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TOWN OF NORTH ANDOVER
NOR .1-11 HEALTH DEP RTMENT
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FORM U - LOT RELEASE FORM rj.
INSTRUCTIONS: This form is used to verify that all necessary approvals/permits from
Boards and Departments having jurisdiction have been obtained. This does not relieve
the applicant and/or landowner from compliance with any applicable or requirements.
*****************************APPLICANT FILLS OUT THIS SECTION
APPLICANT �J PHONE
LOCATION: Assessor's Map Number PARCEL
SUBDIVISION LOT (S)
STREET_ ST. NUMBER
aft( (WMENDATIONS,OF TOWN AGENTS:
CONSERVATION
COMMENTS
TOR
too,
USE ONLY**—**************�
DATE APPROVED '7
DATE REJECTED 0
V
TOWN PLANNER DATE APPROVED
DATE REJECTED
COMMENTS
FOOD INSPECTOR -HEALTH /"� DATE APPROVED
DATE REJECTFn
s}
xr It, IIv5F1:GI UH -HEAL ' �1 \ DATE APPROVED
i DATE- REJECTED
COMMENTS
- -- -4 s:
PUBLIC WORKS - SEWER/WATER CONNECTIONS
DRIVEWAY PERMIT
FIRE DEPARTMENT
RECEIVED BY BUILDING INSPECTOR DATE__
Revised 9197 jm
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Tc ksoll99�r-( $3 6 l' / 10
1 -SOF- 8'y7 �SG7 Ci=LL
255 FOREST STREET
.$I��"I fill
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EXISTING DWELLING
255 FOREST STREET
10,
WELL
NOTE:
EXISTING SEPTIC SYSTEM LOCATION DETERMINED IN
THE FIELD BY BENJAMIN C. OSGOOD JR, CERTIFIED
TITLE 5 INSPECTOR.
20' 0 20' 40' 60'
#'758 BY S.B. WN BY: D BCO jr
3 scAso�v Po I?cN.
11 s o nm 1JooRS U
/7AKA up %hE WAZ-ZS,
0 CC- /V c c it IA7 c,+nc� 0RAL`
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/ 3 SEASON ROOM
DECK
SEPTIC SYSTEM AND WELL LOCATION PLAN
255 FOREST STREET
NORTH ANDOVER, MASSACHUSETTS
PREPARED FOR PHILLIP JACKSON
2 RITA LANE, LAWRENCE, MA
SCALE: 1" = 20' DATE: AUG 1, 2003
NEW ENGLAND ENGINEERING SERVICES INC.,
60 BEECHWOOD DRIVE
lk NORTH ANDOVER, MASSACHUSETTS
(978) 686-1768
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TOWN OF NORTH ANDOVER
PUBLIC HEALTH DEPARTMENT
27 CHARLES STREET
NORTH ANDOVER, MASSACHUSETTS 01.845
Sandra Starr
Public Health Director
July 9, 2003
Phil Jackson
Jackson Bldg & Remodeling
2 Rita Lane
Lawrence, MA
Re: Application for 3 -season room addition
Dear Mr. Jackson:
Telephone (978) 688-9540
FAX (978) 688-9542
Your application for a building permit at 255 Forest Street, North Andover has been reviewed by the Health
Department. The application was denied on July 9, 2003 for the following reasons:
1. X Missing information.
A scaled plot plan no smaller than 1"= 40' must be submitted showing the dwelling, the location of the
existing septic system and the private well, and the proposed addition.
2. X Title 5 inspection of septic system. (Please note that this is one of the easiest ways to locate your septic
system).
3. Location of structure not acceptable
To address the problem(s):
If #1 is checked, please supply:
a. ;1WoorIan of exib.c1`:l�Ist Ian hov�ng e ttm w11 rdla}c��e�_ yap
If #2 is checked:
a. ravethe sz set
tt pea t roped : OR
b. Tie-in to municipal sewer
If #3 is checked:
a. Relocate the project
Please feel free to call the Health Office at 978-688-9540 with any questions you may have.
Sincerely,
Reviewer
Cc: Building Department
Homeowner
,/File
FORM U - LOT RELEASE G
E FORM -113
INSTRUCTIONS: This form is used to verify that all necessary approvals/permits from
Boards and Departments having jurisdiction have been obtained. This does not relieve
the applicant and/or landowner from compliance with any applicable or requirements.
L*****************************APPLICANT FILLS OUT THIS SECTION
APPLICANT // , C
ell
LOCATION:. Assessor's Map Number PARCEL
SUBDIVISION LOT (S)
STREET
ST. NUMBER
CONSERVATION ADM
COMMEN'
TOWN PLANNER
COMMENTS
FOOD INSPECTOR -HEALTH
SEPTIC INSPECTOR -HEALTH
COMMENTS
TOWN AGENTS:
100
USE ONLY****►*��*�*���*�***����
DATE APPROVED '7 D
DATE REJECTED
DATE APPROVED
DATE REJECTED
DATE APPROVED
DATE REJECTED
DATE APPROVED
DATE REJECTED D _
PUBLIC WORKS - SEWER/WATER CONNECTIONS
DRIVEWAY PERMIT
FIRE DEPARTMENT
RECEIVED BY BUILDING INSPECTOR
Revised 9197 jm
DATE
MORTGAGE PLO -1 FLAN
EK SURVEY
17. ROYAL STREET, LAWRENCE, MA. 01 841
TELEPHONE 508---975-1413
MORTGAGOR �Ew� DEED REF. BK. �— I� PG, �---
ADDRESS OF PRINCIPLE BUILDING PLAN REF. '-w''�4�` —
�-a =T- T�"olw-s-�— :s -r. DATE OF INSPECTION
V OF
Y UIJCL
tW4l Q W4Gr No. 362;,0
SCALE 1 " = 50' 1 FURTHER STATE THAT IN MY PROFESSIONAL.
DTE: THIS MORTGAGE INSPECTION WAS PREPARED ` OPINION THE PRINCIPLE STRUGTUREIS AND ACCESSORY
'ECIFICALLY FOR MORTGAGE PURPOSES AND IS NOT TO OUTBUILDINGS ..
REUECI UPON AS A SURVEY, EK SURVEY ACCEPTS I WITH THE .SETBACK REQUIREMENTS OF THE LOCAL
0 RESPONS191UTY FOR DAMAGES TO ANYONE OTHER THAN ZONING ORDINANCES, AND THAT NO ENCHROACHMENTS
9E SAID MORTGAGEE AND ITS ASSIGNS IN CONNECTION WITH OF MAJOR IMPROVEMENTS EITHER WAY ACROSS
'S PROPOSED MORTGAGE FINANCING TO SAID MORTGAGOR, PROPERTY ONES EXCEPT. AS SHOWN.
'ERTIFICAli-ON T0; .� ►* Ip -t-- Also:
t-. ®i. PROPERTY IS NOT 1N THE 100 YR. FLOOD HAZARD AREA
HIS CERTIFICATION IS BASED ON THE LOCATION OF SURVEY MARKERS 02. PROPERTY IS IN A FLOOD HAZARD AREA
F OTHERS, AND DCES NOT REPRESENT A PROP ERTY SURVEY, THEREFORE (J3, INFORMATION IS ISUFFICIENT TO DETERMINE FLOOD HAZARD.
� fFSETS SHOWN ARE NOT TO BE USED FOR THE ESTASUSHMENT OP FLOOD HAZARD DETERMINATION FROM THE LATEST FEDERAL FLOOD
'►PERTY UNES. INSURANCE RATE MAP PANED eCo(>1B �,q C
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W
I'D OF IiL'I I I
Town of North Andover, flass.,
Permit Date -1.1-29-84 19
'APPLICATION FOR WELL, & PUMP PERMIT
Applicat.ion is -hereby made for permit, to drill 'a' well W. Application i s
race to 411§tall a,:A pump ,'system-.
Locati6n: Address _-
u
-oresQTIa'And-veraas 1
Douglas. lunsmore
Owner Peter, Breen
Address 770 Boxford.'Stre6t,' North A n (TcRle ir
1 C o, nt:r;i c t 6 r Charles. M...'Rollins Coi, inc i; d d r e s s 129 Depot Road, Boxfoi-d Massi Te 1887-2320
:
C o n t r, a c L o
r Add r6 s s,,,. Tel.'
'v4'7LT, 0 N'jr'I,t. C' j'0 R (To be COMPle ted'at Li. me of pullip test)
Type of Drilled W e, I I used''. f o r Domestic
.1,Lameter cf- We 11 S i. Ze of s, i I I
Doptl,-j of Led Rock Depth casing inl:o Be(]'.Rock 311
!,vas So,-iltested? Yes U
Dent',
of Wq 1 8801
t!:_1 J:0 tar
2.2-1
No Date o'f, Testing__
I -J e I I Ended i. n k%ll i a t Ma t e r i a I Rock
11,1in. for 4 h -_urs
feet ter pumpi.ng C) 'u r S a L- G P M,
ate of COrPletion
Si�tii_*ture 11 Contra fto-_
PUMP INSTALLER (To ba ... fille'd.-in -before - install.a-Lion)--
S-ize ' Name Pump
Pump Type Used
T ,ater _13umP'_')eIivers:- GPM Size of Tank
L A.
pipe Tiateri4iUsed in Well: Cast Iron Calv�-,nized Plastic
'fell Pit(.:) or Pitle'ss, Adapter
WIN
�'4'as sleevei.us6dto protect i:)i.pe?..Yes NO(' - Type or Name ',-.7ell Seal
nate
1.1 1- _j 3) 5 ta 1. 1 -1. Iq
WWW 1i 1� ,1 1,
a 'a
Date 17ateTanalysis report submitted to Board of Health
Date releasepgiveii W owner Bldg., r of record & g., Tn,sp..
-3 1
iel � -Ch Tnspector
1
l�1- // b� fOW FJWON�
u,h of �L� .J► � r ..-ewo -
' Le V C7 tw ),0 WP)
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Commonwealth of assac usetts
City/Town of
r
System Pumping Recor OLT -- 2008
Form 4-
TOWN' C:
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.
1. Date of Pumping Date a5 d� 2. Quantity Pumped: Ga110hS6
3. Type of system: ❑ Cesspool(s) [Septic Tank ❑ Tight Tank ❑ Grease Trap
❑ Other (describe):
4. Effluent Tee Filter present? ❑ Yes ❑ No If yes, was it cleaned? ❑ Yes ❑ No
5. Condition of System:
6. System Pumped By:
;)jtm Galland
Name 1
Company
7. Location where contents were di
Signature of Hauler
Signature of Receiving Facility
t5form4.doc• 03/06
-7W i
Vehicle License Number
Date
Date
System Pumping Record • Page 1 of 1
A. Facility Information
Important:
When filling out
1. System Location:
forms the
Q C -Fo s � S�
computer, use
J �e
only the tab key
to move your
Address
No, �� A,n� Oy.2,�
�{
I - l(�A 0 � J S
J
cursor - do not
use the return
City/Town
State Zip Code
key.
2: System Owner:
Name
Address (if different from location)
11
City/Town
State Zip Code
Telephone Number
B. Pumping Record
1. Date of Pumping Date a5 d� 2. Quantity Pumped: Ga110hS6
3. Type of system: ❑ Cesspool(s) [Septic Tank ❑ Tight Tank ❑ Grease Trap
❑ Other (describe):
4. Effluent Tee Filter present? ❑ Yes ❑ No If yes, was it cleaned? ❑ Yes ❑ No
5. Condition of System:
6. System Pumped By:
;)jtm Galland
Name 1
Company
7. Location where contents were di
Signature of Hauler
Signature of Receiving Facility
t5form4.doc• 03/06
-7W i
Vehicle License Number
Date
Date
System Pumping Record • Page 1 of 1
Important:
When filling out
forms on the
computer, use
only the tab key
to move your
cursor - do not
use the return
key.
Commonwealth of Massachusetts
City/Town of �35
System Pumping Record NORTH ANDD EF��so,� sg 2Uid
Form 4
TO F T
DEP has provided this form for use by local Boards of Health. Other for n _W �. A
information must be substantially the same as that provided here. Before A*Mour
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:
R SS Foccc-) 57
-- ---- - -- —
Address
CitylTown State
2, System Owner:
_WdO'L'A)
Name
Address (if different from location)
City/Town
Zip Code
S to9F y � 7lgp Code —_---
Te'lephorfe Number
B. Pumping Record
1. Date of Pumping Date 2. Quantity Pumped:
3. Type of system: ❑ Cesspool(s) .Septic Tank ❑ Tight Tank
❑ Other (describe):
Gallons
❑ Grease Trap
4. Effluent Tee Filter present? ❑ Yes [2""No If yes, was it cleaned? ❑ Yes [/No
5. Condition of System:
6. System Pumped By:
am Vehicle License Number
Company
7. Location where contents were disposed:
SignatureofHauler ;9`j��"�^� ,' Date
Signature of Receiving Facility
Date
t5form4.doc• 03/06 System Pumping Record • Page 1 of 1
REC IVED
JAN 3 0 2017
TOWN OF NORTH ANDOVER
HE
AL
TH DEPARTMENT
4\- Commonwealth of Massachusetts
City/Town of
System Pumping Record NORTH ANDOVER
Form 4
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 Soard of Health or other approving authority within 14 clays from the pumping date in
accordance with 310 CMR 15.351.
A. Facility Information
Important,
When filling out 1. System Locatl=
forms onIfte
computer, use
only the tab key Address
to move your cuetor - do riot a
use the return City OV7n state zip Cooe
key. 2. System Owner:
vvloj
AT Name
Address (if different from location)
Zip —Code
Telephone Number
B. Pumping Record
t. Date of Pumping 2. Quantity Pumped;
Gallons
3. Type of system; 0 Cesspool(s) &D -499p -tic Tank ED Tight Tank F-1 Grease Trap
[D Other (describe): ... — I — --
4. Effluent Tee Filter present? El Yes EL -Wo- If yes, was it cleaned? Cj Yes Q --NO
5. Condition of Sy
6. system Pum e
Name Vehicle License Number
7. Location where contents were disposed;
.. .........
%C 24P
Signature of Hauler Date
1j�;-tu-rj of —Da -t -e-*-
03/06 System Pumping Record - Page I of 1