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HomeMy WebLinkAboutMiscellaneous - 240 DALE STREET 4/30/2018 (2)BOARD OF HEALTH 1600 Osgood Street, Suite 2035 North Andover, MA 01845 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 . _ _ .Hda i��� 1' Phone Address)-�(� Contractor hired for work: Name Address Date for scheduled abandonment Phone The septic system at the above address has been abandoned according to Title V specifications. Signature of Contractor Method of septic tank abandonment (check one). ( removal ( ) sandfill ( ) crush ( ) other Name of Offal Hauler wt This form must be returned to the North Andover Board of Health. �J I til 4-&- 5-e we/t - P SE DP NOT WRITE IN THE SPACE BELOW OR H ALTH REPRESETIV NES ONLY 1"U 6, " I 4 Agent Date ` P� FLAGSHIP Innovate I Print I Distribute v JDa r q7(S ISVY Civ s vi ......... ........... ........... ............ ........... ................ Communicate with Confidence. • . 150 Flagship Drive, North Andover, MA 01845 ' T 800.733.1520 r 978.975.3100 F 978.975.0635 www.flagshippress.com mbLi) 45 Uttle River Rd. Iangston, NH 03848 Phone: (603) 642-8910 Fax: (603) 642-8952 Bill To Mike Bubar 240 Dale St. North Andover, MA 01845 To Invoice Date I Invoice # 5/8/2009 1228 Description of Work Completed Amount Sewer service installation completed as proposed: 6,689.00 Saw cut driveway. Supply and install erosion control. Supply and install force main from stub at street to new 500 gal pump tank. Supply 500 gal pump tank with pump and control panel. Pump and crush existing tank. 2" asphalt patch in driveway. (Finish overlay by others.) Clean-up, spread existing top soil, rake, and seed. MICHAEL W. BUBAR17 2113 1973 VIRGINIA L BUBAR 240 DALE ST. / 6 NORTH ANDOVER, MA 01845 DATE //�� /� PAY TO THE !(_ % 8 q- W ORDER QF (� ((} [ d pp :..-,...,- . A S U © Banknorth MEMO 1:21L370SL,Si: &241276034oi• LZ 3 Terms Due Date Total $69689.00 Due on receipt 5/8/2009 �1 u L BOARD OF HEALTH No.Andover, r.•,ass. 4 1 SUBSURFACE DISPOSAL DFMGN CHECK LIST APPROVED DATE__jjjFrS Provided: DISAPPROVID DATES �' �- -7 Reasons: V rAn, CK The submitted plan must show as a minimum: a) the lot to be served-area,dimensions lot #,abutters Ib location and log deep observation hoes -distance to ties c location and results percolation tests -distance to ties d design calculations & calculations showing required leaching area (e) location and dimensions of system -including reserve area S) existing and proposed contours (g) location any wet areas within 100' of sewage disposal system or disclaimer -check wetlands mapping (h) surface and subsurface drains witbin 100' of sewage disposal system or disclaimer (i) location any drainage easements within 100' of sesage disposal system or disclaimer -Planning Board files (j) knova sources of water supply within 2001 of sewage disposal e system or disclaimer (k) location of any proposed well to serve lot -1001 from leaching facility (1) location of water lines on property -101 from leaching facility (m) location of benchmark (n) driveways (o) garbage disposals (p) no PVC to be used in construction (q) profile of system -elevations of basement, plumb, pipe, septic tank, distribution box inlets and outlets, distribution field piping and Othei elevations (r) maximum ground water elevation in area sewage disposal system (s) plan must be prepared by a Professional Engineer or other professional authorized by law to prepare such plans b Reg 6 Septic Tanks (a) capacities -150$ of flow, water table, tees, depth of tees, access, pumping (b) cleanout (c) 101 from cellar wall or inground swimming pool (d) 251 from subsurface drains Reg 10.2 7 Distribution Boxes I(a) slope greater than 0.08 Reg 10.4 (b) sump J'� awn-- i -M milli D r m U) m `-T—. /r -�`,' TG OE DEr.>oG/SfIEO w rza ch r`----. -- i oA�l P4.25' D A 0 U i -A E oW I p o 0 a z Z m 70 o m x m a+ m - m N w m A m A z z m to cn N u W C A v m N Q A y Z� � O b IN I � I I � A A N ml a < g n z O C m D r = O N m -4n r" O $ = D Cll w o i m Z< z 2 O y X W C) m N zsp p p Z ?-. _ N N Z m 2 .n m -C D z G t*1 -n a z :° D a 4 z °' o Z p D t� c D LO n m N O D D N`V Q A y Z� � O b I � I I � A Sulu of HF -,1 NOJ�TH 4ti I�UEI'� , MA, o D04C 5 T w -6R SOPI=2y p re-)wt� CD WEU- AP oucDllJTe S s 5EP171 G SYS 1 EM C -,A 4Ppl-�ovI�v PA -r6, CO/JPiTiO"5 �ISAPPR�VEp D/�1E REASONS /PR�Ovw6 /urhol )Tl/ Dom. StPT'r c SysTEM t � s TA �L,4T��� cX4V4T(OJJ )AJSPEG T IOAj D4rG 3 -Zl�-� ' 015S [1 F4iL RNAL I V,5p6:�:ilo�j 4PPROOED qlm-- 3 APFIrF00iAJG AUTHOI-�� Ty ADD(T(OMAL, 1,A151bc.j jptis ()- k j,/) Dt9vP>;�dvF,D Rt -7A,50 �J5 FwAt_ APPROVAL DA T-5 D,OT� - >►-�� APP OVVJ6 6uiNngi -t\j g�7 WATERSHED RESIDENTS QUESTIONNAIRE 1. Name ` o,'\C Qxr 2. Street Address 1,21Y 0 ) Pf L e �1' 3. How many members are in your household? 4. What type of sewage disposal system do you have? ❑ cesspool K septic tank and leaching area ❑ connection to municipal 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? X 0-5 years ❑ 6-10 years ❑ 11-20 years ❑ over 20 years ❑ do not know 7. Has your sewage disposal system been rebuilt or repaired? l yes ❑ no ❑ do not know If yes, approximately how long ago? e?- years. What was done? 8. How frequently is your sewage disposal system pumped out? ❑ annually ❑ every 2-4 years ❑ every 5-10 years ❑ over 10 years ❑ never 9. Have you had any problems with your sewage disposal system? ❑ yes ❑ no If yes, what problems? ❑ repeated pump -outs needed ❑ system clogs, backs up, or drains slowly ❑ odors ❑ sewage surfaces through ground 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 (quid or powder) of detergent you use for: dishwasher CcSC e d � � e V clotheswasher FQ ;O M'fle- 12. Does your property have a lawn? Nlyes ❑ 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 Season(s) of the year 14. Please state the brand and type (liquid or granular) of lawn fertilizer you use: ❑ Check here if your lawn is maintained by a professional landscape contractor. SEPTIC SYSTEM INSPECTION FORM ADDRESS 2 446 t46 DATE INSPECTED <g PROPERLY FUNCTIONING? N WEATHER CONDITIONS COMMENTS: MATER QUALITY TES,F1�'JZ e!& S? DYE TEST PERFORMED? Y N DATE? SKETCH: 0 a