HomeMy WebLinkAboutMiscellaneous - 97 WINDKIST FARM ROAD 4/30/2018F-'
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Commonwealth of Massachusettrieca'v ®
City/Town of North Andover r.
System Pumping Record CC Q9 Z014
Form 4 TOW UhINURIMAND01l�R
EPARTMENT
��rms» , e used, but the
information must be substantially the same as that provided
DEP has provided this form for use by local Boards ohere. 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:
9:1
on the computer,
use only the tab
key to move your Address 01886
cursor - do not North Andover Ma
State Zip Code
use the return City/Town
key.
VQ 2. System Owner:
C
Name
anon
Address (if different from location)
State Zip Code
CitylTown
Telephone Number
B. Pumping Record (�J 1�590
2. Quantity Pumped: Gallons
1. Date of Pumping Date
3. Type of system: ElCesspool(s)
Septic Tank ❑ Tight Tank E]Grease Trap
❑ Other (describe):
�
No if yes, was it cleaned?
5.
E] No
4. Effluent Tee Filter present. ❑ Yes ❑
5. Condition of System:
5
6. System Pumped By:
Vehicle License Number
Name
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 Receiving Facility
Date
t5form4.doc• 03/06
System Pumping Record • Page 1 0
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MAP # LOT #
PARCEL # STREET w�ry
CONSTRUCTION APPROVA�I.
HAS PLAN REVIEW FEE BEEN PAID? jES\ NO
PLAN APPROVAL: DATE o7 PP. BY
DESIGNER: 6#12 /677 /9iU 5 r�`�`' PLAN DATE
CONDITIONS
•r '
WATER SUPPLY:
WELL PERMIT
WELL TESTS:`
PLUMBING SIGNOFF
COMMENTS:
TO WELL
DRILLER
CHZMICAL DATE APPROVED
BACTERIA -,I DATE APPROVED
BACTERIA II \ DATE APPROVED
WIRING SIGNOFF
FORM U APPROVAL: APPROVAL TO ISSUE YE NO
91,
DATE ISSUED BY
CONDITIONS:
FINAL APPROVAL: ____-��
ALL PERMITS PAID -cz� NO
WELL CONSTRUCTION APPROVAL YES NO
SEPTIC SYSTEM CONSTRUCTION APPROVAL (::2� NO
OTHER YES NO
ANY VARIANCE NEEDED YES NO
FINAL BOARD OF HEALTH APPROVAL: DATE: l�/�/I -BY: /d`''
SEPTIC SYSTEM INSTALLATION
IS THE INSTALLER LICENSED? YES NO
TYPE OF CONSTRUCTION: t ' REPAIR
NEW CONSTRUCTION: CERTIFIED PLOT PLAN REVIEW NO
CONDITIONS OF APPROVAL YES NO
(FROM FORM U)
ISSUANCE OF DWC PERMIT YESNO
DWC PERMIT PAID? ES NO
DWC PERMIT NO. ztO INSTALLER: - zr�, s,9Lvy6jc
BEGIN INSPECTION ES N0:
EX,�AVATION INSPECTION: NEEDED:
_ w=
PASSED 1j<. �T��� BY
CONSTRUCTION INSPECTION: NEEDED:
AS BUILT PLAN SATISFACTORY: YES:z -5. 7
APPROVAL tO BACKFILL: DATE:
FINAL GRADING APPROVAL: DATE-/5;i.,--,--� BY
FINAL CONSTRUCTION APPROVAL: DATE:/ BY
Commonwealth of Massachusetts RECEIVED
W City/Town of No AndoverF
W° System Pumping Record SUN 10 2013
Form 4
'M TOWN OF NORTH ANDOVER
EPARTMENT
DEP has provided this form for use by local Boards of Healt . HEALTH Dmay a 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
on the computer,
use only the tab
key to move your
cursor - do not
use the return
key.
rab
retrm
1. System Location:
97 Windkist Farm Rd
Address
No Andover
Ma
City/Town State Zip Code
2. System Owner:
Pennance
Name
Address (if different from location)
City/Town State Zip Code
Telephone Number
B. Pumping Record
/Sp
1. Date of Pumping ` ate 2. uantity Pumped: Gallons
3. Type of system: ElCesspool(s) Septic Tank El Tight Tank El Grease Trap
❑ Other (describe):
4. Effluent Tee Filter present? ❑ Yes ❑ No If yes, was it cleaned? ❑ Yes ❑ No
5. Condition of System:
6. System Pumped By: ��
J 1,---L, 712-
Name I Vehicle License Number
Stewart's Septic Service
Company
7. Location where contents were disposed:
Stewart's
e -treatment Plant, 20 So. Mill Bradford, Ma 01835
;u atE
.ceiving Facility Date
t5form4.doc• 03/06 System Pumping Record • Page 1 of 1
Page 1 of 1
DelleChiaie, Pamela,
From: MERRENG@aol.com
Sent: Thursday, July 13, 2006 9:28 AM
To: DelleChiaie, Pamela
Subject: Re: Old Business - 97 Windkist Farm Road
Pam:
Are you looking for the septic as -built plan and certification from when the house and system were originally
built? If so, I need a subdivision Lot # to find it. We may or may not have done it. Christiansen & Sergi were
the design engineers however Bill Bartlett bought the project and we did much of the subsequent work relating
to construction. Provide me with the SDL # and I will try to find it.
Thanks
Bill Dufrense
Merrimack Engineering Services
66 Park Street
Andover, MAO 1810
978-475-3555
978-475-1448 FAX
merreng@aol.com
7/19/2006
Commonwealth of Massachusetts
City/Town of North Andover
System Pumping Record
Form 4
M
Important:
When filling out
forms on the
computer, use
only the tab key
to move your
cursor - do not
use the return
key.
V)Q
nen
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 eyed to
the local Board of Health or other approving authority within 14 days from t e pugg WED
accordance with 310 CMR 15.351.
A. Facility Information
1. System Locatit,
-7 (YJ I(-/ i
Address
No.Andover
Ma
TOWN OF NORTH ANDOVSP
_HEALTH DEPARTMEN
01845
City/Town State Zip Code
2. System Owner: Pen n an c
Name
Address (if different from location)
City/Town
State
Telephone Number
B. Pumping Record
1. Date of Pum in q/ ' 2. Quantit Pum ed:
p g Date y p
3. Type of system: ❑ Cesspool(s) [optic Tank ❑ Tight Tank
❑ Other (describe):
Zip Code
/Sad
Gallons
❑ Grease Trap
4. Effluent Tee Filter present? ❑ Yes ❑ No If yes, was it cleaned? ❑ Yes ❑ No
5. Condition of System: C1 o vd Coni
6. rm Pumped By:
I hp-3no tA—)
Name
Stewart's Septic Service
Company
7. Location where contents were disposed:
StemrtgPre-treatment,Plant. 20 So. Mi
Id
Signature o�eceiving Facility
Vehicle License Number
Ma 01835
Date
Date
t5form4.doc• 03/06 System Pumping Record • Page 1 of 1
Pamela DelleChiaie
From: Pamela DelleChiaie [/o=North Andover/ou=First Administrative
Group/cn=Recipients/cn=pdellech]
To: Dufresne Bill (E-mail)
Subject: Old Business - 97 Windkist Farm Road
Importance: High
Hi Bill,
I still need a copy of the As Built for this. We also need the certification form taht the installer and engineer signs. We
cannot issue COC till we have this paperwork. Mike Reilly was the installer. Thomas and Joan Pennance were listed as
the homeowners. Thanks.
$a8f Ragw�ds,
PuyyaBa DaBBaL�lfiwi¢
Health Department Assistant
Town of North Andover
1600 Osgood Street
Building 20, Suite 2-36
North Andover, MA o1845
978.688.9540 - Phone
978.688.8476 - Fax
http://www.townofiiorthandover.com
healthdept@townofnorthandover.com
Sunflower Page 1 of 1
Dellechiaie, Pam
From: Pamela DelleChiaie [pdellechiaie@townofnorthandover.com] on behalf of Dellechiaie, Pam
Sent: Monday, July 12, 2004 1:36 PM
To: Dufresne Bill (E-mail); Dufresne Bill (E-mail 2)
Cc: Sawyer, Susan
Subject: 97 Windkist Farm Road
Importance: High
Sensitivity: Private
Can you get a copy of the As Built to me for 97 Windkist Farm Road? We also need the
certification form that the installer and engineer sign. We are trying to clear up some files,
and we need this before a COC can be issued. Thank you for your assistance.
Pamela DelleChiaie, Health Dept. Assistant
Town of North Andover
Community Development & Services
27 Charles Street
North Andover, MA 01845
pdellechiaie@townofnorthandover.com
Tel. 978-688-9540
Fax 978-688-9542
7/12/2004
Commonwealth of Massachusetts Map. -Block -Lot
109.0- 0053 -
Board Of Health Permit No
North Andover BHP -2004-0343
--------------------
P.I. FEE
F.I. $250.00
----------------------
Disposal Works Construction Permit
Permission is hereby granted Mike Reilly---------------------------------------------------------------------
----------------------
to (Repair) an Individual Sewage Disposal System.
at No 97 WINDKIST FARM ROAD
--- .-.
..--- --------------------------- -------...--------------------------------------------------------------------------------------------------
as shown on the application for Disposal Works Construction Permit No. BHP -2004--0 ted April02,2004
------- - _ _
-----
Issued On: Apr -02-2004 f Health
-----------------------------------------------------------------------------
...............................................................................................................................................................................
Commonwealth of Massachusetts Map -Block -Lot
109.0- 0053-
Board Of Health --------------- -------
North Andover
r_.
Certificate of CoTpJ4rfce
THIS IS TO CERTIFY, That the Individ ewage Disposal System (Repair)
by Mike Reilly-------- -----------
--- --
Installer
at No 97 WINDKIST FARM OAD
- . ... -._. - - - - - ------------
has been installed in ac ce with the provisions of TITLE 5 of the State Environmental Code as described in the
application for D' posal Works Construction Permit No. _BHP -2004-034 _ Dated _.. April 02,_2004
-------
-----------------------------------------------------------
Printed On: Apr -02-2004 Board Of Health
Town of North Andover
Health DepArtmentt Date:
Location: Location
(Indicate Address, if Residential, or Name of Business)
Check #:
Type of Permit or License: (Circle)
➢ Animal
$
➢ Dumpster
$
➢ Food Service - Type:
$
➢ Funeral Directors
$
➢ Massage Establishment
$
➢ Massage Practice
$
➢ Offal (Septic) Hauler
$
➢ Recreational Camp
$
➢ SEPTIC PERMITS:
❑ Septic - Soil Testing
$
❑ Septic - Design Approval
$
[/Septic Disposal Works Construction (DWC)
$
❑ Septic Disposal Works Installers (DWI)
$
➢ Sun tanning
$
➢ Swimming Pool
$
➢ Tobacco
$
➢ Trash/Solid Waste Hauler
$
➢ Well Construction
$
➢ OTHER: (Indicate) /�f
i.1/,
O l 8 Health Agent Initials
White - Applicant Yellow - Health Pink - Treasurer
APPLICATION FOR DISPOSAL WORKS CONSTRUCTION PERMIT
DATE: CURRENT INSTALLER'S LICENSE#
LOCATION:
LICENSED INSTALLER:
SIGNATURE: TELEPHONE#
CHECK ONE:
REPAIR:
NEW CONSTRUCTION:
IF NEW CONSTRUCTION, PLEASE ATTACH FOUNDATION AS -BUILT.
`� ��14 Administr ive Use Only
v
$00 Fee Attached? Yes No
Foundation As -built? Yes No
Floor plans on file? es No_
Approval
Date:
INSTALLER PROJECT MANAGEl 4T OBLIGATIONS
As the North Andover licensed installer for the construction of the septic system for the
property at Co W � c1 �-
�c�r-t� relative to the application
of E. dated 4-a• ,O `i for plans by an(
dated with revisions dated
I understand the following obligations for management of this project:
1. As the installer I am obligated to call for any and all inspections. If homeowner, contra(
project manger, or any other person not associated with my company schedules an inspec
and the system is not ready then item two shall be applicable.
2. As the installer I am required to have the necessary work completed prior to the applic�
inspections as indicated below. I understand that requesting an inspection,_ with
completion of the items in accordance with Tile 5 and the Board of Health Regulations r
result in a $50.00 fine being levied against my company.
a) Bottom of Bed - generally first inspection unless there is a retaining wall which should be d
first. Installle st request the inspection but does not have to be present.
b) Final inspection — Engineer must first do their inspection for elevations, ties, etc. As -built
verbal OK from engineer must be submitted to Board of Health, after which installer calls
inspection time. Installer must be present for this inspection. With pump system all electri
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. Does not have to
on site.
3. As the installer I understand that persons or companies not associated with my company m
not perform the work required by my company to complete the installation of the syst(
identified in. the attached application for installation. I further understand that work by othe
unlicensed to install septic systems in North Andover can constitute reasons for denial of t
system, and/or revocation or suspension of my license in the Town of North Andover pl
significant fines to all persons involved.
4. As the Installer I understand that I must be on site during the performance of the followiv
construction steps:
elevation of the excavation has been reached.
a) Determination that the proper
b) Inspection of the sand and stone to be used.
c) Final inspection by Board of Health staff.
d) Installation of tank; D -box, pipes, stone, vent, pump chamber, retaining wall and oth
components.
5. As the installer I understand that I am solely responsible for the installation of the system
per the approved plans. No instructions by the homeowner, general contractor, or any othi
persons shall absolve me of this obligation.
Undersigned Licensed Septic Installer
Date:
Disposal Works Construction Permit #
9990-9Zt, (91,6) 7Ts
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FORA/A -LOT RELEASE FORM
INSTRUCTION: his form is used to verify that all necessary approvals/permits frori
Boards and De , ents having jurisdiction have been obtained. This does not relieve
the applicant and/or landowner from compliance with any applicable or requirements.
""""""W" www"""""************APPLICANT Fil
APPLICANT
LOCATION: Assessor's Map Number.
THIS SECTION******v********** *
C ISP H E
v""'/— PHONE I
i M
PARCEL
SUBDIVISION LOT (S) n i
STREET tV I N _DK I , + e� ST. NUMBER. `
-OFFICI4L USE ONL ****
OF TOWN AGENTS:
kCON ERVATION ADM STRATOR DATE APPROVED p
DATE REJECTED
st
COMMENTS ;.
TOWN PLANNER
COMMENTS
DATE APPROVED
DATE REJECTED
It
FOOD INSPECTOR -HEALTH DATE APPROVED
DATE. REJECTED
SEPTIC INSPECTOR -HEALTH DATE APPROVED.
DATE REJECTED TT
COMMENTS W ff.�J. G �i�l� is
N6tXbCS_t_ C�2b A)QEA 7N -A (^QT, CQ f A 100
IL tv
UBLIC WORKS - SEWER/WATER CONNECTIONS
DRIVEWAY PERMIT f
RE DEPARTMENT
CEIVED BY BUILDING INSPECTOR DATE I
✓ised 9W im I
FO
INSTRUCTIONS: This form
Boards and Departments hav4
the applicant and/or landowner
LOT }RELEASE FOR11r
ed to verify
that all necessary approvals/permits frog
)risdiction have been obtained. ab his does not or requirements.VE
m compliance with any apple
*****************************APPLICANT ill
THIS SECTION
APPLICANT _ � ,.�y.,vc.--
PARCEL_—
LOCATION: Assessor's Map Number
LOT (S)------/�
SUBDIVISION
K4ST. NUMBER.
STREET
I
)FACIAL USE ONL
REcv mc���.r.
CON ERVATION
COMMENTS-
TOWN
OMMENTS
TOS PN LANNER
COMMENTS
0 INSPECTOR -HEALTH
SEPTIC INSPECTOWria'-" .DATE RE,1ECi -fin
,' `v
COMMENTS
PUBLIC WORKS - SEWERJWATER CONNECTIONS
TOWN AGENTS:
DATE APPROVED
DOTE REJECTED
DATE RO'1
APPED
1?AT,'E REJECTED
DATA ROVED
DATE REJEGTED
DATE APPROVED 03 "fED
't
DRIVEWAY PERMIT
FIRE DEPARTMENT
RECEIVED BY BUILDING INSPECTOR
Revised 9\97 )m
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Form No. 4
Town of North Andover, Massachusetts
BOARD OF HEALTH
December 111,9_22_
CERTIFICATE
,9_22—
CERTIFICATE OF COMPLIANCE
This is to certify that
the Individual Soil Absorption Sewage Disposal System constructed__( x) or repaired ( )
by William Sawyer
at Lot,#7 Windki st
SITE LOCATION
has been installed in accordance with Board of Health Regulations as described in the Design
Approval Site System Permit No. 0.07 dated EPb_LA,---1 9 q�
The issuance of this certificate shall not be construed as a guarantee that the system will
function satisfactorily. _.
OARD OF HEALTH -
._ .
M1
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APPLICATION FOR DISPOSAL WORKS CONSTRUCTION PERMIT
DATE: ( V I CURRENT INSTALLER'S LICENSE#
LOCATION:
LICENSED INSTALLER:
SIGNATURE:
CHECK ONE:
TELEPHONE#
NEW CONSTRUCTION: I
IF NEW CONSTUCTION, PLEASE ATTACH FOUNDATION AS -BUILT.
Administrative Use Only
$75.00 Fee Attached? Yes �-� No
Foundation As -Built? Yes _1� No
' Approval_ 1_ 7 Date: (O
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Town of North Andover, Massachusetts Form No. 3
NORTN BOARD OF HEALTH
A
ate' 1997
7
,n;.oSh DISPOSAL WORKS CONSTRUCTION PERMIT
S^cmus�
Applicant
NAME ADDRESS
TELEPHONE
Site Location T 7
Permission is hereby granted to Construct (fir Repair ( ) an Individual Soil Absorption
Sewage Disposal System as shown on the Design Approval S.S. No. 2/-9 �
CHAIRMAN, BOARD OF HEALTH
Fee X17 �
D.W.C. No.
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Town of North Andover
OFFICE OF
COMMUNITY DEVELOPMENT AND SERVICES
146 Main Street
North Andover, Massachusetts 01845
WILLIAM J. SCOTT
Director
February 24, 1997
Mr. Phil Christiansen
Christiansen & Sergi
160 Summer Street
Haverhill, MA 01830
Re: Lots 1 & 7 Windkist Farm Road
Dear Phil:
This is to inform you that the proposed plans for sites referenced above have been
approved.
If you have any questions, please do not hesitate to call the Board of Health Office at the
number below.
Sincerely,
Sandra Starr, R.S.,
Health Administrator
SS/cjp
cc: William Barrett
BOARD OF APPEALS 688-9541 BUILDING 688-9545 CONSERVATION 688-9530 HEALTH 688-9540 PLANNING 688-9535
FORM U - VERIFICATION FORM
INSTRUCTIONS: This form is used to verify that all necessary
approvals/permits from Boards and Departments having jurisdiction
have been obtained. This does not relieve the applicant and/or
landowner from compliance with any applicable local or state law,
regulations or requirements.
*****************Applicant fills out this section*****************
APPLICANT:
APPLICANT: /.Lf/d' !1e_15 IT' i S // A,--- vhnna l/ 7
LOCATION: Assessor's Map Number / �f Parcel —37
Subdivision Lots) 7
Streety ��/ S St. Number _ q
************************Of 'cial
RECOMMENDATION OF WN 'BENTS:
Conservation Administrator
Use Only************************
Date Approved D /�
Date Rejected
Comments
Date Approved
Town Planner Date Rejected
Comments
Food Inspector -Health
�!- epi Inspector -Health
Comments
Date Approved
Date Rejected
Date Approved
Date Rejected
Public Works - sewer/water connections
- driveway permit
Fire Department 1 ft�m Jou �3� !� () dYG,"
�' :�vhCO�+e� Vic- �
Received by Building Inspector Date
// //''Z4'� PLAN REVIEW CHECKLIST
ADDRESS/�T 7 _1A)8,e15T ENGINEER
GENERAL
3 COPIESy STAMP LOCUSy NORTH ARROW SCALE
CONTOURS t-� PROFILE 4 -"*"(Sc) SECTION C--'- BENCHMARK c/ SOIL &
PERCS ✓ ELEVATIONS WETS. DISCLAIMER L/ WELLS & WETS c�
WATERSHED? /VI) DRIVEWAY WATER LINE (-� FDN DRAIN 2,/ M&P
SCH40 L,-' TESTS CURRENT? �� SOIL EVAL 'C n)JA)
SEPTIC TANK
MIN 1500Gc/ .17 INVERT DROPL/ GARB. GRINDERIL(2 comps +200)
10' TO FDN (/ MANHOLE ELEV GW / # COMPS. / GB 1.1
D -BOX nn
SIZE D 6 6 # LINES FIRST 2' LEVEL STATEMENT
INLET A5 ,ate - OUTLET _ / ( 2" OR .17 FT) TEE REQ' D? &C,
LEACHING
MIN 440 GPD? `/ RESERVE AREA I,� 4' FROM PRIMARY? 20 SLOPE
100' TO WETLANDS t -l____ 100' TO WELLS 4--� 4' TO S.H.GW 4----(5'>2M/IN)
20' TO FND & INTRCPTR DRAINS f--' 400' TO SURFACE H2O SUPP cs
4' PERM. SOIL BELOW FACILITY MIN 12" COVER 4_FILL?zl_,1(15')
BREAKOUT MET?C-"�
TRENCHES
MIN 440 gpdV SLOPE (min .005 or 6"/100' ) SIDEWALL DIST. 3X EFF.
W OR D (MIN 6') ✓' RESERVE BETWEEN TRENCHES? L____ IN FILL? MUST
BE 10' MIN. 4" PEA STONE?(/ VENT? &I--" (>3' COVER; LINES >50')
BOT `�-8 + SIDE r o ¢ = 7 9a2 X LDNG > ,-� = TOT-4J"110—
(L
"110(L x W x #) (DxLx2x#) (G/ft2)
Copyright 9 1996 by S.L. Starr
No................ _.......
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F$s.............................. .
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF I4 ALT11
............. .o.w..w✓......... or .... Nv9 V..11MU.Vex .............................
Applira#ion for Dioltojud Worko T.unotrititiou Vleruti# .
Application is hereby made for a Permit to Gonstruc
System at:
....................W I N �� ........r WAV
..........._.......
.Location - Address
Owner
t OQ or Repair ( ) an IndlV lug] Sewage Disposal
....................................LoT .7.. .................... =--...::P:...------
or Lot No.
.10.411 .... MRN ! T._..1 .:?3I.Y0.aV ..........
Address
...........................................................................................................................................................................
. ..... ..... . . .........
Installer Address AA
Type of Building Size Lot .... r1�J�t7.....Sq. feet
Dwelling — No. of Bedrooms ............. T............................Ex'pansion Attic ( ) Garbage Grinder ( )
Other Type of Building No. of persons ............................ Showers ( ) — Cafeteria ( )
Otherfixtures......................................................................................................................................................
Design Flow..............57 ....................gallons per person per day. Total doily flow .................. ...............gallons.
Septic Tank — Liquid capacity U.gallons Length./W—&.. Width. .— .... Diameter ..... ..-- .... Depth. . S..
Disposal Trench — No. ....... Z.......... Width ...... .......... Total Length ...... glk?....... Total leaching area....:?.1?..... sq. ft.
Seepage Pit No ..................... Diameter.................... Depth below inlet.................:.. Total leaching area .................. sq. ft.
Other Distribution box (K) Dosing tank ( ) I
Percolation 4l.Test Results Performed by.. cNl?!.STH.IN-5. ... ...S PLC7r'+.L � .'........ Date......* .......`..........
.r
-*Z3 Test Pit No. 1.....minutes per inch DepthAof Test Pit ...... ilig"'... Depth to ground water ....... %(o............
4Z¢ Test Pit No. 2....1. minutes per inch Depth of Test Pit .... III ...... Depth to ground water....... .........
....................... ^.....................-----------------..........................................................................................
Description of Soil.........Z4. S ¢..... '.(!� .-- b`l...... 10".........................................................................................
.........................................................................................................................................................................................................
......................................................................................................................................................................................................
Nature of Repairs or Alterations —Answer when applicable..............................................................................................
Agreement
The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with
the provisions of TITLE 5 of the State Sanitary Code — The undersigned further agrees not to place the system in
operation until a Certificate of Compliance has been issued by the board of health.
Signed......................................
...........................................
Date
ApplicationApproved By..........................................................................................................................................
Date
Application Disapproved for the following reasons: ................................................................................................................
.........................................................................................................................................................................................................
Date
CHECKLIST FOR
PLAN REQUIREMENTS
FOR
SUBSURFACE SEWAGE DISPOSAL SYSTEMS
TOWN OF NO. ANDOVER BOARD OF HEALTH
MARCH, 1990
1.
Locus
Map (Suggested Scale: 1" = 20001)
Locus identified.
—�- . Streets and names within 1/2 mile.
,,,*".C. North arrow and scale
2. Site Plan (Suggested Scale: i" = 201)
iA. Lot to be served, its dimensions and area.
Fronting street.
C. North arrow and scale.
_L,-**" -D. Assessor's designation. (Map & Lot Number)
_L, -'-E. Abutters names and lot numbers.
F. Easements.
G. Property lines.
_�H. Footprint of proposed house to be served showing
garage (attached, detached, or garage under house.)
I. Where applicable setbacks to house.
1-,-"_J. Number -of proposed bedrooms.
c/K. Location and elevation of driveway in vicinity of
the leaching facility & dwelling.
Water service line from main in street or well.
M. Location of existing or proposed well.
,,,'-N. Location.of deep observation holes and percolation
tests.
�
0. Existing and proposed contours.
P. Location of bench mark in the vicinity of the
leaching facility.
L,-, J2. Location and dimensions of system (septic tank,
pipes and leaching facility) including the reserve
area.
R. Profile and section arrows.
S. Location of any streams, water bodies, surface and
subsurface drains, known sources of water supply
within 200 -feet, and wetlands within 100 -feet
(locate wetlands, specify type of resource and show
100 -foot buffer zone line if applicable).
T. Erosion control devices as required by Con. Comm.,
Board of mealth or Planning board with detail and
P/ description of device proposed.
U. Limits of topsoil and subsoil excavations shall be
dimensioned clearly on site plan.
.o.
Aj
Z V. Location and elevation of soil tests.
W. Foundation drain outfall shown.
3. Design Calculations and Nates
A. Percolation rate used for design.
_B. Soil log results - designate various strata depths
and description, depth to ledge and/or groundwater
if encountered.
C. Date of percolation and deep hole tests.
D. Number of bedrooms.
E. Elevation of test pits.
4. Profile of System (Suggested Scale: V = 41)
5.
6.
A. Finished floor of house.
-B. Invert elevations at house, septic tank (inlet &
outlet), and distribution box. If applicable for
PUMP systems, inlet and outlet of pump chamber and
pump bloat switch settings with supporting
cal^ 1 t'
u a i ons.
C. Length, type and grade of pipe and length of
leaching facility.
�D. Elevation of ledge and/or groundwater.
Elevation of bottom of leaching facility.
F. Existing and proposed grades.
Slope (breakout) requirement and calculations.
H.
Scale.
_I. Topsoil & subsoil removal shown. (If applicable)
Cross -Section of System (Suggested Scale: V = 41)
tA. Elevations of various components.
B. Existing and proposed grades.
i/ C. Type, dimensions and stone and system components
specifications.
D. Elevation of ledge and/or groundwater.
E. Elevation of bottom leaching facility.
--c/F- Dimensions.
G• Slope (breakout) requirements and calculations.
"k_H. Scale.
I. Top soil and subsoil removal shown. (If applicable)
Additional Notes and Other Details
Owner's name, address and phone number.
B. Applicant's name, address and phone_ number.
C. Eng i neer' s name, address .. and phone number.
�D. The designer should indicate any notes or special
conditions peculiar to the site of interest to the
Board, Installer or Owner.
E. Plans should be dated. Any revised plans after the
initial submission should show a revision date and
abbreviated explanation of the revision.
F. If a pump system, type, make, model, operation
.head, performance curve,and pump rates should be
provided. All required alarm, power and float switch
data/ should be provided for review and approval.
System components ( septic tank, D -box, etc.)
details should be provided if other than standard
as required from local suppliers. Component spec
should be indicated somewhere on the plans for
standard items.
H. Material to replace the topsoil & subsoil shall be
specified. (If applicable.)
Reviewed and recommended by:
Date
Applicant Yy-\DTest No.
Site Location_�_�� _ V0,1 Y\.
Reference Plans and Specs. C%"t" S
ENGINEER DESIGN DATE
Permission is granted for an individual soil absorption sewage disposal system to be installed
in accordance with regulations of Board of Health.
A5 fv
Fee
-, -4 A 4 j -
CHA MAN,BOA D FHEALTH
Site System Permit No. "I b—)
Town of North Andover, Massachtts_ Form No. 2
NORT►f
BOARD OF HEALTH
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A
41
IjbAr.p'�."�
DESIGN APPROVAL FOR
C"
SOIL SOIL ABSORPTION SEWAGE DISPOSAL SYSTEM
Applicant Yy-\DTest No.
Site Location_�_�� _ V0,1 Y\.
Reference Plans and Specs. C%"t" S
ENGINEER DESIGN DATE
Permission is granted for an individual soil absorption sewage disposal system to be installed
in accordance with regulations of Board of Health.
A5 fv
Fee
-, -4 A 4 j -
CHA MAN,BOA D FHEALTH
Site System Permit No. "I b—)
TOWN OF NORTH ANDOVER
SYSTEM PUMPING RECORD
DATE:
�14
SYSTEM OWNER & ADDRESS SYSTEM LOCATION
(example: left front of house)
iso un QAC a-�- �kC)\-? S� "Iv�
DATE 01, PUMPING: 5A/192 QUANTITY PUMPED i O GALLONS
CESSPOOL: NO \),-- YES SEPTIC TANK: NO YES
NATURE OF SERVICE: ROUTINE _ X. EMERGENCY
OBSERI'.�TIONS:
(; OOD CONDITION
H _7AVY GREASE
ROOTS
L:iCESSIVE SOLIDS
S )LIDS CARRYOVER
SYSTE? : PUMPED BY:
COMM.: ,'TS:
z
X FULL TO COVER
BAFFLES IN PLACE
LEACHFIELD RUNBACK
FLOODED
OTHER (EXPLAIN)
CONTE. CS TRANSFERRED TO:
TOWN OF NORTH ANDOVER
SYSTEM PUMPING RECORD
DATE: .3^C;� c� �
SYSTEM OWNER & ADDRESS
SYSTEM LOCATION
P42 t) (ezample: left front of house)
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DATE OF PUMPING: v o29 Q / QUANTITY PUMPEDQ
GALLONS
CESSPOOL: NO YES SEPTIC TANK: NO
t �! YES
NATi7RE OF SERVICE: ROUTINE
EMERGENCY
OBSERVATIONS:
� f ' GOOD CONDITION
HEAVY GREASE FULL TO COVER
ROOTS BAFFLES IN PLACE
EXCESSIVE SOLIDS LEACHFIELD RUNBACK
SOLIDS CARRYOVER FLOODED •
J OTHER (EXPLAIN) )� �/- Powpr saP
' SYSTEM PUMPED BY:.
r
'i ,,.:, • j COMMENTS:
---------------
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VER.WASSACHURATiTIA -
;ry,r t'rt� 4v�, 1r `�?,a•':{,, ,: MAY 10 2007
DEP.haa provided this form for use by local Boards of Health. 5) YM t� rd must
be submitted fo the local'Board of Health or other approving au ~'` � i
r
A:. Facility information
Rortant.,
When• Bung out 1 :: System l.ocatlon _
forms on
computer, use
only the tab key Address
to move your::
cursor do not CI /Town r
use the return - ty State
Zip Code
,. �y�`:.. 2 System Owner.'
me
'"" Address (if different from location)
CIty/Town Stat e
N
Telephone Number
,Y B.`P.UM;)1ng-Record r
,a 1 Date of Pumping : Da 2. Quantity Pumped:
Gallons
`.Type of•system ❑ Cesspool(s)ept(c Tank ❑Tight Tank
L7' Other (describe); .
4 Effluent Tee Filter present? . ❑ Yes o If yes, was It cleaned? ❑ Yes []'No
- ' S Co ditlon of System:!"
6 Sy em Pumped By'
Nama Vehicle Ucen#e Number
t •�i^ vn4 tit .i t4r,1i f1t Ylr,!•../C11i , •';SI �(/] /' ///
`r iGompany.; ,y '� Y,, , ,;li , 7. j• ,
�' 7 Location where contents yvere disposed:
/
Slpnature Of Hauler• ,1Date
httpJAvww.mass.gov/dep/water/ipprOVais/t5forrns.htm#inspect
t5formCdoc} 06103 = System Pumping Record - Page 1 of 1