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Commonwealth of Massachusetts
City/Town of NA4 AP&M."
System Pumping Record
Facility Information:
System Location:
,�7; ),5 -
Address
5 Zi314
Tovvj� "
-LEAL-r
tq
City/Town State Zip Code
System Owner:
1, /1 r
Naine_:
Adress (if different from location of pump)
City/Town State Zip Code
Telephone Number
Pumping Record
Date of Pumping- 91-7 Quantity Pumped3, I)d Z) allons
Type of System—X—Septic Tank—Grease Trap—Other —(what)
System Pumped by: _L�L ',a 1 6 �&W
Company: ROOTER -MAN 46 Portland Street La'wrence, MA 01843
Location where contents were
Signature of Hauler L!
_\1
Commonwealth of Massachusetts
City/Town of � 4t& YVA
System Pumping qecordvi
Facility Information:
System Location:
�� '-� !;-
AddrVs-s
— 14* &
Ci /T own
System Owner:
Name:
Adress (if different from location of pump)
City/Town
Pumping Record
RECEIVED
s!:--; '13 Z013
k_1
TOWN OF NORTH ANDOVER
HEALTH DEPARTMENT
Zip Code
State Zip Code
q�6 _q _23-- ft6
Telephone Number
Date of Pumping_tt��, Quantity Pumped___:� �66b�.gallons
Type of System_�__ Septic Tank Grease Trap_Other (what)
System Pumped by: &4_
Company: ROOTER -MAN 46 Portland Street Lawrence, MA 0 1843
Location where contents were disposed:
Signature of Haule Date
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 SAJ I�Za ti -)6r I /h i PHONE f -?,7C? --(D K --?6
ASSESSORS MAP NUMBER —LOT NUMBER
SUBDIVISION LOT NUMBER
STREET 7 STREET NUMBER 225—
..................
OFFICIAL USE ONLY
RECONMIENDAT1ONS OF TOWN AGENTS
DATE APPROVED
�CONRVATION ADMINISTRATOR
DATE REJECTED
CONMENTS
— lef-t As
TOWN PLANNER
CONWIENTS
FOOD INSPECTOR - HEALTH
S C &PECTOR - HEALTH
#,�,t 'SA
DATE APPROVED
DATE REJECTED
DATE APPROVED
DATE REJECTED
DATE APPROVED
DATE REJECTED
I jree-
PUBLIC WORKS - SEWER / WATER CONNECTIONS
DRIVEWAY PERMIT
DATE APPROVED
FIRE DEPARTNIENT
DATE REJECTED
CONM4ENTS
RECEIVED BY BUILDING INSPECTOR
.32
V\
08/14/00 12:20 RUBY WINES --> 781 937 8410
MORMAGE INSPECTION
SAY STATE SURVEYING ASSOCIATES INC -
100 CUMAMNGS CENTER, SUnM # 316j, SEVERLyMA., 01glS
v - /N/00rH A tJ Do IL164 mA,
LOCATION..__..,
SCALE: I" -60oATE: ---
REFERENCE:
To. -NOR—Ti-t 4 rL4A)'rie_. Alcogr coAP40.
The location at tne JxAdbUs) m dwvv. gaw
="Pffed VAIN We lbcai zoni" miftacics a it* time of
consauman Cris exempt&= vk"dm w I ent Acdon
=der Mam Q:L_ TWe Vs chapW QA 3ection 7
/300
3z 1.4
97
NO.515 P00:5t003
NOTM.
11 TM Is& reartgap Jospeedw unM wul not an
knewsmsd msv". H I I uft plot plan Is for
__ - 1010puesespurpossaftly-
21 surM Is based M SWM wwoft of allum
31 Boehm shru" twoms sowl Irm &M do not
kdkmm pqw ty ft�
41 fteusaw w asm Ja 10 - w ism an knuument
sur vvy krecownsiow 1A 4 - I " opm ty
llom ad my Posmilsk enuvactimemes.
51 OXwo siume are appmakeste6 ind are to be
wed a* fewan doWnbMw id =ning, Not to
beowd fa simob" is opmfy Mm
9) In my 1 9 ' , I Opinion an buildings) am not
locasud In the special Good' — 'zone, an
0 1 k' 1'0�'
GA -113
NOTF_- LOT CONFIGURATION -
TAKEN FROM ASSESSORS MAP
1" 4
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SCALE'
141. .
E R 9tM ACK 046IMS004 t
G ViC, S INC.
PROEE�SONAI jt4EtkS,`*' LAND SURVEYORS 4 PLANNERS
66 PAft PREET *t004R, MA4SACMUU�TS'01810 TE1. -3555� 373 572'
I
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o 'Massachhusetts
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State
7 -ALI
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t 0 orn location of p -
State
o ii
o
,Tm-,io Record
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Quanitiry
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I ank—farease Trap
Ai Lue 7
N
461
d I Sri
—,,s were
SE,5 'i', y � Ulf I
TOWN OF NORTH ANDOVF-R
-�EALT�-j f.'FPARTAAC:1,11,
�41
11 4k
Commonwealth of Massachusetts
TTS'
City/Town of NORTH ANDOVER, MASSACHFSETTS
r.1 1� 9
System Pumping Record
Form 4 TOWN OF NORT H ANDOVER I
HEALTH DEPARTMENT j
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 authority.
Information
Owner:
?
WVC(
MCL .-
State Zip Code
Name
Address (if different from location)
Cityrrown State Zip Code
Telephone Number
B. Pumping Record
1 Date of Pumping '3/jt///0 2. Quantity Pumped: 1500.
Date Gallons
3. !Type of system: Cesspool(s) M/Septic Tank Tight Tank
Other (describe):
4. Effluent Tee Filter present? Yes [I No If yeA,'was it cleaned? E] Yes r No
5. Condition of System:
e1?W-6h1j 11ru fij//
6. System Pumped By -
1z ro" y Son 7 C)
Name Vehicle License Number
�SAe- S�tl( Sf ( vl(
Compari-y
7. �,ocation where contents were disposed:
10 017-) n)
It- y
SighatA of Hauler Date
http:/twww.mass.gov/d
qA5 aterlapprovalsft5forms.htm#inspect
t5form4.doc- 06/03 System Pumping Record - Page 1 of 1
A. Facil
Important:
When filling out
1. Sys�
forms on the
computer, use
only the tab key
ss
to move your
cursor - do not
use the return
Cityrrow
key. ,
VQ
2, Syq1err
- A)h
Information
Owner:
?
WVC(
MCL .-
State Zip Code
Name
Address (if different from location)
Cityrrown State Zip Code
Telephone Number
B. Pumping Record
1 Date of Pumping '3/jt///0 2. Quantity Pumped: 1500.
Date Gallons
3. !Type of system: Cesspool(s) M/Septic Tank Tight Tank
Other (describe):
4. Effluent Tee Filter present? Yes [I No If yeA,'was it cleaned? E] Yes r No
5. Condition of System:
e1?W-6h1j 11ru fij//
6. System Pumped By -
1z ro" y Son 7 C)
Name Vehicle License Number
�SAe- S�tl( Sf ( vl(
Compari-y
7. �,ocation where contents were disposed:
10 017-) n)
It- y
SighatA of Hauler Date
http:/twww.mass.gov/d
qA5 aterlapprovalsft5forms.htm#inspect
t5form4.doc- 06/03 System Pumping Record - Page 1 of 1
Commonwealth of Massachusetts
Ulty/Town of M(4 6VWP-4
1"
.Systern F Umping Record
pqf-i,;
-Z I-Tifor M-ation:
Systenna Location:
Address
— Nb,( -K ..
City/Town Sta!e.
SYStern Owner'.
NT
I a rr, e:
Adress (ilf different frorn location of pump)
City/Town State
.1 elephone
Pumping Record
_LN3[N.LHVd30 HIIV3H
�GAOCINV HDAONJO W01
C4 1
- TOWN OF
r0W
_"IN
VCr
_.eQ6 —
Zip Code
Zip Code
Date of Purnping
Quantity Pumped -all
ions
ly�ie of Svstern
j --,X,,,Septic Tank Grease Trap Other -hat)
System Pumped by:_0 hri:s
Company: ROOTER -MAN 46 Portland Stree avvTence, IMA 0 1843
Location where contents were osed:
2 F
Signature of Hauler7T 7.L Date_ .5 / hohz_
Commonwealth of Massachrj
City/Town of No 6+N W
System Pumping Record v
Facility Informat'-
ion:
System Location-
,-) -1 (�
C>4- I
Address
6�ty_/Town Q-1
System Owner:
Name.-
6V
6bq �
Adress (if different lrof� I�ocationof pump)
City/Town
TO'.
ISY
SEP 19 2008
- ffy� 01
State
Zip Code
State Zip Code
Telephone Number'
Pumping Recorc
Date of Pumping Quantity Pumped 60 0 allons
Type of System ease Trap
OKSeptic Tank_Gr _Other ------ -(what)
System Pumped by:_ V,
Company: ROOTER -MAN 12 East Dracut Rd., Methuer4 MA 0 1844
Location where contents were disposed:
Signature of Hauler
RECEIVED
oornmonvYealt SEP 19 2006
1) of mas
-oWn
qr
�sy��teai pul-ripi TOWN OF NORTH ANDOVE
I . FGCQI 4 ove HEALTH DEPARTMENT
Ne 4�11 0 ro
GEI:� hs-
100;�j C"- Z�Ljb�tzmual 004iro�3 Of Haa[Eh. Och -
Q'a 1: H ly trl- --
to o4at - �:�Me a:j ti)4t PC i qr TQrnjs Cri-aY 1z -
Me c1l"'Ine xllc� ov a ea
olilal- a Pj-'.� in, U;3i5, Thi�,sy$g�,
p v 9 auchofily, m PQfnpin@ PQ I"
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Pun'P'"9 Record
Date Q� F1401pir)q
I
tA
zip cm
01
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Typij '4 (Ii-antity
Q ()Illef (QQ'�cftbay E�aPtio Tank
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7- Locarion
wa� it
8�,-iwn Pwrnp, , fi� R4N(d 1 'Q."�4 1 'if I
r P, I V E D LIX
<L\ Commonwealth of Massachusetts 1VE]D
Zo
City/Town of SEP 15 Z005
A��
TER
System PumpVnog��R�ecord -OWN OF NORUH A��DOVER
P�2T
Form 4 HEALTH DEPARTNIENT
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.
A. Facility Information
Important:
When filling out 1 . System Location:
forms on the
computer, use C�Z5 T
only the tab key Address
to move your
cursor - do not
use the return CityfTown State Zip Code
key. 2. System Owner:
1UFA4.T
Name
Address (if different from location)
City/Town State Zip Code
Telephone Number
B. Pumping Record
1. Date of Pumping 2. Quantity Pumped:
Date Gallons
3. Type of system: El Cesspool(s) E3*Septic Tank E] Tight Tank
El Other (describe):
4. Effluent Tee Filter present? [] Yes 2-'N'o If yes, was it cleaned? Ej Yes E] No
5. Condition of System:
6nIDL>
6. System Pumped By:
n416644161 SOV/d
NamA
k�'t702CRM111V -
Company
7. Location where contents were disposed:
of
Vehicle License Number
Date
t5form4.doc- 06/03 System Pumping Record - Page I of 1
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FO LOT RELEASE FORM
NSTRUCTIONS: This form is used to verify that all -necessary approval I 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.
..............................
PHONE
APPLICANT A IJ 1�$ U2' (I )I
ASSESSORS MAP NUMBER LOT NUMBER
LOTNUMBER
SUBDIVISION
STREET NUMBER
STREET
IAL USE ONLY
OFF C .................. gnomon
TOWN AGENTS mmomommommom ........ momm.mmoomom
RECOMWNDATIONSOF ..................
nmm!!Boon - mommomommoom
ago 1 0 n DATE APPROVED
Coon
RVATION ADMINISTRATOR,
4CONC DATE REJECTED
Lid
—�ej"_ 12\5Sq
DATE APPROVED
TOWN PLANNER DATE REJECTED.
C
DATE APPROVED
FOOD INSPECTQR HEALTH DATE REJECTED .
DATE APPROVED
C ECTOR - HEJALTH DATE REJECTED
PUBLIC WORKS — SEWER / WATER CONNECTIONS
DRIVEWAY PERMIT
FIRE DEP
C
RECEIVED BY BUILDING INSPECTOR
DATE APPROVED
DATE REJECTED
TE
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10
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�rH E:-- Cou STI�>-uCMO�j Ot-- I -HE
SJF-�SURI=-hCE: DISPOSA�- S\� STE�� OU JIDT
7 Nl�,W7T ST-, QOR��
r-,lzh-.Ms P-, c.ousTp->ucMQ IQ
Wl�-h -rHF- PlAkS
F -C H , 19 BE-.
APPeox it
�\B'P�OTT '���)E:�—T
AS BUIL'i PLAN
OF '
SUBSURFACE DISPOSAL -SYSTEM
.WORTH � kMDoVE:Rq m A�ss.
F%Q rr%c rAlltu rvx
MkRik DI-Dio
DATE: AUGVST, lcte>5
S-CALE,: I
MERRIMACK ENGINEERING SERVICtS, INC.
PROUSSIONAL EttraINEERS LAND SURVEYOU o PLANmERS
06 PAO 51RUT AtOOVED, MASSACXUSftt$ 01610 VC (617) AMMS, 373-S.72
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JVEr-T AT (WO:! 11,900
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PORL�
FX kS 77/ IV 6
2) Wt- I I /,y 6-
NORTH AMOVM. BOARD OF HEALTH
I118T.,�LLATTION CiMM LIST
APPANED DISAPPROVED EXCAVATION OK
Date: Date -
Reason:
1 &1ilt S)�bmitted
Chec - ation, dimensions of system) location in regard to
ot loc,
percolation tests., depth of system., vrater table
2. Distance to Wetland Areas, Drains, Street & House., Drainage Easement and Wells.
3. Water Line Location
4. NOXCIPip a
5i Septic Tank - T/e, Cement i e to T Jo ts on both side of Tank.
6. Distribution Box - No cracks ox or cover, all lines I emally fro ox.
7. Leach Fields - Dime ons i �ep
Stone ths3 Cappe
,,�ds, Clean doub -irasshed stone
8. Leach Pits Dimensions, Depth of Stone, Splash pac�tees) Cement -pipe to tank -
joints on both sides of tank, Clean double -washed stone
9. No Garbi/e Disposals
10. Final Grading rricading of sub -surface system�
V
4-
MVAVTT.P z prprnTATION TEST DATA
Town/City_�_ No.&Street Lot No.
Loc./Subd iv. Plan Owner — jde�-.141c_ V,
Investigator Observer
SOIL PROFILES -DATE
2.. 1 4. Elev.
Elev. Elev. Elev.
f% n
A
2enchmark
Elevation
1
2
3
4
5
6
7
8
9
10
1
2
3
4
5
6
7
8
9
10
Location
Datum
Percolation Tests -Date
1
2
3
4
5
6
7
8
9
10
. d
Ilk
NN
Nj
Its
_43
V
Pit Number
2 3 4 5
St -art Saturation
Soa%-Mins.
Start Test -Time
�U
Drop of 311 -Time
5 110
Drop of 611 -Time
Mins.lst 3"Drop
Min�z_�)nH '�ITT)r-nn
J/1
Notes & Sketches on Back
Frank C. Gelinas & Associates, North And.
I
I.
%I
NO1151H AND0VER.BOARD OF HEALTH
4�1 SUBSURFACE DISPOSAL SYSTEM CHEK LIST
kPPROVED PROVIDED DISAPPROVED
A e VC
leg. 2.5
Reg. 6.1
Reg. 6.7
Reg. 6.0
Reg. 6.9
Reg. 6. 1'
Reg.' 6.V
Reg 3.7
Reg 9'1
Reg. 9:6
GO
The submitted plan must show as a minimumo.
(-a) the lot to be served (arealdimensions, lot #, abutters)
�bHocation and dimensions of system (including reserve area)
W -design calculations
(4-4alculations showing recuired leaching area
W -existing and proposed contours
(S)-l-ocation and log of deep observation holes -distance to ties
(g41-ontion and results of percolation tests -distance to ties
Ch) -location of any wet areas within 1001 of the sewage disposal
system or disclaimer
(-i4--surface and subsurface drains within 1001 of sewage disposal
system or disclaimer
W42:6c—ation of any drainage easements within 1001 of sewage
disposal system or disclaimer
W -'Known sources of water supply within 2001 of sewage disposal
system or disclaimer
(-ii-Itcation of any proposed well to serve the lot (100 1 from leaching facility)
(-m)'- location of water lines on property (101 from leaching facilities)
W -maximum ground ivater elevation in area of sewage disposal system
(ZL1.ocation of benchmark
(PI—plan must be prepared by a Professional Engineer or other
professional authorized by law to prepare such plans
�q)-driveways
(-r)-garbage disposers
�s)--a-profile of the system (elevations of basement, plumbers pipe
septic tank,,distribution box inlets and outlets, distribution
field piping and any other elevations)
(t) no Pyz'ts to be used in construction
ptid` Tanks
(a) Capacities - 150% of,flow
(b) Water table
(c) Tee�s
(d) Depth of tees
(e) Access
(f) Pumping
,g) Cleanout
(h) 101 from cellar wall or inground swimming pool
(1) 251 from subsurface drains
Approval
(b) Stand-by power
Worth Andover Subsurface disposal. system check list -Page 2
Fail' - Distributiot Boxes
CK
leg.10.2 (,a)(Slope greater than 0.08
Reg.10.4 ;;I(b) Surap
Leaching Pits
Leaching pits are preferred where the installation is possible
leg.U.2 (a) Calculations of leaching area (minimum 5DO S.F.)
,Reg.3-1.4 (b) Spacing
Reg.11.101 W Surface drainage 2%
Reg.11.111 W Cover material
eachineFi elds
Reg -15-1 /a") Greater than 20 mirmtes/inch
Reg -35-1 (b) Area (minimum 900 S.F.)
TZ eg - 15.4 000,00 W onstruction of field
Rep, J5 8 Y.) Surface drainage 2%
leg: e) 201 from cellar wall or inground swimming pool
Downhill Slop e
(-A) Slope y/x = (to be shown)
,.,#e?b) ylx X 150 = (to be shown)
Elevation Datum
ej Percolation Tests -Date
Pit Number
SOIL PROFILE &
PERCOLATION TEST DATA
q
North Adover Mass. No.&Street
_3
Start Test -Time
Lot No.
Drop of 311 -Time -
Loc./Subdiv.
Drop of 611 -Time
Plan
Mins.1st 3"Drop
Mins.2nd 3"Droo
owner -rat4~
Investigator
Observer
Lee
SOIL
PROFILES -DATE
Elev.
2. Elev.
0
Elev.
1--Elev.
0
0
0
Ties to Test Pits
ofF 9FA4
3
3
3
3
CoKW&Y- AleAe4sr�
4
4
4
4
5
ZWZ-*, 5
5
5
6
6
6
6
7
7
7
7
8
8-
8
8
9
9
9
9
10
10
10
10
Elevation Datum
ej Percolation Tests -Date
Pit Number
2 3 4 5
Start Saturation
q
Soak -Mins.
_3
Start Test -Time
Drop of 311 -Time -
Drop of 611 -Time
it . IS V
Mins.1st 3"Drop
Mins.2nd 3"Droo
Notes & Sketches on Back ./Ij
c
407 Forest St.
'Middleton, MA 01949
(508) 774-2772
f 'Sixo
.40
FILE# 8 70% ?
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
a
PROPERTY OWNER'S NAME: De�4,apQ
f .1 1
PROPERTY ADDRESS: 27"r m, I IL 5:1, Aj,
MaZE
ADDRESS OF OWNER: S'c L
(if different)
DATE OF INSPECTION:
NAME OF INSPECTOR: vean G - Lus co k.--� M
8 THE PROFESSIONAL EXPERTS IN THE SEPTIC AND DRAIN INDUSTRY IP
FILE# 879G13
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORMW!7N �OFF""PMVJ"
PART A 0
'CATI
Property Address:VT A 6
Date of Inspection: 66* .5� A)IZ79dvrye SS ner:
Name of Inspector:1&J&5k '/j /91c, (Ifdifferent)
ea', Q LASCC&,6-07.
Company Name, Adprelss; and Telephone Number: Currier Septic & Drain Service, Inc.
107 Forest Street, Middleton, MA 01949
(508) 774-2772
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 sewage disposal systems. The system:
L/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 within thirty (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 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:
Checo, C, or D:
A) SYSTEM PASSES:
__Zl have not found any information which indicates that the system violates any of the failure criteria as defined in
310 CIVIR 15.303. Any failure criteria not evaluated are indicated below.
6) SYSTEM CONDITIONALLY PASSES:
One or more system components need to be replaced or repaired. The system, upon completion of the
replacement or repair, passes inspection,
Indicate yes, no, or not determined (Y, N, or ND). Describe basis of dtermination in all instances. If "not determined",
explain h not
The septic tank is metal, 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 8il 5/95)
T EFIC
ow"d—
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION F6RM AUG 9 1996
PART A
CERTIFICATION (CONTiNued)
B) SYSTEM CONDITIONALLY PASSES (continued)
"L -
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):
broken pipe(s) are replaced
obstruction is removed
distribution box is levelled or replaced
IJ 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 REOUIRED 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:
tiCesspool 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 PROTECT THE PUBLIC*HEALTH AND
SAFETY AND THE ENVIRONMENT:
The system has a septic tank and soil absorption system and 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 is within a Zone I of a public water supply
well.
The system has a septic tank and soil absorption system and is within 50 feet of a private water supply
well.
The system has a septic tank and soil absorption system and is less than 100 feet but 50 feet or more
from a private water siupply well, unless a well water analysis 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.
D) SYSTEM FAILS:
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.
t2Backup of sewage into facility or system component due to an overloaded or clogged SAS or cesspool.
I
A) Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or
clogged SAS or cesspool.
(revised 8115/95) 2
FILE#8 74?6a
L V
TH-4t�4t, �cv
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION (continued)
D) SYSTEM FAILS (continued)
k) Static liquid level in the distribution box above oulet 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 hM 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 we'll.
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.
GE SYSTEM FAILS:
criteria apply to large systems in addition to the criteria above:
The design flow is 10,000 gpd or greater (Large System) and the system is a significant
health and safet and the emmeament because one or more of the following conditions
— the system is within 400 feet of a
water
the system is within 200 feet of a tribu a surface i Ing water supply,
'ce Ing
the system is loca 7e Itir' � ater supply
_t9eAi Anitrogen sensitive area (interim Wellhead tion Area (IWPA) or a mapped
Z o n �ell 1, o �fa Wit . water supply well) ct
The owner �0? ator of any such system shall bring the system and facility into full com w ti
pliance with th undwater
ffi
Ic e
treatTpt-program requirements of 314 CMR 5.00 and 6.00. Please consult the local regional office of the D ment for
fughl§r information.
(revised 8/15/95) 3
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART 8
CHECKLIST
Check if the following have been done:
_i�pumping information was requested of the owner, occupant, and Board of Health
FILE# 9 7 5�6,8
Zmn
_f0W N —OF %%ORTH ANDW��
IOARD OF
-!/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
/r cently or as part of this inspection.
r
A5s built plans have been obtained and examined. Note if they are not available with N/A.
ZThe facility or dwelling was inspected for signs of sewage back-up.
.ZThe system does not receive non -sanitary or industrial waste flow.
ZThe site was inspected for signs of breakout.
_ZAj1 system components, excluding the Soil Absorption System, have been located on the site.
_L/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 existing
information or approximated by non -intrusive methods.
ZThe facility owner (and occupants, if different from owner) were provided with information on the proper
maintenance of SubSurface Disposal System.
(revised 8/15/95)
4
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION
FLOW CONDITIONS
RESIDENTIAL -
Design flow:. �y3ogallons
Number of bedrooms: ?
Number of current residents: j4
Garbage grinder (yes oRj�. .06
Laundry connected to sqste or no):-LeS
Seasonal use (yes om Uo_100
Water meter readings, if available:
Last date of occupancy: Of-'WafVr toe; Ili
Design flow: -nsida
Grease trap present: (yes
_or npot)------.,_
Industrial Waste Holding Tank present: (yes
Non -sanitary waste discharged to the Tit
Water meter readings, if avialble: --- �0
. Last date of_o;ourancy:
ER: (Describe)
date of occupancy:_
GENERAL INFORMATION
LFILB08796b 1
�0
PUMPING RECORDS and so rmation:
0� of !Pfo
A�q� 101"e'e a elelaoll- aid /6's pk-teaf 91,05 -
System pumped as part of inspection: (yet oK�5)_&jp C/
lf�W, volume pumped:jT00 gallons
Reason for pumping: 7- -,7
k,es 961 C:2p:&�Zr- k
7
TYP10F SYSTEM �A.) o Z) -13,2v
)Z Septic tankANNOMMINOsoil absorption system
Single cesspool
overflow cesspool
Privy
Shared system (yes or no) (if yes, attach previous inspection records, if any)
Other (explain)
APPROXIMME AGE of all cornp nents, date installed (if known) and source of information: Z46--'Irluel- (2,761'rj" aj;�M
erzeT alo, 0"dne'� " 01
f -'p /1 A F -,W -'VSq"ik- -?/"
Sewage odors detected when arriving at the site: (yes 0(9 -A) -o
(revised 8/15/95) 5
IFILE# a7 �?68
FF 1110RIH �P
RD OF
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
SEPTIC TANK: Ye5
(locate on site
-7-4
Depth below grade- 41
Material of construction: �L/concrete Metal FRP other(explain)
uimensions: 5, Deep v� s, / lo, k,
L U- ZW,74/ Baffle Depth Below Outlet Invert:
Sludge depth:_Z11j-,, V C/
Distance from top of sludge to bottom of outlet tee or baffle:
Scum thickness:- <
Distance from1op, of scum to top of outlet tee or baffle: 7"
Distance from bottom of scum to bottom of outlet tee or baffle: -
Comments:
(recommendation for pumping, condition of inlet an outlet teep or baffles, depjh o�liquid level in relation to outlet invgrt,
structural integrity, evidence of leakage,etc.)- I-Ze- S,,ok,- 7;-.
IA An
C �,g ,Soil i%
c- and
ba,
TKQ !!Jal-
J%IE SIT P�a
%j tce �n
Depth below grade:_
'Material of construcTtio—n: concr
--_Soncre etal _FRP other(explain)
s.
DimensiQons:
Scum thickness: Baffle Depth Below Outl
Distance from top Of scum to top of outlet tee or baffle:
Distance from bottom of scum to bottom of outlet te a e:
Comments:
(recommendation for g, condition of inlet and outlet tees or baffles, depth of liquid level i Von to outlet invert,
structural in evidence of leakage, etc.)
(revised 8/15/95) 6
IFILE# &r79673
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (conUnued)
9 1996
TIGH"R HOLDING TANV-PO
(locate 01 it!? plan)
0 p e.
Depth below grade:
10
Material of construc F10r—V co e metal FRP other(explain)
Dimensions:
Capacity: _gallons
Design flow: allons/day
Alarm level:
Comments
(condition of inlet tee, condition of alarm and float switches, etc.)
DISTRIBUTION BOX:-L)—O
=ocate on site plan)
Depth b iow-grade:
Depth of liquid liv-W-abouge outlet invert:
Dimensions of D -Box: of Sump�
Comments:
(note if level and distri �iis equal, evidence of solids carryover,
PUMP CHAMBER: IJO
(16cate-on site plan -r
Depth below graae-.--_
Pumps in working order:(ye
Comments:
(note conditions of pump chamber, condition
leakage into or out of box, etc.)
and ap-0DrteAaQces, etc.)
(revised 8/15/95) 7
� FILE# 871IF68
01,
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued) 9 060
SOIL ABSORPTION SYSTEM (SAS): Yds
(locate on site plan, if possible exca-vaRiolLmot required, but may be approximately by non -intrusive methods)
Depth to bottom of SAS: 449" (Store ci(PiV
If not determined to be present, explain:
Z4 eg 4d 64.4 4al11�
I- -AJ 7 - -,L -� -/ 97'-% . / f ff r 7
Type: leaching pits, number: 3 14,- Pits 6Lr-a 02, / Dee e
1p k (0 1
leaching chambers, number: Lor -6,
leaching galleries, number:_
leaching trenches, number, length: Y(�-
leaching fields, number, dimensions:— czhe.,- F,>�-
sik--e I lxtn "
Comments note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, e
?V, <",);/ "0'
7);,- -Pd-� e. -,e 7n e,.r,�40 U 12 U el -1� -1. -11 1 .-1- 11-1
CESSPOOLSOUX
(I te on site-p-7an)
low g r!
0"�a
Dept low grade:
N lu
umber an nfiguration:
Depth -top of liq6ld4oinlet invert:
Depth of solids layer:
Depth of scum layer:
Dimensions of cesspool:—
Materials of construction:
Indication of groundwater:
0
j
inflow (cessp 0a �bepump )ecfio�
ed as pai of ins. n)—
Comments: (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetatii3n�,
PRIVY:LJ6
(loro_te on site plan)
Materials of
Depth of solids -
Comments: (note condition of soil, signs of hyd
(revised 8115/95) 8
etc.)_
FILE# &7 4?6
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
-,--.-,0 <Anv
PART C
SYSTEM INFORMATION (continued)
Ir
SKETCH OF SEWAGE DISPOSAL SYSTEM:
include ties to at least two permanent references landmarks or benchmarks
locate all wells within 100'
j�-P)
S
Depth to groundwater: F
_ 57� feet
method of determination or approxiTat
Zr& &-
,a $2
a I
1U. Nn-Aevtr
A
(revised 8/15/95) 9
A +& T 46 -'* '? *
8 f.0 -r /off 'Y"
A 6 P
Board of Hcalth.
North An4qjg
OK
lq-(6
Gamiist
SEPTIC MTEM
INSTAILATICK CHECK MST
LOT 5557T
EXCAVATION OK FAI L
1. Distance Tot C4j(z--7D f7Ldk-,-S k-�rrrwj
a* Wet3.ands MvekA/ 15 C/'j
b. Drains
c.. wen 0 PFV5(rt-- fD5-C)F ft0LJ5F -F(-VVj
2. Water Line Location Aiu
3. No PVC Pipe
Septic Tank
a. Tees -Length & To Clean Out Covers
b. Cement Pipe to Tank - Oil Both Sides of Tank
Distribution Box
a. Covers & Box - No Cracks
b. All Lines Flo-Ang Fqual AmOmts
c. No Back Flow
6. - Leach Field or Trench
a. Dimensions
b. Stone Depth
co CappedEnds
d, Clean Double washed Stone
7. Leach Pits
a. DimBasions
b. Stone Depth
c. Splash Pads
d. T&es
e. Cej�t pipe to Pi t 13oth Side
fo nean Double Washed Stone
8. No, Garbage Disposal
9. Tinal Grading Inspection
10. Barricading Covered System
11. As Built Submitted
a. Lot Lor-aticn
b. Dimensions of System
c. 'Location with Regard -to Pere Test
d, 'Elevations
e.* Water Table
' ' Health
V
APPROVED
Providel:
DATE -1/-1115
`P�f
SMSURFACE DISPOSU MICK CMK USr MOO
1ar # Tawiv - ___ -
DISAPPROVED DATE
Reasonsi
IV
Title V FAIL OK
Reg. 2.5 The submitted plan must show as a minirmiml
A) the lot to be eerved-arealdimenBions-lot #.,abutteris
—'b W is- listance to ties
c location and results percolation te"a-& -itance to ties
djlocation and log deep observation
design calculations & calculations showing zequired leaching area
'(e) location and dimensions of Mtem-inolu&,2g veserve area
'(f) existing and proposed contours
(g) location any wet areas -Athin 1001 of sewage disposal system or
disclaimer -check wetlands mapping
(h) surface and subsurface drains within 1001 of sewage disposal
system or disclaimer
(i) location any drainage easements within 1001 of sewage disposal
ten or disclaimer -Planning Board files
(J) known sources of vater supply within 2001 of sevage disposal
system or disclaimer
(k) location of any proposed well to serve lot -1001 from leaching facility
(1) location of water lines on property -101 from leaching facility
'(m) location of benchmark
'(n) driveways
(o) garbage disposals
(p) no PVC to be used in construction
'(q) profile of system-elevationB of basemen' , plumb, pipe,, septic tank,
distribution box Wets and outletsj diL zibution field piping and
fther elevations
r) maximum ground -water elevation in area rrage disposal system
-Al tLgineer or other
s) p an must be prepared by a,Professio.
professional authorized by law to pr pay � such. plans
Reg 6 Septic Tanks
(a) capacities -150% of flow., water table., tebs,, depth of tees,,
access.. pumping
(b) cleanout
.1—(e) 101 from cellar wall or inground swi=dng pool
77(d) 251 from subsurface drains
Reg 10.2 Distribution Boxes
I I (a) - "lope greater U—m 0.08
Reg 10.4 = , __J_ (b) SUMP
N
SOIL PROFILE & PERCOLATION TEST DATA
Lot No
North Andover, Mass. Street No 0
Loc/Subdiv. Pland 0 w n e r —P(RI
investigator I ��Illle�-Iel —I' Observer— h�4��
SOIL PROFILE DATES_
4.Elev
1.�Iev 2.Elev- 3. El ev_
0 0 0 0
Tips to Test
Pits
2 2 2 2
3t— 3- 3
4 Qg!Lr"I 4 4 4
—50 &A-Iq
5 5 5
74
6 6
7
7 7 7
8 8 8
9 9— 9 9
10 10 10
Benchmark Lccation-
Elevation Datim
PIERCOLATION Th'3TS
Pit Number- 2 4
start Saturation
so mffnrut�s
Drop of 3" -Time
Drop of 6'
M6ns-Ist 3" drop
Mins.2nd 3" Drop
ercoia-Clon
Lomm"
�)6
Town of North Andover, Massachusetts
BOARD OF HEALTH
,ED ,
0
"I APPLICATION FOR SITE TESTING/INSPECTION
Form No.1
19
Applicant L.
NAME ADDRESS TELEPHONE
Site Location
Engineer NAME ADDRESS TELEPHONE
Test/l nspection Date and Time
Fee
S.S. Permit No. -5-34-
CHAI RMAN, BOARD OF HEALTH
Test No.
W.C. No. —'-�43 C.C. Date Plbg. Permit No.
DATE:.
[RECEIVED
SEP 16 2004
0 0 T VER
TOWN OF NORTH ANDO
H LT P4 Tj� T
EALTH DEPARTMENT
SYSTEM OWNER & ADDRESS SYSTEM LOCATION
NI, K� (example: left front of house)
915 pcb�T-rl 5
DA I TE OF PUMPING: QUANTITY PUMPEDC2,-q GALLONS
CESSPOOL: NO YES SEPTIC TANK: NO — YES X -
NATURE OF SERVICE: ROUTINE
OBSERVATIONS:
GOOD CONDITION
HEAVY GREASE
ROOTS
EXCESSIVE SOLIDS
SOLIDS CARRYOVER
I
SYSTEM PUMPED BY:
COMMENTS:
EMERGENCY
FULL TO COVER
BAFFLES IN PLACE
LEACHFIELD RUNBACK
FLOODED
OTHER (EXPLAIN)
CONTENTS TRANSFERRED TO:
gordon 0oyd & Company., tqnc.
Multiple Line Adjusters& Surveyors - Established 1926
A Subsidiary of National Claims Service, Inc.
Form of Notice of Casualty Loss to Building
Under Mass. Gen. Laws, Ch. 139, Sec. 3B
To: Building Commissioner or
Inspector of Buildings
Board of Health or
Board of Selectmen
TELEX NO. 466111
CABLE: BOYDCO
ADDRESS REPLY TO:
fo&)A L000,
addresses
horlk rA)tm—fz
Re: Insured:- r- 11 0, 6
Property address: 2 S— /7- S't
Policy No. 6(0Q=T 00 &t
Loss of 19 94
File or Claim No. I—W G
Claim has been made inv I Ing loss, damage or destruction of the above captioned property, which
may either exceed $1,000.0 'or cause Mass. Gen. Laws, Chapter 143, Section 6 to be applicable.
If any notice under Mass G�en. Laws, Ch. 139 Sec. 3B is appropriate please direct it to the attention
of the writer and include a rArence to the captioned insured, location, policy number, date of loss
and claim or file number.
nj
On this date, I caused copies of this notice to be sent to the persons named above at the addresses
indicated above by first class mail. /AM )I I f�
ii'nature and date I
MASSACHUSETTS CONNECTICUT NEWHAMPSHIRE VERMONT MAINE RHODE ISLAND
Boston Lawrence Bridgeport Gorham Burlington Augusta Providence
Barnstable Pittsfield New London Keene Montpelier Lewiston
CLAIMS SERVICE OF Brockton Salem No. Haven Laconia White River Jct. S- Portland NEW YORK
NEW ENGLAND, INC. Fall River Springfield Waterbury Manchester Utica
Fitchburg Worcester W, Hartford Portsmouth
1 Nati
01
ON I 'C"'I'Mal '—m ---s-1
Commonwealth of Massachusetts
City/Townof.
System Pumping Record
RECEIVED
SEP 16 Z009
TOWN OF NORTH ANDOVER
HEALTH DEPARTMENT
Facility Information:
System Location:
( /) r) C-" C
Address
City/Town State Zip Code
System Owner:
Cho
Name:
Adress (if different from location of pump)
City/Town
State Zip Code
q]�-qjs--3q69
Telephone Number
Pumping Record
Date of Pumping c6lq I 09 --Quantity Pumped JJ gallons
Type of System 111�—Septic Tank Grease Trap Other (what)
System Pumped by:
Company: ROOTER -MAN 12 East Dracut Rd., Methuen, MA 01844
Location where contents were disposed: 0 �-'SL I
Signature of Hauler Date
Commonwealth of Massachusetts
City/Town of � 6 �*
System Pumping Record
Facility Information:
System Location:
Address
--L.Y/ . �" VYII
System Owner:
Name:
I
Adress (if different from location of pump)
M�
State
RECEIVED
SEP 16 2009
TOWN OF NORTH ANDOVER
HEALTH DEPARTMENT
Zip Code
City/Town State Zip Code
91 �/- ��S-'3LOI
Telephone Number
Pumping Record
Date of Pumping. Quantity Pumped gallons
Type of System Septic Tank Grease Trap—)—(Other (what)
System Pumped by: DrA J -
Company: ROOTER -MAN 12 East Dracut Rd., Methuen, MA 0 1844
Location where contents were disposed:
Signature of Hauler----� f Date
V)
v
Commonwealth of Massachusetts
City/Town of P0 rq, 4pdwt I/
System Pumping Record
Facility Information: Qt�"j
TOWN OF N(0)AfN ANbDVgF-t
w
System Location: [HEA01H DEPA1qFtTMeNT
t I
,(,R -7 kbbOTT 'S�
Address
NO - ... RD
City/Town State ZIP Code
System Owner:
-AV16mil. Wage -
Name:
Adress (if different firorn location of pump)
City/Town State Zip Code
ql5-q7y- 5VOe)
Telephone Number
Pumping Record
Date of Pumping. ?j / I I I 10 Quantity Pumped_45')U __gallons
Type of System_X Septic Tank Grease Trap______�Other _(what)
System Pumped by: 122 vv-�, To ez V
Company: ROOTER -MAN 46 Portland Street Lawrence, MA 0 1843
Location where contents were disposed: �- 4::�5p
Signature of Hauler Date