Loading...
HomeMy WebLinkAboutMiscellaneous - 453 FOREST STREET 4/30/2018 ...................J ..................I ST STREET 21�106A,0268-00DD0 1 n r r I i i 1 _ nt � .,.r f t7M� e�,vP•'1'rf Y,. _ NY, r+Y''. i,A h .r MAP # LOT:.# PARCEL # STREET �ONSTRUCTIO.N A.PPR_ •_._.L, HAS PLAN REVIEW FEE .BEEN PAID? ES NO KLAN APPROVAL: DATE /7 APPBY /�� . DESIGNER: .��JT/A/(/j X, PLAN DA"fE. �( CONDITIONS WATERZSUPPLY: TOWN WELL WELL PERMIT DRILLER WELL TESTS: MICAL DAIS APPROVED HAC'TERIA I DALE E1I PRUVED BACTERIA II D nPPROVED COMMENTS: FORM U APPROVAL': gr17���7 APPROVAL TO ISSUE ES NO DATE ISSUED 3 BY CONDITIONS= FINAL APPROVAL: . ALL PERMITS PAID YES NO WELL CONSTRUCTION APPROVAL YES NO SEPTIC SYSTEM CONSTRUCTION APPROVAL YES NO OTHER YES NU ANY VARIANCE NEEDED YES NO FINAL BOARD OF HEALTH APPROVAL: DATE: BY: ;: ,�' ����SYS.Z�M�.NSI84�,..8•T�TQN 'J 1� i I., 1. f '• -' -'\ L,•?'Y-:.,•,I• ,._J• .' '7�e.:i�.1.' T ;14 , , . t _L � 1- } . t r IS THE INSTALLER LICENSED? 1 + `'�+ YE NO .TYPE:OF- CONSTRUCTION: NEW REPAIR •,;�' _.. NEW CONSTRUCTION: ,... CERTIFIED PLOT PLAN ,REVIEW YE5 NO e, s , CONDITIONS OF..APPROVAL YES NO (FROM FORM U) ':.�. _` ::: ' • `\ ISSUANCE, OF DWCIPERMIT _ r YES NO 1 . 1-bL VA DWC PERMIT N0. y ��� 1 INSTALLER.�J)U � `BEGIN ..INSPECTION YES 0 .., :EXCAVATION INSPECTION: ; NEEDED: ..4.7 PASS BY CONSTRUCTION INSPECTION: NEEDED( :AS BUILT PLAN SATISFRCTOR' Z YES:- .• , ;,_ • • .• �- � DATE: APPROVAL. TO BACKFILL. , FINAL • GRADING APPROVAL: DATE BY ' ' FINAL CONSTRUCTION APPROVAL. DATE:_________ Commonwealth of Massachusetts RECEIVED H W City/Town of No. Andover System Pumping Record HAY 8 2012 Form 4 TOVJN OF NORTH ANDOVER 41M SV 9 y`ev 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, use only the tab �� - key to move your Address ; cursor-do not No. Andover I Ma use the return key. City/Town State _ _ -. Zip Code 2. System Owner: y-nIA Name mrwn Address(if different from location) City/Town State Y Zip Code Telephone Number B. Pumping Record 1. Date of Pumping 4-/ '��" 2. Quantity Pumped: C � Date Gallons 3. Type of system: ❑ Cesspool(s) Septic Tank ❑ Tight Tank ❑ Grease Trap ❑ Other(describe): 4. Effluent Tee Filter present? ❑ Yes 0-1-0-- If yes, was it cleaned? ❑ Yes, No 5. Condition of System: ' 6. System Pumpe y: r . Name Vehicle License Number Stewart's Septic Service Company 7. Location where contents were disposed: Stewart'sRe-treatment Plant, 20 So. Mill Bradford, Ma 01835 Signatur of Date Signature 1R1 ceiving Facility Date t5form4.doc•03/06 System Pumping Record•Page 1 of 1 Commonwealth of Massachusetts City/Town of A/0 , �. System Pumping Record 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. System Loc atlo : {� on the computer, r ,, k; use only the tab T ps+ S-E fOwN fJ r 5 key to move your Address cursor-do not not v k— (+ use the return City/Town --J— Stated Zip Code key. 2. System Owner: v- aL t44e_..r a J Name ie4im Address(if different from location) City/Town State Zip Code Telephone Number B. Pumping Record 1. Date of Pumping ' V 2. Quantity Pumped: /v ob Date Gallons 3. Type of system: ❑ Cesspool(s) V/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: NaN 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 Zignnature of Hauler Date ature of Receiving acility Date t5form4.doc•03/06 System Pumping Record•Page 1 of 1 II l Commonwealth of Massachusetts fi City/Town of North Andover System Pumping Record � 4, 2014 ! Form 4 M SVB'e OVER 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, use only the tab ' key to move your Address cursor-do not North ANDOVER Ma use the return key. City/Town State Zip Code 2. System Owner: ��rab �I Name reran Address(if different from location) City/Town State Zip Code Telephone Number ­13. Pumping Record h2 Mr 1. Date of Pumping Ph Date 2. Quantity Pumped: Ga ons 3. Type of system: ❑ Cesspool(s) r_1 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: �d. 6. System Pumped By: Name Vehicle License Number Stewart's Septic Service Company 7. Location where contents were disposed: Stewart's Pr -treatment Plant, 2b So. Mill Bradford, Ma 01835 Signature Date tuSignaing Date t5form4.doc•03/06 System Pumping Record•Page 1 of 1 OF I�0R T H AE`MOV:R/ Fr,r-p 6�HEALTH NOV — 4 2002 TOWN OF NORTH ANDOVER SYSTEM PUMPING RECORD � 1 Sl'E:til OWNER & ADDRESS SYSTEM LOCATION (example: Icf( from of house) .Sick l S ! OF PUMPINC: 10-5 -0"- QUANTITY PUMPED l5©� 00L. NO YES SEPTIC TANK . NO YES � ATURE OF SERVICE; ROUTINE EMERGENCY �� li>ERY;�TIONS: GOOD CONDI'T'ION FULL TO COVER HEAVY CREASE BAFFLES IN PLACE _ ROOTS LEACHFIELD RUNBACK . EXCESSIVE SOLIDS FLOODED SOLIDS CARRYOVER Oj�HEfZ (EXPLAIN) i >1 >TLM PUMPED BY: L12, CU�INIFN'TS: U II.NrsTl ANSFEIZREDTO y YI z3 r eR N� ".6 ANl6ver Qwa 4. ��G M4�n Sf MART'S SEPTIC TANK SERVICE Na/l h A 47 RAILROAD STREET BRADFORD, MA 01835 Lh.0 1 Lie. I S/ QG 14 i 978-37277471 MOrrrx of �b er 4600 MONT Y REPORT FOR TOM OF ADD GUWM*T~� �w`-� oza 'y i 6r l un 4-111 1 1lJ�� o�� C ��s��• f Pe=n 6 �A-) ! � 1D �7 4 lJ callolle 6 G/c- CR c _ SM /a 15"3 ' l � i I TOWN OF NORTH ANDOVER BOARD OF HEALTH CERTIFICATE OF COMPLIANCE DATE OF COMPLIANCE: 08/13/99 This is to certify that the individual subsurface disposal system constructed (X) or repaired () by Rainbow Builders at Lot#8 Long Pasture Estates has been installed in accordance with the provisions of Title V of the State Sanitary Code and with the North Andover Board of Health regulations as described in the Design Approval Site System Permit# 868 dated 12/17/96. The Issuance of this certificate shall not be construed as a guarantee that the system will function satisfactorily. Board of Health Inspector RI 14 Am TOWN OF NORTH ANDOVER SEWAGE DISPOSAL SYSTEM INSTALLATION CERTIFICATION The undersigned hereby certify that the Sewage Disposal System constructed; ( )repaired; by I � located at was installed in conformance with the.North Andover Board of Health approved plan, System Design Permit# hdated with an approved design flow of i gallons per day. The materials used were in conformance with those specified on the approved plan;the system was installed iiraccordance with the provisions of 310 CMR 15.000, Title 5 and local regulations, and the final grading-agrees substantially with the approved plan. All work is -accurately represente on the As-built which has been submitted to the Board of Health. Installer Lic. #: 3�..� Date: Design Engineer: Date: AS-BUILT CHECKLIST L- LOT NUMBER, STREET NAME +� ASSESSORS N1AP & PARCEL NUMBER LOT LINES & LOCATION OF DWELLINGS LOCATION & DElIENSIONS OF SYSTEM; INCLUDING RESERVE v TIES TO LOT LINES & DWELLING, WELLS a. FROM SEPTIC TANK b. FROM LEACH AREA LOCATIONS OF DEEP HOLES & PERC TESTS ELEVATIONS OF DISPOSAL SYSTEM i' TOP OF FDN ELEVATION LOCATIONS OF WELLS, DRAINS, WATERCOURSES W/1N 150' OF SYSTEM LOCATION OF WATER; GAS, ELECTRIC LINES, CABLE DISTANCES FROM CORNERS OF HOUSE TO CENTER OF TANK & D-BOX STAMP & SIGNATURE `— IMPERVIOUS AREAS -DRIVEWAYS, ETC. NORTH ARROW FINAL CONTOURS LOCATION & ELEVATION OF BENCHMARK USED y LOCUSPLAN 7-) AS-BUILT CHECKLIST l� t/ LOT NUMBER, STREET NAME ASSESSORS MAP & PARCEL NUMBER —#� LOT LINES & LOCATION OF DWELLINGS LOCATION & D$1MENSIONS OF SYSTEM, INCLUDING RESERVE ri TIES TO LOT LINES & DWELLING, WELLS 3. FROM SEPTIC TANK b. FROM LEACH AREA ' LOCATIONS OF DEEP HOLES & PERC TESTS ELEVATIONS OF DISPOSAL SYSTEM TOP OF FDN ELEVATION �r LOCATIONS OF WELLS, DRAMS, WATERCOURSES W/IN 1 50' OF SYSTEM LOCATION OF WATER,"GAS, ELECTRIC LINES, CABLE DISTANCES FROM CORNERS OF HOUSE TO CENTER OF TANK & D-BOX STAMP & SIGNATURE IIvTERVIOUS AREAS - DRIVEWAYS, ETC. _ NORTH ARROW ®� FI�IAL_CONTOURS LOCATION & ELEVATION OF BENCHMARK USED LOCUS PLAN Town of North Andover, Massachusetts Form No.2 f NORTN BOARD OF HEALTH �0 020 19- o � . F w A DESIGN APPROVAL FOR SSA�MUSEt SOIL ABSORPTION SEWAGE DISPOSAL SYSTEM • Applicant Test No. Site Location R....J P Reference Plans and Specs. • ENGINEER DESIGN DATE Permission is granted for an individual soil absorption sewage disposal system to be installed in accordance with regulations of Board of Health. CHAIRMAN,-IrOARD OF HEALTH : Fee Site System Permit No. r/ Town of North Andover, Massachusetts Form No.3 f NORTH BOARD OF HEALTH o p tt�ao e,tip _ • o � I _ DISPOSAL WORKS CONSTRUCTION PERMIT �SSACHUSEt - Applicant_- DUlS ��G b0(>Jt']r±5 '•. NAME ADDRESS TELEPHONE "It. Site Location_ XYJ% :7�957'U,6� Permission is .hereby granted to Construct ( or Repair ( ) an Individu I Soil Absorption Sewage Disposal System as shown on the Design Approval S.S. No. 07�S CHAIRMAN,BOARD OF HEALTH Fee �` D.W.C. No. ��9 APPLICATION FOR DISPOSAL WORKS CONSTRUCTION PERMIT DATE: 1�IZ� 1 CURRENT INSTALLER'S LICENSE# LOCATION: - LICENSED INSTALL : l,,{� A u-a�- SIGNATURE: TELEPHONE# SZ"6— CHECK ONE: REPS: NEW CONSTRUCTION: IF NEW CONSTRUCTION, PLEASE ATTACH FOUNDATION AS-BUILT. Administrative Use Only $75.00 Fee Attached? Yes No Foundation As-built? Yes No Floor plans on file? Yes No Approval Date: I ``` t r��,�t ��' V � .. � `, � 'cam . \v 4S - . \ (�' 1 \ \\ d �r 4 \\i \�\.` \`\ 31 r ,e, `/ \ \Nle@ t}\\ \\\\: \\ \\ 1 t Jt " { * � . 'y „„�1� \ L" % h N .\ , _' .t `' p \ Ua ]'. f r , .t-k r, Y 1+• R ,I' 1 1. + .,\ tL a , Z. !I #�}�," kir° t,#,, �,\\� K� I j y \ 1 A�.O '; 1 —� t ib , I T S r a i� .. . r .. •. ,\ \\ b` r 'ice 1, .. \\ C, r ...., .1 .. 1` , r ..1 \:`_ 2 / b` +\` . ��, 4 Y � 3 aAt, d - a. i* J.Q. t ., \ ` i r L \\ i ll� \. y )y •t �' r1' l ,O I �.. i } s 7 ;Jtrb. 1 d ��� .4�\fro €` x.. v - + . �, \. .. , Y \ �.• t. lv J i r � 4'Z'V.. ..'� . 1, L s :r \ . �// 1.. \ ,.^ b Iii ,. / _ �/ :" '`t ._.N=• } :.7 `\.�}�.\, 4� \''. J /J�r r I ' �\ � ,fF�(7 Si 1 3 t \ \ 1. 1 u I,• t pr5 - ' 2 I '' , �� y �. A Y +W.^ .. v \, :. � \\ \. s yy �t\� - /. �. \? ) 1 .r\ . a. \� f €r' � � \`„ z .. /` `� 4 ,�l f. i•L° a is j \� \`` t r o O , ; ; . .. , t.. . �. f: �{ ]II1 �.'.i �'i. ,S 1 F'; �t..'� �i I �i� t\ \\c,.� \ �, / 'r�r/ ;A r .,tai L,Y "' \5�.,� .f ( � 4 3 �iiy1'� '1�. W 0I .,'.J 1.. 3 I,I 5 ht� , ti'r+,tr'�t s- ,1, .t`-� ) *, \.,, y`�?`.v� t: 1• \. .// J �. '.may O , .. \, Q K 7 O & /� % A V�) _ f t i 1 tii qq Y. N . . . eft / qP . X31 �:. ��'t ; �, J�r . ." , . . ,in: V.: r Y £ , 5 4y y� §!�1 4 -�V ,i � tY S V S ,; / . ?? �g'SSe, J �Tj F 11 \ 6 '. �\. , r 3 4Y') Y Int t<i At �\ :r :f tl1 r?�, �y>. f�,' i �''.. 1 ,t t yf J` 4.e { �� ' F - 't ; a '£se '-'y t... }tN C. y� ,k j + d 1 st 4i� M} ��'1 � { tr ' - I f fi t ♦ 4 !}t ', ,�+"3, >t f tea -� i Y 1 ' - Y , t 04, { , r r 1� L `: tan' +;Xt:. t "t , , p.. J fir/ r$ I ( r . r. I , $M g °c,r ..t t 1 Y� i { �tlt 'f�A A �:s•''' ,7 'I 5 1.. 4 + 4 { t - ,1 4 } r }} ..Q,. fF 1 (�J 5 I .4� '} . ,.;f 1 Z 1 �,) i t;Y I• ..s= ! Y`'i'.� >;$k r;C'." �yl r� 15t;`T� �, sl ;�� �t t ,�. _ r, } '+ ..p 1 ty ..ltl:.Xr,zS 7' r;�t�.` S' - t iT -�'' r'SW 1 j) 'f.,�','` s S <' s f a. ('{ 7. r"r f: �., t :ir}i ' "• , t: r.f,: f.':•/t fir •hy r fg, a t 'i '�,, , 3 .a r 4' Z �; W:e f i '7'4 f..y .'F ,'g, x r.^ 41t{ �.•.+ k ., r s > . 'r. Vt-y;�,S. A•S" Y+: F MIS _ J.. t t +', 5::: ". ,_ ., .r: t ' '.' �tyF„7 i3:J?.�' f •a' t L t /¢ J I yt 1: .in.. d. ,: .. . .. , ` : .. '..t y ,: ,, i..t l �.� )r' 1Atiy\Yt c. t 1•µ , y ,{, M gr r r ;. F.. ,r a r. ;:,,+k! 4,,, . -t 'i,4 G`1 :�..+: ) .i.'+ +r r r ,!- v.. 3 ! 4, ,, I,,.., -+P .! } •'... �,. J. J.t ,..a. .:a"iurea a 1 el �. s ,.:' , „i. t •,1. .1. n. E., .i- r,T,.u.a,°. :,i r'T l t- ,.;' { .:.,.) 'l' 1. 4. r�r'!+ --"�, w,.. M t+ p.. •{' s fib' Tr -..1. :l "T '�'..ry,t -e,.Y/y."i+ F ,k{t.�i�.,.(') Yv 1fl':: _,,v J ,) 7 \. 9 {- ['. •F. t �, t, dh .#. .zk .a.,}s;' c 3`+, `k +- ::+: 'i .n a :, i. :.e. .,s+r .,.§ .kti. �`+.a,':llr.}�+*zh"F+ .a;,,ui f-. 'S1,k {. { ::�! . .. t a }•;. a .r. ..r -, 'r s.':`F'<f+ :�5'. .S„ ,ast. `^} a .x.+ "r a ,,{c, I. ,.S x: "t14:..i?.t�.�'jt L } _ �r>ctFt .4.fi 1, - , ,�:L r. ) ;t ..a ✓r-'f+-•� nJr 3 r e >' s v y .'r . , .. y, y' Iry+• :. r .�: •', n a k v,:t y; 7 r .+q .,x "�. t- "' -, e• :,! J. 5•),d4,..n'.tl �' ,A.,•I`.. ":.Y P' }.3 k,S. 7: :.t ',r ,.L '- ..5, ., a 1.� 7 Q . .fes -a' a.. s.; �;:•r i L 7y q HCl P:' ,..h'�; h'' t 3 s v t a ,tn: i .t- 7 r .ta:,x %r�, '�r.� ,r r..e 'np3 .,I J E. } {, y� +„y..y �? . T a: hb 1 Sti d ,A k. Y.. .. -�.. ,, . . .,k.-.". ;>:�. .: Ir ... .'; ,r"oto'•, x t M �`<-B.F. n.. ..-�•,� ,.r,.,. r r 1..5. e _ ,t.: L. tl t. o- ,N. �:. r�s w+' _ '4" At'6' kf7 ,:� �r, -"r �a,Y .e! ��`.. ) a.r:. ... .x.3. .. _..a ,..., ,r't n.... �.;.�"...1 •4,- ,o.. 'T.�,y�t: ..;a t'. - fi'r-. •3,r ::ti: +,;.. 'x. ,S• '`f' r� .. �..)y b. t~y.r . t IF :P ?, .y;. t. .c 'Y t. yr +. t •v, ,�- ,=�. :. 5. .�hln 'v ,,l iS v t j;J' -r.t>•.t. .K:. 1' ' ,;r YS .� � 5. ta, .r .A -t#. d, .F e r r . .�; t � - 'k'.. .t "'h y,1 `fir t .l I"l v. 'r.,'F :s' ! 1r " t,. ,++, y f! d ti r. +F • �ir. ' f ..i-w. ..,:�;. f., ....1...a.r. . fir , t ,. ,.t;. _.♦ .Fr �: N.3. �., _ .r. t .'` '..A ♦... -.:l r it :�'J. jj .':"":, y, .•it, .. f •.Eo .,.'Y'ne .:..•rr ..r ,r.,.,. ,"R ,• .. r .,v.#�... ,.. r ,- ..� ti t° r. .a.,,. ;'�(.+. ..1+..- ,p,�'yyt. 1.!`,f'?..: KS. l..s.• 't r��Si' S. `.,:i:,, { .. .. y v,ir+•.. - f W' An �• � � r.��, � Vit': k•7. A'S..q E'"•A,N a'tA�- J 1 1-t � :�(C. M. 'aq E., t b1',, .., .-+. . ..,:.. .:'VT,l V;t),,. a ,T•. ,St.- , - ,)+�•:""':e • > Y ..•1i: Y, r:,;Y., .'� ?`+�- .. ,',,. .0` r- W. {trf- ..?fit ,,.r, a..t 1':,•, .:s. .,.,a... ��tcr.,pp .�s.S,..,..ce5.,. }•,,.,•.n--M 'h"ytG x-t a ).::�` : S �. � .a ': ,. ,. 4}1 ��`.s� �' ,�s.,. .t, 'i ,a;�' - r/` ��^,, •+�' ,•`'},.-. ;".1�t ,!,'�'?. �I/" 'P.• ;, . +�. i ,,�?.;i. .a f F. Fa.a(,u,., .},t � S t t o J;: d 3 '-�tF.S 'g :;Nfir- Tr i ;-.a u.:, . n _}mart,,�:,•.„_ � .,. ,., .r ,. .�.. ..r.:!e,Y .,.J. ,. .., ;r . :. �`` '. r �+�., ;'a �;t� .w :..}-. ,, Y ..�. a�.'� •t s<��:�" . �� •'r '�.n, .t 4 ,t t.1..). 5r-,"' t,i ,1 _h f.., y:..,y c I, pn:a ! ,. ..,'b,>t M`s.. ry, �i. 'ie'•f 'YtY 'S+..,,eXrp:. t. t,.�Sru ^7,r, ..s. *h de ..t. r...,.�.,!�i'�li. :}ii i,}-A'., ,, 1 �y i., �Y, •'+”'• `�:+, t..t�+t`k}`'�•( !\1:i'"r'�y,'• i�} R e,tC., 1t., t`]T • }S9 r �• 40 1 ytd. 1.: p:. w c:4`.r .s.z ,gif is ., i' ?i.1i ,; H,. t.•/� ^;, .. 1,+ �! i s ., s.sfa. t av „aP �a...cfl,:.; .« �tr,. 17+s s a � t, fi -•.1 .._ ^,,.. �' is ejk� win73t�J#rTd 4� 4k ,,.. :-t:;�-,.-, . , - , , , .. - -;;.� ..�-s�-`,L'."),.--�:-!,�. ;�� I'. ,* � . ..:� , � . . , '.- ` ,, - ffl�'I` I .� , . . . - . —,K' ,� � -1. . , . -. . -,� — - ­��- ,, . . ­­­­..Z.,..., : _.� ;*: . . . .. ' ',,i��,.flj­�, .­;l��`��;,-,." , �! �. �! �� . , . - - �. -"'r-I !,: .!: �� �,,- � - � `y y t r ff # 7{ 1 't�^'{v.�gn �F.k, Y i :� t t' '4%!t :S .:A r 1. I �� , 72 uw§ I \i' L j: /� til J�. 'URA t r i / _ ' 1 ' ! \ _ 0 moi . a % r' 2 I `I e k 11 e r} . \ ,f '- ,. % thc�"?1 by a.:+ t t �. . .. - �� r%i rllr S 3, tifj { n.: t - a ;4 ,lm r� F 1% i !,l,' ;:y i / y iii:; �, ¢ ,.. z !G it,y t,,,.., ?, s i a S'L'R r .,, , !. .� .n- ,t,�: t .r i, I ,i.. , :;1. - ,. \ .� it ?'ii,y,ei .\ / } `,f�/`] ti. �:; F t Q3 r . . \ /, rf�j %/f�y Via.. • ` ;-. _," ', VU ps r• ,y. i- >' -1'1t i,�.Ji i ¢/ it/`9� �' :ter,: '. .. Y1. 1. F I GE rj; ,• !/ 5 �,- fy1. 1 � , �\ ,• i.k , :1 } : - - .p' 7 1 ' YM1� �� ;} K1.1. 12 CMP. % �: '' i t r,�� C Y \. VLl F yT C T�' -' 5 , \' f }�-, s , _ f 1 _ 1 , \ \ -_ I. \`. 4 E� 3 �f' 1 V �y .� ':� p„r7 7.. s e 5 .\ Ai } �, f, i,. y<e r r. 2 ar' it 'V-� i `� Y` - 7r h T r + �`� ' q Fy L ll'i y1. r r i v^* r. y w 1. lN' � - 78` >4 _^S�' ..f •"f•• niii' '.',yl �.�• �.I' l r -�� rI I''f D r 1. rr' u i1 ,THIS`._ !�O©Jf7 #4 T ON .I . L M E r< f 11 .1 I �; ,'. „ t 1• , ., 5EP1O IANC .,AND THE f�IPIM r r ROPC?5 '!S .. x. � 11 1. S,.A:) max- r v7i {.:, 3:'. .V:p 'S.r, r , a3� :� : WO HANG S Afi�' r : 1 .• � r i�; - .:., u. R. Sf �. w t. ;, H :.APPl7 , p �+ ij­ at!" .i 3 74 -:r d .. ..->.: .' o ..�.. ..'�•, r,<' - �q 7. .s t ':�, t l���aL _5 S T (C'p;,-_ -y {- .i'. .• 'ta: ,� .-irk - y . 2.. :'tl•.�.�,r! j - , 1 _:, t �f�; H r.. �§', a a y , «r S } ?` =DE z a 1 `5':9. s, Y ).a -:3' �_. _ #. .Y .� i,•r.r„M. +.F i(' .tea„ 1•. .:t '.� �,. •s..> - '(� .�.: ( 1�%. Y3 •ter(}., j,? f k 1 tti��' ; T>. .. ,..f.. F .r.. .. 3 ... M: i... . s a, i,:.-_.. ,.,_. .:x:. .,. 7�R� 1�.�} .r,.` .Y y. - 'C.:, :'3 -, •7:.:_ .:.r }. .,., .r_.-_ _,:a 3 c. * .'Ei "55 §. Tti 'f- 'y r e - s- �2 y,l `§p. .-{ p. -.:v C-.r•:44 8'.�°iq .;3� r .fi. a > f`. ':i.r -.s. k' \ - b L" 4 f •�♦ ` y d-b.& Ss x"'2_`: .f., fr... .S` „v�Ai-i r. .":,' _ I t u k >F S, r. } aG. 4 g �+ i. 4 l -.r• r. ::'• .... o:Y,.a: S, :. . : '-4. .:e..,5 -:;5[,. )'-u���. .(- �. �.� -.:"xi'X2� .1 & 1'':,r .3- -Vxl •e.. z, . r 'i. ..,. .:.. i-r 4-. 1 IdT.. L..3:. '�... y,.... .^ 7 >-:' i a6'..-, f: i'4 -I�.` - .* '+-� x' .�i...rs�n �... ><,... ;•. �S•:.; # ...,,. r..3>•.w• � >rr � 4si��5_.. � I�.. _ .... ,.3:T �_ , _ , s.. ._ z: . :,_•_ ._. _ ,_ SEPTIC PLAN SUBMITTALS LOCATION: W LGY\-Qno-6/� NEW PLANS: YES $60.00/Plan REVISED PLAN YES $25.00/Plan /YLO, � f DATE:- DESIGN ENGINEER: When the submission is all in place, route to the Health Secretary �I 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 local or state law, regulations or requirements. ****************Applicant fills out this APPLICANT: Phone LOCATION: Assessor's Map Number /0 6 Parcel Subdivision Lot(s) Street St. Number ************************Official Use Only************************ RECOMMENDATIONS OF TOWN AGENTS: Conservation Administrator Date Approved Date Refected Comments Town P Date Approved Planner Date Rejected Comments Food I spector-Health Date Approved Date Rejected Septic Inspector-Health Date Approved Date Refected lo Comments Public Works = sewer/water connections - driveway permit Fire Department i Received by Building Inspector Date 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: ; l?G' Phone �6'J'- � 3- 70M�5 LOCATION: Assessor' s Map Number Parcel Subdivision 0011 43&re Lots) A Street - 4- .1,6 -VA-O A St. Number ************************Official Use Only************************ RECOMMENDATIONS OF TOWN AGENTS: Date Approved Conservation Administrator Date Rejected Comments Date Approved Town Planner Date Rejected Comments Date Approved 'Foo In ecto -Health Date Rejected VDate Approved is nspector-Health Date Rejected Comments Public Works - sewer/water connections - driveway permit Fire Department Received by Building Inspector Date �1 PLAN REVIEW CHECKLIST ADDRESS Z6req �DitJ �i�STU�E ENGINEER (J fid /v7 4,US EiC� GENERAL 3 COPIES STAMP LOCUS v NORTH ARROW �� SCALE G� CONTOURS Cl---- PROFILE C---- SECTION v BENCHMARK SOIL & PERCS 6---- ELEVATIONS L--' WETS. DISCLAIMER WELLS & WETS �`-� WATERSHED? DRIVEWAY �(Elev);; WATER LINE FDN DRAIN L--' SCH40 L--' TESTS CURRENT? SOIL EVAL '7) . �VxICGL SEPTIC TANKp / MIN 150OG . 17 INVERT DROP LI-� GARB. GRINDERAO (2 comps +200 10 ' TO FDN t-,-"" MANHOLE Dr- ELEV GW D,C ## COMPS. � GB D-BOX SIZE # LINES o2- FIRST 2 ' LEVEL STATEMENT INLET &)4.q7OUTLET /0*-�& = / - _7 (2 OR . 17 FT) TEE REQ'D?�� LEACHING MIN 440 GPD? RESERVE AREAL-"" 4 ' FROM PRIMARY? �� 20 SLOPE 100 ' TO WETLANDS L�-' 100 ' TO WELLS �� 4. ' TO S .H.GW 20 ' TO FND & INTRCPTR DRAINSL---- 400 ' TO SURFACE H2O SUPP �---- 4 ' PERM. SOIL BELOW FACILITY C/ MIN 12" COVER( FILL? 151 ) BREAKOUT MET? (— TRENCHES MIN 440 gpd SLOPE (min .005 or 6"/1001 ) SIDEWALL DIST. 3X EFF. W OR D (MIN 61 ) L� RESERVE BETWEEN TRENCHES? `-� IN FILL? MUST BE 10 ' MIN. 4" PEA STONE?�- .VENT? (>3 ' COVER; LINES >501 ) BOT -406 + SIDE o X LDNG ' 7�- = TOT_ 7� (L x W x #) (DxLx2x#) (G/ft2) Copyright © 1996 by S.L. Starr FORM - s61L EVALUATOR FORM Page I of 3 Date: No Commonwealth of Massachusetts Massachusetts Soil Suitabjlio� Assessment ror On-site 121SPOS—al ........... Date: .. ... BY: Performed t�x .... .... ....... ........................................... 00 9.......... Witnessed By: ..........Sk"4!9"..... OneNam, L01jG 194ST14kj, �b L=uion Address Of Lp Address.and# r-OVLU-r STra/vr Telephone W , 0,txr-0rW, ,V'A- C)(qz-( ew construction ,-Repair ❑ Office Review Published Soil Survey Available-. No Yes soil Map Unit ............. .1.9.b .... Publication Scale .................... Published ................... ............... ............... Year Pub i soil Limitations ............................................. Drainage Class -it ❑ Surficial Geologic Report Available: No a Yes Publication Scale YearPublished ....................................................... ........ Geologic Material (Map Unit) ............................... ................. . ............................ ... ................. ..... ..... ........ Landform . Flood Insurance Rate Map: Above 500 year flood boundary No ❑Yes Within 500 year flood boundary No ❑0Yes ❑El ❑ Within 100 year flood boundary No DYes Wetland Area: (map unit) .......................... .............................. ....................... National Wetland Inventory Map IV4............................................................................................. map unit) Wetlands Conservancy Program MaP Current Water Resource Conditions (USGS)- Month Range :Above Normal []Normal OBelc-/ Normal ❑ Other References Reviewed' DEP APPROVED FORM 12107/95 FORM 11 - SOIL EVALUATOR FORM 17 Page ? of 3 Location Address or Lot i',io. G,'I'!G On-site Review Deep Hole NumberDate: 5 2,3/Yf Time: /�: Weather '7S Location (identify on site plan) Land Use WCODS Siooe (4%1 0-3 Surface Stones No Vegetation Oak-,) rnaphs, p%rie- Landform Position on landscape (sketch on the back) Distances from: Open Water Body feet Drainage way feet Possible Wet Area feet Property Line feet Drinking Water Well ZOO feet Other DEEP OBSERVATION HOLE OG` I Depth `ram Sod Horizon Soii Texture Soil Color Soil Other j SurTace (Inches) (USDA) I (Munsell} Mottling (Structure, Stones, Bouiders, Consistency, % Gravel) 7-f g W FSL 10Yk 414 E=ria6� 7,;SYi2 ,/V�ass;ve t15_ mzD le ia>Yl Z4- C 5t''Qfifie� At rr Crawlav � x ''19 9 Aedl-am eera U) (oa c- C'oaA's�'e�,(, i (; fir, l, .SY G�vn u1� �D Siyts!� 4'� 9 Co saint( �� 1 Dose , 610 eo 6z MINIMUM OF 2 HOLES REQUIRED A i EVERY PROPOSED Parent Material (geologic) ©LL71orks H DepttttoSedrock: Depth to Groundwater. Standing Water in the Hole: Weeping from Pit Face: Estimated Seasonal High Ground Water: DEP APPROVED FORM-12/07195 FOIZ.M 11 SOIL EVALUATOR FORM Page 2 of 3 Location address or Lot ivo. Ll9'I'!q A,.S,�Z.lJ�.._ On-site Review Pyr C��`G1 Deep Hole Number Date: 6#31 6 Time: 1;N55 Weather 7.S 8 Location (identify onsite plan) NO Land Use WWDS Siooe (°'o) 0-3 Surface Stones Vegetation Whi' Landform Position on landscape (sketch on the back) Dis,ances from: Open Water Body feet Drainage 'Nay feet Possible Wet Area feet Property Line feet Drinking Water Well 900 feet Other DEEP OBSERVATION HOLE _OG* i Deoth from Sod Horizon Soli 'axture Soil Color I Soil I Other Surface (Inches) (USDA) (Munsell) Mottling I (Struc:ure, Stones. Boulders. :.onsistency, Gravel) I /4 F. S .L 0-7 P s�6/3 i 7 _2-6 �� F.S.L, /0 V /0 YR sly /�Qss,'ve Fri"k-- CZ fD C OCWSC, rows below 18 �e 9 96 C o l� a,S Y weak 5 S 9��n C Fe,.v roof-- 4v II -5- MINIMUM UF 2 HULES REUUIRED A i EVERY PRUPQS�-U DISPOSAL AREA Parent Material (geologic) 0CkT"—vv DeothtoSedrock: Ii Depth to Groundwater: Standing Water in the Hale: Tdq Weeping from Pit Face: T11? Estimated Seasonal High Ground Water: /O DEP APPROVED FORM- 12107195 _ FORM 11 - SOIL LVALUATOR FORM Page 3 of 3. Location Address or Lot No. LU I P, t O&)& PWS 1 L X I Determination for Seasonal Hieh Water Table Method Used: ❑ Depth observed standing in observation hole inches ❑ Depth weeping from side of observation hole ........ inches Depth to soil mottles I.$;Z4 inches ❑ Ground water adjustment ................... feet Index Well Number .................. Reading Date .................. Index well level Adjustment factor .................. Adjusted ground water level ................................................... Depth of Naturally Occurring Pervious Material I ' Does at least four feet of naturally occurring pervious material exist in all areas observed throughout the area proposed for the soil absorption system? YES If not, what is the depth of naturally occurring pervious material? 1 Certification I certify that on v (date) I have passed the soil evaluator examination approved by the Department of Environmental Protection and that the above analysis was performed by me consistent with the required training, expertise and experience described in 310 CMR 15.017. Signature Date QZ10 4� DEP APPROVED FORM-12/07/95 Town of North Andover, Massachusetts Form No. 1 NORTH BOARD OF HEALTH 32o�� �eo 0 19� o it APPLICATION FOR SITE TESTING/INSPECTION TED ��SSACHus���y Applicant NAME ADDRESS TELEPHONE Site Location Engineer NAME ADDRESS TELEPHONE Test/Inspection Date and Time CHAIRMAN,BOARD OF HEALTH Fee /SV, O Test No. ' 10/ S.S. Permit No. D.W.C. No. C.C. Date Plbg. Permit No. R Town of North Andover, Massachusetts Form No. 1 NORTH BOARD OF HEALTH o -V 4611 „. A APPLICATION FOR SITE TESTING/INSPECTION 7,9 ADgATED PPP,�(� �� SSaCHus� Applicant . NAME f ADDRESS TELEPHONE Site Location Engineer NAME ADDRESS TELEPHONE Test/Inspection Date and Time CHAIRMAN,BOARD OF HEALTH Fee—' Test No. S.S. Permit No. D.W.C. No. C.C. Date Plbg. Permit No. i SEPTIC PLAN SUBMITTALS LOCATION: NEW PLANS: $60.00/Plan YES; I REVISED PLANS. YES "$25.00[Plan DATE: DESIGN ENGINEER: When the.submission is all in place, route to the Health Secretary CHRISTIANSEN & SERGI, INC. PROFESSIONAL ENGINEERS AND'LAND SURVEYORS 160 SUMMER STREET HAVERHILL, MASSACHUSETTS 01830 (508)373-0310 FAX: (508)372-3960 TOWN OF NURY. �©'ER/ BOARD 0- TO: rtT0: Ms . Sandra Starr Board of Health 2 l9C North Andover P RE: Septic System Design Plans Date: Attached are plans for Thidesign is a new submittal a revision with the following changes i" RS.............................. No................_....... THE COt.1rAOMWEALTH OF MASSACHUSETTS BOARD OF HEALTH T'0 Wi l .............. OF ...Alo..:�.......r7/V D.V. ................... �Iir�tti><ut hIr 111-Till wd M111rim (91111fift Wfitut Ilrrutit Application is hereby made for a Permit to Construct ( X) or Iteprtir ( ) an Individual Sewage Disposal System at: _ n l'ct.5/rtr-- Fd�Q651- s.—.epi -0... ...........................................................•...... .... .......... r.ocafl Ad r ss ✓� ..... 3 1 _ doh Pasfzfcra 1` ¢- LSU-s-'- -- ,. y ..... ...... ..... . ..... -- nerd rC�3 Owner .........................••--•---•--•--........ AtHress •-•---------------------•• tnslaller 2 Size1,ot----------------------------- Type of Building Dwelling— No. of Iledrooms..........I....�........................ Expansion Attic ( ) Garbage Grinder ( ) P, Showers -- Cafeteria ( ) W Other—type of Building ............................ No. of persons....................... ( ) Other fixtnres ...............................:.............................................. ................................. / U Ilona. Design Flow............................................gallons per person per clay. Tt�lal cht)yy (low...._.-.........0�---.. � /$� *tllnns Length.-/O-:�•�.. �Vidtlt_ .. ...... Diacnc•tcr................ I)c ,tlt.. ... Scptic Ta�n,ic -- Liquid cnjntcity............t,s ( L ......s ft. �- ...... Nvidth....3 -------- .l•otal Lcngth...�-�`�.......... Total leaching area...... .... �. x Disposal "I -- No. .............. 3 Seepage Pit No..................... Diameter.................... Depth below inlet.................... Total leaching area..................sh. ft. Z Other Distribution box ( !Yr Dosing tank ( a Percolation Test Results Performer) by.. 17G17►.1.e/...... v/ll! 1........... nate..JS/ ................. a� .� Test Pit No. I......�....ntrmrtcs per inch Depth of Test Pit.........�o....... Depth to ground water. N i...Z., Test Pit No. 2........1;2'.-.minute5 per inch. Depth Of Test,Pit........ ...... Depth to ground n; ........................... .......... ...............................-'..................................................................................... O ............:...•----•-•---•----•-----. Description of Soil �°.�i.11s� .�1...... x U .........•.................•......•--••••-•----•--------• ---......-•.........................................••--•............................------•.......... ................. ------ -----------...,. ........--•---------......................------.....--•---......-----•-----.....•--.......------......--•........ V Nature of Repairs or Alterations— Answer when applicable.................... ..........................•--............------.......----.................. ...................................................... ---•- Agreement The tmdersigned agrees to install the aforedescribed individual Sewage Disposal System in accordance with the provisions of TITCH 5 of the State Sanitary Code — The undersigned further agrees not to place the system in operation until a Certificate of Compliance has been issued by the board of health. Sigoed.................:.....- . ... ................................ . . ........................... -- nate .. A ,lcation Approved B Mite Applicatioct Disapproved dor- the follomirrg r•easotrs:............................................................................................................•... Date PermitNo...... ................................................... Issued---------------- -nate---------•--------•----------•------- THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH { ..........................................OF..................................................................................... Cgrr#ifiratr of T1111tftilattre .. THIS I,S TO CLR7J f', That the Individual Se«•age Disposal System const.riu•ted ( ) or Rewired ( ) by•----•..................•--•-••-•-...........•....-•-........... tt�st,n�. at....................................:................................................................... ......... ..................------......- --------------*.......... .. has been installed in accordance with the provisions of TITLE 5 of The State Sanitary Code as described ill the application for Dislro9al Worl:s C011StrIlditnl f'crrnit No......................................... dated............ THE ISSUANCE OF TIIIS CERTIFICATE SIIALL NOT 13F CONSTRUED AS A GUARANTEE TtIAT TFIE SYSTEM WILL FUNCTION SATISFACTORY. DATIt..................................••••--•-•-•••............---••-------•...--•-- Irispector.................................................................................... THE COMMONWEALTH -OF MASSACHUSETTS BOARD OF HEALTH _..... .............._...... .....I OF.............................................. N,o.........:............. ...................................... Fs H........................ �ir.�I.n�ttl �:�71zIIar �nit3#4•ttxtinit �irrinit I'c�rntission is hcI'el)\� gr;uttcrl..........:..................... ......................................... ........................... to t.,onstruct ( ) or Repairr ( ) all Individnal Scw;tt;c Disposal System :tt No............................................_..... as r;lwxn un tltc al>pli;::tliun fur I)isl>os:�l Worl;, conslruclion Permit No.............. .................................... .Board or rrc•atti, ......... FORM 1255 HOBBS k V✓ARRcN. INC.. PUBLISHERS RECEIVED . .. TOWN _, ...... ... _ ., NOV - 3 2004 NORTH AN DOVE S 'S'T'EM PUMPING} RECOKL� TWA OF klOPTH ANCOVEP U/� l'F. / SYSTEM OWNER.& ADDRESS SYSTEM LOCATION DATE OF PUMPiNU:_ �pI,IgNTiTY PUMPED; C LSSPOOL: Nv�_. .... . b .._.... Saptic Tank: NU_ YES NA PUKE OF SERVICE: KOUTI.NE ERUI~NC'1' 08SERVATIONS; GOOD CONDITION .'�/. PULL TU COVER HEAVY ()"-ASEg ROOTS - APPLES IN PLACE. LRACKR sXCESSIVE SOLIDS FLOODED D RUNBACK SOLID CARRYOVER._.. .OTHER EXPLAIN Jyrtom Pumpcd b /352a'79m; .-ra. (�'UMMENTS. CUN fEN'I'J I KANS.FbiL ED rO .�•C��i'.�1'��d!L�AJ)�il ORTH�ANDOVER MASSACHUSETTSV. :; �' 'FtG,�M ti 3 '1�`>'�'.7y'� ">,Yir k^...•lY�:��. .. •�' A' �' ,•. '"j'�" J�1 yi;'�'.� r.{y ,�Ylr.'.YJ`IY'lt t:J.:i.!r.. •,�,[[ �.,���,.,�q,, I�v,t 1 li l,r?l. .Y+,.'�i:..v Y. � .. , ;':C J +,�; rf it "i'+:J•r^.�. � ,1'�: t�'�r'.ir'1: `t::+•�51`�•{iy r^r'4•. J• r' �1` .r a' , •n 1„�Lc:.• 1.. DEPr.has provided thta form for use by local Boards of Heatth T_ he-System Pumping Record mus; be submitted to the.local'Board of Health or other app t--- roving au orlty. AI Facility Inforlttion NOV 0 5 2007 lin J u,rWhen'fitun�out 1 System Location, ,.,forjru.Ort th0` TC J 1D0VER ort the tab key Address 1n to move your':; — �• .cursor.•do pot;; '• U" the.ietum ,:, C*Town , , , , .';'. i;� ,•:•s'. State ZIP Code Y:r> 0,ker,: Name ,�;:1 ,,:,•.',<.�:.'.� �l^/�/^\`�'� . '::'. r �M.'.1 t ..i•;•," ' ,.i f`rl •`� v:i:li ti+ y • V P , I "°' Address(1(different from location) Cltyrrowrt. State' C 1? Telephone Number - Pu►n.pl g:Re.Pord: .. , .r. 1• r� tQ of Pumping pate 2r Quantity Pumped: Gallons 3"�TYpe Pf system; ❑ Cesspool(s) Septic Tank ❑ Tight Tank ,Jother 1`/describe); Effluent Tee Fllterlpresent?.❑ Yes No t t J If yes, was It cleaned? ❑ Yeses'No ' >'��.:�.� �:;.';� '�''Co►tditlon' yst myr,,i.: .... of t;r yjti Su �?�;'.;.,`ii•�''f, �)14 r.• ,� .. ��, ., r�r.,�ril.T YP:�'�4'r;•d.'•,4 r•, L•�.t... ., .. •''. •.'� 't•' ��I 1, �_, .••;.,,,: .. y 'Pum ,..i .,,••. ped By:. . .. ,r: :.� '•t�.',iiy 'Sjy. .j•":r• is;':• •• .. ••,t� .. �..• ,• �'\i.i'�� t;�'Y:•'i��:%•' am�:1'l:+•i✓":,i.;�'"%°i/i'.'r'r��r+�.•• .4t ::%.� '?:,:,° Ucen*e Number 423�0t: '•� •5,..' •J'.1.J-:� �'• Y- lirV II�+,�,',k'!'1 f}• I�iiylnlria' �.,..,,. J . :✓.:� .� '::Y:�y�r��.•:•t*:r`.�;11�•lr1••�ii:{.�' ,,.y''!,,..41�• t.�jl{y,' Z li.a{,/-•S•f�11.•1''.?: :.y,:;�+.ti+• -�.y Y,� !•,,•;, r;,.;'jv`HYda3l7�•f�W;t:�:,;J•d7.IW�%F��1y.'i',.... ;;�jy'•;• : .. . Locabon.where contents ere dl •J r y,tt`` ` ' ✓' J 1,.r•,••�;�,'•��' r1'1'1+v itLl r,..{:;'',,•r •:I� • •f•••ti.:•.' y �v'{,�.i3;�..�:•!tr F'� r'b'''r•i/;}jr ay ..�rj 1 t 11 �'S r - � � - � / / ' :,�:; :+?•/.:,},fOr•.,1.;J'::,`.4;'•(y'.i+r,';.�l�nawle Ql llalal8�;lr�/•:i,'r�y�.@..'�•:,•.t'.., .�. httpJ/www.mass ov/ ' ' Date g dep/vtiafer/approva�s%t5formsrhtm#Inspect • t5forrr>'�.doa!06lQ3, '� " .. .. System Pumping Record Page t of 1 E �IVE ;:��: , � � b D�R�T�•��JDOVE�: ASRA ,R , �, CHU $ � �,m �, ,, e, o rd MAY ;get' .,,. rad IFTI, 'moi:, �nl 1,,.' , i!,•::;'., . C�EP.hei provldod lhl4 form {or eo TOWN OFNOFtTH ocol Boa%cr or oeH> AL.THQEPARTM NT 00 �':dml(Iod (o u)e 10c41 c arc: C'1 nOJ,(n pi Clnv+ �P?/0;1n Y7:d',1 C � .tnprlry A, Faclliry In(ortw1on , s N 1 I.. 1 !41 44 (114V(6r6n1 rprn buUpnJ l o9nOn, h (no„ no Oop. o! Pum➢lnp ���� ' � r.. Dill � r.':d( '-�, r• �6r •�____ 3. ,Type vl byii's m. c999D001(y) aD(!c Tan,, T 4. EMvon(Too F11(o(P('�senr? [�' Y ii �Ir�lr Y89, X87 ::08n907 yes — I�.r ' �� SY v n/lG;7j,;4 f{ n'. •,�Ir�.a�r,.1:/' ',/1'�' y'il('�,Y ,!�' •,. S,',��',�� T, 7ik /. n.yvhare Gor1lenla'w9fe d15po 1.'..,;1,1f.� •.,,. ;�,,,. 590: ��„^�*�wmasa.gov/doF.tirel•sr/epproveJa/Iblorm�.n�.�naln9oeC1 SPI, -- ,�.. .. ` ,!lei:ll�j:l�l�l�l,y,.l•,'.1.1�..,.'.. HOV — L� 5 TOWN u� NOR-I'll u t�� 5 Y 3'T'E!�1 P lJ M P lN !��'lh,.� Kj— o(f�M1i�r I �Y3reM pwNQR <k --- ----- p p U s s -�------ - - �sYSTE L 1, ;, 1 �;;� .... _ ........... ._, �� . �'t�sPpUt; N 0..,,1. . YNJV; �uuuc YtnA hi rvxi of 3r;RYICe: xVv'rlNe . _ _ . �nitKu►.�c� , Ua��RY,1'f'IU�J. 0000 COtgorrIUN �vLL fU (:0 rx RZAYY QUA,33 KOOT"3.• �Ei�'CKF�I�1.,4 K VN b��'F• Moom $OLrDCAM YQn ,' omen eXPLI,PN _... wm �'uMM�NTs. � uN I�b'N I'y f}l,�Nyt�xK.bU I't �aryjgV'",r�a ?! y n I;�o �llass�chusetts ty io ►t� NORTH,AVt�OVE'R l MAS • SACHUSETTS �'v�ditihl•ifftn ,z - System Pump ng .Red&d x DEP has'prov(ded this for for use by local Boards of Health. Th Syste Pumpin Record must be subml ed `Y g mit.' to the local Board of Health or other approving authority, • 6 00.. A Facility Information �^-1f17R01t8r1t, TOWN OF NORTH ANDOVFR i;4. eri filling Out System Location HEALTH DEPARTMENT :, forms.On the ,: -! 'computer, Y� �% C� CI• only the tab key. Address cursor-do not CI /Town ' use the return tY Stat Zip Code . . { fey v�4 System Owner Name :Address(if different from location) Citwown 14 state � Telephone Number . um in Record p a a ,a 1 Date of Pumping D e 2. Quantity Pumped: Galioris ype of s stem Y ❑ Cesspool(s) Septic Tank ❑ Tight Tank` , I ❑ Other(describe): `r 4 Effluent Tea Filter present? ❑ Yes L�'tio If yes,was it cleaned? El Yes ❑ No f 5 Condition of System , 6 AS em.Pumped Biqj C) y' { Y + Name Vehicle Ucenee Number T !t It m�n I i t ` + )r er 1� iw.r• /F+'.isrJ 7, Location where contents were dIsposed; , r l . •:.,, a,. �t , ��a SID�a e u er a �. • Date http.//uvww mass gov/dep/witer/approvals/t6forms,htm#inspect . t5forrn4 doc•06!03 System Pumping Record•Page 1 of 1 •t +. f ..�,. - u... �, _ _ �. .... .t -_.� ..... I,