HomeMy WebLinkAboutMiscellaneous - 373 RALEIGH TAVERN LANE 4/30/2018 (2)Commonwealth of Massachusetts
City/Town of No Andover RE:21V'_.==z
System Pumping Record
Form 4 1mv 12 2013
H
DEP has provided this form for use by local Boards of Health. Otvvry �r[II'Ftr-r
lC1yh
heraformsrvvrfrnay1iitbelus but the
information must be substantially the same as that provided h6ne — efore'using this form, check with your
local Board of Health to determine the form they use. The System Pumping Record must be submitted to
the local Board of Health or other approving authority within 14 days from the pumping date in
accordance with 310 CMR 15.351.
A. Facility Information
Important: When
filling out forms 1. System Location:
on the computer,
use only the tab
key to move your Address
cursor - do not No Andover
use the return
/I
Ma
key. City/Town State Zip Code
2. System Owner:
VQ ren L)SO
Name
tenon
Address (if different from location)
City/Town
State
Telephone Number
Zip Code
B. Pumping Record
o -c)
1. Date of Pumping Dat G C j 2. Quantity Pumped: Gallons
3. Type of system: ❑ Cesspool(s) Septic Tank ❑ Tight Tank ❑ Grease Trap
❑ Other (describe): ,\
4. Effluent Tee Filter present? ❑ Yes ❑ No If yes, was it cleaned? ❑ Yes ❑ No
5. Condition of System:
6. System Pum
�—o_ �'E�
Name Vehicle License Number
Stewart s Se tic S - Ice
Company
7. Location where contents were disposed:
Stewart's Pre-treatment Plant, 20 So. Mill Bradford, Ma 01835
Signature of Hauler
Signature of Receiving Facility
Date
Date
t5form4.doc• 03/06 System Pumping Record • Page 1 of 1
a
Molt' `1 �, J JjD�.t.1►,�1y�)�� 'Fr+,?j� fj ��o
.I: ..,!(1'�,.',t�Vl„t(�y�, ;,:��il•�f�K%Ji�'�i�l�•lyl ii%r;^ihS;!
p'rovlded jhls form for use by local oar(
:,.be :ubml1ted to the.local'Board of Health or Char
..A Facility Jnfori��a lon
•6,'*.Wiw'0gout 1;; System l.ocatlon; TO\A
tab kay' Address
to move your
.arxor.•do•wt . - '� ,/9l'�dt.P�l J
us+' Utii rotum : ;' ., : ;,. • /I•own
ie
\ .,;•.� 4.ISI'w,dj;��ti�J,•,r.,;'''\,;.':x,17.1:)li•vg.)'.'• \�
411;�;�:4q:\�,•Y;.;..,. S stem owner•',��,,,
:•`rfl•' ..;}c �l�
./s•/.f..;:�. x,:Y,.J,.l.' I, ,t ,. ,;:,'J�.I,;r;�'•,,;,a.,.
' MASSACHUSETTS .
System Pumping Recor•-0 rr, :,
orlry,
DEC 0 7 2007
V OF NORTH ANDOVER
:ALTH DERftftf fi-MT
Slab ZIP Code
: i N •,, � , '•, „ �"�/TCA /
, .L,..�''i':',;'�.)1t:i',l;rf'•ti>'.iJ;� ',,�,• '•'\t'1'!''i•i•.
• `+” ;i.a,,, ,L.i.;),.,J:'J;.`t"t'r�' Narttl • •',1:;:`y' 1-..,,•t",,,'• 'i!,...''.n:.•�...; ..
�,)• , ..I ,.: �:�,.. ,Ir L�,e... •G r.Y�ri: �iLJ:: •J:
"V° Address (If dlNerenl from bcatlon)
Ctq/fovm, ;i' r: State
10.
CQQ d
Telephone Number
i��: 'j��ii' •:•ii%'%f45>I�J:1�,(��'1.iit:��"Ij,7(I�yi:'lii!-J)YSl�bt•Lf''••1� • •. 4z. -Y--
""'
I •'1 Date of Pumpinq, 2aleQuandty Pumped:
TYP.e Pl.aystem: , [] Cesspools) ptic Tank
/.,' i' ❑ Tight Tank
Other (describe);
:ry,;7i :'a;,,. •,'ir1.;1'..•,:,i, '.'";
i. :, :•?, ;jl;l E,fstluari�. ee Fllte{tTresen? •❑
o , If yes, W83 It cleaned? ❑ Yes ❑ No
. ,•, L„ ,�'' -. 'if .�'�'•ti'.1...•,.M4, t[,f"�.r.'i/ti.' A'yj+iYLlfu!t tt\' .'%�' .
alpcn.QG•sX3s
.. ... .\:y•:r.^�••r'; l;i�'L hE,t�' �J'�(:rsh�l �irt Lv.. ji.\\+i ,I 7♦: J L.,':. ``//\' �aJ�//�/��t�� / ^ /� //1
' i!\.1 J_,. •. 9,L�` �,:il' J.Y;L,, ,� ,,•,ri I �•�'�'�'L••' : r /��`•--�. v�� ' // // - C�/�/"'� ! i � ' ,
' :\;., �, It.�'':i ;arlf ►i,''•IoKJ!',�:. ,i'4Y;J�'I,, /. y!.'{1'i.'li'!.'i. i"'' 1/`J ` ( V t/sJ CCVy//
u ,.r :21"iso;::i.ifi't,`•!.;'+a);4o1%;'I{ir;'(}'��(t)l'�i1'`••"�V,
Pumped By,
:;:^:•tip 'r(�
�i.!�'� •,•.�., .• ,�v •S}„i�� •1% arna7�l}.,Ir�JI:J•i 1, \ �., tr �� � ;..
;;'.'\�'�.;'�'%�Ij.�♦•i,!i:9yc��YiJ�,; +�� xll' ' `%c+\l�l
'�'r:'•:.,�r,; ,1j7r;Yi,`r'�S'L't1,�,lgs• ,'d��• .v7X,'. ;a V
::.C�:,av;. �r'.;i �.;� 1\\�;.�ih••y7ri1 t J V r �l+tl� /'�i �rfi�lr'�7�'`�'' i
P- 44""0 ..i;:7;:',. on.where concen Were:dipposed:
'':. •'� a•�il ;•I .,•i:, �; :. 1'.,,; ;;<'�1.••y: r wrt� ••rf ...f. <L' :7}y.•
tN �:.:•: '.•iii:;'•ci!'.�^�.�•vi:��t�,i:)/.\rFi'+, ;�i• j �
:\•'i: � '4��.'ii•,li•'.�•'. I•i�,..'Ci't!'ilh;J�•-}T'n;l �%r'; J�"J1;1 �\J'
':,;''•:,.;::,>ti•;,.�:�'�•.�:,;;;?:SlpnalureolHaula{��.�:;r,;;•r.•:,..:..,:. .
titt� //iti�iwr.mast's,9ov/dep!vater/approva�s%t6forms, htm#Inspect
•t5form4.doa108/QJ •�,� .';� ':�I ' '. ;
I..
f VehlcJe Ucan#e Number
dale
ft
Sytlem Pumping Record ' Paye 1 ^! '
Commonwealth of Massachusetts
ogCity%Townl of. NORTH ANDOVER,
System Pumping Record
'-Fo.rm4
Important:
When filling out
forms on the .
computer, use
only the tab key
to move your
cursor - do not
use the return
key,
SACHUSETTS V
DEP has provided this form for use by local Boards of Health. T� he -ystw
be submitted to the local Board of Health or other approving aut[hority:`—
A. Facility Information
1. System Location:
Rec
DEC 6 2006
TO%o-, . t- wJRTH ANDOVER
HEALTH DEPAPyTMENT
AddressL
City/Town Sat_�Le
2. System Owner:
-- -��� _
Name _���� ---- >----__
Address (if different from location)
mu;
Zip Code ---- - -
Cap I own State..----- ---
Zip Co
Telephone Number ---"-"-' -
B. Pumping Record
•. 1. Date.of Pumping
. Date —�-- 2. Quantity Pumped
3. ype of system: ❑ Cesspool(s) peptic Tank
❑ Other (describe):
Gallons
❑ Tight Tank
4. Effluent Tee Filter present? ❑ Yeo If yes, was it cleaned? ❑ Yes�ONO
5. Condition of System:
Pumped By:
License
6`��Vehicle � ��D 1St, a /�• - -
Company
7. Location where contents were disposed: J
Si ature of Hau----
Date -
http://www.mass.gov/dep/water/ provals/t5forms.htm#inspect
t5form4.doc• 06/03
System Pumping Record • Page 1 of 1
.ri:a.`;:ri;�rf'Si•�;:`••�k��ricf+rir�,ry.• .
�•r'�•LI IhL•;ly rrr:( �, I'' 1�)ii,fjrrlA;..•f; !�(:. '
. ��; 1::{�.1f •�rlr�l r•!:.•Y!. �r4 L:r�i1;Ir�.I, 14 yf!'JV ,�. .;� ;G,.�
:�.���1 •'N.iI ' 1�5 •. •••�iA'i i•.i�ll ilrl, yr•Y:rr r r �:,n •
'M• •
RECE
'f'C)WN U1• NUx'I'It I�r,'th:f,LHEALTH
EC 0 6 2005
u-i'� �/ OS 5YST'P-N4 PIJMPINU Rt'GO
OOR
DEPARTMENT
OVER
�Y51'2M OWNQR � DR.�ss • _-'—�"�`)s(:-l:ti•;� I�?�;;��.� ........_...._..._ _....._ ..
-QUANTITY PUMPEC
14" rukb oN nRYlce;
Uds�RYA'riUNJ. •
OOoocoUfll'rIVN � rvU. ('V k:Cirbx
RZAYY OY. A33 eAMBa IN
KOM,:
"CU ' �� .....r ��Ct•o�l�t,p KVN
MB 3011 PLOODSp 5��'F.
$OLrV OAXAYOnX _... oNeR-EXPLAIN
.r
)�14M f'4rTl�?fcl by �—, -••
,
um vt�N I'v r?l^NSt XK.lsV
a:,
NYvOfi AN- /ER/
B(� OF HEALi
TOWN OF NORTH ANDOVER NO' -4202
SYSTEM PUMPING R-ECORD
L'Y) UWNEK & ADDRESS
SYSTEM LOCATION
(example: left from of hour)
17& � �� ri
E OF PUMPINC:z Lf�4(QUANTITY PUMPED
.: �SPUUL: NO YES SEPTIC TANK: NO YES
",A-1'URE OF SERVICE: ROUTINE _.—X_ EMERCENCY
Ali>FRV \TIONS:
C OOD CONDITION
HFAVY CREASC
ROOTS
EXCESSIVE SOLIDS
SOLIDS CARRYOVER
>1 ) I LN1 PUM1)CD BY
U, I �•I rNTS.
0*.I,!,.'NT� TIZANSFEIZIZED TO
X_ FULL TO COVCIz
BAFFLLS IN P1.AC1:
LEACHFIELD RUNDACK..
FLOODED �
O,�HFR (EXPLAIN)
TOWN OF NORTH ANDOVER
SYSTEM PUMPING RECORD
DATE:
SYSTEM OWNER & ADDRESS
SYSTEM LOCATION
(example: left front of house)
DATE OF PUMPING: —�� I QUANTITY PUMPEDGALLONS
CESSPOOL: NO YES SEPTIC TANK: NO YES
NATURE OF SERVICE: ROUTINE � EMERGENCY
OBSERVATIONS:
GOOD CONDITION
HEAVY GREASE
ROOTS
EXCESSIVE SOLIDS
SOLIDS CARRYOVER
SYSTEM PUMPED BY:
COMMENTS:
r
FULL TO COVER
BAFFLES IN PLACE
LEACHFIELD RUNBACK
FLOODED
OTHER (EXPLAIN)
U � fah idhf?
CONTENTS TRANSFERRED TO: ^ — 7 ?C91
rt�{Wwtt t,r;", t
+I '
I � i !' I I
--—i I
n"- -- - - — - -- --- - -
N
i
7
SUBSURFACE SEWA E DISPOSAL SYSTEM INSPECTION
Address of property
Owner's name
Date of .Inspection
PART;A
CHECKLIST
FORM
Check if the following have been done:
Pumping information was requested of the owner, occupant, and Board of
Health.
-None--of the system components have been pumped for at least two weeks
and the system has been receiving normal flow rates during that
period. Large volumes of water have not been introduced into the
system recently or as part of this inspection.
As built plans have been obtained and.examined. Note if they are not
available with N/A.
The facility or dwelling was inspected for signs of sewage back-up.
VThe site was inspected for signs of breakout.
.� All. system components, excluding the SAS, have been located on the
site.
The septic tank manholes were.uncovered., opened, and the interior of
the septic.tank was inspected for condition of baffles'or tees,
material of construction, dimensions, depth of liquid, depth of
sludge.,. depth of scum.
The -.size and location of the SAS on the site has been determined based
on existing information or approximated by non -intrusive methods.
The facility owner (and.occupants, if different from owner) were
provided with information on the proper,maintenance of SSDS.
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PARTB
SYSTEM:,. INFORMATION
FLOW'CONDITIONS
If residential=
number of b om
.number.of current sidents
garbage grinder es or no'
laundry, connected. o. system,: ,.yes , or no
seasonal use, yes or no
If nonresidential,, calculated flow:.
Water' meter readings, if available;.;
Last date of occupancy
9
SUBSURFACE SEWAGE DISPOSAL. YSTEM INSPECTION FORM
PART' B, '
.SYSTEM INFORMATION continued
SEPTIC TANK:
(locate on site plan)
depth below grade:
material of construction: X concrete::metal FRP other (explain)
dimensions:__$.
x
sludge depth
.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
Comments.....
(recommendation for pumping, condition of inlet and outlet tees or baffles,
depth of liquid level in relation to outlet invert, structural integrity,
evidence of leakage
a recommendations for,repairs, etc.)
DISTRIBUTION.BOX:
(locate,on.site plan)
depth of liquid level above outlet invert
Comments:
(note:if*level and distribution is equal, evidence of solids carryover,
evide ce of leakage into or out of box, a omm
. . _ e datio for repairs, etc.)
- �I AM
- �. _ _ _W911- KA
CJ
PUMP CHAMBER:
(locate on site plan)
pumps in working order, yes or no
Comments:
-(note condition of pump chamber, condition of pumps and appurtenances,
recommendations for maintenance or repairs,etc.)
I
SUBSURFACE SEWAGE DISPOSAL SYSTEM. INSPECTION FORM
SART B
SYSTEM INFORMATION continued
SOIL. ABSORPTION SYSTEM (SAS):
(locate on site plan, if possible; excavation.not required, but may be
approximated'by non -intrusive methods)
If:not determined to be present, explain: -
Type
leaching pits and number
leaching chambers and number
leaching galleries and number
leaching.trenches, number, length
leaching fields, number, dimensions 1 Feel o,�
overflow cesspool, number
Comments:.
(note condition of soil,. signs of hydraulic failure, level of pondirig,
condition..of.vegetation, recommendations for maintenance or repairs,etc.)
CESSPOOLS (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 ('cesspool must be pumped as
part of inspection)
Comments:
(note condition of soil" signs of.hydraulic,failure, level'of ponding,
condition -of vegetation,` recommendations for maintenance or repairs,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;: recommendations for maintenance or repairs,etc.)
11
SUBSURFACE.SEWAGE DISPOSAL SYSTEM INSPECTION FORM
SYSTEM, INFORMATION continued
SKETCH OF. SEWAGE DISPOSAL SYSTEM:`
include ties to at least two permanent. references landmarks or benchmarks
locate all wells within 100'
1.0
DEPTH. TO GROUNDWATER
depth to groundwater
method of determination oDr proximation:
It
SUBSURFACE SEWAGE DI,SPOSAL.SYSTEM INSPECTION FORM
PART C
FAILURE;'CRITERIA
Indicate.yes, no, or not determined:(Y., N, or ND). Describe basis of
determination in all instances. If,"not,determined", explain why not)
Backup -of sewage into Iacility?
Discharge,or ponding'of effluent to the surface of the ground or.
surface.,waters?
Static liquid level in the distribution box.above;outlet invert?
Liquid.depth in cesspool <61"below invert or available volume< 1/2 day
flow?
Required pumping 4,times or more in.the last year?
number of.times pumped
Septic tank is metal? cracked? structurally unsound? substantial
infiltration? substantial exiiltration? tank failure imminent?
Is any portion of the SAS,.cesspool or privy:
.below the high groundwater elevation?
-within 50 feet of a surface water?
within.100 feet of,a surface water supply or tributary to a surface
water supply?
within,a Zone I. of a public. well?
within 50 feet of a bordering vegetated wetland or salt marsh
(cesspools and privies only, not.-the.SAS)?
,'within 50 feet of a private•water supply well-
��' less Athan 100 ' feet but greater'°ahan' 50 feet from a private water
"supply.:well with no acceptable`watet quality analysis? If the well
'has:been analyzed to be acceptable,'.attach copy of well water analysis
..,for-coliform.bacteria,' volatile'organic compounds, ammonia nitrogen
•and nitrate nitrogen.
13
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART D
CERTIFICATION
Name of Inspect
Company Name Sea, v1.3WvC.T�0�
Company Address's S'rCe�c-
Certification Statement
I certify that I have personally inspected the sewage disposal system at
this -address and that the information reported is true, accurate and
complete as of the, time.of inspection. The inspection was performed and
any recommendations regarding upgrade ,'maintenance and repair are
consistent with my training and experience in the proper -function and
manitenance of on-site sewage disposal systems.
Che k one:
I have not found any information which indi
sates.that the system fails
to adequately protect public.health or the.environment as defined in
310 CMR 15.303. Any failure.criteria not evaluated are as stated in
the FAILURE CRITERIA section of this form.
I have determined that the system fails to protect public health and
.the environment as defined in 310 CMR 15.303. The basis for this
determination is provided in the FAILURE CRITERIA section of this
form..
Inspect.or's Signature
Date _� /0118
Original to system owner
Copies to:.
Buyer (if apblicable)
Approving authority
S • _
v •
Ul:-T
r'r n !M m
,y 6
n
I
1
^
n
cu
nIn
n
H
LA
r s►
e a .
o
N
....
cn
n
�
1
Iw--X,
zti
�m
i
a�
AI-
w S.4.
I
a 4.) -aal
�"
u
(
Q6 �i
rte,
r l .
�fi
al
I
a 6
UI
�+
c $-
to N
I
imC.QCI
+$
M
Q1 Cid
W4%1 CO
I
4J
.0
M N
Q
i
*�
S� r•
OJ
Wal
r
C
4A
£
•• M N
•M
nm
wIL
:. I am
Ma
j.
N,
..
fo
01 4.1
J
4'w
M a U
U
••
s,
i (*a Oa k'fj
Z i^
$ Z; •M !C
G
G
1 m 'm m
a
'
M,
, n
as
h-: a
CT
of
> N
— _ _. , .-
Y
OG W.
£
ai S.
L
5,:
p g
, .. r.
S• J
44
ZU1
au1:
Mmaa
a a a
GU
EL Z.
G
a
a
I -Tn Co .4
0,0
w w
- -M
r,
E
I CU -a wl .4
ZU..2:
3 '
a%CA
N
I d `,
Ul
$-
o
¢ ..
h ry
pt
S:
U
4ko
Hz
ro
6
.;
Z
I
OC -P IA ••
G
� rq M M M tIJ
S.
W NU
�.
!
GmmmmaMm
al
S.•crl
r..
U
I
£��%,,.%%♦
4�
O +P •M C C
M Z
S. ••
I-
' V) (U ON ko M (U
al
AE4=1
r:.W
u
UI
I
rn6�+t5►616*+
£
60:
W.
- aaaaa'a
�
N
N (1J
I
4.)
Z
"•T In
6
U)
Ul
1
M4r-mr-U7m
CA
••
h^
-TI
IN
CU
+.)
U0
M •.
6
I
*"
.,
W
QJ
�+GG••
U7
4
G
1
I.N.
�
NG
6Z UU
1
S.
S+
.4Z
'o $a
LGN
•• S: al
U UI
••
••
I
U U7 U7 U7 d •4
W
..
o£,
M -
� of C4-
U+%C S: er.x
o►
p
..
�
x
I
0000 IM
U
.:3
£ W
U al G fo W
S.' G
!CG
a.$.
a!
i
I
i N,.��%%N
I MOW M CJ M'to
UI
W
a z u z 6:3
1
m u -I
I
I GG G►rr6.6
BaaA of
North
a
nT? QV c:D r D-ifF-,
iii_ OK
SFi''2'.TT.0 SrSi EX
INJIkLLATION C K LIST
LQT If � _✓ l r u
JEXCAVAT'ION OK FA t
1. Distance To:
a. Wetlmds
b. Drains
c. Well
-2. Water Line Location
3. No PVC Pipe
4. Septic Tank--.-
a.
ank -.-
a. Tess --Length & To Clean that Covers
b. Cement Pipe to Tank - On Both Sides of Tank
5. Distribution Box
a. Covers & Box - No Cracks
b. All Lines Flo -wing 1agaal lz,omts
c. No Back Flow
b. Leach Field or Trench
a. Dimensions
b. Stone Depth
c. Capped Ends
d. Clean Double Washed Stone
7. Leach Pits
a. Dim3nsions
b. Stone.Depth
c. Splash Pads
d. Tees
e. Cent Pipe to Pit - Both Sides
f. Clean Double Washed Stone
8. No Garbage Di spo sal
9. Final Grading Inspection
10. Barricading Covered System
11. As Built Submitted.
a. Lot Location
b. Dimensions of System
c. Location vdth Regard -to Perc Test
d. Elevations
e. Water Table
FoarA of Health
North. Andover,1iass
SUHSWRFACS DIK'M41 DESIGN CF)r.•K MIST
LOT # �.
APPROVED
Provided:
Title V
Reg 2.5
Reg 6
Reg 10.2
Reg 10.%
RATS
DISAPPROVED DATE
Reasons s
1
VAl",
'h subiitted plan must s42®: as a ffinin:
e lot to be served-area,dimensions lot #,abutters
location and log deep observation hoes -distance to ties
location and remits percolation tests -distance to ties
design calculations do calculations showing required leaching area
location and dimensions of system -including Leserve area
,f� existing and proposed contour's
g), U_ any t areas vithiFi 1,00, of 49wage disposal system or
,,I- discl airor-check ivetlands Toap?ing
h) —face end urINmrfaco drains r,,It,tyun 1001 of set -age disposal
or c��ier
1.)atlon Z�rq der la"go e � > ,�z�Yts � 3$�bin 1001 of le ge disposal.
ylut"a or 7,o1Lrd illes
j }Dvn'�n .o¢u�rhes ys£$�c�. A.L. a sippl-y �:,an 200, of sewage disposal.
1i yV {rcm o dirse. L`AL1 e
Zecation of &-W, proposed va., l to serve lot -1(x0' from leacbi.ng facility
P' cation of ua.tL-r )rocs on pmp ty-1.01 from leaching facility
location of ber chrmark
rr cirx�:.�rs
Vno
arbage disposals
PVC to be used in construction
q) profile of system -elevations of basement, plumb, pipe, septic tank,
stribution box inlets and outlets, distribution field piping and
Other elevations
r maxims ground tester elera►tion in area sewage disposal system
s) plan rrmst be prepared by a Professional. Engineer or other
prufesMfon.al authorized by law to prepare such plans
/' Uptic- is Tanks
a) capecit1.es- 50% of flotf, mter table, tecst depth of tees'l
access, puing
' cleanout
101 from cellar imll or inground mdmning pool
d) 251 from subsurface drains
Distribution Foxes
slope g eatery 0.08
I
r
FAIL I OK,
2
Leaching Pits
Leaching pits are preferred where the installation is possible
.calculations of leaching area -tea 500 eq ft
spacing
surface drainage 2%
cover material
x2 I x4" splash pad
tee at elbow
no bonds in pipe/ from d -box to pipe
Reg 15.1
15.4
15.8
3.7
Reg 14,1
14.3
1.4.4
. 14.6
14..70)
14.10 (�
a) no grea er t 20 Wmuteslinch
a�a-m4 nisi s4 ft
b'cons
c ti of field
d) surface e 2 %
e) 20 frocollar or inground s-.amdng pool
Leaching ca es
a) c c s o eaching area-r&n5DO aq A
(b) spacing -4 f rIn 6 ft with recerve between
d "tsion
d) cen.ste-A
stone
rface drainage 2%
f) surface
��c)
.
� I
s ope x = to be shovM)
y/x g 150 = (to be shown)
s
Reg 9.1 a)'approval
9.6 b) stand-by power
t � j
�� text Ai��vi`
tM
N
1 (�ovT�i
i
LOT 3-5-
6 r ,-
AGK 4�-/C C
- .^O J g o e0 • n
v ° 0 o v a v o
.5 to $jig b
0
L
� c'7
� N c.� I ti9 • � �• ai (� _Q�
Ol/T Lam"
�At ., T" �,v vr� ; nv.�
/02. ov-11
Al
0
. 4-!CP4 A T
• G✓/ r/I • Gly 9 fJt �, - "
/i.47'E.: 57r?/y /)LL TnI^
bE+lov�] c.vJ of c: l
m
North Andover Board of Health
120 Main St.
North Andover Ma.01845
Haul Lic. #151 -OOH
Install Lic. # 128-0
Date Address
11/1/2000 303 Chester St
11/1/2000 50 Willow Rd
11/1/2000 160 Carelton Ln
11/1/2000 165 Bridal Path
11/4/2000 174 Ingals St
11/4/2000 1062 Salem St
11/6/2000 373 Raligh Tavern Ln'
11/6/2000 252 Boxford St
11/6/2000 150 Liberty St
11/6/2000 149 Osgood St
11/7/2000 255 Haymeadow
11/7/2000 850 Winter St
11/8/2000 25 Windsor Ln
11/9/2000 249 Carlton Ln
11/9/2000 767 Johnson St
11/10/2000 56 Academy Rd
11/14/2000 Sugar Cane Ln
11/14/2000 250 Abbott St
11/15/2000 195 Winter St
11/15/2000 187 Winter St
11/16/2000 85 Laconia Cir
11/1612000 86 Willow Ridge
11/17/2000 2135 Turnpike St
11/20/2000 203 Grandville Ln
11/2012000 391 Pleasant St
11/20/2000 124 Tucker Farm Rd
11/22/2000 394 Boston Rd
11/22/2000 728 Forest St
11/22/2000 18 Johnney Cake St
11/24/2000 106 Rockey Brook Rd
11/24/2000 258 Rea St
11/28/2000 1815 Great Pond Rd
11/28/2000 1420 Great Pond Rd
11/29/2000 266 Lacy St
11/29/2000 155 Laconia Cir
Andover Septic
47 Railroad St.
Bradford Ma. 01835
Gallons Comments
1000
1000
1500
1500
1000
1250
1000
1000 Leachfield Run Back/ Ex. Solids
1500
1000
1500
1250
1500
1500
1500
1500
1500
1000 Extra Solids
1500
1500
1500
1000
1500
1000 Flooded
1500
1500
1500
1500
1500
1500
1000
1000
1500
1000
1500
BEG r�
FORM U - VERIFICATION 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: -1a,-6- Phone)
LOCATION: Assessor's Map Number Parcel 3 5
Subdivision / Lot(s)
Street �3 la �, �� eZ�l 1't . t. Number L
************************Official Use Only************************
RECOMMENDATIO ,F AGENTS:
C�
Date Approved Sjr
Conservation Administrator Date Rejected
Comments M{�i�aC V�1I+aNAS aces �e b { IIr
Town Planner
Comments
Food -'Inspector -Health
Septic Inspector -Health
Comments
Public Works - sewer/water connections
- driveway permit
Fire Department
Date Approved
Date Rejected
Date'ypproved _
Date Rejected
Date Approved
Date .Rejected
Received by Building Inspector Date
BOARD OF HEALTH
TOWN OF NORTH ANDOVER, MASS.
6�? Y
1. NAME /'�i(/ Ael- 10'ee Peolf-MY DATE F/-),-/7 l
Sys
2. ADDRESS 61 el ?--4 LOT NO. ?s' TEL .' 7.5
3. NO. OF BEDROOMS DEN YES NO =�
4. GARBAGE GRINDER YES NO
5. SHOW DIMENSIONS OF HOUSE
6. SHOW DISTANCES OF HOUSE TO ALL PROPERTY LINES
7. SHOW DIMENSIONS OF LOT
8. SHOW LOCATION AND SIZE OF SEPTIC TANK OR CESSPOOL
9. NOTE LOCATION AND DISTANCE OF WELL FROM SEWERAGE SYSTEM
10. SHOW LOCATION OF BROOKS, STREAMS, DITCHES, LEDGE OUTCROP, ETC.
11. SHOW DISTANCE OF SEPTIC TANK OR CESSPOOL FROM HOUSE
NOTE: LOCAL REGULATIONS SHOULD BE READ CAREFULLY.
APPLICATION FOR SEWAGE DISPOSAL INSTALLATION
HEALTH DEPARTMENT - NORTH ANDOVER, MASS.
I reby make lication for a permit for a sewage disposal installation at
�( 3 f t-�t/ ,_--� . I will install this system in ac-
cordance with all the laws 59f the Commonwealth of Massachusetts and regulations of
the Board of Health of the Town of North Andover.
Further, I will construct the house sewer of bell and spigot pipe, the minimum
diameter being 4 inches, and will maintain a minimum grade of 1% until 10 feet pre-
ceding the septic tank, where the grade shall not exceed 2%. I will install a con-
crete septic tank of c in size. A manhole (s) permitting easy cleaning
will be provided with removable cover (s) of iron or concrete within 12 inches of
the ground surface. I will provide subsurface disposal field with 4 inch perforated
or open jointed pipe and laid in a series of trenches, the bottom of which will pro-
vide a minimum of lineal (square) feet of effective absorption area.
The pipes will be laid on a 6 inch layer of washed gravel or crushed stone ranging
in size from 3/4 to 1-1/2 inches (dia.) and the pipes will be surrounded by similar
material to a height of 2 inches above the crown of the pipe. The joints of these
pipes will be protected from clogging and before filling the trench, 2 inches of
gravel or stone 1/8" to 1/4" (dia.) will be placed over the course gravel or stone.
The disposal field will be installed at a grade of 4 to 6 inches/100 feet. No single
tile line will exceed 100 feet in length and in any case, two lines of tile will be
installed. A minimum of 6 feet will be maintained between the center lines of the
disposal field trenches and the average depth of trench shall not exceed 36 inches.
No part of the installation will be less than 100 feet from any private water supply,
25 feet from any stream, 20 feet from any dwelling or 10 feet from any property line.
I further agree not to cover any portion of this installation until approved by the
inspection officer, as provided below, and to incorporate any additional requirements
that may be attached to the permit. Plot Plans must be submitted with application.
DATE -7
ignature of App lic t
I hereby issue the above permit for the Board of Health of the To of North
Andover, Massachusetts.
DATE // - / "L - -7 /
Signature of Health Agent
I have inspected the uncovered system indicated above and find everything done
as described.
DATE
Signature of Inspecting Officer
Percolation Test
Garbage Grinder
Q
qg** luoo�
OUP
CLI
�-��� �.-�.-�►� des
ty
/ss�es.
ll- you
tie
�P15 a //
Pow
r+
YA'
If.. 'ft'
P
TO
DAT
TIME �1 AM
'
H
F M
AR CODE
NO.
OF
N
EXT.
E
M
M
E
s
E
M
s
G
E.
_
SIGNED
PHONED 0
1 BAACK ❑
CALL RNED ❑
SEE YO TO ❑ I
WILL AGAIN ALL ❑
WAS IN El
URGENT ❑
7,
q -
P
LfflELL Sn,' EDIT
o o 1., p-1
ILI
ratanding bev�vaen,Ah$tP_
tnp,, ;0q0.,v,' cl (,-;ument -I& a (nern.orandum Of,10nds,
-T L ne,
Fr s,,0wr �of'573 leigh,�avcr.n Here e�
r r .4 r-1,31 I and 1K, D Fangule te,'.
r_aftsd, "Thip, Owners," end It Townf, Nort APC.I(DIer:
p oposod building,
.g Ormit-for tlie 0,
If the Town of
e
a
n' f.fle v4ththe, Town of` North. Andover as ddition o
r 373 Ral�icgt% Tavrllyr� Larn
iL he -Owners agree. to install a new
n-" -,'M1. hael Ky6z, aeGhILGO,") T
"The Frangules Addi.tto
.0 said plans
'y if the I je�nts dei -rrn
vin or, s ac Or , he
m Lo c,,&v' the a opert
septic, yste, J
the Town an The Owners warrant -a new
or plans modified as mutuali.y agreed b�t d
apprc _
-)ve
system. The design of said system must be. d by the Town of No rth, Andover
Board, ofHeaith.
L
UnW S,41 -ft
Qrmlt will ue granted ,, t 1 0
Ti}j,e Owners further understand that no occupancy pe 2
I inspectv)(1
th, which- ould not',occur un"ti
by theTarrof North Andover Board of�Heai
by the Board of lriallb.
be inSIPHeO
Town -d now septic SVq-te-rf Cri ILJZ-- L
It deOMIE'd necessary by the
of Si of this doc:jrr)ei_),L
year i,
Agreed to in. fi-111 t)y the Undersigned-
Atrist P. Frangules
K--,rpr- ij F r a! -i q
a
TO; 3 1' f.- a r -
FROM: Attorney John J,* Ryan,
TOTAL NIABEROF AlfES Uricludin -cover meet)
i
IF YOU DID NOT RE-QEIVE• ALL ICF THIS TRANSAC�IONr PLEASE' CALL
li ry i ',i t;� AT (508) 3.73-J 965
�
� a rte• ��
J � lam'' ..L.
'»
-,k . -
i� a✓'� ,^ � + � e� .r.�.�n.^gi /"
€ .4 _, S t r ? r T A Vi E S iF � I; H L'Ca F A,' IL
'
y E i .: - , %
s
x
• K
DATE,
TO; 3 1' f.- a r -
FROM: Attorney John J,* Ryan,
TOTAL NIABEROF AlfES Uricludin -cover meet)
i
IF YOU DID NOT RE-QEIVE• ALL ICF THIS TRANSAC�IONr PLEASE' CALL
li ry i ',i t;� AT (508) 3.73-J 965
0 7,7 3 b 4-:5J H hLE'= r HI I IG:L G �. _l -ti: Gt 2
We, d , of understanding
Thefoiiow' g dog
€��s tt i i a # ? of riders' in DetG o'er, +
drat aules,and eek. `. bra g�fss, o t fIf
a
wer
called iThe cit 3ortl rCi4
owne,
Andover gr nt buil ink p rrX`i't for the proposed wilding
if the Town of r as
addition for373 1 1eil? Tavern Lane }
1.laps on f it with, the Town of north Andover.
d�tior ,,' i h6 KY ] art stect ,`T-hOwnersarye to` �nst�l� now
The Fran gulesAddition,,"'O...'
E
if tl�te down -or-. ts agents deter,�nins Baia plans -�-
septic ysteM to service the .c +c rhe Owners -- warrant a new
or.pl.ans modified' aS Mutually ag►eed� by the Town and Ti Town of girth Andover .
system. The design o said ystSm u be approved,by the
Board of Health. P
f cher understand tha ted ut, si Hoff
e1it will berr;.
The Owners ,
no occupancy p ,
Town of'lorth Andover Board. of Health, which would not occur until inspection,
by t _
by the Board of Health.
neoe s , by the Tmdvn, said new septic system rnust be instailed vvtti�in fi
If deemed `y
year of signature of this document. f
..1.
Agreed to in full by the Un. ders1gns .
GGA t� � )e)A ' Rj�i
Ari. Frangules
Date
Town of North Andover,
Watershed Septic ;psi
servicing Report
Date: -
Homeowner : . I°( .. ' kialftnA Pumper
Street ` Address:
-Phone : _(pyo_ Phony:
Nature of Service: Routine
Emergency
observations: Good Condition
Full to Cover VU
Baffles in Place
Leachfield Runback O
Excessive Solids 'U
Heavy Grease YUU
Roots
other (Explain) YV6
f NORTH
3? ' �o
O �
F p
SSACHUSE
Applicant��J
NA
Site Location
Town of North Andover, Massachusetts Form No. 3
BOARD OF HEALTH
a ,9 4S
DISPOSAL WORKS CONSTRUCTION PERMIT
Permission is hereby granted to Construct ( ) or Repair) an Individual Soil Absorption
Sewage Disposal System as shown on the Design Approval S.S. No.
��- CHAIRMAN, OARDOF HEALTH
Fe D.W.C. No. C,
NOT- 3 2004
F, WN OF NORTH ANDOVER
1� TOWN OF NORTH ANDO'
SYSTEM PUMPING RECOKL) HEALTH DEPARTMENI
D A 11 \ I
SYSTEM OWNER & ADDRES_ST_�___!
Frol-)elles I
�,73 ale -1 - vellJe
A) 6 J//v& �, �
DATE OF PUMPING:
SYYFEIYI LOCATION
_QUANTITY PUMPED:...
S010C Tank: NU_ y E s
NA rURE OF SERVICE: ROUTINE__.�EtKE EN(,),
GOOD CONDI TION
IFU�'Ty_) COVER
.HF�AVY ()"-ASE _.BAFFLES IN PLACE
ROOTSLBACKRELD RUNBACK
BXCF,SSIVE SOLIDS'-- FLOODED
SOLID CARR YOVElk—......... OTHER EXPLAIN
JYotvm Rwnpcd by
(
,l3raa�iz;` .�rIQ.
�'UMMENTS.
CUNItNI'S r-KANSYbKRBD I -L)
ol
lll�lfl J' ��.,c•...• •
VER` MASSACHUSETTS
DEP.hoi pioYlded M14 loan rcr Lao ;,'y ;c:ol g
00 (o 0e loci' 8carc cr noa (n or c(
A. Facility In(Q--r - lon _
;.: • HEALTH DEPARTME—NT" I
S)'s'.Qrn location,
7"".' 6 1 I ,
f SSI .i;!;12 L.SyJl8f11 OWn6(; 1'
lie
(II14Vflflnl'tQ,,n
'I
-
,
(P'umpin8 Record,
��Oela of Pumping.
� .T YP a o � e •31 a m i,•--,ty�1
C C699p001(y) p(!C Tan^
(.P��.�sn(? [' Yo9
IpQn M:
Pympodl8y
.. �� ,�:�,��J�rJ✓(f �/�1 r Y `7i{i, r;l!I,JI.111 �` �1� I
.4 .1,c;.
on.Whsra'cor�lenU'Ware dlyposaa:
^tea. m a Sj . 0 Y/d e 1
8 p.!weierlepprovalsJlblorm�.r.mnln9oeCf
TIS^( Tan,
n'a) ; e ejana�7 res _
YehIG' UconIa,
�� �7�
I , � L)
0 ep, Olp(PY1191 ola iQrm IQI,V)O V� local 6Q0(Q;I Q( moolm, Q
61, M 0 1Qrmj mjy
OPn rPVI,l Of f 0.4 (A Ut lix V�o �Gmq 4) oil P(QYI090 hqfj. 89(9(1 DO V410
p9ill"91 00 (Qrm V) 1109 1011 IQ=
the 19", ?�.Vlo,
1 , '"' REGISITrID4";;
0( OPP(Qy!lw evthwl(y, V
4' A 9 A (Ir 1111 . 7T _17 1-1 _117 7 T I ----- ------------
UtL
TOWN OF NORTH ANDOVER
Q o HEALTH DEPARTMENT
OPIN Vi 6. 44 :1
N. LO xj
'i''�''` sy31om1OwnerA
ILI-7 I
SNI UD 9-9
Q,,70.'4M,
. =5116
D c4
8.,,'PUrnp1nq.RQQvd
e(l rrof pivimping 2. ovanwy PvmPo' o.
of ;y;l I m:
Tank
Tlqnl Toox
Its
p,10 Yo 3, NQ If yep,
wed 11 CIO 4no 07
CD Y
CD
Hum•
4 1 HYMN/
Y1 *1
Y1
7:
III q
Al 1vt I q( lit
N4 ;A
�lf4
JVIMt,
I , � L)
0 ep, Olp(PY1191 ola iQrm IQI,V)O V� local 6Q0(Q;I Q( moolm, Q
61, M 0 1Qrmj mjy
OPn rPVI,l Of f 0.4 (A Ut lix V�o �Gmq 4) oil P(QYI090 hqfj. 89(9(1 DO V410
p9ill"91 00 (Qrm V) 1109 1011 IQ=
the 19", ?�.Vlo,
1 , '"' REGISITrID4";;
0( OPP(Qy!lw evthwl(y, V
4' A 9 A (Ir 1111 . 7T _17 1-1 _117 7 T I ----- ------------
UtL
TOWN OF NORTH ANDOVER
Q o HEALTH DEPARTMENT
OPIN Vi 6. 44 :1
N. LO xj
'i''�''` sy31om1OwnerA
ILI-7 I
SNI UD 9-9
Q,,70.'4M,
. =5116
D c4
8.,,'PUrnp1nq.RQQvd
e(l rrof pivimping 2. ovanwy PvmPo' o.
of ;y;l I m:
Tank
Tlqnl Toox
Its
p,10 Yo 3, NQ If yep,
wed 11 CIO 4no 07
CD Y
CD
Hum•
4 1 HYMN/
Y1 *1
Y1
7:
III q
Al 1vt I q( lit
N4 ;A
—S. . sachusetts
�-:-,�C'y IT -of NORTH 'ANDOVER, MA55AUMUbt I 1,-�
aystem
Pumping Record..
,
rip "
Form 4 -
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. 'k .
X. Facility Information
Important
"m flWng out 1. System Location:
form on the . -=-, / -;0
com"r, use
only the tab key Address
to move yourN
cursor - do not C-ftyfTown
use the return
key.
2. System Owner.
Name
Address (if different from location) I
M U—M US, INT -1- 9
State
Zip Code
Zip Code
Telephone Number
'ac0rd
B. Pumping Record
AW 0
.
1. Date of Pumping
2. Quantity Pumped:
Gallons
3. Type of system: -❑ Cesspool(s)
Septic Tank E] Tight Tank
Other (describe):
4. Effluent Tee Filter present? [I Yes ❑ No
If yes, was it cleaned? El Yes 0 No
Conditlon of System:.'
6. System Pumped By:
rn
me
Vehicle License Number
mTpany p
7. ocatlon Aere contents were disposed*
Signature of Hauler
Date
http:/ANww.ma$3.90V/d.eptwaterlapprovaistt5forms.htm#4nspect
t5fom)4.doo- 06/03
System Pumping Record - Page 1 of 1
Commonwealth of Massachusetts
City/Town of No.Andover -WOCEIVEt
System Pumping Record
Form 4V U! l, %)(� 1111
c' Y' (s 1d 1 1
Important:
When filling out
forms on the
computer, use
only the tab key
to move your
cursor - do nrit
use the return
key.
OQ
F
DEP has provided this form for use by local Boards of Health. Other o b
information must be substantial) the same as that provided here. B oriNai�iiu with our
Y irl Y
local Board of Health to determine the form they use. The System P itted 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:
Address
-No.Andover-
City/Town
2. System Owner: n
Name U
Address (if different from location)
City/Town
ave
ai t
State
1C
State
Telephone Number
01810
Zip Code
Zip Code
B. Pumping Record
o�o
1. Date of Pumping 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 No 'If yes, was it cleaned? ❑ Yes No
5. Condition of System:
6. System Pumped By: _
Name Vehicle License Number
Stewart's Septic Service
Company
7. Location where contents were disposed:
Stewart's Pre-treatment Plant, 20 So. Mill Bradford, Ma 01835
Signature of Hauler Date
/0 r
Signature of Receiving Mcilfty Date
t5form4.doc• 03/06 System Pumping Record • Page 1 of 1