HomeMy WebLinkAboutMiscellaneous - 295 CANDLESTICK ROAD 4/30/2018z NJ �y
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HAS PLAN REVIEW FEE BEEN PAID? YES NO
PLAN APPROVAL: 2 Ar
DATE APP. BY
DESIGNER: PLAN DATE.
CONDITIONS A16 -6b 4b))'7- z H64
76
1 4067-1,04,1 OA/- 4;,967- OlbE-7 0,'- :SY-57-,E14
7'
WATER SUPPLY:
WELL PERMIT
WELL TESTS:
COMMENTS:
<�,TOWN
WELL
D R I LLE
CHEMICAL DA I E APPRUVED
BACTERIA I DAIE (IPPRUVED
BACTERIA II DRIE APP ROVED
FORM U APP ROVALs APPROVAL TO ISSUE(:2�Nu
DATE rSSUED h,5 By
..........
CONDITIONS:
. ... . ..... ..... ...
FINAL APPROVAL:.
ALL PERMITS PAID NO
WELL CONSTRUCTION APPROVAL NO
SEPTIC SYSTEM CONSTRUCTION APPROVAL( No
OTHER N U
ANY VARIANCE NEEDED YES NO
FINAL BOARD OF HEALTH APPROVAL:
1-0
AT I-QL4
:Is THE'INSTALLER LICENSED?..:*",.;..,....�'.. YES
YEj�
NO
REPAIR",..
i.�:TYPE.OF-CONSTRUCTION
CONSTRUCTION: CERTIFIED PLOT PLAN�REVIEW_ YES
No
.14
CONDITIONS OF.. APPROVAL. YES
NO
(FROM FORM U
-ISSUANCE OF DWC PERMIT. YES
NO
�;-'�DWC 62- VJ Al
PERMIT.N INSTALLER- .7)
0.
.4 7, BEG I N INSPECTION ,,7- NO:
EXCAVATION, INSPECTION: :NEEDED:
PASSED BY
INSPECTION: NEEDEDs
-YES
AS BUILT PLAN SATISFACTORY: 3
BY
APPROVAL TO BACKFILL: DATE.-Lzb
GRADING APPROVAL: DAT E Y
_B
FINAL CONSTRUCTION APPROVAL: DATE: BY
RECEIVED
<C TH ANI)OVER
Commonwealth of Massachusetts Voxn�j 0� t4UR
EPARTMENT
City/Town of
System Pumping Record NORTH ANDOVER
Form 4
jDI="P 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 So2rd of Health to determine the form they use. The System Pumping Record must be submitted to
the local Board of Health or other approving authority within 14 days from the pumping date in
accordance with 310 CMR 15.351,
4. Effluent Tee Filter present? Yes [1;� If yes, was it cleaned? Yes No
5. Condition of System'
6. System Pumped By:
VE4i—icW�1—certi-e- N umoef
7. Location where contents were disposed -
Signature ;f —Hauler Date. Ara—
S 'I)
Signature of Receiving Faahi_y Date
r!5foem4,doc, 03106 System Purripi6g Record - Paige ; of
A, Facility Information
Important
When filling out
forms on the
1 . $ystem Location,
I Q
Computer. use
only the tab key
to move your
Address
cumor - do not
use the return
City/Town
State
Zip code
key.
2. System Owner:
Name
Address (jr different from Yocation)
6
-Ti-teph6ne
Z—ip —cole
Number
B_ Pumping Record
1. Date of Pumping 2. Quantity Pumped:
3. Type of system,. CeSspool(S) EE—SVptIC Tank El Tight Tank
Grease Trap
[3 Other (describe):
4. Effluent Tee Filter present? Yes [1;� If yes, was it cleaned? Yes No
5. Condition of System'
6. System Pumped By:
VE4i—icW�1—certi-e- N umoef
7. Location where contents were disposed -
Signature ;f —Hauler Date. Ara—
S 'I)
Signature of Receiving Faahi_y Date
r!5foem4,doc, 03106 System Purripi6g Record - Paige ; of
Commonwealth of Massachusetts
Massachusetts
System Pumoing Pecord
4
JUL 0 5 2007
TOWN OF NORTH ANDOVER
HEALTH DEPARTMENT
SiitifriW�er' — —L� Y.I�
"qu-I System Location
KO: h(-, f t Kri Ptizary Home,
29'3 C,inciLe-,it-ick Rd )45 C,%n(JI.ejtick 1W
North Andovrer, MA, 0 'A. 84 5 N(jrtlh Andiwor, MA, 0!845
x
Koiihnff KriB
Type: Em
Cesspool: No
bate of Pumping: j
Routine
Yes
System Pumped By: * Wind River Environmental, LLC
Contents Transferred to:
Contents Disposed at:
bate:
Condition of System/Other Comments
Pumper Signature:
Septic Tank: No YesE��
Quantity Pumped: 15
)(D Gallons
Permit #:
W W -V? �/,
bep Approved Form - 12/07/95
Commonwealth of Massachusetts
\40,
Title 5 Official Inspection Form
7
Subsurface Sewage Disposal System Form Not for Voluntary Assessmen
ts;
295 Candlestick Road
it
Property Address
Kris & John Kosheff
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.
VQ
Owner's Name
North Andover
City/Town
MA 01845
State Zip Code
05/25/2017
Date of Inspection
Inspection results must be submitted on this form. Inspection forms may not be altered in any
way. Please see completeness checklist at the end of the form. —90
A. General Information
Inspector:
Robert Herrick
Name of Inspector
Wind River Environmental 40RV
Company Name
163 Western Avenue
Company Address
Gloucester
City/Town
(978) 282-7315
Telephone Number
B. Certification
MA
State
,1 13758
ense Number
01930
Zip Code
I certify that I have personally I, ..e sewage disposal system at this address and that the
information reported below is tru ,;urate 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:
H Passes 0 Conditionally Passes 0 Fails
F-1 Needs Further Evaluation by the Local Approving Authority
05/25/2017
��spector's Signature Date
The system inspector shall submit a copy of this inspection report to the Approving Authority (Board
of Health or DEP) within 30 days of completing this inspection. If the system 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.
"'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.doc - rev. 6/16 Title 5 Official Inspection Form: Subsurface Sewage Disposal System - Page 1 of 17
P A2d L���
�/ f�^9
Y
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.
VQ
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
sz
295 Candlestick Road
Property Address
Kris & John Kosheff
Owner's Name
North Andover
City/Town
MA 01845
State Zip Code
05/25/2017
Date of Inspection
Inspection results must be submitted on this form. Inspection forms may not be altered in any
way. Please see completeness checklist at the end of the form. —to
A. General Information
Inspector:
Robert Herrick
Name of Inspector
Wind River Environmental
Company Name
163 Western Avenue
Company Address
Gloucester
City/Town
(978) 282-7315
Telephone Number
B. Certification
MA
State
S113758
License Number
01930
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:
E Passes El Conditionally Passes El Fails
F� Needs Further Evaluation by the Local Approving Authority
4rrspector's Signature
05/25/2017
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 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.
****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.doc - rev. 6/16 Title 5 Official Inspection Form: Subsurface Sewage Disposal System - Page 1 of 17
�,� ��`'j
,,
U,► ,
, mom
A
W,
Owner
information is
required for every
page.
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
295 Candlestick Road
Property Address
Kris & John Kosheff
Owner's Name
North Andover MA 01845 05/25/2017
City/Town 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:
13) System Conditionally Passes:
F-1 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.
F1 Y El N 0 ND (Explain below):
t5ins.doc - rev. 6/16 Title 5 Official Inspection Form: Subsurface Sewage Disposal System - Page 2 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
295 Candlestick Road
Property Address
Kris & John Kosheft
Owner's Name
North Andover
City/Town
B. Certification (cont.)
RAA
QLOLV
01845 05/25/2017
Zip Code Date of Inspection
El Pump Chamber pumps/alarms not operational. System will pass with Board of Health approval if
pumps/alarms are repaired.
B) System Conditionally Passes (cont.):
F-1 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):
El broken pipe(s) are replaced
obstruction is removed
[-] Y F1 N E] ND (Explain below):
F1 Y 0 N El ND (Explain below):
F� distribution box is leveled or replaced 0 Y F1 N F1 ND (Explain below):
F1 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 F1 Y 0 N El ND (Explain below):
obstruction is removed El Y F� N El ND (Explain below):
C) Further Evaluation is Required by the Board of Health:
F-1 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(l)(b) that the system is not functioning in a manner which will protect public health,
safety and the environment:
El Cesspool or privy is within 50 feet of a surface water
El Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh
t5ins.doc - rev. 6/16 Title 5 Official Inspection Form: Subsurface Sewage Disposal System - Page 3 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form Not for Voluntary Assessments
295 Candlestick Road
Property Address
Kris & John Kosheff
Owner Owner's Name
information is
required for every North Andover MA 01845 05/25/2017
page. City[Town 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:
F� 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.
F-1 The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water
supply.
F� The system has a septic tank and SAS and the SAS is within 50 feet of a private water
supply well.
F-1 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 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 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
0
Backup of sewage into facility or system component due to overloaded or
clogged SAS or cesspool
El
E
Discharge or ponding of effluent to the surface of the ground or surface waters
due to an overloaded or clogged SAS or cesspool
El
Z
Static liquid level in the distribution box above outlet invert due to an overloaded
or clogged SAS or cesspool
El
z
Liquid depth in cesspool is less than 6" below invert or available volume is less
than 1/2day flow
t5ins.doc - rev. 6/16
Title 5 Official Inspection Form: Subsurface Sewage Disposal System - Page 4 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form Not for Voluntary Assessments
295 Candlestick Road
Property Address
Kris & John Kosheff
Owner Owner's Name
information is
required for every North Andover MA 01845 05/25/2017
page. C ityrTown State Zip Code Date of Inspection
B. Certification (cont.)
Yes No
E] 0 Required pumping more than 4 times in the last year NOT due to clogged or
obstructed pipe(s). Number of times pumped: --
El H Any portion of the SAS, cesspool or privy is below high ground water elevation.
El H Any portion of cesspool or privy is within 100 feet of a surface water supply or
tributary to a surface water supply.
El N Any portion of a cesspool or privy is within a Zone 1 of a public well.
El 0 Any portion of a cesspool or privy is within 50 feet of a private water supply well.
El 0 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 0 The system is a cesspool serving a facility with a design flow of 2000gpd-
10,000gpd.
El E 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
E]
F-1
the system is within 400 feet of a surface drinking water supply
E-1
R
the system is within 200 feet of a tributary to a surface drinking water supply
El
1:1
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.
15ins.doc - rev. 6/16 Title 5 Official Inspection Form: Subsurface Sewage Disposal System - Page 5 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
295 Candlestick Road
Property Address
Kris & John Kosheff
Owner Owner's Name
information is
required for every North Andover
page. City/Town
C. Checklist
MA 01845 05/25/2017
State Zip Code Date of Inspection
Check if the following have been done. You must indicate "yes" or "no" as to each of the following:
Yes No
E El
Pumping information was provided by the owner, occupant, or Board of Health
El E
Were any of the system components pumped out in the previous two weeks?
H El
Has the system received normal flows in the previous two week period?
El N
Have large volumes of water been introduced to the system recently or as part of
this inspection?
E El
Were as built plans of the system obtained and examined? (If they were not
available note as N/A)
• El
Was the facility or dwelling inspected for signs of sewage back up?
• El
Was the site inspected for signs of break out?
H E]
Were all system components, excluding the SAS, located on site?
Z El
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?
Z 1:1
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:
Z M
Existing information. For example, a plan at the Board of Health.
El Z
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): 4 Number of bedrooms (actual): 4
660 gpd
DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x # of bedrooms):
t5ins.doc - Fev. 6/16 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
295 Candlestick Road
Property Address
Kris & John Kosheff
Owner Owner's Name
information is
required for every North Andover
page. Cityfrown
D. System Information
Description:
MA 01845
State Zip Code
05/25/2017
Date of Inspection
System is made up of a septic tank, distribution box and soil absorption system.
The clallons oer dav is based off of the last 2 vears of the customer's water records.
Sump pump? El Yes E No
Last date of occupancy: Occupied
Date
Commercial/industrial 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
0
No
El
Yes
F]
3
El
Yes
Number of current residents:
No
Does residence have a garbage grinder?
El
Yes
Z
No
Is laundry on a separate sewage system? (include laundry system inspection
El
Yes
0
No
information in this report.)
Laundry system inspected?
El
Yes
Z
No
Seasonaluse?
El
Yes
E
No
105.3 gpd
Water meter readings, if available (last 2 years usage (gpd)):
Detail:
The clallons oer dav is based off of the last 2 vears of the customer's water records.
Sump pump? El Yes E No
Last date of occupancy: Occupied
Date
Commercial/industrial 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
0
No
El
Yes
F]
No
El
Yes
E]
No
t5ins.doc - rev. 6/16 Title 5 Official Inspection Form: Subsurface Sewage Disposal System - Page 7 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
295 Candlestick Road
Property Address
Kris & John Kosheff
Owner Owner's Name
information is
required for every North Andover MA 01845
page. City[Town State Zip Code
D. System Information (cont.)
Last date of occupancy/use:
Other (describe below).:
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:
Date
05/25/2017
Date of Inspection
Wind River Environmental and Home Owner
Yes Z No
gallons
Type of System:
z Septic tank, distribution box, soil absorption system
El Single cesspool
El Overflow cesspool
El Privy
1:1 Shared system (yes or no) (if yes, attach previous inspection records, if any)
El 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
El Tight tank. Attach a copy of the DEP approval.
1:1 Other (describe):
t5ins.doc - rev. 6/16 Title 5 Official Inspection Form: Subsurface Sewage Disposal System - Page 8 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
295 Candlestick Road
Property Address
Kris & John Kosheff
Owner Owner's Name
information is
required for every North Andover
page. City/Town
State
01845 05/25/2017
Zip Code Date of Inspection
D. System Information (cont.)
Approximate age of all components, date installed (if known) and source of information:
1992: Plans on File
Were sewage odors detected when arriving at the site? E] Yes Z No
Building Sewer (locate on site plan)
Depth below grade: 20"
feet
Material of construction:
Z cast iron E] 40 PVC 0 other (explain):
Distance from private water supply well or suction line: Town Water
feet
Comments (on condition of joints, venting, evidence of leakage, etc.)-.
All joints are solid and there are no signs of leakage. The venting is through the building sewer.
Septic Tank (locate on site plan):
Depth below grade:
Material of construction:
Z concrete F� metal
18"
feet
F-1 fiberglass 0 polyethylene [] other (explain)
If tank is metal, list age: years
Is age confirmed by a Certificate of Compliance? (attach a copy of certificate) El Yes El No
Dimensions: 1010 x 58" x 58"
Sludge depth:
5"
t5ins.doc - rev, 6/16 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
295 Candlestick Road
Property Address
Kris & John Kosheff
Owner Owner's Name
information is
required for every North Andover MA 01845 05/25/2017
page. Cityl-rown State Zip Code Date of Inspection
D. System Information (cont.)
t5ins.doc - rev. 6116
Septic Tank (cont.)
Distance from top of sludge to bottom of outlet tee or baffle 29"
Scum thickness 2"
Distance from top of scum to top of outlet tee or baffle 6"
Distance from bottom of scum to bottom of outlet tee or baffle 14"
How were dimensions determined? Tape measure; Sludge Judge
Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity,
liquid levels as related to outlet invert, evidence of leakage, etc.)-.
Recommend pumping yearly. The inlet and outlet are solid. There are no signs of leakage and the
liquid level is OK in relation to the inverts.
Grease Trap (locate on site plan):
Depth below grade'.
Material of construction:
E] concrete EI metal
Dimensions:
Scum thickness
El fiberglass
Distance from top of scum to top of outlet tee or baffle
Distance from bottom of scum to bottom of outlet tee or baffle
nntim r%f inct "m in @
V F �j 1-1 +
Title 5 Official Inspection Form: Subsurface Sewage Disposal System - Page 10 of 17
feet
polyethylene El other (explain):
Commonwealth of Massachusetts
Title 5 Official Inspection Form
7! Subsurface Sewage Disposal System Form Not for Voluntary Assessments
295 Candlestick Road
Property Address
Kris & John Kosheff
Owner Owner's Name
information is
required for every North Andover
page. City/Town
MA 01845
State Zip Code
05/25/2017
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:
F� concrete El metal El fiberglass 0 polyethylene El other (explain):
Dimensions:
Capacity:
Design Flow:
Alarm present:
Alarm level:
gallons
gallons per day
F-1 Yes 0 N 0
Alarm in working order:
Date of last pumping: Date
Comments (condition of alarm and float switches, etc.):
0 Yes El No
* Attach copy of current pumping contract (required). Is copy attached? El Yes [:] No
15ins.doc - rev. 6116 Title 5 Official Inspection Form: Subsurface Sewage Disposal System - Page 11 of 17
Mimi
L
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
295 Candlestick Road
Property Address
Kris & John Kosheff
Owner Owner's Name
information is
required for every North Andover MA 01845
page. City/Town State Zip Code
D. System Information (cont.)
05/25/2017
Date of Inspection
Distribution Box (if present must be opened) (locate on site plan):
Depth of liquid level above outlet invert 0
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.)-.
The distribution box is solid and has no signs of leakage or carryover. The liquid level is OK in
relation ot the inverts.
Pump Chamber (locate on site plan):
Pumps in working order: Yes No*
Alarms in working order: D Yes No*
Comments (note condition of pump chamber, condition of pumps and appurtenances, etc.)-.
* If pumps or alarms are not in working order, system is a conditional pass.
Soil Absorption System (SAS) (locate on site plan, excavation not required):
If SAS not located, explain why:
t5ins.doc - rev. 6116 Title 5 Official Inspection Form: Subsurface Sewage Disposal System - Page 12 of 17
4'
Commonwealth of Massachusetts
Title 5 Official Inspection Form
t o Subsurface Sewage Disposal System Form Not for Voluntary Assessments
295 Candlestick Road
Property Address
Kris & John Kosheff
Owner Owner's Name
information is
required for every North Andover MA 01845 05/25/2017
page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
Type:
El leaching pits number:
El leaching chambers number:
El leaching galleries number:
E leaching trenches number, length: 2 @ 80'
El leaching fields number, dimensions:
El overflow cesspool number:
El 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.):
The soil is dry and the e are no signs of hydraulic failure. There is no poncling and the vegetation is
normal for the area.
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 El Yes El N o
t5ins.doc - rev. 6/16 Title 5 Official Inspection Form: Subsurface Sewage Disposal System - Page 13 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form Not for Voluntary Assessments
295 Candlestick Road
Property Address
Kris & John Kosheff
Owner Owner's Name
information is
required for every North Andover MA 01845 05/25/2017
page. City/Town 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.doc - rev. 6/16 Title 5 Official Inspection Form: Subsurface Sewage Disposal System - Page 14 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form Not for Voluntary Assessments
295 Candlestick Road
Property Address
Kris & John Kosheff
Owner Owner's Name
information is
required for every North Andover MA 01845 05/25/2017
page. City/Town 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:
F� hand -sketch in the area below
E drawing attached separately
t5ins.doc - rev. 6/16 Title 5 Official Inspection Form: Subsurface Sewage Disposal System - Page 15 of 17
v.Y
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form Not for Voluntary Assessments
295 Candlestick Road
Property Address
Kris & John Kosheff
Owner Owner's Name
information is
required for every North Andover
page. City[Town
D. System Information (cont.)
Site Exam:
0
Check Slope
Surface water
Check cellar
Shallow wells
r-C+iM0+Mrq An +h +n hi h "nA %Atn+nr-
MA 01845
State Zip Code
1001,
05/25/2017
Date of Inspection
F, �f �1 feet
Please indicate all methods used to determine the high ground water elevation:
10-1
AM
I
Obtained from system design plans on record
If checked, date of design plan reviewed: 1990
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..
The estimated high ground water elevation was determined using the 1990 design plan on file with
the Board of Health.
Before filing this Inspection Report, please see Report Completeness Checklist on next page.
t5ins.doc - rev. 6/16 Title 5 Official Inspection Form: Subsurface Sewage Disposal System - Page 16 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
295 Candlestick Road
Property Address
Kris & John Kosheff
Owner
Owner's Name
information is
North Andover MA
required for every
page.
City/Town State
E. Report Completeness Checklist
01845 05/25/2017
Zip Code Date of Inspection
E Inspection Summary: A, B, C, D, or E checked
Z 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.doc - rev. 6/16 Title 5 Official Inspection Form: Subsurface Sewage Disposal System - Page 17 of 17
Summary Reccrd
Card generated on 6,1912017 8:33:18 AM oy Karen Hanlon Page
Location
Town of North Andover
Type Size
Tax Map # 210-106-A-0233-0000.0
36348639 a Active
Parcel Id 17378
ERT HIH
295 CANDLESTICK ROAD
w Water 0.63 O�63
KOSHEFF, JONATHAN
Date
295 CANDLESTICK ROAD
Code
N.ANDOVER,MA
Posted Date
01845
. ... . .........
Class 101 Single Family
...... ..... .......... ... . ------- . . .. . ... . ......... ... .......... ............. ..
Property Type I Residential
Zoning3 1 Residential
Zoning2 1 Residential
27
Size Total 1.8 Acres
-62%
FY 2017
.... ....... .. ........
UB Mailing Index
Name/Address Type Loan Number Active/Inact. From Until
KOSHEFF, JONATHAN Payor
295 CANDLESTICK ROAD
N. ANDOVER, MA
01845
UB Account Maint. Activellinactive
Account No Cycle Occupant Name
Bldg Id. 17655.0 - 295 CANDLESTICK ROAD Last Billing Date 4/6/2017 Active
3170325 03 Cycle 03
UB Services Maint.
Account No. 3170325
Service Code Rate Charge Multiplier/Users
MISCIFEE ADMIN FEE O�63 518 7.82
WTR WATER 01 ALL METER SIZE 114.85
UB Meter Maintenance
Ac-.ount No. 3170325
Serial No Status
Location
Brand
Type Size
YTD Cons
36348639 a Active
ERT HIH
b Badger
w Water 0.63 O�63
2149
Date
Reading
Code
Consumption
Posted Date
Variance
318/2017
2172
aActual
27
4112/2017
-62%
12/912016
2145
a Actual
73
1123/2017
-66%
166%
9/912016
2072
a Actual
205
1012412016
203%
611312016
1867
a Actual
84
8/2/2016
-43%
319/2016
1783
a Actual
26
4/22/2016
12,110/2015
1757
a Actual
47
1120/2016
-74%
84%
9/9/2015
1710
a Actual
182
10/16/2015
246%
619/2015
1528
a Actual
97
7/24/2015
3/11/2015
1431
a Actual
28
4/28/2015
-48%
12111/2014
1403
a Actual
54
1/15/2015
-68%
200%
9111,12014
1349
a Actual
168
10115/2014
105%
6/1'./2014
1181
a Actual
56
7/16/2014
3/1 V2014
1125
a Actual
27
4/1112014
-58%
12110/2013
1098
a Actual
63
1/17/2014
-42%
73%
glil,'2013
1035
a Actual
log
10/15/2013
87%
6/12/2013
926
a Actual
63
712412013
3/13j2013
863
a Actual
34
4/2212013
-3%
12/11/2012
829
a Actual
34
1/912013
-71%
50%
9/13/2012
795
a Actual
121
10115/2012
188%
6/12j2012
674
a Actual
78
7/16/2012
3/14/2012
596
a Actual
28
4/14/2012
-2%
12/12/2011
568
a Actual
28
1/17/2012
-72%
141%
9112/2011
540
a Actual
108
10113/2011
6/7/2011
432
a Actual
42
7120/2011
-7%
3/8/2011
390
a Actual
44
411312011
-41%
1219i2010
346
a Actual
76
1/12/2011
-50%
914.012010
270
a Actual
162
10/1512010
174%
6/712010
108
a Actual
56
7/1512010
49%
3!9/2010
52
a Actual
38
411412010
41/6
79', 2
0
Town of North Andover
HEALTH DEPARTMENT
33 CH
CHECK#: DATE: —A,
LOCATION: �f
H/O NAME:
CONTRACTOR NAME: A
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
Massage Practice
$
0
Offal (Septic) Hauler
$
0
Recreational Camp
$
0
Sun tanning
$
0
Swimming Pool
$
0
Tobacco
$
0
TrashlSolid Waste Hauler
$_
0
Well Construction
$
SEPTIC Systems:
0
Septic - Soil Testing
$
0
Septic - Design Approval
$
0
Septic Disposal Works Construction (DWC)
0
Septic Disposal Works Installers (DW[)
0
Title 5 Inspector
yTitle
5 Report /1(7-'5 -5
$50-
0 Other (Indicate) $
He'aft-Agent Initials
White -Applicant Yellow -Health Pink -Treasurer
Date'�� ...... f....
//A.F
This certifies that ..... .
has permission to perform 7�1
........................
plumbing in the buildings of
at . �Z�
......................... North Andover, Mass.
.............
Fee Lic. No
PLUMBING INSPECTOR
Check # IYV2
8032
T
TOWN OF NORTH ANDOVER
0
PERMIT FOR PLUMBING
SACHU
//A.F
This certifies that ..... .
has permission to perform 7�1
........................
plumbing in the buildings of
at . �Z�
......................... North Andover, Mass.
.............
Fee Lic. No
PLUMBING INSPECTOR
Check # IYV2
8032
MASSA CHUSETTs UNIFORp�j AppL
ICA -TION FOR PERMrT
(7�ype Or print) TO DO PLUMBING
NORTH ANDOVER, MASSACIMSEM
I
I
-1 --
ILZ:� Plans Submitted Yes No
0 MI
`sr`=ng Company Nane. 1.e')I#IAIC1 11C 724y Check one:
Certificate
Corp.
Addr=s El
usiness elephone -/5-f
Name Of Licensed Plumber: F�Co a 2j 6. 2-,
—77u=�n- co �chec �km
lndicat� —the t of e
ype c co�ve-ragt by
ability insurance policy 9 the appropriate box:
Other type Of ind:nlxuty El Bond
lngurance Waiver � the undersigned, have been Made aware that e license
three insurance th of
this 'application does Dot have any one of the above
Signaun-
.rtify that all of the details and information I have submitted
I hereby ce El Agent El
(or ML -red) in above application are true and accurate to the
best of my Imowledge and that all Plumbing work and installation Performed u er Permit ls!�ed for this application will be, in
compliance with all pertinent Provisions of the Ma`sg�� �s Sta' bin I
B.r- I zl__ - Chapter 142 of the General Laws.
C--ity-/Town
.APPRO (GFRCE USE ONLY
Of Plumbing License
j -4 U111L)r'T -
""s'er " Journeyman J�
4,
nc (,Ommonwealth of miessachusefts
,Department 0 -
f Industrial A ccidentv
Office Of Investigations
.600 Washington Street
Boston, MA 0211,
Workers' Compensation lnsurance.Affiday.it: Ruhders/Contrar
Aicant Information _tors/Electridians/Plumbers
"I- - . I-
Nallne (Busin�-ss/Organizationtindividual):-,/-),V,,Vp
Addrtss:
city/State/zip: hnt
Are you an employer? Check the appropriate box:
I F7 T
A
an.. a �PPIoyzr with 4. LJ I am a -en,--i
AKees (full and/or part-time).*
2. LL��arn a.S01e proprietor or partner-
ship and have no employees
working for me in any capacity.
[No workers' comp. imurance
reqwred-j
I an a homeowner doing all work
myself [No workers' comp.
insurance required.] t
M contrautor and I
have hired the sub-contractDrs
listed 'n, the attached sheet I
These sub-cOntractors have
workers, comp. insurance.
ED We area corporation and its
have '-xercised-their
r'g`ht of exemption per MGL
c. 152, § 1 (4), and we have no
empiclYtes. [No workers'
Type Of Project (required):
.6. 11 ew construction
7. Rem- odeling,
8- 0 Demolition
9. [] Building addition
1 0-0 Electrical repairs or additions
I I.E] Plurn bing repairs or additions
12-,[] Roof repairs
13 F7 r)+;..
L�Any applicant that checks box# I must also fill Out the section below showing their
� Homeowners wli(J subMil Alis al—Lidevii indicarjj-j� at L mplansation
ICOnttactom thal checl, this box m EN v -1I
&tml then him-ousicip
, aonftajurb; nits, subm,,
usl a=hed an additional sh�� hawing the- name oft�e -aI R now affidavir in,"cating -Lah.
01 and thIeir wnrk,, _, 7- ,
— —'. I'=1 'r
, aArvvla zg workem'compensallI ip.,
iqformadom rancefaT ng, eployee�, Bel0w is the Policy andjoh size
Insurance CompanyName:
Policy # or Self�ins. Lic. #:
ExPiralJon Date:
Job Sit- Address: -----------
Attach 2 co, . py of the workers, compensation'poficy declaration City/Stattaip:
Pa-�,e (showing
Failure to secure coverage as required under Section 25A Of MGL c. 152 can . the POHrY number and expiration date).
fine up to S1,500.00 and/or one-year impri lead tO the iM.Position
sonment, as well as of criminal penalties of a
rainst the violator. Be adv
of up to S-250.00 R day ac civil penalties in the, form of a STO
P WORK OPDER and a fine
-mg-- verificatioll. statement may be forwarde.d to the Offict of
investigations ofthe DIA for insurance cov 'sed that a CoPy of this
bT �ce PLUMV
under the Y 0 perjuly
rj' �t-4xr -t'he �"fOrmma66017 P�,&,idad =boc is �zrmue and �c=r=�
rr=
A
S
Official use onip. Do not wrile i17 th
is area, to be Completed b), city or town 0jj-jCiaL
City or Town:
Issuinc, PcrmitfLicense 4
. Authority (circle one):
L Board of He . altb 2. Bufiding Department 3. City/Towjo
6. Other Cierk 4. Electrical Inspector S. Plumbinc,
Inspector
Contact Person:
Phone k
Q54
FORM - U - LOT RELEASE FORM
3 — I A
INSTRUCTIONS: . This form is used to verify that all -necessary approval permits from
Boards and Departments having jurisdiction have been obtained. Ibis does not relieve the
applicant and or landowner from compliance with any applicable requirements.
APPLICANT ��Ci
"o PHONE J7
7 9- 6 AV,9 - ao 3a -7 —x r-.
ASSESSORS MAP NUER 106 A LOTNUMBER
2233
SUBDIVISION -LOTNUMBER
STREET 0&0 S b:?�L —red STREET NUMBER Zq-5'
1020680MUSSUMON ...................
a 0 a x a *
OFInCIAL M'"O"N* L"Y....
RECOMNIENDATIONS OF TOWN AGENTS
names owwo now now
DATE APPROVED
_3
C(INSERVATIONAIWPSTRATOR DATE REJECTED
eZaX-4
DATE APPROVED
TOWN PLANNER
DATE REJECIED
CON84ENTS
DATE APPROVED
FOOD INSPECTOR - BEALTH DATE REJECTED
DATEAPPROVED
SEPTIC INSPECTOR - I-IEALTH
DATE REJECTED
COMNIENT'S A, e -!2v/0 -AV U --e� e,6 /-/C-
PUBLIC WORKS - SEWER / WATER CONNECTIONS
DRIVEWAY PERMT
FIRE DEPARTNfENT DATEAPPROVED
DATE REJECTED
RECEIVED BY BUILDING INSPECTOR DATE
e—
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SEPT C SySTEM o* 11
1 06�
ARSA m
r -
L
jrn,portan!:
When filliric OUI
forms on tl�e
compute�, use
only the tab key
10 move yoUr
cursor - do not
use tr)e return
key.
Cc)mrnonwealth of Massachusetts
City/Town of
. I ecord NORTH ANDOVER
ping R
System PUM
Form 4
may be used. but the
has provided this form fOr use by local Boards of Health. Other forms
DEP that provided here. Before using this form, 6eck with your
information must be substantially the same as �y use. The System pumping Record must be submitted to
local E3oard of Health to determine the form th(
the local Board of Health or other approvIng authority within 14 days from the pumping dat I e in
accordance with 31 o CMR 15.351.
A, Facility Information
1 system Location:
9-95
Add
State
C;tyrrown
2. system owner:
-1Z j<c)
Name
��j �ntfom lo�Tti�n)
------- State
1�y—/Town (729
0�.&17-45SJ�
Tele one Number
9 S. -
Zi p Co4de
p, pumping Record
dallon s
2. Quantity Pumped�
Date of pumping 75at ro_Septic Tank Tight Tank �Grease Trap
Type of system: CesspOO1(s)
other (describe):
4. Effluent Tee Filter present? C3 Yes No if yes, was it cleaned? Yes NO
5. Condition of System:
6 System Pumped By:
Nu
-- ---- Vehirle License
Name
Company G.L.S.D.
7. Location where contents were disposed: W(Nrtu
r
Date
j n t re of Hauler TOWN OF NOM H, -,NDOVER
HE
-6�te
�7aT�,;*�f Re Fa�ility
System Pumping Record - Page I of 1
js,,c;crn4.doc- 03106
Al
L
H
44--
im
Form 4 -- System Pumping Record
Commonwealth of Massachusetss
: Massachusetts
System PurnpinQ Record
system Owner System Location
KPIS KOSHEFF KPII�
.95 CANDLEISTICK RCAD 295 1:W)LESTIM FOAD
NOPTH ANDOVER. MA 01615 NORTH AAD0v'FR, MA Ole4S
(0761 689-4551 (913) :89-4551
Type: Emergency PAutine --JYe.
Cesspool: Klo Yes Septic tank-. W F
Date of Pumping: 9L Quantity Pumped: 150c�> Gallons
System Pumped By: W1nd Pjw Enwmnwatal, LLC Permit #:
Contents transferred to:
Contents Disposed at: ( (5 )�--)
bate: C) Pumper Signature:
Condition of Systern/Other Comments
Dep Appmved From - 12107195
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AS -BUILT CHECK LIST
and
FINAL INSPECTION
Proposed Elevations
House /77 4
Tank IN 1-16,70
Tank OUT 17wl.47
D -box IN / 7(� .41
D -box OUT 1-76, Z I
Trench Inverts
Line 1 7,3-, 76
Line 2
Line 3
Line 4
I
As -Built Elevation
/ 7 7, 7
,177,03
176,79
-7 7&;
7,1, (ff :�_'
/ 7,� , 2- * - / X�57
/ -76 ,5 7 - / 7d--94
Bottom of Exc.
Stone OK? D -box checked? L,,,�Pipes cemented?
nk�
-1
N
1c;
N
0: Z
-3�iO
S S
3W
PLAN REVIEW CHECKLIST
ADDRESS
ENGINEER
GENERAL
3 COPIES STAMP LOCUS NORTH ARROW SCALE,,--'
CONTOURS PROFILE SECTION BENCHMARK_�(_ SOIL &
PERC INFO ELEVATIONS WETS. DISCLAIMER WELLS &
WETLANDS WATERSHED?A/0 DRIVEWAY_L:::�'
(Elev) WATER LINE
FDN DRAIN_X SCH4 0 L---- TESTS CURRENT? c-��
SEPTIC TANK
MIN 1500G. .17 INVERT DROP GARB. GRINDERZ�L(+200% EDF)
251 TO CELLAR_L,,�-- MANHOLE TO GRADE ELEV GW
D -BOX
SIZE LINES FIRST 21 LEVEL STATEMENT
INLET OUTLET/76-,7,0 (211 OR .17 FT) TEE REQID?)4/0
LEACHING
RESERVE AREA L"" 4' FROM PRIMARY?ly 1001 TO WETLANDS L,--' 2% SLOPE
1001 TO WELLS z,- 351 TO FND & INTRCPTR DRAINS L,"*' 4 ' TO S. H. GW
325' TO SURFACE H20 SUPP 41 PERM. SOIL BELOW FACILITY
F 71.3,3
MIN 12" COVER L--*"- FILL? (251 if above natural elev; 101if below) kc,
BREAKOUT MET?
TRENCHES
MIN 660 gpd�.4 SLOPE (min .005 or 611/1001) >31 COVER? - VENT
SIDEWALL DIST. 2X EFF. W OR D (MIN IS RESERVE BETWEEN
TRENCHES? IN FILL? L---- MUST BE 10 MIN. (-� 4 PEA STONE?
BOT X LDNGzV + SIDE �o X LDNG TOT—, -07
(G/ft2)
(L x W x #) (DxLx2x#)
q,3,7
10
�00
X
THO
ING
November 17,1993
Ms. Sandy Starr
Health Agent
120 Main Street
North Andover, MA 0 1845
Re: Lot 25 Candlestick
Dear Sandy:
8%9
Find attached revised plans of the above -referenced design. The trenches have been
relocated in order to avoid ledge which was found during the excavation. The new design
still complies with all of the provisions of Title V and the local Board of Health
Regulations.
I have distributed this plan to the owner and installer and they will be calling you in order
to arrange site inspections since the time of the installation of this system is of the
essence.
Thank you for your cooperation. If you have any questions please do not hesitate to
contact me.
Very truly yours,
THOMAS E. NEVE ASSOCIATES, INC.
C4� W�
Thomas E. Neve, PE, PLS
President
TEN/krn
Attachments
cc: John Kosheff
; ENGINEERS e * LAND SURVEYORS
44 Old Boston Road U.S. Route #1
(508) 887-8586
#1272 KOSBEFF.WPS
LAND USE PLANNERS *
Topsfield, MA 01983
FAX (508) 887-3480
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DATE /
Ag&ZYaZ,
BOARD OF HEALTH
Sheet /
of
TOWN OF NORTH ANDOVER
FEE (7��o SUBSURFACE DISPOSAL DESIGN REVIEW
- PERMIT # DATE RECEIVED 1110-5�191ef
APPLICANT ASSESSOR'S MAP
ADDRESS PARCEL #
LOT #
ENGINEER STREET
ADDRESS -447 61,6 Bogmy--Rb Top,51c—1 , L-, z, a 01.,9,6-3
PLAN DATE - /d/o A-4.1 REVISION DATE
CONDITIONS OF APPROVAL:
APPROVED
DISAPPROVED
-T,IV 5 () F,-�IC /,-
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Town of North Andover, Massachusetts Form No.1
BOARD OF HEALTH
APPLICATION FOR SITE TESTING/INSPECTION
Applican
Engineer
Test/l nspection Date and Time
CHAIRMAN, BOARD OF HEALTH
Fee Test No. 5f75-
S.S. Permit No.-D.W.C. No.___--C.C. Date-Plbg. Permit No.
Town of North Andover, Massachusetts Form No.1
tkORTH BOARD OF HEALTH
19
0
"POM
APPLICATION FOR SITE TESTING/INSPECTION
Applicant
NAME ADDRESS TELEPHONE
Site Location � k-�- v;k'-A'� -� I '- :' - "�--t -I , ( 11
Engineer
NAME ADDRESS TELEPHONE
Test/I nspection Date and Time
Fee
CHAIRMAN, BOARD OF HEALTH
Test No.
S.S. Permit No.-D.W.C. No.-C.C. Date-Plbg. Permit No.
FORM U - LOT RELEASE FORM
INSTRUCTIONS: This form is used to verify that all necessary
approvals/permits from Boards and Departments having jurisdiction
have been obtained. This does not relieve the applicant and/or
landowner from compliance with any applicable local or state law,
regulations or requirements.
****************Applicant fills out this section*****************
APPLICANT:
Z;t,� 9-, - 4 Kri
5, �, - Kos6S��
Phone ((*a)
Z4(o - plSlp
LOCATION:
Assessor's Map
Number /o(p - P�
Parcel
233
Subdivision _-Sirr&A Lot (s) zs-
Street St. Number
************************Official Use Only************************
RECOMMENDATIONS OF TOWN AGENTS:
Date Approved
Conservation Administrator Date Rejected
Comments
kT6qQ LAA F& 1, Date Approved 5-1:211
Town Planner Date Rejected
Comments
Date Approved
Food Inspector -Health Date Rejected
It _Z_
Date Approved �f5�61
Septic Inspector -Health Date Rejected
Comments
3s14 Public Works - sewer/water connections
- driveway permit
Fire Department
L Cct X -A
, I
Received by Building Inspector
Date
BOARD OF HEALTH
Neve Associates
447 Old Boston Road
Topsfield, MA 01983
120 MAIN STREET
NORTH ANDOVER, MASS. 01845
TEL. 682-6483
Ext. 32
January 11, 1993
RE: Lots 25 and 27 Candlestick, and Lot 28A Sugarcane Lane
Dear Tom:
This is to notify you that the proposed septic plans for the
above -referenced lots have been disapproved. Please see the
enclosed design review sheets for explanations.
If you have any questions, please do not hesitate to call me
any Monday, Wednesday or Friday.
Sincerely,
!'t- - /_j 0�"b 4--i
Sandra Starr
Health Agent
cc: Karen Nelson
BOH file
Applicant
Tpwn of North Andover, Massachusetts
BOARD OF HEALTH
a AW IYATt"! I
APPLICATION FOR SITE TESTING/INSPECTION
Form No.1
NAME ADDRESS TELEPHONE
Site Location 1 15 C -k 4--d-
Engineer Y�" )�' U-#�
NAME ADDRESS I TELEPHONE
Test/inspection Date and Time
Fee * I -t::5 n%_'
CHAIRMAN, BOARD OF HEALTH
Test No. �4D
S.S. Permit No.-D.W.C. No -------- C.C. Date-Plbg. Permit No.
Town of North Andover, Massachusetts Form No. 1
01, XAORTH BOARD OF HEALTH
0
19'
APPLICATION FOR SITE TESTING/INSPECTION
.q_
Applicant
NAME ADDRESS TELEPHONE
Site Location 0 '7; A- �.---r -x
Engineer
NAME ADDRESS TELEPHONE
Test/Inspection Date and Time
CHAIRMAN, BOARD OF HEALTH
Fee
S.S. Permit No.-D.W.C. No.-C.C. Date
Test No,
Plbg. Permit No.
l"/
CURIRJER
SEPTIC & DRAIN SERVICE
107 FOREST STREET; MIDDLETON, MA 01949
(978) 774-2772
FORM 4 - SYSTEM PUMPING RECORD
COMMONWEALTH OF MASSACHUSETTS
MASSACHUSETTS
S YS TEM P EXI—PING RE CORD
SYSTEM OWNER:
ANN D�Jbc
SYSTEM LOCATION-
ocll�- �314c' k
0�� -�f I Ke, �'
DATEOFPUMPING: QUANTITY PUMPED: ��C)
GALLONS
CESSPOOL: NOE:] YES. E::] SEPTIC TANK: NO F7 YES
SYSTEM PUMPED BY: CURRIER SEPTIC & DRAIN SERVICE
CONTENTS TRANSFERRED TO:
DATE: /0- -30-
Commonwealth of Massachusetts
City/Town of NORTH ANDOVER, MASSACHUSETTS
SystemPumping Record
Form 4
DEP has provided this form for use by local Boards of Health. The Sy tem Rarp—la'-din-M.,
� 1�
be submitted to the local Board of Health or other approving authorit . P:
F11 lKI
A. Facility Information III - 0 IM
wv ' " 7
TOWN OF NORTH ANDO
mportant: LHEALTH DEPARTM
Nhen filling out 1. System Location: TMEN
orms on the
computer, use
nly the tab key Address
o move your CD
ursor - do not Cityrrown State Zip Code
se the return
ey.
2. System Owner:
Name
Address (if different from location)
City/Town State Zip Code
Telephone Number
B. Pumping Record
I
1 . Date of Pumping 2. Quantity Pumped: L
S Z-0
Date Gallons
3. Type of system: El Cesspool(s) LPSeptic Tank F1 Tight Tank
Other (describe):
4. Effluent Tee Filter present? El Yes �6 0 If yes, was it cleaned? El Yes El No
5. Condition of System:
6. System P dB
—
Name Vehicle License Number
Company
7. Location where contents were disposed:
Signatu&&f Hauler
http://www.mass.gov/dep/water/app.rovals/t5forms.htm#inspect
Date
t5form4.doc- 06/03 System Pumping Record - Page 1 of 1
dm st
VER
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0
t
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7. Location where contents were disposed:
Signatu&&f Hauler
http://www.mass.gov/dep/water/app.rovals/t5forms.htm#inspect
Date
t5form4.doc- 06/03 System Pumping Record - Page 1 of 1
Important:
When filling out
forms on the
computer, use
only the tab key
to move your
cursor - do not
use the return
key.
'.P -Q
Commonwealth of Massachusetts
City/Town of NORTH ANDOVER, MASSACHUSETTS
System Pumping Record
Form 4
DEP has provided this form for use by local Boards (
be submitted to the local Board of Health or other ap
A. Facility Information
1. System Location:
a95
Addr W
CityfTow?r
2. System Owner:
Name
Address (if different from location)
City[Town
B. Pumping Record
I
1. Date of Pumping
3. Type of systenri: F�
D Other (describe):
SEP 0 8 Z009
TOWN OF NORTH ANDOVER
HEALTH DEPARTMENT
State
ping Record must
M".
Zip Code
State Zip Code
9 L4 S,5)
Telephone Number
'�- S-09 2. Quantity Pumped: J500
Date Gallons
Cesspool(s) YSeptic Tank Tight Tank
e
4. Effluent Tee Filter present? Xyes [e No If yes, was it cleaned?
5. Condition of System:
GOOJ
6, System Pumped By:
.Jlyy) GCk11QM -7 b b-�
Na A� Vehicle License Number
Company
7. Location where contents were disposed:
G-1 -S-D
Lawrence, MA.
Signature of Hauler Date
http://www.mass.gov/dep/water/approvals/t5forms.htm#inspect
Xyes VNo
15form4.doc- 06/03 System Pumping Record - Page 1 of 1
Commonwealth of ssapbusetts
City/Town of
System Pumpi,ng Recor
Form 4
DEP has provided this form for use by local Boards of Health. Other forms may be used, but the
information must be substantially the same as that provided here. Before using this form, check with your
local Board of Health to determine the form they use. The System Pu ping -eg -must-be-sjj tted to
the local Board of Health or other approving authority within 14 days fr. m th pMb dateA'n
accordance with 310 CMR 15.351. 1
A. Facility Information 3 1 2008 j
. 'u
TOWN OF NORTH ANDOV�ER
Important: LHEALI�_H LXEPAz�TMENT
When filling out 1. System Location:
forms on the
computer, use
only the tab key Address
to move your Nov\\-\ A�)Auve� C\ 0 1 s� L+ 5),
cursor - do not City/Town State Zip Code
use the return
key. 2. System Owner.-
ne—s
Name
Address (if different from location)
City[Town State Zip Code
()73 U?9 455
Telephone Number
B. Pumping Record -7-9-03 )1500
1 . Date of Pumping Date 2. Quantity Pumped: Gallons
3. Type of system: E] Cesspool(s) EVSeptic Tank E] TightTank M Grease Trap
Other (describe):
4. Effluent Tee Filter present? El Yes YNo If yes, was it cleaned? Fj Yes E] No
5. Condition o System:
C-7 - - 3
6. System Pumped By:
Alyy-% GQ�IQY)k - 6'� () 3 1
N gam Vehicle License Number
Company
7. Location J(Le
Sc
Cl?nts were disposed:
Hauler
Signature of Receiving Facility
t5f orm4.doc- 03/06'
-7- L -f -0
Date
Date
System Pumping Record - Page 1 of 1
,Z\ Commonwealth of Massachusetts
City/Town of
Pumping Record NORTH ANI
System
Form 4
DEP has provided this form for use by local Boards of Health. Othi
information must be substantially the same as that provided here.
local Board of Health to determine the form they use. The System
the local Board of Health or other approving authority within 14 days from the pumping date in
accordance with 310 CIVIR 15.351.
5. Condition of System:
6. System Pumped By:
JIM (3011 CA V'). -7 6 (o
7 N vehicle License Number
7%4,nd ivc,( Eovironmcy4al
C�
Company
7. Location where contents were disposed:
G.L.S.D.
�a W r—e'—n c- e-- - FA A. Date
�ignature of Ha uIer
Signature of Receiving Facility
DatE
t5form4.doc- 03/06 System Pumping Record - Page 1 of 1
A.
Facility Information
Important:
When filling out
forms on the
1 .
System Lo cation:
Can d I c
computer, use
only the tab key
to move your
Address
1�0 \\n Andovc;f
MA
0)61 q�)
cursor - do not
- CityrTown ---
'§-tate
Zip Code
use the return
key.
2.
System Owner:
Kri 5 Ko6'rIC4
Name
Address different from location)
(if
City[Town
7
�te Zi Code
C
Lu
Te ephone Number
B. Pumping Record
10-20-10
1 .
Date of Pumping
2. Quantity Pumped:
Gallons
3.
Type of system: Cesspool(s) Vseptic Tank Tight Tank
El Grease Trap
F! Other (describe):
4.
Effluent Tee Filter present? 0 Yes /No
If yes, was it cleaned?
[] Yes [?rNo
5. Condition of System:
6. System Pumped By:
JIM (3011 CA V'). -7 6 (o
7 N vehicle License Number
7%4,nd ivc,( Eovironmcy4al
C�
Company
7. Location where contents were disposed:
G.L.S.D.
�a W r—e'—n c- e-- - FA A. Date
�ignature of Ha uIer
Signature of Receiving Facility
DatE
t5form4.doc- 03/06 System Pumping Record - Page 1 of 1
M"
E�- Commonwealth of Massachusetts
City/Town of
D
System Pumping Record NORTH AN QX
6 C21
Form 4
DEP has provided this form fQr use by local Boards of Health. Other forms may be used, but the
information must be substantially the same as that provided here. Before using this form, check with your
local Board of Health to determine the form they use. The System Pumping Record must be submitted to
the local Board of Health or other approving authority within 14 days from the pumping date in
accordance with 310 CMR 15.351.
Important;
When filling out
forms on the
computer, use
only the tab key
to move your
cursor - do not
use the return
key.
A. Facility Information
i. System Location:
Address
. /V . I . I - . §tate
CiRtown
2. System Owner:
Name
W�dke–s--s (1–fd–W-e—rent fro0i loc'ation)
alTyrrown
B. Pumping Record
Zip Code
State Zip Code
2– J 5--45� 0
1- DateofPumping -6�t . e 2. Quantity Pumpedi Gallons
3. Type of system: E] Cesspool(s) [�JPSeptic3ank E] Tight Tank E] Grease Trap
Other (describe)�
4. Effluent Tee Filter present? Yes Ej No If yes, was it cleaned? F1 Yes El No
5. Condition of System:
6. System Pumped By.
114
Name -�;e�icle —Lir-e--n,se Number
Zo—mpan–y
7. Location w t ts were disposed:
';ierepon en
Sig r of Hau
c—
�-f—Re-7
S nature ceiving Facility
ba - I e jel
Date
15form4.doc- 03/06 System Pumping Record - Page I of 1
Commonwealth of Massachusetts
CityfTown of RE C"" - �%6
System Pumping Record NORTH ANDOVER
Form 4 OCT -0 2011
DEP has provided this form for use by local Boards of Health. Other forms may be used. uvmft ORTH ANDOVER
information must be substantially the same as that provided here. Before using this form, he
J'LDEPARTMENT
:ocal Board of Health to determine the form they use. The System Pumping Record mustLvl
he local Board of Health or other approving authority within 14 days from the pumping date in
accordance with 310 CMR 15.351
A. Facility Information
Imporunt:
When filling .1 1 . System Location,
forms on the
computer, use
only the lab key Address
to move your
CU so( . do not
use the return �Ilyffovvn State Zip Code
key - 2 System Owner;
V Q � 5 6.� 5 h
Name!
-A-defri2ii-s-OfFit—terent
611—y[Tawn state Zip Code
-iii U _'q
Telephone Number
B. Pumping Record
1. Date of Pumping Date
2 Quantity Pumped
Gallons
I Tight Tank
3. Type of system: Ej Cesspool(s) P -§---Pt'- Tank f -
El Grease Trap
Other (describe) -
4 Effluent Tee Filter present? 0 Yes E3 No
If yes, was it cleaned?
0 Yes Ej No
5. Condition of System.
6, Syste Pumped 6
Vehicle License Number
Na
Company
7 Location where contents were disposed:
QL.&D.
-X00hAndovc% MA.
-§iinaiure
of Hauler
bate
Sign f Receiving Facility
Date
1510rff)4.d*C- OYOG System Pumping Record - Page 1 of 1