HomeMy WebLinkAboutMiscellaneous - 30 OAKES DRIVE 4/30/2018C)
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SEPTIC SYSTEM INSTALLATION
IS THE INSTALLER LICENSED? <aE�� NO
TYPE OF CONSTRUCTION: NEW �AIR
NEW CONSTRUCTION: CERTIFIED PLOT PLAN REVIEW YES NO
CONDITIONS OF APPROVAL YES NO
(FROM FORM U)
ISSUANCE OF DWC PERMIT YES NO
DWC PERMIT PAID? NO
DWC PERMIT NO. INSTALLER: e
BEGIN INSPECTION (�YES 0:
EXCAVATION INSPECTION: NEEDED:
PASSED zzit�- BY
CONSTRUCTION INSPECTION: NEEDED:
AS BUILT PLAN SATISFACTORY: YES:
APPROVAL TO BACKFILL: DATE: BY
FINAL GRADING APPROVAL: DATE
q-5 BY
FINAL CONSTRUCTION APPROVAL: DATE:ZoZf-/q
,L T BY
4 --
Commonwealth of Massachusetts REC I D
City/Town of No Andover
JUN 10 2013
System Pumping Record
Form 4 TowN OF NORTH ANDOVER
wr-ALTH DEPARTMENT
DEP has provided this form for use by local Boards of Health. ther forms may be used, but the
information must be substantially the same as that provided here. Before using this form, check with your
local Board of Health to determine the form they use. The System Pumping Record must be submitted to
the local Board of Health or other approving authority within 14 days from the pumping date in
accordance with 310 CMR 15.351.
A. Facility Information
Important: When
filling out forms
on the computer,
use only the tab
key to move your
cursor - do not
use the return
key.
4�� 2
vt�=A
System Location:
30 OakA*S —L -)r,
Address
No Andover Ma
City/Town
System Owner:
Hedstrom
Name
Address (if different from location)
City/Town
B. Pumping Record
1. Date of Pumping
State
State
Telephone Number
Date
3. Type of system: El Cesspool(s)
F1 Other (describe):
uanL!Ly rumped:
;��eptic Tank E] Tight Tank
Zip Code
Zip Code
/S-00
Gallons
El Grease Trap
4. Effluent Tee Filter present? [:1 Yes 0 No If yes, was it cleaned? Ej Yes F No
t5form4.doc- 03/06
5. Condition of System:
(�()o 0
6. System Pumped By: j 4 . _�L.
Name Vehicle License Number
Stewart's Septic Service
Company
7. Location where contents were disposed:
Stewart's Pre-treatment Plant, 20 So. Mill Bradford, Ma 01835
Signatskejf Hauler
Date
System Pumping Record - Page 1 of 1
1C\ Commonwealth of Massachusetts
City/Town of North Andover
x
System Pumping Record
Form 4
5. Condition of System:
Good Condition
6. System Pumped By:
Frank Eldridge
Name Vehicle License Number
Stewart's Septic Service
Company
7. Location where contents were disposed:
Stewart's Pre-treatment Plant, 20 So. Mill Bradford, Ma 01835
(D. I I
Signature of Ha r Date
\ 4i��q —
Signature of R%Qel'ving Facility Date
t5form4.doc- 03/06 System Pumping Record - Page 1 of 1
DEP has provided this form for use by local Boards of Health. Other forms may be used, but the
information must be substantially the same as that provided here. Before using this form, check with your
local Board of Health to determine the form they
use. The System Pumping Record must be submitted to
the local Board of Health or other approving
authority within 14 days from the gdatein
"n
accordance with 310 CMR 15.351.
rR'�OE
dEIVE0
'C �'V 0
E]
A. Facility Information
JUN
Important:
When filling out
1 . System Location:
TOWN OF NORTH ANDOVER
forms on the
HEALTH DEPARTMENT
computer, use
30 Oaks Dr
only the tab key
Address
to move your
North Andover
Ma 01845
cursor - do not
use the return
City/Town
State Zip Code
key.
2. System Owner:
Hedstrome
Name
Address (if different from location)
Cityrrown
State Zip Code
Telephone Number
B. Pumping Record
1. Date of Pumping 5/20/11
2. Quantity Pumped: 1500
Date
Gallons
3. Type of system: Ej Cesspool(s)
Z Septic Tank El Tight Tank El Grease Trap
E] Other (describe):
4. Effluent Tee Filter present? F] Yes F1
No If yes, was it cleaned? 0 Yes 0 No
5. Condition of System:
Good Condition
6. System Pumped By:
Frank Eldridge
Name Vehicle License Number
Stewart's Septic Service
Company
7. Location where contents were disposed:
Stewart's Pre-treatment Plant, 20 So. Mill Bradford, Ma 01835
(D. I I
Signature of Ha r Date
\ 4i��q —
Signature of R%Qel'ving Facility Date
t5form4.doc- 03/06 System Pumping Record - Page 1 of 1
Important:
When filling out
forms on the
computer, use
only the tab key
to move your
cursor - do not
use the return
key.
C
..9mmonwealth of Massachusetts
City/Town of NORTH ANDOVER, MASLSAC�H�U�TTS
Form 4 P Ing Record
system Ump
DEP has provided this form for use by local Boards of Health. The System.punin? Record mu,,
be submitted to the local Board of Health or other approving auth8rity, Ocr 1 0 06
A. Facility Information
1 - System Location:
Address
City/Town
State
2. System Owner:
J�e 6/,S%
30
Addrew (it different from location)
- IAL�WfV'
State
Telephone Number
1p C�
'ZIP Co—de---
B. Pumping Record
1. Dateof.Pumping Date 2. Quantity Pumped:
Gallons
3. Type of system: Cesspooi(s) 2�11eptic Tank Tight Tank
[I Other (describe):
4. Effluent Tee Filter present? [D Yes WKO
5. Condition of System: ootb
If yes, was it cleaned? [I Yes R;* -0-
6. SMem P�umped By:
Vehicle License Number
Name
--- ti r
Company
7. Location where contents were disposed:
i ature I
http://www.ma'ss.gov/dep/water/� provals/t5forms.htm#inspect Date
V r,
t5form4.doc- 06/03
System Pumping Record , Page I of
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Town of North Andover, Massachusetts
BOARD OF HEALTH
25
DESIGN APPROVAL FOR
SOIL ABSORPTION SEWAGE DISPOSAL SYSTEM
Applicant - Test No
Site Location
Reference Plans and Spec
Form No. 2
DA
Permission is granted for an individual soil absorption sewage disposal system to be installed
in accordance with regulations of Board of Health.
4 !��
Fee— 100
CHAIRMAN, BOARD OF HEALTH
Site System Permit No. "?
ri
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BOARD OF HEALTH
OCT 3 0 1995
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Lepi- I
�q4i' I Li s
OA Y--F,'!�
AS BUILT PLAN
OF
� UOUS"URFACE DISPOSAL SYSTEM
LOCATEDIN
I J,
AS PREPARED FOR
PA, 4t, -40,e�%TW�—j
DATE: I
'?c PT, el 5
SCALE: I "..' 40'
MERRIMACK ENGINEERING SERVICES, INC.
PROFESSIONAL ENGINEERS 0 LANDSURVCYORS 0 PLANNERS
66 PARK StREET ANDOVER. MASSACHUSE"S olljo TEL (617) 475-3533.373-5721
v
-04,
TOWN OF NO
SYSTEM PUM�)�'H ANDOV
L) A t'E / [, INQ RECOF
iYSTEM () ER & ADDRESS
#ea�5#0 m * I
13n 60#61 lo/� I
A)
RECEIVED
NOV - 3 2004
TOVv,\. ur WRTH ANDOVER
HEAL'fr; DEPARTMENT
1 0 T a 1 Mm LL)CA-11ON
LJA I h OF PUMPING: �-()-j �UMPED,
-QUANTITY PUMPED:
�-:LSSPOOL: NO
k, YES
SOP -k 1'ank: NO
YES
NA rUKE OF SERVICE: ROU'rINE'...
ObSERVA 171ONS
CK)OD CONDITION -T)o COVER
HF-AVY ORFASE BAMES IN PLACL
ROOTS LEACHJU-LD RUNBACK
BXCUSIVE SOLIJDS.._____ FLOODED
SOLID CAKRYOV'ER,_...,.,. OTKER EXPLAIN
systipm Pwnpcd by
... C-
.j7o.
-7a
2(. .
1,2
�-'Q)MMENTS.
L'UN I'EN I'S f'KANSJ-tRR-BD I -L)
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'ACH
8 FILE
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Town of North Andover, Massachusetts Form No.3
BOARD OF HEALTH
I 9--L
DISPOSAL WORKS CONSTRUCTION PERMIT
Applicant
NAME—
Site Location—, -)--u 0
L
-----------------
Permission is hereby granted to Construct or Repair ' "a"n Individual Soil Absorption
Sewage Disposal System as shown on the Design Approval S.S. No.
C H V R—M A—N, 8 O—A —RD -0 F—H E —AL T —M
F e e
D.W.C. No.
PLAN REVIEW CHECKLIST
ADDRESS .5 ENGINEER 'B16L
GENERAL
I ('OTTPq q TA M T) T.r)OTTC ADVnW
CONTOURS V"'- PROFILE --- SECTION L,- BENCHMARK,/)/C- SOIL,&
PERCS 0' ELEVATIONS WETS. DISCLAIMER WELLS & WETS
WATERSHED? DRIVEWAY_:::��(Elev) WATER LINE FDN DRAIN
SCH40 TESTS CURRENT? SOIL EVAL
, I k),6
SEPTIC TANK 1,51
MIN 1500G_ 0 .17 INVERT DROP
25' TO CELLAR — MANHOLE
GARB. GRINDER/Lb (+200% EDF)
ELEV GW # COMPS.
D -BOX
SIZE # LINES FIRST 21 LEVEL STATEMENT
INLET_jj��O - OUTLET (2" OR .17 FT) TEE REQ'D? 1W
LEACHING
MIN 660 GPD? RESERVE AREA_�/41 FROM PRIMARY?X 2% SLOPE
100' TO WETLANDS 100' TO WELLS L--- 4' TO S. H. GW �-� (5 - >2M/ IN)
35' TO FND & INTRCPTR DRAINS---- 3251 TO SURFACE H20 SUPP "-�
4' PERM. SOIL BELOW FACILITY 4--' MIN 12" COVER FILL? (25 -
if above natural elev; 101if below) BREAKOUT MET?
TRENCHES
MIN 660 gpd)< SLOPE (min .005 or 611/100') 'XsIDEWALL DIST. 3X EFF.
W OR D (MIN 61)t,-- RESERVE BETWEEN TRENCHES?4-� IN FILL? MUST
BE 101 MIN.z 4" PEA STONE?dr VENT? A)O (>31 COVER; LINES >501)
BOT -4-41 + SIDE 2,q4 X LDNG TOT —147411
(L x W x 7-) (DxLx2x#F (G/ft2)
Copyright Q 1995 by S.L. Starr
............
P
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MPOSE
IIIIIIIIIIIINI
OMEN IN I
11101 MINE
INN
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No 131111111
INN Iwo
11111111 WIN I
ME I
MENOMONEE 01111111
INN
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ENRON,
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Mill
mill
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CERTIFIED FOUNDATIONPLAN
LOCATED IN P�3o?--rm A-j-,pawgg-
SCALE.71"- (-o' DATE-'-&�a4
S L. GIL ES R. L. S.
L A WRENCE a NOR TH AlwovER
4-4 (4-S+.S IF
I I ,
L
Vr H be
31't
/CERTIFY THAT THE OFFSETS SHOWN ARE FOR THE USE OF
N THE BUILDING INSPECTOR ONL Y
OFFSETS SHOW a SUCH
CONFORM TO THE USE IS FOR DETERMINA rION OFZONING
ZONING 8 Y L A W OF CONFORMITY OR IVON CONFORMITY
0,,'R,-rw
-1 WHEN TAKEN.
4c- / '-kso + o
�00-T-,
TO: NORTH ANDOVER, MASS 19
BOARD OF HEALTH
F ROM: DESIGN ENGINEER Re: Soil Absorption Sewage
System Inspection
This is to certify that I have inspected the construction of the said disposal system at
13 0 /4 it E -5- North Andover, Mass.
SITE LOCATION
The grades and construction are as specified in my plans and specifications dated
19-
j� OF
P, � 0,�Aat,
TAS A gWnp F& r S
Nn. 464
r 1,
ian
scale:
date:
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ABSORPTION
-%o
-IZ" MIN -TOPSOIL C0VM%t
V'WASIMOPP-ASTONE W -31e
L4 " PERF01PLATEID OPArAGEME VtQ,
16"WASHED CRUSH F-03TOME44"I'li
ASSORP-rkM4 A;tF-A I
# . 20 1 1 - f
BED END SECTION
t7,
0
-0 cb 10.0 -d _0
&ALLOtA �-r,-
SEPTIc 40 bCrr OF rtr=V
TArAK
DISPOSAL SYSTEM PROFILE
I
j7
451
EA
ABSORPTION BED PLAN
OBS. HOLE PERC. HOLE
ii;,o
18�'TON
5 u P,'A, 0 L
7z' 6"uAL
TiLL-
Lj WATV r, &-r 72"
PERC RATE TEST DATE
j,p/mw/mjc,q 11-0-7-4
& PERC TEST
�5ATUZATP-P VEY'AW.
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it- (11
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FORM U
TOWN OF NORTH ANDOVER
LOT RELEASE FORM
SUBDIVISION
ASSESSORS MAP
SUBDIVISION LOT(S)
PERMANENT ADDRESS (Aa5IGNED BY D.P.W.)
STREET 0 CH
APPLICANT -P11ONE _&k�-LO(e
DATE OF APPLICATION
TOWN USE BELOW THIS LINE
PLAN_NI G BOARD
TOW9 LANNER
CONSERVATION COMMISSION
T1, 0��a
CONSERVATION ADMIN.
BOARD OFJ-JE-A�JH
HEALTH SANITAIUIN
DEPARTMENT OF PUBLIC WORKS
DRIVEWAY PERMIT
SEWER/WATER CONNECTIONS
FIRE DEPT.
.DATE APPROVED -5
DATE REJECTED
D4TE
APPROVED
��ATE
REJECIED
DATE APPROVED
DATE REJECTED
RECEIVED BY BUILDING INSPECTION
DATE
64-(C
This form shall be signed by tile agents of the Planning and Health Boards,
the Conservation Commission prior to tile issuance of any building permits
for the subject lot. This form shall not releive the applicant from tile
compliance of any applicable Town requirement or Bylaw.
Fit
SEP 0 8 2008
OF, AN-:
5xvsm ownor
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oy)(orn: n(- Tar-�
EMuant ToQ Fllte(
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4 1 PIPY 100 Jh1i
I I '(J�QMORTWAND
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7� _7�
Massachusetts Department of Public Health
State Laboratory Institute
Rabies Laboratory, Sandra Smole, PhD. Laboratory Director
305 South Street, Jamaica Plain, MA 02130 (617)983-6385
Accession Number: RAII-1406
ATTN: Mark Hedlund
624 Pine St
BRIDGEWATER MA 02325
508-468-1000
Testing Date: 8/3/2011
Report Date: 8/04/2011
Rabies Testing Method: DFA
Rabies Testing Result: Negative
Exposure Informatiow---.---,-
Human Exp-16-surfe
Na e: Paul A Hodstrom
Adclrf�s: 30 Oakes Dr
�QZItANDQV
, ER -MA 01845
Telephone: 978-683-2176
Animal Species: BAT
Animal Located: NORTH ANDOVER
Animal Death Date: 8/2/2011
Bojn jbrtFyqpt vsf
Tqf djf t;
Obnf; )OPOF*
Beesftt; )OPOF*
)OPOF-
Note: If you are aware of any additional exposures or have any corrections to this report, please
contact 617-983-6385.
71,
IMPORTANT: All animals must Be euthanized prior to submission. Rabies testing is provided at no charge as a public
service; therefore, only animals that have potentially exposed a human or domestic animal to rabies should be submittedfor
testing. For most specimens, the head must be removed from the body and the entire head should be submitted. Bats
should be submitted whole, without removing the head. For large animals or those undergoing other diagnostic procedures,
submission of the cerebellum and a complete cross-section of the brainstern is permissible. Failure to submit a complete
sample will usually result in an inconclusive test result. The submitter is responsible for contacting any individual
who needs to be made aware of the rabies test results. For rabies positive animals, anyone listed on the submission
form as being exposed will also be contacted by the Division of Epidemiology and Immunization.
SS -RA -2-09
RA11-1406
Specimen Request Form for Rabies Tes, ing AUG [Lab use Rec'd:
William A. Hinton State Laboratory Institub
305. South Street TOWN OF NORTH A�D eceived
Jamaica Plain, MA 02130 - 3597
Lr:ALTH DF
PLEASE PRINT Tel. 617-983-6385 .*�
z. OWNER INFORMATION (or person who found animal)
1. PROVIDER/SENDER INFORMATION —
I
I ni
Nam Name- Lut First
No(,
zzzv,/-C�
A e s: /Street/Apt.# Ad -- - X
P /'/1 � V-6 1 7'
ity 0 te Zip code
rTZf W V6 -;ea
Jpt
C��6
6
Phone number: &I C/ Phone number: '7
669 - lfl�
3. SPECIMEN INFORMATION a Pet u Stray C3. Wild C3 Unknown
Cause of Q Natural
death: uthanized
Species Age I i Method
—Location Symptoms: Found dead Ll Seizures Reason Tor rabies testing:
where
animal was located: 0 Aggression C3 Lethargy cl Unexplained C3 Human exposure
wound 1 El Pet exposure
C3 Ataxia L3 Paralysis I El Acting sick
Othe
StreeVj1.1A1j),jV&C11,.' Disorientation u Salivation 0 r
Town 10/��
Travel out of state: Bitten by another animal in past 12 Vaccination history: date
E3 Rabies vaccinated
mon
C3 Yes ths:
Date_� C3 Yes (type of animal I 1 0 Not rabies vaccinated (not
(Location
El No Q No current)
Lnknown
jjK Unknown unknown C�zu
4. EXPOSURE INFORMATION
Exposure date Animal(s) exposed: Exposure date
Person(s) exposed:
Ph
Name
Address: No./Street/Ap .#
36 dlmt 6-5 W-1 ve-,
Species Age
IT S Zip Code
Address: No./Street/Apt.# (if different from owner)
i
Phone Physician phone
Number: Number:
City/Town State Zip
Code
Type of 0 Bite Body site
Type of 0 Bite Body site
exposure: E3 Scratch
exposure: 0 Scratch
(check one) El Lick
(check one) 0 Lick
0 Other- Severity
U Other 1 Severity
Q Unknown
-F.P�Unknown
Circumstance El Capture El Specimen
of exposure: 0 Unprovoked attack _--preparation
Circumstance C3 Fight
of exposure: D Vicinity
(check one) El Provoked attack �<� Other
(check one) El Dead animal contact
Cl Handling
El Other_
—
6. FLUORESCENT RABIES ANTIBODY TEST RESULTS Reported by: Date: 611 W/ v [Lab use only]
Positive (rabid) gative (not rabid) I-] Specimen Comments:
nw--,d,8A
vh—
,,�atisfactory
Results read back by: messoe N otified by: Date: I (Lab use only]
IMPORTANT: All animals must Be euthanized prior to submission. Rabies testing is provided at no charge as a public
service; therefore, only animals that have potentially exposed a human or domestic animal to rabies should be submittedfor
testing. For most specimens, the head must be removed from the body and the entire head should be submitted. Bats
should be submitted whole, without removing the head. For large animals or those undergoing other diagnostic procedures,
submission of the cerebellum and a complete cross-section of the brainstern is permissible. Failure to submit a complete
sample will usually result in an inconclusive test result. The submitter is responsible for contacting any individual
who needs to be made aware of the rabies test results. For rabies positive animals, anyone listed on the submission
form as being exposed will also be contacted by the Division of Epidemiology and Immunization.
SS -RA -2-09