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HomeMy WebLinkAboutMiscellaneous - 2189 SALEM STREET 4/30/2018 (2)N O N � to b3 D 6 c O X o M I O � F I Owner information is required for every page. Important: When filling out forms on the computer, use only the tab key to move your cursor - do not use the return key. VQ reMn M Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 2189 Salem Street Property Address Rosemary and Edward Skinner Owner's Name North Andover MA 01845 City/Town State Zip Code 6-23-16 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. A. General Information 1. Inspector: v� l 1puluI, oer%c1vCr1 Benjamin C. Osgood, Jr. Name of Inspector JUN 2 7 2016 none Company Name -ToWm®F NOM ANI ER 157 Bluff Street HW THpEPA t irENT Company Address Salem City/Town 978-435-1324 Telephone Number B. Certification NH State 870 License Number 03079 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 .9'. c 6-".) Inspect Signature 6-23-16 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 2189 Salem Street Property Address Rosemary and Edward Skinner Owner's Name North Andover City/Town B. Certification (cont.) MA 01845 State Zip Code 6-23-16 Date of Inspection Inspection Summary: Check A,B,C,D or E / always complete all of Section D A) System Passes: ® 1 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. 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): N/A 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 2189 Salem Street Property Address Rosemary and Edward Skinner Owner's Name North Andover MA 01845 6-23-16 Cityfrown 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): ❑ ❑ ❑ N/A broken pipe(s) are replaced obstruction is removed distribution box is leveled or replaced ❑ Y ❑ Y ❑ Y ❑ N ❑ N ❑ N ❑ ❑ ❑ ND (Explain below): ND (Explain below): 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): N/A 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 - 3r13 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 2189 Salem Street Property Address Rosemary and Edward Skinner Owner's Name North Andover MA 01845 6-23-16 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 '/ day flow t5ins • 3113 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 Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 2189 Salem Street Property Address Rosemary and Edward Skinner Owner Owner's Name information is required for every North Andover MA 01845 6-23-16 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 Commonwealth of Massachusetts Title 5 official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 2189 Salem Street Property Address Rosemary and Edward Skinner Owner Owner's Name information is required for every North Andover MA 01845 6-23-16 page. City/Town State Zip Code Date of Inspection C. Checklist 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): 4 DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x # of bedrooms): 440 t5ins - 3/13 Title 5 Official Inspection Form: Subsurface Sewage Disposal System • Page 6 of 17 Commonwealth of Massachusetts Title 5 official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 2189 Salem Street Property Address Rosemary and Edward Skinner Owner Owner's Name information is required for every North Andover MA 01845 6-23-16 page. Cityrrown State Zip Code Date of Inspection D. System Information Description: 1,500 Gallon Septic Tank, Distribution Box, 2 -leach trenches Number of current residents: Does residence have a garbage grinder? ® Yes ❑ No Is laundry on a separate sewage system? (include laundry system inspection ❑ Yes ® No information in this report.) Laundry system inspected? ❑ Yes ❑ No Seasonaluse? ❑ Yes ® No Water meter readings, if available (last 2 years usage (gpd)): well Detail: Sump pump? ❑ Yes ® No Last date of occupancy: Current Date Commercial/Industrial Flow Conditions: Type of Establishment: Design flow (based on 310 CMR 1 . 03): Gallons per day (gpd) Basis of design flow (seats/persons/sq.ft., etc.): Grease trap present? ❑ Yes ❑ No Industrial waste holding tank present? ❑ Yes ❑ No Non -sanitary waste discharged to the Title 5 system? ❑ Yes ❑ No Water meter readings, if available: 15ins - 3/13 Title 5 Official Inspection Form: Subsurface Sewage Disposal System - Page 7 of 17 Commonwealth of Massachusetts Title 5 official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 2189 Salem Street Property Address Rosemary and Edward Skinner Owner Owner's Name information is required for every North Andover MA 01845 6-23-16 page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Last date of occupancy/use: Other (describe below): General Information Pumping Records: Source of information: Was system pumped as part of the inspection? If yes, volume pumped: How was quantity pumped determined? Reason for pumping: Type of System: Date Last Pumped in October 2015 per owner gallons ® Septic tank, distribution box, soil absorption system ❑ Single cesspool ❑ Overflow cesspool ❑ Privy ❑ Yes ® No ❑ Shared system (yes or no) (if yes, attach previous inspection records, if any) ❑ Innovative/Altemative technology. Attach a copy of the current operation and maintenance contract (to be obtained from system owner) and a copy of latest inspection of the I/A system by system operator under contract ❑ Tight tank. Attach a copy of the DEP approval. ❑ Other (describe): t5ins - 3/13 Title 5 Official Inspection Form: Subsurface Sewage Disposal System - Page 8 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments M 2189 Salem Street Property Address Rosemary and Edward Skinner Owner owner's Name information is required for every North Andover MA 01845 6-23-16 page. Citylrown State Zip Code Date of Inspection D. System Information (cont.) Approximate age of all components, date installed (if known) and source of information: Constructed in 1985 per as -built plan Were sewage odors detected when arriving at the site? ❑ Yes ® No Building Sewer (locate on site plan): 2' Depth below grade: feet Material of construction: ® cast iron ❑ 40 PVC ❑ other (explain): Distance from private water supply well or suction line: 30' feet Comments (on condition of joints, venting, evidence of leakage, etc.): Pipe OK in basement Septic Tank (locate on site plan): Depth below grade: Material of construction: ® concrete ❑ metal ❑ fiberglass 911 feet ❑ 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 Dimensions: 1,500 gallons Sludge depth: 2" t5ins • 3/13 Title 5 Official Inspection Form: Subsurface Sewage Disposal System - Page 9 of 17 Commonwealth of Massachusetts t W Title 5 official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments M 2189 Salem Street Property Address Rosemary and Edward Skinner Owner Owner's Name information is North Andover MA 01845 6-23-16 required for every page. Citylrown State Zip Code Date of Inspection D. System Information (cont.) Septic Tank (cont.) Distance from top of sludge to bottom of outlet tee or baffle 22" Scum thickness 0" Distance from top of scum to top of outlet tee or baffle 7-1 Distance from bottom of scum to bottom of outlet tee or baffle 24" How were dimensions determined? Measure stick Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): Tank in good condition. Concrete Tee/Baffle cobination in good condition on inlet and outlet. Grease Trap (locate on site plan): Depth below grade: feet 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: Date t5ins - 3113 Title 5 Official Inspection Form: Subsurface Sewage Disposal System • Page 10 of 17 Commonwealth of Massachusetts Title 5 official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 2189 Salem Street Property Address Rosemary and Edward Skinner Owner Owner's Name information is required for every North Andover MA 01845 6-23-16 page. 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: Design Flow: Alarm present: Alarm level: gallons gallons per day ❑ Yes ❑ No Alarm in working order: ❑ Yes ❑ 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 - 3113 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 t/ 2189 Salem Street Property Address Rosemary and Edward Skinner Owner Owner's Name information is North Andover MA 01845 6-23-16 required for every page. CitylTown 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 0" 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.): Box in OK condition. Distribution equal. No evidence of leakage in or out. Top of box 24" below grade. 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 ,M 2189 Salem Street Property Address Rosemary and Edward Skinner Owner Owner's Name information is North Andover required for every page. Cityrrown D. System Information (cont.) Type: ❑ leaching pits ❑ leaching chambers ❑ leaching galleries ® leaching trenches ❑ leaching fields ❑ overflow cesspool ❑ innovative/alternative system MA 01845 State Zip Code 6-23-16 Date of Inspection number: number: number: number, length: number, dimensions: number: 2- 60'x Tx 1' Type/name of technology: Comments (note condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of vegetation, etc.): Leach trench area vegetation looks very dry. No evidence of ponding, damp soil, or unusual 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 ❑ No t5ins - 3113 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 2189 Salem Street Property Address Rosemary and Edward Skinner Owner's Name North Andover Cityrrown D. System Information (cont.) MA 01845 State Zip Code 6-23-16 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 • 3113 Title 5 Official Inspection Form: Subsurface Sewage Disposal System •Page 14 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments „ 2189 Salem Street Property Address Rosemary and Edward Skinner Owner Owner's Name information is required for every North Andover MA 01845 6-23-16 page. Cityfrown 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: t5ins • 3113 Title 5 Official Inspection Forth: Subsurface Sewage Disposal System • Page 15 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form 1 Subsurface Sewage Disposal System Form - Not for Voluntary Assessments a ° 2189 Salem Street Property Address Rosemary and Edward Skinner Owner Owner's Name information is required for every North Andover MA 01845 6-23-16 page. City/Town 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: 8' feet Please indicate all methods used to determine the high ground water elevation: 7' 0 0 Obtained from system design plans on record If checked, date of design plan reviewed: 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: USGS maps indicate soil is Canton soil which is well drained with a water table >6"' below the ground. System built within 3' of the ground surface. Basement dry with no sump pump approximately 8' below ground. 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 �M 2189 Salem Street Property Address Rosemary and Edward Skinner Owner Owner's Name formation is every North Andover squired for eve MA 01845 6-23-16 page. City/Town State Zip Code Date of Inspection E. Report Completeness Checklist ® 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 - 3113 Titte 5 Official Inspection Form: Subsurface Sewage Disposal System - Page 17 of 17 <�\ Commonwealth ®f Massachusetts _ City/Town of -North Andover S- ystemPumping Record Form 4 w` 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. Pufm inslReco Recordng this mustbe submorm, check litted to local Board of Health to determine the form they use. The System Pumping in ate in the local Board of Health or other approving authority within 14 daysC�he-pump. 9 accordance with 310 CMR 15.351. r Address (if A. Facility Informati®n Important When filling out forms on the computer, 1system Location: Y use only the tab D key to move your Address cursor - do not North Andover use the return CityfTown key. 2. System Owner: 4 rzncn Name diff erent from location) Ma State T04Ni4 t) = f4UK i i H At 'RENT R HEALTH DSPAR State CitylTovdn Telephone Number B. Pumping Record 2. Quantity Pumped 1. Date of Pumping Date 3. Type of system: ElCesspool(s) Septic Tank ❑ Tight Tank ❑ Other (describe): 4. Effluent Tee Filter present? ❑ Yes ❑ No 5. Condition of System: G)ao 01886 Zip Code Zip Code I520 Gallons ❑ Grease Trap If.yes, was it clearied? ❑ Yes ❑ No 6. System Pumped BY'. vehicle License Number Name Stewart's Septic Service Company 7. Location where contents were disposed: Stewart's Pre-treatment Plant, 20 So. Mill Bradford, Ma 01835 Signature of Hauler Signature of Receiving Facility t5form4.doc- 03/06 Date Date System Pumping Record - Page 1 Commonwealth of Massachusetts W City/Town of NORTH ANDOVER System Pumping Record Form 4 M DEP has provided this form for use by local Boards of Health. Other forms may be used, but the information must be substantially the same as that provided here. Before using this form, check with your local Board of Health to determine the form they use. The System Pumping Record must be submitted to the local Board of Health or other approving authority within 14 days from the pumping date in accordance with 310 CMR 15.351. RECEJ� D A. Facility Information 1% 1 Important: When filling out forms 1. System Location: on the computer, �n p 1 Q� TpWN OF NORTH ANDOVER use only the tab "J C.� 1� Kn Vl ' HEALT_H DEPARTMENT key to move your Address cursor - do not NORTH ANDOVER Ma use the return key. City/Town State Zip Code �n 2. System Owner: Name reken Address (if different from location) City/Town State Zip Code Telephone Number B. Pumping Record IU n�i3 5 1. Date of dumping Date 2. Quantity dumped: Gallons 3. Type of system: ❑ Cesspool(s) Septic Tank ❑ Tight Tank ❑ Grease Trap ❑ Other (describe): 4. Effluent Tee Filter present? ❑ Yes ❑ No If yes, was it cleaned? ❑ Yes ❑ No 5. Condition of System:00 6. System Pumped By: Name Vehicle License Number Stewart's Septic Service Company 7. Location where contents were disposed: Stewart's Pre-treatment Plant, 20 So. Mill Bradford, Ma 01835 t5form4.doc• 03/06 System Pumping Record • Page 1 of 1 Commonwealth of Massachusetts W City/Town of North AndoverOCT 2012 } System Pumping Record TOWN OF NORTH ANDOVER Form 4 HEA'UH 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. A. Facility Information Important: When filling out forms 1 on the computer, use only the tab key to move your cursor - do not th t System Location: Address North Andover use ere urn City/Town key. 2. System Owner: Name K Address (if different from location) City/Town q �,�Qlem a�c�� Ma State State Telephone Number B. Pumping Recor 1. Date of Pumping Dat2. Quantity Pumped: 3. Type of system: ❑ Cesspool(s) Septic Tank ❑ Tight Tank ❑ Other (describe): Zip Code Zip Code /\50() Gallons ❑ Grease Trap 4. Effluent Tee Filter present? ❑ Yes ❑ No If yes, was it cleaned? ❑ Yes ❑ No 5. Condition of System: 0�� �Ij 6. System Pumped By: Name Vehicle License Number Stewart's Septic Service Company 7. Location where contents were disposed: S rt's Pre-treatment Plant, 20 So. Mill Bradford, Ma 01835 Signatur of Hauler Date Si a LngFacility Date t5form4.doc• 03/06 System Pumping Record • Page 1 of 1 Y Commonwealth of Massachusetts City/Town of ,NORTH ANDOVER, MASSACHUSETTS System Pumping Record Form 4 DEP has provided this form for use by local Boards of Health. The System Pumping Record must be submitted to the local Board of Health or other approving authority. Address (If different from location) r�`.J State Zip Code Cityrrown State Zip Code Telephone Number B. Pumping Record 1. Date of Pumping Date 1 ^ 10 2. Quantity Pumped: �ansJ�l .� 3. Type of system: ❑ Cesspool(s) eptic Tank ❑ Tight Tank ❑ Other (describe): 4. Effluent Tee Filter present? ❑ Yes, es ivo If yes, was it cleaned? ❑ Yes No 5. Condition of System: 6. tem Pumpe e Vehicle License Number mpany 7. contents were di Mil Signature of Hauler Date http:/twww.mass.gov/depANater/approvaistt5forms.htm#4nspect t5form4.doa 0=3 A System Pumping Record • Page 1 of 1 A. Facility Information Important: When fining out I on the 1. System Location: �� computer, use only the tab key Address to move your e cursor - do not City/fown use the return key. 2. System Owner n t , Address (If different from location) r�`.J State Zip Code Cityrrown State Zip Code Telephone Number B. Pumping Record 1. Date of Pumping Date 1 ^ 10 2. Quantity Pumped: �ansJ�l .� 3. Type of system: ❑ Cesspool(s) eptic Tank ❑ Tight Tank ❑ Other (describe): 4. Effluent Tee Filter present? ❑ Yes, es ivo If yes, was it cleaned? ❑ Yes No 5. Condition of System: 6. tem Pumpe e Vehicle License Number mpany 7. contents were di Mil Signature of Hauler Date http:/twww.mass.gov/depANater/approvaistt5forms.htm#4nspect t5form4.doa 0=3 A System Pumping Record • Page 1 of 1 �e�'h�i plorldrd •..,,ylTOVWNOFNORTHAND01l JI IvblI11 1111r 1prrn lir �r0 l� ore erflE � gPARTMENi Iled.lo vtr ry II � "mill Or 011101' $_ A.r Paro rl„0 Faclllty In1.OrMr Hon ,.., � ,.�' Sys �m oc•aUon, hw/ / 1' 07L, � ° � �''''� Z '� r 8 3.► rn Own'.. r ,,,,, .: _ + , ,, '.5. r r rr�� S "1 �r�l'Ih' v'u i r •�drµl ( d � 111111 ran buVvn) �. 0471 T, r 1v! , P1 umDlm ' ., J. rYp► vl +y)Iem, ., Co>> 1 PUC T enA > im Q%.other (desclibo ;1,1. Y O�F��{I • ;'1 �,,,,�/',b11't.„7jif��7!ol,ll�q,r,4tr,'r!�)�i�}!i'�.i�'(. ,�• io7. n'e1 I. c:vane0% � r _. ii„1�IV�'�” 4 'r SY ��,/►''1t Pvm p e d ,8 ' `r�,�i'��S•,�•� � �/,1 �,� ,'irk ',If rlv,l' ►'r'' Yr1tIU1 UO'enl1 77 / rY.✓�)w(., " J''; �iI ' ' I' :�r ; ✓� / r v ' •�'}�'�•�•'t;��•l;'I!,``,V,lti (�1i �r�'r��i,li��''J�i;,�!I,v� t�,�'��:''' � • .._ '•': ;+, ,,, 9.CdrJPrlrWher! 40�I��U,�e/e d►�p . ', ,+i4�, ,1. I,; •,l, "r„ v,� � 0300: • ,i,'�I,, .Ili 'I'y'(I'��4;1•r,.;il :,; i,�',,:Y: ;�;,1, i•'`+'' 3�A1„4Y1 9r h'!V4(jy`t�9'lf�lr•',,,,r� � _ . ld Y r .r,•>r,.,r.mes�,po ep�,Yal'ei/ippwi/,V(41orm).P.VulnI�ocl VIII to rx ( I O TIM! Orr r cl ,S' 'r it Yii(r, t3;. 1�1t('i 7.11 it i. : t.L u'�t.l, .:.• • DEP has prov(dedthis form for use by local B4ardsa eaith T le,Syst m Pumping Record must sumtt.Od to the.(ocaiBoard of Health oro a " • bebl '.., pp ovl�ggau°thorny. -A. Facility Informttlon NOV 0 5 2007 Imkortant.: '. Wben fdUn� out System 1.6catlon TOWN OF NORTH ANDO'vER HEALTH DEPARTME� , computer, use,'._ only the tab.key Address to move your curtot • do ` kuessy t, n'o`t 'the CItygoWn State _ Z1p Code . 2" System Owner, ,. Name AW ;. Address (If different from location Clty/Town . stateM�z Telephone Number <( . Pumping Record �,..r.r• ra-Date of Pumping ' Dat 2. Quantity Pumped: �! Gallons Typa of system ❑ Cess ool s ,,.�.,, ❑ p O 0--b ptic Tank Tight Tank ._❑ .Other (describe);. ' t Effluent Tea Fliter present? ❑ Yes, If yes, was if cleaned? ❑Yes [I No •r ,w, , . • , tit -i �•:a/ 1 ' .• ., - uy tl� '.' P F.. .. -.�. . S, ,Condition of S y� s , .._, , iIY•t-1{� a 7.t,r till lr. ' 8 Sy Pumped al �C Vehicle Ucen*s Number t. .3{ '4 .{5< ,F�, Iyl �¢ `tame• 4l r� , ;1j;,ryr �' .j✓F i L:. ,(, .� S ;` 5 l .U) i:.,. ... +e' 1" i f} �•i M1 iqt, `r lira ..,..fit, , . �' 7 Loootl where oontents�yvt3re dlposed: t, , • . : ° , , •: ` � Glu r i � L i• p ( „: t' S(pna • • o auie(:,,� Date httpJ/www mass gov/dep/water/a pp rovalslt5forms,htm#Inspect z7j t5fdaM.doa'08/03 System Pumping Record Page 1 or t Important: When filling out forms on the computer, use only the tab key to move your cursor - do not use the return key. Commonwealth of Massachusetts ``City/Town of. NORTH ANDOVER, System Pumping Record Form 4 MASSAC DEP has provided this form for use by local Boards of Health. The be submitted to the local Board of Health or other approving autho A. Facility Information 1. System Location: C�,l /% Address /l e s alt�� City/Town 2. System Owner: Name Address (if different from location) City/Town B. Pumping Record 1. Date of Pumping 3. Type of system: ❑ ❑ Other (describe): State State Telephone Number r Dat O 2. Quantity Pumped Cesspools) Septic Tank 4. Effluent Tee Filter present? ❑ Yes ❑ No 5. Condition of System: J NDOVER tJT st Zip Code Zip Code "4) Gallons ❑ Tight Tank If yes, was it cleaned? ❑ Yes ❑ No Sys m Pumped By: (� Name %may Ve icle License Number Company / 7.. Location where contents were disposed: ignature of er Date http://www.mass.gov/dep/wat /approvals/t5forms.htm#inspect t5form4.doc• 06/03 System Pumping Record • Page 1 of 1 Commonwealth of Massachusetts T City/Town of NORTH ANDOVER MASSAC VFX 1 System Pumping Record Form 4 'JUN - 5 2006 DEP has provided this form for use by local Boards of Health. The�"(F MKBART PJN 2 u. be submitted to the local Board of Health or other approving author . HEALTH DEPARTMENT A. Facility Information Important: When filling out forms on the computer, use only the tab key to move your cursor - do not use the return key. 4:1 ratren 1. System Location: Address City/Town 2. System Owner: 4 Name Address (if different from location) Gity/Town 1. Date of Pumping 3. Type of system: ❑ ❑ Other (describe): S e Zip Code GAMIF ) State Telephone Number Dae::� Quantity Pumped Cesspool(s) Septic Tank Zip Code Gallons ❑ Tight Tank 4. Effluent Tee Filter present? ❑ Yes ❑ No If yes, was it cleaned? ❑ `Yes ❑ No 5. Condition of System: 6. SyAern Pumped By: Name Vehicle License Number 6" V41' �5t L Company 7. Location where contents were disposed: Si ature of Haut i f/'/�W'. http://www.mass,gov/de,p/water/ provals/t5forms.htm#inspect Date O t5form4.doc• 06/03 System Pumping Record • Page 1 of 1 NOR -J' t� ,�r�'�r..., NOV - 8 2005 �. v„ I `e / v?E 1� 1 P tJ M P I N U l... C4- H ANDOVER -PA 7-rNE NT `j1 TE01 _ Qo A N71TY H'n ruKFi UI' 3�RYIC'B: KUVTINc Ub4tGA YA f" (>Na. ► 000000HOITION/K PVI,.; KMAYY OUA33 / KQ0n $OLiDCAM YOnR,'--0 NEP, EXPLAIN l'VMM�NT� v!r I �N 1'� 1'j�.1N,ytr.KlLa`3U\ in Owner SkiTin,er- Ed Z '- ri3 iem SI- I North Andover, '214A, 01W: {`173t_.686 --rail? x Form 4 -- System Pumping Record Commonwealth of Massachusetss —OFNOR—T-H---A,N-L)k—,-..,! BOARD OF HEAL111 Massachusetts System Pumping Record System Location r —ma I: Y Home 2189 Salem St Type: Emergency Routine Cesspool: hlo Yes Date of Pumping: System Pumped By: Wind River Ehv#wmental, LLC Contents transferred to: Contents Disposed at: Date: LI 0/0 North krid,nver, IMA, 01845 (978)-686-1387 S kinric_r Dep Approved Form - 12/07/95 Septic tank: W =Yes f-71 Quantity Pumped: a C.11.ns Permit #: .1 JTk74`TA 4 d4i�,\;'• yy�1•�•9r ( '.,.yy 1,,'yy� t _� IfVl1,Y`,VfiYi:YL'----'- /;7i r ,K��Ji- ;�,�>,;,� 1 �,`}y, 7;'�(<3' Sii;��'�� Ir(I�fll4rc(•,;,, J��� 1�(�arlai:�\fA--���•— .-- -. . •Z .Y , .111, {�`1��%:.\':Ij..1,�3 �'l'�.\, Ih� +1; I ,I, .'I v ( NORTH A ? S'YSTI:P.UfY1pf.NC, R'PCO^ -- �� � A\ � aC U ill C,4F?,�MY1�f� C QUANTITY pump 60 c I:>>i'VU� YES SCPTIC'TANK: n0 _ ✓ �1TURE, F.;SER'Y.I,CE.i.':R0UTINE.. EM ERC ENC,r , 1 1. U,UUO'C..V�rUl1IQN FUl I:TU C 0 Y -Y REAS Ir LEACHFIC! C cv,. CXCESSI'YE $QGIoS FLOOD60' . — - ;''>, i54' Io�'�aR�YOY�R ---- ' �j , � �� ���19 ����1� 1 �� I��Y 1`/ �Ffr t i�tf c (• r ! � �1 , J,.�S 1'lli>.11:1i �;�:'{ I �bl��\, I \ 7l, 1. ,)tl.• �r % � 1/ r .�„ � i , 0''0 Y'.. 1 �' I� � . �7;�1 r, r 1 : j�liSY 1 •`'r� rt I a ti� r (f.i�3!;.iI;YI'� ffti�lla�Jll!t�,INjK( ),;; l +ll,ltJ�,Ir t r I _ rJ 1 \ I Ii g� 'JOH-14 AN' , VER/ TOWN OF NORTH ANDOVER dF�L SYSTEM PUMPING RECORD N01 _4 20 �1 STEM OWNER & ADDRESS SYSTEM LOCATION (example: left from of house) U.\"iT OF PUMPINC: /f Z�Ia�D UANTITY PUMPECALLO�� ,)..SPOOL: NO YES . SEPTIC TANK: NO YES ", ATURE OF SERVICE: ROUTINE v EMERGENCY FRV.\TIONS: GOOD CONDITION HEAVY CREASE ROOTS EXCESSIVE SOLIDS SOLIDS CARRYOVER >l > l LM PUMPED BY: LU�IMENTS: UNI L'N I'S T1ZANS11EIZIZED TO: y FULL TO COVER BAFFLES IN I'L.ACE LEACHFIELD RUNBACK . FLOODED Oj�HER (EXPLAIN) TOWN OF NORTH ANDOVER SYSTEM PUMPING RECORD DATE: �` D SYSTEM OWNER & ADDRESS Ae6 SYSTEM LOCATION (example: left front of house) 6,'o c /-(/ DATE OF PUMPING: 11 - 3- o / QUANTITY PUMPED /yr00> 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: FULL TO COVER BAFFLES IN PLACE LEACHFIELD RUNBACK FLOODED OTHER (EXPLAIN) v r�llU �M' i1lC1t� i ri , aNDO% t/ BOARD OF .4E -A H . DEC - 7 2001 CONTENTS TRANSFERRED TO: TOWN OF NORTH ANDOVER SYSTEM PUMPING RECORD DATE: SYSTEM OWNER & ADDRESS SYSTEM LOCATION n „ I (example: left front of house) DATE OF PUMPING: QUANTITY PUMPED A�6 GALLONS s CESSPOOL: NO �_ YES SEPTIC TANK: NO YES >C. NATURE OF SERVICE: ROUTINE _ EMERGENCY OBSERVATIONS: GOOD CONDITION FULL TO COVER HEAVY GREASE BAFFLES IN PLACE ROOTS LEACHFIELD RUNBACK EXCESSIVE SOLIDS FLOODED SOLIDS CARRYOVER OTUF.R IF.XPi.AINI STEWMTIS SEPTIC TANK. SERVICE 47 RAILpOAD STREET BRADFORD, 1h 01835 978-37277471 /a �noover 53 Act rrur) Sf /590 1560 f5� f 5� leo food Iso 1000 1560 Fres �-5>- %0--I / �rr�f�(- 413q �r s 50e�Gl�v ,( -�4 d d 67 d % fi� � "4y 6ff 2 � /e -1r) 6:1 -- Ll 83?54� 5)1- .77771, 55 Fcirr)i)yn,4, bas 136 50,E /14111 53 Act rrur) Sf /590 1560 f5� f 5� leo food Iso 1000 1560 1. 4:� j X '4,)CZ TLt- TIZ , CA "PWIPLIC; rVE C) SEE, C)c), -000, 55y -4- > � 01 cc J.45,5�86 1 S -r I �-A�Jb I!--; UO.AQbOVEZ MASS FW- ,�>I-b Mia /Co�sTi DX -71F -b OC',;CREZ, )IS -lo e'-/ MIE�-VZlHhc-� AS, BUILT fmo-LAN OF AV% buBSURFACE Dle"bP,SAL SYSTEP LOCATED IN AS PREPARED FOR OATE: OC70'M-Z SCALE: MERRIMACK -ENGINEERING SERVICES, INC. PROFESSIONAL ENG04ERS 0 LAND SURVEYORS 0 -PL-At**fl 66 PARK STREET • AtA00VVR,.*A"ACt4ust"_S 01810 o TEL. (6,17),05-1 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: Phone LOCATION: Assessor's Map Number Parcel Subdivision e� Lot(s) StreetSt. Number ************************Official Use Only************************ RECOMMENDATIONS OF TOWN AGENTS: Date Approved Conservation Administrator Date Rejected .Comments Date Approved Town Planner Date Rejected Comments Date Approved Food Inspector -Health Date Rejected ASDate Approved 9.5 Septic Inspector -Health Date Rejected Comments 'i�QD F (OX) -�) e_zcc Public Works - sewer/water connections - driveway permit Fire Department Received by Building Inspector Date r n > m 0 m m m 0 x r m r O c � W m m n J O Z N w 2 N 1 X C 0 1 0 Z N A A> i -1 -4 u Z N> � r O 0 � v n 0 A N O ow X Oo =1 0 n 0 O m < m f Z 9 9 0 �: 0 Z m A 0 X" a o o n n n� IDD C.0 ' --1 m z a c n caCD Z Z 1 m m c CD 1 - O , 0 n (7 Q o 0_ ?: f� ; 0 C 3 -i CCD _ Cpffi� 1 a m y' Z ' 3 1 !� 7 Z m N f f CD f'D 0- F O 0 j j 1 CDD 'D A " .. Z>> .=i C1D ., C Z CD T (D T 3 v' CD ,b Q . C> A� J' CD CD - CD 11 0 r n 69 fA 69}`CD } m co A m m IA Z > -� CD A m 3 m N �� rkAm A Z 0) r m :� .. 0 Z i 1 Z QQ m H © c r n > m 0 m m m 0 x r m r O c � W m m n J O Z N w 2 N 1 X C 0 1 0 Z N A A> i -1 -4 u Z N> � r r n � v n 0 A N > A ow X Oo =1 0 n 0 O m < m f Z 9 9 0 �: 0 Z m A 0 X" a o o n n n� IDD A Z --1 m z '. o r Z Z m r m m O m N 0 m m 0/ 0 C 3 -i Z O 0 -i Z 10 M y y N> _v o v m> 0 0 r- N > A r r m c m c m c m > ml m > D m c D r � x f Z F Z 0 �: 0 Z S o o o n n n� m A A --1 m '. o r Z Z m r m m m N m m 0/ Z O -i Z Z>> Z 0 0 0> m C> 11 0 r o m 3 3 m 3> m A m m IA Z > -� 0 A m 3 m N �� -ni A Z 0) r m 0 Z i 1 Z QQ m H © c _— N I 0 o C i 10 0 M O! j c N m b 3 W rl m + �I b m Z 0. O A m Z A m 4 D D A O Cri m N m N N m O 9 m m c c m c m c _{ m 3 > Z O O v O A D'�m O x _ 2 ZO 0m Z VNE 0 of m O O 'O Z n Z c O Z m I 0 > o r=n r Z m ml r ; m m m m m< O A w m A a 0 v v v o z m a O O O Z m >r O O rr I m v N I G c Z r m Z Z > I >*iv M m A r x= I N O nZi c o v Q m m x I x m r/ 0 C a 0 w e O X o 'D ID Im 10 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***************** 141 APPLICANT:= _ :�n4 rd Phone LOCATION: Assessor's Map Number Subdivision Street a4_ e Parcel Lots) St. Number ************************Official Use Only************************ RECOMMENDATIONS OF TOWN AGENTS: Conservation Administrator Comments Town Planner Comments Date Approved Date Rejected Date Approved Date Rejected Date Approved Food Inspector -Health Date Rejected Date Approved r4 Septic Inspector -Health Date Rejected Comments -� /7 (D4) Public Works - sewer/water connections - driveway permit Fire Department Received by Building Inspector Date si '; ��� q i? I ,,, A CQ O z ON b P w O d _c v w° C/) ci) o w z . w G w° r2 E� U u. w m w a o u � a W cn Li a O U �w,, d y C w z w w v v a, Cn o cn a . c o - OD C ;C O y3 O O C HO 0 Co v V o. Vcp s C co L Ca L Mme o c N � O m o O �! tS c� CA m a : 16- a-,, = ��Of Qm.OJ N ca m � cC C Cow,CD A m orm y O C! = 'C1 C C1 p �? �Q.Oyc� :m�vcy aa. c,o co = cm �o o.o c m N O C C = m Ws C2 N ~ y m C0 H VBD C cc m y=. W O = 41' a.. LL.•y O.= O C Z s =:"r CDLU Q o COD •d m .a O :a FE m I.- = $ c.= CO F 40 0 O i J Q z o P co0 ts O � y C i R z ! o i ooh j o �— y Cw j L- CL � L U co R � C O i co O LO O a e O) Q CO2 C -p O O � C R %.i -� .Q O -1O+ COOC Z c Z V h R � O cc y CD z G z z a 'N / v AGE OF WELL: W`E L DRILLER: Otvv�--�-t .'WELL PElUvEr WELLNtOCATION: v WELL PERNffT DATE: DEP�1-1 YF'WIELL: a tea— TYPE OFWELL: (:a-::D!��LE b. DUG C. UNKNOWN TYPE OF WATER BEARING ROCK: WATER ANALYSIS DATE 5? HIGH MANG Y ANESE: HIGH IRON: N OTHER CONTANDNANTS. Y N BOARD OF HEALTH Town of North Andover,Mass. r _... 19 Permit #,70/ Date APPLICATION FOR WELL & PUMP PERMIT Application is hereby made for permit to drill a well (_). Application is made to install ( ) a pump system. l � Location: Address ..Lot #. �¢'�/ c�� //l!/ �/J/�/C/� Owner o U _Address_fi' 9/C�%l/���V.tJ Tel 6 �l%�� Well ContractorA961- �ilT y,(�vu Address ISr 611(x" ®�tli-Al Tel. !Fj Pump -Contractor `j,gmC_ Address,,., Tel. WELL CONTRACTOR (To be completed at time of pump test) Type of Well �2i//e� Well Diameter of Well Size Depth of Bed Rock j Depth Was Seal Tested? Yes (fi)" No ( ) Date Depth ..I f 1-Je11_ Well used for ars�reS�iG S e— of. Casing casing into Bed Rock of Testing Ended in W.hax- Material ,Ze, Depth to Water / Delivers Gals.Per.Min..for 4 hours Drawdown/feet after pumping hours at _v_GPM Date of CompletionXf6 Signat Vel1TContractor PUMP INSTALLER (To be•filled in before installation) Size & Name Pump -�j,� /�%; %S__Pump Type Used_S,&6me` rAlp Water Pump Delivers ,J� GPM Size of Tank 0260 SZ / Pipe Material Used in Well: Cast Iron (_) Gnivani.zed (_) Plastic Well Pit ( ) or Pitless.Adapter Was sleeve used torotect pipe? Yes ( NO( ) 'I pe or Name Well Sea�&/el P P P _ Date ;:..:, ,... Date Water analysis repor-t'submitted to Board of Health Date release given tD owner of record & Bldg. Insp Health Inspector BOARD OF HEALTH No.Andover; ��ass �LJ } t SUBS1RFACL DISPOSAL DESIGN CHECK LIST APPROM - DATE Provided: L 51( Title V FAIL I M DISAPPROVED DATE �S Reasons: X498 LOT CM Reg 2.5 Reg 6 The submitted plan must show as a minimum a) the lot to be served -area, dimensions jot #,abutters b location and log deep observation hoie9-distance to ties c location and results percolation t-stz-distance to ties d design calculations & calculation shc. ring required leaching area (e) location and dimensions of system-in.clti44ng reserve area f) existing and proposed contours (g) location any wet areas within 1001 of bewage disposal system or • disclaimer -check wetlands mapping (h) surface and subsurface drains within 1001 of sewage disposal system or disclaimer I(i) location any drainage easements within LDOI of sewage disposal system or disclaimer -Planning Board Piles (j) known sources of water supply within 2001 of sewage disposal a _ system or disclaimer (k) location of arq proposed well to serve lot -1001 from leaching facility (1) location of water lines on property -101 from leaching facility (m) location of benchmark (n) driveways (o) garbage disposals (p) no PVC to be used in construction (q) profile of system -elevations of baseme,it, plumb, pipe, septic tank, distribution box inlets and outlets, d.stribution field piping and Other elevations (r) maximum ground water elevation in area sewage disposal system (s) plan must be prepared by a Professions Engineer or other professional authorized by law to prep. re such plans Septic Tanks (a) capac t es- 50X of flow, mater table, tea6, depth of tees, access, pumping (b) cleanout (c) 101 from cellar wall or inground swimming pool (d) �5f from subsurface drains Reg 10.2 Distribution Boxes I(a) slop e greater 0.08 Reg 10.1 (b} SUMP Of-- HFA.. f p. j � LOT ti�►STH /�tiDov�'�, ���lA, ��P�� CAN I �q�v..ri� SVNry�.7 Q��-bwnl—�-�,VEt.� ,���ouCD1YTC 561 Tic SY STEM APR/ o .Aur�joi?jT . (�OAJPITiOtiS _ �►SAPPRQVED 1A T E R�dSoNS = / DL,)C- '5 PI~(C SYSTEM 1 J'Sl;O U -A -Fl OAJ P(NIL lti5P6—�-Tlon) A pFRO V ED U/J rc AVD(T(DUAL Jm5Fb:z; (pNs DiS,�� PP�Uv�D D,a rC R�/jSa tis a FVAL APPROVAL 10- 21 C1 1:O5S L] FAL- iSP1�(�l�VwG ,��r�tD(�i i y a e e Stevens Water Analysi's 38 Montvale Avenue • Stoneham, MA 02180• Mass. (617) 438-6114 • Salem, N.H. (603) 893-3106 LABORATORY NUMBER: 162567 SAMPLE DATE: 4/2/86 SUBMITTED BY: Robert J. DeLuca 193 Rear Salem Street Woburn, MA 01801 SAMPLE SOURCE: New Well/ Lot #2, Salem Street, No. Andover, MA ANALYSIS: According to Standard Methods of Water and Wastewater Analysis, 15th Ed. Total Coliform . . . . . . . . 0 per 100 ml Chlorides . . . . . . . . . . . PH. . . . . . . . . . . . . . Hardness . . . . . . . . . Manganese . . . . . . . . . . . Sodium . . . . . . . . . . . . Iron . . . . . . . . . . . . . Nitrate. . . . . . . . . . . . Nitrite. . . . . . . . . . . . 8 mg/L 7.8 88 mg/L 0.08 mg/L 9.2 mg/L 0.44 mg/L less than 0.10. mg/L less than 0.10 mg/L COMMENT: The results of these analyses meet the required federal and state standards for drinking water. However, the iron and manganese concentrations exceed the recommended standards. Although iron and manganese are not harmful to your health, they can affect the taste, color and odor of your water. Iron and manganese are fre- quently found at elevated levels in new wells; however, it is likely that the concentrations will decrease when the well is put into regular use. Chemist/Microbiolo ist I