Loading...
HomeMy WebLinkAboutMiscellaneous - 246 CANDLESTICK ROAD 4/30/2018 (2)Commonwealth of Massachusetts City/Town of NORTH ANDOVER, MASSACHUSETTS - System Pumping Record RECEIVED Form 4 DEP has provided this form for use by local Boards of Heal h. ThQ SysEem Roo ping ecord must be submitted to the local Board of Health or other approvin .fVA06'rtyJ0RTH ANDOVER HEALTH DEPARTMENT A. Facility Information Important: When filling out forms on the computer, use 1. System Location: oZ 14 b CQnd C,i< only the tab key Addr to move your A &64". W.6 csor - do not use the return City/TowT State Zip Code key. 2. System Owner: 1 Name Address (if different from location) City/Town State Zip Code _ G7S- 5 -i bob Telephone Number B. Pumping Record 1. Date of Pumping Dag- 9 -09 2. Quantity Pumped: Gallon() 3. Type of system: ❑ Cesspool(s) [Septic Tank ❑ Tight Tank ❑ Other (describe): 4. Effluent Tee Filter present? ❑ Yes 2*'No If yes, was it cleaned? ❑ Yes ❑ No 5. Condition of System: - — .6. System Pumped By: j Na e Company 7. Location where contents were disposed: Signature of Hauler http://www.mass.gov/dep/water/approvals/t5forms.htm#inspect -7 6v-) 9 - Vehicle License Number Date G.L.S.D. Lawrence, MA. i5form4.doc• 06/03 System Pumping Record • Page 1 of 1 Commonwealth of Massachusetts �a4 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 auth RECEIVED A. Facility Information Important: NOV 13 2006 When filling out 1. System Location: forms on the f� TOWN OF NORTH ANDOVER computer, use ���Ct /� only the tab key Address to move your N" Aoi��Jk cursor - do not City/Town State Zip Code use the return key. 2 System Owner: Name Address (if different from location) City/Town Stat / Zip Code Telephone Number B. Pumping Record 1. Date of Pumping Date 2. Quantity Pumped: Gallons�� 3. Type of system: ❑ Cesspool(s) [Septic Tank ❑ Tight Tank ❑ Other (describe): 4. Effluent Tee Filter present? ❑ Yes 93-'o If yes, was it cleaned? ❑ Yes ❑ No 1 5. Condition of System: 6. System Pumped By: Name Vehicle License Number C mpany 7. Location where contents were disposed: http://www.mass. t5form4.doc• 06/03 System Pumping Record • Page 1 of 1 D17AZ fiW0FPENJCSAF= per dt No.6 0 3X 8QA1PDOiPF�PBPREVP1V1 WR _ �M7�t12� OCCUvOCy At Fen Checked APPUCATT NFOR PERMIT TO PERFORM ELECTRICAL WORK Am WORK To BE PERFORMIN ACCORDANCE WMI THE MASSACHUSSTS ELECrRXAL cone, 527 chat 12:00 �ZD(PLEASE PRDIT IN INK OR TYPE ALL WORMATION) per Town of North Andover To the Inspector of Wires: The undersigned applies for a permit to perform the electrical work described below. Location (Street R Number)C2 / ,P1, S Owner or Tenant o Owner's Address 5�k Aognllff Is this permit in conjunction with a building permit: yes [o"No a purpose of Building �A �S / �.Ch c e Existing Service Amp� /...Volts Overhead [ New Service Amp..../.Volts Overhead [ Number of Feeders and Ampacity (Check Appropriate Box) Utility Authorization No. Undepound No. of Metas VnderP'otirid [' No. of Meters Location and Nature of Proposed Electrical Work e, i ►'t y 101 p Na or I301ina Ootift No. of Hot Us N0. of Trnnbnnpa TOW No. of lid RIMM Switnadq pool Above KVA KVA No. of Receptock Owft NO. at oil Boman No. of Etowgm cy l3ahtina Battery Uaite No. of Switch Ontim No. of Ou Boman MIRE ALARMS No. of Zona No. of RwW6 No. of Air Cond. TOW TOW Na of DetWW a W No, Of Diapo"k No. of Had Totd ToW PUMP Tone Kw Wtladoa Derider N0. of S01oaft Dander No. of Dishwuhen Space Ana Heather KW No. of SW CootW oWDaftawsomift Devica Mmkipd 0 Odw No. dDryer paw KW No. of Wales Neaten Kw Na Of No. of ShLU Bdhuie No. Hydro Mune Td x No. of Mown TOW Hp t itauan Qmw Ptrotatbbere�icres�dll�tasit3trrmll lhttreaaae�tliabi�isatxRtY+�� a'�sfarttfilirlec}iVd� y� a NO Iharesttsnlbdvefdpta�dseabfreOIDtq Y$9 ryoula�ted�eda+MpkMidrnttlretypedco�etgby I=o o WakbSM —US >rI ..tntrzisIOz� MMNAME ILL F rbdvakzdHmWW Wc* $ Pao l* Liostze t G �/y' ��- iimaeNo �� 5,� y BiailzsTliNn n ,t�.a mrd' � � Aft'MNa OWI�WSiI AtANCEWArMtl nawaetainijm dmmt te'� orkls�ritleMve�c�reguiedbl'1 sztrkCkrnilLawM atdthxrrp�s�r�entfiispetmkapplcttlmwsivsfireQi�t (Man check one) Owner Apat Telephone No. PBRMdTr' FisB s FORM - U - LOT RELEASE FORM INSTRUCTIONS:. This form is used to verify that all -necessary approval /permits from Boards and Departments having jurisdiction have been obtained. This does not relieve the applicant and or landowner from compliance with any applicable requirements. APPLICANT 1 �•y �uv�tn PHONE 17� -17s-- ASSESSORS 975ASSESSORS MAP NUMBER 10(0,4 LOT NUMBER Z° SUBDIVISION LOT NUMBER STREET CC, hJ(e S� STREET NUMBER R .r..rrr.rrrrrrr.....r........................■.............................. OFFICIAL USE ONLY RECONOvIENDATIONS OF TOWN AGENTS ........................................................................... DATE APPROVED CONSERVATION ADMINISTRATOR CONIMENTS TOWN PLANNER COn/Ily1ENTS DATE REJECTED DATE APPROVED DATE REJECTED DATE APPROVED DATE REJECTED DATE APPROVED Q�00 5-1 ft7���lc7�it�C�llr�1�� PUBLIC WORKS — SEWER / WATER CONNECTIONS DRIVEWAY PERMIT DATE APPROVED FIRE DEPARTNIENT DATE REJECTED COMMENTS RECEIVED BY BUILDING INSPECTOR DATE RECEIVED AUG 1 9 2005 BUILDING DEPT. N A W VP -1 .0 VP -2 �.•'�'/ VP -4 VP—,3A. .�• •;i' i� �Wf go VP— VP -6 .•fie nai 106 VPVP-7 ._.� ' e Of WF 105 R +•�"' Edi / II • Pro, Edge I� Fen �i.�" WF 104 of I� WF 103 yVet 6ri Woods et � e. � o T I- WF102/�A �'� J. A\ .I ae F A. — H e. I 10; �I I 101 ill D \C G O • • £xsting • ' A•op. Poo/ Deck E9+�lP Loc _ 50' No / Disturb Ione Existing Xt Dwelling 75' No Proposed Alteration Build Zone Within 75' No Build From Verna/ Zone From Verna/ Poo/ , Pool = 410 SF. Lot B 43, 711 S. F. / 1.00 Acres Approximate L ocoti. Of Existion ng Leaching Facility Token From A Sanitary D/sposo/ System Design, Doted 10/15/86 R=125.00' L=20.00' `roe\ Assessors Map 106A, f /• / 25' from /Wet/ands 50' No , Disturb Zone / Fro7f Verna/ / P / f� 12" •: • . • • Proposed inground 1.30.00' Candlestick (Privote , 50' Wide) 4. 1 --<xis ting Bit. Conc. I Driveway I Roa d Assess ProQose Mitigotic Area 50' Fn Wetland 1 M00% Proposed s Proposed Concrete Patio 4 - LETTER OF TRANSMITTAL North Andover Health Department 400 Osgood Street North Andover, MA 01845 978.688.9540 - Phone 978.688.8476 - Fax h lthd t(a�t f rth d E '1 ea %'L! L"'/ no an over.com - -mai www.townofnorthandover.com - Website Page _/ of 4 NORTH oCoe It � �s�ac ,6 qq►� �y n eh rr� `T IAMf T� TO: DATE: COMPANY: FROM: Pamela bol Chiaie, Health Dept. Assistant Phone: A Fax: SIGNED: We are sending _you: OCopv of Letter 17Plansh- (fill in below) These are transmitted as checked below: OApproved as Noted OAs Requested OAs Required OResubmit OFor approval OFor Review and comment OFor Your Use OSubmit copies for approval copies for dist. REMARKS: COPY TO: COPY TO: SIGNED: COPY TO: TRANSMISSION VERIFICATION REPORT TIME 06/09/2005 11:18 NAME HEALTH FAX 9786888476 TEL 9786888476 SER.# 000B4J120960 DATEJIME 06/09 11:15 FAX N0./NAME 89789750456 DURATION 00:02:06 PAGE(S) 03 RESULT OK MODE STANDARD ECM r- ,s fools & Septic Systems # Why do I need this approval? Unless the hoard _ofHealth approves the location of the proposed pool, the Building Department will not issue a building permit. The Board of Health reviews all applications for residential pools that are proposed for sites with septic systems to make sure that the pool is not being placed on. top of the septic system components, on or in the leach area or on or ►n a reserve area. In addition there are certain setbacks to the septic system and any well on site that must be maintained._ What do I need? For the Health Department review you will need the following documents: • Scaled plot plan with house and septic system accurately located; • Plan location of your proposed pool at the correct scale added to the plot plan If you do not have this information in your own files, the Board of Health may be able to help you by providing a copy of your septicAs--Bui/t plan. Who do I see? To obtain a copy of your As -Built (the plan that shows your lot house and septic system as it was buil4, you may request a copy to be made at the Health Department if one is on file. If you cannot obtain a scaled copy, you may want to request that your septic tank pumper come out and locate the septic system, components. A Civil Engineer may also locate the system and can then prepare a certified plot plan. Once you have the plot plan and are ready to site the pool, there are a few rules you need to keep in mind. They are: ._• In -ground pools must be at least 20 feet from the septic system leach area and at least 10 feet from the septic tank. • Aboveground pools must be at least 10 feet from both the leach area and the septic tank. If there is a well on the property, regardless of the well's use, then: • Both types of pools must be at least 15 feet from the well. These setbacks include all parts of the pool, such as fences, decks, cement walkways and grading. How do I do this? To start the process you mustli'irst go to the Building Department and apply for a permit to install a pool. You will pay a fee and receive some paperwork. You will have to go through the Conserva- ton omm►ssion it you have wetlands on or near _your property. It is always wise to check with the Conservation Department whenever _you are planning an outside project that will x /1 ovoin aon osuior rmtees. Yom - can, at the same time you are working with conservation, sub -mit your paperwork Health Departmen or review and approval. If there is a =problem with the application or if information is missing, You will be contaeted and asked to supply additional paperwork or clarify somet ing on your app kation. final approvai and issuance of a buildin permit will depend on t e approval of all pertinent departments. Other References: • 310 CMR 15.000 of the State Environmental Code, Title 5 (Download a copy online at www.state ma us/dep/brp/wwm/t 5pubs.htm) • Town of North Andover Minimum Requirements for the Subsurface Disposal of Sanitary Sewage • #CD- 01 Notice of Intent (NOI) brochure • #PD -01 Watershed Permit brochure Town of North Andover Health Department - Community Development & Services Division This brochure is intended as education of the local permitting process only. It does not co ver a//jurisdictions or .Vii. scenarios that your permit application maybe subject to, $Permit applications are site specific. , `J -,$--?7 7 WILLIAM F. WELD Governor ARGEO PAUL CELLUCCI Lt. Governor COMMONWEALTH OF MASSACHUSETTS _ EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS DEPARTMENT OF ENVIRONMENTAL PROTECTION ONE WINTER STREET, BOSTON, MA 02108 617-292-5500 V " TRUDY CORE Secretary DAVID B. STRUHS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM Commissioner PART A CERTIFICATION Property Address: 246 Candlestick Rd. Address of Owner: Date of Inspection: N Andover, MA (if different) Name of Inspector: 10 —1 0 — 9 7 Iames I am m a DEP approved systeins actor pursuant to Section 15.340 of Title 5 (310 CMR 15.000) Company Name: _ R . J., TnsDect i ons TNn Mailing Address: 1 Osgood ST, , Methuen, MA 01844 Telephone Number:978 681 —8759 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 ewage disposal systems. The system: Passes _ Conditionally Passes _ NPAds Further Evaluation By the Local Approving Authority Inspector's Sign/5hal�l Date: L� The System Inspubmit a copy of this inspection report to the Approving Authority within thirty (30) days of completing this inspection. If th shared system or has a design flow of 10,000 gpd or greater, the inspector and the system owner shall submit the report to the appropriate regional office of the Department of Environmental Protection. The original should be sent to the system owner and copies sent to the buyer, if applicable, and the approving authority. INSPECTION SUMMARY: Check A, B, C, of 'D: A] SYSTEM P ES: I 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. 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. Indicate yes, no, or not determined (Y, N, or ND). Describe basis of determination in all instances. If "not determined", explain why not. The septic tank is metal, unless the owner or operator has provided the system inspector with a copy of a Certificate of Compliance (attached) indicating that the tank was installed within twenty (20) years prior to the date of the inspection; or the septic tank, whether or not metal, is cracked, structurally unsound, shows substantial infiltration or exfiltration, or tank failure is imminent. The system will pass inspection if the existing septic tank is replaced with a conforming septic tank as approved by the Board of Health. (revised 04/25/97) Pago 1 of 10 DEP on the World Wide Web: http:/twww.magnetstate.ma.us/dep ej Printed on Recycled Paper t Property.Address: Owner: Date of Inspection: SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) 246 Candlestick Rd. Thomas Young 10-10-97 B] SYSTEM CONDITIONALLY PASSES (continued) , N.Andover, MA Sewage backup or breakout or high static water level observed in the distribution box is due to broken or obstructed pipe(s) or due to a broken, settled or uneven distribution box. The system will pass inspection if (with approval of the Board of Health). Describe observations: broken pipe(s) are replaced obstruction is removed distribution box is levelled or replaced The system required pumping more than four times a year due to broken or obstructed pipe(s). The system will pass inspection if.(with approval of the Board of Health): broken pipe(s) are replaced obstruction is removed 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 Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh. 2) SYSTEM WILL FAIL UNLESS THE BOARD OF HEALTH (AND PUBLIC WATER SUPPLIER, IF APPROPRIATE) DETERMINES THAT THE SYSTEM IS FUNCTIONING IN A MANNER THAT PROTECTS THE PUBLIC HEALTH AND SAFETY AND THE ENVIRONMENT: _ The system has a septic tank and soil absorption system (SAS) and the SAS is within 100 feet to a surface water supply or tributary to a surface water supply. The system has a septic tank and -soil absorption system and the SAS is within a Zone l of a public water supply well. The system has a septic tank and soil absorption system and the SAS is within 50 feet of a private water supply well. The system has a septic tank and soil absorption system and the SAS is less than 100 feet but 50 feet or more from a private water supply well, unless a well water analysis for coliform bacteria and volatile organic compounds indicates that the welt is free from pollution from that facility and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm. Method used to determine distance (approximation not valid). 3) OTHER (revised 04/25/97) Page 2 of 10 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: 246 Candlestick Rd., N.Andover, MA Owner: Thomas Young Date of Inspection: 10-10-97 D] SYSTEM FAILS: You must indicate eiv-ier "Yes" or "No" as to each of the following: I have determined that the system violates one or more of the following failure criteria as defined in 310 CMR 15.303. The basis for this determination is identified below. The Board of Health should be contacted to determine what will be necessary to correct the failure. Yes No Backup of sewage into facility or system component due to an overloaded or clogged SAS or cesspool. Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool. Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool. Liquid depth in cesspool is less than 6" below invert or available volume is less than 1/2 day flow. Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number of times pumped _. Any portion of the Soil Absorption System, cesspool or privy is below the high groundwater elevation. Any portion of a cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. Any portion of a cesspool or privy is within a Zone I of a public well. Any portion of a cesspool or privy is within 50 feet of a private water supply well. Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality analysis. If the well has been analyzed to be acceptable, attach copy of well water analysis for coliform bacteria, volatile organic compounds, ammonia nitrogen and nitrate nitrogen. E] LARGE SYSTEM FAILS: You must indicate either "Yes" or "No" as to each of the following: The following criteria apply to large systems in addition to the criteria above: The system serves a facility with a design flow of 10,000 gpd or greater (Large System) and the system is a significant threat to public health and safety and the environment because one or more of the following conditions exist: Yes No the system is within 400 feet of a surface drinking water supply the system is within 200 feet of a tributary to a surface drinking water supply the system is located in a nitrogen sensitive area (Interim Wellhead Protection Area - IWPA) or a mapped Zone II of a public water supply well) The owner or operator of any such system shall bring the system and facility into full compliance with the groundwater treatment program requirements of 314 CMR 5.00 and 6.00. Please consult the local regional office of the Department for further information. (revised 04/2s/97) page 3 of 10 -SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B _. . CHECKLIST Property Address: 246 Candlestick Rd., N.Andover, MA Owner: Thomas Young Date of Inspection: 10-10-.97 Check if the following have been done: You must indicate either "Yes" or "No" as to each of the following: Yes i- No Pumping information was provided by the owner, occupant, or Board of Health. None of the system components have been pumped for at least two weeks and the system has been receiving normal flow rates during that period. Large volumes of water have not been introduced into the system recently or as part of this inspection. As built plans have been obtained and examined. Note if they are not available with N/A. The facility or dwelling was inspected for signs of sewage back-up. The system does not receive non -sanitary or industrial waste flow. The site was inspected for signs of breakout. Le_�_ All system components, excluding the Soil Absorption System, have been located on the site. The septic tank manholes were uncovered, opened, and the interior of the septic tank was inspected for condition of baffles or tees, material of construction, dimensions, depth of liquid, depth of sludge, depth of scum. / The size and location of the Soil Absorption System on the site has been determined based on: C/ The facility owner (and occupants, if different from owner) were provided with information on the proper maintenance of Sub -Surface Disposal System. _ Existing information. Ex. Plan at B.O.H. Determined in the field (if any of the failure criteria related to Part C is at issue, approximation of distance is unacceptable) [I 5.302(3)(b)) (revised 04/15/97) page 4 of 10 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION Property Address: 246 Candlestick Rd., N,Andover, MA Owner: Thomas Young Date of Inspection: 10 —1.0 — 9 7 FLOW CONDITIONS RESIDENTIAL: Design flow: a.p.d;/bedroom for S.A.S. Number of bedrooms: Number of current rest ents:� Garbage grinder (yes or no): Al' e Laundry connected to system (es or no):,Y6� Seasonal use (yes or no): Water meter readings, if available (last two (2) year usage (gpd): Sump Pump (yes or no);� 1 y y 6 _ ,1- 3 --1-- Last date of occupancy: COMMERCIAUI NDUSTRIAL: Type of establishment: Design flow: ¢allons/day Grease trap present: (yes or no)_ Industrial Waste Holding Tank ores Non -sanitary waste di r tett Water meter readings. if avai Last date of occupan OTHER: (Describe)' Last date of occupancy: (yes or no)_ 5 system: (yes or no)_ GENERAL INFORMATION PUMPING RECORDS and source of information: e+/ System pumped as part of inspection: (yes or no)_ If yes, volume pumped: eallons . Reason for pumping: TYPE OF SYSTEM 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) I/A Technology etc. Copy of up to date contract? Other APPROXIMATE AGE of all components, date installed (if known) and source of information: Sewage odors detected when arriving at the site: (yes or no)�' (zavinod 04/25/97) Page 5 of 10 --- - - - -----SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM...- - _ PART C SYSTEM INFORMATION (continued) Property Address: 246 Candlestick Rd., N, Andover, MA Owner: Thomas Young Date of Inspection: 10-10-97 BUILDING SEWER: (Locate on site plan) Depth below gra — Material of construction: t iron — 40 PVC other (explain) Distance from private water su ell suction line Diameter Comments:. (condition of joints, ntin f leakage, etc.) SEPTIC TANK:_ (locate on site plan) Depth below grade:L Material of construction: concrete —metal —Fiberglass —Polyethylene—other(explain) If tank is metal, list age _ Is age confirmed by Certificate of Compliance _ (Yes/No) l Dimensions: /� S Sludge depth:_T5/ �• �� Distance from top of sludge to bottom of outlet tee or baffle: a0 Scum thickness: V /" Distance from top of scum to top of outlet tee or baffle: Vii! •� Distance from bottom of scum to bottom of outlet tee orbaffle: -fid How dimensions were determined: G ' Comments. (recommendation for pumping, condition of inlet and outlet tees or baffles, depth of liquid level in relation to outlet invert, structural integrity, evidence of leakage, etc.) GREASE TRAP: (locate on site plan) Depth below grade: Material of construction: —concrete —metal —Fiberglass —Polyethylene _other(explain) Scum thickness: Distance from top of � et tee or baffle: Distance from bottom of sc t o m of outlet tee or baffle: Date of last pumping: ` Comments: / (recommendation for pumping, condition of inlet and outlet tees or baffles, depth of liquid level in relation to outlet invert, structural integrity, evidence of leakage, etc.) . (revised 04/25/97) page 6 of 10 – - - SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: 246 Candlestick Rd., N;Andover, MA Owner: Thomas Young Date of Inspection: 10-10-97 TIGHT OR HOLDING TANK: (Tank must be pumped prior to, or at time, of inspection) (locate on site plan) Depth below grade: Material of construction: _concrete _metal _Fiberglass _Polyethylene —other(explain) Dimensions: Capacity. gallo Design flow: g on a Alarm level: larm in working order _ Yes; _ No Date of previous pumping: Comments: (condition of inlet tee, condition of alarm and float switches, etc.) DISTRIBUTION BOX:_ (locate on site plan) i Depth of liquid level above outlet invert: Comments: (note if level and distribution is equal ,evidence of solus carryover, evidence of leakage into or out of box, etc.) 67 PUMP CHAMBER: (locate on site plan) Pumps in working order: (Yes or No) Alarms in working order (Yes Comments: (note condition of ump m ondition of pumps and appurtenances, etc.) 0 (revised 04/15/97) page 7 of 10 ..-SUBSURFACE. SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: 246 Candlestick Ad., N.Andover,MA Owner: Thomas Young Date of Inspection: 10-10-97 / SOIL ABSORPTION SYSTEM (SAS): ✓ (locate on site plan, if possible; excavation not required, but may be approximated by non -intrusive methods) If not determined to be present, explain: Type: leaching pits, number:_ leaching chambers, number:_ leaching galleries, number: leaching trenches, number,length: leaching fields, number, dimensions: overflow cesspool, number: Alternative system: Name of Technology: Comments: (note condition of soil, CESSPOOLS: _ (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 (cesspool st be pumped as part of inspection) , etc.) Comments: (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.) PRIVY: _ (locate on site plan) Materials of construction: Depth of solids: Comments: 4 (note condition of soil, signsy is failure, level of ponding, condition of vegetation, etc.) (rwitod 04/25/97) page 8 of 10 Dimensions: SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: 246 Candlestick Rd., N.Andovr, MA Owner: Thomas Young Date of Inspection: 10-10-97 SKETCH OF SEWAGE DISPOSAL SYSTEM: include ties to at least two permanent references landmarks or benchmarks locate all wells within 100' (Locate where public water supply comes into house) (0��^ — -� '/ 1"ele- (revised 04/25/97) Page 9 of 10 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: 246 Candlestick Rd., N,Anodver, MA Owner: Thomas Young Date of Inspection: 10-10-97 Depth to Groundwater 't Feet Please indicate all the methods used to determine High Groundwater Elevation: Obtained from Design Plans on record Oservation of Site (Abutting property, observation hole, basement sump etc.) t—i6etermine it from local conditions Check with local Board of health Check FEMA Maps _ Check pumping records 'Check local excavators, installers Use USGS Data Describe in your own words how you established the High Groundwater Elevation. Must be completed) Fl- 1f�.09rrX y/ ' (revised 04/2S/97) Page 10 of 10 (System Owner 1 i, Commonwealth of Massachusetss : Massachusetts System Pumping Record stem Location .n„H Form 4 -- System Pumping Record LT�: , Type: Emergency Routine Cesspool: ivp Yes Septic took: No =Yes Date of Pumping: l P+mg' 1'� — Quantity Pumped: NU CJ 6nikms System Pumped By: Wind Neer Enyironmentoi, LLC Permit #: Contents transferred to: Contents Disposed at: Date: Pumper Signature: Condition of System/Other Comments h.n Ann—A F:..— - 1101MICK FORM - U - LOT RELEASE FORM .> 4o e g- �'� ►^ � � of S�n,LI+`-- INSTRUCTIONS: This form is.used to verify that all -necessary approval /permits from Boards ,and Departments having jurisdiction have been obtained. This. does not relieve the applicant and or I=downer from compliance with any applicable requirements. i.rr..r.rNEW Was rrrr...rr.r.rrrrr..r.rrrr.r...rramong ..r■■.■..r..rr.rrr.rr.... APPLICANT 11y ot PHONE l �� 7 �"! CD v ASSESSORS MAP NUMBER IGO- OT NUMBER Q SUBDIVISION __ LOT NUMBER ,Z STREET S � TREET NUMBER .2 ...r■..••.••..............rrr....r.rr.r.r•.■.rr........r.r......r......r.r OFFICIAL USE ONLY Ir.ass r.r...r...r.....Woolson r.'r.MEMO awe r....r....soon r..rrr.r..r...........■ RECOMAdFNDATIONS OF TOWN AGENTS .................■arra..`rr■•r..rr..r..r.■r.r....rr..r.rr..rr.'...r.rrr.r...r DATE APPROVED CONSERVATION ADMINISTRATOR DATE REJECTED COQ DATE APPROVED TOWN PLANNER CONBMNTS DATE REJECTED DATE APPROVED FOOD INSTOR -'HEALTH DATE REJECTED DATE APPROVED zj C RJCTOR - BFALTH DATE REJECTED CONRVIENTS PUBLIC WORKS - SEWER / WATER CONNECTIONS D R IVEWAY PERMIT UL , u�� I1 [�e.ci 12 iuc'i�i dl �i iC�i DATE APPROVED FIRE 15EPARTMENT Pavk, k4,r f DATE REJECTED COMMENTS RECEIVED BY BUILDING INSPECTOR DATE CURRIER SEPTIC & DRAIN SERVICE 107 FOREST STREET; MIDDLETON, MA 01949 (978) 774-2772 SYSTEM OWNER: �/O c-( 41 FORM 4 - SYSTEM PUMPINCC RECORD COMMONWEALTH OF MASSACHUSETTS MASSACHUSETTS SYSTEMPUMPIIVG RECORD ,9)0-5 5-_/605 SYSTEM LOCATION: �vlo�� a�U DATE OF PUMPING: 06 QUANTITY PUMPED: GALLONS CESSPOOL: NO E�J- yES D SEPTIC TANK: NO E�] YES SYSTEM PUMPED BY: CURRIER SEPTIC &DRAIN SERVICE CONTENTS TRANSFERRED TO: G C S �) DATE: INSPECTOR: n 15 P -URD of AMTH AtipovLi�, MA. SS � �ISAPPR�VED R�4So�S D 7( GaT cklNDGESTrc t- Z COY-1 J4tiv6;2 �JQrG R 5� P PL7 q j"bc,�nl ❑ UJEU- �Pp�ouCD 1Y�T"C 5EPT'IC SY S TEM -PE-SI 6,-J -ZL -R /JPIT�OUIN6 AUTt-Ioi?ITy G D/�TE 0K- -(Z)� z �O�q VL ',,tk ,b'6 Ci F&OP -,F , T-, A -L" tioC 3) T-2 oL,)T G=7 4V4T(' O )�v�I t-C►r0�1 FINAL l �V 5P� i low '5 Prf c S'6TErtt 1 J SI;O 'I OAJ I1/JiG ' Ii�Ss El F41L. 10-Z�47 - r291v5-1ob7?(N6 Cftot,-E of Pte'" S 0i3TC I_ -� 7 &PITIDMAL- I,�1SFbq (oN j (It= .4jy) DISAPP)�O\j6D D,4rC RCASa NS RAL APPNOVAL /SPl�r�v(�vG �1�T+toi�i �y APPRo,1rJ6 /6uiHogI t y G Z W- 6174 o. - . h /4t/.10 I a 'fir . /4t/.10 I Commonwealth of Massachusetss : Massachusetts System Pumoinw Record system Owner system Location Type: Emergency Routine Cesspool: No Yes Date of Pumping: l System Pumped By: Wind River Enwwnmentoi, LLC Contents transferred to: Contents Disposed at: Date: Pumper signature: Condition of system/Other Comments /Lw I wwwnv�i/ Fwn�n _ 19/iI7/OR Form 4 -- system Pumping Record r !` .I/ Septic tank: No OYes- ©/ Quantity Pumped: l Gallons Permit #: Important: When filling out forms on the computer, use only the tab key to move your cursor - do not use the return key. lC� Commonwealth of assac usetts City/Town of T - i 2008 System Pumping Recor Form 4 rc_. 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 1. System Location: Address Noah AnJoYe( City/Town 2. System Owner: J �+ d ► �h Yo 14Y, Name Address (if different from location) CitylTown B. Pumping Record 1. Date of Pumping _Rd CHO-03 Date MG State o► g,L� S Zip Code State Zip Code q -T'- q-75 ) bo °! Telephone Number 2. Quantity Pumped: % oc) Gallons 3. Type of system: ❑ Cesspool(s) [ir'Septic Tank ❑ Tight Tank ❑ Grease Trap ❑ Other (describe): 4. Effluent Tee Filter present? ❑ Yes [/No 5. Condition of System: If yes, was it cleaned? ❑ Yes ❑ No 6. System Pumped By: JiYYI C a11Qn 766 9 Name ( Vehicle License Number \W iy)J �e, iv< P-'�Viroy)y er1to1 Company 7. Location where contents were disposed: r_ 1 Signature of Hauler ' ` 1_awrence, MA. Signature of Receiving Facility t5form4.doc• 03/06' Date Date System Pumping Record • Page 1 of 1