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HomeMy WebLinkAboutMiscellaneous - 408 BOSTON STREET 4/30/2018 (2) 408 BOSTON STREET t - -210110 000.0 Commonwealth of Massachusetts City/Town of JUN 14 2015 S stem Pumping,Record Toll. , Form 4 li DEP has provided this form for use=by local Boards of Health. Other forms may be used, but the information must be substantially the same as that provided here. Before using-this form,check with your local Board of Health to determine the form they use.The System Pumping Record must be submitted to the local Board of Health or other approving authority. A. Facility, Information 1. System LocatioKLe ig ont obimm eft/Right rear of house, Left/right side of house, Left/ Right side of builMffig, Left/Right front of building, Left/Right rear of building, Under deck 9 9 9. Address Cityfrown y State Zip Code 2. System Owner. Name Address(if different from location) CitylTown � .. State 'a ,-7Code ; Telephone Number B. Pumping Record - - L 1. Date of Pumping Date 2. Quantity Pumped: Gallons :. 3. Type of system' ❑ Cesspool(s) ptic Tank ❑ Tight Tank i ❑ Other(describe): 4. Effluent Tee Filter present? ❑ Yews No If yes, was it cleaned? ❑ Yes ❑ No. " 5. Condition of stem-,�r"`o`-' 6. System Pumped By: Neil.Bateson F5821 Name Vehicle License Number Bateson Enterprises Inc- Company SSjQnHaUW ontents were disposed: Lowell Waste Water Date t6form4.doc-06/03 System Pumping Record•Page 1 of 1 COMMONWEALTH OF MASSACHUSETTS EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS d DEPARTMENT OF ENVIRONMENTAL PROTECTION M Q O� V� V TITLE 5 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM PART A CERTIFICATION Property Address: 422 Boston Street North Andover,MA 01845 RECEIVED Owner's Name: Deven Shah Owner's Address: Same AUG 2 4 2005 Date of Inspection: 08-01-2005 TOWr,i U ,�i:3 i�l ANDOVER HEALTH DEPT�RT U Name of Inspector:(please print)John Soucy Company Name: Soucy Sewer Service,Inc. Mailing Address: 830 Livingston Street Tewksbury,MA 01876 Telephone Number: 978-851-8839 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: X Passes Conditionally Passes Needs Further Evaluation by the Local Approving Authority Fails Inspector's Signature: —4Date: ft—Ol-r�6b5' 4F r 4F 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. NOTE: This Title 5 is NOT a guarantee/warranty of the future function of the septic system. Page 2 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address: 422 Boston Street North Andover,MA 01845 Owner's Name: Deven Shah Date of Inspection: 08-01-2005 Inspection Summary: Check A,B,C,D or E/ALWAYS complete all of Section D A. System Passes: X I have not found any information which indicates that any of the failure criteria described in 310 CMR 15.303 or in 310 CMR 15.304 exist.Any failure criteria not evaluated are indicated below. Comments: B. System Conditionally Passes: One or more system components as described in the"Conditional Pass"section need to be replaced or repaired.The system,upon completion of the replacement or repair,as approved by the Board of Health,will pass. Answer yes,no or not determined(Y,N,ND)in the for the following statements.If"not determined"please explain. The septic tank is metal and over 20 years old*or the septic tank(whether metal or not)is structurally unsound,exhibits substantial infiltration or exfiltration or tank failure is imminent. System will pass inspection if the existing tank is replaced with a complying septic tank as approved by the Board of Health. *A metal septic tank will pass inspection if it is structurally sound,not leaking and if a Certificate of Compliance indicating that the tank is less than 20 years old is available. ND explain: 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: Page 3 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address: 422 Boston Street North Andover,MA 01845 Owner's Name: Deven Shah Date of Inspection: 08-01-2005 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 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: 422 Boston Street North Andover,MA 01845 Owner's Name: Deven Shah Date of Inspection: 08-01-2005 D. System Failure Criteria applicable to all systems: You must indicate"yes"or"no"to each of the following for all inspections: Yes No X Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool X Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool X Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool X Liquid depth in cesspool is less than 6"below invert or available volume is less than'/s day flow X_Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s).Number of times pumped X Any portion of the SAS,cesspool or privy is below high ground water elevation. X Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. X Any portion of a cesspool or privy is within a Zone 1 of a public well. X Any portion of a cesspool or privy is within 50 feet of a private water supply well. X 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 convect 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 11 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 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST Property Address: 422 Boston Street North Andover,AIA 01845 Owner's Name: Deven Shah Date of Inspection: 08-01-2005 Check if the following have been done.You must indicate"yes"or"no"as to each of the following: Yes No x _ Pumping information was provided by the owner,occupant,or Board of Health x Were any of the system components pumped out in the previous two weeks? x _ Has the system received normal flows in the previous two week period? x Have large volumes of water been introduced to the system recently or as part of this inspection? x Were as built plans of the system obtained and examined?(If they were not available note as N/A) x _ Was the facility or dwelling inspected for signs of sewage back up? x _ Was the site inspected for signs of break out? X _ Were all system components,excluding the SAS,located on site? x _ 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? x_ _ 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 x _ Existing information.For example,a plan at the Board of Health. x 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: 422 Boston Street North Andover MA 01845 Owner's Name: Deven Shah Date of Inspection: 08-01-2005 FLOW CONDITIONS RESIDENTIAL Number of bedrooms(design): 4 Number of bedrooms(actual): 4 DESIGN flow based on 310 CMR 15.203(for example: 110 gpd x#of bedrooms): 440 Number of current residents: 4 Does residence have a garbage grinder(yes or no):no Is laundry on a separate sewage system(yes or no): no [if yes separate inspection required] Laundry system inspected(yes or no): no Seasonal use:(yes or no): no Water meter readings,if available(last 2 years usage(gpd)):Well Water Sump pump(yes or no): es Last date of occupancy:_recent COMMERCIAL/INDUSTRIAL N/A Type of establishment: Design flow(based on 310 CMR 15.203): gpd Basis of design flow(seats/persons/sgtetc.): 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: Home Owner Was system pumped as part of the inspection(yes or no): no If yes,volume pumped: 1500 gallons--How was quantity pumped determined?Gage on truck Reason for pumping: System was pumped out 4-20-2005. 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/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 age of all components,date installed(if known)and source of information: 1996 Were sewage odors detected when arriving at the site(yes or no):No Page 7ofII OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 422 Boston Street North Andover,MA 01845 Owner's Name: Deven Shah Date of Inspection: 08-01-2005 BUILDING SEWER(locate on site plan) Depth below grade: 16" Materials of construction: X 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.): SEPTIC TANK: x (locate on site plan) Depth below grade: 4" 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: 10'.5"x 6' Sludge depth: 1" Distance from top of sludge to bottom of outlet tee or baffle: 23" Scum thickness: 1" Distance from top of scum to top of outlet tee or baffle: 8" Distance from bottom of scum to bottom of outlet tee or baffle: 15" How were dimensions determined: Tape&Sludge Tool Comments(on pumping recommendations,inlet and outlet tee or baffle condition,structural integrity,liquid levels as related to outlet invert,evidence of leakage,etc.): GREASE TRAP:_(locate on site plan) N/A 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 I 1 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 422 Boston Street North Andover,MA 01845 Owner's Name: Deven Shah Date of Inspection: 08-01-2005 TIGHT or HOLDING TANK:_(tank must be pumped at time of inspection)(locate on site plan)N/A 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.): Distribution Box Replaced 08-10-2005,See Permit Attached PUMP CHAMBER: N/A (locate on site plan) Pumps in working order(yes or no):T Alarms 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: 422 Boston Street North Andover,MA 01845 Owner's Name: Deven Shah Date of Inspection: 08-01-2005 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:20'x40' 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.): No Sign of Hydraulic Failure. CESSPOOLS: (cesspool must be pumped as part of inspection)(locate on site plan)N/A 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)N/A 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 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 422 Boston Street North Andover,MA 01845 Owner's Name: Deven Shah Date of Inspection: 08-01-2005 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. To wei . e Drirc�+s1► �onfa B%A A to 1 2916" AtaZ�?B'd" S.etfc Tack A to D-D=—431100 r X 3 Bto1-3711" $m2=3311" A B to D Baa-902,r 37' 00 Bmt Page 11 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 422 Boston Street North Andover,MA 01845 Owner's Name: Deven Shah Date of Inspection: 08-01-2005 SITE EXAM Slope Surface water Check cellar x Shallow wells Estimated depth to ground water 4 feet Please indicate(check)all methods used to determine the high ground water elevation: X Obtained from system design plans on record-If checked,date of design plan reviewed:September 14`x' 1995 X Observed site(abutting property/observation hole within 150 feet of SAS) Checked with local Board of Health-explain: Checked with local excavators,installers-(attach documentation) Accessed USGS database-explain: You must describe how you established the high ground water elevation: High ground water elevation determined from test results done on 9-14-1995.Also dug hole with auger in low drop off area. Town of North Andover Health Department Date: Location: (Indicate Address, if Residential,or Name of Business) Check#• /,�!g �;,� Type of Permit or License:(Circle) ➢ Animal $ D Dumpster $ ➢ Food Service-Type. $ ➢ Funeral Directors Massage Establishment $ ' ➢ Massage Practice $ ➢ Offal(Septic)Hauler $ ➢ Recreational Camp $ SEPTIC PERMITS: ❑ Septic-Soil Testing $ ❑ Sep -Design Approval $ eptic Disposal Works Construction(DWC)$ ❑ Septic Disposal Works Installers(DWI) $ Sun tanning $ Swimming Pool $ ➢ Tobacco $ Tras"olid Waste Hauler $ Well Construction $ OTHER:(Indicate) .r _"t 612, 9 ,38 Health Agent Initials . White-Applicant Yellow-Health Pink-Treasurer d} Address 13657-6 A( Title of File Page of Date File Open: Date file closed: Doc Document/Action Title Date of Refer to other Purpose of Document/Action and notes action Document/ document/ Num. Action Department Board of Appeals — Board of Health — Planning Board — Conservation Commission — Building Department i A TO: NORTH ANDOVER, MASS Zs-19 i y�r BOARD OF HEALTH FROM: DESIGN ENGINEER Re: Soil Absorption Sewage System Inspection This is to certify that I have inspected the construction of the said disposal system at .f 7-p,,.,, S T L` r It 2- North Andover, Mass. SITE LOCATION The grades and construction are as specified in my plans and specifications dated A pgl L I S 19.-`-. t—C AS (S Reg. Prof-. Engineer/Reg. Sanitarian T®: NORTH ANS(DVER, MAZS ,/ m 19 7S BOARD ®F HEALTH FR®M: DESIGN ENGINEER Re: Soil Absorption Sewage System Inspection This is to .certify that I have inspected the construction of the said disposal system at Lo ( oS7-0A) North Andover, Mass. SITE LOCATION The grades and construction are as specified in my plans and specifications dated No V /2- 19 75- f P ' eg. rd' ngilner%R`e' . Sanitarian A/ 0 LAL AJ AJ FSS, ei t x.Ti [d4�4 i 1t •uGA5 ED .•hJ�Sour��1 ,Mi.��. • WATT; AT' y /AIN -VI /Alfa i^ Y 45, To S�PTtG T,at.3 ',. d►- .Atm aT• q1.o i t 37' \ Eon C- rA.,4 10+4 ! w Rti4�z q o 104 5� FxF' AT2$O .za' 90o 1� 4,5 1 1 1 27p L I r .A&Cxa ADCP.rs e �osTQ�l �rT= u Joseph j. barbegalio, r.s. I westward circle no. reading mass. r �Aj �d8 4�c zc � -100 U 1 t 1 N } i a Op•�'d GT o o-a o-�o-..• a oc' db a-o c�s3 ¢yo . Joseph j. barbagallo, r.s. 1 westward circle no. reading,mass. 63cloTr i al Tl 1,Q'r 2. fxx; G 1J �e2T ewaco ae dia. o + �Ip Oi?A1ir. eruct., -4 d Kt. CAG-r !� 4 j E : ICA,o ELS(CICS Q LE ` ouot o Q 4r cl - 'i��S. _ ` > C-AL�SEPTIC 7,dIk ul 0. Y4 {o 1y2,�SToN '�,tmmzse Prr ut - F1 'NoSCALP- O{ I-10 5 'f' TZC ` r,.O—T TS-6 -- VATS. 4�,ATVWC-O' ]5 M[KI 10row 4e-l%SaL 5-2©•75 !` '1��9 ,1 1 t Mew, � Cd i SM1N, J � S i JO � UbZ _,-Jo 7-0 �ovE25 14 V A e C, n � 3Z, M,4 o t7 b a' rn t t a � s 4 /GOOD 7-0 qv� L/7 3 �. APPLICATION FOR SEWAGE DISPOSAL INSTALLATION � /J � , 1 HEALTH DEPARTMENT - NORTH ANDOVER, MASS. Newe'W1V: 5, Qvefrzo 1 , fI hereby make application for a permit for a sewage disposal installation at 3 I-will install this system in ac- cordance with all the laws of 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 re-ceding the septic tank, where the grade shall not exceed 290. I will install a con- crete septic tank of /c--c-0 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 Z 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 the 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 Id % 3/- ' Signature of Applicant I hereby issue the above permit for the Board of Health of the.Town of North Andover, Massachusetts. DATE 3 Sign tune of Health Agent I have inspected theuncovered system indicated above and find everything done as described. DATE Signature of Inspecting Officer Percolation Test Garbage Grinder � >CD ` t' 777-7-77777: IIT777— r. BOARD OF HEALTH TOWN OF NORTH ANDOVER, MASS. r 3'% c ' 30 i jS0 5- 30 ` 1ST f� CIA ooaG 1. NAME .T o s c p 1, 0. �l A e_ o N ry DATE r�sT s,vr 2. ADDRESS,&j r,,y ,r, (,re x r k-y;2 ^'-f Otte-'p Mc'r>'F LOT NO. TEL. 3. NO. OF BEDROOMS 3 DEN YES ✓ NO 4. GARBAGE GRINDER YES NO t--- 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 ROUSE NOTE: LOCAL REGULATIONS SHOULD BE READ CAREFULLY. 30 \r" IDI S,q . BOARD OF HEALTH OF NORTH ANDOVER, MASSACHUSETTS ' SEWAGE DISPOSAL DATE 9-23-172 NAME OF APPLICANT Keith Morse LOCATION Next to 122 Boston St. Address of lot no. BUILDING: Dwelling X' Other SYSTEM: New X Repair GENERAL DESCRIPTION OF LAND high SUBSOIL: Clay___.2L_ Gravel Sand PERCOLATION TEST 7 minutes per inch. MINIMUM INSTALLATION RECOMMENDATIONS CONCRETE SEPTIC TANK 1, 000 gallon capacity. LEACH FIELD 200 lineal feet of drain pipe. ailliam J. Dr' s oll , Engineer Board of HealthJ 1 i �f>RtL. 13, t�s�4• Ar',e�G ��, �9�r4 C4 jQ J, j e i 7aP A7o p 11"` : 70 Sa!t , sH��N 5/f Vq .yse t �anirt,r %5,04t< 14sfig /5 -1i v �k << PEA,- k r 8o-i.nr /tA, x 49 t a L) ' © 00 _ ? PPO FILE rla � s J0R t'AwnNDJZyWAS! C S'D✓�tiyElsE1L+ 3G +` ZD'CeP WITH 'Z4r- !%af ATYaNr: .4Rounts Z .rwS7-AJ-4L Z -- 7�e7f SEF,,A4G-- , P,-71; . A s 3'//owA✓ ABOVE. ,, '�`: P/P�' Fi�ewy hta►s.5'c r� 7-.9iw� ra eta 4" Fes_ e4 s T Z'tcv✓ { ' +� 3, t?otTaMG foR 3Ep��t' psr Fie. � S d. 'I/�,elc fs i 7 0 M L..Q T Z a62F. J � Prr Ide t y 3{ I t ,,, �f 't, S'E Epi G E PIT •t � iE cE Trf� S-Y'STEn•1 INST,744Cca ? Cfa�'rvihf 7' tD fit A Oy Ito* 40 i . SCALE �`�_ 40� \ _ < I' �7/ t F Liffff�lui11f1�N1111 �t A�N�ritfaiu�f:lla< rVl�ggl�vll�e�I,�tl°C�1F , d� - ' �t'11ellruun0r � � , 3 t�ilap111�1 hulifp��ll 1 VAId f 1 rl r � uu u 1 � � : Fill � krf,ll�+ 'I'dll�•1 Lfrf l � � r'�1 ,�tl � �. IJ•// luulf 111 1 , . •, : ' i'�' ' ' dYl - ----1: Ll�eihe NI nlrJb, t lenl 1 ' Cun1el�Is.Itnfislefie�l Idt ' �1 ' S'�`�+.` TOWN OF NORTH ANDOVER SYSTEM PUMPING RECORD DATE: SYSTEM OWNER &ADDRESS SYSTEM LOCATION I f (example: left front of house) r Vic. DATE OF PUMPING: a `d1 QUANTITY PUMPED ( 50� GALLONS CESSPOOL: NO YES SEPTIC TANK: NO YES NATURE OF SERVICE: ROUTINE EMERGENCY OBSERVATIONS: GOOD CONDITION FULL TO COVER HEAVY GREASE BAFFLES IN PLACE ROOTS LEACHFIELD RUNBACK EXCESSIVE SOLIDS FLOODED SOLIDS CARRYOVER OTHER (EXPLAIN) SYSTEM PUMPED BY: COMMENTS: CONTENTS TRANSFERRED TO: (-°' Z �5 t TOWN OF SYSTEM PUMPI G RECORD RECEIVED • OCT 19 2004 DATE. ( — TOWN OF NORTH ANDOVER HEALTH DEPARTMENT SYSTEM OWNER & ADDRESS SYSTEM LOCATION (example:left front of house) DATE OF PUMPING: QUANTITY PUMPED : GALLONS CESSPOOL: NO YES SEPTIC TANK: NO YES NATURE OF SERVICE: ROUTINE EMERGENCY OBSERVATIONS: GOOD CONDITION FULL TO COVER HEAVY GREASE BAFFLES IN PLACE ROOTS LEACHFIELD RUNBACK EXCESSIVE SOLIDS FLOODED SOLIDS CARRYOVER OTHER(EXPLAIN) SYSTEM PUMPED BY: Bateson Enterprises, Inc. COMMENTS: CONTENTS TRANSFERRED TO: G.L.S.D Lowell Waste TOWN OF SYSTEM PUMPING RECORD DATE: SEP SYSTEM OWNER& ADDRESS SYSTEM LO�CATIOa.. (example:left front—of Nonse) " DATE OF PUMPING: ( QUANTITY PUMPED : GALLONS CESSPOOL: NO ES SEPTIC TANK: NO YES NATURE OF SERVICE: ROUTINE EMERGENCY OBSERVATIONS: GOOD CONDITION FULL TO COVER HEAVY GREASE BAFFLES IN PLACE ROOTS LEACHFIELD RUNBACK EXCESSIVE SOLIDS FLOODED SOLIDS CARRYOVER OTHER(EXPLAIN) SYSTEM PUMPED BY: Bateson Enterprises, Inc. COMMENTS: CONTENTS TRANSFERRED TO: Commonwealth of Massachusett7.—ea ; :? City/Town of System Pumping Record T 1 5]0'7 Form 4 F NORTTH DE--,A DEP has provided this form for use by local Boards Other forms may be used, but the information must be substantially the same as that provided here. Before using this form,check with your local Board of Health to determine the form they use.The System Pumping Record must be submitted to the local Board of Health or other approving authority. A. Facility Information Important: When filling out 1. System forms on the computer, use only the tab key Address t+ _ to move your Da cursor-do not use the returnCity/Town state/ Zip Code key. 2. System Owner: Name ISI Address(if different from location) Cityrrown State Zip Code Telephone Number B. Pumping Record 1. Date of Pumping Date 2. Quantity Pumped: Gallons 3. Type of system: ❑ Cesspool(s) Septic Tank ❑ Tight Tank ❑ Other(describe): 4. Effluent Tee Filter present? ❑ Y No If yes,was it cleaned? ❑ Yes ❑ No 5. Condition,oSystem: I 6. System Pud A, Name Vehicle License Number Company 7. Location e c ntent re fused: - , P-J_ IN Signat e H ler Date t5form4.doc•06/03 System Pumping Record,Page 1 of 1 &\ Commonwealth of Massachusetts /Town ofNOV y � �o �o Cit a System Pumping Record pHKWOPN° +�D Form 4 � aEPgM DEP has provided this form for use by local Boards of Health. Other forms may be used, but the information must be substantially the same as that provided here. Before using this form, check with your local Board of Health to determine the form they use. The System Pumping Record must be submitted to the local Board of Health or other approving authority. A. Facility Information 1. System Location: Left front of house, right front of hous left side o�h �, right side of house, Left rear of house, right rear of house, left side of building, right rear of building, under deck. City/Town State Zip Code e` 2. System Owner: l ,/U N/ Name r �� Address(if different from location) City/Town Stat �] ip Code 0 Telephone Number B. Pumping Record p 9 fit�3 - �o Com 1. Date of Pumping Date 2. Quantity Pumped: Gallons 3. Type of system: ❑ Cesspool(s) eptic Tank ❑ Tight Tank ❑ Other(describe): 4. Effluent Tee Filter present? ❑ Yes (moo�j If yes, was it cleaned? ❑ Yes ❑ No 5. Condition of System: �Ij0 s�� :�-� �. 6. System Pumped By: Neil J. Bateson F5821 Name Vehicle License Number Bateson Enterprises Inc. Company 7. Locati ere contents were disposed: L.S. ell W to ter t � —� —lv Signatu e H ler Date t5form4.doc•06/03 System Pumping Record•Page 1 of 1