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Town of L) ., J -j 6.W-
SYSTEM PUMPING RECORD
DATE: tC) o2" U --
SYSTEM OWNER & ADDRESS
TAtC
SYSTEM LOCATION
(example: left front of house)
f\ ,oJr o� 6,�s-e-
DATE OF PUMPING:
o - ,:� r ()
QUANTITY PUMPED:
t 000)
GALLONS
CESSPOOL: NO
YES
S PTIC TANK: NO
YES
/-
NATURE OF SERVICE: ROUTINE EMERGENCY
OBSERVATIONS:
GOOD CONDITION
HEAVY GREASE
ROOTS
EXCESSIVE SOLIDS
SOLIDS CARRYOVER
FULL TO COVER
BAFFLES IN PLACE
LEACHFIELD RUNBACK
FLOODED
OTHER (EXPLAIN)
SYSTEM PUMPED BY: Bateson Enterprises, Inc.
COMMENTS:
CONTENTS TRANSFERRED TO: K;
' ' ) J , T)
WELL DATABASE
ADDRESS: -� � o :;,
AGE OF WELL: WELL DRILLER:
WELL PERMIT 4: WELL LOCATION:
.WELL PERMIT DATE: .S' � 2 �f,S DEPTH OF WELI
,
,Zej (�o.
TYPE OF WELL: a.. DRILL b. DOWN
TYPE OF WATER BEARING ROCK.
WATER ANALYSIS DATE: \".-HIGH MANGANESE: Y N
HIGH IRON: Y N OTHER CONTAMINANTS: Y N
WELL DATABASE
ADDRESS: � � -
AGE OF WELL: WELL DRILLER:
WELL PERMIT #: WELL LOCATION:
WELL PERMIT DATE: DEPTH OF WELL:
TYPE OF WELL: a.. DRILLED DUG c. UNKNOWN
TYPE OF WATER BEARING ROCK: *+»�
WATER ANALYSIS DATE: HIGH MANGANESE: Y
HIGH IRON: Y N OTHER CONT ANTS: Y N
F
OFFICIAL
COMMONWEALTH OF MASSACHUSETTS
OF ENVIRONMENTAL AFFAIRS
OF ENVIRONMENTAL PROTECTION
TITLE 5
N FORM — NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM
PART A
CERTIFICATION
Property Address: 370 Forest Street
_ North Andover
Owner's Name: _Innovated Properties_
Owner's Address: _237 Lantern Road_
_ Revere, Ma 02151_
Date of Inspection: 7/23/2004_
Name of Inspector: Neil J Bateson
Company Name: Bateson Enterprises Inc,_
Mailing Address: _111 Argilla Road_
_Andover, Ma. 01810_
Telephone Number: _( 978 ) 475-4786_
CERTIFICATION STATEMENT
RECEIVED
JUL 3 0 2004
TOWNALTH DEPARTMENOF NORTH T
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
X Conditionally Passes
Needs Further Evaluation by the Local Approving Authority
Fail
Inspector's Signature: Date: 7/23/2004
The system inspector shall submit a copy o is 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.
Page 2 of I l
OFFICIAL INSPECTION FORM — NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION (continued)
Property Address: _370 Forest Street_
_ North Andover_
Owner: _Innovated Properties_
Date of Inspection: _7/23/2004_
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:
X 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.
_X 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. Septic tank leaking out.
ND explain:
N_ 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:
N 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:
Page 3 of 11
OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION (continued)
Property Address: _370 Forest Street_
—North Andover_
Owner: _Innovated Properties_
Date of Inspection: 7/23/2004_
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)(6) 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 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 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. Other:
Page 4 of 11
OFFICIAL INSPECTION FORM — NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION (continued)
Property Address: _370 Forest Street _
—North Andover_
Owner: _Innovated Properties_
Date of Inspection: 7/23/2004
D. System Failure Criteria applicable to all systems:
You must indicate "yes" or "no?' to each of the following for all inspections:
Yes No
_ No Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool
_No_ Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or
clogged SAS or cesspool
_No_ Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or
cesspool
No Liquid depth in cesspool is less than 6" below invert or available volume is 1/2 day flow.
_No_ Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s).
Number of times pumped
_ _No_ Any portion of the SAS, cesspool or privy is below high ground water elevation.
_No_ Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface
water supply.
_No_ Any portion of a cesspool or privy is within a Zone 1 of a public well.
_ No Any portion of a cesspool or privy is within 50 feet of a private water supply well.
_No_ 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/No) 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•
You must indicate either "yes" or "no" to each of the following:
(The following criteria apply to large systems in addition to the criteria above)
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.
Page 5 of l l
OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART B
CHECKLIST
Property Address: _370 Forest Street_
—North Andover_
Owner: _Innovated Properties_
Date of Inspection: _7/23/2004
Check if the following have been done. You must indicate `yes" or "no" as to each of the following:
Yes No
Yes_ _ Pumping information was provided by the owner, occupant, or Board of Health
No Were any of the system components pumped out in the previous two weeks ?
No Has the system received normal flows in the previous two week period ?
No Have large volumes of water been introduced to the system recently or as part of this inspection ?
N/A _ Were as built plans of the system obtained and examined? (If they were not available note as N/A)
_No_ Was the facility or dwelling inspected for signs of sewage back up ?
House had fire, unable to see cellar.
Yes _ Was the site inspected for signs of break out ?
Yes _ Were all system components, excluding the SAS, located on site ?
_Yes_ _ 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 ?
_Yes_ _ 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
_No_ Existing information.
_
No 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
OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION
Property Address: 370 Forest Street
—North Andover_
Owner: _Innovated Properties_
Date of Inspection: 7/23/2004
FLOW CONDITIONS
RESIDENTIAL
Number of bedrooms (design): —N/A _ Number of bedrooms (actual): 3_
DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x # of bedrooms): N/A_
Number of current residents: _0
Does residence have a garbage grinder (yes or no): No_
Is laundry on a separate sewage system (yes or no): _ No_
Laundry system inspected (yes or no): ,
Seasonal use: (yes or no): —No _
Water meter readings: _On well water _
Sump pump (yes or no): _No_
Last date of occupancy: No
for 1 year, house had fire
COMMERCIALANDUSTRIAL
Type of establishment:
Design flow (based on 310 CMR 15.203): gpd
Basis of design flow (seats/persons/sgft,etc.):
Grease trap present (yes or no): _
Industrial waste holding tank present (yes or no): _
Non -sanitary waste discharged to the Title 5 system (yes or no): _
Water meter readings, if available:
Last date of occupancy/use:
OTHER (describe):
GENERAL INFORMATION
Pumping Records
Source of information: _Pumped two years ago, owner _
Was system pumped as part of the inspection (yes or no): _No_
If yes, volume pumped: _gallons -- Plow was quantity pumped determined?
Reason for pumping:
TYPE OF SYSTEM
X 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/Altemative 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 age of all components, date installed (if known) and source of information: Unknown_
Were sewage odors detected when arriving at the site (yes or no): _No_
Page 7 of 11
OFFICIAL INSPECTION FORM — NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Property Address: _370 Forest Street_
_ North Andover_
Owner: Innovated Properties
Date of Inspection: 723/2004_
BUILDING SEWER _ X _ (locate on site plan)
Depth below grade: —30" _
Materials of construction: _ cast iron _40 PVC other
Distance from private water supply well or suction line:
Comments (on condition of joints, venting, evidence of leakage, etc.):
SEPTIC TANK: X
Unable to see piping, house had fire. _
Depth below grade: _18"_
Material of construction: X concrete _ metal _fiberglass _polyethylene
other(explain)
If tank is metal list age: _ Is age confirmed by a Certificate of Compliance (yes or no): _ (attach a copy of
certificate)
Dimensions: 7' x 5' x 4'
Sludge depth —1" _
Distance from top of sludge to bottom of outlet tee or baffle:
Scum thickness: _0"
Distance from top of scum to top of outlet tee or baffle:. N/A N/A = tank leaking out
Distance from bottom of scum to bottom of outlet tee or baffle: _N/A_
How were dimensions determined: _
Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels
as related to outlet invert, evidence of leakage, etc.)_ Inlet baffle ok. Outlet baffle ok. Depth of liquid below
outlet invert. Evidence of leakage. _
GREASE TRAP: (locate 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 baffle:
Distance from bottom of scum to bottom of outlet tee or baffle:
Date of last pumping:
Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels
as related to outlet invert, evidence of leakage, etc.):
Page 8 of 11
OFFICIAL INSPECTION FORM — NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Property Address: 370 Forest Street_
_ North Andover_
Owner: _Innovated Properties
Date of Inspection: _7/23/2004
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/day
Alarm present (yes or no):
Alarm level: Alarm in working order (yes or no):
Date of last pumping:
Comments (condition of alarm and float switches, etc.):
DISTRIBUTION BOX: X (if present must be opened)(locate on site plan)
Depth of liquid level above outlet invert: –0
—
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.) -_D -box level & distribution equal. No evidence of leakage. Light carryover. D -
Box cover broken, replaced same._
PUMP CHAMBER: _ (locate on site plan)
Pump in working order (yes or no): _
Alarm in working order (yes or no):
Comments (note condition of pump chamber, condition of pumps and appurtenances, etc.):
Page 9 of 11
OFFICIAL INSPECTION FORM — NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Property Address: 370 Forest Street_
Owner: _Innovated Properties_
Date of Inspection: 7123/2004
SOIL ABSORPTION SYSTEM (SAS): _X (locate on site plan, excavation not required)
If SAS not located explain why:
Type
leaching pits, number:_
leaching chambers, number:
leaching galleries, number:
leaching trenches, number, length:
X leaching fields, number, dimensions: _1 field 10' x 60'_
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.): _ Soil oL Vegetation oL No sign of ponding to surface._
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 or no):
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.):
Page 10 of 11
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Property Address: 370 Forest Street _
—North Andover_
Owner: _Innovated Properties_
Date of Inspection: 783/2004
SKETCH OF SEWAGE DISPOSAL SYSTEM
Provide a sketch 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.
Well
Garage
Driveway
House
B Septic
Tank D -
Box
A�
A to Tank =19'
A to D -Box = 2816"
B to Tank =15'
B to D -Box = 26'6"
Page 11 of 11
OFFICIAL INSPECTION FORM — NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Property Address: _370 Forest Street_
_ North Andover
—
Owner: Innovated Properties_
Date of Inspection: _7/23/2004
SITE EXAM
Slope
Surface water
Check cellar
Shallow wells
Estimated depth to ground water _ >61
_
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 within 150 feet of SAS)
Checked with local Board of Health -explain: _
Checked with local excavators, installers- (attach documentation)
X Accessed USGS database -explain: _ Essex County Soil Map_
You must describe how you established the high ground water elevation: Essex County Soil Map, Sheet # 36,
Canton Soil, Water> 6' Deep. _
Tel: (978) 475-4786
Fax: (978) 475-5451
BATESON ENTERPRISES, INC.
Excavating -Water.& Sewer Lines -Septic Systems & Pumping Service
111 Argilla Road Andover, Mass. 01810
Title 5 Inspection Report
Property Address: 370 Forest Street, North Andover
Owner: Innovated Properties
Date of Inspection: 7/23/2004
My report contained herein does not constitute a guarantee of future usage and the functionality of the existing
septic system. Such report issued herewith is merely based upon my observations, and I hereby disclaim any further
operation of your current septic system.
Neil L Befteson
Bateson Enterprises, Inc.
Town of North Andover
Office of the Health Department
Community Development and Services Divis
400 OSGOOD STREET
North Andover, Massachusetts 01845
http:/ /www.townofnorthandover.com
Susan Y. Sawyer, REHS/RS a -mad: healthdeptC)townofnorthandover.com P (978) 688-9540
Public Health Director F (978) 688-8476
INFORMATION REQUEST
Health Department
Please use this form if the Health Director is unavailable to provide immediate assistance.
Please fill out this form in its entirety to ensure an accurate and prompt response. All requests
for information will be handled as soon as possible.
CONTACT INFORMATION
Date:
Name:/Cid //1— 44fi1//1��s-5'
Phone number: %� X'00 '5:�?s
Fax number:
Address:
INQUIRY - Property in question: (Please include as much information as possible)
Subject:
Inquiry:
Thank you for your interest and inquiry.
2C4--�
BOARD OF APPEALS 688-9541 BUILDING 688-9545 CONSERVATION 688-9530 HEALTH 688-9540 PLANNING 688-9535
Town of North Andover
Office of the Health Department
Community Development and Services Division
400 OSGOOD STREET
North Andover, Massachusetts 01845
Susan Y. Sawyer, REHS/RS
Public Health Director
978.688.9540 - Phone
978.688.8476 - Fax
CWWqI"2E Off' C09V4'LIANCE
As of:
November 17, 2005
This is to cert that
the individual subsurface disposal system
IncCivicCuaCComponent Repair — Tank oncy
6y
2'odd oateson
At
3 70 Forest Street
North Andover, ,SIA 01845
Yfas 6een installed in accordance with the provisions of Titre v of the State Sanitary Code and
with the North Andover Board of Yfealth regulations.
The Issuance of this certificate shall not 6e construed as a guarantee that the system will
function satisfactorily.
Susan 7 Sawyer, RE31S, QU
Tu6lic Ifealth Director
BOARD OF APPEALS 688-9541 BUILDING 688-9545 CONSERVATION 688-9530 HEALTH 688-9540 PLANNING 688-9535
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Town of North Andover
Health` Department Date: D
Location:
(Indicate Address, if Residential, or Name of Business)
Check #• %)
Type of Permit or License: (Circle)
➢ Animal $
➢ Dumpster $
➢ Food Service - Type: $
➢ Funeral Directors $
➢ Massage Establishment $
➢ Massage Practice
$
➢ Offal (Septic) Hauler
$
➢ Recreational Camp
$
➢ SEPTIC PERMITS:
❑ Septic - Soil Testing
$
❑ Septic - Design Approval
$
❑ .,,5 tic Disposal Works Construction (DWC) $- s—,
❑ Septic Disposal Works Installers (DWI)
$
➢ Sun tanning
$
➢ Swimming Pool
$
➢ Tobacco
$
➢ TrashlSolid Waste Hauler
$
➢ Well Construction
$
➢ OTHER: (Indicate)
Health Agent Initials
C4*5
White - Applicant Yellow - Health Pink - Treasurer
9
TOWN OF NORTH ANDOVER NORTH
Office of COMMUNITY DEVELOPMENT AND SERVICES a:°�;`'°
HEALTH DEPARTMENT • x
400 OSGOOD STREET � �o
NORTH ANDOVER, MASSACHUSETTS 01845 �'"a ••_��''��'
s�cHust
978.688.9540 — Phone
Susan Y. Sawyer, REHS/RS 978.688.9542 — FAX
Public Health Director healthdept@townofnorthandover.com - e-mail
www.townofnorthandover.com - website
APPLICATION FOR DISPOSAL WORKS CONSTRUCTION PERMIT
DATE: / — 1 t�_ ,—,IT
LOCATION: 3 9,G T `, J 'S T
LICENSED INSTALLER NAME:
PLEASE PRINT
SIGNATURE: / :7 77C �' TELEPHONE#
� CHECK ONE:
FULL SYSTEM REPAIR:
VCOMPONENT REPAIR (indicate what parts):
* NEW CONSTRUCTION:
* If NEW CONSTRUCTION, please attach the Foundation As -Built Plan.
$250.00 or $125 Fee Attached?
Project Manager Obligation From Attached?
Foundation As -Built?
Floor Plans?
Yes
No
Yes
No
Yes
No
Yes
No
ce
Approval of Health Agent .. -' c�.LL Date:
($250)
($125)
b
INSTALLER PROJECT MANAGEMENT OBLIGATIONS
As the North Andover licensed installer for the construction of the septic system for the
property at 37res `��' relative to the application
of%V-814-100— V.814-100 dated /- /4 -"'/" for plans by
dated with revisions dated
I understand the following obligations for management of this project:
and
1. As the installer I am obligated to obtain all permits and Board of Health approved plans prior
to performing any work on a site. I must have the approved plans and the permit on site
when any work is being done.
2. As the installer I must call for any and all inspections. If homeowner, contractor, project
manger, or any other person not associated with my company schedules an inspection and the
system is not ready then item three shall be applicable.
3. As the installer I am required to have the necessary work completed prior to the applicable
inspections as indicated below. I understand that requesting an inspection, without
completion of the items in accordance with Tile 5 and the Board of Health Regulations may
result in a $50.00 fine being levied against my company.
a) Bottom of Bed - generally first inspection unless there is a retaining wall which should be done
first. Installer must request the inspection but does not have to be present.
b) Final inspection — Engineer must first do their inspection for elevations, ties, etc. As -built or
verbal OK from engineer must be submitted to Board of Health, after which installer calls for
inspection time. Installer must be present for this inspection. With pump system all electrical
work must be ready and able to cause pump to work and alarm to function.
c) Final Grade — Installer must request inspection when all grading is complete. Does not have to be
on site.
4. As the installer I understand that only I may perform the work (other than simple excavation)
required to complete the installation of the system identified in the attached application for
installation. I further understand that work by others unlicensed to install septic systems in
North Andover can constitute reasons for denial of the system, and/or revocation or
suspension of my license to operate in the Town of North Andover; significant fines to all
persons involved are also possible.
5. As the Installer I understand that I must be on site during the performance of the following
construction. steps:
a) Determination that the proper elevation of the excavation has been reached.
b) Inspection of the sand and stone to be used.
c) Final inspection by Board of Health staff or consultant.
d) Installation of tank, D -box, pipes, stone, vent, pump chamber, retaining wall and other
components.
6. As the installer I understand that I am solely responsible for the installation of the system as
per the approved plans. No instructions by the homeowner, general contractor, or any other
persons shall absolve me of this obligation.
Undersigned Licensed Septic Installer
Date:
Disposal Works Construction Permit #
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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.
I*****************************APPLICANT FILLS OUT THIS SECTION***********************
APPLICANT��
LOCATION: Assessor's Map Number.
SUBDIVISION
STREET
PHONE
PARCEL
LOT (S)
ST. NUMBER
***************************************OFFICIAL USE ONLY***********************
RECONNENDATIONS OF TOWN AGENTS:
TION ADMINIAATOR DATE APPROVED 8'ZS'/a y
�� DATE REJECTED
COMMENTS
TOWN PLANNER
DATE APPROVED
DATE REJECTED
COMMENTS
FOOD IN_ SPES,TOR-HEALTH
DATE APPROVED
��
DATE REJECTED
EALTH
DATE APPROVED
DATE REJECTED
COMMENTS Ale -L,, c._� �r� N of za -e--x e-st- cT
PUBLIC WORKS •RtEWPRIWATER CONNECTIONS
DRIVEWAY PERMIT e �Et 5 -� ( #-> i
FIRE DEPARTMENT,
RECEIVED BY BUILDING INSPECTOR DATE
Revised 9197 jm
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NUMBER FEE
3 U THE COMMONWEALTH OF MASSACHUSETTS 25.00
-..TOTAM------ of ........ORTH...ANDOVER.................. ........••.
This is to Certify that...............E . M. Young Well Company
NAME
.............. 36--•Pelham---Streets.-_.Salem ......N.H. 03079
ADDRESS
IS HEREBY GRANTED A LICENSE
For ------------- Well ... -ermit... --... 3.7._O ... Fare.s_t... Streef:............................................................
-------------•----•---------------•-------------....•-----------------------•------•-••---------------••-•---------------•--------•----•-----------------------------------
---------------•------•••---------------------•----•---•--------------------••--•----•------••-•------------...----------------------------•-•---------------•-----------
This license is granted in conformity with the Statutes and ordinances relating thereto, and
expires ----December 31, 199.5 _unless a de r revoke
--------- ------ - -----------9.5
,
00
V..'--•-- . ......... ----- ---...........
--------------May 22'------------- ._.19---95 ..._-.
FORM 433 HOBBS & WARREN. INC.