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HomeMy WebLinkAboutMiscellaneous - 75 EQUESTRIAN DRIVE 4/30/2018N O cn Date..�1 TOWN OF NORTH ANDOVER PERMIT FOR GAS INSTALLATION This certifies that . A.- .. . � ........... . has permission for gas installation in the buildings of ...I=? l i� Cw `�....................... at i1S `,�.... !!?-North Andover, Mass. Fee. � :G �. Lic. D No.. ... 3.6 .�-.. /% ... . GAS INSPECTOR' Check # J 69i -I',' Commonwealth of Massachusetts RECN City/Town of System Pumping- Record �. �,u ;; 32014 Form 4 TOWN OF Nc'lt7H ANDOVER HEAL --;,J DEP has provided this form for use-, by local Boards of Health. OAV`fonns may tie used, but the information must be substantially the same as that provided here. Before using this form, check with your local Board of Health to determine the form they use. The System Pumping Record must be submitted to the local Board of Health or other approving authority. A. Facility Information 1. System Location:d�?Rig o of hou Left / Right rear of house, Left/ right side of house, Left/ Right side of building, Left / Right ron o uildirig, Left / Right rear of building, Under deck Address l S_ Udylrown state Trp Code 2. System Owner. Name ?� Address (if different from location) Cityfrown State Zip de ; f Telephone Number B. Pumping Record 1. Date of Pumping Date 2. Quantity Pumped: Gallons 3. Type of system: ❑ Cesspool(s)eptic Tank ❑ Tight Tank ❑ Other (describe): 4. Effluent Tee Filter present? ❑ Yep a<o If yes, was it cleaned? ❑ Yes ❑ No, 5. Condition of 6. System Pumped By: 7. Neil. Bateson Name Bateson Enterprises Inc Company were disposed: Dwell Waste M F5821 Vehicle License Number Date t5form4.doco 06/03 System Pumping Record • Page 1 of 1 Commonwealth of Massachusetts City/Town of 7E'.dE'-1VE1,1System Pumping Record Form 4 M— 1 fN OF NORTH ANDOVER DEP has provided this form for use -by local Boards of Health.- ROWRM ut 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 Locatio . Le Rig4tf6gahouse Left / Right rear of house, Left / right side of house, Left / Right side of building, Left / Right front of building, Left / Right rear of building, Under deck Address Citylrown ' State Zip Code 2. System Owner. Name t az��we,l,( Address (if different from location) City/Town B. Pumping Record 1. Date of Pumping 3. Type of system: ❑ Date Cesspool(s) ❑ Other (describe): 4. Effluent Tee Filter present? ❑ Yes No State/-) CV 07 C) Code `73 Telephone Number — 2. Quantity Pumped; 0-8�eptic Tank Gallons ❑ Tight Tank If yes, was it cleaned? ❑ Yes ❑ No 5. Conditign of System:� 6. System Pumped By: Neil Bateson Name Bateson Enterprises Inc Company 7. Location where contents were disposed: F5821 Vehicle License Number Lowell Waste Water ule Date (3 t5form4.doc• 06/03 System Pumping Record • Page 1 of 1 MASSACHUSETTS UNIFORM APPLICATON FOR PERMIT.TO DO GAS FTTTING (Type or print) NORTH ANDOVER, MASSACHUSETTS Date 9 /Z Building Locations 7 .� �C%�,.tiJ�, = C��L , Permit # F,�� Amount $— Owner's Name P New ❑ Renovation ❑ Replacement Plans Submitted u ❑ (Print or type) `� Name , I r ��'T Ile P/W i?/J -,0 G , Address '-u 4). ,-)12 Name of Licensed Plumber or Gas Fitter T C" 6 ..e Check one: Certificate Installing Company ❑ Corp. Partner. Firm/Co. INSURANCE COVERAGE Check one: I have a current liability Insurance policy or it's substantial equivalent. Yes ❑" No ❑ If you have checked yes, please indicate the type coverage by checking the appropriate box. Liability insurance policy EI Other type of indemnity ❑ Bond ❑ Owner's Insurance Waiver: I am aware that the licensee does not have the Insurance coverage required by Chapter 142 of the Mass. General Laws, and that my signature on this permit application waives this requirement. Check one: Signature of Owner or Owner's Agent Owner p Agent 0 i ncrcuy mr-my mat au or ine aetatts ana mrormanon 1 nave submitted (or entered) in above application are true and accurate to the best of my knowledge and that all plumbing work and installations pe ormed under Permit Issued for this application will be in compliance with all pertinent provisions of the Massa71State a Code ayd Chap l�p 142 of teneral Laws. By: Title City/Town (OFFICE USE ONLY) Pignature of Licensed Plumber Or GasZitter lumber CJ 0 Gas Fitter lcense um er Master 0 Journeyman x w O H x > w F z F Q H W > w H xI CW7 Z w > W H Z d a CW7 cq O O w rV� H w F x O x w a 3 o C7 d a U x > a a O w W N O SUB-BASEM ENT BASEM ENT 1ST. FLOOR 2ND. FLOOR 3RD. FLOOR 4TH. FLOOR 5TH. FLOOR 6TH. FLOOR 7TH. FLOOR 8TH. FLOOR (Print or type) `� Name , I r ��'T Ile P/W i?/J -,0 G , Address '-u 4). ,-)12 Name of Licensed Plumber or Gas Fitter T C" 6 ..e Check one: Certificate Installing Company ❑ Corp. Partner. Firm/Co. INSURANCE COVERAGE Check one: I have a current liability Insurance policy or it's substantial equivalent. Yes ❑" No ❑ If you have checked yes, please indicate the type coverage by checking the appropriate box. Liability insurance policy EI Other type of indemnity ❑ Bond ❑ Owner's Insurance Waiver: I am aware that the licensee does not have the Insurance coverage required by Chapter 142 of the Mass. General Laws, and that my signature on this permit application waives this requirement. Check one: Signature of Owner or Owner's Agent Owner p Agent 0 i ncrcuy mr-my mat au or ine aetatts ana mrormanon 1 nave submitted (or entered) in above application are true and accurate to the best of my knowledge and that all plumbing work and installations pe ormed under Permit Issued for this application will be in compliance with all pertinent provisions of the Massa71State a Code ayd Chap l�p 142 of teneral Laws. By: Title City/Town (OFFICE USE ONLY) Pignature of Licensed Plumber Or GasZitter lumber CJ 0 Gas Fitter lcense um er Master 0 Journeyman l ... �� rrQn►tiea/fh of Mazaauaefi Uf. DePx%"1e"f .' n -f'Inriustr'ial Arridents isle, J mice Of'�rives�i;afionf 600 T�Tldrhirrh ton Street r� Boston, MA 612111 Worker's' Com ensatioa�'�goV/dna P i usi�tr•anee A�Fi vi 'cant Information RuRders/Contraciwrs/Eiecirieisas/PiQm6ers A . Please Print LeQibf �e ( sines/dr�nniM ion/Fndividnal)• Address CityLStafe/�p: Phone #: Are you an emPioYer'T Cheek.tbe appropriate -box: I:Q I•lima employer with 4. Q 1 atm a Type of project PIoY (flail and/or * gemetai contmator and I . (regai*: part -firer). havc Dred the srrb-cow 6. [] how construction . 2. �] I atm .a.sole. proprietor. or partner- Iist=d . S* and have no employees .I,h A an the attached sheet i 7• Q Remodeling working for me .in Thea__ have �3' �Y• work g Q Demolition. .q�d.] Do p. ias�aarrce 5. Q We are a cormpoi•ati � � 9• Q Brulding addition �c=m have exercised tihesr l0.Q Electrical 3 • ❑ I sin s homeowner doing all work n Tap or additions myssl£ [13o work s* ft of exemption per MCM 1 IQ plumbing COMR-' •- I52, § 14' 'and -we have no �oradditions insur�Ce•req°ired-�.t °n+Plo'yees. [No work=! 12.Q Roogrepairs *Anyappiim.=fiet �P• Maurancercquired.] I3.Q.pm �, chuks be�'1# l most also 5t1 out the station below iiomeow-q who sdbmit this afri'davit huii�ing the} ora aisuwvm s fWrworkme, boripeami Policy information _ ;Caatratnars that rheak this box mustung www er�d f . hie outside evnttaetots must ' ads to add.'tioasl shee[drowing. the num ofthe sur-contraopos artbmit a new affidavit india®6ag such' t art.a.7 e'mPuper t h Pmautg:work�•�•dram wora¢a arn+�inrt ersf rrtf tri irisaraare or nry. MMI -r=. Below.ir a'. ejr � ioF site. Insurance Company Naive: Porcy # or Self --ins Lie. #: Sob Site �•pff Cm Date: Address: . Attach a copy of the workere'co Crh'� clZtp. mPeaesaatioz Pommy d�ar-ntiau Page (sbowiaQ Fie upilure to semwe coverage as required under Section 25A of � PoOry Dumber and e fine in MCiL c. 152 n lead to the imposition of aximirnal irafion tis;tze . . up $1,590.00 and/or one-year 612risonm.=rt as wen as civil Penalties of a . Of up to $250.00 a day against the violator. Be advised that a c penes statement in the form of be of - ORD invesfagafions of the DIA for ins op? of this atstemenf £R soil a Erne ruerree coverage veritic�ticnt, 3 be r'orwarded to file Dfamof t rlo hereby certify under the pains andpenaliies of pe*y tyirr the irtfnrMa ionm Si P vrded above is be and aorrecz Phone #. Date: Offscial asP only. Do not write ia. fit& arra, ria he eonwemed cttj, or town. ir�aL Crty or Town: Fssuint9 Ambo ' Permit/Lix arse # e my (circle oar): I. Board of Firalth Z Sniidiug Department 3. City/Town �lerlt 4 Electrical Ins ector fi Otbei P S. Plumbing Inspector Cortiact Persorz: Phone #: inrormatzon a- incl Wstructions Massachusetts General Laws,chaptnr I S2 requires all eine Ioycrs to provide work=' compensation for their =ployem. Pursuant to this statute, an employee is defined as "..:every person in the service of another under any contract dhirr_, express or implied, oral or writ= - An An wrployer is defined as "an individual partnership, association, corporation or other legal entity, or any two or more, of tht'foragraing engaged in a joint enterprise, and includii"g th6 legal m?r^scmafives of a deceased employer, nr8u receiver ortrarshx•of an individual, partnership, asmciatiaIn or other legal zwty, employing employees. 'Howe=the owner -of a dwelling house having not more than tiux apa:3r ments and who resides therein, or the occupant of the dwelling house of another who employs persons to do maizut=m=, constr uc6on or repair work as such dwelfinghotsse or on tit: grounds or building appurtenant thereto shall nat b=at= of such muployimeru be d -,-rued to be an employer." MGL chapter 152, §25C(6) also states that "every state as- local accusing agency shall withhold the issuenwor renewal of a urease or permit to operate a business or utto constrvet bniiti'mp in the commonwealth for say appBeaut who has oiat produced aeoeptabie evidence of c ompf:ance with the.insaraoee'coverage required." Additionally, MGL chapter I52, §25C(7) st$tns'Neither the commonwealth nor any of its politiad subdivisions shaft enter into any contract for the perf6muffice of public t+votie tastil accepta}ik a vide nee of mmpiiaz= with the insurance Trgt n=erds .of this dsapier have been pr=tMd ta.tht cQrrtr-anfing authority,* Appli®uta .. Please, fill out the workers' compensation. affidavit eompl-em—tely, by checking the boxes f u t appy to your situation and, if necessary, supply sutrcou actors) POMeA. address(e5): amd phone number(s) along with their cartifimt*) of insussnce. Limbmd'Liability Companies (LLC) or Limiu Liability. Peainersiiips (LLP) with no amploy-es other6ma tate members or periners, arc not required,to mrry work:M' co.Tnpcnsation irsunx Van LLC or'LLP doeshave empioyees, a policy is required. Bo advised beat this affidavit maybe submit nd to the Department of Industrial A=idm is for confirmation of inara mce coverage- Ain 'fie sorra to sign and date the affidavit 'The affmavh should be returned to the city or tosm that the zMHcafion for tine Pcimit or license is being requested, nat'the Departmat of Industrial Accident L Should you have -any questions resets -ding, the Iaw or if you are roquirsd to obtain a workers` compensation policy, plmmcall the Depsrtment at the-nnrnberr. fisted below, Self-insured companies should enter their self-huummco'licanac number on tbz'sppropi 6 te'I'm City or Town O>rffieiais Please be sure Out the affidavit is compiett and printed 62; bly. The Departrmmtt hes provided a space at tite boaom of the affidavit for you to fill out in the event the Ofti= of Inves6gatiow has to contact youregarding$s- appr=it Please be sure -to fill in tate permit/license numb=Which v►-fli be used as z., mfe, cd ct number. In addition, an appikant that must submit multiple permh kens: applications in arty given yea=, need only submit one affidavit indicting ctareat '.. policy information ( f necessary) and under "Job Site Address^ tint appiicarn should writt "all locations in (city or town)." A copy ot'•tne affidavit that has bean ,officially staLmped or marked by file city or town may be provided to the applicant as proof the. a valid affidavit is on Me, for nrtma permits or licenses. A new affidavit mue be Med out each year. Where a home owner or citizen is obtaining a lir-nsc or p=it not related to any business or commercial yr unci (i.e. a dog license or permit to bum leaves etc.) said parson is NOT.nxpimd to-completz this aft &viL The O{rrce of Invesfigoons would 10ce to thank you in adr.ance for your cooperation and should you have any questions, pleas- do not hashatt to give; us a call The Depmtme is address, telephone and fax number: The Commonwcftlth of l�iassscli:zsetts IDcpar a= t of IxI t.9tW Accid=as Office -Of EUVIntigsifions " 600 Wad ington Ste=t Bosfa4 MA 0,2111 TeL # 617-727-4900 cert 406 or I-&77-MASSAFE Fax 4 61 7-727-7741 Revised 5 -?b-05 Www.mass.govidia p TOWN OF NORTH ANDOVER SYSTEM PUMPING RECORD DATE: � -I I -o Z & ADDRESS i�15 a�k��re�l --1 5 r Ue4r►a.V\� SYSTEM LOCATION (example: left front of house) 14 -"v-1-+4 kouse DATE OF PUMPING: 6— tq—&Z QUANTITY PUMPED 15ffp GALLONS CESSPOOL: NO /YES SEPTIC TANK: NO YES NATURE OF SERVICE: ROUTINE YEMERGENCY OBSERVATIONS: GOOD CONDITION HEAVY GREASE ROOTS EXCESSIVE SOLIDS SOLIDS CARRYOVER SYSTEM PUMPED BY: COMMENTS: FULL TO COVER BAFFLES IN PLACE LEACHFIELD RUNBACK FLOODED OTHER (EXPLAIN) CONTENTS TRANSFERRED TO: PMM 11141 n v . o n c o � a � a o � D o 0 co0 a 0 = avv r P 0 s M 3 0 .h � 1 3 06 0 o iD ft ID A m c 1 0 3 3 ] C J t � j O H 3 m j 0 1 "'H � v � c �a rt 1 a _ G 7 d 7 � 1 7 I 11141 Connnonw All of Massachusetts �r ,Massachusetts System Pumping Record System Owner Date of Pumping:17 Cesspool: No (. Yes Ll System Location Quantity Pumped: l gallons Septic 'Tank: No L_1 Yes System Pumped by: 5ctt`edart License # Contents transferrred to : Greater Lawrence sanitary District Date: __ Inspector- .t WILLIAM F. WELD Governor ARGEO PAUL CELLUCCI Lt. Governor Property Address: rl 5 Date of Inspection: Name of Inspector: tc IamaO pr Company Name: Mailing Address: L I Telephone NuL t' COMMON WEALTH OF MASSACHUSETTS Col R EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS DEPARTMENT OF ENVIRONMENTAL PROTECTION. ONE WINTER STREET. BOSTON.'NIA 02108 617-292&5500 FEB I t SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICAyT�IQO�N' ��� N��"' Address of Owner. X?A of diffetent) , system,jpspector pursuant to Section 1S.340 of Title 5 (310 CMR, 13.000) . 0010 TRUDY COXE Secretary DAVID 13. STRUHS Commissioner 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 inspection. The inspection was performed based on my 'training and experience in the proper function and maintenance of on-site sewagedi sal systems. The system: _ ast�P ses _ Conditionally Passes Needs Further Evaluation By the Local Approving Authority F i Is i inspector's Signature: + ._ r Date: The System Inspector shall s bmitcopy of this inspection report to the Approving Authority within thiky (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 Department of Environmental Protection. the original should be sent to the systern owner and copies sent to the buyer, if applicable, and the approving authority: INSPECTION SUMMARY: Check A, B, C, or b AI SYSTEM P I have not found any information which indicates that the system violates any of the failure criteria as defined in 310 CMR 15.303. Any failure criteria not evaluated are indicated below. COMMENTS: BI SYSTEM CONDITIONALLY PASSES: One or more system components as described in the "Conditional Pats" 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. Indicate yes, no, or not determined (Y, N, of Nb). Destribe bassi§ of det6mihation 16 all instahtes. if "hot determined% explain why not. _ The septic tank is metal, unless the owner or operator has provided the iystefn inspector with a copy of a tertificate of Compliance (attached) indicating that the tank was installed within twenty (20) years prior to the date of the inspection; or the septic tank, whether or hot metal, is cracked; structurally unsound, shows sUbstantiai ihfiltratioh or exfiltration, or tank failure is imminent. The system will pass inspection if the existing 3eptiic tank is replaced with a conforming septic tank as approved by the Board of Health. (revised 04/25/97) Pati i'at io - DEP on the World Wide Vkb: http:1AWM.11100net itate.rna.usidep 0 printed on Recycled paper SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A ). CERTIFICATION (contitiued) s � Property Address: � �� Q�VQ ,'lgrl U/V. 4'A0 (` Owner: Date of Inspection: B] SYSTEM CONDITIONALLY PASSES (continued) Sewage backup or breakout or high static water level observed in the distribution box is due to broken or obstructed pipes) or due to a broken, settled or uneven distribution box. The system will pass inspection if.(with approval of the Board of Health). Describe observations: broken pipes) are replaced obstruction is removed distribution box is levelled or replaced . . The system required pumping more than four times a year due to broken or obstructed.pipe(s). The system will pass inspection if (with approval of the Board of Health)i broken pipe(s) are replaced obstruction is removed 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 the public health, safety and the environment. 1) SYSTEM WILL PASS UNLESS BOARD OF HEALTH DETERMINES THAT ME SYSTEM IS NOT FUNCTIONING IN A MANNER WHICH WILL PROTECT THE PUBLIC HEALTH AND SAFETY AND THE ENVIRONMENT: _ Cesspool or privy is within 50 feet of a surface waier 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 APPROPRIATE) DETERMINES THAT THE SYSTEM IS FUNCTIONING IN A MANNER THAT PROTECTS TI4E PUBLIC HEALTH AND SAFETY AND THE, ENVIRONMENT: The system has a septic tank and soil absorption system (Seem and the SAS is within 100 feet to a surface water supply or tributary to a 'surface water supply. 4 _ The system has a septic tank and soil absorption system and the SAS is within a Zone I of a public water supply well. _ The system has a septic tank and soil absorption system and the SAS is within 50 feet of a private water supply well. . The system has a septic tank and soil absorption system and the SAS is less than 100 feet but Sri feet or more from a private water supply well, unless a well water analysis for eolifortn bacteria and "volatile organic compounds indicates that the well it free from pollutioh from that facility, and the presence of arnmonfa nitrogen and Nitrate nitrogen Is. equal to or less than 5 ppm. Method used to determine distance (apptoximation .hot valkp. 3) OTHER (revirod 04/25/97) favi .a. ei� Yd r SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A �.r CERTIFICATION (continued) Property Address: s` _ �p /V.. Owner: Date of Inspection: ► �QAn D) SYSTEM FAILS: You must indicate either "Yes" or "No" as to each of the following: I have determined that the system violates one or more of the following failure criteria as defined in 310 CMR 15.303. The basis for this determination is identified below. The Board of Health should be contacted to determine what will be necessary to correct the failure. Yes No Backup of sewage into facility or system component due to an 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 1/2 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 Soil Absorption System, cesspool or privy is below the high groundwater elevation. Any portion of a cesspool or privy is within 100 feet of a surface 'water supply or tributary to a surface water supply. M .. Any portion of a cesspool or privy is within'a Zone i of.a public well.. Any portion of a cesspool or privy is within 50 feet of a private water supply well. Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private Water supply well ikith no acceptable water quality analysis. If the well has been analyzed to be acceptable, attach copy of well wateranalysis for coliform bacteria, volatile organic compounds, ammonia nitrogen and nitrate. nitrogen. El LARGE SYSTEM FAILS: You must indicate either "Yes" or "No" as to each of the fallowing: The following criteria apply to large systems in addition to the criteria above: The system serves a facility with a design flow of 10,000 gpd or greater (Large System) and the system is a significant threat to public health and safety and the environment- because one or more of the following conditions exist: 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 dtihking.water supply _.._ the system is located In a nitrogen sensitive area (Interim Wellhead Protection. Ansa - IWPA) or a mapped Zone II of a public water supply well) The owner or operator of any such system shall bring the system and facility into full complian i with the groundwater treatment program requirements of 314 CMR 5.00 and 6.00. Please consult the local regional office of the Department for further information. sI (revized 04/25/97) M06 3 bi 10 - SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B x CHECKLIST s Property Address: .�VQPS." AA Owner: � ` - � / v Date of Inspection: tel\ � <<X..1�/� . �-h -qa . Check if the following have been done: You must indicate either "Yes" or "No" as to each of the following: Yes o Pumping information was provided by the owner, occupant, or Board of Health. _ None of the system components have been pumped for at least two weeks and the system has been receiving normal flow rates during that period. Large volumes of water have not been introduced into the system recently or as part of this inspection. As built plans have been obtained and examined. Note if they are not available with N/A. _ The facility or dwelling was inspected for signs of sewage back-up. �! The system does not Deceive non -sanitary or industrial waste flow. The site was inspected for Signs of breakout. (/ All system components, excluding the Soil Absorption System, have been located on the site. !+ — The septic tank manholes were uncovered, opened, and the interior of the septic tank was inspected for condition of baffles or tees, material of construction, dimensions, depth of liquid; depth of sludge, depth of scum. The. size and location of the Soil Absorption System on the site has been determined based on: _ The facility owner (and occupants, if different from owner) were provided with information on the proper maintenance of Sub -Surface Disposal System. Existing information. Ex. Plan at B.A.H. _ Determined in the field (if any of the failure criteria related to Part C is at issue, approximation of distance is unacceptable) 115.302(3)(b)) JV_ ("vised 04/25/97) 4 of 10 0 r SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C y SYSTEM INFORMATION Property Address: u�1 `Qv, C1_ j� 1 /�- _��_ Owner: Q T` lJ� i v M'i'l Date of Inspection: L7 'CAI O—kA- a— VI— I e FLOW CONDITIONS RESIDENTIAL - Design flow: t %1D e.p. /bedroom for S.A.S. Number of bedrooms: Number of current residents: a Garbage grinder (yes or no):'�eS Laundry connected to system (yes or no):VeS Seasonal use lyes or no): IVO 1� Water meter readings, if av ilable (last two (2) year usage (gpd). 11 �q 6 40a %9f', = I-l,Lgw�'-kl x Sump Pump (yes or no): (1 7 4q"a s a5 Last date of occupancy: COMM ERC I AUI N D USTRIAL: Type of establishment: Design flow:. gallons/day Grease trap present: (yes or no)_ Industrial Waste Holding Tank present: lyes or no)_ Non -sanitary waste discharged to the title 5 system: (yes or no)_ Water meter readings, if available: Last date of occupancy: OTHER: (Describe) Last date of occupancy: GENERAL INFORMATION PUMPING RECORDS and source of information: System pumped as part of inspection: (yes o no) � If yes, volume pumped: 1 007 - Ilons Reason for pumping: TYPE OF SYSTEM 1,, -'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) VA Technology etc. Copy, of up to date contract? Other APPROXIMATE AGE pf all components, date installed (if known) and source of information: tP E (ill f�N� Sewage odors detected when arriving at the site: (yes or no) IVO r- (x*viaod 0{/23/97) Yate S of 20 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) .M Property Address: 1 � VQ�{'�� a, � , � . i�• .�- Owner: \� , C -A Date of Inspection: r �"`���� BUILDING SEINER: (locate on site plan) In ar Depth below grade: Materi I of construct on: cast iron `'40 PVC _ o her (explain e vs P Distance from private water supply well or suction line Diameter 4 R-_ Commen (con rtion of joints, venting, evidence of leakage, etc.) SEPTIC TANK:. (locate on site plan)i1� CLQ 117 ft'" '\ t _ � � V Depth below grade:y\ ` ; \ ) Material of construction: _oncrete _metal —Fiberglass ,.,,_Polyethylene _other(explain) If tank is metal, list age — Is age confirmed by Certificate of Compliance (Yes/No) Dimensions: to �X 55 2-\ LA I ?�? j = �'S^ .�OACOIS Sludge depth: Disfance from top of sludge to bottom of outlet tee or baffle: tL Scum thickness: a tr / n Distance from top of scum to top of outlet tee or baffle: 6 a t� Distance from bottom of scum to botto of outlet ee or. baffle: -' I How dimensions were determined: � L ©'� .S= V� -k 5 u - Comments: (recommendation for pumping, condi' of inlet and flet tees or ffles, de hof iiq id level in �lati n to outlet invert �ro Vt integrity. evidence of leakage, etc. , _ _ _ , , GREASE TRAPJ[�OMLI (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: (recommendation for pumping, condition of inlet and outlet tees or baffles, depth of liquid level. in relation to outlet invert, structural integrity, evidence of leakage, etc.) (revised 04/25/97) SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C ° SYSTEM INFORMATION (continued) Property hAddress` Owner: Q, Date of Inspection:s TIGHT OR HOLDING TANK:vtj&, (Tank must be pumped prior to, or 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/dav Alarm level:_ Alarm -in working order _ Yes; _ No Date of previous pumping: Comments: (condition of inlet tee, condition of alarm and float switches, etc.) DISTRIBUTION BOX:✓' (locate on site plan) Depth of liquid level above outlet invert: Comments: (Wore if I vel d di tribu ion is equal, evidence of olidscarryoXer widence of leaka a into or out of box; etc.) o' PUMP CHAMBER:—�tO (locate on site plan) V 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.) -- ,. (revised 04/25/97) Pago y bt 10 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C r SYSTEM INFORMATION (continued) Property Address: is Q Q_9A ct/vl, Dc 0, Owner: Date of Inspection:p� - ��- 21.-11.1 —R SOIL ABSORPTION SYSTEM (SAS):_ (locate on site plan, if possible; excavation dot required, but may be approximated by non -intrusive methods) If not determined to be present, explain: Type: leaching pits, number:_ Leaching chambers, number:_ leaching galleries, number: `, leaching trenches, number,ler9eth:�kA/�6\P leaching fields, number, dimensions: overflow cesspool, number: . Alternative system: Name of Technology: Lq'tW\j2 x C t-1 / JC)VX_ t. Comments: (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.) CESSPOOLS: 3mvl e (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 (cesspool must be pumped as part of inspection) Comments: (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.) PRIVY: V�V\w (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.) (revised 04/25/97) ?agi 6 of 10 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: Owner: Date of Inspection: SKETCH OF SEWAGE DISPOSAL SYSTEM: include ties to at least two permanent references landmarks or benchmarks locate all wells within 100' (Locate where public water supply comes into house) AAo k:-1'1 a=c�1 3=a� 3 3 (revised 04/7S/97) rage 9 of 10 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address ��- Owner: Q\`,� Date of Inspection:' v\`P A,(A\ aAA_ �). Depth to Groundwater =1 Feet Please indicate all the methods used to determine High Groundwater Elevation: t �Obined from Design Plans on record . bservation of Site (Abutting property, observation hole, basement sump etc.) ]�;��.ette-rrmiine it from local conditions ✓Check with local Board of health Check FEMA Maps Check pumping records Check local excavators, installers Use USGS Data Describe in your own words how you established the High Groundwater Elevation. (Must be completed) (:�p AA0,Aj, I PC) bojoui &Q a. (revised 04/25/97) Paye 10 at 16 TEL: (508) 475-1474 s FAX: (508) 475-5451 PATESON ENTERPRISES, INC. Excavating - Water & Sewer Lines - Septic Systems & Pumping Service 111 Argilla Road d Andover, Mass. 01810 Title 5 Inspection Report Property Address: ------ - A�--------- Owner: ----------------------------- Date ----Owner:----------------------------- Date Of Inspection; ---------------- My report contained herein does not constitute a guarantee of future usage and the functionality of the existing septic system. Such report issued herewith is merely based upon my observations, and I hereby disclaim any further operation of your current septic system. Neil J. Bateson Bateson Enterprises Inc. 11 of 11' TOWN OF � ' � SYSTEM PUMPING RECORD DATE: 0—�;O-ov SYSTEM OWNER & ADDRESS QS7 V -P SYSTEM LOCATION (example: left front of house) C DATE OF PUMPING: "c 40—OV/QUANTITY PUMPED: GALLONS CESSPOOL: NO SEPTIC TANK: NO YES jl—� NATURE OF SERVICE: ROUTINE OBSERVATIONS: GOOD CONDITION HEAVY GREASE ROOTS EXCESSIVE SOLIDS SOLIDS CARRYOVER EMERGENCY FULL TO COVER BAFFLES IN PLACE LEACHFIELD RUNBACK FLOODED OTHER (EXPLAIN) SYSTEM PUMPED BY: Bateson Enterprises, Inc. COMMENTS: CONTENTS TRANSFERRED TO: G.L.S.D Lowell Waste Board of (Health Nort i Ano. over,M"S. OVID DATE i, FKn OK i` DI SUPROVED easonst SEPTIC SISTEH INSTALLATIQ4 CHECK LIST LOT �?�TR14A J , AVATICH Ob FAIL 1. stance Tot a. Wetlands b, Drains . c .. Well 2. Wat ar tine Location M 3. No .'PC Pipe �i. Sep• Ae Tank a. _Fees -_Length & To Clean Out Covers b. "ement, Pipe .to Tank On Both Sides of Tank 5. Distribution Box a. .Covers & Box - No Cracks b. All Linea ' Flo A_ng Equal Amounts c. No Back Flow f 6. Leach .neld or Trench a. , Iii mansions b. Stone Dept c. Capped Ends d. Clean Double Washed Stone 7. Le -tch Pits a. Dimensions b. Stone Depth c., Sp-.sh Pads d. rebs e. Cemmt Pipe to Pit - Both Sides , f. Olean Double Washed Stone 8. No Garbage Disposal 9. -Fir al Grading Inspection 10. Barricading Covered System ll. As Built Submitted a. Lot Location b. Di-ensions of System CO Location -.4th Regard -to. Pere Test d. Elevations. e. Water Table `!n , +._-307 „ Issued By Conservation Commission Signature This Order must be signed by majority of the Conservation Commission. On this I i.. day of nr r nhn r 19_ R r , before me personally appeared Gig i 1 1 �rm� Vi c Pns , .o me known to be the person described in and who executed the foregoing Instrument and ackno pled, ted that he/she executed the same as his/her free act and deed. Notary Public My commission expires The applicant, the owner, any person aggrieved by this Order, any owner of land abutting the land upon which the proposed work is to be done or any ten residents of the city or town in which such land is located are hereby notified of their right to request the Department of Environmental Ounlity Englneering to Issue a Superseding Order, providing the request Is made by certified mail or hand delivery to the Department within len days from the dale of Issuance of this Order. A copy of the tequesl shall at the same time be sent by certified mail or hand delivery to the Conservation Commission and the appllcant. e Detach on dotted line and submit to the prior to commencement of work. ............................................................................................................................................. . To Assuing'Authonty Please be advised that the Order of Conditions for the project at Filo Number - has been recorded at the Registry of and has been noted In the chain of title of the affected property In accordance with General Condition 8 on . t 9— If recorded land, the instrument nL.,iber which identifies this transaction Is If registered land, the document ,timber which identifies this transaction Is Signature --Applicant II� V7, 77 ��5 7 .. (. .. ?•F �`:� . ..,., Yd Ya. .Y'F i:+.,'i _ ...* �, j.1i t. 77�":NY .' rt'1i�Y . ,. BOARD OF HEALTH Nu.Andover, Mass. SUBSURFACE DISPOSAL DESIGN CHECK LIST w' LOT Z �C� Il U APPROVED DATE DISAPPROVED DATE +. Provided: // Reasons: te ,s Title V FAIL 09 Reg 2.5 The submitted plan must show as a minimum:"„ a) the lot to be served-area,dimensions lot ,abutters bod3e c loca ion and lresultspper+colationntests-distanceeto tiesto s d design calculations & calculations showing required leaching area (e) location and dimensions of system -including reserve area f) existing and proposed contours (g) location any wet areas Atbin 100' of sewage disposal system or disclaimer-check iietlands mapping (h) surface and subsurface drains within 100' of sewage disposal system or disclaimer (i) location any drainage easements with m 100' of serge disposal system or disclaimer-Planning Board Yles (j) known sources of water supply within 2001 of sewage disposal d system or disclaimer (k) location of any proposed well to ser a lot-1001 from leaching facilit (1) location of water lines on property-'01 from leaching facility (m) location of benchmark (n) driveways (o) garbage disposals (p) no PVC to be used in construction (q) profile of system-elevations of basement, plumb, pipe, septic tank, distribution box inlets, and outlets, .tistribution field piping and otter elevations (r) maxiwam ground water elevation in area sewage disposal system (s) plan mast be prepared by a Professional Engineer or other professional authorized by law to prepare such plans Reg 6 Septic Tanks (a) capacities-150$ of .flow, water table, tees, depth of teen, access, pumping (b) cleanout (c) 10' from cellar wall. or inground swimming pool (d) 25+ from subsurface drains Reg 10.2 Reg 10.4 Distribution Boxes (a) slope greater than 0.08 (b) suirp ' kEGkiiVED 1�- Commonwealth of Massachusetts JUL 13 2007 City/Town of TOWN OF NORTH ANDOVER System Pumping Record HEALTH DEPARTMENT Form 4 DEP has provided this form for use by local Boards of Health. Other forms may be used, but the information must be substantially the same as that provided here. Before using this form, check with your local Board of Health to determine the form they use. The System Pumping Record must be submitted to the local Board of Health or other approving authority. A. Facility Information Important: When filling out forms on the computer, use only the tab key to move your cursor - do not use the return key. _ I 1�1 1. System Location: �e,6c–� A 0)-C— C v '`c' uzjl� Address to �n ^ C:K /�/, City/Town Satet Zip Code 2. System Owner: tack Name Address (if different from location) City/Town B. Pumping Record 1. Date of Pumping Stn ^ P7` 1 � ode Telephone Number "?q(-07 Date 2. Quantity Pumped: Gallons 3. Type of system: ❑ Cesspool(s) eptic Tank ❑ Tight Tank ❑ Other (describe): 4. Effluent Tee Filter present? ❑ Yes 9'No If yes, was it cleaned? ❑ Yes ❑ No 5. Condition o�st� L(-Otaj ) A �v 6. Syste P r�ned. By Name Company 7. t5form4.doc• 06/03 Vehicle License Number System Pumping Record • Page 1 of 1 Commonwealth of Massachusetts City/Town of a` System Pumping Record Form 4 Important: When filling out forms on the computer, use only the tab key to move your cursor - do not use the return key. rEIVED DEC 1. 7 2008 TOWN OF N,— "=R HEALTH DEPtin, DEP has provided this form for use by local Boards of Health. Ot a use -b -u the information must be substantially the same as that provided here. Before using this form, check with your local Board of Health to determine the form they use. The System Pumping Record must be submitted to the local Board of Health or other approving authority. A. Facility Information 1. System Location eft froqjAft rear, left si of hou . Right front, right rear, right side of house. Address cn 1 City/Town State Zip Code 2. System Owner: Name Address (if different from location) Cityrrown State�^ `, `Z ode Telephone Number �Ci B. Pumping Record 1. Date of Pumping Date 2. Quantity Pumped 3. Type of system: 0 Cesspool(s) -" Septic Tank Gallons 0 Tight Tank Other (describe): 4. Effluent Tee Filter present? 0 Yes No If yes, was it cleaned? 0 Yes [j No 5. ConditionSystem: C `PtJ Y t t - 47or,-z� 6. System Pumped By: Neil Bateson Name Bateson Enterprises Inc Company 7. Location where contents were disposed: S.D _ owell Waste of F 5821 Vehicle License Number Date t5form4.doc• 06/03 System Pumping Record • Page 1 of 1 Commonwealth of Massachusetts-- -�°- City /Town of uIVISE System Pumping Record MAY 25 2010 Form 4 w TOWN OF NORTH ANDOVER HEALTH DEPARTMENT DEP has provided this form for use by local Boards of Health. Other , information must be substantially the same as that provided here. Before using this form, check with your local Board of Health to determine the form they use. The System Pumping Record must be submitted to the local Board of Health or other approving authority. A. Facility Information 1. System Location: Left side of house, Right side of house eft r tno off ho Right front of house, Left rear of house, Right rear of house. Left rear of building. Right rear of building. Address P-75 City/Town State 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 State ip Code a 7 Telephone Number 7v Date 2. Quantity Pumped Cesspool(s) eptic Tank Gallons ❑ Tight Tank 4. Effluent Tee Filter present? ❑ Yes If yes, was it cleaned? ❑ Yes ❑ No 5. Con ition of System: 6. System Pumped By: Neil Bateson Name Bateson Enterprises Inc Company 7. of contents were disposed: 4 n Lowell Waste Water F5821 Vehicle License Number Date a t5form4.doc• 06/03 System Pumping Record • Page 1 of 1 Commonwealth of Massachusetts City/Town of RECEIVED System Pumping Record Form 4 DEC 8 �Z011 DEP has provided this form for use by local Boards of Health. Other for TOWN OF NORTH ANDOVERbU1fn information must be substantially the same as that provided here. Before using Is orm, 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 Locati(� Rig 't of hous Left / Right rear of house, Left / right side of house, Left / Right side of building, Left / Right front of building, Left/ Right rear of building, Under deck Address City/Town V State 2. System Owner: e)�R6k--� Name Address (it different from location) City/Town B. Pumping Record 1. Date of Pumping 3. Type of system: ❑ ❑ Other (describe): Zip Code State Zip Code Telephone Number Date 2. Quantity Pumped: Gallons Cesspool(s) Septic Tank ❑ Tight Tank 4. Effluent Tee Filter present? ❑ Yes E],Mo If yes, was it cleaned? ❑ Yes ❑ No 5. Condition,�f System: � n A '� ` V�- 6. System Pumped By: Neil Bateson Name Bateson Enterprises Inc Company 7. Location where contents were disposed: /(j.LS.jo Lowell Waste Water o;t F5821 Vehicle License Number Date t5form4.doc• 06/03 System Pumping Record • Page 1 of 1