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Miscellaneous - 826 JOHNSON STREET 4/30/2018 (2)
r Lot & Street Pou Map/Parcel CONSTRUCTION APPROVAL Has plan review fee been paid: YE L NO Plan Approval: Date: - _ _ pproved by Permit# Designer -6E711 -016A) Q5cno Plan Dater-- �- Conditions: Water Supply: Town Well Permit: Well Tests: Chemical Bacteria I Bacteria II Plumbing Sign -Off: Comments: Well Driller: Date Approved Date Approved Sign -off: Form "U" Approval: Approval to Issue< YE NO Date Issued By: Conditions: Final Approval: All Permits Paid? YES NO Well Construction Approval? YES NO Septic System Construction Approval? YES NO Certification? YES NO Other? YES NO Any Variance Needed? YES NO FINAL BOARD OF HEALTH APPROVAL: DATE: APPROVED BY: 0 .+ CONDITIONS: Is the installer licensed? Type of Construction: New Construction: SEPTIC SYSTEM INSTALLATION NO NEW PAI Certified Plot Plan Review YES NO Floor Plan Review YES NO Conditions of Approval from Form U YES NO Issuance of DWC permit: DWC Permit Paid? DWC Permit # 4Q Begin Inspection: Excavation Inspection: Needed: NO NO Installer: YES NO Passed: _ By7-::z. Construction Inspection: Needed: As Built Plan Satisfactory: YES: Approval of Backfill: Date: By: Final Grading Approval: Date: By: Final Construction Approval: Date: By: Certificate of Compliance: Approval: Date: -C-\ Commonwealth of Massachusetts City/Town of System Pumping Record Form 4I DEP has provided this form for use by local Boards of Health. her forxs my,be sed, ut the information must be substantially the same as that provided he . Befft using 11ii� form, heck with your local Board of Health to determine the form they use. The Syst rgCwBIrrggg AMUN t a submitted to the local Board of Health or other approving authority. HEALTH DEPARTMow'r A. Facility Information 1. System Location: Left front of house, right front of hous , side of hous right side of house, Left rear of house, right rear of house, left side of building, right rear of uilding, under deck. City/Town 2. System Owner: Name Address (if different from location) City/Town B. Pumping Record 1. Date of Pumping Date 2. Quantity Pumped: Gallons 3. Type of system: ❑ Cesspool(s) �epticnk ❑ Tight Tank ❑ Other (describe): 4. Effluent Tee Filter present? ❑ Yes No If yes, was it cleaned? ❑ Yes ❑ No State Zip Code St—C( � (�p Code a� Telephone Number 5. Condition )r 4v P\ �, J 6. System Pumped By: Neil J. Bateson Name Bateson Enterprises Inc. Company 7. Lo �here contents were disposed: L.S.D. 1\ Signature F5821 Vehicle License Number Date t5form4.doc• 06/03 System Pumping Record • Page 1 of 1 BUTTERWORTH & O'TOOLE, INC. P.O. BOX 8294 SALEM, MA 01971-8294 TELEPHONE (978) 741-5731 March 23, 2011 ADJUSTERS/APPRAISERS FOR INSURANCE COMPANIES ONLY FORM OF NOTICE OF CASUALTY LOSS TO BUILDING UNDER MASSACHUSETTS GENERAL LAW, CH. 139, SEC. 3B TO: Building Commissioner or Inspector of Buildings ADDRESSES City/Town Hall North Andover, MA 01845 FAX (978) 740-9109 Board or Health or Board of Selectman City/Town Hall North Andover, MA 01845 RE. Insured: Frank M. Gring, Jr. __ i Address: 826 Johnson Street North Andover, MA 018 5 Policy No.: HP1341538 HEA Loss of: February 4, 2011 File No.: 011-0751 Origin: Water damage / ice dam 2a toil OF NORTH ANDOVER Claim has been made involving loss, damage or destruction of the above captioned property, which may either exceed $1,000.00 or cause Mass. Gen Law Chapter 143. Section 6 to be applicable. If any notice under Mass. Gen Law Chapter 139. Sec. 3B is appropriate, please direct it to the attention of the writer below and include a reference to the captioned insured, location, policy number, date of loss and file/claim number. If no reply is received from your office within ten days, we will assume you have no liens of any type against this property and we will recommend to the insuring company that this claim is paid. Thank You, Brad Doherty Adjuster BUTTERWORTH & O'TOOLE, INC. P.O. BOX 8294 SALEM, MA 01971-8294 TELEPHONE (978) 741-5731 March 23, 2011 ADJUSTERS/APPRAISERS FOR INSURANCE COMPANIES ONLY FORM OF NOTICE OF CASUALTY LOSS TO BUILDING UNDER MASSACHUSETTS GENERAL LAW, CH. 139, SEC. 38 FAX (978) 740-9109 TO: Building Commissioner or Board or Health or Inspector of Buildings Board of Selectman ADDRESSES City/Town Hall City/Town Hall North Andover, MA 01845 North Andover, MA 01845 RE. Insured: Frank M. Gring, Jr. Address: 826 Johnson Street North Andover, MA 01845 .P'R N N11Policy No.: HP1341538 F NORTH ANDOVER HEALTH DEPARTMENT Loss of: February 4, 2011 File No.: 011-0751 Origin: Water damage / ice dam Claim has been made involving loss, damage or destruction of the above captioned property, which may either exceed $1,000.00 or cause Mass. Gen Law Chanter 143• Section 6 to be applicable. If any notice under Mass. Gen Law Chapter 139 Sec. 3B is appropriate, please direct it to the attention of the writer below and include a reference to the captioned insured, location, policy number, date of loss and file/claim number. If no reply is received from your office within ten days, we will assume you have no liens of any type against this property and we will recommend to the insuring company that this claim is paid. Thank You, Brad Doherty Adjuster NEW ENGLAND CLAIMS SERVICE. INC. wrandall@newenglandclaims.com Form of Notice of Casualty Loss to Building Under MASS. GEN. LAWS, Ch. 139, Sec 3B To: Building Commissioner or Inspector of Buildings City Hall N Andover, MA 01845 RE: Insured: Frank Gring Jr. Property Address: 826 Johnson Street, N Andover, MA 01845 Cause of Loss/Date: Ice dam Loss of 2/4/2011 File or Claim No: BOSO48865 Claim has been made involving loss, damage or destruction of the above captioned property, which may either exceed $1,000.00 or cause MASSACHUSETTS GENERAL LAWS, CHAPTER 143, SECTION 6, to be applicable. If any notice under MASSACHUSETTS GENERAL LAWS, CHAPTER 139, SECTION 3B is appropriate, please direct it to the attention of the writer and include a reference to the captioned insured, location, policy number, date of loss and claim or file number. Mark Randall Adjuster On this date, I caused copies of this Notice to be sent to the persons named above at the addresses indicated above by First Class Mail. S ignature Date ----Adji 0A11-1 Incorporated 1985 ❑ Reply To , :,r,..n Reply To Mansfield MA 02048 131 Dodge Street, Suite 6 P.O. Box 345 Beverly, MA 01915 TEL. {508} 337-8058 TEL. {978} 927-3000 FAX {508} 339-5835 ;tl„;, 3 L-' FAX {9781927-3002 wrandall@newenglandclaims.com Form of Notice of Casualty Loss to Building Under MASS. GEN. LAWS, Ch. 139, Sec 3B To: Building Commissioner or Inspector of Buildings City Hall N Andover, MA 01845 RE: Insured: Frank Gring Jr. Property Address: 826 Johnson Street, N Andover, MA 01845 Cause of Loss/Date: Ice dam Loss of 2/4/2011 File or Claim No: BOSO48865 Claim has been made involving loss, damage or destruction of the above captioned property, which may either exceed $1,000.00 or cause MASSACHUSETTS GENERAL LAWS, CHAPTER 143, SECTION 6, to be applicable. If any notice under MASSACHUSETTS GENERAL LAWS, CHAPTER 139, SECTION 3B is appropriate, please direct it to the attention of the writer and include a reference to the captioned insured, location, policy number, date of loss and claim or file number. Mark Randall Adjuster On this date, I caused copies of this Notice to be sent to the persons named above at the addresses indicated above by First Class Mail. S ignature Date ----Adji 0A11-1 0 o o 1H vN L) S Y ST E,1,l 1-1 L.vl P I �N C', F�J,'C F 'J & )r,, D DR E SS -,,O-ca *L n FoR5 34)nscjkqj-- lvd 4" loarvell, s Y 51) 1 12, b )F 1-0-ve UI ON W4 RUCTS LEACHED_ 'XCESS!VE SOLIDS FLOOD -l' D SOL.' )S CARRYOVER 0 -HER 'EX "A p! 1. y ------ aln TOWN OF NORTH ANDOVER HEAL'T'H DEPARTMENT 27 CHARLES STREET NORTH ANDOVER, MASSACHUSETTS 01845 Sandra Starr Public Health Director July 17, 2001 Mr. & Mrs. Frank Gring, Jr. 826 Johnson Street North Andover, MA 01845 Re: Septic repair plan for 826 Johnson Street Dear Mr. & Mrs. Gring: Telephone (978) 688-9540 FAX (978) 688-9542 This letter comes to notify you that the proposed septic system plans dated June 21, 2001 designed by New England Engineering Services, Inc. have been approved. Please do not hesitate to call me at 978-688-9540 should you have any questions. Sincerely, Sandra Starr, R.S., C.H.O. Public Health Director Cc: New England Engineering Services File :k�.�.:. Y: • t� . Ste_ .. a : � h:•.+ .. • •. : �. �\� �.:. •.•.:- = : �. . TOWN OF iNORrfH ANDOVER SDYAGE DISPOSALS I- STAL> A-fIOV CERTII=I(ATIOI The uncersismed here,v ceriiv that the Sze%xa2e Disposal System i_ ) const„acted; by located at eat S�H tVS�•.--STrn �` --- was installed in 66dcrtnance with the North And-ov er Board of Huth a-fproved- plan. Svstem Design Permdt = • dated: ;vit an approved design flow of `allons per day The mate: als;used were in con ormarc::vvirh those specined oil the approved- plan; the system was installed in' accordance ,,,.ith the provisions of 3110 CVM 1.5.000, Title 5 and local remulatiors, and the final Qradina aarees substantially ,`ith the approved plan. Ail workis accurateiv represented :�r the As -built has been submitted to the Board e Health. Bed inspection dat'. ! .. - Ens?ineer R:pres•t:::ltive Final inspect -en care:LO -2— E-ngirec. Repress^tat:ve Installer:�� _ �:c. Date: ! �tH Uf Cesium Engineer: Datz . •J• __ _-___ TAN"16 F s �� • i st TOWN OF NORrfH ANDOVER SDvAGE DISPOSAL SYsTupz I_ STALLA'rIO,\i CERTI I�ATIOIN The unce:sivned herei0y certify that the �e age: Disposal S;rsten-1 i: corsuructrd; (Y ) repaired: Y�. by !U - located at ewas installed in confe trance with the NIo th And er Board of die: ith approved plan. Svstem Design Pewit,- , dated_ :vit an approved design low of `aliens per day The mate:als,used were in conformar::L wit`t those specified oh the app'rovea plan-, the system was installed in accordance ,Kith the provisions of 310 CNIR 15-000, Title 5 and 'Local r evilatiors, and the final grading agrees substantially with the approved plan. :til :fork is accurate ti represented ;)r the ;ks-hi!ilt :which has been submitted to the Board ct Health. Bed inspection date- 1Z10 z Final inspecvcn ca[e: J• ( _ Way Installer: ' ` Desiun Engineer; C TANQAM f S r Eneineer R ;�rirsz :1uve j L CD L ,<— EnCireer Represe::tat e Date: _ 1 1- �))�4D_ Date: ! lLd'fC'o v NEW ENGLAND ENGINEERING SERVICES INC November 19, 2002 Francis P. Reilly and Son 206 Andover Street Andover, MA 01810 Re: As built septic system plan f'4 6 Johnson Street, North Andover Dear Mike: IM26M b Enclosed are three copies of the as built plan for the above referenced property. You need to sign the certification and send all of the copies of the plan and the certification to the Board of Health. If you have any questions please do not hesitate to contact me. Sincerely, /% Benjamin C. Osgood, J ., EIT President 60 BEECHWOOD DRIVE - NORTH ANDOVER, MA 01845 - (978) 686-1768 - (888) 359-7645 - FAX (978) 685-1099 i <� INSPECTION CHECKLIST FOR SEPTIC SYSTEMS Yes NO Initials A. Bottom of Bed 1. Excavation to proper depth 2. With trenches, sides of excavation are beneath B horizon 3. Edge of excavation speci ed distance from foundation, etc. Comments: B. Retaining Wall 1. Wall height and width as specified i 2. Waterproofed ! // (!j '� / 3. Wall minimum 10' to leaching facility (� � [/ 4. Wall meets specifications of plan Comments: C. Building,Sewer 1. Pipe diameter minimum 4" 2. Schedule 40 pipe 3. Watertight joints 4. Inlet to tank cemented 5. Slope minimum 0.01 or 1/8" per foot minimum 6. Pipe properly set on compact fine basey - 7. Pipe laid on continuous grade in straight line 8. Cleanouts precede all change in alignment and grade ---- -- -Y 9. Manholes at any 900 change 10. 10' minimum offset to water line �- Comments: D. Septic Tank 1. Level 2. 1,500 gal minimum •/��� 3. Gas baffle present on outlet 4. Manhole to grade 5. Manholes over center and each tee 6. 3-20" manholes 7. Inlet tee minimum 12" under invert 8. Outlet tee minimum 14" under invert f/ 9. Outlet line cemented v 10. Air space 3" above tees 11. 2" - 3" drop from inlet to outlet / 12. Pipe set c 13. Compact base with 6" of 1/4" crushed stone under tank V' 14. Tank is watertight Comments: r r_ Yes E. Pump Chamber 1. If separate from tank, compact base with 6" of '/4" stone underneath 2. Minimum 2" pipe to d -box if gravity system 3. 20" access manhole 4. Tank level ✓ 5. Watertight 6. Tank size agrees with plan specification �7 7. Manhole to grade 8. Check valve and bleeder hole present -� 9. Alarm in building on separate circuit l� 10. Alarm functions 11. Manual operating switch L 12. Pump delivers liquid to d -box' Comments: F. Distribution Box 1. D -box level V 2. Minimum 0.1T' (2") drop from inlet to outlet 3. Minimum 6" sump 4. Outlet pipes show equal distribution 5. Compact base with 6" of stone beneath box 6. Box is watertight 7. All lines cemented with hydraulic cement 8. Schedule 40 pipe Comments: G. Soil Absorption system 1. All stone double -washed -3/4" - 1 ''/z" - pea stone �- Bucket test done? 2. Minimum 2" of pea stone above distribution lines 3. Minimum 6" stone beneath pipe ✓ 4. Distribution lines capped or connected together Z% 5. Grading meets 3:1 slope 6. Minimum of 9" of fill graded over system 7. Toe of slope stops minimum 5' from edge of property; if not, then swale. Comments: H. Leach Trenches 1. Minimum 2 trenches 2. Length of trenches agree with plan. (Max. length 100') 3. Width of trenches agree with plan - Minimum 2'; maximum - 4' 4. Vent present if <50 feet or specified 5. Distance between trenches minimum 4' and maximum of 6' 6. Minimum distance between trenches 10' 7. Pipe slope minimum 0.005 or 6" per 100' 8. Depth of trenches below outlet invert minimum of 6". 061 1) / g)z) Z, Yes NO 9. Pipes set on stable base. Comments: I. Leach Field 1. Maximum length of field 100' \2. Pipe slope minimum 0.005 or 6" per 100' 3.�'Separation between pipe 6' maximum 4. Pipes connected at end 5. Separation betwee 'acent fields 10' minimum 6. Pipes set on stable base 7. Maximum 4' separation from edge of field to first line 8. Minimum two distribution lines 9. Maximum perc rate 20 mpi Comments: I Le hing Pits 1. mum inlet pipe 4" 2. Pits of co rete 3. Sidewall between " and 48" wide 4. Access manholes on eacfr 5. Pipes cemented with hydraulic e Comments: K. Final Grade 1. Slope over soil absorption system minimum 0.02 2. All system components covered by at least 9" soil 3. Cover soil free of stones larger than 6" 4. Grading slopes away from dwelling 5. No areas over system that may pond 4 h 4 9 BOARD OF HEALTH NORTH ANDOVER, MA 01845 978-688-9540 APPLICATION FOR DISPOSAL WORKS CONSTRUCTION PERMIT DATE: 9 -13 - d 4 CURRENT INSTALLER'S LICENSE# LOCATION: 0a JOHN 509 ST 066— I LICENSED INSTALLER: rit,yc_ SIGNATURE: `TELEPHONE# (� �) 7S - i �3 CHECK ONE: REPAIR: NEW CONSTRUCTION: , IF NEW CONSTUCTION, PLEASE ATTACH FOUNDATION AS -BUILT. 160.00 Fee Attached? Project Manager Ob. Foundation As -Built? Floor Plans? Administrative Use Only Yes k, No Yes No_X_ Yes Yes No No TG'.itirN OF NORTH ANDD 3/ a BOARD OF HEALTH t r OGT 2002 Approval _ �---J Date: 1Z 3`. NORTH O p • off+ - T� ���" # SS�CHUSE Applicant_ Site Location Town of North Andover, Massachusetts Form No. 3 BOARD OF HEALTH f1 DISPOSAL WORKS CONSTRUCTION PERMIT AME DDRESS Permission is hereby granted to Construct ( ) or Repair ( an Individual SoiIAAbsorption Sewage Disposal System as shown on the Design Approval S.S. No. Jal,!2 Zi . CHAIRMAN, BOARD OF HEALTH Fee c� D.W.C. No. 1 TOWN OF NORTH ANDOVER HEALTH DEPARTMENT 27 CHARLES STREET NORTH ANDOVER, MASSACHUSETTS 01845 Sandra Starr Public Health Director August 30, 2002 Mr. & Mrs. Frank Gring, Jr. 826 Johnson Street North Andover, MA 01845 Re: Septic repair plan for 826 Johnson Street Dear Mr. & Mrs. Gring: Telephone (978) 688-9540 FAX (978) 688-9542 This letter comes to notify you that the proposed septic system plans dated July 10, 2002, designed by New England Engineering Services, Inc. have been approved. Please do not hesitate to call me at 978-688-9540 should you have any questions. Sincerely, Sandra Starr, R.S., C.H.O. Public Health Director Cc: New England Engineering Services File TOWN OF NORTH ANDOVER HEALTH DEPARTMENT 27 CHARLES STREET NORTH ANDOVER, MASSACHUSETTS 01845 Sandra Starr Public Health Director August 30, 2002 Mr. & Mrs. Frank Gring, Jr. 826 Johnson Street North Andover, MA 01845 Re: Septic repair plan for 826 Johnson Street Dear Mr. & Mrs. Gring: Telephone (978) 688-9540 FAX (978) 688-9542 This letter comes to notify you that the proposed septic system plans dated July 10, 2002, designed by New England Engineering Services, Inc. have been approved. Please do not hesitate to call me at 978-688-9540 should you have any questions. Sincerely, Sandra Starr, R.S., C.H.O. Public Health Director Cc: New England Engineering Services File NEW ENGLAND ENGINEERING SERVICES lk INC Sandra Starr, Administrator North Andover Board of Health 27 Charles Street North Andover, MA 01845 Re: 826 Johnson Street Dear Sandra: August 16, 2002 r 2 0 2D02 It is my understanding that you indicated to the owner of the above referenced project that a stackable block wall constructed from precast, pre-engineered concrete masonry units would be acceptable to replace the proposed poured concrete wall originally designed. The enclosed plans have been modified to indicate a stackable block wall in lieu of the concrete wall. If you have any questions or need additional information please do not hesitate to contact this office. Sincerely, /-,Jr., Benj C. Osgo EIT President 60 BEECHWOOD DRIVE - NORTH ANDOVER, MA 01845 - (978) 686-1768 - (888) 359-7645 - FAX (978) 685-1099 Town of North Andover, Massachusetts HU&. Form No. 2 f MORTq BOARD OF HEALTH 4V3V4 36.) L).� o DESIGN APPROVAL FOR ssACHUSEt SOIL ABSORPTION SEWAGE DISPOSAL SYSTEM Site Location Permission is granted for an individual soil absorption sewage disposal system to be installed in accordance with regulations of Board of Health. Fee -&d CHAIRMAN, BOARD OF HEALTH Site System Permit No. `l ' Town of North Andover, Massachusetts Form No. 1 NORTH BOARD OF HEALTH F eo q� ,6R6 0 19 p ......: .r r.Fp' A APPLICATION FOR SITE TESTING/INSPECTION Applican Site Locc- Engineer Test/I nsl CRAIRNFAN, BOARD OF HEALTH Fee r Test No. S.S. Permit No. ��� D.W.C. No. C.C. Date Plbg. Permit No. Town of North Andover, Massachusetts NORTH •A'- BOARD OF HEALTH .LIED /F �•YA APPLICATION FOR SITE TESTING/INSPECTION Form No. 1 19 Applicant NAME ADDRESS TELEPHONE Site Location Engineer NAME ADDRESS TELEPHONE Test/Inspection Date and Time Fee CHAIRMAN, BOARD OF HEALTH Test No S.S. Permit No. D.W.C. No. C.C. Date Plbg. Permit No. TOWN OF NORTH ANDOVER HEALTH DEPARTMENT 27 CHARLES STREET NORTH ANDOVER, MASSACHUSETTS 01845 Sandra Starr Public Health Director July 17, 2001 Mr. & Mrs. Frank Gring, Jr. 826 Johnson Street North Andover, MA 01845 Re: Septic repair plan for 826 Johnson Street Dear Mr. & Mrs. Gring: Telephone (978) 688-9540 FAX (978) 688-9542 This letter comes to notify you that the proposed septic system plans dated June 21, 2001 designed by New England Engineering Services, Inc. have been approved. Please do not hesitate to call me at 978-688-9540 should you have any questions. Sincerely, Sandra Starr, R.S., C.H.O. Public Health Director Cc: New England Engineering Services File BOARD OF HEALTH � l NORTH ANDOVER, MA 01845 978-688-9540 A 12 APPLICATION FOR SOIL TESTS DATE: �cT3� ( MAP & PARCEL: 1 07/4 o (o LOCATION OF SOIL TESTS: �3 aCq — j-tA) sa,vS� c,e� �� � Mont AvP,),),et, OWNER: AA,. J 2TEL. NO.: ADDRESS: 89a, &i dee i , /00 a: -1-7f ENGINEER: NG. ee 2; Alrj TEL. NO.: q19- c o 6 - t 7 6 - CERTIFIED SOIL EVALUATOR: I'�►cM/NLn C_' Tuve f .n (5sr,-yo0 J,2 Intended Use of Land: Residential Subdivision Single Family Home Commercial Is This: Repair Testing: X Undeveloped lot testing: In the Lake Cochichewick Watershed? Yes No 5t' Bail THE FOLLOWING MUST BE INCLUDED WITH THIS FORM APR - 4 2001 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 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 "A 00') shall be submitted to the Board 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 June 22, 2001 Sandra Starr, Administrator North Andover Health Department Town Hall Annex 27 Charles Street North Andover, MA 01845 Re: 826 Johnson Street, North Andover, Septic system design Dear Sandra: Enclosed are revised plans for the above referenced property. The following changes have been made. The numbers below correspond to the concerns in the consultants letter dated 6/11/2001. 1. The benchmark has been re -set. 2. The second sentence of note # 7 has not been removed. We do not guarantee the functioning of the system. We only design what the regulations require 3. The inverts for trench 3 have been added to the profile. 4. The 12" maximum distance has been shown on the plans. 5. The D -Box has been redesigned to show the 2 feet of level pipe on the profile and plan views. 6. The stamp is compliant. The discipline and registration can be written by the 7 9. 10. 11. 12. 13. engineer. The water line has been labeled as a pressure line The requested wording has been added under general notes. The 200 feet to tributary note was not added since the more restrictive local requirement of 325 feet is noted. _ TU01 OF N� BARD OF H The soil evaluators certification is on the soil sheets. The septic tank sizing calculations have been revised. The riser notes have been revised to address this note. JUU 2 5 2001 The reserve line elevations have been added. The date has been corrected. � 14. The tank label has been revised. 15. The inlet and outlet inverts of the d box have been revised. 16. The lengths of pipe and slope has been added. 17. The building sewer invert elevation at the foundation has been added. 60 BEECHWOOD DRIVE - NORTH ANDOVER, MA 01845 - (978) 686-1768 - (888) 359-7645 - FAX (978) 685-1099 J 18. The d box configuration has been changed on the plan view and profile view to indicate the 2 feet of level pipe. 19. The pump chamber still delivers 4 doses per day. This is required for a class 1 soil. 20. The riser notes for the pump have been revised. 21. A structural engineering review is not needed in the opinion of Richard Tangard. 22. The contours for trench 3 have been moved to comply with the breakout requirement 23. The total head vs. discharge has been plotted on the pump curve. 24. The force main velocity has been calculated. If you have any questions please do not hesitate to contact this office. Sincerely, Benj C. O ood, Jr., EIT President Town of North Andover Office of the Health Department Community Development and Services Division 27 Charles Street North Andover, Massachusetts 01845 Sandra Starr Health Director July 10, 2001 William Schaefer William Schaefer & Associates 15 Bay Street Cambridge, MA 02139 Dear Mr. Schaefer.: Telephone (978) 688-9540 Fax (978)688-9542 In response to your letter of July 5, 2001, Ben Osgood, Jr. of New England Engineering on June 25, 2001 submitted revised plans. The plans were then sent to the consultant on June 25, 2001. We are awaiting a response from the consultant. The engineer and the homeowner will be notified when a response is received. Sincerely, Sandra Starr, R.S., C.H.O. Health Director BOARD OF APPEALS 688-9541 BUILDING 688-9545 CONSERVATION 688-9530 NURSE 688-9543 PLANNING 688-9535 WILLIAM SCHAEFER &AS SOt--IATES/ARCHITECT S iwww. ws a ssoc. com. * emaii-corbuarch@aol com- 617.661.7582- FAX 661.1857- ii • WILLIAM SCHAEFER & ASSOCIATES. ARCHITECTS • 15 BAY STREET • WWW. WSASSOC. COM • • CAMBRIDGE, MA. • 02139 . 617: 661: 7582 • FAX 661:1857 •EMAIL: CORBUARCHC AOL. COM• Town of North Andover TRANSMITTAL #1 Health Dept. Ms. Sandra Starr RE: Review of Septic Permit application for Health Director 826 Johnson Street, N. Andover, MA. 978.688.9540 fax 978.688.9542 5 July, 2001. Thursday Dear Ms. Starr : I am writing to ask for your help regarding the application for a new Septic System for a Renovation being done at 826 Johnson Street, N Andover. I believe that our Engineer, Mr. Ben Osgood of New England Engineering Services, N Andover has answered your Consultants comments and submitted his drawings and comment answers on the 22 nd of June. The Owners of 826 Johnson Street have moved out of their residence, and away form N Andover, to allow the Contractors complete access to do their work. They have small children and unless we can begin construction sh the wnicn as Could you pleases review Ben's additional information to satisfy the Health Dept. and the Town's Consulting Engineering firm, I.E. Mr. John Noonan, of Noonan and McDowell. If there is anything missing I will do my best to expedite getting that information to you. ' but if you can review our submittal and avvrove it if it is acceutable it will mean that we w As stated before, if anything is missing or in question regarding our application we will be most happy to submit that information. Thank you very much for your assistance in these matters. Sincerely yours, William Schaefer Architect 617.661.7582 New England Engineering % Mr. Ben Osgood 978.686.1768 -9 y Progress SEPTIC PLAN SUBMITTAL FORM LOCATION: NEW PLANS: YES REVISED PLANS: YES SITE EVALUATION FORMS INCLUDED: DATE: 6(Z4-4 / $160.00/Plan $ 60.00/Plan YES DESIGN ENGINEER: �/- E EN6 �'� SSC �_ �vn. OF r10� ;Iii At.'D H 6Or:? ,.0 OF HEALTH DATE TO CONSULTANT: , 2 5 2001 When the submission is all in place, route to the Health Secretary. FORM 11 - SOIL EVALUATOR FORM Page I of 3 No. 3 Date:- OZ1401 Commonwealth of Massachusetts A/0- Massachusetts of Su'tabrlity Assessment for . Onsite Sewage D4ppW Performed By:......... .......... Date: A / Witnessed By: ........... ..V� :��/ .. ......... ........ .................................... . .............................................. ... . .. . ... ....... L*ut ion Aftcu orOZ6 Owm's Nam. Aft=. and Tckphom 1 4' 4- Newconstructlon 11 Repair Y1115! -7 49 .0jr ice Revieiv Published Soil Survey Available: No ❑ Yes Year Published ............. Publication Scale I'l-IS6.0, Soil Map Unit C,(f .. ..... Drainage Class 110111-1&44 ............... Soil Limitations A Surficial Geologic Report Available: No 91 Yes ❑ Year Published Publication Scale Geologic Material (Map Unit) ................................ ..... .... ........ ............. .... Landform........................... ......... . ................................................................. Flood Ifisurance Rate Map: Above 500 year flood boundary No E) Yes Within 500 year flood boundary No 0 Yes ❑ Within 100 year flood boundary No EDYes El Wetland Area: National Wetland Inventory Map (map unit) Wetlands Conservancy Program Map (map unit) ........ ............................ ....... .............. . ..................................... I .......................... . Current Water Resource Conditions (USGS): Month �WL Range Above Normal ONormal lZBelci-iNormal Other References Reviewed: DEP APPROVED FOPM • 12MI05 I El FORM 11 - SOIL EVALUATOR FORM Page 2 of 3 Location Address or Lot No. 10�1�,�0•�/ �/. �, ,�iT.�-�1�,�. 4n -bite Review Deep Hole Number ...� Date:.-! ` Time;.Weather Location (identify on site plan) Land Use Slope Slope (%) .Z7. Surface Stones .... . Vegetation.. 0...�� , ......,:.�....:.. w, r Landform Position on landscape (sketch on the back) Distances from: Open Water Body T"feet Drainage way feet Possible Wet Area (�G feet Property Line 30 feet Drinking Water WF/./' -- - feet Other-.- DEEP ther..... DEEP OBSERVATION -MOLE LOG Depth from Soil Horizon Soil Texture Soil Color Soil Other Surface (Inches) (USDA) (Munselli Mottling (Structure, Stones, Boulders, Consistency, % 4 4k 7"-WW4r1_— Parent Material (geologic) Depth to Groundwater: Standing Water In the Hole: Estimated Seasonal High Ground Water:_ 6�4 7 DPP APPROVED FORM • 12/07/9s Weeping from Pit Face: FORM 11 • SOIL EVALUATOR FORM Page 2 of 3 Location Address or Lot No. ? G07& ay On-site Review d Deep Hole Number .. L Date:.. Time:.. 4 v Weathe'�%� Location (identify on site plan)..... �'r,:.,...�`r7' ,........:...w,.�..� ....�� .._.......... Land Use-- Slope M . Z. Surface Stones Vegetation. _ ..,.. ...... ..,. ,.... . Landform !; vCvw... /77G OPi (�... .................:.....:...... Position on landscape (sketch on the back) Distances from: Open Water Body 7�' feet Drainage way ��p. feet Possible Wet Area ���.. feet Property Line . - feet Drinking Water Well — feet Other DEEP OBSERVATION 'HOLE LOG` Depth from Surface (Inches) Soil Horizon Soil Texture (USDA) Soil Color IMunsell] Soil Mottling Other (Structure, Stones, Boulders, Consistency, % Gravel) i Ilk Parent Material (geologic) Depth to Groundwater: Standing Water in the Hole: Estimated Seasonal High Ground Water: �i .� ✓ DepthWBedrock: _ Weeping from Pit Face: —� DEP APPROVED FORM - 12/07/95 �✓ � o6/� : � ✓� FORM 11 • SOIL EVALUATOR FOIINI Page 2 of 3 Location Address or Lot No. —,02,6 On-site Review e Deep Hole Number ....� . Date:.. ...���/ Time:. 4..,.�J Weather ��"` Location (identify on site plan) ..... �.^y��.�.,..��...T�..'�.��.�... G�;..:.�..........:.. Land Use ..... _.....!D!G Slope (%) Z- Surface Stones . Vegetation Landform Position on landscape (sketch on the back) ..... J��.. , .LO:.......... Distances from: Open Water Body feet Drainage way/:7� ... feet Possible Wet Area leet Property Line . feet Drinking Water Well .. feet Other... `- DEEP OBSERVATION HOLE LOG Depth from Soil Horizon Soil Texture Soil Color Soil other Surface (inches) (USDA) (Munsell) Monling {Structure, Stones, Boulders, Consistency, % Gravel) Parent Material (geologic) Depth to Groundwater: Standing Water In the Hole: Estimated Seasonal High Ground Water:8r DeP APPROvep FORM - 12/07/95 i yes Weeping from Pit Face: r FORM II - SOIL EVALUATOR FORM Page 3 of 3 Location Address or Lot No. Method Used: Depth observed standing in observation hole ................... inches ❑ Depth weeping from side of observation hole ............ . inches Depth to soil mottles .. inches �/- moo" ❑ Ground water adjustment .................. feet - -A&Z: 43 " Index Well Number .................. Reading Date ........ ......... , Index well levet ................. Adjustment factor ................... Adjusted ground water level Depth of Naturally Occurring Pervious Mat rial Does at least four feet of naturally occurring pervious material exist in II observed throughout the area proposed for the soil absorption system? s"5areas If not, what is the depth of naturally occurring pervious material? Certification 1 certify that ongdate) !have passed the soil evaluator approved by the Department of Environmental Protection and that the above analysis was performed by me consistent with the re raining, expertise and experience described in 310 CMR 15.017.1 Signature �— a4 AEP APPROVED FORM • 12/07/95 N NEW ENGLAND ENGINEERING SERVICES INC "'Ay 3 May 29,2001 Sandra Starr, Administrator North Andover Health Department Town Hall Annex 27 Charles Street North Andover, MA 01845 Re: 826 Johnson Street, North Andover, Septic system design Dear Sandra: Enclosed are the following documents concerning the above referenced property. 1. 5 sets of design plans, 1 with original signature. 2. Submittal form for approval. 3. Soil evaluator sheets. 4. Check to cover the fee. If you have any questions please do not hesitate to contact this office. Sincerely, D.? 13 12 4f BenjaiKin C. Osgoo ijr., EIT President 60 BEECHWOOD DRIVE - NORTH ANDOVER, MA 01845 - (978) 686-1768 - (888) 359-7645 - FAX (978) 685-1099 SEPTIC PLAN SUBMITTAL FORM LOCATION: ; vZ(0 aC>UAJ so ,j 5.-rajFL ;— NEW PLANS: r—VTS $125.00/Plan REVISED PLANS: YES $ 60.00/Plan SITE EVALUATION FORMS INCLUDED: YES NO DATE: 5I zal DESIGN ENGINEER: A) Gw � � G-�.�4N ,1 1-7yy (,-k,v e e a, L A; G� DATE TO CONSULTANT: *If you want your plans expedited, please submit three plans and included a stamped envelope with the correct amount of postage to mail plans to Port Engineering. When the submission is all in place, route to the Health Secretary. Town of North Andover Office of the Health Department Community Development and Services Division William J. Scott, Division Director 27 Charles Street North Andover, Massachusetts 01845 Sandra Starr Health Director May 17, 2001 Mr. Gring 826 Johnson Street North Andover, MA 01845 Re: Application for addition Dear Mr. Gring: Telephone (978) 688-9540 Fax (978) 688-9542 Your application for an addition at 826 Johnson Street has been reviewed by the Health Department. The application was denied on May 17, 2001 for the following reasons: 1. W Missing information "The Health Department must receive, review and approve your septic system design before this application can be reviewed any further. 2. ❑ Passing Title 5 inspection of septic system required 3. ❑ Location of structure not acceptable To address the problem(s): If#1 is checked, please supply: a. Floor plan of existing and proposed addition b. Certified plot plan showing house, septic system and proposed project in scale If #2 is checked: a. Have the septic system inspected by a certified Title 5 inspector to determine the size of the system and whether it is operating properly; OR b. Tie-in to municipal sewer If 93 is checked: a. Relocate the project Please feel free to call the Health Office at 978-688-9540 with any questions you may have. Sincerely, IX uFord, Health Inspector Cc: Building Department File BOARD OF APPEALS 688-9541 BUILDING 688-9545 CONSERVATION 688-9530 NURSE 688-9543 PLANNING 688-9535 FORM - U - LOT RELEASE FORM INSTRUCTIONS: This 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. 1.........i.................................■■.............................. APPLICANT Fw� �-Al m _PHONE -� :�y • ASSESSORS MAP NUMBER 1�4 OT NUMBER _ SUBDIVISION LOT NUMBER 82.9 �o ��©� � STREETST BEET NUMB R . .......................................................... ................ OFFICIAL USE ONLY I.............................'.■...............■■..............iP'..-s..-ri'. a..■ RECON0 ENDATIONS OF TOWN AGENTS i.._�s.�.......F............................................... ... ........... i f DATE APPROVED �S CO ERVATION ADktINMTRATOR DATE REJECTED TOWN PLANNER DATE APPROVED COMMENTS FOOD INSPECTOR -HEALTH L / SE�PE OR - HEALTH 6'7 E5:5 e- PUBLIC WORKS — SEWER / WATER CONNECTIONS Y PERMIT W COMMENTS Va RECEIVED BY BUILDING INSPECTOR 7 DATE REJECTED DATE APPROVED DATE REJECTED DATE APPROVED rDA� Cq�? 0) c DATE APPROVED DATE REJECTED TC 5 T V� 3E y,2 ,fig � /89 1 n,7 X kDo BOARD OF HEALTH NORTH ANDOVER, MA 01845 978-688-9540 APPLICATION FOR SOIL TESTS t MAP & PARCEL: l o 7 A DATE: 10 Z� LOCATION OF SOIL TESTS:C ..JvI-IK' sL)'." .ST cec- I i w6an-, AvDi )-et, OWNER: A't, .fL TEL. NO.: ADDRESS: '.2 L. 5-0 o,,�3 i fre 1 &),I) Z nI A "P0� /-e.IL ENGINEER: TEL. NO.: c178- 178 CERTIFIED SOIL EVALUATOR:i��c CERTIFIED �dd}f� D C' i c��u,ts2�zrr� C�s c. U4 �� J t Intended Use of Land: Residential Subdivision Single Family Home Commercial Is This: Repair Testing: >( Undeveloped lot testing: In the Lake Cochichewick Watershed? Yes No x' THE FOLLOWING MUST BE INCLUDED WITH THIS FORM App, - 4 2001 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_hole ani -•- 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 and at least one percolation test, at the discretion of the BOH representative. 5. Full payment will be required for all additional tests within two weeks of testing. 6. Within 45 days of testing, a scaled plan (no smaller than 1"-100') shall be submitted to the Board of Health showing the location of all tests (including 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 7 Date Received: Check Amount: Check Date VVN OF NORTH A"I'DOV BOARD OF HEALER APR i CO C7Al -- t Land Reginald Lot fl., Johnson St. APPLICATION FOR SEWAGE DISPOSAL INSTALLATION ��'�� 2 HEALTH DEPARTMENT - NORTH ANDOVER, MASS. I hereby make application for a permit for a sewage disposal installation at Lot # 1, Johnson St. . I will install this system in ac- cordance with all the laws of the Commonwealth of.Massachusetts and regulations of the Board of Health of the Town of North Andover. Further, I will construct the house sewer of bell and spigot pipe, the minimum diameter being 4 inches, and will maintain a minimum grade of lib until 10 feet pre- ceding the septic tank, where the grade shall not exceed 2%. I will install a con- crete septic tank of 1000 Galt in size. A manhole (s) permitting easy cleaning will be provided with removable cover (s) of iron or concrete within 12 inches of the ground surface. I will provide subsurface disposal field with 4 inch perforated or open jointed pipe and laid in a series of trenches, the bottom of which will pro- vide a minimum of U0 lineal (,�s^a4 feet of effective absorption area. The pipes will be laid on a 6 inch layer of washed gravel or crushed stone ranging in size from 3/4 to 1-1/2 inches (dia.) and the pipes will be surrounded by similar material to a height of 2 inches above the crown of the pipe. The joints of these pipes will be protected from clogging and before filling the trench, 2 inches of gravel or stone 1/8" to 1/4" (dia.) will be placed over the course gravel or stone. The disposal field will be installed at a grade of 4 to 6 inches/100 feet. No single tile line will exceed 100 feet.in length and in any case, two lines of tile will be installed. A minimum of 6 feet will be maintained between the center lines of the disposal field trenches and the average depth of trench shall not exceed 36 inches. No part of the installation will be less than 100 feet from any private water supply, 25 feet from any stream, 20 feet from any dwelling or 10 feet from any property line. I further agree not to cover any portion of this installation until approved by the inspection officer, as provided below, and to incorporate any additional requirements that may be attached to the permit. Plot Plans must be submitted with application. DATE Signature of Applicant I hereby issue the above permit for the Board of Health of the Town of North Andover, Massachusetts. DATE L Signature of Health Agent I have inspected the uncovered system indicated above and find everything done as descri d. Signature o nspecting Offic r Percolation Test 6 min. Soil: Sandy Garbage Grinder No BOARD OF HEALTH n TOWN OF NORTH ANDOVER, MASS. 1vI D . 1 N4 [J, fi J V rig �r 2a�Ntl �o 1. NAME P'a-1G� Gr -� *- DATE (2 2. ADDRESS__ // e.sc o �. !tel/ �,1�� LOT NO. % TEL. V 3. NO. OF BEDROOMS --2- DEN YES ` NO 4. GARBAGE GRINDER YES NOy� 5. SHOW DIMENSIONS OF HOUSE 6. SHOW DISTANCES OF HOUSE TO ALL PROPERTY LINES 7. SHOW DIMENSIONS OF LOT 8. SHOW LOCATION AND SIZE OF SEPTIC TANK OR CESSPOOL 9. NOTE LOCATION AND DISTANCE OF WELL FROM SEWERAGE SYSTEM 10. SHOW LOCATION OF BROOKS, STREAMS, DITCHES, LEDGE OUTCROP, ETC. 11. SHOW DISTANCE OF SEPTIC TANK OR CESSPOOL FROM HOUSE NOTE: LOCAL REGULATIONS SHOULD BE READ CAREFULLY. BOARD OF HEALTH OF NORTH ANDOVER, MASSACHUSETTS SEWAGE DISPOSAL DATE Z.,U�, 9 NAME OF APPLICANT RinaI -nnt9 0 -i LOCATION Addrebs'of lot no. BUILDING: Dwelling_x Other SYSTEM: New x,,,_ Repair___.___ GENERAL DESCRIPTION OF LAND SUBSOIL: Clay, Gravel SandZ__„X PERCOLATION TEST is minutes per inch. MINIMUM INSTALLATION RECOMMENDATIONS CONCRETE SEPTIC TANK 1.000 gallon capacity. LEACH FIELD ,g0 lineal feet of drain pipe. 1, J1 . lliam J. DpAscoll, Engine&r Board of Hea h OFFICES OF: APPLALS BUILDING CONSERVATION I ]EALTH PLANNING OF OORtN Town of m a NORTH ANDOVER �ssecNuee�a - DIVISION (W PLANNING & COMMUNITY DEVELOPMENT Steve Landry 826 Johnson St. N. Andover, Ma. KAREN I I.P. NI-iLSO N, UIRFIC•I.OIt 120 Main Street North Andover, Massachusetts 01845 (617) 685-4775 March 23, 1988 re: proposed addition 826 Johnson St. This office has no objection to the proposed addition at this site. A site inspection revealed that the current system is functioning adequately and there is room for repairs. cc: Building Inspector Sincerely, Mike Graf Health Dept. Town of North Andover Office of the Health Department Community Development and Services Division William J. Scott, Division Director 27 Charles Street North Andover, Massachusetts 01845 Sandra Starr Health Director May 17, 2001 Mr. Gring 826 Johnson Street North Andover, MA 01845 Re: Application for addition Dear Mr. Gring: Telephone (978) 688-9540 Fax (978) 688-9542 Your application for an addition at 826 Johnson Street has been reviewed by the Health Department. The application was denied on May 17, 2001 for the following reasons: 1. LSI Missing information "The Health Department must receive, review and approve your septic system design before this application can be reviewed any further. 2. ❑ Passing Title 5 inspection of septic system required 3. ❑ Location of structure not acceptable To address the problem(s): If # 1 is checked, please supply: a. Floor plan of existing and proposed addition b. Certified plot plan showing house, septic system and proposed project in scale If #2 is checked: a. Have the septic system inspected by a certified Title 5 inspector to determine the size of the system and whether it is operating properly: OR b. Tie-in to municipal sewer If #3 is checked: a. Relocate the project Please feel free to call the Health Office at 978-688-9540 with any questions you may have. Sincerely, u ord, Health Inspector Cc: Building Department File BOARD OF APPEALS 688-9541 BUILDING 688-9545 CONSERVATION 688-9530 NURSE 688-9543 PLANNING 688-9535 RECEME-D Commonwealth..of Massachusetts City/Town of I SEP - 6 2006 System Pumping Record TOWN OF NORTH ANDOVER Form 4 HEALTH DEPARTMENT 4,y DEP has provided this form for use by local Boards of Health. The System Pumping Record must be submitted to the local Board of Health or other approving authority. . A. Facility Information Important: When filling out 1. SyStm LOCati forms the computer, use only the tab key Address v v . to move your � cursor - do not elCit /Town use the�return y State Zip Code key. 2. System Owner: r i l>,01 Name Address (i(different from location) http://www Cdy/Town State •.J 'Ctl Telephone Number J B. Pumping Record 1. Date. of Pumping p g Date 2. Quantity Pumped: Gallons 3. Type of system: ❑ Cesspool(s) eptic Tank- ❑ Tight.Tank ❑ Other (describe): 4. Effluent Tee Filter present? ❑ Yes No Ife y s, was It cleaned? El Yes ❑ No 5. Condition f System: alue .7. t5form4.doc• 06103 Loc whe a cont ere d' sed: provals/t5forms. htm#inspect IC Commonwealth of Massachusetts �._... City/Town ofRECEIVEC System Pumping Record Form 4 JUN 2 2 2009 s' `• Important: When filling out forms on the computer, use only the tab key to move your. cursor - do not use the return key. DEP has provided this form for use by local Boards of Health. Other Pfi"A iii information must be substantially the same as that provided here. Be�er�e-t7s>rrg-V form, check with your local Board of Health to determine the form they use. The System Pumping Record must be submitted to the local Board of Health or other approving authority. A. Facility Information 1. System Location: Left front, left re , left side of house. ght front, right rear, right side of house. Address � � `P �(✓ `J`J' ," �-)GV� G�� cityfrown State 2. System Owner: Name Address (if different from locatir Cityrrown B. Pumping Record 1. Date of Pumping 3. Type of system: 8 [ Other (describe): &kC4�k Zip Code State / Ze Telephone Number C Date 2. Quantity Pumped: Gallons Cesspool(s) eptic Tank Tight Tank 4. Effluent Tee Filter present? 0 Yes C:Wo If yes, was it cleaned? [ Yes [ No 5. Condition of System A /�)cvt 6. System Pumped By: Neil Bateson Name Bateson Enterprises Inc Company 7. LocatioaAere contents were disposed: Of Lowell Waste Water F 5821 Vehicle License Number 6'-16--0? Date t5form4.doc• 06/03 System Pumping Record • Page 1 of 1 Commonwealth of Massachusetts City/Town of System Pumping Record Form 4 DEP has provided this form for use by local Boards of Health. Other forms may be used, but the information must be substantially the same as that provided here. Before using.this form, check with your local Board of Health to determine the form they use. The System Pumping Record must be submitted to the local Board of Health or other approving authority. A. Facility Information 1. System Location: Left / Right front of house, Left / Right rear of hou§69) ng si a o� I>-ous a Left / Right side of building, Left / Right front of building, Left / Right rear of -ulding, Under deck Address City/Town 2. System Owner. Name Address (if different from location) TOWN Record 1. Date of Pumping 3. Type of system: ❑ 4. t - 10 -�� Date �. Cesspool(s) ❑ Other (describe): Effluent Tee Filter present? ❑ Yes 211qo 5. Condition of System: 6. System Pumped By: State Zip Code State Zip Code —2aP6 ` q Telephone Number 2. Quantity Pumped: Septic Tank Gallons ❑ Tight Tank If yes, was it cleaned? ❑ Yes ❑ No Neil Bateson F5821 Name Vehicle License Number Bateson Enterprises Inc Company 7. Location where contents were disposed: a.. S. Lowell Waste Water 0iA- Date t5form4.doc• 06/03 System Pumping Record • Page 1 of 1