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Miscellaneous - 701 FOREST STREET 4/30/2018 (6)
� _ -§3 �\ r / � � ƒ N ti L`. O � a0 O H U aWar� > '7 [--IWW77]0 QQQ� O �oz0 b o O � a � o w C 0 G � 3a� y C ° U ^� O O N Cp 0 n ce ami A � •., � ' x L o O. 0 a � aAv�3aa 0 kn v o 0 0 z ° U n 1� I...I L a G7�r�a� �Ao O '41,W `~ MOD y� /nT �m ... . ��. . _.... ..... PARCEL # STREETCONSTRUCTION APPR 7 ; HAS PLAN REVIEW FEE BEEN PAID? NO PLAN APPROVAL: DATE APP. DESIGNER: TE c/ CONDITIONS`-�4��������&�.���v.�.�~� WATER SUPPLY: TOWN -----_- / , WELL PERMIT DRILLER --~--='"" -----'-�r--- --' - WELL TESTS: CHEMICAL DAE APPRUVEQ ..�/Y/-`�--Z.l. BACTERIA I DA[E APPRUVED ,�/&/��Z_ BACTERIA %I DATE APPHUVED________ COMMENTS: FORM U APPROVAL: APPROVAL TO ISSUE DATE ISSUED Y CONDITIONS: FINAL APPROVAL: ALL PERMITS PAID WELL CONSTRUCTION APPROVAL SEPTIC SYSTEM CONSTRUCTION APPROVAL OTHER ANY VARIANCE NEEDED FINAL BOARD OF HEALTH APPROVAL: NO YES NO YES NO YES NO YES NO YES NO DA7E: FINAL GRADING APPROVAL: DATE BY FINAL CONSTRUCTION APPROVAL: DATE:__�__.___.DY Commonwealth of Massachusetts City/Town of No Andover 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 within 14 days from the pumping date in accordance with 310 CMR 15.351. 6.stem Pumped By: SCP Name Stewart's Sentic Service Company 7. Location where contents were disposed: _,Stea s re -treatment Plant. 20 So. Mill Signature of Vehicle License Number Ma 01835 Date Date t5fonn4.doc- 03/06 System Pumping Record • Page 1 of 1 A. Facility Information Important: When filling out forms on the computer, 1. System Location: S + —7�6f ?_�cee use only the tab 01 I ��f key to move your Address cursor - do not use the return No Andover Ma key. City/Town Stat- de RECEIVED 2. System Owner: l�+ln k)R 09Z0 14 Name TOWN OF NORTH ANDOVER Address (if different from location) Citylrown State Zip Code Telephone Number B. Pumping Record )/ 1. Date of Pumping Date i 2. Quantity Pumped: Gallons 3. Type of system: ❑ Cesspool(s) Septic Tank ❑ Tight Tank ❑ Grease Trap ❑ Other (describe): 4. Effluent Tee Filter present? ❑ Yes ❑ No If yes, was it cleaned? ❑ Yes ❑ No 5. Condition of System: lod 6.stem Pumped By: SCP Name Stewart's Sentic Service Company 7. Location where contents were disposed: _,Stea s re -treatment Plant. 20 So. Mill Signature of Vehicle License Number Ma 01835 Date Date t5fonn4.doc- 03/06 System Pumping Record • Page 1 of 1 COMMONWEALTH OF MASSACHUSETTS North Andover Board Of Health Ogden Well & Pump Co., Inc. ---- ----------------- NAME 701 FOREST STREET --------------- --------------------- -------------------------- ADDRESS IS HEREBY GRANTED A PERMIT Well Construction NUMBER BHP -2004-0442 FEE $125.00 This permit is granted in conformity with the Statutes and ordinances relating thereto, and expires ----------- _ _ _ _ _ June 16, 2005 unless sooner suspended or revoked. ------------- - ---------------------- ------------------ June 16, 2004 Board O ----------------- --------- ----- ---------------- Health �C\ --------------------- --- - _-------------------------------------------------- -_ ---------- _----------------------------------------------- Town of North And ver ,�,/ Health Department Date: �/ D Location: (Indicate Address, if Residential, or Name of Business) Check #: 4 ,-: � 4! � 2d(en� Type of Permit or License: (Circle) ➢ Animal $ ➢ Dumpster $ ➢ Food Service - Type: $ ➢ Funeral Directors $ ➢ Massage Establishment $ ➢ Massage Practice $ ➢ Offal (Septic) Hauler $ ➢ Recreational Camp $ ➢ SEPTIC PERMITS: ❑ Septic - Soil Testing $ ❑ Septic - Design Approval $ ❑ Septic Disposal Works Construction (DWC) $ ❑ Septic Disposal Works Installers (DWI) $ ➢ Sun tanning $ ➢ Swimming Pool $ ➢ Tobacco $ ➢ Trash/Solid Waste Hauler $ >,,W -elf -Construction Construction $ Jam. ➢ OTHER: (Indicate) C _ , /tl' 105 Health Agent Initials White,- Applicant Yellow - Health Pink - Treasurer r) TOWN OF NORTH ANDOVER Office of COMMUNITY DEVELOPMENT AND SERVICES HEALTH DEPARTMENT :�•,'..� 27 CHARLES STREET NORTH ANDOVER, MASSACHUSETTS 01845 Susan Y. Sawyer, REHSIRS 978.688.9540 — Phone A Public Health Director 978.688.9542 — FAX healtl)dei)t@townofnortliandever.com www.townofitorthandover.com C�� 3t� LiI Well and/or Pump Application (Please print) DATE: LOCATION to Drill Well or install a pump: (3 1 1 Licensed Well Contractor Name and Company Name. ,= ,- CDCAp to l� L t l ren,'+ G0vA t -S 1 ►M r �� Contact Phone Numbers: Ij Homeowner: JI /I !w �� t l�Q_ �i ►1 Address: -701 Sj--' A., 'AZA al J -e " m Contact Phone Numbers: �f 7�.-.f2 7 3 G 4,5 Rx q 7.X 340 3 WELLS (to be completed at time of pumptest) Type of wetL Vt1 & Use: J+a A e ,e— Diameter of well: ,trl Size of Casing: 42 i ,, Depth of bedrock: Depth of easing into bedrock: Seal been tested? Yes( i No ( ) , Date of test: Depth of well: Water -bearing rock: Depth of water: Delivers: GPM for: (how long) Drawdown: feet after pumping:. hours at: GPM Date of Completion: Signature of Wcll Contractor PUMPS (To be filled in before installation) Name & size of Pump: Type.. Size of Tank: Pump delivers: GPM Pipe used in well: Cast Iron Galvanized Plastic Sleeve used to protect pipe? Yes No Type of well seal: Date: Signature of Pump Installer Date water analysis report submitted to Health Department: Plumbing Wiring Inspector C:1My DocumentsTermiffetnnt ApplicationslWell Application - 2004.doc r t 4 Health Department Representative 701 Forest Street 6/8/04 David Martin called to discuss well and bldg application. The owner wishes to go ahead with excavation of the foundation prior to the new well installation. Susan Sawyer spoke with Tom at Wilmington Pump about proper procedures and best management practices for this situation. 1) Owner should confirm with neighbor that an emergency hook up is possible if needed 2) Tom from Wilmington pump will set up appointment with the owner to go to the home, stake out the new location for the well and elevate the pump for easy access if there are problems with the excavation and work around the well. 3) Wilmington pump will submit a new well application, showing well location. Well location will then be approved by the health office and conservation dept. 4) Health dept will sign off on the building permit for the foundation 0 TOWN OF NORTH ANDOVER f r10RTN Office of COMMUNITY DEVELOPMENT AND SERVICES HEALTH DEPARTMENT p 27 CHARLES STREET n°UZ �9p�AATE° NORTH ANDOVER, MA:SSACHUS TS-Oi-84L5---- _--_, L978.688.9542 540 - Phone Susan Sawyer, REHS/RS - FAXPublic Health Director t@townofnorthandover.com nofnorthandover.coni EW Ta From: Fax: Pages: Phone: Date: Re: / CC: ❑ Urgent ❑ For Review ❑ Please Comment ❑ Please Reply ❑ Please Recycle Please contact the Health Department at the above numbers for further assistance. 11 HP Fax K 1220xi Last Transaction Date Time TVe Identification Log for NORTH ANDOVER 9786889542 Jun 07 2004 10:56am Duration Pages Res 1 Jun 7 10:54am Fax Sent 819786583557 1:39 3 OK TOWN OF NORTH ANDOVER Office.of COMMUNITY DEVELOPMENT AND SERVICES HEALTH DEPARTMENT : ", , ,•':' y9s ,,..o •"".h 27 CHARLES STREET NORTH ANDOVER, MASSACHUSETTS 01845 Susan Y. Sawyer, REHS/RS 978.688.9540 — Phone Public Health Director 978.688.9542 — FAX healthdept@a,townofnorthandover.com www.townofnorthandover.com Well and/or Pump Application (Please print) DATE: LOCATION to Drill Well or install a pump: Licensed Well Contractor Name and Company Name: Contact Phone Numbers: Homeowner: Address: 0 Contact Phone Numbers: WELLS (to be completed at time of pump'test) Type of well: Use: Diameter of well: Size of Casing: Depth of bedrock: Depth of casing into bedrock: Seal been tested? Yes( ) No ( ) _ Date of test: Depth of well: Water -bearing rock: Depth of water: Delivers: GPM for: (how long) Drawdown: feet after pumping: hours at: GPM Date of Completion: Signature of Well Contractor PUMPS (To be filled in before installation) Name & size of Pump: Size of Tank: Type: Pump delivers: GPM Pipe used in well: Cast Iron_ Galvanized Plastic Sleeve used to protect pipe? Yes No Type of well seal: , Date: Signature of Pump Installer Date water analysis report submitted to Health Department: Plumbing Wiring Inspector Health Department Representative C:\My Documents\Permit\Permit Applications\Well Application - 2004.doc Town of North Andover RE: 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 the house and or lot footprint 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. C:\My DocumentsTermitTermit Applications\Well Application - 2004.doc 701 Forest Street Proposed addition by owner, but no Form U submitted to date. FYI, both Conservation and Planning have reviewed this proposal over the past year. A TRC was held, but no written notes from Sandy are available. David Martin is the 978 360-3689 5/24/04 S. Sawyer was requested to review the idea of leaving a 12 yr old drinking water well and building a foundation around it. The driller would have a window placed such that the flexible pipe could be brought out the window in case of repair. 5/26/04 S. Sawyer spoke with a non -biased professional well driller, the Board of Health members and a representative of Wilmington Pump who would be the well installer at this location. To keep the existing well would require extensive work on the well itself. The casing would be changed from a solid to flexible material to allow bending. The wellhead would be cut off and reset at the new elevation. A foundation would be poured around the well. General maintenance on the well in the future would be difficult; but not impossible. A usual single man and a truck would normally be able to lift the numerous pumps from the well, however the 3 -story truck would not be able to be used to pull in this case. At least 3 men would be needed in the basement to pull out the components for repair. This is not allowed by Well Reg. 4.6, (accessibility for repair) The reg also states that the well shall be placed up gradient from any contamination sources. The basement itself could be a source of contaminants i.e. flooding or spills. Again, this is a concern for the health of the occupants. Mr. Martin was advised that before sign off, the BOH would require the well be abandoned and a new one be installed. If an application to do this project as proposed came before the health dept., it would be denied and the applicant could appeal to the BOH at a regular scheduled BOH meeting. TOWN OF NORTH ANDOVER of NORTh Office of COMMUNITY DEVELOPMENT AND SERVICES HEALTH DEPARTMENT 27 CHARLES STREET �AAiEO �P*,y'(h NORTH ANDOVER, MASSACHUSETTS 01845 CHDS�S 978.688.9540 - Phone Susan Sawyer, REHS/RS 978.688.9542 - FAX Public Health Director healthdept@townofnorthandover.com www.towndhorthandover.com FAX Ta Fax: Phone: /' Q From: Pages: Date: CC: ❑ Urgent ❑ For Review ❑ Please Comment ❑ Please Reply ❑ Please Recycle Please contact the Health Department at the above numbers for further assistance. 0 HP Fax K1220xi Log for NORTH ANDOVER 9786889542 Jun 01 2004 10:5 lam Last 30 Transactions Date Time Type Identification Duration Pales Result May 27 9:30am Fax Sent 89787947546 2:28 13 OK May 27 9:41 am Fax Sent 817816727811 2:17 5 OK May 27 11:09am Fax Sent 89786889556 1:24 2 OK May 27 11:26am Received 978 688 9556 1:46 2 OK May 27 11:57am Received CORPORATE 0:45 1 OK May 27 12:27pm Fax Sent 816033828323 1:55 3 OK May 27 12:38pm Received 603-659-0418 1:29 4 OK May 27 4:31pm Received 0:20 1 OK May 27 4:59pm Received 603-659-0418 1:04 3 OK May 28 1:43am Received M.V.Cham 0:47 1 OK May 28 8:41am Received 0:38 0 No fax May 28 10:12am Received 978 682 6378 0:36 1 OK May 28 10:29am Received 19784546394 0:35 3 OK May 28 11:40am Fax Sent 89785578856 0:52 2 OK May 28 2:37pm Fax Sent 819786947274 1:10 3 OK May 28 2:58pm Received 0:38 0 No fax May 28 3:20pm Fax Sent 818779279400 0:48 3 OK May 28 3:34pm Fax Sent 819784638716 1:42 2 OK May 28 3:37pm Fax Sent 816172223605 0:52 2 OK May 28 4:09pm Received 603-659-0418 1:01 3 OK May 28 6:53pm Received 617 983 6770 1:39 2 OK May 28 7:42pm Received 1:48 3 OK May 28 8:43pm Received 0:39 1 OK May 31 6:03pm Received FAX 1:05 1 OK Jun 1 8:51am Fax Sent 816038934608 2:46 3 OK Jun 1 9:07am Received 9786949226 1:09 4 OK Jun 1 9:35am Fax Sent 819786883690 0:52 2 OK Jun 1 9:37am Received 0:22 1 OK Jun 1 9:55am Fax Sent 819786583557 0:54 2 Jammed Jun 1 9:58am Fax Sent 819786583557 5:01 8 OK Town of North Andover Office of the Health Department Community Development and Services Division 27 Charles Street North Andover, Massachusetts 01845 Sandra Starr Public Health Director LEGAL NOTICE Telephone (978) 688-9540 Fax (978) 688-9542 In accordance with the Massachusetts General Laws, Chapter 111, Section 31, the North Andover Board of Health at its regularly scheduled meeting on January 24, 2002 revised the well regulations, including the overall format, to be effective immediately. The changes include. The inclusion of additional definitions, setback requirements, construction requirements, water quality parameters, and well abandonment procedures. Copies of the revised regulations can be reviewed at the North Andover Board of Health office located at 27 Charles Street during office hours and at the Town Clerk's office in the Town Hall on Main Street. Gayton Osgood, Chairman Dr. Francis P. MacMillan Dr. John Rizza, Clerk BOARD OF APPEALS 688-9541 BUILDING 688-9545 CONSERVATION 688-9530 HEALTH 688-9540 PLANNING 688-9535 TOWN OF NORTH ANDOVER BOARD OF HEALTH WELL REGULATIONS The Board of Health of the town of North Andover, Massachusetts acting under Chapter 111, Section 31 of the Massachusetts General Laws, as amended and with reference to Chapter 40, Section 54 of said General Laws has, in the interest of and for the protection of public health and the environment, established and adopted the following rules and regulations: Section 1. DEFINITIONS 1.1 The word "well" as used in these regulations shall include any pit, pipe, excavation, casing, drill hole or other private source of water to be used for the purpose of supplying potable water in the town of North Andover. This includes irrigation wells. 1.2 The words "water systems" as used in these regulations shall include pipes, valves, fittings, tanks, pumps, motors, switches, controls and appurtenances installed or used for the purpose of storage, filtration, treatment or purification of water for any use whether or not located inside of a building. 1.3 The words "well contractor" as used in these regulations, shall mean any person, association, partnership, company or corporation that installs, constructs or repairs a water system associated with a well. 1.4 The words "non-essential well" as used in these regulations refers to all wells that are not the sole source of potable drinking water for a site, whether residential or commercial. Section 2. REGISTRATION AND PERMITS 2.1 No well of pump contractor shall engage in the construction or repair of any part of a well or water system in the town of North Andover without registering with the Board of Health. Such registrations shall expire at the end of the year in which they were issued unless earlier revoked for cause. A non- refundable fee of $50.00 shall be paid to the town of North Andover. 2.2 No well shall be constructed until a well permit has been issued by the Board of Health. Such a permit shall be applied for by a well contractor registered with the town of North Andover. A non-refundable fee of $50.00 shall be paid to the town of North Andover. •sasPo asagq UT gzuiaad TTaM P Jo aouenssz ag14 og aOTad uOTsszunuOD UOTgPnaasuoD aanopuy ggaoN aqq wOaJ TPAO ddp uaggzaM go Adoo P aATaoaa TTPgs HOg eqs 'qOV UOTgoagoad spuPTgaM`aqg Aq UOTgPTnbaa oq goalgns sT puPTgOM P go ,OOT utggTM pagpooT TTaM pasodoad Auv •buzpooT; quagsTsuoo ;o PaaP UP UT ao puPTgaM pauTZap P UTggTM paoPTd aq qou TTPgs TTaM aqs b'C sTood buzumiims punoabaapun pup 'saaMas buzpTznq buTgszx0 WOJJ gaaj OZ (S •saop-;ans buznzap pup sauTT qoT 'sgaaags TTP uzoaJ gaag SZ go Xopgqas umulTUzui P ( b aoanos aagpM Aup go xapw gbTg TPuzaou aqq uioaJ ATTPaagPT gaag 05 (Z xueg oigdas Aup woag gaaj SL (Z sxuPq abpaogs punoabaapun bUTgsTxa ao PTaTj gOPOT OTgdas Aup uioag gaag OOT (T :buTmOTTOJ aqg 90 ssaoxa uz ao og TPnba Oq Og aaP goTgM saouegszp gP pagPOOT aq gsnui pup UozgPUTUIPquoo TPTquagod go saoanos TTP uroaj quazpPab-dn pagonagsuoo aq TTPgs gI '•buzpTznq goea Jog TTaM ageapdas P aq TTPgs aaags Z•S •aOznaas uT.aq TTTM qT 140TLIM UT qoT agg go sazaepunoq aqq UTggTm aq gsnul TTaM P go uozgeOOT agy T•S ONISIS ggSM 'C UOt400S 'ggbnoap go sauzzq UT se 'os OP oq ggTPag OTTgnd go gsaaagUT 0144 UT ST gz uagM TTaM Tetquassa -UOU P. ao; UOTgPOTTddp up Auap APui ggTPaH go papog aqy 8'Z •uiagsAs aageM UmOq aqq oq ssaooP aTgpuospaz seg ATquaaano gegq Agaadoad Aue ao! panssz aq qou TTpgs TTaM P go UOTgonagsuoo aq-4 aog gtuzaad V L'Z • ggTPOH go papog aqq Aq panoadde aq gsnui sivagsAs aagPM ao/puP sTTaM 6uzgsTx0 go a-rpdaa ao uozgPnouaa JOEPW 9'Z •uozgPagszbaa s,aogoPaguoo aqq go uOTgPooAaa aqq ao9 asnPo aq Aeui anTgequasaadaa qou OaP goTgM paATaoaa SWJ02 • UOTq@Tduioo sqz uodn ggTPaH 3o papog aqq qP OTTJ uo gdax sazdoo pup ATageanooe gno paTTTJ aq gsnw uiaoi P gonS •aogopaguoo dumd PUP TTaM aqq Aq qno paTTTJ aq oq gTwaad TTaM agq ggTM buOTP panssz aq TTPgs waOg TTaM V S'Z -aTgPTTPnP sz aagPM aTgpgod 40 ATddns agpnbapp pup a;Ps P gPgg pautuiaagap spq ggTPaH go paPog aqg PUP paTTPgsUT uaaq sPq TTOM P TTqun 'pagonagsuoo aq oq sz buzpTznq aqq aaagM puPT aqq uo pagPooT -7@-412MTTaM P ao; UTaaagq-7@-412MJo asn aqq sagPgTssaoau goTgM buzpTznq P �o uozgonagsuoo aqq ao; panssz aq TTPgs gzuiaad buzpTznq ON •uozgonagsuoo TTaM og aOTad quauigaPdac buzpTznq aqq Aq panssz PUP ao9 paTTddP aq TTPgs sgTwaad bUTgwnTd pup buTaTM agPzadoaddV S•Z Section 4. CONSTRUCTION REQUIREMENTS 4.1 The well contractor shall observe reasonable sanitary measures and precautions in the performance of his work in order to prevent the pollution of contamination of the well. 4.2 Newly constructed wells or wells where repair work has been done shall be thoroughly disinfected before being put into use. 4.3 Every well shall supply adequate water for the purpose for which it is intended and shall give satisfactory evidence of continuing capability to do so. 4.4 Before being approved, every well shall be pump tested by the well contractor (4 hr pump test). The results of the pump test shall be submitted on the well form issued by the Board of Health. A well shall exceed the following flow rates, or it shall be considered inadequate for a single family dwelling. Well Depth Gallons per Minute for Four Hours 0 - 150 5 - 6 150 - 200 4 200 - 250 2 - 3 250 - 300 1 -2 350 and over 1/2 4.5 There shall be a single and separate water system for each dwelling and it shall not be installed or materially altered until the Board of Health is notified. The Board will require a description of the installation or repair to be conducted. Emergency work for repairs or service of existing equipment not amounting to a substantial renovation or overhaul may be done without notification. Appropriate inspections by wiring or plumbing inspectors will be required before final Board of Health approval. 4.6 All pumps, motors and tanks shall be placed on a suitable foundation and all equipment and parts of the system that may require adjustments or service shall be made readily accessible. 4.7 All pump houses, pump or pipe pits and wells shall be designed and constructed so as to prevent flooding and otherwise to prevent the entrance of pollutants or contaminants. 4.8 The Board of Health shall require the installation of all necessary switches, controls and devices, and the satisfactory performance of a pressure and operating test of the system before final approval; the test must demonstrate that the system will deliver adequate pressure and volume consistent with the well and the well requirements. The Board of Health must be given reasonable notice of when the installation is ready for inspection. 4.9 No certificate of occupancy shall be issued until all the provisions of these regulations have been met. The inspections and these regulations cannot be construed as a guarantee by the town of North Andover or its agents that the water system will function satisfactorily. Section 5. WATER QUALITY 5.1 In cases of new construction, the Board of Health shall require the submission of a water analysis report. The report shall include bacterial and chemical evaluations conducted by a laboratory approved by the Board of Health or the Massachusetts Department of Public Health. Laboratories conducting testing must supply a copy of Massachusetts certification as verification that it holds current certification for all types of analysis done on water samples. The submission of a chemical analysis to the Board of Health is required before issuance of a building permit. The bacterial analysis must be conducted after the water system is completely installed. A report must be submitted before the Board of Health will issue final approval. The following minimal parameters must be included in the water analysis. total coliform alkalinity arsenic calcium chloride color copper hardness iron lead magnesium manganese nitrogen (ammonia) * nitrogen (nitrite) * odor pH * potassium sediment sodium sulfate turbidity total dissolved solids * indicates Primary Contaminants Additional information shall be required if the well is in an area of agricultural use or within 500-1000 feet of utility rights -of - .way 5.2 All primary contaminants shall meet EPA standards. Based on the results of the water analysis reports, the Board of Health may require additional treatment of a water supply. Section 6. PERMANENT OR TEMPORARY WELL ABANDONMENT 6.1 All permanently abandoned wells shall be tightly sealed by approved methods to prevent pollution of the ground water. Prior to plugging, the well shall be checked for debris that may interfere with the process. If the integrity of the original well seal is in doubt, the casing shall be removed or perforated. In addition all pumping equipment and associated plumbing shall be disconnected and removed. 6.2 When a well is not abandoned, but is out of use for an extended period of time, it shall be the owner's responsibility to properly maintain the well and to prevent the development of defects which may facilitate the impairment of water quality in the well or in the water bearing formations penetrated by the well. Until a well is permanently abandoned by plugging procedures, all provisions for protection of the water from contamination and for maintaining sanitary conditions around the well shall be carried out to the same extent as though the well were in routine use. 6.3 To temporarily abandon a well, the top of the well casing shall be sealed with a watertight threaded cap or with a steel plate welded watertight to the top of the casing. If the top of well seal is watertight, the pump may be left in place. A well that has, after extended use, been temporarily abandoned for three (3) years shall be considered permanently abandoned, and shall be appropriately plugged. Section 7. PENALTIES 7.1 Any person who shall violate any provisions of these regulations for which a penalty is not otherwise provided in any of the General Laws or Sanitary Code shall upon conviction be fined not less than fifty nor more than five hundred dollars. Section 8. UNCONSTITUTIONALITY CLAUSE 8.1 So far as the Board of Health may provide each section of these rules and regulations shall be construed as separate to the end that if any section, item, sentence clause or phrase shall be held invalid for any reason, the remainder of these rules and regulations shall continue in effect. Gayton Osgood, Chairman Dr. Francis P. MacMillan Dr. John Rizza, Clerk s Published N.A. Citizen, February 9, 1984 Rev. 9/90 Rev. 1/02 Town of North Andover Office of the Health Department Community Development and Services Division 27 Charles Street North Andover, Massachusetts 01845 Sandra Starr Public Health Director LEGAL NOTICE Telephone (978) 688-9540 Fax (978) 688-9542 In accordance with the Massachusetts General Laws, Chapter 111, Section 31, the North Andover Board of Health at its regularly scheduled meeting on January 24, 2002 revised the well regulations, including the overall format, to be effective immediately. The changes include. The inclusion of additional definitions, setback requirements, construction requirements, water quality parameters, and well abandonment procedures. Copies of the revised regulations can be reviewed at the North Andover Board of Health office located at 27 Charles Street during office hours and at the Town Clerk's office in the Town Hall on Main Street. Gayton Osgood, Chairman Dr. Francis P. MacMillan Dr. John Rizza, Clerk BOARD OF APPEALS 688-9541 BUILDING 688-9545 CONSERVATION 688-9530 HEALTH 688-9540 PLANNING 688-9535 Town of North Andover Office of the Health Department Community Development and Services Division AM*, 2/ 4llarle§. Street �l Q�Rnteo�Z North Andover, Massachusetts 01845 VSs aCH6 Sandra Starr Public Health Director LEGAL NOTICE Telephone (978) 688-9540 Fax (978) 688-9542 In accordance with the Massachusetts General Laws, Chapter 111, Section 31, the North Andover Board of Health at its regularly scheduled meeting on January 24, 2002 revised the well regulations, including the overall format, to be effective immediately. The changes include. The inclusion of additional definitions, setback requirements, construction requirements, water quality parameters, and well abandonment procedures. Copies of the revised regulations can be reviewed at the North Andover Board of Health office located at 27 Charles Street during office hours and at the Town Clerk's office in the Town Hall on Main Street. Gayton Osgood, Chairman Dr. Francis P. MacMillan Dr. John Rizza, Clerk BOARD OF APPEALS 688-9541 BUILDING 688-9545 CONSERVATION 688-9530 HEALTH 688-9540 PLAN IING 688-9535 TOWN OF NORTH ANDOVER BOARD OF HEALTH WELL REGULATIONS The Board of Health of the town of North Andover, Massachusetts acting under Chapter 111, Section 31 of the Massachusetts General Laws, as amended and with reference to Chapter 40, Section 54 of said General Laws has, in the interest of and for the protection of public health and the environment, established and adopted the following rules and regulations: Section 1. DEFINITIONS 1.1 The word "well" as used in these regulations shall include any pit, pipe, excavation, casing, drill hole or other private source of water to be used for the purpose of supplying potable water in the town of North Andover. This includes irrigation wells. 1.2 The words "water systems" as used in these regulations shall include pipes, valves, fittings, tanks, pumps, motors, switches, controls and appurtenances installed or used for the purpose of storage, filtration, treatment or purification of water for any use whether or not located inside of a building. 1.3 The words "well contractor" as used in these regulations, shall mean any person, association, partnership, company or ,corporation that installs, constructs of repairs a water system associated with a well. 1.4 The words "non-essential well" as used in these regulations refers to all wells that are not the sole source of potable drinking water for a site, whether residential or commercial. Section 2. REGISTRATION AND PERMITS 2.1 No well of pump contractor shall engage in the construction or repair of any part of a well or water system in the town of North Andover without registering with the Board of Health. Such registrations shall expire at the end of the year in which they were issued unless earlier revoked for cause. A non- refundable fee of $50.00 shall be paid to the town of North Andover. 2.2 No well shall be constructed until a well permit has been issued by the Board of Health. Such a permit shall be applied for by a well contractor registered with the town of North Andover. A non-refundable fee of $50.00 shall be paid to the town of North Andover. 2.3 Appropriate wiring and plumbing permits shall be applied for and issued by the Building Department prior to well construction. 2.4 No building permit shall be issued for the construction of a building which necessitates the use of water therein for a well located on the land where the building is to be constructed, until a well has been installed and the Board of Health has determined that a safe and adequate supply of potable water is available. 2.5 A well form shall be issued along with the well permit to be filled out by the well and pump contractor. Such a form must be filled out ac-curately and copies kept on file at the Board of Health upon its completion. Forms received which are not representative may be cause for the revocation of the contractor's registration. 2.6 Major renovation or repair of existing wells and/or water systems must be approved by the Board of Health. 2.7 A permit for the construction of a well shall not be issued for any property that currently has reasonable access to the town water system. 2.8 The Board of Health may deny an application for a non- essential well when it is in the interest of public health to do so, as in times of drought. Section 3. WELL SITING 3.1 The location of a well must be within the boundaries of the lot in which it will be in service. 3.2 There shall be a separate well for each building.. It shall be constructed up -gradient from all sources of potential contamination and must be located at distances which are to be equal to or in excess of the following; 1) 100 feet from any septic leach field or existing underground storage tanks 2) 75 feet from any septic tank 3) 50 feet laterally from the normal high mark of any water source 4) a minimum setback of 25 feet from all streets, lot lines and driving surfaces. 5) 20 feet from existing building sewers, and underground swimming pools 3.4 The well shall not be placed within a defined wetland or in an area of consistent flooding. Any proposed well located within 100' of a wetland is subject to regulation by the Wetlands Protection Act. The BOH shall receive a copy of written approval from the North Andover Conservation Commission prior to the issuance of a well permit in these cases. Section 4. CONSTRUCTION REQUIREMENTS 4.1 The well contractor shall observe reasonable sanitary measures and precautions in the performance of his work in order to prevent the pollution of contamination of the well. 4.2 Newly constructed wells or wells where repair work has been done shall be thoroughly disinfected before being put into use. 4.3 Every well shall supply adequate water for the purpose for which it is intended and shall give satisfactory evidence of continuing capability to do so. 4.4 Before being approved, every well shall be pump tested by the well contractor (4 hr pump test). The results of the pump test shall be.submitted on the well form issued by the Board of Health. A well shall exceed the following flow rates, or it shall be considered inadequate for a single family dwelling. Well Depth Gallons per Minute for Four Hours 0 - 150 5 - 6 150 - 200 4 200 - 250 2 - 3 250 - 300 1 -2 350 and over 1/2 4.5 There shall be a single and separate water system for each dwelling and it shall not be installed or materially altered until the Board of. Health is notified. The Board will require a description of the installation or repair to be conducted. Emergency work for repairs or service of existing equipment not amounting to a substantial renovation or overhaul may be done without notification. Appropriate inspections by wiring or plumbing inspectors will be required before final Board of Health approval. 4.6 All pumps, motors and tanks shall be placed on a suitable foundation and all equipment and parts of the system that may require adjustments or service shall be made readily accessible. 4.7 All pump houses, pump or pipe pits and wells shall be designed and constructed so as to prevent flooding and otherwise to prevent the entrance of pollutants or contaminants. 4:8 The Board of Health shall require the installation of all necessary switches, controls and devices, and the satisfactory performance of a pressure and operating test of the system before final approval; the test must demonstrate that the system will deliver adequate pressure and volume consistent with the well and the well requirements. The Board of Health must be given reasonable notice of when the installation is ready for inspection. 4.9 No certificate of occupancy shall be issued until all the provisions of these regulations have been met. The inspections and these regulations cannot be construed as a guarantee by the town of North Andover or its agents that the water system will function satisfactorily. Section 5. WATER QUALITY 5.1 In cases of new construction, the Board of Health shall require the submission of a water analysis report. The report shall include bacterial and chemical evaluations conducted by a laboratory approved by the Board of Health or the Massachusetts Department of Public Health. Laboratories conducting testing must supply a copy of Massachusetts certification as verification that it holds current certification for all types of analysis done on water samples. The submission of a chemical analysis to the Board of Health is required before issuance of a building permit. The bacterial analysis must be conducted after the water system is completely installed. A report must be submitted before the Board of Health will issue final approval. The following minimal parameters must be included in the water analysis. total coliform alkalinity arsenic calcium chloride color copper hardness iron lead magnesium manganese nitrogen (ammonia) * nitrogen (nitrite) * odor pH * potassium sediment sodium sulfate turbidity total dissolved solids * indicates Primary Contaminants Additional information shall be required if the well is in an area of agricultural use or within 500-1000 feet of utility rights-of- way 5.2 All primary contaminants shall meet EPA standards. Based on the results of the water analysis reports, the Board of Health may require additional treatment of a water supply. Section 6. PERMANENT OR TEMPORARY WELL ABANDONMENT 6.1 All permanently abandoned wells shall be tightly sealed by approved methods to prevent pollution of the ground water. Prior to plugging, the well shall be checked for debris that may interfere with the process. If the integrity of the original well seal is in doubt, the casing shall be removed or perforated. In addition all pumping equipment and associated plumbing shall be disconnected and removed. 6.2 When a well is not abandoned, but is out of use for an extended period of time, it shall be the owner's responsibility to properly maintain the well and to prevent the development of defects which may facilitate the impairment of water quality in the well or in the water bearing formations penetrated by the well. Until a well is permanently abandoned by plugging procedures, all provisions for protection of the water from contamination and for maintaining sanitary conditions around the well shall be carried out to the same extent as though the well were in routine use. 6.3 To temporarily abandon a well, the top of the well casing shall be sealed with a watertight threaded cap or with a steel plate welded watertight to the top of the casing. If the top of well seal is watertight, the pump may be left in place. A well that has, after extended use, been temporarily abandoned for three (3) years shall be considered permanently abandoned, and shall be appropriately plugged. Section 7. PENALTIES 7.1 Any person who shall violate any provisions of these regulations for which a penalty is not otherwise provided in any of the General Laws or Sanitary Code shall upon conviction be fined not less than fifty nor more than five hundred dollars. Section 8. UNCONSTITUTIONALITY CLAUSE 8.1 So far as the Board of Health may provide each section of these rules and regulations shall be construed as separate to the end that if any section, item, sentence clause or phrase shall be held invalid for any reason, the remainder of these rules and regulations shall continue in effect. Gayton Osgood, Chairman Dr. Francis P. MacMillan U(Pl� Dr. John Rizza, Clerk Published N.A. Citizen, February 9, 1984 Rev. 9/90 Rev. 1/02 FORM U - IAT AFTFM 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***************** t/ -'APPLICANT: WAZ,75n 74l Phone LOCATION: As=sessor's Mac Number Parcel Subdivision Lots) Street 1 .sT St. Number ?61 ************************Official Use Only************************ RECOMMENDATIONS OF TOWN AGENTS: Ll--.-- / cons ar-%anion Ad=inistrator Ccs;.^ e:a- Town Planner Comments Food _rspector-::ealth Sect_c Ir.sce Heat'}^ iNcr S - sewer/water connect ons - dr_vewav permit - Fire Decarzment Date Arcroved Dame Rejected Dame Approved Dame Rejected Dame Arcroved Date Rejected Date Approved k G Date Resected Receive: by Building Insrector Data a �J M • z F - Z W W c i v Z c in u (5, Z H 0 arA �� - •O H i. CL 411 E CL �j c • � L _ :rO z � C � E � — yr - .0 � � � rr c°+ ° a. CO i— V CL V az ::D a. c a to • vi og !_ C C LLJ r x c, •a . a U � e�: w -- Q Q mom° � ? c a o C m Q � �o `o .o tv rr e N W Q e a to 01 O Q •m C C p c Q i* r.• V •E w v e Q ~ F r S. Q � oc Llg06 7 0 y 1 r J W Nd5 � m N* J V m Y 5 O F - Z W W c i v Z c in u (5, Z H 0 arA �� - •O H i. CL 411 E CL �j c • � L _ :rO z � C � E � — yr - .0 � � � rr c°+ ° a. CO i— V CL V az ::D a. c a to • vi og !_ C C LLJ r x c, •a . a U � e�: w -- Q Q mom° � ? c a o C m Q � �o `o .o tv rr e N W Q e a to 01 O Q •m C C p c Q i* r.• V •E w v e Q ~ F r S. Q NUMIzER FEE 33� THE COMMONWEALTH OF MASSACHUSETTS -- __-$ 0.0 .....--.T-OWN.- of ---------ORTH._ ANDOVER.........-. This is to Certify that ------------- Skill -inns ... &...S.Ons...... Inc... .... ..................................... .-- NAME 269 Proctor Road, Hollis, N.H. 03049 ...... ------------------------------------------•------•-•--------------------...-----------....•-----•--•----------.....----------...•--.......-- ................... ADDRESS IS HEREBY GRANTED A LICENSE For ............ Well .... Drilling_.. -__-Lot #4 Forest- - Street -- -------------- -- ----------- -- - ............................. ............ ........... ............ ------------..................----........--------.................. ......... ---- ................ .-- .......................... -.......................................................................... ...---------------------- .................... .------- ----- --- This license is granted in conformity with the Statutes and ordinances relating thereto, and expires ..... .Decembe-r... -31-,----1-9-9.2--- ---------- unless sooner suspended or revoked. '00/0' ............... --- 53-ei- 8- -----pril--..3.0.,..........................1.9..92 v .------------------ .................... FORM 433 HOBBS $ WARREN. INC. 66 LITTLETON ROAD WESTFORD, MA 01886 (508) 692.8395 FAX (505) 692-0023 1.800.649•TEST Report Number: C-wps-5845 Report Date: June 9,1992 Client: Sample Taken At: Wilmington Pump Supply Inc. P.O. Box 517 Wil.miugt:on, MA 01887 Sample Taken By:Client Flifrt:lock Forest St. N. Andover Lot IN On: June 2 & 5,1992 CERTIFICATE OF ANALYSIS TEST PARAMETER: EPA Max Total Coliform (P) Per 100m1 0 Calcium No Limit, Copper (S) mg/I, 1.3 Iron (S) <0.01 0.3 Magnesium No Limit Manganese (S) 68 0.05 Sodium mg/1, 20 Potassium (S) No Limit Alkalinity (S) No Limit Ammonia No LiMit Chloride (S) mg/L 250 Chlurine (total.) 7.2 0.7 Color (S) TON 15 Conductivity No Limit Hardness No Limit Nitrates(as N)(P) 10 Nitr.itea(as N) 1 pH (S) 6.5-8.5 Odor (S) 3 Sulphates (S) 250 Turbidity 5 Sediment, pos/neg RESULTS UNITS 0 Per 100m1 23.8 mg/L <0,01 mg/L <0101 mg/I, 4.5 rrrg/L <0.01 mg/L �U mg/L, 2.2 mg/I, 68 mg/L <0.03 mg/1, 13.2 mg/L <0.02 mg/L 0 CPU 180 umbos/cm 78 mg/L <0.01. mg/L <0.01 mg/L 7.2 Su 0 TON 20 n /L 0.69 NTU neg NT=Not Tested, #=Value Exceeds EPA STD, TNTC=Toa Numerous to Count *L=Background Bacteria Noted, "=EPA Advisory Limit. '=Exceeds EPA Advisory Limit (P)=Primary EPA Standard, (S)=Secondary EPA Standard (may affect aesthetics of drinking water i.e, taste, color, etc.) This waiter- sample, as tested, meets or exceeds EPA health standards for.the parameters listed above. The quality of this water is accepted as POTABLE according to EPA Standards. Massachusetts State Certified Testing Laboratory #MA048 Michael P. Carlson, for Thorstensen Laboratory Inc. i .�'/ Ochai uncal of [nvironmcntal Mml�grtncnUDivision of Water Resources COMPLETION REPORT WATER WELL I GCOGnAPIIIC DESCRIPTION WELL LOOT rN .•�/ G% r ®S G W of Address i city/Town { i Well owner • N, e0 W Of Address v 1 t Board of Ilcallh perlllil: n inirrSC6L wI troadJ ye% r10 to WELL USE WI=LL DATA l � tt' i 'i Domestic 0 PubliC Q well depth Total we lnrlustrial ❑ / It. Depth to bedrock { tylonitoring ❑ Other --- led malerlal: Waler-ba•'srtng tockhulconsolid ' Mothod drilled q Uoscrtptiott,. 1 { Date drilled! p ( 1 — Water•bcaring as -/ Q " To CASING II Frorn Typo 21 From�To .� Length it, Oiaf.LO.j G —ill. 1) Ftont_ To Length up Lcdrock— f t' Gravel pack well: dia, r Ptotee Ive we I s a : Screen: dia.._----�-- Grout_© Other slot ✓ length, -from.^ --to STATIC WATER LEVEL 03 t i Stolle water level below la'rld surfaed It. i' ( WELL TEST r at�OPtn • Drawdowr;,;'''r v It. after pumping fir. n11n. lhr,�tnln. { ` Recovery after Nowmeasured 0 i ! ! LOG of FORMATIONS CommF IS , atdl�rr from To Z /r Driller I I � Mass. Regis 11 ne Firm r i Address I I City/Town t an�l�/a Ol' yal v/ nq /i J/rred welt dI / rl.ar p or lumry _..._..-_-- D R I L L E R COPY -------------------------------------------------------------------------- JUN 10 '92 0:36 P. 2 a Deftartment of Environmental Mal-Went/Division of Water Resources WATER WELL COMPLETION REPORT WELL LO kiN GEOGRAPHIC DESCRIPTION �f Address' t 9 � OS E W of (feet/ (Ci lel �]��,,{/ ' " !1 City/Town ' s Well owner (road) s# Address N' 040 W of (mi. in tenths) (I 1 intersect. w/ (road) Board of Health permit: yes no E] WELL USE WELL DATA Total depthft. Domestic X Public ❑ Industrial ❑ well Monitoring ❑ Other Depth to bedrock ft. Water -bearing rock/unconsolid led material: �-- Method drill p Date drilled(,.�" t Description Description Water -bearings: 1) From MTo CASING Type ttLLhh2) Lengthft. Dia(.I.D.) li in. From To 3) From To Length i o bedrock ft. Gravel pack well: dia. Protec Ave wells al: Screen: dia. Grout.❑ Other Slotl$length from_ to STATIC WATER LEVEL Static below water level land surface ft. Date WELL TEST Drawdown ft. after pumping hr.L�min. at gpm How measuredRecovery.. after-1-4tr, min. 0 LOG of FORMATIONS COMM TS - From To aterialsm Driller / Mass. Regis I ,n r Firm r �f Address CitylTown ' t nature of s t ervising registered well dr! r Plea" print firmly BOARD F HEALTH COPY tl BOARD OF HEALTH Town o£ North Andovez,Mas kop , Permit ;# Jte APPLICATION FOR WELL & PUMP P RM T h,pplication is hereby made for permit to drill. a well Application is made to install (_) a pump system'. Location: Address.. -Lot # Owncr Address _ / el. — t•Iell Contracto ddre, s Pump Contractor Address _ ✓�� Tel. ,)1:LL CONTRACTOR (To be completed at time of pump test) Well used for Type of Well I)i.ametcr. of Well Size of. C'asi.ng Depth of Bed Rock �,7r ! Depth casing into Bed Rock tJ:is Seal Tested? Yes (V) No (—) Date. of Testing Depth ..o-f—We-L].— —AA Well ,Ended in What. Material i)epth to Water DeliversGals. er �€e- ur oi:awdown feet after pumping__ __hours at GPM. i)ate of Completion Signature Well Contractor ' ':C ;Y ;Y r.: ..:.:. •..•.:•..•..•. r; ;...:::: %v i:. is �C .................. ........................' is :. ............................ ...... n if'ti .. i. is * .'�'7k* !'t.HP INSTALLER (To be-- f-illcd in- b,94 o r c i.nsLaI]. tion) i -r.e & Name Pump _ _ _ _ _ ump ype. ed •),iter Pump Delivers GPM i .e of T k 'i.pe Material Used in Well:Cast Iron (_) Gnl.vnni.zed (—) Plastic r Pit ( ) or Piticss .Adapter (�) r� !, sleeve used to protect pipe?. Yes (_) NO(_) 'type or Name Well Seal )ate DP..? MLb Water analysi's r'epor-t submitted to hoard of ;lieal'Eh mt-e. release given tD owner of record & Bldg. r FORM U - LOT RELEASE FORM INSTRUCTIONS: This form is used to verify that all necessary approvals/permits from Boards and Departments having jurisdiction have been obtained. This does not relieve the applicant and/or landowner from compliance with any applicable local or state law, regulations or requirements. ****************Applicant fills out this section***************** APPLICANT: liC , Phone LOCATION: Assessor's Map Number Parcel Subdivision Lots) Street fir« J�z St. Number 'll/ ************************Official Use Only************************ RECOMMENDATIONS OF TOWN AGENTS: Date Approved Conservation Administrator Date Rejected Comments Town Planner Comments Date Approved Date Rejected N!/ -�f 19,t) Date Approved Health Agent Date Rejected Comments �,''� S��n4 IAJP/1 70 be Public Works - sewer/water connections - driveway permit Fire Department Received by Building Inspector Date 'T1 cn LA D «• • row CD fD CD 0 f9 o r ) i,R . d 1 VVV UQ ;acu A a _ (� a S — N CD Z l< O' 3 rLA+ K m 3 w cu � _v y O N r. O D ° Q O O n v � Z O kn 0 D r+ CD 0 r*v D �O tA .-, p ° � -- > Z m o D o ° �' _ X m m -, c0 3 CD ' n -� cu D N 2 A Z C D Z w mCD cov O 3 A ° a z p = a m N rD- O = D � = 3 7 m w Any appeal shall be filed within (20) does after the date r.,f firing of this Notice in tine office of the Town Clerk. µ! N••a i 3: `�tA f• A►nq.719 on lass �'"►,'4SgeHug�Ar �7RVff TOWN OF NORTH ANDOVER MASSACHUSETTS BOARD OF APPEALS NOTICE OF DECISION Date ...May. 18.,..1992............ Petition No.... 012-92 ............. Date of Hearing.. May. .13, . 1992... . Petition of Anna Gilbert .....................................................:......... Premises affected ..7.01. Forest. Street ................................................. Referring to the above petition for a variation from the requirements of the . Section. 7....... Paragraph.4...1..of . the. Zoning. Bylaw .................................................. so as to permit ..the . continued. existence. of..the. structure. on the. premises .......... After a public hearing given on the above date, the Board of Appeals voted to ... DENY .... the , var.iance.......................... and hereby authorize the Building Inspector to issue a Permit' to ..Anna Gilbert................................................................ for the construction of the above work, based upon the following conditions: leman Signed Frank Serio, Jr., •William-Sullivan;.Vice-Chairman ............ Walter• Soule; - Ole'!k • ..... • ............ Anna- W -Connor, ................................. Board of Appeals Any appeal shall b tfiled within (20) dais the date of tiing Of is is �wtice in the Office of the Town Geri,. NORTH 9 O S�f•E0 f6E NO OL O ..�:.... .q: ... A �p ppq�TfO PPP,`,(y AC US TOWN OF NORTH ANDOVER MASSACHUSETTS BOARD OF APPEALS ************************** * Anna Gilbert 701 Forest Street North Andover, MA 01845 * ************************** Petition #012-92 DECISION The Board of Appeals held a regular meeting on Tuesday, May 12, 1992 continued from April 14, 1992 upon the application of Anna Gilbert requesting a variation of the lot width requirement under Section 7, Paragraph 4.1 of the Zoning Bylaw so as to allow for the continued existence of the structure on the premises located at 701 Forest Street. The following members were present and voting: Frank Serio, Chairman, William Sullivan, Vice -Chairman, Walter Soule, and Anna O'Connor. The hearing was advertised in the North Andover Citizen on April 1 and 8, 1992 and all abutters were notified by regular mail. Upon a motion by Mr. Sullivan and second by Mr. Soule the Board voted unanimously to DENY the variance as requested. The Board finds that no hardship is shown and the granting of this variance would derogate from the intent and purpose of Section 10, Paragraph 10.4 of the Zoning Bylaw and would adversely affect the neighborhood. Dated this 18th day of May 1992. BOARD OF APPEALS Frank Serio, Jr Chairman Memorandum To: Justin Wood From: David Martin REV a" APR 1 6 200.3 NORTH ANDOVER PLA►NNINQ PPPARTMSNT Date: 04/15/03 Re: Proposed Addition to 701 Forest Street and Lot Line Changes Dear Justin, As discussed, I would appreciate a slot in the April 24t', Technical Review Committee Meeting. I am considering adding a 26' x 26' addition off the side of my house. The house is currently about 30 feet from the lot line. Also, because of the topography, additional grading may be required. Instead of asking the town for a variance and perhaps a grading easement. I have been informed that it may be more desirable to simply work with my neighbor and redraw the lot lines. I have spoken with my neighbor and he has agreed to do this. My neighbor is Scott Karpinski at 691 Forest Street. The Conservation Committee will be interested because the construction will occur near the 50 feet wetland buffer. I have already spoken with Julie Parrino about this matter. To satisfy the buffer zone requirements, a seven foot corner of the house may need to be overhung over the foundation. I also assume that the Health Department may be interested because I am adding the additional room. The house currently has a kitchen, family room, and living room on the first floor and 4 bedrooms on the second floor. The house was built in 1992 and the septic system was sized for a 4 bedroom house; Sincerely, David Martin 701 Forest Street North Andover, MA 01845 Home 978-687-3665 Cell 978-360-3689 T-7--> . _. -� f» § 4:§ \ .i \ \ j\§ G\d«2» .. .. \\\\\\\\\(,\\ \���. § [\�\ \\\\���\\\\| � }�/ \ \ -rr- \\ \ z\\ � \ / . /: � � z . © .. z r y2 <j\\ § » � ... �\\§/�� � :»®«u : j: T -T ------ — — — % \ \ \ \f i \ \ \ wH : t• i \\/\�. »\\\�� �� \ ���T � \\\ \ ~ r; / \«\92 ! \\ I ' }^ � [ � , � � � \ . .17\2/\} \� % \!(;( \\id©\\\j�I.§/;j§di f | � �� � \(� §dleL22 \�\\\\\ �\ ;:§ �. §,\jSj�«22 � \ / \ /)\ \��\\\� .i\' / \ \ \� / � \ \ \ � �\ , . 9 9 0 cr M (48zhZovsz e I I ^ N m /I a m m Do D z n n m O A z -� Z a ci O r\ a D \ li m m 0 Z z> c p .slt NIr > O D NY SOCiLI MISS E2v�ll-E N pr mD N -� O W Z a) m T 0 x O N m Z Z z o< S m N a N �Yr aYP O D m -lP '� m _ F N a N S B(e' 38Lo "! m .D ,0 O\ N 2 mob. T(e r m 2 A 79 .02' D N a p T Cn _+c 17 A N D OOO N n - 0 z <zc y a O r r D mN v m n Z n a D p T m n p T Vim< v O Z < f r rn- D Iz NCr m I z C>0 -V < O (nZ m < AO Z mnp n co Om O O n p7 D z v, z 3 - x <mnr O pm z z O' < Z r z n I Z to a z m D r D Ll c o c :4 z n m xrn DOo m Z- p U m 1 zrA, c w <r vN 9 w N Glp r - m pr Z d 0 O O N n a n D 0 Z F v m Vx _ z O J �. V - a Z D Z D Z O OZ n r Z Z.D e b Z" a Z O = N ,D D - ZZO O'o ( r _- DD n 0 Z O co Z D m O z N _m0 z v 2 a - a D N m = - - n r • o s � Y W Z z> c p > O D �Yr aYP ID O D N a p O Z n - 0 z y a O r r / S a 4• 1p 4 / S92s.0\ Gti uA N Q a N D � , �ri ' I00 Lr �O .. F. W .am rygem m O O m(1) O � (J1 m _ m —1 W` ?j� � �- 2C 'TI S W5�i3 :q r n ') .i < � —• ry O 0 �1 D\'.`4•• NW e`°2, ��/ 0-4 0 06 O Sir Z ED4E OF WETLAND T j.i'- _ _ �. �4 q �• O r) J w7' fE . FN. �W r p. Ill p j n j enrt T N s W ej. gait +� �E Si. i3 .v ST9 p a _ 0,, a O � , rn a m to • 811 Maple Vln•rl PLAN OF LAND OpgwN: OESrGNEO CHEC�EQ, 1� archio__ a m D ... .. .. 11. 1■ Il�: HoMhesS1A1121811 . r 1-Ax�N•iatrl+, riN•. U fSi` k18-6111 NORTH ANDOVER s DRAWN FOR I:nRuu•rril'g' mil - o l'I:'mmimg C.ai ih.rmr. o FLINTLOCK INC. P.U. BOX 531 j (0/(2/9Z NO. ANDOVER, Mn. SCALE I° -¢O' -AEv,. DESCRIpTIDN DATE. C �e���i�a For f /f0�iA Location Subject Job No. Page _ Date _ 8y — 724A�c For Location Subject Job No. Page Date 8Y - ne <rt'� .IMlSI v Mb 7r, in? -42851 TINE` For — Location Subject Job No. Page _ Date _ By — a4a- i2 -Al Memorandum To: Justin Wood From: David Martin PG +rmna atj ,� �'V, APS 1 6 2003 NOPTH ANDOVeR PhAN iN!n BERARTMENT Date: 04/15/03 Re: Proposed Addition to 701 Forest Street and Lot Line Changes Dear Justin, As discussed, I would appreciate a slot in the April 24t', Technical Review Committee Meeting. I am considering adding a 26'x 26' addition off the side of my house. The house is currently about 30 feet from the lot line. Also, because of the topography, additional grading may be required. Instead of asking the town for a variance and perhaps a grading easement, I have been informed that it may be more desirable to simply work with my neighbor and redraw the lot lines. I have spoken with my neighbor and he has agreed to do this. My neighbor is Scott Karpinski at 691 Forest Street. The Conservation Committee will be interested because the construction will occur near the 50 feet wetland buffer. I have already spoken with Julie Parrino about this matter. To satisfi7 the buffer zone requirements, a seven foot corner of the house may need to be overhung over the foundation. I also assume that the Health Department may be interested because I am adding the additional room. The house currently has a kitchen, family room; and living room on the first floor and 4 bedrooms on the second floor. The house was built in 1992 and the septic system was sized for a 4 bedroom house. Sincerely, David Martin 701 Forest Street North Andover. MA 01845 Home 978-687-3665 Cell 978-360-3689 � �oz • E . s i (9821—zot-9Z TRANE° for Location _ Subject _ Job No. Page _ Date By — lEV% �Z A � 26.102--4285) C, D D � m Jj O I� o N t"gSF� qo9 0�� W yN dn 0 2s Q'\ b ° _ roco r ° ro dt. 6t .�' .5 3� 9 jdi• m D 4• v o Iv a art 9 _(rnn mo .t ti4•. ' � cum P�e a � 3 U) 1gD o �. , na v co 8 £°� e4 $ . ��y •. 1 J "1 'f1 LP. y y1Se13 ill _v^6� vn 7 i i - - N. ' O O D1'. .\4 • _ IV W Wer: aO.4i df� / � �� lo 0 no v O rl T1 \ ED4E OF WETIpu .11• _ . /I' - 4 \ _ ^ /p tl � ITV o.) ° `\ 4 .''i /' r^.pb•"'n � J �Cy 0 0 HIC NIF o+ o w tv - NY SOCKI HISSE2vI��E N y OW zOm Z �� 9i m 0O xr O x Z .v S .'. T o m y n r Z m _ m N y 3 n p nw NZ D m m m xDln f 10 n SP�t.'38Lo V1 0 m.> OT r ON 1'. a m , N z x p 79.02'ID 00N c N m aT PLAN OF LAND � � � �11 DNAWN: DESIGNED C�ECKEO - � m • HIINII 1•Slrrrl 1 Ma m a m� ,•� bmbm ... _ .. - _ HO (�yt�(i hatnt NA II2IH0 l Olil v m n c x D a a Q 1AH-1,121 IN _(6M m f c r a NORTH ANDOVER D O D S 2 m D D N Z c N w s ' N Cr y < �0c: - - O N z m< O mm0z O O n o n c 0 m n m a z T s P.U. 80R 531 z 0 Z - NO. ANDOVER, MA. oz >� �z r>z n noTz o oaym nc nc ..:- ,> o zrbv X z m 1 �p m y 1 d c_ C, r W m 0 r V �D O m m D D x z f 0 1, z J z D Z - O 4 z J n O Z n- z > o Z n G �^ N m = x > D D z Z b V v m r v D a z o m Z D O z m m D m .... .. 'L: SD O z V a• X) ... - N m 0 O ..i t k �- Z •t ( � � Y I A �x -< t ^>' 2: cAll v m D b z Z o - Z a r (�' �•r--I 0 r \, h y .10 '.co . L r \4 d y 1 Q °c. rn p V co t"gSF� qo9 0�� W yN dn 0 2s Q'\ b ° _ roco r ° ro dt. 6t .�' .5 3� 9 jdi• m D 4• v o Iv a art 9 _(rnn mo .t ti4•. ' � cum P�e a � 3 U) 1gD o �. , na v co 8 £°� e4 $ . ��y •. 1 J "1 'f1 LP. y y1Se13 ill _v^6� vn 7 i i - - N. ' O O D1'. .\4 • _ IV W Wer: aO.4i df� / � �� lo 0 no v O rl T1 \ ED4E OF WETIpu .11• _ . /I' - 4 \ _ ^ /p tl � ITV o.) ° `\ 4 .''i /' r^.pb•"'n � J �Cy 0 0 1 G - �� 9i .v S .'. T o 0. �p N y '1 c N m PLAN OF LAND � � � �11 DNAWN: DESIGNED C�ECKEO - � m • HIINII 1•Slrrrl 1 Ma m n ... _ .. - _ HO (�yt�(i hatnt NA II2IH0 l Olil L 1AH-1,121 IN _(6M .. .'. .. .. - NORTH ANDOVER w s DRAWN FOR - NngI•rr ilig:tiul - - - FLINTLOCK INC. SCALE: I- s P.U. 80R 531 t NO. ANDOVER, MA. REV::' `::DESCRIPTION - DATE - ..:- 1 I .f 1 -- -• -, c o -T 35, P. No, 22150 I &Z-971 SF AciC 1 t �r t I Tr11S PLA�J 1S INTENDED F`OR ZONING PURPOSES OINLY, IT WAS COMPILED FROM EYISTING P=LANS AND RECGRDS "Y'lTH '3 LCIt`�r, LOCAT; �NS rCi IF]RIMED IN 7HE F'JELD: IT SHOULD NOT 2c- USED EUSED FOR PROPERTY LINE DE TERMIN— ".Tiu�J. k THE BUILDING IS N07 LOCATED IN AN ESTABIllS?-PED FLOOD HA7ARO AREA. ZONI^JG: R.--1 REOV'RED SETbAOKS: SiDE: REAR: CERTIFIED PLOT PLAN I i`d �T TCAZE•�z)T 5T AS PREPARED FOR Ufa 1`�oX �3t �1� . C�+.�",�cAs �;'�. �`•�. �J t A FILE No.:S�-j YVE HEREBY CERTIFY THAT WE HAVE EX?,YINED THE' PREMISES AND THAT ALL EASEKIENIS, ENIOROACHI> ENTS AND BUIll-DiNGS ARE LOCATED A.S 5H0Y/N. ALL BUILDI�N�"GS Si"7tO,WN CONF+DIN TO THE ZONING I AYVS OF THE �1LJMICIP A.I.IT`, WHEN COi`1STRUC T ED. MARC HIONDA &ASSUC:, INC. -. Er•,IGINEER NG AND PLANNIN'A CONSULTANTS rat lv'ONTVALE AVE„ SUITE I STuNEHAM, ,MA, 024180 (61-7) 438-- 5121 SCAL j "r l DATE: . . , • 3 - i ill[ 1 . _ - -. t• `r.N T� r Jb F- �•��';�� ?�J� i��1 i •--fit` ' [�-�•:, __ l.�� — ---- r i r r_ 1 1 E Q I y : -J'4� tL`.' . SA! , 51,)5 L SYS 76 •b.1f+C! - ...iw<."' W JI .... •s":. . F. u., . waver .. xwaar +�x1"_.ia"' an m'!i. "'+'K-41aKr�ItIYA�(L-KK SRIF �'..ii4llf'ia� ��.a �.. � .'•yc�'..f�s.. .. �-a�..4- •_ ...- DISPOSAL jl'�AARCRONDA & A Bb- SEWAGE :"STE�Al PLAN „ E,flA1 r i i1� � V« '61 4—'8-51,/', ,max • ��..:_�:^rt,•,au�ravc:.cx.:..,...,�c��ri:...:z�,� ... . 'i :r. + •1 Anna Gilbert 701 Forest St. N. Andover, MA. 01845 April 10, 1990 Ms. G i 1 bert : On a recent site visit to your property on 701 Forest St., it was evident that construction debris is being improperly stored. We must request that you clean all debris on your property as it is a health concern. It provides a breeding ground and harborage for insects and rodents and because it is in the watershed area, the water supply is at risk. We will give you 30 days from the date of this notice to rectify this problem. A site inspection will be done on the 30th day. If You can accompany the health inspector it would be beneficial. Please contact the Health office with your plan of action by calling 682-6483. Thank you, Stephanie J. L. Foley Health Agent a 310 CMR 10.99 Form 9 • Commonwealth F of Massachusetts From DEP File No. tGQ (To be provided by DEP) City Town North A'n'dover, MA ADDhcant r`?' i'r I Enforcement Order Massachusetts Wetlands Protection Act, G.L. c. 131, §40 AND UNDER THE TOWN OF NORTH ANDOVER BYLAW, CHAPTER 3, SECTION 3.5 North Andover Conservation Commission Issuing Authority To. Anna Gilbert Date of Issuance April 3, 1990 Property lot/parcel number, address 701 Forest Street Extent and type of activity: Dumping of construction debris in and near a wetland. The North Andover Conservation Commission has determined that the activity described above is in violation of the Wetlands Protection Act, G.L. c. 131, §40, and the Regulations promulgated pur- suant thereto 310 CMR 10.00, because: XK Said activity has beeniis being conducted without a valid Order of Conditions. ❑ Said activity has been/is being conducted in violation of an Order of Conditions issued to dated File number 242— Condition number(s) Other (specify) , The North Andover Conservation Commission hereby orders the following: The property owner, his agents, permittees and all others shall immediately cease and desist from further activity affecting the wetland portion of this property. Wetland alterations resulting from said activity shall be corrected and the site retumed to its original con- dition. Effective 11/10/89 , 9-1 North Andover Conservation Commission Issued by Completed application forms and plans as required by the Act and Regulations shall be Med with the North Andover Conservation CommissiPorbefore (date) and no further work shall be performed until a public hearing has been held and an Order of Conditions has been issued to regulate said work. Application forms are available at. NACC Of f ice . 120 Main St., (Town Hall) ep{specify) roperty owner shall lake every reasonable step to prevent further violations of the act No. Andover,MA Tel. 11682-6483 01845 Other All debris will be removed. Failure to comply with this Order may constitute grounds for legal action. Massachusetts General Laws Chap- ter 131. Section 40 provides: Whoever violates any provision of this section shall be punished by a fine of not more than twenty-five thousand dollars or by imprisonment for not more than two years or both. Each day or portion thereof of continuing violation shall constitute a separate offense. Questions regarding this Enforcement Order should be directed to Richard Doucette Issued by North Andover Conservation Commission Signature(s) (Administrator) 9-2b (S!onature of delivery person or certifiec mail number) DATE // 9r - Sheet of BOARD OF HEALTH TOWN OF NORTH ANDOVER SUBSURFACE DISPOSAL DESIGN REVIEW FEE_ PERMIT ## DATE RECEIVED a 21/2/0 APPLICANT --D. A', n d r 1 at, ASSESSOR'S MAP ADDRESS ENGINEER ADDRESS PLAN DATE CONDITIONS OF APPROVAL: • •� .. +Uv v L U V DISAPPROVED PARCEL ## LOT # STREET p/ REVISION DATE A Y%, P 390 315 475 RECEIPT F CERTIFIED MAIL NO INSURANCE -COVERAGE PROVIDED NOT FOR INTERNATIONAL MAIL ISee Reverse) _ Sent to NA GILA Street and No. or f:6kUT. ST. N A P.O.. State and ZIP Code Postage S Certified Fee 2 Special Delivery Fee Restricted Delivery Fee Return Receipt showing to whom and Date Delivered Return Receipt showing to whom. Date. and Address of Delivery TOTAL Postage and Fees Postmark or Date .� ®/J )f @ — cm c uj \$L . _ CD )\ _ . « �_� \ �� � ®a [{ Ea= /E \\ \\ \\ \\ -LL §§ 2 \\ \)}\ cD )/ \ /§ / {S j \$ {§ o« /- -_- \\\\)E &@ a\ Anna Gilb t 701 Sai St. N. Andover, MA. 01845 May 3, 1990 Ms. Gilbert: A site visit was conducted on 4/30/90 to your property. While some of the debris has been removed from the area around the wetlands, a considerable amount of debris remains that must be removed in order to protect the wetlands. I have discussed this problem with the Conservation Administrator and it was agreed that the debris be moved back, away from the wetlands, at least 10 feet from where it presently exists. If you have any questions regarding this matter, please contact me at 682-6483. Sincerely, 11 Stephanie J. L. Foley Health Sanitarian Richard Doucette Conservation Administrator SJLF/RD/pd 1. 4 Anna Gilbert 701 Salem St N. Andover, MA. OIS45 May 3, 1990 Ms. Gilberti A site visit was conducted on 4/30/90 to your property. While some of the debris has been removed from the area around the wetlands, a considerable amount of debris remains that must be removed in order to protect the wetlands. I have discussod this problem with tho Conservation,Administrator and it was agreed that the debris be moved back, away from the wetlands, at least 10 feet from where it presently exists. If you have any questions regarding me at 682-6483. Sincerely, Stephanie J. L. Foley Health Sanitarian Richard Doucette Conservation Administrator SJLF/RD/pd this matter, please contact 4-01-1996 7:19PM Jsn .U'7 04 10:55a FROM WILMINGTON PUMP SUPP 9786583557 NORTH HOOVER 97868996* 1. RECEIVED . p-2 SEP 2 3 2004 1'OWN OF NORTH ANDOVER ' . TT Office o,LCOMMUNITY DEVELOPMENT -AND 9.ERVI S� 1 HEALTH DEPARTMENT , : 27 CHARLEs STREET NORTH ANDOVER., MASSACHUSfi lTS 01845 Soup Y. Snwyr. REfdb " 4'181681*50 - phone Public Healtb Director 979.688,9542.- FAX • tualtAdeot,rhtown9fnt><ihor+doyeccom www_10wn0f110ritiar1d0ver!coot Weld 49SLgr•pump Application (Pkitae Pdnt) ' LOCATION to DAU WL41 or laat:all a pump IM Wei( Lil wdl Coatrmctor Nam and comp ay P1Am• v� W g 1„' N 44. W t. q •' .. � ,ice. � Contaet Phpne 1410netler•: of 7o' %!j[ :7 7 �Q i �! EQ 3 two �s 4L I QQ %Yit.1S Ito R1V�if) 1EVtllt+r!; 'type Yf freY• ..3%AL l)inooaorefwdl:, Deph of eta��>G � � otwbq bm ta!dfodo:_„ DopfA of Nell: � watenlrarl� reaY: !!f S Deplhet�raKv: w Ddlrr4m__Z0__. G►M lar: prxwdosrr;;���/ �� / �.,1feet atter pxeptef,,,� ' alll.a�.1 [� (t�„plyjlo�J A.eeaf4?n•lpppoa:....�,�y�1L'iL(�� �"`r � __� . 'T/- !T �asdros! �arewr MMP6 (Tobe idled in befet* ht"ImMoo) x*me,&sueofpump:,_.— L&W*ML'J tri • Typat .%cafTaok: �C s�a� >rom�tlrtlrers: tiPM fto end la. odll_ � Can iron— Qslvang" Plante Skew* M•odID ptogat pipe? Yes-- No��''�S`na of wdl seyt: a."r- Mote Sipttmneof[Map tas•ellet Duet wooer xaaly0s repad sebmitted to Health Depaftratet _. • `7 r ignmbiagf -•--- WLigIItntpeetor �- HealEhDelaeteeeeelpepsoaRrave C.Wy Doalmtx VN:1mitlP&=d ApplicatiftiN 01 A>7PU=iitm - 200440C is 0 b �i • 0 2 U 4� Z U) J 4J Cl- N CL a% � I.- 0 C W a O Za O Z H- O C Z_ Q v 0 J I CO .H fo Q m O Q LU W d' � I I a c� ao Co Ln Ln Lo U H - M Ln W 4J $I 4J•— O M .. O O .. O M .. O O .• O M .. O O .. O M .. O O .. O M .. 09/17/2004 10:40 9786920023 THORSTENSEN LAB P96L W 66 LITTLETON RbAD, WESTFORD, MA 01686 Rdport Number 86417 Client: (978) 692-8395 FAX(978)692-0023 1 -800 -649 -TEST Report Date: 9117/04 Sample Information. Wilmington Pump Supply David Martin PO Box 517 Forest St Wilmington MA 01887 N. Andover, MA Sampled by: Clicnt Date Received: 9/15/04 Date Sampled: 9/15/04 Certificate of Analy7ti§ Test Parameter EPA Lanit &SQ 1,&iu Total Coliform (P) 0 0 per100ml Fecal Coliform/ E.coli (P) Absent Absent perl00ml Calcium Not Spec. 66.4 mg/L Copper (S) 1.3 <0.02 mg/L Iron (S) 0.3 # 4.2 mg/L Magnesium Not Spec. 15.9 mg/L Manganese (S) 0.05 # 0.53 mg/L Potassium Not Spec. 2.6 mg/L Sodium See Note 40.5 mg/L Alkalinity (S) Not Spec. 138 mg/L Ammonia -N Not Spec. <0.03 mg/L Chloride (S) 250 136 mg/L Chlorine Not Spec. <0.02 mg/L Color (S) 15 12.5 CPU Conductivity Not Spec. 738 umbos/cm Hatdness Not Spec. 231 mg/L Nitrate -N (P) 10 0.43 mg/L Nitrite -N (P) 1 <0.01 mg/L Odor 3 2 TON PH (S) 6.5-8.5 7.0 SU Sulphate (S) 250 48.2 mg/L Turbidity Not Spec. 9.1 NTU Sediment pos/nog pos Legends: (P)=Primary EPA Standard, (S)=Secondary EPA Standard, #=Exceeds EPA Limit, TNTC=Too Numerous to Count, *=Background Bacteria Noted,' = Exceeds Advisory Limit Sodium Advisory Limits, Mass.�--20, NH=250. This water sample as submitted is considered SAFE to drink according to EPA guidelines. However, one or more parameters exceeds secondary limits as denoted by theed# sign. �,"�l� a Massachusetts Certification # MA048 Michael P. Carlson, for Thorstensen Laboratory Inc. Page 1 of 1 DelleChiaie, Pamela From: Sawyer, Susan Sent: Thursday, June 17, 2004 7:48 AM To: DelleChiai Forest Street - Well Construction ----- riginal Message ----- From: DelleChiaie, Pamela Sent: Wednesday, June 16, 2004 4:18 PM To: Sawyer, Susan Cc: McGuire, Mike Subject: 701 Forest Street - Well Construction Permit Hi Susan, This request for a well permit is coming in the same time as a building permit for an addition, so I added the permit under the same project number for tracking purposes. I will pull the file and leave the application in your box for review. 6/17/2004 FORM U e LOT RELEASE FORM 6- 3 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 or requirements. *****************************APPLICANT FILLS OUT THIS SECTION*********************** APPLICANT / ° � �`� y,PHONE LOCATION: Assessor's Map Number PARCEL SUBDIVISION LOT (S) / Qj STREET '274? "T. NUMBER ****** ********** 'OFFICIAL USE ONLY********'�****��************ 1,RECOMMENDATIONS OF TOWN AGENTS: CONSERVATION ADMINI TOR DATE APPROVED ! 2y i —h -z ( DATE REJECTED COMMENTS TOWN PLANNER COMMENTS FOOD INSPECTO"EALTH COMMENTS. &X., DATE APPROVED.. DATE REJECTED DATE APPROVED DATE REJECTED DATE APPROVED DATE REJECTED PUBLIC WORKS - SEWER/WATER CONNECTIONS DRIVEWAY PERMIT FIRE DEPARTMENT RECEIVED BY BUILDING INSPECTOR DATE Revised 9197 jm R A TITLE 5 OFFICIAL INSPECTION FORM — NOT FOR VOLUNTARY ASSESSMENT SUBSURFACE SEWAGE DISPOSL SYSTEM FORM PART A CERTIFICATION Property Address: 701 Forest Street North Andover, MA Owner's Name: David & Carol Martin Owner's Address: 701 Forest Street North Andover, MA 01845 Date of Inspection: October 14, 2003 Name of Inspector: (please print) George Norris Company Name: D.F. Clark, Inc. Mailing Address: P.O. Box 265, Ipswich, MA 01938 Telephone Number: (978) 356-5638 nc;t 2 � 203 CERTIFICATION STATEMENT I certify that I have personally inspected the sewage disposal system at this address and that the information reported below is true, accurate and complete as of the time of the inspection. The inspection was performed based on my training and experience in the proper function and maintenance of on site sewage disposal systems. I am a DEP approved system inspector pursuant to Section 15.340 of Title 5 (310 CMR 15.000). The system: X Passes Conditionally Passes Needs Further Evaluation by the Local Approval Authority /' + ?ev Fails Inspector's Signature: ,x 1. Plt" Date: 1 o 0 9 (a j The system inspector shall submit a copy of this inspection report to the Approving Authority (Board of Health or DEP) within (30) days of completing this inspection. If the system is a shared system or has a design flow of 10,000 gpd or greater, the inspector and the system owner shall submit the report to the appropriate regional office of the DEP. The original should be sent to the system owner and copies sent to the buyer, if applicable, and the approving authority. Notes and Comments ****This report -only describes conditions at the time of inspection and under the conditions of use at that time. This inspection does not address how the system will perform in the future under the same or different conditions of use. Title 5 Inspection Form 6/15/00 page I I Page 2 of 11 OFFICIAL INSPECTION FORM — NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: 701 Forest Street North Andover, MA 01845 Owner: David & Carol Martin Date of Inspection: October 14, 2003 Inspection Summary: Check A, B, C, D or E / ALWAYS complete all of Section D A. System Passes: X I have not found any information which indicates that any of the failure conditions described in 310 CMR 15.303 or in 310 CMR 15.304 exist. Any failure criteria not evaluated are indicated below. COMMENTS: B. System Conditionally Passes: One or more system components as described in the "Conditional Pass" section need to be replaced or repaired. The system, upon completion of the replacement or repair, as approved by the Board of Health, will pass. Answer yes, no or not determined (Y, N, ND) in the for the following statements. If `not determined' please explain. The septic tank is metal and over 20 years old* or the septic tank (whether metal or not) is structurally unsound, exhibits substantial infiltration or exfiltration or tank failure is imminent. System will pass inspection if the existing tank is replaced with a complying septic tank as approved by the Board of Health. *A metal septic tank will pass inspection if it is structurally sound, not leaking and if a Certificate of Compliance indicating that the tank is less than 20 years old is available. ND explain: Observation of sewage backup or break out or high static water level in the distribution box due to broken or obstructed pipe(s) or due to a broken, settled or uneven distribution box. System will pass inspection if (with approval of Board of Health): broken pipe(s) are replaced _ obstruction is removed _ distribution box is leveled or replaced ND explain: The system required pumping more than 4 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: Page 3 of 11 OFFICIAL INSPECTION FORM — NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: 701 Forest Street North Andover, MA 01845 Owner: David & Carol Martin Date of Inspection: October 14, 2003 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 1 of a public water supply. The system has a septic tank and SAS and the SAS is within 50 feet of a private water supply well. The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or more from a private water supply well*". Method used to determine distance "*This system passes if the well water analysis, performed at a DEP certified laboratory, for coliform bacteria and volatile organic compounds indicates that the well is free from pollution from that facility and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis must be attached to this form. 3. Other: Page 4of11 OFFICIAL INSPECTION FORM — NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: 701 Forest Street North Andover, MA 01845 Owner: David & Carol Martin Date of Inspection: October 14, 2003 D. System Failure Criteria applicable to all systems: You must indicate either "yes" or "no" to each of the following for all inspections: Yes No X Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool X Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool X Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool X Liquid depth in cesspool is less than 6" below invert or available volume is less than 1/2 day flow X Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s) Number of times pumped X Any portion of the SAS, cesspool or privy is below the high ground water elevation X Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply X Any portion of a cesspool or privy is within a Zone 1 of a public well X Any portion of a cesspool or privy is within 50 feet of a private water supply well X Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality analysis. [This system passes if the well water analysis, performed at a DEP certified laboratory, for coliform bacteria and volatile organic compounds indicates that the well is free from pollution from the facility and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis must be attached to this form.] No (Yes/No) The system fails. I have determined that one or more of the above failure criteria exist as described in 310 CMR 15.303, therefore the system fails. The system owner should contact the Board of Health to determine what will be necessary to correct the failure. E. Large Systems: To be considered large system the system must serve a facility with a design flow of 10,000 gpd to 15,000 gpd. You must indicate either `yes" or "no" to each of the following: (The following criteria apply to large systems in addition to the criteria above) Yes No the system is within 400 feet of a surface drinking water supply _ the system is within 200 feet of a tributary to a 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: 701 Forest Street North Andover, MA 01845 Owner: David & Carol Martin Date of Inspection: October 14, 2003 Check if the following have been done: You must indicate `Yes" or "no" as to each of the following: Yes No X Pumping information was provided by the owner, occupant, or Board of Health X Were any of the system components pumped out in the previous two weeks? X _ Has the system received normal flows in the previous two week period? X Have large volumes of water been introduced to the system recently or as part of this inspection? X _ Were as built plans of the system obtained and examined? (If they were not available note as N/A) X _ Was the facility or dwelling inspected for signs of sewage back up? X _ Was the site inspected for signs of break out? X _ Were all system components, excluding the SAS, located on site? X _ Were the septic tank manholes uncovered, opened, and the interior of the tank inspected for the condition of the baffles or tees, material of construction, dimensions, depth of liquid, depth of sludge and depth of scum? X _ Was the facility owner (and occupants, if different from owner) provided with information on the proper maintenance of subsurface sewage disposal systems? The size and location of the Soil Absorption System (SAS) on the site has been determined based on: Yes No X _ Existing information. For example, a plan at the Board of Health. X _ Determined in the field (if any of the failure criteria related to Part C is at issue approximation of distance is unacceptable) [3 10 CMR 15.302(3)(b)] Page 6 of 11 OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION Property Address: 701 Forest Street North Andover, MA 01845 Owner: David & Carol Martin Date of Inspection: October 14.2003 FLOW CONDITIONS RESIDENTIAL 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 Number of current residents: 5 Does residence have a garbage grinder (yes or no): Yes Is laundry on a separate sewage system (yes or no): No ; [if yes, separate inspection required] Laundry system inspected (yes or no): Seasonal use: (yes or no): No Water meter readings, if available (last 2 years usage (gpd)): Well water Sump Pump (yes or no): No Last date of occupancy: Currently Occupied COMMERCIALANDUSTRIAL Type of establishment: Design flow (based on 310 CMR 15.203): Basis of design flow (seats/persons/sgft, etc.): _ Grease trap present (yes or no): Industrial waste holding tank present (yes or no): Non -sanitary waste discharged to the Title 5 system (yes or no): Water meter reading, if available: gpd Last date of occupancy/use: OTHER: (Describe) GENERAL INFORMATION Pumping Records Source of information: System was last pumped on October 20 2002 according to owner Was system pumped as part of inspection (yes or no): No If yes, volume pumped: _gallons — How was quantity pumped determined? Reason for pumping: TYPE OF SYSTEM X Septic tank, distribution box, soil absorption system Single cesspool Overflow cesspool Privy Shared system (yes or no) (if yes, attach previous inspection records, if any) Innovative/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: System was installed in 1992 according to owner Were sewage odors detected when arriving at the site (yes or no): No i Page 7 of 11 OFFICIAL INSPECTION FORM — NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: 701 Forest Street North Andover, MA 01845 Owner: David & Carol Martin Date of Inspection: October 14, 2003 BUILDING SEWER (locate on site plan) Depth below grade: 15" Material of construction: _cast iron X 40 PVC _ other (explain): Distance from private water supply well or suction line: 18' Comments: (on condition of joints, venting, evidence of leakage, etc.): Building sewer pipe and venting are in good condition no sign of leakage. SEPTIC TANK: Yes (locate on site plan) Depth below grade: 9" Material of construction: X concrete _metal _ fiberglass_polyethylene _other (explain) If tank is metal list age _ Is age confirmed by a Certificate of Compliance (yes or no): (attach a copy of certificate) Dimensions: 5'W x 10'L x 49" D Sludge depth: 6" Distance from top of sludge to bottom of outlet tee or baffle: 29" Scum thickness: 0" Distance from top of scum to top of outlet tee or baffle: N/A Distance from bottom of scum to bottom of outlet tee or baffle: N/A How were dimensions determined: Measured Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): Inlet and outlet baffles are in placeliquid level is at outlet invert, tank is in good condition and does not require pumping at this time. GREASE TRAP: No (locate on site plan) Depth below grade: Material of construction: concrete metal fiberglass _polyethylene _other (explain): Dimensions: Scum thickness: Distance from top of scum to top of outlet tee or baffle: Distance from bottom of scum to bottom of outlet tee or baffle: Date of last pumping: Comments: (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): 7 Page 8 of 11 OFFICIAL INSPECTION FORM — NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: 701 Forest Street North Andover, MA 01845 Owner: David & Carol Martin Date of Inspection: October 14, 2003 TIGHT or HOLDING TANK: No (tank must be pumped at time of inspection)(locate on site plan) Depth below grade: Material of construction: concrete metal fiberglass polyethylene _other (explain): Dimensions: Capacity: gallons Design flow: gallons/day Alarm present (yes or no): Alarm level: Alarm in working order (yes or no): Date of last pumping: Comments (condition of alarm and float switches, etc.): DISTRIBUTION BOX: Yes (if present must be opened)(locate on site plan) (Depth below grade = #1-7' ' 1-7", #2-16") Depth of liquid level above outlet invert: 0" Comments (note if box is level and distribution to outlets equal, any evidence of solids carryover, any evidence of leakage into or out of box, etc.): No evidence of solids carryover in either d -box no sign of leakage in either, both d -boxes are in good condition. PUMP CHAMBER: No (locate on site plan) Pumps in working order (yes or no): Alarms in working order (yes or no): Comments (note condition of pump chamber, condition of pumps and appurtenances, etc): Page 9 of 11 OFFICIAL INSPECTION FORM — NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: 701 Forest Street North Andover, MA 01845 Owner: David & Carol Martin Date of Inspection: October 14, 2003 SOIL ABSORPTION SYSTEM (SAS): Yes (locate on site plan, excavation not required) If SAS not located explain why: Type _leaching pits, number: _leaching chambers, number: _leaching galleries, number: X leaching trenches, number, length: 4 leach trenches — 50' long_ _leaching fields, number, dimensions: _overflow cesspool, number: _innovative/alternative system Type/name of technology: Comments (note condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of vegetation, etc.): SAS is under back lawn no damp soil or ponding present. Inspected all four (4) leach trenches with a video inspection camera and found no signs of hydraulic failure. CESSPOOLS: No (cesspool must be pumped as part of inspectionXlocate on site plan) Number and configuration: Depth - top of liquid to inlet invert: Depth of solids layer: Depth of scum layer: Dimensions of cesspool: Materials of construction: Indication of groundwater inflow (yes or no): Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): PRIVY: No (locate on site plan) Materials of construction: Dimensions: Depth of solids: Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): W Page 10 of 11 OFFICIAL INSPECTION FORM — NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: 701 Forest Street North Andover, MA 01845 Owner: David & Carol Martin Date of Inspection: October 14.2003 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. / O Well A-1=18'2" B-1=21'4" A-2=82' B-2=85'6" A-3= 134' B-3=137'6" Well to SAS =180' Page 11 of 11 OFFICIAL INSPECTION FORM — NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: 701 Forest Street North Andover, MA 01845 Owner: David & Carol Martin Date of Inspection: October 14,20E SITE EXAM Slope Surface water Check Cellar Shallow wells Estimated depth to ground water 6'/Z' feet Please indicate (check) all methods used to determine the high ground water elevation: X Obtained from system design plans on record — If checked, date of design plan reviewed: _ Observed Site (abutting property/observation hole within 150 feet of SAS) _ Checked with local Board of Health -explain: Checked local excavators, installers — (attach documentation) Accessed USGS database -explain: You must describe how you established the high ground water elevation: Bottom of SAS is 32" below grade. According to soil testing performed on February 28, 1992 groundwater was observed in the following test holes #3 A 78" #4 0) 100" #6 (a) 100" #7 Q 84" #8 A 84" 11 TOWN OF NORTH ANDOVER SYSTEM PUMPING RECORD % D DATE: SYSTEM OWNER & ADDRESS /6 d - 4o e SYSTEM LOCATION (example: left front of house) DATE OF PUMPING: 10 '// - 0 � QUANTITY PUMPEDGALLONS 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: ,) r) 0d ver COMMENTS: CONTENTS TRANSFERRED TO: `n ` r/1/1cL ray -kD �Iwv, mcN'n fM TOWN OF NORTH ANDOVER SYSTEM PUMPING RECORD 1 E.h1 OWNER & ADDRESS xxc). I OF HEALTH Ni:. - 4 20 SYSTEM LOCATION (example: Icf( from of hou�t) J604A 0� A ao 6 L) 0 c OF PUMPINC: QUANTITY PUMPCDIS1C ; L NO YES SEPTIC TANK: NO YES ATURE OF SERVICE: ROUTINE . EM ERCENCY Ali>FfZV \TIONS: C OOD CONDITION FIFAVY CREASE ROOTS EXCESSIVE SOLIDS SOLIDS CARRYOVER f,'ULL TO COVC;I _ 13AFFLLS IN PLACF LEACHFIELD RUNDACK.., FLOODED, O.�HFR (EXPLAIN.) >1 ) I LM PUMPED BY: C Z�%/ �C Y� �l l(� r� 71 U,I M FLATS: UI I'S TIZANSFCIZIZED TO fUD( Avz� wcr 2.6.4.: IJb 01n Sf A/,d r1h A nna✓er v f W-0Lie- �1-cam 165q' 0,56:ew' ,5 �UUO ✓ STROaT ° S SVTIC TANK SWITCE 47 Mij; D WAWM# MR 01835 978-372-7471 ADEEMS GUWM IS'oa dem .5114 /oav 165q' 0,56:ew' ,5 �UUO ✓ 17d� D/ym��� 4? ✓ /907 Sq /d ✓6 � �a�Gsi`�.Sf: Cue- � f - 10,3 �&0 ✓ � 1550 .S,c /P� � ,� /6C6 66o F -Z,4 ^/ � ►� l �✓ 6 �ro Oyu �btsr�r� �. 1660 ',� 1.1 r� •YII1V ER". MASSA T? \ �ii �l"�I{�I�'�i�'i ��t�,ii't)I;i I��✓n��j)�,Y/�I�I',', , , ,. r ,,yl'I'IVi Qr'P,hI.r G/vrld�dlhlr Iprrn f�, pro �;' Io; o, 6oelcl o -nor'r'bnt!Ilo11 dJc 0 IOCrI 8crr�; c•r no�Iln 1L HEA �•,.� � sy rvm loca��on; . 0-7�"'� ' 09 �1Q✓ty / U ''�'' Y'�I',��1'i�Y'•'�''�'•f'�tl'C.'1''"'4'' '� 1 III • ,:'r • ,,,; I r�l;'1�' •!�sr�1em Qwner"��' ,�'�� . . ,. ',/, V' '�rl, ,,, f,;j '' i/%ir t''+i\r'�I•,,iy , 1./,� .1.,, ('�;;,//�yy���_��.. ,.� rl ,'r.r ',S, rl(u`I�I,Ij wr rr'Y %,I'/• '', - V��� , •I • r l l;r I r � i;l 1 1/, 0 rrinl rcrn buVon) C4r�o.n r ` ri`,I I � 111;,,4.11,4,111./ilrl`I"r•'1 ' ogle of PumDjm, ypf , ..'�71Other� '1,•.r,•'1i (dei rib Y,10'n Irl` I)lj(+p(,0,a0nr? Yp� i'`'''.Il j','�,i1; �1+i;/^��?�i�/f!�'VI?'ll1il�"a141i;'QQ�/��f j'il �'ir�'''1 ',•" '�; i�',7,'s�;ils'+r''J'/ rl'1,1'n,��U1J���'+Cj;,''" • �•p�'r��Sy �ij PV�1Ped,8''"' ' �Yjl i ��,i ,i `I'r ri ►i;�)`�(/',•�� Iiff,�I�}� �� Il lfl► �; ', ,I, )�� !�,; 'I'+I `''''t �/ • • • • �!;r,)lh'tN�l'1',///j'�'j 1(jy,J'�AI i�� J �� I!I'I)SVl { f, �' 1 (', r13�(,tY �I ' 1 . ' ; '''f,�t • �,:r ' �,1 r«��ia1 I1r11 r`1 ���,.,;�II�r,; . � .._ `�' ;�r:>•�, '',I,t�/fl�'ll,%� '�r'�,; ell,:40 ,fi,e/0 dl)pO30o: . 1 dt; , y !Iry � L4 ,' \ ��•' ' ... '.'',��, •'r. � 'FYI' ' iJ `dl .._ / .,,�; ,1;h r: Y�i��,IiL:J^,1� ,(�'�1,y/fel, •'pu ,l , . • r.m6s� oYld0 . ,. .. , '� . A'�e1e�lipP ,141orm�,r;'npin��oc� +'�19�On1 n,mpit — ii171 z _— C9779001(7) 0,p0 IS^1 r3, Ilye7 811;C!oanW /7 Tes _ � Yltllul'J04nlr n'u�*,;rr r /ter `C\N Commonwealth of Massachusetts _ City/Town of System Pumping Record Form 4 'IM 5ey`e DEP has provided this form for use by local Boards of Health. Other forms may be used, but the information must be substantially the same as that provided here. Before using this form, check with your local Board of Health to determine the form they use. The System Pumping Record must be submitted to the local Board of Health or other approving authority within 14 days from the pumping date in accordance with 310 CMR 15.351. A. Facility Information Important: When filling out forms 1. Syst Location: on the computer, 01 77�n nf s — use only the tab key to move your A dre cursor - do not I �I Ma R E E V7Code use the return City/Town State Zkey. 2. System Owner:. Jl1(� '1 1 rad i Name HEALTH DEPARTMENT mMn Address (if different from location) City/Town State Zip Code Telephone Number B. Pumping Record 5-1 (0—/_ 1. Date of Pum in .Quantity Pumped: � p g Date Gallons 3. Type of system: ❑ Cesspool(s) A Septic Tank ❑ Tight Tank ❑ Grease Trap ❑ Other (describe): 4. Effluent Tee Filter present? ❑ Yes ❑ No 5. Condition of System: 6. rem Pumped By: Name Stewart's Septic Service Company 7. Location where contents were disposed: If yes, was it cleaned? ❑ Yes ❑ No Vehicle License Number Stewart's Pre-treatment Plant, 20 So. Mill Bradford, Ma 01835 Signature of Hauler Signature of Receiving Faci Date Date t5form4.doc• 03/06 System Pumping Record • Page 1 of 1 Commonwealth of Massachusetts L City/Town of System Pumping Record Form 4 M u t5form4.doc• 06/03 RECEIVED OCT 20 2012 TOWN OF NORTH ANDOVER HEAL'rH DEPARTMENT DEP has provided this form *for use by local Boards of Health. Other forms may be used, but the information must be substantially the same as that provided here. Before using this form, check with your local Board of Health to determine the form they use. The System Pumping Record must be submitted to the local Board of Health or other approving authority. A. Facility Information 1. System LocatioRigh o t of hous Left / Right rear of house, Left / right side of house, Left / Right side of buil Ing, Left / Right front of building, Left / Right rear of building, Under deck Address �S , Citylrown S;at tate 2. System Owner. Name Address (if different from location) City/Town B. Pumping Record 1. Date of Pumping 3. Type of system: ❑ ❑ Other (describe): Zip Code stat Zip Code eS-6:36--:�L Telephone Number . Date 2- Quantity Pumped: Gallons Cesspool(s) eptic Tank ❑ Tight Tank 4. Effluent Tee Filter present? ❑ Yes ER<o— If yes, was it cleaned? ❑ Yes ❑ No 5. Condition of Syste?Uo ���ek � ms 6. System Pumped By: .Neil Bateson Name Bateson Enterprises Inc Company 7. Location where contents were disposed: .L S. Lowell Waste Water i It F5821 Vehicle License Number Date System Pumping Record • Page 1 of 1 No Andover J&S Development dba 1600 Osgood St Stewart's Septic Building 20 Suite 2-36 Andover Septic No. Andover, Ma 01845 58 South Kimball Street Bradford, MA 01835 Date Name & Address Gallons Comments 1-M4,fatter reality 81 Sawmill Rd 1500 Good 2 -May -Mulcahy 350 Sharpners Pond Rd 1500 Good Greene 62 Willow Ridge Rd 1000 Good 3 -May acr ,9'259 Grandville 2500 Good 4 -May, R rlcon�115 Sherwood Dr 1500 Xsolids HG 9-May�Callahn 940 Foster St 1500 Good 10-May'�Melerim�1444 Salem St 1500 Xsolids 15 -May, it ffdh Brenkin ridge Rd 1500 Good CDeparir1`75 Stone Cleave 1500 Good 16 -May Martin 701 Forest St 1500 Good CMur fi 16 Carleton Lane 1500 Good 18 --May Vandergraaf267 Old Cart Way 1500 Good olanoY2198 Tnok St 1000 Rh 21-May�Tomicho 1:15 Laconia Cir 1500 Good Reti 42 Cross Bow 1500 Good 24-MaNcarbonell 1560 Salem St 1000 Good 29 -May Thurber 210 Farnum St 1500 Good QltMay'Cle_ ary405 Wintergreen Dr 1000 Good TOWN OF NORTH ANDQVgR H- ALTH DEPAR.TMI=NT