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HomeMy WebLinkAboutMiscellaneous - 757 FOREST STREET 4/30/2018 (2)MAP # PARCEL # LOT ##_.._...._ .............Lo STREET .. ................ ..... . .. ... .C-D.N.,$-T.RU.CI.T.I.-O.td -AW.P.R-OVAL. HAS PLAN REVIEW FEE BEEN PAID? NO 40Y PLAN APPROVAL: DATE--- 13 APP. Y . .... ..... . ..... . ......�0,4 . .... DESIGNER:rAPOL481A PLAN Dn'I-E.--- CONDITIONS_--D—SOV, ---- ----- --- ----- - --------- --- -------- ------_....- WATER ----- WATER SUPPLY: TOWN WELL ff WELL PERMIT DRILLER---,., WELL TESTS: CHEMICALDA T APPROVED BACTERIA I DATE (IPPROVED BACTERIA II DATE APPROVED COMMENTS: `14u on— —k-rj cc 0 FORM U APPROVAL: APPROVAL TO ISSU- Y NO DATE ISSUED BY CONDITIONS: KI Z -44---+t if -.111111 FINAL APPROVAL: ALL PERMITS PAID YES NO WELL CONSTRUCTION APPROVAL YES NO SEPTIC SYSTEM CONSTRUCTION APPROVAL YES NO OTHER YES NO ANY VARIANCE NEEDED YES NO FINAL BOARD OF HEALTH APPROVAL: DATE: k IS THE INSTALLER LICENSED? 'YES NO TYPE OF CONSTRUCTION: _ NEW REPAIR NEW CONSTRUCTION: CERTIFIED PLOT PLAN REVIEW YES NO CONDITIONS OF APPROVAL YES NO (FROM FORM U) ISSUANCE OF DWC PERMIT QYi) NO DWC PERMIT NO. INSTALLER : _.__.__._• BEGIN INSPECTION YES 0 : { EXCAVATION INSPECTION: NEEDED: PASSED BY - CONSTRUCTION INSPECTION: NEEDEDr_.__.._._._.__....._._...___.._._.__._._............. AS AS BUILT PLAN SATISFACTORY: YES: r APPROVAL TO BACKFILL: DATE: 3 3 �Z BY FINAL GRADING APPROVAL: DATE Commonwealth of Massachusetts City/Town of North Andover System Pumping Record ,wM Form 4 DEP has provided this form for use by local Boards of Health. Other forms may be used, but the information must be substantially the same as that provided here. Before using this form, check with your local Board of Health to determine the form they use. The System Pumping Record must be submitted to the local Board of Health or other approving authority within 14 days from the pumping date in accordance with 310 CMR 15.351. RECEIVED JUL 07 2014 TOWN OF NORTH ANDOVER HEALTH DEPARTMENT City/Town B. Pumping Record 1. Date of Pumping 3. Type of system: ❑ Other (describe) Ma 01886 State Zip Code State Zip Code Telephone Number b Date 2. Quantity Pumped. ❑ Cesspool(s) T Septic Tank ❑ Tight Tank 4. Effluent Tee Filter present? ❑ Yes ❑ No 5. Condition of System: 6. System Pumped By: lUr� Gallons ❑ Grease Trap If.yes, was it cleaned? ❑ Yes ❑ No 'I J Name Vehicle License Number Stewart's Septic Service Company 7. Location where contents were disposed: Stewart's Pre-treatment Plant. 20 So. Mill Bradford. Ma 01835 Signature of Hauler Signature of Receiving Facility Date Date t5form4.doc• 03/06 System Pumping Record • Page 1 of 1 A. Facility Information Important: When filling out forms 1. System Location: on the computer, �-7� use only the tab key to move your Address cursor - do not North Andover use the return key. City/Town 2. System Owner: / ' Name renon Address (if different from location) City/Town B. Pumping Record 1. Date of Pumping 3. Type of system: ❑ Other (describe) Ma 01886 State Zip Code State Zip Code Telephone Number b Date 2. Quantity Pumped. ❑ Cesspool(s) T Septic Tank ❑ Tight Tank 4. Effluent Tee Filter present? ❑ Yes ❑ No 5. Condition of System: 6. System Pumped By: lUr� Gallons ❑ Grease Trap If.yes, was it cleaned? ❑ Yes ❑ No 'I J Name Vehicle License Number Stewart's Septic Service Company 7. Location where contents were disposed: Stewart's Pre-treatment Plant. 20 So. Mill Bradford. Ma 01835 Signature of Hauler Signature of Receiving Facility Date Date t5form4.doc• 03/06 System Pumping Record • Page 1 of 1 y '.V.TP.V, of INassachusetts MASSAGE �,City/Town of NORTH ANDOVER, ys# tr:r.q rI ping Record. Form 4 DEP has provided this form for use by local Boards of Health. The be submitted to the local Board of Health or other approving autho A: Facility Information Important: 1. system Location, when sum w Y form= on the I computer, use oNy the tab key to mow your ausor • do got 6k. -hum uss - key'.- 2. system 0wner. �mmDEEpC 18 2010 AWN Ow ord r ANDOVER 'HEALTH DEPARTMENT State Zip Code Name Address (h different from location) CitiRowm State Zip Code Telephone Number B. Pumpi*ns Record 1. Date of Pumping a ( 2. Quantity Pumped: Gallons 3. Type of system: (] Cesspool(s) � `ptic Tank ❑ Tight Tank ❑ Other (describe): . 4, Effluent Tee Filter present? ❑ Yes ❑ No 5, Condition of System: If yes, was it cleaned? ❑ Yes ❑ No 8. %stem.Pumped By: Vehicle License Number y. T. . tion 9 contents were disposed: St httpJtwww,mass.gov%deptwater/approvWaASforms.htm#inspect t5form4.dW 060 System Pumping Record • Page 1 of 1 s d � ;; .,.�I ...,}. TITLE 5 OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS Name of Inspector: (please print) George Norris O Company Name: D.F. Clark Inc. Mailing Address: P.O. Box 265, Ipswich, MA 01938 Telephone Number: (978) 356-5638 CERTIFICATION STATEMENT I certify that I have personally inspected the sewage disposal system at this address and that the information reported below is true, accurate and complete as of the time of the inspection. The inspection was performed based on my training and experience in the proper function and maintenance of on site sewage disposal systems. I am a DEP approved system inspector pursuant to Section 15.340 of Title 5 (310 CMR 15.000). The system: , X Passes Conditionally Passes Needs Further Evaluation by the Local Approval Authority A�� FailsI,,"I/�'1/loInspector's Signature: %l `Tl Date: 9f),41 03 The system inspector shall submit a copy of this inspection report to the Approving Authority (Board of Health or DEP) within (30) days of completing this inspection. If the system is a shared system or has a design flow of 10,000 gpd or greater, the inspector and the system owner shall submit the report to the appropriate regional office of the DEP. The original should be sent to the system owner and copies sent to the buyer, if applicable, and the approving authority. Notes and Comments ""This report only describes conditions at the time of inspection and under the conditions of use at that time. This inspection does not address how the system will perform in the future under the same or different conditions of use. Title 5 Inspection Form 6/15/00 page 1 SUBSURFACE SEWAGE DISPOSL SYSTEM FORM PART A - --CH ' TOWIN t RF ,-.- -H �� CERTIFICATION HEN Property Address: 757 Forest Street �T Y 5 2003 North Andover, MA Owner's Name: Dennis & Linda Jillson Owner's Address: 757 Forest Street North Andover, MA 01845 Date of Inspection: September 24, 2003 Name of Inspector: (please print) George Norris O Company Name: D.F. Clark Inc. Mailing Address: P.O. Box 265, Ipswich, MA 01938 Telephone Number: (978) 356-5638 CERTIFICATION STATEMENT I certify that I have personally inspected the sewage disposal system at this address and that the information reported below is true, accurate and complete as of the time of the inspection. The inspection was performed based on my training and experience in the proper function and maintenance of on site sewage disposal systems. I am a DEP approved system inspector pursuant to Section 15.340 of Title 5 (310 CMR 15.000). The system: , X Passes Conditionally Passes Needs Further Evaluation by the Local Approval Authority A�� FailsI,,"I/�'1/loInspector's Signature: %l `Tl Date: 9f),41 03 The system inspector shall submit a copy of this inspection report to the Approving Authority (Board of Health or DEP) within (30) days of completing this inspection. If the system is a shared system or has a design flow of 10,000 gpd or greater, the inspector and the system owner shall submit the report to the appropriate regional office of the DEP. The original should be sent to the system owner and copies sent to the buyer, if applicable, and the approving authority. Notes and Comments ""This report only describes conditions at the time of inspection and under the conditions of use at that time. This inspection does not address how the system will perform in the future under the same or different conditions of use. Title 5 Inspection Form 6/15/00 page 1 Page 2 of 11 OFFICIAL INSPECTION FORM — NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A . CERTIFICATION (continued) Property Address: 757 Forest Street North Andover, MA 01845 Owner: Dennis & Linda Jillson Date of Inspection: September 24, 2003 Inspection Summary: Check A, B, C, D or E / ALWAYS complete all of Section D A. System Passes: X I have not found any information which indicates that any of the failure conditions described in 310 CMR 15.303 or in 3l0 CMR 15.304 exist. Any failure criteria not evaluated are indicated below. COMMENTS: B. System Conditionally Passes: One or more system components as described in the "Conditional Pass" section need to be replaced or repaired. The system, upon completion of the replacement or repair, as approved by the Board of Health, will pass. Answer yes, no or not determined (Y, N, ND) in the for the following statements. If "not determined" please explain. The septic tank is metal and over 20 years old* or the septic tank (whether metal or not) is structurally unsound, exhibits substantial infiltration or exfiltration or tank failure is imminent. System will pass inspection if the existing tank is replaced with a complying septic tank as approved by the Board of Health. *A metal septic tank will pass inspection if it is structurally sound, not leaking and if a Certificate of Compliance indicating that the tank is less than 20 years old is available. ND explain: Observation of sewage backup or break out or high static water level in the distribution box due to broken or obstructed pipe(s) or due to a broken, settled or uneven distribution box. System will pass inspection if (with approval of Board of Health): broken pipe(s) are replaced _ obstruction is removed distribution box is leveled or replaced ND explain: The system required pumping more than 4 times a year due to broken or obstructed pipe(s). The system will pass inspection if (with approval of the Board of Health): 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: 757 Forest Street North Andover, MA 01845 Owner: Dennis & Linda Jillson Date of Inspection: September 24, 2003 C. Further Evaluation is Required by the Board of Health: Conditions exist which require further evaluation by the Board of Health in order to determine if the system is failing to protect public health, safety or the environment. 1. System will pass unless Board of Health determines in accordance with 310 CMR 15303(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 i 2. System will fail unless the Board of Health (and Public Water Supplier, if any) determines that the system is functioning in a manner that protects the public health, safety and environment: The system has a septic tank and soil absorption system (SAS) and the SAS is within 100 feet of a surface water supply or tributary to a surface water supply. The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water supply. _ The system has a septic tank and SAS and the SAS is within 50 feet of a private water supply well. The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or more from a private water supply well". Method used to determine distance "This system passes if the well water analysis, performed at a DEP certified laboratory, for coliform bacteria and volatile organic compounds indicates that the well is free from pollution from that facility and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis must be attached to this form. 3. Other: Page 4 of 11 OFFICIAL INSPECTION FORM — NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A . CERTIFICATION (continued) Property Address: 757 Forest Street North Andover, MA 01845 Owner: Dennis & Linda Jillson Date of Inspection: September 24, 2003 D. System Failure Criteria applicable to all systems: You must indicate either "yes" or "no" to each of the following for all inspections: Yes No X Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool X Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool X Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool X Liquid depth in cesspool is less than 6" below invert or available volume is less than '/z day flow X Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s) Number of times pumped X Any portion of the SAS, cesspool or privy is below the high ground water elevation X Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply X Any portion of a cesspool or privy is within a Zone 1 of a public well X Any portion of a cesspool or privy is within 50 feet of a private water supply well X Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality analysis. [This system passes if the well water analysis, performed at a DEP certified laboratory, for coliform bacteria and volatile organic compounds indicates that the well is free from pollution from the facility and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis must be attached to this form.] No (Yes/No) The system fails. I have determined that one or more of the above failure criteria exist as described in 310 CMR 15.303, therefore the system fails. The system owner should contact the Board of Health to determine what will be necessary to correct the failure. E. Large Systems: To be considered large system the system must serve a facility with a design flow of 10,000 gpd to 15,000 gpd. You must indicate either `yes" or "no" to each of the following: (The following criteria apply to large systems in addition to the criteria above) Yes No the system is within 400 feet of a surface drinking water supply the system is within 200 feet of a tributary to a surface drinking water supply the system is located in a nitrogen sensitive area (Interim Wellhead Protection Area — IWPA) or a mapped Zone II of a public water supply well If you have answered "yes" to any question in Section E the system is considered a significant threat, or answered "yes" in Section "D" above the large system has failed. The owner or operator of any large system considered a significant threat under Section E or failed under Section D shall upgrade the system in accordance with 310 CMR 15.304. The system owner should contact the appropriate regional office of the Department. 4 Page 5 of 11 OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST Property Address: 757 Forest Street North Andover, MA 01845 Owner: Dennis & Linda Jillson Date of Inspection: September 24, 2003 Check if the following have been done: You must indicate `yes" or "no" as to each of the following: Yes No X Pumping information was provided by the owner, occupant, or Board of Health X Were any of the system components pumped out in the previous two weeks? X _ Has the system received normal flows in the previous two week period? X Have large volumes of water been introduced to the system recently or as part of this inspection? N/A Were as built plans of the system obtained and examined? (If they were not available note as N/A) X _ Was the facility or dwelling inspected for signs of sewage back up? X _ Was the site inspected for signs of break out? X Were all system components, excluding the SAS, located on site? X _ Were the septic tank manholes uncovered, opened, and the interior of the tank inspected for the condition of the baffles or tees, material of construction, dimensions, depth of liquid, depth of sludge and depth of scum? X _ Was the facility owner (and occupants, if different from owner) provided with information on the proper maintenance of subsurface sewage disposal systems? The size and location of the Soil Absorption System (SAS) on the site has been determined based on: Yes No X Existing information. For example, a plan at the Board of Health. X _ Determined in the field (if any of the failure criteria related to Part C is at issue approximation of distance is unacceptable) [3 10 CMR 15.302(3)(b)] Page 6 of 11 OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION Property Address: 757 Forest Street North Andover, MA 01845 Owner: Dennis & Linda Jillson Date of Inspection: September 24, 2003 FLOW CONDITIONS RESIDENTIAL Number of bedrooms (design): 3 Number of bedrooms (actual): 3 DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x # of bedrooms): 330 Number of current residents: 5 Does residence have a garbage grinder (yes or no): No Is laundry on a separate sewage system (yes or no): No ; [if yes, separate inspection required] Laundry system inspected (yes or no): Seasonal use: (yes or no): No Water meter readings, if available (last 2 years usage (gpd)): Well water Sump Pump (yes or no): No Last date of occupancy: Currently Occupied 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 reading, if available: Last date of occupancy/use: OTHER: (Describe) GENERAL INFORMATION Pumping Records Source of information: Svstem was last Dumped two (2) vears ago according to owner Was system pumped as part of inspection (yes or no): No If yes, volume pumped: _gallons — How was quantity pumped determined? Reason for pumping: TYPE OF SYSTEM X Septic tank, distribution box, soil absorption system Single cesspool Overflow cesspool Privy Shared system (yes or no) (if yes, attach previous inspection records, if any) Innovative/Alternative technology. Attach a copy of the current operation and maintenance contract (to be obtained from system owner) Tight Tank Attach a copy of the DEP approval Other (describe): Approximate age of all components, date installed (if known) and source of information: System was installed in 1992 according to owner Were sewage odors detected when arriving at the site (yes or no): No 6 Page 7 of 11 OFFICIAL INSPECTION FORM — NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: 757 Forest Street North Andover, MA 01845 Owner: Dennis & Linda Jillson Date of Inspection: September 24, 2003 BUILDING SEWER (locate on site plan) Depth below grade: 22" Material of construction: _cast iron X 40 PVC other (explain): Distance from private water supply well or suction line: 34' Comments: (on condition of joints, venting, evidence of leakage, etc.): Building sewer pipe is in good condition no sign of leakage SEPTIC TANK: Yes (locate on site plan) Depth below grade: 15" Material of construction: X concrete _metal _ fiberglass_polyethylene _other (explain) If tank is metal list age _ Is age confirmed by a Certificate of Compliance (yes or no): (attach a copy of certificate) i Dimensions: 5' W x 10'L x 52" D Sludge depth: 11" Distance from top of sludge to bottom of outlet tee or baffle: 27" Scum thickness: 0" Distance from top of scum to top of outlet tee or baffle: N/A Distance from bottom of scum to bottom of outlet tee or baffle: N/A How were dimensions determined: Measured Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): Inlet and outlet baffles are in place liquid level is at outlet invert, tank is in good condition. GREASE TRAP: No (locate on site plan) Depth below grade: Material of construction: concrete metal fiberglass _polyethylene _other (explain): Dimensions: Scum thickness: Distance from top of scum to top of outlet tee or baffle: Distance from bottom of scum to bottom of outlet tee or baffle: Date of last pumping: Comments: (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): Page 8 of 11 OFFICIAL INSPECTION FORM — NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: 757 Forest Street North Andover, MA 01845 Owner: Dennis & Linda Jillson Date of Inspection: September 24, 2003 TIGHT or HOLDING TANK: No (tank must be pumped at time of inspection)(locate on site plan) Depth below grade: Material of construction: concrete metal fiberglass polyethylene _other (explain): Dimensions: Capacity: gallons Design flow: gallons/day Alarm present (yes or no): Alarm level: Alarm in working order (yes or no): Date of last pumping: Comments (condition of alarm and float switches, etc.): DISTRIBUTION BOX: Yes (if present must be opened)(locate on site plan) (Depth below grade = 20") Depth of liquid level above outlet invert: 0" Comments (note if box is level and distribution to outlets equal, any evidence of solids carryover, any evidence of leakage into or out of box, etc.): Distribution is equal small amount of solids carryover, no sign of leakage, d -box is in good condition. PUMP CHAMBER: No (locate on site plan) Pumps in working order (yes or no): Alarms in working order (yes or no): Comments (note condition of pump chamber, condition of pumps and appurtenances, etc): Page 9 of 11 OFFICIAL INSPECTION FORM — NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: 757 Forest Street North Andover, MA 01845 Owner: Dennis & Linda Jillson Date of Inspection: September 24, 2003 SOIL ABSORPTION SYSTEM (SAS): Yes (locate on site plan, excavation not required) If SAS not located explain why: Type _leaching pits, number: _leaching chambers, number: leaching galleries, number: --k-leaching- trenches, number, length: 3 leach trenches – 50' long _leaching fields, number, dimensions: _overflow cesspool, number: _innovative./alternative system Type/name of technology: Comments (note condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of vegetation, etc.): SAS is under front lawn, no damp soil or ponding present no signs of hydraulic failure Inspected all three (3) leach trenches with a video inspection camera and found them dry with no standing liquid. CESSPOOLS: No (cesspool must be pumped as part of inspection)(locate on site plan) Number and configuration:. Depth - top of liquid to inlet Depth of solids layer: Depth of scum layer: Dimensions of cesspool: — Materials of construction: invert: Indication of groundwater inflow (yes or no): Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): PRIVY: No (locate on site plan) Materials of construction: Dimensions: Depth of solids: Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): Page 10 of 11 OFFICIAL INSPECTION FORM — NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: 757 Forest Street North Andover, MA 01845 Owner: Dennis & Linda Jillson Date of Inspection: September 24, 2003 SKETCH OF SEWAGE DISPOSAL SYSTEM Provide a sketch of the sewage disposal system including ties to at least two permanent reference landmarks or benchmarks. Locate all wells within 100 feet. Locate where public water supply enters the building. A-1=34' B —1 = 40'8" A-2=33'5" B-2=43'6" A — 3 = 33'6" B- D -t We O Well 10 Page 11 of 11 OFFICIAL INSPECTION FORM — NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: 757 Forest Street North Andover, MA 01845 Owner: Dennis & Linda Jillson Date of Inspection: September 24, 2003 SITE EXAM Slope Surface water Check Cellar Shallow wells Estimated depth to ground water 9' feet Please indicate (check) all methods used to determine the high ground water elevation: X Obtained from system design plans on record — If checked, date of design plan reviewed: _ Observed Site (abutting property/observation hole within 150 feet of SAS) _ Checked with local Board of Health -explain: Checked local excavators, installers — (attach documentation) Accessed USGS database -explain: You must describe how you established the high ground water elevation: Bottom of SAS is 28" below grade According to soil testing performed on May 15 1991 by Stowers Associates, no groundwater was encountered Q) 9' below grade 11 Ace& FORM U - LOT RELEASE FORM INSTRUCTIONS: This form is used to verify that all necessary approvalsfperrnits fro Boards and Departments having jurisdiction have been obtained. This does not relievE the applicant and/or landowner from compliance with any applicable or requirernents *APPLICANT FILLS OUT THIS SECTION APPLICAN10 T_ els: J SQir,PHONE% �S LOCATION: Assessor's Map Number. PARCEL SUBDIVISION" LOT (S) STREET f ores+ STrE? }/13-T. NUMBER. J`+ ****** t* -A***** -►****************"'**"OFFICIAL USE CONSERVATION ADM TOWN AGENTS: DATE APPROVED DATE REJECTED COMMENTS sti TOWN PLANNER DATE APPROVED DATE REJECTED COMMENTS FOOD INSPECTOR—HEALTH DATE APPR.46VED DATE REJECTED IC INSPECTOR -HEALTH DATE APPROVED. 0 4 ® ` I DATE REJECTED r- - :O'M'MENTS s`Y Q S� a t• vu e 4 �s,ra T 2� 0 3 PUBLIC WORKS - SEWERAVATER CONNECTIONS DRIVEWAY PERMIT FIRE DEPARTMENT RECEIVED BY BUILDING IMSPECTO Revised 9W jm TE 2a, � �Dl't 0 r -t TITLE 5 OFFICIAL INSPECTION FORM -- NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSL SYSTEM FORM PART A CERTIFICATION Property Address: 757 Forest Street North Andover, MA Owner's Name: Dennis & Linda Jillson Owner's Address: 757 Forest Street North Andover MA 01845 Date of Inspection: September 24 2003 Name of Inspector: (please print) George Norris Company Name: D.F. Clark. Inc. Mailing Address: P.O. Box 265 Ipswich MA 01938 Telephone Number: (978) 356-5638 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 d 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: an X Passes Conditionally Passes Needs Further Evaluation by the Local Approval Authority Fails (� j 103 Inspector's Signature:Date: —I�� J The system inspector shall submit a copy of this inspection report to the Approving Authority (Board of Health or DEP) within (30) days of completing this inspection. If the system is a shared system or has a design flow of 10,000 gpd or greater, the inspector and the system owner shall submit the report to the appropriate regional office of the DEP. The original should be sent to the system owner and copies sent to the buyer, if applicable, and the approving authority. Notes and Comments ****This report only describes conditions at the time of inspection and under the conditions of use at that time. This inspection does not address how the system will perform in the future under the same or different conditions of use. Title.5 Inspection Form 6/15/00 page 1 e2of11 PECTION FORM — NOT FOR VOLUNTARY ASNENN OFFICIAL INSION FORM TS SUBSURFACE SEWAGE DISPOSAL ASySTEM CERTIFICATION (continued) verty Address: 757 Forest Street North Andover MA 01845 vner: Dennis & Linda Jillson 3 ate of Inspection: Se tember 24 200 spection Summary: Check A, B, C, D or E / ALWAYS complete all of Section D System Passes: information which indicates that any of the failure conditions described in X I have not found any failure criteria not evaluated are indicated below. 310 CMR 15.303 or in 310 CMR 15.304 exist, Any ,OMMENTS: 8. System Conditionally Passes: ction need to be laced or repaired. The One or more system components as described in the "Conditional Pass Board of Health, will pass. roved by system, upon completion of the replacement or repair, as app lain. Y, N, ND) in the for the following statements. If `mot determined" please exp Answer yes, no or not determined ears old* or the septic tank (whether metal or not) is structurally unsound, . The septic tank is metal and over 20 y inspection if the existing exhibits substantial infiltration or exfiltration or tank failure isimminent- oard of Health.will pass tank is replaced with a complying septic tank ra approved by * septic tank will pass inspection if it is structurally sound, not leaking and if a Certificate of Compliance indicating A metal p that the tank is less than 20 years old is available. ND explain: tion box due to broken or observation of sewage backup or break out or high static water level box. System wit ppass inspection f (with obstructed pipe(s) or due to a broken, settled or uneven distribution approval of Board of Health): _ broken pipe(s) are replaced _ obstruction is removed distribution box is leveled or replaced ND explain: requiredpumping.more than 4 times a year due to broken or obstructed pipe(s). The system will pass The system req ro al of the Board of Health): inspection if (with app _ broken pipe(s) are replaced obstruction is removed ND explain: 2 age 3of11 OFFICIAL INSPECTION FORM — NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM s{ PART A CERTIFICATION (continued) ,roperty Address: 757 Forest Street North Andover MA 01845 mer: Dermis & Linda Jillson )ate of Inspection: September 24 2003 Further Evaluation is Required by the Board of Health: Conditions exist which require further evaluation by the Board of Healthin 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: e4of11 OFFICIAL INSPECTION FORM — NOT FOR VOLUNTARYI S SS TS SUBSURFACE SEWAGE DISPOSAL ASYSTE CERTIFICATION (continued) )perry Address: 757 Forest Street North Andover MA 01845 vner: Dennis & Linda Jillson Lte of Inspection: S tember 24 2003 System Failure Criteria applicable to all systems: for all inspections: z)u must indicate either `yes" or `,no" to each of the following es Noonent due to overloaded or clogged SAS or cesspool _ X Backup of sewage into facility or system comp ground or surface waters due to an overloaded or clogged _ X Discharge or ponding of effluent to the surface of the gr SAS or cesspoolabove ed SAS or cesspool _ X Static liquid level in the distribuoann 6 below inverttorlavai able volume is les than 1/2 flow X Liquid depth in cesspool is less ed or obstructed pipe(s) X Required pumping more than 4 times in the last year NOT due to clogged Number of times pumped is below the high ground water elevation to a surface }� Any portion of the SAS, cesspool or privy 1 or tributary X Any portion of cesspool or privy is within 100 feet of a surface water Supply y water supplyublic well X Any portion of a cesspool or privy is within a Zone 1 of a p 1Y well X Any portion of a cesspool or privy is within 50 feet of a private water supply private water X Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from e sse supply well with no acceptable water qualityfor lysis coliform bacteria his andavolat les if horganic compoundsindicates d nitrate performed at a DEP certified laboratory, that the well is free from pollution fro m the facility and the presence of ammonia nitroered.nA c py of nitrogen is equal to or less than 5 ppm, Provided that no other failure criteria are triggered. the analysis must be attached to this form.] ve failure criteria exist as in No (Y es/No) The system fails. I have determined that one more of the should contact the Board of Health o 310 CMR 15.303, therefore the system to corraeot the failure. wner determine what will be necessary E. Large Systems:with a design now of 10,000 gpd to 15,000 gpd. To be considered large system the system must serve a facility You must indicate either "yes" or "no" to each of the following: (The following criteria apply to large systems in addition to the criteria above) Yes Nowater supply _ the system is within 400 feet of a surface drinking _ 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 1 or answered Zone II of a public water supply well If you have answered "yes" to any question in Section E the system is considered ea significant threat a significant threat 1 Section "D" above the large system has failed. The owner or operator accordance with 310 CMR 15.304. The system owner under Section E or failed under Section D shall upgrade the system should contact the appropriate regional office of the Department. 4 e5of11 OFFICIAL INSPECTION FORM - NOT FOR VOL INSCTION FORM TS .SUBSURFACE SEWAGE DISPOSAL SYSTEM CHECKLIST )perty Address: 757 Forest Street North Andover MA 01845 vner: Dennis & Linda Jillson tte of Inspection: Se tember 24 2003 'es No provided b the owner, occupant, or Board of Health K pumping information wasp Y _ X 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? _ X Have large volumes of water been introduced to the system recently or as part of this inspection? _ N/A Were as built plans of the system obtained and examined? (If they were not available note as ) X Was the facility or dwelling inspected for signs of sewage back up? X Was the site inspected for signs of break out? X — Were all system components, excluding the SAS, located on site? Were the septic tank manholes uncovered, opened, and the interior of the tank inspected for the condition of the X depth of scum? baffles or tees, material of construction, dimensions, depth of liquid, depth of sludge and dep X Was the facility owner (and occupants, if different from owner) provided with information on the proper maintenance of subsurface sewage disposal systems? The size and location of the Soil Absorption System (SAS) on the site has been determined based on: Yes No plan at the Board of Health. X Existing information. For example, a X Determined in the field (if any of the failure criteria related to Part C is at issue approximation of distance is unacceptable) [3 10 CMR 15.302(3)(b)] ,e 6 of 11M —NOT FOR VOLUNTARY ASSESSMENTS OFFICIAL INSPECTION FOR SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION operty Address: 757 Forest Street North Andover MA 01945 a+ner: Dennis & Linda Jillson ate of Inspection: S tember 24 2003. FLOW CONpITIONS / ESIDENTIAL 3 Number of bedrooms (actual): -330 umber of bedrooms (design): 110 gpd x # of bedrooms : t �`y ,ESIGN flow based on 310 CMR 15.203 (for example: (umber of current residents: 5 es or no): �J ►oes residence have a garbage grinder (y if es, separate inspection required] laundry on a separate sewage system (yes or no): No , [ Y p d ,aundry system inspected (yes or no): _— seasonal use: (yes or no): No — Well water Nater meter readings, if available (last 2 years usage (gpd)): lump pump (yes or no): N— o -ast date of occupancy: Currently Occupied COMMERCIAUMUSTRIAL 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 (y es or no). Water meter reading, if available: Last date of occupancy/use: OTHER: (Describe) GENERAL INFORMATION Pumping Records Source of information: S stem was laser t (yes o)two ears a o according to own Was system pumped as part of inspection (y u: No pumped determined? If yes, volume pumped: _gallons — How was g Reason for pumping: TYPE OF SYSTEM X Septic tank, distribution box, soil absorption system Single cesspool Overflow cesspool Privyattach previous inspection records, if any) Shared system (yes or no) (if yes, Attach a copy of the current operation and maintenan Innovative/Alternative technology - (to 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: S stem was installed in 1992 accordm* to owner Were sewage odors detected when arriving at the site (y no): No No 6 e7of11 OFFICIAL INSPECTION FORM—NOT FOR VOL INSPECTION FORM TS SUBSURFACE SEWAGE DISPPOSSAT CYSTEM SYSTEM INFORMATION (continued) iperty Address: 757 Forest Street North Andover MA 01845 vner: Dennis "L da Jillson Lte of Inspection: Se tember 24 2003 UQ,DING SEWER (locate on site plan) epth below grade:22" —40 PVC , other (explain): [aterial of construction: cast iron X 34' listance from private water supply well or suction line: etc.): omments: (on condition of joints, venting, evidence of leakage, Buildinp, sewer i e is in good condition.no Sim of leaka e. 3EPT1C TANK. Yes _ (locate on site plan) depth below grade: 15" fiberglass—Polyethylene Material of construction: X concrete metal _ attach a copy of °ther (explain) Is a e confirmed by a Certificate of Compliance (yes or no): if tank is metal list age — g certificate) Dimensions: 5' W x 10'L x 52" D Sludge depth:_l l= Distance from top of sludge to bottom of outlet tee or baffle: _ 27= Scum thickness: 0' Distance from top of scum to top of outlet tee or baffle: N/A Distance from bottom of scum to bottom of outlet tee or baffle: N/A gri liquid levels How were dimensions determined: Measured Comments (on pumping recommendations, inlet and outlet tee or bale condition, structural integrity, q as related to outlet invert, evidence of leakage, etc.): tank is iood condition. . , _ _ ,:..,,:a I—A il, at outlet rove n GREASE TRAP: No (locate on site plan) Depth below grade:fiber lass polyethylene _other Material of construction: concrete metal g (explain): Dimensions: Scum thickness: p of outlet tee or baffle: from top of scum to to Distance from bottom of scum to bottom of outlet tee or baffle: gr liquid levels as related Date of last pumping: I Comments: (on pumping recommendations, inlet and outlet or baffle condition, structural irate ity, q to outlet invert, evidence of leakage, etc.): I ige8of11 FORM —NOT FOR TEM SCTION FORM OLUNARTS OFFICIAL INSPECTION SUBSURFACE SEWAGE DISPp RT CY SYSTEM INFORMATION (continued) toperty Address: 757 Forest Street North Andover MA 01845 )wner: Dennis & Linda Jillson )ate of Inspection: Ser+tember 24, 2003 LIGHT or$OLDING TANK: No (tank must be pumped at time of inspection)(locate on site plan) Depth below grade: _other (explain): Material of construction: concrete metal fiberglass __polyethylene Dimensions: gallons Capacity: Design flow: gallons/day Alarm present (yes or no): Alarm level: Alarm in working order (yes or no): Date of last pumping: Comments (condition of alarm and float switches, etc.): DISTRIBUTION BOX: Yes (if present must be opened)(locate on site plan) (Depth below grade = 20") Depth of liquid level above outlet invert: 0" evidence of solids carryover, any evidence of Comments (note if box is level and distribution to out equal, any leakage into or out of box, etc.): _, __ 11 ... ,,,,,r of cnfids carryover no si of leaka a d -box is' ood condition. pUMp CHAMBER: No (locate on site plan) Pumps in working order (yes or no): Alarms in working order (yes or no): Comments (note condition of pump chamber, condition of pumps and appurtenances, etc): Page 9 of 11 OFFICIAL INSPECTION FORM — NOT SYSTEM INSPECTION FORM TS SUBSURFACE SEWAGE DISPOSAL PART C SYSTEM INFORMATION (continued) Property Address: 757 Forest Street North Andover MA 01845 Owner: Dennis & Linda Jillson Date of Inspection: September 24 2003 SOIL ABSORPTION SYSTEM (SAS): Yes (locate on site plan, excavation not required) If SAS not located explain why: Type _leaching pits, number: leaching chambers, number: leaching galleries, number: X leaching trenches, number, length: 3 leach trenches — 50' long _leaching fields, number, dimensions: overflow cesspool, number: innovativelalternative system Type/name of technology: Comments (note condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of vegetation, etc.): SAS is under front lawn, no damp soil or ponding present no signs of hydraulic failure. Inspected all three (3) leach trenches with a video ins ion camera and found them dry with no standm h uid. CESSPOOLS: No (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: No (locate on site plan) Materials of construction: Dimensions: Depth of solids: Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): 9 Page 10 of 11 OFFICIAL INSPECTION FORM — NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: 757 Forest Street North Andover, MA 01845 Owner: Dennis & Linda Jillson Date of Inspection: September 24 2003 SKETCH OF SEWAGE DISPOSAL SYSTEM cluding ties to at least two permanent reference landmarks or benchmarks. Provide a sketch of the sewage disposal system in Locate all wells within 100 feet. Locate where public water supply enters the building.. O Well A-1=34' B — 1 = 40'8" A — 2 = 33'5" B-2=43'6" B- D -t We 10 Page 11 of 11 OFFICIAL INSPECTION FORM — NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: 757 Forest Street North Andover, MA 01845 Owner: Dennis & Linda Jillson Date of Inspection: September 24, 2003 SITE EXAM Slope Surface water Check Cellar Shallow wells Estimated depth to ground water 9' feet Please indicate (check) all methods used to determine the high ground water elevation: X Obtained from system design plans on record — If checked, date of design plan reviewed: _ Observed Site (abutting property/observation hole within 150 feet of SAS) _ Checked with local Board of Health -explain: Checked local excavators, installers — (attach documentation) _ Accessed USGS database -explain: You must describe how you established the high ground water elevation: Bottom of SAS is 28" below grade. According to soil testing performed on May 15, 1991 by Stowers Associates, no groundwater was encountered @ 9' below grade. 11 '. a Department of Environmental Management/Division of Water Resources WATER WELL COMPLETION WELL LO TI a GEO res `GJO !N S E W of (feet) (circle) City/Town :��72.Gad Well owner 0 (mad) Address � N S§ W of (mi. in tenths) fc rclel LOG of FORMATIONS• "`°'""""""" BOARD"OF HEALTH COPY% Board of Health p rmit: A no ❑ intersect. w/ yes (road) WELL USE WELL DATA �� Domestics, Public ❑ Industrial ❑ Total well depth ft. Monitoring ❑ Other Depth to bedrock ft. Waterbeanng rockhidated material: Method drilled — L; _ A 3 Description Date drilled Water -bearing zones: CASING'���/��l/ 1) From To C6D Type f l/, Length�ft. Dia(1.D.)4m. 2) From To Length Int bedrockft. 3) From —To I t Gravel pack well: dia. Protective I seal: Screen: dia. Grout -El Other Slot'` length from_ to STATIC WATER LEVEL Static below Date water level land surfaced//© ft. WELL TEST umping�hr. Drawdown ft.aftZcovery Te-4—,,,ft� Q min. atgpm How n}easure ! 3o ft. afted�_hr. min. LOG of FORMATIONS• "`°'""""""" BOARD"OF HEALTH COPY% ---•., c ,- r . ,. .- � � . � � . �. `�, .. .. _ � '.' � BOARD OF HI"ALTHD " Town of North Andover' Mass . Permit u Date /A -y/?_ . 19c/'/ APPLICATION FOR WELL & PUMP PERMIT Application is hereby made for permit to drill a well made to install () a pump system'. (). Application is Location: Address /} P ST / Lot# Owner-ejWiej!yj _Address FS-XV,14X1 r of • Te1.G6` Well Contractor dresAi � �� 967--no- Pump Contractor �l Address IV (i Tel.- WELL CONTRACTOR (To be completed at time of,pump test) Well used or Type of Well for // • Diameter of Well G �r Size of. Casing Gf� 1 %1,J• Depth of Bed Rock Depth casing into Bed Rock Was Seal Tested? Yes (iC) No (_) Date. of Testing Depth of �Jel1 - �� , Well Ended in Wha-t. Material Depth to Water-� Delivers L3-- Gals.Per Min. for 4 hours Drawdown` —feet after pumping—Z--hours- at GPM � r Date of Completion. ignature lel ntractor \.. _\_J.: _.\_�...�. J. i; ...L .\. t\_.\_�.\. J_ i; i; is i; -i; i; n i; i; i; is i\ .. .. •. .. •. .. .. •. •; I. i .. .. •• PUMP INSTALLER (To be~ filled in- before installation) r Size .& Name Pum �i-_�%j__ .--- -- Pump Type Used Water Pump Delivers _GPM Size of Tank I Pipe Material Used in Well: Cast Iron (_) Gnl.vnni.zed (_) Plastid I Well Pit(_) or Pitless,Adapter (y) Was sleeve used to protect pipe?. Yes () NO( ) lype or Name Well Seal Date / d �4i'r�t�r�4�r�t�4�4�'r�1r�k�4�'c�'ci��M��r4r��rti'r�4►M�'t�'t�4�Y�4�'riM�'r�Y�4r�4r4�'r�'rtiY�Y�4 �4�'rt'rtir�`r,': ;; ;".:;,:ti�G r:�;: r) �icD;F;dhtk�vt4tMt�rtk Date Water analysis report •submitted to Board of J-ieal•th Date,release given tD„owner of record & Bldg. NUM,ZF.R FEE THE COMMONWEALTH OF MASSACHUSETTS $25.00 TOWN...... of ....... .NORTH ... ANDOVER.................. .... . i This is to Certify that ...._._--LeRo.... Ski11ings.t...Skillings-..&... S.ons................ NAME 269 Protor Hill Road, Hollis, N.H. ------------•----------------------------------................................................. -....................................................................... ADDRESS IS HEREBY GRANTED A LICENSE For ............................Well - Lot# -6 Forest Street ....................................... ............................•---•---•.......... ......................................................................... .. . ........•------...........-----------....---------•----•-------............................ --------------•---............................................ ..................-----•--- ........... ----.....---.........................-- ...... .................. ................... ..................................................................-----...................................------..........----... I ....................... This lieense is (,ranted in conformity with the Statutes and ordinances relating thereto, and expires ----- Dec -ember ... 31.,....1.9.9.1............_nn.less sooner suspended or revoked. .. . ...... ............... ......... ._................ -.... ... Dacembex --1.9......................1.9.._.91 .. . • .------• .-...-. . 2c�2. --.. . _...1'::...c. ... t ..... . -- -.. ..................... FORM 433 HOBBS & WARREN. INC. 161 DATE j4LI-9—L Sheet ( of BOARD OF HEALTH TOWN OF NORTH ANDOVER SUBSURFACE DISPOSAL DESIGN REVIEW FEE� o PERMIT # APPLICANT . b A 4672" ADDRESS ENGINEER _CEJ ADDRESS PLAN DATE �! CONDITIONS OF APPROVAL: APPROVED DISAPPROVED A DATE RECEIVED ASSESSOR'S MAP PARCEL # LOT # STREET REVISION DATE `�`c,i°'t 6010 c 1 -el) Cp. vS tlc , ,Qee +� . t v4 v- 1510s (+e) . ") Pot,& T -lie, b.(>060 - �,o ) -o o bIeYIc 1?TO iac,v—f-c ( l t ` 'Plsi"2cg Z L� 6S� h7a Town of North Andover, Massachusetts Form No. 1 BOARD OF HEALTH 19 wC A APPLICATION FOR SITE TESTING/INSPECTION �4 Qg4TFOE PPa�� Applicant NAME ADDRESS, TELEPHONE Site Location ' Engineer—") NAME iADDRESS TELEPHONE Test/Inspection Date and Time CHAIRMAN, BOARD OF HEALTH Fee Test No. S.S. Permit No. D.W.C. No. C.C. Date Plbg. Permit No. e--? � C -0-m- �� �� - O-V?Y-()\i- 2.z()Vy-A_ tied 0416t,� pqocl- --� ra2 V"ZUotot WELL DATABASE ADDRESS: Jf� AGE OF WELL: WELL DRILLER: WELL PERMIIT 7: 3 WELL LOCATION: / _2 $ , WELL PERMIT DATE: J.Z DEPTH OF WELL: Gib TYPE OF WELL: a.. DRILLED b. DUG c. UNKN N TYPE OF WATER BEARING ROCK. A WATER ANALYSIS DATE: IIGH,i?4GANESI HIGH IRON: Y N OTHER CONTA DTANTS: Y WELL DATABASE ADDRESS: l ( ��-— AGE OF WELL: WELL DRITDVR: _ WELL PERMIT fi: WELL LOCAON: WELL PERMIT DATE: DEPTH MJF TYPE OF WELL: a.. DRILLED b. DUG c. vOWN TYPE OF WATER BEARING ROCK: WATER ANALYSIS DATE: HIGH IRON: Y N m0 LU Y N N HIGH MANGANESE: Y OTHER CONTAML CANTS: Y N N �iti��•NkZ ��Sr -, rc.Imr 1, ,j r' r �� x 'fir 1 , 1 ' ''11 t �t� +� +��'If ,i.r. �;�t` . .1.(r >t `• ��}l, G+1 ��, �, � i S. is , a +'� ' ' yT r{Ii , , z TOWN OF.Np�2rTH ANDO OCT OVER SYSTEM PP'ING RECORD~. ' •3+� h�a/i � '��� �- rF II'AI'� 1 1, / a' . � y�jr:r� `171{-1 .!f r a '' s ^+-_ +.. _ MATFAt, 1 1 r ''1 1 0. 4. d1 a + �• .i � _ w ��:?f. t e1' rq �t f :1 � M 1 ir.k�Irl »i.�i �+:+�'t.lt} ���C4r?•i' !t t �, + , TEM O & .. DRESS SYSTEM LOCATION `'! y Y�' }MRr ` '. ! �'•�•Mp�i -fro ut of house) - Y^qLv ! 1'f rte" -7n •Ytf �' I. � � :7F/ IL/ 1F�y/1aJ//�x{ i 7� .. y+("�.4r`(!� �h'y., !'in�`A•..�i' ir''rlih t e 1 r .. — �++� aa4JY ��+dM1 ,�_T �" i' 4 -1 f', '� +*1 e1 4�ri��j CY. fir': i. + .: .. .• .f•^r F �1 OXV+i" -tr �� QUANTITY PUMPED GALLONS . 1�a�K1 �p1 t .>• 7� ,,Y �••'^T' ��'i *.. e,S,� 4aUxnr.�.� � n. 'S•,tll �! . 6 � t �, ri•:�,Ir'i 7� ., li G�'r.> (I ♦ t t�:lr , ii at at f'1 T i NO� F ... 4 Yt <� Q I. YES ;SEPTIC TANK: NO '.'..... YES ' r11_}yl`' •s i'!J4 1'?�J >. dt S: a: ! 4 t , .. Il .. - _0X S 1 _ T 1 �` t� `' 1; • 'F��ti�`..` ' r, ERVICE: ROUTINE ; .�, f, , EMERGENCY f liij�,, j Aw,t1 fi�Ir �. �- - ' V�l►TION t rGO i s � �" HEAVY ONDITION . FULL TO COVER tkt�r+i 1'rxr r' VY GREASE:.. <i " BAFFLES AFFLES IN PLACE LEACHFIELD RUMBA CIC ..+. : EXCESSIVE SOi.mS � �, }}rr�p1j , ►, k SOLIDS FLOODED CX '�*�wew . i t �%�j O . ER Ti OT xP A7N •.! r'k,l'rf>� � 1af'rr �., �s I,, 1 it .ir�»:�) ?, T 41 X .� - .. ., , , , r�t.,i7. ;��Y• '� •� t� a i,f^•x r J F4Q �f tt 1 , 1 " 1. 5t • t'F't}r012UL • 4, 111r.IN a IA .(� jn'�lr i. ���r t i,+ �QS 1 !1�i} Ya�,i,r •.«! . : s; 4 W" `a,�r ,, Jr ! 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System Locatlon •form= on the': w.� ..•.,T•...corYtjiuW7f tine .'. only the tab key Address to move your curso�.•do�ot use the rietum 0417own :a V. jai t,l,f, 2 System Ownerl vi n,paim; ar no, zsystem ppro� frig authorlty� NOV 0 5 2007 Town, r NDOVER f , ENT NT -071 State Ing Record must Zip Code •T 4 , .. r 1 "+ NameAMWO �v Address (if different from locatlon) Clt)+!1 own State }p� 97�'��A5-• code Telephone Number q . ,J .Pumping Record '.�V//r/�/ ,,, "1' • . ,.1 3 "p':�1it ,{.. r: •rY fl .,lu )��'Y. �:7 ��'{ /[ � �,• r• :>�, 1' Date of Pum (n r P g 2. Quantity Pumped: E Date Gauons 3 ' Te of system:`,`,:: YP Y ❑ Cesspooi(s) eptic Tank ❑Tight Tank Other (describe), EffluentTee Filter present?. ❑ Yes Ew If yes, was it cleaned? ❑ Yes ❑ No y�1 F, ht' f�l. •,J7 ' .yr t I�t`,''•t F , i N }_ �i Gf 8ystgmlr ,Y j IfCo�dlticn 1. t f f 1• �1 •11 t+ fi r K • 11 y Y i'.. .. � �Q � Sy. aSrt Pumped By'' � i ,� t7r yrr ><r•�rr� • � ^If��/jVijl )�t„� ••,�°� Vehicle Ucen a Number • 7,+7}y, t, �'�, � <k (_Ji—(]/ �%%� �.,. . Wj ...a�.!!!ly,"1�`+;1 <''j'�'1!•sr11���1Ln�w" Y� 7, Location where contents Were d1;3posed: 4.7 J y r • a', •J.:•.:• � ��:....:: SlpnaGue of.Hauler.�,..,� u::�•..Y •'• • • .: http //www.mass.9ov/deplwafer/approv4ls/t5formsrhtm#Inspect t5forrn4.doca.06/03 w Date System Pumping Record • Page 1 of i TOWN OF NORTH ANDOVER HEALTH DEPARTMENT n 27 CHARLES STREET } �� NORTH ANDOVER, MASSACHUSETTS 01845 �9 sass Sandra Starr , R.S., C.H.O. (978) 688-9540 - Telephone Public Health Director 1078) ARR-oaay Fax: Pages: Phare: Date: ❑ Urgent ❑ For Review ❑ Please Comment 0 Please Reply O Please Recycle Please. call 978-688-9540 for assistance with any questions. Thank you. xc: Address File Chrono File HP Fax K1220xi Last Transaction Date Time Sep 29 4:25pm J-ype identification Fax Sent 819783565500 Log for NORTH ANDOVER 9786889542 Sep 29 2003 4:37pm Duration Faces Result 1:12 3 OK �' t • �; t C c F`3"� r K S ."d''f�,kYn x`i Ys: w '�. ri `,"?,.x'"W t_pt''5t?,"p};r�9•'a n .cGr.,4+n1 r gip..? . • E 4 - ? f -� in r. • ;� % i � r i t xk "u ay ! `' ': t � �' r �r �r�*'�'��*•a .. h kr i r't A.i j, L \ 1 ��1 •7; ��� ray Sty ` 3 C.: t • fi�'5 Y�l ��' t b. 1� 1 A '. l' 'I � ' :Y Rt �jF ^t �f, i _� �..�} .r'��j�'�^x r 5 f Ib � 'y3��� t •C it i i. !` . r - ..t• f� S t t t• F e: 1 s ! r � p f ,. { r m No. 2 Form Town of MassahAndover c h u s e t is MpR,,, BOARD OF HEALTH %ter —19 O • 40 DESIGN APPROVAL FOR SA 14 t` SOIL ABSORPTION SEWAGE DISPOSAL SYSTEM Test No Applicant Site Location S�D�cJE� DATE Reference Plans and Specs. ENGINEER, -DESIGN 'on is ranted for an in soil absorption sewage disposal system to be installed • Permission Perm g Health.. T • s Board of in accordance with regulations of B Glti b tr-lU t� • e hlJ vs - SERA E� I GHA RMAN, Bo D OF TH i _ � Site System hermit No. +n TIUD - STOWERS ASSOCIATES, INC. REGISTERED LAND SURVEYORS MASSACHUSETTS & NEW HAMPSHIRE PINE STREET GEORGE M. RICHARDSON METHUEN, MASSACHUSETTS REGISTERED LAND SURVEYOR 617-685-5262 MAIL ADDRESS: P.O. BOX 92, METHUEN,*MASS.01844 Iilo-,,th Andover oard of Health Main Street North Andove,-, Muss. North Andover 4oard of Health/ Marchionda & Associates HUGH F. DUNKLEY REGISTERED PROFESSIONAL ENGINEER REGISTERED LAND SURVEYOR May 6, 1991 We hereby request to have soil test witnessc-4 at Lot 6 shown on North Essex "egistry of Dedds playa # 11810. This lot is located on the westeily side of Forest Street between house # 769 and # 701. Number of holes to be witnessed 2 Owner - Mary Koontz Assessors Map J-020 ilarce, /7 Str,lie-s Associetes Inc. fig" Tt4- Lveorge M. Richardson HP Fax K 1220xi Last Transaction Date Time Sep 30 3:05pm Type identification Fax Sent 819783565500 Log for NORTH ANDOVER 9786889542 Sep 30 2003 3:07pm Duration Pages Result 1:30 3 OK T w W> W.O�l 0 W lej +f Z Z c Ilk 4 5 :5 L 0 ol 27, LW F— >- (E W > W W td 0 (l) w R. F- W; Z � D :!5 ct 0 III Z z -Z Lo Z (r z ffi \0 tu (r W_ —i w D - Q 00 7z C/) w of w 10 X — D '(y II U > 0 w u W LLJ ..z W F- w q: F- 0 Z QZ :cu 0) 0 0 U) 500 W ei C/) T w W> W.O�l 0 W lej +f Z c Ilk 4 5 :5 L ol 27, (U C\i W W td (l) F- W; Z D :!5 0 Z z -Z 41 ffi \0 tu W. a: IL 7z T w W> W.O�l 0 W lej +f Z c Ilk 4 5 :5 L ol 27, (U T w W> W.O�l 0 W \j U13AN A3-13 A313 J.U3AN I't -f'f&f jjj A313 1371n 0 '\3-13 13 -IN 4;4 o 0 tj LA -ru rd x ej. W r 'A3-13 I -UnO X 'A-3-13 31N I 04' _4 w 0 03-1 /V Z . 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This does not relieve the applicant and/or landowner from compliance with any applicable local or state law, regulations or requirements. ****************Applicant fills out this section***************** � n (Sok) "' APPLICANT: 1 nN, S . Z I\Phone 202S -ySGS LOCATION: Assessor's an Number 1045 Parcel 9011a Lots) -44 Subdivision Street 1F0c2S 'S�'+_ • St. Number °-15'-1 Use only************************ REC DATIONS OF TOWN AGENTS: a Date Approved d �/ x� Conservation Administrator Date Rejected Comments Date Approved Town Planner Date Rejected Comments . X-_>1_ Health Agent Comments Public Works - sewer/water connections - driveway permit Fire Department Date Approved Date Rejected Received by Building Inspector Date TAN 07 '92 13:23 t5Uli1C1� u1 ji�ni.1 /2G P.2%2 ` Z ' ' Town of _North AndoV'er,Mass . .. Rate /��/ O 19 Permit #_ APPLICATION FOR WELL & PUMP PERMIT .. Application i.s hereby made for permit to drill a well: (`�i) . Application -is' made to install () a pump system'. Lodation: Address FoyePT / Lot. # • - Address,�jrs"in//f� -T- % h Owner;%� Z-- ` el .v _LLi ' ;r-� Well Contractor SAdsre Pump Contractor Address l ( (1 Tel. • WELL CONTRACTOR (To be completed at, time of pump test) Type of Well Well used for ,a r Diameter of Well 4;/( size of. Casing Depth of Bed Rock Depth casing into Bed Rock Was Seal Tested? Yes (� No (_} Date, of Testing ,Depth Well Ended in Wha-t. Material Depth to Water s r Delivers, Gals.per Min. for 4 houz Tlrawdown _feet after pumping hours- t ..'GPM - Date of Completion zgnature a retractor PUMP INSTALLER (To b6'- E'i.1.1cd in' before installation) Size & Name Pump Rump Tyrie Used Water Pump Delivers GPM Size of Tink Pipe Material. Used in Well: C�st Iran {T) C�1.v,-ini.zed {_) Plastic laell Pit ( ) or Pitl.ess .Adapter (X) Was sleeve used to protect Pipe?. Yes (X) NO ) Type or Name Well Seal Date }- �r*,��r�M•heti+'rik�4'�'+r�tr�Yti4Y�4��r�'��M��r�t�tS�e�4�4�ti+k+4��tRt�F�1r�Y�'o��r+4ti4t��'rti'rti'r�'rtie�4,'::;:;.''r,`�i��<t�� t:'�e�-�.•:2���ti��r �P�Pr[l�fg41' Date Water analysis rbpor--t submitted to Board of ,i-(cal'th--- Dat:e..release given t owner of record & Bldg. Insp Health Inspector, JAN 07 1132 13:23 C1. :. ,- . Departaneut Of Euvironmcutsi Maitsgemant/Division of Water Resources WATER WELL COMPLETION REPQRT Ti GEOGRAPHIC DESCRIFT ee 'a /- S E W r�J Gtty/Towd :bo,d) Wril1: _owner N SOW • ;p1,tldrC;�•.' . ,.,.r,.. •• � (n. Jn raniAfJ !dr IaJ • ••� lntersccr. wG� fBq rd:;o4:1,fealtit p rfojt: yes ,� no WELL DATA YI( 'l l `USE Gcs� it. i. `0o'mestic' Pubtic Cl Industrial ❑ Total well depth �— 1ylaRitoring Depth to bedrock �f - h• Water-bcann4 took/tincon olidatod mz !'' Ma1ho¢• drilled' I' 00scription DateArilled' r' ,. .• Water -bearing zones: Z j iC�1SI,NG 11 FromTo----'cD � 21 From_. To Length' it. dia(.I;D i ;) n. 31 From�To I,,t'ngth'Int '.bdiock,,; i • • Gravel pack well:— I Protect Y8•" a ��. ea Scroolr dia. _�'Qlhttr_ Sloth_ longth —frorr-_ I G:�put'X3 .. S,let�c writor ley pl.bslornc•land surface. _ ft. Date. Iys+I:yLESr ,: at 9P u I Ijr... min. m • �cawdawii' i.t, ., . alloy' mp ng� HQvir asure.! acoveiy. it. aitorhr.—rein 4�'�Qa:::of''tRruigIoay.$ I ENTs.•pflirm` '•'•T "Driller • . -:Mass. Regi io `FJr .• � Qi~ Addresv�l> •GI:N/Town Pffv 7 n ra limmd wall yr eu.«prrnr Hurry O. LER COPY ZZ A ocaloratorpr, 90C. ' aa uTTLET0w n0Ao wsSTrOno. wm 01886 . (508) 69e-8395 Report Number: C-sks-4760 Client: ATTN:Mr. Romer Skillinos Skillings and Sons 269 Proctor Hill Rd' Hollis , N. H. 03049 Report Date: December 30,1991 Sample Taken At: KDCC Construction Lot 6 Forest Rd N. Andover,Mass. Sample Taken By:Skillings Staff On:December 26,1991 CERTIFICATE OF ANALYSIS ------------------------ {`J� � Test Parameter EPA Max Results EPA Coliform Bacteria(P) 0 0 � Numerous To Sodium 20" advisory limit,no formal,limit pH (S) 6.5-8.5 8.2 - Copper(S),. 1.0 <0.01�^/ EPA Standard Hardness No Limit 81 EPA Standard Iron (S) .3 0.46 # &*� Manganese(S) .050 0.06 # gAU Calcium Not set 24.1 'v Magnesium Not set 5.9 - Conductivity Not set 220 ' Chloride (S) 250 10.6 Sulfates (S) 250 17.9 Nitrates(P) 10 0.31°1 Units per 100mL'' mg/L SU mg/L mg/L mg/L mg/L mg/L mg/L umhos/cm mg/L mg/L mg/L NT = Not Tested # = Exceeds EPA Secondary Maximum Standards TNTC = Too Numerous To Count "=EPA advisory limit,no formal,limit '=Exceeds advisory limit *=Advisory limit (P) -Primary EPA Standard (S) -Secondary EPA Standard This water sample, as tested, does not meets EPA Health Standards for all the secondary parameters listed above. The quality of this water sample is considered Safe To Drink, according to EPA Standards. Massachusetts State Certified Michael P. Carlson , for Testing Laboratory #MA048 Thorstensen Laboratory, Inc. BOARD OF Fif:ALTH Town of North Andover,Mass.. Permit # Date ;' �fT 19 �'/ r APPLICATION FOR WELL & PUMP PERMIT Application is hereby made for permit to drilla well (X). Application it' made to install (X) a pump system'. Location: Address roKel, � �']� Lot . # •� Owner c�Alit� Address Ac ,JCS S7-` re l • P'.,6� ` 7 c1 ! Pi✓/YPI�— a �� c.Iell Contractor AddressAL,4,0 �o,� y,%//2a/ //�� %r/,`Tel • } - �'�9.rS'n /', Pump Contractor Address Tel WELL CONTRACTOR (To be completed at time of pump ,test) Type of Well Well us -ed i:or 1` Diameter of Well Size o"f. Cas1n U, Depth of Bed Rock Depth casi.n` into =Dieds`Rock t Was Seal Tested? Yes ( ) No (_) Date o TrcA;fitan•g • i• r i Wel] ,Ended'' in 'Whdit: Material Depth of--•1eJ-�— — Depth to Water Delivers GalsPer Min. for 4: hours Drawdown feet after pumping ho`crrS at trCPM Date of Completion S .u'rc, ontr0-c -to r . PUMP INSTALLER (To be-- fi.11cd in- before installation) >i_ ze & Name Pump _ Pump Type. Used �Alnter Pump Delivers GPM Size of Tank Pipe Material Used in Well: Cast Iron (_) GnJ.vnni.zed (_) Plastic (y) t�Jcl.l Pit ( ) or Pitless Adapter ,,Jas sleeve used to protect pipe?. Yes (_) NO(—) 'hype or Name Well Seal "1 I Da t e "!9V . ii iSc c ,:c t'1 �cnG; .:c';�, ,'`FthdtSkrM:tAi;tklk Date Water analysi's repor-t 'submitted to Board of iucil'th Date,. release given tD owner of record & Bldg.. Insp Health Inspector- Ll M. 0 Vq NUM1kVR FEE THE COMMONWEALTH OF MASSACHUSETTS TQWN ..... of ........ UQUIff $25.00 This is to Certify that --------- LeRoy ... ... S.Ons ................ NAME 269 Protor Hill Road, Hollis, N.H. .................................................................................................. ..........................------------------------ ADDRESS IS HEREBY GRANTED A LICENSE For ............................ Well Lot#6 Forest Street ............ ................................................................................................. ............... .......................................... .................................... .................... ....................................................................... ...................................................................... ...................................................................................................... .................................................... .......................... ............................................................................................. This license is granted in conformity witit the Statutes and ordinances relating thereto, ani expires ..... Der-e-mber-31 ...... 1.9.9.1 .............. unless sooner suspended or revoked. .. ..... .... .... rrQ'C'LLJJ .... Decembe-r-,19 . ...... ............. ------------- > L-� ..................... 19 .... 91 ------------------- fi.1­r . ........ ........ a -------- ......... ...................... FORM 433 HOBBS a WARREN, INC. ...................... I ff OKI 0 A90 COco Z. O —J.J UJ J 0 ir Ix cc 0 m CL N w 0 W H Lu aQO0 U) ir 0 cr 0 Ll i7n 0 0 0 C- .0 ru E%— Ln .-a 0 0 FOR1%1 U TOWN OF NORTH ANDOVER LOT RELEASE FORPI SUBDIVISION ASSESSORS MAP 0000 SUBDIVISION LOT(S) r P RMAN � NT DRESS (ASSIGNED BY D.P.W. �- �.-U� STREET of'061 APPLICANTe`y�yt�-� PHONE DATE OF APPLICATION TOWN USE BELOW THIS LINE PLANNING BO TOWN NER CONSEIkVATION C01MISSION M ERVATION ADMIN. BOARD OF HEAL LTH SANITARIAN 4' ,39rzy DEPARTMENT OF PUBLIC WORKS DRIVEWAY. PERMIT SEWER/WATER CONNECTIONS FIRE DEPT. i--Y-f A-", -,7 � - DATE APPROVED _ DATE REJECTED F APPROVED 9� TE REJECTED DATE APPROVED / DATE REJECTED V RECEIVED BY BUILDING INSPECTION DATE � y '-, -L d This form shall be signed by the agents of the Planning and Health Boards, the Conservation Commission prior to the issuance of any building permits for the subject lot. This form shall not releive the applicant from the compliance of any applicable Town requirement or Bylaw. DATE IL21 /j Fef Sheet— ( Of (/ BOARD OF HEALTH TOWN OF NORTH ANDOVER SUBSURFACE DISPOSAL DESIGN REVIEW FEE PERMIT # DATE RECEIVED APPLICANTASSESSOR'S MAP ADDRESS ENGINEER ADDRESS PLAN DATE PARCEL LOT # STREET REVISION DATE CONDITIONS OF APPROVAL: I APPROVED D�,APPROVED ),Ahr�xc,m -5c, 571seo . vs �Y Q/,Q -N�tizcc>lunoo zo ra—pjm�� (wo& a -CA PC- - zl" sov4.c) Pic, enn) P,Z A N O r 1 A No Av MAO R Y�'�/ /QNDO vrR, MASS. vxY-bo f oR R.ERATY TjW s!ST -SCA/,E 1'2� SrowARs Rssoc/prrs XNc. R.8 -G. 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