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Miscellaneous - 90 BOSTON STREET 4/30/2018
til 1 �. .1 .•M. 'i � 7`� , * MFF �L �A ,J'•�• � r �',1S'ii y ^ �a� �17y '�'` • �' 1 'r � -� - l , r 5'. !S t�� i � Si...'..,w Y�.,�Lt� �7 �'Ky t1.j � � � �i+•. MAP #F ; - LOT • # PARCEL # STREET ' �O.NSTRUCTIO.IV APP __. V:... HAS PLAN REVIEW FEE .BEEN PAID? YES NO r PLAN APPROVAL: DATE 1 Z �s APP. BY� DESIGNER: J1 / U� �� PLAN Dam. CONDITIONS WATER SUPPLY: TOWN ) WELL WELL PERMIT DRILLER, WELL CHEMICAL DAIE APPROVED .; BACTERIA I DA I E ()PPRUVED BACTERIA II� - _ DA7•E APPROVED COMMENTS: FORM U APPROVAL: APPROVAL i'U ISSUE YES NO DATE ISSUED BY CONDITIONS: FINAL APPROVAL: ALL PERMITS PAID YES NO WELL CONSTRUCTION APPROVAL YES NO SEPTIC SYSTEM CONSTRUCTION APPROVAL YES NO OTHER YES NO ANY VARIANCE NEEDED YES NO FINAL BOARD OF HEALTH APPROVAL: DATE: IIY: �' �_: -,::�� . , �EPTIC�S��Z�M�.NSIfl�L.gtIQN • - .. •_ .. <_ y 'LrI •�, •i. � . r;•:_" ,. 1 y 'ir':.. .-';�.• 1.'.:r•°.:,_ "i ";1 t a r 7 �, 1. ' _ - �.x 1 IS THE INSTALLER LICENSED? i ` yrl YES NO - ,. TYPE.OF CONSTRUCTION: _ NEW REPAIR NEW CONSTRUCTION: CERTIFIED PLOT -PLAN REVIEW : YES NO CONDITIONS OF.. APPROVAL YES NO (FROM FORM U) _ _.,ISSUANCE OF DWC PERMIT YES NO DWC PERMIT`' N0. / INSTALLER: .aur: �'' . ' . TBEGIN INSPECTION YES N0. .._ EXCAVATION, INSPECTION: 'NEEDED: ' PASSED � 5 .. rCONSTRUCTION INSPECTION: NEEDED: As BUILT PLAN SATISFACTORY:•-� vF�, APPROVAL TO BACKFILL. DATE: �7 BY X7A .;F3NAL.GRADING APPROVAL: DATE % DATE: lz wlk BY Commonwealth of Massachusetts T City/Town of JUL 3 2014 System Pumping Record TOWN OF NORTH ANDOVER Form 4 HEALTH DEPARTMENT �il 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 house, Left/ right side of house, Left/ Right side of building, Left / Right front of building, Left / Right rear of building, Under deck Address /� V 2)0�— City/Town State 2. System Owner. 1 �' Name Trp Code Address ('d different from location) CitylTown State pe Telephone Number B. Pumping Record Com.` 1. Date of Pumping Date ;Septic . Q ntlty Pumped: Gallons 3. Type of system: F]Cesspool(s) Tank ❑ Tight Tank ❑ Other (describe): 4. Effluent Tee Filter present? ❑ Yes to If yes, was It cleaned? ❑ Yes ❑ No. 5. Condition stem: J. bai � 6. System Pumped By.- Nell y: Neil Bateson Name Bateson Enterprises Inc- Company naCompany 7. Lgce*"ere contents were disposed: Waste Water F5821 Vehicle License Number r?-- 2 Y— Date t5form4.doc• 06/03 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. Commonwealth of Massachusetts City/Town of No Andover System Pumping Record Form 4 RREc `: t aD SEEP '12 2013 TOWN OF NORTH ANDOVER HEALTH DEPARTMPniT 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. Befo;e using this form, check with your local Board of Health co determine the form they use. The System Pumping Record must be submitted to the local Board of Health or other approving authority within 14 days from the pumping date in accordance with 310 CMR 15.351. A. Facility Information 1. System Address No Andover Cityrrown 2. System Owner: Name C\� Address (if different from location) City/Town B. Pumping Record 1. Date of Pumping Date 3. Type of system: ❑ Cesspool(s) ❑ Other (describe): 4. Effluent Tee Filter present? ❑ Yes 5. Condition of System: 6. Sys m Pumpe Name Stewart's Septic Service Company 7 Location where contents were disposed: S7 Ma State State Telephone Number 3 , 2. Quantity Pumped: Tank ❑ Tight Tank Zip Code Zip Code (6GU Gallons ❑ Grease Trap If yes, was it cleaned? ❑ Yes ❑ Vehicle License Number Stewart's Pre-treatment Plant, 20 So. Mill Bradford, Ma 01835 ignature of Hau er Date Signature of Receiving Facility Date t5form4.doc• 03/06 System Pumping Record • Page 1 of 1 Commonwealth of Massachusetts I* City/Town of NORTH ANDOVER_ , MASSACHUSETTS System Pumping Record Form 4 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. System Location: forms on the computer, use only the tab key Address to move your cursor - do not City/Town �l use the return key. 2. System Owner: Name -- (S4,22if--- '" Address (if different from location) City/Town B. Pumpi MAY 11 2006 TOWN OF NORTH ANDOVER Date of Pumping Type of system Zip Code State / �Zii Code 977f-— GOPc5r �'Co Telephone Number Ulu 2. Quantity Pumped ❑ Cesspool(s) Septic Tank ❑ Other (describe): Gallohs ❑ Tight Tank 4. Effluent Tee Filter present? ❑ Yes 4 No If yes, was it cleaned? ❑ Yes ❑ No 5. Condition of System: O� C:1 Syst m Pumped By: Name Vehicle License Number A6 �0 CSS e Company 7. Location where contents were disposed: z I —elle e—, —zvg�� Si ature of Hau Date http://www. mass. gov/dep/water/approvals/t5forms. htm#inspect t5form4.doc• 06/03 System Pumping Record • Page 1 of 1 IUer Alvrbvcr UJb Minin St Jt/e fl A runa/err "v1 MORT' S SE MC TANK SERVICE 47 RAIlx= gi'gELrp WNNM,, Iii 81835 978.372-7471 mom OF ADEPMS G- �� lS�p vec / 90 7 7 /U� For-sl-�5-1 /d ,a �Saa �3 �xbeL4j C,,,- } 520 ��- lo 7bck 'Fct (m P b 1 15,50 1� do 16�p FORM 4 - SYSTEM PUMPNG RECORD Commonwealth of Massachusetts & ���Gv�, , Massachusetts S stem t'um rn Record wne f ystem ocatton Senrx &S4e)" s1 CGvc,r -0 Grade k a C 4rAe MJ1 ? -}�--- -TOWN OF NORTH ANDOVER r.�,pe Emergency ❑ Routine is HEALTH DEPARTMENT ❑ S� tic Tangy:: No ❑ Yes Cesspc 01: No ❑ Yes P Quantity Pumped: gallons Date (.:' Pumping:_.--- ,BORACZEK'Spermit Sestet:: Pumped by (Company): Conic .is transferred to: Cont -,.tis disposed at: 1 w z,, isD pate —3— /7 1t Pumper Signature G�Uri! Conc ition of system/other comments: DEP APPROVID FORM • 1:/07/95 I certify that I have personally inspected the sewage disposal system at this address and that the information reported below is true, accurate and complete as of the time of the inspection. The inspection was performed based on my training and experience in the proper function and maintenance of on site sewage disposal systems. I am a DEP approved system inspector pursuant to Section 15.340 of Title 5 (310 CMR 15.000). The system: ® Passes ❑ Conditionally Passes ❑ Fails ❑ ly ecjs Furt*r Ev , IIq ation b)pthe Local Approving Authority F;//�. Date The system inspector sho sub a copy of this inspection report to the Approving Authority (Board of Health or DEP) within ys of completing this inspection. If the system is a shared system or has a design flow of 10,000 gpd or greater, the inspector and the system owner shall submit the report to the appropriate regional office of the DEP. The original should be sent to the system owner and copies sent to the buyer, if applicable, and the approving authority. ****This report only describes conditions at the time of inspection and under the conditions of use at that time. This inspection does not address how the system will perform in the future under the same or different conditions of use. t5ins • 3/13 Title 5 Official Inspection Forth: Subsurface Sewage Disposal System • Page 1 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form SEP ► 203 ER Subsurface Sewage Disposal System Form - Not for Voluntary Assessments TOWN o� NOIZT �*lDO T 9 P Y rY HEALTH DEF r . 7M�NT �A 90 Boston street Property Address Jennifer Ross Owner Owner's Name (/ information is required for every North Andover Ma 01845 8/15/13 Y page. Citylrown State Zip Code Date of Inspection Inspection results must be submitted on this form. Inspection forms may not be altered in any way. Please see completeness checklist at the end of the form. Important: When A. General Information filling out forms on the computer, use only the tab 1. Inspector: key to move your cursor - do not John DiVincenzo use the return Name of Inspector key. Stewarts Septic Serive � Company Name 58 South Kimball street Company Address » Bradford MA 01835 Citylrown State Zip Code 978-372-7471 S113386 Telephone Number License Number B. Certification I certify that I have personally inspected the sewage disposal system at this address and that the information reported below is true, accurate and complete as of the time of the inspection. The inspection was performed based on my training and experience in the proper function and maintenance of on site sewage disposal systems. I am a DEP approved system inspector pursuant to Section 15.340 of Title 5 (310 CMR 15.000). The system: ® Passes ❑ Conditionally Passes ❑ Fails ❑ ly ecjs Furt*r Ev , IIq ation b)pthe Local Approving Authority F;//�. Date The system inspector sho sub a copy of this inspection report to the Approving Authority (Board of Health or DEP) within ys of completing this inspection. If the system is a shared system or has a design flow of 10,000 gpd or greater, the inspector and the system owner shall submit the report to the appropriate regional office of the DEP. The original should be sent to the system owner and copies sent to the buyer, if applicable, and the approving authority. ****This report only describes conditions at the time of inspection and under the conditions of use at that time. This inspection does not address how the system will perform in the future under the same or different conditions of use. t5ins • 3/13 Title 5 Official Inspection Forth: Subsurface Sewage Disposal System • Page 1 of 17 Owner information is required for every page. Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 90 Boston street Property Address Jennifer Ross Owner's Name North Andover Ma 01845 8/15/13 CitylTown State Zip Code Date of Inspection B. Certification (cont.) Inspection Summary: Check A, B,C,D or E / always complete all of Section D A) System Passes: ® I have not found any information which indicates that any of the failure criteria described in 310 CMR 15.303 or in 310 CMR 15.304 exist. Any failure criteria not evaluated are indicated below. Comments: B) System Conditionally Passes: ❑ One or more system components as described in the "Conditional Pass" section need to be replaced or repaired. The system, upon completion of the replacement or repair, as approved by the Board of Health, will pass. Check the box for "yes", "no" or "not determined" (Y, N, ND) for the following statements. If "not determined," please explain. The septic tank is metal and over 20 years old* or the septic tank (whether metal or not) is structurally unsound, exhibits substantial infiltration or exfiltration or tank failure is imminent. System will pass inspection if the existing tank is replaced with a complying septic tank as approved by the Board of Health. * A metal septic tank will pass inspection if it is structurally sound, not leaking and if a Certificate of Compliance indicating that the tank is less than 20 years old is available. ❑ Y ❑ N ❑ ND (Explain below): t5ins - 3/13 Title 5 Official Inspection Form: Subsurface Sewage Disposal System - Page 2 of 17 Owner information is required for every page. Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 90 Boston street Property Address Jennifer Ross Owner's Name North Andover Ma 01845 8/15/13 Cityfrown State Zip Code Date of Inspection B. Certification (cont.) ❑ Pump Chamber pumps/alarms not operational. System will pass with Board of Health approval if pumps/alarms are repaired. B) System Conditionally Passes (cont.): ❑ Observation of sewage backup or break out or high static water level in the distribution box due to broken or obstructed pipe(s) or due to a broken, settled or uneven distribution box. System will pass inspection if (with approval of Board of Health): ❑ broken pipe(s) are replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below): ❑ distribution box is leveled or replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ The system required pumping more than 4 times,a year due to broken or obstructed pipe(s). The system will pass inspection if (with approval of the Board of Health): ❑ broken pipe(s) are replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below): C) Further Evaluation is Required by the Board of Health: ❑ Conditions exist which require further evaluation by the Board of Health in order to determine if the system is failing to protect public health, safety or the environment. 1. System will pass unless Board of Health determines in accordance with 310 CMR 15.303(1)(b) that the system is not functioning in a manner which will protect public health, safety and the environment: ❑ Cesspool or privy is within 50 feet of a surface water ❑ Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh t5ins - 3/13 Title 5 Official Inspection Form: Subsurface Sewage Disposal System • Page 3 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 90 Boston street Property Address Jennifer Ross Owner Owner's Name information is required for every North Andover Ma 01845 8/15/13 page. City/Town State Zip Code Date of Inspection B. Certification (cont.) 2. System will fail unless the Board of Health (and Public Water Supplier, if any) determines that the system is functioning in a manner that protects the public health, safety and environment: ❑ The system has a septic tank and soil absorption system (SAS) and the SAS is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water supply. ❑ The system has a septic tank and SAS and the SAS is within 50 feet of a private water supply well. ❑ The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or more from a private water supply well**. Method used to determine distance: ** This system passes if the well water analysis, performed at a DEP certified laboratory, for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis must be attached to this form. 3. Other: D) System Failure Criteria Applicable to All Systems: You must indicate "Yes" or "No" to each of the following for all inspections: Yes No ❑ ® Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool ❑ ® Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool ❑ ® 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 Y day flow t5ins • 3/13 Title 5 Official Inspection Form: Subsurface Sewage Disposal System - Page 4 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form a Subsurface Sewage Disposal System Form - Not for Voluntary Assessments �nM 90 Boston street Property Address Jennifer Ross Owner Owner's Name information is required for every North Andover Ma 01845 8/15/13 page. Cityrrown State Zip Code Date of Inspection B. Certification (cont.) Yes No ❑ ® 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 SAS, cesspool or privy is below high ground water elevation. ❑ ® Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ ® Any portion of a cesspool or privy is within a Zone 1 of a public well. ❑ ® 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. [This system passes if the well water analysis, performed at a DEP certified laboratory, for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis and chain of custody must be attached to this form.] ❑ ® The system is a cesspool serving a facility with a design flow of 2000gpd- 10,000gpd. ❑ ® The system fails. I have determined that one or more of the above failure criteria exist as described in 310 CMR 15.303, therefore the system fails. The system owner should contact the Board of Health to determine what will be necessary to correct the failure. E) Large Systems: To be considered a large system the system must serve a facility with a design flow of 10,000 gpd to 15,000 gpd. For large systems, you must indicate either "yes" or "no" to each of the following, in addition to the questions in Section D. Yes No ❑ ❑ the system is within 400 feet of a surface drinking water supply ❑ ❑ the system is within 200 feet of a tributary to a surface drinking water supply ❑ ❑ the system is located in a nitrogen sensitive area (Interim Wellhead Protection Area — IWPA) or a mapped Zone II of a public water supply well If you have answered "yes" to any question in Section E the system is considered a significant threat, or answered "yes" in Section D above the large system has failed. The owner or operator of any large system considered a significant threat under Section E or failed under Section D shall upgrade the system in accordance with 310 CMR 15.304. The system owner should contact the appropriate regional office of the Department. t5ins • 3/13 Title 5 official Inspection Form: Subsurface Sewage Disposal System • Page 5 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments On Rnctnn ctrPPt Property Address .IPnnifer Rnss Owner Owner's Name information is North Andover Ma 01845 required for every page. Citylrown State Zip Code C. Checklist 8/15/13 Date of Inspection Check if the following have been done. You must indicate "yes" or "no" as to each of the following: Yes No ® ❑ Pumping information was provided by the owner, occupant, or Board of Health ❑ ® Were any of the system components pumped out in the previous two weeks? ® ❑ Has the system received normal flows in the previous two week period? Have large volumes of water been introduced to the system recently or as part of ❑ ® this inspection? ® El as built plans of the system obtained and examined? (If they were not available note as N/A) available ® ❑ Was the facility or dwelling inspected for signs of sewage back up? ® ❑ Was the site inspected for signs of break out? ® ❑ Were all system components, excluding the SAS, located on site? ® ❑ Were the septic tank manholes uncovered, opened, and the interior of the tank inspected for the condition of the baffles or tees, material of construction, dimensions, depth of liquid, depth of sludge and depth of scum? ® ❑ Was the facility owner (and occupants if different from owner) provided with information on the proper maintenance of subsurface sewage disposal systems? The size and location of the Soil Absorption System (SAS) on the site has been determined based on: ® ❑ Existing information. For example, a plan at the Board of Health. ® ❑ Determined in the field (if any of the failure criteria related to Part C is at issue approximation of distance is unacceptable) [310 CMR 15.302(5)] D. System Information Residential Flow Conditions: Number of bedrooms (design): 4 Number of bedrooms (actual): 4 DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x # of bedrooms): 440 t5ins • 3/13 Title 5 Official Inspection Form: Subsurface Sewage Disposal System • Page 6 of 17 Water meter readings, if available (last 2 years usage (gpd)): Detail: Sump pump? Last date of occupancy: Commercial/Industrial Flow Conditions: Type of Establishment: Design flow (based on 310 CMR 15.203): Basis of design flow (seats/persons/sq.ft., etc.): Grease trap present? Industrial waste holding tank present? Non -sanitary waste discharged to the Title 5 system? Water meter readings, if available: ❑ Yes ® No Occupied Date Gallons per day (gpd) ❑ Yes ❑ No ❑ Yes ❑ No ❑ Yes ❑ No t5ins - 3/13 Title 5 Official Inspection Form: Subsurface Sewage Disposal System - Page 7 of 17 Commonwealth of Massachusetts 2 Title 5 Official Inspection Form Subsurface Sewage Disposal System Form Not for Voluntary Assessments 90 Boston street Does residence have a garbage grinder? ❑ Property Address ® No Jennifer Ross ❑ Owner Owner's Name No information is required for every North Andover Ma 01845 8/15/13 page. City/Town State Zip Code Date of Inspection ❑ Yes ❑ No D. System Information ❑ Yes Description: No Water meter readings, if available (last 2 years usage (gpd)): Detail: Sump pump? Last date of occupancy: Commercial/Industrial Flow Conditions: Type of Establishment: Design flow (based on 310 CMR 15.203): Basis of design flow (seats/persons/sq.ft., etc.): Grease trap present? Industrial waste holding tank present? Non -sanitary waste discharged to the Title 5 system? Water meter readings, if available: ❑ Yes ® No Occupied Date Gallons per day (gpd) ❑ Yes ❑ No ❑ Yes ❑ No ❑ Yes ❑ No t5ins - 3/13 Title 5 Official Inspection Form: Subsurface Sewage Disposal System - Page 7 of 17 2 Number of current residents: Does residence have a garbage grinder? ❑ Yes ® No Is laundry on a separate sewage system? (Include laundry system inspection ❑ Yes ® No information in this report.) Laundry system inspected? ❑ Yes ❑ No Seasonal use? ❑ Yes ® No Water meter readings, if available (last 2 years usage (gpd)): Detail: Sump pump? Last date of occupancy: Commercial/Industrial Flow Conditions: Type of Establishment: Design flow (based on 310 CMR 15.203): Basis of design flow (seats/persons/sq.ft., etc.): Grease trap present? Industrial waste holding tank present? Non -sanitary waste discharged to the Title 5 system? Water meter readings, if available: ❑ Yes ® No Occupied Date Gallons per day (gpd) ❑ Yes ❑ No ❑ Yes ❑ No ❑ Yes ❑ No t5ins - 3/13 Title 5 Official Inspection Form: Subsurface Sewage Disposal System - Page 7 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 90 Boston street Property Address Jennifer Ross Owner Owner's Name information is North Andover required for every page. Citylrown D. System Information (cont.) Last date of occupancy/use: Other (describe below): Ma 01845 State Zip Code General Information Pumping Records: Source of information: Was system pumped as part of the inspection? If yes, volume pumped: How was quantity pumped determined? Reason for pumping: Date Andover septic 1000 gallons gallons Site guage on truck Type of System: ® Septic tank, distribution box, soil absorption system ❑ Single cesspool ❑ Overflow cesspool ❑ Privy 8/15/13 Date of Inspection ❑ Shared system (yes or no) (if yes, attach previous inspection records, if any) ❑ Innovative/Alternative technology. Attach a copy of the current operation and maintenance contract (to be obtained from system owner) and a copy of latest inspection of the I/A system by system operator under contract ❑ Tight tank. Attach a copy of the DEP approval. ❑ Other (describe): t5ins • 3113 Idle 5 Official Inspection Forth: Subsurface Sewage Disposal System • Page 8 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments w 90 Boston street Ma 01845 State Zip Code 8/15/13 Date of Inspection D. System Information (cont.) Approximate age of all components, date installed (if known) and source of information: Were sewage odors detected when arriving at the site? Building Sewer (locate on site plan): 3'-0" Depth below grade: feet Material of construction: ® cast iron ❑ 40 PVC ❑ other (explain): Distance from private water supply well or suction line: feet Comments (on condition of joints, venting, evidence of leakage, etc.): Septic Tank (locate on site plan): Depth below grade: Material of construction: ® concrete ❑ metal B.T.G. feet ® Yes ❑ No ❑ fiberglass ❑ polyethylene ❑ other (explain) If tank is metal, list age: years Is age confirmed by a Certificate of Compliance? (attach a copy of certificate) Dimensions: Sludge depth: ❑ Yes ❑ No t5ins • 3/13 Title 5 Official Inspection Form: Subsurface Sewage Disposal System - Page 9 of 17 Property Address Jennifer Ross Owner Owner's Name information is required for every North Andover page. City/Town Ma 01845 State Zip Code 8/15/13 Date of Inspection D. System Information (cont.) Approximate age of all components, date installed (if known) and source of information: Were sewage odors detected when arriving at the site? Building Sewer (locate on site plan): 3'-0" Depth below grade: feet Material of construction: ® cast iron ❑ 40 PVC ❑ other (explain): Distance from private water supply well or suction line: feet Comments (on condition of joints, venting, evidence of leakage, etc.): Septic Tank (locate on site plan): Depth below grade: Material of construction: ® concrete ❑ metal B.T.G. feet ® Yes ❑ No ❑ fiberglass ❑ polyethylene ❑ other (explain) If tank is metal, list age: years Is age confirmed by a Certificate of Compliance? (attach a copy of certificate) Dimensions: Sludge depth: ❑ Yes ❑ No t5ins • 3/13 Title 5 Official Inspection Form: Subsurface Sewage Disposal System - Page 9 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 90 Boston street D. System Information (cont.) Ma 01845 8/15/13 State Zip Code Date of Inspection Septic Tank (cont.) Distance from top of sludge to bottom of outlet tee or baffle 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 26" 3" 3" 14" How were dimensions determined? Tape measure & Sludge judge Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): Both baffles in good shape no leakage and liquid levels are good. Grease Trap (locate on site plan): Depth below grade: Material of construction: ❑ concrete ❑ metal Dimensions: Scum thickness feet ❑ fiberglass ❑ polyethylene ❑ other (explain): Distance from top of scum to top of outlet tee or baffle Distance from bottom of scum to bottom of outlet tee or baffle Date of last pumping: t5ins - 3113 Date Title 5 Official Inspection Form: Subsurface Sewage Disposal System • Page 10 of 17 Property Address Jennifer Ross Owner Owner's Name information is required for every North Andover page. Citylrown D. System Information (cont.) Ma 01845 8/15/13 State Zip Code Date of Inspection Septic Tank (cont.) Distance from top of sludge to bottom of outlet tee or baffle 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 26" 3" 3" 14" How were dimensions determined? Tape measure & Sludge judge Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): Both baffles in good shape no leakage and liquid levels are good. Grease Trap (locate on site plan): Depth below grade: Material of construction: ❑ concrete ❑ metal Dimensions: Scum thickness feet ❑ fiberglass ❑ polyethylene ❑ other (explain): Distance from top of scum to top of outlet tee or baffle Distance from bottom of scum to bottom of outlet tee or baffle Date of last pumping: t5ins - 3113 Date Title 5 Official Inspection Form: Subsurface Sewage Disposal System • Page 10 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments �M 90 Boston street Property Address Jennifer Ross Owner Owners Name information is required for every North Andover Ma 01845 8115/13 page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): Tight or Holding Tank (tank must be pumped at time of inspection) (locate on site plan): Depth below grade: Material of construction: ❑ concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other (explain): Dimensions: Capacity: gallons Design Flow: gallons per day Alarm present: ❑ Yes ❑ No Alarm level: Alarm in working order: ❑ Yes ❑ No Date of last pumping: Date Comments (condition of alarm and float switches, etc.): * Attach copy of current pumping contract (required). Is copy attached? ❑ Yes ❑ No t5ins • 3/13 Title 5 Official Inspection Forth: Subsurface Sewage Disposal System • Page 11 of 17 r.. Owner information is required for every page. Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 90 Boston street Property Address Jennifer Ross Owner's Name North Andover Ma 01845 8/15/13 City/Town State Zip Code Date of Inspection D. System Information (cont.) Distribution Box (if present must be opened) (locate on site plan): Depth of liquid level above outlet invert 0 Comments (note if box is level and distribution to outlets equal, any evidence of solids carryover, any evidence of leakage into or out of box, etc.): No soilds carryover, no leakage, equal dist. Pump Chamber (locate on site plan): Pumps in working order: ❑ Yes ❑ No" Alarms in working order: ❑ Yes ❑ No" Comments (note condition of pump chamber, condition of pumps and appurtenances, etc.): " If pumps or alarms are not in working order, system is a conditional pass. Soil Absorption System (SAS) (locate on site plan, excavation not required): If SAS not located, explain why: t5ins • 3/13 Title 5 Official Inspection Form: Subsurface Sewage Disposal System • Page 12 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments M 90 Boston street D. System Information (cont.) Ma 01845 8/15/13 State Zip Code Date of Inspection Type: Property Address Jennifer Ross Owner Owners Name information is required for every North Andover page. Cityrrown D. System Information (cont.) Ma 01845 8/15/13 State Zip Code Date of Inspection Type: ❑ leaching pits number: ❑ leaching chambers number: ❑ leaching galleries number. ❑ leaching trenches number, length: ® leaching fields number, dimensions: ❑ overflow cesspool number: ❑ innovative/alternative system 1-20'X 45' Type/name of technology: Comments (note condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of vegetation, etc.): No hydraulic failure, no ponding in pipe, camered lines no damp soils Cesspools (cesspool must be pumped as part of inspection) (locate on site plan): Number and configuration Depth — top of liquid to inlet invert Depth of solids layer Depth of scum layer Dimensions of cesspool Materials of construction Indication of groundwater inflow t5ins - 3/13 ❑ Yes ❑ No Title 5 Official Inspection Form: Subsurface Sewage Disposal System - Page 13 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 90 Boston street Property Address Jennifer Ross Owner Owner's Name information is required for every North Andover Ma 01845 page. City[Town State Zip Code D. System Information (cont.) 8/15/13 Date 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.): t5ins - 3113 Title 5 Official Inspection Form: Subsurface Sewage Disposal System • Page 14 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 90 Boston street Ma 01845 8/15/13 State Zip Code Date of Inspection D. System Information (cont.) Sketch Of Sewage Disposal System: Provide a view of the sewage disposal system, including ties to at least two permanent reference landmarks or benchmarks. Locate all wells within 100 feet. Locate where public water supply enters the building. Check one of the boxes below: ❑ hand -sketch in the area below ® drawing attached separately t5ins - 3113 Title 5 Official Inspection Form: Subsurface Sewage Disposal System - Page 15 of 17 Property Address Jennifer Ross Owner Owner's Name information is required for every North Andover page. Citylrown Ma 01845 8/15/13 State Zip Code Date of Inspection D. System Information (cont.) Sketch Of Sewage Disposal System: Provide a view of the sewage disposal system, including ties to at least two permanent reference landmarks or benchmarks. Locate all wells within 100 feet. Locate where public water supply enters the building. Check one of the boxes below: ❑ hand -sketch in the area below ® drawing attached separately t5ins - 3113 Title 5 Official Inspection Form: Subsurface Sewage Disposal System - Page 15 of 17 1 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments °M 90 Boston street Property Address Jennifer Ross Owner Owner's Name information is North Andover Ma 01845 8/15/13 required for every page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Site Exam: ® Check Slope ❑ Surface water ® Check cellar ❑ Shallow wells Estimated depth to high ground water: 42"feet Please indicate all methods used to determine the high ground water elevation: ® Obtained from system design plans on record FE— OR If checked, date of design plan reviewed: November 13 1995Date Observed site (abutting property/observation hole within 150 feet of SAS) Checked with local Board of Health - explain: pulled files ❑ Checked with local excavators, installers - (attach documentation) ❑ Accessed USGS database - explain: You must describe how you established the high ground water elevation: Bottom of bed at Elevation 88.20 4' above S.H.W.T. drawn by scott giles R.P.L.S. as built 12/12/1995. Before filing this Inspection Report, please see Report Completeness Checklist on next page. t5ins - 3/13 Title 5 Official Inspectiga!a n: Subsurface Sewage Disposal System - Page 16 of 17 ry Commonwealth of Massachusetts Title 5 Official Inspection Form s Subsurface Sewage Disposal System Form - Not for Voluntary Assessments °wM 90 Boston street Property Address Jennifer Ross Owner Owners Name information is North Andover Ma 01845 required for every City/Town State Zip Code page. E. Report Completeness Checklist 8/15/13 Date of Inspection ® Inspection Summary: A, B, C, D, or E checked ® Inspection Summary D (System Failure Criteria Applicable to All Systems) completed ® System Information — Estimated depth to high groundwater ® Sketch of Sewage Disposal System either drawn on page 15 or attached in separate file t5ins - 3/13 Idle 5 Official Inspection Form: Subsurface Sewage Disposal System • Page 17 of 17 IP SEPTIC SYSTEM AS BUILT TOPOGRAPHICAL PLAN OF LAND IN NORTH ANDOVER, MASS. SCALE:1 "=40' NOV. 8,1995 AS BUILT DATE 12/12/95 SCOTT L. GILES R.P.L.S. 50 DEER (MEADOW RD. NORTH ANDOVER, MASS. TOVJi1 0NORTH ANDOVER/30A3iD Or HEALTH & .8\1.9 #1 � 1 9.9 PIT I ` 81.9 #2 93.2 \ \ 87.5. CL\ \ 83.0 N.A, \ wd° \ 5b EDGE TLS \ 90.1 30 \ I 1 \ 1\ I //� 87 24" 1 Q ' EDGE WETLANDS PER 972 EXISTING ,000' GLS. TANK I \ .e. ,83,.C. '96' I 1 I 1 .2 OP#&P1 1 43 N.A.C.C.\82.9 #3 04 8�.4 1184.4 N.A.C.C. �sG?g- I EED LINES\ s oN� s o000 \ 89.0. S. 1 QOR.GA7. As II 1 oke" 2$c,. TABLE OF ELEVATIONS INV. OUT HSE. = INV. IN TANK= is OUT TANK =91.78 IN D.BOX =89.16 OUT D. BOX=88.98 END LINE ##1=88.72 #2,#3 °° END LINE #A=88.71 PER S. D'Uf Town of North Andover, Massachusetts Form No. 2 Of MORTFI, BOARD OF HEALTH F 19—iL w _ F DESIGN APPROVAL FOR ass"C"j5`t� SOIL ABSORPTION SEWAGE DISPOSAL SYSTEM Applicant Test No. Site Location Reference Pla Permission is granted for an individual soil absorption sewage disposal system to be installed in accordance with regulations of Board of Health. P Fee i CHAT AN, BOARD OF HEALTH Site System Permit No. 797 _ Town of North Andover*NORTH Ot`tO°,ti0 OFFICE OF COMMUNITY DEVELOPMENT AND SERVICES A 146 Main Street �•.1 TfO ^.P�<y KENNETH R MAHONY North Andover, Massachusetts 01845 4SSACFIUS�s Director (508) 688-9533 TOWN OF NORTH ANDOVER BOARD OF HEALTH CERTIFICATE OF COMPLIANCE This is to certify that the individual subsurface disposal system constructed ( ) or repaired by _ _� V� 14119'/IV/, ,e b installer at 9D �o�7-01J J 7-;,-- l has been installed in accordance with the provisions of TITLE 5 of the State Sanitary Code and with Board of Health regulations as described in the Design Approval Permit # %97 dated ///,q — THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE SYSTEM WILL FUNCTION SATISFACTORILY. Board of Health Inspector BOARD OF APPEALS 688-9541 BUILDING 688-9545 CONSERVATION 688-9530 HEALTH 688-9540 PLANNING 688-9535 Julie Parrino D. Robert Nioetta Michael Howard Sandra Start Kathleen Bradley Colwell No................ -....... Fmc .............................. THE COMMONWEALTH OF MASSACHUSETTS /lBOARD ,9F HEALTH ............oF....../Y.�%..../4J D 1/�.... Apli iratiou for Biopoottl Workii Tonotrnr#ion ramit Application is hereby made for a Permit to Construct ( ) or Repair ()C) an Individual Sewage Disposal System at �ca.......... .--------- �—iLLotNo V�_....D Owner Address W Installer Address d Type of Building Size Lot ------ .....-.Sq. fee UDwelling — No. of Bedrooms ................ ---------------------- Expansion Attic ( ) Garbage Grinder 44 Other — Type of Building ............................ No. of persons ............................ Showers ( ) — Cafeteria ( ) Q' Other fixtures ___ d --------- ----•-•- - ---------------- W Design Flow ------------------------------- ...._.gallons per person per day. Total daily flow_.______.___._.... ........................ gallons. Wg??C Septic x Ta — Liquid capacity_�gallons Length ________________ Width ---------------- Diameter_ ------------- Depth ................ Disposal tm� No........./.......... Width ----- 2_Q_-._.__ Total Length ----- ` ..... Total leaching area---_9-----sq. ft. Seepage Pit No --------------------- Diameter -------------------- Depth below inlet .................... Total leaching area .... .............. sq. ft. Z Other Distribution box ( ) Dosing tank Percolation Test Results Performed by .............. ......C......__T�--��.._..��5....... Date. �� �� gS Zt� l --•-•--••---•---- Z-.-.----.. Test Pit No. I .... .._..._ minutes per inch Depth of Test Pit----�d�...... Depth to ground water ..... lidzl� .......... Test Pit No. 2................minutes per inch Depth of Test Pit -------------------- Depth to ground water ........................ A+'---••------------------•---------------••-...................--••••---•••-•-••-........-••--................•---•-•••.......••---•......•-•-----...------.... 0 Description of Soil----------------------------------------------------------• ......... ------------------------------------------------------------------------------ x W-•••••-------------•------ ----------------------------------------------------------------------------------------------------------------------------------------------------------------------------- U Nature of Repairs or Alterations — Answer when applicable ----------- J._. x .. .................................... Agreement: The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of TITLE 5 of the State Environmental Code — The undersigned further agrees not to place the system in operation until a Certificate of Compliance ha been issued y t' oard of health. Signed..,,,1-.... `"---------------------- ------- --------------------------------------- ------ Date Application Approved By---------------------------------------------------------------------------------------------....__------..._..------. .................Date ----------------------- Application Disapproved for the following reasons- ------------------- ------------------------------------------------------------------------------------------------------------------ .... .. ........... ........... ...... . .----......... . ...................................................... . .......................... ..... ........................................ Date PermitNo------------------------------------------------------------------ Issued ------------------ ---- Date No................ ......... THE COMMONWEALTH OF MASSACHUSETTS BOARD F HEALTH to .......... OF ...........: �-'� /V L��� Fizz Appliratiou for Di -n -Vasal Workii Tomitrurtion rrrmit Application is hereby made for a Permit to Construct ( ) or Repair X) an Individual Sewage Disposal System at: ......... ................................................. .......... Owner --------------••---- -- -•---g-••------- ......•.. . ---•---•••.....•• ....................•-•-•-.......-- W Address Installer Address Q Type of Building G� Size Lot ------ 4...................:`.Sq. feet U Dwelling —No. of Bedrooms ................ f ---------------------- Expansion Attic ( ) Garbage Grinder (/\40 aOther — Type of Building ............................ No. of persons ---------------------------- Showers ( ) — Cafeteria ( ) a' Other fixtures --- W___ WDesign Flow ................................ _.._.gallons per person per day. Total daily flow -------------------------------------------- gallons. Gd �� Septic Ta Liquid capacity. Ogallons Length ................ Width ................ Diameter ................ Depth ................ Disposal t" = F — No. -------- .......... Width ..... ~4'-.O........ Total Length ------ /.S. --_-___• Total leaching area --- C-1 ------ sq. ft. Seepage Pit No ----_----_--------- Diameter -------------------- Depth below inlet .................... Total leaching area ................ ..sq. ft. Z Other Distribution box ( ) Dosing tank . t -a – 11) a Percolation Test Results Performed b--------------------------------------------------------------------- -----g ate �' ... Test Pit No. I ___-�0..._minutesper mch Depth of Test Pit._.J.' Depth to round water.._. !Y----____--__-_.. Gr. Test Pit No. 2................minutes per inch Depth of Test Pit .................... Depth to ground water ....................... 0+ ----•----•-------------------------•----••-•----••--•--•--••.......--•-••••••-•-••-----••---•-•••••.....•--••.......-••-•••••-•-•---••......--•--•...-•.•••-- Description of Soil - U ----------------------•-----------••-------------------------------- x ---------------------------------------------------------------------------------------------- W-----------------------------------------------------------------------------------------------------------------------------------------------------------------------................................ U Nature of Repairs or Alterations — Answer when applicable --------- ----------------------- _.---_�___________ -----------------------------------••• C. Agreement: The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of TITLE 5 of the State Environmental Code — The undersigned further agrees not to place the system in operation until a Certificate of Compliance has been issued by the board of health. Signed--- X----------------_--- -------- --- --.._................—---------------------------------- --.........-----Date Application Approved By Date Application Disapproved for the following reasonr---------------------------------------------------------------------------- ------------------------------------------- ------------------------------------------------------------------------------------------------------------------------------------ - --------------------------------------- ---------------------------------------- Date PermitNo- -------------------------- ------------- Issued ................................--....--.............--....... Date Town of North Andover, Massachusetts Form No. 3 pORTM BOARD OF HEALTH --� F19 p �is�,,.o'Eth DISPOSAL WORKS CONSTRUCTION PERMIT SACHUS Applicant NAME 2 ADDRESS TELEPHONE Site Location 10 l J syr �4 —�5 Permission is hereby granted to Construct ( ) or Repair ()�,an Individual Soil Absorption Sewage Disposal System as shown on the Design Approval S.S. No. 0 Fee D.W.C. No. PITS MIN 660 LEACHING MIN 1 (131x16') PIT MANHOLE/PIT GW MIN 4' BELOW BOTTOM EXC 2x EFF W OR D 12"-48" STONE BOT + SIDE x LOAD = TOTAL (L x W x #) (2x(L+W)xD x #) (G/ft2) CHAMBERS MIN 660 LEACHING GW MIN 4" BELOW COVER >3 FT - VENT MANHOLES 12"-48" STONE SPLASH PADS SLOPE .005 BED/TRENCH (Bed max. 60' X 601) MIN 13' X 16' PIT BOT + SIDE X LOAD = TOTAL (L x W x #) (2 x (L+W)xD x #) (G/ft2) FIELDS MIN 660 GPD \, 900 ft2 BED �� GW MIN 4' BELOW BOTTOM OF FIELD,�- PIPE ENDS JOINED? 'f 4" PEA STONE? L—'� DIST LINE SLOPE .005? >31COVER-VENT SCH 40 MIN 12" COVER RATE LDG 53 X_ %,6 ,45'- X TOTAL �77 G/ft2 REQ'D (ft2) ILXW DOSING TANKS AND PUMPS DIMENSIONS X L W DISCHARGE SIZE MANHOLES TO GRADE inlet) HWL LWL OP. SWITCH Copyright ® 1995 by S.L. Stan X = PUMP CAPACITY gpm D Vol. DISCHARGE RATE ALARM SEP. CIRC. CHECK VALVE gpm DISCHARGE TIME GW (Min. 1' below BLEEDER HOLE MANUAL � �/ ��. ` � �--� J � �� fi �� �. � ��� �� '� �' f L. `� i �� ,% ;� f eo�t!l),�a PLAN REVIEW CHECKLIST r ADDRESS - .. '� ENGINEER GENERAL 3 COPIES STAMP ��� LOCUS �� NORTH ARROW SCALE CONTOURSS,.,_� PROFILE t� SECTION t-✓ BENCHMARK `/ SOIL & PERCS ✓ ELEVATIONS WETS. DISCLAIMER WELLS & WETS WATERSHED?/V 0 DRIVEWAY -'- (Elev) WATER LINE �� FDN DRAIN f SCH40,)( TESTS CURRENT? C� SOIL EVALT/W SEPTIC TANK MIN 1500G'00 .17 INVERT DROP GARB. GRINDER(+200% EDF) 25' TO CELLAR --' MANHOLE ELEV GW ## COMPS. D -BOX SIZE ## LINES FIRST 2' LEVEL STATEMENT INLETS l - OUTLET ,gR. q7 = 'l % ( 2" OR .17 FT) TEE REQ' D?�S LEACHING MIN 660 GPD?', RESERVE AREA 4' FROM PRIMARY? 20 SLOPE 100' TO WETLANDS 100' TO WELLS 4' TO S.H.GW Y (5'>2M/IN) 35' TO FND & INTRCPTR DRAINS `/ 325' TO SURFACE H2O SUPP ✓/ 4' PERM. SOIL BELOW FACILITY MIN 12" COVER 1_1_11 FILL? `_ (25' if above natural elev; 10'if below) BREAKOUT MET? TRENCHES MIN 660 gpd SLOPE (min .005 or 6"/100') SIDEWALL DIST. 3X EFF. W OR D (MIN 6') RESERVE BETWEEN TRENCHES? IN FILL? MUST BE 10' MIN. 4" PEA STONE? VENT? (>3' COVER; LINES >501) BOT + SIDE X LDNG = TOT (L x W x ##) (DxLx2x##) (G/ft2) Copyright © 1995 by S.L. Starr �, 4i�re.$.e�:,'a .. �..z5..v.. ., l vti�;,, A... a„�.v.. �. R ? _.. ,.45��N'�t._ ��.,itch'��E'�:�:�s�sr�:�'�'.r'�I�"���`�.:1;=�; SEPTIC SYSTEM AS BUILT TOPOGRAPHICAL PLAN OF LAND IN NORTH ANDOVER, MASS. TOvvN.OF NORTHaN©av��t SCALE: 1"=40' . NOV. 8, 1995 BOARD OF HEALTlf AS BUILT DATE 12112 /95 1 SCOTT L. GILES R.P.L.S. 50 DEER MEADOW RD. IN�- NORTH ANDOVER, MASS. 81.9 #1 \ 9.9 PIT 81.9 #2 87.5 CO, 83.0 N.AiC. EDGE TLAND PER S. D'URE co ' ii, / 87. 24° EDGE WETLANDS PER C.C. 97.2 LS.;fANK 1 OST .s. 83.6 N.A.I.C. ,DI , � ccs 3$ .2 OP#&P1 IPAA S , *$4.3 N.A.C.C+$2.9 #3 i� . ` ti -a 184.4 N.A.C.C.. . �,,� \5`�, I, . E ED LINES' Ofl G) t ` 89.0.5. IPAx1 TABLE OF ELEVATIONS INV. OUT HSE. INV. IN TANK OUT TANK=91.78. IN D.BOX =89.16 OUT D. BOX=88.98 END LINE #1=88.72 #2,#3 END LINE #4=88.71 i q S� Q) 1p- 0 N.A Oo0 'L •o N,A SEPTIC SYSTEM AS BUILT TOPOGRAPHICAL PLAN OF LAND IN NORTH ANDOVER, MASS. TOWN OF NORTH ANpOVER SCALE:1 "=40' NOV. 8,1995 BOARD OF HEALTH AS BUILT DATE 12/ 12 /95 SCOTT L. GILES R.P.L.S. 50 DEER MEADOW RD. NORTH ANDOVER, MASS DEC 12 \ 906 81.9 #1 9.9 PIT81.9 #2 93.2 ' Q0\ 87.5 CL1 83.0 N.A,C. 90.1 30" EDGE TL \ `//t 87. 24" I EDGE WETLANDS PER 97.2\.\ EXISTING ,000' GLS.,iANK ' '83.6 N.A. ,.C. 06' B. ' ' 1 N �I/ 1 ,�4.3 N.A.C.C��82.9 #3 8 . S. 66 8 4 I , \ 1184.4 N.A.C.C. ED LINES\ 89.0. S. 1 EoN��S�M�� 9 �OR.GT. PS oke" 2a1' TABLE OF ELEVATIONS INV. OUT HSE. = INV. IN TANK= ItOUT TANK =91.78 it IN D. BOX =89.16 OUT D. BOX=88.98 END LINE #1=88.72 #2,#3 END LINE #4=88.71 PER S. D'URS O� 14ORT11 q BUILDING PERMIT 10_ TOWN OF NORTH ANDOVER ° APPLICATION FOR PLAN EXAMINAT( N Permit NO: Date Received -W 1 J7. ED Date Issued: IMPORTANT: Applicant must complete all items on this page LOCATION�O 0 0h —e' n -7-0 • Al - Print ._ PROPERTY OWNER 6 Print _MAP.NO, _ 9PARCELbQ ZONING. DISTRICT:, Historic District. yes=.nn Machine Shop Village yes TYPE OF IMPROVEMENT PROPOSED USE Residential Non- Residential ❑ New Building VOne family ❑ Addition ❑ Two or more family ❑ Industrial ❑ Alteration No. U1 U11ILS: I u UU1111111rf Call ❑ Repair, replacement ❑ Assessory Bldg ❑ Others: ❑ Demolition ❑ Other n_C�n47n n \A/.�,IL... _ _ ._ _ , - LS VG'JIIV'- Li YVG'll` -' - _.._l: =1-4�1–;n _ _ n 1Alei�lnrlr7�.� -LJ'I IWWMFIGIII-'-U"VYCUGIIGJ-'- -' f-1. lAln��rnhr.rl 7�in�rinF .LJ YYGIGI JIIGV-VIJll1<rl - - ❑ Water/Sewer � & ti 12'/-33' Ob l; u -c— 6—n ' V4 P&01— d OWNER: Name: 8A%eln Address: CONTRACTOR Name: Identification Please "Type or Print (Yearly) Phone: Address: - - - Supervisor's Construction License: Exp. Date: Home Improvement License: Exp. Date: ARCHITECT/ENGINEER Phone: Address: Reg. No. FEE SCHEDULE: BULDING PERMIT: $12.00 PER $1000.00 OF THE TOTAL ESTIMATED COST BASED ON $125.00 PER S.F. Total Project Cost: $ 2,4rlrl'ao FEE: $ So,c262 Check No.: Receipt No.: NOTE: Persons contracting with unregistered contractors do not have access to the guaranty fund Signature of Agent/Owner"9-4ew_z_Signature of contractor , Yn c Plans Submitted Plans Waived ❑ Certified Plot Plan ❑ Stamped Plans ❑ FWell EWERAGE DISPOSAL er ❑ Tanning/Massage/Body Art ❑ Sv'i��g Pools ❑ ❑ Tobacco SalesFood Packaging/Sales ❑ tic tank, etc. ❑ Pennanent Dumpster on Site ❑ THE FOLLOWING SECTIONS FOR OFFICE USE ONLY INTERDEPARTMENTAL SIGN OFF - U FORM PLANNING & DEVELOPMENT Reviewed On Signature COMMENTS CONSERVATION Reviewed on Q, )� Si natur i � - W6�7� COMMENTS HEALTH COMMENTS Reviewed on G ' -s )2I) If S I Zoning Board of Appeals: Variance, Petition No: Zoning Decision/receipt submitted yes Planning Board Decision: Comme Conservation Decision: Comments Water & Sewer Connection/Signature & Date Driveway Permit DPW Town Engineer: Signature: Located 384 Osgood Street "FIRE DEPAR .-- - �. r ,tTMENT Temp Q umpstOr-On site Lyes___ na Located,at 124,iM Street - -- Fire (Department signature/d at e COMMENTS �,��_