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Miscellaneous - 940 FOREST STREET 4/30/2018 (2)
r'1 _ North Andover Board of Assessors Public Access t 4 Parcel ID: 210/105.D-0006-0000.0 SKETCH Click on Sketch to Enlarge Community: North Andover PHOTO N o Pi' ct u re Available Location: 940 FOREST STREET Owner Name: BURKE, RICHARD A CORINNE A BURKE Owner Address: 940 FOREST STREET City: NORTH ANDOVER State: MA ZIP: 01845 Neighborhood: 6 - 6 Land Area: 1.03 acres Use Code: 101 - SNGL-FAM-RES Total Finished Area: 1450 sgft 7 ASSESSMENTS CURRENT YEAR PREVIOUS YEAR Total Value: 433,900 403,900 Building Value: 223,800 209,500 Land Value: 210,100 194,400 (Market Land Value: 210,100 Chapter Land Value: LATESTSALE Sale Price: 30,000 Sale Date: 05/03/1984 Arms Length Sale Code: Y -YES -VALID Grantor: Cert Doc: Book: 01805 Page: 0025 http://csc-ma.us/NandoverPubAcc/j sp/Home.j sp?Page=3 &Linkld=808409 Page 1 of 1 10/30/2006 a v 0 O O O Oct H _O fn @ N � �.i "0 "0 C C N Y Y CD � Z o� y. 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Mailing Address: 270 Lawrence Street Methuen, MA 01844 Telephone Number: 800-253-4402 CERTIFICATION STATEMENT 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: _ basses Conditionally Passes _ Needs Further Evaluation by the Local Approving Authority Fails Inspector's Signature: The system inspector s submit a copy of this inspection report to the Approving Authority (Board of Health or DEP) within 30 days of completing this inspection. If the system is a shared system'or has a design flow of 10,000 gpd or greater, the inspector and the system owner shall submit the report to the appropriate regional office of the DEP. The original should be sent to the system owner and copies sent to the buyer, if applicable, and the approving authority. Notes and Comments O v/ /10 O /°%/leGij. ****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. Title 5 Inspection Form 6/15/2000 page 1 Pdge 2 of 11 OFFICIAL INSPECTION FORM — NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: _o_��TgSt Bit - o end 1Pr MA 01845 Owner: Fa nn .--N- P Ma Date of Inspection: _IQ 0 / 10 / 0 6 .Inspection Summary: Check A,B,C,D or E / ALWAYS complete all of Sectiou 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" s 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. Answer yes, no or not determined (Y,N,ND) in the 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. ND explain: 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 ction is removed distribution box is leveled or replaced ND explain: __ 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): ND explain: _ broken pi a replaced _ obs on is removed 2 Page 3 of 11 OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: _940 Fnr Gt St Nn_ r Andov ' MA 01845 Owner: Fannie Mae Date of Inspection: l() / 1 0 0 h C. Further Evaluation is Required by the Board of Health: Conditions exist which require further evaluation a Board of Health in order to determine if the system is failing to protect public health, safety or the envir ent. I. System will pass unless Board o ealth determines in accordance with 310 CMR 15.303(1)(b) that the system is not functioning in anner which will protect public health, safety and the environment: — Cesspool or privy 4s within 50 feet of a surface water _ Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh 2. System will fail unless the Board of Health (and Public Water Supplier, if 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 suonly: _ The system has a septic tank and.SrA'S and the SAS is within a Zone 1 of a public water supply. ._''' — The system has a septi ank 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 coliform bacteria and volatile organic compounds indicates that the well is free from pollution from that facility and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis must be attached to this form. 3. Other: Page 4 of 11 OFFICIAL INSPECTION FORM — NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: 940 Forest St No. Andover, MA 01845 Owner: Ranni a Map Date of inspection: 9/ 9 () f 0 6 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 logged 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 '/z day flow (/!/ vc,;^Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number ones pumped _ Any portion of the SAS, cesspool or privy portion of cesspool or privy is within 100 feet ofta selevation. a water supply watly or tributary mater supply. ary to a surface /_. qty portion of a cesspool or privy is within a Zone 1 of a public well. ✓_ _y portion of a cesspool or privy is within 50 feet of a private water supply well. y 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 coliform bacteria and volatile organic compounds indicates that the well is free from pollution from that facility and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis must be attached to this form.] �YeslNo) The system fails. I have determined that one or more of the ab ove ria exist as described in 310 CMR 15.303, therefore the system fails. The system owner shouilure ld 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. You must indicate either "yes" or "no" to each of the following: (The following criteria apply to large systems in addition to the criteria above) yes no Zsy hin 400 feet of a surface drinking water supply — theithin 200 feet of a tributary to a surface drinking water supply cated in a nitrogen sensitive area (Interim Wellhead Protection Area — IWPA) or a mapped Zone Il 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. Page 5 of 11 OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST Property Address: 940 ForPG� Qt No. Andover., MA 01g45 Owner: -Fannie Map Date of Inspection: 10 -110 . 16 6 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 y or as part of this inspection . ere as built plans of the system obtained and examined? (If they were not available note as N/A) ✓ f 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 ? _—baffles 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: Yes no —/ 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(3)(b)] Pp Page 6 of 1 I OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION Property Address: 9e n E'exast St . N d v a- I� X1 845 Owner: � A4 -e Date of Inspection: 10/06— FLOW nincFLOW CONDITIONS RESIDENTIAL Number of bedrooms (design): Number of bedrooms (actual): DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x # of bedrooms): Number of current residents: O �/ Does residence have a garbage grinder (yes or no): y Is laundry on a separate sewage system (yes or no): /`� [if yes separate inspection required] Laundry system inspected (yes o no): _ Seasonal use: (yes or no): Water meter readings, if avail le (last 2 years usage (gpd)): &,//7, Sump pump (yes or no): Last date of occupancy: COMMERCIAL/INDUSTRIAL Type of establishment: Design flow (based on 310 CMR 15.2034 _gpd Basis of design flow (seats/persons/s, c.): Grease trap present (yes or no);-' _ Industrial waste holdi nk present (yes or no): Non -sanitary wa ischarged to the Title 5 system (yes or no): — Water meter readings, if available: Last date of occupancy/use:. OTHER (describe): Pumping Records GENERAL INFORMATION Source of information: Was system pumped as part of the inspection (yes or no): If yes, volume pumped: Qallons -- How was quantity pumped determined? Reason for pumping: TYPF SYSTEM Septic tank, distribution box, soil absorption system _ Single cesspool _ Overflow cesspool _ Privy — Shared system (yes or no) (if yes, attach previous inspection records, if any) _ Innovative/Alternative technology. Attach a copy of the current operation and maintenance contract (to be obtained from system owner) — Tight tank V Attach a copy of the DEP approval — Other (describe): Approximate age of all components, date installed (if known) and source of information: 0k . Were sewage odors detected, when arriving at the site (yes or no): Page 7 of I 1 OFFICIAL INSPECTION FORM — NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: q40 Pori -qt- Sfi- —�'�.—n.�.n Andover, 1�A 01845 Owner: Fannia Ma Date of Inspection: 1 0/ 1 0/ 0 6 BUILDING SEWER (locate on site plan) Depth below grade: Materials of constructi _cast iron _40 PVC _other (explain): Distance from pr a water supply well or suction line: Comments ( condition of joints, venting, evidence of leakage, etc.): SEPTIC TANK: _ (locate on site plan) Depth below grade:_ Material of construction: rete _meta] fiberglass _polyethylene _other(explain) If tank is metal list age: _ Is age confirmed by a Certificate of Compliance (yes or no): _ (attach a copy of certificate) , Dimensions: �p S Sludge depth: y �� Distance from top of sludge to bottom of outlet tee or baffle: Scum thickness: -1-Z Distance from top of scum to top of outlet tee or baffle: Distance from bottom of scum to bottom of outlet tee or ba e: How were dimensions determined: (716F/moo Continents (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as relaj;� to outlet invert, evidegce of leakage, etc.): GREASE TRAP: _(locate on site plan) Depth below grade: _ Material of construction: _concrete _metal fiberglass __polyethylene _other (explain): — Dimensions: Scum thickness: Distance from top of sc o top of outlet tee or baffle: Distance from bo of scum to bottom of outlet tee or baffle: Date of last pum ing: Coiiiments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): 7 'Page 8 of 11 OFFICIAL INSPECTION FORM — NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: a40 EQ=ez Gt Owner:— No. ��� , *A 01845 --a--14�e Date of Inspection: TIGHT or HOLDING TANK: Depth below grade: Material of construction: concrete (tank must be pumped at time of inspection)(locate on site plan) fiberglass _polyethylene other(explain): Dimensions: Capacity: _ allons Design Flow: gallons/day Alarm present (y or no): Alarm leve Alarm in working order (yes or no): Date of last pumping: Continents (condition of alarm and float switches, etc.): DISTRIBUTION BOX: (if present must be opened)(locate on site plan) Depth of liquid level above outlet invert: Comments (note if box is level and distribution to outlets equal, any evidence of solids carryover, any evidence of leakage into or out of b x, etc.): PUMP CHAMBER: (locate o tte plan) Pumps in working order ( r no): Alarms in working o (yes or no): Comments (note ndition of pump chamber, condition of pumps and appurtenances, etc.): Page 9 of 11 OFFICIAL INSPECTION FORM — NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: _940 Forest St. No. Andover, MA 01845 Owner: Fannip Ma Date of Inspection: _ 1 ().110.1 () 6 SOIL ABSORPTION SYSTEM (SAS): (locate on site plan, excavation not required) If SAS not located explain why: Type leaching pits, number: _ leaching chambers, number: �— leaching galleries, number: leaching trenches, number, length: leaching fields, number, dimensions: overflow cesspool, number: innovative/alternative system Type/name of technology: Comments (note condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of vegetation, etc.): 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 constru n: Indication of groundwater inflow (yes or no): - 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: U Depth of solids: Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): 9 Page 10 of 1 I OFFICIAL INSPECTION FORM — NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: 940 Forest St. NQ- Andover., MA 01845 Owner: Fannie Mae Date of inspection: SKETCH OF SEWAGE DISPOSAL SYSTEM Provide a sketch 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. 10 Page 11 of 11 OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: 9-40—Fexest St Ne. Andover-, Mn 01845 Owner:–Iti'3re Mae Date of Inspection: 10 / 1OTO 6 S XAM Slope r a ow wells Estimated depth to ground water effeet Please indicate (check) all methods used to determine the high ground water elevation: jObtained from system design plans on record - If checked, date of design plan reviewed: Observed site (abutting property/observation hole within 150 feet of SAS) Checked with local Board of Health -explain: Checked with local excavators, installers- (attach documentation) _! Accessed USGS database -explain: You must describe how you established the high ground water elevation: 11 Page 1 of 6 SUMMARY OF GROUND -WATER LEVELS SEPTEMBER 2006 PROVISIONAL (NOTE: Wells with * also available in real-time at top of Ground -Water Data page; OWc, monthly measured value used in high ground -water level estimation report, USGS Open -File Report 80-1205.) WELL L START NET CHANGE DEPARTURE WATER LEVEL T I YEAR IN MONTH IN ONE FROM BELOW LAND - 0 T OF YEAR MONTHLY SURFACE P H RECORD MEDIAN DATUM 0 O (OWc) DAY (FEET) (FEET) (FEET) (FEET) MASSACHUSETTS ACTON 158 * TS 1965 - 0.62 + 1.49 + 2.13 17.71 > 25 ANDOVER 462 VS 1968 - 0.39 + 0.46 + 0.34 14.94 26 ATTLEBORO 83 VS 1964 + 0.04 - •0.09 - 0.09 4.43 27 BARNSTABLE 230 FS 1957 - 0.74 + 0.42 + 1.17 23.40 28 BARNSTABLE 247 FS 1962 - 0.58 + 0.87 + 2.30 22.68 28 BECKET 12 TS 1986 + 1.11 - 0.67 + 0.77 2.82 28 BLANDFORD 9 VS 1986 + 0.67 + 0.55 + 0.55 2.03 28 BOURNE 198 FS 1962 - 0.74 + 1.00 + 1.24 32.76 28 BREWSTER 21 FS 1962 - 0.27 + 0.60 + 2.06 8.11 26 BREWSTER 22 * FS 1962 - 0.64 + 0.70 + 1.80 29.54 27 CHATHAM 138 FS 1962 - 0.64 - 0.15 + 0.59 23.84 26 CHESHIRE 2 HT 1951 + 0.07 + 5.07 + 2.74 5.96 27 CHICOPEE 95 TS 1984 - 0.47 + 0.94 + 0.51 21.63 27 COLRAIN 8 VS 1965 - 0.96 - 0.51 + 0.20 20.81 27 CONCORD 165 TS 1965 - 0.56 + 2.01 + 2.98 38.63 25 CONCORD 167 TS 1965 - 0.29 + 1.53 + 0.32 8.13 25 CUMMINGTON 13 VS 1986 - 0.09 + 0.37 - 0.08 5.76 27 http://ma.water.usgs.gov/current-cond/data/2006-09.txt 10/20/2006 DEDHAM 231 ST 1965 - 1.41 + DEERFIELD 44 VS 1965 - 0.28 + DOVER 10 TS 1965 - 0.77 + DUXBURY 79 * VS 1965 - 0.21 - DUXBURY 80 VR 1965 - 0.22 - EAST BRIDGEWATER 30 HT 1958 - 1.47 + EDGARTOWN 52 VS 1976 - 0.64 + FOXBOROUGH 3 TS 1965 - 0.72 + FREETOWN 23 TS 1964 - 0.59 + GEORGETOWN 168 VS 1965 + 0.19 + GRANBY 68 VS 1954 - 0.59 + GRANVILLE 5 TS 1965 - 0.81 + GRANVILLE 6 SS 1965 + 0.30 + GREAT BARRINGTON 2 VT 1951 + 0.52 + HANSON 76 VS 1964 - 0.05 - HARDWICK 1 TS 1965 - 0.54 + HAVERHILL 23 TS 1960 - 1.09 + HAWLEY 8 ST 1986 - 0.13 + LAKEVILLE 14 * TS 1964 - 1.18 + LEXINGTON 104 VS 1965 + 0.62 + MASHPEE 29 FS 1976 - 0.74 + MIDDLEBOROUGH 82 VT 1965 - 2.71 + MONTGOMERY 19 SS 1986 - 0.06 + NANTUCKET 228 FS 1976 - 0.50 - NEW BEDFORD 116 VS 1964 + 0.24 - NEWBURY 27 VT 1965 - 0.86 + NORFOLK 27 * VS 1965 - 0.44 + NORTHBRIDGE 54 VS 1984 - 0.23 + NORTON 37 FS 1964 - 0.94 - ORANGE 63 TS 1985 - 0.50 + OTIS 7 VS 1965 + 0.24 + PELHAM 23 * SR 1981 + 0.17 + http://ma.water.usgs.gov/current-cond/data/2006-09.txt 0.54 - 0.52 11.63 25 0.23 + 0.14 2.98 28 0.48 + 0.63 33.68 25 0.20 + 0.46 8.68 26 0.09 + 0.65 22.00 26 2.42 + 1.60 12.00 26 0.69 + 2.35 15.70 26 0.33 + 0.40 19.77 28 0.50 + 0.86 13.20 27 0.58 + 0.32 5.32 26 0.95 + 0.20 9.25 27 1.01 + 0.67 32.92 28 0.86 + 0.02 6.77 28 0.57 + 0.90 11.61 27 0.20 + 0.05 4.97 26 0.64 + 0.18 15.92 25 0.38 + 0.43 13.34 26 1.36 + 0.56 4.14 27 1.10 + 3.06 14.74 26 1.23 + 1.05 2.08 25 0.85 + 1.06 8.06 28 0.88 + 0.88 14.25 26 1.52 - 0.32 2.63 28 0.54 + 0.75 23.85 28 0.29 + 0.08 4.26 27 1.39 + 1.74 8.85 26 0.26 - 0.28 6.90 28 0.33 + 0.31 4.18 26 0.27 + 0.19 8.58 27 0.39 - 0.20 7.84 25 0.91 + 0.26 9.13 28 0.15 - 2.65 17.58 25 Page 2 of 6 10/20/2006 PELHAM 24 SS 1984 - 0.01 + PETERSHAM 16 ST 1984 - 0.55 + PITTSFIELD 51 * VS 1963 - 0.83 + PLYMOUTH 22 TS 1956 - 1.12 + PLYMOUTH 494 SS 1985 - 0.45 + SANDWICH 252 FS 1962 - 0.15 + SANDWICH 253 FS 1962 - 0.26 + SEEKONK 275 VS 1964 + 0.04 - SHEFFIELD 58 FS 1987 - 0.61 + SOUTHBOROUGH 12 HT 1990 - 0.22 + STERLING 1 ST 1947 + 3.43 + STERLING 177 SS 1995 - 0.21 + SUNDERLAND 7 SS 1957 - 1.50 + SUNDERLAND 68 VS 1983 - 0.37 + TAUNTON 337 TS 1964 - 0.48 - TEMPLETON 3 VS 1957 + 0.06 + TOPSFIELD 1 HT 1936 - 0.66 + TOWNSEND 13 TS 1965 - 0.75 + TRURO 1 TS 1950 - 0.04 + TRURO 89 TS 1962 - 0.28 + WAKEFIELD 38 * FS 1965 + 0.32 + WARE 43 VS 1965 - 0.31 - WAREHAM 51 TS 1959 - 0.69 - WAYLAND 2 TS 1965 - 0.62 + WEBSTER 1 HS 1958 - 0.03 + WELLFLEET 17 VS 1962 - 0.54 + WENHAM 76 VS 1965 + 0.04 + WEST BOYLSTON 26 SS 1995 - 0.74 + WEST BROOKFIELD 2 TS 1959 - 0.41 + WESTHAMPTON 20 SS 1986 - 2.04 + WESTFIELD 62 SS 1957 - 0.69 + WESTFIELD 152 TS 1986 - 0.05 + http://ma-water.usgs.gov/current-cond/data/2006-09.txt 0.80 - 0.51 5.84 ' 25 0.49 - 0.04 15.43 25 5.37 + 1.81 18.79 27 0.75 + 1.97 22.75 26 2.82 + 3.75 26.08 26 0.32 + 0.48 47.02 28 1.96 + 2.57 47.78 28 0.21 + 0.49 6.50 27 1.07 + 0.39 13.20 27 2.19 + 1.58 10.63 25 6.43 + 5.20 5.13 25 0.24 + 0.19 15.21 25 0.26 + 0.13 15.12 28 0.00 - 0.32 3.96 28 0.62 - 0.10 9.80 27 0..33 + 0.05 3.94 25 1.34 + 1.06 13.71 26 0.51 + 1.30 12.68 > 25 0.08 + 0.48 10.46 27 0.17 + 0.47 12.03 27 1.67 + 1.24 6.96 26 0.52 + 0.00 9.23 25 0.31 + 0.37 8.64 26 0.28 - 0.42 17.10 25 1.29 + 0.35 14.76 27 0.14 + 0.39 10.35 27 1.01 + 0.62 2.83 26 0.20 + 0.67 8.79 25 0.96 + 0.96 18.32 25 1.52 + 0.75 14.48 28 0.29 - 0.43 9.15 28 0.13 + 0.39 3.06 28 Page 3 of 10/20/2006 ' Page 4 o WESTFORD 160 VS 2001 - 0.15 + 1.17 + 0.73 11.75 26 WEYMOUTH 2 FT 1965 - 2.57 - 2.60 + 2.55 15.01 28 WEYMOUTH 3 VS 1965 - 1.33 - 1.53 + 0.03 6.69 28 WEYMOUTH 4 TS 1965 - 0.83 - 0.62 - 0.04 7.72 28 WILBRAHAM 55 TS 1965 - 2.29 + 1.82 + 1.62 40.73 27 WILMINGTON 78 * FS 1951 - 0.41 + 1.30 + 0.17 9.05 26 WINCHENDON 13 ST 1939 - 1.35 - 0.05 - 0.50 11.15 25 WINCHESTER 14 ST 1940 + 0.33 + 1.65 + 1.75 11.65 26 RHODE ISLAND BURRILLVILLE 187 TS 1968 - 0.40 + 1.06 + 0.80 16.22 27 BURRILLVILLE 395 UT 1992 ----- ----- ----- _-_- BURRILLVILLE 396 VT 1992 ----- ----- ----- ---- BURRILLVILLE 397 HT 1992 ----- ----- ----- ---- BURRILLVILLE 398 HT 1992 ----- ----- ----- ---_ CHARLESTOWN 18 FS 1946 - 0.57 + 1.94 + 1.45 18.06 29 CHARLESTOWN 586 VT 1992 ----- ----- ----- _-_- CHARLESTOWN 587 ST 1992 ----- ----- ----- -_-- COVENTRY 342 VS 1991 - 0.24 + 0.72 + 0.10 10.69 27 COVENTRY 411 SS 1961 - 0.23 + 0.86 + 0.66 21.73 27 COVENTRY 466 VT 1992 ----- ----- ----- -_-- CRANSTON CITY 439 ST 1992 ----- ----- ----- ---- CUMBERLAND 265 SS 1946 + 0.17 + 0.69 + 0.68 13.99 27 EXETER 6 VS 1948 - 0.25 + 0.51 + 0.21 6.57 27 EXETER 158 ST 1991 - 0.77 ----- + 1.34 14.90 27 EXETER 238 FT 1991 + 0.05 + 0.26 - 0.02 12.54 29 EXETER 278 HT 1991 - 1.68 ----- + 3.00 17.19 29 EXETER 475 VS 1981 - 0.63 + 1.08 + 0.35 15.44 27 EXETER 554 SS 1988 - 0.21 + 0.85 + 0.29 10.60 29 FOSTER 40 HT 1991 + 1.26 + 3.12 + 0.29 7.65 27 FOSTER 290 HT 1992 ----- ----- ----- http://ma.water.usgs.gov/current-cond/data/2006-09.txt 10/20/2006 >> SET NEW HIGH OR EQUALED HIGHEST RECORDED WATER LEVEL FOR PERIOD OF RECORD > SET NEW HIGH OR EQUALED HIGHEST RECORDED WATER LEVEL FOR END OF SEPTEMBER << SET NEW LOW OR EQUALED LOWEST RECORDED WATER LEVEL FOR PERIOD OF RECORD < SET NEW LOW OR EQUALED LOWEST RECORDED WATER LEVEL FOR END OF SEPTEMBER ------ - DATA NOT AVAILABLE TOPOGRAPHIC (TOPO) SETTING: F=FLAT, G=FLOOD PLAIN, H=HILLTOP, S=HILLSIDE, T=TERRACE, U=UNDULATING, V=VALLEY, W=UPLAND DRAW LITHOLOGY (LITHO): G=GRAVEL, R=ROCK, S=SAND, T=TILL http://ma.water.usgs.gov/current-cond/data/2006-09.txt 10/20/2006 Page 5 HOPKINTON 67 ST 1991 - 0.64 - 6.71 + 0.98 18.90 27 LINCOLN 84 VS 1946 - 0.03 + 0.68 + 0.81 5.04 27 LITTLE COMPTON 142 ST 1992 ----- ----- ----- ---- NEW SHOREHAM 258 UT 1991 ----- ----- ----- ---- NORTH KINGSTOWN 255 VS 1954 + 0.15 + 1.15 + 1.11 8.48 29 NORTH SMITHFIELD 21 TS 1947 - 0.09 + 0.84 + 0.91 9.02 27 PORTSMOUTH 551 HT 1992 ----- ----- ----- ---- PROVIDENCE 48 TS 1944 - 0.13 + 0.34 + 2.49 4.21 > 29 RICHMOND 417 VS 1976 - 0.21 + 0.48 + 0.25 7.30 29 RICHMOND 600* TS 1977 - 0.50 + 1.40 + 0.61 34.00 27 RICHMOND 785 FS 1989 - 0.53 + 1.66 + 1.57 23.24 27 SOUTH KINGSTOWN 6 VS 1955 - 0.27 + 0.85 + 0.99 12.38 29 SOUTH KINGSTOWN 1198FS 1988 - 0.13 + 0.82 + 0.57 9.69 29 TIVERTON 274 TT 1990 ----- ----- ----- ---- WARWICK 59 ST 1991 - 1.09 + 5.05 + 2.24 11.62 29 WESTERLY 522 FS 1969 + 0.33 + 1.16 + 0.78 12.77 29 WEST GREENWICH 181 US 1969 - 0.05 + 0.69 + 0.33 16.19 27 WEST GREENWICH 206 ST 1991 + 0.11 + 0.74 + 0.57 4.98 29 >> SET NEW HIGH OR EQUALED HIGHEST RECORDED WATER LEVEL FOR PERIOD OF RECORD > SET NEW HIGH OR EQUALED HIGHEST RECORDED WATER LEVEL FOR END OF SEPTEMBER << SET NEW LOW OR EQUALED LOWEST RECORDED WATER LEVEL FOR PERIOD OF RECORD < SET NEW LOW OR EQUALED LOWEST RECORDED WATER LEVEL FOR END OF SEPTEMBER ------ - DATA NOT AVAILABLE TOPOGRAPHIC (TOPO) SETTING: F=FLAT, G=FLOOD PLAIN, H=HILLTOP, S=HILLSIDE, T=TERRACE, U=UNDULATING, V=VALLEY, W=UPLAND DRAW LITHOLOGY (LITHO): G=GRAVEL, R=ROCK, S=SAND, T=TILL http://ma.water.usgs.gov/current-cond/data/2006-09.txt 10/20/2006 CONTENTS OF MAJOR RESERVOIRS (ESTIMATED END OF MONTH READINGS) (MILLIONS OF CUBIC FEET) MONTH-END PERCENT OF PERCENT RESERVOIR CONTENTS AVERAGE FULL BORDEN BR + COBBLE MTN RES, MA 2712 108 80 QUABBIN RESERVOIR, MA 51784 --- 94 SCITUATE RESERVOIR, RI 4381 113 90 SECOND) DATE STREAM STREAMFLOW FOR SELECTED INDEX STATIONS (CUBIC FEET PER MONTH-END PERCENT MAXIMUM DATE MINIMUM MEAN MEDIAN FOR MONTH . FOR MONTH CHARLES RIVER, MA 113 118 200 06 56 30 E. BR. HOUSATONIC RIVER, MA 33.1 63 64 15 18 13 PAWCATUCK RIVER, RI 107 132 143 01 79 30 WARE RIVER, MA 30.8 81 ---- ------------------------------------------------------------------------------ A MONTHLY REPORT PREPARED BY THE U.S. GEOLOGICAL SURVEY MASSACHUSETTS -RHODE ISLAND WATER SCIENCE CENTER 10 BEARFOOT ROAD, NORTHBOROUGH, MA 01532 IN COOPERATION WITH THE MASSACHUSETTS DEPT. OF CONSERVATION AND RECREATION, MASSACHUSETTS DEPT. OF ENVIRONMENTAL PROTECTION, CAPE COD COMMISSION, RHODE ISLAND DEPT. OF ENVIRONMENTAL MANAGEMENT, AND THE PROVIDENCE WATER SUPPLY BOARD http://ma.water.usgs.gov/current cond/data/2006 09.txt Page 6 of 6 10/20/2006 O�ttu NORTy 1 6gti0 be ; .1, a OL O 1� Ty +� yyT PUBLIC HEALTH DEPARTMENT Community Development Division C(F127IFICA7E OFC09l�l�LIA�ICE As of: November 22, 2006 This is to cert that the individuaCsu6surface disposaCsystem received a SATISTACTORT IMT ECTIOX of the: Distribution Bo,-� replacement �y. ,john DiVincenzo At: 940 Forest Street North Andover, WA 01845 The Issuance of this certificate shad not 6e construed as a guarantee that the system wdf function satisfactoriCy. Ll [ -7 � L E, 9IlicheCe E. Grant 1Tu6Cic Aealth Inspector 1600 Osgood Street, North Andover, Massachusetts 01845 Phone 918.688.9540 Fax 918.688.8416 Web www.townofnorthandover.com 01 W, TOWN OF NORTH ANDOVER NORTH of , �q Office of COMMUNITY DEVELOPMENT AND SERVICES •'y'^_ - '• �p HEALTH DEPARTMENT 0r 1600 OSGOOD STREET; BUILDING 20; SUITE 2-36 NORTH ANDOVER, MASSACHUSETTS 01845 Susan Y. Sawyer, REHS/RS 978.688.9540 — Phone Public Health Director 978.688.8476 — FAX ONSITE WASTEWATER SYSTEM CONSTRUCTION NOTES LOCATION INFORMATION ADDRESS: y'�lJ�,�'�5��1 MAP INSTALLER: �1'y/IL'zO DESIGNER: PLAN DATE: BOH APPROVAL DATE ON PLAN: INSPECTIONS TANK INSPECTION: DATE OF BED BOTTOM INSPECTION: DATE OF FINAL CONSTRUCTION INSPECTION: DATE OF FINAL GRADE INSPECTION: SITE CONDITIONS Comments: 4:12#16411_1►`I 1 LOT: ❑Existing septic tank properly abandoned ❑Internal plumbing all to one building sewer []Topography not appreciably altered ❑ Bottom of tank hole has 6" stone base ❑ Weep hole plugged ❑ 1500 gallon tank has been installed H-10 loading Monolithic construction ❑ Water tightness of tank has been achieved (Visual or Vacuum Test or Water held for 24hrs) ❑ Inlet tee installed, centered under access port ❑ Outlet tee (gas baffle or effluent filter) installed, centered under access port ❑ 24" inch cover to within 6" of final grade installed over one access port, must be over outlet of tank if effluent filter is present ❑ Hydraulic cement around inlet & outlet Wastewater System Documentation — Feb 2006 Page 1 of 6 TOWN OF NORTH ANDOVER NORTot Office of COMMUNITY DEVELOPMENT AND SERVICES F? •'`� °°p HEALTH DEPARTMENT 1600 OSGOOD STREET; BUILDING 20; SUITE 2-36 c• ,- NORTH ANDOVER, MASSACHUSETTS 0 184 �'SsC U t� Susan Y. Sawyer, REHS/RS 978.688.9540 — Phone Public Health Director 978.688.8476 — FAX Comments: PUMP CHAMBER ❑ Bottom of tank hole has 6" stone base ❑ Weep hole plugged ❑ Combo Tank installed. Size: ❑ 1000 gallon Pump Chamber installed H-10 loading Monolithic construction) ❑ Inlet tee installed, centered under access port ❑ Pump(s) installed on stable base ❑ Alarm float working ❑ Pump On/Off floats working ❑ Separate on/off floats ❑ Drain hole in pressure line ❑ 24" inch cover to within 6" of final grade installed over pump access port ❑ Water tightness of tank has been achieved Visual testing ❑ Hydraulic cement around inlet & outlet Comments: ADVANCED TREATMENT TECHNOLOGY ❑ Type of treatment device: Comments: ❑ Installed per manufacturers requirements ❑ All components working in accordance with manufacturer's requirements Wastewater System Documentation — Feb 2006 Page 2 of 6 TOWN OF NORTH ANDOVER Hor+rH Office of COMMUNITY DEVELOPMENT AND SERVICES f HEALTH DEPARTMENT _ p 1600 OSGOOD STREET; BUILDING 20; SUITE 2-36 NORTH ANDOVER, MASSACHUSETTS Ol 845 �'SS„C,,,;; <� Susan Y. Sawyer, REHS/RS 978.688.9540 — Phone Public Health Director 978.688.8476 — FAX D -BOX f ❑ Installed on stable stone base )ti3`1 ©� Inlet tee (if pumped or >0.08'/foot) ❑' Hydraulic cement around inlet 8k outlets (( t ❑ Observed even distribution ❑ Speed levelers provided (not req fired) CLQ- v 1� - SOIL ABSORPTION SYSTEM El Comments: Bottom of SAS excavated down to soil layer, as provided on plan Size of SAS excavated as per plan Title 5 sand installed, if specified on plan 3/4-1 Y2" double washed stone installed 1/8-1/2" (peastone) double washed stone installed Laterals installed and ends connected to header Laterals vented if impervious material above Orifices @ 5 & 7 o'clock positions Gravel -less disposal systems: type, number and location as per plan Elevations of laterals installed as on approved plan 40 Mil HDPE barrier installed Retaining wall (boulder / concrete / timber/ block) Final cover as per plan Wastewater System Documentation — Feb 2006 Page 3 of 6 TOWN OF NORTH ANDOVER Office of COMMUNITY DEVELOPMENT AND SERVICES •`���� `' ��°op HEALTH DEPARTMENT F: 1600 OSGOOD STREET; BUILDING 20; SUITE 2-36 `► ", F; NORTH ANDOVER, MASSACHUSETTS 01845 �''SS„C,,,;s <� Susan Y. Sawyer, REHS/RS 978.688.9540 — Phone Public Health Director 978.688.8476 — FAX PRESSURE DISTRIBUTION ❑ -- inch manifold ❑ laterals installed with end sweeps size: material: ❑ Squirt test ft in height ❑ Equal distribution to all laterals ❑ orifice size inch as per plan Comments: CONTROLPANEL Comments: ❑ Alarm & Pump are on separate circuits ❑ Alarm sounds when float is tripped ❑ Location of control panel: ❑ Rated for exterior if placed outside Wastewater System Documentation — Feb 2006 Page 4 of 6 • 1 'Alp rm 11 est sq-lot11 Commonwealth of Massachusetts Map -Block -Lot ��°; ••`° •. �o°t 105.D- 0006 - Board of HealthO 9 � Permit No North Andover BHP -2006-0737 - ------------ -- P. 1. FEE �334CHUst� F.I. $125.00 Disposal Works Construction Permit Permission is hereby granted John DiVincenzo to (Repair -DISTRIBUTION BOX) an Individual Sewage Disposal System. at No 940 FOREST STREET ------------ - --------- - ---- ------ ----- ---- ---- as shown on the application for Disposal Works Construction Permit No. BHP -2006-073 Dated November 17, 2006 Issued On: Nov -17-2006 Board of Health Commonwealth of Massachusetts Map -Block -Lot Fo°D 105.D- 0006 - Board of Health ° • North Andover . -.4 CHUr A St Certificate of Compliance S�NU THIS IS TO CERTIFY,That the Individual Sewage Disposal System (Repair -DISTRIBUTION BOX) by John DiVincenzo at No 940FOREST STREET has been installed in accordance with the provisions of TITLE 5 of the State Environmental Code as described in the application for Disposal Works Construction Permit No. BHP -2006-073 Dated __November 1-7,-2006 Printed On: Nov -17-2006 Board of Health � NORiH r F i r Town of North Andover �b'•�, :o ::' HEALTH DEPARTMENT / ssACHUSt� // f X/ -1 CHECK #: X71 -f LOCATION: %%lI �t'�`Sy 7 s H/O NAME:r/,f'�� CONTRACTOR NAME: Type of Permit or License: (Check box) ❑ Animal $ ❑ Body Art Establishment $ ❑ Body Art Practitioner $ ❑ Dumpster $ ❑ Food Service - Type: $ ❑ Funeral Directors $ ❑ Massage Establishment $ ❑ Massage Practice $ ❑ Offal (Septic) Hauler $ ❑ Recreational Camp $ ❑ Sun tanning $ ❑ Swimming Pool $ ❑ Tobacco $ ❑ TrashlSolid Waste Hauler $ ❑ Well Construction $ SEPTIC Systems: ❑ Septic - Soil Testing $ ❑ Septic - Design Approval $ M,Septic Disposal Works Construction (DWC) $ ❑ Septic Disposal Works Installers (DWI) $ ❑ Title 5 Inspector $ ❑ Title 5 Report $ ❑ Other. (Indicate) $ nn`°a - Health Agent Initials White - Applicant Yellow - Health Pink - Treasurer O� pORTN wo Application for ,Septic Disposal System /� 1,/ �4 �� ?.07 p,Construction Permit - TOWN OF TODAY'S DATE �'• �' MA 01845 - Ful' Repair ORTH ANDOVER �1sSACHUg 4� ' - Compon $125.00 Important: Application is herebv made for a permit to: When filling out ❑ Construct a new on-site sewage disposal system* forms on the computer, use❑ epair or replace an existing on-site sewage disposal system* only the tab key to move your Repair or replace an existing system component — What. cursor - do not use the return key. A. Facility Information x-11 Address or Lot # City/Town 2.- *TYPE OF SEPTIC SYSTEM*: ❑ Pump ❑ Gravity (choose one) ***If pump system, attach copy of electrical permit to application*** ❑ Conventional System (pipe and stone system) ❑ Infiltrator or Biodiffuser (Gravel -Less) (Attach a copy of your certification to install this type of system. ❑ Pressure Distribution S.A.S. (No D -Box) (Attach Draft Maintenance Agreement) ❑ Pressure Dosed (D -Box Present) S.A.S. 2. Owner Inf rmatio rt.- // 9, r , L --_e Name 9 VC) 7ro f- cp i Addres (if ifferent fr abov) /I lQ �N � t~-2/` �fiL O /8yS City/Town State Zip Code Telephone Number 3. Installe Information NameName of Company -/ (�10 r- �c s� Address WGiv� Cit;fr6wn State Zip Code Telephone Number (Cell Phone # if possible please) a. Designer Information Name Name of Company Address City/Town State Zip Code Telephone Number (Best # to Reach) Application for Disposal System Construction Permit • Page 1 of 2 Application for Septic Disposal System -Construction Permit - TOWN OF ORTH ANDOVER, MA 01845 PAGE 2OF2 A. Facility Information continued.... 5. Type of Building: ❑Residential Dwelling or ❑Commercial B. Agreement Ax�la TODAY'S DATE $ - it 125. 00 - Compone The undersigned agrees to ensure the construction and maintenance of the afore -described on-site sewage disposal system in accordance with the provisions of Title 5 of the Environmental Code, as well as the Local Subsurface Disposal Regulations for the Town of North Andover, and not to place the system in operation until a Certificate of Compliance has been issued by this Board of Health. Name Date Application Approved By: (Board of Health Representat ve Name Date Application Disapproved for the following reasons: For Office Use Only: 1. Fee Attached. 2. Project Manager Obligation Form Attached. 3. Pump Sys tem? If so, Attach copy ofElectrical Permit 4. Foundation As -Built. (new construction ronly): (Same scale as approved plan) 5. Floor Plans? (new construction only): Yes Yes ,.IZ Y Y I! No No No No `L� Application for Disposal System Construction Permit • Page 2 of 2 SEPTIC SYSTEM INSTALLER PROJECT MANAGEMENT OBLIGATIONS As the North Andover licensed installer for the construction for the septic system for the property at: 9 c 1'6 41,e s -r- IS) " (-address of septic system) Relative to the application of V (' %i h�y t %� cen (Installer's name) Dated o ay s ate For plans by And dated With revisions dated I understand the following obligations for management of this project: (Engineer) ngina ate (Last revised date) 1. As the installer, I am obligated to obtain all permits and Board of Health approved plans prior to performing any work on a site. I must have the approved plans and the permit on site when any work is being done. 2. As the installer, I must call for any and all inspections. If homeowner, contractor, project manager, or any other person not associated with my company schedules an inspection and the system is not ready, then item three shall be applicable. 3. As the installer, I am required to have the necessary work completed prior to the applicable inspections as indicated below. I understand that requesting an inspection, without completion of the items in accordance with Title 5 and the Board of Health Regulations may result in a $50.00 fine being levied against me and/or my companY. a. Bottom of Bed — Generally, this is the first (V5 inspection unless there is a retaining wall, which should be done first. The installer must request the inspection but does not have to be present. b. Final Construction Inspection — Engineer must first do their inspection for elevations, ties, etc. As -built of verbal OK (or e-mail to: healthdeptQtownofnorthandover.com) from the engineer must be submitted to the Board of Health, after which installer calls for an inspection time. Installer must be present for this inspection. With a pump system, all electrical work must be ready and able to cause pump to work and alarm to function. c. Final Grade — Installer must request inspection when all grading is complete. Installer does not have to be on-site. 4. As the installer, I understand that only I may perform the work (other than simple excavation) and I am required to complete the installation of the system identified in the attached application for installation. I further understand that work done by others unlicensed to install septic systems in North Andover can constitute reasons for denial of the system and/or revocation or suspension of my license to operate in the Town of North Andover, significant fines to all persons involved are also possible. 5. As the installer, I understand that I must be on-site during the performance of the following construction steps: a. Determination that the proper elevation of the excavation has been reached. b. Inspection of the sand and stone to be used. c. Final inspection by Board of Health staff or consultant. d. Installation of tank, D -Box, pipes, stone, vent, pump chamber, retaining wall and other components. 6. As the installer, I understand that I am solely responsible for the installation of the system as per the approved plans. No instructions by the homeowner, general contractor, or any other persons shall absolve me of this obligation. Undersigned Licensed Septic Installer: ,, t J u (? 2 Q (Today's Date civKi6 ame —Print) ame — igne TOWN'OF NORTH ANDOVER Office of COMMUNITY DEVELOPMENT AND SERVICES HEALTH DEPARTMENT 1600 OSGOOD STREET; BUILDING 20; SUITE 2-36 NORTH ANDOVER, MASSACHUSETTS 01845 Susan Y. Sawyer, REHS/RS 978.688.9540 — Phone Public Health Director 978.688.8476 — FAX Well and/or Pump Application (Please print) LOCATION to Drill Well or install a pump: www.townofnorthandover DATE: -16120 /0f, Licensed Well Contractor Name and Company Name: 3(o (L, x�, Contact Phone Numbers: IVED OCT 3 0 2006 QM 0 - iN6iN, )7 F•NDOV5R HEALTH DEPARI MENT r- n-7. VOL)P1 G c( rv• oY 0"? Homeowner:. )Gt , V- Address: LI 3T (- RECEIVED Contact Phone Numbers: YY)U y �n l — 9) 1�= LOU — ?c9j—1 WELLS (to be completed at time of pump test) Type of well: I `rc�i /I Diameter of well: f Depth of bedrock: Seal been tested? Yes ( No ( ) Date of Use: Z, k,r OWN OF NORTH ANDOVER HEALTH DEPARTMENT Size of Casing: Depth of casing into bedrock: o(p tt11 Depth of well: 3o5-' Water -bearing rock: C931r / Depth of water: �S Delivers: GPM for: / •O(J)� �� J (how long) Drawdown:_ feet after pumping: % hOcSr� ours at: / GPM Date of Completion: // to o (0 PUMPS (To be filled in before installation) Name & size of Pump: _Toe,) Z/• ` Size of Tank: 7? Type; S,).S . Pump delivers:_..!i1 GPM Pipe used in well: Cast Iron_ Galvanized Plastic ✓ 16 4 pT Sleeve used to protect pipe? Yes No Type of we al: �C J )e -t_ Date: f l 06 i� Signailof Pump Date water analysis report submitted to Ilealth Department: 40 Plumbing � Wiring Inspecto Health Department Representative C:\Documents and Settings\pdellech\My Documents\COMMERCIAL PERMITS\Permit\Permit Applications\Well Application.doc Massachusetts Department of Conservation and Recreation Office of Water Resources TYPE OR PRINT ONLY Well Completion Report �s 1. WELL LOCATION GPS (Required) North Q -3-7. West j'• Address at Well Location: CT b 1'�3t Property Owner/Client: '" C'0 Subdivision Name: ..-.- Mailing Address: ��3Sr 45�� City/Town: /J6 }-Jk City/Town: YM le'1V e kN Assessors Map Assessors Lot #: NOTE: Assessors k4ap and Lot mandatory if no street address availa le bf �, 4� Board of Health permit obtained: Yes ELI -"""Not Required ❑ mpitVuiS�tier �•.- Date Issued 3a 2. WORK PERFORMED 3. WELL TYPE14. DRILLING METHOD 16. CASING �❑❑� lij Overburden Bedrock From (ft) To (ft) Type Thickness Diameter FA [A� o yo Ul10G4 17 ❑ 1:11:1 5. WELL LOG OVERBURDEN Water Loss or Addition of Fluid Drop in Drillow Stem Extra Fast or Drill Rate El 1:11:1 LITHOLOGY Bearing T' SCREEN From (ft) To (ft) V Type Slot Size Diameter From (ft) To (ft) Code Color Comment Zone 0 G Q 0 ` Y / Y / r F / S ❑ ❑ ❑ — — — Y / N Y / N F / S ❑❑❑ ❑❑❑ _ Y/ N Y/ N F/ S g_ ANNULAR SEAL/FILTER PACK/ABA,%D0N 7ENrT , "TL. Y / N Y / N F / S From (ft) To (ft) Material Description Purpose Y Y F 4(.D LN ®Q Y Y F/S ❑❑ ❑❑ Y/ N Y/ N F/ S ❑❑ ❑❑ Y/ N Y/ N F/ S El El El El WELL LOG BEDROCK - Water Bearing Zone Drop in Extra Drill 9 Lar a Stem Chips Extra Visible Fast or Rust Drill SIow Rate Staining Loss or # of Addition Fracture of Fluid per foot 9. SITE SKETCH LITHOLOGY i� {� I From (ft) To (ft) Code Comment rJ0 Y/ N Y/ / Q Y/ / N / S Y/ Y/ UO- S" _� /3/�, Y/ /N1`/S Y/ Y/ S0 j /N '/N S N 30S` L 1A Yl /N /S Y/ Y Y/ N Y/ N F/ S Y/ N Y/ N Y/ N Y/ N F/ S Y/ N Y/ N Y/ N Y/ N F/ S Y/ N Y/ N Y/ N Y/ N F/ S Y/ N Y/ N Y/NY/N F/S Y/N Y/N 10. WELL TEST DATA (ALL SECTIONS MANDATORY FOR PRODUCTION WELLS) 11. STATICWAT R LEVEL (AL1_ `^!ELr_S) Depth Below Date Measured Ground Surface (ft) Yield Time Pumped Pumping Level Time to Recover Recovery Date Method (GPM) (hrs & min) (Ft. BGS) (hrs & min) (Ft. BGS) 12. PERMANENT PUMP (IF AVAILABLE) ; 13. ADDITIONAL %. IELL IRFORC::ATION Pump Description _ Horsepower Developed Y / OFracture Enhancement Y / 1 Pump Intake Depth 7 (ft) Nominal Pump Capacity (gpm) Disinfected Y / N Surface Seal Type `! 14. COMMENTS Total Well Depth -L Depth to Bedrock 15. WELL DRILLER'S STATEMENT This well was drilled, altered, and/oaadoned under my supervision, according to applicable rules and regulations, and this repomplete and correct to the best of my knowledge. + Driller: �t 7 �) f } / t)� Supervising Driller Signature: % Registration #: L Pt Firm: !~' art 6 u/' G (^!-G�( �°d Date Complete: ' ' Dtco —Rig Permit #: J NOTE: Well Completion Reports must be filed by the registered well driller within 30 days of well completion. BOARD OF HEALTH COPY Well Completion Deport Codes Section 2 - Section 3 Section 5 Overburden Work Screen Type Well Work Performed Lithology Type Performed Code Well Type Code Decommission DC Cathodic Protection CTPR Deepen DP Domestic DMST Hydrofracture HF Geoconstruction GCON New Well NW Geothermal Closed Loop GTCL Repair RP Geothermal Open Loop GTOL Replacement RE Industrial INDS Coarse Sand CS Injection INJC Diorite DI Irrigation IRRG Greenish Gray GG Monitoring MONT Fine Sand FS Public Water Supply PBWS Gneiss GN Recovery RCVR Reddish Brown RB Test Wells TSTW Section 5 Overburden Screen Screen Type Code Carbon Steel CST Lithology Overburden Overburden Overburden Perforated Pipe Bedrock Name (OB) Code Color Color Code Bedrock Name (BR Code) Artificial Fill AF Black BL Amphibolite APA Boulders B Bluish Gray BG Basalt BS Clay CL Brown BR Conglomerate/ Breccia CG/BR Coarse Sand CS Dark Gray DG Diorite DI Cobbles C Greenish Gray GG Gabbro GB Fine Sand FS Light Gray L3 Gneiss GN Fine to Coarse Sand FCS Reddish Brown RB Granite GR Gravel G Yellowish Brown YB Limestone LS Medium Sand h"S Marble MA Organics 0 Quartzite OZ Sand & Gravel SG Rhyolite RH Silt SI Sandstone SS Silty Clay SICL Schist SC Silty Sand SIS Shale SH Silty Sand & Gravel SISG Slate/Phyllite SL/PH Till T Pegmatite Pht Section 7 Section 8 19 Section 4 Screen Screen Type Code Carbon Steel CST Continuous Wire PVC CWP Galvanized Wire Wrapped GWW Perforated Pipe PFP Pre -pack PVC PPP Pre -pack Stainless PPS Slotted PVC SLP Stainless Steel Vee Wire SSV Stainless Steel Well Point SSP Section 8 19 Section 4 Section 6 Drilling Air Lift Mlethod Drilling Method Code Air Hammer Ah Air Rotary AR Auger AG Cable Tool CT Casing Advancement CA Core CR Direct Push DP Drive and Wash DW Dug DG Mud Rotary MR Reverse Rotary RR Sonic SN Section 6 Section 12 Casing Air Lift Description Type Thickness Casing Type Code Thickness (NO CODE) Certa-Lok CTL Schedule 5 Fiberglass FBG Schedule 10 Galvanized Pipe GLP Schedule 40 HDPE HDP Schedule 80 NSF Coated Steel NCS Schedule 160 PVC PVC SDR 13.5 Stainless Steel SST SDR 17 Steel STL SDR 21 NM SDR 26 2C0 SDR 32.5 SDR 40 17# 19# Section 12 Annular Seal/Filter Air Lift Description Annular Seal/Filter Pack/Abandonment 2 Wire Constant Speed Submersible Purpose Pack/ Abandonment Material Code Purpose Code Bentonite Chips/Pellets BC Fill FL Bentonite Grout BG Filter FT Cement/ Bentonite Grout CB Seal AS Concrete CT 7 112 10 Sand SD 10 125 Native Material NM Section 12 Section 10 Method Method Code Air Blow with Drill Stem Pump Air Lift Description Pump Description Coda 2 Wire Constant Speed Submersible 2VlSS 3 Wire Constant Speed Submersible 3WSS Constant Speed Submersible Turbine CSST Variable Speed Submersible Turbine VSST Jet JET Line Shaft Turbine LST Centrifical CENT Section 10 Method Method Code Air Blow with Drill Stem AB Air Lift AL Bailing BL Constant Rate Pump CR Variable Rate Pump VR Slug SG Section 13 Well Seal Horsepower Surface Seal Typ3 Type Coda 1,2 20 Cement C,.; 3/4 25 Cement;'Bentenite C3 1 30 Concrete Cr 11i2 40 None NO 2 50 3 60 5 75 7 112 10 10 125 15 150 2C0 Cf ,NO OTM , i~ G�:.. Touf'n of North Andover J `+rs .,,,, HEALTH DEPARTMENT/� S�Cow CHECK #: LOCATION: H/O NAME: �� L C CONTRACTOR NAME:G�i Type of Permit or License: (Check box) ❑ Animal ❑ Body Art Establishment ❑ Body Art Practitioner ❑ Dumpster ❑ Food Service - Type. ❑ Funeral Directors ❑ Massage Establishment ❑ Massage Practice ❑ Offal (Septic) Hauler ❑ Recreational Camp ❑ Sun tanning ❑ Swimming Pool ❑ Tobacco ❑Tra Solid Waste Hauler Zell Construction SEPTIC Systems: ❑ Septic - Soil Testing ❑ Septic - Design Approval ❑ Septic Disposal Works Construction (DWC) ❑ Septic Disposal Works Installers (DWI) ❑ Title 5 Inspector ❑ Title 5 Report i ❑ Other. (Indicate) $ r/ r1. O r Health Agent Initials White - Applicant Yellow - Health Pink - Treasurer NORTH ,. COMMONWEALTH OF MASSACHUSETTS North Andover IL Board of Health 1SSAC"USti BURKE, RICHARD A CORINNE A BURKE ------------- NAME 940 FOREST STREET ---------- I ----------- ------------ - --------- ----------- ADDRESS IS HEREBY GRANTED A PERMIT Well Construction This permit is granted in conformity with the Statutes and ordinances relating thereto, and expires -__ unless sooner suspended or revoked. October 30, 2006 NUMBER BHP -2006-0723 FEE $135.00 Board of Health N IOWN'OF NORTH ANDOVER Office of COMMUNITY DEVELOPMENT AND SERVICES ` HEALTH DEPARTMENT 1600 OSGOOD STREET; BUILDING 20; SUITE 2-36 NORTH ANDOVER, MASSACHUSETTS 01845 Susan Y. Sawyer, REHS/RS 978.688.9540 — Phone Public Health Director 978.688.8476 — FAX www.townofnorthandover IVSD OCT 3 0 2006 MM OI- i4..jN 7 ANDOV1_R HEALTH DEPARI MENT Well and/or Pump Application (Please print) DATE: D30 0f' LOCATION to Drill Well or install a pump: y �o �,es7' ,G Licensed Well Contractor Name and Company Name: X::,' m' y0c) h 6 ('-CL C e • Q V/-/ O 97 Contact Phone Numbers: ( ("'()1) F�? _arC) Y C-1 6 o a 3) -51911 — 0 Yr d Homeowner: b r, �`e Y //cc . Address: c)3J_ JT m-cjAL-*h, Contact Phone Numbers: M6 Ir k,, /— 9)�__ L0f— ?19-r1 WELLS (to be completed at time _o/f pump test) Type of well: I Yvt Use: t� ki r WL h Diameter of well: 6 Size of Casing: (v ;V 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: Signature of Well Contractor PUMPS (To be filled in before installation) Name & size of Pump: Type: Size of Tank: Pump delivers: GPM Pipe used in well: Cast Iron_ Galvanized Plastic Sleeve used to protect pipe? Yes No Type of well seal: Date: Signature of Pump Installer Date water analysis report submitted to Health Department: Plumbing Wiring Inspector Health Department Representative C:\Documents and Settings\pdellech\My Documents\COMMERCIAL PERMITS\Permit\Permit Applications\Well Application.doc - -T own 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 to file with the Conservation Commission if wetlands are near to the proposed well, and to the Planning Board if you are located in the Watershed District. • 0 + , 1 f ,D,BoX� csE'�fC x7/:E DelleChiaie, Pamela From: Health Department[healthdept@townofnorthandover.com] Sent: Monday, October 30, 2006 2:21 PM To: Merrill, Pamela Cc: DelleChiaie, Pamela Subject: 940 Forest Street - Well Permit Application GeoTMS.rtf Hi Pam, This application for a well came in today. Susan would like you to take a look at it regarding any possible Conservation issues. Thank you. P 4 w O 6l G� aAv�3o:a` ° U G 00 kr) o ei'IT 0o 3 E _ � O �� dU ��•V 3 U .. � M N O110 U CO O C � q goo w O 6l G� aAv�3o:a` ° U G 00 kr) o ei'IT 0o 3 E _ � O �� dU ��•V 3 � U I. w Permit n If Uf L111 Town of North Andover,Mass. Date - 9 WELL CONTRACTOR (To be completed at time of pump test) Type of WellWell used fore Diameter of Well /y� _Size of Casing Depth of Bed Rock �� I Depth casing into Bed Rock Was Seal Tested? Yes ( ) No ( ) Date -of Testing Depth of Well /d _ _1•Jell Ended in [,That Material Depth to Water Delivers Gals . Per ;'lin Drawdown__ feet after pumping hours at. 7�1.2 GPM Date of Completion � �1 Signa ' i,'ei-- ntracto,-_--- PUMP INSTALLER- (To be filled—in-bef-ore-installation)-- Size & Name -Pump Pump Type Used 1•'ater Pump Delivers=- - GPM = - Size -of -Tank Pipe Material Used in '.'ell: -Cast Iron ( ) Galvanized-(--) Plastic*(—) Uell Pit (_) or Pitless Adapter {_) 1,as sleeve used to -protect. pipe? --Yes {^) NOC Type or Nati e viell Seal Date N'A:, Yf:i Oe YcY; >.- .�..i— ii ,. A : „ ,r �r Date 1•'ater analysis report submitted to --Board of Health Date release given tD ox:-ner of record & B1dg..Insp- Health-Inspector APPLICATION FOR WELL & PUMP PERMIT Application is hereby made for permit to drill a well (iK Application is made to install (_) a pump system. "Location: Address—/ Jc � J �� Lot ## 0 n e r e^,fh,2�� ,�� Address e�-_ — /'G T e I Well Con tractgr_ 4��w Address, f// � ��Tel Pump Contractor _Address_ Tel :_- . WELL CONTRACTOR (To be completed at time of pump test) Type of WellWell used fore Diameter of Well /y� _Size of Casing Depth of Bed Rock �� I Depth casing into Bed Rock Was Seal Tested? Yes ( ) No ( ) Date -of Testing Depth of Well /d _ _1•Jell Ended in [,That Material Depth to Water Delivers Gals . Per ;'lin Drawdown__ feet after pumping hours at. 7�1.2 GPM Date of Completion � �1 Signa ' i,'ei-- ntracto,-_--- PUMP INSTALLER- (To be filled—in-bef-ore-installation)-- Size & Name -Pump Pump Type Used 1•'ater Pump Delivers=- - GPM = - Size -of -Tank Pipe Material Used in '.'ell: -Cast Iron ( ) Galvanized-(--) Plastic*(—) Uell Pit (_) or Pitless Adapter {_) 1,as sleeve used to -protect. pipe? --Yes {^) NOC Type or Nati e viell Seal Date N'A:, Yf:i Oe YcY; >.- .�..i— ii ,. A : „ ,r �r Date 1•'ater analysis report submitted to --Board of Health Date release given tD ox:-ner of record & B1dg..Insp- Health-Inspector f e e E Stevens Water Analysis 38 Montvale Avenue • Stoneham, MA 02180 * Mass. (617) 438-6114 • Salem, N.H. (603) 893-3106 LABORATORY NUMBER: 12946 SAMPLE DATE: 6/22/84 SUBMITTED BY: John J. Decoulas 30 Moonpenny Drive Boxford, MA 01921 SAMPLE SOURCE: Well/collected from pump R. Burke, Lot 1 Forest St., No. Andover, MA ANALYSIS: According to Standard Methods of Water and Wastewater Analysis, 15th Ed. Total Coliform . . . . . . . • not requested Chlorides. . . . . . . . . . . . 9 mg/L pH. . . . . . . . . . . . . . . Hardness. . . . . . . . . . . . Manganese. . . . . . . . . . . . Sodium . . . . . . . . . . . . . Iron . . . . . . . . . . . . . . Nitrate . . . . . . . . . . . . . Nitrite . . . . . . . . . . . 7.6 66 mg/L 0.10 mg/L 11.4 mg/L 0.05 mg/L less than 0.10 mg/L less than 0.10 mg/L COMMENT: The results of these analyses meet the required federal and.state standards for drinking water. However, the manganese concentration exceeds the recommended standard. Although manganese is not harmful to your health, it can affect the taste, color and odor of your water. Manganese is frequently found at elevated levels in new wells. It is likely that the con- centration will decrease when the well is put into regular use. Chemist/Microbiologist North Andover Board of Assessors Public Access : 210/105.D-0006-0000.0 SKETCH n Sketch to Enlarge Community: North Andover PHOTO No Picture Ava Location: 940 FOREST STREET Owner Name: BURKE, RICHARD A CORINNE A BURKE Owner Address: 940 FOREST STREET City: NORTH ANDOVER State: MA ZIP: 01845 Neighborhood: 6 - 6 Land Area: 1.03 acres Use Code: 101 - SNGL-FAM-RES Total Finished Area: 1450 sqft ASSESSMENTS CURRENT YEAR PREVIOUS YEAR Total Value: 433,900 403,900 Building Value: 223,800 209,500 Land Value: 210,100 194,400 Market Land Value: 210,100 Chapter Land Value: LATESTSALE Sale Price: 30,000 Sale Date: 05/03/1984 Arms Length Sale Code: Y -YES -VALID Grantor: Cert Doc: Book: 01805 Page: 0025 Page 1 of 1 http://csc-ma.us/NandoverPubAcc/jsp/Home.jsp?Page=3&Linkld=808409 11/1/2006 i6*'NC0 O'1)4T 7,4 q�RAviv SSACHUS� PUBLIC HEALTH DEPARTMENT Community Development Division C'E127IrFICA7E OE C09YPGIA9VM As of: November 22, 2006 This is to cert that the individua(subsurface disposafsystem receiveda S37IS(FACTORT lYST EC` OY of the: Distribution (Bo,-,( Replacement Oy. john DiVincenzo At: 940 Forest Street North Andover, 911,4 01845 The Issuance of this certificate shad not 6e construed as a guarantee that the system will function satisfactorify. --) /7 ( 7 Michele E. Grant (Public Yfeafth Inspector 1600 Osgood Street, North Andover, Massachusetts 01845 Phone 918.688.9540 Fox 918.688.8416 Web www.townofnorthandover.com 0 Q rt a N V) mi h LC (D zn rt 0 A v 0 n c � 3 a � o n D o. a � ry �; 1 y Z v rt A (D C S 7 3 O 1 N 3 u 3 3 © CL M 3 m 0 a i @ rOi O rt rt � 3 17 C 1 'a t 0 1 i U) m j O1 j fl O A C 3 rt 1 � O 3 fy @. 7 0 Q rt a N V) mi h LC (D I Form Number 4 Town of North Andover, Massachusetts BOARD OF HEALTH t 19 .. CERTIFICATE OF COMPLIANCE This is to certify that the Individual Soil Absorption Sewage Disposal System constructed ( ) or repaired ( ) by INSTALLER at SITE LOCATION has been installed in accordance with Board of Health Regulations as described in the Design App4oval Site System Permit No. dated 19 . The issuance of this certificate shall not be construed as a guarantee that the system will function satisfactorily. BOARD OF HEALTH ENGINEER TO: NORTH ANDOVER, MASS �Q 19 V `5 BOARD OF HEALTH FROM: DESIGN ENGINEER Re: Soil Absorption Sewage System Inspection / JThis is to cer't'ify that I have inspected the construction of the said disposal system at /O/��(L `QlN�1P.0 Az 1<<21C. kMee North Andover, Mass. SITE LOCATION The grades and construction are as specified in my plans and specifications dated 19 Loe /Prot. t'ngineerkKeg. sanitarian o' jot yes ' z m C c 'Gi. LOSCn i w f r 0 Board of Health Nord AndoverzHaae. ,�P C1VID DATZ DI SAPPFMR 9 : eammst OK 1-745 7�22�J SEPTIC SISTEK INSTALLATICK CHBCK LIST 5 . lS ai) C_�Z 1. Distance Tot a. Wetlands b. Drains c. Well 2. Wa.er mine Location 3• No PPC Pipe 4. Se; ,tic Tank a. Tees -_Length & To Clean Out Covers b. Cement Pipe to Tank -,On Both Sides of Tank 5. Distribution Box a. Covers & Box - No Cracks b. All Line's Flo Ang Equal Amounts c. No Back Flow 6. Leach Field or Trench a. Dimensions b. Stone Depth c. Capped Ends d. 'Clean Double Washed Stone 7. Leach Pits a. Dimensions L Stone Depth c. S�- ash Pads d. T6ds e. Cert Pipe to Pit - Both Sides f. Clean Double Washed Stone 8. Nc+ Garbage Di spo sal 9. YJ ial. Grading Inspection 10. Barricading Covered System 11. As Built Submitted a. Lot Location b. Dimensions of System c. Location with Regard -to Pere Test d. Elevations e.' Water Table EXCAVATICN OK EAU Board of Health Ncrt),. Jlbdoversyass SUBSURFACE DISPOSAL DESIGN CHECK LIST( r LOT J I E�2r DATE ^ �G DISAPPROVED DATE- 7- 1Z / APPROVED-';,;,� Reasons: Provided*. l�E�JIS � p f��. �. p) �T60 CiDSy S1P is S- �C` c.e�M CoAjrc= k)C ti Title V Reg 2.5 FAIL. CIE V The submitted plan must show RS a n ni num: a) the lot to be served -area dimensions lot #sabutters location and log deep observation holes -distance to ties location and results percolation tests -distance to ties design calculations & calculations showing required leaching area e location and dimensions of system -including reserve area f) existing and proposed contours location arty vet areas within Do' of swage disposal system or g) disclaimer -check wetlands mapping ( surface and subsurface drains vithin 100' of sewage disposal stem or disclaimer location drainage easements within � disposal (i) 100 of stege dispo system or disclaiirer-Planning Board files (j) knoz.a sources of mater supply within 2001 of stege disposal a _ — ---- -- 1-1 system or diselainer (-k) -location-of-srT proposed-wel1_to serve j -0—t-1 i�-om_leachin9 fac. from leaching Sacili� (1) location of mater lines on property -10' pm) location of benchmark c (n) drive-,a.Ys r (o) garbage disposals _ no PVC to be used in construction (q) profile of s3stem-elevations of basement, plumb, pipe, septic tan distribution box inlets and outlets, distribution field piping an Other elevations (r) maim ground later elevation in area sez.-age disprsal systema Cl l'�l (s) plan must be prepared by a Professional Engineer or other professional authorized by law to prepare such plans P.eg 6 Sep_ticTanks flow., Nater tables tees depth of tees A(a) capacities -150- of flo accecsi Pe --ping (b) cleanout (c) 1D, from cellar Na11 or isq;round sr,ng Pool 1 (d) 25' from subsurface drains Reg 10.2I I Distribution Faxes (a) slope greater th= 0.08 Reg 10.E b) stamp n 1' v r Mass. Street No - - - - I Lot No__ 0 V .r Orth �.ndo e , T/`�ubciiv. Pland Owner TTives ci gator SOIL PROFILE DATES 2.Flev --- - --3•F1ev 4.Flev AVA 1z, 0 0 0 0- Ti -is s to Te-- - Pits 2 2 - T 2 ----- -- --- 2 - -- - - - ill �A,� -- -- (�cv� 6 vu - 6 j 7 = -- -- 7 --- - - 7 - 3 8 -- - 8 - -- 8 9 0 _ •n ' lcvation :-Wrption - D,�up of i)rup of G"-Jlime _ -- -- - - - „�.l drop- Yins. ?,d ))s()pon - -- - - - - f -o do o� I kk� utN.hai provldo01hll�lo rn log neo �, tocol 8oerc CO 1':CI111110d 10 1118 ICG 11 8^art; C'I np�,,n pr Clllor FacillInform'a(lon 7:,7 .,v;t,;.'•r ,'�.., ` ;:, �.�',;,..:.., . SIM —�--- ,,y,J�Sya(am Ownar, �dt1i+ (114Vf1rinl rcvn buUcn) C p , Q' B,:P..umping ord rYPQ C! iy)(am; 7 C999�001(9) olh9/ (d9SClib81: Ehlvanl ioo; Flljc•�G;` •• , ( P(.owr? [' Yo9 n'o r • 9, •.. Y Q�1 Pti�mpv d 8 Lm •.a,ti:�,,..r,i';���'�� IY��.r�1.4't I�(!yJt �•',I��j�J/li 1,�;,, C I ' I�!'��•(•'I''/',`� :. •,•�'�,'°Yn'i,�1� (Ih�l,.: �, f��'dl I''�1 �J'��i1 vl�•.��, �•1!�,... • ,�.:, �' e/�•�cor�lony',were d!ypossa: its 7 S n►ku ma �, gor/dsrilre(si/s pp(OvaJa/161orm�.n: naln9�acl I $m!c Tan,, 7 7 ^ IS..I Teri If y99 ^a9 i; C'0ana)7 r7 r es _ Yfhlvl 'j, 0 rA gmg 091, A. M— Ir Commonwealth of Massachusetts City/Town of No. Andover System Pumping Record Form 4 M 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 CMR 15.351. A. Facility Information Important: When filling out forms 1. System Lso on the computer, F� ! use only the tab LS7 key to move your Address cursor - do not No. Andover Ma use the return key. City/Town State Zip Code 2. System Owner: RECEIVED Name JUN 2"12012 renun Address (if different from location) TOWN OF NORTH ANDOVER HEALTH DEPART City/Town State Zip o e Telephone Number B. Pumping Record 1. Date of Pumping D to 2. Quantity Pumped: Gallons 3. Type of system: ❑ Cesspool(s) Septic Tank ❑ Tight Tank ❑ Grease Trap ❑ Other (describe): 4. Effluent Tee Filter present? ❑ Yes kNo If yes, was it cleaned? ❑ Yes ❑ No 5. Condition of System: T �' d 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 Signature of Hauler Date Signature of Receivingci ity Date t5form4.doc• 03/06 System Pumping Record • Page 1 of 1 No Andover 1600 Osgood St Building 20 Suite 2-36 No. Andover, Ma 01845 Date Name & Address 1 -May Patter reality 81 Sawmill Rd 2-May'Mulcahy 350 Sharpners Pond Rd Greene 62 Willow Ridge Rd 3 -May `Laoross 259 Grandville 4 -Ma Rincon 115 Sherwood r J&S Development dba Stewart's Septic Andover Septic 58 South Kimball Street Bradford, MA 01835 Gallons Comments 1500 Good 1500 Good 1000 Good 2500 Good 1500 Xsolids HG -May.Ca lahn 9401 St (R& 1500 Good 10 -May Melenm em St 15-May'Diraffel 3 Brenkin ridge Rd Depari 175 Stone Cleave Rd 16 -May Martin 701 Forest St Murphy 16 Carleton Lane 18.May Vandergraaf 267 Old Cart Way • Solano 2198 Tnok St 21 -May �omicho 115 Laconia Cir . Reti 42 Cross Bow 24 -May Carbonell 1560 Salem St 29 -May Thurber 210 Farnum St 31 -May Cleary 105 Winter green Dr 1500 Xsollds 1500 Good 1500 Good 1500 Good 1500 Good 1500 Good 1000 Rh 1500 Good 1500 Good 1000 Good 1500 Good 1000 Good TOWN Or- NORTH ANDQVU[Z HEALTH DEPARTMENT