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HomeMy WebLinkAboutMiscellaneous - 683 Forest Street (2) 683 FOREST STREET et Jl 21D/1D5.D-0172-0000.0 � U4 a h r MAP #-- — __— LOT it ........... '._. .. PARCEL # STREET,____�.�� _....__...... CONSTRUCT I pN APP.RQ-V L HAS PLAN REVIEW FEE BEEN PAID? YES NO PLAN APPROVAL: DATE..__._ �_z_..-_ - - APP. BY...._ _.... ... DESIGNER: / l en S C _..... ___.__._----- PLAN Dn l-Eil sh z.._............. CONDITIONS --� WATER SUPPLY: TOWN WELL WELL PERMIT DRILLER DRILLER � ,_ ---_ WELL TESTS: CHEMICAL VA 1 E AI-PROVED-_-47,/0_,%4 BACTERIA I DAIE 611-3ROVED, a�L BACTERIA II DAZE APPROVED .__......._.............. _..._.._... COMMENTS: FORM U APPROVAL: APPROVAL TO ISSUE YES NO DATE ISSUEDZY CONDITIONS: FINAL APPROVAL: ALL PERMITS PAID _Y.-ES NO WELL CONSTRUCTION APPROVAL S NO SEPTIC SYSTEM CONSTRUCTION APPROVAL ES Nl] OTHER ES NO ANY VARIANCE NEEDED YES FINAL BOARD OF HEALTH APPROVAL: DATE:.._9//5 _._BY:_____�.._ i SEPTI.C-_ IS THE ' INSTALLER LICENSED? YES NO TYPE OF CONSTRUCTION: NEW fZEPAIf7 NEW CONSTRUCTION: CERT II=IED PLOT PLAN REVIEW YI;S 1\10 CONDITIONS OF, APPROVAL YES NU (FROM FORM U) - ISSUANCE OF DWC PERMIT YES NO DWC PERMIT NO. C,C6 7 INSTALLER.-"-NIL BEGIN .INSPECTION '4�E-SNO: EXCAVATION INSPECTION: NEEDED: PASSED BY. _--- ----------^� CONSTRUCTION INSPECTION: NEEDED z-_•._,______•____.,__.______, AS BUILT PLAN SATISFACTORY: APPROVAL ,TO BACKFILL: DATE: ZO �� _BY--- -• -.--._......----_-_ '-__-_^-- FINAL . GRADING APPROVAL: DATE Z7- -.BY- ---��- FINAL CONSTRUCTION APPROVAL: DATE:_9111 Z .BY_ Address k N. -3 5Z—Title of Hie Page / of . Date File Open: Date file closed: Doc -DocDate of Refer to other Purpose of Document/Action and notes action Document/ document/ Num. Action Department v ery a oa� f ris �T s��e /cans 6 e -C'Drle Q (� e r�1 11q awerya eiocfqK g d c`.t v ce i ro o m s Board of Appeals - Board of Health - Planning Board - Conservation Commission - Building Department o � 0 X� � `a��� 5 COMMONWEALTH OF MASSACHUSETTS EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS a DEPARTMENT OF ENVIRONMENTAL PROTECTION r TITLE 5 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM PART A CERTIFICATION Property Address: D N r Owner's Name: Mo AA---1 Owner's Address: Date of Inspection: 7 — /T-7 3 1J ) (� Name of Inspector: (please print) ,A6 h j.) L o t V/ N e E r-- •o Company Name: Lv T i r Mailing Address: 71— u+' m G, Telephone Number: 9 ? - 7 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: asses Conditionally Passes N eds urther valuation by the Local Approving Authority / ils Inspector's Signature: Date: — /1-0/ The system inspector shall ubmit a copy of this inspection report to a Approving Authority(Board of Health or DEP)within 30 days ofa mpleting 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 6/15/2000 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: 4? GI'e- r O Owner: 7746h J Date of Inspection: Inspection Summary: Check A,B,C,D or E/ALWAYS complete all of Section D A. System Passes: have not found any information which indicates that-any'of the failure criteria 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 replacedC�t obstruction is removed distribution box is leveled or replaced ND explain: r ' The system required pumping more than 4'times a year due to broken or obstructed pipe(s):The system will pass inspection if(with approval of the Board of Health): ' y } broken pipe(s)are replaced '' obstruction is removed t ND explain: 1 < 2 Page 3 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A /' CERTIFICATION(continued) Property Address: (� 'P',r ti S 7--07A �--* Owner:,,.t o AJ Date of Inspection: 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's, 1. System will pass unless Board of Health determines in accordance with 310 CMR 15.303(1)(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 thepresence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 m provided that no other P g g q PP failure criteria are triggered.A copy of the analysis must be attached to this form. 3. Other: r 3 a Page 4 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address:b 8 3 7 .s r --�-+ / /UG Owner: J Date of Inspection: 16-0 ( ( D. System Failure Criteria applicable to all systems: You must indicate."yes"or"no"to each of the following for all inspections: - Yes No 3 kup of sewage into facility or system component due to overloaded or clogged SAS or cesspool Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or ,clogged SAS or cesspool Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool _ Liquid depth in cesspool is less than 6"below invert or available volume is less than '/2 day flow _ TZRequired pumping more than 4 times in the last year NOT.due to clogged or obstructed pipe(s).Number f times pumped Any portion of the SAS,cesspool or privy is below high ground water elevation. iy portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. _"Any portion of a cesspool or privy is within a Zone 1 of a public well. /'Any portion of a cesspool or privy is within 50 feet of a private water supply well: _�ny 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 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.] -sem(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 a 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 surface drinking water supply the system is located in a nitrogen sensitive area(Interim Wellhead Protection Area-_IWPA)or a mapped Zone 11 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 I I OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST Property Address: 6 9 3 "I"D rcg sr Owner• _ Date of Inspection: $ Q 1 Check if the following have been done.You must indicate"yes"or"no"as to each of the following: V-0 - Pumping information was provided by the owner,!occupant,or Board of Health Were any of the system components pumped out in the previous two weeks? V Has the system received normal flows in the previous two week period? ave large volumes of water been introduced to the system recently or as part of this inspection? Were as built plans of the system obtained and examined?(If they were not available note as N/A) Was the facility or dwelling inspected for signs of sewage back up? Was the site inspected for signs of break out? Were all system components,excluding the SAS, located on site? j/ 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? —L.00— 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 _ /Existing information. For example,a pian at the Board of Health. 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 F + Page 6 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION Property Address: /r %r5- ) Acv CO'p(AAA-, Owner•��/1�✓ Date of Inspection: 7/—T--6 1 FLOW CONDITIONS RESIDENTIAL Number of bedrooms(design): Number of bedrooms(actual): DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): k Number of current residents:_ Does residence have a garbage grinder(yes or no): ,JQ Is laundry on a separate sewage system(yes or no)N�[if yes separate inspection required] Laundry system inspected(yes or no):_ Seasonal use:(yes or no):Al fj Water meter readings,if available(last 2 years usage(gpd)): Sump pump(yes or no):�� Last date of occupancy:/ncc'VP t C COMMERCIALANDUSTRIAL 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 readings, if available: Last date of occupancy/use: OTHER(describe): GENERAL INFORMATION Pumping Records Source of information: 9 L et s T 12, r+,X7 c'04 S Q r G Was system pumped as part of the inspection,.(yes.,or no): If yes; volume pumped: gallons-'How vvg quantity pumped determined? s /f-C ci U 4 Reason for pumping: //V S V e G T �fC 0 TYPE,OF SYSTEM eptic 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/Alternative 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 com onents,date installed(if known)and source of information: Were sewage odors detected when arriving at the site(yes or no):I'll G 6 Page 7 of I I i, OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C, SYSTEM INFORMATION(continued) Property Address: �"-s '• 5 /— I NO IVN WZ&Ll Owner: /► Date of Inspection: 9;777 —01 BUILDING SEWER(locate on site plan) Depth below grade: , Materials of construction: i cast iron At X40 PVC_oth6(explain):. Distance from private water supply well or suction line:Q l4 r /d p Comments(on condition of joints,venting,evidence of leakage,etc.): SEPTIC TANK: cate on site plan) Depth below grade: Material of construction: 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: Sludge depth: Distance from top of sludge to bottom of outlet tee or baffle: a Scum thickness:_' If Distance from top of scum to top of outlet tee or baffle: ! Distance from bottom of scum to bottom of outlet tee or baffle: �� How were dimensions determined: ! t° a 41 r-e- Comments(on pumping recommendation ,inlet and outlet tee or baffle condition,structural integrity,liquid levels as related to outlet invert,evide nce f leakage,etc.): GREASE TRAP:_(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 Page 8 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C // SYSTEM INFORMATION(continued) Property Address:6e Owner: 0 Date of Inspection: — —D TIGHT or HOLDING TANK: (tank must be pumped at time of inspection)(locate on site plan) e Depth below grade: Q Material of construction: concrete metal fiberglass_polyethylene other(explain): Dimensions: Capacity: gallons 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: L-0 lif present must be opened)(locate on site plan) Depth of liquid level above outlet invert: 6 Comments(note if box is level and distribution to outlets equal,any evidence of solids carryover,any evidence of leakage into or out f bo ,etc.): R No SG t S Ca l r,4 0!A-cr /V O /90 N 0/1 •J ( G L.. I S PUMP CHAMBER: (locate on site plan) Pumps in working ordef(yes of no): s Alarms in working order(yes or no): Comments(note condition of pump chamber,condition of pumps and appurtenances,etc.): 8 I Page 9 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address:6M t-Q T S r Owner: J G�,.l Date of Inspection: 1 SOIL ABSORPTION SYSTEM(SAS): (locate on site plan,excavation not required) If SAS not located explain why: I Type leaching pits,number:_ leaching chambers,number: leaching galleries,number: leaching trenches,number,length: !i w 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.): ' / /VU /'f QULI GJC.vr ND P6N01I'" CESSPOOLS: (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): I' Comments(note condition of soil,signs of hydraulic failure,level of ponding,condition of vegetation,etc.): PRIVY: (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 yt++ OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C 4 SYSTEM'INFORMATION(continued) Property Address: e S O lic�1' Owner: Date of Inspection: "O 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. r i A 5o 10 Page 11 of 11 ;k OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PAR,,T C L, SYSTEM INFORMATION(continued) Property Address: 6 3 ✓ P_�7- J Owner: To Date of Inspection: 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: 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.with local excavators,installers-(attach documentation) Accessed USGS database-explain: You must describe how you sstabli hed the high ground water elevation: .sV S TC t-" i�tJCt y`C/' 7"2�la Z C .r 4 � t li t, n 1y,{K}•s(t. ��'�1 ��i!t'; r` r� rri Ir } oJ"fY •J41� 11' 77["TTC�E4� r t.jl� •r!i {.�1+d ��t ��, rtl+t I' r ` , '�� 4t��Ur,1S, nyil �il�`�i �`h�: � a.�Ay 17M S', ' ,, ,;.s • �tly (tt � +M1L, jT.i I t� �A,i�.�Y� �r ,r J �. I }._'• , i ', +� ` t I .e1, p3 mil ..�1 tt�y}dq� .1\+�.i �1 F 7 5 .A 1 I -�,• •���%'J -(]•`.. p } , Yr,••• ji , i i.i• t 1i Ij. A� ti I ,a,i �, i ,�i r y . "F I��Q71 H� _ x ti 55 i r g �r•,. . 'rid,` }, 1 , �.�,� r1`<�1���-."•. !J ,2.'. 1 1 L* 5 td"� { ` �� J ANDOVER SYSTEM PUMPING RECORD 2001 i +� � h��"� i( '`(j��.FeFi'�tl�,, �ri� nA r'�y`f;..jy�o�}*y `� tdYj r^�'ri" �/ref 1r 1,R•i�� SS�rlt•' ,.`+..'-.M:.-'--,._a +' l ..yr• �4k e - 1r 4 r/•.�.•ri O ,rp �5 r,, i♦ t' _ r •: �t k A +N1'�#11171st •�'.r i `, I.'t '. C ^C, ;1 �y Vi � .� ,'�fe �� C• ly!M�.�1: r( .t � Y. -'� I � ! `11 ,,.hl �, .. .. r SYSTEM OWNER&ADDRESS , SYSTEM ` 'LOCATION t t (exaRaple.�ft•froAt of 6oun i" •�'+i f� �}t,♦f 1 W}�r'}r:�h Sir,r• r I� 1 ��;}✓� I I .t-� .64 , •�` }{J�'4 /y'Y,�� (`� t� Jrte. syt}r 1 �L� + .`f\k'2 Jr1��Fr�l�p .�.fl' it!\�' Y J{ •• �,� .,• °,� ;+ , , QUANTITY PUMPED �� s GALLONS yl� I .N �+� 1 tl�; � �, t Lt Il ✓ ,� y't�,bra i�l .� �. `r; '1t`�1 i,`�y ; •---�-� SEPTIC TANK: NO YES 4 044 +,y' r� r�J Li.eft{'I I "'',rnt#E OA' ,S �:•rw• .+',lt5`. .'. .. ROUTINE �. M � EMERGENCY ,.• ry, l �� Wk ¢ �9t V t IPttI. O CONDITION •,. +•r•.., FULL TO COVER HEAVY GREASE. BAFFLESw PLACE ROOTS ., t EXt*ES wrz SODS LEACAFlEI.D ItUNB��CK __ . FLOODED CARRYOVER .—......_ 0 (LAIN) t tib+ �' DY: r[ b y � • .-♦�� ,V c�ti 1 rt --�y1,1,5��f(Sw1 r. �L i'1+• t t ! r ~ ,I L• . y, p •+4�F 14 �, r�:�,`,�°'1 ,,r' a F t.; ; G� S r;.r S � ., '. 1' ► r c �.. i •1+ met.... rif 1 - �t'•p 'i I S1'7 `� t; t s 1 ''f .. u,� :•� I£f I�e t�,a. {i,•e>.�' 'Fry:., � r S AI ' �o- 1 w CAL ,'HKENI A7 TC-r" OF ;= E st%y } t - I.�Tr +. '.JC�` .+'.i� �..-.t�,�J �51�V � WV,r,1«.`�`iv�V! 1�•• - J i ) - �` t. ?:�,�#t`ykL FAY MARCJ�PCI Jr�l.,,��ati • t ♦.-«'.•testi 1 �. �,« {', ,E � cl- 44 �VVAG )'SPOSA' ��'A `��.KCVL A s C �r'JT'".�,� t�—''�.. �,;`l C%'�„1•" r. `?,;tiy ��,J ti��;����.L.r,�=L � �� ` - .10 I - i Town of North Andover, Massachusetts Form No.3 t NORT11 BOARD OF HEALTH TT 19� b•, DISPOSAL WORKS CONSTRUCTION PERMIT ,S2 CHUSEt Applicant NAM ADDRESS TELEPHONE Site Location 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,BOARDOF HEALTH Fee D.W.C. No. G AS-BUILT CHECK LIST and FINAL INSPECTION Proposed Elevations As-Built Elevation House Tank IN 75 Tank OUT � �`�—G 3 q -q 0 D-box IN D-box OUT Trench Inverts Line 1 J36 'C1/ Line 2 1:3 -7- 91 - 13 7' 139, S' Line 3 / 30.9/ _ l3£f, 137, �y- 13 7 Dy Line 4 Bottom of Exc. 13P .,51 /33„S 13 Stone OK?OK? .. D-box checked? Pipes cemented? L� Department of Environmental Management/Division of Water Resources 4\ 4 WATER WELL COMPLETION REPORT FWELQ P1 GEOGRAPHIC DESCRIPrTIONtq vv > s / Wd t t gof=: C City/T' Well owne 3/ Address N Q©�W`x'O( Ud A-4O 8 ' lml.!n tenths) c6clel Board of Health permit: yes no ❑ #11—M. W/ f WELL USE WELL DATA L! F Domestic Q Public❑ Industrial ❑ Total well depth Monitoring[] Other Depth to bedrock,_ Water•bearing.rock/un onsoidatedtmat"erlal: ! Method drille Date drilled Description ...ter-bearing zones: CASING 1) From-7 To Typo e� . 2) From—To Length,2r� It, Dia(.I.D.) in. 3) From To Length i to bedrock le ft. Gravel pack well: dia. Protective wet sea : Screen: dia. Grout-0 Other Slot" length from_.:to STATIC WATER LEVEL q. Static wator level below land surfaco � ft. Date �'�'•/ WELL TEST Drawdown/�d ft. after pumping hr. '& _min.at �d gpm Q How measuredAdt Recovery 36it. after—Lhr. min: o. LOG of FORMATIONS COP4M.W NTS Materials From To ! Driller 7 / r Mass. Regi on r o Address �j/ » ► City/Town rLH 1 n i Si nature o upervis n srervd well er t Please prier firmly DRIL ER COPY .i y Town of ,North Andovci Mass . C' •li D&te APPLICATION FOR WIILL & PUMP PERMIT �l l, ,cation i. hcr.cbv made_ for permit to drill' a well ' ( Applica4ta.�on' 4�.s „ e_to install ( ) n pump system. 1tti.on : AddrC11 c,r, eV A cl cl r c s t. Contra Co A< dre s ; 'Contractor Address' Tel t � z 1 L: CONTRACTOR ( To be compl.cued a t time of purnp Ucsr ) /� ye Of Well wcl..I used fortt- ,•nctt:cr of Well Size of. Casing � , ,,�i � , .ti fir•� � r�� �,t �,� ;:h ;o.f Bed RockDepth casa n� xrntgo 4;;�ed R�o�ck� � � mrn S`c a 1 T e s t c d? Y c s ( N o i`) D az:- o f` T c ti`n g `�•a. �.� K y M12 ra's ,Gap +%. 6 v F tf wc11 .Ended n WthatMa t`er�al F' Lo :h; to Wa tc Dcliver. s l� Gals Pc.x Min';: M odown f.cct ;.iftcr pumping ---hours• at t: . of* 'Complction lglc-' a r c�sr �r r:'� _•Y �rY j .i'•it i�-i• •. .. •• •• .. ..:. .. .. .. .. • 1:.• .. .• ♦. .. •. .. •• .. .. .• ♦• •• •. •• •• •• •• •• .♦ •♦ I. • n •� �Zn�-n 1 1.}'T(• 5 �+���V��� Y �k�i �i�i��*/r�*�* INSTALLED (To b , fil•l:ccl i.n before i.nst�a].l.a' io • &: Name Pump _..—._ Dump ype• se'd` �tl •r Pump Delivers I'i1 z of T nlc '" xu% f es N Material Used�l i.n tJcl.l. : Cnst Iron ( ) C:n I vnni-zcd i — 1 Pit ( ) o�: Pi. tl.c.,., Aclaptcr S.�.ccvc used to protect j>i.pc? 1'c:; (�) 1\10(—) Type or Name Wel.1 • 1` ', 1'f.1�'14 1�!l�f 1�f 14 1�f,r,�f,4,'(,'f,�'1'(1�f,'(1�f 1'(1�(1't 1'f 1'f 1'f,'t,�,f 1'f,�1�f,'r,'t 1'f,�S'!1'f 5'f 1'f 1'/1'f 1'I i;I�!:Q i1 i�•r:1-4i'�'G'df�!•i:•(,G'!7�.¢•�ii1Y�1�i�;F` ��iF(}�YYilY;14( ��Tfj141r(`'' 11aL'er an�aly;i' rcj�orL, submitted to Board of ,l•te6J.'th n. r . . reJ ease �,ivcn to owner of record & 1�l.dl; . Insp t H e a l t h. Ln°s p e c}torr' 7houtewev eahratorq, 9"e. 66 LITTLETON ROAD WESTFORD, MA 01886 (508) 692-8395 FAX (508) 692-0023 1-800-649-TEST Report Number: C-wps-5844 Report: Date: June 03, 1992 Client: Sample Taken At: Wilmington Pump Supply Inc. Flintlock P.O. Box 517 Forest St . Wilmington, y.A 01.887 N. Andover Lot 02 Sample. Taken By:Client On: June 02, 1992 CERTIFICATE OF ANA L.YS i S TEST PARAXETER: FPA `"ax RESULTS 10 US Total Coliform (P) 0 0 Per 100ml Calcium No Limit 22.9 mg/L Copper (S) 1 .3 MOM mg/I: Iron (S) 0.3 <0.01. mg/I, Magnesium No Limit 5 .4 alt /1- Yanganese (S) n ,05 10.01 mg/L Sodium 20 7 .4 mg/L Potassium (S) No Liimn t _ 2. 1 mg/1; Alkalinity (S) No Limit 70.5 mg/L Ammonia No Limit <0.03 mg/T: Chioride (S) 250 11 -1 mg;L Chlorine (total) 0.7 <0.02 mg/L Color (S) 15 0 CPI: Conductivity No Limit 200 umhos/cm Hardness No Limit 79 mg/L Nit:rates(as NQ) 10 0.03 mg/L \itri.tps(a5 A wn': pH (S) 6.5-8.5 8.1. SU Odor (S) 3 0 TON Sulphates (S) 250 19 mg/L Turbidity 5 0.3 NTLI Sediment Poslneg neg NT=Not Tested, Malue Exceeds EPA STD, TNTC=Too Numerous to Count `==Background BacteriaNoted, ..=EPA Advisory Limit Exceeds EPA Advisory Limit (P)=Primary EPA Standard, (S)=Secondary EPA Standard (may affect aesthetics of drinking water i .e. taste, color, etc. ) This water sample, as tested, meets or exceeds EPA health Standards for the parameters listed above . The quality of this water is accepted as POTABLE according to FPA Standards. Xassachusetts State Certifier: Vi.cnael P. Carlson, for Testing Laboratory #MA048 Thorstensen Laboratory Inc.. JUN 10 '92 08:37 P.3/3 f f Drparunent of r,'vilOnrMel,131 Manarper"CAI t/Division of Water Rasourees WATER WELL COMPLETION REPORT �`• GEOGRAPHIC DESCRIPTION WELL LW` of dr sfl Ci tylTown rro„n. W 01 Well owne !�3( Ir� N -- (n,l.M uncurl < c111 Addrnss k)(r:rseC1. v r Qoard of Itcalth pcmtit: yes no ❑ ! , WELL USE WELL DATA Public❑ lncA,suiaDe I ❑ Total well Domestic ft: Monitoring❑ har Ot ��------ pth to bedrock Walcc•bcanng ,ocklu onso dated materiel: Method drillc Description • � 1 Date drilled Water-bearing=ones:/ T� CASING 11 From 7—To 7' Type / 21 From----To J._.__..----- Lengtlt�.—ft.Dia(.I.D.) 311-(orn, ---To Length I� drock --��It. Grwrl pack well: dia. • Iiia. ProtoctiVa wcl sca scrcl:ll: Slot'' length Irnm_._--to Grout.© 0111” STA71C wATEn LEVEL D 1 It, Dr+tC Static wstor lovel below land surfaco..� WELL TEST //�, DrawdownZ!� f t. allot pttmPl!sg' Iu.L_ rain.nt�e/- . gPm How moasured�d•4—�—Rccovory In LOG LOG of FORMATIONS C�0 NTS �iu'i'+� I Atrpd��, From To . �r17 / -71 , griller 7 / 1 Mass. Regi on r Fir City/Town ��_ t/(Y� �.uNr�o ,.Parva rI t11nd well d/ n 1luae pn lr lumry _j)n ll.t E13 COPY Department of Environmental Managemei es I I ,y WATER WELL COMPLE ION E f WELL L GEOG APHIC DESCRIPTION A dr s s� ! NS �W of �'�' 1 City/Town 0 4 (road) Well ow ne �T #1 Address I A N (DQW of (mi.in tenths) ircle) Board of Health permit: es 14 no ❑ F intersect. w/ a WELL USE WELL DATA t� / Domestic X Public❑ Industrial ❑ Total well depth � ft. Monitoring Other- Depth to bedrock ft. Water-bearing rockiun onso idaled material: Method drill e Q � Description Date drilled•_ng�" Water-bearing zones:/ CASING , t) From_"7 To Type 21 From To Length 1210 DiaD.) fin. if 3) From To Length ito bedrock ft- ,go pack well: dia. Protective well sea Screen: dia. Grout-E] Other Slot v length from_to STATIC WATER LEVEL f Static water level below land surface ft. Date-^' '"" WELL TEST Drawdown''/40 ft. after pumping—hr.,,�� T�hr. 11 min.at c _gpm How measured &E Ai Recovery 36 afterhr. min. 0 LOG of FORMATIONS pCONj FNIS eQ Materials From To R p° ! -71 Driller AW Mass. Regi on W I -jr4 V Firm, %N. c� " Addressa 1� r City/Town h Si nature of uperwsing re tstenrd well dr!er Pleast print firm/y BOARD Of HEALTH COPY U Town of North Andover, Massachusetts Form No. 1 NORTH 4A' BOARD OF HEALTH Illy) o APPLICATION FOR SITE TESTING/INSPECTION ��SSacHus���y y Applicant 1. `�-1 OC-14-1 —�V C -, Pr) - �9 NAME ADDRESS TELEPHONE Site Location LoT Z -'1;7O�'C.,a " Engineer y , 0'%x—'t&-V"C "-� NAME ADDRESS TELEPHONE r Test/Inspection Date and Time �--�� CHAIRMAN,BOARD OF HEALTH Fee Test No. 44 -3"-1 S.S. Permit No. D.W.C. No. C.C. Date Plbg. Permit No. PLAN REVIEW CHECKLIST ADDRESS -' zpl , � ✓ ENGINEER � ��,(' GENERAL 3 COPIES STAMP v� LOCUS ✓ SCALE CONTOURS C---- PROFILE t-� SECTION C_-' BENCHMARK ✓' ELEVATIONS t--- ' SOIL & PERC INFO WETS. DISCLAIMER WELLS & WETLANDS AAr �-- WATERSHED DISTRICT /V D DRIVEWAY WATER LINE Is-'' DRAINS �--- RESERVE AREA (/ SCH40 L--- SLOPE SEPTIC TANK /��j� MIN 1500G. (,,-- . 17 INVERT DROP ✓ GARB. GRINDEltryy (+200% EDF) 25' TO CELLAR MANHOLE TO GRADE ELEV ,/ GW D-BOX # OUTLETS FIRST 2' LEVEL STATEMENT INLET /,37, )7 - OUTLET),37, /7 (2" OR . 17 FT) LEACHING 100' TO WETLANDS -- 100' TO WELLS 325' TO SURFACE H2O SUPP 35' TO FND & INTRCPTR DRAINS4' TO S.H.GW_z 2% SLOPE L� 4' PERM. SOIL BELOW FACILITY MIN 12" COVER L-- FILL? (25' if above natural elevation; 101if below) TRENCHES MIN 660 � ' w SLOPE (min . 005 or 6"/1001 ) >3' COVER? - VENT SIDEWALL DIST. 2X EFF. W OR D .(MIN 61 ) IS RESERVE BETWEEN TRENCHES? L.--' IN FILL? MUST BE 10' MIN. (/ p BOT V''rD X LDNG + SIDE--,2016 X LDNG 4 (()`' �--�TOT (L x W x #) (G/ft2) (DxLx2x#) DATE Sheet of BOARD OF HEALTH TOWN OF NORTH ANDOVER SUBSURFACE DISPOSAL DESIGN REVIEW �y FEE PERMIT # DATE RECEIVED ,(/ APPLICANT l l�! /) /} ( � ASSESSOR'S MAP ADDRESS A , a PARCEL # LOT # w STREET ENGINEER 9'jLZ,J-A--71 ADDRESS PLAN DATE ��� �� REVISION DATE �5 l ehz CONDITIONS OF APPROVAL: APPROVED 4DISAPPROVED c3— a1A �� �