Loading...
HomeMy WebLinkAboutMiscellaneous - 415 BOXFORD STREET 9/24/2015 (2) COMMONWEALTH OF MASSACHUSETTS ✓✓ 1 i EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS DEPARTMENT OF ENVIRONMENTAL PROTECTION ♦� SdW4 TITLE 5 OF'F'ICIAL INSPECTION FORM —NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM PART A CERTIFICATION Property Address:_415 Boxford Street_ _North Andover_ Owner's Name:_Brian Courtney_ Owner's Address: 415 Boxford Street V B °j ®_North Andover,Ma 01845_ Date of Inspection:- ns ection:_2/7/2001 HEA Name of Inspector: Neil J.Bateson_ Company Name: liateson Enterprises Inc._ Mailing Address:_111 Argilla Road_ _Andover,lVMa.01810 Telephone Dumber:_(978)4754786 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: Passes Conditionally Passes Needs Further Evaluation by the Local Approving Authority X s Inspector's Signature: Date: 2/7/2006 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 1 i OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address:_415 Boxford Street _North Andover_ Owner:—Courtney_ Date of Inspection:_2/7/2006 Inspection Summary: Check A,B,C,D or E/ALWAYS complete all of Section D A. System Passes: I have not found any information which indicates that any of the failure criteria described in 310 CMR 15.303 or in 310 CMR 15.304 exist.Any failure criteria not evaluated are indicated below. Comments: B. System Conditionally Passes: One or more system components as described in the"Conditional Pass"section need to be replaced or repaired.The system,upon completion of the replacement or repair,as approved by the Board of Health,will pass.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 1 i OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address:_415 Boxford Street_ _North Andover- Owner:_Courtney_ Date of Inspection:_2/7/2006 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:_415 Boxford Street_ _North Andover- Owner:_Courtney_ Date of Inspection:_2/7/2006 D. System Failure Criteria applicable to all systems: You must indicate"yes"or"no"to each of the following for all inspections: _Yes_ _ Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool —No— or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool _Yes_ _ 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 1 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.] _Yes_(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 gpd• You must indicate either"yes"or"no"to each of the following: (The following criteria apply to large systems in addition to the criteria above) yes no the system is within 400 feet of a surface drinking water supply the system is within 200 feet of a tributary to a surface drinking water supply the system is located in a nitrogen sensitive area(Interim Wellhead Protection Area—IWPA)or a mapped Zone II of a public water supply well If you have answered"yes"to any question in Section E the system is considered a significant threat,or answered "yes"in Section D above the large system has failed. The owner or operator of any large system considered a significant threat under Section E or failed under Section D shall upgrade the system in accordance with 310 CMR 15.304.The system owner should contact the appropriate regional office of the Department. Page 5 of 1 i OFFICIAL INSPECTION FORM —NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST Property Address:_415 Boxford Street_ _North Andover_ Owner:_Courtney_ Date of Inspection: 2/7/21146_ 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? 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_ T Existing information. _Yes_ _ Determined in the field(if any of the failure criteria related to Part Cis at issue approximation of distance is unacceptable)[3 10 CMR 15.302(3)(b)] Page 6 of I! i OFFICIAL INSPECTION FORM v NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM 1 PART C 1 SYSTEM INFORMATION 1 Property Address:_415 Boxford Street _North Andover_ Owner:_Courtney_ Date of Inspection:_2/7/20416_ FLOW CONDITIONS RESIDENTIAL Number of bedrooms(design):_4 Number of bedrooms(actual):_3_ DESIGN flow based on 310 CMR 15.203 660_ Number of current residents: Does residence have a garbage grinder(yes or no): _Na Is laundry on a separate sewage system(yes or no):_N Laundry system inspected(yes or no): Seasonal use: (yes or no): No Water meter reading:_NO,on well water_ Sump pump(yes or no):_No Last date of occupancy:—Current- COMMERCULANDUSTRIAL 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): 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: O'I HE R(describe): GENERAL INFORMATION Pumping Records Source of information:_Pumped 1997,owner_ Was system pumped as part of the inspection(yes or no):_No If yes,volume pumped:_gallons--How was quantity pumped determined? Reason for pumping: 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/Alternative technology.Attach a copy of the current operation and maintenance contract(to be obtained from system owner) _Tight tank _Attach a copy of the DEP approval Other(describe): Approximate age of all components,date installed(if known)and source of information:_12 years old,6/14/1994, as built plan_ Were sewage odors detected when arriving at the site(yes or no):No_ Page 7 of 11 OFFICIAL INSPECTION FO —NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address:_415 Boxford Street _North Andover_ Owner:_Courtney_ Date of Inspection: 2/7/2006_ BUILDING SEWER_X_ (locate on site plan) Depth below grade:_3' 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 TANKS: X Depth below grade:_2'_ 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):a(attach a copy of certificate) Dimensions: 10'x 5'x 4'— Sludge depth: 5"_ Distance from top of sludge to bottom of outlet tee or baffle: 2211 Scum thickness:_2" 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: 19" How were dimensions determined:_Tape Measure_ Comments(on pumping recommendations,inlet and outlet tee or baffle condition,structural integrity,liquid levels as related to outlet invert,evidence of leakage,etc._Inlet tee ok.Outlet tee ok.Depth at outlet invert.No evidence of tank leaking. 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 PANT C SYSTEM INFORMATION(continued) Property Address:_415 Boxford Street _ _North Andover- Owner:_Courtney_ Date of Inspection:_2/7/2006_ TIGHT or HOLDING T (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 BOXES: X Depth below grade _3'_ _ Depth of liquid level above outlet invert: " _2 _ 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.Evidence of carryover.No evidence of leakage.Liquid 2"above outlet inverts.Camera leach pipes,found outside trench full of liquid.Inside trench normal. 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 I 1 OFFICIAL INSPECTION FO —NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address:_415 Boxford Street_ North Andover_ Owner:_Courtney— Date of Inspection:_2/7/2006_ SOIL ABSORPTION SYSTEM(SAS):_X (locate on site plan,excavation not required) If SAS not located explain why: Type leaching pits,number:_ T leaching chambers,number:_ leaching galleries,number: leaching trenches,number,length: 2 trenches 35'long_ leaching field,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 No sign of ponding to surface.Liquid above invert in outside leach trench.Inside trench has normal level. CESSPOOLS: Number and configuration: Depth—top of liquid to inlet invert:_ Depth of sludge 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 OFFICIAL, INSPECTION FORM —NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE IDISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address:_415 Boxford Street _North Andover_ Owner:_Courtney_ Date of Inspection:_2/7/2006 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. Well Head O Driveway House A A to Tank=51'6" Septic Tank A to D-Bog=65'7" B to Tank=30'6" B to D-Bog=47' 0- Box Page 11 of 11 OFFICIAL INSPECTION FORM —NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FOAM PART C SYSTEM INFORMATION (continued) Property Address:_415 Boxford Street _ _North Andover- Owner:_Courtney_ Date of Inspection:_2/7/2006_ 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:_5/10/1993T 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:_Design plan test pit data_ Tel: (978) 475-4786 Fax: (978) 475-5451 Excavating-Water.& Sewer Lines-Septic Systems &Pumping Service 111 Argilla Road Andover, Mass. 01810 Title 5 Inspection Report Property Address: 415 Boxford Street, North Andover Owner: Courtney Date of Inspection: 2/7/2006 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. Bateson Bateson Enterprises, Inc. horatemoev o4a oratdrg, Poe. 66 LITTLETON ROAD WMFORD, MA 01886 (508) 692.8398 FAX (508) 692.0023 1 800 649 TEST Report Numbert C-wpsµ10246 Report Datet October 25, 1993 Client: Sample Taken At: Wilmington Pump supply Inc. rlintlock P-0. Box 517 Lot 3 soxford St. Wilmington, MA 01887 N. Andover,Mass. Sample Taken By% WPS staff on: October 21 1993 CERTIFICATE or ANALYSIS TEST PARAMETER: EPA Max RESULTS UNITS Total Col.iform (P) 0 0 per 100m1 calcium No Limit 25.3 mg/4 Copper (0) 1.3 <0402 mg/L Iron (6) 0.3 0.08 mg/L Magne®ium No Limit 3.2 mg/r, Manganese (s) 0.05 0101 mg/L Sodium " 20 11 mg/L Potassium (s) No Limit 2.0 mg/L Alkalinity (S) No Limit 67.3 mg/L Ammonia No Limit <0.03 mg/L Chloride (s) 250 17 m9 1L Chlorine (total) 0.7 <0402 mg/L Color (8) 15 7.5 CPU Conductivity No Limit 211 umhon/cm Hardness No Limit 76 mg/L Nitrates(as N) (P) 10 0.1 mg/L Nitriteb(as N) 1 <0.01 mg/L pH (s) 6.5-8.5 6.9 at) odor (5) 3 0 TON Sulphates (0) 250 19 Mg/L Turbidity 5 1.7 NTU godimont Poe/nag nag NT-Not Tested, #Value Excesde EPA STD, TNTC=Too Numerous to Count *=Background Bacteria Noted, "-$pA Advisory Limit I-Nxceeds EPA Advisory Limit (P)-Primary EPA Standard, (S)-$econdary EPA standard (may affeat aesthetics of drinking water i.e. ttate, color, atu. ) This water sample, as tested, meets or exceeds EPA health standard>a for the parameters listed above. The quality of this water is aocepted as POTABLE aaaording to EPA Standards. Massachusetts state Certified Michael P. carbon, for 66 LITTLETON ROAD WESTFORD, MA 01885 (508) 692.8395 FAX (508) 692-0023 1.800.649•TEST Report Numbers C-wps-12458 Report Date: June 28, 1994 Clients Sample Taken At: Wilmington Pump Supply Ina. Lot 3 P.O. Sox 517 Boxford St. Wilmington, MA 01887 N. Andover,Mass. i Sample Taken By: client on: June 27, 1994 CERTIFICATE OF ANALYSIS ----------------:------- Test Parameter: EPA Max Results Units Coliform Bacteria 0 0 per 100ml Method of Analysis: SM 9222B The quality of this water sample SATISFIES all State, Federal (EPA) and local requirements for coliform bacteria. Massachusetts State Certified Mivhael P. Carlson, for Testing Laboratory #MA048 Thvrstensen Laboratory, Inc. I r 1 t wORTN A Q 4y 480 i0v'l�a �a a° , • at F 7D �rtirr i1 w"I 1 to BOARD OF HEALTH ' �SSACPlU��4 NORTH ANDOVER, MASS. , APPLICATION FOR WELL AND PUMP PERMIT Permit # �'�c% Date Z2 L02-/2 � f A permit is requested to: drill a well install a pump LOCATION:— <' oz/1 -&kk- 3r, �1Lot # -3 Owner Address �,°'r' Tel ' -/ -5I : Wel? Contrctr �_,11116ZIIV�s q. (SnA)r3 . Add._Z-62e- 15 Tel Pump Contrctr-a)AJq/NG e),J/ TP/M/. Add. Tel WELLS (To be completed at time of pump test. ) Type of well /,1C7_61,5_,�4,�°�' Use �J��✓G 5%�� Diameter of well Size of casing .. e Th- Depth ,6t bed rock 1/0 Depth casing into bedrock / Seal been tested? Yes ( ) No (_) Date of test Depth of well A;W Water-bearing rock 6/ -?N/ Depth to water Delivers GPM for how 1 Drawdown ( �;> feet after pumping / , hou at G Date of completion , 4 ign ure well tractor PUMPS (To be filled in before installation. ) Name & size of pump Z w Typea ° Size of tank ; >�„ � Pump delivers GPM Pipe used in well: Cast iron (_) Galvanized (_) Plastic (_ -<ell ' 7-91-6 Sleeve used to protect pipe? Yes (_) No ( j "Type well seal ������ Date Signature of pV6p in 64a, ler Date Tter analysis report submitted to Board of Health %r�/"'q Plu ,ing inspec i7,, insp or "�°, w a Board of Hea cl) 'o M co > m CD 0 m Col- a 11 r 0 4a M (D CD C7 0- =r C; C) C- 0 CD CD CD CD rn CD U) m C<D rn F- (D 01 0 0 > 0 B 5; 31 El 0 -4, o C' M Cb Ts 0 o 0 CD 5- 72 Q AIUU am VZlJJQ a) 0 LIE ........... z Aa NoRTr� - O`4TL•O 1.1�Q p $ 7 a r o `ha BOARD OF HEALTH 'f1 +O+.n°Jp• ,sSA c►+usE� NORTH ANDOVER, MASS. APPLICATION FOR WELL AND PUMP PERMIT Permit # Date d /��/J A permit is reeq—uested to: drill a well install a pump LOCATION: 57_. Lot # 0 Owner ��/,�TGOC.,C Address Tel Well Contrctr y14116Z1,V65 4 S6A)J S Add. j,Zo&I-i5. IV AI 030A�, Tel (/,Q3 Pump Contrctr 1, &1giNG%O1t1 AW ) Add. Tel WELLS (To be completed at time of pump test. ) Type of well 1;;l'72�,-5/X i/ Use ` pn CST/C Diameter of well Size of casing Depth of bed rock Depth casing into bedrock Seal been tested? Yes (_) No (_) Date of test Depth of well c/) Water-bearing rock 6'P/9N Depth to water Delivers GPM for (how long?) Drawdown DU feet after pumping hours at 1-3- GPM Date of completion Signature of well contractor PUMPS (To- be filled in before installation. ) Name & size of pump Type Size of tank Pump delivers GPM Pipe used in well: Cast iron (_) Galvanized (_) Plastic (_) Sleeve used to protect pipe? Yes (_) No (_) Type well seal Date Signature of pump installer Date water analysis report submitted to Board of Health Plumbing inspector Wiring inspector Board of Health FORM U - LOT RELEASE FORM IN UCTIONS: This form is used to verify that all necessary ap ovals/permits from Boards and Departments having jurisdiction h e been obtained. This does not relieve the applicant and/or downer from compliance with any applicable local or state law, regulations or requirements. ****************Applicant fills out this section***************** APPLICANT: ���� Su �••,6o�+ inn „+ Phone 21 /10 S.C -0.01 0 .0000.0 LOCATION: Assessor' s Map Number Parcel Subdivision Lot(s) Street �C. �� r St. Number ************************Official Use Only************************ REC D T.IONS� OF TOWN A ENTS: Date Approved Cons rvation Administrator Date Rejected Comments oil I r. /00 S4 J-0 n A lam- . . Date Approved Town Planner Date Rejected Comments Date Approved i� Food Inspector-Health Date Rejected Date Approved S e is Inspector-Health Date Rejected Comments Public Works - sewer/water connections - driveway permit Fire Department Date Received by Building Inspector „ T1 G r emw,i�Ni 's r lop ---------------------------------------------------------------------------------------------------------- OCT 27 „33 06.41�-V F.:3/.3 . Uapartntent of[nvironrnuntal Managumcntlf7ivisiort of Water Resources WELL COMPLETION REPORT WELL LOCATION Gi t7rsRAlylftC DESCRIPTION Ad ress S.�.i�� y�ry��� �(/�7 ( -- pearl fnJnlel �^ Clt /Town `1�—.L--4.�•. ,r- -��- Y Well owner t 1�7 ( r ag. s _. Address Pn,'_5.-3._y N S OW of �f% �'' i T-I (�LL�V�_�r1..L�� Im.mtonrnrl fc/ratel Board of Health permit obtained: yes no © intersect, uaedl WELL USE WELL DATA Domestic Yuhlic Q Industrial Q Total well dupth. Et. Monitoring❑ Ctlter ,D ,+�cu,tErr b �trtng rock unconsolidated material:1JR Method drilled _ {�eSC� rl~jdCioft ~�rYfL�'L'r Date drilled_ .......beuriny zones: CASING 1) Front 0 To Type LL I __. ?) From Tom Length.8C ft. 3) From To Length into hedrock, ft. Gravel pack well: dia. Protuctivu wall seai; �.,�Tpy�r! Screen: dia. Gloot.e Other , )v��?4E' Slot' length from—to._._,. STATIC WATER LEVEL(all wells) _ Static water level below land surface ft. Date 1 WELL TEST(production wells) 'T S _ Drewdowr a f t. aftor pumpiny...,..�..� hr._.c min,at _,gPtn )low measured Arm iiecovary ft. after—hr rain. nt jJe d f LOG of FORMATIONS OMMEN'rS n Materials Frmu T4 _ jo prillerl r!r p �l '71{!.i'� Firm } Address ,� ) N, C4/Town Supervising Driller Reg,# � to r qni a 0,- vrsln;7 rapJstmed ws J(ler Plda Prrnr hrmty D R I L L C O P Y ----------------------------------------------------------------------------------------------------- NUMBER FEE THE COMMONWEALTH OF MASSACHUSETTS $25 . 00 ....TOWN------ of --------xon_Fl:._mamIZ_..----•--••---..•___._. This is to Certify that &ki•11 ngs---- ---Sons---------------------------------------------------------------- NAME 269 Proctor Hill Road, Hollis, N.H. 03049 ....................................._•••__---___-___•---••••-__-.-__. ......................... ADDRESS IS HEREBY GRANTED A LICENSE For .....Well_•Drling-_Permit-_•for-•-Lot-•• 3_•_Boxford ,Stree.c --•--•--•••--••-•••--•-•---•••--••----•-----------•- ---•--•---•--•...... ......................... -•-••----•••--••--•-•---•••--••-•---•-••-•----•••-•-•------•---••-----------••--•-------.-•--.•-----•--••••----- This license is granted in conformity with the Statutes and ordilwi6vs relating thereto, and December 31 1993 tix expires.-----.-..•_._--.--••-----•---•-•_-..�..--•-- (unless sooner ape rd or re ed. • •-- --- • --- -••-- October 6, 93 --------- __-•••----- ... ------ =- r ` - - ----------------- - .............. FORM 433 HOBBS a WARREN. INC. ••----•- o �J „%°'"•••--- i 1 Commonwealth of Massachusetts City/Town of NORTH ANDOVER, MASSACHUSETTS System Pumping Record y Form 4 DEP has be submitted to the local Board of Health or otherdapprov approving au he $ µ p mpmtecrd muss ority. : { A. Facility Information SE'x 2007 C Important: .I OWN GF1 t OR,i k S When filling out 1. stem Lo tion: HEM..��� "� "IM' `� �.II forms on the ' computer,use only the tab key Ad es to move your AJ. o cursor-do not City/Town Sate Zip Code use the return key. 2. System Owner: Q a me Address(if different from location) City/Town State Z_iq C Telephone umber �lL B. Pumping Record 1. Date of Pumping Date 2. Quantity Pumped: Gallons 3. Type of system: ❑ Cesspool(s) P"'Septic Tank ❑ Tight Tank ❑ Other(describe): 4. Effluent Tee Filter present? ❑ YesXNo If yes, was it cleaned? ❑ Yes ❑ No 5. Condition of System: 6. Sy em Pumped By: -4 2 ?me D�N Vehicle License Number (<�`✓ - Company 7. Loca ' where co tents were disposed: . SAD; J' Sig ture fHauler Date r http://www.mass.gov/dep/water/approvals/t5f .htm#inspect t5form4.doc•06/03 System Pumping Record-Page 1 of 1