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Town of North Andover, Massachusetts Form No. 1
p1ORTHdd BOARD OF HEALTH 1 �
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APPLICATION FOR SITE TESTING/INSPECTION
Appl is
Site Lc
Engine
Test/Inspection Date and Time 1.0 A-7 t L/ ) Z01E34 7--15 C) -�
—'64-0<
CHAIRMAN, BOARD OF HEALTH
Fee 5 Test No.
S.S. Permit No. D.W.C. No. C.C. Date Plbg. Permit No.
Tim
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Applican
Site Location
Town of North Andover, Massachusetts
BOARD OF HEALTH
Form No. 1
19��r�
APPLICATION FOR SITE TESTING/INSPECTION
NAME ADDRESS
Engineer
NAME
Test/Inspection Date and Time
Fee
AUUKLJ
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CHAIRMAN, BOARD OF HEALTH
�
Test No. i .7 r7
S.S. Permit No. D.W.C. No. C.C. Date Plbg. Permit No.
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BOARD OF HEALTH
NORTH ANDOVER, MA 01845
978-688-9540
APPLICATION FOR SOIL TESTS
DATZ� MAP & PARCEL:
LOCA ON OF SOIL TESTS: Z ¢ a L. r- C c: 2
O WNER: R e e 4c z b F TEL. NO.: —,7g F7
ADDRESS: Z 4-ci "a e j L � a, .6 G,: 7S
ENGINEER: .J.4,c j �4, D!-t�pix,
TEL. NO.:
CERTIFIED SOIL EVALUATOR:
A 6.4 4LO
Intended Use of Land: Residential Subdivision
Single Family Home Commercial
Is This: 70aKw4TL:2 ��c�a�r,„•,.
—s---/f,
Repair Testing: Undeveloped lot testing:
In the Lake Cochichewick Watershed? Yes
✓ No
THE FOLLOWING MU
HIS FORM
n 4-
1. Proof of land ownersh
2. Plot plan & Location (I
er permitting test)
3. Fee of $275.00 per lot f vers the minimum two deep holes and
two percolation tests rei
_ __J Fee of $75.00 per lot for repairs or upgrades.
GENERAL INFORMATION
1. Only Certified Soil Evaluators may perform deep hole inspections.
2. Only Mass. Registered Sanitarians and Professional Engineers can design septic plans.
3. At least two deep holes and two percolation tests are required for each septic system disposal area.
4. Repairs require at least two deep holes and at least one percolation test, at the discretion of the
BOH representative.
5. Full payment will be required for all additional tests within two weeks of testing. _
6. Within 45 days of testing, a scaled plan (no smaller than 1"-100') shall be submitted to the Board - •
of Health showing the location of all tests (including aborted tests).
7. Within 60 days of testing soil evaluation forms shall be submitted.
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Please Do Not Write Below This Line
N.A. Conservation Commission Approval:
Date Received: Check Amount: Check Date:
BOARD OF HEALTH
NORTH ANDOVER, MA 01845
978-688-9540
APPLICATION FOR SOIL TESTS
DAT Z i v MAP & PARCEL: 3 7
LOCA ON OF SOIL TESTS: Z 4q RA d L r- /Z40�>a c; 2
O WNER: R e b F TEL. NO.: S 7 7g F7
ADDRESS: Z¢ 9 ",4,2 3 L, a r N r,, 7S
ENGINEER �1 �� j • F��� y TEL. NO.
CERTIFIED SOIL EVALUATOR: 612 L
Intended Use of Land: Residential Subdivision
Is This
o5T02/4 4.14 rL:R �?trcv4AT, o"r
Repair Testing: Undeveloped lot testing:
76 -48;- - 4.5 U
'943 02 ��C 7 �1,4a"i G 4LLu
Single Family Home Commercial
In the Lake Cochichewick Watershed? Yes ✓ No
THE FOLLOWING MUST BE INCLUDED WITH THIS FORM
1. Proof of land ownership (Tax bill, or letter from owner permitting test)
2. Plot plan & Location of Testing
3. Fee of $275.00 per lot for new construction. This covers the minimum two deep holes and
two percolation tests required for each disposal area. Fee of $75.00 per lot for repairs or upgrades.
GENERAL INFORMATION
1. Only Certified Soil Evaluators may perform deep hole inspections.
2. Only Mass. Registered Sanitarians and Professional Engineers can design septic plans.
3. At least two deep holes and two percolation tests are required for each septic system disposal area.
4. Repairs require at least two deep holes and at least one percolation test, at the discretion of the
BOH representative.
5. Full payment will be required for all additional tests within two weeks of testing.
6. Within 45 days of testing, a scaled plan (no smaller than 1"-100') shall be submitted to the -Board
of Health showing the location of all tests (including aborted tests). - -
7. Within 60 days of testing soil evaluation forms shall be submitted.
Please Do Not Write Below This Line _._--
N.A. Conservation Commission Approval:
Date Received: Check Amount: Check Date:
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TedmologEvaluafion.Coll,
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500 Unicorn Park Di-ive, Suite 404, Woburn, Massachusetts 0 i 801!
Tel.: 781-376-2800 - Fax: 781-756-0245 - www-technologyevaluation-com
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BOARD OF HEALTH f
NORTH ANDOVER, MA 01845
978-688-9540
APPLICATION FOR SOIL TESTS
DAT MAP & PARCEL: T
LOCA ON OF SOIL TESTS: 7-49 lr'lAa L iZ e: %Z
OWNER: 'O r ����r �'� b F TEL. NO.: 7 -6 P6 78 FZ
ADDRESS: 2 4- -r "d R 3 L u 2 I b 4, 7S
ENGINEER: .J11t, -s A, DLSAY TEL. NO.: i 7 6 - - G 3 S o
CERTIFIED SOIL EVALUATOR: (A 2 c;
Intended Use of Land: Residential Subdivision
Is This• -57r 0 2 u cv /4 z +: a � irc'y /- ra ,
6 ®2 , I o j--SA2INA6 44Lv
Single Family Home Commercial
,,/'!,'
Repair Testing: Undeveloped lot testing:
In the Lake Cochichewick Watershed? Yes vl--L No
THE FOLLOWING MUST BE INCLUDED WITH THIS FORM
1. Proof of land ownership (Tax bill, or letter from owner permitting test)
2. Plot plan & Location of Testing
3. Fee of $275.00 per lot for new construction. This covers the minimum two deep holes and
two percolation tests required for each disposal area. Fee of $75.00 per lot for repairs or upgrades.
GENERAL INFORMATION
1. Only Certified Soil Evaluators may perform deep hole inspections.
2. Only Mass. Registered Sanitarians and Professional Engineers can design septic plans.
3. At least two deep holes and two percolation tests are required for each septic system disposal area.
4. Repairs require at least two deep holes and at least one percolation test, at the discretion of the
BOH representative..
5. Full payment will be required for all additional tests within two weeks of testing.
6. Within 45 days of testing, a scaled plan (no smaller than 1"-100') shall be submitted to the Board
of Health showing the location of all tests (including aborted tests).
7. Within 60 days of testing soil evaluation forms shall be submitted. JUI, .� 9 r
Please Do Not Write Below This Line
N.A. Conservation Commission Approval: rd.S
Date Received: Check Amount: Check Date:
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SEPTIC SYSTEM INSPECTION FORM
ADDRESS -24) d'
DATE INSPECTED
PROPERLY FUNCTIONING? OY N
WEATHER CONDITIONS
COMMENTS:
WAS Ti A L I Ty 1 ES"►t.,� �' j;�SvL►s?
DYE TEST PERFORMED? Y N
DATE?
SKETCH:
4
4�,Ib ,71
Please forward us as much of the following information that i.s possible;
1, Type of system
2. Age
7
3. Location. E- -1 c -`� L/ _-
4. Maintenance records and date of la.st pumping; out �/�� � / -7-)
LLA G-e"'X -Ct4A _C—I,
btu-t�ec . (�7J rc`-tL. ✓ i..�G' ' V I C.¢__
5. Documentation of repairs and reconstruction
6. Site conditions
7. Builder of system
8. Engineer who approved% Iq'
Site G- --<L 4-
FZLC CL
-- S-ys tem (JJ�
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-a-
9. Installation Procedure
1.0. Problems '1 771
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WATERSHED RESIDENTS QUESTIONNAIRE
1. Name
2. Street Address " ``2
3. How many members are in your household?
4.
What type of sewage disposal system do you have?
2 cesspool
❑ 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?
❑ yes ❑ no ❑ do not know
6. How old is your sewage disposal system? ❑ 0-5 years ❑ 6-10 years ❑ 11-20 years
N' over 20 years Eldo not know
7. Has your sewage disposal system been rebuilt or repaired?
❑ yes ❑ no ❑ do not know
If yes, approximately how long ago? t' =` years. What was done?
8. How frequently is your sewage disposal system pumped out? ❑ annuallyy c
Rr 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 --k,
11. Please state the brand and type (liquid or powder) of detergent you use for:
dishwasher C- /'?c ' r�''). ^ -
�~ V ` ��
clotheswasher
12. Does your property have a lawn?
If yes, approximately what size?
❑ less than 1/4 acre — I N_ 1/4 acre
❑ more than 1 acre (Specify)
£yes ❑ no
❑ 1/2 acre ❑ 3/4 acre ❑ 1 acre
acres
13. How often do you fertilize your lawn?
No. of applications per year A�/ 5
OSeason(s) of the year F A � �. ; fi i_ t- s� 7-Jy ..–rte /='� Y -c t��i3 1. �'v G'y' /f f7
14. Please state the brand and type (liquid or granular) of lawn fertilizer you use:
N U L � Z -- �S R J )'Vi 15
❑ Check here if your lawn is maintained by a professional landscape contractor.
QUEST ONNAIRE
1. Name �, ,�1, , . r* c R �� '
2. Street Address
3. Hevi many members are in your household?
4. vYiat type of sewage disposal system do you have?
7-m cesspool
❑ 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?
yes ❑ no ❑ do not know
6. c %v old is _your sewage disposal system? ❑ 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? e
❑ yes ❑ no ❑ do not know
If yes, approximately how long ago? ;A 0 -- 2 4y ears. What was done?
� y -1-/-c w/9 i'e "Q D F l --i _ ;T
How frequently is your sewage disposal system pumped out? ❑ annually '157 OC"
'�f' every -4 years ❑ every 5-10 years ❑ over 10 years ❑ never It r'lr`
9. ;-lave you had any problems with your sewage disposal system? ❑ yes no
yes, what problems?
❑ repeated pump -outs needed
❑ system clogs, backs up, or drains slowly
❑ odors
❑ sewage surfaces through ground
1cr. vz many of each appliance are connected to your sewage disposal system?
cshing machine dishwasher �a� garbage disposal
_'tumidifier drain sump pump toilet _
pavement drains shower/bathtub _k,
11. ?.)ease state the brand and type (liquid or powder) of detergent you use for:
dishwasher C RS C_;-� Z) tz-
_lotheswasher Y
12. Does your property have a lawn? Noyes ❑ no
If yes, approximately what size?
❑ less than 1/4 acre — I K 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 7-1" A` G/v"c It S- /l'Ci
Sear=on(s) of the year `n
14. Please state the brand and type (liquid or granular) of lawn fertilizer you use:
r z? r\/ tj [ _- is R d ) Lt J e- t< /)I R /v 15
❑ Check here if your lawn is maintained by a professional landscape contractor.
BOARD OF HEALTH
)a
'146 MAIN STREET
TELEPHONE# (508) 688-9540
f
APPLICATION FOR ABANDONMENT
OF SUBSURFACE DISPOSAL SYSTEA1
(SEPTIC SYSTEM)
Pursuant to Section 310 CMR 13.354
of the State Environmental Code, Title V
Name C u 00-
Address
Contractor hired for work:
Named ✓-e o
Address el
V4 4
Phone
_ Phone 6o3 Z 4 zzp
A> -Z q'� zr Al 4
Date for scheduled abandonment 7 9— ��
The septic system at the above address has been abandoned according to
Title V specifications.
Signature oc or
Method of septic tank abandonment (check one). () removal () sandfill
( V crush ( ) other
Name of Offal Hauler —Pa 0 a i'q r l
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
j ANC
HEAL:
Date
z_ x'--99
n
FORM - U - LOT RELEASE FORK[
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 _,5;22W --f _,K-COfU �/�PHONE
coo 3 876) vv �Pj'
ASSESSORS MAP NUMBER LOT NUMBER
SUBDIVISION
OT NUMBER
XSMj.T 2 YY17...■....�.....8.[.L=..i.Q.�i.../.�...........■ ..R.E.E.T..NUMBER Z 5,,:,,,
...............
OFFICIAL USE ONLY
............................................................................
RECOMNIENDATIONS OF TOWN AGENTS
CONSERVATION ADMINISTRATOR
DATE APPROVED
DATE REJECTED
U_
DATE APPROVED
TOWN PLANNER
DATE REJECTED
COMMENTS
DATE APPROVED
FOOD INSPECTOR,- HEAL
DATE REJECTED
DATE APPROVED Z Z ®�
SEP PE R - HEAL
DATE REJECTED
COMMENTS
PUBLIC WORKS - SEWER / WATER CONNECTIONS
DRIVEWAY PERMIT
FIRE DEPARTMENT
DATE APPROVED
DATE REJECTED
COMMENT'S
RECEIVED BY BUILDING INSPECTOR
DATE