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Home My WebLink AboutMiscellaneous - 325 BERRY STREET 4/30/2018 (2)L a It MAP # LOT #____"�^�y PARCEL _ S|REE�T '^��7 .ON_APPRO�AL HAS PLAN REVIEW FEE BEEN PAID? PLAN APPROVAL: DATE APP. BY DESIGNER: PLAN DAlE � CONDITIONS WATER SUPPL WELL PERMIT WELL TESTS: Y: TOWN ^\ DRILLER____—~-�=^��v COMMENTS CHEMICAL 8AClEHlA I BACTERIA II , � ° FORM U APPROVAL: AP __ _ _ _ _ 6ADATE ISSUEBY CONDITIONS: DAIE APPROVE DUlL U|'PRUVE DAlE APPROVED_ 0,74,72— 449iltl " FINAL APPROVAL: ALL PERMITS PAID WELL CONSTRUCTION APPROV0L SEPTIC SYSTEM CONSTRUCTION APPROVAL OTHER ANY VARIANCE NEEDED FINAL BOARD OF HEALTH APPROVAL: YES NU YES NO YES NO YES NU , YEB X �~ ^ a It MAP # LOT #____"�^�y PARCEL _ S|REE�T '^��7 .ON_APPRO�AL HAS PLAN REVIEW FEE BEEN PAID? PLAN APPROVAL: DATE APP. BY DESIGNER: PLAN DAlE � CONDITIONS WATER SUPPL WELL PERMIT WELL TESTS: Y: TOWN ^\ DRILLER____—~-�=^��v COMMENTS CHEMICAL 8AClEHlA I BACTERIA II , � ° FORM U APPROVAL: AP __ _ _ _ _ 6ADATE ISSUEBY CONDITIONS: DAIE APPROVE DUlL U|'PRUVE DAlE APPROVED_ 0,74,72— 449iltl " FINAL APPROVAL: ALL PERMITS PAID WELL CONSTRUCTION APPROV0L SEPTIC SYSTEM CONSTRUCTION APPROVAL OTHER ANY VARIANCE NEEDED FINAL BOARD OF HEALTH APPROVAL: YES NU YES NO YES NO YES NU , YEB X | �� K � NU �xmm�x DAlE: BY �v / . SEPT _5JEM _JNSTOLA IS THE INSTALLER LICENSED?NO TYPE OF CONSTRUCTION: EW REPAIR LNL NEW CONSTRUCTION: CERTIFIED PLOT PLAN REVIEW <= NO CONDITIONS OF APPROVAL —7E-9No (FROM FORM U) ISSUANCE OF DWC PERMIT YES NO DWC PERMIT NO. INSTALLER: BEGIN INSPECTION YES NO: EXCAVATION INSPECTION: NEEDED: NEEDED: AS BUILT PLAN SATISFACTORY: YES: APPROVAL TO BACKFILL: DATE:-- BY FINAL.GRADING APPROVAL: DATE BY FINAL CONSTRUCTION APPROVAL: DATE:__ BY Commonwealth of Massachusetts �W Title 5 Official Inspection For RECEIVED Subsurface Sewage Disposal System Form - Not for Voluntary Assessments SEP 12 2011 TOWN OF NORTH ANDOVER ,H 325 Berry Street CDAQT1ri 1 D raTLE�� Property Address ERk �t Sean M. Dunn Owner Owner's Name information is required for every North Andover MA 01845 08/10/2017 page. City/Town State Zip Code 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. Important: When A. General Information filling out forms on the computer, use only the tab 1. Inspector: key to move your cursor - do not Robert Herrick use the return Name of Inspector key. reb Wind River Environmental Company Name 163 Western Avenue Company Address Gloucester City/Town (978) 282-7315 Telephone Number B. Certification MA State SI 13758 License Number 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: ® Passes ❑ Conditionally Passes ❑ Fails ❑ Needs Further Evaluation by the Local Approving Authority spector's Signature 08/10/2017 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. 6116 Title 5 Official Inspection Form: Subsurface Sewage Disposal System • Page 1 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 325 Berry Street Property Address Sean M. Dunn Owner's Name North Andover City/Town B. Certification (cont.) MA 01845 08/10/2017 State Zip Code Date of Inspection Inspection Summary: Check A,B,C,D or E / always complete all of Section D A) System Passes: ® I have not found any information which indicates that any of the failure criteria described in 310 CMR 15.303 or in 310 CMR 15.304 exist. Any failure criteria not evaluated are indicated below. Comments: B) System Conditionally Passes: ❑ One or more system components as described in the "Conditional Pass" section need to be replaced or repaired. The system, upon completion of the replacement or repair, as approved by the Board of Health, will pass. Check the box for "yes", "no" or "not determined" (Y, N, ND) for the following statements. If "not determined," please explain. The septic tank is metal and over 20 years old* or the septic tank (whether metal or not) is structurally unsound, exhibits substantial infiltration or exfiltration or tank failure is imminent. System will pass inspection if the existing tank is replaced with a complying septic tank as approved by the Board of Health. * A metal septic tank will pass inspection if it is structurally sound, not leaking and if a Certificate of Compliance indicating that the tank is less than 20 years old is available. ❑ Y ❑ N ❑ ND (Explain below): t5ins.doc • rev. 6/16 Title 5 Official Inspection Form: Subsurface Sewage Disposal System • Page 2 of 17 Commonwealth of Massachusetts N v Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 325 Berry Street Property Address Sean M. Dunn Owner information is required for every page. Owner's Name North Andover MA 01845 08/10/2017 City/Town State Zip Code Date of Inspection B. Certification (cont.) ❑ Pump Chamber pumps/alarms not operational. System will pass with Board of Health approval if pumps/alarms are repaired. B) System Conditionally Passes (cont.): ❑ 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): ❑ broken pipe(s) are replaced ❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below): ❑ Y ❑ N ❑ ND (Explain below): ❑ distribution box is leveled or replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ The system required pumping more than 4 times a year due to broken or obstructed pipe(s). The system will pass inspection if (with approval of the Board of Health): ❑ broken pipe(s) are replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below): C) Further Evaluation is Required by the Board of Health: ❑ Conditions exist which require further evaluation by the Board of Health in order to determine if the system is failing to protect public health, safety or the environment. 1. System will pass unless Board of Health determines in accordance with 310 CMR 15.303(1)(b) that the system is not functioning in a manner which will protect public health, safety and the environment: ❑ Cesspool or privy is within 50 feet of a surface water ❑ Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh t5ins.doc • rev. 6116 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 ,,1 y 325 Berry Street Property Address Sean M. Dunn Owner information is required for every page. Owner's Name North Andover MA 01845 08/10/2017 CitylTown 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: ❑ 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. ❑ The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water supply. ❑ The system has a septic tank and SAS and the SAS is within 50 feet of a private water supply well. ❑ 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 ❑ ® Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool ❑ ® Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool ❑ ® Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool ❑ ® Liquid depth in cesspool is less than 6" below invert or available volume is less than % day flow t5ins.doc • rev. 6/16 Title 5 Official Inspection Form: Subsurface Sewage Disposal System • Page 4 of 17 Commonwealth of Massachusetts v Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 325 Berry Street Property Address Sean M. Dunn Owner Owner's Name Information is North Andover MA 01845 08/10/2017 required for every page. City/Town State Zip Code Date of Inspection B. Certification (cont.) Yes No ❑ ® Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number of times pumped: El® Any portion of the SAS, cesspool or privy is below high ground water elevation. El® Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. [I® Any portion of a cesspool or privy is within a Zone 1 of a public well. E]® Any portion of a cesspool or privy is within 50 feet of a private water supply well. El® 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.] ❑ ® The system is a cesspool serving a facility with a design flow of 2000gpd- 10,000gpd. ❑ ® 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 ❑ ❑ the system is within 400 feet of a surface drinking water supply ❑ ❑ the system is within 200 feet of a tributary to a surface drinking water supply ❑ ❑ the system is located in a nitrogen sensitive area (Interim Wellhead Protection Area — IWPA) or a mapped Zone II 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. t5ins.doc • rev. 6/16 Title 5 Official Inspection Form: Subsurface Sewage Disposal System • Page 5 of 17 Commonwealth of Massachusetts �W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments °M 325 Berry Street Property Address Sean M. Dunn Owner Owner's Name information is required for every North Andover page. City/Town C. Checklist MA 01845 State Zip Code 08/10/2017 Date of Inspection Check if the following have been done. You must indicate "yes" or "no" as to each of the following: Yes No ® ❑ Pumping information was provided by the owner, occupant, or Board of Health ❑ ® Were any of the system components pumped out in the previous two weeks? ® ❑ Has the system received normal flows in the previous two week period? ❑ ® Have large volumes of water been introduced to the system recently or as part of this inspection? ® ❑ Were as built plans of the system obtained and examined? (if they were not available note as N/A) ® ❑ Was the facility or dwelling inspected for signs of sewage back up? ® ❑ Was the site inspected for signs of break out? ® ❑ Were all system components, excluding the SAS, located on site? ® ❑ Were the septic tank manholes uncovered, opened, and the interior of the tank inspected for the condition of the baffles or tees, material of construction, dimensions, depth of liquid, depth of sludge and depth of scum? ® ❑ Was the facility owner (and occupants if different from owner) provided with information on the proper maintenance of subsurface sewage disposal systems? The size and location of the Soil Absorption System (SAS) on the site has been determined based on: ® ❑ Existing information. For example, a plan at the Board of Health. ❑ ® Determined in the field (if any of the failure criteria related to Part C is at issue approximation of distance is unacceptable) [310 CMR 15.302(5)] D. System Information Residential Flow Conditions: Number of bedrooms (design): 4 Number of bedrooms (actual): 3 DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x # of bedrooms): 600 gpd t5ins.doc • rev. 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 �M 325 Berry Street Property Address Sean M. Dunn Owner Owner's Name information is required for every North Andover MA 01845 page. City/Town State Zip Code D. System Information Description: 08/10/2017 Date of Inspection This system is made up of a gallon septic tank, distribution box and soil absorption system. Sump pump? Last date of occupancy: 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: ❑ Yes ® No Occupied Date Gallons per day (gpd) ❑ Yes ❑ No ❑ Yes ❑ No ❑ Yes ❑ No t5ins.doc • rev. 6/16 Title 5 Official Inspection Form: Subsurface Sewage Disposal System • Page 7 of 17 Number of current residents: 4 Does residence have a garbage grinder? ❑ Yes ® No Is laundry on a separate sewage system? (Include laundry system inspection information in this report.) ❑ Yes ® No Laundry system inspected? ❑ Yes ® No Seasonal use? ❑ Yes ® No Water meter readings, if available last 2 ears usage d 9 ( Y 9 (gP ))� Well Water Detail: Sump pump? Last date of occupancy: 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: ❑ Yes ® No Occupied Date Gallons per day (gpd) ❑ Yes ❑ No ❑ Yes ❑ No ❑ Yes ❑ 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 325 Berry Street D. System Information (cont.) Last date of occupancy/use: Other (describe below): Pumping Records: Source of information: MA 01845 08/10/2017 State Zip Code Date of Inspection Date General Information Was system pumped as part of the inspection? If yes, volume pumped: How was quantity pumped determined? Reason for pumping: Wind River Environmental / Home Owner gallons Type of System: ® Septic tank, distribution box, soil absorption system ❑ Single cesspool ❑ Overflow cesspool ❑ Privy ❑ Yes ® No ❑ Shared system (yes or no) (if yes, attach previous inspection records, if any) ❑ Innovative/Alternative technology. Attach a copy of the current operation and maintenance contract (to be obtained from system owner) and a copy of latest inspection of the I/A system by system operator under contract ❑ Tight tank. Attach a copy of the DEP approval. ❑ Other (describe): t5ins.doc - rev. 6/16 Title 5 Official Inspection Form: Subsurface Sewage Disposal System - Page 8 of 17 Property Address Sean M. Dunn Owner Owner's Name information is required for every North Andover page. City/Town D. System Information (cont.) Last date of occupancy/use: Other (describe below): Pumping Records: Source of information: MA 01845 08/10/2017 State Zip Code Date of Inspection Date General Information Was system pumped as part of the inspection? If yes, volume pumped: How was quantity pumped determined? Reason for pumping: Wind River Environmental / Home Owner gallons Type of System: ® Septic tank, distribution box, soil absorption system ❑ Single cesspool ❑ Overflow cesspool ❑ Privy ❑ Yes ® No ❑ Shared system (yes or no) (if yes, attach previous inspection records, if any) ❑ Innovative/Alternative technology. Attach a copy of the current operation and maintenance contract (to be obtained from system owner) and a copy of latest inspection of the I/A system by system operator under contract ❑ Tight tank. Attach a copy of the DEP approval. ❑ Other (describe): t5ins.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 GSM 325 Berry Street Property Address Sean M. Dunn Owner Owner's Name information is North Andover required for every page. CityrTown D. System Information (cont.) MA 01845 08/10/2017 State Zip Code Date of Inspection Approximate age of all components, date installed (if known) and source of information: 1990: Plans on File Were sewage odors detected when arriving at the site? Building Sewer (locate on site plan): Depth below grade: Material of construction: ❑ cast iron ® 40 PVC ❑ other (explain): 30' feet ❑ Yes ® No Distance from private water supply well or suction line: 1004 feet Comments (on condition of joints, venting, evidence of leakage, etc.): All joints are solid. There are no signs of leakage and venting is through the building's sewer. Septic Tank (locate on site plan): Depth below grade: Material of construction: ® concrete ❑ metal 24" feet ❑ fiberglass ❑ polyethylene ❑ other (explain) If tank is metal, list age: years Is age confirmed by a Certificate of Compliance? (attach a copy of certificate) ❑ Yes ❑ No Dimensions: 1010" x 68" x 68" Sludge depth: 4" t5ins.doc • rev. 6116 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 325 Berry Street Property Address Sean M. Dunn Owner Owner's Name information is North Andover required for every page. City/Town D. System Information (cont.) Septic Tank (cont.) State 01845 Zip Code Distance from top of sludge to bottom of outlet tee or baffle Scum thickness Distance from top of scum to top of outlet tee or baffle Distance from bottom of scum to bottom of outlet tee or baffle 35" 1'1 6" 14" 08/10/2017 Date of Inspection 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 baffles 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: ❑ concrete ❑ metal Dimensions: Scum thickness feet ❑ fiberglass ❑ polyethylene ❑ other (explain): Distance from top of scum to top of outlet tee or baffle Distance from bottom of scum to bottom of outlet tee or baffle Date of last pumping: t5ins.doc • rev. 6116 Date Title 5 Official Inspection Form: Subsurface Sewage Disposal System • Page 10 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 325 Berry Street Property Address Sean M. Dunn Owner Owner's Name information is required for every North Andover page. City/Town State 01845 08/10/2017 Zip Code Date of Inspection D. System Information (cont.) Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): Tight or Holding Tank (tank must be pumped at time of inspection) (locate on site plan). Depth below grade: Material of construction: ❑ concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other (explain): Dimensions: Capacity: gallons Design Flow: gallons per day Alarm present: ❑ Yes ❑ No Alarm level: Alarm in working order: ❑ Yes ❑ No Date of last pumping: Date Comments (condition of alarm and float switches, etc.): * Attach copy of current pumping contract (required). Is copy attached? ❑ Yes ❑ No t5ins.doc • rev. 6/16 Title 5 Official Inspection Form: Subsurface Sewage Disposal System • Page 11 of 17 Commonwealth of Massachusetts w Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments '.,, 1.,325 Berry Street Property Address Sean M. Dunn Owner Owner's Name information is required for every North Andover page. City/Town State Zip Code D. System Information (cont.) Distribution Box (if present must be opened) (locate on site plan): Depth of liquid level above outlet invert 0 08/10/2017 Date of Inspection Comments (note if box is level and distribution to outlets equal, any evidence of solids carryover, any evidence of leakage into or out of box, etc.): The distribution box is solid. There are no signs of carryover or leakage in or out of the box and the liquid level is OK in relation to the inverts Pump Chamber (locate on site plan) Pumps in working order: ❑ Yes ❑ No* Alarms in working order: ❑ 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 Commonwealth of Massachusetts Title 5 Official Insp Subsurface Sewage Disposal System Fo °M 325 Berry Street D. System Information (cont.) ection Form ® leaching pits rm - Not for Voluntary Assessments ❑ leaching chambers number: ❑ leaching galleries number: ❑ leaching trenches Property Address ❑ leaching fields number, dimensions: ❑ overflow cesspool Sean M. Dunn ❑ innovative/alternative system Owner Owner's Name Comments (note condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of vegetation, etc.): information is required for every North Andover MA 01845 08/10/2017 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Type: ® leaching pits 3 number: ❑ leaching chambers number: ❑ leaching galleries number: ❑ leaching trenches number, length: ❑ leaching fields number, dimensions: ❑ overflow cesspool number: ❑ innovative/alternative system Type/name of technology: Comments (note condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of vegetation, etc.): The soil is dry and there are no signs of hydraulic failure or ponding. 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 ❑ Yes ❑ No 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 °M& 325 Berry Street Property Address Sean M. Dunn Owner Owner's Name information is required for every North Andover page. City/Town D. System Information (cont.) nen 01845 Zip Code 08/10/2017 Date of Inspection 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. 6116 Title 5 Official Inspection Form: Subsurface Sewage Disposal System - Page 14 of 17 Commonwealth of Massachusetts i Title 5 Official Inspection Form l Subsurface Sewage Disposal System Form - Not for Voluntary Assessments I 325 Berry Street _ Property Address Sean M. Dunn Owner Owner's Name information is required for every North Andover MA 01845 08/10/2017 -. — -- - 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: ® hand -sketch in the area below ❑ drawing attached separately &C 3331 s r A— Oa'`7n $-c 38`s' B -A 88'�K D p�fs �v owd/ 15ins doc • rev. 6/16 Title 5 Official Inspection Form: Subsurface Sewage Disposal System • Page 15 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments M 325 Berry Street Property Address Sean M. Dunn Owner Owner's Name information is required for every North Andover MA 01845 page. CitylTown State Zip Code D. System Information (cont.) Site Exam: ® Check Slope ® Surface water ® Check cellar ® Shallow wells 94.57 08/10/2017 Date of Inspection Estimated depth to high ground water. feet Please indicate all methods used to determine the high ground water elevation: // ■❑ Obtained from system design plans on record 1990 If checked, date of design plan revlewe . 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: Obtained the estimated ground water using the 1990 design plan on record with the Board of Health. The bottom of the leach chamber is at an elevation of 98.57 giving 4' of seperation between the ground water. 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 v Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments M 325 Berry Street Property Address Sean M. Dunn Owner Owner's Name information is required for every North Andover page. City/Town MA 01845 08/10/2017 State Zip Code Date of Inspection E. Report Completeness Checklist ® Inspection Summary: A, B, C, D, or E checked ® Inspection Summary D (System Failure Criteria Applicable to All Systems) completed ® System Information — Estimated depth to high groundwater ® Sketch of Sewage Disposal System either drawn on page 15 or attached in separate file t5ins doc - rev. 6/16 Title 5 Official Inspection Form: Subsurface Sewage Disposal System - Page 17 of 17 Of NORTH ,� e •I Town of North Andover HEALTH DEPARTMENT s.�cwust CHECK #: 0 T6DATE: LOCATION: S54 H/O NAME:--,. CONTRACTOR NAME: G �; Type of Permit or License: (Check box) ❑ Animal $ ❑ Body Art Establishment $ ❑ Body Art Practitioner $ ❑ Dumpster $ ❑ Food Service - Type: $ ❑ Funeral Directors $ ❑ Massage Establishment $ ❑ Massage Practice $ ❑ Offal (Septic) Hauler $ ❑ Recreational Camp $ ❑ Sun tanning $ ❑ Swimming Pool $ ❑ Tobacco $ ❑ Trash/Solid Waste Hauler $ ❑ Well Construction $ SEPTIC Systems ❑ Septic - Soil Testing $ ❑ Septic - Design Approval $ ❑ Septic Disposal Works Construction (DWC) $ ❑ Septic Disposal Works Installers (DWI) $ ❑ Title 5 Inspector $ Title 5 Report 0.,5 5 $50- 0 50— ❑ Other: (Indicate) $ Hea ent Initials White - Applicant Yellow - Health Pink - Treasurer L 2t. 22, 31. 91' MORTGAGE INSPECTION PLAN 3-A BERRY STREET No. ANDOVER , MASS, SCALE: I"= 100 ` OCTOBER 16 , 1991 WILLIAM G. TROY REGISTERED LAND SURVEYOR 12 EUCLID ROAD-TEWKSBURY, MASS. I HEREBY CERTIFY TO THE TITLE INSUROR AND TO THE BANK THAT f T"HE DWELLING IS LOCATED ON THE LOT AS SHOWN AND THAT IT DOES CONFORM WITH THE TOWN OF NO. ANDOVER ZONING REGULATIONS REGARDING SETBACKS FROM STREETS AND LOT LINES. I FURTHER CERTIFY THAT THIS DWELLING IS NOT LOCATED fN 'THE FEDERAL FLOOD HAZARD AREA AS SHOWN Obi MAP DATED JUN. S tggg REGISTERED LANG SURVEYOR _. THIS PLAN FOR MORTGAGE PURPOSES -NOT FOR BOUNDARY DETERbiNATioN_ BOUNDARY INFORMATION TAKEN FROM: M.N.R.O. PLAN 13892. :AND 40OVE Rl, MASS. k .BulullSANITARY DISPOSAL SYSTEM it- STREET :, RIDING -REALTY TRUST FAIAILy GATE SAVINGS BANK $9PTEWR 25090-1 TW- 'Ac; BLAt T'GONDI -'!WS 'F �j. SySrEM -INSTALLED ON rHE, ,VAS DONE IN SUBMNTLAL .)ESIGN PLAN$, Az NiTHiN THrr (,ONSTRULIP—W FOR A JOB OF THIS TYPE 15S0(,lATFS INL: TORS -i' 'AND USE P! - ANNERS IOAD U S R0 USETTS LOT 6 A LOT I A WT 3 A. -3 x4.31-4,792 W:zt, un op ol 4�cE. r- TAW TAW,< A DelleChiaie, Pamela From: DelleChiaie, Pamela Sent: Thursday, September 06, 2007 2:33 PM To: 'dfarrell@ushome om' Cc: Sawyer, S , Grant, Michele Subject: Form U's 325 Berry Street & 16 Duncan Drive - Request for As-Builts re Importance: High Dan Farrell US Home Systems Phone: 617.785.8744 Fax: 775.458.9667 Dear Dan, building of decks Probably the easiest way is to print them, draw in the deck on the As Built, scan, and send back. Or, if you can, fax to the below number. Otherwise, you will need to come in and draw them directly on the As-Builts. goW Rog vdk, PwyyaBw D¢0.40671W O Health Department Assistant Town of North Andover 1600 Osgood Street Building 20, Suite 2-36 North Andover, MA 01845 9978.688.9540 - Phone A 978.688.8476 - Fax http://www.townofnorthandover.com healthdept@townofnorthandover.com Message from Message from KMBT_600 KMBT_600 Dan Farrell US Home Systems Phone: 617.785.8744 Fax: 775.458.9667 Dear Dan, building of decks Probably the easiest way is to print them, draw in the deck on the As Built, scan, and send back. Or, if you can, fax to the below number. Otherwise, you will need to come in and draw them directly on the As-Builts. goW Rog vdk, PwyyaBw D¢0.40671W O Health Department Assistant Town of North Andover 1600 Osgood Street Building 20, Suite 2-36 North Andover, MA 01845 9978.688.9540 - Phone A 978.688.8476 - Fax http://www.townofnorthandover.com healthdept@townofnorthandover.com Permit N0: Date Issued: BUILDING PERMIT TOWN OF NORTH ANDOVER APPLICATION FOR PLAN EXAMINATION Date Received � % ,10RTN O tt�eo '6'q • 0 it Ar �SSACHUs�t IMPORTANT: Applicant must complete all items on this page LOCATION Szs 6crry % I Print PROPERTY OWNER z) V Ly= Print - - MAP NO; PARCEL; ZONING DISTRICT. Historic District yes no -- lMachine Shop Village yes no TYPE OF IMPROVEMENT PROPOSED USE Residential Non- Residential New Building%Mre i ion family Industrial eration No. of units: Commercial Repair, replacement Assessory Bldg Others: Dem_o.lition Other e ell Floodplain Wetlands Watershed District' ater/Se . . DESCRIPTION OF WORK TO BEP EFORMED: 1 �1 i ? 7--1, c� in 1). f) -&l l-. 1`14 Identification Please Type or Print Clearly) OWNER: Name: )Av L f5UV_L^eC_ es Phon. �j''�' "'� 2 4 Address: � 26 tSe CONTRACTOR -1'LPhone: SCe6_3 63 Address -1 2.5- re-LY9 n5 c s�`�3c d vh c)./Sof Supervisor's Construction License: Exp. Date: a% 'Home Improvement Licenses Exp. Date: 2-- U d ARCHITECT/ENGINEER Phone: Address: Reg. No. FEE SCHEDULE: BULDING PERMIT: $12.00 PER $1000.00 OF THE TOTAL ESTIMATED COST BASED ON $125.00 PER S.F. Total Project Cost: $ -�5 O FEE: $ Check No.: Receipt No.: NOTE: Persons contracting with unregistered contractors do not have access to the guaranty fund Signature of AgentlI wne ! Lir gna#ure of_contrac# r. U) C: ca .l W Q l Q Q W O 3 U 0 0 Z Z Z W O W Q l Q Q U) o z ca w O co CD c O N Important: when filling out forms on the computer, use only the tab key to move your cursor - do not use the return key. Commonwealth of Massachusetts City/Town ofMW .! 4 2013 System Pumping Record NORTH AND DV,111E RTHANDOVER HEALTH DEPARTMENT 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. A. Facility Information 1. System Location: a- e- r(',! - r, - `' Address 44 de, _ .. Zip Code City own State 2. System Owner: Name Address (if different from tocati City/Town —_--- --_ State Zip Code Telepho�Vmber B. Pumping Record 2 , ... 1. Date of Pumping "Vb- --- ---- 2. Quantity Pumped: Gallons Date 3. Type of system: ❑ Cesspool(s) kseptic,Tank ❑ Tight Tank ❑ Grease Trap ❑ Other (describe): - - - --- 4. Effluent Tee Filter present? ❑ Yes If yes, was it cleaned? ❑ Yes \ 5. Condition of System: 6. System Pumped By: / Name ,r^�� VWhcfb License Number Company ��♦♦ 7. Location where contents were disposed: 1Pwkbq MA. Si re f Haute i nature of Receiving Facility Date Date 15form4.doc• 03/06 System Pumping Record - Page t of t <2�, Commonwealth of Massachusetts Cjty/ Town of System pumping Record NORTH ANDOVER _ A ,UL U3 2014 TOWN OF NORTH ANDOVER HEALTH DEPARTMENT --� - :; Farm local Boards of Health. Other forms may be used, but the DEP has provided this form for use by here. Before in Record must be submitted to information must be substantially the same as that provided stem pumping using this form. check with your local Board of Health to determine the foo; they sty within 14 days from the pumping date to the local Board of Health or other approving accordance with 310 CMR 15.351. A• f=acility Information importar°: 1 System Location: When f!tiinc out y _ forms on the -- computei, use - only the tab key Address - ��/ to move your �i� �cv �i State Zip Code cursor - do not cityT wn _. ----- use the return key. Z. System Owner: VCp — _ �liJ9/� .._. _ - --' - _.. _. _. .... - --- •--... Name w Address (if different from location) — __._—_ _... —... .. Zip Code State CityfTown _ Telephone Number — mu ping Record /1 .... `.tl �._2. Quantity Pumped: GauonsDate of Pumping Dat� !!! Tight Tank ❑ 'Grease Trap ,j Type of system: C]Cesspool(s) otic Tank E]Ti 9 ❑ Other (describe): - - _ nt. ❑ Yes o if yes, was it cleaned? E] yes ❑ No a. Effluent Tee Filter prese 5. Condition of System: 5. System Pumped By o. --- -- Vehicle License Number Name � I.W.WT.p Company.......- - bo^ W* 19 & 7. Location where contents were disposed: -- Date Signature of Hauler _ Signature of Receiving Facility System Pumping Record . Page t of t ;S;crma.doc 0310c �L\ Commonwealth of Massachusetts City/Town of System Pumping Record NORTH ANDOVER 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 form, with to your 1oc21 Board of Health to determine the form they useTh System Pumping RectSrd the local Board of Health or other approving authority within 14 days from the pumpimut be subng date in accordance with 310 CMR 15.351. A. Facility information RPR '111 2012 Important: System Location: Mien filling out y TOWN OF NORTH ANDOVER forms on tits /' --HEALTH 9EPARTMEI4T• computer, use only the tab key Address to move your%� " ' Zi Code �" .... " __.. _... State cursor - do not .—e Gikyrrown use me relurn . key. 2. System owner: QName�,. -�.^......r....�. --•----..... rao Address (if differenk from SZip COde CitylTown .� _.. -� • - - tate TOL-pnone Number B. pumping Record 1. Date of Pumping eke 2, Quantity bumped: Gallons 3. Type of system: ❑ Gesspool(s)tic Tank ❑ Tight Tank Grease Trap a Other (describe)' 4, Effluent Tee Filter present? Cj Yes ❑ No if yes, was it cleaned? ❑ Yes ❑ No 5, Condition of System: 6. System Pumped By: __-....�-.....—. � / .-, �. � Vettide l,itense Number Name �. Company 7. Location where contents were disposed: Signature of Hauler Signsture of Reeeiving Facility i5rorrnCdoc• 03106 System Pumping Retard * Page t of t Commonwealth of Massachusetts City/Town of NORTH ANDOVER, MASSACHUSETTS System Pumping Record Form 4 DEP has provided this form for use by local Boards of Health. The ust be submitted to the local Board of Health or other approving autho ity.. RECEIVED A. Facility Information NOV 13 2006 Important: When filling out 1. System Location: TOWN OF NORTH ANDOVER forms on the HEALTH DEPARTMENT computer, use only the tab key Address to move your nov%,) f � � ' ( �, f (� Y\-) cursor - do not — L� r use the return City/Town State Zip Code key. 2. System ner: y� _ r)40(- Name Address (if different from location) City/Town State Zip Code Telephone Number B. Pumping Record 1. Date of Pumping 3. Type of system: ❑ to/3/ Date Cesspool(s) ❑ Other (describe): 4. Effluent Tee Filter present? ❑ Yes No 5. Condition of System: 2. Quantity Pumped: 13b d Gallons Septic Tank ❑ Tight Tank If yes, was it cleaned? ❑ Yes ❑ No 6. System P ----r+ P— Nam p Vehicle License Number Company 7. Location where contents were disposed: Signature of Hauler http://www.mass.gov/dep/waterlapprovals/t5forms.htm#inspect Date t5form4.doc• 06/03 System Pumping Record • Page 1 of 1 NAN lA/►NrNM P%C n-rnnnn Commonwealth of Massachusetts Form 4 -- System Pumping Record Massachusetts System Pumping Record REsnq wt) S sfem Owner System Location TOWN tOF NORTH ANDOVER Dunn Sean AS. Prinary Hone HEAL.TN DEPARTMENT 325 Berry Street 325 Berry Street Ibrth Andover, ASA, 01845 Uorth Andover, 19, , 01845 (978)-582-3295 x (978)-682-3295 x Dunn Sean i;. Type: Emergency Routine Cesspool: No Yes Septic Tank: No Yes Date of Pumping: .- Cs Quantity Pumped: Gallons System Pumped By: Wind River Environmental, LLC Permit #: Contents Transferred to: haverhill WWTP Contents Disposed at: 40 Porter;;435 Date: — J f C Pumper Signature: Condition of System/Other Comments 1) printed on recycled paper Dep Approved Form - 12/07/95 FORM - S STEM PUMPING RECORD CURRIER SEPTIC & DRAIN SERVICE 107 FOREST STREET; MIDDLETON, MA 01949 (978) 774-2772 CQMMONWEALTH OF MASSACHUSETTS N (`/ /�LA ,�O cJ P ✓` , MASSACHUSETTS SYSTEM PUMPING RECORD SYSTEM OWNER: JAS �cv, NA,Jove— SYSTEM LOCATI N: I e; � S� os T+ 0q DATE OF PUMPING: 121� y QUANTITY PUMPED: GALLONS CESSPOOL: NO YES F7 SEPTIC TANK: NO F7 YES SYSTEM PUMPED BY: CURRIER SEPTIC & DRAIN SERVICE CONTENTS TRANSFERRED TO: DATE: �� INSPECTOR: S1014 ti Commonwealth of Massachusetss : Massachusetts System Pumeino Record System Owner ,lee p - N AAJ ova (oS � Type: EmergencY�.F Routine Cesspool: No Yes Date of Pumping: System Pumped By. Contents transferred to: 0 Wind River Enwmnmento% LLC Contents Disposed at: 6C,S)b Location Form 4 -- System Pumping Record Septic tank: No Yes [ " Quantity Pumped: 4SoJ Gallons Permit #: i Dep AA"ved frons- 12/07/95 yevBGART3 OF s- �s I rb 10 e -t CD O h TI h z�o = rt O O n ,liftn O O O rb 10 e -t CD O h TI h FORM U TOWN OF NORTH ANDOVER LOT RELEASE FORM SUBDIVISION ASSESSORS MAP / ei" C SUBDIVISION LOT(S) 3 PERMANENT ADDRESS (ASSIGNED BY D.P.W. STREET APPLICANT ��:� rc,en2i PHONE DATE OF APPLICATION TOWN USE BELOW THIS LINE TOWN PLANNER DATE APPROVED - '// DATE REJECTED CONSERVATION COtq1ISSION DATE APPROVED CONSERVATION ADMI . /j DATE REJECTED BOARD OF HEAL DATE APPROVED HEALTI ITIrKIKN DATE REJECTED DEPARTMENT OF PUBLIC WORKS �A-) DRIVEWAY PERMIT �.b W ��/�l [ 6C(7 ) SEWER/WATER CONNECTIONS FIRE DEPJ\QP (--)Par, ou i C RECEIVED BY BUILDING INSPECTION DATE This form shall be signed by the agents of the Planning and Health Boards, the Conservation Commission prior to the issuance of any building permits for the subject lot. This form shall not releive the applicant from the compliance of any applicable Town requirement or Bylaw. I� Type: Emergency Cesspool: !Jo Date of Pumping: S ,Q System Pumped By: Contents transferred to: Contents Disposed at: Commonwealth of Massachusetss : Massachusetts System Pumping Record Routine Yes Wind River Enwromwto% LLC Date: Pumper Signature: of System/Other Comments Location Dep Approved firm► - 12/07/95 Form 4 -- System Pumping Record Septic tank: W =Yes Quantity Pumped: 15290 6anons Permit M 11 I NEW ENGLAND RADON, LTD 373 Main Street i' r S Salem, New Hampshire 03079 WATER ANALYSIS RESULTS 603-893-4260 1-800-637-2366 1 i NAME: E.M. YOUNG ART. WELL CO. DATE: 12 -Jun -91 I 36 PELHAM ROAD SALEM, NH 03070, AMPLE LOCATION: CHANNEL BUILDERS J LOT 3A - BERRY ROAD -----------------------NORTH------------------------ANDOVER,MA ---------------------------- I TEST RESULT REQUIREMENTS STANDARD I MIN. MAX UNITS 1 119.7 0 HARDNESS ............. 0.03 0 MANGANESE............ 0.005 0 HY6ROGEN SULFIDE.,--- 0 0 pH.................. TU SIDITY............ 0 0 CH ORIDES............ 35 0 NI IFRATES............. 0.2 0 1 0.02 0 N11TRITES............. PER ............... SODIUM ............... I T6TAL DISOLVED SOLIDS I I COLIFORM BACTERIA.... NUN -COLIFORM BACTERIA W TEP, MEETS ERA STANDARDS FOR SAFE DRINKING WATER. I I I i I 1 Mg/l 0.3 0.05 0 , 3 a.5 5 FTU 250 Mg/l 10 Mg/1 1 Mg/1 0.01 0 1 mg/1 21 0 250 mg/l 183 0 500 ►n9/1 0 <1 Colony/100 ml * Secondary Secondary Secondary Secondary Secondary PRIMARY Secondary PRIMARY PRIMARY Secondary Secondary Secondary PRIMARY 0 <200 CoiS./100 ml PRIMARY f Tested by: ,�T 1,131dS__3133M 'M- =;r. T6; -T Pjnr,._..�— 3y �' Department of Environmental Management/Division of Water Resources WATER WELL COMPLETION REPORT WELL LOCATION GEOGRAPHIC DESCRIPTION Address LO.L 3A 3 Bt' i t V S ;; . N S E W of "orth Andover (feet) (circle) City/Tow n Well ovv Lf-,nity 1, i1co;c (road/ Address l D-nairmount PL. N S E W of t aur -,u S , .,;A 01003 (mi. in tenthsl (circle) Board of Health permit: yes[ no C] intersect. w/ (road) WELL USE WELL DATA Domestic [ Public ❑ Industrial E] Total well depth 1421 ft. Monitoring ❑ Other t Depth to bedrock 10ft. Water -bearing rock/unconsolidated material: Method drilled IlF.Itl7ttP.?' 0-19--91 Description b'edroc,', Date drilled Water -bearing zones: CASING Type Steel 17,;i 1) From ry. I � t To 195 t Length 20 ft. Dia(.). tn• 2) From To � tJ/ct 10, 3) From To Length into bedrock ft. Gravel pack well: dia. Protective well seal: Screen: dia. Grout-[] Otherdriyo shg Slot$ length — from -PUMP TEST Static water level below land surface r'. ft. Date Drawdown 341 ft. after pumping 7 hr.l .5 min. at gpm How measured air Recovery 80 ft. after—hr. min. 1 LOG of FORMATIONS 1 COMMENTS topsoil 1 4 t; yl � Driller b0 d ro C.. 1 Q _ Al 2 Mass. Registration # 5n Firm Down ed.^'i: Dr •+ 1'_11' C.7. Ir C. Addressit . 12.) . City/Town .3,; r i7 3- tl"'i 011 1 1610240 OF ft l_ I N GLIFY BOARD OF HEALTH Town of 'North Andover'Hass. Date _�j 1991 APPLICATION FOR WELL & PUMP PERI-li'r ication.is hereby made for permit to drill a well (_). Application i -s to install (_) a pump system. tion: Address O t�' Lot -Address Icl. Contractor , W_.& Astr c/li�,� ress Contractor -�� Address L 'I -el. CONTRACTOR (To be completed at time of pump test) of Well Well used for�,��c� e--- f Well Size of Casi.rng feter oI :h of Bed Rock I t:h casing into Bed Rock /0 De Seal Tested? Yes A No (_) Date of 'I'cstin9 Qj :h of—Ale=1— —�y`� - Well Ended in W11a_t- I-Iaterial- I -��Qc�_ :h to Water_ J� �Z Delivers Gals.I'er Hin. for 4 hours odown�Q feet after pumping jl� hours. at of Completion __- - Sil;nature 1Jel ontractor .INSTALLER (To be filled in- before instal.l.ati_on) / S Pump Type Used /V5�/3�� & Name Pump 'r Pump Deliversy GPM Size of T;1111( _ Material Used in Well: Cast Iron (K) Galvanized (_) Plastic (J 1 Pit (_) or Pitless.Adapter sleeve used, -to protect Pipe? Yes W) I10(_) Type or Name Well Seal � a; s•�ci�*�M��'c�'��Sit��ti�4�Y��4t�ir�9r�M�'c►4tY�'t�'r4c�4�Yti'r�`t�'r�'��4�Y�4irti'rti'ciir5`r,':s�:�;�1��UZG��:DG �,:°„�`��4�,�drdr�t��, e Water analysis repor-t 'submitted to Board of 1(eaIth_ =Ee release given tD owner of record & Bldg. Insp Health Inspector f • 1_� �.'� � �� . � r, f; �, � 1; ��.�c�� 4 q BOARD OF HEALTH II Town of North Andovcr,Mass. l� Date S ; 192L F . APPLICATION FOR WELL & PUMP PERMIT l :.1ppi�cation .is hereby made for permit to drill a well (_) • Application is nade to install ( ) a pump system. r+ ` Lot `.ocation: Address S/�E /� �� rc1 ,.� Address 3 �< 6 Address �{�} �.-1 /l; Tel. • ;dell Contractor ,� ht 0 :�✓ re� S,4 le �h ` '' /I Address= Tel. %pump Contractor `BELL CONTRACTOR (To be completed at time of pump test) Type of Well Well used for Diameter of We11 h Size of Casing Depth of Bed Rock Depth casing; into Bcd hock .Was Seal Tested? Yes (_) No (`) Date. of Testing; De P th Well Ended in What. Material Depth to Water_ Delivers _Gals.Per Min. for 4 hours hours' a C GI'M Drawdown feet after pumping _— Date of' Completion Signature We Co ractor PUMP INSTALLER (To be'• filled i.n' before instal.].ation) Pump Type Used Size & Name Pump -.-:-------- --- Water Pump Delivers --- CPM '' size of "1'anlc •-- astic Pipe e Material Used in Well: Cast Iron (_) Gnivanized (_) Pl(_1 Well Pit (_) or Pitless.Adapter (_) Was sleeve used to protect pipe? Yes t_) ISO(_) 'ry( �e or Namc Well Seal Date ,'r* yttictt,rtirti`r,: „ ,. It Date eater analysis.report 'submitted to Board of Health Do_e .release given tD owner of record & Bldg. Insp Ihh Inspector _. t �:.t t <'i.-i: �- a tf, - � 'Y •��x� 7 ��i .�„ r -mss- . v'�'f.- . � NUMiZF.R i319 '. ' THE COMMONWEALTH OF MASSACHUSETTS FEE t . TOWN of NORTH ANDOVER -x-25- 0 0 1 ........ ............................... ,. This if to Certify t 1 - er f y c lac .... •L.....Yauxig ........................... NAME 36 Pelham Road, Salem, N.H.03079 ..................... : ADDRESS IS HEREBY GRANTED A LICENSE For .................Well & Pump Permit .......... ............. ......................... t 3A-. Berry...Strept ................................................... This license is granted in conformity with the Statutes and ordinances relating tliereto, and expires ........... December---3-1 f....1991........unleas sooner sus OF y or revoked. ... ....n ..Xa. 3 D • .. .. ................... ....--------•-� . !ter .. __ __ FORM 433 HOBBS & WARREN, INC. A a BOARD 017 HI;ALTII Town of North Andover,Mass. pit # �� ._. Date 19-f/ APPLICATION FOR WELL & 1'UH1' PERI -11'r ication is hereby made for permit to drill a well (_). Application i„s to install (_) a pump system'. Cion: Address A/, ..Lot # � r Address Tel. Contractors - `//` Address i /.2,-,t3G,,..,,=•��r,�Jel.��-m2/// �nl fa o r� iwcs, Contractor Address CONTRACTOR (To be completed at time of Dump test) of Well peter of Well :h of Bed Rock Seal Tested? Yes (_) :h --h to Water No ( ) Well used for Size of Casing 0_ 're 1 . Depth casing; into Bed Rock Date of TcrU .ng Well Ended in Wha.t.Material Delivers Gals.Per Hin. for 4 hours idown feet after pumping --Hours. at __ GPM of Completion �gj _sture IitContractor INSTALLER (To be'- filled i.n before in:�tal.l.ati-on) & Name Pump Purn1) Type Used ar Pump Delivers GPM Size of rank Material Used in Well: Cast Iron (/ Gnlv.1nized (_) Plastic (_1 L Pit ( ) or Pitless•Adapter sleeve used to protect pipe? Yes (_) NO(_) 1•ype or name Well Seal ►4iF��t��Y4�'r*�M�4��F�M��4�4t�iY****4t t4�r�Y�M��rM�4r4�'��4tiY�4�'rti'�J�irti'rti`r,':�,,�',�1��1�;C','�)''�:DC ��,u�t��drdv�r�v�r� e Water analysis repor-t •submitted to board of HeaILh_ e release given w owner of record & Bldg. Insp Health 111Fpector t DATE I f Sheet C of BOARD OF HEALTH TOWN OF NORTH ANDOVER SUBSURFACE DISPOSAL DESIGN REVIEW FEE &0 PERMIT #, APPLICANT ADDRESS DATE RECEIVED 12 Z% j�d ASSESSOR'S MAP lobe - PARCEL # i�, (�c 24 LOT # iIT 3 STREET # ENGINEER q6dC- 5 C.. ADDRESS 4-1 0-0 5;a�-00 Qrj i � &10(44 PLAN DATE I( 2b [CrO REVISION DATE CONDITIONS OF APPROVAL: APPROVED DISAPPROVED X Sysrc-H Ss o" ,o -3<-r- G cry c��Pos� -n� CEI& j aa 3 Low 7Fsr lis l,rj �� t -C, � of L.� (Q -,C—si tilt -Ds�F, (H,, 1�1orE �� Esc G� C -*16 l Q6r—:2 X54611 *A&V-6 ��L� Chia tc.� ilv SP cc-Tto� S c TA5, 0�-- '- - C� �� l �s�. s �-tz�� ►�-�2�� r �t� acv N � 'v.�A-1 l ,AORTq � w 2 K • i SSACMUSEt Town of North Andover, Massachusetts BOARD OF HEALTH DESIGN APPR SOIL ABSORPTION SEWAI Bruce To ma I Applicant Riding alty Trust Site Location Lot , BAr St. , No. SAL FOR DISPOSAL SYSTEM Test No. r, MA Form No. 2 Reference Plans d Sped. V ENVINEE DESIGN DATE Permission is grante for a inl soil absorption sewage disposal system to be installed in accordance with reg atio s of Board of Health. rh CHAT N, BOAR EALTH `ir>> / Jam. Fee Site System Permit No. Z71� FOR'114 = SYSTEM PLIIPD�G RECORD 107 Forest St. Middleton, MA 01949 QRP`N (508) 774-2772 SO,91��GE Commonwealth of Alassachus' :tts ,.Massachusetts Date of Pumping Quantity Pumed../rUO, g allons Cesspool: No E Yes ❑ Septic Tank: No ❑ Yes 8%.stem Pumped bv: ` License M Contents transferred to: Date Inspector WELL DATABASE ADDRESS: AGE OF WALL : ti �. WELL DRILLER: WELL PERMET. 3 WELL LOCATION: E WELL PERMTI' DATE: DEPTH OF WELL. --TYPEOF WELL:��. DRLLLE�L b. DLG c. Lei1,�iV TYPE OF WATER BEARING ROCK: WATER ANiALYSM DATE_ L - 12 - \GH W A HIGHIRON: Y OT=CONTAl S: Y Y N WELL. DATABASE f ADDRESS: AGE OF WELL: j ` WELL DRILLER: WELL PERNUTT: 3 v WELL LOCATION: 01 LA 116 WELL PER!YfIT DATE: 7 -(YJ/ DEPTH 0'( WELL. w S T TYPE OF W ELL: b. DUG c. L`�iKN04Ytii " TYPE OF WATER BEARL TG ROCK. WATER ANALYSIS DATE: HIGH titAN GANESE: Y HIGH IRON: Y OTHER CONTAi'YfNA- TS: Y N Commonwealthof assac usetts City/Town of System Pumping 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 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. System Location: forms on the computer, use I only the tab key Address/�_` _ to move your NwAVx N)d oyc. Iota as 4s cursor - do not City/Town State Zip Code use the return key. � 2. S stem Owner: Name Address (if different from location) City/Town State Zip Code r?- 1 'S9- 0030 Telephone Number B. Pumping Record >5�p 1. Date of Pumping 10 -a? -0? Date 2. Quantity Pumped: Gallons 3. Type of system: ❑ Cesspool(s) [Septic Tank ❑ Tight Tank ❑ Grease Trap ❑ Other (describe): 4. Effluent Tee Filter present? ❑ Yes R"No If yes, was it cleaned? ❑ Yes ❑ No 5. Condition of System: (300d 6. System Pumped By: J ,-n (�c�'t i o.r� -76679 Name SWIG n� Vehicle License Number 1�,�ir,j R+vcf VE1 $ Company C ^ O 7. Location where contaRtvPA- Pir° osed: ` Sign—ature of Hauler Signature of Receiving Facility t5form4.doc• 03/06' Date Date System Pumping Record • Page 1 of 1 Commonwealth of Massachusetts RE El711 City/Town of FF / System Pumping Record NORTH ANDOV9R I' 1y �i 1 v 4 Form 4 TOWN OF NORTH ANDOVER "EALTU EgP MENT DEP has provided this form for use by local Boards of Health. Other forms m 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. System Location: forms on the computer, use _ Cr � ,�- ---— ------------ -- only the tab key AddfeSS to move your cursor - do not City/Town State Zip Code use the return key. 2. System Owner: nn LL PG K_l Name Address (if different from location) --- --- -- -- — - — --- - City(fon -- — -- State Zip Code w - " Telephone Number B. Pumping Record 1. Date of Pumping �atZ�� 2. Quantity Pumped: � Gallons ons ---- 3. Type of system: ❑ Cesspool(s)eptic Tank ❑ Tight Tank ❑ Grease Trap ❑ Other (describe): - --- -- --- -- -- — - 4. Effluent Tee Filter present? Yes ❑ No If yes, was it cleaned? Yes ❑ No 5. Condition of S stem: - -- -- 6. System Pumped By: 4 / IfC�_ -- -- _r�-------- - --- Name Vehicle License Number Company 7. Location where contents were disposed: Signature of Hauler Date ' Signature of Receiving Facility Date t5form4.doc• 03/06 System Pumping Record • Page 1 of 1 Commonwealth of Massachusetts City/Town of System Pumping Record NORTH ANDOVER 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 Pumpingecord, must be submitted to the local Board of Health or other approving authority within 14 days from th punjlp�i accordance with 310 CMR 15.351. �^, �1 5. Condition of System: 6. System Pumped By — Company 7. Location where contents were disposed: Signature of Hauler Signature of Receiving Facility t5form4.doc• 03106 Vehicle License Number Date "" 4 ,. -, .... _.- Date System umping Record • Page 1 of 1 7 A. Facility Information 'TOWN OF NORTH ANDOVER Important: When filling out 1. System Location: MAtfiM DEpARTM'ov forms on the J� l� computer, use only the tab key to move your�d%.--- — Address Com- `- --- f — -- – cursor - do not City/Town Sate Zip Code use the return key., 2. System Owner: Name different from location) ---- --- --- --- — --- ----- - Address (if --- –-------- CitylTown -State --- - Zip Code ---- -- q7,?- G-:�'q -o Telephone Number B. Pumping Record 2�9 `��--- --- 1. Date of Pumping- -11-- Date 2. Quantity Pumped: Gallons 3. Type of system: ❑ Cesspool(s) Septic Tank ❑ Tight Tank ❑ Grease Trap l ❑ Other (describe): - —— -- --- -------- -- — --- 4. Effluent Tee Filter present? ❑ Yes ❑ No If yes, was it cleaned? ❑ Yes ❑ No 5. Condition of System: 6. System Pumped By — Company 7. Location where contents were disposed: Signature of Hauler Signature of Receiving Facility t5form4.doc• 03106 Vehicle License Number Date "" 4 ,. -, .... _.- Date System umping Record • Page 1 of 1 7