HomeMy WebLinkAboutMiscellaneous - 280 CANDLESTICK ROAD 4/30/2018 (3)n
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WATER SUPPLY:
WELL PERMIT_
WELL TESTS:
COMMENTS:
WELL
DRILLER___________�_
CHEMICAL DA\E RUVEU________
BACTERIA I AlE [U`pRUVED _
BA DAIE APPROVED________
FORM U APP P
DATE ISSUED BY
CONDITIONS:
FINAL APPROVAL:
ALL PERMITS PAID
WELL CONSTRUCTION APPROVAL
SEPTIC SYSTEM CONSTRUCTION APPROVAL
OTHER
ANY VARIANCE NEEDED
FINAL BOARD OF HEALTH APPROVAL:
YES
NO
YES
NO
YES
NO
YES
NO
YES
NAP #
DATE:____._.._BY:____
LOT # ��i_... ... ..... ... ____
.
PA�CEL
STREET __________—___ _
/
'
HAS PLAN REVIEW FEE
BEEN PAID?
NO
t^��~
, «
.i
PLAN APPROVAL:
DATE APP.
BY
' ~
�
DESIGNER:
� «
PLAN DATE __
CONDITIONS
WATER SUPPLY:
WELL PERMIT_
WELL TESTS:
COMMENTS:
WELL
DRILLER___________�_
CHEMICAL DA\E RUVEU________
BACTERIA I AlE [U`pRUVED _
BA DAIE APPROVED________
FORM U APP P
DATE ISSUED BY
CONDITIONS:
FINAL APPROVAL:
ALL PERMITS PAID
WELL CONSTRUCTION APPROVAL
SEPTIC SYSTEM CONSTRUCTION APPROVAL
OTHER
ANY VARIANCE NEEDED
FINAL BOARD OF HEALTH APPROVAL:
YES
NO
YES
NO
YES
NO
YES
NO
YES
NO
DATE:____._.._BY:____
IS THE INSTALLER LICENSED? CD NO
TYPE OF CONSTRUCTION: NEW REPAIR
NEW CONSTRUCTION: CERTIFIED PLOT PLAN REVIEW NO
CONDITIONS OF APPROVAL YES NO
(FROM FORM U)
ISSUANCE OF DWC PERMIT YES NO
DWC PERMIT NO. INSTALLER:—— — --------
BEGIN INSPECTION YES NO:
EXCAVATION INSPECTION: NEEDED:
0 v
PASSED BY --
CONSTRUCTION INSPECTIONs NEEDED: . ............ ................... / ........... .... — — ------
-TO
AS BUILT PLAN SATISFACTORY: YES:. ----- --
00/0
BY
APPROVAL TO BACKFILL: DATE:
FINAL GRADING APPROVAL: DATE
FINAL CONSTRUCTION APPROVAL: DATE: . .....
Commonwealth of Massachusetts
City/Town of SEP Z 3 2013
System Pumping Record TOWN OF NORTH MDOVER
Form 4 . 1__jtEALTH DEPART,i,-:Nrr
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
1. System Location: LeVIfighf7front of �house
��, Left / Right rear of house, Left / right side of house, Left
Right side of building, Left / Right front of building, Left / Right rear of building, Under deck
Address
Cityrrown State Zip Code
2. System Owner
Name
Address (if different from location)
Cityfrown Zi Code
es
Telephone Number
B. Pumping Record
1. Date of Pumping 2. Quantity Pumped:
Date Gallons
m'.
3. Type of syste El Cesspool(s) ET -Sep ic Tank El Tight Tank
4.
Other (describe):
Effluent Tee Filter present? Yes 0 If yes, was it cleaned? E] Yes E] No
5. Condit f System:
1. rYM7.4� �
6. System Pumped By:
Neil Batesion
Name
Bateson Enterprises Inc -
Company
7. Loca��ere contents were disposed:
/aU.J? j - Lowell Waste Water
F5821
Vehicle License Number
q--( �� - ls�
Date
t5fbrm4.doc- 06/03 System Pumping Record - Page I of I
Commonwealth of Massachusetts
City/Town of
System Pumping Record
Form 4
DEP has provided this form for use by local Boards of Heaith. 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 I . System Location: Left front left rear, left side of house ht rear, right sidCof Lhou-s
forms on the
computer, use
only the tab key Address 0
to move your.
cursor - do not
use the return Cityfrown State Zip Code
key. 2. System Owner
Name
Address (if different from location)
Cityfrown
B. Pumping Record
1. Date or Pumping
3. Type of system: C]
[j Other (describe) -
rMM
State-� r -
o -50-3 '7 /'P� Code
Telephone Number
2. Quantity Pumped:
Gallons
Cesspool(s) G-ge"pfic Tank Tight Tank
4. Effluent Tee Filter present? Ij Yes Q -Wo
5. Condition of System:
nc)_�-v�A�AA v,,
6. System Pumped By -
Neil Bateson
Name
Bateson Enterprises Inc
Company
7. Location where contents were disposed:
S. D Lowell Waste Water
If yes, was it cleaned? [] Yes C] No
F 5821
Vehicle Ucense Number
'4 - - --,)?
of H;Mbr Zii-e
I
t5form4.doc-.06103 System Pumping Record - Page I of I
Town of North Andover
U
CHECK
LOCATION:
H/0 NAME:
CONTRACT(
4'18 7
Type
of Permit or License: (Check box)
0
Animal
$
0
Body Art Establishment
$
0
Body Art Practitioner
$
0
Dumpster
$
0
Food Service - Type:
$
0
Funeral Directors
$
0
Massage Establishment
$
0
M assage Practice
$
0
Offal (Septic) Hauler
$
0
Recreational Camp
$
0
Sun tanning
$
13
Swimming Pool
$
0
Tobacco
$
•
TrashlSolid Waste Hauler
$—
•
Well Construction
$
SEPTIC Sustems:
• Septic - Soil Testing $
• Septic - Design Approval $
[3 Septic Disposal Works Construction (DW0 $
0 Septic Disposal Works Installers (DW[) $-
0 Title 5 Inspector $ A
.0 5—e. O'V
�j �itle 5 Report w
0 Other (Indicate) $
Health Agent Initials
White - Applicant Yellow - Health Pink - Treasurer
Owner
information is
required for
every page.
Important:
When filling out
forms on the
computer, use
only the tab key
to move your
cursor - do not
use the return
key.
rltQ
T�A
Com'monwealth of'Massachuseft
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Foffn - Not for Voluntary Assessments
280 Candlestick Road
Property Address
Paula Condon
Owners Name
North Andover MA 01845 5/27/2009
City/Town State Zip Code Date of Inspection
Inspection results must be submitted on this form. Inspection forms may not be aftered in any
way. Please see completeness checklist at the end of the form.
A. General Information
1. Inspector:
Neil J. Bateson
Name of Inspector
Bateson Enterprises Inc.
Company Name
111 Argilla Road
Company Address
Andover
City/Town
978-475-4786
Telephone Number
B. Certification
Ma
State
S115
License Number
01810
Zip Code
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:
Z Passes E] Conditionally Passes E] Fails
Needs Further Evaluation by the Local Approving Authority
5/27/2009
inspectors Signature V 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 DER The original should be sent to the system owner
and copies sent to the buyer, if applicable, and the approving authority.
""This report only describes conditions at the time of inspection and under the conditions of use
at that time. This inspection does not address how the system will perform in the future under
the same or different conditions of use.
t5ins - 09108 Title 5 Official Inspection Form: Subsurface Sewage Disposal System - Page I of 17
Owner
information is
required for
every page.
Coinmonwealth of �assachuseft
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
280 Candlestick Road
Property Address
Paula Condon
Owners Name
North Andover MA 01845 5/27/2009
CityfTown State Zip Code Date of Inspection
B. Certification (cont.)
Inspection Summary: Check A,B,C,D or E / always complete all of Section D
A) System Passes:
Z I have not found any information which indicates that any of the failure criteria described
in 310 CMR 15.303 or in 310 CMR 15.304 exist. Any failure criteria not evaluated are
indicated below.
Comments:
B) System Conditionally Passes:
one or more system components as described in the "Conditional Pass" section need to be
replaced or repaired. The system, upon completion of the replacement or repair, as approved by
the Board of Health, will pass.
Check the box for "yes", "no" or "not determined" (Y, N, ND) 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.
El Y F-1 N n ND (Explain below):
t5ins - 09/08 Title 5 Official Inspection Form: Subsurface Sewage Disposal System - Page 2 of 17
obstructipn is removed Y F1 N [] ND (Explain below):
distribution box is leveled or replaced Y E] N E] ND (Explain below):
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):
broken pipe(s) are replaced 0 Y El N El ND (Explain below):
obstruction is removed E] Y F1 N El ND (Explain below):
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 pass unless Board of Health determines in accordance with 310 CMR
15.303(i)(b) that the system is not functioning in a manner which will protect public health,
safety and the environment:
F� Cesspool or privy is within 50 feet of a surface water
F1 Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh
t5ins - 09/08 Title 5 Official Inspection Form: Subsurface Sewage Disposal System - Page 3 of 17
Co6imonwealth of Massachusetts
Title 5 Official Inspection Form
o Subsurface Sewage Disposal System Form Not for Voluntary Assessments
280 Candlestick Road
Property Address
Paula Condon
Owner Owners Name
information is
required for North Andover MA 01845 5/27/2009
every page. Cityrrown State Zip Code Date of Inspection
B. Certification (cont.)
B) System Conditionally Passes (cont.):
El 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):
n broken pipe(s) are replaced n Y El N El ND (Explain below):
Owner
information is
required for
every page.
Coinmonwealth of Massachuseft
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
280 Candlestick Road
Property Address
Paula Condon
Owner's Name
North Andover MA 01845 5/27/2009
Cityrrown State Zip Code Date of Inspection
B. Certification (cont.)
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:
F1 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.
E] The system has a septic tank and SAS and the SAS is within a Zone 1 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.
E] 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 indicates absent 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:
D) System Failure Criteria Applicable to All Systems:
You must indicate "Yes" or "No" to each of the following for all inspections:
Yes No
El Z Backup of sewage into facility or system component due to overloaded or
clogged SAS or cesspool
E] Z Discharge or ponding of effluent to the surface of the ground or surface waters
due to an overloaded or clogged SAS or cesspool
n z Static liquid level in the distribution box above outlet invert due to an overloaded
or clogged SAS or cesspool
Liquid depth in cesspool is less than 6" below invert or available volume is less
than Y2day flow
t5ins - 09/08 Title 5 Official Inspection Form: Subsurface Sewage Disposal System - Page 4 of 17
<C_N , Coinmonwealth of Massachusetts
Title 5 Official Inspection Form
o Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
280 Candlestick Road
Property Address
Paula Condon
Owner Owner's Name
information is
required for North Andover MA 01845 5/27/2009
every page. City/Town State Zip Code Date of Inspection
B. Certification (cont.)
Yes No
El 0 Required pumping more than 4 times in the last year NOT due to clogged or
obstructed pipe(s). Number of times pumped:
E] Z Any portion of the SAS, cesspool or privy is below high ground water elevation.
El 0 Any portion of cesspool or privy is within 100 feet of a surface water supply or
tributary to a surface water supply.
Z Any portion of a cesspool or privy is within a Zone 1 of a public well.
El 10 Any portion of a cesspool or privy is within 50 feet of a private water supply
well.
Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet
from a private water supply well with no acceptable water quality analysis. [This
system passes if the well water analysis, performed at a DEP certified
laboratory, for fecal coliform bacteria indicates absent 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
and chain of custody must be attached to this form.]
El Z The system is a cesspool serving a facility with a design flow of 2000gpd-
10, OOOg pd.
The system fails '. I have determined that one or more of the above failure
criteria exist as described in 310 CMR 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.
For large systems, you must indicate either "yes" or "no" to each of the following, in addition to the
questions in Section D.
Yes No
El n the system is within 400 feet of a surface drinking water supply
El 0 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 11 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 "yes" 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 310 CMR 15.304. The system owner should contact the appropriate
regional office of the Department.
t6ins - 091G8 Title 5 Official Inspection Form: Subsurface Sewage Disposal System - Page 5 of 17
Owner
information is
required for
every page.
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
280 Candlestick Road
Property Address
Paula Condon
Owner's Name
North Andover MA 01845 5/27/2009
Cityfrown State Zip Code Date of Inspection
C. Checklist
Check if the following have been done. You must indicate "yes" or "no" as to each of the following:
Yes No
0 11
El 0
E El
n Z
0 EJ
Z El
0 El
Z E]
0 n
Z El
Z El
Z El
Pumping information was provided by the owner, occupant, or Board of Health
Were any of the system components pumped out in the previous two weeks?
Has the system received normal flows in the previous two week period?
Have large volumes of water been introduced to the system recently or as part of
this inspection?
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?
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 the baffles 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 subsurface sewage disposal systems?
The size and location of the Soil 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) [310 CMR 15.302(5)]
D. System Information
Residential Flow Conditions:
Number of bedrooms (design): 5 Number of bedrooms (actual): 5
DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x # of bedrooms): 825
t5ins - 09/08 Title 5 Official Inspection Form: Subsurface Sewage Disposal System - Page 6 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
280 Candlestick Road
Property Address
Paula Condon
Owner Owner's Name
information is
required for N rth Andover MA 01845 5/27/2009
every page. City/Town State Zip Code Date of Inspection
D. System Information
Description:
5
Number of current residents:
Does residence have a garbage grinder?
El
Yes Z
No
Is laundry on a separate sewage system? [if yes separate inspection required]
M
Yes 0
No
Laundry system inspected?
E]
Yes El
No
Seasonaluse?
r-1
Yes Z
No
Water meter readings, if available (last 2 years usage (gpd)):
Yes
Detail:
Sump pump?
R
Yes H
No
Current
Last date of occupancy:
Date
Commerciallindustrial Flow Conditions:
Type of Establishment:
Design flow (based on 310 CMR 15.203):
Basis of design flow (seats/persons/sq.ft., etc.):
Grease trap present?
Industrial waste holding tank present?
Non -sanitary waste discharged to the Title 5 system?
Water meter readings, if available:
Gallons per day (gpd)
El Yes El No
0 Yes [] No
El Yes El No
t5ins - 09/08 'ritle 5 Official Inspection Form: Subsurface Sewage Disposal System - Page 7 of 17
Owner
information is
required for
every page.
Coinmonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
280 Candlestick Road
Property Address
Paula Condon
Owners Name
North Andover
Cityrrown
D. System Information (cont.)
Last date of occupancy/use:
Other (describe below):
MA 01845 5/27/2009
State Zip Code Date of Inspection
Date
General Information
Pumping Records:
Source of information:
Was system pumped as part of the inspection?
If yes, volume pumped:
How was quantity pumped determined?
Reason for pumping:
Pumped 2007,owner
1500
gallons
Measured tank
Inspect tank & tees
Type of System:
z Septic tank, distribution box, soil absorption system
n Single cesspool
n Overflow cesspool
n 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 obtained from system owner) and a copy of latest
inspection of the I/A system by system operator under contract
Tight tank. Attach a copy of the DEP approval.
Other (describe):
t5ins - 09/08 Title 5 Official Inspection Form: Subsurface Sewage Disposal System - Page 8 of 17
Owner
information is
required for
every page.
Coinmonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
280 Candlestick Road
Property Address
Paula Condon
Owner's Name
North Andover
Cityrrown
D. System Information (cont.)
MA 01845
State Zip Code
5/27/2009
Date of Inspection
Approximate age of all components, date installed (if known) and source of information:
18 years old, 12/16/1991
Were sewage odors detected when arriving at the site? El Yes Z No
Building Sewer (locate on site plan):
2.5
Depth below grade: feet
Material of construction:
F� cast iron Z 40 PVC other (explain):
Distance from private water supply well or suction line: feet
Comments (on condition of joints, venting, evidence of leakage, etc.):
4"PVC thru wall, 3" PVC in house, no leaks visible
Septic Tank (locate on site plan):
Depth below grade:
Material of construction:
Z concrete E] metal
1.7
feet
F� fiberglass [] polyethylene R other (explain)
If tank is metal, list age: years
Is age confirmed by a Certificate of Compliance? (attach a copy of certificate)
10'x5'x 4'
Dimensions:
3"
Sludge depth:
El Yes R No
t5ins - 09/08 Title 5 Official Inspection Form: Subsurface Sewage Disposal System - Page 9 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
280 Candlestick Road
Property Address
Paula Condon
Owner Owners Name
information is
i—I f— North Andover MA 01845 5/27/2009
every page. Cityfrown
t5ins - 09/08
D. System Information (cont.)
state Zip Code
Septic Tank (cont.)
Distance from top of sludge to bottom of outlet tee or baffle 24-1
Date of Inspection
51'
Scum thickness
Distance from top of scum to top of outlet tee or baffle 81'
Distance from bottom of scum to bottom of outlet tee or baffle 1611
How were dimensions determined? Tape Measure
Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity,
liquid levels as related to outlet invert, evidence of leakage, etc.):
Pumped septic tank. Inlet tee ok. Outlet tee ok. Depth of liquid at outlet invert. No evidence of
Grease Trap (locate on site plan):
Depth below grade:
Material of construction:
EI concrete E] metal
feet
n fiberglass El polyethylene [:1 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: Date
Title 5 Official Inspection Form: Subsurface Sewage Disposal System - Page 10 of 17
Owner
information is
required for
every page.
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
280 Candlestick Road
Property Address
Paula Condon
Owners Name
North Andover
MA 01845 5/27/2009
City/Town State Zip Code Date of Inspection
D. System Information (cont.)
Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity,
liquid levels as related to outlet invert, evidence of leakage, etc.):
Tight or Holding Tank (tank must be pumped at time of inspection) (locate on site plan):
Depth below grade:
Material of construction:
0 concrete El metal
Dimensions:
Capacity:
Design Flow:
Alarm present:
Alarm level:
El fiberglass r-1 polyethylene E] other (explain):
gallons
gallons per day
El Yes El No
Alarm in working order: D Yes R No
Date of last pumping: Date
Comments (condition of alarm and float switches, etc.):
* Attach copy of current pumping contract (required). Is copy attached? El Yes E] No
t5ins - 09108 Title 5 Official Inspection Form: Subsurface Sewage Disposal System - Page 11 of 17
1 1 , Lv-aj 14
�141-
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
280 Candlestick Road
Property Address
Paula Condon
Owner Owners Name
information is
required for North Andover MA 01845
every page. Cityrrown State Zip Code
D. System Information (cont.)
Distribution Box (if present must be opened) (locate on site plan):
Depth of liquid level above outlet invert
N
5/27/2009
Date of Inspection
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.):
Drop box cover broken, replaced same. No evidence of leakage. Light carryover, pumped box to
clean. D -Box # 1 level & distribution equal. No leakge. Evidence of carryover, pumped d -box to clean.
D -box # 2 level & distribution equal. No evidence of leakage. Evidence of carryover, pumped d -box to
clean
Pump Chamber (locate on site plan):
Pumps in working order:
R Yes F1 No
Alarms in working order: F1 Yes F1 No
Comments (note condition of pump chamber, condition of pumps and appurtenances, etc.):
Soil Absorption System (SAS) (locate on site plan, excavation not required):
If SAS not located, explain why:
t5ins - 09/08 Title 5 Official Inspection Form: Subsurface Sewage Disposal System - Page 12 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
280 Candlestick Road
Property Address
Paula Condon
Owner Owners Name
information is
required for North Andover
every page. Cityrrown
D. System Information (cont.)
Type:
MA 01845 5/27/2009
State Zip Code Date of Inspection
0 leaching pits
number:
El leaching chambers
number:
El leaching galleries
number:
leaching trenches
number, length:
leaching fields
number, dimensions: 2 [each fields
both 30'x 37'6"
overflow cesspool
number:
innovative/alternative system
Type/name of technology:
Comments (note condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of
vegetation, etc.):
Soil ok. Vegetation ok. No sign of ponding to surface.
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 E] Yes No
t5ins - 09108 Title 5 Official Inspection Form: Subsurface Sewage Disposal System - Page 13 of 17
Owner
information i's
required for
every page.
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
280 Candlestick Road
Property Address
Paula Condon
Owner's Name
North Andover
MA 01845
5/27/2009
Cityrrown State Zip Code Date of Inspection
D. System Information (cont.)
Comments (note condition of soil, signs of hydraulic failure, 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.):
t5ins - 09/08 Tille 5 Official Inspection Form: Subsurface Sewage Disposal System - Pago 14 of 17
Owner
information is
required for
every page.
Corhmonwealth of Massachuseft
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
280 Candlestick Road
Property Address
Paula Condon
Owner's Name
North Andover MA 01845 5/27/2009
CttyfTown state Zip Code Date of Inspection
D. System Information (cont.)
Sketch Of Sewage Disposal System: Provide a view 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. Check one of the boxes below-.
hand -sketch in the area below
drawing attached separately
()(- t' Q Q_t-�
D
A -A-0 () -G c)- (65 1 2, 11
ps _�_o -:_- _�a .111
\C) BOK=- CO a'
&_e� = ('0
4oQ2,(2_
0
U.�J><_
a
=1
_8
t5ins - 09108 Title 5 Official Inspection Form: Subsurface Sewage Disposal System - Page 15 of 17
Owner
information is
required for
every page.
Coinmonwealth of Massachuseft
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
280 Candlestick Road
Property Address
Paula Condon
Owner's Name
North Andover
CityTrown
D. System Information (cont.)
Site Exam:
0
Check Slope
Z
Surface water
Z
Check cellar
Z
Shallow wells
A 11 1"; k .4 +-
MA 01845
State Zip Code
4'
5/27/2009
Date of Inspection
f-- 1111CILU UVPL LU V UI%JU" WO Im feet
Please indicate all methods used to determine the high ground water elevation:
Obtained from system design plans on record
A
4/18/1989
ii c"ecreu, uate ol desiqn pican ev ewe . Date
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:
As per design plan test pit data
Before filing this Inspection Report, please see Report Completeness Checklist on next page.
t5ins - 09/08 Title 5 Official Inspection Form: Subsurface Sewage Disposal System - Page 16 of 17
Owner
information is
required for
every page.
Coinmonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
280 Candlestick Road
Property Address
Paula Condon
Owners Name
North Andover MA 01845 5/27/2009
City/Town State Zip Code Date of Inspection
E. Report Completeness Checklist
inspection Summary: A, B, C, D, or E checked
inspection Summary D (System Failure Criteria Applicable to All Systems) completed
System Information — Estimated depth to high groundwater
Sketch of Sewage Disposal System either drawn on page 15 or attached in separate file
t5ins - 09/08 Title 5 Official Inspection Form: Subsurface Sewage Disposal System - Page 17 of 17
Swwary Record card generated on &=009 3:42:25 PM by Liss Evaris Page I
Town -of Nofth Andover
Tax Map # 210-106.A-0245-0000.0
Parcel Id 17390
280 CANDLESTICK ROAD
JOHN CONDON
280 CANDLESTICK ROAD
NORTH ANDOVER, MA 0180
Class 101 Single Family Property Type 1 Residential
Size Total I Acres
FY 2009
UB Mailina Indek
Name/Address
JOHN CONDON
280 CANDLESTICK ROAD
NORTH ANDOVER, MA 01845
LAFLAMME, ROBERT
280 CANDLESTICK ROAD
NO.ANDOVER,MA
01845
UB Account Maint.
Type Loan Number
Owner
Previous Customer
Activellinact. From
Inactive 12/29/2004
Account No Cycle Occupant Name Activelinactive
Bldg Id. 17648.0 - 280 CANDLESTICK ROAD Last Billing Date 4/6/2009
3170318 03 Cycle 03 Active
UB Services Maint
Account No. 3170318
Service Code Rate Charge MultipliedUsers
MISCFEE ADMIN FEE 0.635/8 7.82 11
WTR WATER 01 ALL METER SIZE 106.44 /1
UB Meter Maintenance
Account No. 3170318
Brand
Serial No Status
YM Cons
36081444 a Active
Date Reading
3/13/2009
3963
12/9/2008
3935
91812008
3900
6/6/2008
3817
3/7/2008
3770
12/11/2007
3733
9/5/2007
3683
6/18/2007
3602
3/15/2007
3523
12/8/2006
3498
Trouble Code:03
a Actual
9/12/2006
3451
Trouble Code:03
a Actual
6/14/2006
3331
3/8/2006
3282
Trouble Code:03
10/12/2007
12/21/2005
3260
Trouble Code:03
7/20/2007
9/2012005
3210
Trouble Code:03
4/16/2007
6/13/2005
3082
3/25/2005
3030
12/30/2004
3009
9/24/2004
2996
Until
Location
Brand
Type size
YM Cons
ENC RT
w Water 0.630.63
193
Code
Consumption
Posted Date
Variance
a Actual
28
4/29/2009
-22%
a Actual
35
1/20/2009
-57%
a Actual
83
10/10/2008
71%
a Actual
47
7116/2008
21%
a Actual
37
4/11/2008
-17%
a Actual
50
1/22/2008
-50%
a Actual
81
10/12/2007
23%
a Actual
79
7/20/2007
223%
m Manual estimate
25
4/16/2007
-52%
a Actual
47
1119/2007
-59%
a Actual
120
10/2Or2OO6
167%
a Actual
49
7/10/2006
75%
a Actual
22
411712006
-47%
a Actual
50
1117/2006
-58%
a Actual
128
10IM005
99%
a Actual
52
7/15/2005
163%
a Actual
21
4/5/2005
84%
f Final Bill
13
12130/2004
-53%
m Manual estimate
30
10/8/2004
-36%
I
,N, Commonwealth of Massachusetts
V. City/Town of
System Pumping 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.
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
1. System Location: Left front, left rear, left side of house ht rear, right sidCof :hou
_0�i;�g 5s i?
Address . I
cl;� CA-�
City/Town State Zip Code
2. System Owner:
Name
Address (if different from location)
Cityrrown
B. Pumping Record
1. Date of Pumping
Date
3. Type of system: Ej Cesspool(s)
Other (describe):
4. Effluent Tee Filter present? El Yes G-wo
�fOAC�&[\
Stat 73 "7 Code
Telephone Number
r)"-nnfi D" �A
/6_z_ -L;) ,
Gallons
Tank Tight Tank
If yes, was it cleaned? 0 Yes [j No
5. Condition of System:
V\ _—A-47k/�
6. System Pumped By:
Neil Bateson
Name
Bateson Enterprises Inc
Company
7. Location where contents were disposed:
��. S. �D� Lowell Waste Water
. F 5821
Vehicle License Number
of Hifulbr Date
t5form4.doc- .06/03 System Pumping Record - Page I of I
�L\ Commonwealth of Massachusetts
C 't /Town of
1 y
System Pumping Record
Form 4
u,p
TOWN OP NORTH ANDMIR
DEP has provided this form for use by local Boards of Health. OtheUe"W��;�iF, 6itffle
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
1. System Location: Left front of housea� �hron �ofho � left side of house, right side of house, Left
rear of house, right rear of house, left side of building, right rear of building, under deck.
2)'So /"
Cityrrown State Zip Code
2. System Owner: 1"'e�
Name
Address (if different from location)
Cityrrown
B. Pumping Record
1. Date of Pumping
3. Type of system: E-]
F� Other (describe):
State '�� S Zip Code
-5-- 5��6'5-
Telephone Number
10,D -G (()
Date 2. Quantity Pumped:
Cesspool(s) D-Te-p—bc Tank
Gallons
Tight Tank
4. Effluent Tee Filter present? [:] Yes Er -No If yes, was it cleaned? n Yes E] No
5. Condition of System:
6. System Pumped By:
Neil J. Bateson
Name
Bateson Enterprises Inc.
Company
7. �Loc�atioere contents were disposed:
L S�- �.Lqwq# Waste YV er
C--- I // // - A/, IV
Signature
F5821
Vehicle License Number
Date
t5form4.doc- 06/03 System Pumping Record - Page I of 1
BUILDING PERMIT
TOWN OF NORTH ANDOVER
APPLICATION FOR PLAN EXAMINATION
Permit NO: Date Received
N%
Date Issued: IMPC)RT T: Applicant must complete all items on this page
ow .. - r�!f -" ___ "r
I.n
(DO
ION
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IRR Tili�_JOW
pg q
in
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IIVIAP�N
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a i
'S No -,.y
4.
TYPE OF IMPROVEMENT
PROPOSED USE
Residential
Non- Residential
New Building
One family
Addition
Two or more family
Industrial
Alteration
No. of units:
Commercial
Repair, -replacement
Assessory Bldg
Others:
Demolition
Other
w
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DESCRIPTIUN Ul- VVUMM I U tst rMt:rum'v1r-LJ;
e:p rQ 00 rJ C) F'\ V IE� PEN C LC
2QQL %P
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Identification Please Type or Print Clearly)
OWNER: Name: Phone:
AA
'7
60, N AIRA Q �T - OR, �Nbme
Slu
ken
pi�rvi§Qr(,�iCbngt�uctibn,�,L-
icbn-s'-6_i�_
A 5�_ N
ARCHITECT/ENGINEER Phone:
Address
Reg. No
FEE SCHEDULE: BULDING PERMIT., $12.00 PER $1000.00 OF THE TOTAL ESTIMATED COSTBASED ON $125.00 PER S.F.
Total Project Cost: $ FEE: $
Check No.: Receipt No.:
NOTE: Persons contracting with unregistered contractors do not have access to the guarantyfund
'Si1g.naturb -of -contractor
signature ofAqe_06kn
Plans Submitted Plans Waived Certified Plot Plan Stamped Plans
TYPE OF SEWERAGE DISPOSAL
Public Sewer
Tanning/Massage/Body Art
Swimming Pools
Innu
FFood
Well
Tobacco Sales
Packapoing/Sales
Private (septic tank, etc.
Permanent Dumpster on Site
THE FOLLOWING SECTIONS FOR OFFICE USE ONLY
INTERDEPARTMENTAL SIGN OFF - U FORM
PLANNING & DEVELOPMENT
COMMENTS
CONSERVATION Reviewed on
COMMENTS
/'J -
HEALTH Reviewed
COMMENTS <::::�
DATE REJECTED DATEAPPROVED
WN
S
Signature
A,
cool (V\ 'Al -k-. L/J 0-
natu
2—r-) - / 12� / �) "' -,?/.
Zoning Board of Appeals: Variance, Petition No: Zoning Decis.ion/receipt submitted yes
Planning Board Decision: Comments
Conservation Decision: Comm
Water & Sewer Connection/signature & Date DrivewaV Permit
DPW Town Engineer: Signature:
Located 384 Osgood Street
O.IRE'bEPAkTMEN"t*--".T6i�'O,Dumpser�on�sit no.
..P .-.Yps:
ca dt,124;Main§treet
FireD60attmerif signAtiureldatb
COMMENTS
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TOWN OF NORTHANDOVER
SYSTEM PUMPINC R-ECOR-D
2003
I'EM OWNER & ADDRESS
Ima
SYSTEM LOCATION
(ex -ample: lef( Iron( of hou��)
lt-lzon
QUANTITY PUMPED L5-0 0/� L L
C. l'O 0 L: N 0 YES SEPTIC TANK: NO YES
ATURE OF SERVICE: ROUTINE m E R C E N C Y
F f� V.:\ T 10 N S:
COOD CONDITION-
HFAYY CREASE
ROOTS
EXCESSIVE SOLIDS
SOLIDS CARRYOVER
1)TLM PUMPED BY:
� UN l.'yI F� N T S:
� U -� tl � A N S F E I Z I Z E D TO:
FULL TO COVEk
BAFFLE'S IN PLACE
LEACHFIE LD RUNBACK
FLOODED
,,Q�HFR (EXPLAIN)
Insurance Adjustment Service Inc.
Date: /
Board of Health: v,
Building Inspector:
Fire Department:
Re: Insured:
Location:
Claim Number:
PolicyNumber:
Our File Number:
Cause of Loss:..
Date of Loss:
Dear Sir/Madam:
531 King Street - Unit 2, Second Roor
Littleton, MA 01460
978-952-6966 - Fax 978-952-2459
Email: iaslitfleton@netlplus.com
TO111M OF NORT H ANQP�JF-7
BOARD OF HEAL -l'
L!APR 2 5' 1WJ
A claim has been made involving loss, damage or destruction of the above
captioned property which may either exceed $1,000 or cause Massachusetts
General Laws, Chapter 143, Section 6 to be applied.
If any notice under Massachusefts General Laws, Chapter 139, Section 3B is
appropriate, please direct that information to my attention and include a
reference to the captioned insured, location, date of loss and file number.
Thank you for your cooperation.
Very truly yours,
Scott O'Neil
Adjuster
Ext. 129
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SEPTIC TAW: N
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F.SER
ROU"JEW
EMERGENCY
"Bv
ONS:
GQOD-WNbMbN"
FULL To COVER
ROOTS' BAFnES IN PLACE
EXCESSIVE So LEACHFULD RUNBACK
LIDS. FLOODED
ARRYOVEIC
OTJIER (EXPLAIN)
_7 1!-- .PUWFZ BY!"
Y. 04
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wg:. P-4
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& ADDRESS SYS
CATION
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PUMPED
GALLONS
NJ,
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W-0
.0 YES.
SEPTIC TAW: N
0
YES
F.SER
ROU"JEW
EMERGENCY
"Bv
ONS:
GQOD-WNbMbN"
FULL To COVER
ROOTS' BAFnES IN PLACE
EXCESSIVE So LEACHFULD RUNBACK
LIDS. FLOODED
ARRYOVEIC
OTJIER (EXPLAIN)
_7 1!-- .PUWFZ BY!"
7777"�
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7'7--.,77-.- ;7,
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A7,-- C�,.-j
THOMAS E. NEVE ASSOCIATES, INC.
Engineers - Land Surveyors - Land Use Planners
447 Boston Street US Route #1
TOPSFIELD, MASSACHUSETTS 01983
(508) 887-8586
FAX (508) 887-3480
TO
)VII a'�
> WE ARE SENDING YOU El Attached El Under separate cover via
El Shop drawings EJ Prints El Plans
El Copy of letter El Change order F] -
LIEUTEIN @)IF MUSOUVIL
DATE
_rB
NO.
ATTEN7��,�
0 For your use
RE:
0 Submit -copies
for distribution
El As requested
El Returned for corrections
0 Return -corrected
prints
El For review and comment
F1
the following items:
0 Samples 0 Specifications
COPIES
DATE
NO.
DESCRIPTION
0 For your use
0 Approved as noted
0 Submit -copies
for distribution
El As requested
El Returned for corrections
0 Return -corrected
prints
El For review and comment
F1
0 FOR BIDS DUE
19
El PRINTS RETURNED
AFTER LOAN TO US
REMARKS
THESE ARE TRANSMITTED as checked below:
A For approval
0 Approved as submitted
El Resubmit -copies
for approval
0 For your use
0 Approved as noted
0 Submit -copies
for distribution
El As requested
El Returned for corrections
0 Return -corrected
prints
El For review and comment
F1
0 FOR BIDS DUE
19
El PRINTS RETURNED
AFTER LOAN TO US
REMARKS
COPY TO SIGNED:
PRODUCT 240-2 J� Im, GmWn, Mm 0 14 7 1. Of enclosures are not as noted, kindly notify us at once.
j >-, /90?0
Aia* 94, L9-�&
Town oj Noxth AndoveA
BoaAd oj Heatth
120 Main StAeet
No&th AndoveAJ. MA 01845
To Whom It May ConceAn:
We have te-designed the septic sy.6tem on Lot #38 to con6van to the Buitding
Inspectox',s Requitement that petimeteA dAainz be &equiked 6o& au 6oundation,6,
and that septic tanks and teach jietd,s be tocated a minimum o6 25' and 35' tes-
pectivety. I have shown a copy oj the pAio,% de.6ign app&ovat 6o& tevision oj
thi,s ptan.
Si nce
,,tety,
RobW
t J. nuz z
40 Sun,6et Rock Road
AndoveA, MA 01810
P.S. The house siting iz azentiatty the same az in the pAiot ptan but Aeitect's
a customized house unde& ag)teement. I am the cu�ftent owneA and the statement
"De,signed 6o& Musina Deveiopment Cotp." can be temoved and changed to RobeAt
Janusz,, i6 it maka a di��eAence.
FOIUI U
T014N OF NORTH ANDOVER
LOT RELEASE FOM
SUBDIVISION e cl
ASSESSORS �LA2
SUBDIVISION LOT(S)
.PERMA NT ADPRES SSI W.)
IfSTREET aA.1 dup BY D. P rr 0
APPLICANT PHONE 6 FS -7
DATE OF APPLICATION
-PLANNING BOARD
TOWN PLAENER
&,/CONSERVATION COMMISSION
I/
T014N USE BELOW THIS LINE
.DATE APPROVED
DATE REJECTED
DATE APPROVED
DATE REJECTED
00, 0000,
'000� "'oo, DATE APPROVED
I FE AAT��A If ff Af -A—N DATE REJECTED
DEPARTMENT OF PUBLIC WORKS
�5--T)PTNITLIAV -PPT2MTT
--&EitE'R/WATER CONN
FIRE DEPT.
RECEIVED BY BUILDING INSPECTION
DATE
This forin shall be signed by the agents of the Planning and Health Boards,
the Conservation Commission prior to the issuance of any building permits
for the subject lot. This form shall not releive the applicant from the
compliance of any applicable Town requirement or Bylaw.
"OKI"
tD
CHUS
B O -ARD OF HEALTH
120 MAIN STREET
NORTH ANDOVER, MASS. 01845
Thomas E. Neve, Assoc., Inc.
447 Boston Rd.
Topsfield, MA 01983
Re: Lot 38 Candlestick Rd.
(Jerad Place II)
No.. Andover, MA
Dear Tom:
June 26, 1990
I--- �-
tu�
f'*, or
dy�
I have conducted a review c
lot 38 dated 5/23/90. The septic
approved until the following concerns are aaaL.---
TEL: 682-6483
Ext. 32 or 33
or
e
1. Elevation of bed bottom - previous designs for this lot
indicate a bottom of bed at elevation 159.00. The new design
calls for a bottom of bed at elevation 157.50. It also appears
that the topography in the area of tp 30 has changed. Please
explain this discrepancy.
la. None of the test holes conducted indicate a greater
depth to ledge than 9611 yet, the southwest corner of
the leachfield is as deep in the ground as if ledge
were at 10811 to 11411 +/ -. Either the leachfield
should be re -orientated or a test hole should be
conducted at the south west corner of the leachfield.
2. Regrading easement - A copy of the regrading easement
shown on lot 37 shall be signed by the owner and submitted as
part of the plan review.
3. Stone depth North Andover regulations require a
minimum of 1211 of stone under the leaching pipes. Please provide
and adjust inverts of field accordingly.
4. Plan deficiencies - Please show the following:
4 RT
-14,
0
B O -ARD OF HEALTH
120 MAIN STREET TEL: 682-6483
NORTH ANDOVER, MASS. 01845 Ext. 32 or 33
June 26, 1990
Thomas E. Neve, Assoc., Inc.
447 Boston Rd.
Topsfield, MA 01983
Re: Lot 38 Candlestick Rd.
(Jerad Place II)
No. Andover, MA
Dear Tom:
I have conducted a review of the latest plan revision for
lot 38 dated 5/23/90. The septic plans as submitted will not be
approved until the following concerns are addressed:
1. Elevation of bed bottom - previous designs for this lot
indicate a bottom of bed at elevation 159.00. The new design
calls for a bottom of bed at elevation 157.50. It also appears
that the topography in the area of tp 30 has changed. Please
explain this discrepancy.
la. None of the test holes conducted indicate a greater
depth to ledge than 9611 yet, the southwest corner of
the leachfield is as deep in the ground as if ledge
were at 10811 to 11411 +/ Either the leachfield
should be re -orientated or a test hole should be
conducted at the south west corner of the leachfield.
2. Regrading easement - A copy of the regrading easement
shown on lot 37 shall be signed by the owner and submitted as
part of the plan review.
3. Stone depth North Andover regulations require a
minimum of 1211 of stone under the leaching pipes. Please provide
and adjust inverts of field accordingly.
4. Plan deficiencies - Please show the following:
A
Page 2
Lot 38 Candlestick Rd.
June 26, 1990
4a. Location of bench mark in area of leachfield
4b. Limits of top and subsoil excavation shown in plan
view.
Thank you for your cooperation in this matter. Should you
have any questions, please do not hesitate to call. "1 15;"
MJR/rel
Very truly y drs
Mic -'el J. Rosati
Acting Health Agent
MEMORANDUM
Date: May 10,1990
To: Ms. Stephanie Foley
Board of Health
North Andover, Ma 01810
From: Yankee Engineers
110 Jackson St.
Methuen, Ma. 01844
Dear Stephanie,
Per your request to Bob Messina, we have set a benchmark on Lot 38
Candlestick Rd., North Andover. The benchmark is a spike set in an 8"
diameter tree near the northwest lot corner = El. 158.68.
Sincerely,
John McQuilkin, P.E.
SURD op
MA,
7,
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NEW ENGLAND E INEERING SERVICES
N
71 � C
ir. n
REC
2 1 9qO4
-f OW
OF- L
October 19, 2004
North Andover Board of Health
Town Hall Annex
27 Charles Street
North Andover, MA 0 1845
RE: TITLE V REPORT: 280 Candlestick Road, North Andover, MA
Dear Sir or Madam:
Enclosed is a copy of the Title V report for the above referenced property. The system PASSED
our inspection.
If there are any questions please call me at my office, 686-1768.
Sincerely
Benjanuin C. Osgood, Jr. (Y
Certified Title 5 inspector
60 BEECHWOOD DRIVE - NORTH ANDOVER, MA 01845 - (978) 686-1768 - (888) 359-7645 - FAX (978) 685-1099
COMMONWEALTH OF MASSACHUSETTS
EXECUTIVE OFFICE OF ENVIRONMENTAL AFF
DEPAP,TMENT OF ENVIRON4E'NTW71.rV'ft'd1—T1
OCT 2 1 ?nn4
TOWN Or: NU, � I," ik�i� '-wER
HEALTH DEPARTMENT
I TITLE 5
'OFFICLkL INSPECTION FORM — NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM
PART A
CERTIFICATION
Property Address: 2 8 0 CA,,,Jou��—r)r-v,
Owner's Name:
Owner's Address: 7-�,, AN -b L -c- s C lk
Date of Inspection: Zo/ oc-/
Name of Inspector. Wease print) Benjamin C. Osgood, Jr.
Company Name: New England Engineering Services Inc.
WRingAddress:60 Beechwood Drive,
North Andover. MA 01 845
Telephone Number. 978-686-1768
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. ne inspection was performed based on my
training and experience in the proper fimction and maintenance of on site sewage disposal systems. I am a DEP
approved system inspector pursuant to Section 15.340 of T'ide 5 (310 CMR 15.000)� 1he system-
, --Passes
Conditionally Passes
Needs Further Evaluation by the Local Approving Authority
Fails
InsPector's Signature:
Date:
61 / L
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 irispection. 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
****Tbis report only describes conditions at the time of inspection and under the conditions of use at that
time. This inspection does not address how the system will perform in the future under the same or different
conditions of use.
t. ,
Page 2 of 11
OFFICIAL INSPECTION FORM — NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION (continued)
PropertyAddresst 2,90
P. O-T� <5
Owner: 016 I -A Ft,,'�M AA
Date of inspection: 0/ 2 L-/
inspection Summary: Check ABCD or E ALWAYS complete all of Section D
A. System Passes:
UE5 I have not found any information which indicates that any of the failure criteria described in 3 10 CMR
T5.303 or in 3 10 CMR 15.304 exist. Any failure criteria not evaluated are indicated below.
Comments:
B. System Conditionally Passes:
One or more system components as descri-bed in the -Conditional Pass?- section need to be replaced or
repaired. 1he system, upon completion of the replaoment or repair, as approved by the Board of Health, will pass.
Answer yes, no or not determined (YNND) in the for, the following statements. If "not determiner please
explain.
The septic tank is meW and over 20 years old* or the septic tank (whether metal or not) is structurally
;�d, eAibits substantial itiffitration or exfiltrahon or tank fitilure is immment. System will pass inspection if the
vxisting 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 Ctrtificate of Compliance
indicating that the tank is less than 20 years old is available.
ND explain:
Observation of sewage badcup or break out or high static water level in the dk*ibution box due to broken or
obstructed pipe(s) or due to a broken, settled or uneven distribution box. System will pass inspect n if with
jo
approval of Board of Health):
broken pipe(s) are replaced
obstruction is removed
distribution box is leveled or replaced
ND explain:
The system required pumping more than 4 times a year due to broken or obstructed pipc(s). The system will.
pass inspection if (with approval of the Board of Health):
broken pipe(s) are replaced
obstruction is removed
ND explain:
Page of 11
OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION (continued)
Property Address: C Ayo -t5 C- C---5 r'? C I,,,
No 0-TIf At- D aej- A-.,+
Owner: '60L3
Date. of Inspection:
T
C. Further Evaluation is Required by the Board of Health:
M) Conditions acist which require fin-dier evaluation by the Board of Health in order to determine if the system
Is &�diftg to protect public health, safety or the eavironmeniL
System win pass unless Board of Health determines in accordance with 310 CMR 15-303(l)(b) that the
system is not functioning in a manner which will protect public health, safvty and the environment:
_ Cesspool or privy is within 50 fed of a surface water
— Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh
2. SYstem WM fall 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 fed 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.
1he. 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 end SAS and the SAS is less thatt 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 amlysis, performed at a DEP certified laboratory, for coliforka
bacteria and volatileorganic 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 1hat no other
failure criteria are triggered. A copy of the analysis must be attached to fids forni.
3. Other.
Page 4 of I I
OFFICIAL INSPECTION FORM — NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION (continued)
'Propertykddress; 7 Bc�,
/U 'D (�7'tt P,^JO a_rC_j -,4,,,.q
Owner:
Date of inspection:
10- System Failure Criteria applicable to all systems -
You must indicate 'W or "nd'to each of the following for III hispections:
Yes No
f' Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool
Discharge or ponding of effluent to the suifice of the ground or surface waters due to an overloaded or
-clogged SAS or cessiml
Static liquid level in the distribution box above outlet mvert due to an overloaded or clogged SAS or
cesspool
Liquid depth in cesspool is less than 6bqow invert or available volume is less than V2 day flow
_L.- Required pumping more d= 4 times in the last year NOT due to cloned or obstructed pipe(s). Number
of times pumped
Any portion of the SAS, cew4ml or privy is below high ground water elevation.
Any Portion Of cesspool or Privy is within 100 feet of a su&ce water supply or tnixtary to a mace
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 wilhiri 50 feet of a private water supply well,
Any portion of a cesspool or privy is less than 100 feet but greaWr than 50 feet from -a private water
supply well with no acceptable water quality analysis. UM system passes if the well water analysis,
performed at -a DEP certified laboratory, for colilbrin bacteria and volatile organic compounds
indicates that the well is free from pollution from that facility and the presence of.ammonis
nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria
are triggere& A, copy of the analysis must be attacked to tl& rernq
&2 - (YmNo) ne system La Lis. I have dotermiried that one or more of the above failure criteria adst as
described in 3 10 CMR 15.303, 1herefore the system ffil& The system owner should contact the Board of
Health to determine what will be necessary to cmect the failure.
IL 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 in Ist either 'W or "noP to each of tile following:
f
0
(The ( Ilowmg i ia apply to large system ift addition to the criteria above)
yes no
the system is withm. 4 of a surfitce drinldn supply
the system is within 200 feet of a to a surface drinking water supply
the system is I in a nitrogen sens ve (Interim Wellhead Protection Area - IWPA) or a mapped
a public water supply well
idert
If you have answered "yesP to any question in Section E the system considered a significant threat or answered
"yes!' in Section D above the large system has failed. Ile owner or r of any large system considered a
7
significant threat under Section E or failed under Section D dWl upgrade the em in accordance with 3 10 CUR
15-304. The system owner should contact the appropriate regional office of the Department.
Page 5 of 11
OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART B
CHECKLIST
Property Address: 7 0 o Cerk)DC_G__5_j_Acjk �_o
—P-, A"-) C> 3 �)-ek /6,L,4 -
Owner: 'R I A -Pi_ A^A,,-_t e7
Date of Inspection: /0 / -z- / C, -/
Check if the following have been done. You must indicate "yer or "no!' as to each of the following:
Yes No
Pumping infamation was provided by the owner, occupant, or Board of Health
_j:!� Were any of the system components pumped out in the previous two weeks
Has the system received normal flows in idle previous two week period
Have large volumes of water been introduced to the system recently or as part of this inspection
Were as built plans of the system obtained and examined? (If they were, not available note as WA)
Was the facility or dwelling inspected for signs of sewage back up,)
Was the site inspeded for signs of break out
Were all system components, excluding idle SAS,. located on site
Were the septic tank manholes uncovered, opened, and the interior of the tank inspected for the condition
Of the baffles or teesi, material of construction, dimensions, depth of liquid, depth of sludge and depth of scum I
L'� Was the facility owner (and occupants if difterent from owner) provided with information on the proper
maintenance of mbsurface sewage disposal systems ?
The size and lomfion. of the SoR Absorption System (SAS) on the site has been determined based oix
Existing information., For example, a plan at the Board of Health.
_____�Crmined in the field (if any of the failure criteria related to Part C is at issue approximation of distance
is unacceptable) [310 CMR 15.302(3)(b)]
page 6 of 11
OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION
'Property Address: !I- P c, c rq-ti D c �F-5 p, p��,
A,,,j D o R.,z-
Owner:
Date of bispection:
FLOWCONDITIONS
RESEI)ENTIAL
Number Of bedroom (design): Number of bedrooms (actual):
DESIGN flow based on 310 CMR 15203 (for example* 110 gpd. x #of bedrooms): 825 -
Number of current residents: 3
Does residence have a garb -age grinder Cyes or no).,,��
is laundry on a separate sewage systeta (yes or no): tt rif Yes separate inspection requiredi
Laundry system inspected (yes or no): —
Seasonal use: Cyes or no),
Water meter reading;, if available (last 2 years usage (gpd)):
Sump pump Cyes or no): t /o
I'ast date of 2govPW
COMMERCIAL11NDUSTRUL
1�ix of establishment:
Design flow (based on 3 10 CMR 15203): ____gpd
Wis of design flow (seats/persons1sq%etc.)-
Grease trap present (yes or no):
Industrial waste holding tank present (yes or no):
N -switary waste discharged to the Title 5 system (yes or no):
on
Water meter readings, if available:
Iast date of occupancy/use:
OTHER (describe):
GENERAL INFORBA&TION
Pump�mg Records
Source of information: �019 D'�'
was system pumped as part of the inspection (yes or no):
If yes, volume pumped: ___p11ons — How was quantity pumped determined?
Reason for pumping:
TYPE OF SYSTEM
Septic tank distribution box, soil absorption system
Single cesspool
Overflow cesspool
Privy
Shared system (Yes Or no) (If Yes, attach previous inspection records, if any)
111110vative/Alternative technology. Attach a copy of the current operation and maintenance contract (to be
obtained from system owner)
Tighttank Attach a copy of the DEP approval
Other (describe):
Approximate age of all components, date instal1ed (if known) and source of information:
901 L Ij cl,
Were sewage odors detected when arriving at the site (yes or no): &,�o
Page 7 of 11
OFFICIAL INSPECTION FORM — NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (conti=4
Property Addresst Zlao Crl,�-JD-0 6�i)c v, ao
k7l�-t A �- Z) 0 L�_
Owner:
Date of Inspection: 2-1,3
BUILDING SEWER 0ocate on site plan)
Depth below grade: IS-
MitcAals of construction: cast iron ---40 PVC other (explain):
Distance from private water supply well or suction line
Comments (on condition ofjoimts, venting, evidence of leakage, etc.):
— 9. �9 E_ I A-/ CrTu> z, P COAD,7\4A k &-i ,�, (+.y A;,(-
SEMC TANIL- _ (locate on site plan)
Depth below grade: I
Material of construction: concrete metal _fiberglass _1361yethylene
_other(expLim)
if tank is Metal list aW. Is age confirmed by a Certificate of Compliance (yes or no):
(aftch a copy of
certificate)
Dimensions:
Sludge depth:
-Distance frotii top of sludge to bottom of outlet tee or baffle: Z/_
Scum thidmess;
Distance from top of Scum to top of outlet tee or baffle: 6
'Distance from bottom of scum to bottom of outlet tee or baffte-
How were dimensions determined: _,-Acnoffoet� '577c//
q Comments (on pwnpmg recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels
as related to outlet invert, evidence of leakage, etc.):
T) C),q, P_ 6-C a
^j (�-_y
GREASIE TRAP;A/�cate on site plan)
Depth below grade:
Material of construction: concrete metal—fiberglass
__poly-thylene ___other
(explain):
Dimensions:
Scum thidmWs:
Distance from top of scum to top of outlet tee or bafftv.
Distance from bottom of scum to bottom of outlet tee or baffie:
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, dc.):
Page 8 of 11
OFFICIAL INSPECTION FORM — NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Property Address: z- a a C 4-ej D ce & j) r (1,
Aj 0 a -
Owner:
Date of inspection:
TIGHT or HOLDING TANK- LeL (tank must be pumped at time of inspection)(locate on site plan)
Depth below grade
Material of constructiow. concrete metal
Dimensions:
Capacilt5r.
--Puons
Design Flow: ______gal1ordday
Alarm present (yes or no):
Alarm level: Alarm in woricing order (Yes or no):
Date of last pumping:
Comments (condition of alarm and float switches, dc.):
�DWMMUTION BOX* — (if present must be openedXtocate on site plan)
Depth of liquid level above outlet invert: 0 "
Comments (note if box is level and distribution to MfletS ennal stnv i-v;APn^-^fe^1;Av �AA- �P
PUM CHAMEP.-�� (locate on site plan)
Pumps in woticing order (yes or no):
Alarms in working order (yes or no):
Comments (note condition of pump diamber, condition of pumps and appurtenances� etc.)-
Page 9 of 11
OFFICIAL INSPECTION FORM — NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORK
PART C
SYSTEM INFORMATION (continued)
PrOperty,kddr= 2 2)D �' D LC --C -(-)C fi_-,
AJ I prl� 3 '1 �e & .4 rq
Owner: Oc�b L-t-4-F=i_AmtA [--
Date of Inspection.: (0 L-2- 1 0,/ ,
SOIL ABSORPTION SYSTEM (SAS): — (locate on site plan, excavation not required)
If SAS not located explain why:
Type
leaching pits, number:
leachin2 chambers, number:
leaching galleries, number:
leaching trenches, number, leag�h:
_�L leaching fields, number, dimensions: Z Z:)
overflow cesspool, number:
innovativelalternative system Type/name of technology:
Comments (note condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of vegetation,
etc.)-.
K --s
-(cesspool must be pumped as part of inspectionXiocate on site plan)
CESSPOOIS: A,11i
Number and configuration:
Depth —top of liquid to inlet invert:
Dept1i of solids layer:
Depth of scum layer:
Dimensions of cesspool:
Materials of construction:
Indication of groundwater inflow (yes or no):
Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.):
PRIVY;M_ (locate on site plan)
Materials of construction:
Dimensions:
Depth of solids:
Comments (note condition of soiL signs of hydraulic fititure, level of ponding, condition of vegetation, etc.):
Pageloall
OFFICIAL INSPECTION FORM — NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Property Address: 2- 2 o C-A1'J'D
,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
benehmarks. Locate all wells within 100 feet. Locate -where public water supply enters 1he building.
Page 11 of 11
OFFICIAL INSPECTION FORM — NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Property Address:
Owner: 0D
Date of Inspection:
SMEXAM
Slope 7�
Surface water
Check collar
Shallow wells ev'r."'If
Estimated depth to ground water feet
Please indicate (check) all methods used to determine the high ground water elevation:
—Obtained from system design plans on record - If checked, date of design plan reviewed:
Observed site (abAting propertylobs�on hole within ISO feet of SAS)
Checked with local Board of Health -explain:
Checked with local excavators, installers- (attach documentation)
Accessed USGS database -explain:
You must desc;ribe how you established the high ground water elevation:
V, e:v
,rowN OF No 11 ANDOV" P,
SYSTEM PU 0 _C
L) A VE M71N RF ORI)
Y NJ-hM OWNER & ADDRESS'
I
141-r1-01nme— 0
C2,80 OOA101190�1'- -
IV, OMM4 / Ina,
I SYSTEM LOCKTf6)_N_______�
C) ot 89
0100 s Q_
DATE OF PUMPINO: Y PUMPED:
YES'. SOPUC Tank: NO
NA FURE OF SERVICE: Rou'ri
NE il
013SERVATIONS. DEC 0 7 2004
OOOD CONDITION FULL'Iyj COVER
HEAVY O"AsE BAMES IN PLACL TOWN 0'
KOOT3 LEACHFIELD RUNBACK
6XCESSIVE SOLIDS
SOLID CAKRYOVER,'_.._._. OTHER EXPLAIN
systvm Pumpzd by
.. - 6- -Ls-o/
0 1,
177a.
COMMENTS.
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has pro�Oded O1*fQrm for U'80 bY local Boards of Heilth.
of Health or other
apprQylng a
Faclilt nfQr "'ation
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anUty PUmped:
2,
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it oileahed?
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SWom Pumping l;tswro pjQ4 1
'Commonwealth of Massachusetts OCT 16 2012
City/Town of TOWN OF NORTH ANDO-VER
hrLHEALTH DEPARTMENT
System Pumping Record
Form 4
DEP has provided this form lor 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 submitled to
the local Board of Health or other approving authority.
A. Facility Information
1 . System Location: Left / Right front of house, Left / Right rear of house, Left I right side of house, Left
Right side of building, Left Right front of building, Left / Right rear of building, Under deck
Address
41,90
City/Town State Zip Code
2. System Owner
Name
Address (if different from location)
Cityrrown State Zip Code -
Telephone Number
B. Pumping Record
I . Date of Pumping 2. Quantity Pumped:
Date Gallons
3. Type of system: Cesspool(s) B --Septic Tank El Tight Tank
El Other (describe):
4. Effluent Tee Filter present? E] Yes E3"�-o If yes, was it cleaned? El Yes Ej No
5. Condition 9ff Sbystem:
6. System Pumped By:
Neil Bat6son F5821
Name Vehicle License Number
Bateson Enterprises Inc
Company
7. LocatLo—n-vAie-re contents were disposed:
G. L, S. P Lowell Waste Water
zc)—
Sbg-n�e �Haule
Date
t5form4.doc- 06/03
It
System Pumping Record - Page 1 of I
Commonwealth of Massachusetts
City/Town of NORTH ANDOVER, MASSACHUSETTS
System Pumping Record
A,
Form 4
DEP has provided this form for use by local Boards of Health. The ysteX i2M cord ust
um; ng e
be submitted to the local Board of Health or other approving autho i YOWN OF NORTH ANWVUA
f5jpA=KMNT
A. Facility Information
Important:
When filling out 1. System Location:
forms on the
computer, use C()nC)1C5�'kCL<
only the tab key Addr
to move your sk
cursor - do not amumm)E94
use the return City/TowT State Zip Code
key.
2. System Owner:
Name
Address (if different from location)
City/Town State Zip Code
9 79 I)S-5 - b 6
Telephone Number
B. Pumping Record
I
1 . Date of Pumping 2. Quantity Pumped: 1,500
Date Gallons
3. Type of system: Ej Cesspool(s) 10"Septic Tank Tight Tank
F Other (describe):
4. Effluent Tee Filter present? Ej Yes /NO If yes, was it cleaned? E] Yes /No
5. Condition oflystern:
6. System Pumped By:
Jim
Na Vehicle License Number
Company
7. Location where contents were disposed:
Signature of Hauler Date
http://www.mass.gov/dep/water/approvals/t5forms.htm#inspect
t5form4.doc- 06/03 System Pumping Record - Page 1 of 1
Commonwealth of Massachusetts
City/Town of
EUIVEE
System Pumping Record
Form 4 OCT I q �011
DEP has provided this form for use by local Boards of Health. Other form Yl6&rUN@&TU
M_I?,jN VEMRjy
DA%%
information must be substantially the same as that provided here. Before T our
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
1. System Location: Left front of hot
rear of house, right rear of house
left side of house, right side of house, Left
ht rear of building, under deck.
�-�-250 cjj�ec�' P-�\--- Wo
City/Town State
2. System Owner:
Name
Address (if different from location)
City/Town
B. Pumping Record
1. Date of Pumping
3. Type of system: R
E] Other (describe):
Zip Code
Staw- — Zip GQde
53 S:--- S &6 'CS
Telephone Number
J0-1-3-�( � 9 �: �z
Date 2. WuUa ity Pumped: Gallons
Q
S t
1c Te
Cesspool(s) Septic Tank El Tight Tank
4. Effluent Tee Filter present? [I Yes 0-'Wo--� If yes, was it cleaned? El Yes M No
5. Conditio of ystem*
KZ-a� \ V\- 4z�'V�c-
6. System Pumped By:
Neil J. Bateson
Name
Bateson EnterDrises Inc.
Company
7. Locati e contents were disposed:
,4c
7Si.D7 bll Was r
AoW
Signature
F5821
Vehicle License Number
Date
(0 - F
— It
t5form4.doc- 06/03 System Pumping Record - Page 1 of 1
TOWN OF NORTH ANDOVER
APPLICATION FOR PLAN EXAMINATION
Permit NO: Date Received
Date Issued:
IMPORTANT: Applicant must complete all items on this pag e -
LOCA
-Z,
PROPERTY OWNER-1-
MAPNO: PARCEL.
C
TYPE OF IMPROVEMENT
PROPOSED USE
ResidLe�a
Non- Residential
New Building
'015:::
Two or more family
Industrial
MAdd*
I raftr
tera
No. of units:
Commercial
i�'e �arr, Feplacement
Assessory Bldg
Others:
Demolition
Other
��fl C Well
-Flood I i Wetlands
p ain
Watershed Disffict
'eZ�isewer - .
DESCRIPTION OF WORK TO BE PERFORMED:
Identification Please Type or Print Clearly)
OWNER: Name: Phone: 3-35- 5-2,0:5-�
Address: -Z-.e-0 kuA&�,
ARCH ITECT/ENG I NEER Phone:
Address: Reg. No. '
FEE SCHEDULE. BULDING PERMIT.'$lZOO PER $1000.00 OF THE TOTAL ESTIMATED COST BASED ON $125.00 PER S.F.
Total Project Cost: $ 19k, I -t V 0 FEE: $ 36-5
Check No.: Receipt No.:
NOTE: Persons contracting with unregistered contractors do not have access to the guarantyfund
�-a—ture of Agent/OwnerA�, -V 4
—�,�naturqof
Permit NO:
Date Issued:
TOWN OF NORTH ANDOVER
APPLICATION FOR PLAN EXAMINATION
Date Received-��R -1d
TYPE OF IMPROVEMENT
PROPOSED USE
Resid
!PntLalz-�
Non- Residential
New Building
L6ne fa
Add' 110151-
Two or more family
Industrial
kt
ltera��p5
No. of units:
Commercial
f�e'oair, replacement
Assessory Bldg
Others:
Demolition
Other
e i c
"X6
i6o pain--- I d
Ve an s -
d6i, �iT�
Se,wer
DESCRIPTION OF WORK TO BE PERFORMED:
Identification Please Type or Print Clearly)
OWNER: Name: Za, -z tv,-. Phone: ctnc- 335- 5-zo5-
L"'k
ARCH ITECT/ENG I NEER Phone:
Address: Reg. No. I
FEE SCHEDULE. BULDINGPERMIT: $1Z00 PER $1000.00 OF THE TOTAL ESTIMATED COSTBASED ON $125.00 PER S.F.
Total Project Cost: $ V 1) FEE: $ 365
Check No.: Receipt No.:
NOTE: Persons contracting with unregistered contractors do not have access to the zuarantv fund
Dimension
Number of Stories: Total square feet of floor area, based on Exterior dimensions.—'1,7-14
Total land area, sq.ft.: Y-�-,513
ELECTRICAL: Movement of Meter location, mast or service drop requires approval of
Electrical Inspector Yes No
DANGER ZONE LITERATURE: Yes No
MGL Chapter 166 Section 21 A —F and G min.$100-$l 000 fine
NOTES and DATA — (For deDartment use
U Notified for pickup - Date
Doc:.Building Pennit Revised 2008
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0-6f,
100.20'
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09
Sol
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it 3
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Plans Su6mitted
Plans Waived Stamped Plans
TYPE OF SEWERAGE DISPOSAL
Public Sewer
Tanning/Massage/Body Art
Swimming Pools
Well
Tobacco Sales
Food Packaging/Sales
Permanent Dumpster on Site
THE FOLLOWING SECTIONS FOR OFFICE USE ONLY
INTERDEPARTMENTAL SIGN OFF - U FORM
PLANNING & DEVELOPMENT
COMMENTS
CONSERVATION
COMMENT
I HEALTH
COMMENTS
Reviewed on
DATE REJECTED DATEAPPROVED
L.(A, —
�A
Reviewed o
Zoning Board of Appeals: Variance, Petition No: Zoning Decision/receipt submitted yes
Planning Board Decision:
Conservation Decision:
Comments
Comments
Water & Sewer Connection/signature & Date Driveway Permit
DPW Town Engineer: Signature:
Locatea ;Jt34-L -itreet
L�gooaz
1�-3. - , I - % "7�
-A-1 ffiiTf .-F]XbftiDU� -t'- - �i e-,, yes�.i -k..
At ff.pFA t1li-E -4 "ii
i MUStreot
'�,'L.odbted Ot 12 4�M`a
"Aturi
e"p-'artmd
,'-,Firq.D' ldhte
-ITS
N
Building Department
The following is. a list of the required forms to be filled out for the appropriate permit to be obtained.
Roofing, Siding, Interior Rehabilitation Permits
• Building Permit Application
• Workers Comp Affidavit
• Photo Copy Of H.I.C. And/Or C.S.L. Licenses
copy of Contract
Floor Plan Or Proposed Interior Work
a Engineering Affidavits for Engineered products
NOTE: All dumpster permits require sign off from Fire Department prior to issuance of Bldg Permit
Addition Or Decks
Building Permit Application
c3 Certified Surveyed Plot Plan
Workers Comp Affidavit
Photo Copy of H.I.C. And C.S.L. Licenses
Copy of Contract Of Proposed Work With Sprinkler Plan And
Floor/Crossection/Elevation Plan
Hydraulic Calculations (If Applicable)
Mass check Energy Compliance Report (if Applicable)
Engineering Affidavits for Engineered products
NOTE: All dumpster permits require sign off from Fire Department prior to issuance of Bldg Permit
New Construction (Single and Two Family)
Lj Building Permit Application
Certified Proposed Plot Plan
Photo of H.I.C. And C.S.L. Licenses
Workers Comp Affidavit turned) to Include Sprinkler Plan And
Two Sets of Building Plans (One To Be Re
Hydraulic Calculations (if Applicable)
Copy of Contract
Mass check Energy Compliance Report
Engineering Affidavits for Engineered products
NOTE: All dumpster permits require sign off from Fire Department prior to issuance of Bldg Perrr
In all cases if a variance or special permit was required the Town Clerks office must stamp the decision from the Board of Appeal
that the appeal period is over. The applicant must then get this reco . rded at th e Registry of Deeds. One copy and proof of recordi
must be submitted with the building application
Doc: Doc.Building permit Revised 2008
2.0
Plans Su6mitted
Plans Waived Certified Plot Plan Stamped Plans
TYPE OF SEWERAGE DISPOSAL
Public Sewer
Tanning/Massage/Body Art
Swimming Pools
Well
Tobacco Sales
Food Packaging/Sales
Permanent Dumpster on Site
THE FOLLOWING SECTIONS FOR OFFICE USE ONLY
INTERDEPARTMENTAL SIGN OFF - U FORM
DATE REJECTED DATEAPPROVED
PLANNING & DEVELOPMENT
COMMENTS
CONSERVATION
COM . MENTS��
I HEALTH
COMMENTS
Reviewed o
Reviewed on
�Z
Zoning Board of Appeals: Variance, Petition No: Zoning Decision/receipt submitted yes
Planning Board Decision:
Comments
Conservation Decision: Comments
Water & Sewer Con nection/signature & Date Driveway Permit
DPW Town Engineer: Signature:
Locatea iq1AQqooq 6treet
FIRE DEPARTMENT - Temp,Dumpster 6n site -yes. no -2
'Located at 124 Main Street
Fire Department signature/date
COMMENTS