HomeMy WebLinkAboutMiscellaneous - 43 STONECLEAVE ROAD 4/30/2018 (2) STONMCz tEIZOaO )ad
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Commonwealth of Massachusetts
N V
City/Town of NORTH ANDOVER, MASSACHUSETTS
System Pumping Record
Form 4
DEP has provided this form for use by local Boards of Health. The stem Pumping Record must
be submitted to the local Board of Health or other approving auth rity. RECEIVED
A. Facility information JUL 0 7 2008
Important:
When filling out 1. System Location: TOWN OF NORTH ANDOVER
forms on the a HEALTH DEPARTMENT
computer,use
only the tab key Address � {
to move your Al , C.��..,LY—tif �� tDi a & q
cursor-do not Citylrown State Zip Code
use the return
key. 2. System Owner:
s
t
[ ire
Name
Address(if different from location)
City/Town State Zip Code
Telephone Number
B. Pumping Record
x (
1. Date of Pumping Date 2. Quantity Pumped: Gallons
3. Type of system: ❑ Cesspoof(s) Septic Tank ❑ Tight Tank
❑ Other(describe):
4. Effluent Tee Filter present? ❑ Yes 1 No If yes, was it cleaned? ❑ Yes ❑ No
5. Condition of System:
6. S tem Pumped B
Ne Vehicle License Number
n "Q01 c
Company
7. Location where contents were disposed:
'i
. Signature of Hauler Date
http://www.mass-gov/dep/Water/approvals/t5forms.htm#inspect
t5form4.doc•06/03 System Pumping Record•Page 1 of 1
FORM U - LOT RELEASE FORM
INSTRUCTIONS: This form is used to verify that all necessary approvals/permits from
Boards and Departments having jurisdiction have been obtained. This does not relieve
the applicant and/or landowner from compliance with any applicable or requirements.
APPLICANT FILLS OUT THIS SECTION***********************
APPLICANT �`t.,�'fn 1 Y)�i7� r t' PHONE 9�: -
8 3 7S
LOCATION: Assessors Map Number 104 8 PARCEL
SUBDIVISION LOT (S)
STREET 11�21°L �t�� �� ST. NUMBER
OFFICIAL USE ONLY**'"t***"****"-**� '
DA F TOW b ENTS:
NSERVATION ADMINISTRATOR DATE APPROVED
DATE REJECTED
! COMMENTS ^ �n n
TOWN PLANNER DATE APPROVED
DATE REJECTED
COMMENTS
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40;D INS ECTOR-HEALTH DATE APPROVED
DATE REJECTED
INSPECTO EA DATE APPROVED
DATE REJECTED
' COMMENTS 7 -�- �-t--•.- _�—�i-�.
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PUBLIC WORKS-SEWERIWATER CONNECTIONS
I
DRIVEWAY PERMIT
FIRE DEPARTMENT
RECEIVED BY BUILDING INSPECTOR DATE
} I Revised 9197Im
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'WELL DATABASE
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T-,,?E OF WELL: DRiL.LED b. DUG c. U,+iG`fc w-,N
TYPE OF WATERBEA:RL�'G ROCK:
-WATER ANA L YSIS DATE: HIGh tiL��iGAN�SE: Y N
NECH IRON: Y N OT�� CONTA- N "A-NL TS: Y 'N
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TO: NORTH ANDOVER, MASS 19 27
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
1: 3 1 TO/VC- 3Z 4 YC North Andover, Mass.
SITE LOCATION
The grades and construction are as specified in my plans and specifications dated
19— commok
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NORTH ANDOVER BOARD OF HEALTH 4-T 3 5.�,,,,�QU
INSTALLATION CHECK LIST
AP ROVED DATE DISAPPROVED DATE tXCAVATION OK
z� SOIdS:
FAIL OK_
1 . istance To:
Wetlands
Drains
, Well
,,,, /Water Line Location
No PVC Pipe
4: eptic Tank
Tees - Length & To Clean Out Covers
Cement Pipe to Tank - On Both Sides of Tank
5. D' stribution Box
Cover & Box - No Cracks
All Lines Flowing Equal Amounts
No Back Flow
6. Leac Field or Trench
imensions
Stone Depth
Capped Ends
Clean Double Washed Stone
7. Leach Pits
Dimensions
Stone Depth
Splash Pads
Tees
Cement Pipe to Pit - Both Sides
IClean Double Washed Stone
. N o Garbage Disposal
inal Grading Inspection
Barracading Covered System
11 . As Built Submitted
ot Location
Dimensions of System
Location with Regard to Pere Test
Elevations
Water Table
r `
t' NORM AND0VER .BOARD OF HEALTH
9 f
SUBSURFACE DISPOSAL SYSTEM CHECK LIST
_ a
AP COVED PROVIDED DISAPPROVED
r�
General Information
Reg. 2.5 Fail 0 The submitted plan must show as a minimum:
�e lot to be served (area,dimensions, lot #, abutters)
fib} location and dimensions of system (including reserve area)
:�.__(dj design calculations
calculations showing required leaching area +'
existing and proposed contours
f) location and 2 of deep observation holes-distance to ties
(g) location and results of percolation tests-distance to ties
r ( ) location-of any wet areas within 100' of the sewage disposal
system or disclaimer
,(i)--surface and subsurface drains within 100' of sewage disposal �
system or disclaimer
�(.,}location of any drainage easements within 100' of sewage
disposal system or disclaimer
(- wn sources of water supply within 200' of sewage disp
kms osal
system or disclaimer
-(1) location of any proposed well to serve the lot(100' from leaching facilii
location of water lines on property (10' from leaching facilities)
---(-n-)-maximum ground water elevation in area of sewage disposal system
�--(o)—location of benchmark
(p_),glan must be prepared by a Professional Engineer or other
professional authorized by law to prepare such plans
q)'--driveways �
_r)) garbage disposers
(s)a' profile of the system (elevations of. basement, plumbers pipe '
septic tank) distribution box inlets .aa1d outlets, distribution
, field piping and any other elevations)
t)FPVC is to be used in construction
Septic Tanks
Reg. 6.1 Zlfa) Capacities - 150% of, flow I
Reg. 6.7 (b)_ ,Tater table
Reg. 6.$ '(c) Tees
Reg. 6.9 d} Depth of tees
Reg. 6.1 1W--(e): Access
Reg. 6.1 � �(f) Pupping
(g). Cleanout
Reg 3.7 ' (h) 10' from cellar z--all or inground swimming pool
(i) 25' from subsurface drains
r..
Reg: 9:1 ' E!?aT Approval
Reg. 9.6 (b) Stand-by power
North Andover Subsurface disposal system check list-Page 2
Fai OKDistribution Boxes
Reg.'10.2 (-a'�SJ.6pe greater than-0.08
Leaching Pits
Leaching pits are preferred where the installation is possible
Reg.11.2 -(a) Calculations of-leaching area (minimum 500 S.F.)
Reg.11.4 (b) Spacing
Reg.11.10 (c) Surface drainage 2%
Reg.11.11 (d) Cover material
each'inn ' Fields
Reg.35.1 Greater than 20 minutes/inch
Reg.]5.1 `(b) Area (minimum 900 S.F.)
Reg.15.4 (c) Construction of field
Re-, 15 8 Y,) Surface drainage 2h
Reg-:3.1 e) 2.01 from cellar gall or inground swimming pool
Do 11 Slope
a)Slope y/x = (to be shown)
(b) y/x X 150 = (to be shown)
SOIL PROFILE & PERCOLATION TEST DATA
Town City C/OUB No.&Street Lot No.
,Loc./Subdiv.L� jr,e ClecZ, � Plan Owner �--�
Investigator Com-- g4_'520&_ Observer
.01
SOIL PROFILES-DATE
1' �' Elev. 4'Elev.
p � 3 7 0 3.
lev. Elev.
0 0
S
1�2 2
2 2
4' 3 4
_ 3 3 3
4 . 4 4 4
\5 JJ 5 5 5
� 0
� 6 6 6 6
7 7 7 7
8 8 _ 8 8
9 9 9 9
10 10 10 10
Benchmark Location
Elevation Datum
Percolation Tests-Date
Pit Number 1 2 3 4 5
Start Saturation— -
Soak-Mins.
Start
Start Test-Time
Drop of 3"-Time
Drop of 6"-Time
Mins.lst 31Dro
Mins.2nd ..3"Drop
Notes & Sketches on Back Frank C. Gelinas & Associates, North And.
/Oz 3
61,P/,
Gv CL �--- '
• SOIL PROFILE & PERCOLATION TEST DATA
North Andover,Mass. No.&Street (;t� a Lot No.
Loc./Subdiv. Plan Owner
Investigator Observer °
SOIL PROFILES-DATE -
1' Elev. 3' Elev. 3' Elev. 4'Elev.
0 0 0 0
1 1 1 1
Ties to Test Pits
2 2 2 2
4
3 3 3 3
4 4 4 4
5 5 5 5
6 6 6 6
7 7 7 7
8 8' 8 8
9 . 9 9 9
10 10 10 10
Benchmark Location
Elevation Datum
Percolation Tests-Date
Pit Number 1 2 3 4 S
Start Saturation
Soak-Mins.
Start Test-Time _
Drop of 3"-Time -
Dro of 611-Time
Mins. lst 3"Dro
Mins. 2nd 3"Dro
Notes & Sketches on Back
SOIL PROFILE & PERCOLATION TEST DATA
Lot No.
No.&Street �' a
North Andoner,Mass. �� ..�
Loc./Subdiv. cL Plan 'Owner I�
Investigator Observer -
I
SOIL PROFILES-DATE
1' ' Elev. 3' Elev. 4'Elev.
Elev.
0 0 0 0
1 1 1 1
Ties to Test Pits
2 2 2 2
3 3 3 3
4 4 4 4
5 5 5 5
6 6 6 6
7 7 7 7
8 8- 8 8
9 . 9 9 9
4
10 10 10 10
Benchmark Location
Elevation Datum
Percolation Tests-Date /z-l(.-77
Pit Number 1 2 3 4 5
Start Saturation 2=y�
Soak-Mins.
Start Test-Time
Drop of 311-Time -
Drop
"-Time -Dro of 6"-Time
Mins. lst 3"Dro
Mins. 2nd 3"Dro
Notes &. Sketches on Back