HomeMy WebLinkAboutMiscellaneous - 84 ACADEMY ROAD 4/30/2018 (2)m
I
-0
MR-
North Andover Board of Assessors Public Access
Parcel ID: 210/096.0-0036-0000.0
SKETCH
Click on Sketch to Enlarge
Community: North Andover
PHOTO
No Picture
Available
Location: 84L -B ACADEMY ROAD
Owner Name: WORDEN, JAMES D
ANITA RAJAN WORDEN
Owner Address: 84 ACADEMY ROAD
City: NORTH ANDOVER State: MA ZIP: 01845
Neighborhood: 7 - 7 Land Area: 4.01 acres
Use Code: 101 - SNGL-FAM-RES Total Finished Area: 5029 sqft
ASSESSMENTS CURRENTYEAR PREVIOUS YEAR
Total Value: ' 775,400 728,100
Building Value: 546,100 514,900
Land Value: 229,300 213,200
Market Land Value: 229,300
Chapter Land Value: I
LATESTSALE
Sale Price: 435,600 Sale Date: 01/30/1997
Arms Length Sale Code: Y -YES -VALID Grantor: 84 ACADEMY RD/STEVEN
Cert Doc: Book:04684 Page:0137
Page 1 of I
http://csc-ma.usNandoverPubAcc/jsp/Homejsp?Page=3&Linkld=806937 9/22/2006
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�L\ Commonwealth f Maksac�usetts
City/Town of
Anciove, r
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 within 14 days from the pumping date in
accordance with 310 CIVIR 15.351.
A. Facility Information RECEIVED
Important: When
filling out forms
on the computer,
use only the tab
key to move your
cursor - do not
use the return
key.
VQ
1 .
2. System Owner:
Name
Address (if different from location)
City/Town
B. Pumping Record
State
State
Telephone Number
1. Date of Pumping �71) / 11 1 1 2. Quantity Pumped:
Date '
3. Type of system: El Cesspool(s) VSeptic Tank El Tight Tank
El Other (describe):
JUN 15 2019
HEALT,q M-PARTMENT
Zip Code
Zip Code
Gallo s
El Grease Trap
4. Effluent Tee Filter present? El Yes El No If yes, was it cleaned? Fj Yes 0 No
5. Condition of System:
T
6. -System Pumped By:
Na'Me— Vehicle License Number
Stewart's Septic Service
Company
7. Location where contents were disposed:
Stewart's Pre-treatment Plant, 20 So. Mill Bradford, Ma 01835
Signat Date
a eceiving Facility Date
t5form4.doc- 03/06 System Pumping Record - Page 1 of 1
TOWN OF NORTH ANDOVER
APPLICATION FOR PLAN EXAMINATION
Date R eceived
Permit NO:
Date issued: ORTANT: Applicant must complete all items on this page
V Iv f""
LOCATION T, I J 4,
P n
0
(z - Z ,
PPOPERTIYQVVN- --- _. I - �w 1 ob �y ear OKStrupture yes no
Print
isto-ric Qistric yes no
A � M NO: PARCEL: ZONING U)ISTRICT: H
P Machinp� Shop Y!Hage yes ho]
.TYPE OF IMPROVEMENT, PROPOSED USE
Residential Non- Residential
f
jJ.y
0 ne am Ily
0 New Building 0 One family tam 11 Industrial
di
Ing re
ED] Two or more family
E�l Addition f t Commercial
7 No. of units: -
0 Alteration 0 Assessory Bldg El Others:
El Repair, replacement [I Other - -_;
El Demolition 0 Watershedbisfr�
_�Ioo in 0 Wetlands
El SqptiQ Q Well
E! ater/Sewer
DESCRIPTION OF WORK TO BE PERFORMED:
-5
L) CL —rO
L)C--T /v L L_
identification Please Type or Print Clearly) Phone:
OWNER: Name:
Address:
C CONTRACTOR Name: aojl'Llj�,4 (�'Aqjvo "Rhone:-
O'*�
Addr
S -E-xp
�S p! Construction License:
,qpprvisQr,5
_u
-,:Exo. P?LIE�:
ry
Hprpg �mpjovQment Lig n e:
ARCHITECT/ENGINEER Phone:
Address: Reg. No. R S.F.
TED COST BASED ON $125-00 PE
FEE SCHEDULE. BULDING PERMIT.- $12.00 PER $1000-00 OF ThE TOTAL ESTIMA
FEE:
Total Project Cost: $
Check No.:- Receipt No.: ty und
NOTE: Persons contracting with unregistered contractors do not liave access to the guaran f
af
Stamped Plans L1
gi*�jre_pi .9--
C' . . L_ - :4 4� - 14 1 1 PlnnQ IA/Aivpri F1 Certified plot Plan L1
IV,
14
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38
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P
Plans -Submitted 11 Plans Waived - El
- ..Certified Plot Plan Stamped Plans
TWEOUEWERAGEDI
Public Sewer El
TanningrMassagelBody- Art E].
Swimming Pools
well
Tobacco Sales E1
-Tood Pack�ging/Sales
Private�,(,septic ta*, etc-
Pemla]66fttI36mpster oif:Site El
.-THE...FOLLOWING SECTIONS FOROFFICE USE ONLY
INTERDEPARTMENTAL SIGN OFF - U FORM
-DATE REJECTED DATE.APPR-OVEQ
�PLANVIN '& DEVELOPMEN* El
COMMENTS
.CONSERVATION
COMMENTS
HEALTH
Reviewed
Reviewed o
COMMENTS AD
C, 5
4� 'EX
Zoning Board of Appeals: Variance, Petition No: Zoning Decisionfreceipt submitted yes_,.
Planning Board Decision: Comment
Conservation Decision: :Comment
Water & Sewer Connectio
DPW Tow;! Engineer: Signature: Located 384 Osgood Street
'"NT: Tei�hp Dumot& on site yps.
FIRE -DE1 AkfMk- no
PA
Lbbateffat:124 MairiStrdet'--
'Fire Depafti-nefltsigh4tueeldatq�
9.1
COMMENtS
'43,43 b Massachusetts Department of Conservation and Recreatio i NOV 2 9 2006
Office of Water Resources
TYPE OR,PRiNT,0NLY Wellrompletion Report., TOWN OF NORTH ANDUR' �3 18 0
1. WELL LOCATION _rGPS
T_ West 7"
(Required) North 0 �1 I— - - � . -
Address at Well Location: erty Owner/Client: 7 -a4we- e -
Subdivision Name, A V Mailing AddressA Ca
City/Town: d�) CityrTown: Ad
Assessors Mapi —Assessors Lot#: NOTE: Assessors Map and Lot # mandatory i no,street ad'ress available
Board of Health permit obtained: Yes M 00e Not Required 0 Permi6l suedjo-a-5--t,
2. WORK PERFORMED
3. WELL TYPE
4. DRILLING METHOD
6. CASING
Overburden
Bedrock
From (ft) To (fill Type, Thickness Diq'Wetej
At I V11-
130 t9v IL
5. WELL LOG
OVERBURDEN
I Water
Bearing
Zone
Loss or
Addition
of Fluid
Drop in Extra
Drill Fast or
Stem Slow
Drill Rate
EIDD
LITHOLOGY I
7. SCREEN
From (ft) To (ft) - Type Slot Size Diameter
From (ft) To (111) Code
Color Comment
Y N
Y / N F S
El El 0
,�L6 `40 C -L
Y N
F S
Y/ N �v
El 0 El
tL
Y/ N
Y/ N S
11 El El
Y / N
Y/ N CT� S
8. ANNULAR SEAL/FILTER PACK/ABANDONMENT MTL,
1W ICA_
LG
I Y / N
Y N S
From (ft) To (ft) Material Description Purpose
L
Y/ N
Y N
El 1:11:1
Y I N
Y N F/ S
E]E] D E]
Y N
Y N F S
-1 E
1:11:1 E -1
ILoss
Y
N
Y N F S
D F] F1 F]
WELL LOG
BEDROCK
Water
Bearing
Zone
Drop in
Drill
Stem
Extra Extra
Large Fast or
Chios Slow
Drill Rate
Visible
Rust
Staining
or
�Addition Fractures
of Fluid
9 of
perfDot
9. SITE SKETCH
LITHOLOGY
A
From (ft) To (ft) Code
Comment
10;1@L00 Tiz
;�,n
LY) / N
Y / N S
Y/ N
Y / N
zlo(.� 2" 1 T) Z
k)l N
Y /N S
Y/ N
Y/ N
Roo 400 DT
Y /N
Y /N S
Y / N
Y / N
Y / N
Y N S
I
Y/ N
Y1 N
()u k�o
Y I N
Y N I S
Y/ N
Y/ N
660 Dou
Y / N
Y N S
Y/ N
Y1 N
Y N
Y N F/ S
Y1 N
Y1 N
Y N
Y N F/ S
Y/ N
Y/ NJ
Y N
Y NIF I SlY
/ N
Y/ Nj
1
1 F / SJY
/ N -Y
/ NJ
10. WELL TEST DATA (ALL SECTIONS MANDATORY FOR PRODUCTION
WELLS)
11.
STATIC WATER LEVEL (ALL WELLS)
Date .Method
Yield Time Pumped Pumping Level Time to Recover Recovery
(GPM) (hrs & min) (R. BGS) (hrs & min) (ft. BGS)
Depth Below
Date Measured Ground Surf
,4c e (ft)
16-
as- X: -0 60
12. PERMANENT PUMP (IF AVAILABLE)
13. ADDITIONAL
WELL INFORMATION
Pump Description
PumpintakeDepth
Horsepowe,
(ft) Nominal Pump Capacity (gpm)
Developed Y / N Fracture Enhancement Y
Disinfected N Surface Seal Type
Fotal Well epth -:70-a Depth to Bedrock
14. COMMEN TS
15. WELL DRILLER'S STATEMENT This well was drilled, altered, andfor abandoned under my supervision, according to-appliGable
ct
b, kind regulations,'and this reporW mplete and cNect to the best of my knowledge.
Driller: Ve
ising Driller Signature: Registration #J
=- altGftplete: A/__
Firm: (X!5 f Rig Permit#: -7
NOTE.- Well Comptietion Reports must be filed by the regis4qed well dyiller within.30 days of well completion.
01
Section' 2
Well
Work
Work
Performed
Performed
Code
Decommission
DC
Deepen
DP
Hydrofracture
HF
New Well
NW
Repair
RP
Replacement
RE
Section 5
Well Completion Report Codes
Section 3
Section 4
Well
PM
Type
Well Type
Code
Cathodic Protection
CTPR
Domestic
DIVIST
Geoconstruction
GCON
Geothermal Closed Loop
GTCL
Geothermal Open Loop
GTOL
Industrial
INDS
Injection
INJC
Irrigation
IRRG
Monitoring
MONT
Public Water Supply
PBWS
Recovery
RCVR
Test Wells
TSTW
Section 4
Section 6
Overburden
Drilling
PM
Method
Drilling Method
Code
Air Hammer
AH
Air Rotary
AR
Auger
AG
Cable Tool
CT
Casing Advancement
CA
Core
CR
Direct Push
DIP
Drive and Wash
DW
Dug
DG
Mud Rotary
MR
Reverse Rotary
FIR
Sonic
SN
Section 6
Overburden
Pegmatite
PM
Section 7
Casing
Lithology,
Overburden
Overburden
Overburden
Bedrock
Anr�uiar Seal/Filter
Type
Thickness
Name
(OB) Code
Color
Color Code
Bedrock Name
(BIR Code)
Casing Type
Code
Thickness (NO CODE)
Artificial Fill
AF
Black
BL
Amphibolite
AM
Cerla-Lok
CTL
Schedule 5
Boulders
B
Bluish Gray
BG
Basalt
BS
Fiberglass
FBG
Schedule 10
Clay
CL
Brown
BR
ConglomeFa—te/Breccia
CG/BR
Galvanized Pipe
GLP
Schedule 40F
Coarse Sand
CS
Dark Gray
DG
Diorite
DI
HDPE
HDP
Schedule 80
Cobbles
C
Greenish Gray
GG
Gabbro
G13
NSF Coated Steel
NCS
Schedule 160
Fine Sand
FS
Light Gray
LG
Gneiss
GN
PVC
PVC
SDR 13.5
Fine to Coarse Sand
FCS
Reddish Brown
RB
Granite
GR
Stainless Steel
SST
SDR 17
Gravel
G
Yellowish Brown
YB
Limestone
LS
Steel
STL
SDR 21
Medium Sand
MS
Description
Marble
MA
Well Seal
SDR 26
Organics
0
Type Code
Quartzite
OZ
20
Cement
SDR 32.5
Sand & Gravel
SG
3WSS 3,14
25
Rhyolite
RH
Constant Speed Submersible Turbine
SDR 40
Silt
Sl
CT
Sandstone
SS
40
None
17#
Silly Clay
SICL
JET 2
50
Schist
SC
Line Shaft Turbine
19#
Silty Sand
SIS
Shale
SH
75
Siltv Sand & Gravel
SISG
7-1/2
100
Slate/Phvilite
SUPH
Till T
Pegmatite
PM
Section 7
Section 8
Section 10
Anr�uiar Seal/Filter
Screen
Annular Seal/Filter
Vack/ Abandonment
Purpose
Method
Screen Type Code
Pack/ Abandonment
Material Code
Purpose Code
Method
Code
Carbon Steel CST
Bentonite Chips/Pellets
BC
Fill FIL
Air Blow with Drill Stem
AB
Continuous Wire PVC CWP
Bentonite Grout
BG
Filter FT
Air Lift
AL
Galvanized Wire Wrapped GWW
Cement/ Bentonite Grout
CB
Seal AS
Bailing
BL
Perforated Pipe PFP
Concrete
CT
Constant Rate Pump
CR�
Pre -pack PVC PPP
Sand
SID
Variable RatcPwmp.�T
_VF -
Pre -pack Stainless PIPS
Native Material
NM
Slug
Slotted PVC SLP
Stainless Steel Vee Wire SSV
Stainless Steel Well Point SSP
Section 12
Section 13
Pump
Description
Well Seal
Pump Description
Code Horsepower
Surface Seal Types
Type Code
2 Wire Constant Speed Submersible
2WSS 1/2
20
Cement
CM
3 Wire Constant Speed Submersible
3WSS 3,14
25
Cement/ Bentonite
C13
Constant Speed Submersible Turbine
CSST 1
30
Concrete
CT
Variable Speed Submersible Turbine
VSST 1 1/2
40
None
NO
Jet
JET 2
50
Line Shaft Turbine
—LST 3
60
Centrifical
CENT 5
75
7-1/2
100
COMMONWEALTH OF MASSACHUSETTS
North Andover
Board of Health
WORDEN, JAMES D & ANITA RAJAN WORDEN
-----------
NAME
84 ACADEMY ROAD
------ ----------------------------------------------------------------------------------- --------
ADDRESS
IS HEREBY GRANTED A PERMIT
Well Construction
This permit is granted in conformity with the Statutes and ordinances relating thereto, and
expires ---------------- Octob-er-2-5-,-2-006 --------------- unless sooner suspended or revoked.
September 25, 2006
--0 ---------------
---------------------
NUMBER
BHP -2006-0259
FEE
$135.00
Board of
Health
Town of North Andover
HEALTH DEPARTMENT
Li
CHECK#: 7
LOCATION:
H/O NAME: �;V zi
CONTRACTOR NAME:
Type of Permit or License: (Check box)
0 Animal
0 Body Art Establishment
0 Body Art Practitioner
0 Dumpster
0 Food Service - Type.
0 Funeral Directors
0 Massage Establishment
0 Massage Practice
0 Offal (Septic) Hauler
0 Recreational Camp
0 Sun tanning
0 Swimming Pool
0 Tobacco
0 TrashlSolid Waste Hauler
eWell Construction
SEPTIC Systems:
0 Septic - Soil Testing
0 Septic - Design Approval
0 Septic Disposal Works Construction (DWQ
13 Septic Disposal Works Installers (DWf)
[3 Title 5 Inspector
0 Title 5 Report
5
T"
C
0 Other (Indicate) $
1810 Health Agent Initials
White - Applicant Yellow - Health Pink - Treasurer
TOWN OF NORTH ANDOVER
Office of COMMUNITY DEVELOPMENT AND SERVICES
HEALTH DEPARTMENT
1600 OSGOOD STREET; BUILDING 20; SUITE 2-36
NORTH ANDOVER, MASSACHUSETTS 0 1845
Susan Y. Sawyer, REHS/RS 978.688.9540 —Phone
Public Health Director 978.688.8476 — FAX
healthdeptgtownofnorthandover.com
www.townofnorthandover.com
Well and/or Pump Application
(Please print) DATE:
LOCATION to Drill Well or install a pump:
Ak
Licensed Well Contractor Name and Company Name:m
On (Ol +
Contact Phone Numbers:
' '
Homeowner.�CLVN'\e—,Zjj ('0 "4%'y
Address: S'� Aaje4M,4--\�O
-72 �t
Contact Phone Numbers:
WELLS (to be completed at time of pump test)
Typeofwell: b-zc, lhut.%J Use:
Diameter of well: Size of Casing:
Depth of bedrock: Depth of casing into bedrock:
Seal been tested? Yes( No( Date of test:
Depth of well: Water -bearing rock:
Depth of water: Delivers: GPM for:
(how long)
Drawdown: feet after pumping: hours at: GPM
Date of Completion:
PUMPS (To be filled in before installation)
Name & size of Pump:
Size
Pipe used in well: Cast Iron
Sleeve used to protect pipe? Yes
Date:
Date water analysis report submitted to Health Department:
Plumbing
Signature of Well Contractor
Type:
Pump delivers: —GPM
Galvanized Plastic
No_ Type of well seal:
Wiring Inspector
Signature of Pump Installer
C:\DOCUME—I\bcurran\LOCALS—I\Temp\WelI Application.doc
Health Department Representative
1 A
4
J_j
aAl
xj.
I
3-1
14.
4' AL I
Town of North Andover RE: Applications for a permit to drill a well:
Before a permit can be issued, you must have your contractor submit the following:
1. Submit to the Health Department a site plan showing the house and or lot
footprint
2. Indicate any wetlands within 200 feet of the proposed location for the well
3. Indicate the well location
4. Submit a check for $135.00 with the application
Note: All submittals must be drawn to scale. Please note that you may also be
required tofile with the Conservation Commission if wetlands are near to the
proposed well, and to the Planning Board ifyou are located in the Watershed
District.
Commonwealth of Massachusetts
City/Town of No Andover
System Pumping Record
Form 4
RECEIVED
JUL '10 2013
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 within 14 days from the pumping date in
accordance with 310 CIVIR 15.351.
A. Facility Information
Important: When
filling out forms
1 . System Location:
on the computer,
use only the tab
84 Academy Rd
key to move your
Address
cursor - do not
No Andover
use the return
City/Town
key.
2. System Owner:
Worden
Name
Address (if different from location)
City/Town
B. Pumping Record
1. Date of Pumping
3. Type of system:
El Other (describe)
Ma
State
State
Telephone Number
Zip Code
Zip Code
&' j I-V n-
2.. antity Pumped:
Date Gallons
Ptic
El Cesspool(s) ;�S�epticTarnk Tight Tank El Grease Trap
4. Effluent Tee Filter present? El Yes [:] No If yes, was it cleaned? E] Yes Ej No
5. Condition of System:
C- Cj C)
6. System Pumped By:
Name Vehicle License Number
Stewart's Septic Service
Company
7. Location where contents were disposed:
Stewart's Pre-treatment Plant, 20 So. Mill Bradford, Ma 01835
�ate
Sign iving Facility Date
t5form4.doc- 03/06 System Pumping Record - Page 1 of 1
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SUBSURFACESEWAGE DISPOdAt BYSTEM'INSPECTION FORM
I
pr rty
Address of sf A mJe44,w'
Owner's name %A*AS1!7MRVU . � f,
Date of Inspection
7
PART A �7
CHECK.LiST-
Check if the*following have been done;
Pumping information was requdst.ed,of the owner, o cupan oard of
Health.
L) -None --of the*system compon I ents 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-thl's inspection.
As built plans have been obtained andlexamined. Note if they are not
available with.N/A.
.The. 'facility or dwelling was insp'ecte-d, f or, signs of..sewage back7up.
The.* site was i
_A system com v - e been 1 ocat ed on t I he
4*�— The septic tan ried,.and the interior of
the septic.tan Df -'-baffles . or tees,
co
Df liquid, depth of
sludge,:,depth
si ze and 1 has been determined based
on existing in Pn-intrusive methods.
The facility.o :.-nt from owner) were
..provi.ded with
:enance of SSDS.
r"ZIL-11
SUBSURFACE SEWAGE DISPOgAi S'Y'ST'EH'INSPECTION FORM
A
Address of pr . o gi A
,perty
Owner's name
Date of Inspection
7
PART A
CHECK.41ST,
Check if the*following have been done:
Pumping information was requdsted-of the owner, o cupan oard of
Health.
t)_ -None ---'0f the system compon . ents have been pumped for at least two weeks
and the system has been receiving normal flow rates during that
..period. Large volumes of water have not been introduced into the
system recently or, as part of -this inspection.
As built plans have been obtained and,examined. Note if they are not
available with.N/A.
The -facility or dwelling
'was is i66t6d,f o
n c
r, signs of..sewage back7up.
The'si'te was inspected for signs. -.Jo -,,�br6akout.
-Z.-Al 1. system components, :.excludingz'Ahe, SAS, hay.e,-been located on the
'4� -The septic tank manh'6146'-' 'were - uncovered, opened, and the interior of
the septic.tank was inis�,�'cted�-forcondition of' -baffles or tees,
�"-material,�of construction, --dimensions, depth of liquid, depth of
sludge.,.,depth of scum...
e.size and location*of the SAS.on the site has been determined based
...on'existing information or _ approximated by non -intrusive methods.
The facility -owner (and.occupant s, if different from owner) were
....provided with information,on th'
e.proper,maintenance of SSDS.
9
SUBSURFACE SEWAGE DI6POSA INSPECTION FORM
P T
AR B
-SYSTEM INFORMATION coptinuad
SEPTIC TANK: j(.
(locate on site plan)
f
depth b6lo"w. grade:
material of construct ion conoireite"'iL�, metal ;FRP -other(explain)
dimensions:
L v &-6 " t J V - 6
W0rQ_ sludge',depth
�Aistanc.e,from top of.sludge to.-b6ttom of outlet tee or baffle
X)nvQ scum 'thicIcneSs
distance'from top,of.scu
to.7top of outlet tee or baffle
distance-.ftom bottom,.of.scum to bottom:of outl'
et tee or baffle
Comments:
(ieco,ime"ndaition for pumping . .condition of inlet and outlet tees or baffles,
depth of liquid level in relation to outlet invert, structural integrity,
evidence�,of,leakacw, repommvndat�"s ,:.for repairs., etc.)
No. tv,.ka r. n' x1v - I LA .0 .0
DISTRIBUTION.BOX:
Jlocate'-on.. site plan)
depth of li quid level above outlet invert
comments:
Ano'td7if.�level and distribution is equ . al, evidence of solids carryover,
evidpncp ofjyj��ge i to'6t-out of. pbpi� recorPpnd9t1Rnjfor.repairs, etc.)
Comments:
(not'6'cond'it'ion of Pump.chamber.,.condition of -pumps and appurtenances,
recommendations for maintenance or repairs*,etc.)
SOIL ABSORPTION SYSTEM"(SAS):
(locate on site plan, if possible,-..�"excavAtio.'n..not required, but may be
4pproximated',by non-intrusive.methode.)
.If..:not.:determined* to be prpppnt,-.� e�cpjal
Wype,
leaching
leaching
leaching
leaching
leaching
overflow
pits and number
chambers and number
galleries,and number.,
trenches,.nuib.er','length, s5r
fields, number, dimensions:
cesspool, number
Comments:
(note condition
CFPCIAtlop, of' Ye
� �% A .1 - t 1- 10 &-,1 1
of soil'...s i
gns.of hydraulic,,failure,
eta:ti e -d
91? i, &9Vftm t '.for.ma
Ant?c
CESSPOOL$ (locate on sitepian)':
number and configuration
depth top of liquid to inlet invert-
depth.'of solids layer
.depth of scum layer
dimensions of cesspool
materials -of construction
indication,.' of,groundwater
inf 1 o*w-'(6es spool must be -pumped as:�'�
part of inspection)
level of pondirig,
tnc,e or repairs,etc.)
Comments:
(note condition of soil, signs -of..'hydraulicfailure, level,'of ponding, -
condition of vegetation, recomme'riditi6fis'for maintenance or r p'i
e a rs,etc.
PRIVY:..s
(locate'on 'site plan)
materials.of construction
..dimensions.,
depth,of.:.�olids
Comments:'.-
(note--condition'of soi
1,,si4ns of'hydraulic' jailure,-level of ponding,
condition -'of --vegetation, rec'
..,''.,",..o=enddt'i,�ps,-,f.o,r ma ntenance or repairs,etc.)
8K Rimy ('�
..SUBSURFACE, SEWAGE, DIP.)NAA
--T,��OYSTZM INSPECTION,FORM
SYSTEMINFOI
,XTION:cohtinued
0
SKETCH `IOFI`.`SEWAGE DISP SAVSYST M
include ties:to at least two, pgrmaLnent,...t:,,i74iferiBnces-' landmarks or benchmarks
-locate all wells within 1001.
�,.�DEPTli:'.TO"-'-..'dROU14Dl4ATER:"- :P 10,
depth to groundwater
��;-,.�method.-�of �'determinat4on. or,approxiiationo."
� f,!6-
77 -7,;W:
SUBSURFACE.,SE,WAGE�DI:SPOSAL,SYSTEM INSPECTION FORM
FiXtUMORtTERIA
or KD) Describe basis of
Indicate,yes,. no, or not.:. mindd..."-(Y: N
determin.ation.in all �instance.s.: �!,-.if-..�.�,�,!'.,n6t,,determined",- explain why not)
sewage. into -facility
Discharge. or ponding of. e,f f the surface of the ground or
sukfac
e.,waters?
_�Static :liquid level,in.'the �dis '"ib* i
tr ut on box,above.outlet invert?
---Liquid.-depth. in.cesspo ol <691'be10w* invert or. available volume< 1/2 day
flow?
W_Required pumping-4..times or tore in.th'e last year?
number of times putpo_d�
Septic tank is.metal?. crackevifstructurally unsound? substantial
infiltration?.substantial exfiltr.ation?: tank. -f a I ilure imminent?
__L.Is any portion of the,SAS,,cesspool or privy:
.below.the high groundw.a.ter,eley'ation?
within 50 feet of a surface water?
-.:Within'.100 feet of -a surface'water:su ply or tributary to a surface
..,.water supply? P.
within a Zone 1. of a public well?
within 50 feet of a borderin"
svegetated wetland or..salt marsh
.(cesspools and privies.-only'l. :not:,,'the�, tASj?'
..��L,�within 56 feet of a priVate,,waterl.supply well?
100 'feet, but"''greater"'thari 5 0 feet fr' 'a'private water
om
.,.Supply:'well'' with. no�':acceptabl, t, - 1" t "analysis? If the well
p. wa. er qua 1 y
has.'.!,b tp'.��'wbei �,accep
een analyzed� tabl'i"'
a, ei,.attach'copy)of�well water analysie
F�1111f�!�7,for"*coliform, bacteria;'--.volati compounds.'*'' ammonia -nitrogen
tg,4nic"
nitrate nitrogem
13
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
VART D.
Name of Inspector.
Company Name
company Address'
Certification Statement
I certify that.I have personally inspected the sewage disposal system at
this -address and:that the information reported is true, accurate and
complete as of the.time.of inspection The inspection was performed and
.any recommendations regarding.upgrade; maintenance and repair are
consistent with my training and experience in the proper function and,
manitenance of on-site sewage disposal systems.
dheck one:
Y- I have not f ound any information which indicates.that the system fails
..to adequately protect public-,h.e.alth or the.environment as defined in
310 CMR 15.303. Any failure criteria not evaluated are as stated in
the FAILURE -CRITERIA section of this form.
I'h,ave determined that.,the system fails to protect.public health and
the -environment as defined.in :.31.0..,.C.MR 15.303. . The basis for this
:.determihation'is provided in.the�FAILURE CRITERIA section of this
form.
.Inspectorl.s Signature
Date Cn �5�
Original to system owner
copies to: -
Buyer (if applicable)
Approving authority
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be submitted to the.local'Board of H -Ith or other approv 9 a t rity.
ea
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�.!�cWfiinlilllng out'. 1 Systeni Locatlon::*..
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Y. Mp Pode
12 System
.0
Name
v:
Addrm (if different from 10 Uon)
C4
-State
Zip Code
olophone N m or
P mping R666rd.��:�r
U
-o Pumoing,,".-
f
2. Qua'nUty Pumped:
Date/
Gallons
ypQ pf'system:
*Meptic Tank
Tight Tank
T,
ther (describe):
0,
Efflueht
4
Tee' FlIter Ores� If yes, was It cleaned? E) Yes--S;jkO
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tion,whOrs' re disposed:
con ntswe
Date
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. . . . . . . . . . .
2ZI
Telephone Nurn4�
LIMAM
Date
.06/Q3
t5formCdw
SYStem Pumping Record Page 1 of 1
Important:
When filling out
forms on the
computer, use
only the tab key
to move your
cursor - do not
use the return
key.
'14" 41
....... V....QnW6a1th:of Massachusefts
�-:Clt
WTown of,*NORTH ANDOVER, MASS ACRUSHTTS
SYstem Pu"'mPing Record
-,.Torm 4 SEP 6 2006
DEP has provided this form for use by local Boards of HealthL�,f,'V'
,yj,jj(A �, %
, y-,,piMRecord mu,,
be submitted to the local Board of Health or other approvIn _,T#, ,
g tAority-.=z--J
A. Facility Information
1. System Location:
2
Address
CityfTown
SvstemOwnpro
-�t —at 8 Zip Code
Ni—M-9
Addrem (if different fro�;-1ocati�—n)---'
�E—fty(T�w—n C de
Te �ephone i;6� 4er
B. Pumping Record
1, Date of Pumping
I Type of system: 0
COO C)
2. Quantity Pumped:
DaW Gallons
Cesspool(s) 11.,�Septic Tank Tight Tank
— [I Other (describe):
4. Effluent Tee Filter present? El Yes El No
5 Condition nf.4z ata
Pumped By:
I - -.1 1 - A n
If yes, was it cleaned? 0 Yes [I No
Name
Vehicle License Number
Company
7. Location where contents were disposed:
Aw
I S ature ot Haul
40 ot Hau Date
http://www,mas§go ep/W ter/
V/Oip a Provals/t5forms.htm#inspect
(5form4.doc- 06/03
SYst8M Pumping Record - Page I ot
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TOWN OF NORTH ANDOVER
SYSTEM PUMPING RECORD
DATE:
S� STEM OWNER & ADDRESS
SYSTEM LOCATION
(example: left front of house)
FK -c m cc&, 0
Yll/ 01w sl-t�c (OvItr
DATE OF PUMPING:& -/3-62- QUANTITY PUMPED7—OVt GALLONS'
Cf'SSPOOL: NO Vl---�YES SEPTIC TANK: NO YES V/111�
NATURE OF SERVICE: ROUTINE V---<MERGENCY
013SERVATIONS:
GOOD CONDITION
HEAVY GREASE
ROOTS
EXCESSIVE SOLIDS
SOLIDS CARRYOVER
�'Y.STE.P�l PUMPED BY:
CONINI E N T S:
CO."NTENTS TRANSFERRED TO:
FULL TO COVER
BAFFLES IN PLACE GIX
LEACHFIELD RUNBACK
FLOODED
OTHER (EXPLAIN)
ORT A
TOWN OF N /NDOV
p I
L) A t'F. SYSTEM PUM NO KECOR
A & ADDRESS
SYSTEM OWNIE.
AA 47 1456141��
RECEIVED
NOV - 3 2004
TOWN OF NORTH ANDOVER
HEALTH DEPARTMENT
SYSTEM LOC�ATION
m
DATE OF PUMPING: PUM`PED:
CL.'3SP(X)L: SOP(ic Tank: NO� YEOC
�4A ruRb OF SERVICE: KOUTtNE. FLMIRC!EN(,')'
06-ShRVA r1UNS:
GOOD CONDITION FULL 'T)() covER
HEAVY OREAsE BAFFLES IN PLACL
ROOTS LEACKMELD RU`NBACK
6XCUSIVE SOLIDS _____FLOODED
SOLID CARRYOV'ER,'-.,,,._, OTtfER EXPLAIN
systom Rumpcd by
-7
'�K
J-4- + 4-
44 4
j4
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-4- 4-4- -
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1 40
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4- 4
+ 4. 4. 1 L.-
Boa -rd of Haalth
North And_OV_e_r__,'V-�33*
FAIL
00/93, .. �
SEMO SISTEK
INsTALLATICK CHIM LIST
LOT"O'
[�XOAVAffN OK FAIL
OK
1. Distance To't
a. Wetlands
b. Drains
0.� wen
2., Water Location
3- No PVC Pipe
Septic Tank
a. -Tees !.-Length To Clean Oat Covers.
b. Cement Pipe to Tank - On Both Sides of Tank
Distribution Box
a. Covers & Box - No Cracks
b. All Lines Flowing Equal Amounts
c. No Back Flow
Leach Field or Trench re-z-zo;�040 ee,,
a. Dimensions
b. Stone Depth
ae Capped -Ends -
d. - --Clean Double Washed Stone 70
7.
Leach Pits
a*
Dimensio
�tt_-hn
b
2-�O
C:
rim""P—ads
d 0
8
ment pipe to Pit Both Sides.
CGlarbage-
Zlo
Clean Double Washed Stone-
8 .
ar Disposal
9.
Final,
Grading Inspection
10.
Barricading Covered System
11.
As
Built Snbndtted
a.
Lot Location
b.
Dimensions of System
c.
-Location with Regard -to Pere Test
d.
.-Elevations
e.'
Water Table
ozc>
>e ee"a
7,7* r7l
Board of Health"�"
',ndov-er.,rIaB3'/
APPROVED
Provide,d:
A
1.),
SU3SRFkCE DISPOSAL -DESIRI CEMOK LIST
DISAPFROVED DATE
Reasons:
LOT AcAI)eqv- �c,
I
Title V FATLL OK 12,
Reg 2.5 The submitted plan ITaBt Tffi ni raum:
P1
the lot to be served 9di-mens-ions lot # abutters
1b, location and log de observation holes-dis2tance to ties
�c location and results percolation tests -distance to ties area
d . design calculations & calculations showing requireA leaching
'(e) location and dimensions of system-inclu ding r-esexy area
(f ) existing and praposed contours
(g) location any wet are�as Athln 100' of sewage disposal system or
. di sclaimer- check watlandB mapping e -,,-age disposal
(h) surface and subsurface drains within 1001 of s
system or disclaimer
(i) location any draina-ge easements vithin 1001 of sei�Age disposal
system or disclairer-Plauuiing Board files
(J) kno-= som-ces of vater sL-pply within 2001 Of SE-,�e disposal a
systen or disclainer
(k) location of any proposed izell to serve lot -1001 from leaching facill
(1) location of ,,-ste-r lines on property -101 from leaching facility
_(m) location of benchmark
(n) driveways
-j __(o) garbage disposals
I (p) no PVC to be used in construction
T_ (q) profile of system- el evation s of basen-ent., plumb., pipe., septic tank.9
distribution box inlets and outlets., distribution field piping and
OtLer elevations
(r)-ma-ximam ground water elevation in area sewage disposal system
s plan mst be -prepared by a professional Ragineer or other
e such plans
pA-ofessional authorized by law to prcpar
Reg 6 Septic Tanks
(a) 'ii_�scitie,5-150,% Of flow) -,Fater table., t�ees., dep-Lb of tees,,
accees' pu;rping
(b) .1 -,Ian-ut
(c) 10, from cellar -,,-all or inground s-u.�-�g Pool
251 from subsurface 6rains
Reg 10.2 Distribution Boxes
I I (a) slope gr� �ter t�han 0-08
Reg 10.4 -] It b) suvp
Subsurface Desip heek'.List Page 2
Reg 1.1.2
11.4
11.10
11.11
Reg 15.1
15.4
15.8
3.7
Reg 3-4.1
14.3
1h.4
3-4.6
14.7
]J,. 10
Reg 9.1
9.6
FAIL
OK
LeachLng Pits
Leaching pits are preferred where the installation is possible
a) calculations of :Leaching area"-'rdninum 500 eq ft
b) spacing
c
a surface drainage 2%
d� cover material
e) 2'x2'x4II splash pad
f) tee at elbow
g) no bends in pipe from d -box to pipe
Leaching Fields
a) no gmater than 20 udzutes/inch
,b) area-rdnizrm 900 sq ft
e) construction of field
.d) surface drainage 2 %
e) 201 fi-om cellar or inground swimving pool
Leaching Tronches
a) calculations of leaching area -min 5CO sq ft
spacing -4 ft zdn 6 ft, with reserve between
c) dim-misions
d) constaaction
e) Stone
6 f) surface drainage 2%
Dowahill Slope
a) _sl;�DTey x__:-�JEo be sho,,nn)
b) y/x X 150 = (to be shown)
PW. -z a
�a) approval
starrid-by power
':b)
-=]:--,b)
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