HomeMy WebLinkAboutMiscellaneous - 623 OSGOOD STREET 4/30/2018 (2)�6?�5 blkf0bd M'
Commonwealth of Massachusetts RECEI.VED
_
n City/Town of .
System Pumping.Record jUN o 8 2015
Forfti'1 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
r f
the local Board o Health or other approving authority.
.
PP 9 tY
A. Facility. Information
1. System Location: LeftRigh#front of Nous Left/Right rear of house, Left/right side of house, Left/
Right side of building, Left lg t ron of building, Left/Right rear of building, Under deck
Address i
ro
Citylrown ( state c, Zip Code
2. System Owner. /
Name'
Address(if different from location)
Civrown ' 74P Code
Telephone Number
i
B. Pumping Record
1. Date of Pumping Date 2. Quantity Pumped:
Gallons r
3. Type of system: ❑ Cesspool(s) ErSepfic Tank ❑ Tight Tank
❑
Other(describe):
4. Effluent Tee Filter present? ❑ Yes [ d� If yes,was it cleaned? ❑ Yes ❑ No.
' 5. Condition of System:
6. System Pumped By:
Neil.Batesbn F5821
Name Vehicle License Number
Bateson Enterprises Inc-
Company
ncCompany
7. Loca' ere contents were disposed:
CZe
Lowell Waste Water
SignWU
Date
t5form4.doc•06/03 System Pumping Record•Page 1 of 1
Commonwealth of Massachusetts
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 housQ,15P Right r of house ft/right side of house, Left/
Right side of building, Left/Right front of building, Left/Rig rear of bul iing, Under deck
Address
c4frown State C Mcode
2. System Owner.
Du A?R 14 2014
Name
TOWN OF NORTH ANDOVER
HEALTH DEPARTMENT
Address(if different from location)
city/Town state
Tip Code
Telephone Numberi
B. Pumping Record
1. Date of Pumping Date 2. Quantity Pumped: t S
Gallons
3. Type of system: ❑ Cesspool(s) Septic Tank ❑ Tight Tank
❑ Other(describe):
4. Effluent Tee Filter present? ❑ Yep No If yes, was it cleaned? ❑ Yes ❑ No:
5. Condition of System:
00
d�
6. System Pumped By.
Neil.Bateson F5821
Name Vehicle License Number
Bateson Enterprises Inc
Company
7. Location where contents were disposed:
Cx S. Lowell Waste Water
Sig HaulwU Date
t5form4.doc-06/03 System Pumping Record•Page 1 of 1
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Department of Public Safety 3
Permit . ?�
P t No _
BOARD OF FIRE PREVENTION REGULATIONS 527 CMR 12:00 W
(3ccupancy tz I r•r• r 11.v#c11 —
l/90 (le1r hank)
APPLICATION FOR PERMIT TO PERFORM ELECTRICAL `JORK
All work to be perknmrtil in accordance with the Massachucenc F114 I64.1I r.-f--. CMR 12:00
(PLEASE:PRINT IN INK OR TYPE ALL INFORMATION) �J� Dale
City or Town of A , �r�✓����� In Ilw InclMrtnr of kklire•
The undersigned villie% fora permit to perform Ili(-electrical woekk described below.
Location(Street R Nlunherl 6�2 3 OJQ,00,131 S T
Owner or Tenant
Owners Addre« SA
Is this permit in conjunction with a building permit: Yes No (Check Appropriate Box)
Purpose of Building t Itility Audrnriratinn No.
Existlng Service __.Amiss / UPIls Overin•arl 0 Undgrd E3 No. of Melnr.
New Service Amps % Volts :)`•erhe.vI ❑ Unogrd `j .:o, of MIO.ers
Number of Feeders and Ampacity
Location and Nature of Proposed Electrical Work �/�L/9�C E�1F/JT /S�l t{Jj9S f/�f2
TOI AL
No.of Lighting Outlets No. of I•lot Tubs No. of Transformers KVA
Above in. 1
No.of Lighting Fixtures SwimmingPool rnd. EDnxl. Ll l wnerators KVA
'401. of Emergency Ligh1m:
No.of Receptacle Outlets No.of Oil Burners Battery Units
No.of Switch Outlets No. of Gas Burners rIVF. ALARMS Nn, of 7.onec
No. of Detection and
No.of Ranges No. of Air Conditioners Ton';
Initiating Devices
Heat Total lol.11No. of Sounding Dr•:it r c
No.of Disposals No. of Pumps Tons KW No. of Self Cnntainnl
f>etcction/Scwnding IIt i,m
No.of Dishwashers S ncclArea f lectin KW � iri�.•! r--1
No. of Dryers HeatingDevices KW I IX AI Connection l)cher
No. ot No. ol I ov, Voltage
No.of Water Heaters KW Signs Ballasts Wiring
No. Hydro Massage Tubs_ No. of Motors Total HP ({ ['F1 111
OTHER:
2 6
.. 1
i
INSURANCE COVERAGE: Pursuant to the requirements of Massachusttes General Laws _
have a current Liability Insurance Policy including Completed Operations Coverage or its cuha.mu.,t.•.tui\alvnt.YES G`NO) )^a r. ••.11bii1il(rrf J.1h', pr
of same.to this office. YES U NO O
If you have checked YES, please indicate the type of coverage by checking the appropriate I>,ts.
INSURANCE [3180ND ❑ OTHER❑ (Please Specify) Q N r L E
(Expiration Dalry)
Estimated Value of Electrical Work$
Work to Start Inspection Date Requested: Rough Final
Signed under the Penalties of you
Philip A. Pa r7i: rat
FIRM NAME LIC. NO. f qq/71/e
.Licensee BOX 6.43 23 Mair Sign LIC. NO.
Address Atkinson, N.H. 0381 i Bus. Tel. No.6,03 3" V66S
1-603-362-4065
Alt.Tel. No
OWNER'S INSURANCE WAIVER:I am aware that the Licensee does not have the in-mranre rove•.we rn itc i,ob.rantial equivalent ac rerluire•d by Mascarhusenc
General Laws,and that my signature on this permit application waives this requirement. Owner (Please check one)
Telephone No. PERMIT fFF S ���0 y
(Signature of Owner or Agent)
. � Dt
c 290
.NORTH
TOWN. OF NORTH ANDOVER
3a
{ PERMIT FOR WIRING
•L
fn'._ ,SSACMUSES ..
This certifies that .........
has permission to perform .. ' f! °....... t., i:�r. �� �' ---�-
wiring ........in the bu'ding of 1� r a - ..................... :.
4 f
at. ..'... '' �,d. :. ..... ....:.... .......:.... North AndovMas. er, .
s
pw Fee ► Lic:No:�/.. f >. .... ..... .. .. .
, .... ELECTRICAL . .. .O ....
z � LECT LINSPECTR
LdCs+ 1 :y
Ap I rf
PIIP�t�96 16:
` WHITE: NARY: Buil16epiPAID PINK:Treasurer _ GOLD: File
MASSACHUSETTS PROPERTY INSURANCE UNDERWRITING ASSOCIATION
Two Center Plaza --
Boston, Massachusetts 02108-1904
(617) 723-3800, Ma Only (800) 392-6108, Fax (617) 557-5675
07/29/05
Form of Notice of Casualty Loss to Building
Under Mass. Gen. Laws, Ch. 139, Sec.313
RE
DHIEATER
NORTH ANDOVER HEALTH DEPT.
NORTH ANDOVER TOWN HALL NORTH ANDOVER MA 01845
Re: Insured: GEORGE & DEANNA OUSLER
Property Address: 623 OSGOOD ST, NORTH ANDOVER, MA 01845
Policy Number: 0830719
Type Loss: Water Damage
Date of Loss: 06/15/05
Claim Number: 219833
Claim has been made involving loss, damage or destruction of the above captioned property,
which may either exceed $1,000.00 or cause Massachusetts General Laws, Chapter 143,
Section 6 to be applicable. If any notice under Massachusetts General Laws, chapter 139,
t
Section 3 B is appropriate, please direct it to the attention of the writer and include a
reference to the captioned insured, location, policy number, date of loss and claim or file
number.
MPIUA Claims Division
CMA00021
MASSACHUSETTS . NIFORK'APPLI.CATION FOR. PERMIT TO DO PLUMBING z
Ma Dateg„',-' Perm # �'
-uAding-Location Ownet's Name .�-�
Ty of Occupan -cam
New ❑ Renovation D Replacement ti Plans Submitted: Yes.[] No O
F�XTUR.ES '.
B.P.# SEWER# SEPTIC#
's • Z
Z� �, v
'Z
Vf
• � W.. 0 W0 dc 01 Z CC
O O • J N. CC < Y O O W C1 3a
i- V > pZ C Y a �: H F :Y' a. O _Z _X .90 0 w u Y 7 41
r < < (A (A < a 4 J _j < IC OC < 9 Q V :x
SUB—BSMT.
BASEMENT
1.ST FLOOR
2ND FLOOR•
3RD FLOOR
4TH FLOOR
STH FLOOR .
6TH FLOOR'
7TH FLOOR
STH FLOOR
Installing Company Name &DONNELLIS'K"Allm,INR..•• Check one: Certificate #
dress BALES! {N.H_03�7g O Corporation
�.::.. . .[];Partnership
business Telephone D Iti IFirm/CO,
Name of Lkensed}Plumber r . 'eVw�l"JU. 0 L.L
INSURANCE,COVERAGE:
I have a currenUlabiiity insurance policy or its substantial Q4uivalent which meets the-requirements of MGL Ch. 142-
ye; •Ir No O
If ,ou have checked_y�e. , please:indicateahe type coverage:by checking the;appropriate box
i ,;ability Insur.nci' d;;y, Othertype ofoindemnfty O Bond O
4NER'S INSURANCE WAIVER: I am aware that the.licensee does not have the Insurance coverage required by
apter 142 of the Mass. General Laws. and that my signature on this permit application waives this requirement
Check one:
.Owner .EY Agent O
Signature of Owner,or,Owners Agent
I hereby certify that all of the details and information I have submitted(or entered)in above application are true and accurate to the best of my
knmviedge and that all plumbing work and installations performed under the permit issued for this application will be in compliance with all
pertinent provisions of,the Massachusetts S7ql.
:Plumbi a,andGha t .7d f,the.t3eneral Laws,
or
By
natu p 3 ce urho
r r
Title
City/Town 7 199 T!!pe'of t.iS�nse Master p // .loumeyman
N License Numberld ca
........... ..,..,.a.,[ +>. .�f.�aa.s..W«— –cit:a.+..�.kwr,�e�::,d.,wwavewl:i�.raRe.«c.:ws:`a+..,o.-�:ys.«.m�x��+�.n+ .•zz"Mc.a¢+w,w.,..0 ...w.,....... .. . .:•a.. 1...- '..m::.soc.a•,..re•+<.'�...b..._.'-
BELOW FOR OFFICE USE ONLY
' FINAL INSPECTIONS SKETCHES � PROGRESS INSPECTIONS
FEE
NO.
APPLICATION FOR PERMIT TO DO PLUMBING
r _
{ NAME A TYPE OF BUILDING
LOCATION OF BUILDING
r
-PLUMBER
1 PERMIT GRANTED
{ DATE 19
ti
7. s
r t.•
en..
PLUMBING INSPECTOR
t Date.,?'.-2.�-.%mo7-?
2862
' ,o°T•��p TOWN OF NORTH ANDOVER
p PERMIT FOR PLUMBING
SS
CHUS
This certifies that . . L }.TSG. �? t�<:r.(.�• . , , .��°�• l • • , ,
4 has permission to perform.. . jws/.tom !? �.�.�/ti
plumbing in the buildings of . .-.L?,s. . . . . . .
at. . . .6A3. .0.s O.O .
d. . . . . . . . . , North Andover, Mass. .
c. .
F . 7,. . . .Lic. No..16.3
PLUMBING INS CTOR
V, 04/01/96 15:465.00 PAID
Y
. WHITE: Applicant. CANARY: Building Dept. PINK:Treasurer GOLD: File
POffi
The Commonwealth of Massachusetts ce
�o
C Pe n No.
•11 tOccuwnKY & Fee Checked
Department of Public Safety 3/90 (less blank)
BOARD OF FIRE PREVENTION REGULATIONS S27 CMR 1200
APPa All LICATION
iobe FOR
m�PERMIT rdance WTOth e PERFORM
atELECTRICAL WORK
CMR 12.00
(PLY-SSE PRINT IN INK OR TYPE ALL INFORMATION) Date Z-/f- 9 7
City or Town Of /tiOt2�r(F Q �pV@It- To the Inspector of Wires:
The undersigned applies for a permit to perform the electrical work described below.
Location (Street b Number)_�p2
Ou-ner or Tenant-L-e,
Cl-men's Address
Is this petnit in conjunction with a building permit: Yes ❑ No 0--� (Check Appropriate ?"x)
Purpose of Building i2e�'1C�entlal Utility Authorization NO.
Existing Service Amps / Volts Overhead ❑ Undgrd U No. of !`.eters
New Service Ames / volts Overhead
ElUndgrd ❑
No. of
?Sete..-s
Number of Feeders and Ampacity
Location and Nature of Proposed Electrical Work Central air conditioning system
No. of Lighting Outlets No. of Hot Tubs Toca_
� No. of Transfomcrs
z No, of Lighting Fixtures Swimming Pool Above h,�,A
grnd. ❑ In- 11Frnd. C--ncrators Ky„
No, of Receptacle Outlets No. of Oil Burners No. of Emergency Lighting
Battery Units
c No. oL Switch Outlets No. of Gas Burners FIRE ALAR..11S No, of Zones
oNo. of Ranges No. of Air Cond, Total No. of Detection and
z Cons Initiating Devices
No. of Disposals No, of Heat Total Total
-J PumpsTons KW No..of
J Sounding Devices
D No. o_` Dishwashers No, of Self Contained
L, No.Heating Detection/Sounding Device::
No. o: Dryers Heating Devices KW Local❑ Mtunicipal Other
a
Connection❑
4 No. of Water Heaters Kw Noy of No, of Low Volta
y Siens Ballasts Wirie
ne g
o No. Hydro Massage Tubs No. of Motors Total HP
OTNrR:
INSUR;NCE CCVERAGE: Pursuant to the requirements of Massachusetts General Laws
I have a current Liability Insurance Policy including Completed Operations Coverage or is
equivalent. YESS NO E) I have submitted valid proof of same to this office. YESW NO
If yo.i have checked YES, please indicate the type of coverage by checking the appropriate box.
ICvSUn��CE BOND ❑ OTHER ❑ (Please Specify) Marr-han _s Tnsura_nee Group>?�nfi��F,/qg
Estimated Value of Electrical Work $ lExpirat:or, Date
Work to Start Inspection Date Requested: Roti,^h
Final 7-/5-'? 7
Signed under the penalties of perjury:
FIRM t,A_urateg Inc._ e
LIC. CPQ.
Robert a! irhant Signatur �._..__..
T LIC. tip. X121.35
A0,1r,, 24 Town Crest Drive Wakefield, Ma. 018808 Ti1 tlo Ei17_4 -1213
"'`:=' INcJ'NCE WAIVER: I am aware that the Licensee dans n, t_ Alt. Tel. :+o.—
t_.,. t!Qu` 'a lent as h:'," the lnsurac e con th.:s c.-
required by Massachusetts Ce neral L.:::• ant
waives this Ple :ltat n, i�:.tt"c on thi p c
requirement. Owner Agent (t lease ct:ccF: ons•)
rr.
Telephone No. mac•. _ -•-
' t..r..tT_ :.
pIINUll:VVLINU t511IMAIt Anv rnvrvop+L nu.
6LECHECKNUMgER
EARSROFEBUCK AND CO.. ;
,l 'STALLEA•COPY.
3V
IT 0. I LIC.
DATA OF ESTIMATE � _....STORE AD wIItsS - CIlt/I�
STATE ,, �� ',�. EiJ 7.', ���• ;
CUS ER'S NAME HOME PHONE O,F.I E PHONE
ADDRESS r CITY / ST TE ZIP CODE
INSTALLATION ADDRESS IF DIFFERENT CITY - !STATE Ili` 21 CODE
SYSTEM RATING ifU'3: �r
COOLINGJ SEER /A HEATING AFUE#
EQUIPMENT MODEL#'S.. FLUE VENT AND/OR CHIMNEY:
FURNACEIAIR HANDL):6 rrip�I®" T.-STAT EXISTING SEWN USE EXISTING VENT OR CHIMNEY,❑.REPLACE FLUE
! CONDENSERUNIT ,C�Til COOLER# INSTALL NEW CHIMNEY LINER ❑ SIZE__
PACKAGE UNIT# BOILER# PVC VENT PIPE FOR HI-E FURNACE FIORZ❑ VERT❑ e
EVAPORATOR:COIL N..•,: OTHER# �. v� V L.. COMBUSTION AIR± ; ,0 , EXISTING0';MODIFY❑,�I )
1 PIPE INSTALLON❑: '2 PIPE) ,STALLAT
ATIION❑ ; ,.,;'
i RETURN AIR ❑ `EXISTING:❑ MODIFY-El; r;
EQUIPMENT SPECIFICATIONS: /
FURNACEIAIR HANDLER: EXISTING❑. NEWLam/ DRAIN LINE. EXISTING❑ NEW,B,",+�
CONDENSER UNIT EXISTING❑ NEW i CONDENSATE PUMP EXISTING❑: NEWa. . t 1 I '
EVAPORATOR COIL EXISTING❑ NEW�� SLAB EXISTING❑ NEW SIZEY;x .7*
.
LINE SET JEXISTING❑ NEW U-,-' OTHER EXISTING❑ NEW❑ 1.*A liAx.
REMOVE OLD EQUIPMENT FROM SITE❑ LEAVE ON SITE❑
A
i
i DUCT SYSTEM•- ELECTRICAL:
t USE EXISTINGSYSTEM� A,DDDD TO EXISTING❑ CONNECT TO.EXISTING PANEL C INSTALL NEW DISCONNECT ❑ i r (�
INSTALLING NEW SYSTEM L7 SSE SPECIAL INSTRUCTIONS INSTALL NEW ❑ AMP SEEtVICE ❑ SAME LaCATION d NEW
REGISTERS USE EXISTING NEW El ADDITIONAL;WO.RK
INI i. �`f� F
SPECIAL INSTRUCTIONS:
S�A .r Gv��f /�lTA�/ .°l CG� I�tf • t".`/�D�'f /� ��:,�yl r;t!I
3. D foul. S/rf S'IA
/A1'f / �� is
(ftf4 pm1, f'A ,fr,
A ti d �'r r ��J�,G r w s ��� .r, 147 Out/Etr, .� I�� w�,�•s �� w,� st.� �:
i
S �A�'s w,'// v rE �'xi'f��,,G� /��-'i.r tf•�r G�l��v�►� Elitr � s ;04
sys tE,�rs w/ V bf ����� ���� fa two . ao./• G�' �� � 1,� ,
S��i�rs a.� �l ,vvr GvA�s�.� t�f- C�sto�OTs'. ,� �s'�itis :tst�ft -,1 , !;:, , . .;,-�L•I
�f /9 n� -4afti//�'� 'AI-0 0ifl�,44
CONTRACTOR' PHONEC! <':; I I „LICENSE N•-'!1 4 :.
;; ! ir, :s
ADDRESS
I ,
THIS CONTRACT PRICE INCLUDES:.
YEAR MAINTENANCE AGREEMENt � yf'PrIGf ASBESTOS ABATEMENT ":' 1 '► '• ,t`
5 YEAR
REP P Q THIS ESTIMATE AND PROPOSAL ASSUMES NO A BE$jOS WILL SE.DISTURIJ Iff1�
NPS CODE. ,`, l' t ys? THE':h0OWANCE OP WORk-11P UPON �UATHER INhkCti6N bY`CdNW bd
'OR.OTHERS,!ASBEStr ' ^E DISTURBED"TO'PERFORM'WORK;'CUSTOMeA—
CUSTOMER AGREES:BEARS ISNOT RESPONSIBLE FOR ANY EXISTING CODE VIOLA,. MUST-ARRANGE ANI ;,ATEMENT OF ASBESTOS PRIOR+TO-THE START OR't
TIONS OR PREEXISTING CONDITIONS OF ANY DUCTWORK,PIPING,ELECTRICAL SUPPLIES CONTINUATION OF 'rn11STOMER FAILS TO ARRAAGE FOR NECESSARY
OR EQUIPMENT NOT BEING REPLACED AT THIS TIME.IF ADDITIONAL WORK IS REQUIRED, ASBEST ,N I HIRTY(30) DAYS;SEARS MAYc?AOCEL:THIS PRO.
IT WILL BE THE CUSTOMER'S RESPONSIBILITY. ANY ADDITIONAL CHARGES WILL BE POSAL UPONIa,,iiiENNOTICET000STOMER.1 .
1 QUOTED AND APPROVED PRIOR TO THE START OF ADDITIONAL WORK.
I_
��� I UNDERSTAND.THAT THIS IS.ONLY AN FPI!
.
/ .lI p
Date.. f. ILI
1048
HORTM
°f "o TOWN OF NORTH ANDOVER .
' PERMIT FOR WIRING
,SS�ICMUSEt '-y7
• a
This certifies that .... ..... . ..S...S....L.�.7. :..d- ....`?.0--.. ........... o
has permission to perform ...... .
�y µ
�' .......Z��Z c Chu
wiring in the building of........ ........ ......
at..(?�2.?a.. Ca .. 1' x...1MM7..................... .North Andover,Mass. ;
\ a
F4.PO.P...S Lic.No A Y/35
- - ELECTRICAL INSPECTOR
�k 33 ?3
WRITE: Applicant CANARY: Building Dept. PINK:Treasurer
Com nwea h of Massachusetts
'J 'Massachusetts
System Pumping Record
System Owner System Location
ou �.
Date of Pumping: `l �� Quantity Pumped:/0=gallons
Cesspool: No [-�� Yes [] Septic Tank: No [] Yes [
System Pumped by: 164&44W License#
Contents transferred to: Greater Lawrence Sanitary District
Date: Inspector:
m i
Town of North Andover MA .
Watershed Septic System
servicing Report
Date:-
Homeowner:
ate:Homeowner: _rf%ecA 6QS Pumper
StreetAddress: l i of
Phone C�v -4 Phone
Nature of Service: Routine
Emergency
Observations: Good Condition
Full to Cover
Baffles in Place 7�
Leachfield Runback
Excessive Solids ?�
Heavy Grease
II ,.
Roots
Other (Explain)
Description of Work:
Comments:
Board of Health SEPTIC S15TEli
North Anoover2,M"80
INSrAMATICK CHECK LIST LO?'f
,
OVED DAT DI SAPPSOE"ED
AVATI M Ob I�71I L',
5-2Z-95
v
— safes-son`st
nn OK �wtj A5U u'� SYS ►C"i-)
I. Distanee To':.. .
a. WetL-mds
b. Drains
c.. Well
i
2. Water Line Location
3. N6 PVC Pipe
Septic Tank -
a. -Tees -_Length & To Clean Oat Covers.
b. ement Pipe to Tank On Both Sides of Tank
5. Distribution Boa
a.' Covers & Box - No Cracks
b. All Lines Flowing Equal Amounts
C. go Back Flow `
6. Leach Field or Trench
a. Dimensions
b. Stone Depth
c: Capped Inds
d. Clean Double Washed Stone
7. Leach Pits
a. Di=snsions _
b. Stone Depth
c. Splash Pads
d.. Tees
e.' Cement Pipe to Pit - Both Sides
f. Clean Double Washed Stone
8. No Garbage Disposal.
9. -Final Grading Inspection
10. Barricading Covered System
11. As Built Submitted
a. Lot Location
b. Dimensions of System
c. Location with Regard-to Pere Te: t
t, d. Elevations
e. Water Table
�.� U. y ORTH�A�IDOVER., MASSACHUSETTS
-6 R666
MO
4
��'1'F'T��YJi4:'f,,'� I •h.Il•It'.�af!„yll•:
•1\'4,,,i;:',,;:,+„r. hl•,,:,1.!?•ii:.t::•:r.' ;��+,LR,rI`;it,,.,
DEP,,has provided this form for use by localDoards of Health. The System Pumping Record must
be:ubmttted to the.local'Board of Health or other approving authority.
El a .
A ..Fac111ty Inforri��tlon
TOWN,OF NORTH ANDOVER
f>rur►g out 1 System Locatlon: r ` HEALTH DEPARTMENT
f�y'0.Olt'lp t�8r�0• l.[��..J C,/ � �U� s�r
`.only the tab key Address
" to move your
.cursor,•do pot
use the,retum.:%= COM W. ' State -
1. } . ,. ;:.;r,:i;i':r•>'' :.:.:; p Code
System Owner':,' „
Name
Address(If different from"Yon)
' C411own. StatCod
e'
Telephone Number
umping:Re ord:
.v�it :p•, .,'t; =..M' rata.:it�•}':.t,�.J�ilu••.:a7�Gr 1�•Ili.t'';a
,• r 1r'
Oat Pumping ' Date 2• Quantity Pumped.
, Gal ons
Type pf systemi. ❑ Cesspools) ptfc Tank
;. ❑ Tight Tank
'Other(descr(be)
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' t5forrM.docr'06103 .
r System Pumping Record t
C Page t 1
Board of Health
!JQr;.Y :,ndover,Masa c
-__-- SUBSURFACE DISPOSAL DESIGN CHECK LIST ���a ark 1�
APPROM DATE tZ-3 DISAPPROVED PAT8�
Provided: Reasons:
<r
Title V FAIL
Reg 2.5 The submitted plan must show, as a m1nimmm,s
a)' the lot to be served-area,dimensions lot ! ,abutters
Ib location 'and log deep observation hoes-distance to ties
c location and results percolation tests-distance to ties
d design calculations & calculations showing required leaching area
(e) location and dimensions of system-including reserve area
f) existing and proposed contours
(g) location any Wet areas within 100' of sewage disposal system or
disclaimer-check wetlands mapping
(h) surface and subsurface drains-within 1001 ,of sewage disposal
system or disclaimer
(i) location any drainage easements within 100' of sewage disposal
system or disclaimer-Planning Hoard files
(3) known sources of Water supply within 200' of seVaege disposal e _
system or disclaimer
(k) location of any proposed Well' to serve lot-100' from leaching facility
(1) location of water lines on property-10' from leaching facility
(m) location of benchmark
(n) driveways
(o) garbage disposals
(p) no PVC to be used,in construction
(q) profile of system-elevations of basement, plumb, pipe, septic tank,
distribution box inlets and outlets, distribution field piping anu
Other elevations
(r) maximum ground water elevation in area sewage disposal system
(s) plan must be prepared by a Professional Engineer or other
professional authorized by law to prepare such plans
Reg 6 S tic Tanks
(a) capacities-150A of flow, water table, tees, depth of.tees,
access, pumping
- (b) cleanout
(c) 10' from cellar wall or inground swimming pool
(d) '25' from subsurface drains
v Reg 10.2 Distribution Boxes
- L3b)
a) pe greater 0.08
Reg 1.0.4 sunp _