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Miscellaneous - 64 SUGARCANE LANE 4/30/2018 (2)
64 SUGARCANE LANE . 1 210/106.A-0238-0000.0 y _ _ 1 L)6PtG f f 'v. t•' rf?pta `tt! y �..,_a�� -ri,wx -s,t ,� g>,+xr✓r<vn.R Frn.uaos f r.: '1 y/g^a'Y"s '� t A.�•. ^s: +�y..v. •�+,� r...j1Yr��•Sd4��rw�4�����"+:n����T�./,.�}'`r''�s•.ts:'<-�5��.,,, ��`c"t'� sr. p c tit < 3' xa�' .4 x • 1 k. ..,z '.� x h �ti.( a ,, �t p, " L $ti .-� 4 a`t <°' .. 1 "St'` "� ?i,�x+�`„•L <-�i .. •,,,`+� ?,"T,«a � F^fi. •H6 ;r�r`"�, `+.. iii - ! T Tae✓ v' - ', YS.� ,q Gas rr ) fah i , I ' • �m . z°w.»F s '.�y •• Y P,�w CSS. •vF "}`'4 : .•.. �c t;n� Sh t w ✓{ S .'.�+ I. � E r,, r�i;��rpy n"���?"'�"�`'s-.r "ti-3 cr;. ,,,�;. �'{�. g�i��zv'�1'�kya'�a:2�c•K �,vy�t.§#t"��j��:�y�}'at �Y"`� .' xy`` �' 'S �. Ae LOW MAPa .s C .-v ,-i"' 'e1 iu,� � L•5 2 L j..r r� LOT, -�S••g�j''�:5 �.a.,r,�.�''�• J < ;p �?$ "s4 + f <tN^h ttE''..k; ' `3�-G` J•t R�',:'•'f ..'•f' (t a 1}.4�, L�'.._y T' 1,�y� t .) 1 rir7 r 1�` i a f..•C5? 4 i Y.+� � iti+"QRS . PARCEL{# �� fin ,t STREET �7G/�i'G.Q/G / `� i: � b x'�)y R k`T"+.'R i k�� .w�i c:: -f�s"r%t�s��r 3 t a .a; � t.,r.') , '� .s.u. •...+i+,;.,r _, \ - I-S t Y w-i,•r. FJ,SiN f`L�RO s - HAS, PLAN REVIEW FEE BEEN PAID? + NO t t � t ii ,,a r_y't"t 4,a "•}� ay s 1 :: � { e v- .. , r r ; PLAN, APPROVAL: zf } DATE APP. BY 4 DESIGNER= r ✓ PLAN DATE II G, rCONDITIONS YSN i �tf I' t - t! �,`{ �• � ��ly'S�,q,-..yc�, fr��". / i}fix yfL is i)�. �•fi^` i ces��' �'t -�` 'er '3 aly < r D���/,/��. J'/' +` "+'a K v."•� `Af L.J/l` �f '�Ey ar k } '7e` �• 7 < �`/ '� wi }(r1.r �•��� y.k SR. `"-,1 iN �I t �4 WATER SUPPLY:` } TOWN } _ WELL ,I. ...- k t J, ;_Sy 7�-, t E�z!�,� t �. f -• s. r 3- < ,+ ' ' WE PERMIT �f DRILLER CHEMICAL x,_ DATE APPROVED ' III. r > WELL TESTS:. Y ,` q< ` 4 BACTERIA I DATE APPROVED__ BAC IA II DATE APPROVED ` ' COMMENTS• - ' t FORM U APPROVALS / �! APRROVAL TO ISSUE YES NO DATE .ISSUED `=���"�� BY j x • CONDITIONS: . + : F I NAL APPROVAL a' , -- ,:'ALL'PERMITS PAID - NO 1, NO WELL.CONSTRUCTION APPROVAL SEPTIC SYSTEM .CONSTRUCTION .APPROVAL ' ES NO OTHER YES NO ANY. VARIANCE NEEDED YES NO FINAL BOARD OF HEALTH APPROVAL: DATE:------BY: 'i. id+4' y s! . s '', } S ro td,-y° R iii , :t7 `k ��y�r4 -s.11 k1 ,s'1 n,^�°' sc'oa:7 "F 2 'S+ J.1_•kr s .,.,fir "'C'i;i` 5 C., , 'tas FYr+,w �k star' 7jfi."�^ 'S zT} '4 t}+�'" �`�. ,h .` �` j fi 1 i '. .it .x'11 ,.,�,rv,t.x4 1r`.�'ti* ."a 0 4 1V�r Fy `- `+'`.'� e�";'. .�+Y ti �1 r 'lR .t s ke '�,.s >e ,gVt� 4.f-.� �.;+�'.#1 2 }l�,,c�; q..f�', d . . 11 hl a .� .yk 'S 6 y t U'= o c y^� ,g,,� fr-�:..ry„t„�1 h'i's 3r `s cr� K- - ;,Yt'3 �j�, tjy.`} •.:•X6.4 7: _r 'fir. f'{^ r t.'x-,.,. '-1, tfi ti M3wa p ?."� r,>xa'tr�. .4 'k" ;' ;, `Ytr'Ji'' 'i r iWWd,d yX is« µ 7,.. k} a, _,,,. •t-: Z.t,2 Sy�r.K, J3,1°�K" :ltd 'k LM' t .1.95. K?',s cKF]: ? �� 41r t {. r ,•.i,hr � 'y'., 4. >7 t{.^'r'�• x r�,f•s,r { .lit. ;-it- s2 . x#Ci�- + v sk 1:�' tjf^' ^ '�`t'�°'• S 7�,t FH � nv` #C.,';` *' t:° f '^f r _ �k' '" tr^} i'Ifl J 1 -f..r yy, `yt"k ,* { i< kcj}.U. p r.2 x yyJ sn lia t.!r<:r,< } q� .e I ,' �1i:�1 i 1 rm�3 4,ti 7 2 :i:'. E e }ks7�.' a}fY � Y:f� r t't� k 7 d* — 11 , f" .,� J �i sir #•}55 a '�1' •'�iC+W t -2 e ,,i.m i;.' .. ,y'C.. tn- ,ix 3,`:v''�- F z! a \ a' t.� ; _ ' 1, 7.. ii`x' s�.4r d l3 SAl ,+ a�7§?3� p^t Hf�tty-R`2 F;`r .: - t r -T r J n ' c s y t4jsy* tiE': ! to ,;wy.all 'zt: i � ��^5 r� ` 34 .p3,fPT_ G $JLI�M= NSI94l..8iTQN h. ,-.� , k3. . .,`';5 '+.,l- ,�'4"'t1C'thi'> �i ' '. �.- .•� ;,,..,., �° .�% ':°P'x* e, , .'?E>r' ',;,.7?'*''' i -':�} 'ct .:a,.,; y<�.r. _ �. "}.$t1'"t k ?.ra', > :, k!.' ''' °.�4;t *,;�r.f �'. Y t-q .l;.r ,r.'f - ., a..;�_x`ikia ,{. t d; 't' -<,.a Y -.lw u`$.>ir�u ,w --?; {,..n:-d 1 .a„. . ,. )?" .{. 3• r r ,, Txx ', fit:. r.. ,s�'l � ! t ! t 1 tis.�i . � J �, ' , ,fir ., r ;,+�' %t J,� t,`ft, ti.R,-�, 1rq+:,.7�. t 3�� t't .. :-;.fir, ....., v.r,"I .,•a;k," *,"', _�i >#.} t '' "'? i'•�1,."1.{' a r 1 Y r_.: s% ' �� O;; HE.INSTALLER ;.LICENSED? ,n."' �; t r Yf,,r� fi NOR , tt -n.�.'f'ta,fir�fCrx'..r,r, ? ��.. �;ez4;Y-e+ f�; 4 i 7 ,ff*'' P i} 4.,nf'r fx,�a n.�""[ ##; fh'4,` h`'•t ih+r} y...>; .., k T t ., - 1 I c,.i urx fh Tr! .$: r .y?,xf #�' :;t.r p,�'"{.s,` .L>-./;9<. l? e ..' t t. a ��1. 19 Y' �: k A•',= t k... f +:k:>, °3«,,r- t,- , `iiT >K'"+" aS ;41s't"~,a {s -:RS:.y.yen. f"_,4 -x .�f]}�drlk s a;�'fr{ trr - .+°t'Y`0` � - _ 5-...a y -ad� �(s I 47, Yr.y'e�! r,�i"J�.., � l,'krr& ki'i. .- Al,, .5. r ;.,y.a'F.1''....;€< t y^;;,k. ;+• ",M yre rtr'2:Y k ',f'f `�'Z ,�.,.1 fi 4'S .S -: _ 4 .. R A..; ° a x �'x.Nfli t ,+e sts I- 11 K j'ts a to-� +; sF!'F' ''t.yi r..:t7°J4 tti t i'"^#• 1 r' , 1 - (TYPE" OF CONSTRUCTION: fm t &jk ', , 7 tf, wx=.� r illt` RERAIR ` ` t t�¢a--�kY k'Nq•}I. <4 l y,�,y,� .V�, b i zYr k... s r "• ..� '{ `ix t ,.4 1 r � '"'°�"+4�`'S .>e 4 s - t ,�' r 'k ' i�l 71 Y1.i .' , t�fii't r a7�,.J�•i �f .'�tf:1, 2a.,'`x}•',ea< sr. .<:.L-">.h 11, ,r'•- j k±ys } .'i:�.' ;�sf'>.:k �l�1'ls- {+s, ...� �` t.. 5 ; r,.~r�•`��NCW CONSTRUCTION: ~CERTIFIED -PLOT.PLAN REVIEW ` N0 f ',i '.x -r 4yd ,i I is s,", 7he.. * ',:. - f,r y i ,} [ t.. -0 " t• °°� r kj"1�� — n� ,'' � f 'r� COND IT I ONS; OF APPROVAL �" " ' R ` t YES NO 2 iN L i A"� } A� t.} P k '� is C Y 1 : i*°<, ,;t. ^� y ,tu„1{7i' tv s i`7�, ? S y - t r4 ,.,F °s ry ., t z x xI Xri�4� x�.Wc 2 � a r � a �� vr� , 4 a ; r t .14" �r pit ]� � s �� :(FROM FORM U) -<� - � 5 ;, i } * t a� a'��r u y.11 .S��Y� ��a'.' ti'"`j�e e a{r xr ss:-„a i �x p i�^�a�,o r,'>. ,$F ��s ,.:�?e. ,+' T. =,�,ry,°��+�A,JptI9,ln,a�`R�.�,I�_,jj v ��, -s.1.t ra'a,� ,��¢§« �;f x s.,':� ° t ^�a'rteA:"lr'e y2'. d ;, ,L3"11; t' '44.4y",'�F., E4J. :Sii f.f--Y .q;i} Yy lYf L �4,h"ri,lt� 2.i �''FaF,•..t,' lR �, �$St. }+!• 51 .I.,,Y- {'.'. e �: R y��+,^hi f5 t.._?....s'•,•,t .,.:R!,. ri t ..7: ,. T.- - -c.x. .T-" "'t Xt lk" r >`"}r'vi a }`t'cghl $'f '..a-•t f."� t. :''� s <}.c,. Ys �v 1•i'Jr o- 1 ti .]'tc�' kf"5}c r 4 w'a, '. t t .: 4 x > NO, [ ISSUANCE OF DWC PERMIT S ,; , [ i = _ ,CC � cc,a x ! ''•.' i'° ie5 r.a�[-'t2y�l'Ij ':7ij11 7xie r.u�,t'� J'j: c < % , a i ( ii is`t fxaf t!C ' t -A,y`¢k p ,t° �j. xk �'�r Ise i�.t f 1 .>'.g6z{r. ,+�'<;�r' r: Il 1 -7 kip.ba V 2 `ir '2�'4.0,le,J-'•-;;..,:i,-iF.r W o- .is'. ej yq'- ca` ' { .eft i t, �,''' t 4 s. !1 `-��^- V-,.% 4, '� i , a(j v n _ '= INSTALLER IU C U jr 3) 111, {�} DlW1.C PERMIT N0. t y r �( *.tpA� �, - —` 1 Y•``. ' i t{��`C 3`'! S 4.' F� r a ' i 7 e t- .'t1 "t 2"°1,4 v,}':x� u1.. 7 �i" 4 7 - T,� •k C m rr 1. .f r ,,; ee w r'f r , ] �t'o43 v i t ,t,� - 4 1j { ' Y F Vt� -!.qlr �'1 �:.YSltN.✓SS° l -!.I f. : 2 lN,t*j {, .7'y v t� ki;,4,f_,i'i}try2 # 4I k 2 ^'.A ,N a:^'f, y�.ll�,(rr;l;Y 71}i.k f t9'� L9F1 �j'. �• 3, ..:� G -!S 4 '.. .2.>. r S x:�j '� V -:'SF 8 J+ii'r.'.k t e.+r�y 4i.+� t. % _ I 1 , .� 7.BEGIN 'INSPECTION .�� ,t--' _ YES NO- ` "° >° " .' S _ . { , S rk t r°, t'i i" '"'4f 1 F -Of. TI, a r i s c t A --r,,.r h.-i'0lflx�R°���",,:;1 i} 4 1.c f,fi '.e '1,-}. "F.- k 'a 'f 1 x s{�'r ":EXCAVATION .INSPECTION: �i`V ,r ;� NEEDED: " ` '"r ' !i r t r'"1.4, .:.t x x d:'.0 r>r a 't,t„t c k i a vt'r' ,7 t.S 1 '�t y.>4 t .. , , a''s ,✓ .1 S` h 'Tl• ,,VA a Sh ��1 's,r' } `�`i�1,• Y„2 gA. J„ ti.i �r M.�an p f3 £ } =5 b i r.n. �,� ,1..{}.� ^�'u;.s���•yx"` .� rF �t s� Lk- y, i:i:' kr� r tir.�, r,i"}` n h �a 1tZ?t •,^. ,� hf 4$Yw.b4 ra.'r:{ci t, ♦ �j.•• t .i t �• '� z+:t,zx♦{ Y a .'`r a: c. dx'•xa -tt4.0 2 zc'. '� -x.:, E x a> .;a ��,:. ' ix Ear t r #t r if; r p; c ^;N 4 t x - . : J . 2: Z" V�5fnj t,t ' q 5y ". 'i. 't•'.NY� *i V" M t,° ill• s' t }Y Yr SrxM,}A �".�, ate�p�€Ykts,,,: , u• i *sS rY ? : t ,.4 s Eaxt }'.her} s rays i s `•>. ata , \ s �. .F 'y 1 R , } l,{ y 3`e"ft 4'Ya`•„ 'k ? 's h, -',t.: . *}t X34:a�t✓ 7.a1`5,,, . ;,} .rA y, . �z&S• i1.�.. ate. }�`�'},•"e`1 t..} .rite `' :�k'� r_r.�( q ''M•f,�,X�', 34r "✓Fk �. vj R t, y at rV, F''M < 'r L t � ''1tArt,s�,g�q F' t� r .'W." - L xH ,i IMrrt- -F S - -tl r.` 4 '�i i a J> >. r r "i t S " - _I. >ts �} j k, s -s x+,.u,;, rc-�:. ntC t t h 1 i5 7 F •Y g,J tr '' i F` „f 3 1Wft'J c yyr ° a t�"t 7?k'tfuiu7;�1'}-.�: s v,f �.� 'y-' j . s t3 x»c-.ham 4 r,,,,.�,] 4 _°F dz ': }1s.�''t�"'}' va fl.h.:i 1. '` n fix:]3 a •�Lt� y73` 3,1m ',; a }�, 'r'• c �� HY a y ''r K`�+kPASSED •br k*7 , 2 f;: 1 ..'•s�Ft e R.�y ,1 srv4rml-�-rtta.fC xcr 1{?r,`+�' ` 1'??r.'A.,� .�-t r..a r�t a� -+ ,r, [w +,¢ 1. 1 zf� I � �q . 1. f� CONSTRUCTION INSPECTION: ' ' , NEEDEDr r t ° 1 ' " y, h tt.. °t Yy t.4r Sd 1y, " S Fj. ¢'. t'#'`. '£ ,,`#:•, �' ; T?{- r RF ifi i�,�'R t #w; ,ters�� '.:; 15 }. f h ;;'�'` t m2'aa i..z+ r r L iaj' �fi rr i i 4i.' -�t s( !t .+ k u qhs ,�'Sk,'', �`ry,4 <t.a�. r t '`i',,. } ':.i ,,z: ,. s}Lr r.c,3t 5d> 3.k �s* 1 .y 2'> T iK est f7.�1tr5 :{I/L °11 ere, R:;dti}jJ 2 F ],F. hi .... Y J Y" 4 4 4, '�i 4'"-s> .# S 4'F'r ,.,�5•;.J 1 p e.1t ,,� - :.. °t r Xi sf'` (c• ,;.wf ". , P'-°,.3,..��"t,:t ^t,} -ts.` ,xtL' :;- t t21.. ,, ill�,s^.st yyr i � +_• K ,S- L3�^i'r yr,FR'!V .. !'�'� . °I F L i- 1.4,,.i h ' 44-fr y ..5. 2"'c R..kr . ,. }4, ;; q �p2, „5..:a r< rf`"r.' K �� .4;.5'•' '%'v !,#• y.,. X •• ° pr+Z I ,t€` sYr , 'Yq ..gy 7 ,rt ti s _ s t ` 2-i <F � 4 t" '�? ♦ a+• / 14 ti k :d A -+i t., ST 4 s 3Js 4�-�''J•"" i t , a k r •i .r ,'z., a.�'" " , t -a•`a 1•:Y F r :♦ f'-�' L4 '� rt5 . i k ",5. .t Y+y �1.1 +.,t . A r ,.. 4. T s e t� k>`r>, x ti Y] ye1.n,F,"}i i 6 x {- s, > � .,' � ; V �,},.s t ? t.y, r - 1..,+ .-+`.4' 5th ` r ta'`.r , "SCS' R ,3t R '` `. ^�'' .•+y;'4 ;.= Q: �i . If }' t n 1': y x + , 5 L. c� i ,t-' Z ^AS BUILT KLAN SATISFACTORY: , ' Ft:YESs 5 is 1 y ' eTL - s.S _7 r �� +v }t q a`s t7 , v t �_` - re its .°a rr A 1 t - -t. ,, ' f t -12 7j pS fr ° 5 y-itL dt1+J 1� 4, i' Yi•.tz c.e�F S.. e '� ' �4>xr ,''� -ds ._i• � t Y�' - t^w yr,..., '�, 1• ^„ `"F: r'f N. .s.y, .a`'• '};}.., ; ° , .tip. .,w.t.. y - 4 % 1. } /f It-.,, t; t� .fgP A p r, xa r- r z, i x,? }..-c[ •�• s� :3t'� r .11 , F �l. t t L'_ F li ', , yi , , APRROVAL. TO BACKFILL: DATE: 7 r rBY , k a } .1., E r fi:2}sballrai t�•a i....+ ia, .`,r r " . 1 t ti *' 1 r t11 . C j'" - HY ' , '" - -.uFINAL GRADING APPROVAL: r DATE ,. :i: IL - ,t {.1 i} Ii I t: d Y F r yi. x- ', s y.. Y .:4 t e r°,'�K ru?; - a FINAL CONSTRUCTION APPROVAL: t h ` r DATE: BY I. I r 4 t i , ,, h R• :. r m r. I zt 1`:V ,t ,x -- 1'I. . :., ,4 y}}Ird,..'' y -'5 On,r a t.^ :'/ #. ,( rk ai s,� 1 ` s , 1 L y , 4 r t f a 1.I $ r [ '�' Z ; 1 s i"t t .,i t [a f F r nx.. x ,�,#7!]i t` _^s,}, t`- R ri1 t SL'c } t'�"al It is t t ;l'l ati , t SJ' a - fx J¢ i yf 1 I L TR.Y4 4� ` �' \ t PJ°' v r.t 1 t+ e2 ?t T r '�." v.g}t•, y, ; ^ ri L 4K `^ i. # # _t �. ?:.a� 2 rl 'vi _ P{ 5' g �A `.1 - ,gf r, °%' +, �• 4, 'sr. ! h u >_ J..}{6F > iP•y 'i '^�' -e1 s ,`t ^� . . ° ,�'Y xli,F re r y'' ,*.y,y = 1• �i� +'k z y r r i 7. r t !t z nt+ '�w Y i. t - ' 4 T '-„ . r Y ,.. y,_ Tt t? - r 1 w ta �- 3. -'.s i� t c1° •t .s 1 - - J �V, i K L a z j•-. Sh'Z t r } .P jt,.l �• R �Li t` .f t4- 1- 1 t r 7 t t: (II 1 �� r .]5 �! etj ° t mss. t s 'f(' qct ti 5� t /t. } 5� G K .} Y 1. 1 'ri -v.: .'-J q >y f ::{ 5'..•j +S h y R, C a1.�,, t} .` . - t -l ,5 " , �? f - r i -k .. of ° ., f. 7 _ - t k 2 1 `t ! >1 Z. 1 3 1.1. ° _ D.F. CLARK D.F. CLARK, INC. TITLE RECEIVED SEPTIC SYSTEM PROFESSIONALS INC. LIAR 3 0 2005 TOWN OF NORTH ANDOVER HEALTH DEPARTMENT March 24, 2005 Mrs. Debbie Samargya 64 Sugar Cane Lane North Andover, MA 01845 RE: Subsurface Sewage Disposal System Inspection 64 Sugar Cane Lane Dear Debbie: Please find enclosed the Subsurface Sewage Disposal System Inspection Report for the above referenced property. As noted on Part A of the report,the system Passes the inspection criteria. The inspection is good for the next two (2) years;,you may extend the life of the inspection to three (3)years by having the septic tank pumped:annually (before anniversary date of inspection). Thank you for allowing us to be of service on this project. Please contact us if you have any questions regarding this matter. Sincerely, D.F. Clark, Inc. Matthew A. Boucher Inspector i Enclosure cc: North Andover Board of Health D.F. Clark,Inc. file PO Box 265 24A Mitchell Road Ipswich, MA 01938 978-356-5638 Fax 978-356-5500 Toll Free 888-DF-CLARK TITLE 5 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSL SYSTEM FORM PART A RECD VED CERTIFICATION Property Address: 64 Sugar Cane Lane MAR 3 o 2005 North Andover.MA TOWN OF NORTH ANDOVER HEALTH DEPARTMENT -Owner's Name: Debbie Samaraya Owner's Address: 64 Sugar Cane Lane North Andover,MA 01845 _ Date of Inspection: March 22,2005 Name of Inspector:(please print) " Matthew A.Boucher Company Name: D.F.Clark,Inc. Mailing Address: P.O.Box 265,Ipswich,MA 01938 Telephone Number: (978)356-5638 CERTIFICATION STATEMENT I certify that I have personally inspected the sewage disposal system at this address and that the information reported below is true,accurate and complete as of the time of the inspection. The inspection was performed based on my training and experience in the proper function and maintenance of on site sewage disposal systems. I am a DEP approved system inspector pursuant to Section 15.340 of Title 5(310 CMR 15.000). The system: X Passes Conditionally Passes Needs Further Evaluation by the Local Approval Authority Fails Inspector's Signature: U�2�wAaA: Date: 14 The system inspector shall submit a copy of this inspection report to the Approving Authority(Board of Health or DEP) within(30)days of completing this inspection. if the system is a shared system or has a design flow of 10,000 gpd or greater, the inspector and the system owner shall submit the report to the appropriate regional office of the DEP. The original should be sent to the system owner and copies sent to the buyer,if applicable,and the approving authority. Notes and Comments ****This report only describes conditions at the time of inspection and under the conditions of use at that time. This inspection does not address how the system will perform in the future under the same or different conditions of use. Title 5 Inspection Form 6/15/00 page 1 Page 2 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address: 64 Sugar Cane Lane North Andover,MA 01845 Owner: Debbie Samarga Date of Inspection: March 22,2005 Inspection Summary: Check A,B,C,D or E/ALWAYS complete all of Section D A. System Passes: X I have not found any information which indicates that any of the failure conditions described in 310 CMR 15.303 or in 310 CMR 15.304 exist. Any failure criteria not evaluated are indicated below. COMMENTS: B. System Conditionally Passes: One or more system components as described in the"Conditional Pass"section need to be replaced or repaired. The system,upon completion of the replacement or repair,as approved by the Board of Health,will pass. Answer yes,no or not determined(Y,N,ND)in the for the following statements. If`not determined"please explain. The septic tank is metal and over 20 years old*or the septic tank(whether metal or not)is structurally unsound, exhibits substantial infiltration or exfiltration or tank failure is imminent. System will pass inspection if the existing tank is replaced with a complying septic tank as approved by the Board of Health. *A metal septic tank will pass inspection if it is structurally sound,not leaking and if a Certificate of Compliance indicating that the tank is less than 20 years old is available. ND explain: Observation of sewage backup or break out or high static water level in the distribution box due to broken or obstructed pipe(s)or due to a broken,settled or uneven distribution box. System will pass inspection if(with approval of Board of Health): broken pipe(s)are replaced _ obstruction is removed _ distribution box is leveled or replaced ND explain: The system required pumping more than 4 tunes a year due to broken or obstructed pipe(s). The system will pass inspection if(with approval of the Board of Health): _ broken pipe(s)are replaced _ obstruction is removed ND explain: 2 Page 3 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address: 64 Sugar Cane Lane North Andover,MA 01845 Owner: Debbie Samargya Date of Inspection: March 22,2005 C. Further Evaluation is Required by the Board of Health: Conditions exist which require further evaluation by the Board of Health in order to determine if the system is failing to protect public health,safety or the environment. 1. System will pass unless Board of Health determines in accordance with 310 CMR 15303(l)(b)that the system is not functioning in a manner which will protect public health,safety and the environment: Cesspool or privy is within 50 feet of a surface water Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh 2. System will fail unless the Board of Health(and Public Water Supplier,if any)determines that the system is functioning in a manner that protects the public health,safety and environment: _ The system has a septic tank and soil absorption system(SAS)and the SAS is within 100 feet of a surface water supply or tributary to a surface water supply. The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water supply. The system has a septic tank and SAS and the SAS is within 50 feet of a private water supply well. _ The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or more from a private water supply well". Method used to determine distance "This system passes if the well water analysis,performed at a DEP certified laboratory, for coliform bacteria and volatile organic compounds indicates that the well is free from pollution from that facility and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm,provided that no other failure criteria are triggered. A copy of the analysis must be attached to this form. 3. Other: 3 Page 4 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address: 64 Sugar Cane Lane North Andover,MA 01845 Owner: Debbie Samargya Date of Inspection: March 22.2005 D. System Failure Criteria applicable to all systems: You must indicate either"yes"or"no" to each of the following for all inspections: Yes No X Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool X Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool X Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool X Liquid depth in cesspool is less than 6"below invert or available volume is less than'/2 day flow X- Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s) Number of times pumped X Any portion of the SAS,cesspool or privy is below the high ground water elevation _ X Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply X Any portion of a cesspool or privy is within a Zone 1 of a public well X Any portion of a cesspool or privy is within 50 feet of a private water supply well _ X Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality analysis. (This system passes if the well water analysis, performed at a DEP certified laboratory,for coliform bacteria and volatile organic compounds indicates that the well is free from pollution from the facility and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm,provided that no other failure criteria are triggered. A copy of the analysis must be attached to this form.] No (Yes/No) The system fails. I have determined that one or more of the above failure criteria exist as.described in 310 CMR 15.303,therefore the system fails. The system owner should contact the Board of Health to determine what will be necessary to correct the failure. E. Large Systems: To be considered large system the system must serve a facility with a design flow of 10,000 gpd to 15,000 gpd. You must indicate either"yes"or"no"to each of the following: (The following criteria apply to large systems in addition to the criteria above) Yes No the system is within 400 feet of a surface drinking water supply the system is within 200 feet of a tributary to a surfice drinking water supply the system is located in a nitrogen sensitive area(Interim Wellhead Protection Area—IWPA)or a mapped Zone II of a public water supply well If you have answered`yes"to any question in Section E the system is considered a significant threat,or answered"yes"in Section"D"above the large system has failed. The owner or operator of any large system considered a significant threat under Section E or failed under Section D shall upgrade the system in accordance with 310 CMR 15.304. The system owner should contact the appropriate regional office of the Department. 4 Page 5 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST Property Address: 64 Sugar Cane Lane North Andover,MA 01845 Owner: Debbie Samargya Date of Inspection: March 22,2005 Check if the following have been done: You must indicate`des"or"no"as to each of the following: Yes No X Pumping information was provided by the owner,occupant,or Board of Health X Were any of the system components pumped out in the previous two weeks? X Has the system received normal flows in the previous two week period? X Have large volumes of water been introduced to the system recently or as part of this inspection? X Were as built plans of the system obtained and examined? (If they were not available note as N/A) X _ Was the facility or dwelling inspected for signs of sewage back up? X Was the site inspected for signs of break out? X Were all system components,excluding the SAS,located on site? X Were the septic tank manholes uncovered,opened,and the interior of the tank inspected for the condition of the baffles or tees,material of construction,dimensions,depth of liquid,depth of sludge and depth of scum? X _ Was the facility owner(and occupants,if different from owner)provided with information on the proper maintenance of subsurface sewage disposal systems? The size and location of the Soil Absorption System(SAS)on the site has been determined.based on: Yes No X Existing information. For example,a plan at the Board of Health. X _ Determined in the field(if any of the failure criteria related to Part C is at issue approximation of distance is unacceptable)[3 10 CMR 15.302(3)(b)] 5 Page 6 of 11 OFFICIAL, INSPECTION FORINT-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION Property Address: 64 Sugar Cane Lane North Andover,MA 01845 Owner: Debbie Samargya Date of Inspection: March 22,2005 FLOW CONDITIONS RESIDENTIAL Number of bedrooms(design): 5 Number of bedrooms(actual): 4 DESIGN flow based on 310 CMR 15.203(for example: 110 gpd x#of bedrooms): 825 Number of current residents: 5 (as per original design plan) Does residence have a garbage grinder(yes or no): No Is laundry on a separate sewage system (yes or no): No ;[if yes,separate inspection required] Laundry system inspected(yes or no): Seasonal use: (yes or no): No Water meter readings,if available(last 2 years usage(gpd)): Sump Pump(yes or no): No Last date of occupancy: Present Occupied COMMERCIALJINDUSTRIAL Type of establishment: Design flow(based on 310 CMR 15.203): gpd Basis of design flow(seats/persons/sgft,etc.): Grease trap present(yes or no): Industrial waste holding tank present(yes or no): Non-sanitary waste discharged to the Title 5 system(yes or no): Water meter reading,if available: Last date of occupancy/use: OTHER: (Describe) GENERAL INFORMATION Pumping Records Source of information: System was last pumped 1 1/2-2 years ago according to the owner. Was system pumped as part of inspection(yes or no): No If yes,volume pumped: gallons—How was quantity pumped determined? Reason for pumping: TYPE OF SYSTEM X Septic tank,distribution box,soil absorption system Single cesspool Overflow cesspool Privy Shared system(yes or no)(if yes,attach previous inspection records,if any) Innovative/Altemative technology.Attach a copy of the current operation and maintenance contract (to be obtained from system owner) Tight Tank Attach a copy of the DEP approval Other(describe): Approximate age of all components,date installed(if known)and source of information: System was installed in 1995/1996 according to the owner Were sewage odors detected when arriving at the site(yes or no): No 6 Page 7 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: 64 Sugar Cane Lane North Andover,MA 01845 Owner: Debbie Samargya Date of Inspection: March 22,2005 BUILDING SEWER(locate on site plan) Depth below grade: 29" Material of construction: cast iron X 40 PVC_other(explain): Distance from private water supply well or suction.line: 23' Comments:(on condition of joints,venting,evidence of leakage,etc.): Building sewer pipe is in good condition no signs of leakage SEPTIC TANK: Yes (locate,on site plan) Depth below grade: 36" Material of construction: X concrete_metal fiberglass_polyethylene _other(explain) If tank is metal list age_ Is age confirmed by a Certificate of Compliance(yes or no): (attach a copy of certificate) Dimensions: 5' W x 10'L x 3' D Sludge depth: 10" Distance from top of sludge to bottom of outlet tee or baffle: 26" Scum thickness: 0" Distance from top of scum to top of outlet tee or baffle: N/A Distance from bottom of scum to bottom of outlet tee or baffle: N/A How were dimensions determined: Tape measure Comments(on pumping recommendations,inlet and outlet tee or baffle condition,structural integrity,liquid levels as related to outlet invert,evidence of leakage,etc.): Inlet and outlet tees are in place,liquid level is normal. There are no signs of leakage into or out of the tank. GREASE TRAP: No (locate on site plan) Depth below grade: Material of construction: concrete metal fiberglass_polyethylene_other (explain): Dimensions: Scum thickness: Distance from top of scum to top of outlet tee or baffle: Distance from bottom of scum to bottom of outlet tee or baffle: Date of last pumping: Comments:(on pumping recommendations,inlet and outlet tee or baffle condition,structural integrity,liquid levels as related to outlet invert,evidence of leakage,etc.): 7 i Page 8 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: 64 Sugar Cane Lane North Andover,MA 01845 Owner: Debbie Samargya Date of Inspection: March 22,2005 TIGHT or HOLDING TANK: No (tank must be pumped at time of inspection)(locate on site plan) Depth below grade: Material of construction: concrete metal fiberglass_.polyethylene_other(explain): Dimensions: Capacity: Qallons Design flow: gallons/day Alarm present(yes or no): Alarm level: Alarm in working order(yes or no):_ Date of last pumping: Comments(condition of alarm and float switches,etc.): DISTRIBUTION BOX: Yes (if present must be opened)(locate on site plan) (Depth below grade=48") Depth of liquid level above outlet invert: 0" Comments(note if box is level and distribution to outlets equal,any evidence of solids carryover,any evidence of Ieakage into or out of box,etc.): Distribution box is level distribution is equal speed levelers are in place,there is minimal evidence of solids carryover. PUMP CHAMBER: No (locate on site plan) Pumps in working order(yes or no): Alarms in working order(yes or no): Comments(note condition of pump chamber,condition of pumps and appurtenances,etc): 8 Page 9 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: 64 Sugar Cane Lane North Andover,MA 01845 Owner: Debbie SamgM Date of Inspection: March 22,2005 SOIL ABSORPTION SYSTEM(SAS): (locate on site plan,excavation not required) If SAS not located explain why: Type leaching pits,number: X leaching chambers,number: 3 leaching chambers _leaching galleries,number: _leaching trenches,number,length: _leaching fields,number,dimensions: _overflow cesspool,number: innovative/alternative system Type/name of technology: Comments(note condition of soil,signs of hydraulic failure,level of ponding,damp soil,condition of vegetation,etc.): No signs of ponding or hydraulic failure present CESSPOOLS: No (cesspool must be pumped as part of inspection)(locate on site plan) Number and configuration: Depth-top of liquid to inlet invert: Depth of solids layer: Depth of scum layer: Dimensions of cesspool: Materials of construction: Indication of groundwater inflow(yes or no):_ Comments(note condition of soil,signs of hydraulic failure,level of ponding,condition of vegetation,etc.): PRIVY: No (locate on site plan) Materials of construction: Dimensions: Depth of solids: Comments(note condition of soil,signs of hydraulic failure,level of ponding,condition of vegetation,etc.): 9 Page 10 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: 64 Sugar Cane Lane North Andover,MA 01845 Owner: Debbie Samargyq Date of Inspection: March 22.2005 SKETCH OF SEWAGE DISPOSAL SYSTEM Provide a sketch of the sewage disposal system including ties to at least two permanent reference landmarks or benchmarks. Locate all.wells within 100 feet. Locate where public water supply enters the building. B ter w r A #2—D-box #1 —Septic Tank #5-Leach hamber #3—Leach Chamber #4—Leach Chamber A- 1 =29' B- 1 = 71' A-2 =42' B-2=43'5" A-3 = 52'5" B-3 =41' A-4 = 58'5" B-4= 37'5" A-5 =65' B -5 = 35' Sugar Cane Lane Page 11 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: 64 Sugar Cane Lane North Andover,MA 01845 Owner: Debbie Samargn Date of Inspection: March 22,2005 SITE EXAM Slope Surface water Check Cellar Shallow wells Estimated depth to ground water feet Please indicate(check)all methods used to determine the high ground water elevation: X Obtained from system design plans on record—If checked,date of design plan reviewed: Observed Site(abutting property/observation hole within 150 feet of SAS) _Checked with local Board of Health-explain: _Checked local.excavators,installers—(attach documentation) Accessed USGS database-explain: You must describe how you established the high ground water elevation: Bottom of SAS is 99"below grade According to soil testing performed on April 9 1992 and June 17, 1992 groundwater was determined(a,96"in Test Pit 31-2 no groundwater was encountered in Test Pit 31-2A(a, 102", and groundwater was na 132"below grade in Test Pit 31-4 11 �7„�4�rg4�r J }k yt,.�! ,+�4 �'".• fa N 3,�J � - 1 -�'y'+`i.#a�H`"S�i �.}3�'4G',}� tld.' '"�V7�'�1•`�. - �*Y - - iat,�:+gs . ''�, '{ ;..a•rt �,/''r I• l.., . '�. P� �;_ ` .,... of"Y"�'"• ��' �+F&.``'tiY` viv 17 1-44 WY • ly ell e, TAr4e, 7'1 -7i ' . ;,. r t. / , : vv. Fora 131•ss , "" d'1 ST�l �E �1Z' —1�.5' .�,s �,, _apy��-S. st '°" `�'+,yrs �� PiT "i 5z,5' y �* 13 I,05 bac• Prf+�2,,, 58,5' 07. _ IH IZq (• 7 vrr�jj�..� 4i t t - a4' I" F i' i 2G 0 a. ���•Yr1' F LoT-`3l Q a;.r 1' r ; "I IF,fo t ` Q. Ga►b4 LA u e- SUBSURFACE DIS-POSAL SYSTEM- LOCATEDIN IJ��T�I Q tip 0\16 C2 , Ma, _ -- - AS PREPARED FOR 616FLOQI &L, VjL'L' A'6l& 09W. COT, DATE: Ak-MIL) 7, 1,1-1 SCALE: MERRIMACK ENGINEERING SERVICES, INC. PROFESSIONAL ENGINEERS • LAND SURVEYORS • PLANNERS 66 PARK STREET • ANDOVER, MASSACHUSETTS 01810 TEL (617) 475-3555, 373-3721 a 3o.. - -- - DE51GN DATA I PERCOLATION TEST WAS PERFORMED ON JUNF 17, 1992 BY NEVE ASSOCIATES AND OBSERVED A BY SANDY Sr Tr?R FOR THE NOR-r" ANDOVER BOARD OF HEALTH. 2 PERCOLATION RATE ' 1' IN Z MINUTES. 3 DESIGN FLOW - S SEDQOON49 X 16S GALS. PER BEDROOM, PER DAY 'EOUALS Bzs GALS PER DAY 4, SEPTIC TANK REQUIRED DESIGN FLOW; OZS G PD X 150/, f ! EOUAL5 Zj8 GALS, PER DAY. 5 SEPTIC TANK. SELECTED : 1500 GALS. 6 5HALLOW LEACH 'CHAMSER CAPACITY FOR THE DESIGN PERC RATE ABOVE BOTTOM CAPACITY 421.D3 S.F. X I.00 GAL /S.F.= 421. 3 GALS. SIOEWALL CAPACITY 181.33 S.F. X 2.5C GAL.IS.F =453,33 GALS. T TOTAL CAPACITY PER JHAMBER SYSTEM AS DESIGNED= 875 GAIr_S ' g FOR PIPING SPEC'S SM SYSTEM PROFILE, 9 ANY UNUSED INLETS AND OR OUTLETS SHALL BE PLUGGED. 10. USE HYDRAULIC COMPOUND CONNECTIONS TO PROVIDE WATERTIGHTNF-55 AT SEPTIC TANK AND DISTRIBUTION BOX INLETS AND OUTLET'S 11. THIS SYSTEM IS NOT DESIGNED FOR A GARBAGE GRINDER 12 MATERIALS AND INSTALLATION SHALL BE IN ACCORDANCE , WITH THE MASS. ENVIRONME`JTAL CODE (TITLE 5) AND THE SANITARY CODE OF THE BOARD OF HEALTH. 13. THE DE915N ENGINEER IN THE PRESENCE OF THE TOWN P HEALTH A6ENT SHALL PERFORM PERIODIC INSPECTIONS OP i THIS FACILrtY. UPON COMPLETION OF THE CONSTRUCTION, { - THE DESIGN ENGINEER BALL CERTIFY THAT THE INSTALLATION �� WAS MAOE 'IN ACCORDANCE WITH H15 DESIGN r ,., 1; (� J -1— 14 NO PORTION OF THIS SANITARY DISP05AL SYSTEM SHALL -1 BE WITHIN 10 FEET OF ANY CONSTRUCTED WATER SYSTEM. l 5 THiS DESIGN IS NOT A GUARANTY OF THE SYSTEM'S PERFORMANCE. THIS SYSTEM SHALL BE SERVICED ON AN ' ANNUAL BASIS TO INCREASE IT'S OVERA.-L LIFE EXPECTANCY. v I ti 501 L LOGS, :. Z DATE PERFORMED: PIT3{ `1 � 1g PIT 31-LA. JL..INE 1-7r 19g ✓ a � Y ... DEEP OBSERVATION: TEST PIT LOCt1T1dN PERCOLATION TEST LOCATION Pyr X31-2 `\, Pt-r 31-2A Ptir".31_ _ 4 F-LEV.=128.7' _ EV-ISI. 0 'r' ELEV.= 133.4',. 3 �1 C�'SGiL - - I rnr'so L o TDpSCIL [ E.LY SUE1501C.. \ SUESOIL ZW 3C �TFZAT1 Er"EQ SANG, GfcAVEL MED Utw T✓ ' rOARSE isRi.•( - .. `(Vv�1xti1.7rl1"s+.�`P+N't.,. I.',• 11 SANDY T ISL - - r ti 10 vo _ 1� $ NO G(ZOUN(ON/ATEfY' _N�CiuNT'FCcEt7 � I w �,r F"'tKC'. ..;J•Z,A't'� 4t. ►. ( }..132 y^ Ftr11t"C NYtN,IIN. 1i,:C.",JI-4- 9..5 4' j ru a rg RECEIVED Commonwealth of Massachusetts AUr, V = City/Town of System Pumping Record NORTH ANDOVE ` 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 within 14 days from the pumping date in accordance with 310 CMR 15.351. A. Facility Information Important: When filling out 1. System Location: i forms on the / computer.use --W= i• — -- --- — -- only the tab key Address to move your cursor-do note-` --—use the return City/Town State Zip Code key. 2. System Owner: r,�/�j♦I��� Name ]� Address(if different from location) ------ --- City/Town State Zip Code ol am ----- lephone Number B. Pumping Record 1. Date of Pumping 2. Quantity Pumped: Date Gallons 3. Type of system: ❑ Cesspool(s) Septic Tank ❑ Tight Tank ❑ Grease Trap ❑ Other(describe): ---- — — - - - 4. Effluent Tee Filter present? ❑ Yes I-No If yes, was it cleaned? ❑ Yes ❑ No 5. Condition of System: 6. System P mped By: vQQr" Name Vehicle License umber —--- 163 Western Ave. Company OU=telly MA 01930 7. Location where contents were disposed: C�L•S.D' North Andover MA• Signature of Hauler Date Signature of Receiving Facility Date t5form4.doc•03/06 System Pumping Record•Page 1 of 1 Commonwealth of Massachusetts lipCity/Town of System Pumping Record NORTH ANDOVER Form 4 DEP has provided this form for use by local,Bnards 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. Facili lnf�ti - Important: When 7 i g out System Location: forms on th _e l computer, e _ orgy the to ey Address Dl to move your cursor-do not Ci �" - ti_.__ State Zip Cade use the return key 2. System owner. / Name �► Address(If different from location) Citylrovrrt State XZ; Code Telephone Number B. Pumping Record 1. Date of Pumping Date _ 2. Quantity Pumped: Gallons 3. Type of system: ❑ Cesspool(s) eptic Tank ❑ Tight Tank ❑ Grease Trap ❑ Other(describe): _. ,, _ _.. -- .. . ...._.... ... - - _.. . 4. Effluent Tee Filter present'? ❑ Yes ❑ No if yes, was it cleaned? ❑ Yes ❑ No 5. Condition of System: G1�tr�C� u 6, System Pumped By: Name VehEcle i'L renumber coown 7. location where contents were disposed: Signature O(Hauier Date Signature of Receiving fiat itity Date t5farim.doc•03106 System Pumping Record•Page i of 1 Commonwealth of Massachusetts City/Town of System Pumping Record NORTH ANDOVER 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 within 14 days from theppingate accordance with 310 CMR 15.351. A. Facility information Important: TOWN OF NORTH ANDOVER When filling out 1. System Location: 6iEALT14 DEPARTMENT forms on the /, c/ computer,use _.—l1 only the tab key Address to move your -- -- t � --- cursor-do not -"� -_---- ---� ---- —---- Slate Zip Code use the return City/Town key. 2. System Owner: Name Address(if different from location) City/Town State — Zip Code 61'7 7 Z Telephone Number B. Pumping Record _ _— 1. Date of Pumping Date -� 2. Quantity Pumped: Gallons 3. Type of system: ❑ Cesspool(s) eptic Tank ❑ Tight Tank ❑ Grease Trap ❑ Other(describe): - --T----— -` "- 4. Effluent Tee Filter present? ❑ Yes ❑ No If yes, was it cleaned? ❑ Yes ❑ No 5. Condition of stem: 6. System Pumped By: Name Vehicle License Number Y'7 Company 7. Location where contents were disposed: Si nature of Hauler Signature of Receiving Faci�i y��'� ��" 15form4.doc•03106 System Pumping Record•Page i of 1 Commonwealth of assac usettsotif -�- City/Town ofC 'V�® • System Pumping Recor JUL 31 2008 Form 4 TOWN OF NORTH ANDOVER DEP has provided this form for use by local Boards of Health. Other form �_bTu �'�P'b�tT � T 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 1. System Location: forms on the r 1 1 computer,use �l u� � Cpa)'e. only the tab key Address to move your N o v \'n And ov cX 01` ' q cursor-do not City/Town State Zip Code use the return key. 2. System Owner: GC Name Address(if different from location) City/Town /i State Zip Code Telephone Number B. Pumping Record 1. Date of Pumping Date 7 - 95 -o 1500 2. Quantity Pumped: Gallons 3. Type of system: ❑ Cesspool(s) [Septic Tank ❑ Tight Tank ❑ Grease Trap ❑ Other(describe): 4. Effluent Tee Filter present? ❑ Yes Eg"'No If yes, was it cleaned? ❑ Yes ❑ No 5. Condition of System: 6. System Pumped By: jim GCLO tn � �� � 3 ) Name Vehicle License Number W � Rile �vir®n�r,eln a( Company 7. Location where contents were disposed: G.L.S.D. Lawrance; MA Signature of Hauler Date Signature of Receiving Facility Date t5form4.doc•03/06 System Pumping Record•Page 1 of 1 1 Commonwealth of Massachusetts _ City/Town of System Pumping-Record Form 4 b� 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: Le igh#front of hou Left/Right rear of house, Left/right side of house, Left/ Right side of building, Left Right front of building, Left/Right rear of building, Under deck Address & q CityiTown State Zip Code 2. System Owner. LA . Name Address(if different from location) CitylTown State s-,e� Z* de L7 p� ? 1 2015 Telephone Number —; a i OWN OF NORTH ANDOVER B. PuMpinglue6rvd, 1. Date of Pumping Date 2. Quantity Pumped: Gallons 3. Type of system: ❑ Cesspool(s) eptic Tank El Tight Tank ❑ Other(describe): 4. Effluent Tee Filter present? ❑ Yes a4go If yes,was it cleaned? ❑ Yes ❑ No. 5. ConditionSy tem: �. 6: System Pumped By: Neil.Bateson F5821 Name Vehicle License Number Bateson Enterprises Inc Company 7. Lo a contents were disposed: GLLS-D Lowell Waste Water 41 Sign Haul Date I t5form4.doe-06/03 System Pumping Record•Page 1 of 1 Form No.3 Town of North Andover, Massachusetts BOARD OF HEALTH ct H o o tri J P 9� 3j `.' . ° OL t O 9 DISPOSAL WORKS CONSTRUCTION PERMIT �9SS�cHus�t Applicant ADDRESS TELEPHONE NAME Site Location J Permission is hereby granted to Construct ') or Repair ( ) an Individual Soil Absorption Sewage Disposal System as shown on the Design Approval S.S. No. CHAIRMAN,BOARD OF HEALTH �Fee D.W.C. No. IT_ Town of North Andover, Massachusetts Form No.2 01t14ORTit BOARD OF HEALTH a t t t `"''`'"�' DESIGN APPROVAL FOR swcwus t� SOIL ABSORPTION SEWAGE DISPOSAL SYSTEM r' Applicant Test No. Site JLocation_ _0 �, 1 - ,� i ., V.. Reference Plans and Specs. I Q�Vy. .cam ENGINEER DESIGN DATE r Permission is granted for an individual soil absorption sewage disposal system to be installed _ in accordance with regulations of Board of Health. .Ai 3' ' CHAIRMAN,BOARD OF HEALTH oe Fee Site System Permit No. ���7tya� .: tpd ;.0 t t 4� •.. 1 t;t� a�- } t �'tr �tl ttt t � + ':\`. ti �t,.�t�t��:it���4�.�•{,'.���tl�,�..s....r�4 } et l� �`'�>> ��t,1 fir.EC9 '�`s�� 2t �� ,..5 .. .. ... . . -. .. l -. ., .. .. .. . 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 section***************** APPLICANT: rte A t' Phone 6fs 7 Z_'_7;) LOCATION: Assessor's Map Number 'J 661- Parcel trlA Subdivision /q2 c4-7-2_ Z44-e Z-- Lot(s) l Street �c•c � .Q. L.�,✓� St. Number ************************Official Use Only************************ REC NDATI S OF TOWN AGENTS: Date Approved CC servat on Administrator Date Rejected Comments Date Approved Town Planner Date Rejected Comments Date Approved Food Inspector-Health Date Rejected / / Date Approved /. //y/ �f d Septic Inspector-Health Date Rejected Comments 7:5 j-�z.,4.3,-i PAn:.l BGG UT/G 17-Ie 5 r25 Public Works - sewer/water connections /J�J /`� �� ✓P�( !o-%�`� - driveway permit Fire Department Received by Building Inspector Date NORTF� Of «ao A 3? BOARD OF HEALTH s i ,°• 120 MAIN STREET TEL. 682-6483 �9SSACHUSEt�y NORTH ANDOVER, MASS. 01845 Ext. 32 February 19, 1993 Bob Janusz 40 Sunset Rock Road Andover, MA 01810 Dear Mr. Janusz: This is to notify you that the proposed septic plans for Lot 31A Sugarcane Lane have been approved with the conditions that a benchmark be set in the work area of the system prior to construction and that concrete splash pads be installed in the leaching chambers. If you have any questions, please do not hesitate to call the office. Sincerely, I Sandy Starr Health Agent cc: Tom Neve File PLAN REVIEW CHECKLIST ADDRESS Z, au61aRe gA1,6 2,4. ENGINEER -"oN! /1/�✓�� GENERAL 3 COPIESy STAMP �� LOCUS NORTH ARROW SCALE L--- CONTOURSC� PROFILE L/ SECTION L/ BENCHMARK 21U SOIL & PERC INFO ELEVATIONS �� WETS. DISCLAIMER WELLS & WETLANDS WATERSHED?/4/6 DRIVEWAY L---- (Elev) WATER LINEt/ FDN DRAIN ,-' SCH40 j/' TESTS CURRENT? SEPTIC TANK MIN 1500G._L . 17 INVERT DROP GARB. GRINDER ,/!/0(+200% EDF) 25' TO CELLAR MANHOLE TO GRADE ,-y ELEV GW 4- D-BOX SIZE # LINES 13 FIRST 2' LEVEL STATEMENT INLET - OUTLET lZe 71 = : Z-0 (2" OR . 17 FT) TEE REQ'D? NA � LEACHING RESERVE AREAJ4' FROM PRIMARY? 100' TO WETLANDS 2% SLOPE ✓" 100' TO WELLS c/ 35' TO FND & INTRCPTR DRAINS 4' TO S.H.GW L--- 3251 TO SURFACE H2O SUPP L,,-' 4' PERM. SOIL BELOW FACILITY C/" MIN 12" COVER FILL? y (25' if above natural elev; 101if below) BREAKOUT MET? TRENCHES MIN 660 gpd SLOPE (min . 005 or 6"/1001 ) >3' COVER? - VENT SIDEWALL DIST. 2X EFF. W OR D (MIN 61 ) IS RESERVE BETWEEN TRENCHES? IN FILL? MUST BE 10' MIN. 4" PEA STONE? BOTX LDNG 2+ SIDE X LDNG = TOT (L x W x #) (G/ft ) (DxLx2x#) - .......... _ N4 -- -..... s-+�:,z-a---.. .n mm; . �""'s•'f►_'_"�'�.,.:'..*."::—'"_`.'�"t--.:__ �"�19'-. Lia fi.�� ,,.�'..a tl - - q' _ .... -,.---. � °^f,,, RM 4 YS;1.1.1M PUh1f')NC kf,('OR.0 S "LRiL 1 OF,':.'�hxxV. !!�1 19 r},3{_ '1 -( 1(v -:S i•�,i'{: ! 'J"I tit N, 20A, 01949 Ntr A i I ;!.S'`[5 HU.S`>f�. i 4 !! i +s ` + 1 � i /%�/ t 2( i +-j i f i +� +} � r.^-;✓..ate,,.., ( n {...N f � � 1 � �e (,.�11 1l�-1. /�'/V_ 9/.,. �✓v: .lrr�'T'�`�'1.��1 i �' � v l.r'��.. 1'.,'11 l.tlJ SCI i3_ IAN!','_- Nr) Yf.� Ia HC D7.ZAI3 "i SE.�.`°`^V SC F_ - t i' JAN I 0 2000 u ' r I r 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 section****/************* APPLICIST: _/"//� � Phone ( F?--7,F 71— LOCATION: Assessor' s Map Number 040 Parcel Subdivision S-T/fi2 CAyUC (_i/- u Lot(s) Street SOS(A " St. Number ************************Official Use Only************************ RECOMMENDATIO OF TOWN AGENTS: : Date Approved Conservati. n Administrator Date Rejected Comment ffzll_l,�G_ `� S`��`- : "i2��.� .1 "��' , F ��%`, :/' ' %g .�- Date Approved Town Planner Date Rejected Comments Date Approved Food Inspector --HHealth Date Rejected Date Approved /!'� �/94 Septic Inspector-Health Date Rejected Comments Public Works -_sQwQ /water connections 1/_1W (�L)JjU driveway permit , � Fire Department Received by Building Inspector Date = .!:�I�lIIIIn11111iG0��t11��% �� ILgill EmiL�11111n1111G71Lli111s 1 IIIIIIIIIIIIItIt�1111GCeQ�JG111111 ILi!►�11111IIIIIGn1111111ElBItEatll C ILtIlIRi1L1111��1.Li111111111L�lI�llLl 117111ZlGLIIIIII�i(illllllllhl�lllGll IIIi1LlIL1lIIIIIn11111tG1t'�LLLLII iz1�IGG11!ii11t1�1i1111111L011i11 r IttIL11111111111n1111111111111111 IIG��JIit71!l1111�l�lL/�IIILL4!JIIII 11►�i�illlllllll��/1!l111J�111;11111 [I®111111�lILLl�IIIIIn111111111 a . . . b PITS MIN 660 LEACHING GW MIN 4' BELOW BOTTOM MANHOLE/PIT EXCAV 2x EFF W OR D 12"-48" STONE SURROUNDING BOT + SIDE x LOAD = TOTAL (L x W x #) (2 x (L+W) x D x #) CHAMBERS gr,4 MIN 660 LEACHING GW MIN 4" BELOW COVER >3 FT - VENT MANHOLES -L--" 12"-48" STONE t�-' SPLASH PADS ,--� SLOPE . 005 BED/TRENCH (Bed max. 60' X ,601 ) 416 BOT �/I + SIDE aoX LOAD = TOTAL (L x W x #) i (2 x (L+W) x D x #) 7 ���d L/2/.83 r �� FIELDS MIN 900 ft2 LEACHING PERC RATE FASTER THAN 20M/IN GW MIN 4' BELOW BOTTOM OF FIELD PIPE ENDS JOINED W/NON-PERF. PIPE? 4" PEA STONE? DIST LINE SLOPE . 005? >3 ' COVER - VENT SCH 40 MIN 12" COVER L x W = T x LDNG > DESIGN FLOW? DOSING TANKS AND PUMPS DIMENSIONS X X = PUMP CAPACITY gpm L W D Vol. DISCHARGE SIZE DISCHARGE RATE DISCHARGE TIME gpm MANHOLES TO GRADE ALARM SEP. CIRC. GW (Min. 1' below inlet) HWL LWL CHECK VALVE BLEEDER HOLE MANUAL OP. SWITCH i '1 OCTOBER 8, 1992 J BOARD OF PUBLIC HEALTH 120 MAIN STREET NORTH ANDOVER, MA. 01845 ATTN: MS . SANDY STARR DEAR MS . STARR: V ' I HAVE ENCLOSED SEPTIC DESIGNS FOR LOTS 28A, 30A, 31A, 32A, 33A, AND 35B, FOR SUGARCANE LANE (JERAD PLACE II SUBDIVISION ) , AND A CHECK FOR THE PLAN REVIEWS . THERE HAS BEEN A LOT OF INTEREST ON SITE, SO I WOULD LIKE TO PRIORITIZE THE LOTS FOR REV EW: FIRST LOT 3 5 B SECOND LOT 3 2 A THIRD LOT 33A�--F/zS FOURTH LOT 30A FIFTH LOT 28A SIXTH LOT 31A CONCERNING OVERALL PRIORITIES, WE HAVE THE FORM U'S SIGNED AND READY TO GO TO THE BUILDING INSPECTOR FOR THE FIRST THREE LOTS ( 35B, 32A, 33A) . THE LAST THREE WILL REQUIRE NOTICES OF INTENT WHICH WILL PROBABLY TAKE A MONTH OR POSSIBLY LONGER. THANK YOU FOR YOUR CONSIDERATION. SINCERELY, ROBE JAN 40 SUNSET ROCK RD. ANDOVER, MA. 01810 I it TOWN OF NORTH ANDOVER BOARD OF HEALT �- 3—, 3 S C' 30 j 3 1 3 co LocationlV�C�I Permit Food Service $ Retail Food $ Limited Retail $ Seasonal $ Disposal Works Installers $ Disposal Works Construction $ Soil Testing 1Z i(� ��CZ) Design Approval Permit $ Dumpster Permit $ Burial Permit $ Swimming Pool Permit $ Animal Permit $ Recreational Camp Permit $ Well Construction Permit $ Funeral Directors Permit $ Massage Establishment License $ Massage Practice License � � $ tl�j Suntanning Estab 1ishmenJv $ Offal/Trash Hau er Other �'� 1'YA �/$ 1, Q 3" 0000 / Health Agent White - Applicant Yellow - Dept. Pink - Treasurer Town of North Andover, Massachusetts Form No. 1 NORTH BOARD OF HEALTH OF���eo b gti0 OL —19 APPLICATION FOR SITE TESTING/INSPECTION �I�A�RATED Ppp���J i SSACNUS� Applicant 6 � —CJ AME ADDRESS TELEPHONE Site Location Engineer � `�- �c�lr-CAL NAME ADDRE TELEPHONE Test/Inspection Date and Time i CHAIRMAN,BOARD OF HEALTH Fee TestNo. i ` S.S. Permit No. D.W.C. No. C.C. Date Plbg. Permit No. Town of North Andover, Massachusetts Form No. 1 NORTH qA' BOARD OF HEALTH //7) p 111" /64'YO V ►- yK A 4/Jc0 APPLICATION FOR SITE TESTING/INSPECTION 7q ADFATED 4'Pa�.�S SSACHUSE Applicant & 10 I c .L. �� /;.,��_ � �j ✓ C� NAME ADDRESS TELEPHONE Site Location 1 •./( /�- �'t' Ly Engineer C' c� NAME ADDRESS TELEPHONE Test/Inspection Date and Time CHAIRMAN,BOARD OF HEALTH Fee ,L) Test No. `+ S.S. Permit No. D.W.C. No. C.C. Date Plbg. Permit No. ASSOCIATES, IN .. � [LEEVVIE � OF VMRSO MIL NEVUse planners )7447 d gyrveyors • La' cute #1 ers . 1471 US R S 01933 BOStOr1 Street DATE JOB NO. TOPSFIELD, MASSACHUSETT �©V 2 (5O8) 8876 ATTENTION ! FAX (508) 8807)3480 .SAIJ0 STA. R f RE: TO 50AR® a� CALTI-1 RE�/ISIO,JS TO SAn11T/aP.`{ i plSQosA�L sY5'rEMS L_o-r5 3olA 31 A 3ZA 33A 3bB 5LXV R-LA"E IVOtZTM .�t�1rD0`/�iZ MA L/a1JE WE ARE SENDING YOU ® Attached ❑ Under separate cover via the following items: ❑ Shop drawings H Prints ❑ Plans ❑ Samples ❑ Specifications ❑ Copy of letter ❑ Change order ❑ COPIES DATE NO. DESCRIPTION Of-'r'7,•,.,VZ :5^f-31-rA,RY 1>1SP0S.A.T_ SYS'T'EM LOT 3oA SQ(sARGAoJa t.AnJP- REV. 1jog3` 3°�"3cZ 3 ,JEvr: ASSoc_iA rE5 tJ(-. oe-T 7J19`)Z 5Ar.J1TA rx a p1SP(Fgia._ SYSTEM LOT 3jA 5JOAMCANe. 6.AAJ I REV, IJat.3':Dz 105-31A BY r46%fC, ASSoc.1 A.-res .Jc,. 5i tr N�0 GT • E 3C5-3ZA 13-y ",S /a AS oc-1 AYG Iwc.. sc.-r7� .9°JZ k#jiRY T�1sPoSA%,. Sy iC/n l.oi 33A SUVA2CA I- I MF-%i NeV„a9z 305-33AvG A55oc_IAr`3 I'N�.. OLT 7) I'.199� q--Y P15PO�SAL SYS-ree-1 1-oT 35S 5U(_vAzr_A"e L.14..J61 REV..3CV3 '�L 3a3-35Be ASS a(-IA-re1+3C-. THESE ARE TRANSMITTED as checked below: 0 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 ❑ ❑ FOR BIDS DUE 19 ❑ PRINTS RETURNED AFTER LOAN TO US REMARKS DCAR :SAa10Y PLEASE T= 0 ENCL-o5GD o1= 'rHF- A00V6 RSFE(Ze.JG..Ep S. .l.J1 T AR -? 0115POSAU SYSTEM DE51C�N5 RE�/ISGD —, 0 H©W NO 5AJ17 est-©W T+-e L EALV1 G i-i AM 13E 25. AIJy 4UESTIprJS 01Z Pizoat-EMS PIrEASI C.AI-L. T1-A14N`4. YOy 916e2 'Youm, TIME Aojr> EFF02T 1of TH► 5 MATfE2 , VEfty T1zyi--/ Yo c)RS COPY TO SIGNED: PRODUCT 240-2 Inc,Ghon,Mess 01471. If enclosures are not as noted, kindly notify us at once. I THOMAS E. NEVE ASSOCIATES, INC. ������ OF ID e M �,v� e f1 Engineers - Land Surveyors - Land Use Planners I.l- IrMUSIJUUOTMI. 447 Boston Street US Route #1 TOPSFIELD, MASSACHUSETTS 01983 DATEJOB NO. (508) 887-8586 1 30S FAX (508) 887.3480 ATTENTION O O SAr st>`f S--ARR RE: TO I30/-\R0 ol= HEAt_-rH "ro 5At-jI_1-Ak 2 TOW N 1-1 A L L. D 1 SP®S L SYS-rF-M DE5 1 LOTS 30A 31 A tJ©lt-T h1 A�NaoV�2 MA 5 t2Cs RCAt'1tr L. Ar-.1L. WE ARE SENDING YOU ® Attached ❑ Under separate cover via the following items: ❑ Shop drawings 9 Prints ❑ Plans ❑ Samples ❑ Specifications ❑ Copy of letter ❑ Change order ❑ COPIES DATE NO. DESCRIPTION 2. REV:It:/3i/9305-3:)A SAI.11TAm-( D15QOSAL Sl-(S'r&M CE6'C-v0 I-O'T BOA 5uCS^ c_ArJE 1_AaE H E. OSVE oc-IA tf-G.. RE�/:1Z I 5A1JtTA" p'SPoiA1_ 5YS-rEM DESwr,3 Lo-r 3 1 A Z I� �� 3oa- 1A SucsARCA�IC t-AI.IE HoehA A I t 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 ❑ ❑ FOR BIDS DUE 19 ❑ PRINTS RETURNED AFTER LOAN TO US REMARKS DEAR, SANDY FL.EASE P"I113 EINI="OSI:p T1-rE ACio�IE, RE>^EREac.c.C> PLAIDS. THE REV'S'©t.1S I` At>F- To Lo-r 3oA ARE. TME St_1C�HT c-»/-\agrE I1V CsRA=% JQr 70 Td1:Ft_EC.-r -r1-1E RE-/1SCD CsRP.o114C., of L-o-r 31 A . THE RG VIStotJS MADE,. To Lc>-r 31 A AtZIS -17 14 1— RZEL-®C_AT'orJ oir -rPe SEPT'C. SYS 1 er-1 TO AG.COMODATE. A IJ0-vki I-IoL)SE I7ESIGIJ. TAAT IS OUISioF_ T1AE S® IJ© G®A~1ST2�+�-rtc�e�1 Z®NE A,J0 REV 150- ^t-L. IaJ'Vef2T ELE\/A`y'10rJy AP41> L c)"r GsRqol t.i& Ac_c_axaItJGrtL�, iF -foy WAve At.3Y Oty_--S-rj"j o2 P2oai.exYN5 PLMASE C-At,.t.,. 'r I-1Ar11(. Y'oo Fort YoL)2 T ire AND E,F'F'0154-r )Q —, 141S 1'x'1 A''Tt MIZ. COPY TO SIGNED: PRODUCT2402 Ees 1i ,Groton,Mem()1471. If enclosures are not as noted, kindly notify us at once. �s.���r�i��r•►���iiiiiiia�ii� ���;i��■ivriii����i�ii�iiii iii�ii•���i■i■��i�i��ii�iiiii � ze�ir��ai�r�■� � i����i�i HI�!�Hi<]� ,litll C�C�4tHtiHOiiHiiiiii F-0 77- rl/fHl>•i�1C�i�'.V r ���7iiiiiHiiiiiii Town of North Andover, Massachusetts Form No. 1 NORrN BOARD OF HEALTH - 32phss`eo `� 0 13 19 92e FO � A r * o # APPLICATION FOR SITE TESTING/INSPECTION 7�Q�AATE.PPR��S SSACHUS� Applicant NAME ADDRESS p TELEPHONE Site Location ltifi ' —n c^—) .� Engineer x 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. Town of North Andover, Massachusetts Form No. 1 NORTH q �' BOARD OF HEALTH Oy�"`ED '646"YOL IVF ',� 4.� a 3 19 O APPLICATION FOR SITE TESTING/INSPECTION X1,9 q�RAiED P?R�'�5 _ SSACHUSE Applicant ('t� � ✓1�-f�c-- . NAME ,� ADDRESS TELEPHONE Site Location v"r l/� CJfv�- a-s-. Engineer eI_ x��- +cvs�• �Lr(_nr NAME ADDRESS TELEPHONE Test/Inspection Date and Time CHAIRMAN,BOARD OF HEALTH Fee 1`�` Test No. S.S. Permit No. D.W.C. No. C.C. Date Plbg. Permit No. ;FORM 4-SYSTEM PUMPIN CORD CURRIER SEPTIC & DRAIN SERVICE 107 FOREST STREET; MIDDLETON,MA 01949 r (978)774-2772 COMMONWEALTH OF MASSACHUSETTS MASSACHUSETTS SYSTEM PUMPING RECORD 0 SYSTEM OWNER: SYSTEM LOCATION: : G FAk . Fa - 5760 i DATE OF PUMPING: 5~ QUANTITY PUMPED: / � GALLONS CESSPOOL: NO F-1 YES 0 SEPTIC TANK: NO F7 YES SYSTEM PUMPED BY: CURRIER SEPTIC & DRAIN SERVICE CONTENTS TRANSFERRED TO: I i i . i DATE: INSPECTOR: I . I Form 4 -- System Pumping Record Commonwealth of Massachusetss Massachusetts System Pumping Record System Owner System Location Debbie SAMARGIA Debbie 64 SUGARCANE LN 64 SUGARCANE LANE NORTH. ANDOVER, MA 01845-3248 NORTH ANDOVER, MA 01845 (978) 688-5760 (978) 686-5760 Debbie Type: Eil Routine Cesspool: Yes Septic tank: No =Yes Date of Pumping: p Quantity Pumped: 4�b. Gallons System Pumped By: Wind Rives Enwronmenfo% LLC Permit#: Contents transferred to: Contents Disposed at: ! S ( \ 1, _J Date: �l Pumper Signature: Condition of System/Other Comments C! Dep Approved from - 12/07/95 Cal Form 4 -- System Pumping Record Commonwealth of Mossachusetss Massachusetts System Pumping Record System Owner System Location :aCtwrg l8 DAb:E° ;aiad .gia Debbiin i ugarcane fen, n 5ugnrranN Ln, loo th Andover, MA, 018 lnrth Andnv©r. K4. 01845 )786885;60 %78€8 5740 amargia Type: EmergeJ. -- Routine ^ Cesspool: ldoYes Septic tank: No l lyes �� Date of Pumping: �j� Quantity Pumped: 1,5aCY6allons System Pumped By: Wind River Environmental, LLC Permit#: Contents transferred to: Contents Disposed at: Date. Pumper Signature: Condition of System/Other Comments Dep Approved from - 12/07/95 .y Form 4 System Pumping Record Commonwealth of Massachusetss Massachusetts System Pumpina Record r, System Owner System Location Honore Samargia Debbie Primary Hme 64 Sugarcane Lane 64 Sugarcane Lane - North Andover, MA, 01845 North Andover, MA, 01845 (978)-688--5760 (978,)-688-5760 Type: Emergency Routine Cesspool: No Yes Septic tank: W =Yes Date of Pumping: QD3 Qua" Pumped: o L-> Gallons System Pumped By: Wmd River Envirm~ftl, UC Permit Contents transferred to: .V vas �t'�Ov 1UU C's Plant, Contents Disposed at: MA. Date: Pumper Signature: Condition of System/Other Comments Dep Approved Form - 12/07/95 DATE /2f 3/r//z Sheet of BOARD OF HEALTH TOWN OF NORTH ANDOVER SUBSURFACE DISPOSAL DESIGN REVIEW FEE PERMIT # _ sfT_Z DATE RECEIVED APPLICANT o g Zq//OS ASSESSOR'S MAP /aWI,q ADDRESS PARCEL # - z a s LOT # 61/9 STREET �uGA��/-1 K/ G9iv13- ENGINEER T A16 ADDRESS PLAN DATE // /�Z REVISION DATE CONDITIONS OF APPROVAL:-/) APPROVED DISAPPROVED /Vo 7-;z-57-6 1 Sys"T� �- M �NIIYWM o/-- opo 14 5Y-5-7,9111 �l I _ liol111 r:. ► 111 111 f _ 111 i 111 i ' 111 111 111 111 111 11 11 111 111 1 ' 1 1 4�� ; tom..N .7 J,+^4;4,' .�,"-ib,��<�''� - _•y. :" "'"'+r; ...K«,.,. . �� z,,.. ..�..'„ Y � w 207.0 2� Lot 3 z �y K �A5cC1;rtS i -7 S.6 a' � •��tza.aZ �� �aR Ga� E Lc��►� 's aE,P�Y cE.cr/Fr ro E �ocrl A4 f'L O T I P4 4.�V �UIGDH►1+ Pl�',r ry'`rr T,VE M, /-f ov Ile GOT.qS SfiGiYN ANO TiGGIT?QG16S e*cwF,;Ieyf !Y/Tf1 TL/E7�W O,- !-b. ANaVEQ-2oN/N6 .CE6�/LAT,t9,NS REG�4.Q0/N6 .SET�C.t'S Fzaw ST.eEETS GF_. T/FY TiYi/T TW/S �D7�►. _ /s,voT O,PAN�it/ jO.P GOG4TE0/N Tif�E FEGE.PAG FLAOO H�7_.O.CO A.PEA. Syaw�v av FE.4..�r• CGn.iyvvirY P.tvGG "'�' Z 50o9�b 00p'76 - PA-i S D ,.l Wt J9 2, t q'l 3 GOLo t`I IAL VtLLr�G�� t OF Al s JE P.G.S. oATE o ,J"N HOFMANN 'y#36381 SS�o`' ANO SURA C(4- ) s � I'1z-err' a� ?>. EXE �y l o� • EAS�rtEl.�" r 75,62' .1,x.3 '�• - es126•$2 B S f/EPEB�rY .CE.cTIFY TO E �oeT� a,4 vOVre /7L O T �z 4/�/ gU l(.D f r u F T.SGQT THE N, /:r 41,41 /,V lY/7.�1 T.ciE'(D�1f� ' Of Fes. ANA�/Ea-ZO.v/.vG CE6vG4T.rtvs ,PF�.oeoi.✓G sETeucrs F.eo.�sT.PE�- f for c%vEs:� �p e T� �!�Poi Q� ! rtA�. �nc.�v UTA/�v r�TF�ee�,scaoo �L4.�0 A.PE oT O.PAN�j(/ fD.P Syaw.v ov FE,�+.►• �'o�+.�vN�rY P,•r.vct "� 250091 b oopgG DATCP J"nig Z I11'13 G D Lo hl IAL„ 1/l LLaG�� DEv'cI,��E�Y OF M / 3 -7 , JE iP.L.S. GATE % (vo �A� . ✓ , I�GI7 HOFMANN y E #36381�w ANO SURV