Taken At: Mr. Roger Skillings Federal Realty Trust Skillings and Sons Rt. 114 269 Proctor Hill Rd. Lot 1B Hollis NH 03049 N.Andover,Mass. Sample Taken By: SKS Staff On: November 9,1992 CERTIFICATE OF ANALYSIS TEST PARAMETER: EPA Max RESULTS UNITS Total Coliform (P) 0 0 Per 100ml Calcium No Limit 68 mg/L Copper (S) 1.3 <0.01 mg/L Iron (S) 0.3 4r--17-97;1 mg/L Magnesium No Limit 4.7 mg/L Manganese (S) 0.05 mg/L Sodium 11 20 # 34:79>t mg/L Potassium (S) No Limit 2 mg/L Alkalinity (S) No Limit 97.5 mg/L Ammonia No Limit 0.04 mg/L Chloride (S) 250 37 mg/L Chlorine (total) Not Spec <0.02 mg/L Color (S) 15 10 CPU Conductivity No Limit 606 umhos/cm Hardness No Limit 189 mg/L Nitrates(as N)(P) 10 0.69 mg/L Nitrites(as N) 1 <0.01 mg/L pH (S) 6.5-8.5 7.1 SU Odor (S) 3 1 TON Sulphates (S) 250 15.9 mg/L Turbidity 5 4.8 NTU Sediment pos/neg neg NT=Not Tested, #=Value Exceeds EPA STD, TNTC=Too Numerous to Count *=Background Bacteria Noted, =EPA Advisory Limit '=Exceeds EPA Advisory Limit (P)=Primary EPA Standard, (S)=Secondary EPA Standard (may affect aesthetics of drinking water i.e. taste, color, etc.) This water sample, as tested, is considered SAFE to drink according to EPA guidelines. However, one or more of the parameters exceeds EPA secondary standards as indicated by the (#) sign. Massachusetts State Certified Testing Laboratory #YA048 Mi�,a l P. Carlson, for Thorstensen Laboratory Inc. Town of North Andover, Massachusetts Form No. 3 BOARD OF HEALTH NOFTN p 19 Y 3?eT.. '•OG R F A -�.,,,o.•�"� DISPOSAL WORKS CONSTRUCTION PERMIT ,SgACHUSEt Applicant_T;�NAMEM ADDRESS TELEPHONE Site Location L Permission is hereby granted to Constructor Repair ( ) an Individual Soil Absorption Sewage Disposal System -as shown on the D ign Approval S.S. No. 4, �_A CHAIRMAN, BOARD OF HEALTH 57 Fee D.W.C. No. toiS P. l (Q N LO jr �1 7 fi `� _�-- M N -N-N 00ff N �N i �- DATE Sheet of BOARD OF HEALTH TOWN OF NORTH ANDOVER ,i,// SUBSURFACE DISPOSAL DESIGN REVIEW FEE Y'C�d PERMIT #-' DATE RECEIVED 7 APPLICANT Q �_�P ASSESSOR'S MAP ADDRESS PARCEL # LOT # / y� STREET # -T�rnl�i,�� ENGINEER //�s✓1.Q� ADDRESS j 1ZnaVl &10 PLAN DATE �� �� REVISION DATE CONDITIONS OF APPROVAL: 9 �CEY. 0,F DAA/A% z) �Gif 4D APPROVED I i - DISAPPROVED PLAN REVIEW CHECKLIST ADDRESS ,/, p / (� �l�j�p�,�� ENGINEER GENERAL 3 COPIES v STAMP L--' LOCUS G/ SCALE L--- CONTOURS L---- PROFILE_L.::�-- SECTION BENCHMARK ELEVATIONS SOIL & PERC INFO WETS. DISCLAIMER WELLS & WETLANDS WATERSHED?/t/0 DRIVEWAY C.i WATER LINE DRAINS SCH40_Z SLOPE SEPTIC TANK MIN 1500G. .17 INVERT DROP GARB. GRINDER(+200% EDF) 25' TO CELLAR ✓ MANHOLE TO GRADE ELEV L/ GW D -BOX SIZE -DO-3 # LINES FIRST 2' LEVEL STATEMENT INLET,61.S�I- - OUTLET99. 3,5' = : /7 (2" OR .17 FT) LEACHING RESERVE AREA 4' FROM PRIMARY? ?/ 100' TO WETLANDS z-�2% SLOPE 100' TO WELLS 325' TO SURFACE H2O SUPP 35' TO FND & INTRCPTR DRAINS 4' TO S.H.GW_Z 4' PERM. SOIL BELOW FACILITY 9 MIN 12" COVER � FILL? -%(251 if above natural elevation;(10''f below) TRENCHES / MIN 660 gpd v SLOPE (min .005 or 611/100')t/ >3' COVER? - VENT SIDEWALL DIST. 2X EFF. W OR D (MIN 61) f IS RESERVE BETWEEN TRENCHES? "IX IN FILL?--- MUST BE 10' MIN. L- 4" PEA STONE? BOT X LDNG,506 + SIDE ;z0b X LDNG S-� = TOT -810 �� Goo d (L x W x #) (G/ft2) (DxLx2x#) FEE NUMBER THE COMMONWEALTH OF MASSACHUSETTS 25.00 TOWNNORTH ANDOVER ------•-------------- of.-----...----•---------------------------------.....-•------••- --... This is to Certify that ............Skillin..s ...Sons .............................. NAME 2-69--•Proctor---H111_ Road_.. -Hollis•. N.H.--•------••------•---•----••-------------------------- ADDRESS IS HEREBY GRANTED A LICENSE For •---•-----•------------ We.u...Dri_1.1ing...Parini_t.--•----1&---T.u=pike....Street------------------- ..-- -•---•-------•----...-- .-.-•---------•-----••---•----•------•--•-----••-•-----------------------•----------•--••---------••---•------ --•----------------•---•--•---•--•-•---•-••----....-------•••-----•------••--...-•--•--------•---------------••---•••••--- This license is granted in conformity with the Statutes and ordinances relating thereto, and expires December 31, 1992 .....until sooner suspended or revoked. ---------------------- November 2, --•-----19-- 92 ---------------------------------- FORM 498 HOBBS & WARREN. INC. ('onunonwealdi of hiassachusells 4A�wMassachuscl(s Svstern Puinpi g Record System Owner i c1/1 An Dale of 11umping: 6, "),D' 9e�' Cesspool: Nu Yes �.. Syslem Location lluai►lily Pumped: G` gallons Seplic 7 -auk: No L I Yes Syslem Pumped by: FetreQore gitre'z4,sijed License Conlenls iiansleirred to : gma Ue Lawtance salillarY-U) iuitil -- Dale.- -------_._._ _____--------------- lnspeclur. TOWN OF NORTH ANDOVER SYSTEM PUMPING RECORD DATE: � D SYSTEM OWNER & ADDRESS bOG��/I 02/6,3 /U/2/ 6f SYSTEM LOCATION (example: left front of house) DATE OF PUMPING: - QUANTITY PUMPED�GALLONS CESSPOOL: NO YES SEPTIC TANK: NO YES NATURE OF SERVICE: ROUTINE EMERGENCY OBSERVATIONS: GOOD CONDITION HEAVY GREASE ROOTS EXCESSIVE SOLIDS SOLIDS CARRYOVER SYSTEM PUMPED BY: COMMENTS: CONTENTS TRANSFERRED TO: FULL TO COVER BAFFLES IN PLACE LEACHFIELD RUNBACK FLOODED OTHER (EXPLAIN) le System Owner Acigmq David 2163 t.urnpi.ke stroet North Andrver, MA, 01.84.5 (978)-686-:1980 x Commonwealth of Massachusetts Massachusetts System Pumping Record nii''nVO, \ \ ��j Form 4 -- System Pumping Record r-RE-C�EIVED JUL 0 5 2007 System Location HEALTH DEPq(�j Primary Home 2163 turnpike street Forth f'ln(iover., MA, 01845 t978)-686-1980 x AcIams Type: Emergent Routine Cesspool: No Yes Septic Tank: No F—I Yes Date of Pumping: Quantity Pumped:�j� C7d Gallons System Pumped By: Wind River Environmental, LLC Permit #: Contents Transferred to: Contents Disposed at: Date Condition of System/Other Comments Pumper Signature: Dep Approved Form - 12/07/95 L--\ Commonwealth of Massachusetts Cityrrown of AUG -: 3 2011 System Pumping Record NORTH ANDOV NOFNORTHANDOVER HEALTH Form 4 DEPARTMENT 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 the pumping date in accordance with 310 CMR 15.351, Important: When filling out forms on the computer, use only the tab key to move your cursor - do not use the return key. 15form4.doc• 03106 A. Facility Information 1. System Location: Address City/Town 2. System Owner: Name Address (ifditlerent from location) -- -- — — - — State Zip Code Stale Zip Code 90 Telephone Number B. Pumping Record 1. Date of Pumping —�= --- 2. Quantity Pumped: Date Gallons 3. Type of system: ❑ Cesspool(s) eptic Tank ❑ Tight Tank ❑ Grease Trap ❑ Other (describe): 4. Effluent Tee Fitter present? ❑ Yes ❑ No If yes, was it cleaned? ❑ Yes ❑ No 5. Condition of System: 6. System Pumped By: Name /f 'r. _ Company 7. Location where contents were disposed: Signature of Hauler Signature of Receiving Facility Vehicle License Number Date -- Date System Pumping Record - Page 1 of 1