HomeMy WebLinkAboutMiscellaneous - 624 BOXFORD STREET 10/23/2015 1
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BOARD OF HEALTH
TOWN OF NORTH ANDOVER, MASS.
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1. NAME DATES ._
2. ADDRESS �. w .,, LOT NO. TEL.
3. NO. OF BEDROOMS ... DEN YES NO
4. GARBAGE GRINDER YES NO
5. SHOW DIMENSIONS OF HOUSE
6. SHOW DISTANCES OF HOUSE TO ALL PROPERTY LINES
7. SHOW DIMENSIONS OF LOT
8. SHOW LOCATION AND SIZE OF SEPTIC TANK OR CESSPOOL
9. NOTE LOCATION AND DISTANCE OF WELL FROM SEWERAGE SYSTEM
10. SHOW LOCATION OF BROOKS, STREAMS, DITCHES, LEDGE OUTCROP, ETC.
11. SHOW DISTANCE OF SEPTIC TANK OR CESSPOOL FROM HOUSE
NOTE: LOCAL REGULATIONS SHOULD BE READ CAREFULLY.
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APPLICATION FOR SEWAGE DISPOSAL INSTALLATION
HEALTH DEPARTMENT - NORTH ANDOVER, MASS.
I h reby make ,a plication�� a permit for a sewage disposal installation at
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I'�S ',��; � I will install this system in ac-
cordance with all the Aws of the Commonwealth of Massachusetts and regulations of
the Board of Health of the Town of North Andover.
Further, I will construct the house sewer of bell and spigot pipe, the minimum
diameter being 4 inches, and will maintain a minimum grade of 1% until 10 feet pre-
ceding the septic tank, where the grade shall not exceed 2%. I will install a con-
crete septic tank of /j-Z.- e) in size. A manhole (s) permitting easy cleaning
will be provided with removable cover (s) of iron or concrete within 12 inches of
the ground surface. I will provide subsurface disposal field with 4 inch perforated
or open jointed pipe and laid in a series of trenches, the bottom of which will pro-
vide a minimum of -_/ � J _lineal (square) feet of effective absorption area.
The pipes will be laid on a 6 inch layer of washed gravel or crushed stone ranging
in size from 3/4 to 1-112 inches (dia. ) and the pipes will be surrounded by similar
material to a height of 2 inches above the crown of the pipe. The joints of these
pipes will be protected from clogging and before filling the trench, 2 inches of
gravel or stone 1/8" to 1/41' (dia. ) will be placed over the course gravel or stone.
The disposal field will be installed at a grade of 4 to 6 inches/100 feet. No single
tile line will exceed 100 feet in length and in any case, two lines of the will be
installed. A minimum of 6 feet will be maintained between the center lines of the
disposal field trenches and the average depth of trench shall not exceed 36 inches.
No part of the installation will be less than 100 feet from any private water supply,
25 feet from any stream, 20 feet from any dwelling or 10 feet from any property line.
I further agree not to cover any portion of this installation until approved by the
inspection officer, as provided below, and to incorporate any additional requirements
that may be attached to the permit. Plot Plans must be submitted with application.
DATE 1 /7/
Signature of Applicant
I hereby issue the above permit for the Board of Health of the Town of North
Andover, Massachusetts.
DATE / i
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Signature of Health Agent
I have inspected the uncovered system indicated above and find everything done
as described.
DATE
Signature bf Inspecting Officer
Percolation Test` � ��• ,1��,�,1�-�
Garbage Grinder
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BOARD OF HEALTH OF NORTH ANDOVER ' MASSACHUSETTS
SEWAGE DISPOSAL
DATE C47,/
NAME OF APPLICANT Richard . radshaL#
LOCATION Lot #r)' Boxford mat.
Address of lot nos
BUILDING: Dwelling X Other
SYSTEM: New X Repair
GENERAL DESCRIPTION OF LAND high
SUBSOIL: Clay Gravel Sandy :}
PERCOLATION TEST minutes per inch®
MINIMUM INSTALLATION RECOMMENDATIONS
CONCRETE SEPTIC TANK -
- L.000 gallon capacity.
LEACH FIELD LS lineal feet of drain pipe®
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'William J.....D�i coil' Engineer
Board of Heart
C�rnnnbnw 3alth.,�f I�s� �husetts �
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a system Plumping Record
Forte 4'
T00/1`4�. N(( Rj H ANDOVCE.R
iir:a?v i I wi r� ����RI u'f`
DER has rovided this
p form for use by local Boards of Health. The System Pumping Record must
be submitted to the local Board of Health or other approving authority.
A. Facility Information
,Important:
When filling out 1. System Location:
forms on the Q
computer,use
only the tab key Address
to move your �( ��
cursor-do not Cltyfrown State f Zip Code
Use the return • .
key.:
2. System,Owner:
Name
Address(if different from location)
City/Town State d' ✓Zip ' /
Telephone Number
Pumping Record
1. Date of Pumping _ ®ate 2. Quantity Pumped: Gallons
Type of system: ❑ Cesspool($) Septic Tank ❑ Tight Tank
❑' Other(describe):
4. Effluent Tee Filter present? ❑ Yes,E]"'No If yes, was it cleaned? ❑ Yes ❑ No
5. Condition of System: f
Lx
6. Sysfem P umped By:
Name_ Vehicle License Number
Company
7. Location where contents were disposed:
Signature of Hauler Date
)ttp://www.mass,gov/dep/water/approvals/t5forms.htm#inspect
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