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HomeMy WebLinkAboutMiscellaneous - 71 OLYMPIC LANE 4/30/2018Important: When filling out forms on the computer, use only the tab key to move your cursor - do not use the return key..�� r`, y Ill Commonwealth of Massachusetts City/Town of System Pumping Record Form 4 FOEC 16 2010 DEP has provided this form for use by local Boards of Health. Other forms may be JsTaWI§ RTH ANDOVER information must be substantially the same as that provided here. Before using this 'ft0 i }R WWT 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 1. System Location: Address ' ' North Andover City/Town 2. System Owner: Name Address (if different from location) Cityr town ma State State Telephone Number 01886 Zip Code Zip Code B. Pumping Record '` I 1 0-6— 1. Date of Pumping 2. Quantity Pumped: Date Gallons 3. Type of system: ❑ Cesspool(s) [ASeptic Tank ❑ Tight Tank ❑ Grease Trap ❑ Other (describe): 4. Effluent Tee Filter present? ❑ Yes ❑ No 5. Condition of System: 6. yst m Pumped Name Stewart Septic Service Company If yes, was it cleaned? ❑ Yes ❑ No Vehicle license Number 7. Location where contents were disposed: Stem" Fire treatmenkant 20 So. Mill St. Bradford Ma 01835 Signature of Receiving Facility 03106 Date Date System Pumping Record • Page 1 of 1 e TRANSMISSION VERIFICATION REPORT TIME 07/10/2006 10:55 NAME HEALTH FAX 9786888476 TEL 9786888476 SER.# 000B4J120960 DATE DIME 07110 10:52 FAX NO./NAME 816177617607 DURATION 00:02:25 PAGE(S) 14 RESULT OK MODE STANDARD ECM North Andover Health Department 1644 Osgood Street Building 20, Suite 2-86 North Andover, MA 01845 978.688.9540 - Phone 978.688.8476 — Fox healthdeot@townAfnorthandon.er.com - E-mail www.tanoLfn.o(thandaver.com - Websits Letter of Transmittal, [Page Z of T0: DATE: 1711 COMPANY: FROM: Pamela DelleChioie, Health department Assistant Phone: �^�� �rP�• 1�y�� � -- kE: rte/ � - � Fax �D / /• UJ r/ / We are sending you; © Copy of ietter O Plans C Other (fill in below) These are transmitted as checked below: ➢ L74W=WxNMd g _f "&9ts O,& TO: > j©7fi r,�qv� y ➢ L7l rpt_-. a�slbr i ©%qr rOri! > OSI�r/si llxa r ' North Andover Health Department 1600 Osgood Street Building 20, Suite 2-36 North Andover, MA 01845 978.688.9540 - Phone 978.688.8476 — Fax healthdept(a)-townofnorthandover.com - E-mail www.townofnorthandover.com - Website � A Letter of Transmittal Page of �5 NORTt� q Q �.fLlD ,6' tiO OL °� \�A-O9q tOCMICMtwKK `y^' 7a_DRAreD TO:01 DATE: / f% ®/ - COMPANY: FROM: Pamela DelleChiaie, Health Department Assistant Phone: RE: Fax: l0 / /- COPY TO: We are sending you. O Copy of Letter O Pans O Other (fillin he%w) These are transmitted as checked below: ➢ O as&AW ➢ OAsRagtiW ➢ Okr4iaavnl ➢ akrlPe►aewardcamn�nt ➢ Okr ra w n ➢ DAwhrrit &*sfbr• ' qpl xd ➢ O.Smko cgaiKf0r&t. REMARKS: LG�� COPY TO: COPY TO: SIGNED: � J COPY TO: 1 Tb" O.FNORTH 'ANDOVER SYSTEM PUMPINC RECORD -22003 >> > i em UYYM�K &A DDRESS t SYSTEM LOCATION _T (example; left front of house) boC �1 0-� h®v�,,c_ U.\TC OF PUMPING; QUANTITY P U M P C D 0 -L, L UUL: N YES SEPTIC: TANK: NO YE5 '-\TURE OF SERVICE; ROUTINE EMERGENCY ��II.>rriv.�TloNs; COOD CONDITION. NULL TO COVER HPAYY CREASE BAFFLES IN PLACE ROOTS LEACHFIELD RUNBACK... CXCESSIVE SOLIDS FLOODED SOLIDS CARRYOVER p HF,R (EXPLAIN) PUMPED BY; `���%'i�hc�'Y� . VIP u M kI ANTS; u� I I:N r5 TJ ANSFCIZRED To; ` 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 TOWN OF NORTH ANDOVER BOARD OF HEALTH CERTIFICATE OF COMPLIANCE DATE OF COMPLIANCE 00W This is to certify that the distribution box was constructed () or repaired (X) by John DiVincenzo at 71 Olympic Lane Telephone (978) 688-9340 Fax (978) 688-9542 has been installed in accordance with the provisions of Title V of the State Sanitary Code and with the North Andover Board of Health regulations. The Issuance of this certificate shall not be construed as a guarantee that the system will function satisfactorily. , I /- /,L 4 � �- n J. LaGrasse Board of Health Inspector BOARD OF APPEALS 688-9541 BUILDING 688-9545 CONSERVATION 688-9530 HEALTH 688-9540 PLANNING 688-9535 r r - COMMONWEALTH OF MASSACHUSETTS EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS DEPARTMENT OF ENVIRONMENTAL PROTECTION TITLE 5 OFFICIAL INSPECTION FORM — NOT FOR VOLUNTARY ASSESSMENT$, SUBSURFACE SEWAGE DISPOS SYSTEM?FORM :,.� PART A _ ... CERTIFICATION 2 3 203 Property Address: / - / �lr �i APR g Owner's Name: /// 11Z)k' Owner's Address: Date of Inspection: Name of Inspector:( lease print)/1l �1//. Company Name:, //_ ,!�// %S' �1i7f /67/ Mailing Address, Telephone Number: 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: Passes Conditionally Passes Needs Further Evaluation by the Local Approving Authority r, ails Inspector's Signature: �,/�h c/�l Date: U5 The system inspector shall submi�copy of this inspection report to the Approving Authority (Board of Health or DEP) within 30 days of completing this inspection. If the system is a shared system or has a design flow of 10,000 gpd or greater, the inspector and the system owner shall submit the report to the appropriate regional office of the DEP. The original should be sent to the system owner and copies sent to the buyer, if applicable, and the approving authority. Notes and Comments ""This report only describes conditions at the time of inspection and under the conditions of use at that time. This inspection does not address how the system will perform in the future under the same or different conditions of use. Title 5 Inspection Form 6/15/2000 page 1 `"P�e l of 11 'OFFICIAL INSPECTION FORM — NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A � i / CERTIFICATION (continued) Property Address: �� G L�rt* %o/r Owner: i Date of Inspection: Inspection Summary: Check A,B,C,D or E / ALWAYS complete all of Section D A. System Passes• �1 I have not found any information which indicates that any of the failure criteria described in 310 CMR 15.303 or in 310 CMR 15.304 exist. Any failure criteria not evaluated are indicated below. Comments: B. System Conditionally Passes: ( e S 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 V --'distribution box is leveled or replaced ND explain: �) -- Al r ��. /� •1 / //✓G 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): ND explain: broken pipe(s) are replaced obstruction is removed - 2 Page 3 of 11 OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: Owner: Date of Inspection: C. Further Evaluation is Required by the Board of Health: &, /1 honditions 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: 4Page 4 of I 1 OFFICIAL INSPECTION FORM — NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: Owner: W14t1,1117 Date of nspection: D. System Failure Criteria applicable to all systems: You must indicate "yes" or "no" to each of the following for all inspections: Yes No _ _v' Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool "Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or ,,,,,clogged SAS or cesspool Static liquid level in the distribution box above outlet invert due to`an overloaded'or clogged SAS or cesspool Liquid depth in cesspool is less than 6" below invert or available volume is less than '/z day flow Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number of times pumped Any portion of the SAS, cesspool or privy is below high ground water elevation. _ Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. Any portion of a cesspool or privy is within a Zone 1 of a public well. Any portion of a cesspool or privy is within 50 feet of a private water supply well. Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality analysis. [This system passes if the well water analysis, performed at a DEP certified laboratory, for coliform bacteria and volatile organic compounds indicates that the well is free from pollution from that facility and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis must be attached to this form.] hi b (Yes/No) The system fails. I have determined that one or more of the above failure criteria exist as described in 310 CMR 15.303. therefore the system fails. The system owner should contact the Board of Health to determine what will be necessary to correct the failure. E. Large Systems: To be considered a large system the system must serve a facility with a design flow of 10,000 gpd to 15,000 gpd• - You must indicate either "yes" or "no" to.4ach of the following: (The following criteria apply to large systems in addition to the criteria above) yes 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 • � pPage 5 of 11 OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST Property Address: Owner. Date of Inspection: Check if the following have been done. You must indicate "yes" or "no" as to each of the following: Yes No L/"' Pumping information was provided by the owner, occupant, or Board of Health Were any of the system components pumped out in the previous two weeks? Has the system received normal flows in the previous two week period? !/Have large volumes of water been introduced to the system recently or as part of this inspection ? V Were as built plans of the system obtained and examined? (If they were not available note as N/A) V Was the facility or dwelling inspected for signs of sewage back up ? Was the site inspected for signs of break out? Were all system components, excluding the SAS, located on site ? Were the septic tank manholes uncovered, opened, and the interior of the tank inspected for the condition of the baffles or tees, material of construction, dimensions, depth of liquid, depth of sludge and depth of scum ? Was the facility owner (and occupants if different from owner) provided with information on the proper maintenance of subsurface sewage disposal systems? The size and location of the Soil Absorption System (SAS) on the site has been determined based on: Yes Existing information. For example, a plan at the Board of Health. Determined in the field (if any of the failure criteria related to Part C is at issue approximation of distance is unacceptable) [3 10 CMR 15.302(3)(b)] Page 6 of 1 I OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION Property Address: J ). / p, Owner: Z&1tA IF Date of Inspection: J—� FLOW CONDITIONS RESIDENTIAL I J Number of bedrooms (design): `T Number of bedrooms (actual): DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x # of bedrooms): Number of current residents:y A/ Does residence have a garbage grinder (yes or no): L U Is laundry on a separate sewage system (yes or no):,L/.�[if yes separate inspection required] Laundry system inspected (yes or no): _ Seasonal use: (yes or no): 1 10 Water meter readings, if available (last 2 years usage (gpd)): — Sump pump (yes or no): 4W Last date of occupancy:' J f COMMERCIAL/INDUSTRIAL Type of establishment: Design flow (based on 310 CMR 15.203): gpd Basis of design flow (seats/persons/sgft,etc.): Grease trap present (yes or no): _ Industrial waste holding tank present (yes or no): _ Non -sanitary waste discharged to the Title 5 system (yes or no): Water meter readings, if available: Last date of occupancy/use: OTHER (describe): GENERAL INFORMATION Pumping Records a ✓ T S {— �'vS TGku -f' �/ Source of information: !/S r f Was system pumped as part of the inspection (yes or no): _ . If yes, volume pumped:/ T gallons -- How was quantity pumped determined.?% /� file- /tf P Reasonfor pumping: h 'a ,r T /1r-/ ie TYPE - OF SYSTEM, _ Septic tank, distribution box, soil absorptiam 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: / T Were sewage odors detected when arriving at the site (yes or no): A /U • ' "'Page 'f of 11 OFFICIAL INSPECTION FORM — NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: 0iG ll Owner: AUI-Ao Date of Inspection: BUILDING SEWER (locate on site plan) Depth below grade: Materials of construction: Z,/ t iron _40 PVC _other (explain): Distance from private water supply well or suction line: %G VG f r [.C.hf r f Comments (on condition of joints, ventin evidence of leakage, etc.): G013 CG1/iilT-7 r 4A SEPTIC TANK/- A (locate on site plan) Depth below grade: Material of construction: ✓ o crete _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: ;c Sludge depth: './ Distance from top of sludge to bottom of outlet tee or baffle: Scum thickness: " Distance from top of scum to top of outlet tee or baffle: "2 Distance from bottom of scum to bottom of outlet tee or baffle/ V/ How were dimensions determined: - A f / � j 1—cComments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): 64 op %'af /# I 1—/o.A-1 /-/Cj 4---P 2/� 5 GREASE TRAP:_(1 Cate 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.): bl . , lage 8 of 11 OFFICIAL INSPECTION FORM — NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address:,;?�' Owner• Date of Inspection: TIGHT or HOLDING TANK: (tank must be pumped at time of inspection)(locate on site plan) Depth below grade: Material of construction: concrete metal fiberglass _polyethylene other(explain): Dimensions: Capacity: gallons Design Flow: ,. gallons/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 BOX00 (if present must be opened)(locate on site plan) Depth of liquid level above outlet invert:(,J�2 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.): PUMP CHAMBER: (locate on site plan) Pumps in working order (yes or no): Alarms in working order (yes or no): Comments (note condition of pump chamber, condition of pumps and appurtenances, etc.): 8 Page 9 of 11 OFFICIAL INSPECTION FORM — NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: Owner: O Date of Inspection: SOIL ABSORPTION SYSTEM (SAS): (locate on site plan, excavation not required) If SAS not located explain why: Type leaching pits, number: _ leaching chambeis, number: leaching galleries, number: leaching trenches, number, length: leaching fields, number, dimensions: .2 f- �J 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.): p& CESSPOOLS: (cesspool must be pumped as part of inspection)(locate on site plan) Number and configuration: Depth — top of liquid to inlet invert: Depth of solids layer: Depth of scum layer: Dimensions of cesspool: Materials of construction: Indication of groundwater inflow (yes or no): Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): PRIVY: (locate on site plan) A Materials of construction: Dimensions: Depth of solids: Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): R . • Page. 1.0 df 11 OFFICIAL INSPECTION FORM — NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEMINFORMATION (continued) Property Address: >/ ! Owner: / Date of Inspection: 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. .' t o L OY R/c 10 3-7 o L OY R/c 10 'Page 11 of 11 A OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: Owner: /ID / Date of Inspection: lJ.3 SITE EXAM Slope Surface water s Check cellar Shallow wells f Estimated depth to ground water I feet Please indicate (check) all methods used to determine the high ground water elevation: , /Obtain ted from system design plans on record - If checked, date of design plan reviewed: Observed site (abutting property/observation hole within 150 feet of SAS) Checked with local Board of Health -explain: Checked.with local excavators, installers- (attach documentation) Accessed USGS database -explain: You must describe how how you /e,stablished th/e high ground water elevation: i/ V `/ .// f�/ii.� �"� 7/-F I w N 11 Commonwealth of Massachusetts City/Town of NORTH ANDOVER, - System Pumping Record Form 4 TOWN OF ham; HEALTH DEP DEP has provided this form for use by local Boards of Health. The System Pumping be submitted to the local Board of Health or other approving authority, Important: When filling out forms on the . computer, use 7 9, only the tab key to move your cursor - do not use the return key. ASSA SETTS . �� 0 4 2006 A. Facility Information 2N1 :cord mu; 1. System Location: Address ._.-___.. ...—_.... _.. ..... ` ��-�_. City/Town -�.--- State----------- --- ... Zip Code 2. System Owner: me Address (if different from location) _ City/Town ----- -- - ----------- State ---- -- -- i Code -- - Telephone Number B. Pumping Record 1. Date of Pumping Type of system: ❑ ❑ Other (describe): Date u__-- 2. Quantity Pumped Cesspool(s) U Septic Tank Gallons ❑ Tight Tank 4. Effluent Tee Filter present? ❑ Yes E�-No If yes, was it cleaned? ❑ Yes ❑ No 5. Condition of System: m Pumped By: Vehicle License Number c5t�fa jm��. 7. Location where contents were disposed: $I BtUre Of HeU http://www.ma's$.gov/'dep/water/ provals/t5forms.htm#inspect t5form4.doc, 06/03 Date System Pumping Record • Page 1 of 'I• JC •.^• S`� i'^:•� � �,f.i,;••!r �1/i'� 1 li• � , r .\''a?h ... 'fqr :/' � J• �% 1MRS s A, FacIInfor— tion �7644 �Otoofl rpm bcaUon) • ' .r;; (':Pum Ing Record oath Of Pumpin9 i7 To;epnona N mpor --- 3. TYpa Pf aya(em (^) CesSpool(s)evc!c TanK L, Ochor (doscriba), 4, EMUM T88 FMo( prgsent? n /, PP �''1' • s•,/:• �.c. I y�,;ff,. yJ''i�' `1 1{,/J(1 �/'r �'1 i`�r`r,, - ., r`.,�.,i�r�,� :. 'r:�iM�i�Iaa. {1��ar•.�,,4;d�,I�Y� 111'�if�r�j:�l.Iri1., / Loca on whar �, e Cor�lenls'Were dI�posao: („ ,l.' •. t.., ,, ., ' fir, :'.;;:%'• i'r, ,;'!, Sin+.�' 01 iva(,�/:�:;)ro,.Y, ,1 . ,---•--__. ^�;;Jnan;'w,mass.8ov/dop�weior/approvals/l6(orm9,r,��-��ina�ecl 17 Tl3,nf Tan, 1( yes, n'85 1; .!oanao? �- Yes _ - �VehlGe Ucen�e rr'�T�er r Q /Ta,m m Owner �7644 �Otoofl rpm bcaUon) • ' .r;; (':Pum Ing Record oath Of Pumpin9 i7 To;epnona N mpor --- 3. TYpa Pf aya(em (^) CesSpool(s)evc!c TanK L, Ochor (doscriba), 4, EMUM T88 FMo( prgsent? n /, PP �''1' • s•,/:• �.c. I y�,;ff,. yJ''i�' `1 1{,/J(1 �/'r �'1 i`�r`r,, - ., r`.,�.,i�r�,� :. 'r:�iM�i�Iaa. {1��ar•.�,,4;d�,I�Y� 111'�if�r�j:�l.Iri1., / Loca on whar �, e Cor�lenls'Were dI�posao: („ ,l.' •. t.., ,, ., ' fir, :'.;;:%'• i'r, ,;'!, Sin+.�' 01 iva(,�/:�:;)ro,.Y, ,1 . ,---•--__. ^�;;Jnan;'w,mass.8ov/dop�weior/approvals/l6(orm9,r,��-��ina�ecl 17 Tl3,nf Tan, 1( yes, n'85 1; .!oanao? �- Yes _ - �VehlGe Ucen�e rr'�T�er r E ' Permit NO BUILDING PERMIT TOWN OF NORTH ANDOVER APPLICATION FOR PLAN EXAMINATIO Date Received - o p TYPE OF IMPROVEMENT PROPOSED USE Residential New Building One family Two or more family Addition Alteration ��'' No. of units: Repair, replacement Assessory Bldg — Demolition . X11, Other =loodpla�ra :Seg tic.. p water/Sewe� DESCRIPTION OF WORKJO . I a Non- Residential Industrial Commercial Others: �tlani fs=W1katershed' Oistrpt' w BE PREFORMED; �^ Please Type or Print Clearly) OWNER: Name: ARCHITECT/ENGINEER Phone: Address: Reg. No. FEE SCHEDULE: BOLDING PERMIT.- $12.00 PER $1000.00 OF THE TOTAL ESTIMATED COST BASED ON $125.00 PER S.F. Total Project Cost: $ 3 -�? FEE: $ Check No.: Receipt No.: NOTE: Persons contracting with unregistered contractors do not have access to the�ty� d Pians Submitted Plans Waived Certified Plot Plan Stamped Plans TYPE OF SEWERAGE DISPOSAL Public Sewer Tanning/Massage/Body Art Swimming Pools Well Tobacco Sales Food Packaging/Sales Private (septic tank, etc. Permanent Dumpster on Site THE FOLLOWING SECTIONS FOR OFFICE USE ONLY INTERDEPARTMENTAL SIGN OFF - U FORM PLANNING & DEVELOPMENT COMMENTS CONSERVATION Reviewed DATE REJECTED DATE APPROVED Siqnature COMMENTS Zoning Board of Appeals: Variance, Petition No: Zoning Decision/receipt submitted yes Planning Board Decision: Comments Conservation Decision: Comments Water & Sewer Connection/Signature & Date Driveway Permit DPW Town Engineer: Signature: n' a. G G � Cn 'd rt . n cy, H LTI tr rr t -h O H n E o rr < H m H n arf. H n( 0. w �• O t-+ "� �• j rt - sr� u � i tro n O I d` co O ' r G O C CD rt H o' a m� rt H � W A ri r tr rD ~• a !D rt o a' rl y t7 cD d 0 a 1 a 'D- y fDJ (-h y N• o� (D \ M 0 w rh O G H N• a- W V CD rt P- aab aP. o IT M. LA5 3y.3� i LOT 35- .5 FE 5- .5F OL Yl7/�JC c.f3HE R AND DW ON cow twmrroNs r res• _ t R; XOP SHOl►J1f ON. M"4UW AMU AS Zsoa�3 ST1c�P rigs PLAN ,j,; -" sx, — XOT FOR EDUNI]ARY D '1W— DO[IMD"r ,W,I� MA"M TAM FROM RgComS PLOT PLAN IN N012rH le-hVCbtrC2 J "145 DRAWX FOR, CHf2I57-OPHER �N � /y,9N[.E' Al IF �7aG1p SCK R.VC[JVVRMXC SRR UZ 86 PARK SRP "DOVCg MASSACHUSETTS Di Bf o �• O t-+ "� �• j rt - sr� F• - rt (D o .' •o � .-I p 0 o (D. G o �1 CD rt m� 09 H• tr rD rt cD ID. 1 a 'D- y fDJ o� \ (n •b w a- W V rt P- aab o IT M. LA5 3 �. 7 .' •� d CD oq `! 3y.3� i LOT 35- .5 FE 5- .5F OL Yl7/�JC c.f3HE R AND DW ON cow twmrroNs r res• _ t R; XOP SHOl►J1f ON. M"4UW AMU AS Zsoa�3 ST1c�P rigs PLAN ,j,; -" sx, — XOT FOR EDUNI]ARY D '1W— DO[IMD"r ,W,I� MA"M TAM FROM RgComS PLOT PLAN IN N012rH le-hVCbtrC2 J "145 DRAWX FOR, CHf2I57-OPHER �N � /y,9N[.E' Al IF �7aG1p SCK R.VC[JVVRMXC SRR UZ 86 PARK SRP "DOVCg MASSACHUSETTS Di Bf o Board of Health North Andrverj9%Ws. WED DATE %, 1 1 A FAIL OK SEPTIC SZSTEK INSTALLATICK CHECK LIST Lar f� REAVATIM OS FAIL 1. Distance To: a. Wetlands b. Drains c. Well ,?,ir- Water Line Location 3. No PVC Pipe 14. Septic Tank a. Tees - Length & To Clem Out Covers b. Cement Pipe to Tank- On Both Sides of Tank 5. Distribution Box a. Covers & Box - No Cracks b. All Lines Flowing Equal Amounts c. No Back Flow 6. Leach Field or Trench a. Dimensions b. Stone Depth c. Capped Ends d. Clean Double Washed Stone 7. LeajShs a*ions b. Depth c. Pads d. e. Pipe to Pit - Both Sides f.Double Washed atone �. No Garbage Disposal 9. Final Grading Inspection 10. Barricading Cowered System 11. As Built Submitted a. Lot Location b. Dimensions of System c. Location with Regard -to Pere Test d. Elevations e: Water Table lJ' r 'y V 1 :A" L I VV SUBSURFACE DISPOSAL SYSTEM CHECK LIST NORTH ANDOVER BOARD OF HEALTH APPROVED DATE PROVIDED DISAPPROVED DATE TIME REASON Title 5 Reg. 2.5 Fail ?" Reg. 6 The submitted plan must show as a minumum: the lot to be served (area,dimensions,lot #,abutters) _ (Planning Board files) b location and log of deep observation holes -distance to ties e-)- location and results of percolation tests -distance to ties d7 -design calculations & calculations showing required leaching area e ---location and dimensions sf system (including reserve area) existing and proposed contours ;4_ location of any wet areas within 100' of the sewage disposal system or•disclaimer (check wetlands mapping) h)--- surface and subsurface drains within 100' of sewage disposal system or disclaimer i -) location of any drainage easements within 100' of sewage disposal system or disclaimer (planning board files) �) known sources of water supply within 200' of sewage disposal system or disclaimer k-) location of any proposed well to serve the lot (100' from leaching facility) i-)- location of water lines on property (10' from.leaching facilities) m-} location of benchmark Pi driveways o-)- garbage disposers p-)- no PVC is to be used in construction q -)--a profile of the system (elevations of basement, plumber pipe septic tank, distribution box inlets and outle,-s, distribution field piping and any other elevations) r)-- maximum ground water elevation in area of sewage dispose system plan must be prepared by a Professional Engineer or other professional authorized by law to prepare such plans Septic T (a) apacities - 150% of flow, water table, tees, depth of tees, access, pumping, b) Cleanout (c) 10' from cellar wall or inground swimming pool (d) 25' from subsurface drains No3 'h "Andover Subsurface disposal system check list - Page 2 Reg.10 '2 Reg.10.4 Reg. 11 .2 Reg. 11 .4 Reg.11 .1 C Reg.11.11 Reg.15.1 Reg. 15.1 Reg. 15.4 Reg. 15.8 Reg. 3.7 Reg.14.1 Reg.14.3 Reg.14.4 14.5 Reg.14.6 Reg.14.'7 Reg.14.1C Reg. 9.1 Reg. 9.6 it IOKI Distribution Boxes Ia) Slope greater than 9.08 b) Sump Leaching Pits Leaching pits are preferred where the installation -�Ls possible (a) Calculations of leaching area (minimum 500 S.F.) (b) Spacing (c) Surface drainage 2% d) Cpver,material PIA I'll Leaching Fields (3) "_ -(-a) WiGreater than 20 minutes/inch � ) Area (minimum 900 S.F.) Construction of field t -d-) Surface drainage 2% ke­�'20' from cellar wall or inground swimming pool Leaching Trenches (a Calculations of leaching area (min. 500 S.F.) (b Spacing (4 ft. min. 6 ft. with reserve between). (c Dimensions (d) Construction (e) Stone (f) Surface drainage 2% Downhill Slone lope y/x = (to be shown Tb) y/x X 150 = (to be shown PUMP -0 (a) Approval (b) Stand-by power SOIL PROFILE & PERCOLATION TEST DATA 4 5 6 6 7 7 8 8 9 9 10 10 Benchmark Elevation 7 8 :M 10 4' S 6 7 8 9 MIM Location Datum Percolation Tests -Date f2 -9 18' Lo T 3(.. Pit Number 1 2 3 4 S Start Saturation Soak -Mins. Start Test -Time Drop of 3" -Time Drop of 6" -Time Mins.lst 3"Dro Mins.2nd 3"Dro P. ceo� + -rSIS7 P CT Notes & Sketches on Back Frank C. Gelinas & Associates, North And. q -fl -A Town/City pN D. No. &Street r) M p!( L-A,() E Lot No. J cJ Loc./Subdiv. 1 N CIA LUIS CRbS4b4O&P1an Owner Investigator- T-:�,A (Z L�A /S Lc -d ObserverURC.�S c -t p G—' C'Et. 1 cv�.S SOIL PROFILES -DATE GI ) 8�.� � � h 1' lev. �' Elev. 3' Elev. t 4'Elev. 1 0 51i-di77 0 -To 0 0 P TTA Ct L C- 2 2 � �L`f 2 2 2 �L_AN Gia 3 3 C A 3 3 1\� 4 5 6 6 7 7 8 8 9 9 10 10 Benchmark Elevation 7 8 :M 10 4' S 6 7 8 9 MIM Location Datum Percolation Tests -Date f2 -9 18' Lo T 3(.. Pit Number 1 2 3 4 S Start Saturation Soak -Mins. Start Test -Time Drop of 3" -Time Drop of 6" -Time Mins.lst 3"Dro Mins.2nd 3"Dro P. ceo� + -rSIS7 P CT Notes & Sketches on Back Frank C. Gelinas & Associates, North And. q -fl -A IUV- PAOL-LtAW TA"14, Iia. PAPL Oul-OF rA6uL i bi V- 171 F!E JXTa A21 �0�' Lbk�L Pt M OL) -r 0- piny, .41 tc) u I L -T L- "b*Yd5-F EM A �uiL—r .45 rJ A lldL SYSTEM "IVA, l Al V LUY-RIPSS O_U T a &V. ELSM.0 F- - P i, Pt- - A �uiL—r .45 rJ A lldL SYSTEM "IVA, 1 __ --�►__ EJ U-11 L, -r �"JY5►T EM - � QRr_�-tiT'EGT-S -4�i 4tiL�c�v�Q `3_t_ No A.rV c��E 1NV P1P ►�T' ` -- 'Ny-Tr-%LQ_2E-PI—V __ --�►__ EJ U-11 L, -r �"JY5►T EM - � QRr_�-tiT'EGT-S -4�i 4tiL�c�v�Q `3_t_ No A.rV c��E Town of North Andover, Massachusetts Form No. 3 NORTH BOARD OF HEALTH �f - P '°•.,,o:�'"� DISPOSAL WORKS CONSTRUCTION PERMIT �SSACHUSE Applicant�%%t�✓��/�'//�1� / c�i�—%i ;7 NAME / ADDRESS TELEPHONE Site Location �✓ ��%��� /���� Permission is hereby granted to Construct ( ) or Repair (-4--�rhh Individual Soil Absorption Sewage Disposal System as shown on the Design Approval S.S. No. f CHAIRMAN, BOARD OF HEALT Fee D.W.C. No. 9(/i AORTH ' TOWN OF NORTH ANDOVER �2 "' ;�:;"oolotL HEALTH DEPARTMENT 27 CHARLES STREET NORTH ANDOVER, MASSACHUSETTS 01845 9SSACHU Sandra Starr, R.S., C.H.O. (978) 688-9540 - Telephone Public Health Director (978) 688-9542 -Fax D TO: From: Fax: 1'7j-9/�/ Pages: Phone: Date: Re: CC: 0 Urgent ©-Foy Review 11 Please Comment ❑ Please Reply 11 Please Recycle Please call 978-688-9540 for assistance with any questions. Thank you. xc: Address File Chrono File H? Fax K 1220xi Last Transaction Date Time Type Jul 2 11:50am Fax Sent Identification 89784755101 Log for NORTH ANDOVER 9786889542 Jul 02 2003 11:50am Duration Pages Result 0:31 OK TOWN'OF NORTH ANDOVER y BOARD OF HEALTH Location Permit. /1�1�iJ�✓/ !'//�/��/✓fir} Food Service Retail Food Limited Retail�r� $ Seasonal $ Disposal Works Installers $ Disposal Works Construction $ l> Soil Testing $ S > Design Approval Permit $ Dumpster Permit $ Burial Permit $ Swimming Pool Permit $ Animal Permit $ Recreational Camp Permit $ Well Construction Permit $ Funeral Directors Permit $ Massage Establishment License $ Massage Practice License $ Suntanning Establishment $ Offal/Trash Hauler $ Other $ 6L0R Health Agent White - Applicant Yellow - Dept. Pink - Treasurer r t(t e C. APPLICATION FOR DISPOSAL WORKS CONSTRUCTION PERMIT DATE: 71-9 G LOCATION: 7 LICENSED INSAL R: ° SIGNATURE: CHECK ONEd REPAIR: CURRENT INSTALLER'S LICENSE# ONE# q 2 Z , 2 2'.2 , f NEW CONSTRUCTION: IF NEW CONSTRUCTION, PLEASE ATTACH FOUNDATION AS -BUILT. 11Usla11 Administrative Use Only $175.00 Fee Attached? Yes No Foundation As -built? Yes No Floor plans on file? Yes No Approval Date: ti vv v U O c a w O W a .. • "' &"`•"` j --- ---• ST'FWART 0 S SEPTIC TANK SERVICE »d Main Sf 47 RAILROAD STREET Ne /lh A BRADFORD, IOW 01835 W P tjI Lie- I Sl -c6 978-372-7471 ,nC4-all Lr- OF Gc+-d b9r- REPORT FOR Town of ltdD A n r we — z�TE �►DDREss Ip /f- 14 10-3- ' /a5 Vicky Bre e liz.1 vlYAW JC /qt7e-. 76 TUC /® 3q Fab+ la L166 Win r 5t 16 —(v `7Sa 14?d,46C. l� lit n 11 a rl v q? lObc) I'DO6 15co �5 P11�6 15Qo 1 so L'eld