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AS PREPARED FOR
DATE: FEBIRUARY27, 5�,I-
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MERRIMACK ENGINEERING SERVICES, INC.
PROFESSIONAL ENGINEERS 0 LAND SURVEYORS 0 PLANNERS.'
66 PARK STREET 0 ANDOVER, MASSACHUSETTS 01810 0 TEL. (Cafl 475-3555, 373-5721
PD, FG , 0
Important: When
filling out forms
on the computer,
use only the tab
key to move your
cursor - do not
use the return
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4��
VS2L_41
Commonwealth of Ma8sachusetts
City/Town of North Andover
System Pumping Record
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 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'. ci 1_0 GA
Address
North Andover _--RE-GE1VEDj--
CityfTown State ip Code
2. System Owner:
Name
Address (if different from location)
City/Town
JUN 15 2015
W, -- . , -
HEALTH DEPARTMENT
st-a* We
Telephone Number
Zip Code
B. Pumping Record
1. Date of Pumping 2. Quantity Pumped: Gallons
3. Type of system: Cesspool(s) M/Septic Tank 0 Tight Tank El Grease Trap
El Other (describe):
4. Effluent Tee Filter present? [I Yes 0 No
If yes, was it cleaned? 0 Yes E] No
5. Condition of System, -
6. Syst e y:
Name Vehicle License Number
a s Septic Service
Company
7. Location where contents were disposed:
Stewart's Pre-treatment Plant, 20 So. Mill Bradford. Ma 01835
Signature of Hauler
Signature of Receiving Facility
Date
Date
t5form4.doc- 03/06 System Pumping Record - Page 1 of 1
/^1
CommonweannOT Massachusetts RECE-NED
City/Town of North Andover
o System Pumping Record AUG U 4 2014
Form 4 TOWN OF NORI H ANDOVER
P4'Qv,','_ATh,J
DEP has provided this form for use by local Boards of Health. Other fo 9sd,-
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
Important: When
filling out forms
1. System Location:
on the computer,
use only the tab
c:� 6e 17 0
key to move your
Address
cursor - do not
— fl, , + ,
North Andover
0Q, (-� 4),
Ma
01886
� � � u City/Town State Zip Code
key.
2. System Owner:
VAr-) d C-_ rq!�
Name
A=
Address (if different from location)
City/Town
State
Telephone Number
B. Pumping Record
1. Date of Pumping .7 2. Quantity Pumped:
Date
3. Type of system: E] Cesspool(s) JfTo"Septic Tank El Tight Tank
0 Other (describe):
4. Effluent Tee Filter present? [:1 Yes El No
5. Condition of System:
6. S stem Pumped By:
1�
: 1�s " C_ Sc,
Stewart's Septic
Company
7. Location wherp.
Stew_a� `<re -tri
ianature of Hauler
Service
nts were disposed:
!nt Plant, 20 So. Mill
Zip Code
15W
Gallons
F-1 Grease Trap
Iflyes, was it clean -ed? El Yes El No
Q� 0
Vehicle License Number
Ma 01835
Date
Date
t5form4.doc- 03/06 System Pumping Record - Page 1 of 1
i ivain
Important: When
filling out forms
on the computer,
use only the tab
key to move your
cursor - do not
use the return
key.
O'L�
V%=A
16 i�_ *,& t.- il Id kr.- M.#
Commonwealth of Massachusetts SEP '12 2013
TOWN OF NORTH ANDOVER
City/Town of NORTH ANDOVER I HEALTH DEPARTMENLJ
System Pumping Record
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 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:
,�( , 72 0 1 C24 rd:: I A 4 44
Address I — — I
NORTH ANDOVER Ma
Cityrrown
2. System Owner:
V C) tj r -o
Name
Address (if different from location)
City/Town
B. Pumping Record
State
State
Telephone Number
1. Date of Pumping On 12 2. Quantity Pumped:
Date
Zip Code
Zip Code
Gallons
rVi
3. Type of system: El Cesspool(s) L6� Septic Tank El Tight Tank 0 Grease Trap
El Other (describe):
4. Effluent Tee Filter present? Ej Yes El No If yes, was it cleaned? Ej Yes E] No
5. Condition of System:
6. System Pumped By:
Name
Stewart's Septic Service
Company
7. Location where contents were disposed:
Stewglql� Pre-treatment Plant, 20 So. Mill
Signature of Receiving Facility
t5form4.doc- 03/06
Vehicle License Number
Ma 01835
Date
Date
System Pumping Record - Page 1 of 1
Commonwealth of Massachusetts
City/Town of No andover
System Pumping Record
I:nrm A
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 CIVIR 15.351.
A. Facility Information
Important: When
filling out forms
1. System Location:
on the computer,
-2(-o7
use only the tab
key to move your
Address
cursor - do not
No Andover
use the return
key.
City/Town
t4Q
2. System Owner:
Name
Address (if different from location)
City/Town
Ma
State
State
Telephone Number
Code
RECEIVED
� ... I
HEALTH DEPARTMENT
Zip Code
B. Pumping Record
1. Date of Pumping 2. Quantity Pumped:
?ate Gallons
3. Type of system: El Cesspool(s) F-1 Septic Tank El Tight Tank El Grease Trap
El Other (describe):
4. Effluent Tee Filter present? Ej Yes 0 No
5. Condition of System:
(s, c,- C> 0
6. System Pumped By:
If yes, was it cleaned? El Yes 0 No
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
Signature of Hauler
Signature of Receiving Facility
Date
Da—
t5form4.doc- 03/06 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.
VQ
Commonwealth of Massachusetts
City/Town of North Andover
System Pumping Record
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 Board of Health or other approving authority within 14 days from thex=ping date in
accordance with 310 CIVIR 15.351. F
A. Facility Information
1. System Location:
267 Old Cart Wa
Address
North Andover
Ma
JON - 7 zU11
TOWN OF NORTH ANDOvER
HEALTH DEPARTM
- "-���NT
01845
City/Town State Zip Code
2. System Owner:
Vandegroaf
Name
Address (if different from location)
City/Town
State
Zip Code
Telephone Number
B. Pumping Record
1 . Date of Pumping 5/18/11
Date
2. Quantity Pumped:
1500
Gallons
3. Type of system: El Cesspool(s)
Z Septic Tank El Tight Tank
El Grease Trap
F-1 Other (describe):
4. Effluent Tee Filter present? F-1 Yes F�
No If yes, was it cleaned?
0 Yes E] No
5. Condition of System:
Good Condition
6. System Pumped By:
Frank Eldridge
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
Signature of Ha er
1;2V
's
Date
�
Signature of Re6eiving F�cility
Date
t5form4.doc- 03/06 System Pumping Record - Page 1 of I
Important:
When filling out
forms on the
computer, use
only the tab key
to move your
cursor - do not
use the return
key.
SO
Commonwealth of Massachusetts
E[Dq
City/Town of NORTH ANDOVER, MAS AC U
System Pumping Record APR - 9 2010
Form 4
TOWN OF NORTH ANDOVER
DEP has provided this form for use by local Boards of Health. Thels'V'Wemmammol&A ust
be submitted to the local Board of Health or other approving authority.
A. Facility Information
1. System Locatiow.
2.
f-1
M Ad s
rk Ve r
Cityfrown State
roo.
Address (if different from location)
City/Town
State
Felephone Number
CA /,�&�.
Zip Code
Zip Code
B. Pumping Record
1. Date of Pumping Date 2. Quantity Pumped: Gallons
1, Type of system: E] Cesspool(s) eseptic Tank 0 Tight Tank
Other (describe):
4. Effluent Tee Filter present? E] Yes E] No If yei,'Was it cleaned? [I Yes No
5. Condition of System: — I
6. Systern Pumped By:
K -a V
Vehicle License Number
C
C6mpany
7.
Hiqnn-qPH-
MUMM
http:/A&ww.mass.gov/de�twater/approvaistt5forms.htm#inspect
t5forTn4.doc- 06/03 System Pumping Record - Page 1 of 1
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DEP hai prcMd4d thli use by local So
f6rm'for lards of Health., -The System Pumping ReCorc mus�
b
,,e submJ4�d to thijo,cal.'Boarcl of Health or otIijFjPPF6YIh6'iuth
�A4 FPC111ty
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w*l1&Qout,,- 1 System L don:"..�
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to move your -
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u3e thi1r0jih-;.J/.�,-'.
..C1tyfTQwn
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ks' �4* ZIP Pode
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..;.Name
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Telephone NumUer
4,
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y System Cesspool(s) 2'leptic Tank
P9
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�Other
E Jte� pi�esent? Ej Yes No' It yes, was It 61eaned? Yes
fflu0t Te6 FI
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SYStem Pumping Rec, oro - Page I of
.',—.Oommohw�alth�of Ma*
ssachusett
Cit * y /T
own of NORTH ANDOVER
Sys0e.m1pu''m . p1n.g Record
Form 4
Important:
When filling out
forms on the
computer, use
only the tab key
to move your
cursor - do not
use the return
key.
SACHUSETTS
. OC� 12 MG
DEP has provided this form for use by local Boards of Health� 7he�Nsvy te`m' Pumpi`ng'R�
be submitted to the local Board of Health or other approving authority.'
A. Facility Information
1. System Location:
Addre
Clty/Town
Zip Code
2. System Owner:
Name
Addrem (It different from location)
City/Town
Zip Code
a
Telephone Number
E3. Pumping Record
1 - Date of Pumping
9 2. Quantity Pumped:
Dai Gallons
'3� - Type of system: C3 Cesspool(s) .,eeptic Tank [3 Tight Tank
[3 Qther (describe): . . .......
4. Effluent Tee Filter present? 0 Yes � �o If yes, was it cleaned? [I Yes [3 No
5. Condition of System: lle�
6. SyAem Pumped By:
z 1111rz ZJ� W 1^—,(/ 1 it ]IV,,,
Name
Vehicle License Number
Compa ny
7. L*ocatlon where contents were disposed:
81 Mure of Ma
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t5form4.doc- 06/03
System Pumping Record , Page 1 of 1.
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N 0 RT HAND 0 V E R.
SYSTEM PUM-pi
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TANK: N(D.
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ATURE OF SERVICE: ROUTINE
EMERCE N'C Y
C'00.D'CQN U Jill ON,
FU L. L'T 0 C 0 Y C,
13, A'
.8 A F.FL ES IN PL, A C P
LEACHFIELD RUNUACK.,
C. XCESSI-YEISOL4 IDS
FLOODM
s LI ().�:CAR.RYO.YER.�
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m p v P c b:'.'D.Y,
C' U.%;l yI R N Ts
v,�
TOWN OF NORTH ANDOVER
SYSTEM PUMPING RECORD
DATE:
SYSTEM OWNER & ADDRESS -
160. 4
All
SYSTEM LOCATION
(example: left front of house)
DATEOFPUMPING: LI—Il-01 QUANTITY PUMPED_,4-�'GALLONS
CESSPOOL: NO �YES SEPTIC TANK: NO YES
NATURE OF SERVICE: ROUTINE IZEMERGENCY
OBSERVATIONS:
GOOD CONDITION
HEAVY GREASE
ROOTS
EXCESSIVE SOLIDS
SOLIDS CARRYOVER
SYSTEM PUMPED BY:
COMMENTS:
CONTENTS TRANSFERRED TO:
FULL TO COVER
BAFFLES IN PLACE
LEACHFIELD RUNBACK
FLOODED
OTHER (EXPLAIN)
-1 VA
,AORTH
-6 0
41
�SA US�
Applicant
tw-�
"A"
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N!
Town of North Andover, Massachusetts Form No. 3
BOARD OF HEALTH
-2-3-19 q
DISPOSAL WORKS CONSTRUCTION PERMIT
NAME AVUKtb!� I rL-r-r Mill C
Site Location
Permission is hereby granted to Construct (�,�or Repair an Individual Soil Absorption
Sewage Disposal System as shown on the Design Approval S.S. No.
Fee
CHAIRMAN, BOARD OF HEALTH
- -1"A
D.W.C. No.
;1
'0
6
NUMBER
THE COMMONWEALTH OF MASSACHUSETTS
TD_Wnof _ North Andover _
Board of Health
This is to Certify that p.Qqer J. Richard E
t
B.averhill, M2'
ADDRESS
FEE
IS HEREBY GRANTED A "DISPOSAL WORKS INSTALLER'S PERMIT" TO
CONSTRUCT, ALTER, INSTALL or REPAIR,
Individual Sewage Disposal Systems
This permit is granted in conformity with the State Environmental Code Title V, Regulation
2.2, and expires December 31, 19 9 5,�, '-unless sooner supsended or revoked.
November 8,19 94
Board
Original
F 0 R M 12 5 6 (:H::�W::) HOBBS & WARREN TM
of
Health
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DATE /Zc� 161 �-,
Sheet of
BOARD OF HEALTH
TOWN OF NORTH ANDOVER
SUBSURFACE DISPOSAL DESI
FEE PERMIT #
APPLICANT
ADDRESS
ENGINEER
ADDRESS
/-o /3� q?
DATE RECEIVED�=
ASSESSOR'S MAP
PARCEL
LOT #
STREET
PLAN DATE M REVISION DATE
CONDITIONS OF APPROVAL: 1) z6c, 4&/-&V. ox- -PV. b/?/4//v oci 04
3h2zl-
APPROVED Zz,'1AX,0,Q'7-4 SQ,,e5 7,,-I-s>—
DISAPPROVED
PLAN REVIEW CHECKLIST
ADDRESS Z. XJ_ 0,60 -ENGINEER 11t--_We11qGCk
GENERAL
I rOPTV.R c__- qrrAmp L--' T.OrTTR &-___ MnRTR ARROW ';-� qr A TY. t ---
CONTOURS PROFILE L---- SECTION L---- BENCHMARK'ro 566�r SOIL &
PERC INFO ELEVATIONS _� WETS. DISCLAIMER WELLS &
WETLANDS L,,,-' WATERSHED? A10 DRIVEWAY (Elev) WATER LINE
-Z
FDN DRAIN_,,�-' SCH40 TESTS CURRENT? IC7,g6
SEPTIC TANK
MIN 1500G. .17 INVERT DROP GARB. GRINDER,2V
0 (+200% EDF)
251 TO CELLAR MANHOLE TO GRADE ELEV GW't�-'
D -BOX
SIZE # LINES -S- FIRST 2' LEVEL STATEMENT—
INLET,9/f,6_,7 - OUTLET,�/4,6_ = / 7 (211 OR .17 FT) TEE REQ'D?_J_13
LEACHING
RESERVE AREA L-�41 FROM PRIMARY? 100' TO WETLANDS -' 2% SLOPE L----
1001 TO WELLS 35' TO FND & INTRCPTR DRAINS --' 41 TO S.H.GwL--'
3251 TO SURFACE H20 SUPP 41 PERM. SOIL BELOW FACILITY
MIN 1211 COVER t.,-' FILL? L-�2_51 if above natural elev; 101if below)
BREAKOUT MET? L-'�
TRENCHES
MIN 660 gpd --""
SLOPE (min
.005 or 611/1001)�Z >31
COVER? - VENT
SIDEWALL DIST.
2X EFF. W OR
D (MIN 61)L-� IS RESERVE BETWEEN
TRENCHES? L,,-'
IN FILL?
MUST BE 10 1 MIN. C--' 4
PEA STONE?
BOT q176
X LDNG 30+
SIDE Zi�00 X LDNG330
TOT
(L x W x #)
(G/ft2)
(DxLx2x#)
MERRIMACK
ENGINEERING SERVICES INC.
Engineers* Surveyors 9 Planners
66 Park Street
ANDOVER, MASSACHUSETTS 01810
(617) 475-3555
TO EkAep
-T31j
)j )q - I zc> ml A w T
�JO- Akj bovF-70, H 6 - OtOlqr
WE ARE SENDING YOU El Attached 0 Under separate cover via
• Shop drawings V -"Prints 0 Plans
• Copy of letter 0 Change order F-1
LEEUTEM OF CTRUS MODUUM
DATE _
10 Iq-qZ
IJOB NO.
ATTENTION
CA,Ui�y 9TAP-P—
RE:
3
El
Approved as noted
P6AQ OF gy-cn-:7H
0 As requested
0 Samples
the following items:
0 Specifications
COPIES
DATE
NO.
DESCRIPTION
3
El
Approved as noted
P6AQ OF gy-cn-:7H
0 As requested
0
Returned for corrections
0 Return —corrected prints
0 For review and comment
El
0 FOR BIDS DUE
_19— El
PRINTS RETURNED AFTER LOAN TO US
THESE ARE TRANSMITTED as checked below:
9 --For approval
0
Approved as sUbmitted
0 Resubmit—copies for approval
El For your use
El
Approved as noted
El Submit—copies for distribution
0 As requested
0
Returned for corrections
0 Return —corrected prints
0 For review and comment
El
0 FOR BIDS DUE
_19— El
PRINTS RETURNED AFTER LOAN TO US
REMARKS
COPY T
SIGNED:
PRODUCT 240-2 J� I ., Gtn, M— 0 14 7 1. It enclosures are not as noted, kindly notify us at once.
FORM U - LOT RELEASE FORM
INSTRUCTIONS: This form is used to verify that all necessary approvalsipermits from
ion have been obtained. This does not relieve
Boards and Departments having jurisdicti
the applicant and/or landowner from compliance with any applicable or requirements.
------ ****************APPLICANT FILLS OUT THIS SECTIO
APPLICANT�
LOCATION: Asseswes Map Number
PHONE
PARCEL__!2�
LOT (S)
STREET ST. NUMBER-
------------- ------
OFFICIAL USE ON.Y********
1� RECOMMENDATIONS OF TOWN AGENTS:
I
CON TION MINISTRATOR DATE APPROVED
DATE REJECTE
COMMENT
TOWN PLANNER DATE APPROVED
DATE REJECTE
COMMENT'S
1 7 DATE APPROVED
P90 TOIIIEI��!'/
,.INSPEC -DATE REJECTE
I -
�EOVC INSPECTOR -HEAL DATE APPROVED
DATE REJECTE
PUBLIC WORKS - SEWERIWATER CONNECTIONS
DRIVEWAY PERMI
FIRE DEPARTMEN T
DATE.
RECEIVED AY §UILDING INSPECTOR_ -
lu L
ilu
vaaivl N d
90-
F—I
V,3mv, I= --------
jg 1: 1 � s"m
3: lu
SECTION 4 - WORKERS COMPENSATION (XG.L C 152 § 25c(6) I
Workers Compensation Insurance affidavit must be completed and submitted with this application. Failure to provide this affidavit will resut,
in the denial of the issuance of the building permit.
Signed affidavit Attached Yes ....... 0 No ....... 0
SECTION 5 Description o Proposed Work (check applicable)
New Construction 0 Existing Building V Repair(s) 0 Alterations(T—�'T ddition 0
Accessory Bldg. 0 Demolition 0 Other 0 Specify
Brief Description of Proposed Work:
?�'U,,Ae -Ar W C ccy ft�l
I SECTION 6 - ESTIMATED CONSTRUCTION COSTS i
Item
Estimated Cost (Dollar) to be
Completed by permit applicant
OFFICIAL USE ONLY
I . Building
1,2,
(a) Building Permit Fee
Multiplier
2 Electrical
L; 3
(b) Estimated Total Cost of
Construction
3 Plumbing
Building Permit fee x (b)
4 Mechanical (HVAC)
5 Fire Protection
3 -1, n
6 Total (1+2+3+4+5)
/'�:' o '�� ��
Check Number
SECTION 7a OWNER AUTHORIZATION TO BE COMPLETED WREN
OWNERS AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT
as 0ximer/Authorized Agent of subject property
Hereb� authorize C"4"� to act on
MN 11ehalf, in all matters relativ to w k autho%zed by this building pennit application.
S -fOwner
igua re 0 Date
SECTION 7b OWNER/AUTHORIZED AGENT DECLARXTION
as Owner/Authorized Agent of subject
PropertV
Hereby declare that the statements and information on the foregoing application are true and accurate, to the best of my knowledge
and belief
Print Name
Signature ot 1ATier/ -ent Date
NO 21M'42 -11i'
NO. OF STORIES SIZE
BASENIENT OR SLAB
SIZE OF FLOOR TDviBERS I ST 2 ND 3 RD
SPAN
DBIENSIONS OF SILLS
DD.ENSIONS OF POSTS
DfNIENSIONS OF GIRDERS
HEIGHT OF FOUNDATION TBICKNESS
SIZE OF FOOTING X
MATERIAL OF CHNNFY
IS BUILDING ON SOLID OR FILLED LAND
IS BUILDING CONNECTED TO NATURAL GAS LINE
9
I
COMMONWEALTH OF MASSACHUSETTS
k
EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS
DEPARTMENT OF ENVIRONMENTAL PROTECTION
1v -)RTH Al,'�-'
k
TITLE 5
OFFICIAL INSPECTION FORM — NOT FOR VOLUNTXRY ASSESSME�T—�
SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM
PART A
CERTIFICATION
Property Address: t -q-1. n\A Cr -A -
JV AP
6�.(:
Owner's Name:
Owner's Address:
Date of Inspection:
Name of Inspecto ase Drint)---- r -n —f8s�6 a -
Company Name:
Mailing Address:,�n Y,
Telephone Numb 8:z:� — —7 V-7
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 the inspection. The inspection was performed based on my
training and experience in the proper function and maintenance of on site sewage disposal systems. I am a DEP
approved system inspector pursuant to Section 15.340 of Title 5 (310 CMR 15.000). The system:
Passes
Conditionally Passes
Needs Further Evaluation by the Local Approving Authority
Fails
Inspector's Signature: Date:
The system inspector shall submit a copy of this inspection report to the Approving Authority (Board of Health or
DEP) within 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
DEP. The original should be sent to the system owner and copies sent to the buyer, if applicable, and the approving
authority.
Notes and Comments
****This report only describes conditions at the time of inspection and under the conditions of use --t that
time. This insDection does not address how the system will verform in the future under the same or different
conditions of use.
Title 5 Inspection Form 6/15/2000 page I
age 2 of 11
OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION (continued)
Property Address: -I
n\ c --
Y.
Owner:
Date of Inspection:
Inspection Summary: Check A,B,C,D or E / ALWAYS complete all of Section D
A. System Passes: )? �V5
I have not found any information which indicates that any of the failure criteria described in 3 10 CMR
15.303 or in 3 10 CMR 15.304 exist. Any failure criteria not evaluatedare indicated belo�v.
Comments:
B. System Conditionally Passes: A/
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.
Answer yes, no or not determined (Y,N,ND) in the for the following statements. If "not determined" please
explain.
- The septic tank is metal and over 20 years old* or the septic tank (whether metal or not) is structurally
unsound, exhibits substantial infiltration or exfiltration or tank failure is imminent. System will pass inspection if the
'existing tank is replaced with a complying septic tank as approved by the Board of Health.
*A metal septic tank will pass inspection if it is structurally sound, not leaking and if a Certificate of Compliance
indicating that the tank is less than 20 years old is available.
ND explain:
Observation of sewage backup or break out or high static water level in the distribution box due to broken or
obstructed pipe(s) or due to a broken, settled or uneven distribution box. System will pass inspection if (with
approval of Board of Health):
broken p4*s) are replaced
obstruction is removed
distribution box is leveled or replaced
�M explain:
- The system required pumping more than 4 times a year due to broken or obstructed pipe(s). The system will
pass inspection if (with approval of the Board of Health):
ND explain:
broken pipe(s) are replaced
obstruction is removed -
PA
Page 3 of I I
OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION (continued)
Property Address: C�2\'\
Jy
Owner: Akj.14:�'k % %'-p
Date of Inspection:
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 public health, safety or the environment.
1. System will piss�unlesvfloard of Health"determines in iciordance with 310 CMR 18.303(l)(b) that the
system is not functioning in a manner which will protect public health, 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 any) determines that the
system is functioning in a manner that protects the public health, safety and environment:
— The system has a septic tank and soil absorption system (SAS) and the SAS is within 100 feet of a
surface water supply or tributary to a surface water supply.
The system has a septic tank and SAS and the SAS is within a Zone I of a public water supply.
— The system has a septic tank and SAS and the SAS is within 50 feet of a private water supply well.
— The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or more from a
private water supply well". Method used to determine distance
"This system passes if the well water analysis, performed at a DEP certified laboratory, for coliform
bacteria and volatile organic c6mpotinds indicates' that thewell is free from pollution from that facility and
the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other
failure criteria are triggered. A copy of the analysis must be attached to this form.
3. Other:
a,
Page 4 of I I
OFFICIAL INSPECTION FORM — NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION (continued)
Property Address: �Z -1 rp(�
Owner:
Date of Inspection:
D. System Failure Criteria applicable to all systems:
You must indicate "yes" or "no" to each of the following for all inspections:
Yes No
coo0fackup of sewage into facility or system component due to overloaded or clogged SAS or cesspool
::��iichirge7 -or p'onding of effluent to the'surface of the grodnd 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
_LZ'Liquid depth in cesspool is less than 6" below invert or available volume is less than 1/2 day flow
wolkequired pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number
of times pumped
6o0ooXny portion of the SAS, cesspool or privy is below high ground water elevation.
Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface
water supply.
Ats Any portion of a cesspool or privy is within a Zone I of a public well.
#40 Any portion of a cesspool or privy is within 50 feet of a private water supply well.
Q. 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. [This system passes if the well water analysis,
performed at a DEP certified laboratory, 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, provided that no other failure criteria
are triggered. A copy of the analysis must be attached to this form.]
(Yes/No) The system fails. I have determined that one or more of the above failure criteria exist as
described in 3 10 CNfR 15.303. therefore the system fails. The system owner should contact the Board of
Health to determine what will be necessary to correct the failure.
E. Large Systems:
To be considered a large system the system must serve a facility with a design flow of 10,000 gpd to 15,000
gpd.
You must indicate either "yes" or "no" to.each of the following:
(rhe following criteria apply to large systems in addition to the criteria above)
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
If you have answered "yes" to any question in Section E the system is considered a significant threat, or answered
14yes" in Section D above the large system has failed. The owner or operator of any large system considered a
significant threat under Section E or failed under Section D shall upgrade the system in accordance with 3 10 CMR
15.304. The system owner should contact the appropriate regional office of the Department.
4
Page 5 of I I
OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART B
CHECKLIST
Property Address: C)\A c rJ4
Owner:
Date of Inspection:
Check if the following have been done. You must indicate "yes" or "no" as to each of the following:
0 - Pumping inTormation was provided by the owner, -occtfpant, or Board 'of Health
--4ere any of the system components pumped out in the previous two weeks ?
Has the system received normal flows in the previous two week period ?
— -4e-*ffave large volumes of water been introduced to the system recently or as part of this inspection ?
4o1""— Were as built plans of the system obtained and examined? (If they were not available note as N/A)
Was the facility or dwelling inspected for signs of sewage back up ?
j,Z Was the site inspected for signs of break out '.)
Were all system components, excluding the SAS, located on site ?
Were the septic tank manholes uncovered, opened, and the interior of the tank inspected for the condition
of t6—ba-ffles or tees, material of construction, dimensions, depth of liquid, depth of sludge and depth of scum ?
Was the facility owner (and occupants if different from owner) provided with information on the proper
maintenance of subsurfac� sewage disposal systems 9
I The size and Ideation of the,SojI Absorption System.(SAS) on the site has been determined based on:
Existing information. For example, a plan at the Board of Health.
— — Determined in the field (if any of the failure criteria related to Part C is at issue approximation of distance
is unacceptable) [3 10 CMR 15.302(3)(b)]
Page 6 of I I
OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION
PropertyAddress: �Qt.-3-t ou cor�
AL _Anc�er
Owner: re --Ix In, % I 'j �0
"' ' v"
Date of Inspection:
FLOW CONDITIONS
RESIDENTIAL
Number of bedrooms (design): Number of bedrooms (actual):
DESIGN flow based on 3 10 CMR 15.203 (for example: I 10 gpd x # of bedrooms):
Number of current residents: Q r /�
Does residence have a garbage grinder (yes or no): � f 70 8C 'Uf t.
-T
Is laundry on a separati sewage system'(yes or no); 0 yes se0arate -inspection required]
(if
Laundry system inspected (yes or no):
Seasonal use: (yes or no):,�h
Water meter readings, if av ilable (last 2 years usage (gpd)):
Sump pump (yes or no): - I I
Last date of occupancy: 0 cell e
COMMERCIAL/INDUSTRIAL
Type of establishment:
Design flow (based on 3 10 CMR 15.203): gpd
Basis of design flow (seats/persons/sqft,etc.):
Grease trap present (yes or no): _
Industrial waste holding tank present (yes or no):
Non -sanitary waste discharged to the Title 5 system (yes or no):
Water meter readings, if available:
Last date of occupancy/use:
OTHER (describe):
GENERAL INFORMATION
Pumping Records
Source of information: — ith - 6,
Was system pumped as part of the inspection (yes or no):
If yes, volume pumped: 500gallons How was q ity pum ed determined? 7"R U cle- 1w C r to it
Reason fbnpum�ing:
TY3ZOF SYSTEM
V Septic tank, distribution box, soil absorptiim sy.ftm
Single cesspool
Overflow cesspool
Privy
Shared system (yes or no) (if yes, attach previous inspection records, if any)
Innovative/Alternative technology. Attach a copy of the current operation and maintenance contract (to be
�btained from system owner)
— Tight tank _ Attach a copy of the DEP approval
Other (describe):
Approximate age of all components, date installed (if known) and source of information*. Y��5
Were sewage odors detected when arriving at the site (yes or no): Wo
.Page 7 of I I
OFFICIAL INSPECTION FORM — NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Property Address: cq�
Owner: te
Date of Inspection:
BUILDING SEWER (locate on site plan)
Depth below grade: I,?
Materials of construction: —cast iron 4- 40 PVC —other (explain):
Distance from privatq water supply well or suction, line:
(on c dition o joints venting, evidefice of leakage', etc):
Comments 0 1 f* *
MHr% �; Od D C6 Ain) -r) v -Y
SEPTIC TANK: *i (locate on site plan)
Depth below grade:
Material of construction: �'�rncrete —metal —fiberglass __polyethylene
__other(explain)
If tank is metal list age: _ Is age confirmed by a Certificate of Compliance (yes or no): (attach a copy of
certificate)
Dimensions:
Sludge depth:
Distance from top of sludge to bottom of outlet tee or baffle: 3 V
Scum thickness: 1.- 1.
Distance from top of scum to top of outlet tee or baffle:
Distance from bottom of scum to bottom of outlet tee or baffle: / v
How were dimensions determined: 0 q S / 7-C
Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels
as related to outlet invert, evidence of leakage, etc.):
4 7-,4wle 4 do L) 41010 1,rue-1 f 0 2
7-0 Od7-4r7—
GREASE TRAP: —6ocate on site.*pl*�
Depth below grade:
Material of construction: —concrete —metal —fiberglass ___polyethylene —other
(explain):
Dimensions:
Scum thickness:
Distance from top of scum to top of outlet tee or baffle:
Distance from bottom of scum to bottom of outlet tee or baffle:
Date of last pumping:
Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels
as related to outlet invert, evidence of leakage, etc.):
P�age 8 of I I
OFFICIAL INSPECTION FORM — NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Property Address: 5:4 �,-1 ( i�
Owner: A 10M ',e
Date of Inspection:
TIGHT or HOLDING TANK-htL (tank must be pumped at time of inspection)(locate on site plan)
Depth below grade:
Material of construction: concrete metal —fiberglass olyethylene _other(explain):
Dimensions:
Capacity: gallons
Design Flow: gallons/day
Alarm present (yes orho): _
Alarm level: Alarm in working order (yes or no):
Date of last pumping:
Comments (condition of alarm and float switches, etc.):
D ISTRIBUTION BOX: 4 (if present must be opened)(locate on site plan)
Depth of liquid level above outlet invert: ' Elvd /
Comments (note if box is level and distribution to outlets equal, any evidence of solids carryover, any evidence of
leakage into or out of box, etc.):
,60X 6 0 0 n Od -A / 0 / 17 d &/ — or --Z 0 (w 5' /7 !� &J/ — C -) t -*!x .0 u
PUMP CHAMBER: ", (locate on site plan)
Pumps in working order (yes or no): _
Alarms in workini, order (yes or no): A
Comments (note condition of c�ambgr, condition of pumps and appurtenances, etc.):
PUMP
Age 9 of I I
OFFICIAL INSPECTION FORM — NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C.
SYSTEM INFORMATION (continued)
Property Address: Q 6-1 QJ�A----CC24
4 1 -
Owner: J\JQPS� I I e
Date of Inspection:
SOIL ABSORPTION SYSTEM (SAS):X-p-, (locate on site plan, excavation not required)
If SAS not located explain why:
Type
— leaching pits, number:
— leaching chambers, number:
�hing galleries, number:
Ieaching trenches, number, length:
leaching fields, number, dimensions:
overflow cesspool, number:
innovative/alterriative system Type/name of technology:
Comments (note condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of vegetation,
etc.): NO 'T/!�zer e) 4 A) o / -4/ r. 0 e- R a u e,4 c- o t2 r
-:0, HeJ 4Z 44 -1
CESSPOOLS: _ (cesspool must be pumped as part of inspection)(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 (yes or no):
Comments (note 6nditioh of soil, signs of hydraulic failu!re, level of ponding, condition of vegetation, etc.):
PRIVY: (locate on site plan)
Materials of construction:
Dimensions:
Depth of solids:
Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.):
e0e 10 of 11—
OFFICIAL INSPECTION FORM — NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM'INFORMATION (continued)
Property Address: vo C-
Nkz�h
Owner:
Date of Inspection:
SKETCH OF SEWAGE DISPOSAL SYSTEM
Provide a sketch of the sewage disposal system including ties to at least two permanent reference landmarks or
benchmarks. Locate all wells within 100 feet. Locate where public water supply enters the building.
P W C 0 JQ4
h - T=. J1 L—
jt3- 7--% 43/
30-6
7 -Aft 'A-
13 a J.
0;
,.� ;reen c#, -s
S -r g e e --r'
10
41 Me 11 Of 11
OFFICIAL INSPECTION FORM — NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Property Address:
Y_ Airv+zidf
Owner: 42-(6, P_
Date of Inspection: ' ;i___1
SITE EXAM
Slope
Surface water
Check cellar
Shallow wells
Estimated depth to*grou'nd'wa'ter ieet
Please indicate (check) all methods used to determine the high ground water elevation:
lqqrL �bta ed from fy;stern design plans on record - If checked, date of design plan reviewed:
Observed site (abutting property/observation hole within 150 feet of SAS)
Checked with local Board of Health -explain:
Checked.with local excavators, installers- (attach documentation)
Accessed USGS database -explain:
You must describe how you established the high ground water elevation:
I) If r 42 A - 11 r 6 " tyl z, to ? —r a op a i
0
I I
LETTER OF TRANSMITTAL ViOR-rh
North Andover Health Department
400 Osgood Street
North Andover, MA 01845
978.688.9540 - Phone
978.688.8476 - Fax
healthdeptna,townofnorthandover.com - E-mail
www.townofnorthandover.com - Website Page of
TO:
DATE:
COMPANY:
FROM: PatneldDell Chiaip, Health Dept. Assistant
Phon ef
RE:
_zg V7
Fax:
L"I Z'11
We are sending you: _ OCo OP/ans 00ther (rill in below)
py of Letter
These are transmitted as chesk<dlbei W: �
17Approved as Noted CAT11equested 17As Required OResubmit copiesfor approval
L7For approval 17For Review and comment LEor, Your Use 0S.ubmit copiesfor dist.
REMARKS:
COPY TO:
COPY TO:
COPY TO: SIGNED:
Town of North Andover, Massachusetts Form No. 2
BOARD OF HEALTH
40
DESIGN APPROVAL FOR
SOIL ABSORPTION SEWAGE DISPOSAL SYSTEM
Appl i can 1 /"N 0 — Test No
Site Location n -f -j C a-'� UJCA-,--,
Reference Plans and Specs
ENGINEER
Permission is granted for an individual soil absorption sewage disposal system to be installed
in accordance with regulations of Board of Health.
CHAIMAN, BOARD OF HEAL
Fee— 4C)
Site System Permit No. 596
FORM U - WT RErEME FORM
INsTRUqTIONS: This form is used to verify that all necessary
approvals/permits from Bo ' ards and Departments having jurisdiction
have been obtained. This does not relieve the applicant and/or
landowner from compliance with any applicable local or state law,
regulations or requirements.
* ant fills out this section*****************
APPLICANT: 111t C -e Phone
LOCATION: Assessor's Map Number Parcel
S u b d i v i s 41. o n
Lot(s)
Street �1611 St. Number
************************Official Use
RECOM7M�END ONS OF TOWN AGENTS:
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Date Approved
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Comments
Town Planner
Comm ents
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Date Approved
Date Rejec--ed
Date Approved
Date Re-iec--ed
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Date Re-ieczed
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Fire Demartment
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