HomeMy WebLinkAboutMiscellaneous - 45 LIBERTY STREET 4/30/2018 45 LIBERTY STREET _
210/105.D-0164-0000.0
Commonwealth of Mass se setts
9
City/Town of
System Pumping Recor
Form 4
' M
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 within 14 days from the pumping date in
accordance with 310 CMR 15.351.
A. Facility Information
Important:When
filling out forms 1. Sy to \�,tlon:
on the computer, JJ
use only the tab _
key to move your AdNO6cz
cursor-do not r l
use the return ' ----
key. City/Town State Zip Code
2. System Ownolo
t� klC
Name
reeen
Address(if different from location)
City/Town StateZip Code
�71 0
Telephone Number
B. Pumping Record )
1. Date of Pumping Date/ 1 2. Quantity Pumped: Gallons� ~�
3. Type of system: ❑ Cesspool(s) dNSeptic Tank ❑ Tight Tank ❑ Grease Trap
❑ Other(describe):
4. Effluent Tee Filter present? ❑ Yeso�No If yes, was it cleaned? E] Yes E] No
5. Condition of System: A-0
'"'' \� t
6. System PumpedB�:
Name Vehicle License Number
Stewart's Septic Service
Company
7. Location where contents were dispo d:
Stewart's Pre-treatment Plant, 20 ! Mill Bradford, Ma 01835 <
Sign e r Date
gn t e of Receiv' Fa 'ity Date
Z
t5form4.doc•03/06 System Pumping Record•Page 1 of 1
Commonwealth of Massachusetts MOD
City/Town of No Andover JUN 10 2013
° System Pumping Record
Form 4 TOWN OF NORTH ANDOVER
HEALTH DEPARTMENT
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 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, J
use only the tab �k- z-I b{'t4
key to move your Address
cursor-do not No andover Ma
use the return City/Town State Zi Code
key. P
2. System Owner:
VQ iA-rlIn�
Name
nom
Address(if different from location)
City/Town State Zip Code
Telephone Number
B. Pumping Record
1. Date of Pumping 2. Qu ty Pumped:
Date Gallons
3. Type of system: ❑ Cesspool(s) eptic 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: (/f)
Name Vehicle License Kumber
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
Signature of Receiving Facility Date
t5form4.doc-03/06 System Pumping Record-Page 1 of 1
Commonwealth of Massachusetts
I^ City/Town of NORTH ANDOVER, MASSACHUSETTS
System Pumping Record
Form 4
�Ny a• a
DEP has provided this form for use by local Boards of Health. The System Pu ust
be submitted to the local Board of Health or other approving autho y. RECEI En
A. Facility Information 2006
Important: JUN —
When filling out 1. System Location:
forms on the � Tp OF NORTH ANDOVER
computer, use LTH DEPARTMENT
only the tab key Address '
to move your
cursor-do not - LILA
use the return City/Town State Zip Code
key.
2. System Owner:
Name — +
Address(if different from location)
City/Town State
Zip Co
Telephone Number
B. Pumping Record
1. Date of Pumping Date�3 2. Quantity Pumped:
Gallons
Type of system: ❑ Cesspool(s) Septic Tank ❑ Tight Tank
❑ Other(describe):
4. Effluent Tee Filter present? ❑ Yes ❑ No If yes, was it cleaned? ❑ Yes ❑ No
5. Condition of System:
6. System Pumped B
k5'2Lr---'
"42y'02&
Name Vehicle License Number
Company
7. Location where contents were disposed:
ignature of H J r Date
http://www.mass.gov/dep/wate aapprovals/t5forms.htm#inspect
t5form4.doc•06/03 System Pumping Record•Page 1 of 1
TbWN OF NORTHANDOVFR
SYSTEM PUMPING R. cou
TT. OWNER & ADDRESS .. SYSTEM LOCATION
(example; lef( front of house)
,A1, �
U:\'I'C OF PUMAINC, QUANTITY pUM!'CD _0 L,Lu� ,
C'A'S>11001—; NO YES SEPTIC TANK: NO YES
ATURE OF SERVICE; ROUTINE/�� EMERGENCY
X111.>F(ZV;ITIONS;
COOD CONDITION. --, FULL TO COVE
HRAYY CREASE BAFFLES IN I'L,ACL-
ROOTS LEACHFIELD RUNBACK...
CXCESSIVE SOLIDS FLOODED
SOLIDS CARRYOVER P1HRR (EXPLA.IN)
>>'>'1'LNl PUM PCD By i.�
� u 11�l rNTS,
I'lZANSf ERRED TO.
I
pt '
N WELL
N/F
H.G. SONS & ASSOCIATES
9R EXISTING FNDN.
7-210.52
ti •
N
DOSII ' 10Q,4•
.110
oT Oki D-80X V
�26.3w
�
6
LOT 5 A b" 135.2' �yj
Q ° 87,120 S.F.
oti s9 8, 73.1'
3�
LOT 6A 504.58'
LOT 4A
THIS IS TO CERTIFY THAT I HAVE INSPECTED
THE CONSTRUCTION OF THE SAID DISPOSAL
SYSTEM LOCATED AT LOT 5A, LIBERTY ST.,
NORTH ANDOVER, MA. THE GRADES ARE AS
SPECIFIED PLANS AND PECIFICATIONS
DATED agpi ICH J ROSATI."
GRADES
ELEVATION TO TOP OF PIPE `'
DWELLING:
TANK IN: 206.96
TANK OUT: 206.71
D—BOX IN: 204.91 Y ti ,5 e
D-BOX OUT: A 204.76
B 204.78 MICR J: ROSATI DATE
C 204.79
D 204.79 AS BUILT SEWAGE
T DISPOSAL
LINE: OF
FADISTRIBUTION
204.49 TION MTEM PLA
B 204.52 IN NORTH ANDOVER, MA.
C 204.56
D 204.58 AS PREPARED FOR NORTH MIDDLESEX CONSTRUCTION CO.
SCALE 1"=100' DATE MAY 1989
MARCHIONDA & AS SOC , INC
ENGINEERING AND PLANNING CONSULTANTS
80 MAPLE STREET R.F.D. 16
STONEHAM, MASS. 02180 MANCHESTER, NH 03103
(617) 438-6121 (603) 434-8725
1 b Ma1n St, T S SEPTIC TANKSII�IICE
47 Rm RoAD SPRHEr
Na il�, A rZranti/er BWFORD, MA 01835
W.moi L« t5/-pp 4
978-372-7471
in 1J Lc- Af /
MORM OF
MM- LY RMRT FOR TOWN OF 1: )
DATE
ADDRESS GALWNSnd,
J -1
5
•
iCJ
� la
1
if
RFU
��,9� � � �
� , �� TA�v
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6 \99l
v �
June 15, 1996 _.
SANDY STARR
TOWN OF NORTH ANDOVER BOARD OF HEALTH
TOWN HALL ANNEX
MAIN STREET
NORTH ANDOVER,MA. 01845
Dear SANDY:,
IN ACCORDANCE WITH OUR PREVIOUS DISCUSSION, PLEASE FIND ENCLOSED A COPY OF
EXISTING SEPTIC SYSTEM DESIGN AND AN OUTLINE OF THE PROPOSED ADDITION AT SAME
LOCATION.
THE PROPOSED RENOVATIONS WILL NOT INCLUDE ANY ADDITIONAL BEDROOMS. THE
PROPOSED CONSTRUCTION INCLUDES A"GREAT ROOM°AT THE FIRST FLOOR LEVEL AND
EXPANSION OF AN EXISTING BEDROOM AT THE SECOND FLOOR LEVEL FOR A NEW MASTER
BEDROOM SUITE WHICH WILL INCLUDE A MASTER BATH.
PLEASE EVALUATE THE ATTACHED PLAN AND ADVISE AS CONCERNS ANY BOARD OF HEALTH
WOR TITLE V CODE CONCERNS. THE APPROI OF THE BOARD OF HEALTH IS THE FIRST
STEP IN THE DESIGN OF THE PROPOSED ADDITION.
SHOULD YOU HAVE QUESTIONS PLEASE CONTACT ME AT 681-8600.
THE OWNERS (MR. &MRS. ARLING) CAN ALSO BE CONTACTED AT (508)659-2349 DAYS AND AT
681-1295 EVENINGS.
I WILL ALSO ATTEMPT TO CONTACT YOU AT THE COMMUNITY DEVIELOPMENT OFFICE PRIOR
TO YOUR VACATION DEPARTURE.
i
SINCERELY:
I
STEPHEN E. FOSTER
�aGi2t
C
Dutton & Garfield, Inc.
CONTRACTORS
1 STEPHEN E. FOSTER /
1 � Vice President
70 Fla shi9 Drive 109 Hillside Avenue P
North Andover,MA 01845 Londonderry,NH 03053
(508)681-8600 (603)425-2600
FAX:(508)681-7570 FAX:(603)434-9568
SNL
�A. �v� •��'� TYPE_� NOTE
Q�1 iw51= 'R� ��y TO DE USED WI
a ` NOTE% WHERE THE
TO BE USED 1N LOCATIONS GROUND SLOPE
EXis-fING GROUND SLOPES 1N TOWARD THE TOE OF T}
~i �� �F THE TOE OF THE EMBANKMENT. EROSION 0�
HAY OR STRAW
BALED xOT TO SCALE
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PROVIDE I I AIR INSULATION
SPAGE ADOVE I NSUL. I
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..
MASTER DEDROOM foETAL OR EDGE
5NW/ICE DARKIER
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BOX-DAY/DORMER FASTEN JO I STS SEE SAVE DETA I L T AI
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HEADER:
FADER HEIGHT
I /2' 60 ON
TYP I LPL FALL SEGT I ON: I X 3 AT f 6' 0/G % SOFFIT I -TYPE DETA I L5MATCH � W
51DIN6 TO MATCH EX15T'6. DOLS TOP PLATE
TYPAR DU I LD I N6 WRAP W I NDOV/ SEAT I
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EX 15T I N6 GENTER.SPAN NA I L a 615E TO
FIN 15H FLOOR _ FLOOR JOIhTh
................... .................
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ANG-M W-TS/STRAPS
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DOUME 2 X 6 TREATED INhULATION
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FIN 151 6RADECONCRETE FILLED 4' COW RETE I I
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DAWMOOF I N6 '• GOI-uw FOUNDAT 1 ON
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~
Water Works
L---- -' --~~~" "~~~", Inc.
88Elm Hill Aveo
ue " P.O- 8ox687 ^ Le0rr1if1Sef, Maf-;S2(;huse11,s 01453 (508)534-1444 1-800-LAB-0094
0 (|nMass)
Name z Sons
Address : 265 Proctor Mill RdSample Location :No'Middlesex Cor
City : Hollis ^ Lot 5A Shwrpner5 Rd. N. Andover, �
State : NH Zip Code ; 01049 Sampled By 5kiIling5 & Son-,
Attn : Invoiw No. : 46914-227
Date ; 4/17/09 P.O. No.
____ �
�______-_-_____-_-________-_~
,
WATER DUALITY TEST RESULTS ----
[P] �
----------------------------------------
PRIMARY STANDARD [S] SECONDARY STANDARD
RESULTS
----------------------________________� LIMITS
Coliform Bacteria [P] 0/180 - ----------------------------------
� Fecal Bacteri, 4/1{}0 ml
NT
Standard Plate Count 0/100 m1 ^
MT
NO LIM4T
Arsenic [P]
� ND
�
Sodium [S] 7.60 0-0^05 mg/1
Copper [�] ^ {/-250 mg/ l
i�.02
Iron [5] 0-1 mg/l
0.4��
0-0.�0 mg/l
Lead [p]
ND
Manganese [S] 0.07 O-0^()20 mg/l
Magnesium 4^40 0-0.05 mg/l
Calcium 1 ~ , 50 0-208 mQll
' 0-200 mg/l
Alkalinity [��J 59 �0
Chlorine ^ NO 41MIT
ND
Potassium [S] 2.6() 0-0.05 mg/l
Chloride CS] 1 ^ 0-�50 m�/%
� 00
Hardness - ` O-250 mg/l
83 �>0
� Nitrate [P] NJ)
0-160 mg/l
� Nitrite I0-0 mg/l
ND
Ammonia ND 1 .0 mg/l
� Sulfate [S] � 0-0 1 mg/l
1� �0 ^
� , 0-250 m-/l
PH [Sl
7.20
Conductivity 126.0C)
6. 5-8, �
2b 00
Color [S] ^� ^ O-��0
10.00
Odor [S] ^ 0-1� ��
l 00
Turbidity [P] ` 0-3 TON
3.R0
0-5 NTU
� Comments �
NTR=TNot tested ND = 1�elow level �f detection for this�uINKMUS�
ITEMS TESTED THIS SAMPLE MEETS THE FOLLOWING
Parwmete�
DRINKING WATER [ X � PRIMARY [ ] SECONDARY [ �� EPA CRITERIA FOR
� ] NEITHER
�
Reported By : Eric J . Knsln�s�i
^ n�
�
�
'''' - ' '' ' '- ' '' ' -'-'''-''-- - -'- ' - ' ' -'-' -- -'' - ' '' ' ' ' '' - -- - '''-- -' '
*
P . 01 *
*
TRANSACTION REPORT ' *
*
APR- 19-89 WED 9 : 53 *
*
*
* DATE START SENDER RX TIME PAGES NOTE *
*
*
* APR- 19 9 ^ 52 �3
. 1 ' 14n 2 OK *
*
' -' '''-'-''-''- - ''-'''-'-''-''--'--''-'''''-'''- '' -''- -' ' �
BOARD OF'. HI"ALTH
Town :of North Andover ,Mass .
0 / 19c5 7
Permit # =3 Date
APPLICATION FOR WELL & PUMP PERMIT
Application is hereby made for permit to drill a well ( Application i's
( made to install (L-I' a pump system.
Lot
Location: Address
#
OwneR, \ , Address�Q G ( �/rc��� _Tel . —
Address / e1 • �5 —
Well Contractor?' '
Pump Contractor �,.,�.,��- Address Tel . 4424k�_
WELL CONTRACTOR (To be completed at time of pump test )
Type of Well atL _,deli. used for
Diameter of Well Size of Casing
� f
Depth of Bed Rock _7 Depth casing into Bed Rock
Was Seal Tested? Yes No ( ) Date. of Testing
Depth --af--W-k-- Well Ended in Wha-t. Material _
a ( Delivers � Gals . Per Min . for 4 hours
Depth to Water
Drawdown feet 9FktAer pu ping______iours- at
Date of Completion
ignature We Contractor
' PUMP INSTALLER (To be- filled in before installation)
Size & Name Pump y9 ��Ge� _S____....___..___._�._-Pump Type Used SU D
Water Pump Delivers GPM Size of .Tank
Pipe Material Used in Well : Cast Iron ( ^) Gnlvnnized (_) Plastic (�
Well Pit (_) or Pitless .Adapter ( �
Was sleeve used to protect pipe? Yes ( _) NO(l "Type or Name Well Seal
Date �J/
I
ieS�Q,11 e'1t11e.:.1'';r� TDtktk�rlrtk�rlk
9t�r�t1M�M*eF�M 'c�'c�4►M�M��r�F►4iM�N�4�M�Ir�M�r�M�4�Y�M�kt4►44rt4�4t'� 4�tti4tirorr,r�r�rtir�`ri'. .c.;•..,.icic,c,.s.,c,.1. .::
Date Water analysis repor-t 'submitted to Board of )feal'th
Date release given tD owner of record & Bldg . Insp
Health Inspector
Department of Environmental Management/Division of Water Resources
x v ' -WATER WELL COMPLETION REPORT
WELL LOCATION t
Address Libery Struet Lot 54 / �`A f •\
City/Town i • Anaover, A 1
`'..
G.S.Quadrangle Map r `s
Grid Location r +,t,a
.. -ai..41.:�3 vii +J•/a�U CIi baa�{+�1 �
Owner
Address P03 331 J. Andover, ,A 0:
WELL USE CONSOLIDATED WELL
Domestic Public ❑ Industrial ❑ -
Other Type of Water-bearing Rock,?--4,0./-2.1-,/t
Water-bearing Zones j _
Method Drilled Rotary 1) From ��, 1 To_�
21 From To
Date Drilledn 31 From Tc
i U9 4) From To
CASING Depth to Bedrock
Length ;)I Diameter �t
Type ct,r»I UNCONSOLIDATED WELL
STATIC WATETLEVEL Water-bearing Materials
Feet below land sur 7e -9-
Sand: fine❑ medium❑ coarse❑
Date measured �y// Gravel: fine❑ medium❑ coarse❑
GRAVEL PACK WELL
Screen:
�s Slot length from to
Yes ❑ No Lj
Split Screen(or 2nd screen)
WATER QUALITY TESTS MADE Slot# length from to
Chemical ❑ Biological ❑ Depth To Bedrock
PUMP TEST
Drawdown feet after pumping days hours at 15 GPM.
How measured_� Q�T r-g.ftcgyery feet after hours.
LOG of FORMATIONS COMMENTS: (On well or water)
Materials From To
0
M
r)
Cb
DRILLER y
Firmikillin s and Sons, InE,
Address 269 Proctor dill ROE-1
City gO111s. :TH 03049
Registration No. 203
• perator s ignature
Please print tirmly
BOARD OF HFAt TH r.npv 25M10.85.807101
DRi7' A�IIDOVER
Mq
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O�P.he� provided )hlo loan so/ neo �,;• tocol 8oarci �'lvty '.
OC MqR�
00 «'=�rl'lllod so use lis 8^e/c: rr �oa,tn
, o, cu,o, a `rH 07 TVER
A. Faclllty In(ort�Uon MENT
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�L\ Commonwealth of Massachusetts
City/Town of NORTH ANDOVER RECEIVED
System Pumping Kecord NOV 10 2009
Form 4
TOWN 0F NORT ER
DEP has provided this form for use by local Boards of Health. Other fo msIRC1l9 p4�
information must be substantially the same as that provided here. Before usingI 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 1. System Location:
forms on the 1 I.1C� L-I 1_D�c k, S-T
computer,use "f -- — -- ---
only the tab key Address /^�
to move your �Q<�h din 4 DYc� —
cursor-do not City/Town State Zip Code
use the return
key. 2. System Owner:
-- --
Name
Address(if different from location) --
City/Town State Zip Code
Telephone Number
B. Pumping Record
1. Date of Pumping �— 2. Quantity Pumped: Gal1500
Date
3. Type of system: ❑ Cesspool(s) YSeptic Tank ❑ Tight Tank ❑ Grease Trap
❑ Other(describe): ,/ -
4. Effluent Tee Filter present? ❑ Yes LvJ No If yes, was it cleaned? ❑ Yes /No
5. Condition f System:
Goo
6. System Pumped By:
_ J iYY-) GGl
Na�ar Vehicle License Number
1N in 1�,iVec �nyi�dnm_cn�al
Company
7. Location where contents were disposed:
Signature of Hauler ' awmnce- � Date
Signature of Receiving Facility Date
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