HomeMy WebLinkAboutMiscellaneous - 814 OSGOOD STREET 4/30/2018N
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Town of North Andover, Massachusetts Form No. 1
NORTH BOARD OF HEALTH C:��0
OF 9 —7
,t `ED /6460
L
\AoFwoP ^" APPLICATION FOR SITE TESTING/INSPECTION
Applic
Site Lc
Engine
Test/Irispecucan vale ansa i Iffle
CHAIRMAN, BOARD OF HEALTH
Fee Test No. L7 '
S.S. Permit No. D.W.C. No. C.C. Date Plbg. Permit No.
Town of North Andover, Massachusetts Form No. 1
NORTH BOARD OF HEALTH
X11" 16 6
19
o
J°R °° w°• ''0' APPLICATION FOR SITE TESTING/INSPECTION
9 AORATED PPP\ �5
�SSACHUS��
Applicant
NAME ADDRESS TELEPHONE
Site Location
Engineer
NAME ADDRESS 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.
• • r r
_ � �OunEzy �iofe�.
TOW BOARDOF HA���
k; -c- C,4� f �
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16dn
Jvvl�
N TH 978-688-9540
ANDOVER, MA 01845
APPLICATION FOR SOIL TESTS
ra
DATE: I -' o % ' MAP & PARCEL:
LOCATION OF SOIL TESTS:
�'— ,- F 9,,4A—TEL. NO.: Cr
OWNER: �f�� ti t - 'Cd
V
ADDRESS:
„i
ENGINEER: ` �t'� �'��fn_- r�c� TEL.NO.: �� `'� � �,r_- `7c,
CERTIFIED SOIL EVALUATOR:
Intended Use of Land: Residential Subdivision Single Family Home
Is This:
Repair Testing:
In the Lake Cochichewick Watershed?
Undeveloped lot testing:
Yes at; No
THE FOLLOWING MUST BE INCLUDED WITH THIS FORM
Commercial
1. Proof of land ownership (Tax bill, or letter from owner permitting test)
2. Plot plan & Location of Testing
3. Fee of $275.00 per lot for new construction. This covers the minimum two deep holes and
two percolation tests required for each disposal area. Fee of $75.00 per lot for repairs or upgrades.
GENERAL INFORMATION
1. Only Certified Soil Evaluators may perform deep hole inspections.
2. Only Mass. Registered Sanitarians and Professional Engineers can design septic plans.
3. At least two deep holes and two percolation—tests—are—required for each septic system disposal area.
4. Repairs require at least two deep holes I, at the discretion of the
BOH representative.
5. Full payment will be required for all adl t,' 's of testing.
6. Within 45 days of testing, a scaled plan ! ?ll be submitted to the, oard
of Health showing the location of all to
7. Within 60 daysg of testing soil evaluation
i
Please
N.A. Conservation Commission Approval *\ �—
Date Received: . Check Amount: Check Date:
B14osgo"�S �7' -Pr6B,W --
DAVID FLEMING & ASSOCIATES
LAND SURVWYORS
38 POND STREET FAX
(6 17) 436-0136 STONEHAM, MASS. (W) 279-0725
/.5
Jz- y / W 0,-4,c ,z sk,C't
MORTGAGE INSPEC77ON PLAN
This plan was not done with an Instrumentonly.
and /s to be used for mortgage purpmens y
DATE: 10-3-99 SCALE. • 1"= 30'
I certify that this dwelling Is located approximately os shown and conformed to
the zoning bylaws of the Town of No Andover MA
when constructed and is not located in a flood plain hazard zone.
�,E2TIFi� � tvEST P ivc
Deed & Plan Reference
Essex County Reg. of Deeds
BOOK 808 / PAGE 93
N/r
SMI TN
N/F
SM/ TH
OSCOOD STREET
I.
BOARD OF HEALTH
NORTH ANDOVER, MA 01845
978-688-9540
APPLICATION FOR SOIL TESTS
DATE: '�2 MAP & PARCEL:
LOCATION OF SOIL TESTS:
OWNER: � fe��frc�s5s�+ Ali M-kTEL. NO.:
ADDRESS: % 14
ENGINEER: TEL. NO.: It,
CERTIFIED SOIL EVALUATOR:
Intended Use of Land: Residential Subdivision Single Family Home Commercial
Is This:
Repair Testing: Undeveloped lot testing:
In the Lake Cochichewick Watershed? Yes to No
THE FOLLOWING MUST BE INCLUDED WITH THIS FORM
1. Proof of land ownership (Tax bill, or letter from owner permitting test)
2. Plot plan & Location of Testing
3. Fee of $275.00 per lot for new construction. This covers the minimum two deep holes and
two percolation tests required for each disposal area. Fee of $75.00 per lot for repairs or uQ rg ades.
GENERAL INFORMATION
1. Only Certified Soil Evaluators may perform deep hole inspections.
2. Only Mass. Registered Sanitarians and Professional Engineers can design septic plans.
3. At least two deep holes and two percolation tests are required for each septic system disposal area.
4. Repairs require at least two deep holes and at least one percolation test, at the discretion of the
BOH representative.
5. Full payment will be required for all additional tests within two weeks of testing.
6. Within 45 days of testing, a scaled plan (no smaller than 1"-100') shall be submitted to tl- oard
of Health showing the location of all tests (including aborted tests). -
7. Within 60 days of testing soil evaluation forms shall be submitted.
Please Do Not Write Below This Line
N.A. Conservation Commission Approval:
Date Received: Check Amount: Check Date:
NEW ENGLAND ENGINEERING SERVICES
INC
April 10, 1997
Blair Roberts
814 Osgood Street
North Andover, MA 01845
RE: Title V Report at 814 Osgood Street, North Andover, MA 01845
Dear Sir:
Enclosed is your copy of the Title V Report. Your systemap ssed the inspection. A copy of the report has
been mailed to the North Andover Board of Health for their records.
If there are any questions regarding the report please feel free to call.
Yours truly,
Jamin C. Osgood Jr., E.I.T.
resident
33 INALKER RD. - SUITE 22 - NORTH ANDOVER. MA 01845 - (508) 686-1768
Wllllam F. Weld
Governor
Argeo Paul Cellueel
LL C'ummor
Commonwealth of Massachusetts
Executive Office of Environmental Affairs
Department of
Environmental Protection
Trudy Coxe
wast"
David B. Struhs
Commbsloner
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION
Property Address8 / Y S G �o D 5 i _ ,v�. /{ iv p �R Address of Owner.
Date of Inspection: 312 (-/ 9 7 (If different)
Name of Inspector. Benjamin C. Osgood Jr.
Company Name, Address and Telephone Number. New England Engineering Services, Inc.
33 Walker Road, North Andover, Ma 01845
CERTIFICATION STATEMENT Tel. 508-686-1768 Fax. 508-685-1099
I certify that I have personally inspected the sewage disposal system at this address and that the information reported below is true, accurate
and complete as of the time of inspection. The inspection was performed based on my training and experience in the proper function and
maintenance of on-site sewage disposal systems. The system:
—lL. Passes
Conditionally passes
Needs Further Evaluation By the Local Approving Authority
Fails
Inspector's Signature:8 / eDate:
The System Inspector shall submit a copy of this inspection report to the Approving Authority within thirty (30) days of completing this
report to the appropriate regional office of the Department of Environmental Protection. 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
The original should be sent to the system owner and copies sent to the buyer, if applicable and the approving authority.
INSPECTION SUMMARY:
Check A, B, C, or D:
Al SYSTEM PASSES:
I have not found any information which indicates that the system violates any of the failure criteria as defined in 310 CMR 15.303.
Any failure criteria not evaluated are indicated below.
Bl SYSTEM CONDITIONALLY PASSES:
One or more system components need to be replaced or repaired. The system, upon completion of the replacement or repair, passes
inspection.
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, cracked, structurally unsound, shows substantial infiltration or e:flitration,.or tank failure is
imminent. The system will pass inspection if the existing septic tank is replaced with aponforming septic tank as approved
by the Board of Health.
(revised 11/03/95)
One Winter Street • Boston, Massachusetts 02108 a FAX (617) 556-1049 • Telephone (617) 292-5500
w
iet Primed on Recycled Paper
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION (continued)
Property Address /`l OS &v,9 p 5T /V, 19.I O C �!(
Owner.
%jln i r
Date of Inspection:
31z(-197
B] SYSTEM CONDITIONALLY PASSES (continued)
Sewage backup or breakout or high static water level observed in the distribution box is due to broken or obstructed pipe(s)
or due to a broken, settled or uneven distribution box. The system will pass inspection if (with approval of the Board of
Health):
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
inspection if (with approval of the Board of Health):
broken pipe(s) are replaced
obstruction is removed
C] FURTHER EVALUATION IS REQUIRED BY THE BOARD OF HEALTH:
Conditions exist which require further evaluation by the Board of Health in order to determine if the system is failing to protect the
public health, safety and the environment.
1) SYSTEM WILL PASS UNLESS BOARD OF HEALTH DETERMINES THAT 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 PROTECT THE PUBLIC HEALTH AND
SAFETY AND THE ENVIRONMENT:
The system has a septic tank and soil absorption system and 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 is within a Zone I of a public water supply well.
The system has a septic tank and soil absorption system and is within 50 feet of a private water supply well.
The system has a septic tank and soil absorption system and 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.
9) OTHER
(revised 11/03/95)
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION (continued)
Property Addreaw g/y
O c� co s,rK r T /V, /�+•v o u v c',e
Owner. , r3l�cr 2.� %jer^ (
Date of Inspection: lS
D) SYSTEM FAILS:
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.
NBackup of sewage into facility or system component due to an overloaded or clogged SAS or cesspool.
Q[ Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or
cesspool.
/V Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool.
Liquid depth in cesspool is less than 6" below invert or available volume is less than 1/2 day flow.
Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s).
Number of times pumped
& Any portion of the Soil Absorption System, cesspool or privy is below the high groundwater elevation.
Any portion of a cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply.
AZ Any portion of a cesspool or privy is within a Zone I of a public well.
/L Any portion of a cesspool or privy is within 50 feet of a private water supply well.
Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water supply well with no
acceptable water quality analysis. If the well has been analyzed to be acceptable, attach copy of well water analysis for
coliform bacteria, volatile organic compounds, ammonia nitrogen and nitrate nitrogen.
El LARGE SYSTEM FAILS:
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 pc
ubli
health and safety and the environment because one or more of the following conditions exist:
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)
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.
(revised 11/03/95)
3
• SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART B
CHECKLIST
Property Address: 8/ +{ 0_5 Cr c U p 5% IV_ /9 N D O V C Q
Owner. / H i 2 /Z v +3 r 2 TS
Date of Inspection:
3126% R7
Check if the following have been done:
Pumping information was requested of the owner, occupant, and Board of Health.
V'rNone of the system components have been pumped for at least two weeks and the system has been receiving normal flow rates
during that period. Large volumes of water have not been introduced into the system recently or as part of this inspection.
Al As built plans have been obtained and examined. Note if they are not available with N/A
VThe facility or dwelling was inspected for signs of sewage back-up.
VThe system does not receive non -sanitary or industrial waste flow
VThe site was inspected for signs of breakout.
All system components, excluding the Soil Absorption System, have been located on the site.
The septic tank manholes were uncovered, opened, and the interior of the septic tank was inspected for condition of baffles or
tees, material of construction, dimensions, depth of liquid, depth of sludge, depth of scum.
The size and location of the Soil Absorption System on the site has been determined based on existing information or
approximated by non -intrusive methods.
The facility owner (and occupants, if different from owner) were provided with information on the proper maintenance of Sub -
Surface Disposal System.
(revised 11/03/95) 4
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION
Property Address: $/ y 0 S Cr U rip
Owner -15;-r- ^/, is N D O V E2
. 131q f (' /�o � c r t'S
Date of Inspection
3%,qqr7
FLOW CONDITIONS
RESIDENTIAL;
Design flow gallons
Number of bedrooms:
Number of current residents:
Garbage grinder (yes or no):_
Laundry connected to system (yes or no):
Seasonal use (yes or no): IV
Water meter readings, if available:
Last date of occupancy: Gv,- ret l
COMMERCIAL/INDUSTRLA -
Type of establishment:
Design flow:---gallons/day
Grease trap present: (yes or no)_
Industrial Waste Holding Tank present: (yes or no)_
Non -sanitary waste discharged to the Title 5 system: (yea or no)
Water meter readings, if available:_
Last date of occupancy:
OTHER: (Describe)
Last date of occupancy:
GENERAL INFORMATION
PUMPING RECORDS and source of information:
MRS
System pumped as part of inspection: (yes or no)_
If yes, volume pumped:I S D O ¢allons
Reason for pumping: ro I n c n e ct ( f
TYPE QF SYSTEM
Septic t uWdistribution box/soil absorption system
Single cesspool
Overflow cesspool
Privy
Shared system (yes or no) (if yes, attach previous inspection records, if any)
Other (explain)
APPROXIMATE AGE of all components, date installed (if known) and source of information: /9 Fj 3 e< C—
O cr— t/ C %—
Sewage odorS detected when arriving at the site: (yes or no) /V -
(revised 11/03/95)
Property Address:
Owner.
Date of Inspection:
SEPTIC TANK_
(locate on site plan)
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
�lY Os 6-QC)b sT_
3)Z(.19 -7
u
Depth below grade::
Material of construction: Zconcrete _metal _FRP —other(explain)
Dimensions: !TUU [r ff L 60 IV
Sludge depth: !o 11
Distance from top of sludge to bottom of outlet tee or baffle: ,
.Scum thickness: f c
Distance from top of scum to top of outlet tee or baffler
Distance from bottom of scum to bottom of outlet tee or baffle: 2 /
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.) TnA/ 14 w i}S A) EY 3 TAN X (/u Croon
eJAJO( F26 M
GREASE TRAP:_
(locate on site plan)
Depth below grade:
Material of construction: _concrete _metal _FRP —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:
Comments:
(recommendation for pumping, condition of inlet and outlet tees or baffles, depth of liquid level in relation to outlet invert, structural integrity,
evidence of leakage, etc.)
(revised 11/03/95)
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Property Address: $J y O s T, N. # N D 0 \) C 2
Owner.
Date of Inspection:
TIGHT OR HOLDING TANK:_
(locate on site plan)
Depth below grade:
Material of construction: _concrete _metal _FRP —other(explain)
Dimensions:
Capacity: eallons
Design flow: ¢allons/day
Alarm level:
Comments:
(condition of inlet tee, condition of alarm and float switches, etc.)
DISTRIBUTION BOX:
(locate on site plan)
Depth of liquid level above outlet invert:
Comments:
(note if level and distribution is equal, evidence of solids
19nK /n GlbucX lv.nJ
PUMP CHAMBER_
(locate on site plan)
Pumps in working order:(yes or no)
evidence of leakage into/p or out of box, etc.)
Comments:
(note condition of pump chamber, condition of pumps and appurtenances, etc.)
(revised 11/03/95) 7
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Property Addreax / y (�s c� t. �v
Owner. v ,
Date of Impection:
SOIL ABSORPTION SYSTEM (SAS):_
(locate on ate plan, if possible; excavation not required, but may be approximated by non -intrusive methods)
If not determined to be present, explain:
Type:
leaching pits, number:_
leaching chambers, number:_
leaching galleries, number:
leaching trenches, number,length: n
leaching fields, number, dimensions: / c lcSc
overflow cesspool, number:
Comments: (note condition of soil, s' of hydraulic failure, level of pondin condition of vegetation etc.
a -c a o f f,� c Q_ /0 t[-5 o"
0 e�_
CESSPOOLS: _
(locate on site plan)
Number and configuration:
Depth -top of liquid to inlet invert:
Depth of solids layer-
Depth
ayerDepth of scum layer:
Dimensions of cesspool:
Materials of construction:
Indication of groundwater:
inflow (cesspool must be pumped as part of inspection)
Comments: (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.)
PRIVY.• _
(locate on site plan)
Materials of construction: Dimensions:
Depth of solids:
Comments: (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.)
(revised 11/03/95)
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
Cj
SYSTEM INFORMATION (oontinued)
Property Address: U/ Y
Owner.
Date of Lugmetion:
3%z��9y
SI;ETCH OF SEWAGE DISPOSAL SYSTEM:
include ties to at least two permanent references landmarks or benchmarks
locate all wells within 100'
DEPTH TO GROUNDWATER
Depth to groundwater. feet
method of determination or approximation: /'�n �� oG e- v
P.s
(revised 11/03/95) 9
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
► PART C
SYSTEM INFORMATION (continued)
Property Address 0/,y U s nv,Q S (,
0' R C� V e_—
Date of
Inspection:
3f Z��97
SIWMH OF SEWAGE DISPOSAL SYSTEM: '
include fiat to at leert two permanent references landmarks or benchmarks
locate all wells within 100'
DEPTH TO GROUNDWATER
Depth to groundwater.._feet
method of determination or approximation: 14,
(revised 11/03/95)
OS�rOC�t� .S'r 2Et;T
e
gv�
—
9
SUBSURFACE SEWAGE DISPOSALS
PART C YSTEM INSPECTION FORM
j SYSTEM INFORMATION (continued)
�
Property
e �' Address U/Y CJs 0OC9 Sf s � (J
81a r-
I Date of Inspection; i tv b e r fs / V U
SKETCH OF SEWAGE DISPOSAL SYSTEM: '
include ties to htleast two perma8ent references landmarks or benchmarks
locate all wells within 100'
DEPTH TO GROUNDWATER S o o t ST R E 1=
Depth to groundwater. -feet
method of determination or approximation: U.5 S,
(revised 11/03/95)
9
I
a
FORM - U - LOT RELEASE FORM
INSTRUCTIONS: ri`his form is used to verify that all -necessary approval / permits from
Boards and Departments having jurisdiction have been obtained. This does not relieve the
applicant and or landowner from compliance with any applicable requirements.
APPLICANT
ASSESSORS MAP NUMBER
SUBDIVISION
PHONE
LOT NUMBER
LOT NUMBER
STREET 6e7�61> STREET NUMBER ?/Vy
.......................................................................... ■
OFFICIAL USE ONLY
lagoon...................................................0..04...X..........
RECOIVA ENDATIONS OF TOWN AGENTS
...........(....(.........................................../..(...............
DATE APPROVED
CONSERVATION ADMINISTRATOR
DATE REJECTED
COMMENTS
FOOD INSPECTOR - HEALTH_0 7
/ /
�( SEPTIC INSPECTOR - HEALTH
DATE APPROVED
DATE REJECTED
DATE APPROVED
DATE REJECTED
DATE APPROVED
DATE REJECTED 7 / -/L/ ") (r, )
sF k'
i e- V Lit 1 U ( _ e_ .? 11/ �� v), ; ..Y
PUBLIC WORKS — SEWER / WATER CONNECTIONS
DRIVEWAY PERMIT
FUZE DEPARTMENT
CONffVfENTS
RECEIVED BY BUILDING INSPECTOR
DATE APPROVED
DATE REJECTED
DAVID FLEMING & ASSOCL4TES
LAND SDRYNYOAS
38 POND STREET 11"
(6») 4.a-otj6 STONEHAM, MAW. (e17) 279-0725
<30—/5= 30 6Ef
&4.er-s�,ek
MORTGAGE INSPECTION PLAN
This plan was not done with an instrument
survey
and is to be used for mortgage purposes only.
DATE: 10-3-99 SCALE. 1 "= 30'
I certify that this dwelling is located approximately as shown and conformed to
the zoning bylaws of the Town of ":o andomr MA
when constructed and is not located in a flood plain hazard zone
C,I11�D ' tdFST P �•�•C
Deed & Plan Reference
Essex County Reg. of Deeds
BOOK 808 /PAGE 93 N/r
SM17H
N/F
SMI TH
OSOOOD STREET
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Property Addretm
..!�
fQYl tbuc� s SS
Owner. L;er
Date of Inspection:
�Up
3%z�/q7
r.
i
SKETCH OF SEWAGE DISPOSAL SYSTEM:
include tid to atleast two permanent references landmark, or benchmark,
locate all wells within 100'
1-�c,usc
p,
DEPTH TO GROUNDWATER D S o o i� .ST
Depth to vaundwatsr. -feet
method of determination or approximation:
(revised 11/03/95)
9
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DATE TIME AM
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FROM ARE CODE
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4 O E SIGNED
PHONED ❑ CALL RETURNED ❑ WANTS TO WILLCALL ❑ WASIN ❑ URGENT ❑
BACK
Town of North Andover, Massachusetts Form No. 1
NORTH BOARD OF HEALTH
0* LEo b16tiO0� 19
04 0 w • '0 APPLICATION FOR SITE TESTING/INSPECTION
�9SsaC US���y
ApplicantC11-ain labs QlV)
NAME ADDRESS TELEPHONE
Site Locations
Engineer
Test/Inspection Date and Time
Fee
-� S
CHAIRMAN, BOARD OF HEALTH
Test No,
S.S. Permit No. D.W.C. No. C.C. Date Plbg. Permit No. -) 5CL—
Town of North Andover, Massachusetts
BOARD OF HEALTH
o
\'Li Rp�agreoWaPP,�45 APPLICATION FOR SITE TESTING/INSPECTION
Form No. 1
19
Applicant
NAME ADDRESS TELEPHONE
Site Location
Engineer
NAME ADDRESS TELEPHONE
Test/Inspection Date and Time
Fe
CHAIRMAN, BOARD OF HEALTH
Test No.
S.S. Permit No. D.W.C. No. C.C. Date Plbg. Permit No.
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SEPTIC SYSTEM INSPECTION FORM
ADDRESS j'{ '66L
DATE
DATE INSPECTED
PROPERLY FUNCTIONING? Y N
WEATHER CONDITIONS
COMMENTS:
DYE TEST PERFORMED? Y N
DATE?
SKETCH:
DATE OF SERVICE
--S
SOUCU's
SEWER SERVICE INC.
COMPLETE SEWER -SEPTIC
SERVICE
INVOPpe_��3 I
CUER NAME
(508) 683-5709
Methuen, MA
(508)937-9889
Dracut, MA
(603) em, NH 39
Salem, NH
(508) 470-1400
Andover, MA
(508) 851-8839
Tewksbury, MA
( Bill rica, M 33
Billerica, MA
BILLING ADD ss
! C
CITY
r
ellJOB
STATE
ZIP
PHONE:
q �j
/ c•o
ADDRESS IF DIFFERENT THAN BILLING ADDRESS
ADDRESS
STATE
ZIP
DESCRIPTION OF WORK
Of0
VACUUM PUMP
Lt"S'EPTIC TANK GALS. DO ❑ CESSPOOL ❑ OVERALL SYSTEM
❑ DRYWELL ❑ BASEMENT ❑ FAILED SYSTEM
DRAIN LINES CLEANED
❑ MAIN LINE: FT.
❑ BATHTUB:
FT.
❑ KITCHEN SINK: FT.
[]TOILET BOWL:
FT.
❑ FLOOR DRAIN: FT
❑ VANITY:
FT.
❑ OTHER LINE:
FT.
WORK ORDER AUTHORIZATION
USE ONLY ON CHARGES
GUARANTEES
PARTS
LABOR
OTHER
OTHER
INVOICE AMOUNTS
I hereby authorize you to perform the above described services and
1 agree to pay the amounts indicated to the right. I hereby certify
that I am duly authorized to order and approve the work requested.
Interest Q 1.5 per month 18% per annum on past due balances.
SIGNATURE TITLE
$
,
l j
TERMS OF PAYMENT TYPE OF SERVICE
TAX EXEMPT
# TAX
TOTAL
CASH ❑ RES/COMM ❑
INDUSTRIAL ❑
CHECK ❑ CHARGE ❑ PLUMBING 0
$11V 00
JOB COMPLETION
DATE
This is to acknowledge completion of the above described work which has been d ie to 4comgkte satisfaction.
CUSTOMER SIGNATURE
'S NAME
Address
814 Osgood St,
Lot
Ass'rs
I
Ass'rs
.'S7 do
W
> N
0
Z N
Q W
W
T N
Subd. No.
Plan No. 91
Lot No.
Owner: Arthur S. & Martha J Larson Date
LAND VALUATION
Robbins, Peter W 1260-80 1-275
Area
Rate
Value ¢"
Robbins Peter W & Lucy M9 the 1278-103
Front
W 1 '4par
(°o%Enhancement
Total Area
21,000 sq/ft.
Phys. Depr.
Net Land ValueS ;� 00
BUILDING DESCRIPTION
BUILDING VALUATION
Age No. Stories Assr's Class
Building Reprod. Cost Depr. Cl. Sound Value
Remod. No. Rooms Area
H;
Q
Condition Rent
Area Add't'ns
`
Exterior Description
Interior Description
0
Q
ZQ
O
F-
-�
1 \
:L
Q
Q
O
Ql
Use
Single Dwg.
Double Dwg.
Duplex Dwg.
Apartment
Store Bldg.
Office Bldg.
Factory
Warehouse
Garage
Construction
Wood Frame
Steel Frame
Brick
Brick Veneer
Reinf. Concrete
Con. Block
Mill Const.
Foundations
Concrete
Con. Block
Stone
Brick
Piers
Posts
Exterior Walls
Clapboards
Wood Shingles
Asbestos Shingles
Siding
Face Brick
Common Brick
Con. Block
Stucco
Roof Type
Gable
Hip
Flat
Gambrel
Mansard
Dormers
Roof Covering
Wood ShinglesConcrete
Asphalt Shingles
A.ebestoa Shingles
Slate
Tar & Gravel
Metal
Roll Asphalt
Basement Desc.
None
Part
Full
Cement Floor
Earth Floor
Fin. Rooms
Interior Walls
Plastered
Plaster Bd.
Composition Bd.
Brick
Wood
Floors
Common
Hard Wood
Reinf. Con.
Slab
Lineoleum
Asphalt Tile
Attic Rooms
Number
Walls
Floors
Plumbing
None
No. Baths
No. Toilets
Modem Pl.
Old Style
Heating
Stoves
Hot Air (gray.)
Hot Air (forced)
Steam (1 pipe)
Steam (2 pipe)
HotWater(gravJ
Hot Water (circ.)
Coal Fired
Oil Fired
Gas Fired
Stoker
Miscellaneous
No. Fireplaces
Type Insulation
Tiled Baths
Wood Sash
Metal Sash
COMPUTATIONS
/J�J L�—f//l O
REMARKS
"1
WATERSHED RESIDENTS QUESTIONNAIRE
1. Name C. U Me c0
2. Street Address
3. How many members are in your household?
4. What type of sewage disposal system do you have?
❑ cesspool
septic tank and leaching area ( `tel -Y C_DLDo14 g
❑ connection to municipal sewer
❑ other (describe)
❑ do not know
5. Are the plans (drawings) for your sewage disposal system on file with the Board of Health?
[SK yes ❑ no ❑ do not know
6. How old is your sewage disposal system? d 0-5 years ❑ 6-10 years ❑ 11-20 years
❑ over 20 years ❑ do not know
7. Has your sewage disposal system been rebuilt or repaired?
❑ yes ❑ no ❑ do not know
If yes, approximately how long ago?
years. What was done?
8. How frequently is your sewage disposal system pumped out? Er- annually
❑ every 2-4 years ❑ every 5-10 years ❑ over 10 years ❑ never
{ 9. Have you had any problems with your sewage disposal system? ❑ yes [ono
If yes, what problems?
❑ repeated pump -outs needed
❑ system clogs, backs up, or drains slowly
❑ odors
❑ sewage surfaces through ground
10. How many of each appliance are connected to your sewage disposal system?
washing machine dishwasher garbage disposal
dehumidifier drain sump pump toilet V
roof/pavement drains shower/bathtub
11. Please state the brand and type (liquid or.powder) of detergent you use for:
dishwasher 0-10
clotheswasher
12. Does your property have a lawn? Nyes ❑ no
If yes, approximately what size?
❑ less than 1/4 acre lV 1/4 acre '❑ 1/2 acre ❑ 3/4 acre ❑ 1 acre
❑ more than 1 acre (Specify) acres
13. How often do you fertilize your lawn?
No. of applications per year f
Season(s) of the year
14. Please state the brand and type (liquid or granular) of lawn fertilizer you use:
❑ Check here if your lawn is maintained by a professional landscape contractor.