HomeMy WebLinkAboutMiscellaneous - 59 SUNSET ROCK ROAD 4/30/2018 (2) 59 SUNSET ROCK ROAD Road --'
210/106.A-0221-0000.0
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MAP #
PARCEL # STREET
•: mss-� ,
CONSTRUCTION APPROVAL
HAS PLAN REVIEW FEE BEEN PAID? J YES NO
PLAN APPROVAL: DATE APP. BY.-
DESIGNER:
Y_DESIGNER: ��U� PLAN DATE:__ 'S
CONDITIONS
WATER SUPPLY: TOWN WELL
WELL PERMIT DRILLER.__.._._____._....__._...___.__._.._... ___._:_.._... .._...........
WELL TESTS: CHEMICAL DAIE OPPRUVED,...._______..__._.___.
BACTERIA I DA fE (IPPRUVED
BACTERIA II DATE
COMMENTS:
FORM U APPROVAL: APPROVAL 1*0 ISSUE YE �NO
DATE ISSUED / f 9 { 7 BY <
CONDITIONS:
FINAL APPROVAL: .
ALL PERMITS PAID YES NO
WELL CONSTRUCTION APPROVAL YES NU
SEPTIC SYSTEM CONSTRUCTION APPROVAL YES NO
OTHER YES NU
ANY VARIANCE NEEDED YES NO
FINAL BOARD OF HEALTH APPROVAL:
"a'. moi. :•\% ,.`J� :,t. . .� :a--.;+�-,..;�• .7"'':i•.< ,� -
;ti'
': LER LICENSED?_: NO
.SIS THE� •INSTALYES
:i.
- AIR'
REPAIR'
,, .TYPE_. OF- CONSTRUCTION: NCW
~NEW CONSTRUCTION:', CERTIFIED PLOT PLAN •REVIEW `( NO
CONDITIONS OF..APPROVAL ... YES NO
(FROM FORM U) .'. .'
ISSUANCE OF DWC. PERMIT _ • ' ? ` ES NO
DWC PERMIT NO. INSTALLER:
BEGIN .INSPECTION ES
EXCAVATION . INSPECTION: : NEEDED:
PASSEL , py
CONSTRUCTION INSPECTION: NEEDED:
t'
1.4P,1
(� AS BUILT PLAN SATISFACTORY: Y/ ESs1
APPROVAL TO BACKFILL: DATE: DY
FINAL . GRADING APPROVAL: DATE HY
:..`, FINAL CONSTRUCTION APPROVAL:
DATE. ��/y BY
Commonwealth of Massachusetts C ^ ? 2012
City/Town of
.° System Pumping Record
Form 4
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/Right front of house, Left I h rear of ho , Left/right side of house, Left/
Right side of building, Left/Right front of building, Left/Right rear of building, Under deck
Address 6'-—nSCAAI�
om •,/ ,C�%�� V "\
Cityfrown cc State Zip Code
2. System Owner.
Name
Address(if different from location)
Citylrown Stat e��� i Code
Telephone Number
B. Pumping Record
1. Date of Pumping Date 2. Quan ' Pumped: Gallons
3. 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:
Y
6. System Pumped By:
Neil Bateson F5821
Name Vehicle License Number
Bateson Enterprises Inc
Company
7. Lti a contents were disposed:
7.L S. Lowell Waste Water
Sign a Haule Date
t5form4.doc•06/03
System Pumping Record•Page 1 of 1
FORM 4-SYSTEM PUMPING RECORD
CURRIER
SEPTIC & DRAIN SERVICE
107 FOREST STREET; MIDDLETON, MA 01949
(978)774-2772
COMMONWEALTH OF MASSACHUSETTS
MASSACHUSETTS
SYSTEM PUMPING RECORD
SYSTEM OWNER: SYSTEM LOCATION:
VoC V'
EAc
l (,:,
/v. �•1 d✓ c r
ID s jC
� S S
DATE OF PUMPING: j QUANTITY PUMPED: `SO 6 GALLONS
CESSPOOL: NO YES 0 SEPTIC TANK: NO F-] YES
SYSTEM PUMPED BY: CURRIER SEPTIC & DRAIN SERVICE
CONTENTS TRANSFERRED TO:
DATE: a l INSPECTOR: 6 v► �
14
JUL 2 9 1997
AS BUILT SEPTIC SYSTEM PLANE _
SUNSET ROCK ROAD, NORTH ANDOVER, MA
DRAWN BY
NEW ENGLAND ENGINEERING SERVICES INC,
33 WALKER ROAD, SUITE 23 NORTH ANDOVER, MA 01845
JULY 15, 1997 SCALE 1" = 40'
DISTANCES INVERT ELEVATIONS
1 TO TANK 46.0' D-BOX IN 159.72
' D-BOX OUT 159,55
2 TO TANK 31.7
1 TO D-BOX 53.5' TANK OUT 159.73
2 TO D-BOX 39.0TANK IN NOT INSTALLED
1 TO A 46,7
A
15 9,01
2 TO A 97,6
B 15 9,3 5
1 TO B 61,2
C 15 9.01
2 TO B 60,8' D 159.37
1 TO C 35,0'
2 TO C 89,4'
1 TO D 52.0'
2 TO D 45,6'
RICHARD
o �'� -~ '
w TANG A RD
h /
' Lot 16
z
Z �
eV 40,002 SF
DISTRIBUTION BOX
P.
S!y 4•
: 1
: 1500 GALLON
� VENT f' �`
r L SEPTIC TANK
This is to certify '�e► ,r`J 2,. N
that New England 2
Engineering Services, .� . 1��
Inc, has inspected the ii EXISTING HOUSE
subsurf ace disposal ._
system installed at �
Lot 16, Sunset Rock
Road, North Andover,
MA, The grades and �S
locations are as
specified on the plan
i dated 1/29/97 bye
Thomas E, Neve Assoc.,
except as shown 74.76'
herein on this plan
except for finalr
SUNSET ROCK ROAD
grading,
..............................................................................................................._....................................................................._ ....._.._._......_............__...._---__........._.._. #
i
E-
ASS ING
January 22, 1997
'JAN 2 31997
Ms. Sandy Starr, R.S.
Board of Health
146 Main Street
North Andover, MA 01845
Re: Lot 16 Sunset Rock Road
Dear Sandy:
Please find enclosed 3 prints of the above-referenced septic design.
On January 8, 1997 I submitted the revised plan to you for your review. Per our client's
request the garage elevation has been revised resulting in the elimination of a breakout
retaining wall.
Please accept these plans as the record design plan for this lot.
If you have any questions please do not hesitate to call.
Very truly yours,
THOMAS E. NEVE ASSOCIATES, INC.
John Morin, E.I.T.
Civil Engineering Consultant
JM/km
Enclosures
cc: Dr. Howard Zolot #1603 ZOLOT.WPS
• ENGINEERS • • LAND SURVEYORS • • LAND USE PLANNERS •
447 Old Boston Road U.S. Route #1 Topsfield, MA 01983
(508) 887-8586 FAX (508) 887-3480
Avlr�-
THO NEVE ►
ASS( UTM, INC.
January 8, 1997
Sandy Starr
Board of Health 'Z Q 199
146 Main Street
North Andover, MA 01845
Re: Lot 16 Sunset Rock Road
Dear Sandy:
Please find attached 3 copies of the revised sanitary disposal system design for the above-referenced lot
for your review.
As we had discussed in October 1996, the system location is being revised to accommodate a proposed
house footprint that our client would like to build on the lot. We concluded that we would design the
system on new "Title V" criteria so a new test pit was dug on October 23, 1996. Please note that the
system design is based on 165 Gal/Bedroom/Day as was the original design.
Thank you for your time and effort in this matter. If you should have any questions, please do not
hesitate to call.
Sincerely,
THOMAS E.NEVE ASSOCIATES, INC.
John Morin, EIT
Civil Engineering Consultant
JM/ec
Attachments
cc: Dr. Zolot
John\1449-3.doc
• ENGINEERS • • LAND SURVEYORS • • LAND USE PLANNERS •
447 Old Boston Road U.S. Route #1 Topsfield, MA 01983
(508) 887-8586 FAX (508) 887-3480
Pan Of L an d
/n
Fl-
Lot 17 North Andover, Mass..
��� "s •� showing
— 240-47' �Q "As—Built" Foundc Mbn Locution
Lot 16 Sunset Rock Road
�. Prepared For
r Lot 1. 6
Dr. Ho ward Zol o t
40,002 S F. ti f
0.92 Acres p, -4 Scale: 1" = 40' Date: Moy 12, 1997
Upland = 40,002 S.F. ', 3.
L
Zoning District: R- 1
Top of Foundation , o ry (Residence 1 District)
Elevation = 162.70 . `, °j o
Lot17 (Planned Residential Development)
o ,31. 1' ` Note: Property line data taken from a Planned Residential
Lot 15 �� Development by Thomas E. Neve Associates, lnc.,dated
Existing Concrete April 22, 1994, revised to Sept. 21, 1994.
Foundation
=OW_ In my opinion, the existing foundation is not in a
Flood Hazard Zone as shown on the U.S.D.H.U.D.
Flood Hazard Boundary Maps, Community Panel
oJ. No. 250098 0009 C, Revised to June 2, 1993.
hereby certify that the foundation on this property
^; is located as shown and complies with the
zoning requirements of the Town of North Andover,
Massachuse s.
<< 100. 16' >
R=30.00' ,
d=48°30'37.0".. •'� 74.76
L=25.40'
Profess' � �! n E. � �, y°r
NEVE .q
Sunset, Rock RoadNo.31724
(Private 50' Wide) '�+r�i 1AN0 SJa
Thomas E. Neve Associates, Inc.
Engineers — Surveyors — Land Use Planners
447 Old Boston Road — U.S. Route 1
Topsfield, Massachusetts 01983 887-8586
— - - - - -
1601
FORM I I - SOIL E .aLUATOR FORM
Page 1 of 3
bio. IIgS — Ica Date_
Commonwealth of Massachusetts
, Massachusetts
Soil Suitabdity Assessment for On-sire Sewaoe Disvosal
Performed By: S"«J ..... '...... Sa Date:
WitnessedB v: ...�—.�.AE--�D ... CAZ2..... ..................................................... . . ......... ..... ......
o
Laauc�Hadco:or Wmr-i;hme. (]2. H0,-SA(t-� ZdL-CS'; I
�� SU►-�S¢�'C iZpc.� epA-p �,p . 0\j P�4-N otF'4S
ew Constructcn ► Reoair [i
Office Review
Published Soil Survey Availabie: No ❑ Yes l�
Year Pubiished. nbp�A99,51---••• Publication Scale Sol! Map Unit
Drainage Class '- - pe ",'.aa. Soil Limitations ` ?. ....C.�AczL S-To ���.................�_.._
Surficial Geologic Report Available: No 'Z Yes
Year Published Publication Scale
Geologic.Material (Map Unit) ..........................................................................................................._. ..-_-
Landform Z '-'rte..__? !.-4.._.........................._......._...............................................
_.......__....._..._�.
Flood-Insurance.Rate Map:
Above 500 year flood_boundary No ❑Yes 0
Within 500 year flood boundary No 2Yes ❑
Within 100 year flood boundary No UYeS ❑
I
Wetland Area:
National Wetland Inventory Map (map unit) ...........................................................................................
_. .._.__..
Wetlands Conservancy Program Map (map unit) .............................................................................................
Current Water Resource Conditions (USGS): Month
Range :Above.Normal ❑Normal ZBekw Normal
Other References Reviewed:
DFP AppROVFD FOPUM•1210719S
FORM II - SOIL EVALUATOR DORM � G
i
Pace ? of 3
Locc:ion address o Lot ;vo ' �Jl3t�S�'T �Zejc-►L- �� �
On-site Review
Deep Hole Number Date:. �0�23Time: Weather KLA k .,
Location (identify on site plan) 5CzC- 5..,/ '.\"AC�"f
Land Use eAce Tt(-)1-- Siope (°'o) e> -\S Surface Stones
Ve^_etation
Landform
Position on landscape (sketch on the back) -S4r:jr-_- Si-A.%
Distances from:
Open Water Body 1\'5' feet Drainage way Nk feet
Possible.Wet Area \ \5i' feet Property Line U'S' feet (riezM L-Er-1
Drinking Water Well tJk feet Other
DEEP OBSERVATION HOLE ! OG_
Oeoth from Soil Horizon Soil Texture Soil Color Soil Other
Surface(Inches) I (USDA) (Munsell) Mottling (Structure,Stones,Boulders, Consistency, %
Gravel)
byeAA- kjb�-sc
l
u — 12'1 G I 5��' 2•�7Y5I4— Q�-poiC ��l.nC-�`{ MASStJE �tABC.E f
5/�a C?�u I
o`0 C.2 5/Llo
!
MINIMINNU M OF 2 H=i Rt UI t o T-EvERY HROPOSED DISPOSALA to
Parent Material (geologic) !LkILL_1 Oeo toSedrock:
Deoth to Groundwater-. Standing Water in the Hole: (a1g a Weeping from Pit Face:
Estimated Seasonal High Ground Water: 4�u
DEP APPROVED FO%%t-12107195
i
i
FORM 11 - SOIL L:VALUATOR FORM
Page 3 of 3
Location Address or oDNO 1Co Qespn�
Determination for Seasonal' High Water Table
Method Used:
❑ Depth observed standing in observation hole ........ . ... inches
❑ Depth weeping from side of observation hole ..... inches
JZDepth to soil mottles inches
❑ Ground water adjustment .................. feet
Index Well Number ........ ........ Reading Date ..... . Index well level
Adjustment factor Adjusted ground water level . ...
Deoth of Naturally Occurrina Pervious Material
Does at least four feet of naturally occurring pervious material exist in all areas
observed throughout the area proposed for the soil absorption system?
If not, what is the depth of naturally occurring pervious material?
Certification
I certify that on (date) I have passed the soil evaluator examination
t .
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.
Signatur / ate i )7�
DEP APPROVED FORM- 12/07/95
FOR_' I 11 SOIL EVALUATOR FORM
Page I of 3
0. Date:
Commonwealth of Massachusetts
I Massachusetts
Sod Suitability Assessment for On-site Sewage DisvosaZ
Performed Bv: 5 rsj.. Dace:
. ......... ............... ...................... ....... .........
WimessedBv: ... .... ....... ..... ............................................... .......... . ......... .....
Lo=tan Ad&=z or 0.='s Manw. C7 M )fi 01\---I A C=)
Aodr=$.IM NA pt P�
MPt (njgAc,
ew ConszructRepair s,on i r
Office Review
Published Soil Survev Available: No El Yes
Year Published Publication Scale Soil Map Unit C
Drainage Class Soil Limitations ...................
Surficial. Geologic Report Available: No 0 Yes 71
Year Published Publication Scale
GeologicMaterial (Map Unit) .......................................................................................................................
Landform � .. . . ..........
......................................................................................................
..
Flood Insurance Rate Map:
Above 500 year flood-boundary No OYes
Within 500 year-flood boundary No 21Yes 7
Within 100 year flood boundary No EYes 7
Wetland Area:
National Wetland Inventory Map (map unit) ...........................................................................................
Wetlands Conservancy Program Map (map unit) .........................................................................................
Current Water Resource Conditions (USGS): Month
Range :Above Normal C]Normal ZBe!cw Normal ❑
Other- References Reviewed:
DEP AppROVIM FOPUM-12107195
FOR 111 - SOIL EVALUATOR DORM
Page ? of 3
L oca;ion .address
On-site Review
Deep Hole Number Date:. 1o�Z31�O Time: Weather P14kC.
Location (identity on site plant
Land Use eA*5- A(-- Slope M Fj—1S Surface Stones
Vecetation wcso��
Landform
Position on landscape (sketch on the back) 54er—RE SA►-s►� "� pts�oS ��+—� '
Distances from:
Open Water Body 1\5+ feet Drainaae way NA feet
Possible.Wet Area N 1Si- feet Property Line 05a- feet (¢Za7h L-C;--1 t�-)
Drinking Water Well t"l, feet Other
DEEP OBSERVATION HOLE =0G~
Death from Sail Horizon Soil Texture Soil Color Soil Other
Surface llncnes) I (USDA) I (Munsell) I Mottling (Structure.Stones.Boulders, Consistency, %
Gravel)
� L j
2•SOt:2'{ MASSWC FQtPtSUE
r
o`Yy @
t
11 mULcz rtt I t Ai cV ri ED DiSPOSALA
Parent Material (geologic) 64.PC-000- ��t'1 ` E'�S Oeothto8edrock: t<bt--Z>�
Death to Groundwater' Standing Water in the Hole: @ 1g„ Weeping from Pit Face: 1s6 t-xi:S
Estimated Seasonal High Ground Water: G4 g u
DEP APPROVED FORM-12107/95 '
. i
FORM 11 - SOIL EVALUATOR FORM
Page 3 of 3
Location Address or of vo ezy-w�
Determination ,for Seasonal High Water Table
Method Used:
❑ Depth observed standing in observation hole........... inches
❑ Depth weeping from side of observation hole....... . inches
JZDepth to soil mottles inches
❑ Ground water adjustment ................. feet
Index Well Number ....... ........ Reading Date Index well level ..... .
Adjustment factor ..... Adjusted ground water level . ... ........... ....... _.......
Deoth of Naturallv Occurrina Pervious Material
Does at least four feet of naturally occurring pervious material exist in all areas
observed throughout the area proposed for the soil absorption system? _
If not, what is the depth of naturally occurring pervious material?
Certification
I certify that on I9T (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.
Signatur / ate 1 7
DEP APPROVED FORUM-12/07/95
FOR11 11 - SOIL EV.aLUATOR FOR11
Page 1 of 3
bio. t19S — Ito Date:
Commonwealth of Massachusetts
Massachusetts
Soil Suitability Assessment for On-site Sewage Disaosal
Performed. By: .
S--CEJce—A ... ................... Date: t O'23'�Ca
A4.�t��A .C..lie....... .....................................................
Witnessed By: �. ............................ ... .... ..
C]M.
lcauon naarss a Or.rcr's V.me. HO�„jglL� ZcS�-�[ E
AddMIS.3m "T 2 M 1 0 t_E To.� fLb FSO
reirmm r ND A.�o oVE-�L M�} OI P�4S
ew consrruc7ion
Repair ❑. (5oe� SSS _co�ss
Office Review
Published Soil Survey Available: No ❑ Yes lb
\981ISg°�. Ylao Univ
Year Published. ..... Publication Scale. �' Soil
Drainage Class
'-saw pert' 4Sa. Soil Limitations ���'� �--G_. _1.A2G ..S�co!-�E- .................�...-
Surficial Geologic Report Available: No 0, Yes
Year Published. Publication Scale _...,..
Geologic Material (Map Unit) ...........................................:..................................._. .._ _...�.._
�—� _ ?! _......_................................................__....._...
Landform .
_.......... .... __.....................................
Flood Insurance.Rate Map:
Above.500 year flood.boundary No ❑Yes Q
Within 500 year flood.boundary No 0-Yes ❑
Within 100 year flood.boundary No Yes ❑
I
1
Wetland Area:
National Wetiand.Inventory Map (map unit) ••-------- .••-•...........
Wetlands Conservancy Program Map (map unit) ..................................................................._..........._..........
�
Current Water Resource.Conditions (USGS): Month
Range :Above.Normal ❑Normal DBelc,.•r Normal ❑
Other References Reviewed:
OF3 APPROVED FOP-M-12107195
FOR.'1I 11 - SOIL EVALUATOR FOIt,M
Parc '_ of 3
Location address
On-site Review
Deep Hate Number Date:. 1o'Z3y�O iIme: PM Weather Ffl>>Z,
Location (identity on site plan)
Land.Use –1S Surface Stones `"L�-�-. .
Vecetatiort vtao��
Landform
Position on landscape (sketch on the back) -SXr:e_-- Ste+—tt'TA�rf ��Sgo� �L• �`��''' '
Distances from:
Open Water Body .l V5—t feet -Drainage way NA feet
Possible-Wet Area. X 151 feet Property Line b`tea--. feet (Pezm L-CP-T l6
Drinking Water Well N*, feet Other
DEEP OBSERVATION HOLE =0C~
Oeoth from Sail Horizon Soil texture Soil Color Soil Other
Surface ilnches) I (USDA) (Munsell) Mottling (Structure.Stones.Boulders, Consistency, %
nn Gravel)
1St'SI-� .S?QATIf1�K�
r
l
l
MINIMUM M Ltznt ui t Ai EVEriY PRUPOSEDALA
Parent Material(geologic! DeothtoEledrock: E
(Death to Groundwater: Standing Water in the Hole: @ 1g Weeping from Pit Face: Abe•-SE
Estimated Seasonal High Ground Water: 4g u
DEP APPROVED FORM-1'107!95
FOR11 11 - SOIL LVALUATOR FORM
Page 3 of 3
Location ,address or of No 1(o
Determination for Seasonal� High Water Fable
Method Used:
❑ Depth observed standing in observation hole........... ... inches
❑ Depth weeping from side of observation hole ....... . . inches
Depth to soil mottles inches
❑ Ground water adjustment .................. feet
Index Well Number ... ....... Reading Date ._.._. Index well level ..... . . .
Adjustment factor ....__......... Adjusted ground water level ..... . ............ ...... ..........
Depth of Naturallv Occurrina Pervious Material
Does at least four feet of naturally occurring pervious material exist in all areas
observed throughout the area proposed for the soil absorption system? _
If not, what is the depth of naturally occurring pervious material?
Certification
I certify that on I97 (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.
Signatur / ate 1 7
DEP APPROVED FOR.%1- 12/07/95
f
-----------------
313
SL
y;.
-le
. f
J
Ala
of
�s� +1';R-- •' a{n�„ y a.y• h �_r ' j'+ �
•.� _ � 3 � c,' 1 •gid!°'� � J4� ! � � //
tilt'
t^f` x A ?�. �DG 7 mac*►-` -fPe
MAP AND PARCEL /ab A 9--q'— [
ADDRESS
OWNER
SIZE OF LOT IN SQUARE FEET Li 6 0 0 � S
#BEDROOMS
SEPTIC SYSTEM LOCATION C? 1 i�rY j
(For example,FRONT YARD SOUTHEAST CORNER)
FINAL GRADING DATE
AS BUILT PLAN IN FILE?_ 4
INSTALLER . 14
v^12r
DWC PERMIT DATE '- �1-3 C
CERTIFICATE OF COMPLIANCE DATE
ENGINEER ��
I Tri', r P0.17-i
0:vrp
MAY 19
AS BUILT SEPTIC SYSTEM PLAN
SUNSET ROCK ROAD, NORTH ANDOVER, MA
DRAWN BY
NEW ENGLAND ENGINEERING SERVICES INC,
33 WALKER ROAD, SUITE 23 NORTH ANDOVER, MA 01845
JULY 15, 1997 SCALE 1" = 40'
DISTANCES INVERT ELEVATIONS
IuivS
1 TO TANK 46,0' D-BOX IN 159,72
2 TO TANK 31.7' D-BOX OUT 159,55
1 TO D-BOX 53,5' TANK OUT 159.73
2 TO D-BOX 39.0' TANK IN NOT INSTALLED
1 TO A 46,7' A 15 9.01
2 TO A 97.6' B 159.35
1 TO B 61.2' C 15 9.01
2 TO B 60.8' D 15 9,3 7
1 TO C 35,0' F .,
2 TO C 89.4'
1 TO D 52.0'
2 TO D 45,6
}1
OF -
RICHARD 'S`
o f�-
�" TANG.RD
lop
Lot 16
40,002 SF
DISTRIBUTION BOX
Ln
1500 GALLON
\ VENT ;
L SEPTIC TANKtD
OU
This is to certify
that New England 2
};
Engineering Services, �� '° - lll `�/ f`Z71/
Inc, has inspected the �� EXISTING H❑USE
subsurface disposal � . ,
�
......:::. . r
system installed at `.
Lot 16, Sunset Rock
Road, North Andover, •�
MA The grades and
locations are as
specified on the plan
dated 1/29/97 by
Thomas E, Neve Assoc,,
except as shown 74.76'
herein on this plan
except for final SUNSET ROCK ROAD
grading,
f
1'��1111Y1�� U U - LOT RELEASE FORM
POOLS PATIO INC"
I`1t,.
�� used to verify that all necessary approvals!
Jy, our Ad onitructio�2 g jurisdiction have been obtain Pe�tB from
ed. This does not relieve
`- S'pae S."" s'PPAM from compliance with any applicable or requirements. ;.
I92 South Broadway Glenn Wiggin .IC�NT FILLS OUT THIS SECTION
Lawrence,MA 01843 Tel(508)688-8307 6';
Fax(508)688-1949 ext.22 U
PHONE
LOCATION: Assessors Map Number
PARCEL
l SUBDIVISION ` C �
I LOT (S)
�. STREET_
ST. NUMBER S
OFFICIAL USE ONLY -
RECQM,M. ENDATIONS OF TOWN AGENTS:
MAY 1 9
CONSERVATION ADMINISTRAT R
DTPAAPROVED
{" ,GATE REJECTED �~
COMMENTS
U y
G YYL���t,lc.
TOWN PLANNER DATB APPROVE "�-
D
DATE REJECTED
COMMENTS . !.
FOOD INSP CTOR-HEALTH
DATE APPROVED
DATE REJECTED
SEP C'INSPECTOR- TH
DATE APPROVED o-
DATE REJECTED
COMMENTS
t
' PUBLIC WORKS -SEWER/WATER CONNECTIONS .
DRIVEWAY PERMIT ,
v FIRE DEPARTMENT
j `
RECEIVED BY BUILDING INSPECTOR GATE
r
APPLICATION FOR DISPOSAL WORKS CONSTRUCTION PERMIT
DATE: S-) 231 c?-?, CURRENT INSTALLER'S LICENSE#
LOCATION: Lo� h seI IRec b 2�a f Jul
LICENSED INSTALLER: vi pocll J 2
SIGNATURE: TELEPHONE# 8� 7
CHECK ONE:
REPAIR: NEW CONSTRUCTION:
IF NEW CONSTUCTION, PLEASE ATTACH FOUNDATION AS-BUILT.
Administrative Use Only
$75.00 Fee Attached? Yes_ No
Foundation As-Built? Yes No
Approval .�'` ,`n J`' /C(� J Date: �_jc 3 V
i
Town of North Andover, Massachusetts Form No.3
BOARD OF HEALTH
• yORTry of •° :°14, d-3 19 I�
}�►''°�,,.o �"�# DISPOSAL WORKS CONSTRUCTION PERMIT
,SSACHU`���
Applicant O's ce a--L
NAME AQPRESS TELEPHONE
Site Location��� _•��:�1V�-d-� Eb
Permission is hereby granted to Constructor Repair ( ) an Individual Soil Abs rpti n
Sewage Disposal System as shown on the Design Approval S.S. No.
CHAIRMAN,-BOARD OF HEALT
Fee l� D.W.C. No.
.... ...: t :t. .....
(
7:
Form N0. 4
Town of North Andover, Massachusetts
BOARD OF HEALTH
Sept i 7 19 -7—
CERTIFICATE OF COMPLIANCE
This is to certify that
the Individual Soil Absorption Sewage Disposal System constructed (X ) or repaired
by Ben Osgood ,Jr. ( )
INSTALLER
at Lot #16 Sunset Rock Road North Andover MA 01845
has been installed in accordance with Board f HeIt alth Regulations as described in the Design
Approval Site System Permit No. 703 dated_1 2/1 'j
-1994
The issuance of this certificate shall not be construed as a guarantee that the system will
function satisfactorily.
BOARD OF HEALTH
r
JUL 2 9 1997
AS BUILT SEPTIC SYSTEM PLAN
SUNSET ROCK ROAD, NORTH ANDOVER, MA
DRAWN BY
NEW ENGLAND ENGINEERING SERVICES INC,
33 WALKER ROAD, SUITE 23 NORTH ANDOVER, MA 01845
JULY 15, 1997 SCALE 1" = 40'
DISTANCES INVERT ELEVATIONS
1 TO TANK 46.0' D-BOX IN 159.72
2 TO TANK 31,7' D-BOX OUT 159.55
1 TO D-BOX 53.5' TANK OUT 159.73
2 TO D-BOX 39,0 TANK IN NOT INSTALLED
1 TO A 46.7' A 15 9.01
2 TO A 97.6' B 15 9.3 5
1 TO B 61.2' C 15 9.01
2 TO B 60,8' D 15 9.3 7
1 TO C 35.0' ;
2 TO C 89,4'
1 TO D 52.0'
2 TO D 45.6'
F
RICHARD
o C.A
TANG
Ci Lot 16
IjJ/� ` 40,002 SF-
DISTRIBUTION BOX
P�9 f
LO
VENT 1500 GALLON
L SEPTIC TANK
This is to certif ,f }� 2 N
that New England ° 2
Engineering Services, � ��-' ill Z
Inc. has inspected the EXISTING HOUSE
f subsurf ace disposal
system installed at
Lot 16, Sunset Rock
Road, North Andover,
MA, The grades and
locations are as
specif led on the plan
dated 1/29/97 by
Thomas E. Neve Assoc,, �
except as shown 74.76' E'fx
herein on this plan
except f or final
p SUBSET ROCK ROAD
grading,
G
..........._........._......_........._...._._.............___..........__.........................._.._................................................ ............
f;:
NEW ENGLAND ENGINEERING [LIEVVIgQ W UIUMMO44QI
SERVICES, INC.
33 Walker Rd. Suite 23
NORTH ANDOVER, MA 01845
DATE r JOB NO.
PHONE (508) 686-1768 FAX (508) 685-1099 ATTENTI N
TO Af�l1'W°V✓L. Y/'D �G�1 -1 RE: 6 t�G 1
i
A)
WE ARE SENDING YOU 9 Attached ❑ Under separate cover via the following items:
❑ Shop drawings I)t—Prints ❑ Plans ❑ Samples ❑ Specifications
❑ Copy of letter ❑ Change order ❑
COPIES DATE NO. DESCRIPTION
v- 3 6,J4
Al. AH Dom. I
i
. t
i
THESE ARE TRANSMITTED as checked below:
91 For approval ❑ Approved as submitted ❑ Resubmit copies for approval
❑ For your use ❑ Approved as noted ❑ Submit copies for distribution
❑ As requested ❑ Returned for corrections ❑ Return corrected prints
❑ For review and comment ❑
❑ FORBIDS DUE 19 ❑ PRINTS RETURNED AFTER LOAN TO US
REMARKS
I
i
i
COPY TO
SIGNED:
If enclosures are not as noted,kindly notify us Mllonce.
JUL 2 9 1")S7
AS BUILT SEPTIC SYSTEM PLAN
SUNSET ROCK ROAD, NORTH ANDOVER, MA
DRAWN BY
NEW ENGLAND ENGINEERING SERVICES INC,
33 WALKER ROAD, SUITE 23 NORTH ANDOVER, MA 01845
JULY 15, 1997 SCALE 1" = 40'
DISTANCES INVERT ELEVATIONS
1 TO TANK 46.0' D-BOX IN 159,72
2 TO TANK 31.7' D-BOX OUT 159.55
1 TO D-BOX 53.5TANK OUT 159.73
2 TO D-BOX 39.0' TANK IN NOT INSTALLED
1 TO A 46,7' A 159,01
2 TO A 97,6' B 159.35
1 TO B 612' C 159.01
2 TO B 60.8' D 159.37
1 TO C 35,0' ;f,
2 TO C 89.4'
1 TO D 52.0'
2 TO D 45.6'
� 6
ja OF
WHARD N '
C.
l� TANGARD
Lot 16
1 j07 40,002 SF
DISTRIBUTION BOX
1500 GALLON
\�VENT , f
L SEPTIC TANK �
Cd
This is to certify , '~
that New England ° 2
Engineering Services, r . / ill
Inc, has inspected the EXISTING HOUSE
subsurface disposal
system installed at �
Lot 16, Sunset Rock �'�
Road, North Andover,
MA, The grades and S
locations are as ,
specified on the plan
dated 1/29/97 by i
i Thomas E. Neve Assoc,,
except as shown , 74,76'
herein on this plan
i
except for final SUBSET ROCK ROAD - �
radin
9 ,g
•------...................._..._........ ......�_..._._.........._......................................._........................................_
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: /746,4sn I'9 . Phone 6Ir-Os:r'
LOCATION: Assessor' s Map Number Parcel
Subdivision Lot(s)
Street Sv,✓_re TdcK ?L�. 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
Food Insp or- 1 h Date Rejected
Date Approved 9
ep c f5s-pector-itealth Date Rejected
Comments
Public Works - sewer/water connections
- driveway permit
Fire Department
Received by Building Inspector Date
THOMAS E. NEVE ASSOCIATES, INC. I[EVVEn @1P
Engineers • Land Surveyors • Land Use Planners I�U1
447 Boston Street US #1
TOPSHELD, MASSACHUSETTS 01983
(508) 887-8586 DATE JOB NO. iloo3
FAX (508) 887-3480 ATTENTION
Sa.n4St-ace• ��,
TO RE:
i
SA+yOY S'T'ARK L_o} t(o " S.ans��_ ,•Rac.K' �Zoa,d�,
North Ar�d.o�le.c' � MA Ot$1� �;
l
WE ARE SENDING YOU XAttached ❑ Under separate cover via the following items: '
❑ Shop drawings Prints Plans Samples ❑ Specifications I
❑ Copy of letter ❑ Change order ❑
COPIES DATE NO. DESCRIPTION
3 Rav:scd
14o03 Sqa i-rA l27 Vis PoSAk_ SYS7,6oj PES t Csrj F:o✓Z
i
►fo S.jr.sc-r ROrrK i2ol QrepAreak Fo{ F�o•.�aral $olot
THESE ARE TRANSMITTED as checked below:
For approval ❑ Approved as submitted ❑ Resubmit copies for approval
❑ For your use ❑ Approved as noted ❑ Submit copies for distribution
❑ As requested ❑ Returned for corrections ❑ Return corrected prints
❑ For review and comment ❑
❑ FORBIDS DUE 19 ❑ PRINTS RETURNED AFTER LOAN TO US
REMARKS 'DGotr Sand," please -'.calk Grne-tokak 3 M'_'"'seol o[`6nA-
0JF0 JF
tl% o toayt f-eFk'renc-e at I o+ '77he pla►n 1-%a3 beer. i' %j seot
oor C,o(nverSa�:Or. on Wtc� Jarwa.r- Z9.
Rt.�iStors act aS �tbws t� GaS peFlec-ier -adel•ed -�o scp+iC,
K C6-+.. a-kc-eaff dr •� -D-13o� o.��ta,4 l:rn¢�,
la;� le•Jc! .�c Mini M JM m-�r' 2.` Qa(d,d
_3l t3e.+0�-+.Y,a►��� radonde
T-e%)( Wa -fir oar ¢;rV,e and ef>'r4 regaroVl r, tti&i *;ec4
P1 easP r..,l! X !tew ha%K any ad 'fiiD ria( r
Q.ras+,of,c
COPY TO _ -Diz t4vwA/Z4> &oLoT S;,,Cerely�
RECYCLED PAPER:
�P Contents:40 Pre-Consumer-t0/Post-Consumer SIGNED:
`_` If enclosures are not as noted,kindly notify us at once.
✓e«e♦:.1L:�P� a�J��' x;.f.a a'�t'+.4 f '� ea>� "+'tM„� .r c.�'y�1�1�� ''4�•-'`t:`-�.Cr
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.''.;;..?.ptS:C. �'fi:- -�:�rlr�...•T,�"�a3'Ca"S '��1.`,.."` '4'r"�a �i ale ''-.t.r,�'iy' "1IRt' i�S':�,1� „)ts it,9'�
T
�.�•a.�Jfri,r. a
J
PLAN REVIEW CHECKLIST�/
ADDRESS T ZCe ENGINEER
GENERAL
3 COPIES STAMP LOCUS &---' NORTH ARROW �� SCALE -�
CONTOURSPROFILESECTION C,--- BENCHMARK_ SOIL &
PERCS '- ELEVATIONS WETS. DISCLAIMER !/ WELLS & WETSy
WATERSHED? Q DRIVEWAY ✓(Eley) WATER LINE FDN DRAIN
SCH40 � TESTS CURRENT? SOIL EVAL !f5 • b
SEPTIC TANK
MIN 1500G �--� .17 INVERT DROPL' GARB. GRINDERjjLL(2 comps +200)
10 ' TO FDNB MANHOLE-�LELEV -- - GW v # COMPS.j GB
D-BOX
SIZE # LINES a"t— FIRST 2 ' LEVEL STATEMENTL
INLET OUTLET / _ (2" OR . 17 FT) TEE REQ'D? /0�
LEACHING
MIN 440 GPD? RESERVE AREA `- 4 ' FROM PRIMARY? 61---"'2o SLOPE
100 ' TO WETLANDS 100 ' TO WELLS Z-' 4 ' TO S.H.GW 6-----(5 ' >2M/IN)
20 ' TO FND & INTRCPTR DRAINS ' 400 ' TO SURFACE H2O SUPP
4 ' PERM. SOIL BELOW FACILITY O/C— MIN 12" COVER FILL? x(151 )
BREAKOUT MET?
TRENCHES
MIN 440 gpd SLOPE (min .005 or 6"/1001 ) �SIDEWALL DIST. 3X EFF.
W OR D (MIN 61 ) i/ RESERVE BETWEEN TRENCHES? 1- fIN FILL? �,-- MUST
BE 10MIN. y� 4" PEA STONE? VENT? [,----- (>3 ' COVER; LINES >501 )
BOT 6 + SIDE Z- X LDNG - �Z = TOT ly 7 'V-&
(L x W x ##) (DxLx2x##) (G/ft2)
Copyright @ 1996 by S.L. Starr SPJ ee- 7-0 J QHA�) /V0el
/zq
Town of North Andover, Massachusetts Form No. 1
NORTH BOARD OF HEALTH
��Q�tt IED ,6 AOL - 19
_ Y
Ew , �> APPLICATION FOR SITE TESTING/INSPECTION
��SSACHUs���y
Applicant
NAME 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
OCT-17-1996 15:51 THOMAS E. h-,aEVE ASSOC. P.02
'41, - A7
4
aA4 s �1 e1
1 p a
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� 1
c�
tation o+1o± left
Datum)
ark closer .+' -
action.} �J CA �-
TOTAL P.O_
i
- - ASSOC. I
OCT-17-1996 15:51 THOMAS E. f dEVE P.01
r.' ' '
From: John Morin Thomas F. Neve Associates, Inc
Questions? Call (508) 887-8585 447 Old Boston Road
Fax (508) 887-3480 Topsfield, MA 01983
To: Sandy Starr
Company: N.A.B.O.H.
Address:
Date: October 17, 1996
Time: 5:10 PM Pages: 2 (including this one)
Dear Sandy: Per our discussion on Thurs. ,Oct. 17 , please find attached a sketch for
Lot 16 - Sunset Rock Road for Mr. Howard Zolot showing the new proposed dwelling
and septic system locations for your review.
You have informed me that you will try to get Susan out to the site as soon as possible
once you have reviewed the sketch. Please notify our office once you have scheduled
this time and date so that we can make proper arrangements.
Thank you in advance for your time and effort in this matter.
Sincerely,
' Town of North Andover, Massachusetts Form No. 1
N°RTH BOARD OF HEALTH
y,,I E �" r3 4�,
° :. —19
` ry
APPLICATION FOR SITE TESTING/INSPECTI
SSACNus���y
Applicant
-- 1`MEE ADDRESS TELEPHONE
Site Location �T L
Engineer
NAME ADDRESS TELEPHONE
Test/Inspection Date and Time
4 �j CHAIRMAN,BOARD OF HEALTH
Fee 1 Test No.
S.S. Permit No. D.W.C. No. C.C. Date Plbg. Permit No.
pD
HOYM E ,NEW
ASSOCIATES., T 8 NQ
WN
• SRO Fl kq to
sip �
September 11, 1996 3 1996
Ms. Sandy Starr
Board of Health
146 Main Street
North Andover, MA 01845
Re: Lot 16 Sunset Rock Road
Dear Sandy:
Our client, Dr. Howard Zolot, is interested in relocating the system on the above-
referenced lot. Pursuant to your telephone conversation with John Morin of our office
you stated that in order to relocate this system additional 4e9 hole observation test pits
would be necessary(either 1 or 2 tests).
You also requested that we redesign the system according to the new Title V, if possible.
Find enclosed a check in the amount of$175 which is the soil testing fee. Please contact
me at your earliest convenience so that we may schedule the testing as soon as possible.
Very truly yours,
THOMAS E. NEVE ASSOCIATES, INC.
Kathy Molina
Personal Assistant
Enclosure
cc: Dr. Howard Zolot
zOLOT.wrs C
• ENGINEERS • • LAND SURVEYORS • • LAND USE PLANNERS •
447 Old Boston Road U.S. Route #1 Topsfield, MA 01983
(508) 887-8586 FAX (508) 887-3480
HORT1G
BOARD OF HEALTH
N A /
120 MAIN STREET TEL. 682-6483
9sSACHUSEt NORTH ANDOVER, MASS. 01845 Ext 23
January 26, 1995
Mr. Thomas Neve
Neve Associates
447 Old Boston Road
Topsfield, MA 01983
Re: Lot #16 Sunset Rock Road
Dear Tom:
This is to inform you that the proposed plans for site
referenced above have been disapproved for the following reasons:
1) Perc test 93-11 done in tan, sandy till at 44"
change of soil occurs at 72" at elevation 151. 01.
There must be permeable soil 4 feet below the
bottom of the leaching area; this has not been
demonstrated. The system must either be raised or
a deeper percolation test done.
If you have any questions, please do not hesitate to call
the Board of Health Office at the number above.
Sincerely,
Sandra Starr, R.S.
Health Administrator
SS/cjp
PLAN REVIEW CHECKLIST
ADDRESS ,Z/6 SO4),51-TrTOCK 'pel ENGINEER 7tieyc
GENERAL
3 COPIES ✓ STAMP ✓ LOCUS NORTH ARROW ✓ SCALE
CONTOURS ✓ PROFILE ✓ SECTION BENCHMARKI SOIL &
PERC INFO ELEVATIONS WETS. DISCLAIMER WELLS &
WETLANDS WATERSHED?,A/-a DRIVEWAY �Elev) WATER LINE L/
FDN DRAIN t✓ SCH40 ✓ TESTS CURRENT?
SEPTIC TANK 98" leom Wcrc.ANps
MIN 1500G ?✓ . 17 INVERT DROP ✓ GARB. GRINDER L1(+200% EDF)
25 ' TO CELLAR ✓ MANHOLE TO GRADE ELEV GW t--�
D-BOX
SIZE # LINES FIRST 2 ' LEVEL STATEMENT
INLET/��-30- OUTLET 16•49 _ b (2" OR . 17 FT) TEE REQ'D? /t/O
LEACHING
MIN 660 GPD? RESERVE AREA " 4 ' FROM PRIMARY? """"2% SLOPE
100 ' TO WETLANDS L,-' 1001 TO WELLS c/ 4 ' TO S.H.GW t/
35 ' TO FND & INTRCPTR DRAINS co/ 325 ' TO SURFACE H2O SUPPy"
4 ' PERM. SOIL BELOW FACILITY ? MIN 12" COVER 4✓ FILL? x (25 '
if above natural elev;` 0 ' if belov7) BREAKOUT MET? ✓�
TRENCHES
MIN 660 gpd v SLOPE (min . 005 or 6"/1001 ) Ll""' >31COVER?-VENT
SIDEWALL DIST. 2X EFF. W OR D (MIN 61 ) L----- IS RESERVE BETWEEN
TRENCHES? ✓ IN FILL? L--�MUST BE 10 ' MIN. L/ 4" PEA STONE? t�✓
BOT (Q X LDNGa%l + SIDE X LDNG461 = TOT COIo �lo�d
(L x W x #) (G/ft2) (DxLx2x#) (G/ft2)
Copyright O 1993 by S.L.Starr
�/ � of
DATEa'�4rJA� ?-J— Sheet
BOARD OF HEALTH
TOWN OF NORTH ANDOVER
SUBSURFACE DISPOSAL DESIGN REVIEW
FEEPERMIT703 DATE RECEIVED
APPLICANT08 � /UU Z ASSESSOR' S MAP
ADDRESS PARCEL 7
LOT /fin
STREET 7 iStIU<5G��C��-iG �
ENGINEER
ADDRESS -447
PL!, DATE �' _ �O, l9Q
CONDITIONS OF APPROVAL:
APPRO1•'ED
� Dl.,yr_ _... ✓ED
\�
jT)�,e C T-�sT %-�/ a dv� i�/ T .v, /�of A3/ Ti
A) l5e16
OJl
1-9
T r��
DATE94ll /7� Sheet of
BOARD OF HEALTH
TOWN OF NORTH ANDOVER
SUBSURFACE DISPOSAL DESIGN REVIEW J
FEE PERMIT ` ��._�_. DATE RECEIVED /a /�/moi IL
APPLICANT-- � /UUS Z ASSESSOR' S MAP
ADDRESS PARCEL rt
LOT
STREET
ENGINEER f ADDRESS .44;r.44;r Dt-b'665-70JD
PLA.d DATE �� 17g REVISION DATE
COJIDITIONS OF APPROVAL:
APPROVED
`
�. DIS:�r_ ....'�pTJO
Vr.D
,'�, � , �E,eC T`�5T 93._ii �a.vt- ��1 /�•v, �-/an���e Tim � .C' ��
149 le 6Z9� T se f ,Ile 7-
Town of North Andover, Massachusetts Form~O.2
f NORTH BOARD OF HEALTH
O' No y•��0
3? O tLe 19-1-
o �
p
s •���•`"'����►►►...+++4 ' DESIGN APPROVAL tc
b
ss"C"°SES SOIL ABSORPTION SEWAG DIS
Applicant Site Location T �°
Reference Plans and Specs.
ENGIN Ell R DESIGN DATE
Permission is gran e r an indivl ual soil absorption sewage disposal system to be installed
in accordance with regulati of B and of Health.
CHAIRMAN,-BOARDOF-HEALTH
: Fee C."V ' Site System Permit No. �U 3
TOWN OF
SYSTEM ITMPINO RECOTDREC
BATE: ' "(? Nor
OF N
i SYSTEM OWNER& ADDRESS i SYSTEM LOCATION i
CO ! :example:left front of house)
�d 11
I
�A_ �ac� a
U5
5
DA T E OF PUMPING: ` Q y QIJAiNTITY PUMPED : 1.�-Q� GALLONS
CESSPOOL: NO YES DTIC TANK: NO YES
NATURE OF SERVICE: ROUTINE S EMERGENCY
OBSERVATIONS:
GOOD CONDITION FULL TO COVER
HEAVY GREASE BAFFLES !N PLACE
ROOTS LEACIIFIELD RUNBACK
EXCESSIVE SOLIDS FLOODED .
SOLIDS CARRfOVER OTIJER(EXPLAIN)
SYSTEM PUMPED BY: Bateson Enterprises, In%.
COMMENTS:
comm,NTs TRANSFERRED TO: G.L.S.1) Lowell Waste
Commonwealth of Massachusetts
City/Town of
System Pumping Record OCT 2 3 2008
Form 4
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
Important:
When filling out 1. System Location: Left fron eft rear eft si of hou e. Right front, right rear, right side of house.
forms on the
computer,use
only the tab key Address � ,.,� A
to move your V��
cursor-do not
use the return City/Town State Zip Code
key. 2 System Owner:
Name
Address(if different from location)
CitylTown Stat
de
Telephone Number J
B. Pumping Record
1. Date of Pumping 2. Quantity Pumped:
Date Gallons
3. Type of system: El Cesspool(s) 0-9-eptic Tank Q Tight Tank
Other(describe):
4. Effluent Tee Filter present? [] Yes , No If yes,was it cleaned? 0 Yes Ll No
5. Condition of System: V\1
6. System Pumped By:
Neil Bateson F 5821
Name Vehicle License Number
Bateson Enterprises Inc
Company
7. Location where contents were disposed:
L.S.D Lowell Waste Water
igna ure of H u r Date
t5form4.doc°06/03 System Pumping Record°Page 1 of 1
N Commonwealth of Massachusetts
City/Town of RIECE
IVEb
W° System Pumping Record JAN - 3 2011
Form 4 TOWN OF NORTH ANDOVER
Q,M Svey,..
HEALTH DEPARTMENT
DEP has provided this form for use by local Boards of Health. Other forms May De usea, CUTusee
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. Syste ocktion: Left front of house, right front of house, left side of house, right side of hou �eft
ear ofo , right rear of house, left side of building, right rear of building, under deck.
City/Town State Zip Code
2. System Owner:
Name
Address(if different from location)
Cityrrown State Zip Code
—7 7
Telephone Number
B. Pumping Record
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 Q"NO If yes, was it cleaned? ❑ Yes ❑ No
5. Condit' j�fs' ystem:
1�
6. System Pumped By:
Neil J. Bateson F5821
Name Vehicle License Number
Bateson Enterprises Inc.
Company
7. Locatio ere contents were disposed:
.S.D ell WastqWalK
C( 0
Signature o Huler Date
t5form4.doc•06/03 System Pumping Record•Page 1 of 1