HomeMy WebLinkAboutMiscellaneous - 940 JOHNSON STREET 4/30/2018 (3)Date..... .I..........................................
TOWN OF NORTH ANDOVER
PERMIT FOR GAS INSTALLATION
t Vrv-, C� Ars
Thiscertifies that...................................................................................................................
bjs permission for gas installation......�.!.`.........................................
in the buildings of ........................21.�e
........ --........
at'Y �v . c ��'� ....., North Andover, Mass.
Fee... �W....... Lic. No. �.��� �. �.......... .................................................
�j GAS INSPECTOR
Check # 1
S, ,
N/ %'14 AoW-3
MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK
/ / i ' l
CITYC�1r MA DATE Q f PERMIT #
JOBSITE ADDRESS�II 0 Ed NAME
GOWNER
---
ADDRESS 3 I I C r--]TEJFAX �!
TYPE OR
OCCUPANCY TYPE COMMERCIAL [J] EDUCATIONAL ® RESIDENTIAL
PRINT
CLEARLY
NEW: RENOVATION: [ REPLACEMENT: El PLANS SUBMITTED: YES NOD
APPLIANCES 1 FLOORS- BSM' 1 1 2 3
4 5 6 7 8 9 10 11 12 13 14
BOILER
BOOSTER
CONVERSION BURNER. --
COOK STOVE _ J1____j �.. ... __ . ._ . ! -— A ... __.. - - - _ .. .. .
DIRECT VENT HEATER
DRYER -
FIREPLACEl-�
FRYOLATOR
FURNACE
GENERATOR
GRILLE
INFRARED HEATER
LABORATORY COCKS
MAKEUP AIR UNIT
OVEN
POOL HEATER
ROM/ SPACE HEATER
ROOFTOP UNIT _
TES'
UNIT HEATER
UNVENTED ROOM HEATER I _
WATER HEATER 1
OTHER_ �_ -
.............._.............. ..............a ............... J. ............. _
- - -
INSURANCE COVERAGE
have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL. Ch. 142 YES NO
IF YOU CHECKED YES, PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW
LIABILITY INSURANCE POLICY OTHER TYPE INDEMNITY ® BOND Fil
OWNER'S INSURANCE WAIVER: I am aware that the licensee does not have the insurance coverage required by Chapter 142 of the
Massachusetts General Laws, and that my signature on this permit application waives this requireme
CH CK ONE ON Y: OWNERE T
�o
SIGNATURE OF OWNER OR AGENT
1 hereby certify that all of the details and information I have submitted or entered regarding this applicatio are true and ccur t be t knowledge
and that all plumbing work and installations performed under the permit issued for this application will be in comp ance ith P — i nt oA on of the
Massachusetts State Plumbing Code and Chapter 142 of the General Laws.
PLUM BER-GASATTER NAM j LICENSE # CI / SI ATURE
MP [X MGF JP ® JGF 0 LID GI E1 CORPORATIONe# PARTNERSHIP LLC [I#
COMPANY NA �. 7�1_� ADDRESS
CITY STATEZIP TEL
FAX
FAX CEI -6 �% I
01
N/ %'14 AoW-3
ry The Commonwealth ofMassachusetts
Department of 1ndustrigl Aceidiiits
Office oflnvestigations
600 Washington. Street
Boston, MA 02111
www•mass gov1d1a
Wgr ers' Compensation.)(nsurance Afrdayff: BuRders/Contrac
Name (Business/Organizationft(I` .attf ):�_
Address:
2
City/State/Zip:'✓(✓ Phone
Are yquran employer? Check the appropriate box:
4ff 1 to er �� `l• ❑ I am a general contractor and I
Type of project (required):
'
am a y emp with
6, Now cOnsiruction
_1,
employees (full. and/or part lime) *
2.01 am a sole proprietor or partner
have Hired the sub -contractors
listed on the attached sheet.
7• ❑Remodeling
ship and`have no employees
These sub -contractors have
8. [] Demolition
working for me in any capacity.
workers' comp. insurance,9.
5. ❑ We area corporation and its
❑ 13ui1ding addition
[No workers' comp. insurance
required.]
officers have exercised.their
ME] Blectricalxepaixs or ac]diiions
3. 1 am a homeowner doing all work
right of exemption per MGL
11.[[ Plumbing repairs or additions
myself [No workers' comp.
c.152, §1(4), and we have no
12.ElRoofrepairs
�. �
insurancere ed
employees. [No workers'
13.[] Ocher
comp. insurance required.]
'Any applicant that checks box#1 mustalso fdl out the section beldw showingtheir Workers' compensation policy information.
i Homeowners who submit this affidavit indicating they Aie doing allworlc and then hire outside contractors must submit a new affidavit indicating such.
tContractors that cheekthis box must attached as additional sheet showingthe name oftime sub -contractors and their workers' comp. policy information.
1 atn an employer that ispro workers' compensation insurance formy employees Below is thepolicy imd joh site
infox7nation.
Insurance Company Name%
Policy # or Sol£ ins. Lic. M.
Expiration Date:,
Job Site Address: k)� Pity/State/Zip:
Attach a copy of the workers' compensation -policy declaration page (showing the policy number and expiration date).
Failure to secure ooverage as reguiredunder Section 25A ofMGL o.1.52 can lead to the imposition of criminal penalties of a
line. up to $1,500.00 and/or 6nc:-year imprisonment, as well as civil penalties in the form of a STOP WORK ORDER and a fine
of up to $250.00 a day against the violator. Be advised t copy of this statement may be forwarded to the Office of
7nvesiigaiio s�ofMrD A. for hisurance wverago vex cati /7
I do Jier'eb%ertifv under
the information provided above is true and correct.
Of use ortly. Do not {vrUe in this area, to be completed by city or town official.
City or Town: Permit/License #
Issuing Authority (circle one):
1. Board of Health 2. Building Department 3. CityiTown Clerk 4. Electrical Inspector 5. Plumbing Inspector
6. Other - - -
Contact Person: Phone M.
Information and Instrnctions
Massachusetts General Laws chapter 152 requires all employers to provide workers' compensation for their employees.
Pursuant to this statute, an employee is defined as "...every person tri. the service of another under any coriixact of hire;
express orimplied, oral orwxitien."
An employe is defined as "an individual, partnership, association, corporation or other legal entity, or an two or
more
of the foregoing engaged in a joint enterprise, and including the legal representatives of a deceased employer, ox the
xedeiver ox fnisfee of an individual, partnerslvp, as§ociation or other legal entity, employing employees. However the
owner of a dwelling house having not more than three apartments and who resides therein, or the occupant of the
dwelling house of another who employs persons to do maintenance, construction or repair work on such dwelling house
ox on the grounds or building appurtenant thereto shall not because of such employment be deemed to be an employes."
MGL chapter 152, §25C(6) also states that "every state or local licensing agency shall withhold the issuance or
renewal of a license or permit to operate a business or to construct buildings in the commonwealth for any
applicant who has not produced -acceptable evidence of compliance with the insurance coverage required:'
Additionally, MGL chapter 152, §25C(7) states "Neither the commonwealth nor any of its political subdivisions shall
enter into any contract for the performance ofpublic work until acceptable evidence of compliance with the insurance
requirements of this chapter have been presented to the contracting authority."
Applicants
Please fill, out the workers' compensation affidavit completely, by checking the boxes that apply to your situation and, if
iiecessar ,supply sub -contractors) name(s), addresses) andphone number(s) along with their certificate(s) of
insurance. Limited Liability Companies (LLC) or Limited Liability Partnerships (LLP) with no employees other than the
members ox partuexs, are notrequired to carry workers' compensation insurance. If au LLC or LLP does have
employees, a policy is required. Be advised that this affidavit may be submitted to the Department of Industrial
Accidents fax confirmation of insurance coverage. Also be sure to sign and date the affidavit. The affidavit should
be returned to the city or town that the application for the permit or license is being requested, not the Department of
Industrial Accidents. Should you have any questions regarding the law or if you are required to obtain a workers'
compensationpofzcy, please call the Department at the number listed below. Self-insured companies should enter their
self-insurance license number on the appropriate line.
City or Town Officials
Please be sure thatthe affidavit is complete andprinted legibly. The Department has pxovided a space at the bottom
of the affidavit for you to fill out in the event the Office of Investigations has to contact you regarding the applicant.
Please be•sure to fill in the permit/license number which will be used as a reference number. In. addition, an applicant
thatmust submitmultiple permit/license applications in any given year, treed only submit one affidavit indicating current
policy information (if necessary) and under "Job Site Address" the applicant should write ,all lo
towu): ' A60' or
py of the affidavit that has been officially stamp ed or marked by the city or town maybe provided to the cations in (city
applicant as proof that a valid affidavit -is on file for future permits or licenses. Anew affidavit nut st be filled out each
year. Where a home owner or citizen is obtaining a license or permit not related to any in or commercial venture
(i,e, a dog license orperxnit to bum leaves eta.) said person is NOT required to complete this affidavit.
The Of ice of Investigations would like to thank you in advance for your cooperation and should you have any cluestions,
please do not hesitate to give us a call.
The Department's address, -telephone and fax number:
The Coat.man
woajtbt of as achuseifs -
Dapa .ela# of Industdal Acoldolita
Off toe o Ilmostliwons
6.04 W48M
13 Woo, MA 02111
TO.0 617-7.27-4900 at 406 or 1•-877-MAM
Revised 5-26-05 Fax# 617"727'7749
WWW xMaSs,go fcl a
Date,/
f �+0RTM 1
do TOWN OF NORTH ANDOVER
«
PERMIT FOR PLUMBING
'sS/ICMUSE<
This certifies that ..f,G��!Sl�f?.� .... �� y................. .
has permission to perform .. .. "�........ • .. • ..... • .
plumbing in the buildings ofR.
at ..1f.�1. r � f F 7'� i•i �� • • . AI(....... , North Andover, Mass.
�--� t
Fee ... -d 1.!"Lic. No. � 7-V-10 . .................,? . ......
4UMBING INSPECTbR
Check # �>
7972
A
r, r
MASSACHUSETTS UNIFORM APPLICATION
FOR PERMIT TO DO PLUMBING
ypt or print)
NORTH ANDOVER, MASSACHUSETTS
Building
)wners Name Date
Permit #2 Z
of Occu anc <ac, ',"-z Amount - ' >>
New ri Renovation / Replacement'
Pans Submitted Yes ❑ No
Ti T rrrr Tir. -- `I
-_- -� r -
Installing Company Name - Ag 43O11✓5-
-
Check one: Certificate
--- -_�.Corp.
Address
0 Panner.
Busmess Tale -phone
Finn/Co.
Name of Licensed Plumber. `j /a �c � �j� % S'c,/�S
Insurance Coverage: Indicate the type of insurance coverage by checking the appropriate box:
Liability insurance policy Er Other type of indem
�' n
Bond
Insurance Waiver. I, the undersigned, have been made aware that the licensee of
three insurance
this application does not have
any one of the above
c b y
�rgnature Owner ❑
Agent
❑
I hereby certify that all of the details and information I have submitted (or entered) in above application are true and accurate to the
best of my knowledge and that all work installations
plumbing and performed under Permit Issued for this application will be in
compliance with all pertinent provisions of the Massachusetts State Plumbing Code
By: - -
and Chapter 142 of the General Laws.
rgn Lure of i.rcens umber
Title Type of Plumbing License
lCity/TownI/:zy
l s
Licens vumoer Master
to�tcE usE oras
EJ Journeyman E3APPROVED
LI
Important: When
filling out forms
on the computer,
use only the tab
key to move your
cursor - do not
utis the return
key.
VQ
Commonwealth of Mass chus tts
City/Town of /U6 , RECEIVED
System Pumping Record
Form 4 MAY 112015
DEP has provided this form for use by local Boards of Health. Other forms341
��"A R
information must be substantially the same as that provided here. Before uis o�m, 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
1 Rvctam I ncatiAn•
City/Town State Zip Code
2. System
Name
Address (if different from location)
City/Town
State
Telephone Number
Zip Code
B. Pumping Record
1. Date of Pumping Date 2. Quantity Pumped: Galloi s
3. Type of system: ❑ Cesspool(s) Septic Tank ❑ Tight Tank ❑ Grease Trap
❑ Other (describe):
4. Effluent Tee Filter. present? ❑ Yes/No If yes, was it cleaned? ❑ Yes ❑ No
5. Conditiof §system:
- L leleclk ro� I L_
6. System PT,_�_ 3.,
�^
71�
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
Receiving Facility
Date
Date
t5form4.doc• 03/06' System Pumping Record • Page 1 of 1
j
Cornrnonwe 41h of Massachusetts
a. (p City/Town of No Andover
System Pumping Record � �O� 07 2014
re
a7
Form 4 } TOWN U NORTH ANDOVER '
" H5_TA'H DEPARTA4 NT
DBP has provided this term for use by local Boards of Health. Other formb-may be used, but the
information must be substantially the same as that provided here. Before ising 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 Heal,;h or other approving authority within 14 days from the pumping date in
accordance with 310 r,MR 15.351..
A. Facility Information
important: When
filling out forks 1, System Location:
on the computer, 361
use only the tab 3lal�ilii;Kerit'r iaCl }
key to move your Address
cursor - do npt No Andover MA
use the return Ta
Cit !Town _r,.. :� ,. _.-.9 -�
key, y a#ate ?ip Code
2, System Owp r;
rib
Berube
- game
. Address (if difrerent f�orn'o��r�tian�
tfltylrown State zip Cade
Telephone Number
B. Pumping Record
41-
1. Date of Pumping { 2, Quantity Pumped:
ete palions
3. Type of system: EJ Cesspool(s) Septic Tank [ Tight Tank Grease Trap
[j Other (describe):
4, t?ffluent Tee PEiti?r present? IJ Yes No
If ues, was it elear;fact? E pec D silo
5. C .,. S
5. Syste ° ped By:
Nacos
Vehicle license Number
Stewart�.'saeptic Service
Company. _ _ _
7, location where contents were disposed:
mate
Gate .._
system Pumping Recon • page 1 of 1
Commonwealth of Massachusetts :T
City/Town of North Andover
o System Pumping Record 0 6 2014
Form 4 _ aovl R
1M yes`
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 Location:
on the computer,
361 Ch I Gk's
use only the tab
key to move your
Address
cursor - do not
North ANDOVER Ma
use the return.
key.
City/Town State Zip Code
2.
System Owner:
tenon
e 44(
Name
Address (if different from location)
City/Town State Zip Code
Telephone Number
B. Pumping Record
1. Date of Pumping % 7-72. Quantity Pumped:
Date Gallons
3. Type of system: ❑ Cesspool(s) Septic Tank ❑ Tight Tank ❑ Grease Trap
❑ Other (describe):
4. Effluent Tee Filter present? ❑ Yes ❑ No If yes, was it cleaned? ❑ Yes ❑ No
5. Condition of System:
6. System_Purhped By.��---�
Name Vehicle License Number
Stewart's Septi Ice
Company
7. Location where contents were disp ed:
Stewart's Pre-treatment Plant, 20 So. Mill Bradford, Ma 01835
Signature of Hauler Date
Signature of Receiving Facility Date
t5form4.doc• 03/06 System Pumping Record • Page 1 of 1
Z.`
Commonwealth of Massachusetts �W��-
W City/Town of NORTH ANDOVER OCT O 12013
System Pumping Record
Form 4 TOWN OF FORTH ANDOVER
M SVy'W HEALTH DEPARTMENT
DEP has provided this form for use by local Boards of Health. Other forms may be used, but the
information must be substantially the same as that provided here. Before using this form, check with your
local Board of Health to determine the form they use. The System Pumping Record must be submitted to
the local Board of Health or other approving authority within 14 days from the pumping date in
accordance with 310 CMR 15.351.
A. Facility Information
Important: When
filling out forms
1. System Location:
on the computer,
use only the tab
I_ i c
l' chic
key to move your
Address
cursor -do not
NORTH ANDOVER
use the return
key.
—
City/Town
2. System Owner:
�n
Name
Address (if different from location)
City/Town
B. Pumping Record
1. Date of Pumping
3. Type of system:
❑ Other (describe)
Ma
State
State
Telephone Number
Zip Code
Zip Code
Date 0 2. Quantity Pumped: /0
Gallons
❑ Cesspool(s) ,,a Septic Tank ❑ Tight Tank ❑ Grease Trap
4. Effluent Tee Filter present? ❑ Yes ❑ No
5. Condition of System:
6. System Pumped By:
----Start's Septic Sery
Company
7. Location where conte
Stewart's Pre4reatme
Signature of
Signaturebf'�jAng Facility
were disposed:
Plant, 20 So. Mill
If yes, was it cleaned? ElYes ElNo
V
V
Vehicle License Number
Ma 01835
Date
Date
t5form4.doc• 03/06 System Pumping Record • Page 1 of 1
Commonwealth of Massachusetts
_ v City/Town of No.Andover
a System Pumping Record
4„M SVey`vv
Form 4
DEP has provided this form for use by local Boards of Health. Other forms may be used, but the
information must be substantially the same as that provided here. Before using this form, check with your
local Board of Health to determine the form they use. The System Pumping Record must be submitted to
the local Board of Health or other approving authority within 14 days from the pumping date in
accordance with 310 CMR 15.351.
Important:
When filling out
forms on the
computer, use
only the tab key
to move your
cursor - do not
use the return
key.
Q
AV
so
rewn
A. Facility Information
1. Sy%q Location:
w f 1 il, h car-
No
Andover - iia V rLJ
City/Town State Zip Code
2. System Owner: JAN 10 2012
TOWN OF NORTH ANDD'
Name RMEN
Address (if different from location)
City/Town State Zip Code
Telephone Number
B. Pumping Record
f ~ C)
1. Date of Pumping Date2. Quantity Pumped: al�Gallons
3. Type of system: ❑ Cesspool(s) Septic Tank ❑ Tight Tank ❑ Grease Trap
❑ Other (describe):
4. Effluent Tee Filter present? ❑ Yes 6 No
5. Condition of System:
X- 50t tA5 , kc'.1,
6.Syst Pumped y:
t
Stewart's Septic Service
Company
If yes, was it cleaned? ❑ Yes ❑ No
Vehicle License Number
7. Location where contents were disposed:
,5ttewart's Pre-treatment Plant, 20 So. Mill Bradford, Ma 01835
Signature
Date I I
Date
t5form4.doc• 03106 System Pumping Record • Page 1 of 1
0 ,,:
DOVE
..�,�
MASSACHUSETTS
'!.
�a!;e ump�t� `Record
rm11'Gjy " l:Y:,�'a,'{Y,•:
1 i "'„r?:�yJ ,��\ills.:,. •'''
1�,`,j��.� t t
CICni t\'v,{1 •; ,r�;:, !; j5 ,
.51.\1, ,1.1 �',�.•jt.:•D 1.,�6.,:.Ir,'. p,. ., l��.�, ,..uv••, 9't.• :.: ,• _
{ la:.: R F�
EP,.hai rovlded thls form for use by loc I Boar oC teUafthpThe
be submittedyto the.Iocal'Board of Health r other approving author
;.A;.facili InforMation .
.. tY
'`'' � :� •. �• , • TOWN OF NORTH ANDOVER
1,rVYhen MAO out I:. System Locatlow` /HEALTH DEPARTMENT
f'�'ccrTiputerl u,Se11 ,ii . C3LY
"the tab key Address
to move your
' ;.arson• do not .
`U the'rotum'•
' `"�,•�5J 4. 11j•�it ,t�:: ��i, '• ''�I'i�:''••.��{, 1�, 1,;��.�J �1'. �'�.ir,; •' .. ;
:Y.r.'
JA
Nam
"", Address (11 different from bcatlon)
stem Pumping Record mL•s!
Lam, U
State Zip Code
State . p
Telephone Number —
"Pum plg ,• ,
.Record.
. '
DatQ of Pumping %`;; ..:'
A02)
' :.;:i::,'.•:'• '.:,';.: oat
2 Quantlty Pumped;
:.:
_
Gallons
3 .•
„ ,• :.Type pt system, ❑ Cesspool(s)
Septic Tank ❑ Tight
Tank
. C'fOther (describe);--
' Emu
entTeeFllterpresent?'.❑ Yes ❑
,:;: ;�%.;:a;4'ii ' ',:,•
No If es
Y was It cleaned?
❑ Yes ❑ No
,,�, {;,i +s'
- •• :>: ',',.,�.: fir,:.",;.,•,;; :'��; ..., i'::;:.i:•:.•'r'..rvwlh,.:., . •:• .'j
yst"m,,,;,::.
•' ,'•''
.. -...._ y.,5.•,,c=i,i:
,,.:v .lj'fi�iJj �, i.a:ri,:,. ,il�ll fir, 1: ..
• `i � ,F r, A;'%li' (. V.,/Ilr.,.j�t;'•{:". 'Y t;i •.i
i
.
� _�,, ;+I 11,, ..{v,,r7l. ,ur',!�•'.{i bii. '��^.�, Ild't, :'�..,%,,, '
.� ''(:' :;:1:' ; ,,�•r J13:�r�.i:f. (��, ri ri'l, �•'1 .5� '
y Pumped
�}R'
•.'.;
'1�%r;!•ti"'•. A• K`ri'u^ �•;1i1;,it:�l1,V..1�?Cu,J':191'11��cJ.�l/':/ln'�l/`:`.\-�•
:1t.,i-' .r' ..�;• %:. >:•:!::,,. .:7�.ln.r.'il.;:�' ,,q �..tJf,��l�, 6��.r•+'ra6/-.�.,jfi!j�:�.
Locadon.whore contelits yvere`dl�posed;
' •� :i:' :. Ti .�.. .;,tri-'/•;": „'; 1(; '�'.4��, '; .r; •�.�(1' 1'•:. •T.. :I
`.1;: -!1,.: ;;�Y,:,),�';�,,`�:1.�'"'r'::i Sf�nacure o(Haularw ' �,;•:.ti..',.:,.,. • •
fiUPJ vr4v,m8ss;90v/deg!wafer/6pprovals/t5forms,htm#inspect
t5forrry4.docr061oj ,' , � .
I
nVehicle -cen4e Number
Sytlem Pumping Record • Page t o1 )
v �L—IV D
w
C'C)w'N U� NOK -I-11 ,'lh'Lh..! ',::.
U� i k
SYS'rTN'1 PUMPIN() F Cl7k1 SEP — 7 2005
�TOWN OF
NORTH ANDOVER
EeM
HH gRTMNTYs_......._.__...__..._.
..QUAN71TY Pl.lWPCC-
SPOO L: Nvy�Y�'S
14^ rVK� UN sbxv►c p, xovrtN� .��
Ub�tGJi V�t'i`�UN3. / �
(3000 CVNOITIUNULL tlJ c Ciurk
K�VY p>it�,�g ..� 9AYFl,BS IN f'LA�:,
KO T'3
�+�C�SSIY6 s0�,tp8 LaA•CKF'I�1.p KVN6n�'w
SOL fD CA RJB Yp y�r'"'"" p"00D8p
_......OrNER EXPL,n)N
�'UMMtNTs.
TOWN OF NORTH-AN'DOVSR
SYSTEM PUMPING RECORD
)1 STEM OWNER & ADDRESS w
(36 f c/) I cH e�rin
/vo
SYSTEM LOCATION _
(example: left iron( of house) ~
U:�'I C OF PUM1'INC: 5'-��3 QUANTITY PUMPCD aCALLuv,
-- .SPOOL: NO YES SEPTIC TANK: NO YES
�a
� ATURE OF SERVICE; ROUTINE EMERGENCY
>> LM PUMPc.0 0Y:_
CU )1I.M f:NTS.
TRANSFERR21) TO:
��I�.>rrzV.�TIoNs:
COOD COND111I0N.
FULL TO COY cIk
HEAVY CREASE
BAFFLES IN Pl.,ACE
ROOTS
LEACHFIELD RUNUACK...
CXCESSIVE SOLIDS
FLOODED
SOLIDS CARRYOVER
AHFR (EXPLA.)N)
>> LM PUMPc.0 0Y:_
CU )1I.M f:NTS.
TRANSFERR21) TO:
TOWN OF NORTH ANDOVER
SYSTEM PUMPING RECORD
DATE: t1g Ag 1&77
SYSTEM OWNER & ADDRESS
;6�
\&61
DATE OF PUMPING:/&& -cam
C'f�SSIOUL. NO YES
NATURE OF SERVICE: ROUTINE
OBSERVATIONS
SYSTEM LOCATION
(example: left front of house)
r
QUANTITY PUMPED GALLONS
SEPTIC TANK: NO YES
EMERGENCY
GOOD CONDITION FULL TO COVER
HEAVY GREASE BAFFLES IN PLACE
ROOTSEACHFIELD RUNBACK
EXCESSIVE SOLIDS FLOODED
SOLIDS CARRYOVER OTHER (EXPLAIN)
SYSTEM PUMPED BY:
C'O..N,IMENTS:
CONTENTS TRANSFERRED TO:
CD
ff,
r+
(D
0
Oh
-n
h
J
Date: le) —19 —5r _.
OoMrj
TOWN OF ANDOVER
SEPTIC SYSTEM SERVICING
REPORT
Homeowner: Pumper
Street '36 Address:
Phone Phone
Nature of Service: Routine
Emergency
Observations: Good Condition
Full to Cover
Baffles in Place
Leachfield Runback
Excessive Solids
Heavy Grease
Roots
Other (Explain)
Description of Work;
Comments:
✓ ', !EPLICATION FOR SEWAGE
HEALTH DEPARTMENT -
r
DISPOSAL INSTALIATION
NORTH ANDOVER, IHSS.
I hereby make application for a permit for a sewage disposal installation at
I will install this system in ac-
cordance with all the laws of the Commonwealth of Massachusetts and regulations of
the Board of Health of the Town of North Andover.
Further, I will construct the house sewer of bell and spigot pipe, the minimum
diameter being 4 inches, and will maintain a minimum grade of 1% until 10 feet pre-
ceding the septic tank, where the grade shall not exceed 2%. I will install a con-
crete septic tank of e &2 V in size. A manhole (s) permitting easy cleaning
will be provided with removable cover (s) of iron or concrete within 12 inches of
the ground surface. I will provide subsurface disposal field with 4 inch perforated
or open jointed pipe and laid in a series of trenches, the bottom of which will pro-
vide a minimum of %'fiU lineal (square) feet of effective absorption area.
The pipes will be laid on a 6 inch layer of washed gravel or crushed stone ranging
in size from 3/4 to 1-1/2 inches (dia.) and the pipes will be surrounded by similar
material to a height of 2 inches above the crown of the pipe. The joints of these
pipes will be protected from clogging and before filling the trench, 2 inches of
gravel or stone 1/8" to 1/4" (dia.) will be placed over the course gravel or stone.
The disposal field will be installed at a grade of 4 to 6 inches /100 feet. No single
tile line will exceed 100 feet in length and in any case, two lines of tile will be
installed. A minimum of 6 feet will be maintained between the center lines of the
disposal field trenches and the average depth of trench shall not exceed 36 inches.
No part of the installation will be less than 100 feet from any private water supply,
25 feet from any stream, 20 feet from any dwelling or 10 feet from any property line.
I further agree not to cover any portion of this installation until approved by the
inspection officer, as provided below, and to incorporate any additional requirements
that may be attached to the permit. Plot Plans must be submitted with application.
DATE
Signature of Applicant
I hereby issue the above permit for the Board of Health of the Town of North
Andover, Massachusetts.
DA TE
Signature of, Health Agent
I have inspected the uncovered system indicated above and find everything done
as described.
DATE 6
Signature of nspecting Officer
Percolation Test
Garbage Grinder
AIPLICATION FOR SEWAGE DISPOSAL INSTAUATION
HEALTH DEPARTWNT - NORTH ANDOVER, M&SS.
I hereby make application for a peimit for a sewage disposal installation at
I will install this system in ac-
cordance with all the laws df the Commonwealth of Massachusetts and regulations of
the Board of Health of the Town of North Andover.
Further, I will construct the house sewer of bell and spigot pipe, the minimum
diameter being 4 inches, and will maintain a minimum grade of 1% until 10 feet pre-
ceding the septic tank, where the grade shall not exceed 2%. I will install a con-
crete septic tank of eta eU, in size. A manhole (s) permitting easy cleaning
will be provided with remov le cover (s) of iron or concrete within 12 inches of
the ground surface. I will provide subsurface disposal field with 4 inch perforated
or open jointed pipe and laid in a series of trenches, the bottom of which will pro-
vide a minimum of\ (I D lineal (square) feet of effective absorption area.
The pipes will be laid on a 6 inch layer of washed gravel or crushed stone ranging
in size from 3/4,to°,1-1/2 inches (dia.) and the pipes will be surrounded by similar
material to a height of 2 inches above the crown of the pipe. The joints of these
..,--,,--,pipes will be protected from clogging and before filling the trench, 2 inches of
gravel or stone 1/8" to 1/4" (dia.) will be placed over the course gravel or stone.
The disposal field,'will be installed at a grade of 4 to 6 inches/100 feet. No single
tile line will exceed 100 feet in length and in any case, two lines of tile will be
installed. A minimum of 6 feet will be maintained between the center lines of the
------disposal field trenches and the average depth of trench shall not exceed 36 inches.
No part of the installation will be less than 100 feet from any private water supply,
25 feet from any stream, 20 feet from any dwelling or 10 feet from any property line.
.. I further agree not to cover _any portion of this installation until approved by the
inspection officer,.as provided below, and to incorporate any additional requirements
that may be attached to the permit. Plot Plans must be submitted with application.
DAll ,3
Signature of Applicant
I hereby issue the above permit for the Board of Health of the Town of North
Andover, Massachusetts.
DATE �� 1Z_
S/Ignature of Health Agent
I have inspected the uncovered system indicated above and find everything done
as described.
DATE
Signature of Inspecting Officer
Percolation Test .�ir� ••.yo-c-� sa C
Garbage Grinder ��•, '
w
November 4, 1961
Miss Mary Sheridan R. N.
Health Agent
Board of Health
North Andover, Mass.
Dear Miss Sheridan:
An examination was made as requested in order to determine
the suitability of the soil for the subsurface disposal of sewage
on the proposed Chickering Road building site of Walter Pendak,
The land in general is high.
The subsoil in the area wasof sandy clay content and a
5 -minute percolation test was conducted.
It is recommendedthat a 11000 gallon concrete septic tank be
installed together with 210 lineal feet of drain pipe.
Very truly yours,
i iam J riscoll
WiD: hd
BOARD OF HEALTH
TCWil OF NORT11 AIMOtiERs USS.
_ R
X-
1 NAP; .. . . . . . . . DATE . . . . .
2. ADDRESS . :: v 1 ".J /. 1) Gr �r . LOT TdO. .TEL. .
3. NO, OF BEDROOIfxS . ..". . DEN YES . NO.. .
/+. GARBAGE GRINDER YES NO.. . . .
5. SHOW DIIlICNSIONS OF HOUSE 3 � � �16� +—rRZ",(1e %f e s
6, SHOW DISTANCES OF HOUSE TO ALL PROPERTY LINES
7. SHOW DIP;1EMIONS OF LOT }'
8. SHOW LOCATION AND SIZE OF SEPTIC TANK OR CESSPOOL
9. NOTE LOCATION AND DISTANCE OF WELL FROM SEWERAGE SYSTEPl
10. SHOW LOCATION OF BROOKSp STREAIZ, DITCHES, LEDGE OUTCROP, ETC,
11, SHOW DISTANCE OF SEPTIC TALK OR CESSPOOL FRO1.4 HOUSE
NOTE: LOCAL REGULATIONS SHOULD HE READ CAREFULLY.
BOARD OF HE ATH
TOWN OF NORTH ANDOVER, MASS.
z l
1009 It. .
--XV ~�„ •�
op e-
1. NAME . V:�t !;1 ,.I� t✓�... . . . . . . . DATE
Z O �- c.
2. ADDRESS .�.-. � . �. �. LCT N0. .TEL. .
3. NO. OF BEDROOMS (. DEN YES . ' . N0.
4. GARBAGE GRINDER YES . . NO. ". ti .'.
5.
SHOW DII1,1ENSIONS
OF HOUSE
a X b
b.
SHOW DISTANCES
OF HOUSE TO
ALL PROPERTY LINES
7. SHOW DIi:ENSIOIkB OF LOT
g. SHOW LOCATION AND SIZE OF SEPTIC TANK OR CESSPOOL
g. NOTE LOCATION AND DISTANCE OF WELL FROM SEWERAGE SYSTEM
10. SHOW LOCATION OF BROOKS, STREAM,, DITCHES, LEDGE OUTCROP, ETC.
11. SHOW DISTANCE OF SEPTIC TANK OR CESSPOOL FROTl HOUSE
NOTE: LOCAL REGULAT IOIALS SHOULD BE READ CAREFULLY.
RECEIVED
NOV --3 2004
TOWN OF ORTH ANDOVEE
TOWN OF NORTH AND VER
L
4*N4 U'Ch T
DA I' SYS M UMPINQ RECORI.)
NOV
DEPART ENT
SYSTEM OWNER &-ADDRESS
'561 A� ,
DATE OF PUMPING:
�i Y STEM LOCATION
<
-QUANTITY PUMPED:
Ct�SSPOOL: NOV" YES
Septic Tank: NO_ y F s P--,
NA CURE OF SERVICE: RUUTINE.V-11"'. FLMEROENC),
OBSERVATIONS:
GOOD CONDITION FULI.'iyj COVER
HEAVY GREASE BAMES IN PLACE.
ROOTS LEACKKELD RUNBACK
BXCMIVE SOLIDS FLOODED
SOLID CARRYOVER, . .. ... OTHER EXPLAIN
systvm pwnpcod by
ex 1-2-7a.
COMMENTS.
�'UNTEN*1'8 r'KANSFhKRBD I -L)
I
2
13
Important:
When filling out
forms on the
computer, use a
only the tab key
to move your
cursor - do not
use the return
key.
Commonwealth of Massachusetts
City/Town of NORTH ANDOVER,
System Pumping Record
Form 4
ASSAC -USSEToTS/ED
AUG 0 4 2006
DEP has provided this form for use by local Boards of Health. Thejg s emFPumTaAAr'R ANDOVER
mu:
be submitted to the local Board of Health or other approving authority =�ri "` p g -R
A. Facility Information -
1. System Location:
-
Address --- -------------- ----- --- --
City/Town Sta e—
_-.___.---- Zip Code
2. System Owner:
Name---- -- --- - -----...__._ _---- —
Ad -
dress (if different from location—)----.._....
� ---------•--------------
Cityrrown -- ----- ——__---__-- State
B.)Pumping Record
1. Date of Pumping
Type of system: ❑
Telephone Number
Zip Code
-- _
Date 2. Quantity Pumped: - --�------_-.
Gallons
Cesspool(s) D/Septic Tank ❑ Tight Tank
❑ Other (describe): --___—--------------—_---....--_—.__.. ----- ----
4. Effluent Tee Filter present? ❑ Yes 0-- o If yes, was it cleaned? ❑ Yes ❑ No
5. Condition of System:
R
t. Location where contents were disposed:
Si ature of Hau t/ % " "` ' • --- _ —
http://www.mass.gov/dep/water/ provals/t5forms.htm#inspect
http://www.missb,gov,/�dep/water/
Vehihiic�le License Number
Date —------- -- —
t5form4.doc- 06/03
System Pumping Record , Page 1 of
r
r. ` NTu
IT,
• •
y . •
I
...
1100 IQ LAI
' :..
,
A.
AUG — 6 2009
t8WN 7Ulr'd4(DRTH'YANDOVER
HEALTH DEPARTMENT
!19nOn, ry ,mQ„
r'• r..'
Yds pl+yilemi.,
CIO 79Poo1(�)
.,.. '',;'.•,' ,��•�';.:;,';'. 8D1!C Tens
. �Q � O+,tor•( "� �• ' � •.
,•,, ., doscriDo�: .
• �., :.,,;� , Too' lFllle(, 1f,9„aonr7 [' YO) n'
7. ,,I
�G
It it
�• l�” (;I/, `v!a`14k (l�ll��''bd�11I� ��111,'i, +!I:•1.
�.+ '1•, ha�f,ppAlenla;w@ro dl�posoa:
. �. ;,:/�;�:,,,'�.'+, Sl�nt,u.v1 olN1v4(yf;r,�,,,.•,,,„,
.ma4.por/deeier/e�P�ore/�Ib{orm�.r,!'nvin7�bcl
O'D
�
Il ya7. ^81 Il C 98nt>p7 yes _
(36/
1:''A4'dlµ4 (II OV(trinl1lcvn lou Von)
I
AUG — 6 2009
t8WN 7Ulr'd4(DRTH'YANDOVER
HEALTH DEPARTMENT
!19nOn, ry ,mQ„
r'• r..'
Yds pl+yilemi.,
CIO 79Poo1(�)
.,.. '',;'.•,' ,��•�';.:;,';'. 8D1!C Tens
. �Q � O+,tor•( "� �• ' � •.
,•,, ., doscriDo�: .
• �., :.,,;� , Too' lFllle(, 1f,9„aonr7 [' YO) n'
7. ,,I
�G
It it
�• l�” (;I/, `v!a`14k (l�ll��''bd�11I� ��111,'i, +!I:•1.
�.+ '1•, ha�f,ppAlenla;w@ro dl�posoa:
. �. ;,:/�;�:,,,'�.'+, Sl�nt,u.v1 olN1v4(yf;r,�,,,.•,,,„,
.ma4.por/deeier/e�P�ore/�Ib{orm�.r,!'nvin7�bcl
O'D
�
Il ya7. ^81 Il C 98nt>p7 yes _
Commonwealth of Massachusetts
W City/Town of North Andover
System Pumping Record
G„M y ey`v.
Form 4
DEP has provided this form for use by local Boards of Health. Other forms may be used, but the
information must be substantially the same as that provided here. Before using this form, check with our
local Board of Health to determine the form they use. The System Pumpind u5t to
the local Board of Health or other approving authority within 14 days from t e pu�aie In
accordance with 310 CMR 15.351.
Z011
1. Date of Pumping
3. Type of system:
❑ Other (describe)
Date
2. Quantity Pumped:
❑ Cesspool(s) ® Septic Tank ❑ Tight Tank
1000
Gallons
❑ Grease Trap
4. Effluent Tee Filter present? ❑ Yes ❑ No If yes, was it cleaned? ❑ Yes ❑ No
5. Condition of System:
Extremly heavy soilds
6. System Pumped By:
Bruce Merrill
Name
Stewart's Septic Service
Company
7. Location where contents were disposed:
Stewart's Pre-treatment Plant, 20 So. Mill Bradford
re of
Signature
Vehicle License Number
a 01835
Date
X511\.
Date
t5form4.doc• 03/06 System Pumping Record • Page 1 of 1
A. Facility Information
TOWN OF NORTH ANDOVER
Important:
HEALTH DEPARTMENT
When filling out
1. System Location:
forms on the
computer, use
361 Chickering Rd
only the tab key
Address
to move your
North Andover
Ma
01845
cursor - do not
use the return
City/Town
State
Zip Code
key.
2 System Owner:
QBerube
IL
Name
'ehA1
Address (if different from location)
City/Town
State
Zip Code
Telephone Number
B. Pumping Record
1. Date of Pumping
3. Type of system:
❑ Other (describe)
Date
2. Quantity Pumped:
❑ Cesspool(s) ® Septic Tank ❑ Tight Tank
1000
Gallons
❑ Grease Trap
4. Effluent Tee Filter present? ❑ Yes ❑ No If yes, was it cleaned? ❑ Yes ❑ No
5. Condition of System:
Extremly heavy soilds
6. System Pumped By:
Bruce Merrill
Name
Stewart's Septic Service
Company
7. Location where contents were disposed:
Stewart's Pre-treatment Plant, 20 So. Mill Bradford
re of
Signature
Vehicle License Number
a 01835
Date
X511\.
Date
t5form4.doc• 03/06 System Pumping Record • Page 1 of 1