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HomeMy WebLinkAboutMiscellaneous - 362 SHARPNERS POND ROAD 4/30/2018 (2)G„ 1 9 2005 k '"r r LAUG F NO iTfi ANDOVE-�LT�10 f'A'T ,j A FILE #N A n d 8 '; a TITLE V INSPECTIONS Dean G. Luscomb II & Sons w P.O. Box 135 Middleton, MA 01949 978-774-4065 Licensed Plumber #20285 SUBSURFACE SEWAGE DISPOSAL SYSTEM INPSECTION FORM PROPERTY OWNERS NAME J e - i> r)y t A r+h L(r FpS� (r) PROPERTY ADDRESS- (n Q S k a r p r-) C rS PD r -,d Rd N At hdover. MA ADDRESS OF OWNER (if different) S a IYPC'_ 0 DATE OF INSPECTION U Q L[ S 1 L J S, 2� 0 0 G Ij NAME OF INSPECTOR D f Q r) G. 1_ u S e C) M QUALITY IS NUMBER ONE TO US COMMONWEALTH OF MASSACHUSETTS EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS DEPARTMENT OF ENVIRONMENTAL PROTECTI DEAN G. LUSCOMB II & SONS P.O. BOX 135 MIDDLETON, MA 01949 1-978-774-4065 TITLE 5 : ED A u G 19 2005 \ -i- N04RTH ANDOVER _ -k;`i DEPARTMENT OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM PART A CERTIFICATION Property Address: 362 Sbarpr)e s Mohd Rd N. /kodouer, MA Owner's Name: Jenrw * A r4ku r pS`i'ei n Owner's Address: Sra Me Date of Inspection: A t{Q U si a, x005 Name of Inspector: (please print) Dean G. Luscomb II Company Name: Dean G. Luscomb II & Sons Mailing Address: p_ O_ Box 1 3 5 Middleton, MA 01 949 Telephone Number: 978-774-4065 CERTIFICATION STATEMENT 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 Needs Further Evaluation by the Local Approving Authority Fails Inspector's Signature: Date: Au�14S �5 0 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 is a shared system or 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. Notes and Comments ****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. P.O. Box 135 Page 2 of 11 Middleton, MA 01949 1-978-774-4065 OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: 3( Z S h Q r p hers Po n d Pd N, Am nyP_Y. M,4 Owner: F p s+e i n Date of Inspection: g - 15.0 5 Inspection Summary: CheckQB,C,D or E / ALWAYS complete all of Section D A. System Passes: -Z, 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. Answer yes, no or not determined (Y,N,ND) in the for the following statements. If "not determined" please explain. A/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. ND explain: 0 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 distribution box is leveled or replaced ND explain: /'�/ 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 obstruction is removed ND explain: uccua v. -- u ......— Page 3 of 11 P.O. 13ox 135 Middleton, MA 01949 1-978-774-4065 OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: 3(02, 5 hR r p hP_r'S Po hd Rd N.Andnuef, AAA Owner: _L (:) S4e i n Date of Inspection: 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 2. System will fail unless the Board of Health (and Public Water Supplier, if any) determines that the system its 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 I of a public water supply. bJ The system has a septic tank and SAS and the SAS is within 50 feet of a private water supply well. dThe 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 coliform bacteria and volatile organic compounds indicates that the well is free from pollution from that facility 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. Oth, Page 4 of 11 P. o. Box 135 Middleton, MA 01949 1-978-774-4065 OFFICIAL INSPECTION FORM — NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: 362 Shot r pars Pond Rd N • An CLnUer+ M A Owner: ED S+9— i r) Date of Inspection: g- I !D- 0 rJ D. System Failure Criteria applicable to all systems: You must indicate "yes" or "no" to each of the following for all inspections: Yes No _ t-) Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool f7 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 Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number of times pumped _ lj Any portion of the SAS, cesspool or privy is below high ground water elevation. Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. Any portion of a cesspool or privy is within a Zone 1 of a public well. /J Any portion of a cesspool or privy is within 50 feet of a private water supply well. N 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 coliform bacteria and volatile organic compounds indicates that the well is free from pollution from that facility 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.] No (Yes/0 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 I gpd• You must indica i her "yes" or "no" to each of the following: (The following criteria a lX_to large systems in addition to the criteria above) yes no _ the system is within 400 feet of a s ce drinking water supply _ the system is within 200 feet of a tributary to a s ce d ' mg water supply the system is located in a nitrogen sensitive a (Interim We ad Protection Area— IWPA) or a mapped Zone 11 of a public water supply well If you have answered "yes" to any ion in Section E the system is considered a signifisagnt threat, or answered "yes" in Section D above the 1 system has failed. The owner or operator of any large syste sidered a significant threat under S on E or failed under Section D shall upgrade the system in accordance wit 310 CMR 15.304. The system ner should contact the appropriate regional office of the Department. Page 5 of 11 P.O. Box 135 Middleton, MA 01949 1-978-774-4065 OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST Property Address: 3G2- SharDne�S pendcl M. R Owner S 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 Zwere 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'? L,/— 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 `? V/— 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 ? _L-`/_ 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: Yes no 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) [3 10 CMR 15.302(3)(b)] Page 6 of 11 P.O. Box 135 Middleton, MA 01949 1-978-774-4065 OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION Property Address: 3 62 Sh a. r p r� rS P+Ond Rd' N),AndnuP+", MA Owner: EDS+e_f n Date of Inspection: Z- b 5- O S FLOW CONDITIONS RESIDENTIAL Number of bedrooms (design): �/ Number of bedrooms (actual): '/z4/ ! DESIGN flow based on 3 10 CMR 15.203 (for example: l 10 gpd x # of bedrooms): Number of current residents: I,— _ Does residence have a garbage grinder (yes or . Is laundry on a separate sewage system (yes oro /W [if yes separate inspection required] Laundry system inspected (yes oro 12D Seasonal use: (yes orcQ11 L -J / Water meter readings, if avaible (last 2 years usage (gpd)): p l a') Sump pump (yes o�o�: /� Last date of occupancy: e„'ur'rL* of- Type f- Type of establishment Design flow (based on 310 15.203): gpd Basis of design flow (seats/persoN�,gft,etc.): / Grease trap present (yes or no): _ Industrial waste holding tank present Non -sanitary waste discharged_jpA+r6 Water meter readings, i Last date of occupa<y�, OTHER (describe): or no): GENERAL INFORMATION `{ Pumping RecordsJ/ �� �c. C3 �� Gtv7 Cw-rd, 2 �ez,r � (OW, /J Source of information: S-(- ?jy, p, e .S Was system pumped as part of the inspectio es r no): _eS ' If yes, volume pumped:/ �QQ gallons -- Ho was quantity pumped determined? 6'I Reason for pumping: c OF SYSTEM Septic tank, distribution box, soil absorption system Single cesspool _ Overflow cesspool _ Privy _ 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) Tight tank _ Attach a copy of the DEP approval _ Other (describe): Approximate ague of all ./,louse a. �.ai, sof s if known) and source of informat, n: Were sewage odors detected when arriving at the site (yes or(O. /UD N Page 7 of 1 I P.O. 'Box135~ Middleton, MA 1-978-774-4065 OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: 362 Shargr�erS Pond PCI N. A-,doue-r MA Owner: ED G+? -1 r) Date of Inspection: 9 - f �- D 5 BUILDING SEWER (locate on site plan) y'C� Depth below grade:_ ( Materials of construction: cast iron _40 PVC _other (explain): Distance from private water supply well or suction line: Comments (on condition of joints, venting, evidence of leakage, etc. )i SEPTIC TANK: (locate on site plan) 01949 tl Depth below grade: /�� Material of construction: /concrete _metal _fiberglass _polyethylene _other(explain) t' rp t V'cr6, /5� gI,/ If tank is metal list age: !�!e Is age confirmed by a Certificate of Compliance (yes or Vo LJO (attach a copy of certificate) n � Dimensions: `��Qe�,� u� rWi�G %C f0' Lo "q Sludge depth: <2,"'2-3 Distance from top of sludge to bottom of outlet tee or baffle: Scum thickness: < Z" Distance from top of scum to top of outlet tee or baffle: 6 Distance from bottom of scum to bottom of outlet tee or baffle: 7i/,, How were dimensions determined: N ski cks Cij rja� yyy'a" Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related --�tto--outlet invert, vi enc leakage, etc.): r",fei a:2!ii n� Ar r4rre-c 11'.1'f�el,t� f GREASE TRAP:00ocate on site plan) Depth below grade: _ Material of construction: concrete metal fiberglass _polyethylene _other (explain): �. Dimensions: Scum thickness: Distance from top of scum to top of outlet tee or battle Distance from bottom of scum to bottom of outlet tee or Date of last pumping: Comments (on pumping recommend , inlet and outlet tee or baffle as related to outlet invert, ce of leakage, etc.): 7 structural integrity, liquid levels Page 8 of I 1 P.O. Box 135 Middleton, MA 01949 1-978-774-4065 OFFICIAL INSPECTION FORM — NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: 3 2 S h ca E n e rS Pon d Rd r A Owner: EPSfei h Date of Inspection: g - d5.O5 TIGHT or HOLDING TANK: " (tank must be pumped at time of inspection)(locate.on site plan) Depth below Material of c metal fiberg�_polyethylene other(explain): Dimensions: Capacity: gallon"- Design Flow:o1T ns/day Alarm present (yes or no Alarm level: Alarm in working order (yes or no): Date of last_.p ping: Comments (condition of alarm and float switches, etc.): v` i5y30 3r, �u� ��c4e, DISTRIBUTION BOX: � (if present must be opened)(locate on site plan)17–k .....—_ 30 Depth of liquid level above outlet invert: Z4xV Comments (note if box is level and distribution to outlets equal, any evidence of solids carryover, any evidence of PUMP CHAMBER: A (locate on site plan) Pumps in working order(q%.ornc) Alarms in working order (yes or no; Comments (note condition of pump '2>,.y cc/AJO SJ�+�S Qr' 6tn7 ( X0,0 � m.A I appurtenances, etc.): Page 9 of I I P.O. Box 135 Middleton, MA 01949 1-978-774-4065 OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: 3%2 S k g ro n e rs Pond Rd N. A�ncfnuer. M Owner: FpS-�e I Y} Date of Inspection: _ g- �6- ds SOIL ABSORPTION SYSTEM (SAS): Y (locate on site plan, excavation not required) If SAS not located explain why: -D-!3o V)el/ Type leaching pits, number: _ leaching chambers, number: aching galleries, number: leaching trenches, number, length: _ - zaaa41 his leaching fields, number, dimensions: , ,62- - W'l 'f?VC , i n� 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, CESSPOOLS: Pi (cesspool must be pumped as part of inspection)(locate on site plan) Number and configuration: Depth -top of liquid to inlet invert: Depth of sol►dh-*ea,:. Depth of scum layer: Dimensions of cesspool: _ Materials of construction: Indication of groundwater Comments (note conditipr PRIVY: PO (locate on site plan) Materials of construction: Dimensions: Depth of solids: Comments (note condition of soil, yes-t-rno): signs of hydraulic failure, level of ponding, condition of vegetation, etc.): c failure, level ofpo.nding, condition of vegetation, etc.): Eel Ne P.O. Box 135 Page 10 of 11 Middleton, MA 01949 1-978-774-4065 OFFICIAL INSPECTION FORM — NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address:3(,,Z Pond Rd ( N-Ar,doutr, Mf! Date of lns ection: Z -6-D5 SKETCH OF SEWAGE DISPOSAL SYSTEM Provide a sketch of the sewage disposal system including ties benchmarks. Locate all wells within 100 feet. Locate where -f \ gcv-av s 1140 l a2.7 7" a .10 k1fast two permanent reference landmarks or c water supply enters the building. .n")W,?\ 4 1� P.O. Box 135 • Page l l of 11 Middleton, MA 01949 1-978-774-4065 OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address:3(D2 ShQ_rphe aPond RC? N. A n o0ef, MA Owner: EDJ-ke, I l7 Date of Inspection: 9 -15. 0 5 SITE EXAM lope f kl*rface water �c _ ►/',heck cellar D, -j Shallow wells Estimated depth to ground water feet Please indicate (check) all methods used to determine the high ground water elevation: `Obtained from system design plans on record - If checked, date of design plan reviewed: Observed site (abutting property/observation hole witPin 150 feet of SAS) V'Checked with local Board of Health -explain: F % .'',''"% '"` •- Checked with local excavators, installers- (attach documentation) L/ Accessed USGS database -explain: You must describe how you established the high ground water elevation: 77,T /3as„�� e r7'�/G� il/te_ �.�4 �� Z ci yar-1 Lle C, A- �e l,✓�i�G J`u r�� � vi,�� G- il7cl' A/ rr �3ile -led, 20 PC loid $ C`?j%t. A.- 3- 4'� i'�ii e �✓tX-.� 7j l��Gc t � � I _C� 4 E w zaa; i Aa (/ .” �'' ac /uw q1 4/ a S 7 ; f�13e loe,) Important: When filling out forms on the computer, use only the tab key to move your cursor - do not use the return key. sewn , Commonwealth of Massachusetts City/Town of NORTH ANDOVER, System Pumping Record Form 4 MASSACH y rV S ET73 0 2006 TOWN OF NORTH ANDOVER HEALTH DEPART"VENT 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 1. System Location: Address (U City/Town State Zip Code 2. System Owner: G� c C� A e v v` k �' e c - Name _ Address (if different from location) City/Town B. Pumping Record 1. Date of Pumping 3. Type of system: ❑ ❑ Other (describe): State Zip Code Telephone Number r o G Date — 2• Quantity Pumped Cesspool(s) MIteptic Tank 4. Effluent Tee Filter present? ❑ Yes D -f o 5. Condition of Sys m: 6— 6. System Pumped By: Name Company 7. Location where contents were disposed: l SaCD Gallons ❑ Tight Tank If yes, was it cleaned? ❑ Yes ❑ No .��6 Vehicle License Number (S d� Si nature of Hauler Date http://www.mass.gov/dep/water/approvals/t5forms.htm#inspect t5form4.doc• 06/03 System Pumping Record • Page 1 of 1 t, for TOWN OF NORTH ANDOVER Ot NORT111 Office of COMMUNITY DEVELOPMENT AND SERVICES �: •'' �° HEALTH DEPARTMENT ~ WF~OOWp 400 OSGOOD STREET NORTH ANDOVER, MASSACHUSETTS 01845cMu CHU Susan Y. Sawyer, REHS/RS. Public Health Director April 11, 2005 To all Sharpeners Pond Road Residents: 978.688.9540 — Phone 978.688.9542 — FAX E-MAIL: healthdept@townofnorthandover com WEBSITE: hqp://www.townofnorthandover.com Please note that it has come to the attention of the Health Department that many residents are leaving their trash barrels and trash bags out at the curbside for days, or weeks at a time. Empty trash barrels blowing about in the road are a safety hazard, and trash and debris along the roadway is a health hazard. Please be mindful of this, as the Health Department will conduct periodic inspections of the area to determine who is in violation, and fines will be issued if protocol is not followed. The Board of Health follows the State Sanitary Code regarding Human Habitation, 105.CMR.410, Section 1: 410.600 (A): Garbage or mixed garbage and rubbish shall be stored in watertight receptacles with tight- fitting covers. Said receptacles and covers shall be of metal or other durable, rodent -proof material. Rubbish shall be stored in receptacles of metal or other durable, rodent -proof material. Garbage and rubbish shall be put out for collection no earlier than the day of collection. (B): Plastic bags shall be used to store garbage or mixed rubbish and garbage only if used as a liner in watertight receptacles with tight -fitting covers as required in 105 CMR 410.600(A), provided that the plastic bags may be put out for collection except in those places where such practice is prohibited by local rule or ordinance or except in those cases where the Department of Public Health determines that such practice constitutes a health problem. For purposes of the preceding sentence in making its determination the Department shall consider, among other things, evidence of strewn garbage, torn garbage bags, or evidence of rodents. 410.602 (A) Land. The owner of any parcel of land, vacant or otherwise, shall be responsible for maintaining such parcel of land in a clean and sanitary condition and free from garbage, rubbish or other refuse. The owner of such parcel of land shall correct any condition caused by or on such parcel or its appurtenance which affects the health or safety, and well-being of the occupants of any dwelling or of the general public. (D) Common Areas. The owner of any dwelling abutting a private passageway or right-of-way owned or used in common with other dwellings or which the owner or occupants under his control have the right to use or are in fact using shall be responsible for maintaining in a clean and sanitary condition free of garbage, rubbish, other filth or causes of sickness that part of the passageway or right-of-way which abuts his property and which he or the occupants under his control have the right to use, or are in fact using, or which he owns. Residents should know the following: • The Town has a mandatory paper and cardboard recycling ordinance that requires residents to separate these items from their household trash. Paper and cardboard are collected every other week on the same day as the household's normal trash. Residents can call the DPW at 978.685.0950 to get their recycling schedule. • Residents are responsible for picking up loose trash left at the curb after collection. Banned Items and Recycling Requirements: Please refer to the DPW website for a complete list of all the recycling requirements: http://www.northaiidoverrecycles.com. Please contact the Health Department if you have any additional questions. Thank you. Sincere i44�""` r an Y. Sawyer, R S/RS Public Health Director File '': :, 3(+iln.'{,i�(j'V':��{j',!4S' �;;j:'(�'•;l `�,� r'bk t 1•'+(: .. ., y: '�... .. ,I .. aft a?�a a%� .''?'sll ' • ,''' r,.i...,; . rYVYtir{,i, .14 ,Ytl.. tkl'',t% ' f tnI•�;;( !j � ' '>( �r't i y i � ('7, fCfr, r t' i r L r ,lJ ^ r� i �.,..:—.-�-�.�.._.,:. _ :...... �_ ,;,' ; x;n a r. i..5'! ���; �� � ��+'�'�,� � � �� fir. ►;'r:;�l.�.r•.,��,�`'��a • ''"•.:1 �'I. 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'.._. .. .,,1C..�y ���.lid'i�Ci;.'.�''��4'%ili',•taV:<PJI�,�IjI���.11�I,;Pi'jll`"r,•.'. .iq:l II'�II'J'1'Ita'NS'rC1�l�(;'D'1'U, I; : , . r .I I:,1'til J o ^„{,,,,s,1 „r�?,,,r,:v.. .I ,. ,t .. ” __.__•_ TOWN OF NORTH ANDOVER YSTEM PUMPING RECORD DATE: 1 �7 SYSTEM OWNER & ADDRESS Al, SYSTEM LOCATION (exam le: left front of house) Cr - 3 ?rn DATE OF PUMPING: 7'D% QUANTITY PUMPED %r©y GALLONS CESSPOOL: NO ✓ YES SEPTIC TANK: NO NATURE OF SERVICE: ROUTINE i✓ EMERGENCY OBSERVATIONS: GOOD CONDITION HEAVY GREASE ROOTS EXCESSIVE SOLIDS �— SOLIDS CARRYOVER YES ✓ FULL TO COVER BAFFLES IN PLACE LEACHFIELD RUNBACK FLOODED OTHER (EXPLAIN) SYSTEM PUMPED BY: Anooyer- �-1G COMMENTS: 1 CONTENTS TRANSFERRED TO: S5) . . r M� 09/07/2000 10:09 FAX 978 688 9556 04/06/1997 15:02 5083736611 1/16(41 ANlwvrr 12.©. 4. )Z6 Mo#n St, A/e ,-4, A naa✓�� W4 u) L'.4. SSI -cae N inS4-r'tl Lt ;It, iayo TOWN OF NORTH ANDOVER CUS 002 STEWART/ANDOVER PAGE 02 ms's SEPTIC Tua sE�t am 47 lWyAOAD STFdM ' MtNX�M. M O1935 978.372.7471 M0t m DF M MHLY REi� Fit '!MN Or Z(� 3 FORM U - LOT RELEASE FORM INSTRUCTIONS: This form is used to verify that all necessary approvals/permits from Boards and Departments having jurisdiction have been obtained. This does not relieve the applicant and/or landowner from compliance with any applicable or requirements. ****APPLICANT FILLS OUT THIS SECTION*********�** %7Y- 750 y63 APPLICANTIViie, �00J. hh-Co.rPHONE �V 3- 3VY LOCATION: Assessor's Map Number 090 SUBDIVISION STREET h ers ,► 6, PARCEL LOT (S) 005 ST. NUMBER 36 �L *************OFFICIAL USE ONLY********* ********** RECOMMENDATIONS OF TOWN AGENTS: CONSERVATION ADMINI§TRATOR COMMENTS DATE APPROVED DATE REJECTED TOWN PLANNER DATE �PPROVED DATE REJECTED COMMENTS FOOD INSPECTOR -HEALTH DATE APPROVED DATE REJECTED SEPTIC rNSPECTOR-HEALTH DATE APPROVED_ DATE REJECTED COMMENTS ���,�� - .� .^r., r ,d2 ✓d cl , 'c,-.1� 4� PUBLIC WORKS - SEWER/WATER CONNECTIONS DRIVEWAY PERMIT • FIRE DEPARTMENT RECEIVED BY BUILDING INSPECTOR DATE SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: 3 c a Owner. Date of Inspection: � S SKETCH OF SEWAGE DISPOSAL SYSTEM: include ties to at least two permanent referenc locate all wells within 100' (Locate where pub 3 = tl�1t L10 t' l fp/10Se G (� a) 'L4 l 3. 3c)1 6 11 Q �gc)-?` = -3g t l o" y,o (revirod 04/25/97) cAI2 : 1 4 6FT. 0 � in.�>v�ytoq- nY ,Jona oac,.�3'-rr<r�wt,�n A* NVTfirp d + P h V' I)D //ej De- N�� 93 Q 41 �2 M h � L• S�rprcrs � �� 1� oa CAMERON BISHOP ENGINEERING CORP. Date t G - 14 - 88 1 (617) 279-0733 :orrowe r: 4 125 MAIN ST., STONEHAM, MA 02180 SA:Z� No. I ZS Addresst 362 54-►�ct-arte� Pnrci Q� i� t,��.)�Y X55 Book. -Z2-I6 Page ;T6— Plan i oott Certif. 7R0 -+ AND TITLE INSURERS I hereby certify that, based on an inspection of the premises, all buildinzs, known easements and observable encroachments are located approzi.-ately as shown hereon, that according to the F.I.R.M, dated G - 1T.83 the premises do r,,,4 -fall rjithin a flood hazard zona and that in my professi nal o,Pinion the premicos conform to tho zoning requirements requirements of N. Y- t.F-nhPlicable at the time of construction. i Zt1 OF MAss��y� o`er CHARLES r. 17. MASON q V J1. ,A No. 953G O ' �O/ST£l' �O SUit, � Reg. Land Surveyor the location of property lines shown hereon is lased on plans by others and on information f^om various sources and is to be used for mort(;nge purpo^es only and not for establishirg lo: lines, location of 1'ertcej, ot• con:;tructlon. Theon of field measurements con- lo: to the technical standards of the A:;sn. of 1-ind Surveyors and Civil Engineers. An instruncnt survey i:: advi-able if ::trucLure:; are loc:tLcd within one foot of a lot line. �'LF�Cg�ioN S /1'=ILO ` s CO M 0 IN T n fR NC 3 �X 72"— fir. Important: When filling out forms on the computer, use only the tab key to move your cursor - do not use the return key. Q nam Commonwealthof assac usetts City/Town of System Pumping Recar 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 Syste Pumpi�;g;Feco� irp�s e�ubmitted to the local Board of Health or other approving authority within 14 d ys from the pumping date it accordance with 310 CMR 15.351. I A. Facility Information 1. System Location: Address City own 2. System Owner: 1 Name Address (if different from location) City/Town B. Pumping Record TOWN OF NORTH ANDOVER HEALTH DEPARTV, 1v-1 M0- CO 12 State Zip Code State Zip Co Telephone Number 1. Date of Pumping 2Quantity Pumped: Date . y umpe: Gallons 3. Type of system: ❑ Cesspool(s) Septic Tank ❑ Tight Tank ❑ Grease Trap ❑ Other (describe): 4. Effluent Tee Filter present? 0 Yes ❑ No 5. Condition of T tem: 6 R If yes, was it cleaned? ❑ Yes ❑ No System Pumped By: Name Vehicle License Number nA 9'j-9- �i Ru Pr"P 1 or - Company 7. Location where contents weWdisposed: Sionbturk of Hauler Signature of Receiving Facility t5form4.doc• 03/06' S-13 -6 Date Date System Pumping Record • Page 1 of 1 Commonwealth of Massachusetts City/Town of No. Andover RECEIVED o System Pumping Record Form 4 Nov 2 6 2007 M TOMN Ur N(A i ri ANL1O�/ DEP has provided this form for use by local Boards of Hkt�# 1m}vUe ed, but the information must be substantially the same as that provided here. Before using Is orm, 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. Important: When filling out forms on the computer, use only the tab key to move your cursor - do not use the return key. t� reaAn /� A. Facility Information 1. System Location: 362 Sharpner's Pond Rd. Address No. Andover City/Town 2. System Owner: Jennie Eostein Name Address (if different from location) City/Town B. Pumping Record 1. Date of Pumping 3. Type of system: ❑ ❑ Other (describe): 8/16/05 Date Cesspool(s) 4. Effluent Tee Filter present? ❑ Yes 0 No 5. Condition of System: 6. System Pumped By: Benjamin Shute Name J's Septic & Drain Company 7. Location where contents were disposed: GLSD MA State State Telephone Number 2. Quantity Pumped ® Septic Tank 01845 Zip Code Zip Code 1500 Gallons ❑ Tight Tank If yes, was it cleaned? ❑ Yes ❑ No H79 406 Vehicle License Number 8/16/05 Date t5form4.doc• 06/03 System Pumping Record • Page 1 of 1