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CONSTRUCTION APP__...._._...
HAS PLAN REVIEW FEE BEEN PAID? YES NO
PLAN APPROVAL: DATE �
APP. BY -_--- -- -_ -
DESIGNER: PLAN
CONDITION
i
WATER SUPPLY: TOWN WELL
2s
(� 1
WELL PERMIT _ DRILLER. 90.....__._....._.T.... ,�1�/'��
' WELL TESTS:
CHEMICAL DAIE APPRUVEU
BACTERIA I DA 1 E F1F•PRUVED g%hr5'
BACTERIA II DA 1 E APPROVED._./1
COMMENTS:
FORM U APPROVAL: APPROVAL TO ISOUE <z" NO
DATE ISSUED /� _BY-___. _.__.___..__....__.... ...... .__
CONDITIONS:
FINAL APPROVAL:
ALL PERMITS PAID _i _YES _� NO
WELL CONSTRUCTION APPROVAL .YES _� NU
SEPTIC SYSTEM CONSTRUCTION APPROVAL,_ YES 140
OTHER YES NU
ANY VARIANCE NEEDED
FINAL BOARD OF HEALTH APPROVAL:
_YES NO
DATE ::'�:..�..�.._._•..._ ...IIY: h:�
IS THE INSTALLER LICENSED?.,::...:..,-..;...'•"'°/ �.
NO
TYPE
NE REPAIR'
.OF
..NEW CONSTRUCTION:,-. CERTIFIED PLOT PLAN REVIEW"
NO
CONDITIONS OF.. APPROVAL
YES NO
(FROM FORM U) }..,... ;
_`-ISSUANCE OF DWC PERMIT `. -
YES NO
J%�coff INSTALLER.
--DWC PERMIT N0. �:
„BEGIN
.INSPECTION _ YES�NO:
:^EXCAVATION.INSPECTION: :NEEDED:
PASSED ,BY
CONSTRUCTION INSPECTION: ;, NEEDED:
AS BUILT PLAN SATISFACTORY: vFG=
APPROVAL TO BACKFILL: DATE: BY
' D �3 HY
FINAL.GRADING APPROVAL: DATE
FINAL CONSTRUCTION APPROVAL: DATE:
BY—�f–-
Commonwealth of Massachusetts
City/Town of .
System Pumping- Record
Form 4
DEP has provided this form for use=by local Boards of Health. Other forms may be Used, but the
information" must be substantially the same as that provided here. Before using.this form, check with your
local Board of Health to determine the form they use. The System Pumping Record must be submitted to
the local Board of Health or other approving authority.
A. Facility. Information
1. System Location: Left / # front of Nous , Left / Right rear of house, Left / right side of house, Left /
Right side of building, Left / Right front of building, Left / Right rear of building, Under deck
Address
City/Town State lJ� Zip Code
2. System Owner.
Name
Address (d different from location)
Ci /Town State de
RECEIVED 15? 1-?,S--5_L(
Telephone Number
JUL 13 2015 3
TOWN OF �,
l.,_,.1,,'; ,,PUu raping Record
1. Date of Pumping
3. Type -of system: ❑
❑ Other (describe):
Date 2. Quantity Pumped: Canons
Cesspool(s) pfic Tank ❑ Tight Tank
4. Effluent Tee Filter present? ❑Ye
s LUIo If yes, was it cleaned? ❑ Yes ❑ No,
5. Condition of st ✓�
6.. System Pumped By:
Neil. Bateson
Name
Bateson Enterprises Inc'
Company
7. Locative contents -were disposed:
Waste Water
F5821
Vehicle License Number
41
Date
t5form4.doc 06/03 System Pumping Record • Page 1 of 1
Commonwealth of Massachusetts
City/Town of
System Pumping Record
Form 4
V
DEP has provided this form for use by local Boards of Health. Other forms may be used, but the
information must be substantially the same as that provided here. Before using.this form, check with your
local Board of Health to determine the form they use. The System Pumping Record must be submitted to
the local Board of Health or other approving authority.
A. Facility Information
1. System Location: Left 49i ht fr nt of hour Left / Right rear of house, Left / right side of house, Left /
Right side of building, Left / Right front of building, Left / Right rear of building, Under deck
Address /�� � � C
C r
Cityrrown state Zip Code
2. System Owner.
Name
Address (if different from location)
CitylTown State/—)N
Telephone Number
B. Pumping Record
1. Date of Pumping
3. Type of system: ❑
❑ Other (describe):
Date 2• Quantity Pumped:
Cesspools)eptic Tank
Gallons
❑ Tight Tank
4. Effluent Tee Filter present? ❑ Yes D-9-0 If yes, was it cleaned? ❑ Yes ❑ No.
'5. Condition /of stem:
6. System Pumped By.-
Neil
y:
Neil Bateson
Name
Bateson Enterprises Inc
Company
7. Localiohere contents were disposed:
/'GLL S.�,1 Lowell Waste WatE
No
F5821 Zl sM- v
Vehicle License Number
- �-- t3 ,
Date
t5form4.doc• 06/03 System Pumping Record • Page 1 of 1
Important:
When filling out
forms on the
computer, use
only the tab key
to move your
cursor - do not
use the return
key.
Commonwealth of Massachusetts
City/Town of
System Pumping Recordr IE1z -;V -'34Form 4
DEP has provided this form for use by local Boards of
information must be substantially the same as that prc
local Board of Health to determine the form they use.
the local Board of Health or other approving authority.
A. Facility Information
AA Ay bE used, but the
Aore using, thi 3 form, check with your
]Im`ns ; I J must be submitted to
1. System Lo cation-�
City/rown (n State Zip Code
2. System Owner:
Address (if different from location)
City/Town
B. Pumping Record
1. Date of Pumping
3. Type of system: ❑
❑ Other (describe):
F�) f-rc-2.+e
State � � � Z�P&.q��
Telephone Number
—J
Date 2. Quantity Pumped:
Gallons
Cesspool(s) 2aeptic Tank ❑ Tight Tank
4. Effluent Tee Filter present? ❑ Yes to If yes, was it cleaned? ❑ Yes ❑ No
5. Condition of System:
6. System Rumped
�j e:�J( e) ���
Name
Company
7. Location
Signature
Vehicle License Number
Date
t5form4.doc• 06/03 System Pumping Record • Page 1 of 1
FORM U - LOT RELEASE 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 or requirements.
APPLICANT FILLS OUT THIS SECTIO
J� APPLICANT_ lya "_,0'
—�`raD PHONE f,7
r LOCATION: Assessors Map Number / 6 PARCEL
SUBDIVISION LOT ($)
STREET / m rff S° --► C� p,
ST. NUMBER / `�
OFFICIAL USE ONL
RECOMMENDATIONS OF TOWN AGENTS:
CONSERVATION ADMINISTRATOR DATE APPROVED
DATE REJECTED
COMMENTS •
TOWN PLANNER DATE APPROVED
DATE REJECTED
COMMENTS
r VULP Im Cb 1 K-r1CAL 11'1
I ECTOR TH
COMMENTS
DATE APPROVED
DATE REJECTED
DATE APPROVED Za
DATE REJECTED
47-1-c_ L- y- L.0 z-Tcr /i.-,
PUBLIC WORKS - SEWERMATER CONNECTIONS
DRIVEWAY PERMIT
FIRE DEPARTMENT
RECEIVED BY BUILDING INSPECTOR DATE
RevbW irli7 jm
s
A0w V"
TOWN OF NORTH ANDOVER
APPLICATION FOR PLAN EXAMINATJON
s
ms'ACMU�� BUILDING PERMIT APPLICATION
SSE
60
Permit NO: Date Received:Z.L--;v' �/
Date Issued:
IMPORTANT: Applicant must complete all items on this page I
LOCATION 750 Ao r,- ;Y S,tj 1z
_ Print
PROPERTY OWNER %t" r kg k ; rr"L 4'f2
Print n
MAP NO.: In ,� t U PARCEL:
TVPF. ANn ITCR nF R1111,DING
ZONING DISTRICT: I`C —
HISTORIC DISTRICT YES ❑
TYPE OF IMPROVEMENT
PROPOSED USE
Residential
Non- Residential
❑ New Building
['Addition
❑ Alteration
❑ One family
❑ Two or more family
No. of units:
❑ Industrial
❑ Repair, replacement
❑ Demolition
❑ Assessory Bldg
❑ Commercial
❑ Moving relocation
.Other C-
❑ Others:
❑ Foundation only
DESCRIPTION OF WORK TO BE PREFORMED
11 t
! `X33r�,'r +� W�. S <� Z r fv_Ysr�rt �,,, r� P r ^4,tsi�^.Z
OWNER: Name: Phone: 11!1-51V
Address: "I O �- r- s, ata � �i • p��`i� O t ` L0
CONTRACTOR Name: MvrGky' � fl- U` f��%t'�,^ , !` G -[y Phone "7aW- iS `-W /0
Address: /00 "` -) I Ay A'7 G30 7 -�
Supervisor's Construction License: 0-k,57-0 Exp. Date:
Home Improvement License: �' s j <� Exp. Date: 10/?. -/,?
ARCHITECT/ENGINEER ,Jr� r I J lorri gr fI TA Name: Phone:
Address: /i; " �'�>/�, �" is -.�1 , J i"�'�, Reg. No. ;' ?.S"
FEE SCHEDULE: BULDING17,
IT. • 510.00 PER $1000.00 OF THE TOTAL ESTIMATED COST BASED ON 5125.00
PER S.F.
Total Project Cost :$t.za 0 x10.00=FEE:$
Check No.: Receipt No.:
DT 1A
WN OF NORTH ANDOVER/
BOARD OF HEALTH
SEP 2 9 1995
w—
TA NI K
► m
L07' 2A.
571 64/ S.F.
`k--- -TOP OF FOUNDr103. 62 -
SEPTIC A5 -BUILT ELEVATIONS
INV. OUT HSE. =101.23
IN TANK =100.63
OUT TANK =100.43 441.10
IN D. BOX = 100.26
OUT D.BOX = 100.08/3x ;
END PIPE = 99.6811
= 99.80
=99.6813
.en QA'
SEPTIC 4S -BUILT
p'yc
s NO ANDOVER, MA.
-FOR-
COLONIAL VILL. DEV.
9128195
SCALE.' I "- 40DATE.' 9 j
SCOTT L. GILESl
NO. A ND 0 VER , MA.
. ?s,
cnRE
)F SEWARGE DISPOSAL
Tanning/Massage/Body Art ❑
;mer
Tobacco Sales
J t n Site
Swimming Pools El
Food Packaging/Sales
Permanent Dumps et o
(septic tank, etc. Electric Meter location to
project
Z: Persons contracting with unregister d tactors do not have access to4guarantyfunedtore of Agent/OwnSignature of contrSubmitted ❑ lans aived ❑ Certified Plot Plan ❑ Plans ❑
THE FOLLOWING SECTIONS FOR OFFICE USE ONLY
INTERDEPARTMENTAL SIGN OFF - U FORM
NNING & DEVELOPMENT
4MENTS
vSERVATI
AMENTS
ALTH
MMENTS�-
ing Board of Appeals: Variance, Petition N
DATE REJECTED
❑ F] -
❑Water Shed Special Permit
❑ Site Plan Special Permit
❑ Other
DATE APPROVED
u
)ATE REJECTED DATE AYYRU V t✓L)
DATE REJECTED
ing Decision/receipt submitted yes
ming Board Decision: Comments
I
I
1
I
DATE PROVED
El 3/D4. 3/D4.
servation Decision: Comments
ter & Sewer connection/Si nature & Date Driveway Permit
np Dumpster on site yes—no— Fire Department signature/date
0
4
LOT I A
ml
WN OF NORTH ANDOVEI
BOARD OF HEALTH
SEP 2 9 1995
LOT 2A�
z 87, 64/ S.F.
TA IQ K
am
—TOP OF FOUNDFI03.62 -
SEPTIC AS -BUILT ELEVATIONS
INV. OUT HSE.= IGY.23
IN TANK =100.63
OUT TANK =100.43 441,10
IN D.BOX =100.26 ,-
OUT D.BOX = 100.0813x ;
END PIPE = 99.6811
99.80
=99.6813
SEP TIC 45-BUILT
h�
-IN-
NO. ANDOVER, MA.
FOR -
COLONIAL VILL. DEV.
91 2819 5
� SCALE.' /l 40' DATE.' 9
SCOTT L. GILES s f'
NO. A NO O VER MA.
TREET
— 0 3 Fo8Csr S
DRIVEWAY & UTUITY
EASEMENT
A'
$ 5083 i 23960
31.6'
1p�
1
-5, 30.5'
EXIST.
FMD. �'
U.
LOT ,'rA
AREA=401 AO.t
EXCLUSIVE USE
� � EASEMENT
EXCLUSIVE USE
EASEMCNT
FOUNDA TION LOCATION PLAN
CLIENT., COLONLU VILLAGE DEV. COR; .
THIS CERTIFICATION /S MADE AND LIMITED
TO NE ABOVE CLIENTT,
LOWION; LOT2A FOREST ST„NO.ANDOVER,MA.
SCALE. I = 100' DA TE. -8125195 REV. 911195
CHRIS TIANSEN ,.SERGI "53 1L C��DM
180 SU WMER Sr. HAVERNILL,MA, 01830 TFL. S08-373-0510
0lJos BY cHRIsrANSFM d saw ING.
WE44 EASEMENT
kp
1 �'
002
I CERTIFY THAT THF PmimAmr smucruRE smowN L:L' Fwus To
THE h MZOWTAL SEMCK REOULWMENTS OF TUE LOCAL
APPLICABLE ZONWO BY-4AWS IN EFFECT WHEN CONSTRWTED.
OM CIS WJTIQM ARES NOT CONSIOI O ANY OTHER
ROTRACTTONS SUCH AS COVEIVAMTS,WFTLAMDSVSEMGVT$
akwas OK CONORnKfTr-)
rW DRAWWO SMALL NOT 8E USED BY TTA[ WENT rW ANY
PURPOSE OTHER THAM THAT 60rf)MED AWVffyoM WON TME
VMTTE / PERMISSION OF CHRISTTANSEN d sm INC
nJR7 ERMORE THIS DRA*06 Is THE CLaMMM PffaftWTY
OF CHRWIAM-qW t SM INC— AND ANY UNAUMONZED USE
IS PRLMNTEACFlAlS7 MSEN R SEMO TAKES AAO 0C PaWWTY
FUR THE UMAU7MOAVZEA USE OF THIS DRAwAW OR ANY INFw-
MAWN COMMINED HEREON.
WED ON Seaga WrA ONLY rNF PRfAWY SMXnff MOM
IS LWATEb W A 70NC r As CU01W ON ffW
FLOOD IMSURAWX RATF AWP-
CaWNU ITr NO.: 25008 CC= WTE16/21&3
N QF
Mr
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rs
DWG. 0..
COMMONWEALTH OF MASSACHUSETTS
EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS
DEPARTMENT OF ENVIRONMENTAL PROTECTION
TITLE 5
OFFICIAL INSPECTION FORM -- NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM
PART A
CERTIFICATION
Property Address: 990 Forest Street
_ North Andover_Y�'_ . a� Q NacP.►
Owner's Name: Steven Daly _
Owner's Address: _990 Forest Street_
_ North Andover, MA 01845 ' 6
Date of Inspection: _4/6/2004_ _
Name of Inspector: Neil J. Bateson—
Company Name: Bateson Enterprises Inc._
Mailing Address: _111 Argilla Road_
_Andover, Ma. 01810_
Telephone Number: _( 978 ) 475-4786_
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:
X Passes
Conditionally Passes
Needs Further Evaluation by the Local Approving Authority
ai
Inspector's Signature: Date: _4/6/20044_
The system inspector shall 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:
****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.
Page 2 of 11
OFFICIAL INSPECTION FORM — NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION (continued)
Property Address: 990 Forest Street_
_ North Andover_
Owner: Daly_
Date of Inspection: 4/6/2004_
Inspection Summary: Check A,B,C,D or E /ALWAYS complete all of Section D
A. System Passes:
X I have not found any information which indicates that any of the failure criteria described in 310 CMR
15.303 or in 310 CMR 15.304 exist. Any failure criteria not evaluated are indicated below.
Comments:
B. System Conditionally Passes:
One or more system components as described in the "Conditional Pass" section need to be replaced or
repaired. The system, upon completion of the replacement or repair, as approved by the Board of Health, will pass..
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
obstruction 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):
broken pipe(s) are replaced
obstruction is removed
ND explain:
Page 3 of 11
OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION (continued)
Property Address: _990 Forest Street
_ North Andover
—
Owner: Daly_
Date of Inspection: 4/6/2004
C. Further Evaluation is Required by the Board of Health:
Conditions exist which require further evaluation by the Board of Health in order to determine if the system
is failing to protect public health, safety or the environment.
1. System will pass unless Board of Health determines in accordance with 310 CMR 15.303(1)(b) that the
system is not functioning in a manner which will protect public health, safety and the environment:
Cesspool or privy is within 50 feet of a surface water
Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh
2. System will fail unless the Board of Health (and Public Water Supplier, if any) determines that the
system is functioning in a manner that protects the public health, safety and environment:
_ The system has a septic tank and soil absorption system (SAS) and the SAS is within 100 feet of a
surface water supply or tributary to a surface water supply.
_ The system has a septic tank and SAS and the SAS is within a Zone I of a public water supply.
— The system has a septic tank and SAS and the SAS is within 50 feet of a private water supply well.
_ The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or more from a
private water supply well". Method used to determine distance _ _
"This system passes if the well water analysis, performed at a DEP certified laboratory, for 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: _990 Forest Street _
_ North Andover
—
Owner: Daly_
Date of Inspection: 4/6/2004_
D. System Failure Criteria applicable to all systems:
You must indicate "yes" or `no" to each of the following for all inspections:
Yes No
_ No_ Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool
—No Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or
clogged SAS or cesspool
No Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or
cesspool
No_ Liquid depth in cesspool is less than 6" below invert or available volume is 1/2 day flow.
_No_ Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s).
Number of times pumped
No_ Any portion of the SAS, cesspool or privy is below high ground water elevation.
_No_ Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface
water supply.
No Any portion of a cesspool or privy is within a Zone I of a public well.
_ _No Any portion of a cesspool or privy is within 50 feet of a private water supply well.
_ _No_ Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water
supply well with no acceptable water quality analysis. [This system passes if the well water analysis,
performed at a DEP certified laboratory, for 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.]
No (Yes/No) The system fails. I have determined that one or more of the above failure criteria exist as described
in 310 CMR 15.303, therefore the system fails. The system owner should contact the Board of Health to
determine what will be necessary to correct the failure.
E. Large Systems:
To be considered a large system the system must serve a facility with a design flow of 10,000 gpd to 15,000
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
— _ the system is within 400 feet of a surface drinking water supply
— _ the system is within 200 feet of a tributary to a surface drinking water supply
_ the system is located in a nitrogen sensitive area (Interim Wellhead Protection Area — IWPA) or a mapped
T Zone II of a public water supply well
If you have answered "yes" to any question in Section E the system is considered a significant threat, or answered
"yes" in Section D above the large system has failed. The owner or operator of any large system considered a
significant threat under Section E or failed under Section D shall upgrade the system in accordance with 310 CMR
15.304. The system owner should contact the appropriate regional office of the Department.
Page 5 of 11
OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART B
CHECKLIST
Property Address: 990 Forest Street_
_ North Andover_
Owner: Daly_
Date of Inspection: _4/6/2004_
Check if the following have been done. You must indicate "yes" or "no" as to each of the following:
Yes No
Yes _ Pumping information was provided by the owner, occupant, or Board of Health
No Were any of the system components pumped out in the previous two weeks ?
Yes _ Has the system received normal flows in the previous two week period ?
No Have large volumes of water been introduced to the system recently or as part of this inspection ?
Yes Were as built plans of the system obtained and examined? (If they were not available note as N/A)
Yes Was the facility or dwelling inspected for signs of sewage back up ?
Yes Was the site inspected for signs of break out ?
Yes Were all system components, excluding the SAS, located on site ?
_Yes_ _ 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 ?
_Yes_ _ 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
_Yes_ Existing information.
_No__ Determined in the field (if any of the failure criteria related to Part C is at issue approximation of
distance is unacceptable) [3 10 CMR 15.302(3)(b)]
Page 6 of I 1
OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION
Property Address: 990 Forest Stmt
_ North Andover
–
Owner: Daly_
Date of Inspection: _4/6/2004
FLOW CONDITIONS
RESIDENTIAL
Number of bedrooms (design): _4_ Number of bedrooms (actual): _4_
DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x # of bedrooms): 660_
Number of current residents: _5
Does residence have a garbage grinder (yes or no): No
Is laundry on a separate sewage system (yes or no): _ No
Laundry system inspected (yes or no): —
Seasonal use: (yes or no): No
Water meter readings: _On well water_
Sump pump (yes or no): No
Last date of occupancy: _Current
COMMERCIAL/INDUSTRM L
Type of establishment:
Design flow (based on 310 CMR 15.203): gpd
Basis of design flow (seats/persons/sgft,etc.):
Grease trap present (yes or no): T
Industrial waste holding tank present (yes or no):
Non -sanitary waste discharged to the Title 5 system (yes or no):
Water meter readings, if available:
Last date of occupancy/use:
OTHER (describe):
GENERAL INFORMATION
Pumping Records
Source of information: Pumped two years ago, owner
Was system pumped as part of the inspection (yes or no): Yes _
If yes, volume pumped: _1500Jgallons -- How was quantity pumped determined? _Measured tank
Reason for pumping: Inspect tank & tee_
TYPE OF SYSTEM
_X 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/Altemative technology. Attach a copy of the current operation and maintenance contract (to be
obtained from system owner)
T Tight tank , Attach a copy of the DEP approval
_ Other (describe): _
Approximate age of all components, date installed (if known) and source of information: 9 years old, 9/28/1995, As
built plan_
Were sewage odors detected when arriving at the site (yes or no): _No
Page 7 of 11
OFFICIAL INSPECTION FORM -- NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Property Address: 990 Forest Street
_ North Andover
—
Owner: Daly_
Date of Inspection: _4/6/2004_
BUILDING SEWER _ X _ (locate on site plan)
Depth below grade: _18"_
Materials of construction: —cast iron _X_40 PVC other
Distance from private water supply well or suction line:
Comments (on condition of joints, venting, evidence of leakage, etc.): _4" PVC thru wall. 3" PVC in house, no
leaks visible
SEPTIC TANK: _X _ (locate on site plan)
Depth below grade: 6"_
Material of construction: _X concrete _metal _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: 10' x 5' a 4'
Sludge depth 3"_
Distance from top of sludge to bottom of outlet tee or baffle: 24"_
Scum thickness: _3"
Distance from top of scum to top of outlet tee or baffle: _8"_
Distance from bottom of scum to bottom of outlet tee or baffle: _18"_
How were dimensions determined: _
Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels
as related to outlet invert, evidence of leakage, etc.):_ Pumped septic tank. Inlet tee ok. Outlet tee ok. No
evidence of septic tank leaking. Depth of liquid at outlet invert. _
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 scum to top of outlet tee or baffle:
Distance from bottom of scum to bottom of outlet tee or baffle:
Date of last pumping:
Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels
as related to outlet invert, evidence of leakage, etc.):
Page 8 of 11
OFFICIAL INSPECTION FORM — NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Property Address: 990 Forest Street
_ North Andover
Owner: Daly_
Date of Inspection: 4/6/2004
TIGHT or HOLDING TANK: (tank must be pumped at time of inspection)(locate on site plan)
Depth below grade:
Material of construction: concrete metal fiberglass _polyethylene other(explain):
Dimensions:
Capacity: gallons
Design Flow: gallons/day
Alarm present (yes or no):
Alarm level: Alarm in working order (yes or no):
Date of last pumping:
Comments (condition of alarm and float switches, etc.):
DISTRIBUTION BOX: X (if present must be opened)(locate on site plan)
Depth of liquid level above outlet invert: _0"_
Comments (note if box is level and distribution to outlets equal, any evidence of solids carryover, any evidence of
leakage into or out of box, etc.):_ D -box level & distribution equal. No evidence of leakage out of d -box.
Evidence of solid carryover, pumped d -box to clean. D -box cover broken, replaced same._
PUMP CHAMBER: _ (locate on site plan)
Pump in working order (yes or no): —
Alarm in working order (yes or no):
Comments (note condition 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: 990 Forest Street
_ North Andover
—
Owner: Daly_
Date of Inspection: _4/6/2004_
SOIL ABSORPTION SYSTEM (SAS): X (locate on site plan, excavation not required)
1f SAS not located explain why:
Type
leaching pits, number: _
leaching chambers, number:
leaching galleries, number:
_X leaching trenches, number, length: 3 trenches 63' long_
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.): _ Soil oL Vegetation oL No sign of ponding to surface_
CESSPOOLS: (cesspool must be pumped as part of inspectionXlocate on site plan)
Number and configuration:
Depth — top of liquid to inlet invert:
Depth of solids layer:
Depth of scum layer:
Dimensions of cesspool:
Materials of construction:
Indication of groundwater inflow (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:
Depth of solids:
Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.):
Page 10 of 11
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Property Address: 990 Forest Street
_ North Andover
—
Owner: Daly_
Date of Inspection: 4/6/2004
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.
ank = 53'
-Box = 60'
ank = 32'
-Box = 47'9"
Page 11 of 11
OFFICIAL INSPECTION FORM — NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Property Address: 990 Forest Street
_ North Andover_
Owner: —Daly—
Date
aly_Date of Inspection: 4/6/2004
SITE EXAM
Slope
Surface water
Check cellar
Shallow wells
Estimated depth to ground water _ 4'_
Please indicate (check) all methods used to determine the high ground water elevation:
X Obtained from system design plans on record - If checked, date of design plan reviewed: _8/5/1994_
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: As per design plan_
Tel: (978) 475-4786
Fax: (978) 475-5451
BATESON ENTERPRISES, INC.
Excavating -Nater.& Sewer Lines -Septic Systems & Pumping Service
111 Argilla Road Andover, Mass. 01810
Title 5 Inspection Report
Property Address: 990 Forest Street, North Andover
Owner: Daly
Date of Inspection: 4/6/2004
My report contained herein does not constitute a guarantee of future usage and the functionality of the existing
septic system Such report issued herewith is merely based upon my observations, and I hereby disclaim any further
operation of your current septic system.
Neil J. B eson
Bateson Enterprises, Inc.
TOWN OF NORTH ANDOVER
SYSTEM PUMPING RECORD
�> > l•EM OWNER & ADDRESS
rc�sfi :5�
Alb - �}nna✓�
SYSTEM LOCATION —_'.__
(example: left front of house)
U \"I'C OF PUMPINC: 5'TQIJ,R QUANTITY f UMPCD—L�SWC•,�LL U-�,
NO YES SEPTIC TANK: NO YES
w
� ATURE OF SERVICE: ROUTINE EMERGENCY
ffl FRVAT IONS:
COOD CONDITION. FULL TO COVER
HFAVY CREASC 13AFFLES IN PLACE.
ROOTS LEACHFIELD RUNUACK .
CXCESSIVE SOLIDS FLOODED
SOLIDS CARRYOVER •Oj�HFR (EXPLAIN)
> >TL.m PUMPcD BY:
� U MM FNTS:
0N TI:N r5 !'IZANSFCIZIZED TO:
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FORM U - LOT RELEASE 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 or requirements.
*****************APPLICANT FILLS OUT THIS SECTION
x00,7
APPLICANT
LOCATION: Assessor's Map Number.
SUBDIVISION p
STREET -V—D 5'
PHONE
PARCEL
LOT (S)
ST. NUMBER 19C)
**********************************OFFICIAL USE ONLY
RECOMMENDATIONS OF TOWN AGENTS: ~' ----- - -
CONSERVATION ADMINISTRATOR
COMMENTS
TOWN PLANNER
COMMENTS
FOOD INSPECTOR -HEALTH
IN Cf -OR -HEAL
DATE APPROVED
DATE REJECTED_
DATE APPROVED
DATE REJECTED_
DATE APPROVED
DATE REJECTED.
DATE APPROVED
DATE REJECTED -
COMMENTS ;�/< -f,- ad op- / r a—L
PUBLIC WORKS - SEWER/WATER CONNECTIONS
DRIVEWAY PERMIT
FIRE DEPARTMENT
RECEIVED BY BUILDING INSPECTOR
Revised 9197 jm
DATE_��
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16 EAST MAIN STREET, P.O. BOX 1153, GLOUCESTER, MASS. 01931-1
TELEPHONE: (508) 281.0222 FAX: (508) 283-3374
CERTIFICRTE OF RNRLYSIS
Mr. Charles Piscatelli
Colonial Village Development Corp.
701C Salem Street
N. Andover, MA 01845
Report P
October
BACTERIOLOGICAL RNRLYSIS
Well Description: New well, 210 feet deep, located on Lot 2, Forest Street, N. Andover, MA.
Sampling: Sample taken by customer on October 21, 1995.
Findings:
Total Coliform Bacterial Count/100 mL . . . . . . 0
Methods: Analysis performed in accordance with Standard Methods for the
Examination of Water & Wastewater, 17th Edition, 1989.
Remarks: The bacteriological quality of this sample was found to meet the requirements of
Mass. Department of Environmental Protection's 310 CMR 22.00, "Drinking Water Regulations"
for human consumption.
JM/ds
John Marietta
Lab Director .
MASS CERTIFIED LABORATORY # MA026
M.
t NORTH
9
,$S^CHUSEt
Applicant
Site Locat
Town of North Andover, Massachusetts
BOARD OF HEALTH
Form No. 3
JP Z)J7 . 19 q5
DISPOSAL WORKS CONSTRUCTION PERMIT
Permission is hereby granted to Construct P� or Repair ( ) an Individual Soil Absorption
Sewage Disposal System as shown on the Design Approval S.S. No.
OR
Biomarine
16 EAST MAIN STREET, P.O. BOX 1153, GLOUCESTER, MASS. 01931 -
TELEPHONE: (508) 281-0222 FAX: (508) 283-3374
Mr. Doug Strong
Colonial Village Development
701C Salem Street
North Andover, MA 01845
CERTI F I CRTE OF RNRLYS 1 S
Report No.: 951484
August 16, 1995
WRTER WILITY RNRLYSIS
Well Description: New well, 190 feet deep, located on Lot 2A, Forrest Street, North Andover, MA.
Sampling: Samples taken by Charles Xenos on August 10, 1995.
Findings:
Parameter
Level Detected
EPR Guideline*
Total Coliform Bacteria/100 mL
0
0
Specific Conductance (prnhoskrn)
350
-
pH Value
7.39 (slightly alkaline)
6.5-8.5
Total Dissolved Solids (mg/L)
241
500
Calcium Content (mg/L)
49.4
150
Copper Content (mg/L)
<0.01
1.0
Hardness (CaCO3, mg/L)
161 (hard)
-
Iron Content (mg/L)
1.09
0.3
Lead Content (mg/L)
<0.001
0.015
Magnesium Content (mg/L)
9.25
-
Manganese Content (mg/L)
0.5
0.05
Sodium Content (mg/L)
8.0
28
Fluoride Content (mg/L)
0.21
2.0
Chloride Content (mg/L)
34
250
Nitrite Nitrogen Content (mg/L)
<0.04
0.1
Nitrate Nitrogen Content (mg/L)
<0.1
10
Sulfate Content (mg/L)
18
250
Alkalinity Content (CaCO3, mg/L)
107
100
Ryznar Stability Index (20°C)
8.1 (optimum)
noncorrosive
Methods: Analyses performed in accordance with Standard Methods for the Examination of
Water & Wastewater, 17th Edition, 1989. `Based on the recommended maximum contaminant levels
of the Mass Department of Environmental Protection Agency's 310 CMR 22.00, "Drinking Water
Regulations" and the "Safe Drinking Water Act" of the United States Environmental Protection Agency.
Mass. Certified Labs MA026 and MA123
t Biomarine
Report No.: 951484
August 16, 1995
Remarks: The Iron and Manganese levels detected may cause the water to taste "rusty" and stain
clothing and plumbing fixtures. Filtration is available to correct these levels if continued usage and
flushing of the well does not cause them to abate.
By: zz__�:L
John Marl etta
Lab Director
JM/ds
cc: North Andover Board of Health
Mass. Certified Labs MA026 and MA123
FORM U - IAT RELEASE 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: 4�l xPhone �'�` -2326)
LOCATION: Assessor's Map Number /�5 �Z_ Parcel
Subdivision ifJ2vS,� Lot(s) ZJL
Street a-.3 V, S� St. Number ( l�
************************Official Use Only************************
RECOMMENDATION OF OWN GENTS:
Conservation Administrator
Comments
Town Planner
Comments
Food Inspector -Health
Septic Inspector -Health
Comments
Date Approved v S
Date Rejected
Date Approved S �1SS
Date Rejected
Date Approved
Date Rejected
Date Approved 7/5Z5—
Date Rejected
Public Works - sewer/water connections 777 -Z -O-18
- driveway permZlk)
Fire Department
„—
Received by Building Inspector Date
B10MARINE P.03 t.
E3iomarine
16 EAST MAIN STREET, P.O. BOX 1153, GLOUCESTER. MASS. 01931.1153
TELEPHONE, (508) 281.0222 FAX: 1508) 283.3374
CERTIFICRTE OF ANALYSIS
Mr. Doug Strong Report No.: 951484
Colonial Village Development August 16, 1995
701C Salem Street
North Ando4, , MA 01345
WRTER OURLITY RNRLYSIS
Well Descri ion: New well, 190 feet deep, located on Lot 2A, Forrest Street, North Andover, MA.
Sa-mvilty; Skimples taken by Charles Xenos on August 10, 1995.
�Indings: 3.
Parameter
; Leuel Detected
EPR Guidetine+
Total Ccpitorm Bacteria/l00 mL
0
0
Specific Conductance (pmhoslcm)
350
.
pH Value
7.39 (slightly alkaline)
0.5-8.5
Total i * Ived Sonde (mgA.)
241
500
Calcium Content ft.Q
49.4
150
Copper 1pontent (mg&)
,c0.01
1.0
Hardness (CaCA3, MQQ
151 (hard)
-
Irvn Content (mgll)
1.09
0.3
Lead Content (mg1L)
4.001
0.015
Magn um Content (mgll)
9.25
Mangan6se Content ("V&)
0.5
0.05
Sodium Content (n1ylL)
8.0
28
F Content (mgk)
0.21
2.0
Chloridd Content (rngk)
34
250
NWe Nitrogen Content (mg/L)
40.04
0.1
Nitrate Oftrogen Content (mg)L)
40.1
10
Sulfate Content (mgA.)
18
250
Alkalinitj►Content (CaCO3, mgA.)
107
100
Ryznar Stability Index (20"C)
8.1 (optimum)
noncorrosive
Methods: Analyses performed in accordance with Standard Methods for the Examination of
Water & Wa4tawater, 17th Edition, 1989. 'Based on the recommended maximum contaminant levels
of the Mass q9partment of Environmental Protection Agency's 310 CMR 22.00, "Drinking Water
Regulations" end the "Safe Drinking Water Act" of the United States Environmental Protection Agency.
,7:
Mass. Cwgled Labs MA025 and MAI 23
` ,45 15:49 BIOMARINE P.04
f
1 f
Biomarine
Report No.: 951464
August 16, 1995
Remarks: The Iron and Manganese levels detected may cause the water to We "rusty" and stain
clothing and plumbing fixtures. Filtration is available to correct these levels it continued usage and
flushing of 1h6 well does not cause them to abate.
,i
JfWds
cc- North Andover Board of Health
.• 's: John Marietta
Lab Director
r;
{
Mass. Certified labs MA026 and MA123
4 TOTAL P.04
NUMBER FEE
�Lb THE COMMONWEALTH OF MASSACHUSETTS 25.00
..... OWN.---... of .........NORTH ANDOVER
This is to Certify that ...........DnwnEast..Drilling............................................................
NAME
23 Pierce Road, Barrington, N.H. 03825
--------------------•----•-----.....-•---------•---•----------•------------------------•-•-•---------••---....---....---...----------•-------..........----......------...
ADDRESS
IS HEREBY GRANTED A LICENSE
For .......Well Drilling Permit — Lot 2A Forest Street
------------------•-- ------.....----------------------.....-----------•----------------.....-----•--------•---•---------------------------
..---------------------------------------------------------•-----•.----------------------•-------------•-------------••--•---------•--------------•--•----------------•----
.------------------------------------------------------------------------------------------------------------- ............................................................
This license is granted in conformity with the Statutes and ordinances relating thereto, and
expires ---- De.Gemb�er...31.,....1.9-95...............unless sgoWe s*@IPended.*erevoked.(
..... A.uguat-... 7-. ......................... 19---9.5
FORM 433 HOBBS & WARREN. INC.
--- ---... ..`
PLAN REVIEW CHECKLIST
ADDRESS 6T at3 ENGINEER ST/ �iiJ SGitJ
GENERAL
3 COPIES STAMP LOCUS 4--' NORTH ARROW SCALE
CONTOURS c- ~ PROFILE SECTION 50 orr- BENCHMARK SOIL &
PERC INFO ELEVATIONS ✓r WETS. DISCLAIMER WELLS �T
WETLANDS'--'-- WATERSHED? V DRIVEWAY�Elev) WATER LINE L/'
FDN DRAIN SCH40 C/ TESTS CURRENT?
P-EuxA�� 7
SEPTIC TANK
MIN 150OG 4-""'�.17 INVERT DROPL,-' GARB. GRINDER 200% EDF)
25' TO CELLAR MANHOLE TO GRADE ELEV GW
D -BOX
SIZE # LINES FIRST 2' LEVEL STATEMENT
INLET/60,6Z - OUTLET 9q. 8 / (2" OR .17 FT) TEE REQ' D?/6/b
LEACHING / L,,"""41
/ , /
MIN 660 GPD? `' RESERVE AREA !/ 4' FROM PRIMARY? v 2% SLOPE
100' TO WETLANDS (-,� 100' TO WELLS t/ 4' TO S . H. GW
35' TO FND & INTRCPTR DRAINS Z,� 325' TO SURFACE H2O SUPP
4' PERM. SOIL BELOW FACILITY d !C MIN 12" COVER °� FILL? l/ (25'
if above natural elev• 10 if elow) BREAKOUT MET?
TRENCHES
MIN 660 gpd V SLOPE (min .005 or 6"/100') ✓ >3'COVER?-VENT
SIDEWALL DIST.. 2X EFF. W OR D (MIN 61)✓fir IS RESERVE BETWEEN
TRENCHES? ✓ IN FILL? t-� MUST BE 10' MIN. 4" PEA STONE?61-----
BOT 079 X LDNG + SIDE 7�Z X LDNGL10,q�= TOT
(L x W x #) (G/ft2) (DxLx2x#) (G/ft2)
Copyright 0 1993 by S.L. Starr
Town of North Andover, Massachusetts Form No. 2
NORTH BOARD OF HEALTH
� w
19 ��
P
DESIGN APPROVAL FOR
as"CHU SOIL ABSORPTION SEWAGE DISPOSAL SYSTEM
Applicant Test No.
Site Location �'��
Reference Plans and Specs. { 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.
-7 ,N
Fee C
CHAIRMAN, BOARD OF EALTH
Site System Permit No.
No......................... Fuu..............................
THE COMMONWEALTH OF MASSACHUSETTS p �,
BOARD O F HEALTH r
77Xj) A) ... ......0F./l%�C'TH......�%
�l�.
.�..Q................
� pptiratioli for Dl!ijjll,. 1l Worltry Tollvitrartlull Funllt
Application is hereby made for a Permit to Construct ( ) or Repair ( ) an Individual Sewage Disposal
System at
... ......................................................res� .S
.. ........
'.ol an...a..l......V..,..1. uye.....�� LIC � rr ........ ...l u..�i...��:;cN�...............
Owner Address
....................................................................................................................................................................................................
I—tattcr Address ` .../
Type of Building L! Size Lot... feet
Dwelling — No. of Redroorrts.......... I ...... ......................Expansion Attic ( ) Garbage Grinder ( )
Othcr — "hype of L'uilcling No. of persons ............................ Showers ( ) Cafeteria ( )
Other fixtures..............................................................
Design Flow............................................gallons per person per day. Total daily flow.......... �i.�i ..................gallons.
Septic 'hank ••-- Liyuid c;tpacity.�.�r&...*gaIIons Lcngt11.I.Q... .... idth�r�..8....... Diameter ................ De tl
Disposal Trench - N4,...., ............ bVidth..... .......... 'I'ofa1 Len t ... 6t,�.......... Total leaching area...�.��......... sq. ft.
Seepage Pit No .................... Diameter.................... Depth below inlet.................... Total leaching area .................. sq. ft.
Other Distrihution box
Percolation "hest Results Performed by, ..].. %S..Q................. Date ...... s'/. �Q .............
jj ......
/ ; ..............
Test Pit No. ).. /..........In11lUt.CS per inch Depth of Test PIP,.......����.... Depth to ground water....
Test Pit No%.L.......ntinutes per hell Depth of Test ......��,t...... Depth to ground
Description of Soil........Zi... f..� �'c��� .......5Gt.....1...... '.
..y...4a�...� I:...tN,h.�..
.............C.�.%?�/.G4. ....... G9.I.2r-o/...............................................................................................I...................
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 TillLE 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...................................................................................... ................
Application Approved Dy..............................................................Date
.................
...........................................................
ace
Application Disapproved for the following reasons:............................................................................................Dat c......
.....................................................................................................................................
Dace
PermitNo ......................................................... Issued...............
.........................................
Date
THE COMMONWEALTH OF MASSACHUSETTS 'tt"
BOARD OF HEALTH
..........I ............................ OF
Tntifirtttp of Tumpliana
THIS IS TO CERTIFY, That the Individual Sewage Disposal System constructed ( ) or Repaired ( )
by..........................................................................................i„st,iier .....................
at............................................................................ . .
........................................................................................
................................
has been installed in accurtlance with the pr•nvisioos of TITLE 5 of The State Sanitary Code as described in the
application for Disposal \Vorks Const.rur(io n Permit Na .................... dated ....................
THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE
SYSTEM WILL FUNCTION SATISFACTORY.
DATE ............... .
.....................
THE COMMONWEALTH "OF MASSACHUSETTS
BOARD OF HEALTH
......................................... OF ......................................... ...................... I.....................
ork,5 Tum3trartiun prutt -
Permission is hereby granted ...............
to Construct ( ) ol• Rep;tir ( ) ;ut Individual Scw;.ttre Disposal System
atNn.......•.........................................................................................
..............................................................................................
Strccl
as shown on (he applic:Itiun fur Disj)W;: l \Turks Cunstrttction Permit No ..................... Dated.................
.................................................................................................
DATE............................................................................... lloard of frcaltlt
FORM 1255 HOBBS a WARREN. INC.. PUBLISHERS
No.........................
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
-Tvt,)_? AJ _ OF N..o�eTH......�.�Y.l�.a...............
Fico
? 1}Ilir�lfi��lj for llrljjaai R1111 a-1 T1111x7trurtiull vmlit
Application is hereby made for a Permit to Construct ( ) or Repair ( ) an Individual Sewage Disposal
System at:
......................................... r s� S
...................... ��............�-�:.
OnIa n.r'.R..... VjJuae..... � v o r/ � .. ? `f...��'r��.� h.. C'�i: Lot N ...............
o„ ncr
Address
.....................................................................................................................................................................................
1 �i,i:�ncr ddress
Type of Building Aj
L�' Size Lot. ..I �,�.r!o.�i.�.....Sq. feet
Dwelling -- No. of f3c�lr�,oms..................T........................Expansion Attic ( ) Garbage Grinder ( )
Other — Type of Builcliug ............................ No. of persons............................ Showers ( ) — Cafeteria ( )
OtherFixtures.....................................................................................:.................................
Design Flow........:...................................gallons per person per day, Total daily flow...........6.6.0................... gallons,
i , „
Septic "1 ;ml< •- I_,clulcl c;th;tcity.h`L �g;tlluns Lengtlt.� ...iv.�� �1/tdth lv..rc�....... Diameter ................ Deptl ..6. ��..
Disposal Trench - - Nu...., ............ Wi<lth.....sr .......... "Total I_enktfi... (�t.:.......... Total leaching area.. j.�.�.....sq. ft.
ll. .
Seepage Pit No .................... Diameter.................... Depth below inlet.................... Total leaching area .................. sq, ft.
Other Distribution box ( ) Dosing tank ( )
Percolation 'fest Results Perforated bya� .4.k.S• .G .............. Date......�� ..,�..1 .............
�:.r..
Test I'll No, bi?.. j..ntinutes per inch Depth of rest Pi ..
to ground water .... ,,11%OA/.•�...
Test Pit N o/ . y. ...,..minutes per inch Depth of Test ......9 .!.. Depth to ground water ... /l!C9N.. F.
Description of Soil........�i � - f ............... ....... ..................................... ................
Il...J%'4LG..... ��C�1L�./.....C�G.Y%....`{,a/.!✓....C� L?. a...... <<!1,6�..................
.rr'9.4c:%f....9.n:�L'Y,& ..........................................................................................................................
...................................................................
..............................
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 !Tr is 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..................................................................................
Application Approved By..................................................................................................Date
........................................
Application Disapproved for the follozving reasons: Date.......................
........................................................................ .........:......
................................................................................................................................
Date
PermitNo ......................................................... Issued .................
......................................
Date
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
........................... O F .....................................................................................
Tertif irMtr of Tnntpliantle
THIS IS TO CERTIFY, That the Individual Sewage Disposal System constructed ( ) or Repaired ( )
by...............................................................
........ ........................
tnstaIIor
at....................................................................................................................................................................................................
has peen installed in ;accordance with tilt: provisiogs of TITI.I;' 5 of The State Sanitary Code as described in the
application for Disposal Works Construction Permit No .................... dated ................................................
............
THE ISSUANCE OF THIS CERTIFICATE SHALL NOT aE CONSTRUED AS A GUARANTEE THAT THE
SYSTEM WILL FUNCTION SATISFAC'rOpY.
DATI............................................ .... fttspector... :.............................
.....................................................................................
THE COMMONWEALTH'OF MASSACHUSETTS
BOARD OF HEALTH
....................... OF..............................................................................
Di,Eipmrinf 1vorlini kTV11 ArtTr fV11 Flermit
Permission is hereby gr taterl.........................................................................................
to Construct ( ) or l:cl,;tir ( ) ;LI) IndiVitlll;d S(.wane I)isposal System
atNo ...............................................................................................
................................
street
as shown on the applic;ttiun for Disposal Works Construction .Permit No ..................... Dated ..........................................
.........................................................................................................
Board of flcalth
DATE.............................................................................
FORM 1255 H0813S a WARREN, INC.. PUSLISHCRS
a Department of Environmental Management/Division of Water Resources
a
14; WELL COMPLETION REPORT
WELL LOCATION /
Addres �':O/
Address/ �r (.
GEOGRAPHIC DESCRIPTION
/(y) "')
E IN
Ileerl �/�c—rc-le!
1
City/Town
Supervising Driller RegA
City/Town-
ity/Town
/7
o 1, �lrA�l��4;; At v/
(road)
WeII owner[ -1
We
Address 0� •ti
7/• !
-7 j�
!i N S ( E W of
Inti. in tenths) Q, cal
w/ '5',4 -Id 5F
Board of Health permit obtained:
yes no ❑
intersect.
WELL USE
WELL DATA
Domestic Rr Public ❑ Industrial
❑
Total well depth .�2o2 it.
Depth bedrock ft.
Monitoring ❑ Other
to
Water -bearing rock/unconsolidated material:
o �r, y
Method drilled
�S
Date drilled^
CASING %�"F L
Type
Length ft. Dia(.I.D.) in.
Length into bedrock A ft.
�`vt
Protective well seal: l0�
Description
Water -bearing zones: /7��
1) From �To
2) From To
3) From To
Gravel pack well: dia.
S Screen:
Grout -El Other I Sloth'
ISTATIC WATER LEVEL (all wells) �J
Static water level below land surface j � ft.
dia.
length from— to—1
Date
WELL TEST (production wells)
Drawdown' 2 ft. a.11er pumping W_
/ min. at gpm
How measured ' " Recovery ft. after—hr. ' min.
LOG of FORMATIONS ]COMMENTS
�Nd
Driller
Firm
n
c
A
Address/ �r (.
1
City/Town
Supervising Driller RegA
Signature a! supervis)00 registered well driller
c
A
i
WELL DATABASE
ADDRESS:
AGE OF WET M WELL DRILLER: f
WELL PERMIT:i;: WELL LOCATION:
_-WELL PER!vfIT DATE: `� (7 -
d � � DEPTH OF WELL:
TYPE OF WELL: DRIL b. DUG c. U1VKNi C
TYPE OF WATER BEARING ROCK: G a A-* l i
WATER ANALYSIS DATE. � � � ' �,5� HIGH MANG
FUGHIRON: N OTHER CONT°A�
F
WELL DATABASE
ADDRESS: D o
AGE OF WELL: WELL DRILLER:
WELL PERMIT T: WELL LOCATION:
WELL PERItifIT DATE: DEPTH OF LL:
SE:
N
TYPE OF W LLL: a.. DRILLEDb. DUG c. UNKNOWN
TYPE OF WATER BEARING ROCK:
WATER ANALYSIS DATE: HIGH tifANGA.NESE
HIGH IRON: Y N OTHER CONTAIMINANTS: Y
lit/A-c q .
D .
N
Y N
N
n
TOWN OF P'
SYSTEM PUMPING RECORD
DATE: 4.—G
SYSTEM OWNER & ADDRESS
001, t
I? X10 �(2�4 S17
DATE OF PUMPING:
SYSTEM LOCATION
(example: left front of house)
\J
�Avu.
�0 Y QUANTITY PUMPED :
CESSPOOL: NO `AYES SEPTIC TANK: NO YES
NATURE OF SERVICE: ROUTINE /' EMERGENCY
OBSERVATIONS:
GOOD CONDITION
HEAVY GREASE
ROOTS
EXCESSIVE SOLIDS
SOLIDS CARRYOVER
FULL TO COVER
BAFFLES IN PLACE
LEACHFIELD RUNBACK
FLOODED
OTHER (EXPLAIN)
SYSTEM PUMPED BY: Bateson Enterprises, Inc.
COMMENTS:
CONTENTS TRANSFERRED TO: G.L.S.D Lowell Waste
GALLONS