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�'�s�..,o •E� BOARD OF HEALTH a` 't' .: . , 1r•�
S„` NORTH ANDOVER, MASS . / k,4 -
APPLICATION
,4JAPPLICATION FOR WELL AND PUMP PERMIT
Permit # Da� I,/�
A permit is requested to: drill a well install a pump
Lot #
Owner Wdl e, ylj)nf-e� Address /3 6 d /42 Tel �14 003 1_ U
Well Contrctr Add. Tel
I
Pump Contrctr Add. Tel
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WELLS (To be completed at time of pump test. ).
Type of well � Use Gp J "e-i—
Diameter - -
Depth of AID A/6-/7—
Seal beer "
Depth o f
Depth to [
Drawdown I AC O �- T /�. /v / 1 ",�', � - long?)
Date of d -P&4itractor
,� ���
rEY�eYkk�et**�
PUMPS ( ,
Name & sl*'
Size of tank Pump delivers GPM
Pipe used in well: Cast iron (_) Galvanized (_) Plastic (_)
Sleeve used to
Post-it®Fax Note '"x/671 Date1 O paOf I,- seal
Date T04 W? From 4k
f P
Co./Dept. Co. a l l er
Phone# Phone# K43
Date water analy Fax# 8 /�J,.S Fax#
o
Plumbing inspector Wiring inspector
DEC — A 2001
Board of Health
t HORT/y' J
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��''�,,,o ••�� BOARD OF HEALTH
..SAC US NORTH ANDOVER, MASS .
APPLICATION FOR WELL AND PUMP PERMIT
Permit # Dat'�
A permit is requested to: drill a well !/ install a pump
LOCATION:"2 l rI�l �e Lot #
Owner Nkje, X1q)Wee4 Addressc;VV 13r/ d X e A Tel 176p-
Well Contrctr Add. Tel
Pump Contrctr Add. Tel
WELLS (To be completed at time of pump test. ).
Type of well Use
Use `e
DiameterF - - -
Depth of
AID
N6 7`-
/9;2-7Ae<O
Seal beef
Depth of G G / '� �. 11-
Depth to �� �
Drawdown_ ® m- �/� JU /� Ut / , � long?)
Date of o
itractor
PUMPS
e-ola:5 com)(I ,D
Name & sig IZ121/0 f
Size of tank Pump delivers GPM
Pipe used in well: Cast iron (_) Galvanized (_) Plastic (_)
Sleeve used to protect pipe? Yves (_) No (_) Type well seal
Date
Signature of pump installer
Date water analysis report submitted to Board of Health
Plumbing inspector Wiring inspector,
DEC - 42001
Board of Health
Address 1
K) 1 )6 A Title of File Page of
Date f=ile Open: nate foie closed:
Doc Document/Action Title Date of Refer to other Purpose of Document/Action and nates
action Document/ document/
Num• Action De artment
Board of Appeals — Board of Health - Planning Board _ Conservation Commission — Building Department
173
� 5
APPLICATION FOR SEWER SERVICE CONNECTION
g �p�
North Andover, Mass.
Application by the undersigned is hereby made to connect with the town sewer main in r f Street,
subject to the rules and regulations of the Division of Public Works.
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The premises are known as No. l.s f �L Street
i
or subdivision lot no.
I�
Oner Address I
Contractor Address
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Applicant's Signature
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CoA15t--- e V'q i!ox/
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PERMIT TO CONNECT WITH SEWER MAIN
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The Division of Public Works hereby grants permission to d
to make a connection with the sewer main at Street
subject to the rules and regulations of the Division of Public Works..
Division of Public Works
By
Inspected by
t '
Date I
See back for rules and regulations
Date. .!�. . `3C .r
N°- 447 �.
"o o TOWN OF NORTH ANDOVER
o : PERMIT FOR PLUMBING
49
k SACMUS�
I! This certifies that .!`-! . . . . . . . . .
has permission to performr--�"/. :�. �
plumbing in the buildings of,: . `'"``��"-'. . . . . . . . . . . . . . . .
at cr,�. _ /. . . . . . . . . .. North Andover, Mass.
Fee" . . . . . . .Lic. No.. . . . . . . . .
/ PLUNIBv: INSPECTOR
{ Check #
WHITE: Applicant CANARY: Building Dept. PINK:Treasurer
MASSACHUSETTS UNIFORM APPLICATION FOR PERMIT TO DO PLUMBING
(Type or print)
NORTH ANDOVER,MASSACHUSETTS622 61,
�Date luo
Building Location / Owners Name .K:/ Permit#
Amount
Type of Occupancy
New Renovation Replacement Plans Submitted Yes No
FIXTURES
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RASM*ir
MFLOM
MFLOCR
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4M MOOR
SIH ROM
6M H OCR
RaR
SIH H.00R
(Print or type)// Check one: Certificate
Installing Company N Corp.
Ad ` Partner.
f Q�
usiness Telephone Firm/Co.
a Name ofLicensed Plumber.
Insurance Coverage: In 'cate the a of insurance coverage by checking the appropriate box
Liability insurance policy Other type of indemnity Bond
I
Insurance Waiver. L the dersigned, ave been made aware that the licensee of this application does not have any one of the above
three insurance
Signature Owner El Agent
r
I hereby certify that all of the details and information I have submitted(or entered)in abov pplicati true and accurate to the
best of my knowledge and that all plumbing woos and instal o er rt fo s application will be in
compliance with all pertinent assatfi tate Plu 2 of the 1 Laws.
By: aude icens r
Type of lu mg Lice
Title
City/Townicense i um er Master Journeyman
APPROVED(OFFICE USE ONLY
Town of North Andover, MA
Watershed Septic System p D
Servicing Report �9
Date: e-1- 4
DANIEL A. GIARD
Homeowner: Pumper SEPTIC SERVICE
street3 ✓ dw� Address:
NO. ANDOVER, MA
Phone 2? coo Phone
U t
Nature of Service: Routine Ll--,,
Emergency
Observations: Good Condition •'
Full to Cover
Baffles in Place
Leachfield Runback
Excessive Solids
Heavy Grease
Roots
Other (Explain)
Description of Work:
Comments:
BOARD OF HEALTH
TOWN HAIL • 120 MAIN STREET
NORTH ANDOVER, MA 01845
Yameen, Kenneth
224 Bridle Path
r, North Andover,
MA 01845
/ V
-- - -- ,�►=::1;:711=:i:tl::i��:3:::i:� I-,tk1.,,111..1?i
DATE ( INVOICE NUMBER/DESCRIPTION I CHARGES I CREDITS I BALANCE
BALANCE FORWARD
tiv C/Ci
J
--
.......................................e-`.
_....._._.........
--..__.. ..... .....
................ _.._. .... ....
..........___.. _ .._...__..
Cil G1C�Ytf?i Q
DANIEL A. GIARD ( 61U PAY LAST AMOUNT
v IN THIS COLUMN
PRODUCT 100.2;a Anc..Groton.Mau 01471.To Order PHONE TOLL FREE 1 800.225 5icCi
NORTH ANDOVER, .BOARD OF HEALTH '
SUBSURFACE DISPOSAL SYSTEM CHPxK LIST
4PPROVED PROVIDED DISAPPROVED
of ��
General Information
Reg. 2.5 ail OE The submitted plan must show as a minimum:
a the lot to be served (area,dimensions, lot #, abutters)
location and dimensions of system (including reserve area)
design calculations
calculations showing recuired leaching area
existing and proposed contours
location and log of deep observation holes-distance to ties
ocation and results of percolation tests-distance to ties
location of any wet areas within 100' of the sewage disposal
system or disclaimer
surface and subsurface drains within 1001 of sewage disposal
system or disclaimer
location of any drainage easements within 1001 of sewage
disposal system or disclaimer
known sources of water supply within 2001 of sewage disposal
system or disclaimer
location of any proposed well to serve the lot(1001 from leaching facilit
cation of water lines on property (10t from leaching facilities)
(Tr)—maximum ground water elevation in .area of sewage disposal system
o location of benchmark
lan must be prepared by a Professional Engineer or other
professional authorized by law to prepare such plans
veways
arbage disposers
profile of the system (elevations of basement, plumbers pipe
septic tank, .,distribution box inlets and outlets, distribution
field piping and any other elevations)
no PVC is to be used in construction
Septic Tanks
Reg. 6.1 a Capacities - 150% of. flow
Reg. 6.7 Water table
Reg. 6.$ c Tees
Reg. 6.9 Depth of tees
Reg. 6.1 a Access
Reg. 6.1 Pumping
g Cleanout
leg 3•7 (h) 101 from cellar wall or inground swimming pool
�5t from subsurface drains
Pums
leg: 9.1 a Approval
leg: 9.6 : (b) Stand-by power
SOIL PROFILE & PERCOLATION TEST DATA
i
T ewn/ No.&Street Lot No.
Loc./Subd}16TCi�aGc�od� c�.,_ Owner_
Investigato,I� .e.Ag w Observer
SOIL PROFILES-DATE
p 1' E v. 2' Elev.� 3' Elev. 4'Elev.
5124177 0 0 0
X
. 2 2 2
N
3 3 3 3
4 4 4 4
S _ . _ $
6 6 6 G
__ 7.
- 7 _ . 7 \
V
—_ 8 - 8 = 8
E�
9 9 9 _
10 10 10 10
Benchmark Location- i
Elevation- - - Datum
Percolation Tests-Date -
77 3- 77 N? 7
Pit Number 1 2 3 4 S I
Start Saturation /
Soak-Mins.
Start Test-.Time
Drop of 3"-Time
Drop of 6"-Ti-me
Mins. lst "Dro
Mins.2nd 3"Dro
Notes--&-Sketches7on Back Frank -C.- G/e"linas-& Associa/te-s,--North And.V ^ -
NORTH ANDOVER,-BOARD .OF HEALTH
INSTALLATION CHECK LIST
AP VED DATE DISAPPROVED DATE EXCAVATION OK
REASONS: _
FAIL OK o� f
1 . Distance To:
Wetlands
Drains
Well
Water Line Location
3. No VC Pipe
4. Sep c Tank
Tees - Length & To Clean Out Covers
Cement Pipe to Tank - On Both Sides of Tank
5. Distribution Box
over & Box - No Cracks
All Lines Flowing Equal Amounts
No Back Flow
i
6. Leach Field or Trench
' mensions
tone Depth
Capped Ends !
Clean Double Washed Stone
7. Leach Pits
Dimensions
Stone Depth
Splash Pads
Tees
Cement Pipe to Pit - Both Sides
Clean Double Washed Stone
No Garbage Disposal
. nal Grading Inspection
'i B Covered System
b�nitt
Lot Location
Dimensions of System
-Location with Regard to Perc Test
Elevations
Mater Table
r
andover
consultants EIGHT TILTON STREET
METHUEN. MASSACHUSETTS 01844
inc. (617) 687-3828
fProjr.,.1(,na1 (engineers
i liATL f ���U
and Cl it"eyors — -
TO . NORTH Ai';DOV2R HEAL`IH-tiRTLIENT
T041"\_ FL4LL , 1r0. ANDOV2R , 1._-ASS .
RE, : SUBSURFACE 6Ei4AGE, DISPOSAL SYSTEM
eZ-A PA771 , NO. ANDOVER 1 ASS .
I hereby certify that I have inspected the construction of the
disposal system at L,oT Z 2-4 BkF40e,6_= ,-;477--1 North Andover, Mass .
and that the location and elev s are as shown on the As-Built
Drawing dated .S&-P . fZ /7 pp
MAs`91
WILLIAM �yc AN OVER CONS. TANTSS �/�, INC.
U S fL`
T�
MALL"tOD y v
A No. 742 L4 illiam S . I�_acLeod
�F0STER�� ��Q� Registered Sanitarian
S' �P
This c ti ic4L is not t 'A LC ued as a -uarantee of the system.
�2T CLEV14 T/ONS',.
°
513 b°' � A T IIOUSC. . .
TA/vK INLET
13 5 TW,,Vk 00 TL t 7'
BOX /NLET- - - - - - 174 83
BOX OUTLET - - - - - -/7¢6,�-
> Z-AID OF 3,6-D - - - - " / 74-.50
,SOT. 0,-r'- 3ED . . - - - - . /7.3. rZ10
o7 5� 2
5 �� UT
14, 0
b � 2
a
)0'
5� po
E"x P AREA
goo-S-F J o
0
ass BED �.
goo S F
?o AS - gLz/L T D/,::,.LaW15-00 ,5AZ-L OA/
/N
' � �� '° cJUB�SU.2.C�1C'E c.SE lit/A�E D/SP�SAL sYS TE,'1/I
TANK 1�
�CILE '
D,4 7-,E: SEPT. /2, /978
E-X�S,T Dlrv�v��e: L 0ND01U 1-10,4-IE"s, /NC.
Dc
C R O S S S T. 4AJD O VEW) ,OA-5S.
Zoc,4rio" L07- 22 ,4 8)e/OLE Pi4TH
g ,Doe T/o/v OF /VOR TH AADO XER , ,0A S S-
L07- 22 A
andover WILLIAM
L:s26s'.. consultants S
:.. Q=224.03'-"� �ct�p ti
inc. , �o � o. 2 Pa
OZ' PA 8 Tilton Street, Methuen , Mass. �Gh'At_sPi
/0 .35 Tel. 687- 3828
. .�/ v1e4vv//l/ 6L /T�/ aTrQCNE C
a
SEPTIC SYSTEM INSPECTION FORM
r
)DRESS
DATE INSPECTED 7 1 f
i
iPROPERLY FUNCTIONING? Y N
WEATHER CONDITIONS
COMMENTS :
DYE TEST PERFORMED? Y N
DATE?
SKETCH:
WATERSHED RESIDENTS QUESTIONNAIRE
1. Name Z '/11
2. Street Address
3. How many members are in ,your household?
4. What type of sewage disposal system do you have?
❑. cesspool I
�[2 septic tank and leaching area
❑ connection to municipai sewer
❑ other (describe)
❑ do not know
5. Are the plans (drawings) for your sewage disposal system on file with the Board of Health?
/Q yes ❑ no ❑ do not know
6. How old is your sewage disposal system? ❑ 0-5 years D' 6-10 years El 11-20 years
❑ over 20 years ❑ do not know
7. Has your sewage disposal system been rebuilt or repaired?
❑ yes ❑, no C do not know
If yes, approximately how long ago? years. What was done?
8. How frequently is your sewage disposal system pumped out? 01annually
❑ every 2-4 years ❑ every 5-10 years 01 over 10 years Elnever
9. Have you had any problems with your sewage disposal system? ❑ yes Z no
If yes, what problems?
❑ repeated pump-outs needed
❑ system clogs, backs up, or drains slowly
❑ odors
❑ sewage surfaces through ground
I
10. How many of each appliance are connected to your sewage disposal system?
washing machine - dishwasher >% garbage disposal
dehumidifier drain sump pump toilet
roof/pavement drains shower/bathtub _
11. Please state the brand and type (liquid or powder) of detergent you use for:
dishwasher
clotheswasher ,4
12. Does your property have a lawn? yes ❑ no
If yes, approximately what size?
❑ less than 1/4 acre ❑ 1/4 acre ❑ 1/2 acre ❑ 3/4 acre , 1 acre
❑ more than 1 acre (Specify) acres
13. How often do you fertilize your lawn?
No. of applications per year 2 -
Season(s) of the year =r ;` <;
14. Please state the brand and type (liquid or granular) of lawn fertilizer you use:
1 , P
Check here if your lawn is maintained by a professional landscape contractor.
BOARD OF HEALTH
27 CHARLES STREET
NORTH ANDOVER, MA 01845
TELEPHONE# (978) 688-9540
APPLICATION FOR ABANDONMENT
OF SUBSURFACE DISPOSAL SYSTEM
(SEPTIC SYSTEM)
Pursuant to Section 310 CMR 15.354
of the State Environmental Code, Title V
Name m t A) Phone
Address 2 idlc-
Contractor hired for work:
Name DANIEL A. GIARD Phone (978 ) 686-7653
Address 130-A APPLETON ST. NO. ANDOVER MASS.
Date for scheduled abandonment q- / Z - 0-0
The septic system at the above address has been abandoned according to
Title V specifications.
Signatide of Contractor
Me od of septic tank abandonment (check one). ( ) removal ( ) sandfill
(. crush ( ) other
Name of Offal Hauler DANIEL A. GIARD
This form must be returned to the North Andover Board of Health.
PLEASE DO NOT WRITE IN THE SPACE BELOW FOR HEALTH
REPRESENTATIVE'S USE ONLY.
Inspecting Agent Date