HomeMy WebLinkAboutMiscellaneous - 770 FOREST STREET 4/30/2018N.. Commonwealth of Massachusetts
CEI
City/Town of
System Pumping Record S!-.
,r4' 1.6 2014
Form 4
• TOWN Uh NURTH ANDOVER
MA -LTM pEPARTMENT
DEP has provided this form for us&by local Boards of Health. Other orms may be used, but the
information must be substantially the same as that provided here. Before using.this form, check with your
local Board of Health to determine the form they use. The System Pumping Record must be submitted to
the local Board of Health or other approving authority.
A. Facility Information
1. System Location. Righ of house Left / Right rear of house, Left /right side of house, Left /
Right side of buil Eng, Left / Right front of building, Left / Right rear of building, Under deck
Address r1r7 O
City/Town 7`—U State Zip Code
2. System Owner. 1
Name J
Address (d different from location)
Cityrrown State
_
k-7 1?
F.
Telephone Number
B. Pumping Record
1. Date of Pumping gate 2. Quantity Pumped: Canons
3. Type of system: ❑ Cesspool(s)eptic Tank ❑ Tight Tank
❑ Other (describe):
4. Effluent Tee Filter present? ❑ Yep Q-wo
5. Condition of System:
6. System Pumped By:
If yes, was it cleaned? ❑ Yes ❑ No.
c Y
Neil. Bateson F5821
Name Vehicle License Number
Bateson Enterprises Inc
Company
contents were disposed:
Lowell Waste Water
t5form4.doc• 06/03 System Pumping Record • Page 1 of 1
Commonwealth of Massachusetts
City/Town of
System Pumping Record
Form 4
M"
r
DEC 112012
TOWN OF NORTH ANDOVER
HEALTH DEPARTMENT
DEP has provided this form for use -by local Boards of Health. Other forms may be used, but the
information must be substantially the same as that provided here. Before using.this form, check with your
local Board of Health to determine the form they use. The System Pumping Record must be submitted to
the local Board of Health or other approving authority.
A. Facility Information
1. System Location, L/ Righ ront of ho�us eft /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
2. System Owner.
Name
Aaaress (it different from location)
City/Town
B. Pumping Record
state
Zip Code
State Zip Code
Telephone Number
1. Date of Pumping Date 0-2. q ntity Pumped
3. Type of system: ❑ Cesspool(s) Septic Tank
❑ Other (describe):
4. Effluent Tee Filter present? ❑ Yes [Sr No
5. Condition of System:
6. System Pumped By:
7.
M
cc
Gallons
❑ Tight Tank
If yes, was it cleaned? ❑ Yes ❑ No
Neil Bateson F5821
Name Vehicle License Number
Bateson Enterprises Inc
Company
contents were disposed:
_ Lowell Waste Water
- Ll r�
Date
t5form4.doc• 06/03 System Pumping Record • Page 1 of 1
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ISI
Commonwealth of Massachusetts
City/Town of
System Pumping Record
Form 4
JUN 0 9 2008
TOWN
ALTH DEP RME ANDOVER
DEP has provided this form for use by local Boards of Health. Other forms may be used, but the
information must be substantially the same as that provided here. Before using this form, check with your
local Board of Health to determine the form they use. The System Pumping Record must be submitted to
the local Board of Health or other approving authority.
A. Facility Information
1. System Location:
Address 'T-70 V-cx---o-AA- S+-" A , 4
Citylrown State
2. System Owner: �/ I )
(P
Name
Address (if different from location)
City/Town
Tip
State9'`Zi Cod
--O:S�s
Telephone Number
B. Pumping Record 6 4;� -OS7 6
1. Date of Pumping 2. Quantityed:
p g Date Pumped: Gallons
3. Type of system: ❑ Cesspool(s) Septic Tank ❑ Tight Tank
❑ Other (describe):
4. Effluent Tee Filter present? ❑ Yes ®-Plo If yes, was it cleaned? ❑ Yes ❑ No
5. Condition �of�System-
6.
yste�V m-
v
6. SystQm ,Pun �d By:
Name x�U Vehicle License Number
Company
7.
contentse disposed:
Date
t5fonn4.doc- 06/03 System Pumping Record a Page 1 of 1
TOWN OF
SYSTEM PUMPING RECORD
DATE: V rs JUN 1 6 2003
SYSTEM OWNER & ADDRESS
SYSTEM LOCATION
(example: left front of house)
�e�4lC)
VLO')S"��
DATE OF PUMPING: &--S--�--03QUANTITY PUMPED : lo� GALLONS
CESSPOOL: NO YES SEPTIC TANK: NO YES
NATURE OF SERVICE: ROUTINE ../ EMERGENCY
OBSERVATIONS:
GOOD CONDITION
HEAVY GREASE
ROOTS
EXCESSIVE SOLIDS
SOLIDS CARRYOVER
FULL TO COVER
BAFFLES IN PLACE
LEACHFIELD RUNBACK
FLOODED
OTHER (EXPLAIN)
SYSTEM PUMPED BY: Bateson Enterprises, Inc.
COMMENTS:
CONTENTS TRANSFERRED TO:
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TOWN OF NORTH ANDOVER
SYSTEM PUMPING RECORD
DATE: _S-0
iia �=ore��
(example: left front of house)
A- (sk
DATE OF PUMPING: '8I QUANTITY PUMPED I W6 GALLONS
CESSPOOL: NO J YES SEPTIC TANK: NO YES 'V
NATURE OF SERVICE: ROUTINE EMERGENCY
OBSERVATIONS:
GOOD CONDITION
HEAVY GREASE
ROOTS
EXCESSIVE SOLIDS
SOLIDS CARRYOVER
SYSTEM PUMPED BY:
q� i
CO1V�IVIENTS:
FULL TO COVER
BAFFLES IN PLACE
LEACHFIELD RUNBACK
FLOODED
OTHER (EXPLAIN)
C- 0
CONTENTS TRANSFERRED TO:
01i23/1991 08t23 FROM Corey & Donahue. Inc
TO Carusso Law Off P.01i01
cfl a
IAA,l "IC"
V
,lob No.
�C:"` ' lt'!"..✓' . Com' 1G '1 64S —6"7
This plan was not preparedfrom an instrument
survey. Offsets and distances shown should not
be used to establish property lines.
This plan is Intended for mortgage• purposes
only,
I certify that the structure 27.70 shown on this
Plan In conformance. with the zoning
setbacks in effect at the time of construction.
I certify that the parcel shown is ^.—
ocated within a flood hazard area' as depicted
3WW
OPNIN-1
MORTGAGE LOAN INSPECTION
LOCATION: _T70w-
SCALE'. DATE:
REGISTRY: I -.---` "-'-s''
TITLE REFERENCE, "ve'
PLAN REFERENCE: 1-24" '/'o/
COREY & D•ONAHUE, INC.
zo 7-
3
{
vI
I. J? 10
S�
cfl a
IAA,l "IC"
V
,lob No.
�C:"` ' lt'!"..✓' . Com' 1G '1 64S —6"7
This plan was not preparedfrom an instrument
survey. Offsets and distances shown should not
be used to establish property lines.
This plan is Intended for mortgage• purposes
only,
I certify that the structure 27.70 shown on this
Plan In conformance. with the zoning
setbacks in effect at the time of construction.
I certify that the parcel shown is ^.—
ocated within a flood hazard area' as depicted
3WW
OPNIN-1
MORTGAGE LOAN INSPECTION
LOCATION: _T70w-
SCALE'. DATE:
REGISTRY: I -.---` "-'-s''
TITLE REFERENCE, "ve'
PLAN REFERENCE: 1-24" '/'o/
COREY & D•ONAHUE, INC.
NEW ENGLAND ENGINEERIN
INC
October 10, 1997
North Andover Board of Health
Town Hall Annex
School Street
North Andover, MA 01845
RE: TITLE V REPORT 770 Forest Street.
TOV�ia+ C•= i•;�+� •
OCT 1 4 1997
Enclosed is the Title V report for 770 Forest Street, North Andover, MA. The system passes our
inspection.
If there are any questions please call me at my office, 686-1768.
Yours truly,
B aurin C. Osgood Jr., E.I.T.
President
33 WALKER RD. - SUITE 22 - NORTH ANDOVER, MA 01845 - (508) 686-1768
WILLIA%! F WELD
Govcmo:
ARGEO PAUL CELLUCCI
Lt. Governor
F
x 71- �9
r 4
COMIAO`XVEALTH OF MASSACHUSETTS ---!A :
EXECUTIVE OFFICE OF ENVIRONMENTAL AFF_A-I-RS
DEPARTMENT OF ENVIRONMENTAL PROTECTION
ONE WINTER STREET. BOSTON. NIA 02108 617-292-5560
TRUDY COXE
Sccrcur%
DAVID B. STRUHS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM Commissioner
PART A
CERTIFICATION
Property Address: 770 �Ks� 5t 'V' f}.�cQv✓<. Address of Owner:
D-alelof Inspection: 17/181Qr7 (If different)
Name of Inspector: BENJAMIN C. OSGOOD JR.
I am a DEP approved system inspector pursuant to Section 15.340 of Title 5 (310 CMR 15.000)
Company Name:
NEW ENGLAND ENGINEERING SERVICES INC. '
Mailing Address: 33 WALKER ROAD, NORTH ANDOVER, MA 01845
Telephone Number: 508-686-1768
CERTIFICATION STATEMENT
1 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 expierience in the proper function and
maintenance of on-site sewage disposal systems. The system: i
Passes
_ Condrttonalh Passes
Needs Further (valuation By the Local Approving Authority
Fails
Inspector's Signature: A Date: 10 y 9
The Svstem Inspector shall submit a copy of this inspection report to the Approving Authority within thirty (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 system owner
and copies sent to the buyer, if applicable. and the approving authority.
INSPECTION SUMMARY:
Aj SYSTEM PASSES:
Check A, 8, C, or D:
I have not found any information which indicates that the system violates any of the failure cr-te:ia ss dtfined•in 310 C.h4R 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 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.
Indicate yes, no, or not determined (Y. N. or ND). Describe basis of determination in all instances. If -not determined", explain why not.
The septic tank is metal, unless the owner or operator has provided the system inspector with a copy of a Certificate 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 not metal, is cracked, structurally unsound, shows substantial infiltration or exfiltration, or tank
failure is imminent. The system will pass inspection i(the existing septic tank is replaced with a conforming septic tank
as approved by the Board of Health.
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION (continued)
Property Address: i 7 v 1`o re c—i
Owner: `('% rA
Date of Inspection: cl
B] SYSTEM CONDITIONALLY PASSES tcontinuedl
Sewage backup or breakout or high static water level observed in the distribution box is due to broken or obstructed
pipe(s) or due to a broken. settled or uneven distribution box. The system will pass inspection if 1with approval of the
Board of Health). Describe observations:
broken pipe(s) 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
I inspection if (with approval of the Board of Health): i I
broken pipe(s) are replaces
obstruction is removed
I I
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 THE 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 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 APPROPRIATE) DETERMINES THAT
THE SYSTEM IS FUNCTIONING IN A MANNER THAT PROTECTS THE PUBLIC HEALTH AND SAFETY AND THE
ENVIRONMENT:
The system has a septic tank and soil absorption system (SAS) and the SAS is within 100 feet to a surface water supply or
tributary to a surface water supply.
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 50 feet or more from a
private water supply well. unless a well water analysis 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. Method used to determine distance (approximation not valid).
3) OTHER
Propertv Address: 770 ST. A) Je.2
Owner: 1
Date of Inspection: sem` 5
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
I I i I
Static liquid level in the distribution boa above outlet invert due to an overloaded or clogged SAS or cesspool.
l qu.d depth in cesspool is less than 6- below invert or available voluni a 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 Mmes pumped _
Any porton of the Soil Absorption System, cesspool or privy is below the high groundwater elevation.
Acv pon con of a cesspool or privy is within 100 feet of a surface waters supply or tributary to a surface water supple.
Any portion of a cesspool or privy is within a Zone I of a public well.
Am ponion of a cesspool or privy is within 50 feet of a private water supply well.
Anv porton 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. If the well has been analyzed to be acceptable, attach copy of well water analysis for
colnorm bacteria, volatile organic compounds, ammonia nitrogen and nitrate nitrogen.
E) LARGE SYSTEM FjkILS:
5
You must indicate either -Yes- or `No- as to each of the following:
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 drinking water supply
_ the'system is located in a nitrogen sensitive area (Interim Wellhead Protection Area - IWPA) or a mapped Zone 11 of a
public water supply well)
The owner or operator of any such system shall bring the system and facility into full compliance 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.
(r.wiy.d 04/25/97) Paq• 3 of 10
9;17 Y91
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART B
CHECKLIST
Property Address: 77(D Fc, -t-_,T- S1. N, F},,jDaoCR
Owner: 7/-,( n.. S �, S
Dale of Inspection:
q) 1147
Check if the following have been done: You must indicate either "Yes" or 'No' as to each of the following:
Yes No
Pumping information was provided by the owner, occupant, or Board of Health.
1! _ 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 pang of this inspection. i
I
✓ _ As built plans have been obtained and examined. Note .i they ere not available with N/A.
1 ,
_ The facility or dwelling was inspected for signs of sewage back-up. '
_ The system does not receive non -sanitary or industrial waste flow.
_ The site was inspected for signs of breakout
_ All system componepts. excluding the Sod Absorption System, have been located on the bite.
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 faeility owner (and occupants, if different from owners were provided with information on the proper maintenance of
Sub -Surface Disposal System.
_ Existing information. Ex. Plan at B.O.H.
_ Determined in the field (1f any of the failure criteria related to Part C is at issue, approximation of distance is
unacceptable) (15.302(3)(b)J ,
(r -i -d 04/75/971 P.C. 4 �r 10
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION
Property Address: '7 7o F1d r -es }- S1� )'J.R D"'Lt,
Owner: )il m $crcNS
Date of Inspection: 1'!S'4-7
FLOW CONDITIONS
RESIDENTIAL:
Design flow:�#og.p.dJbedroorn for S.A.S
Number of bedrooms: q
Number of current residents: Z
Garbage grir.der (yes or not -
Laundry connected to system dyes or no): l�
Seasonal use (yes :or no)://
Water meter readings, if available (last two (2) year usage (gpd): W e I
Sump Pump (yes or no): IV
I I I I
Last date of occupancy: 'v 1r e.i (
COMMERCIAL/INDUSTRIAL: i
Type of establishment:
Design flow: eallons/dav
Grease trap present: (yes or no!_
Industrial Waste Holding Tank present: (ves or no)_
Non -sanitary waste discharged to the Title 5 sys[em (yes or no)_
Water meter readings, d available
I
I
last date of occupancy:
OTHER: (Describe)
Last date of occupancy.
I
GENERAL INFORMATION
PUMPING RECORDS and sp.urce of information
System pVmPeJ as pan of inspection: (yes or no)�V
If yes, volume pumped: galldns '
Reason for pumping
TYPE OF SYSTEM
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 of all components, date installed (if known) and source of information: 1 t3 ucars 'J p
Sewage odors detected when arriving at the site: (yes or no) A-1
(revised 04/25/97) - page 5 of 10
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Property Address: ? o fJ .C,5J- tice
Owner: t WV S S
Date of Inspection: q I1�1�1
BUILDING SEWER: ll
(Locate on site plan)
t
Depth below grade:.,
Material of construction: _Zeast iron _ 40 PVC _ other (explain)
Distance from private water supply well or suction lirt 30r
Diameter gif v
.
Comments: (condition of joints, venting, evidence of leakage" etc.) \
et Deis tire- 't ✓` pi cg cD if u±%
i
SEPTIC TANK:_
(locate on site plant
1 t
u
Depth below grade: l
Material of construction: (concrete _metal _Fiberglass _Polyethylene _other(explain)
If Lank is metal, Inst age _ Is age conirrmed by Cenii,cate of Compliance _ (Yes/No)
Dimensions:_ /odC 6 -44,1 -OBJ i
Sludge depth- O `-
Dislance from top of sludge to bottom of outlet tee or baffle 30"
Scum thickness: D"
Distance from top of scum to top of outlet tee or baffle.
Distance from bottom of scum to bosom of outlet tee or barite: L .
How dimensions were determined: m taste �-c .' ,tl,, s � c4
Comments:
(recommendation for pumping, condition of inlet and outlet tees or baffles, depth of liquid level in relation to outlet invert, stru ural
integrity, evidence of leakage, etc.) N/A t eS
GREASE TRAP:
(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.)
Ir -i ..d 04/71,/97) 9.... a .,. ,.
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C =
SYSTEM INFORMATION (continued)
Property Address: -7 7J 'j-
Owner:14,v^ Sac1r►S
Date of Inspection: 7
TIGHT OR HOLDING TANK: iTank 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)
.3
Dimensions
Capacan gallons
I I
Design f!oA gallonJda% I
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 plant
ri
Depth of liquid level above outlet im•en:
Comments:
(note ii level and distribution is equal, evidence of solids carryover, evidence of leakage into or out of box, etc.)
gaz< v �n 4F�Oc)l fcir� /1011 _ So.»e elJ�LcXe�t -C �� CC�'✓1tO�C�
PUMP CHAMBER:
(locate on site plan)
Pumps in working order: (Yes or Not
Alarms in working order (Yes or No)
Comments:
(note condition of pump chamber, condition of pumps and appurtenances, etc.)
ireviaad 04/75/97) Page 7 of 10
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Property Address: 77,�, 10- 4-v1bzz-jet_
Owner:
Date of Inspection: 4118��i`j
SOIL ABSORPTION SYSTEM (SAS):_
(locate on site plan, if possible; excavation not required. but may be approximated by non -intrusive methods)
If not determined to be present, explain:
Type:
.S
leaching pits. number:_
leaching chambers. number:_
leaching galleries. number:
leashing drenches. number.length: i
leaching fields, number, dimensions:_
overflow cesspool, number:
Alttrnatiye system:.
i
Name of. Technology:
Comments:
(note condition of soil, signs of hydraulic failure, level of ponding, conditiopt of vegetation, etc.)
CESSPOOLS: _
(locate on site plan)
Number and configuration
Depth4op of liquid to inlet invert:
Depth.of solids layer:
Depth of scum laver:
Dimensions of cesspool:
Materials of construction:
Indication of grouridwatec
inflow (cesspool must be pumped as pan of inspection)
Comments:
(note condition of soil. signs of hydraulic failure, level of ponding, condition of vegetation, etc.)
PRIVY: _
(locate on site plan)
Materials of construction:
Depth of solids:
Comments:
(note condition of soil. signs of hydraulic failure, level of ponding, condition of vegetation, etc.)
(r—i■•d 04/]5/97) P.q• 6 of 10
Dimensions:
2) 175.
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Property Address: 7 7 0 l=am -e >T- 54, N , �K� o J et
Owner: ly, 5 a
Date of Inspection: fc1't8`q'
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)
ftf'c l cc<c �,.i ..
� o T � y
P.p. 9 of 10
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
PropeOwner:
Address: -77o
% o/ ts� sfi A) .
Date of Inspection: i"� t M t s
'I11bjrl-7
Depth to Groundwater & Feet
Please indicate all the methods used to determine High Groundwater Elevation:
Obtained from Design Plans on record
Observation of Site (Abuning property observation hole, basement sump etc.)
Determine (t from local conditions
Check .vtth !ocai. Board of healtl4
Che6 FEMA Maps
t
Checkt
pumping records
Check local excavators, installers
Use USGS Data
Describe in your own words how you established the High Groundwater Elevation. (Must be completed)
li• Stk S��(�eJ( coin;, CD^ -V� v�ee sees et�rct+.�
G'"f-`^ oi' s�, a Lowu, c✓t?c.? C4 -.-f Cttt d/r)
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o4/15/97) P.q. 10 of 10
TOWN OF
SYST:
DATE: S -)_;-c,)
�
SYSTEM OWNER & ADDRESS
,Jf"" sov"
RECEIVED
MAY 2 5 2005
SYSTEM LOCA'IWX L
(example: left front of house)
fay �� 0� 6-k-s-c-
DATEOFPUMTING:<-X�-o-S
QUANTITY PUMPED :_4,,C 0 GAL ONS
CESSPOOL: NO YES EPTIC TANK: NO YES
NATURE OF SERVICE: ROUTINE EMERGENCY
OBSERVATIONS:
GOOD CONDITION
HEAVY GREASE
ROOTS
EXCESSIVE SOLIDS
SOLIDS CARRYOVER
FULL TO COVER
BAFFLES IN PLACE
LEACHFIELD RUNBACK
FLOODED
OTHER (EXPLAIN)
SYSTEM PUMPED BY: Bateson Enterprises, Inc.
COMMENTS:
CONTENTS TRANSFERRED To: G.L.S.DVI/ Lowell Waste
MAP SKETCH ADDENDUM
Borrower/Client Bruce & Kimberli,e Sachs
Property Addrees 770 Forest Street
City North Andover _ County Essex _ State �MA zlpCode 01845
Lender Andover Savings Bank
LOCATION MAP [*SUBJECT PROPERTY)
8
01
♦ s
s '♦ 0
'��" ••"�� BOARD OF HEALTH
S$
"`""5� NORTH ANDOVER, MASS.
APPLICATION FOR WELL AND PUMP PERMIT
Permit # Date( Z(�; )CICi5
A permit is requested to: drill a well x install a pump
LOCATION: x,770 ;C,,X�ST 57 IV. 4',4UDdVcr�< Lot # 43
Owner -&ucc- Address SAME Tel
Well Contrctr C. M. Rollins Co., Inc.Add. Boxford, MA —Tel 508-887-2320
Pump Contrctr Same Add. Tei
WELLS (To be completed at time of pump test.)
Type of well Drilled Use
Domestic
Diameter
of well 6"
Size
of casing
6"
Depth of
bed, rock 38'
Depth
casing into
bedrock 28'
Seal been tested? Yes ( x ) No (_)
Depth of well 505'
Date of test
Water -bearing rock
Depth to water 51' Delivers 3j GPM for
(how long?)
Drawdown feet after pumping hours at GPM
Date of completion 9-23-92
Signat e of W-eil dontractor
PUMPS (To be filled in before installation.)
Name & size of pump G'V�? P. I ddupld Sub T.5r~' _. j, PUO Type '-' `� "Submersibl
Size of tank F0844Gal.
Pump delivers -77 GPM
Pipe used in well: Cast iron
Sleeve used to protect pipe?
(_) Galvanized (_) Plastic (k -A )
Yes (_) No (fix) Type well seal
Date 9-25-93 L14� /h •0-1'����
Signatu a of pump in taller
**********************************************************************
Date water analysis report submitted to Board of Health
Plumbing inspector Wiring inspector
NUMBER FEE
0 THE COMMONWEALTH OF MASSACHUSETTS
$25.00
..TOWN..---... of ------ MORT.R.-MMVER ------------------- -------------
This is to Certify that ............. Charles Rollins Company
...................................................... . ...... .........................................
NAME
129 Depot Road, Boxford, MA 01921
........................... Depot Roads ........................ . .............................................................................................
ADDRESS
IS HEREBY GRANTED A LICENSE
For ......... We.Ll ... Drzill.ing ... Permit-for—J.7.0 ... F.areat ... S.t-reet ................................
............................................................................... ...........................................................................................
............................................................................................................................................................................
............................................................................................................................................................................
This license is granted in conformity with the Statutes a4,�-
expires ------Wgijaances relating thereto, and
December 31 1993
................................., ........................... _.0 ess sooner spended o'mrevoked.
----------
... ..... .........
. ..... . -------- . ...... ....
Se"
20, 93
..................p...................................... 19 ------- ......-•----••--------- --- -------
FORM 433 HOBBS & WARREN, INC.
rno
WELL DATABASE
ADDRESS:
AGE OF WELL: `r WELL DRILLER:
WELL PERNIIT L4 WELL LOCATION 1 D D
._ WELL PERMIT DATE: DEPTH 0 WELL:
TYPE OF WELL: a.. DRILLED b. DUG c. UNKNOWN
TYPE OF WATER BEARING ROCK:
s'
WATER ANALYSIS DATE. HIGH MANGANESE: Y
HIGH IRON: Y N OTHER CONTAMIlVANTS: Y N
J
WELL DATABASE'
ADDRESS: ?o ��
AGE OF WELL: u�
WELL PERMIT,',-: l 1 W
WELL PERMIT DATE: — 1 �`� 7
TYPE OF WELL: a.. DRILLE "
TYPE OF WATER BEARING ROCK:
DRILLER: W
LOCATION:
V0 WELL:
b. DUG"`" c. UNY- OWN
N
WATER ANALYSIS DATE: HIGH MANGANESE: Y N
HIGH IRON: Y N OTHER CONTAN vNiT� AINTS: Y N
TOWN OF tj�
SYSTEM. PI
DATE: ry
SYSTEM OWNER & ADDRESS
G RECORD IRecetvED
SYSTEM LOCATION
(example: left front of house)
(e
mi OL) S -'c
DATE OF PUMPING-
QUANTITY PUMPED
MAY 31 2005
TOWN OF NORTH ANDOVER
HEALTH DEPARTMENT
CESSPOOL: NO YES SEPTIC TANK: NO YES
NATURE OF SERVICE: ROUTINE EMERGENCY
OBSERVATIONS:
GOOD CONDITION
HEAVY GREASE
ROOTS
EXCESSIVE SOLIDS
SOLIDS CARRYOVER
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
GALLONS
%✓ CJ
%a PRi4 '7f
-is------ ( �
1
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3 0— TAP,I K { a;
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10
t� rNW0?,MON ARe-4 - l D 0 l�t
AF�op�pTiON 5FD Pt --AN
om� HOLE
i
t
PERC. HOL-E
r -f
7I LL
I,
I
Julius Kay, M.D., Chairman
R. Q; orge Caron
Fdtvard J. Scanlon
Mr. Paul Pappalardo
531 Forest St.
No .Andover, Mass.
Dear Sir:
BOARD OF HEALTH
NORTH ANDOVER
MASSACHUSETTS
01845
March 85 1978
Lot 2 Forest St.
Our records indicate that no final inspection was
made of your septic system by the inspector of this Board.
^40.
o9go +
9SSRCHUSEt
TEL. 682-6400
It is requested that an excavation of the distribution
box be made for an inspection and approval by our inspector before
May 30, 1978. Please notify this office when you are ready for
said inspection.
No occupancy permit, which is required by law, can
be issued until we have made this inspection.
jk;mj
I
Very truly yours,
Julius Kay, M.D.
Chairman
Julius Kay, M.D., Chairman
R..G�orge Caron
Edward J. Scanlon
Mr. Paul Pappalardo
531 Forest St.
No . Andover, Mass.
Dear Sir:
BOARD OF HEALTH
NORTHANDOVER
MASSACHUSETTS
01845
March 8, 1978
Lot 2 Forest St.
Our records indicate that no final inspection was
made of your septic system by the inspector of this Board.
30etf�o,'4,
o
o
o�,
S
�SSACH05Et
TEL 682-6400
It is requested that an excavation of the distribution
box be made for an inspection and approval by our.inspector before
May 30, 1978. Please notify this office when you are ready for
said inspection.
No occupancy permit, which is required by law, can
be issued until we have made this inspection.
jk;mj
;f
4
Very truly yours,
Julius Kay, M.D.
Chai r,-nan
,C\- Commonwealth of Massachusetts
City/Town of RECEIVED
System Pumping Record
Form 4 JUN 2 5 2007
DEP has provided this form for use by local Boards of H+R'Vj4r-,'%has; ',i)'Ued, but the
information must be substantially the same as that provid "asiltUrtl S-f6rm, 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-
VQ
eyVISI
reiom
1. System L�
City/Town (� State
2. System Owner: V
Name
(if different from location)
City/Town
Code
Stateg `� 9 ! �� e
TelephoneNumber
B. Pumping Record
1. Date of Pumping ^ " 2. Quantity
p g DatePumped:
Gallons
3. Type of system: ❑ Cesspool(s) Septic Tank ❑ Tight Tank
Other (describe):
4. Effluent Tee Filter present? ❑ Yes No If yes, was it cleaned? ❑ Yes ❑ No
5. Condition of System:
Company6. System Purqped-By:
Name
7. Location
Vehicle License Number
Date
t5form4.doc• 06/03 System Pumping Record • Page 1 of 1
0
Commonwealth of Massachusetts
City/Town of
System Pining Record
Form 4
DEP has provided this form for use by local Boards of Health.
_\ \ \\J,
t the
information must be, substantially the same as that provided here. Before using this form, check with your
local Board of Health tQ determine the form they use. The System Pumping Record must be submitted to
the local Board of Health or-oMer approving authority.
A. Facility Information
1. System Location: Left side of house, Right side of hous Left fronto ous , Right front of house,
Left rear of house, Right rear of house. Left rear of building. Rlg rear of building.
Address
Sf
City/Town State Zip Code
2. System Owner: ^ ,�
Name
Address (if different from location)
Cityrr wn State Zip ode
Telephone Number
B. Pumping Record
1. Date of Pumping Date 2- Quantity Pumped: Gallons
3. Type of system: ❑ Cesspool(s) Septic Tank ❑ Tight Tank
❑ Other (describe):
4. Effluent Tee Filter present? ❑ Yes No If yes, was it cleaned? ❑ Yes ❑ No
5. Condition of System:
6. System Pumped By:
Neil Bateson
Name
Bateson Enterprises Inc
Company
7. Location here contents were disposed:
S 1, Rowell Waste Water
F5821
Vehicle License Number
Date
t5form4.doc• 06/03 System Pumping Record . Page 1 of 1
511 RT. 17K — WALDEN, N.Y. 12586
PHONE: (914) 564-1230
FAX: (914) 64-1232
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L-.epcu
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NEW & USED STEEL PIPE :: WATER WELL CASING
WELDING FITTINGS & FLANGES :: CULVERT PIPE
z GIANT GLASS CO.
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WEYMOUTH 617-331-3550 CANTON 617-575-1150 CHELSEA 617-889-4590 LAWRENCE 508-686-81080
Commonwealth of Massachusetts
City/Town of I Pf�i!!}d
o System Pumping Record
0�.
Form.4 `"� ' 4 N11
-
WN OF NORTH AND VER
DEP has provided this form for use by local Boards of Hea , 6brift�m- u d, but the
information must be substantially the same as that provided here. Before using rm, 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.
t5form4.doc• 06/03
A. Facility Information
1. System Location Left ff nt fo house right front of house, left side of house, right side of house, Left
rear of house, right reaFo-M se, left side of building, right rear of building, under deck.
1 r7 UNom% 14-1-1A(:�✓-moi
City/Town State Zip Code
2. System Owner:
Address (it different from location)
City/Town
B. Pumping Record
1. Date of Pumping
3. Type of system: ❑
❑ Other (describe):
Date
Cesspool(s)
State
q r 1 ...._o3 � � Code
t "t S
Telephone Number
— 2. Quantity Pumped:
❑apt ci Tank
4. Effluent Tee Filter present? ❑ Yes g-9-0-
5. Condition of System:
cv& s j—"'-��
6. System Pumped By:
Neil J. Bateson
Name
Bateson Enterprises Inc.
Company
7. Location where contents were disposed:
G. L.S. ._,,A Lowell AALaste Water
Gallons
❑ Tight Tank
If yes, was it cleaned? ❑ Yes ❑ No
F5821
Vehicle License Number
of auler e
System Pumping Record • Page 1 of 1
DelleChiaie, Pamela
From:
ejslivka@comcast.net
Sent:
Wednesday, September 21, 20112:53 PM
To:
DelleChiaie, Pamela
Subject:
Re: I.R. - 775 Forest Street - MISSING FILE
Hi Pamela,
Thanks for the information. I have an appointment for septic service on Friday, but I know where my access cover is for
the tank, which I think is all they'll need. (fingers crossed) I look forward to hearing from you whenever you can locate
the file.
Thanks again,
Erik Slivka
----- Original Message -----
From: "Pamela DelleChiaie"<pdellech@townofnorthandover.com>
To: "ejslivka@comcast.net" <ejslivka@comcast.net>
Sent: Wednesday, September 21, 20112:45:31 PM
Subject: FW: I.R. - 775 Forest Street - MISSING FILE
Dear Mr. Slivka,
I have been unable to locate a physical (hard copy) Health Department file for the address at 775 Forest Street. Therefore,
I have sent an email through the office to see if perhaps someone has pulled it for another purpose. I will let you know as
soon as I do. Thank you.
Reference: 339-645-6790
Best Regards,
Pamela DelleChiaie
Departmental Assistant I Community Development I Health Department Town of North Andover 1600 Osgood Street
Bldg 20 1 Suite 2-36 North Andover, MA 01845
( Office - 978-688-9540
2 Fax - 978-688-8476
Email - pdellechiaie@townofnorthandover.com
; Website http://v<,ww.to A nofnorthandover.com/Pages/index
"We can never see the path of our life if we are too busy focusing on the pebbles under our feet."—Anonymous
North Andover Board of Assessors Public Access
f NORTH 7
O ••NO � .VO
t
♦ i #
SACMUSE
Click Seal To Retum
Search for Parcels
Search for Sales
Summary
Residence
Detached Structure
Condo
Commercial
Page 1 of 1
roperty Record Card
Tl... --I TT\ .�%I All ne T nnnl nnnn n —1—.. i'a _ -T - ,
Location: 775 FOREST STREET
Owner Name: SILVKA, ERIK, J.
SILVKA, DEBORAH, A
Owner Address: 775 FOREST STREET
City: NORTH ANDOVER State: MA Zip: 01845
Neighborhood: 6 - 6 Land Area: 1.04 acres
Use Code: 101-SNGL-FAM-RES Total Finished Area: 2808 sqft
ASSESSMENTS
CURRENT YEAR
PREVIOUS YEAR
Total Value:
526,900
550,000
Building Value:
319,700
342,800
Land Value:
207,200
207,200
Market Land Value:
207,200
Chanter Land Value:
http://csc-ma.us/PROPAPP/display.do?linkld=1707605&town=NandoverPubAcc 9/21/2011
�L\ Commonwealth of Massachusetts
City/Town of
System Pumping Record NORTH ANDOVER
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 Pure .
the local Board of Health or other approving authority within 14 days f m the p q
accordance with 310 CMR 15.351.
Important:
When filling out
forms on the
computer, use
only the tab key
to move your
Cursor • do not
use the return
key
A. Facility Information
1, System Location:
jAjdddre�sssss
2 System Owner
SIiV K- -
Name
Address (if different from location)
Cityrrown — - -
B. Pumping Record
1 Date of Pumping 2
Dale
3. Type of system: ❑ Cesspool(s)
❑ Other (describe)
4 Effluent Tee Filter present? ❑ Yes 1D No
5. Condition of System: � r
"i
6. System Pumped By:
_ 1�'6 _ - -
Name
Company
OCT
TOWN OF NORTH ANDOVER
HEALTH DEPARTMENT
Mei Zip Code
State ~r Zip Code
Telephone Number
— 2 Quantity Pumped- / — -
Gallons
ieptic Tank ❑ Tight Tank ❑ Grease Trap
If yes. was it cleaned? ❑ Yes A
Vehicle License. Number
7. Location where contents were disposed G•L•S.D
North And,,
Signature of Hauler Date
Stgnature of Recewing Faaiity- Dale
15form4.doc• 03106 System Pumping Record • Page i or 7