HomeMy WebLinkAboutMiscellaneous - 31 OXBOW CIRCLE 4/30/2018 (2) _ 31 OXBOW CIRCLE _
i 210/107.8-0141-0000.0
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f
Lot & Street c2/ Qx/SO co C Map/Parcel
CONSTRUCTION APPROVAL
Has plan review fee been paid: \ 'ES NO Permit#
Plan Approval: Date: l' Approved by: �(�L/�/�-�
0
Designer: M 4 Plan Date:
Conditions:
r
I
Water Supply: _own Well
lermit: Driller:
Well Tests: Chemical---- Date Approved
Bacteria I Date.Approved
Bacteria II Date Approved--__
i
Plumbing Sign-Off: Wiring Sign-Off:
Comments:
Form"U" Approval: Approval to Issue: YES NO
Date Issued By:
Conditions:
Final Approval:
All Permits Paid? YES NO
Well Construction Approval? YES NO
Septic System Construction Approval? YES NO
Certification? YES NO
Other YES NO
Any Variance Needed? NO
FINAL BOARD OF HEALTH APPROVAL:
DATE:
APPROVED BY:
• 'k
SEPTIC SYSTEM INSTALLATION
Is the installer licensed? NO
Type of Construction: NE REPAIR
New Construction: Certified Plot Plan Review AYE NO
Floor Plan Review YES NO
Conditions of Approval from Form U YES NO
Issuance of DWC permit: NO
DWC Permit Paid? S NO
DWC Permit # /pp Installer: yG,C
Begin Inspection: YES NO
Excavation Inspection:
Needed:
Passed: By:
Construction Inspection:
Needed:
As BUt Plan Satisfactory:
YES: f
Approval of Backfill: Date: /A/ By:
Final Grading Approval: Date: 1 By:
Final Construction Approval: Date: By:
Certificate of Compliance: Approval: Date:
Commonwealth of Massachusetts
=_ City/Town of Noah Andover
System Pumping Record -�o, ,�W- t►iHrvUOVER
HElit:-"" •L+=:•,RTMENT
Form 4
DEP has provided this form for use by local Boards of Health. Other forms may be used, but the
k with your
information must be substantially the same as that provided here. Before using this must be submitted to
form, c
local Board of Health to determine the form they use. The System Pumping date in
the local Board of Health or other approving authority within 14 days from the pumping,
accordance with 310 CMR 15.351.
A. Facility Information
Important When
filling out forms 1. System Location:
on the computer, c.3/ d x f
use only the tab
key to move your Address 01886
cursor-do not North Andover Ma
State Zip Code
use the return City/Town
key.
2. System Owner:
Name
raum
Address(if different from location)
State Zip Code
city/Towh
Telephone Number
B. Pumping Record
--9—/9—/ 2. Quantity Pumped: Gallons
1. Date of Pumping Date
Tight Tank E] Grease Trap
3. Type of system: ❑ Cesspool(s) [�` Septic Tank ❑ Ti 9
❑ Other(describe): .\ .
4. Effluent Tee Filter present. ❑ Yes ❑
No if.yes, was it cleaned? E] Yes ❑ No
5. Condition of Systeme
6. System Pum pe y:
Vehicle License Number
Name
Stewart's Septic Service
Company
7. Location where contents were disposed:
Stewart's Pre-treatment Plant, 20 So. Mill Bradford, Ma 01835
Signature of Hauler Date
Signature of Receiving Facility Date
System Pumping Record•Page 1 c
t5form4.doc-03/05
r
Commonwealth of MassachusettsR��EIVED
City/Town of No Andover
System Pumping Record JUN 10 2013
yForm 4 TOVVN OF NORTH ANDOVER
HEALTH DEPARTMENT
DEP has provided this form for use by local Boards of Health. Other forms may be used, but the
information must be substantially the same as that provided here. Before using this form, check with your
local Board of Health to determine the form they use. The System Pumping Record must be submitted to
the local Board of Health or other approving authority within 14 days from the pumping date in
accordance with 310 CMR 15.351.
A. Facility Information
Important:When
filling out forms 1. System Location:
on the computer,
use only the tab ( ) J l C
key to move your Address
cursor-do not No andover — Ma
use the return City/Town State Zip Code
key.
2. System Owner:
Name
Bnm
Address(if different from location)
F
Citylrown State Zip Code
Telephone Number
B. Pumping Record
r �
1. Date of Pumping Date 2• Quantity Pumped: G{dons
3. Type of system: ❑ Cesspool(s) [Septic Tank ❑ Tight Tank ❑ Grease Trap
❑ Other(describe):
4. Effluent Tee Filter present? ❑ Yes No If yes, was it cleaned? ❑ Yes ❑ No
5. Conditionof System:
45)V
V-e 5D
6. Sys te d By:
-Name Vehicle License Number
Stewart's Septic Service
Company
7. Location where contents were disposed:
Ste,kkt's Pre-treatment Plant, 20 So. Mill Bradford, Ma 01835
Si natu auler Date
ignature Date
t5form4.doc•03/06 System Pumping Record•Page 1 of 1
OR'iT�I A1JD0VE. . ASSAC
R M HUSE7
Record
�'�' is .�'•�'O� '�;j'�(,1`'ti,/��w.i'/.���'!�{IYr� y;�C�;,.'.,, ,.
•t�_,,�I�tS,Yr,Y;•�, r��.fi.�1,1�����,G�i;�r'^pry,, lel' '•'i,.',�',�,,�'�r�'
" . P.hai provided shli lore; foreo �y local Bo
ba iUonlll(Od !o aha IOCeI ScarC 01 i3Oailn or Thar i �� d� v Sys a'� P_rr
A. Facility Infor nlatIon
AUG _ 4 2008 -
.T,
WN OF NORTH ANDOVER
H DEPART ENT
UMpym
n um'Y CItY/T
�y�. 'v;; ;;'-;• ,` :';,`� .�),j..,:,:`'� '': " , , sloe �"-----
2.
Owner,..
( dVferrnl rwn huU�n)
' B,':PumpIng Regord -
Pu7pin9';
;TYP.e P! ayalem; [) Casspool(s) e
Oc T
' 131I Tangy
—J/-7
Ef>9uenl Tee Fllla resent? '� Yo c r
(.P yes
''.Ntr' ..g,r�'i.C.0(1d1�0r1'P�;BY�f rTl;',•. ., , .
5 L/
P
;( .\r` '� s'�i�^;1''�'y,�r•,'�" � I�f� 'i�;� {n .1'�J�.�fi''�L�; V9hIG9 :1 +0 N T -_-
7.
. -1>•Y,�, 4� ,k' �'��. . ��, �� ;,, � '�`• C r cen �w gar
i
LOU onvinare cQn onls'were c sposac
�;' ;,`%''a.r., „Ir,S�nil11` K1U�(;�. ,,<.r...• ,, . - C�.i
ww mass,gov/da;�walel
r/epprova)s/161orm9 rl1. ac! —
�• � dT - fir:. .
Commonwealth of Massachusetts
"City/Town of.NORTH ANDOVER MASS USETTS
System Pumping Record
w
Form 4 OCT 1 2 2006.
DEP has provided this form for use by local Boards of Health. The System Pumping Record must
be submitted to the local Board of Health or other approving authority.
(–=----— —'
A. Facility Information
Important:
When filling out 1. System Location: �D
forms on the I
computer, use
only the tab key Address
to move your
cursor-do not
use the return City/Town State Zip Code
key. 2. System Owner:
Name
31 Cox 10a,,j
Address(if different from location)
di
City/Town State Zip Code
Telephone Number
B. Pumping Record a,
1. Date of Pumping Date / �ea
mped: Gallons
3. Type of system: ❑ Cesspool(s) El Tight Tank
❑ Other(describe):
4. Effluent Tee Filter present? ❑ Yes o If yes, was it cleaned? ❑ Yes ❑ No
5. Condition of System: /)
6. Sy em Pumped By:
OlG
NameVehicle License Number
s� ru.�a�l 3f, ac d." Ana.
Company
7. Location where contents were disposed:
o . w ,�,Y. a0l ; r
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
r Br 0- HEALT
TOWN OF NORTH ANDOVER IdG. — 4 200
SYSTEM PUMPING RECORD _
I'E"I'l OWNER & ADDRESS SYSTEM LOCATION
(example: left from of hou�t)
i
I C OF PUMPINC: J`D '�� d�' QUANTITY PUMPED/ ?
. I'UUL: NO YES SE['T1C' TANK : NO YES
� A-l"URE OF SERVICE: ROUTINE EMERGENCY
Ali>r�zV �TIoNs: ,
GOOD CONDITION FULL TO COVE;t
HFAVY CREASC BAFFLLS IN I'1.ACF
ROOTS LEACHFIELD "UNIJACK ..
CXCESSIVE SOLIDS FLOODED
SOLIDS CARRYOVER Oj�HER (EXPLAJN,)
> 1 >
11M PUMPED (3Y� Y'.
FNTs
u1 11:x' 15 TIZANSFCIZIZED TO:
1 ��1, S� lam.-�.. � � ►''Z��h+- �
1
C ��'YS:�T •^ - -_- `lr '1•S..hr�`i 1�"r'--� _.4'-."Sa
„��ie1 K..".. ��•�b".M1..� _ _ __ _ .. .!f^J+�:r:s.'7`...��:i-�J,R..i - M1r<:f:
fib I: Si nafure� erson to recE
_ 9 of_Pe _
6 CUliOOME Use
...v F �
Vaccine:name._ - - -
�n+r•�-.•..�9r-r �•a � � Y :�.� (fir,,,���•�. _ _ :•. . �;. �-.
x jgInfection site Date VIM give
Z..Vaccine.manufacturer:
DEB.
RlLllk,
r Name
and-tit e of vaccine ad ministrator: $:
Clinic/office address:
NO.ANDOVER BOARD F HEALTH
27 CHARLES STREET
I VV.Ju JVVJf OUU.L.L JI EzwHr-,1/Hi Ivu VC[`. rHl7G UG
M6(4h AMT�6vf r 9111MVS SEPT.IC TANK SMMCS
47 RMLRoAD S-rREer
BRADFORD, M 01835
tam cji Lie- iGl-Q64 978-372-7471
in-C-Pn4i) Liz- A� 1,-9-n
MONM OF
MMIULY REPORT FOR TCWN OF
DATE ADDRESS
GAlWNS cm4nm
K I !�-Vc,
7-S
564412mai.
er,
'/—�3c,3'L `15Ls
V5 ZAs lea))
<
f3 e arc :V.-
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X 1,30 L., 1-f-
.. ....
+- FORM U - LOT RELEASE FORM
INSTRUCTIONS: This form is used to verify that all necessary approvals/permits from 7.
:guards and Departments having jurisdiction have been obtained. This does not relieve
the applicant and/or landowner from compliance with any applicable or requirements. -
AFFLICANT FILLS OUT THIS SELTIO�I��
APPLICANT .Ito a1�-1 ��f-e-� � PHONE ? 9 X
LOCATION: Assessors Map Number �PARCE_
SUBDIVISION t LOT (S)
STRI=ET �100"� Y
ST. NUMEER '3 _
1-
OFFICIAL USE ONLY'
RECOMMENDATIONS OF TOWN AGENTS: ,aUc xSG Int e.•�-E- }>(/l�(R�o N'1 /
CONSERVATION ADMINISTRATOR DATE APPROVED
f
DATE REJECTED
COMMENTS —
TOWN PLANNER DATE APPROVED
DATE REJECTED
COMMENTS
FOOD INS CTOR-HEALTH DATE APPROVED
DATE REJECTED
h
. TIC E OR-HEALTH DATE APPROVED
,/ DATE REJECTED
COMMENTS �4 --o C—
PUELIC WORKS -SEWER/WATER CONNECTIONS
DRIVEWAY PERMIT
09
FIRE DEPARTMENT
•�
RECEIVED EY EUILDING a ISPECTOR DATE
Revised 9197 im
UUP 63, ' , Die-
GLOSt;r
-SLIDINCs
1 STAY / S►N V-
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CLOSET of
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LC
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Town of North Andover, Massachusetts
BOARD OF HEALTH
Date: July 23, 1998
CERTIFICATE OF COMPLIANCE
This is to certify that
the Individual Soil Absorption Sewage Disposal System constructed (x ) or repaired ( )
by, Charles Zaher, Installer, at Lot 21 Oxbow Circle, North Andover, MA 01845
has been installed in accordance with Board of Health Regulations as described in the
Design Approval Site System Permit # 969 dated April 28, 1998.
The issuance of this certificate shall not be construed as a guarantee that the system will
function satisfactory.
oard of Health
S S/cjp
Revised: 7/20/98
TOWN OF NORTH ANDOVER
SEWAGE DISPOSAL SYSTEM
INSTALLATION CERTIFICATION
The undersigned hereby certifytthonstructed; ( )repaired;
bylocatedat Lo-T
was installed in conformance with the.North Andover Board of Health approved plan, System
Design Per= # dated �g 1.0 with an approved design flow of
gallons per day. The materialsused were ig conformance with those specified on the approved
plan;the system was installed in-accordance with the provisions of 310 CMR 15.000,Title 5 and
local regulations, and the final grading-agrees substantially with the approved plan. All work is
accurately represented on the As-built which has been submitted to the Board of Health.
Installer: LLic.#: Date: 6 3
Design Engineer: pt-:� 44Z7-?l Date—73t,94 a
T
SEPTIC PLAN SUBMITTALS
LOCATION: ,� 1 ✓� �U �� 1'c/o..
NEW PLANS: YES v $60.00/Plan t/
REVISED PLANS: YES $25.00/Plan
DATE: �Y7
DESIGN ENGINEER: 2 a A 9C a Pied S
When the submission is all in place, route to the Health Secretary
FORM 11 - SOIL EVALUATOR FORM
Page I
No. ....................................
Datee,
Commonwealth of Massachusetts
Mov—VvA AwWEZ, Massachusetts
Soil Suitability- Assessment —
for On-site Sewage Disposal
Performed By: ....W..I.Llt-A-M ......................... ..Of4 .-1.7
Witnessed ..........
...................................................................................................................................................................................................................................................................
Location Address or A.C. BUUDEPZ!�- lrl�JC--
Lot# Address.and '33 WALVeR- QOAD
-r *7.1 0 X.60,.j e',ac j'a Telephone
J-6 WozrH kiiDovore, HA.
DI SNS
kOobLA WD 15-'5-rA1M;S - I
New Construction Repair ❑
Office Review
Published Soil Survey Available: No ❑ Yes
f............... Soil Ma it v6a,
Year Published 1.0LO.)... Publication Scale
Drainage Class ..5........ Soil Limitations ......5f�0;-F. ............................................................................. ...
Surficial Geologic Report Available: No El Yes El
Year Published ........... Publication Scale ..................
GeologicMaterial (Map Unit) .........................................................................................................................................
Landform ................. .............................................................................................................................................................................................
Flood Insurance Rate Map: +1 Z-,&7-D0,jf3 00 to B 01
Above 500 year flood boundary No F1 Yes
Within 500 year flood boundary No Yes ❑
Within 100 year flood boundary No IVl Yes ❑
Wetland Area:
National Wetland Inventory Map (map unit) ..............Ow.....!;.LT-f .......
Wetlands Conservancy Program Map (map unit)................. ............................................................................
Current Water Resource Conditions (USGS): Month Sv4e`/
Range Above Normal ❑ Normal � Below Normal El
Other References Reviewed: - V s U.S MAPS
� ~ FORM It - SOIL EVALUATOR FORM
/
Page 2
On-site Review
Deep Hole Number ..!.^.Z-' Dete:..&.-Z.4i-ql Tinme:'R..t.l. VVeother -�P I
Location (identify mnsite plan) A--Al A�.........................................................................................................................................
Land Use ..... Slope 1.0-- Surface Stones -.��A�*/
Vegetation -.��������----------------------------------------------------______---------.
��&
Landformn --."=^��,^ ................................................................................_.............................................................................................................................
�g�� �6a���
Pomibmnunlandscape (sketch mnthe back) ------.-.�~~~......................................................................................................................
Distances from:
Open Water Body - fao1 Drainage vxoy-.-Z.5�.t. feet
Possible Wet Area '(PP.:T. feet Property Line -10 17.. feet
Drinking VVa1ur Well feet Other -................................
DEE :' OBSERVATION HOLE LOG
Depth from Surface Soil Horizon Soil Texture Soil Color Soil Mottling Other
(inches) (USDA) (Munsell) (Structure, Stones,Boulders,
Consistency, %Gravel)
A 104a 11Z
10 N' 1 E3 '
�
34 46" C RAV
v4s v.
.'
�
�
�
'
Panan1h8atmria| (geadoQic) - ,.L .................................................... Depth toBedrock: -'.-_-
Depth to Groundwater: Standing Water in the Hole: '. ......... Weeping from Pit Face: 00160
^
Estimated Seasonal High Ground VVatan S.7.1-244^
FORM 11 - SOB, EVALUATOR FORM
Page 3
Determination for Seasonal High Water Table
Method Used:
❑ Depth observed standing in observation hole.......7inches
❑ Depth weeping from side of observation hole inches
9? Depth to soil mottles 51J inches
❑ Ground water adjustment ................... feet
Index Well Number ...... Reading Date ................... Index well level ...................
Adjustment factor ........"�... Adjusted ground water level ........................ ............................
Depth of Naturally Occurring Pervious Material
Does at least four feet of naturally occurring pervious material exist in all areas
observed throughout the area proposed for the soil absorption system?
i
If not, what is the depth of naturally occurring pervious material?
Certification
I certify that on 7(p (date) I have passed the examination approved by the
Department of Environmental Protection and that the above analysis was
performed by me consistent with the required training, expertise and experience
described in 310 CMR 15.017.
Signature Date g��7-
FORAZ 12 - PERCOLATION TEST
COMMONWEALTH OF MASSACHUSETTS
WOM &►shout=IZ , Massachusetts
Percolation Test
Date: .:7..-....1.-... 7... Time: .......?-fl.................
Observation Hole #
P ZR
Depth of PercSy +161, �-t Z i
7 5�. z1[3"
Start Pre-soak
• Z
End Pre-soak
Time at 12"
Time at 9"
Time at 6"
Time (9"-6")
S� P� i1,I L3 MtQ
Rate Min./Inch
Site Passed 0Site Failed ❑
P -c�
Performed By: br-S 60r)( A...i
Witnessed By: �L) SAW rd P-D
Comments:
..............P-.�...... .......... .........Ce.....z,�.-..`l.1....................._.__......................
put' 6?4,,Lzw4T0Z•,
/g PLAN REVIEW CHECKLIST
ADDRESS �Z/ C/XC� ENGINEER
GENERAL
3 COPIES/ STAMP C--- LOCUS L" NORTH ARROW SCALE
CONTOURS PROFILE L----(Sc) SECTION L-- BENCHMARKSOIL &
PERCS EELEVATIONS WETS . DISCLAIMER v WELLS '& WETS
WATERSHED?,d& DRIVEWAY � WATER LINE 41""' FDN DRAINy M&P
SCH40 L/' TESTS CURRENT? SOIL EVAL /GL ZJUf.eES.U�
SEPTIC TANK
MIN 150OG . 17 INVERT DROP `/ GARB. GRINDERcomps +200 )
10 ' TO FDN L/ MANHOLE ELEV 1--' GW L---'�/## COMPS . GB
D-BOX
SIZE
# LINES FIRST 2 ' LEVEL STATEMENT
INLET FS� - OUTLET /JfC-a = '/7 ( 2" OR . 17 FT) TEE REQ ' D? A
LEACHING /
MIN 440 GPD? RESERVE AREAy 4 ' FROM PRIMARY? 4-"'- 2o SLOPE L/
100 ' TO WETLANDS 100 ' TO WELLS 4 ' TO S .H.GW 'C"*'�(5 ' >2M/IN)
20 ' TO FND & INTRCPTR DRAINS C/' 400 ' TO SURFACE H2O SUPP
4 ' PERM. SOIL BELOW FACILITY L� MIN 12" COVER L--- "FILL? ( 15 ' )
BREAKOUT MET?
TRENCHES
MIN 440 gpd SLOPE (min . 005 or 6"/1001 ) y SIDEWALL DIST . 3X EFF.
W OR D (MIN 6 ' ) L---- RESERVE BETWEEN TRENCHES? L----- IN FILL? L---� MUST
BE 10MIN. 4" PEA STONEDIC VENT? ( >3 ' COVER; LINES >50 ' )
BOT a� 86 + SIDE 04 - X LDN ?TOT
( L x W x #) (DxLx2x#) (G/ft2 )
Copyright @ 1996 by S.L. Starr
Town of North Andover f „ORTH ,
OFFICE OF 3�0�'teD °�a4,
COMMUNITY DEVELOPMENT AND SERVICES °
30 School Street ` 9
North Andover,Massachusetts 01845 '' '°q, •o °"` 5
WILLIAM J. SCOTT 9SSAcMUs�t
Director
October 7, 1997
Aurele Cormier
AC Buiilders
33 Walker Road
North Andover, MA 01845
RE: Woodland Estates
Dear Aurele:
This letter is to inform you that the proposed septic plans for Lots 21 and
26 Oxbow Circle have been approved. However, before the Board of Health can
sign off on the Form U for Lot 26 Oxbow Circle, evidence of the recording of the
proposed lot line change must be filed with the department.
If you have any questions, please do not hesitate to call the Board of
Health office at the number below.
Sincerely,
Sandra Sta , R.S.
Health Administrator
cc: Wm. Scott, Dir. CD&S
Merrimack Engineering
Kathleen Colwell, Town Planner
File
CONSERVATION,688-9530 . HEALTH 688,-9540 --P1 ANNING 688-9535
FORK U - IAT RELEASE FORK
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.
****************Appli
cant fills out this section*****/*Q***********
APPLICANT: A . C, ',.A G Phone
LOCATION: Assessor's Map Number Parcel
Subdivision I�a0G1 I and ES I AftS Lot(s) 02
Street Qn. St. Number
************************Official Use Only************************
RECOMMENDATIONS OF TOWN AGENTS:
Date Approved
Conservation Administrator Date Rejected
Comments
Date Approved
Town Planner Date Rejected
Comments
Date Approved
Food Inspector-Health Date Rejected
'"; Date Approved
Septic Inspector-Health Date Rejected
Comments
Public Works - sewer/water connections
- driveway permit
Fire Department
Received by Building Inspector Date
MERRIMACK ENGINEERING SERVICES, INC,
PROFESSIONAL ENGINEERS • LAND SURVEYORS • PLANNERS
66 PARK STREET • ANDOVER, MASSACHUSETTS 01810 • TEL. (508)475-3555, 373-5721 • FAX(508)475-1448
September 25, 1997
Town of North Andover
Board of Health
Town Hall
30 School Street
North Andover, MA 01845
RE: Lot 21 Oxbow Circle -Woodland Estates
A.C. Builders, Inc.
Dear Board Members:
Due to dimensional constraints and wetland locations on the subject lot, we find it necessary
to request a variance to the"Town of North Andover Minimum Requirements for the
Subsurface Disposal of Sanitary Sewage"Regulation 5.02 so that a leaching facility may be
98' from a wetland in lieu of 100' as required.
Please schedule this item for action at the next available meeting of the Board of Health and
feel free to call me if you have any questions or comments.
Very truly yours,
MERRIMACK ENGINEERING SERVICES
Les Godin
Project Manager
cd
Town of North Andover, Massachusetts Form No.3
• BOARD OF HEALTH
e2 C-11
f NORTH 1
h
•' "� `�' DISPOSAL WORKS CONSTRUCTION PERMIT
r
• �,sACNU��
• Applicant (./� C "F�
NAME ADDRESS TELEPHONE
Site Location z.
-az— -,z/ �Xf w C ee-e-6
Permission is hereby granted to Construct (L-ror Repair ( ) an Individual Soil Absorption
Sewage Disposal System as shown on the Design Approval S.S. No.
•
CHAIRWAN,BOARD OF HEALTH
Fee 4717 D.W.C. No. �G G2
APPLICATION FOR DISPOSAL WORKS CONSTRUCTION PERMIT
DATE:. t `7( CURRENT INSTALLER'S LICENSE#
LOCATION: (�� �? � oy- ow
LICENSED INSTALLER:
SIGNATURE: C � h — TELEPHONE#
CHECK ONE: r
REPAIR: NEW CONSTRUCTION:
IF NEW CONSTUCTION, PLEASE ATTACH FOUNDATION AS-BUILT.
Administrative Use Only
$75.00 Fee Attached? Yes 'V No
Foundation As-Built? Yes r / No
Floor Plans? Yes No
Approval `f Date:
.. .. t ',t'ti?Chyi�r�•+t'�.i;:ti:x_ .:� S.'n��.y;:.�.:1�• 7Gr:'�.:., :�Y^:
--�-vWT ` ti " � `i'"t`."`';• �'; i fid'
97
,
O
S X .J6
`` �,' ;.� � W;�J�.' J^,dill? iii .. �/,�?..� iib li��,... .. , . ,�• .i
J \ -0'•
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IG
y"p�[�LR;1•Y '�ra '( i.t t . - - ------'---- - , r� _ r _ ..-- - ,. ' y` '
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Town of North Andover, Massachusetts Form No.2
NOItTN BOARD OF HEALTH
O 4L
P
DESIGN APPROVAL FOR
ssA�"�Sft SOIL ABSORPTION SEWAGE DISPOSAL SYSTEM
Applicant �G ('iGl���s Test No.
Site Location SOT on/ Q7��D�y ( , /4L',1-6—
Reference Plans and Specs._- P&,ee/MA,-r--
ENGINEER DESIGN DATE
Permission is granted for an individual soil absorption sewage disposal system to be installed
in accordance with regulations of Board of Health.
CHAIRMAN,BOARD OF HEALTH
Fee ��� Site System Permit No. ��c/
El-,c&EIVIlli.
NOV - 3 2004
'rowN OF NORTH NDOVER
SYSTEM PUMPIN UCORI) TOWN OF NORTH AN[
U^ t'k /&y Zl HEALTH DEPARTMI
SYSTEM OWN F.R 8t AQQRESS
SYSTEM LOCATION
DATE OF PUMPINO:
7—
QUANTITY PU)�MPED: J/
L'LSSP(X)L: NO YES
SOPLiC Tank: NO- YES
NA rUKE OF SERVICE: ROUTINE `',v,.
EMERUEN(,).
OBSERVATIONS:
GOOD CONDITION X PULL 'TO COVER
HEAVY OREASE .—. BAFFLES IN PLACL
ROOTS ------- LEACHFIELD RUNBACK
BXCF,SSIVE SOLIDS FLOODED
SOLID CAkRYOVER,' OTHER EXPLAIN
sy"m Pwnpcd by
O�
L5L
k:UMMhNTS,
..........
"N I-hN I-S fXANSFhRRBD 11)
V,:-'`Jc.4`t,i
....,.Commonwealth of Massachusetts
City/Town of NORTH ANDOVER TI S
System Pumping Record
Form 4 �U� 7 2010
DEP has provided this form for use by loyal BoardsVAKlQF'1 4 ping Record must
be submitted to the local Board of Health or other ap TMENT
A.•Facility Information
Important:
When filling out 1, System Location:
forms the
computer,use
only the tab key Address .
to move your
curuse the.et not Clty/Town State
use the return Zip Code,
key' 2. System Owner.
brei
Name
Address(if different from location)
City/Town State Zip Code
Telephone Number
B. Pumping Record
1. Date of Pumping ' Date 2. Quantity Pumped: J
Gallons
I.,Type of system: ❑ Cesspool(s) N-haptic Tank ❑ Tight Tank
Other(describe):
4. Effluent Tee Filter present? ❑ Yes ❑ No If yes,was it cleaned? ❑ Yes ❑ No
5. Condition of System:
Oad
6. S stem Pumped By:
�Or -0.
e Vehicle License Number
Company
7, . Location where contents were disposed:
ign ure of Hauler Date
http://www.mass.gov/depAvater/approvalsASforms.htm#inspect •i='
t5form4.doa 06103 i n., System Pumping Record•Page t of t
Commonwealth of Massachusetts
W City/Town of No.Andover
System Pumping Record
Form 4
M
DEP has provided this form for use by local Boards of Health. Other forms may be used, but the
information must be substantially the same as that provided here. Before using this form, check with your
local Board of Health to determine the form they use. The System Pumping Record must be submitted to
the local Board of Health or other approving authority within 14 days from the pumping date in
accordance with 310 CMR 15.351.
A. Facility Information
Important:
When filling out 1. Sy m Location:
forms the
computer,use
only the tab key Ad ress
to move your No Andover Mia
cursor-do not City/Town State Zip Code
use the return
kkey. 2. System Owner: RECEIVED R
tQ
Name 'AN 'j
Address(if different from location) TOWN OF NORTH ANDOVER
HEALTH DEPARTMENT
City/Town State Zip Code
Telephone Number
B. Pumping Record �d
15
1. Date of Pumping `ate 2. Quantity Pumped: talions
3. Type of system: ❑ Cesspool(s) [, Septic Tank ❑ Tight Tank ❑ Grease Trap
❑ Other(describe):
4. Effluent Tee Filter present? ❑ Yes ❑ No If yes, was it cleaned? ❑ Yes ❑ No
5. Condition of System:
6. System Pump d
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
Sig to o auler Date
Si na g Facility Date
t5form4.doc•03/06 System Pumping Record•Page 1 of 1