HomeMy WebLinkAboutMiscellaneous - 734 FOSTER STREET 4/30/2018 (2)I
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Certificate of Compliance: Approval: Date: -
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Commonwealth of Massachusetts
"City/Town of NORTH ANDOVER,
.System Pumping Record
MASSACHUSE
RECEI EV p
Form 4 TOWN OF NORTH ANDOVER
HEALTH DEPARTMENT
DEP. has provided this form for use by local Boards of Health. The System Pumping Record must
be submitted to the local Board of Health or other approving authority.
A. Facility Information
1. System Location:
Address
�Q'
City/Town
2. System Owner:
Name
Address (it different from location)
City/Town
. Pumping Record
\ • 1. Date of Pumping
Type of system: ❑
❑ Other (describe):
l/'m,
State ,
4
Zip Code
State Zip Code
Telephone Number
-� Da/J6-),06 2. Quantity Pumped:
Gallons
Cesspool(s) [f] Septic Tank ❑ Tight Tank
4. Effluent Tee Filter present? ❑ Yes Lam' No
\ 5. Condition of System:
xk 9-0C
6. SAem- Pumped By:
If yes, was it cleaned? ❑ Yes ❑ No
Namee i Vehicle License Number
Company
7. Location where contents were disposed:
CN . .
Aignature of Hpor Date
http://www.mass.gbv/dep/wate approvals/t5forms.htm#inspect
t5form4.doc• 06/03 System Pumping Record • Page 1 of 1
COMMONWEALTH OF MASSACHUSETTS
Board of Health,NORTH ANDOVER , MA.
:.._ .:.:_.:.�. CERTIFICATE OF COMPLIANCE
Description of Work: 0 Individual Component(s) ' '.® Complete System_
The.undersigned hereby certify that the Sewage Disposal System; '
Constructed bd, Repaired (), Upgraded (), Abandoned ( )
by: PETER BREEN
at: 734 FOSTER STREET
has been installed in accordance with the provisions of 310 CMR 15.00 (Title 5) and the
approved design plans/as-built plans relating to application No. '
dated Revised 6/26/00 ,approved Design Flow477 . (gpd)
Installer
• Designer: Inspec br
Date ece ber 1 , 2000'
The issuance of this permit shall not be construed as a guarantee that the system• will ..
function -as designed.
T(7'4k1 i, Cr PID Cp-
1
PRI 12001 � . -
DEP AFFROVED FORM Si46
R I ED 11,1011;4
Town of North Andover
Office of the Health Department
Community Development and. Services Division
27 Charles Street
North Andover, Massachusetts 01845
Sandra Starr
Health Director
February 22, 2002
Mr. and Mrs. James Clawson
734 Foster Street
North Andover, MA 01845
Re: Application for an addition and deck to an existing home
Dear Mr. and Mrs. James Clawson:
Telephone (978) 688-9540
Fax(978)688-9542
Your application for an addition at 734 Foster Street has been reviewed by the Health Department. The application
was denied on February 22, 2002 for the following reasons:
1. X Missing information;
Passing Title 5 inspection of septic system may be required;
3. X Location of structure is not in an acceptable location.
To address the problem(s):
If #1 is checked, please supply:
a. Floor plan of the existing dwelling and the proposed addition;
b. Certified plot plan showing the house, septic system and proposed project including the
deck, in scale and including any associate grading.
If #2 is checked:
a. Have the septic system inspected by a certified Title 5 inspector to determine the size of the system and
whether it is operating properly: OR
b. Tie-in to municipal sewer.
If #3 is checked:
a. Relocate the project. The deck appears to traverse the septic line between the existing
dwelling and septic tank. Covering an existing septic line with any type of structure is not
acceptable.
Please feel free to call the Health Office at 978-688-9540 with any questions you may have.
Sinc,Rre ,
ian J. LaGrasse, Health Inspector
Cc: Creative Builders, Inc., 58 Water St., North Andover, MA 01845
Building Department
File
BOARD OF APPEALS 688-9541 BUILDING 688-9545 CONSERVATION 688-9530 NURSE 688-9543 PLANNING 688-9535
FIq x4 qW_ 'T3j - 0i0z
AS -BUILT CHECKLIST
73 el r -.s )
LOT NUMBER, STREET NAME
ASSESSORS MAP & PARCEL NUMBER
LOT LINES & LOCATION OF DWELLINGS
LOCATIONS & DIMENSIONS OF SYSTEM,
I�CLUDING R _SERV ;
t/f TIES TO LOT LINES & DWELLING, WELLS
a. FROM SEPTIC TANK
b. FROM LEACH AREA
LOCATIONS OF DEEP HOLES & PERC
TESTS
✓ ELEVATIONS OF DISPOSAL SYSTEM
TOP OF FDN ELEVATION
LOCATIONS OF `
WITHIN 150' OF ; �l
n
LOCATION OF W �/ ` C�/✓ _` /
DISTANCES FROP
TANK & D -BOX
ORIGINAL STAMI
✓ IMPERVIOUS ARE
NORTH ARROW
LOCATION & ELE`
F'�qx0 qu-0/0
AS -BUILT CHECKLIST
LOT NUMBER, STREET NAME
ASSESSORS MAP & PARCEL NUMBER
LOT LINES & LOCATION OF DWELLINGS
t�'" LOCATIONS &. DIMENSIONS OF SYSTEM,
I�CLUDINCr RESERV �h�.i s,� ;
TIES TO LOT LINES & DWELLING, WELLS
a. FROM SEPTIC TANK
b. FROM LEACH AREA
LOCATIONS OF DEEP HOLES & PERC
TESTS
✓ ELEVATIONS OF DISPOSAL SYSTEM
TOP OF FDN ELEVATION
r__O_s�
e -p -
LOCATIONS OF WELLS, DRAINS, WATERCOURSES
WITHIN 150' OF SYSTEM
LOCATION OF WATER, GAS, ELECTRIC LINES, CABLE
DISTANCES FROM CORNERS OF HOUSE TO CENTER OF
TANK & D -BOX
ORIGINAL STAMP & SIGNATURE
v
IMPERVIOUS AREAS - DRIVEWAYS, ETC.
NORTH ARROW
LOCATION & ELEVATIONS OF BENCHMARK USED
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CO MONWFAIT14 Of MASSAC14USETTS 2870
Board of Health, NORTH ANDOVER , MA. 7-17-00
APPLICATION FOP DISPOSAL SYSTEM CONSTRUCTION PERMIT
Application for a Permit to Construct Repair( ) Upgrade( ) Abandon( ) - R Complete System ❑ Individual Components
Location 734 FOSTER STREET
Owner's Name JAMES CLAWSON
Map/Parcel# MAP 90A LOT 32
Address 7-34 FOSTER STREET
Lot# LOT C
Telephone#
Installer's Name jAdMES CtjpDesigner's
Name
Address 131 FOREST STREET-,
I Address 248 ANDOVER ST PEABODY,MAO] 91
-MUM—F—Inw
Telephone#0781-774-6685
Telephone#
Type of Building DWELLTNCT Lot Size Z 13 _A_CR_ES sq. ft.
Dwelling - No. of Bedrooms 4 Garbage grinder ( )
Other - Type of Building No. of persons Showers ( ), Cafeteria ( )
Other Fixtures
Design Flow (min. required) 55 gpd Calculated design flow 440 Design flow provided --444gpd
Plan: Date 7-13-99 Number of sheets 1 Revision Date 6,26-00
Title SEWAGTBT)TSPOSAT, SVSTFMFOR • TAMES C1.AWSON 734 1E0STFR CTRFRT
Description of Soil (s) SEF 1N0ITI RD SHEETS
Soil Evaluator Form No. 11 Name of Soil Evaluator date of Evaluation 6_-21-99
DESCRIPTION OF REPAIRS OR ALTERATIONS
The undersigned agrees to install the above described Individual Sewage Disposal System in accordance with the provisions of TITLE 5 and
further a e to place system in operation until a Certificate of Compliance has been issued by the Board of Health.
Date
Signed 1'�
Inspections
No.
COMMONWEALTH Of MASSAC14USETTS
Board of Health, , MA.
CERTIFICATE Of COMPLIANCE
FEE
Description of Work: ❑ Individual Component(s) ❑ Complete System
The undersigned hereby certify that the Sewage Disposal System; Constructed ( ), Repaired ( ), Upgraded ( ), Abandoned ( )
by,
at
has been installed in accordance with the provisions of 310 CMR 15.00 (Title 5) and the approved design plans/as-built plans relating to
application No. dated Approved Design Flow (gpd)
Installer
Designer: Inspector: Date:
The issuance of this permit shall not be construed as a guarantee that the system will function as designed.
No.
COMMONWEALTH OF MASSAC14USETTS
Board of Health, , MA.
DISPOSAL SYSTEM CONSTRUCTION PERMIT
FEE
Permission is hereby granted to; Construct( ) Repair( ) Upgrade( ) Abandon( ) an individual sewage disposal system
at as described in the application for
Disposal System Construction Permit No. dated
Provided: Construction shall be completed within three years of the date of this permit. All local conditions must be met.
Form 1255 Rev. 5/96 A.M. Sulkin Co. Boston, MA Date Board of Health
r
No. FEE
CO' MONWFALT14 Of MASSAC14US ETTS 2870
Board of Health, NORTH ANDOVER MA
7-17-00
APPLICATION FOP DISPOSAL. SYSTEM CONSTRUCTION PERMIT
Application for a Permit to Construe ) Repair( ) Upgrade( ) Abandon -X❑ Complete System ❑ Individual Components
Location 734 FOSTER
Owner's Name
Map/Parcel# MAP 90A, LOT 32
Address 734 FOSTER STREET
Lot# LOT C
Telephone# (978)682-5611 �K
Installer's Name JAMES CURRIER
Designer's Name JOHN J. DECOULOS*'
Address 131 FOREST STREET MIDDLETON
Address 248 ANDOVER ST. PEABODY,MA01960
Telephone# (978)-774=6685." - - —, - + -
Telephone# 1-978-532-4102 '
Type of Building DWELLING Lot,Size 2.13 ACRES_sq. ft.
Dwelling - No. of Bedrooms 4 3 Garbage grinder ( )+
Other - Type of Building No. of persons Showers ( ), Cafeteria ( )
Other Fixtures
t
Design Flow (min. required) 55 gpd Calculated design flow 440
Plan: Date 7-13-99 Number of sheets 1
Title SEWAGE DISPOSAL SYSTEM FOR: JAMES CLAWSON 734 FOSTER STREET
Design flow provided 444 gpd
Revision Date 6-26-00
Description of Soil (s) SEE INCLUDED SHEETS
Soil Evaluator Form No. 11 Name of Soil Evaluator JOHN 7 DEC07ULOS Date of Evaluation 6-22-99
DESCRIPTION OF REPAIRS OR ALTERATIONS
The undersigned agrees to install the above described Individual Sewage Disposal System in accordance with the provisions of TITLE 5 and
further agr' a to no ,to place the system in operation until a Certificate of Compliance has been issued by the Board of Health.
Signed Date %%72:1d,
Inspections
No. (` �/� �T}��1 j�� j� (` ��� T �"
COMMOlY V'V' LALT14 OjC MASSA'L.�Jl�I SETTS
Board of Health; MA.
CERTIFICATE Of COMPLIANCE
FEE
Description of Work: ❑ Individual Component(s) ❑ Complete System ;
The undersigned hereby certify that the Sewage Disposal System; Constructed ( ), Repaired ( ), Upgraded ( ), Abandoned ( )
by:
at _
has been installed in accordance with the provisions of 310 CMR 15.00 (Title 5) and tht approved design plans/afbuilt plans relating to'- -,
.« - ... .
application No. dated Approved Design Flow (gpd , �} �.*
Installer
Designer: 'Inspect6r: Dater• t
-The issuance of --this -per-mit shall:not-he construed'as a guarantee that the system will function as -designed.: ,
No. FEE
COMMONWFALT14
MASSACHUSETTS ¶' T
Board of Health, MA.
DISPOSAL SYSTEM CONSTRUCTION PERMIT
Permission is hereby granted to; Construct( ) Repair( ) Upgrade( ) Abandon( ) an individual sewage disposal system
at as described in the application for
Disposal System Construction Permit No. dated
Provided: Construction shall be completed within three years of the date of this permit. All local conditions must be met.
Form 1255 Rev. 5/96 A.M. Sulkin Co. Boston, MA Date Board of Health
INSPECTION CHECKLIST FOR SEPTIC SYSTEMS
A. Bottom of Bed
1. Excavation to proper depth
2. With trenches, sides of excavation are beneath B horizon
3. Edge of excavation specified distance from foundation, etc.
Comments:
73Y �S`f
Yes
B. Retaining Wall
1. Wall height and ' th as specified
2. Waterproofed
3. Wall minimum 10.' to lea ' g facility
4. Wall meets specifications of p
Comments:
C. Building Sewer
1. Pipe diameter minimum 4"
2. Schedule 40 pipe
3. Watertight joints
4. Inlet to tank cemented
5. Slope minimum 0.01 or 1/8" per foot minimum =,--
6. Pipe properly set on compact firm base
7. Pipe laid on continuous grade in straight line
8. Cleanouts precede all change in alignment and grade T-
9. Manholes at any 90° change
10. 10' minimum offset to water line
u0i
Initials
D. Septic Tank
1. Level
2. 1,500 gal minimum
3. Gas bathe present on outlet
✓'
4. Manhole to grade
5. Manholes over center and each tee
6. 3-20" manholes
7. Inlet tee minimum 12" under invert
8. Ouilet tee minimum 14" under invert
9. Outlet line cemented
10. Air space 3" above tees
11. 2" - 3" drop from inlet to outlet
12. Pipe set
13. Compact base with 6" of 3/4" crushed stone under tank
14. Tank is watertight
t�
Comments:
Yes NO
E. Pump Chamber
1. If separate from tank, compact base with 6" of 1/4" stone underneath
2. Minimum 2" pipe to d -box if gravity system ✓
3. 20" access manhole
4. Tank level
5. Watertight
6. Tank size agrees with plan specification
7. Manhole to grade
8. Check valve and bleeder hole present
9. Alarm in building on separate circuit
10. Alarm functions
11. Manual operating switch
12. Pump delivers liquid to d -box
Comments:
F. Distribution Box
1. D -box level
2. Minimum 0.1T' (2") drop from inlet to outlet r/
3. Minimum 6" sump
4. Outlet pipes show equal distribution
5. Compact base with 6" of stone beneath box
6. Box is watertight
7. All lines cemented with hydraulic cement
8. Schedule 40 pipe
Comments: A� (
t 1 VAA J , - 14r-, X( -IS
G. Soil Absorption system
1. All stone double -washed -'/4" - 1 ''/z" ✓�
- pea stone .�
'Bucket test done?
2. Minimum 27of pea stone above distribution lines
3. Minimum 6" stone beneath pipe
4. Distribution lines capped or connected together
5. Grading meets 3:1 slope
6. Minimum of 9" of fill graded over system
7. Toe of slope stops minimum 5' from edge of property; if not, then swale.
Comments:
H. Leach Trenches
1. Minimum 2 trenches
2. Length of trenches agree with plan. (Max length 100')
3. Width of trenches agree with plan - Minimum 2'; maximum - 4'.
4. Vent present if <50 feet or specified
5. Distance between trenches minimum 4' and maximum of 6'
6. Minimum distance between trenches 10'
7. Pipe slope minimum 0.005 or 6" per 100'
8. Depth of trenches below outlet invert minimum of 6".
Yes NO
9. Pipes set on stable base.
Comments:
I. Leach Field
1.
Maximum length of field 100'
2.
Pipe slope minimum 0.005 or 6" per 100'
3.
Separation between pipe 6' maximum
4.
Pipes connected at end
5.
Separation between adjacent fields 10' minimum
—�
6.
Pipes set on stable base
7.
Maximum 4' separation from edge of field to first line
8.
Minimum two distribution lines
/
9.
Maximum perc rate 20 mpi
Comments:
I Leaching Pits
1.
Minimum inlet pipe 4"
2.
Pits of concrete
3.
Sidewall between 12" and 48" wide
4.
Access manholes on each pit
5.
Pipes cemented with hydraulic cement
Comments:
K. Final Grade
1.
Slope over soil absorption system minimum 0.02
2.
All system components covered by at least 9" soil
3.
Cover soil free of stones larger than 6"
4.
Grading slopes away from dwelling
5.
No areas over system that may pond
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V�
APPLICATION FOR DISPOSAL WORKS CONSTRUCTION PERMIT
DATE: o I � CURRENT INSTALLER'S LICENSE#
LOCATION: % yoT ,dee � �
LICENSED INSTALLER: �� e -r Q r� fo-.
SIGNATURE: ��/t TELEPHONE#
CHECK ONE:
REPAIR: \_�
NEW CONSTRUCTION:
IF NEW CONSTUCTION, PLEASE ATTACH FOUNDATION AS -BUILT.
$75.00 Fee Attached?
Foundation As -Built?
Administrative Use Only
Yes No
Yes 6-- No
Floor Plans? Yes No
Approval Date: CCJ
INSTALLER PROJECT MANAGEMENT OBLIGATIONS
As the North Andover licensed installer for the construction of the septic system for the property
C k4w Som
at 7 9 Y (-Ds i ems- S relative to the application of
dated for plans by and dated with
revisions dated
I understand and agree to the following obligations for management of this project:
1. As the installer I am obligated to call for any and all inspections. If homeowner, contractor,
project manger, or any other person not associated with my company schedules an inspection
and the system is not ready then item two shall be applicable .
2. As the installer I am required to have the necessary work completed prior to the applicable
inspections as indicated below. I understand that requesting an inspection, without completion
of the items in accordance with Title 5 and the Board of Health Regulations may result in a
$50.00 fine being levied against my company.
a) Bottom of Bed — generally first inspection unless there is a retaining wall which should be done first Installer
must request the inspection but does not have to be present.
b) Final Inspection — Engineer must first do their inspection for elevations, ties, etc. As -built or verbal OK from
engineer must be submitted to BOH, after which installer calls for inspection time. Installer must be present
for this inspection. With pump system all electrical work must be ready and able to cause pump to work and
alarm to function.
c) Final Grade — Installer must request inspection when all grading is complete. Does not have to be on site.
'i
3. As the installer I understand that persons or companies not associated with my company may
not perform the work required by my company to complete the installation of the system
identified in the attached application for installation. I further understand that work by others
unlicensed to install septic systems in North Andover can constitute reasons for denial of the
system, and/or revocation or suspension of my license in the Town of North Andover plus
significant fines to all persons involved.
4. As the Installer I understand that I must be on site during the performance of the following
construction steps:
a) Determination that the proper elevation of the excavation has been reached
b) Inspection of the sand and stone to be used.
c) Final inspection by Board of Health staff.
d) Installation of tank, D -box, pipes, stone, vent, pump chamber, retaining wall and other components.
5. As the installer I understand that I am solely responsible for the installation of the system as per
the approved plans. No instructions by the homeowner, general contractor, or any other persons
shall absolve me of this obligation.
Undersigned Licensed Septic Installer ;
Date: llJ D d
Y
f'f
s
NORTy q
Town Of North Andover
of
Community Development & Services
40 p
27 Charles Street
North Andover, Massachusetts 01845
�gSSACHU55t4y
Fax 978-688-9542
Board of
Appeals July 26, 2000
(978) 688-9541
Building John Decoulos
Department 248 Andover Street
(978) 688-9545 Peabody, MA 01960
Conservation
Department Re: 734 Foster Street
(978) 688.9530
Health Dear John:
Department
(978) 688-9540 This is to inform you that the revised septic system plans dated 6/26/00 for the
site referenced above has been approved for repair.
Public Health
Nurse
(978) 688-9543 an If Y Y you have questions, please do not hesitate to call the Board of Health
Office at 978-688-9540.
Planning Sincerely,
Department
(978) 688-9535
Sandra Starr, R.S., C.H.O.
Health Director
SS/smc
cc: Clawson
File
William J. Scott
Director
(978) 688-9531
Jul -24-00 11:27A Paul D. Turbide, PE/PLS
1
July 24, 2000
Sandra Starr
North Andover Board of Health Administrator
Office of Community Development and Services
30 School St.
North Andover, MA 01845
RE: Title V third review for 734 Foster Street
Dear Sandra,
I find that the design plan with revision date of June 26, 2000 adequately addresses the
concerns outlined in my report dated June 16, 2000.
If you have any questions or comments please feel free to contact me.
Sincerely
Carlton A. rown, �PE/PLS ,p
Foster734c.doc / ~
� P�0�4P E�P�
PORT
INGINEERING
Civil Engineers &
Land Surveyors
One Harris Street
Newburyport,NtH
01950
(978)465-8594
6 /'�-6 /d6
John J. DecouloS 248 Andover Street
at Wiillowdale Lane
Registered Professional Engineer Peabody, MA 01960
Professional Land Surveyor 978-532-4102
July 5, 2000
28703
Sandra Starr, R.S.
Health Administrator
Town of North Andover
Community Development and Services
27 Charles Street
North Andover, MA 01845
Re: 734 Foster Street
Dear Ms. Starr,
JUL6 #
Enclosed please find three copies of revised plan for 734 Foster Street addressing the four issues in
your letter of June 16, 2000.
Very yours,
ohn . Decoulos
JJD/sc
enc.
SEPTIC PLAN SUBMITTAL FORM
LOCATION: Ci!
NEW PLANS: YES $125.00/Plan
REVISED PLANS: YES $ 60.00/Plan
SITE EVALUATION FORMS INCLUDED: YES NO
DATE:
DESIGN ENGINEER:
DATE TO CONSULTANT:
*If you want your plans expedited, please submit three plans and included a
stamped envelope with the correct amount of postage to mail plans to Port _
Engineering.
When the submission is all in place, route to the Health Secretary.
JUL 19
f gORTF�
�ss�c«usE��
Fax 978-688-9542
Board of
Appeals
(978) 688-9541
Building
Department
(978) 688-9545
Conservation
Department
(978) 688-9530
Health
Department
(978) 688-9540
Public Health
Nurse
(978) 688-9543
Town Of North Andover
Community Development & Services
27 Charles Street
North Andover, Massachusetts 01845
June 16, 2000
John Decoulos
248 Andover Street
at Willowdale Lane
Peabody, MA 01960
Re: 734 Foster Street
Dear John:
William J. Scott
Director
(978) 688-9531
This is to inform you that the proposed plans for the site referenced above have
been disapproved for the following reasons:
1. The effluent is being pumped to the dbox, and therefore a vent must be
designed as per the regulations.
Planning
Department 2• An impervious membrane is being proposed as an impermeable barrier in lieu
(978) 688.9535 of the required fill. This will need a waiver from local regulations, which
require that impermeable barriers be made of poured concrete (NA 9.02).
3. Distribution lines of field must be connected by solid pipe (NA 15.01).
4. Outlet pipes from the dbox must be laid level for the first two feet (310 CMR
232 (3) (c)).
If you have any questions, please do not hesitate to call the Board of Health
Office.
Sincerely,
/'Sandra Starr, R.S., C.H.O.
Health Director
cc: James Clawson
file
Jun -16-00 09:33A Paul D. Turbide, PE/PLS
June 16, 2000
Sandra Starr
North Andover Board of Health Administrator
Office of Community Development and Services
30 School St.
North Andover, MA 01845
RE: Title V second review for 734 Foster Street
Dear Sandra,
978-465-0313 P.02
Enclosed find the "Checklist for North Andover Septic System Plans" for the above-
mentioned site. The following is a list of all the `Problem' areas and deficiencies Port
Engineering has found. (Note that the original design was for trenches, this design uses
a field).
o The effluent is being pumped to the dbox, and therefore a vent must be designed as
per the regulations.
o An impervious membrane is being proposed as an impermeable barrier in lieu of the
required fill. This will need a waiver from local regulations, which require that
impermeable barriers be made of poured concrete (NA 9.02).
v Distribution lines of field must be connected by solid pipe (NA 15.01)
o Outlet pipes from the dbox must be laid level for the first two feet (3 10 CMR
232(3)(c))
If you have any questions or comments please feel free to contact me.
Sincerely ,
t-
_ /`�--
Carlton A. Brown, PE/PLS
Foster734B.doc
PORT
INGINIIRING�
Civil Engineers R
Land Surveyors
One Harris Street
Newburylwrt, MA
01950
(978)465-8594
John I Decoulos 248 Andover Street
at Willowdale Lane
Registered Professional Engineer Peabody, l0'IA 01960
Professional Land Surveyor 978-532-41€22
June 7, 2000
Sandra Starr, R.S.
Health Administrator
Town of North Andover
Community Development and Services
27 Charles Street
North Andover, MA 0184 -
Re: 734 Foster Street
Bear Ms. Starr,
Enclosed please find check- for $60.00 and three revised copies of Sewage Disposal System Plan, 6-6-
00 for James Clawson., 734 Foster Street.
We have revised the system to a leaching field to reduce the amount of mounding in Mr. Clawson's
backyard where he intends to add a room
Decoulos
enc.
SEPTIC PLAN SUBMITTAL FORM
LOCATION:_
NEW PLANS:
REVISED PLANS:
YES
YES
$125.00/Plan
$ 60.00/Plan L/
SITE EVALUATION FORMS INCLUDED: YES NO
DATE:
DESIGN ENGINEER:
DATE TO CONSULTANT:
*If you want your plans expedited, please submit three plans and included a
stamped envelope with the correct amount of postage to mail plans to.Port
Engineering.
When the submission is all in place, route to the Health Secretary. '1'v++i4 2
t 93
BOARD OF HEALTH TEL. 688-9540
NORTH ANDOVER, MASS. 01845
APPLICATION FOR SOIL TESTS
DATE: /.3 —�Y
LOCATION OF SOIL TESTS: %�� ����'�►��
Assessor's map & parcel number:M
OWNER: iyie'v` IGrSo� TEL. NO.:-// Vo-
ADDRESS: 7Sl iZLS i
ENGINEER: ?-j l TEL. NO.: 5W—'6-&'C"2—
CERTIFIED
W'&'C"2
CERTIFIED SOIL EVALUATOR: 2jj>��p
Intended use of land: residential subdivision, single family home, commercial
Repair testing Undeveloped lot testing
N. A. Conservation Commission Approval:
THE FOLLOWING MUST BE INCLUDED WITH THIS FORM:
1. Proof of land ownership (Tax bill, deed, or letter from owner permitting
tests)
2. Plot plan
3. Fee of JL75.0o per lot for new construction. This covers the minimum two deep holes
and two percolation tests required for each disposal area. Fee of JZLoo per lot for
repairs or upgrades.
GENERAL INFORMATION
1. Only Certified Soil Evaluators may perform deep hole inspections.
2. Only Mass. Registered Sanitarians and Professional Engineers can design septic
plans.
3. At least two deep holes and two percolation tests are required for each septic system
disposal area.
4. Repairs require at least two deep holes and at least one percolation test, at the
discretion of the BOH representative.
5. Full payment will be required for all additional tests within two weeks of testing.
6. Within 45 days of testing, a scaled plan (no smaller than 1"- 100') shall be submitted to
the Board of Health showing the location of all tests (including abort
7. Within 60 days of testing soil evaluation forms shall be submitted.BOARDaF L HEALTHVER;
MAY I ®11999
DATE:
LOCATION:
ENGINEE Ez'
BOi—I WI 1 NESS:
FE~COLn,,I ION TEST- -G
5�� 7
3 Z��
EO I 1 0NI DEFT Gr =cC TEST:
T11 M E OF SK.: _ aL.� (At IES inut�s Icnc j
TiN1E AT 1'2"
TIME AT _
TIME "�T E
Cv`E.NIGr,— SOAK
l_l,^.K
i
IME S , T EL
i iMEr, l
SEPTIC PLAN SUBMITTAL FORM
LOCATION: � S� Fb,576k 773(IW E J
NEW PLANS: Z?) $125.00/Plan LX
REVISED PLANS: YES $ 60.00/Plan
SITE EVALUATION FORMS INCLUDED: YES NO
DATE:
�-- SJ
DESIGN ENGINEER: 7 n 0t� bf- C d CSG- f}S
DATE TO CONSULTANT:
*If you want your plans expedited, please submit three plans and inaci
stamped envelope with the correct amount of postage to mail plans to Port a
Engineering.
When the submission is all in place, route to the Health Secretary.
Town of North Andover
OFFICE OF
COMMUNITY DEVELOPMENT AND SERVICES
WILLIAM J. SCOTT
Director
(978)688-9531
September 15, 1999
RE: 734 Foster Street
John Decoulas
Dear Mr. Decoulas:
27 Charles Street
North Andover, Massachusetts 01845
Fax(978)688-9542
This letter is to inform you that the proposed septic plans for the repair of the system at
734 Foster Street have been disapproved for the following reasons:
1. The bottom of the system is less than 4' to groundwater. The elevation of the
existing grade at the high end of the proposed leaching system is about 143'.
Groundwater was observed to be 54" below the surface in Test pit 2, thus
groundwater at the high end of the system is presumed to be about elevation 138.5'.
(3 10 CMR 15.220(4)(n)).
2. Baffle in d -box missing. (3 10 CMR 15.232(3)(a)).
3. Assessor's map and lot number missing. (3 10 CMR 15.220(4)(u)).
4. Abutters' names missing. (NA 8.02j)
5. Fill on northeast side of system inadequate. (May be addressed as a result of
comment # 1) 1.
Please remember that all revisions require a $60.00 submittal fee.
Sincerely,
Sandra Stan, R.S.
Health Administrator
Cc: James Clawson
File
BOARD OF APPEALS 688-9541 BUILDING 688-9545 CONSERVATION 688-9530 HEALTH 688-9540 PLANNING 688-9535
Sep -09-99 01:06P Paul D. Turbide, PE/PLS
September 9, 1999
Sandra Starr
North Andover Board of Health Administrator
Office of Community Development and Services
30 School St.
North Andover, MA 01845
RE: Title V review for 734 foster Street
Dear Sandra,
508-465-0313 P.02
Enclosed find the "Checklist for North Andover Septic System Plans" for the above-
mentioned site. The following is a list of all the `Problem' areas and deficiencies Port
Engineering has found.
o ESHW elevation must be adjusted. The elevation of the existing grade at the high
end of the proposed leaching trench system is about 143'. ESHW was observed to
be 54" below the ground surface in Test Pit 2. Thus ESHW at the high end of the
system is presumed to be about elevation 138.5'. The bottom of the trenches must
be four feet higher, or elevation 142.5'. This would mean that the trenches must be
raised by about 3.8'. 310 CMR 220(4)(n)
❑ The elevation where the 3:1 slope starts should be about 141.5'. It appears that the
northeast side of the trench has a design elevation of 140' at the 15' offset. Thus it
appears that there should be more fill placed on the northeast side. (This may be a
moot point because the final grading will have to be totally redone for the above-
mentioned comment that the entire system may have to be raised by 3.8').
❑ The effluent is being pumped to the dbox, and therefore a vent must be designed as
per the regulations.
❑ The effluent is being pumped to the dbox and therefore a baffle must be installed in
the dbox. 3 10 CMR 232(3)(a).
❑ The assessor's map and lot number must be referenced. 310 CMR 220(4)(u)
u The abutters' names must be shown. NA 8.02j
If you have any questions or comments please feel free to contact me.
Sincerely
PORT Carlton A. Brown, PE/PLS
it I Foster7,3.doc
ENGINEERING �� �----
Civil Engineers &
Land Surveyors
One Harris Street
Newburyport, MA
01950
(978)465-8594
To
7Y)S,3Z— Y/Z) Z,
%.3 LI
Health Department
Town of North Andover
27 Charles Street
North Andover, MA 01845
(978)688-9540
Fax: (617)338-0122
Date: 05/23/00
Pages: 1
^,omment ❑ Please Reply ❑ Please Recycle
lead paint case, 19 Second Street, North
i update on the status of the case. Things
'hoped. Mr. Thornton has contacted me a
ended actions. Apparently he is now trying
itement on this own. I reminded him that
ection .of the lead inspector and that it was
?h has been
Town of North Andover, Massachusetts Form No. 2
� 14ORTN BOARD OF HEALTH
c•t,•e •,��19
� w
p
DESIGN APPROVAL FOR
ssACNUSEt SOIL ABSORPTION SEWAGE DISPOSAL SYSTEM
Site Location
Reference Plans and Specs
DA
Permission is granted for an'individual soil absorption sewage disposal system to be installed
in accordance with regulations of Board of Health.
Fee
CHAIRMAN, BOARD OF HEALTH
Site System Permit No. 16 7J
No.
FEE
COMMONWEALT14 Of MASSACHUSETTS
Board of Health, 4/0 /A AC7OV6K , MA.
APPLICATION FOP, DISPOSAL SYSTEM CONSTRUCTION PERMIT
Application for a Permit to Construct( ) Repair (t<Upgrade ( ) Abandon( ) - Complete System ❑ Individual Components
Location 73 Us rV Ce f
Owner's Namec,701nej ooi
Map/Parcel#
Address 77/t vP
Lot#
Telephone#
Installer's Name vWmeg
Designer's Name c l emw16X
Address 131`Ile y(ollAddress
Telephone# /75/—���
Telephone# 9% 6d: _010ol -
Type of Building
Dwelling - No. of Bedrooms
Other - Type of Building _
Other Fixtures
No. of persons
Design Flow (min. required) gpd Calculated design flow 7'V40
Plan: Date 7-/.3 _ 109 Number of sheets
10C
Desc
Lot Size OV, /VX0y&-5"7.4.
Garbage grinder( )
Showers( ), Cafeteria ( )
Design flow provided 571W gpd
Revision Date
Soil Evaluator Form No.
DESCRIPTION OF REPAIRS OR ALTERATIONS
Name of Soil Evaluator✓h/1J-C&tIOS Date of Evaluation 6 `.;p — `/ y
The undersigned agrees to install the above described Individual Sewage Disposal System in accordance with the provisions of TITLE 5 and
further a ees to t to p e the system in operation until a Certificate of Cg�o�^n. fiance has been issued by the Board of Health.
Signed Date d�
Inspections
No. C®MMONWLALT14 OF MASSACHUSETTS FEE
Board of Health, , MA.
CERTIFICATE OF COMPLIANCE
Description of Work: ❑ Individual Component(s) ❑ Complete System
The undersigned hereby certify that the Sewage Disposal System; Constructed ( ), Repaired ( ), Upgraded ( ), Abandoned ( )
by:
at
has been installed in accordance with the provisions of 310 CMR 15.00 (Title 5) and the approved design plans/as-built plans relating to
application No. dated Approved Design Flow (gpd)
Installer
Designer: Inspector: Date:
The issuance of this permit shall not be construed as a guarantee that the system will function as designed.
No.
COMMONWEALTH OF MASSACHUSETTS
Board of Health, , MA.
DISPOSAL SYSTEM CONSTRUCTION PERMIT
FEE
Permission is hereby granted to; Construct( ) Repair( ) Upgrade( ) Abandon( ) an individual sewage disposal system
at as described in the application for
Disposal System Construction Permit No. , dated
Provided: Construction shall be completed within three years of the date of this permit. All local conditions must be met.
Form 1255 Rev. 5/96 A.M. Sulkin Co. Boston, MA Date Board of Health
.
i
No - FEE
Board of Health, Ai,0/T`► 1106 J 0Y , MA.
APPLICATION FOR DISPOSAL SYSTEM CONSTRUCTION PERMIT
Application for a Permit to Construct( ) Repair((,<UpgradeO Abandon( OComplete System ❑ Individual Components
Location 7,37 Fs - Jfre-e r"
Owner's Name (//y?to r 014
Map/Parcel#
Address 7-3z
Lot#
Telephone# l/57
Installer's Name XMIOS
�c
Designer's Name✓Q�r �P� fes^
1
Address 131 /mss/ V'7�f
Address ��i �/ L
`�'�
Telephone# 77V—
Telephone# (q 7d') —0/Oc7—
Type of Building 4 ;lIsyl/hq 2)Alellll7 r Lot Size off,
Dwelling - No. of Bedrooms Garbage grinder( )
Other - Type of Building No. of persons Showers ( ), Cafeteria ( )
Other Fixtures J
Design Flow (min. required)/ pgpd Calculated design flow T�� Design flow provided `�'� gpd
Plan: Date Number of sheets TRevision Date
Title -!5��ew de.c%G1�7% SLiiS /Yl /e'/ • c/" //Y,Yws (- /e57 C.'Go 77 Fs r Cie 7"
Description ofSoil (s) �� ��� �t�SCS" 117C,1',�l&-1-7�W-el,,,W& G(�
Soil Evaluator Form No. Name of Soil Evaluator✓O /7 ,/ CO t lcSi Date of Evaluation
k
.j
DESCRIPTION OF REPAIRS OR ALTERATIONS
The undersigned agrees to install the above described Individual Sewage Disposal System in accordance with the provisions of TITLE 5 and
further aees to of to pl a the system in operation until a Certificate o Co fiance has been issued by the Board of Health.
Signe Date 17/11199
Inspections
l
No. 'l_®MMONWLALT14 OF MASSAC14US ETIS FEE
Board of Health, , MA.
CERTIFICATE OF COMPLIANCE
Description of Work: ❑ Individual Component(s) ❑ Complete System
The undersigned hereby certify that the Sewage Disposal System; Constructed ( ), Repaired ( ), Upgraded ( ), Abandoned ( )
by:
at
has been installed in accordance with the provisions of 310 CMR 15.00 (Title 5) and the approved design plans/as-built plans relating to
application No. dated Approved Design Flow (gpd)
Installer
Designer: Inspector: Date:
The issuance of this permit shall not be construed as a guarantee that the system will function as designed.
No. FEE
COMMONWEALTH OF MASSAC14USETTS
Board of Health, , MA.
DISPOSAL SYSTEM CONSTRUCTION PERMIT
Permission is hereby granted to; Construct( ) Repair( ) Upgrade( ) Abandon( ) an individual sewage disposal system
at as described in the application for
Disposal System Construction Permit No. dated
Provided: Construction shall be completed within three years of the date of this permit. All local conditions must be met.
Form 1255 Rev. 5/96 A.M. Sulkin Co. Boston, MA Date Board of Health
7-54 FOSTER STREET
june 22. 1999
OHI............
`-;urface Elevation
.....
................
140.0
140.0
3-0"
0-7 A SL
10YR/2
.....
Friable.. .....
139,42
7-36 Bw SL
10YR4/6
Friable...... —.137.00
137.12
36-122 0 SL
2.5Y5/6
Firm. gravelly
-129.83
Mottles at 97"
7.5YR518
Concentrations
5Y6/3
Depletions.—.031.92
134.70
No observed
Groundwater
No weeping
No Weeping
#2 RATE - 18 Minutes/inch at 73" Deep ... 133.12
o
'Surface Elevation
.....
................
139.2
139.20
3-0" 0
0-6 A SL
I0YR3/3
........ I.
Friable .........
.
13870
6-25 B SL
IOYR5/8
Friable .........
137.12
_U n"
b-0, C, SL
2.5Y5/6
Firm ...... ......
131.03
Refusal at 92"
mottles at 54"
7.5YR5/0
entraton
Concis
SY6/4
Depletions ......
134.70
No Observed Groundwater
No weeping
s�,L zoe!;�
734 FOSTER STREET
june 22. 1.999
0141.
........
!-..'urface Elevation
-----------
. 140. 0
139.20
1...
140. 0'0
3-0" 0
130.70
....
6-25 B SL
0-7 A SL
10YR12
Fr QN:::.--139.42
7-36 Bw SL
IOYR4/6
Friable .........
137.00
36-122 C SL
2.5Y5/6
Firm, gravel , ly,.129.03
Motties at 97" 7.5YR5/0
Concentrations
Mottles at 54"
7.5YR5/8
SY6/3
Depletions
131.92
SY6/4
Depletions ......
134.70
No Observed
Groundwater
No Weeping
No Weeping
42 RATE = 18 Minutes/inch at 73" DeeP ... 133.12
oH2
Surface Elevation
........
139.20
'13
0-6 A SL
IOYR3/3
......
......
130.70
6-25 B SL
IOYR5/8
Friable .........
137.12
25-92 C SL
2.5Y5/6
Firm ............
13VY.;
Refusal at 9211
Mottles at 54"
7.5YR5/8
Concentrations
SY6/4
Depletions ......
134.70
No observed Groundwater
No Weeping
No.
2870
FORM 11 - SOIL EVALUATOR FORM
Page 1 of 3
CommoawtaUh of Massachusetts
Date: JUY 22,199-(
North Andover , Massachusetts
Soil Suitability Assessment fo On-site Sewage Disposal
Performed By: JOHN J,.DECOTL.QS......................................................... Date: JUNE 22,.1999
WitnessedBy:-SANDRA..STARR........ .................... .... ..... ................... ..... ............ --- ....... ..... ..... .... ........ ........ ...... ........ .
[ti=wn Add= or '
`A`" 734 FOSTER STREET
dew Construction ❑ Repair CR
Ow-'` Na-. JAMES CLAWSON
Ad&u=. ud
rkpt.. r 734 FOSTER STREET
NORTH ANDOVER
682-5611
urnce xeview
Published Soil Survey Available: No ❑ Yes
Year Published 1981 ... Publication Scale 1:15840 Soil Map Unit CrC
Drainage Class Well Drained ... Soil Limitations .............. .
Surficial Geologic Report Available: No ❑ Yes
Year Published 1963 Publication Scale 1:24000
GeologicMaterial (Map Unit) 'Q'gm.......................................................................-.................................._ ..........
Landform .. Ground, Moraine..............
....................................................................................................................... ........._....---
Flood Insurance Rate Map:
Above 500 year flood boundary No ❑ Yes
Within 500 year flood boundary No ®Yes ❑
Within 100 year flood boundary No ®Yes ❑
Wetland Area:
National Wetland Inventory Map (map unit) ... :................... ........ ... ....... ..............
Wetlands Conservancy Program Map (map unit) ..........................................
Current Water Resource Conditions (USGS): Month June
................
Range :Above Normal ❑Normal ❑Belt?v Normal
Other References Reviewed:
SFS - 21999
DEP APPROVED FORM - 1210719S ,
I
OHI
0112
FORM 11 - SOIL EVALUATOR FORM
Page 2of3
2870
Location Address or Lot i4o. 734 FOSTER STREET
On-site Review
Deep Hole Number 1 & 2 Date: JUNE 22, 1999 Time: 11:45
Location (identify on site pian)
Land Use Forest Slope (%) 3-5% Surface Stones
Vegetation OAK & PINE TREES
Landform .Ground Moraine
Position on landscape (sketch on the back)
Distances from:
Open Water Body 100+ feet Drainage way 100+ feet
Possible Wet Area 100+ feet Property Line 30+ . feet
Drinking Water Well 100+ feet Other
DEEP OBSERVATION HOLE LOG
Weather CLEAR
Depth from Soil Horizon Soil Texture Soil Color Soil add
Surface (inches) (USDA) (Munsell) Mottling (Structure, Stones, Boulders, Consistency, %
Gravel)
3-0 O
0-7 A
Parent Material (geologic) Glacial Till
Depth to Groundwater; Standing Water in the Hole: NONE
Estimated Seasonal High Ground Water: 54"
DEP APPROVED FORM - 12/07/95
DepthtoSedrock:
Weeping from Pit f=ace: NONE
SL
10YR3/2
Friable
7-36
B w
SL
10YR4/6
@ 97"
Friable
36-122
C
SL
2.5Y5/6
7.5YR5/8
Finn, very gravelly
OH 2
5Y6/3
(C3P)
3-0
O
0-6
A
SL
10YR3/3
Friable
6-25
B`,`,
SL
10YR5/8
@ 54"
Friable
25-92
C
SL
2.5Y5/6
7.5YR5/8
Firm, gravelly (C2P)
5Y6/4
Refusal @ 92"
Parent Material (geologic) Glacial Till
Depth to Groundwater; Standing Water in the Hole: NONE
Estimated Seasonal High Ground Water: 54"
DEP APPROVED FORM - 12/07/95
DepthtoSedrock:
Weeping from Pit f=ace: NONE
J
FORM 11 - SOIL EVALUATOR FORM
Page 3 of 3
I'4:fr111
Location Address or Lot No- 734 FOSTER STREET
Determination for Seasonal High Water Table
Methbd Used:
❑ Depth observed standing in observation hole
❑ Depth weeping from side of observation hole
K Depth to soil mottles 54" inches
❑ Ground water adjustment feet
Index Well Number
Adjustment factor
Reading Date
inches
inches
Index well level
Adjusted ground water level
Depth of Naturally Occurring Pervious Material
Does at least four feet of naturally occurring pervious material exist in all areas
observed throughout the area proposed for the soil absorption system? yES
If not, what is the depth of naturally occurring pervious material?
Certification
I certify that on JULY, 1995 (date) I have passed the soil evaluator examination
approved by the Department of Environmental Protection and that the above analysis
was performed by me consistent with the required training, expertise and experience
described in 310 CMR 15.013. _
Signatu
DEP APPROVED FORM - 12107/95
Date JULY 22, 1999
I
2870
FORM 12 - PERCOLATION TEST
Location Address or Lot No. 734 FOSTER STREET
COMMONWEALTH OF MASSACHUSETTS
l�Vl 6f1
North Andover , Massachusetts
Percolation Test*
Date: JUNE 22, 1999 Time: 12:50
Observation Hole #
2
Depth of Perc
7310
Start Pre-soak
12:50
End Pre-soak
1:05
Time at 12"
1:05
Time at 9"
1:35
Time at 6"
2:28
Time (9"-6")
53'
Rate Min./Inch
20
* Minimum of 1 percolation test must be performed in both the primary area AND
reserve area.
Site Passed 21 Site Failed ❑
....................................................................
Performed By: JOHN J. DECOULOS
Witnessed By: R. ROTOLO
Comments:..:...
iiDEP APPROVED FORM-12WI95
J �"•
® MARILYN J. CLAWSON
Mass. Licensed Residential Appraiser #1838
734 FOSTER STREET
NORTH ANDOVER, MA. 01845 Office: 9781356-9200
Fax: 9781356-7008
7.3
el
-7 7
"J. x S �
7.3 Z
&VIC U.-4
P, -n
Pi 4-
ov. .... . ...
--- - -------
30
VL
Applican
Site Location
Engineer
Town of North Andover, Massachusetts
Form No. 1
BOARD OF HEALTH
19
APPLICATION FOR SITE TESTING/INSPECTION
OW
Test/Inspection Date and Time
v rte.. •
-` CHAIRMAN, BOARD OF HEALTH
Fee "�_ d-0 Test No. q% ,�7--
S.S. Permit No. D.W.C. No. C.C. Date Plbg. Permit No.
ED
Town of North Andover, Massachusetts
BOARD OF HEALTH
19
Form No. 1
APPLICATION FOR SITE TESTING/INSPECTION
Applicant
NAME ADDRESS TELEPHONE
Site Location
Engineer
,NAME ADDRESS TELEPHONE
Test/Inspection Date and Time
Fee �'✓ '�
CHAIRMAN, BOARD OF HEALTH
Test No.
S.S. Permit No. D.W.C. No. C.C. Date Plbg. Permit No.
_r
zag4c) :�q panss? suD?4-p-=4sz5a.
_ auDuaaTay
T?Egad ( )
_ - --: TaIIDt�daTaz
:OtE,b xRq `(�1
UaA CKW , I
412
...,:11V . r..n. _ ... .... .. . _ ..
WE, Peter Madden and Nancy M. Madden, husband and wife, both
of Middleton,
Essex County, Massachusetts,
for the full consideration of $66,000.00 paid
grantto James R. Clawson and Marilyn J. Clawson, husband and wife
as joint tenants
of 734 Foster Street, North Andover, Massachusetts
with quitrlatm routnattte
A certain parcel of land in North Andover, Essex County,
Massachusetts, with all the buildings now or hereafter placed thereon,i
being shown as Lot C on a plan entitled: "Plan of Land Owned by
North Andover Associates Located in North Andover, Ma." scale 1" = 401,
dated December 7, 1976, Frank C. Gelinas & Associates, Engineers
and Architects, said plan being recorded with the North Essex Registry
of Deeds as Plan No. 7546.
Said lot is more substantially bounded and described as follows:
Running Easterly by Foster Street, 192.45 feet;
Running Northerly by land now or formerly of North Andover
Associates, 488.39 feet;
Running Westerly by Lot 31 and Lot 30 as shown on said plan,
200 feet; and,
Running Southerly by Lot B as shown on said plan, 471.90 feet,
all as shown on said plan.
Said Lot C contains according to said plan, 2.13 acres, more
or less.
Being the same premises conveyed to us by deed of Barco
Corporation dated March 7, 1977, and recorded in North Essex Registry
of Deeds, Book 1303, Page 671.
Executed as a sealed instrument this
cam _
C) of 19 78
Sat (ffomauattmtaIta of Aao=#=tts
Essex, ss. ,7 e ) L/l 19 78
Then personally appeared the above named Peter Madden and Nancy Madden
and acknowledged the foregoing instrument to he their ffreeAwt and deed, ^
Before me, N ea Public
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i'';•�•'"'r:•u•rnp,�:.,r',,�/',,•:?.:.1 ....
DEP,.has proWded thls form for use by local
be subrnl4ed to the.local'Board of Health or
Setts:'
%ER'�.MASSACH
USETTS
RECEIVED
oaro'sUCU. 091e Sytem Pumping Record mus;
ther approving authorlt
TOWN OF NORTH ANDOVE
:.,A:.Facllity Inform,otion HLAL I UEP
"
�,Yyr1e1 fiilln� out: .1.. System Location
only the tab key Address
to move your:; .
cursor • do pot
use the.,roturn CItY/lown � State
4, t�,,: ,:;;; ,:';: jy'' > . ; ..:;, .. 7Jp Code
:System Owner:;ko
,
�•�,:,;rl• ;.. : r'1Kj••;'}4•;'�?�'i,:fr;r 'r t. �l' ;r�jr•;l, ;.''1,�
'.1 +,1 J t � Name ±' r• ) •,.�r'f,, „ - '/ /
r\n,rnr
r' m ,/`��
"" . Address (If different from location)
• - �.. ,. ' Cltyylrown•;.:a; :,; ':1;::` ; r:', State'
Telephone Number
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`:Type gf:system; . ❑ cesspool(s) ' Septic Tank ❑Tight Tank
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Effluent Tea Filter present? . ❑ Yes C3 No'
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If yes, was It cleaned? ❑ Yes ❑ No
�Vehlcle Ucen#e Number
System Pumping Record ' Page t o! t