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HomeMy WebLinkAboutMiscellaneous - 235 FARNUM STREET 4/30/2018 235 FARNUM STREET /-.- 210/107.A-0054-0000.0 - % / r i I z '{ 1� f 1.` J `nJ _ � ,� \ � ,\ � � . �' � _.. _ ----�.�..---�----7 � �; \ � � i { J I. 1 � ,. MAP #. -- —__-- LOT #__...._._._.-�..... PARCEL #____ ------- STREET__._-Ad�-�. .� �......_ .1 ........_.. ... CON.STRU-CT.I_Q.N-..._APPROVAL HAS PLAN REVIEW FEE BEEN PAID? YES NO PLAN APPROVAL: DATE__ �fZ.........___._-_. APP. BY...._,,/ -. . ._. DESIGNER: _ PLAN DA f"E f j./ , _.................. CONDITIONSof yG—Y1e – -- --- ----_-- ............-------_.._......._.._._. _._ WATER SUPPLY: TOWN WELL WELL PERMIT-----_-_ WELL TESTS: C M I CAL DA I'E A{='PIlUVEU CTERIA I DA I E W."PROVED BACTE II DATE APPROVED COMMENTS: FORM U APPROVAL: APPROVAL NO DATE ISSUED_ CONDITIONS: FINAL APPROVAL: ALL PERMITS PAID YES NO WELL CONSTRUCTION APPROVAL YES NO SEPTIC SYSTEM CONSTRUCTION APPROVAL NO OTHER YES NO ANY VARIANCE NEEDED YES FINAL BOARD OF HEALTH APPROVAL: DATE: UY: SEPTIC._ S_Y_SZE.ht__xN. ..T_9.4L.A.Z _QN. IS THE INSTALLER LICENSED? YE NO TYPE OF CONSTRUCTION: NEW' REPAIR NEW CONSTRUCTION: CERTIFIED PLOT PLAN REVIEW YES NO CONDITIONS OF APPROVAL YES NO (FROM FORM U) ISSUANCE OF DWC PERMIT YES NO ' DWC PERMIT N0. �"T� INSTALLER:_iv BEGIN INSPECTION YE NO: EXCAVATION . INSPECTION: NEEDED: PASSED BY ------__ - CONSTRUCTION INSPECTION: NEEDED=�-••_.___ AS BUILT PLAN SATISFACTORY: YES APPROVAL TO BACKFILL: DATE: za A/Z/ BY-- -.-�_ _ FINAL . GRADING APPROVAL: DATE ^BY_ FINAL CONSTRUCTION APPROVAL: DATE:-_-----_BY Commonwealth of Massachusetts City/Town of No Andover IiAY .l 9 2014 System Pumping Record TOWN Or-NOKTNANDOVER Form 4HEA1. H DEPARTh:ENT__� 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 Informati®n Important:When filling out forms 1. System Location: on the computer, use only the tab E key to move your Address earsor-do not No Andover use the return key. Cityfrown State Zip Code 2. System Owner: ( Q /-� �V Name am Address(if different from location) City/Town State Zip Code Telephone Number B. Pumping Record . lr � 1. Date of Pumping ate 2. Quantity Pumped: Gallons 3. Type of system: ❑ Cesspool(s) �ptic Tank ❑ Tight Tank ❑ Grease Trap ❑ Other(describe): 4. Effluent Tee Filter present? ❑ Yes ❑. No If yes, was it cleaned? -1 Yes F-1 No 5. Condition of System: 6. Sy 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 i of auler Date Date t5form4.doc•03/06 System Pumping Record•Page 1 of 1 TOWN OF NORTH ANDOVER SYSTEM PUMPING RECORD �1 /02- STEM OWNER & ADDRESS SYSTEM LOCATION (example; left front of house) U \"I E OF PUMPING: �C/_f $��� QUANTITY PUMPED /6760 NO YES SEPTIC TANK; NO YES '.ATURE OF SERVICE: ROUTINE V EMERGENCY uul FRV.:ITIONS: GOOD CONDITION _ FULL TO COVER }-HEAVY CREASE BAFFLES IN PLACE ROOTS LEACHFIELD RUNBACK EXCESSIVE SOLIDS FLOODED SOLIDS CARRYOVER O�jHER (EXPLAIN) PI M i>ED BY. , Ix, Y' �(i' 711— — c UIMFNTS: UN I,'N'I'S TRANSFERRED TO: Address Z3�i`�' UAt ST Title of File Page of Date File Open: Date file closed: Doc Document/Action Title Date of Refer to other Purpose of Document/Action and notes action Document/ document/ Num. Action Department Board of Appeals - Board of Health - Planning Board - Conservation Commission - Building Department Gh -�`rC�,O rR�"Flt`�r�I'1.i'- w= '-' n oV o ndover No. �F t � NB�!"ji. ja'<Alrl. [R�I.e A� _ , North�TAncic er, Mass 4, —199 `` BOARD OF HEALTH PERMIT T UILD THIS CERTIFIES THATr LCU/�49 VVf W dri®pp"SAO` )Or .......................................................................... .... has permission to av o ..�ftlbuildings on Z.35... o9&N& ...S� u p Chimney to be occupied aSSAW" .....j AfIt. .... &-:-P,r.ec.' Final L�/ `��' 7 "J 7 w� provided that the person accepting this permit shall in every respect conform to the terms of the application on file in S �� `�—9 Z_ U BIN 1 PECTOR this office,and to the provisions of the Codes and By-Laws relating to the Inspection,Alteration and Construction of Roui� g L Buildings in the Town of North Andover. PERMIT FOR FOUNDATION ONLY VIOLATION of the Zoning or Building Regulations Voids this Pe it. r f REGULATED BY PARA: 112.7 S.B.C. �J C� 0J i 1"I'DATE: y/100 Z FEE PAID: UD- ELECTRICAL INSPECTOR ii k f I y f c Rough J).�� j 1. H1.I_.'1 1 ��-�i 7 1 ��J�� ��_� `� 7 . i Service PERMIT FOR FRAME/BUILDING Final Q .. .. .. . .... . ... ............ ... . ..... .... DATE: FEE PAID:______.._ BUIL G INS P CTOR GAS INSPECTOR Rou h i0 Occupy B1111211, 4 � 0' U� 9 LESS FDA FE �o O, O D � ` V DUE FRAME PERMIT$ EE. o0 Display in a Conspicuous Place on the Premises FIRE DEPT. Do Not Remove Burner , >> N Lathing to Be Done Until Inspected and Approved b r) K�. No t g p pp Y Smoke Det. � Building Inspector Town of North Andover, Massachusetts Form No.3 NORTI{ BOARD OF HEALTH . O A �• '+.,.o•�'`c9 DISPOSAL WORKS CONSTRUCTION PERMIT • 7SgACMUSEt Applicant AME d ADDRESS TELEPHONE Site Location b5 ---11C Permission is hereby granted to Construct ( or Repair ( ) an Individual Soil Absorption Sewage Disposal System as shown on the Design Approval S.S. No. CHAIRMAN,BOARD OF HE TH Fee D.W.C. No. 1 AS-BUILT CHECK LIST and FINAL INSPECTION Proposed Elevations As-Built Elevation /q3, 3 7 House J93 ,43 Tank IN 1 g 3Iv , i Tank OUT jqa. 7? D-box IN l9a- 7T D-box OUT j Trench Inverts Line 1 Line 2 , 75 Line 3 Line 4 Bottom of Exc. Stone OK? c� D-box checked? �/ Pipes cemented? �-� FORM U TOWN OF NORTH ANDOVER LOT RELEASE FO1k1 SUBDIVISIONr 1�r:_AJ (KA ASSESSORS MAP S3 — Sy SUBDIVISION LOT(S) 7 /7 PERMANENT ADDRESS ASSIGNED BY U.P.W. STREET APPLICANT f)PC)e�OWW PW I PHONE DATE OF APPLICATION TOWN USE BELUW THIS LINE PLA N NG BO AA DATE APPROVED �-- TOW PLANN .� � llA'lE REJECTED CONSERVATION COMMISSION 1�T�GC DATE APPROVED 4VI J CONSERVATION ADMIN. ,/ TE REJECTED BOARD OF HEALTH DATEAPPROVED 4LOZ . HEALTH SANITARIAN DATE REJECTED DEPARTMENT OF PUBLIC WORKS DRIVEWAY PERMIT i SEWER/WATER CONNECTIONS FIRE DEPT. L �r� RECEIVED BY BUILDING INSPECTION DATE This form shall be signed by the agents of the Planning and Health 11o.-Inds, the Conservation Commission prior to the issuance of any building permits for the subject lot. This form shall not releive the applicant from the compliance of any applicable Town requirement or Bylaw. tea . I I it _ Q •- FILE# .S 3 7 4'v�09 107 Forest St �P\'tk M(508)774-2772 s OR 5�v G� MPy SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PROPERTY OWNER'S NAME: PROPERTY ADDRESS: az 3 Fa.rn um A n OIO vt r" ADDRESS OF OWNER: 54A-(' (if different) DATE OF INSPECTION: 2 NAME OF INSPECTOR: �CG✓1 G. iC.NfCO/►�S •THE PROFESSIONAL EXPERTS IN THE SEPTIC AND DRAIN INDUSTRY• x r FILE# SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A ERTIFICATION Property Address: 33 Fvn jf0V s* Al.A ✓r r'�a• p rty Address of Owner: Date of Inspection: /J�4,� ��9� (If different) Name of Inspector: „ � Company Name, Address and elephone Number: Currier Septic&Drain Service, Inc. 107 Forest Street, Middleton, MA 01949 (508) 7742772 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 Further Evaluation By the Local Approving Authority Fails Inspector's Signature: �.GC ate: The System Inspector shall submit a copy of 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: Checld B, C, or D: A) SYSTEM PASSES: 1 have 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. B) SYSTEM CONDITIONALLY PASSES: One or more system components need to be replaced or repaired. The system, upon completion of the replacement or repair, passes inspection. Indicate yes, no, or not determined (Y, N,or ND). Describe basis of dtermination in all instances. If"not determined", explain why not The septic tank is metal, 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. (revised 8/15/95) ' FILE# SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (coNTiNUEd) 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): 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 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 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 Cesspeol 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 PROTECT THE PUBLIC HEALTH AND SAFETY AND THE ENVIRONMENT: L The system has a septic tank and soil absorption system and 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 is within a Zone I of a public water supply well. A) The system has a septic tank and soil absorption system and is within 50 feet of a private water supply well. The system has a septic tank and soil absorption system and 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 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. D) SYSTEM FAILS: 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. 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. (revised 8/15/95) 2 a ' FILE# .S3 91� j SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) D) SYSTEM FAILS(continued) Static liquid level in the distribution box above oulet 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 Ili 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. N Any portion of a cesspool or privy is within a Zone I of a public well. N 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: ' ollowing criteria apply to large systems in addition to the criteria above: The design flow o is 10,000 gpd or greater(Large System)and the system is a significant,.threat-to-public health and safety and the en nt because one or more of the following con " ' xist: — the system is within 400 feet of a surface w pply — the system is within 200 feet of ary to a surface drinkin er supply the system is in a nitrogen sensitive area(Interim Wellhead Protection (IWPA)or a mapped Zone public water supply well) The_g r or operator of any such system shall bring the system and facility into full compliance with the groundwa treatment program requirements of 314 CMR 5.00 and 6.00. Please consult the local regional office of the Department fo further information. (revised 8/15/95) 3 I FILE# SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST Check if the following have been done: ' Pumping information was requested of the owner, occupant, and 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 as part of this inspection. /As built plans have been obtained and examined. Note if they are not available with N/A. V The facility or dwelling was inspected for signs of sewage back-up. ✓The system does not receive non-sanitary or industrial waste flow. jef�The site was inspected for signs of breakout. !!!""All system components, excluding the Soil Absorption System, have been located on the site. ZThe septic tank manholes were uncovered, opened, and the interior of the septic tank was inspected for condition of baffles or tees, material of construction, dimensions, depth of liquid, depth of sludge, depth of scum. L/The size and location of the Soil Absorption System on the site has been determined based on existing information or approximated by non-intrusive methods. Z_The facility owner(and occupants, if different from owner)were provided with information on the proper maintenance of SubSurface Disposal System. (revised 8/15/95) 4 i 'I FILE# 573 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION FLOW CONDITIONS RESIDENTIAL: Design flow: _gallons Number of bedrooms: Number of current residents: 3 Garbage grinder©or no): Laundry connected to s stere or no): Vcs Seasonal use(yes 3:1VU _ Water meter readings, if available: dQ n O906o or x33 qa Last date of occupancy: Nrretlt— Type stablishment: Design flow- Grease trap presen Industrial Waste Hot: r no) Non-sanitary wastei : (yes or no)Water meter readin Last d occupancy: ' OTHER: (Describe) Last date of occupancy: GENERAL INFORMATION PUMPING RECORDS and source of' formation: System pumped as part of inspection yes r no) &s If yes, volume pumped: /s'avallons Reason for pumping:_< 1' b,ei lad d►.2 i'd � a.1 H..-- S KS TYPE STEM Septic tank/distribution box/soil absorption system Single cesspool Overflow'cesspool Privy Shared system(yes or no) (if yes, attach previous inspection records, if any) Other(explain) APPROXIMATE AGE of all components, date installed (if known)and source of information: Sewage odors detected when arriving at the site: (yes oretlal� & (revised 8/15/95) 5 LFILE* S �� SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) SEPTIC TANKAan(locate on site Depth below grade: �.� Material of construction: ✓concrete Metal FRP other(explain) clean ac- 'JVAk I au in vat; 5 a„ Dimensions: 5 ' e 5V. Baffle Depth Below Outlet Invert: /6" Sludge depth: G" Distance from top of sludge to bottom of outlet tee or baffle: � Scum thickness:a" Distance from top of scum to top of outlet tee or baffle:_ Distance from bottom of scum to bottom of outlet tee or baffler Comments: (recommendation for pumping,condition of inlet and outlet tees or baffles, depth of liquid level in relati n to outle invert structural integrity, evidence of leakage,etc) � i a u Sa.re johq iDas it rignA i 'i a/oan r CLrLu°. i S L' rdn N GREASE TRAP:-k)Q ' (locate on site a P ) Depth below Material of construction._ crete_metal_FRP_other(explain) Dimensions: Baffle Depth Below O Scum thickness: Distance from top of scum to top of outlet tee or baffle: Distance from bottom of scum to bottom of outlet tee Comments: (recommendation for g, condition of inlet and outlet tees or baffles, depth of liquid level in relati outlet invert, structural inte idence of leakage, etc.) (revised 8/15/95) 6 } FILE# SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) TIGHT OR HOLDING TANK: /"v (locate on site plan) Depth beTdade: Material of constr _concrete_metal_FRP—other(explain) Dimensions: Capacity: gallons Design flow: gallons/day Alarm level: Comments (condition of inlet tee ition of alarm and float switches, etc.) DISTRIBUTION BOX: KS (locate on site plan) Depth below grade:-24 Depth of liquid level above outlet invert: j�' rta Dimensions of D-Box: S"X//''Depth of Sump: Comments: (note if level and distribution is equal, evidence of solids carryover, evidence of leakage into or out of box etc.) - a&t 2 /n c u-. 75 a "to It is n' PUMP CHAMBER:A)d (I to on site plan Depth below gra e. Pumps in working order:(yes Comments: (note conditions of pump cha ndition of pumps and appurtenances, e . (revised 8/15/95) 7 r FILE# SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) SOIL ABSORPTION SYSTEM (SAS): eS (locate on site plan, if possible excava ion not required, bu may be approximately by non-intrusive methods) Depth to bottom of SAS:1K(Stone or Pit) Facf�w.4�,c @o o� Tru+d�es If not determined to be present, explain: / Type: leaching pits, number: leaching chambers, number: leaching galleries, number: leaching trenches, number, length: 40 Te 'd-csUS��t� � se m Tv PVC leaching fields, number, dimensions: Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.) iJr HS Ot �/ CJ G L reLn 0' C SSPOOLS: (loc on site p an) Depth be rade: Number and con ration: Depth-top of liquid to i invert: .. Depth of solids layer: Depth of scum layer: Dimensions of cesspool: Materials of construction: Indication of groundwat inflow(ces of must be pumped as part of inspection) Comments: (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetatio , PRIVY: (locate' site plan) Materials of construction: Dimensions: Depth of solids: Comments: (note condition of gns of hydraulic failure, ev in , condition of vegetation, etc.) (revised 8/15/95) 8 FILE# I SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) SKETCH OF SEWAGE DISPOSAL SYSTEM: include ties to at least two permanent references landmarks or benchmarks locate all wells within 100' Atoow ,235- ra,rncnm 5�. /q }eD = 361 qn0lovye- to D 46% A /SDO�w l 3 ix 6 N PTH OF GROUNDWATER Depth to groundwater: feet method of determination or approximation: oast �`fs ���k car �t ,�W g i w/cx. 20► f 0 r_ .,�,010. CTJ R-coup, s i. /+OK Se. has GL 0411 c t 1I� KJ� Nw �sUtwdJ 1�bt/Ma ar .�a�rir r (revised 8/15/95) 9 i G A t,.r(F- , t�,.i osis-r i--i A f...,n civ r�� , M A ss• 0 rtG 0 f:o� la(aZ 0 ov r H sty 14 o�rr-t-e�cC l`i2.�o�S •. l" sox t4z.s,` •• ¢3 ¢ �I ovr tax t42..3Q .• > gel 5,� 2Q.Gr�Z l P1�•61 .. �� I tU SPtc.GT�O Tl-tE - \ Ce�•.�� '�,VGTto�..l. of � rCsc�'`cr.l-F-+E.�*•1fl 'TH '� � tS D�SPes� - �Ew TN AT t TH C--- C_,j,ST-VjC7t .0 U tJ A� Ca F-i&j q_.�.2.A�atG /1, ,to6 rias F5 t..t .v f f4c'�eo fZD�4JGt✓V-)TH I / dlt? 1s R3, Tt+E DESIC�{E2.S S !O ��.•►'ZTcA-IT A...ro THgT D� �T••3 Tt•+f?,t-,t A'�L'Tzf Ac..S �,�� - v�EC7 Cou 6e• SU4 4,, a...`pn 3toGc•-f�.lSoo (V 't2 roo' �Q I _ OGS Cy F•'FSe— S-r- +tow►J A>zE Fosz. 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AO '�ih��r� �(1�.. .• Hrsr7rl '' .��` �.R�D h�o (jJ�� t`+'. • 1P, ..• r; ;PV..•..; ;�� . Ido iA r. .,. 11 ` f •� �"d`\;�� iLu.Mv�:a.-..m4-y':a���i•�4 1.�.-:.s:_»...d.r'dudVIJ..�+..• .. .._.�..........�..r..a. ' ,e•- #N' _ W tf r�,00 GBo.0 f' .. x'471,14 �11 277 FARMIMST• Town of North Andover, Massachusetts Form No. 1 F NORTH qA BOARD OF HEALTH--,,,,,,, `A t F6•Y�L 19 * 1 rp O APPLICATION FOR SITE TESTING/INSPECTION ��SSACHUs���h Applicant` NAME ADDRESS TELEPHONE Site Location Engineer NAME ADDRESS TELEPHONE Test/Insppeection Date and Time CHAIRMAN,BOARD OF HEALTH Fee ? 6 Test No. � - S.S. Permit No. D.W.C. No. C.C. Date Plbg. Permit No. Town of North Andover, Massachusetts Form No.s f AORTil BOARD OF HEALTH � w F • i • ---- �' ' DESIGN APPROVAL FOR +I. b,,..e.•" • �ssACNUSEt� SOIL ABSORPTION SEWAGE DISPOSAL SYSTEM Applicant Test No. : Site Location Reference Plans and Specs. • ENGINEER DESIGN DATE 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 L Site System Permit No. f! l«7N,.Y {r;'il�y�i JI�1 t���,y �'4Y4 M•�'�11� 111 S .. '9 �rl4 iS4f y "�� Ijr� t31'1 � pp��Ppp� V �IIwCEI ,Commonwealth'of Massachusett SCP `� 3 2010 wn'of.NORTH ANDOVERMASSTS S S@h1 Pim 1t1 R@COrd HEALTH DEPARTMENT Y Form,.4: �. 9:. DEP has provided this form for use by local Boards of Health. The System Pumping Record r be submitted to the local Board of Health or other approving authority. A.Facility Information ung out 1. stem Lo tion: 1 the r,use tab key. VI :-, Y ,our qzj10.not cl /Towetum ty n StateC e 2. System 0 Name . I I Address(If different from location) City[Town State Zip Code Telephone Number B. Pumping Recor ,, a 1. Date of Pumping 2. Quantity Pumped: Gallons 3, 1 Type of system.: ❑ Cesspool(s) ❑ eptic Tank ❑ Tight Tank ' Other(describe); 4. Effluent Tee Filter present? ❑ Yes ❑ No If yes~was it cleaned? ❑ Yes ❑ No 5. Condition of System; em Pumped 6 . By: an me Vehicle License Number al=-±,c aymce- Company, 7.~. Locatlo where contents were disposed; Date � it mass.gov/dep/water/approvalsft5forms,'htm#Inspect •08/03 c � ,.. System Pumping Record•Page i of