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HomeMy WebLinkAboutMiscellaneous - 70 WINDKIST FARM ROAD 4/30/2018A r t Lot & Street' —//' Map/Parcel l' 9 CONSTRUCTION APPROVAL Has plan review fee been paid: YES NO Permit# qs� off. r Plan Approval: Date --7a G Approved by: Designer: a6hans-en—1 Plan Date: Conditions: Water Supply: wn Well Well Permit: `e Driller: Well Tests: Chemical Da roved Bacteria I Date Approv Bacteria II Date Approved Plumbing Sign -Off: Wiring Sign -Off. Comments-.— Form omments:Form "U" Approval: Approval to Issue: YES NO Date Issued 7 }q,By: Conditions: Final Approval: All Permits Paid? Sla% NO Well Construction Approval? YES NO Septic System Construction Approval? CYE NO Certification? YES NO Other YES NO Any Variance Needed? YES NO FINAL BOARD OF HEALTH APPROVAL: DATE: APPROVED BY: r .y 1 SEPTIC SYSTEM INSTALLATION Is the installer licensed? YE NO Type of Construction: REPS New Construction: Certified Plot Plan Review YE NO Floor Plan Review YES NO Conditions of Approval from Form U YES NO Issuance of DWC permit: NO DWC Permit Paid? !'� NO DWC Permit # (/ ! ( Installer: Begin Inspection: YES NO Excavation Inspection: Needed: Construction Inspection: Needed: As Built Plan Satisfactory: -,6 YES: Approval of Backfill: Date: By: i Final Grading Approval:Date: %/ '7/I/- By - — I Final Construction Approval: Date'.% �, % ��G' By: �7 �f Certificate of Compliance: Approval: —�� Date: 0. i w U a b 0 9 L I 0 DD O O x � Q x Woo3 A�z� o a O � a V O 0 o 3AB � � w C a� O U 0 o x � U � O O C 0 0, U aoi w � � A z Q 40 aA�3aa.'� U C 0 y 000 O z ° w cd % Q o ►� O i w U a b 0 9 L I 0 Owner information is required for every page. Important: When filling out forms on the computer, use only the tab key to move your cursor - do not use the return key. _ I�= Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 70 Windkist Farm Road' Property Address Anthony Delauri Owner's Name North Andover City/Town MA 01845 State Zip Code 3/18/2009 Date of Inspection Inspection results must be submitted on this form. Inspection forms may not be altered in any way. Please see completeness checklist at the end of the form. A. General Information RECEIVED q 1. Inspector: MAR 2 9 2009 Neil J. Bateson rnlnfki „inoru nnrnn Name of Inspector HEALTH DEPARTMENT Bateson Enterprises Inc. Company Name 111 Argilla Road Company Address Andover City]Town 978-475-4786 Telephone Number B. Certification Ma 01810 State Zip Code SI15 License Number 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: ® Passes ❑ Conditionally Passes ❑ Fails El Need Further Evaluation by the Local Approving Authority 3/18/2009 Inspe is S"ignaturdi Date 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. ****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. t5ins • 09/08 Title 6 Official Inspection Form: Subsurface Sewage Disposal System • Page 1 of 17 Owner information is required for every page. Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 7n Winrlleict Farm Rnarf Property Address Anthony Delauri Owner's Name North Andover MA 01845 3/18/2009 Citv/rown State Zip Code Date of Inspection B. Certification (cont.) Inspection Summary: Check A,B,C,D or E / always complete all of Section D A) System Passes: ® I 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. Check the box for "yes", "no" or "not determined" (Y, N, ND) 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. ❑ Y ❑ N ❑ ND (Explain below): t5ins - 09/08 Title 5 Official Inspection Form: Subsurface Sewage Disposal System • Page 2 of 17 Owner information is required for every page. Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 70 Windkist Farm Road' Property Address Anthony Delauri Owner's Name North Andover MA 01845 3/18/2009 Cityfrown State Zip Code Date of Inspection B. Certification (cont.) B) System Conditionally Passes (cont.): ❑ 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 ❑ Y ❑ Y ❑ Y ❑ N ❑ N ❑ N ❑ ❑ ❑ ND (Explain below): ND (Explain below): ND (Explain below): ❑ 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 ❑ Y ❑ N ❑ ND (Explain below): ❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below): 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 t5ins • 09108 Title 5 Official Inspection Form: Subsurface Sewage Disposal System • Page 3 of 17 Owner information is required for every page. Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 70 Windkist Farm Road' Property Address Anthony Delauri Owner's Name North Andover MA 01845 Cityfrown State Zip Code B. Certification (cont.) 3/18/2009 Date of Inspection 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 indicates absent 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: D) System Failure Criteria Applicable to All Systems: You must indicate "Yes" or "No" to each of the following for all inspections: Yes No ❑ ® Backup 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 t5ins • 09/08 Title 5 Official Inspection Form: Subsurface Sewage Disposal System • Page 4 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form a Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 70 Windkist Farm Road' Property Address Anthony Delauri Owner Owner's Name nformation is required for North Andover MA 01845 3/18/2009 for every page. Citylrown State Zip Code Date of Inspection B. Certification (cont.) Yes No ❑ ® Required pumping more than 4 times in the last year NOT due to clogged obstructed pipe(s). Number of times pumped: ❑ ® Any portion of the SAS, cesspool or privy is below high ground water elev ❑ ® Any portion of cesspool or privy is within 100 feet of a surface water supp 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 supp well. ❑ ® Any portion of a cesspool or privy is less than 100 feet but greater than 50 from a private water supply well with no acceptable water quality analysis. system passes if the well water analysis, performed at a DEP certifie laboratory, for fecal coliform bacteria indicates absent and the pres( of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 p provided that no other failure criteria are triggered. A copy of the ana and chain of custody must be attached to this form.) El® The system is a cesspool serving a facility with a design flow of 2000gpd- 10,000gpd. E]® The system fails. I have determined that one or more of the above failu criteria exist as described in 310 CMR 15.303, therefore the system fails. system owner should contact the Board of Health to determine what will b 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. i or ation. ly or ly feet [This d nce pm, lysis re For large systems, you must indicate either "yes" or "non to each of the following, in addition to the questions in Section D. 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. t5ins • 09108 Title 5 Official Inspection Form: Subsurface Sewage Disposal System • Page 5 of 17 The e For large systems, you must indicate either "yes" or "non to each of the following, in addition to the questions in Section D. 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. t5ins • 09108 Title 5 Official Inspection Form: Subsurface Sewage Disposal System • Page 5 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 70 Windkist Farm Road' Property Address Anthony Delauri Owner Owner's Name information is required for North Andover MA 01845 3/18/2009 every page. City/Town State Zip Code Date of Inspection C. Checklist Check if the following have been done. You must indicate "yes" or "no" as to each of the following: Yes No ® ❑ 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? ® ❑ 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) ® ❑ 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: ® ❑ Existing information. For example, a plan at the Board of Health. E ❑ Determined in the field (if any of the failure criteria related to Part C is at issue approximation of distance is unacceptable) [310 CMR 15.302(5)] D. System Information Residential Flow Conditions: Number of bedrooms (design): 4 Number of bedrooms (actual): 4 DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x # of bedrooms): 440 t5ins • 09108 Title 5 Official Inspection Forth: Subsurface Sewage Disposal System • Page 6 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 70 Windkist Farm Road' Property Address Anthony Delauri Owner Owner's Name information is required for North Andover MA 01845 3/18/2009 every page. Cityrrown State Zip Code Date of Inspection D. System Information Description: Number of current residents: 1) Does residence have a garbage grinder? ❑ Yes ® No Is laundry on a separate sewage system? [if yes separate inspection required] ❑ Yes ® No Laundry system inspected? ❑ Yes ❑ No Seasonaluse? ❑ Yes ® No Water meter readings, if available last 2 ears usage d 9 ( Y 9 (gp ))� Yes Detail: Sump pump? ❑ Yes ® No Last date of occupancy: Current Date Commercial/Industrial Flow Conditions: Type of Establishment: Design flow (based on 310 CMR 15.203): Gallons per day (gpd) Basis of design flow (seats/persons/sq.ft., etc.): Grease trap present? ❑ Yes ❑ No Industrial waste holding tank present? ❑ Yes ❑ No Non -sanitary waste discharged to the Title 5 system? ❑ Yes ❑ No Water meter readings, if available: t5ins • 09/08 Title 5 Official fnspection Form: Subsurface Sewage Disposal System • Page 7 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 70 Windkist Farm Road' Property Address Anthony Delauri Owner Owner's Name information is required for North Andover MA 01845 3/18/2009 every page. Citylrown State Zip Code Date of Inspection D. System Information (cont.) Last date of occupancy/use: Other (describe below): General Information Pumping Records: Source of information: Was system pumped as part of the inspection? If yes, volume pumped: How was quantity pumped determined? Reason for pumping: Date Pumped last year, owner gallons Type of System: ® Septic tank, distribution box, soil absorption system ❑ Single cesspool ❑ Yes ® No ❑ 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) and a copy of latest inspection of the I/A system by system operator under contract ❑ Tight tank. Attach a copy of the DEP approval. ❑ Other (describe): t5ins • 09108 Title 5 official Inspection Form: Subsurface Sewage Disposal System • Page 8 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form o Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 70 Windkist Farm Road' Property Address Anthony Delauri Owner Owner's Name information is required for North Andover MA 01845 3/18/2009 every page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Approximate age of all components, date installed (if known) and source of information: 10 years old, 12/16/1999, as built plan Were sewage odors detected when arriving at the site? ❑ Yes ® No Building Sewer (locate on site plan): Depth below grade: 2 feet Material of construction: ❑ cast iron ® 40 PVC ❑ other (explain): Distance from private water supply well or suction line: feet Comments (on condition of joints, venting, evidence of leakage, etc.): 4" PVC thru wall to septic tank, 3" PVC in house no leaks visible. Septic Tank (locate on site plan): Depth below grade: Material of construction: ® concrete ❑ metal If tank is metal, list age: ❑ fiberglass 1 feet ❑ polyethylene ❑ other (explain) years Is age confirmed by a Certificate of Compliance? (attach a copy of certificate) ❑ Yes ❑ No Dimensions: Sludge depth: 10'x5'x4' 0 t5ins - 09108 Title 5 Official Inspection Form: Subsurface Sewage Disposal System • Page 9 of 17 Owner information is required for every page. Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 70 Windkist Farm Road Property Address Anthony Delauri Owner's Name North Andover Cityrrown D. System Information (cont.) Septic Tank (cont.) MA 01845 3/18/2009 State Zip Code Date of Inspection 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 How were dimensions determined? 25" ill 8" 20" 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 tee ok. Outlet tee ok. Depth of liquid at outlet invert. No evidence of leakage. Grease Trap (locate on site plan): Depth below grade: Material of construction: ❑ concrete ❑ metal Dimensions: Scum thickness feet ❑ fiberglass ❑ polyethylene ❑ other (explain): 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: Date t5ins • 09/08 Title 5 official Inspection Form: Subsurface Sewage Disposal System • Page 10 of 17 Owner information is required for every page. Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 70 Windkist Farm Road' Property Address Anthony Delauri Owner's Name North Andover Cityrrown MA 01845 State Zip Code 3/18/2009 Date of Inspection D. System Information (cont.) Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): 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: gallons per day Alarm present: ❑ Yes ❑ No Alarm level: Alarm in working order: ❑ Yes ❑ No Date of last pumping: Date Comments (condition of alarm and float switches, etc.): * Attach copy of current pumping contract (required). Is copy attached? ❑ Yes ❑ No t5ins - 09/08 Title 5 Official Inspection Form: Subsurface Sewage Disposal System • Page 11 of 17 Owner information is required for every page. Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 70 Windkist Farm Road' Property Address Anthony Delauri Owner's Name North Andover MA 01845 3/18/2009 City/Town State Zip Code Date of Inspection D. System Information (cont.) Distribution Box (if present must be opened) (locate on site plan): Depth of liquid level above outlet invert N Comments (note if box is level and distribution to outlets equal, any evidence of solids carryover, any evidence of leakage into or out of box, etc.): D -box level & distribution equal. No evidence of leakage. Evidence of light carryover.D-Box is under the front walk 15" deep Pump Chamber (locate on site plan): Pumps in working order: ❑ Yes ❑ No Alarms in working order: ❑ Yes ❑ No Comments (note condition of pump chamber, condition of pumps and appurtenances, etc.): Soil Absorption System (SAS) (locate on site plan, excavation not required): If SAS not located, explain why: t5ins • 09/08 Title 5 Official Inspection Form: Subsurface Sewage Disposal System • Page 12 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form a o Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 70 Windkist Farm Road' Owner information is required for every page. Property Address Anthony Delauri Owners Name North Andover City/Town D. System Information (cont.) Type: MA 01845 State Zip Code 3/18/2009 Date of Inspection ❑ leaching pits number: ❑ leaching chambers number: ❑ leaching galleries number: ® leaching trenches number, length: ❑ leaching fields number, dimensions: ❑ overflow cesspool number: ❑ innovative/alternative system 2 trenches 88' & 90' long Type/name of technology: Comments (note condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of vegetation, etc.): Soil ok. Vegetation ok. No sign of ponding to surface 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 ❑ No t5ins • 09/08 Title 5 Official Inspection Forth: Subsurface Sewage Disposal System • Page 13 of 17 Owner information is required for every page. Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 70 Windkist Farm Road' Property Address Anthony Delauri Owners Name North Andover MA 01845 3/18/2009 City(rown State Zip Code Date of Inspection D. System Information (cont.) 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.): t5ins • 09/08 Title 5 Official Inspection Form: Subsurface Sewage Disposal System • Page 14 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 70 Windkist Farm Road' Property Address Anthony Delauri Owner Owner's Name information is required for North Andover MA 01845 3/18/2009 every page. Cityrrown state Zip Code Date of Inspection D. System Information (cont.) Sketch Of Sewage Disposal System: Provide a view 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. Check one of the boxes below: ® hand -sketch in the area below ❑ drawing attached separately dm Tovlk 144 �� I 3S J a _ L41) Isms • 09!08 Title 5 Official inspection Fom Subsurface Sewage Oisposai System • Paye 15 d 17 Owner information is required for every page. Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 70 Windkist Farm Road' Property Address Anthony Delauri Owner's Name North Andover MA 01845 3/18/2009 Cityrrown D. System Information (cont.) Site Exam: ® Check Slope ® Surface water ® Check cellar ® Shallow wells Estimated depth to high ground water: State Zip Code Date of Inspection 4' feet Please indicate all methods used to determine the high ground water elevation: 0 X Obtained from system design plans on record If checked, date of design plan reviewed: 5/13/1997 Date 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 established the high ground water elevation: Design plan test pit data. Before filing this Inspection Report, please see Report Completeness Checklist on next page. t5ins - 09708 Title 5 Official Inspection Form: Subsurface Sewage Disposal System - Page 16 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments M 70 Windkist Farm Road' Property Address Anthony Delauri Owner Owner's Name information is required for North Andover MA 01845 3/18/2009 every page. Cityrrown State E. Report Completeness Checklist ® Inspection Summary: A, B, C, D, or E checked Zip Code Date of Inspection ® Inspection Summary D (System Failure Criteria Applicable to All Systems) completed ® System Information — Estimated depth to high groundwater ® Sketch of Sewage Disposal System either drawn on page 15 or attached in separate file t5ins - 09108 Tdle 5 Official Inspection Form: Subsurface Sewage Disposal System • Page 17 of 17 Summary Record Card generated on 3/13/200910:19:55 AM by Lisa Evans Town of North Andover Tax Map # 210-109.0-0059-0000.0 Page 1 Parcel Id 18876 70 WINDKIST FARM ROAD DELOURI, TONY 70 WINDKIST FARM ROAD NORTH ANDOVER, MA 01845 Class 101 Single Family Property Type 1 Residential Size Total 1 Acres FY 2009 UB Mailina Index Name/Address Type Loan Number Active/Inact. From DELOURI, TONY Payor 70 WINDKIST FARM ROAD NORTH ANDOVER, MA 01845 UB Account Maint. Account No Cycle Occupant Name Active/Inactive Bldg Id. 13797.0 - 70 WINDKIST FARM ROAD Last Billing Date 2/3/2009 1090473 01 Cycle 01 Active UB Services Maint Account No. 1090473 Service Code Rate Charge Multiplier/Users MISCFEE ADMIN FEE 1 1 9.18 1/ WTR WATER 01 ALL METER SIZE 47.46 /1 UB Meter Maintenance Account No. 1090473 Serial No Status Location Brand Type 32948538 a Active 00 b Badger w Water Date Reading Code Consumption Posted Date 1/23/2009 385 a Actual 14 2/10/2009 10/22/2008 371 a Actual 11 11/12/2008 7/22/2008 360 a Actual 54 8/15/2008 4/23/2008 306 a Actual 12 5/19/2008 1/28/2008 294 a Actual 12 2/19/2008 10/24/2007 282 a Actual 124 11/16/2007 7/20/2007 158 a Actual 85 8/15/2007 4/20/2007 73 a Actual 12 5/21/2007 1/29/2007 61 a Actual 15 2/20/2007 10/25/2006 46 a Actual 23 11/16/2006 7/28/2006 23 a Actual 18 8/18/2006 5/2/2006 5 a Actual 5 5/16/2006 3/4/2006 0 n New Meter 0 5/16/2006 3/4/2006 1172 r Replacement 3 5/16/2006 1/30/2006 1169 a Actual 9 2/13/2006 10/27/2005 1160 a Actual 122 11/9/2005 Trouble Code:03 7/26/2005 1038 a Actual 105 8/10/2005 4/22/2005 933 a Actual 8 5/13/2005 2/2/2005 925 a Actual 8 2/15/2005 10/27/2004 917 a Actual 161 11/15/2004 Trouble Code:03 8/3/2004 756 a Actual 266 8/25/2004 Trouble Code:03 5/10/2004 490 a Actual 14 6/8/2004 2/4/2004 476 a Actual 15 2/24/2004 Size 11 Until YTD Cons 79 Variance 26% -80% 330% 12% -90% 38% 530% -5% -40% 25% 144% -100% -100% -4% -93% 19% 991% 24% -96% -39% 2046% -10% 0% TOWN OF NORTH ANDOVER BOARD OF HEALTH CERTIFICATE OF COMPLIANCE DATE OF COMPLIANCE: January 27, 2000 This is to certify that the individual subsurface disposal system constructed ( ) or repaired ( X ) by Ben Osgood, Jr. at 70 Windkist Farm Road (Lot # 14) has been installed in accordance with the provisions of Title V of the State Sanitary Code and with the North Andover Board of Health regulations. The Issuance of this certificate shall not be construed as a guarantee that the system will function satisfactorily. Board of Health Inspector I 10+#'r4 (70)WInk d. TOWN OF NOR'T'H ANDOVER SEWAGE DISPOSAL SYSTEM INSTALLATION CERTIFICATION The undersigned hereby certify that the Sewage Disposal System 0(') constructed; { ) repaired; by �e�l a• �r C QsG-o�n �1 �2 located at Z c W 1A) D i4 tsT ';rR2A R C) L O T I J4) was installed in conformance with the North Andover Board of Health approved plan, System Design Pcrnait # W- dated . with an approved design flow of `iy0 .gallons per day. - The materials used were in conforms= with those specified on the approved plan; the system was.installed in accordance with the provisions of 310 CMR 13,000, Title S and local regulations, and the final grading agneas substantially with the approved plan, All work is -accurately represented on the As -built which has boon submitted to the Board of Health. Installer. Design Engineer: Date: / ;z Date: DEC L 3 LU z O o — z = Q E L O O N LL Fi Q N a O LL. Z -D O � o U co w � Z L U a� Q N ce a L W N o Z Q o00 c O u ` a Q 0u Y o Q Y c Z m O YJ O p 4 3 U O J O 3 c 3 vQi -a c O O tA N b ro � 00 E w1 .. n Q L N z d s 0 a r ''tCrJ� C Ri O o A',MO.L **r `r Q Cn CL N U- cj/� I S- � 62 APPLICATION FOR DISPOSAL WORKS CONSTRUCTION PERMIT DATE: / CURRENT INSTALLER'S LICENSE LOCATION: LICENSED INSTALLER:/L— SIGNATURE: _ _TELEPHONE#_ 1766 CHECK ONS: REPAIR: NEW CONSTRUCTION: IF NEW CONSTUCTION, PLEASE ATTACH FOUNDATION AS -BUILT. 575.00 Fee Attached? Foundation As -Built? Administrative Use Only Yes No Yes ✓ No Floor Plans? Yes No Approval �,� z2tL L 01999 Date- F..,01999 ate- c7 LU c Z O Z _ E LL a w a Ln AJ, Q1 W N Q c w Z E_ Q 3 w ro Z c a CL O N U ro = F' L ro rt Q vii M F- U a > U Q w HNZ Qa >-0 LL O N : oao Q C) oz s 3 c 0 O JO U O Q o O N O G. c N N ro cro � H � Q � ro 'O Ld N � N `^ in a� by 0- N LL Aug -02-99 10:35A North Andover Gam. Dev. 508 688 9542 APPLICATION FOR DISPOSAL WORKS CONSTRUCTION PERMIT DATE: ,Q�i CURRENT INSTALLER'S LICENSE# 39 I LOCATION: W� � Ll w( K l LICENSED INSTA ER: SIGNATURE: CHECK ONE: REPAIR: TELEPHONE# NEW CONSTRUCTION: IF NEW CONSTUCTION, PLEASE ATTACH FOUNDATION AS -BUILT. Administrative Use Only $75.00 Fee Attached? Yes V No Foundation As -Built? Yes No Floor Plans? Yes LINo Approval Date: TCWN OF NORTH ANDOVER/ BOARD OF 4EALTH tit'? 18 1999 4 P.01 SEPTIC PLAN SUBMITTALS LOCATION: Z07- NEW PLANS: YES $60.00/Plan REVISED PLANS: YES $25.00/Plan DATE: DESIGN ENGINEER: 0-1/Z/s� /'� When the submission is all in place, route to the Health Secretary No. THE COMMONWEALTH OF MASSACHUSETTS FEE BOARD OF HEALTH Toww OF APPLICATION FOR DISPOSAL SYSTEM CONSTRUCTION PERMIT Application for a Permit to Construct Repair ( ) Upgrade ( ) Abandon ( ) - ❑ Complete System ❑ Individual Components 109L1C1`�/�12 Map/Pared _a) k) cl 1 I/ls Ito h /4 Lot # Installer's Name Address Telephone P Type of Building: [A )bp Ff_/f yrlC Dwelling — No. of Bedrooms q Other — Type of Building No. of persons Other fixtures Design Flow (min. rwu Plan: Date 6//0 Description of Soil(s) Soil Evaluator Form No. SrtA&Ch111 1111t Address L Telephone H Lot Size F 3 S-60 Sq. feet Garbage Grinder ( ) Showers ( ), Cafeteria I� gpd Calculated design flow gpd Design flow provided-ilb- gpd Number of sheets eoP- Revision Date DESCRIPTION OF REPAIRS OR ALTERATIONS The undersigned agrees to install the above described Individual Sewage Disposal System in accordance with the provisions of TITLE 5 and furthel s not to place the system in operation until a Certificate of Compliance has been issu d by the Board of Health. Signed i�—C Date l z 7% Inspections FORM 1 - APPLICATION FOR DSCP DEP APPROVED FORM 5/96 No. THE COMMONWEALTH OF MASSACHUSETTS FEE BOARD OF HEALTH CERTIFICATE OF COMPLIANCE Description of Work: ❑ Individual Component(s) ❑ Complete System The undersigned hereby certify that the Sewage Disposal System; Constructed ( ), Repaired ( ), Upgraded ( ), Abandoned ( ) by: at has been installed in accordance with the provisions of 310 CMR 15.00 (Title 5) and the approved design plans/as-built plans relating to application No. dated . Approved Design Flow (gpd) Installer Designer: Inspector Date The issuance of this certificate shall not be construed as a guarantee that the system will function as designed. FORM 3 - CERTIFICATE OF COMPLIANCE DEP APPROVED FORM 5/96 No. THE COMMONWEALTH OF MASSACHUSETTS FEE BOARD OF HEALTH DISPOSAL SYSTEM CONSTRUCTION PERMIT Permission is hereby granted to Construct ( ) Repair ( ) Upgrade ( ) Abandon ( ) an individual sewage disposal system at as described in the application for Disposal System Construction Permit No. dated Provided: Construction shall be completed within three years of the date of this permit. All local conditions must be met. Date FORM 2 - DSCP FORM 1255 (REV 5/96) Board of Health DEP APPROVED FORM 5/96 H&W HOBBS& WARREN TM PUBLISHERS - BOSTON AS -BUILT UIECKLIST 'OZ4, LOCATIONS OF DEEP HOLES & PERC TESTS iz ELEVATIONS OF DISPOSAL SYSTEM _ TOP OF FDN ELEVATION y LOCATIONS OF WELLS, DRAINS, WATERCOURSES W/IN 150' OF SYSTEM LOCATION OF WATER, GA9, ELECTRIC LINES, CABLE DISTANCES FROM CORNERS OF HOUSE TO CENTER OF / TANK & D-BOX y STAMP & SIGNATURE lMPERVIOUS AREAS - DRIVEWAYS, ETC. lir -77mce; 9!r " NORTH ARROW Stll*7 FINAL CONTOURS LOCATION & ELEVATION OF BENCHMARK USED LOCUS PLAN ply LOT NUMBER, STREET NAME _ ASSESSORS MAP & PARCEL NUMBER ✓ LOT LINES & LOCATION OF DWELLINGS LOCATION & DEMENSIONS OF SYSTEM. INCLUDING RESERVE TIES TO LOT LINES & DWELLING, WELLS a. FROM SEPTIC TANK b. FROM LEACH AREA 'OZ4, LOCATIONS OF DEEP HOLES & PERC TESTS iz ELEVATIONS OF DISPOSAL SYSTEM _ TOP OF FDN ELEVATION y LOCATIONS OF WELLS, DRAINS, WATERCOURSES W/IN 150' OF SYSTEM LOCATION OF WATER, GA9, ELECTRIC LINES, CABLE DISTANCES FROM CORNERS OF HOUSE TO CENTER OF / TANK & D-BOX y STAMP & SIGNATURE lMPERVIOUS AREAS - DRIVEWAYS, ETC. lir -77mce; 9!r " NORTH ARROW Stll*7 FINAL CONTOURS LOCATION & ELEVATION OF BENCHMARK USED LOCUS PLAN ply AS -BUILT CHECKLIST LOT NUMBER, STREET NAME y ASSESSORS MAP & PARCEL NUMBER LOT LINES & LOCATION OF DWELLINGS 1/ LOCATION & DEMENSIONS OF SYSTEM, INCLUDING RESERVE TIES TO LOT LINES & DWELLNG, WELLS a. FROM SEPTIC TANK b. FROM LEACH AREA LOCATIONS OF DEEP HOLES & PERC TESTS ELEVATIONS OF DISPOSAL SYSTEM TOP OF FDN ELEVATION LOCATIONS OF WELLS, DRAINS, WATERCOURSES W/N 1 50' OF SYSTEM LOCATION OF WATER, GAS, ELECTRIC LINES, CABLE DISTANCES FROM CORNERS OF HOUSE TO CENTER OF TANK & D -BOX STAMP & SIGNATURE IMPERVIOUS AREAS - DRIVEWAYS, ETC. V NORTH ARROW FINAL CONTOURS LOCATION & ELEVATION OF BENCHMARK USED LOCUS PLA -Ni Town of North Andover t N 9 T OFFICE OF e o 16 ti0 C COMMUNITY DEVELOPMENT AND SERVICES p 146 Main Street a� North Andover, Massachusetts 01845 WILLIAM J. SCOTT Director July 28, 1997 Christiansen & Sergi 160 Summer Street Haverhill, MA 01830 RE: Windkist subdivision Dear Phil: This letter is to inform you that the proposed septic plans for Lots 14 & 15 Windkist Farm Road have been approved. If you have any questions, please do not hesitate to call the Board of Health office at the number below. Sincerely, - - 6�� Sandra Starr, R.S. Health Administrator J cc: Wm. Scott, Dir. CD&S Bob Messina Colonial Village Dev. File BOARD OF APPEAIS 688-9541 RTTTT-DING 688-9545 CONSERVATION 688-9530 HEALTH 688-9540 PIANNW 6$9-9535 FORM 11 -'SOIL EVALUATOage R FORM P 1 of 3 Date: No. Commonwealth of Massachusetts lz�4 jt,�� Massachusetts for On-site Sewa e Dism—sal Soil Suitability Assessment . .. ......... ... Date -111 IJ -1-3.197 Ut Performed By: . ...... .. .. Witnessed BY: OWMI'SN... 6`01owd tldlio 457' A a(k T 64IM5 Address. and L=ztton Address Of Lot Telephom -24�_ 14 Ah. L NI -W Construction Repair Office Review Y es FD� Published Soil Survey Available: No . ........... Year Published .............. .. . Publication Scale ............. ................ We Drainage Class Soil Limitations Surficial Geologic Report Available: No T�Yes Publication Scale Soil Map Unit YearPu 5(map Unit) ................................................................... ............. Geologic Material ra ............... ......... Landform ............. Flood Insurance Rate Map: No ElYes Above 500 year flood boundary 2 -Yes El Within 500 year flood boundary No ❑ Within 100 year flood boundary No�es Wetland Area: it) .... ................ National Wetland Inventory Map (map un .................... Wetlands Conservancy Program Map (map unit) Current Water Resource Conditions (USGS): Month Range :Above Normal []Normal E]Belc�,iNormal ❑ Other References Reviewed: iiDEP APPROVED FORIM - 12107195 Town of North Andover, Massachusetts Form No. 2 f,AORTot BOARD OF HEALTH 1 91—z— o � A y s DESIGN APPROVAL FOR sSACHUSE� SOIL ABSORPTION SEWAGE DISPOSAL SYSTEM Applicant ---Bo,8 Re-651o"t-) Test No. Site Location Z.67- /'f ZV1A)bK15T Reference Plans and Specs. ENGIN 'a7/ce Permission is granted for an individual soil absorption sewage disposal system to be installed in accordance with regulations of Board of Health. CHAIRMAN, BOARD OF HEALTH Fee 5q e. Site System Permit No. FORM 11 - SOIL EVALUATOR FORM Page Z*of 3 Location Address or Lot IJo�If-,'rl4�i%S� �Gt &(4 On-site Review Deep Hole Number �T�� Date: S/13 Location (identify on site plan) - Land Use .. Slope M) Vegetation Landform . Ora M P ✓1 Position on landscape (sketch on the back) Distances from: Time: Weather Surface Stones Open Water Body feet Drainage way Possible Wet Area feet Property Line Drinking Water Well feet - other feet feet iaDEP APPROVED FORM - 12/07/95 - DEEP OBSERVATION HOLE _OG` Soil Texture (USDA) Soil Color (Munsell) Soil Mottling Other Boulrs, Consistency, °/o (Structure, Stones Gravel) Depth from Surface (Inches) Soil Horizon Z 12— 8,� �► ,M�s�s f � �r�`a � �c.. - L.s. t TI Standing High Ground Water: t i EVERY t! Water in the Hole: t L DepthtoBedrock: ARET /> Weeping from Pit Face: — Parent Material. (geologic) Depth to Groundwater: Estimated Seasonal iaDEP APPROVED FORM - 12/07/95 - FORM 11 - SOIL EVALUATOR FORM Page ''oi 3 Location Address or Lot 1�0./ �/✓lC��/'S� �Gi��'►� UG On-site Review naen Hole Number Date:����� Location (identify on site plan) Land Use Slope M) Vegetation - - Landform . PrL'k M..1'A Position on landscape (sketch on the back) Distances from: Time: Weather Surface Stones Open Water Body - feet Drainage way Possible Wet Area feet Property Line W t r Well feet Other feet feet Drinking a e DEEP OBSERVATION HOLE _OG` Depth from Soil Horizon Soil Texture Soil Color Soil Other (USDA) (Munsell) Mottling (Structure, Stones, Boulders, Consistency, Surface (Inches) ©�- A FSZ�o 3% . . ar15 6 f� F L rsY Mass; pe, Fi'rw t t t t L c rr -' � Depthto8edrock: Parent Material- (geologic) ±1 Depth to Groundwater: Standing Water in the Hole: • Weeping from Pit Face: Estimated Seasonal High Ground Water: DEP APPROVED FORA( - 11107/95 1t DORM I I - BUIL L� ALL UK UbUNI Pa,,e 3 of 3 Location Address or Lot No. f� �nalion for Seasonal Hio, Wi Method Used: I! Depth observed standing in observation hole Depth weeping from side of observation hole 2 Depth to soil mottles j00 inches Ground water adjustment feet r Fadi inches inches index Well Number Reading Date ................. Index well level J Adjusted ground water level Adjustment actor ... ... Denth o Naturally Occurrino Pervious Material Does at least four feet of naturally occurring pervious material exist in all. areas observed throughout the area proposed for the soil absorption system? If not, what is the depth of naturally occurring pervious material? ��rt1i1C8tiOn examinatio I certify thaton�� ca viieronmental Protection ction and that) I have passed the soil the above analysis approved by she Department of �n was performed by me consistent with the required training, expertise and experienc: described in 310 CMR Signature L L Date 6 DEP APPROI.'ED FOFUM - 12107195 FORM 12 - PERCOLATION TEST Location Address or Loi No. /�/_- Windh-c-f &94 COMMONWEALTH OF MASSACHUSETTS N'-�, Massachusetts Percolation Test* —� Date:._ . �Rl"�7 Time:, Observation Hole # Depth of Perc Start Pre-soak 0UeAV lo;W ; s� End Pre-soak 3 Time at 12" Time at 9" 3 ; 2 9 Time at 6" 7 Time (9"-6") Rate Min./Inch * Minimum of 1 percolation test must bo p rform i ad in both tr ie primary area AND reserve area. Site Passed 2' Site Failed ❑ ......................................................................................................................................_.__......._......... Performed By: L)Mll j'a/ ®, ernnG`j Witnessed By: tsc"-nd sit" Z si(j 1pf /1/x Comments: 11 P DEP APPROVED FORM - 12/07/95 1 `'1 PLAN REVIEW CHECKLIST 1DDRESS ? ENGINEER ;ENERAL 3 COPIES// STAMP LOCUS v NORTH ARROW SCALE `�/ 'ONTOURSPROFILEy (Sc) SECTION BENCHMARK � SOIL & 3 E R C S ELEVATIONS L-� WETS. DISCLAIMER f WELLS & WETS c/ JATERSHED?�% DRIVEWAY v WATER LINE —_'_ FDN DRAIN `� M&P'� 3CH40 t/ TESTS CURRENT? SOIL EVAL �. (� �C�O��CiL-�� G�����✓7���5�� SEPTIC TANK/ IIN 150OG 10' TO FDN L,--' .17 INVERT DROP GARB. GRINDER_,Ab_(2 comps +200) MANHOLEOL ELEV L--- GW t--- # COMPS. GB D -BOX SIZE # LINES FIRST 2' LEVEL STATEMENT I NLET al3?, 4 - OUTLET;(37 �'g - ( 2" OR .17 FT) TEE REQ' D?A6) LEACHING MIN 440 GPD?RESERVE AREA 4' FROM PRIMARY? Ll ----2o SLOPE 100' TO WETLANDS 100' TO WELLS L-`_ 4' TO S.H.GW (5'>2M/IN) 20' TO FND & INTRCPTR DRAINSy� 400' TO SURFACE H2O SUPP e_� 4' PERM. SOIL BELOW FACILITY MIN 12" COVERL� FILL? x(15') BREAKOUT MET? TRENCHES MIN 440 gpd 1"/ SLOPE (min .005 or 6"/100') ZSIDEWALL DIST. 3X EFF. W OR D (MIN 6') RESERVE BETWEEN TRENCHES?// IN FILL? MUST BE 10' MIN. ✓ 4" � PEA STONE?�VENT? 1/ (>3' COVER; LINES >50') SOT '7�(D + SIDE c3� _ / d4 X LDNG ' = TOT 1417 T76 �(L x W x #) (DxLx2x#) (G/ft2) •.\ 0 1996 by S.L. Starr FORM U - VERIFICATION FORM INSTRUCTIONS: This form is used to verify that all necessary approvals/permits from Boards and Departments having jurisdiction have been obtained. This does not relieve the applicant and/or landowner from compliance with any applicable local or state law, regulations or requirements. ****************Applicant fills out this section***************** APPLICANT: �iUCL<�i5 fCd/i Z G Phone I fZ LOCATION: Assessor's Map Number Parcel Subdivision Lot(s) Street�i?/.j ,5 j� V",4�i�I �� St. Number ************************Official RECOMMENDATI t TO AGENTS: Conservation Administrator Comments P1 Comments Use Only************************ Date Approved Date Rejected Date Approved Date.Rejected k-7/97 Date Approved Food Inspector -Health Date Rejected 7 0� Septic Inspector -Health Date ApprovedDate Rejected Comments Public Works - sewer/water connections (-f - driveway permit Z7 Fire Department � 2cu J-tTjeC �%�2� 1, / /l f Pte' `� ��<� (�Z1 6/�c�/ F% Received by Building Inspector Date d l� 00 0 O O O 5� O W> w O w a � a �0 L O M z aN �� � v 5 o � � 0 3arn 0 a 0 x t- o 0 N 4 0 tQo�j� 00 ti A � V] V P Z O m wl aa�3aa c 0 c 3 O N 2 en en Z N �0 a M z aN �� do N I NUMBER FEE BHP -2003-0112 COMMONWEALTH OF MASSACHUSETTS $12500 North Andover Board of Health C. M. Rollins Co.,- Inc-.,- Well Drilling Contractors ---------------------------- --- ----------------------------------------- ------------------------------- NAME 70 WINDKIST FARM ROAD ----------------------------- ADDRESS IS HEREBY GRANTED A PERMIT Well Construction This rmit is ted in conformi with the Statutes and ordinances relating thereto and Pe l� ty g , expires ------------ September 09,_2003 ---__--_ __ unless sooner suspended or revoked. ----------------------------------------------------------------- June 09, 2003 ------------------------------------------------------------- Board -----------------------------�1�----------------------- of Health ----------------------------------------------------------------- TOWNf OF NORTH ANDOVER BOARD OF HEALTH 6 � Location / v _` "'�✓Jj[ �`sJ "�/�% ' `-� Permit # Food Service $ Retail Food $ Limited Retail $ Seasonal $ Disposal Works Installers $ Disposal Works Construction $ Soil Testing $ Design Approval Permit $ Dumpster Permit $ Burial Permit $ Swimming Pool Permit $ Animal Permit $ Recreational Camp Permit $ $ Well Construction Permits/ Funeral Directors Permit $ Massage Establishment License $ Massage Practice License $ Suntanning Establishment $ offal/Trash Hauler $ Other $ 6;39;4. L/I Health Agent White - Applicant Yellow - Dept. Pink - Treasurer Permit # 2003 BOARD OF HEALTH NORTH ANDOVER, MASS. Djpti S APPLICATION FOR WELL AND PUMP PERMIT Date �o A permit is requested to: drill a well X install a pump kc LOCATION: -70 W /nim K 1'57- 7AA-OA R A Lot # Owner N►� V2C-N10 Address`7�0 ca.�a�DK�sT (-'w.. R Tel 27��9'��f�QlZef co, Well Contrctr= PaL0'JS S+►c • Add. 0-9 far W 6OW49bTel R7? Pump Contrctr 5�1"�' Add. Tel frie�ririek�e9eir�ekir*FicirFlc�e*�r9eiefrk�ek�slr�cilr�elr�eir4e9rieife�e*9eicifrfri�r**fr9e9e*�e�e�e�eiirielriekfr*k4c***** WELLS (To be completed at time of pump test.) Type of well VA iL'Ltf3 Use Diameter of well 6 Size of casing t/ Depth of bed rock Seal been tested? Yes (_) Depth of well Depth casing into bedrock No (_) Date of test Water -bearing rock Depth to water Delivers GPM for (how long?) Drawdown feet after pumping hours at �jGPM Date of completion (/�� ° ��-�i�'"-•�, Sigh-a'tureCAf well contractor PUMPS (To be filled in before installation.) Name & size of pump Size of tank Pump delivers Type GPM Pipe used in well: Cast iron (_) Galvanized (_) Plastic (_) Sleeve used to protect pipe? Yes (_) No (_) Type well seal Date Signature of pump installer Date water analysis report submitted to Board of Health Plumbing inspector Board of Heal Wiring inspector p � N ..0 TOWN OF NORTH ANDOVER HEALTH DEPARTMENT 27 CHARLES STREET NORTH ANDOVER, MASSACHUSETTS 01845 Sandra Starr Telephone (978) 688-9540 Public Health Director FAX (978) 688-9542 Applications for a permit to drill a well: Before a permit can be issued, you must have your contractor submit the following: 1. Submit to the Health Department a site plan showing your house footprint and location on the lot 2. Indicate any wetlands within 200 feet of the proposed location for the well 3. Indicate the well location 4. Submit a check for $125.00 with the application Note: All submittals must be drawn to scale. Please note that you may also be required to file with the Conservation Commission if wetlands are near to the proposed well, and to the Planning Board if you are located in the Watershed District. ***** Please turn over to fill out application ***** CA\Documents and Settings\pdellech\My Documents\Wells\Well Drill Applications.doc 2003 rvv 1.) PROPERTY LINES SHOWN WERE TAKEN FROM EXISTING PLANS AND RECORDS. 2.) THIS PLAN IS INTENDED FOR NORTH ANDOVER BOARD OF HEALTH PURPOSES ONLY. �.�e,76e' pLAN 0 12�s'% �►�ra �c� 1 � i�r� srT� 5) -r,4 ►� P I s z ,� r C d� v -ro � a -t" + Low•• �-r i bi5rn44-L �Y���1 Q4 GA��*�Yr�.,.►G,"t�: 'j'►�5 �C. ��J G,) -r►a p�- t , . was T4,L_j_.E r2 00 1 L -L r FA L ►J r% �.1fj-�1' i ,a• S Le ,+�'i '°ii r- I ,� o F <t S - � c i I t�'� 5 t,� ►� �r� � �"' . ''f �..{ � GOtJ n1 � G" j j# ph`� � � �►e'�` U I � t""�.;N�. �»� �'''� 1s-� �,� 1 h'i ���c;� i Z j xA ,00 L e•1,- F u *T Ij E;►L,% Q r l� 61h+� �/ �.� I.T"t-I r (�J.e:►-�) �3 h► r �-� 1. `�' 11Jr�CY"ty' A an g Y 0,14 r+v ook Vl.c� I � � 'ro Pit C�ji�c'—� F'► ��C v �Y ' H o,µ, a. 04 . 4(e 2� -7, q- I DANML XORAVpg \ 'CIVIL o, No. 37752 GRAPHIC SCALE 10 20 40 (IN FEET ) 1 inch = 20 ft. ."AS -BUILT", -7 ;1 i IN . 12- 14w - ? �7 80 PLAN NORTH AND 0 VER, MA SSA CH USE T TS AS PREPARED FOR SCALE: 1 "=20' DATE: 12 14, -ll ASSESSORS MAP # 1 �� LOT SUBDIVISION LOT # IMERRIMACK ENGINEERING SERVICES 66 PARK STREET ANDOVER, MASSACHUSETTS 01810 u 0, I N10 WETLAN�� 5140 wo 0 f -i oN2 G►np�L 1 `Ro,M InJEIL L L0 o RT�o N ��.(J�� ,�� �'� �' � r � � �,-.� �_� i 6'-2" Lol I I FC71 iN-CF NOCR 7'Z 7:5 a. WILLIAM L�UIL)rrl OF; FIM HOMF-!5 Flr5f FLOM MAN -rot2t2 HOOPF-P, ---------- -------- AZ - -------- — — — — — — — — - --------- - — — — — — — — — — — - —oo Foo Lol I I FC71 iN-CF NOCR 7'Z 7:5 a. 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