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FEE
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9
PLAN APPROVAL:
DATE APP. BY
DESIGNER:
/ �Y
_
�C 5 ��l/ L /99
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PLAN DATE. —
CONDITIONS
WATER SUPPLY: TOWN WELL
WELL PERMIT
WELL TESTS:
COMMENTS:
DRILLER
CHEMICAL DATE APPROVED
ERIA I DA T E (IPPRUVED
BACTERIA—Ih.—` DA T•E APPROVED_
FORM U APPROVAL: �j APPROVAL 7.O ISSUE YES NO
DATE ISSUED / BY '
CONDITIONS:
FINAL APPROVAL:
ALL PERMITS PAID YES NO
WELL CONSTRUCTION APPROVAL YES NU
SEPTIC SYSTEM CONSTRUCTION APPROVAL YES NO
OTHER YES NU
ANY VARIANCE NEEDED YES NO
FINAL BOARD OF HEALTH APPROVAL: DATE ;..I,j� BY:
40
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t• IS THE INSTALLER LICENSED? �' `� �t , YES NO
.TYPE . OF CONSTRUCTION: - NEW,/' 'REPAIR
1 ..
NEW CONSTRUCTION:•,.•. CERTIFIED PLOT PLAN REVIEW -YES NO
CONDITIONS OF:.APPROVAL YES NO
(FROM FORM U) l:
r
ISSUANCE OF DWC PERMIT ��`-.YES �. NO
DWC PERMITNO. t INSTALLER:
' -BEGIN, INSPECTION 0: -
EXCAVATION, INSPECTION: NEEDED:Zj-
'
- ,j4
RASSED ii� BY
.:CONSTRl1CTION INSPECTION: NEEDED:
it - ::` ` •_ I: - _ • V - • ••
AS BUILT PLAN SATISFACTORY:
APPROVAL.' TO BACKFILL: DATE: •=-f BY _
.." tF'INAL . GRADING APPROVAL: DATE ��` BY 11�� .-
Commonwealth of Massachusetts
City/Town of NORTH ANDOVERL. MASSACHUSETTS
-: System Pumping Record
Form 4
DEP has provided this form for use by local Boards of Health. The cor mu:
be submitted to the local Board of Health or other approving autho ity.
A. Facility Information JUL 19 2006 i
Important:
When filling out 1. System Location: TOWN OF NORTH ANDOVER
forms the _ — HEALTH DEPARTMENT
computer,
r, use
only the tab key Address - - ----- _..----------_.--- -- - -.— -
to move your
cursor - do not---------'t—l---------------- - — -------------
use the return City/Town - te --- - -- ---
State Zip ----- Code
key.
2. System Owner:
Name --- - - - ---.. -- -- - - -
Address (if different from location) �—
City/Town ---------------------..
Stat - -----
/Zipp Code
Telephone Number
umping Kecord
1. Date of Pumping
3. Type of system.-
El
ystem:
❑ Other (describe):
D e Quantity Pumped: - - -
Gallons
Cesspool(s) Septic Tank ❑ Tight Tank
4. Effluent Tee Filter present? ❑ Yes Z -No
5. Condition of System:
If yes, was it cleaned? ❑ Yes ❑ No
6. Sy em Pumped By:
Name Vehicle
6License Number
��_ ��z_. --fit � -= r�%r,>n�.
Company -
7. Location where contents were disposed:
21
c___�` --- - -- --- -
/,i,t,re of Haul
http://www.mass.gov/dep/water/ provals/t5forms.htm#inspect
t5form4.doc• 06/03
- -- ----------
Date
V
System Pumping Record • Page 1 of 1
TOWN OF NORTH ANDOVER
SYSTEM PUMPING RECORD
DATE: 1 (< 1—_
SYSTEM OWNER & ADDRESS SYSTEM LOCATION
(example: left front of house)
DATE OF PUMPING: /O-// o / QUANTITY PUMPED v -b GALLONS
CESSPOOL: NO L,YES SEPTIC TANK: NO YES
NATURE OF SERVICE: ROUTINE L ---,"'EMERGENCY
OBSERVATIONS:
GOOD CONDITION L FULL TO COVER
HEAVY GREASE BAFFLES IN PLACE
ROOTS LEACHFIELD RUNBACK
EXCESSIVE SOLIDS FLOODED
SOLIDS CARRYOVER OTHER (EXPLAIN)
SYSTEM PUMPED BY: Andover a-c4c,
COMMENTS:
CONTENTS TRANSFERRED TO: �) so. r}'1�, s I ' ��raj Mal,-
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PLAN REVIEW CHECKLIST
ADDRESS <�3 4!e7A.ST �A:5 ENGINEER
GENERAL / /
3 COPIES L ------"STAMP �'� LOCUS'S NORTH ARROW v SCALE
CONTOURS PROFILE SECTION BENCHMARK,- SOIL &
7
PERCS ELEVATIONS WETS. DISCLAIMER l" WELLS & WETS
WATERSHED?- DRIVEWAY Elev) WATER LINE t,"" FDN DRAIN
SCH40 TESTS CURRENT? ` �IZl3 SOIL EVAL
SEPTIC TANK /
MIN 150OGy/' .17 INVERT DROP l/ GARB. GRINDER(+200% EDF)
25' TO CELLAR 4,-' MANHOLE ELEV GW # COMPS. I
D -BOX
SIZE 13 # LINES FIRST 2' LEVEL STATEMENT
INLET )?0-6 O - OUTLET l y0� _ 7 (2" OR .17 FT) TEE REQ' D?
LEACHING
MIN 660 GPD?/ RESERVE AREA v 4' FROM PRIMARY? /,� 2% SLOPE,�--"
100' TO WETLANDS '� 100' TO WELLS 4' TO S.H.GW (5'>2M/IN)
35' TO FND & INTRCPTR DRAINS c/ ^325' TO SURFACE H2O SUPP
4' PERM. SOIL BELOW FACILITY MIN 12" COVER ✓ FILL? (25'
if above natural elev; 101if below) BREAKOUT MET? rl"
TRENCHES
MIN 660 gpd_),/ SLOPE (min .005 or 6"/1001) 1,�SIDEWALL DIST. 3X EFF.
W OR D (MIN 6') RESERVE BETWEEN TRENCHES?A IN FILL? / MUST
BE 10' MIN._0/6 4" PEA STONE? -e"" VENT? !� (>3' COVER; LINES >501)
BOT q&L) + SIDE l Z kIL X LDNG Z = TOT 0 0
(L x W x #) (DxLx2x#) (G/ft2)
Copyright 0 1995 by S.L. Starr
APPLICATION FOR DISPOSAL WORKS CONSTRUCTION PERMIT
DATE: _Z, (v CURRENT INSTALLER'S LICENSE#
LOCATION: *�-_ S LICENSED INSTALLER:
INSTALLER:
SIGNATURE: 1zl, TELEPHONE#
CHECK ONE:
REPAIR: NEW CONSTRUCTION:
IF NEW CONSTUCTION, PLEASE ATTACH FOUNDATION AS -BUILT.
Administrative Use Only
$75.00 Fee Attached? Yes v No
Foundation_ As -Built? Ye1s� No
Approval
Date: /,/,/
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FORK U — IAT R=ZASE FORM
INSTRUCTIONS: This form is used to verify that all necessary
approvals/permits from Boards and Departments having jurisdiction
have been obtained. This does not relieve the applicant and/or
landowner from compliance with any applicable local or state law,
regulations or requirements.
****************Applicant fills out this section*****************
APPLICANT:
APPLICANT: Phone
LOCATION: Assessor's Map Number l 6 Parcel
Subdivision Q�-,r :4Q C5�A Lots)
Street �kx� A 2i71,1P r, A ris St. Number
************************Official use Only************************
RECOMMENDATIONS OF TOWN AGENTS:
Date Approved
i Conservation Administrator Date Rejected
Comments
Date Approved
Town Planner Date Rejected
Comments
Food Inspec or -Health
Septic Inspector -Health
Comments
Public Works - sewer/water connections
- driveway permit
Fire Department
Date Approved
Date Rejected
Date Approved 7 ��
Date Rejected
Received by Building Inspector Date
(\S
no
HAYES ENGINEERING, INC.
603 SALEM STREET
WAKEFIELD, MA 01880
TEL.: (617) 246-2800
FAX: (617) 246-7�599�6C-n p
TO
/VQ
GENTLEMEN:
LE77 IR OF 7HANOMMQL
DATE+) /
4
.108 NO. a />t 00 q
/11 v
ATTENTION
RE:
H A�y�DVEW
SOW B01A 01 cr4
juil
WE ARE SENDING YOU ❑ Attached ❑ Under separate cover via
❑ Shop drawings ❑ Prints ❑ Plans ❑ Samples
❑ Copy of letter ❑ Change order ❑
the following items:
❑ Specifications
COPIES
DATE I
NO.
DESCRIPTION
THESE ARE TRANSMITTED as checked below:
1K For approval
❑ Foryour•use
❑ As requested
❑ For review and comment
❑ FOR BIDS DUE
REMARKS:
❑ Approved as submitted
❑ Approved as noted
❑ Returned for corrections
❑
❑ Resubmit copies for approval
❑ Submitcopies for distribution
❑ Returncorrected prints
19 ❑ PRINTS RETURNED AFTER LOAN TO US
COPY TO:
SIGNED:
I/ enclosures are not as noted, kindly notify us at ons
NORTH ANDOVER BOARD OF HEALTH
DESIGN REVIEW REPORT
FEE: -;160 PERMIT ## S�� DATE RECEIVED
APPLICANT Doo4e,6 3Oli4)5>pcJ
ADDRESS
MAP
LOT # 1�3
PARCEL
ENG . , �, 2/,-S 7/t)c STREET
ADDRESS C O-�3 5 %G �/�� :5r
PLAN DATE /1119/ZC// a �, / �'/ REV. DATE
CONDITIONS OF APPROVAL
APPROVED
DISAPPROVED
REASONS FOR DISAPPROVAL:
04
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9, Ivo7- I/t) /3ve�1v DG 5 Y5rEI`/
OL -4, 725-5,r-6 0,6)7- d
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D lG Co . %BGG A5� v i/D u-) G C/v6 7 -AA 9z- 4012)7-;;V 0,C
C) /CJ 5 / T,:!!�-
Town of North Andover AORTk ,
OFFICE OF 3? 01
COMMUNITY DEVELOPMENT AND SERVICES ° .
146 Main Street �` 9
pqT IP` -•1 L
North Andover, Massachusetts 01845 9SSACHUS�`
(508)688-9533
January 29, 1996
Hayes Engineering
603 Salem Street
Wakefield, MA 01880
Re: Lot #3 East Pasture Circle
To Whom it May Concern:
This is to inform you that the proposed plans for the site
referenced above have been disapproved for the following reasons:
1) No soil tests in reserve area.
2) Perc test elevations missing.
3) Benchmark not in work area of system.
4) Deep hole tests out of date.
5) Note: garbage grinder not allowed.
6) Please show length & width of trenches on site plan along
with distance between trenches.
If you have any questions, please do not hesitate to call the Board
of Health Office at the number below.
Sincerely,
Sandra Starr, R.S.
Health Administrator
SS/cjp
BOARD OF APPEALS 688-9541 BUILDING 688-9545 CONSERVATION 688-9530 HEALTH 688-9540 PLANNING 688-9535
Julie Parrino D. Robert Nicetta Michael Howard Sandra Starr Kathleen Bradley Colwell
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No
THE COMMONWEALTH OF MASSACHUSETTS
North Andover
, MASSACHUSETTS
FEE$ 60.00
ckyptirttftun for Pispoe-al Sgs#em (guns#rnc#`tun jhrmit
Application is hereby made for a Permit to Construct (X ) or Repair ( ) an On-s:te Sewage Disposal System at:
Location Address or Lot No.
Owner's Name, Address and Tel. No.
East Pasture Circle - Lot 3
Donald Johnston 1-508-682-1619
North Andover, MA 01845
114 Boston St., North Andover, MA
Installer's Name, Address, and Tel.No.
Designer's Name, Address and Tel. No.
Hayes Engineering, Inc. 617-246-2800
603 Salem St., Wakefield, MA 01880
Type of Building:
Dwelling
Other
Design Flow
No. of Bedrooms
Type of Building
Other Fixtures —
165
4
Garbage Grinder (Y )
No. per Persons Showers ( ) Cafeteria ( )
gallons per day. Calculated daily flow 660 gallons.
Plan Date March 31, 1995 Number of sheets one Revision Date --
Title Septic System Design in North Andover, Mass.
Description of Soil See soil log on plan.
Nature of Repairs or Alterations (Answer when applicable)
Date last inspected:
Agreement:
The undersigned agrees to ensure the construction and maintenance of the aforedescribed on-site sewage disposal
system in accordance with the provisions of Title 5 of the Environmental Code and not to place the system in operation until a
Certificate of Compliance has been issued by this Board of Health.
Signed
Application Approved by
Application Disapproved for the following reasons
Permit No.
Date
Date
Date Issued
THE COMMONWEALTH OF MASSACHUSETTS
, MASSACHUSETTS
Ter#tfira a of (outlatiance
THIS IS TO CERTIFY, that the On-site Sewage Disposal System installed
by for
at has been constructed in
accordance with the provisions of Title 5 and the for Disposal System Construction Permit No. dated
. Use of this system is conditioned on compliance with the provisions set forth below:
) or repaired/ replaced ( ) on
The issuance of this certificate shall not be construed as a guarantee that the system will function as designed. This
Certificate expires on
DATE Inspector
THE COMMONWEALTH OF MASSACHUSETTS
No. , MASSACHUSETTS FEE
,Disposal oSgotrnt 10-Iuns#rurttun f ernti#
Permission is hereby granted to
to construct ( ) or repair ( ) an On-site Sewage System located at
and as described in the above Application for Disposal System Construction Permit. The applicant recognizes his/her
duty to comply with Title 5 and the following local provisions or special conditions.
All construction must be completed within three years of the date below.
10.11114
FORM 1255 Rev. 3/95 A.M. SULKIN CO. - BOSTON. MA
Approved by
TOWN OF
SYSTEM
DA tl-
-
SYSTEM OWNER &
DDRESS
A
DATE OF PUMPING:
TH. ANDOVE1,
'INO RECORD
by N I -hM LOCATION
-QUANTITY PUMPED:
YES- NO_
NAruKboF SERVICE: ROU'FINE
.R
tNcY---
013SER.VA CIONS:
GOOD CONDITION /FULL ,To COVER
HEAVY GRF-ASE BAFFLES IN PLACE
ROOTS LEACHMELD RUNBACK
EXCESSIVE SOLIDS ------ FLOODED
SOLID CARRYOVER -
,..-.,, ... - 9THER EXPLAIN
C(L)MME,N-17N,
�ZUN FEN I'S FKANSYhRRED I -Ci
REC_EIVED
OCT o 5 2004
TOWN OF NORTH ANDOVER
HEALTH 6!�P�ARTMENT
YES
SO ru
PLAN OF LAND I {�
2 1996 �
/A/
NO* AND 0 VER I is
MA , v
SCALE.' 1 " = 40' OCTOBER ,, 1,995
HAYE,S ENG/NEER/NG, /NC. 603 SALEM STREET
CIVIL ENG/NEERS & WAKEFIELD, MASS. 01880
LAN9�5D SURVEYORS W.
(617) 245-2800
/ CERTIFY THAT TH/S FOUNDATION /S LOG4TEL% ON THE GROUND AS SHOWN, AND THAT /T
CONFORMS TO THE ZONING BY-LAWS OF rHi" TOWN OF NORTH ANDOVER. / FURTHER CERTIFY
THAT THIS PROPERTY DOES NOT LIE WUH/N .A FLOOD HAZARD AREA (ZONE A OR V� AS
SHOWN ON FLOOD INSURANCE RATE MAP COMMUN/TY PANEL NUMBER 250098 0010 B. �� of
EFFECTIVE DATE.' JUNE 15, 1983
THOMASc
F.
DATE.' �CC'O_ 3 I99� WINSLOW
----
-------------- ,�---- - `------------=- -- -- #30320 co
PROFESSIONAL LAND SURVEYOR �w
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CIRCLE