HomeMy WebLinkAboutMiscellaneous - 7 SOUTH CROSS ROAD 4/30/2018 (4) �'^u f��€a€���fir,,ss d
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' MAP # LOT #___
PARCEL '# J8
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QN..SIRU1ZLIMt APERWOL
HAS PLAN REVIEW FEE BEEN RAID? YESNO
PLAN APPROVAL= DATE / 29 / f APP. BY_-� ..--
DESIGNER: /
PLAN DA•TE.J�L'tJ
CONDITIONS
WATER SUPPLY: fTOWN WELL
WELL PERMIT DRILLER
' WELL TESTS: CHEMICAL DATE APPROVED.—---
BACTERIA I DATE APPROVED
BACTERIA II DATE APPROVED.—--
COMMENTS:
FORM U APPROVAL: APPROVAL TO ISSU'EF S • NO
DATE ISSUED 1 _8Y
CONDITIONS:
FINAL APPROVAL:
ALL PERMITS PAID YES NO
WELL CONSTRUCTION APPROVAL YES NO
SEPTIC SYSTEM CONSTRUCTION APPROVAL YES NO
OTHER YES NO
ANY VARIANCE NEEDED YES NO
6 qL3FINAL FOARD OF HEALTH APPROVALs DATE:__. � _
I
IS THE INSTALLER LICENSED? NO
TYPE OF CONSTRUCTION: NEW REPAIR
NEW CONSTRUCTION: CERTIFIED PLOT PLAN REVIEW NO
CONDITIONS OF APPROVAL YES NO
(FROM FORM U)
ISSUANCE OF DWC PERMIT YES NO
DWC PERMIT NO. INSTALLER:__........ ._
BEGIN INSPECTION YE 0:
EXCAVATION I NSPECT I
32
. PASSEDBY -..._._... .._
CONSTRUCTION I NSP CT I ON: NEEDED: --------- .......... .............................
.......... .._..... ...................._........._._...._.... ................
_......_
` vs� �s �
� f1I ✓LAS i,2t _.__......_..........
�
--......................................-- . ... . . -_ . _..........-.
AS BUILT PLAN SATISFACTORY: YES: _._. _._ ._.........
APPROVAL TO BACKFILL: DATE:
� / A
FINAL GRADING APPROVAL: DATE� .._.f BY.�r/� � _...._. ....
---_.._._. _ ..._.._... ......... . .. ......__...................
FINAL CONSTRUCTION APPROVAL: DATE:._._.. -_. _ .- BY..... ....... ..
Commonwealth of Massachusetts RECEIVED
City/Town of .
System Pumping Record JUN 01 2015
Form 4 TOWN OF NORTH ANDOVER
HEALTH DEPARTMENT
DEP has provided this form for useby local Boards of Health. Other forms may be'used, but the
information must be substantially the same as that provided here. Before using.this form,check with your
local Board of Health to determine the form they use.The System Pumping Record must be submitted to
the local Board of Health or other approving authority.
A. Facility. Information
1. System Location: Left/Right front of house, Left/Right rear of house rig side o -ho , Left/
Right side of building, Left/Right front of building, Left/Right rear of building, Under deck
Address
City/Town State Zp Code
2. System Owner.
Name
Address(d different from location)
CitylTown • State' .� ��C de ,
f /
Telephone Number
B. Pumping Record ✓�� _� ,� ,
1. Date of Pumping - nate 2. Quantity Pumped:
Gallons ,
3. Type of systemhd�: ❑ Cesspool(s) eptic Tank ❑ Tight Tank
❑ Other(describe):
4. Effluent Tee Filter present? ❑ Ye No If yes, was it cleaned? ❑ Yes ❑ No.
5. Condition of stem:
6. System Pumped By.-
Nell
y:Neil.Bateson F5821
Name Vehicle License Number
Bateson Enterprises Inc
Company
7. Lo here contents were disposed:
aL S: Lowell Waste Water
Signitufe Cf Haul Date
t5form4.doc•06/03 System Pumping Record•Page 1 of 1
Commonwealth .of Massachusetts
_ City/Town of MEIV`BC�
System Pumping Record
Form 4 NOV 12 2012
tbWN 01F N=.ORT
DEP has provided this form for use by local Boards of Health. Other for s Owl@ lWhe
information must be substantially the same as that provided here. Befo Is Torm, cneCK with your
local Board of Health to determine the form they use.The System Pumping Record must be submitted to
the local Board of Health or other approving authority.
A. Facility Information
1. System Location: Left/Right front of house, Lefh/Right rear of house eft rig side o ouse Left/
Right side of building, Left/Right front of building, Left/Right rear of b Ing, UnRei
deck
Address
Cityrrown State Zip Code
2. System Owner:
NaeJ\ I6
Name
Address(if different from location)
City/Town State
' ` Zip Code
CLG�� V `7�O f
Telephone Number
B. Pumping Record
1. Date of Pumping Date 2. Quantity Pumped: Gallons
3. Type of system: ❑ Cesspool(s) Septic Tank ❑ Tight Tank
❑ Other(describe):
4. Effluent Tee Filter present? ❑ Yes No If yes,was it cleaned? ❑ Yes ❑ No
5. Condition of System:
6. System Pumped By:
Neil Bateson F5821
Name Vehicle License Number
Bateson Enterprises Inc
Company
7. Location where contents were disposed:
S. Lowell Waste Water
U —
Sign t e I-Haulejj Date
t5form4.doc•06/03 System Pumping Record•Page 1 of 1
I
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 house, Left/Right rear of house eeg side of house Left/
Right side of building, Left/Right front of building, Left/Right rear of buirding, Under ec
Address }�
City/Town State Zip Code
2. System Owner. l
Name
Address(if different from location)
City/Town State
.._S !7 L —' Lf
p'a��
Telephone Number
B. Pumping Record
-a
1. Date of Pumping Date 2. Quantity Pumped: Gallons
3. Type of system: ❑ Cesspool(s) Septic Tank ❑ Tight Tank
❑ Other(describe):
4. Effluent Tee Filter present? ❑ Yes No If yes, was it cleaned? ❑ Yes ❑ No:
5. Condition of stem J�
RECEIVED
6. System Pumped By.
Neil.Bateson F5821 MAY Z 7 2014
Name Vehicle License Number T(MN OF NORTH AN
Bateson Enterprises Inc
'HEALTH DEPARTMENT
Company
7. Location where contents were disposed:
Lowell Waste Water
Sig aItHaul Data
t5fomut.doo•06/03 System Pumping Record•Page 1 of 1
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COMMONWEALTH OF MASSACHUSETTS
EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS
r
DEPARTMENT OF ENVIRONMENTAL PROTECTION
A
Y
N
—TOvtfiV OF NORTH Ah1DM.
BOARD OF HEALTH
V
APR 2 3 2002
TITLE 5 _
OFFICIAL INSPECTION FORM—NOT FOR_VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM
PART A
CERTIFICATION
Property Address: 7 South Cross Road
North Andover, MA
Owner's Name: Tony Liu
Owner's Address: Same
Date of Inspection:
Name of Inspector: (please print) James Wright
CompanyNamel2.J. Inspections, Inc.
Mailing Address: One Osgood Street
Methuen, MA 01844
Telephone Number: 978-681 -8759
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: ,
i/ Passes -
Conditionally Passes
Needs Further Evaluation by the Local Approving Authority
Fails
t
Inspector's Signature: Date: 3-25-02
The system inspector sha bmit 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 6/15/2000 page 1
r t
Page 2 of 11
I
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION(continued)
Property Address: 7 South Cross Road
North ANdover, MA
Owner:_Tony Liu
Date of Inspection: 3-2r,—()2
Inspection Summary: Check A,B,C,D or E/ALWAYS complete all of Section D
Y3O3
mPasses:
ave not found any information which indicates that any of the failure criteria described in 310 CMR
15or 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__fog 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:
i
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 times 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
i
OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION(continued)
Property Address: 7 South Cross Road
North Andover., MA
Owner: TanNz T.i n
Date of Inspection: 325 02
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 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 I 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: 7 South Cross Rd.
North Andover, MA
owner: Tony Liu
Date of Inspection: 3 9 r;_0 2
D. System Failure Criteria applicable to all systems:
You must indicate"yes"or"no"to each of the following for all inspections:
Yes No/
:/ $ackup 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
c�ngged 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 '/z day flow
✓Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s).Number
o times pumped
Any portion of the SAS,cesspool or privy is below high ground water elevation.
Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface
Water supply.
./` MA,y portion of a cesspool or privy is within a Zone I of a public well.
,/_
Any portion of a cesspool or privy is within 50 feet of a private water supply well.
_,/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 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.]
LV (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.
i
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 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: 7 South Cross Road
North Andover, MA
Owner: Tnn)z T.i u
Date of Inspection: -1-9,;–()2
Check if the following have been done.You must indicate"yes"or"no"as to each of the following:
Yes o
Pumping information was provided by the owner,occupant,or Board of Health j
ere any of the system components pumped out in the previous two weeks?
Has the system received normal flows in the previous two week period?
'� Have 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)
J — 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?
_✓ _ 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?
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:
Yeo
Existing information.For example,a plan 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
Page 6 of 11
OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION
Property Address: 7 South Cros Road
North ANdo pr f MA
Owner: Toni T.;
Date of Inspection: 3=25_02
FLOW CONDITIONS
RESIDENTIAL
Number of bedrooms(design): Number of bedrooms(actual): L
DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of 1 edrooms):
Number of current residents:—_
Does residence have a garbage grinder(yes or no):/f/4
Is laundry on a separate sewage system(yes or no):�[if yes separate inspection required]
Laundry system inspected(yes or no):—
Seasonal use: (yes or no):
Water meter readings, if available(last 2 years usage(gpd)):
Sump pump(yes or no): /f/4
Last date of occupancy:
COMMERCIAL/INDUSTRIAL
Type of establishment:
Design flow(based on 310 CMR 15.203): gpd
Basis of design flow(seats/persons/sgft,etc.):
Grease trap present(y *ailab :
Industrial waste ho ingyes orno):
Non-sanitary waste discharTitle 5 system(;res or no):Water meter readings,if
Last date of occupancy/use:
OTHER(describe):
GENERAL INFORMATION
Pumping Records
Source of information:
Was system pumped as part of the inspection(yes or no):et--C
If yes,volume pumped: gallons--How was quantity pumped determined?
Reason for pumping:
TY"SYSTEM
_/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/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 components,date installed(if known)and source of information:
��C / 0
Were sewage odors detected when arriving at the site(yes or 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: 7 South Cross Road
North Andover, -MA
Owner: Tony Liu
Date of Inspection: 3-2i-02
BUILDING SEWER(locate on site plan)
Depth below grade:
Materials of construction:_cast iron _40 PVC_other explain):
Distance from private water supply well or suction line:
Comments(on condition of joints,v nting, vidence of leakage,etc.):
SEPTIC TANK:_(locate on site plan)
Depth below grade:/�fi
�
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: /p X X /0
Sludge depth: �;Z If _
Distance from top of sludge to bottom of outlet tee or baffle:
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.1 '�
How were dimensions determined:
Comments(on pumping recommendations,inlet and outlet tee or baffle condition,structural integrity, liquid levels
as related to outlet invertevidence of 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 o c to op t-tee or baffle:
Distance from bottom of s om 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: 7 South Cross Road
Owner: Tony LNorth Andeyer MA
Date of Inspection: 3—2 5—n 2
TIGHT or HOLDING TANK: (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: gallons
Design Flow: allons/day
Alarm present(yes orn _
Alarm level: Al - working order(yes or no):
Date of last pumpi
Comments(condition of alarm and float switches,etc.):
DISTRIBUTION BOX: (if present must be opened)(locate on site plan)
Depth of liquid level above outlet invert:
Comments(note if box is level and distribution to outlets equal,an evidence of solids carryover,an evidence of
Y �' � Y
leakage into t of box,etc.): ,
PUMP CHAMBER: (locate onsite plan)
Pumps in working order(yes or no):
Alarms in working order(yes or no):
Comments(note condition of c awe ,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: 7 South Cross RoAd
North Andover, MA
Owner: TnnI7 T.iu
Date of Inspection: -i_2
SOIL ABSORPTION SYSTEM(SAS): (locate on site plan,excavation not required)
If SAS not located explain why:
Type
leaching pits,number:_
leaching chambers,number:
leaching galleries,number:
leaching trenches,number, length: �� O
leaching fields,number,dimensions:
overflow cesspool,number:
innovative/altemative system Type/name of technology:
Comments(note condition of soil,signs of hydraulic failure,level of ponding,damp soil,condition of vegetation,
etc.): � � �/SNS �/� /��/�(/ �'.'"-,- /I/d �D�-/���1�' �L'✓ �
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 laye
Dimensions of cesspool:
Materials of constructio .
Indication of ground ter inflow(yes or no):
Comments(note co dition 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 conditio)of il, gns dulic 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: 7 South Cross Road
North Ananypri_MA
Owner
Date of Inspection: 3_2 1,_0 2
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.
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10
' Page 11 of 11
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM !
PART C
SYSTEM INFORMATION(continued)
Property Address: 7 South Cross Road
North Andover, MA
Owner: Tony Liu
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:
tamed from system design plans on record-If checked,date of design plan reviewed:
Observed site(abutting property/observation hole within 150 feet of SAS)
— ecked with local Board of Health-explain:
s/ Nticked with local excavators,installers-(attach documentation)
Accessed USGS database-explain:
i
You must describe how you established the high g ound water elevation: r
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Town of North Andover, Massachusetts Form No. 1
14ORTH BOARD OF HEALTH
0*tT IE° Ib
0- L r „_ J 19
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APPLICATION FOR SITE TESTING/INSPECTION
°RATE°
�SSACHUS��
Applicant
NAME ADDRESS TELEPHONE
Site Location
r y'
Engineer
NAME ADDRESS (/ TELEPHONE
Test/Inspection Date and Time
CHAIRMAN,BOARD OF HEALTH
Fee �`� ' c-' / Test No.
S.S. Permit No:, D.W.C. No. C.C. Date Plbg. Permit No.
Commonwealth of Massachusetts
City/Town of I RECEIVED
System Pumping Record L 2 5 2006
.G,4 SV•
Form 4
TQ'tNrl OF NC7h;;: AN :OVER
DEP has provided this form for use by local Boards of Health..The S s'te'm P'�irfi':n s e�cor must
T'
be submitted to the:locai Board of-Health or other approving authority. . p .
A. Facility Information
Important:
When filling out 1. Syste Locatio :
forms the c47— f
computer,use sl �
only the tab key Address
to move your
cursor-do not. G /Town
use the return ,tY State Zip Code
key.
2.. System Owner
- _
Name
Address(if different from location)
CdylTown State de
re one Number
..B. Pumping Record
1. Date of Pumping
Date Quantity Pumped: Gallons
3. Type of system: ❑ Cesspool(s) eptic Tank- ❑ Tight Tank
ElOther(describe):
4. Effluent Tee Filter present? ❑ Yes0<0
If yes, was it cleaned? E] Yes F] No
5. Condition of System:
t n
6. System Pumped y'
Name Vehicle License.Number
Company
7. Location7re cohtents wer isp0AA
Signature a er Date
http://www.mass.gov/dep/water/approvaIS/t5forms.htm#inspect
t5form4.doc•06103 System Pumping Record•Page 1 of t
t NORTH 1
-' ?0 ° BOARD OF HEALTH
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°'+ 120 MAIN STREET TEL: 682-6483
�9SSgCHU"f. NORTH ANDOVER, MASS. 01845 Ext. 32 or 33
December 13, 1990
Mr. Robert Masys
Ram Engineering
One Masys Way
Haverhill, MA 01.830
Dear Bob:
This office is in receipt of proposed septic designs for
Lots 1 and 2 So Cross Rd.' According Board of Health records, no
fees to this Department were ever paid for any of these lots.
Please inform your client that all fees must be paid before
a review of the plans will be conducted.
The following fees must be paid:
- Soil Testing ($150/lot) 4 lots $600. 00
- Plan Review Fee ($60/lot) 2 lots 120. 00
Total $720. 00
Once these fees have been received, a review of the plans
submitted will commence.
Sincerely,
� J �
Michael J. Rosati
Health Agent
MJR/rel
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DATE Z� `� Sheet l Of 1
BOARD OF HEALTH
TOWN OF NORTH ANDOVER
SUBSURFACE DISPOSAL DESIGN REVIEW
FEE ��y PERMIT # DATE RECEIVED
APPLICANT .AILek) Cos'.-t A ASSESSOR'S MAP 3$
ADDRESSy �O 9S 2' PARCEL # i gjO
tit A. LOT # I
STREET Sa daoss 2.0
ENGINEER � �*1G',
ADDRESS
L L I
PLAN DATE REVISION DATE
CONDITIONS OF APPROVAL:
APPROVED
DISAPPROVED -K
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DATE 114 li Sheet i Of
BOARD OF HEALTH
TOWN OF NORTH ANDOVER
SUBSURFACE DISPOSAL DESIGN REVIEW c�
FEEPERMIT # DATE RECEIVED__j !�
APPLICANT � � �lS���-� ASSESSOR'S MAP
ADDRESS PC) 8CC �5�. PARCEL #
LOT #
STREET
ENGINEER 1U1,/
ADDRESS l 1&5V15
PLAN DATE cCE'% F+ REVISION DATE I Z C7
CONDITIONS OF APPROVAL:
APPROVED
DISAPPROVED X
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01=1=ICES OF: p m Town of 120 Main Street
APPEALS r' NORTH ANDOVERNorth Andover,
BUILDING ; '�:`;;o~:�. y Massachusetts o 1845
CONSERVATION 'SS,CHU9ES� DIVISION OF (617)685-4775
HEALTH
PLANNING PLANNING & COMMUNITY DEVELOPMENT
KARL-'N H.P. NELSON, DIRECTOR
MEMORANDUM
TO: Conservation Commission
Board of Health
FROM: Scott A. Stocking,,pWlanner
DATE: September 14 , 1988
RE: Septic System Suitability
Frances/Florence Estates Modification
The Planning Board directed me to request from your office a
clear and definitive determination regarding septic system
suitability for the above cited subdivision modifications .
The Board needs this information prior to closing the public
hearing on this matter and writing a decision on allowing septic
systems in these subdivisions,
TOWN OF NURTII ANDOVER
LOT RELEASE FUII!
SUBDIVISION GSS
ASSESSORS 11U1
SUBDIVISION LOT(S) Luh 0.
PERMANENT ADDRESS ASSIGNED BY D. P.W.
STREET
APPLICANT ��� i��� k- ��u ���� P!lONE
i
DATE OF APPLICATION
TOWN USE BELOW THIS LlIIE
i
PLACIT;4NC BUAIZD
DATlE APPROVED
TOS-,H' PLANNER DATE•' REJECTED
CONSERVATION COMMISSION
DATE APPROVED
CONSERVATION I�.DI• IN. DATE REJECTED
BOARD OF HEALTH �
— 1 (P:4!44 DE)
APPROVED tDATL
HEALTH SANITARIAII DA' E REJECTED
' DEPARTMENT OF PUBLIC WORKS
'
DRIVEWA,.v PER1-1IT
SET-JER/WATER CONNECTIONS
TIRE DEPT. D�� �i�C� ( l POC- /
c"sed �� �c k �—
• RECEIVED BY BUILDING INSPECTION
DATE
This form shall be signed by the agents of the Planning and Health Boards,
the Conservation Coimnission prior to the issuance of any building permits
for the subject lot. This form stall not releive the applicant from the
compliance of any applicable Town requirement or Bylaw.
Town of North Andover, Massachusetts Form No. 1
NORTH BOARD OF HEALTH
OL /5 1917
FO �
AIL ? s n
APPLICATION FOR SITE TESTING/INSPECTION
SSACHU5���y
Applicant a'm"
NAME ADDRESS TELEPHONE
Site Location
Engineer
AME ADDRESS 61 TELEPHONE
Test/Inspection Date and Time
CHAIRMAN,B A ALT
Fee
/—;57D CHAIRMAN,
Test No.
S.S. Permit No D.W.C. No. C.C. Date Plbg. Permit No.
BOARD of H�,I�`� �T I S,.C�55-
Nd{�"�N
.,'�-� ..:_:_, .__ Q r6Wnl ❑ WL LC.. AP�oUC.D lYJ C
5S 5 Prlc SYSTEM 1��StG
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P(A,\1 DE546ivC- ( FL ON 7ii
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W SPF�T �-�vc fo TJ 0 [:11 A S5 `Q RJB
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DISA P11�ovED Da rc
FIti,QL APPROVAL
�'� RECE1`f EQ
FORM Q
NORTN NDOR
PLANNING BOARD
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SEP Who( -9 AARTH ANDOVER MASSACHUSETTS
-CERTIFICATE OF AMENDMENT , MODIFICATION OR RESCISSION OF
APPROVAL OF DEFINITIVE SUBDIVISION PLAN
September 23, 19 88
TOWN CLERK
TOWN OF North Andover Massachusetts
Allan E. Cuscia and
On the �b� /petition of Joseph O. Levis , dated June 20 ,
1988 and in accordance with Massachusetts General Laws ,
Chapter 41 , Section 81-W, it is hereby certified by the Planning Board
of the town of North Andover , Massachusetts , that at
a duly called and properly posted meeting of said Planning Board , held
on Se to , it was voted to xNXdWmodi fy/t �KRX&
the approval of the definitive subdivision plan of land entitled :
"Francis Estates" owned by : E.C.S . , Inc.
of : PO Box 177 , Pinehurst, Mass . , plan ( s ) dated :
November, 1984 , and revise—d--. June, 1985
y : Merrimack Engineering Services, Inc. , a n d recorded a t the :
Essex North District Registry of Deeds , P1an -AkNo. 10015,
T&tCovenants, b e i n g dated June 2 8 19 8 5
and recor a Book 2032 , Page 193 an ocate
off Rea Street, North Andover , MA , and showing eight (8)
propose lots , y ma ung the following amendments/modification s :J�'"
to amend Condition of Approval 11, set forth on Sheet 5 of said Plan
so as to allow Developer to complete the lots not previously released
and shown thereon with septic systems and leaching fields , as shown
9n Sheet 2 of said Plan.
All prior conditions of approval shall remain in full force and effect
until such time as they are met ; pursuant to Massachusetts General Laws ,
Chapter 41 , Section 81-W, this xkrxvix�tuj§[Rk/Modi f cation/R9 YsxsXX shall
take effect when duly recorded by the Planning Board at the Essex
North District Registry of Deeds the plan or originally approved ,
or a copy thereof, a certified copy of this vote making such
Modification and any plan or other document referred to
in this vote . Said recording to be at the expense of the applicant
in the case of Amendment or Modification .
The X"XM9K XModi fi cation/Rb �>& of the approval of this plan
shall not affect the lots in the subdivision which have been sold or
mortgaged in good faith and for a valuable consideration or any
rights appurtenant thereto , without the consent of the owner of such
lots , and of the holder of the mortgage or mortgages , if any , thereon .
tpnna 1 of 9 )
• s
RECEfVE0
Written c JAS UL.-I ;rom said owners and mortgages , if any , is attached
hereto . NORTH OWNCLE
RR
NOTE TIPC �ERK,: 3T�hp ,,Jlanning Board should be notified immediately of
ff
Pry ppeal to the Superior Court on this subdivision
Amendment/Modification/Rescission of the approval
made within the statutory 20-day appeal period .
If no appeal is filed with your office , the Planning
Board should be notified at the end of the 20-day
appeal period in order that ' the originally approved
plan may receive an appropriate endorsement and be
recorded along with a registered copy of the certi -
fied vote Amending/Modifying/Rescinding the approval .
THE PLANNING BOARD VOTED TO AMEND THEIR DECISION BY ADDING THE
ATTACHED CONDITIONS.
A True Copy , attest :
Clerk ,
Planning Board
Duplicate copy sent to applicant :
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>-FU�C"I Planning Board
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Frances Estates - Definitive SubdivisIon Modification
RECEIVED
Conditional Approval DANIEL LONG
TCLE
A. NORTH ANDOVER
��
The Planning Board makes the foliowzng findings of���tf dY�f ��i ��y' «@����
subdivision modification submitted under M.G. L . Chapter 41 , Section 8W
and the Rules and Regulations Governing the Subdivision of Land in North
Andover :
1 .' The Planning Board in our conclitional approval of the
- Frances Estates Subdivision , dated 4/5/85, required that the
sewer be installed in accordance with the Board of Public
Works under Condition #1lr 1whirh contained 9 design
specifiCationS and related pLans shoming a line and
lift station. This condition was placed in the decision
upon input from Town Gtaff and the applicant �t that time .
The Board ag,eed with the request and placed condition # ll
in our original decision. Since that original decision was
issued the Board finds no specific and material changes in
the condition uf this OF Surrounding property or
any physicai improvements to the design or
construction of the sewer system near this subdivision which
mould wa/ rant a elimination of Condition #11 and
not require the develnper to rnnstruct and tie into an
existing sewer system to �5ubdivision.
2 . The Planning Board inpi/ t 'Irom Tnwn Staff that the
� continued construction nf t|�e sewer �ithin this �ubdi �ision
should proceed in accnrdance ui !,|, our prior decision for
this subdivision, issued 4/5/85 in conformence with Town ' s
Master Sewer Plan for the Mosquito Bi drainage area .
3. The Board has been inform�d hy 5ta [[ that off-site enrl'
related to extending the semer system to the Coventry lift
station located near Salem Strp-�t was not clearly addressed
in our initial decision issued 4/5/85, The Board finds that
the applicant , prior to prcceeding in the interim , to
install septic systems in this sobdivi7- inn until the
availability of sewer service can be provided to thjs
subdivision, must provide the Board with sufficient security
for their portional share of the cost to construct off-site�
sewer improvement7, called for by D.P.W . and in addition,
provide sufficient docUMP/Its +o lnsure their continued
participation in seeing that this subdivision will , at a
future date , be supplied with sewer service '
Upon making the findinqs cited above the P1anning Board conditionally
approves this definitive subdivision modification before us by adding
the following conditions upon our original decision [or this subdivision
issued on 4/5/85:
Condition #11 shall remain unchanged rplated to the 9
specifications ( labellpd A thru J ) in our 4/5/R5 decision. The
following additional and requirements shall be
added to this condition :
L. The plan shal1 be changed to shot.) the sewer line extended in
North Cross Road from its current terminus uphill to the
intersection of Abbott Street at the design grade shown on
the Abbott Village Subdivision off-site sewer plan .
M. A sewer line shall be installed from the existing manhole �t
the low point of North Cross Road downhill along Lots 1 and
*X» 2 property line to the abutting land of John Kozdras . This
sewer shall be installed at minimum grade to allow its
extension to the Coventry Estates pumping station. A 20 '
o2' -- wide sewer easement shall be shown and granted to the Town
_
-j =�
>
=x �� A signed agreement with Coventry Estates to allow a tie in
W. to their pumping station '
��c�'
cc CVn
oc
&_ A covenant placed upon the reweining unbuilt lots which will
require the owner to connect to the " live sewer system" once
it is in place and available for homes to connect with the
system.
P. A signed agreement with the Toyn your intentions to
participate in securing a sewer- easement on land of Kozdras
to allow the future extension of the sewer through his
property to tie into the Coventry pumping station .
Q. A bond , in the amount determined by D,P.W. , shall be placed
with the Board which will provide the Town adequate security
to insure the following work and agreements are adhered to
by the applicant :
I . The portional share of the cost to provide off-site
sewer improvements for this subdivision .
2. Any connection fees to the pump station required by
Coventry Estetes ,
3. The portional share of the cost to secure a se�er
easement to allow the jn�tallation of the sewer .
R. Conditions L thru Q inclusive listed in this condition -,hall
be submitted and approved by the Planning Board to linal
form, and filed with the Registry of Deeds Office.
S. Upon the applicant meeting the requirements contained in
conditions L through R inclusive listed in this condition ,
they may apply to the Board of Health for septic system
approval under the requirements of Title V. In addition,
all septic systems contained within this subdivision must be
included in an Order of Conditions from the NACC , if
applicable.
\
`
TOWN OF NORTH ANDOVER
SYSTEM PUMPING RECORD
,
.DATE.
SYSTEM OWNER`&ADDRESS SYSTEM LOCATION
(example: left front of house)
tlV1
r"�' �F�p '1{gift r Qd`i .�Y •°`� 4 -<sr a,(r.• A + 6 r r ... .. � .. . .
DATE OF PUMPING. QUANTITY PUMPED GALLONS
E CESSPOOL: NO YES SEPTIC TANK: NO YES
t
'! NATURE OF SERVICE: ROUTINE� y EMERGENCYV
Jt�k r i s OBSER_ ATIONS:
GOOD CONDITION FULL TO COVER
HEAVY GREASE BAFFLES IN PLACE
ROOTS
LEACHFIELD RUNBACK
EXCESSIVE SOLIDS FLOODED _
SOLIDS CARRYOVER OTRER (EXPLAIN)
L � J
fi
PUMPED. BY:
e F
pt ff r s
1,,COMMENTSc
..� '' r
2001
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,
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t /
CONTENTS.TRANSFERRED TO: l 1 �T1 �TnO oJ
F t .fir.
i
TOWN OF
UV`
SYSTEM PUMPING RECORD
DATE:
/ Coq ��,% 50 f,181E
SYSTEM OWNER& ADDRESS SYSTEM LOCATION-�j aA �''"'
ve (example:left front of house)"-✓'
sc�
DATE OF PUMPING: I QUANTITY PUMPED . c�> GALLONS
CESSPOOL: NO
YES SEPTIC TANK: NO YES
NATURE OF SERVICE: ROUTINE EMERGENCY
OBSERVATIONS:
GOOD CONDITION FULL TO COVER
HEAVY GREASE BAFFLES IN PLACE
ROOTS LEACHFIELD RUNBACK
EXCESSIVE SOLIDS FLOODED
SOLIDS CARRYOVER OTHER(EXPLAIN)
SYSTEM PUMPED BY: Bateson Enterprises, Inc.
COMMENTS:
CONTENTS TRANSFERRED TO: G.L.S.D Lowell Waste
i
TOWN OF RECEIVED
SYSTEM P PING REC "AY 2 5
ENT
2005
TOWN OF N0i7H FJV�OV
DATE: HEALTH DEPARTN DOVER
SYSTEM OWNER& ADDRESS SYSTEM LOCATION
Lt (example:left front of house)
�0
DATE OF PUMPING: ' Q QUANTITY PUMPED : n GALLONS
CESSPOOL: N YES ✓
O SEPTIC TANK: NO YES
NATURE OF SERVICE: ROUTINE EMERGENCY
OBSERVATIONS:
GOOD CONDITION FULL TO COVER
HEAVY GREASE BAFFLES IN PLACE
ROOTS LEACHFIELD RUNBACK
EXCESSIVE SOLIDS FLOODED
SOLIDS CARRYOVER OTHER(EXPLAIN)
SYSTEM PUMPED BY: Bateson Enterprises, Inc.
COMMENTS:
CONTENTS TRANSFERRED TO: G.L.S. Lowell Waste
RE—CEI E
Commonwealth of Massachusetts
City/Town of JUL 13 2007 ,
System Pumping Record TOWN�OFHNORTH
DEPARTMENT CVER
Form 4
M yvey
DEP has provided this form for use by local Boards of Health. Other forms may be used, but the
information must be substantially the same as that provided here. Before using this form, check with your
local Board of Health to determine the form they use. The System Pumping Record must be submitted to
the local Board of Health or other approving authority.
A. Facility Information
Important:
When filling out 1. System Location:
forms on the
computer,use
only the tab key Address C�
to move your -..�
cursor-do not
use the return city/Town State Zip Code
key.
� 2. System Owner:
Name
11 Address(if different from location)
City/Town Stayq �� V��� i p Code
Telephone Number
B. Pumping Record
1. Date of PumpingDate 2. Quantity Pumped: Gallons
3. Type of system: ❑ Cesspool(s) Septic Tank ❑ Tight Tank
❑ Other(describe):
4. Effluent Tee Filter present? ❑ Yes Er No If yes, was it cleaned? ❑ Yes ❑ No
5. Condition of System-
6. Sy to Pu ped By:
Nam Vehicle License Number
G�
Company
7. Loc to w ere peRterere disposed:
Sigp(atuA of auler Date
t5form4.doc•06/03 System Pumping Record•Page 1 of 1
Commonwealth of Massachusetts
City/Town of OCT - 2008
System Pumping Record 9
Form 4 TOYIN CF r:Oq�H ANTIC)SER
lug
HL..ALTH U, 1'F:( r.
DEP has provided this form for use by local Boards of Health.Other forms may be used, but the
information must be substantially the same as that provided here. Before using this form,check with your
local Board of Health to determine the form they use. The System Pumping Record must be submitted to
the local Board of Health or other approving authority.
A. Facility Information
Important: QQ
When filling out 1. System,Locat� C� y `
forms on the
computer,use
only the tab key Address
to move your -
cursor-do not
y�own St a Zip Code
use the return
key. 2. System Owner: /
Name
ISI Address(if different from location)
Cityrrown State ZiC
ra (r?`-a 3 Lf'—p
bo'!�q Y
Telephone Number
B. Pumping Record ,
��f 5
1. Date of Pumping Date 2. Quantity Pumped: Gallons
3. Type of system: ❑ Cesspool(s) eptic Tank ❑ Tight Tank
❑ Other(describe):
4. Effluent Tee Filter present? ❑ Yes L-No If yes,was it cleaned? ❑ Yes ❑ No
5. Condition KSystem: 1 A sd
6. System Pu By:
Name �^ "—� Vehicle License Number
Company
7. Locat here content re disposed:
Signature/of Wule Date
t5form4.doc•06/03 System Pumping Record•Page 1 of 1
�L\ Commonwealth of Massachusetts
City/Town of
a° System Pumping Record NOV ZJi
Form 4
wM
TOWN 8�N DEP has provided this form for use by local Boards of Health. Ot r fbf�ofhe
information must be substantially the same as that provided here. Be ore using k 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 front of house, right front of hous eft side of house�rfight side of house, Left
rear of house, right rear of house, left side of building, right rear o ul— ing, under deck.
City/Town State Zip Code
2. System Owner: 1
r V C� � `�—
Name
Address(if different from location)
City/Town StateZip Code
(o ( ?-9'3 �.- a3gc�
Telephone Number
B. Pumping Record
1. Date of Pumping Date 2. (quantity Pumped: Gallons
3. Type of system: ❑ Cesspool(s) Septic Tank ❑ Tight Tank
❑ Other(describe):
4. Effluent Tee Filter present? ❑ Yes �No If yes, was it cleaned? ❑ Yes ❑ No
5. Condition pf System*
6. System Pumped By:
Neil J. Bateson F5821
Name Vehicle License Number
Bateson Enterprises Inc.
Company
7. Location where contents were disposed:
L.S.D Lqyvell Wa Wat
Signat/reiWAuler V Date
t5form4.doc•06/03 System Pumping Record•Page 1 of 1
�L\ Commonwealth of Massachusetts "ZTEI'VED
City/Town of ` '
System Pumping Record OCT 3 0 2009
Form 4
TOWN OF NORTH ANDOVER
DEP has provided this form for use b local Boards of Heal�F QTVher AR MENT
P Y fors-ray used, but the
information must be,substantially the same as that provided here. Before using this form, check with your
local Board of Health t4,determine the form they use.The System Pumping Record must be submitted to
the local Board of Health or=otttec approving authority.
A. Facility Information
1. System Location eft de of house.,Right side of house, Left front of house, Right front of house,
Left rear of house, lg rear of house. Left rear of building. Right rear of building.
Address
City/Town State Zip Code
2. System Owner:
Name
Address(if different from location)
City/Town State (�a� p -
Telep one Number �b1
B. Pumping Record
l n -1-7 -C,
1� ,
1. Date of Pumping Date 2- uantity Pumped: Gallons
3. Type of system: ❑ Cesspool(s) eptic Tank ❑ Tight Tank
❑ Other(describe):
4. Effluent Tee Filter present? ❑ Yes If yes, was it cleaned? ❑ Yes ❑ No
5. Condition of System: v\-
6. System Pumped By:
Neil Bateson F5821
Name Vehicle License Number
Bateson Enterprises Inc
Company
7. Location ere contents were disposed:
D Lowell Waste Water
Signature of Hauler Date
t5form4.doc•06/03 System Pumping Record.Page 1 of 1