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PARCEL # STREET A
CONSTRUCI-ZON
-9PPROVAL
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HAS PLAN REVIEW FEE BEEN PAID? YES 0
nPP.
PLAN APPROVAL2 DATE APP. BY -
DESIGNER: PLAN DATE.
CONDITIONS
WATER SUPPLY: TOWN
WELL PERMIT DRILLER. -..-V
WELL TESTS: CHEMICAL DAIE APPRUVED.akcoh�
BACTERIA I DAIE (IPPRUVED
BACTERIA II
COMMENTS:
DAT'E APPROVED -
FORM U APPROVAL: APPROVAL TO ISSUE <��(NO
DATE ISSUED BY
CONDITIONS:
FINAL APPROVAL:
ALL PERMITS PAID YES NO
WELL CONSTRUCTION APPROVAL YES NO
SEPTIC SYSTEM CONSTRUCTION APPROVAL YES NO
OTHER YES NO
ANY VARIANCE NEEDED
FINAL BOARD OF HEALTH APPROVAL:
YES NO
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YES
NO
4., -.-TYPE. OF-
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'REPAIR.*'
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CERTIFIED PLOT -PLAN REVIEW.
.....NEW CONSTRUCTION
NO
CONDITIONS OF..APPROVAL..
YES NO
(FROM FORM U)
—"ISSUANCE OF DWC PERMIT
-YES NO
14
PERMIT.
NO. t:��
..�JNSTALLER:
BEG I N ..I NSPECT I ON
NO:
EXCAVATION,
INSPECTION:
;NEEDED:
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..:-PAS ED
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.-CONSTRUCTION INSPECTION: NEEDEDI
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ACTORY:
AS BUILT PLAN SATISF
APPROVAL To BACKFILL DATE:
—BY
APPROVAL: DATI --
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5� By
w:..FINAL CONSTRUCTION APPROVAL: DATE:' BY
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: –1 Scott Circle –
– North Andover_
Owner's Name: – Andrew Mngswoo4
Owner's Address: –1 Scott Circle –
North Andover, MA 01845_
Date of Inspection: 7/27/2005
Name of Inspector: Neil J. Bateson–
Company Name: – Iiateson 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:
Passes
—X Conditionally Passes
,Needs Further Evaluation by the Local Approving Authority
ils
Inspector's Signature ate: 7/27/2005
The system inspector shall submit a copy of thvis 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
DER 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 I I
OFFICIAL INSPECTION FORM — NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION (continued)
Property Address: —1 Scott Circle —
— North Andover—
Owner: — Kingswood_
Date of Inspection: 7/27/2005
Inspection Summary: Check AB,CD 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 3 10 CMR 15.303 or in 3 10 CMR 15.304 exist. Any failure criteria not evaluated are indicated
below.
Comments:
B. System Conditionally Passes:
X One or more system components as described in the "Conditional Pass" section need to be
�eplaced 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 (YN,ND) in the for the following statements. If "not determined7
please explain. Leaking septic tank needs replaced.
Y 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:
N Observation of sewage backup or break out or high static water level in the
distribution �o—xdue 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:
N 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 I I
OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION (continued)
Property Address: —1 Scott Circle —
— North Andover—
Owner: Kingswoo(L
Date of &spection: 7/27/2005_
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(l)(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
iWface 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
j�nivate 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 I I
OFFICIAL INSPECTION FORM — NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION (continued)
Property Address: –1 Scott Circle –
– North Andover–
Owner: – Kingswood_
Date of Inspection: 7/27/2005
D. System Failure Criteria applicable to all systems:
You must indicate "yes" or "no" to each of the following for all inspections:
–No– Backup of sewage into facility or Ustem 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 3 10 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 How 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 3 10 CMR
15.304. The system owner should contact the appropriate regional office of the Department.
Page 5 of I I
OFFICIAL INSPECTION FORM — NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART B
CHECKLIST
Property Address: —1 Scoff Circle —
Owner: Kingswoc� North Andover—
Date of linspection: �/27/2005_
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 fitcility 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.
Yes Determined in the field (if any of the failure criteria related to Part C is at issue approximation of
Istan—ce is unacceptable) [3 10 CMR 15.302(3)(b)]
Page 6 of I I
OFFICIAL INSPECTION FORM — NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION
Property Address: —1 Scott Circle —
Owner: Kingswoci North Andover—
Date of &spection: �/27/2005
FLOWCONDITIONS
RESIDENTIAL
Number of bedrooms (design): — 4 — Number of bedrooms (actual): —4—
DESIGN flow based on 3 10 CMR 15.203 600
Number of current residents:
Does residence have a garbage grinder (yes or no): —Yes—
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 reading: _On well water
Sump pump (yes or no): —NoL
Last date of occupancy: —Current—
COMIVIERCIAL/04DUSTRL&L
Type of establishment:
Design flow (based on T16 -CUR 15.203): __gpd
Basis of design flow (seats/persons/sqft,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: _
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): —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: -25 years old, 8/22/2005,
as built plan_
Were sewage odors detected when arriving at the site (yes or no): _Nq.-
Page 7 of I I
OFFICIAL INSPECTION FORM — NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Property Address: —1 Scott Circle —
North Andover
Owner: Kingswoo4_
Date of &spection: 7/27/2005
BUJOLDING SEWER — X — (locate on site plan)
Depth below grade: — 2411 —
Materials of construction: X cast iron X 40 PVC —other
Distance from private water Wply well or suc—tion line:
Comments (on condition ofjoints, venting, evidence of leakage, etc.)
SEPTIC TANKS: —X
—4" Cast iron thru wall, 3" PVC in house_
Depth below grade: _121_
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: 101 x 51—x 41
Sludge depth: 311
Distance from top of sludge to bottom of outlet tee or baffle: —30"
Scum thickness: —3"
Distance from top of scum to top of outlet tee or baffle: —12"
Distance from bottom of scum to bottom of outlet tee or baffle: —22"
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.)_ Depth of liquid below outlet invert 6". Evidence of tank
leakage. Tank needs replaced. _
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 I I
OFFICIAL INSPECTION FORM — NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Property Address: —1 Scott Circle —
— North AndoveK-
Owner: Kingswood—
Date of in-spection: 7/27/2005
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 olyethylene other(explain):
Dimensions:
Capacity: _____gallons
Design Flow:
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:
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. No evidence of
carryover._
PUMW 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 I
OFFICIAL INSPECTION FORM — NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Property Address: —1 Scott Circle —
North Andover
Owner: — Kingswo(k
Date of Inspection: 7/27/2005
SOIL ABSORPTION SYSTEM (SAS): _ (locate on site plan, excavation not required)
If SAS not located explain why:
Type
—X— leaching pits, number: 3
leaching chambers, nur�6�:
leaching galleries, number:
leaching trenches, number, length:
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. Liquid below all inverts of pits.
CESSPOOLS: _ (cesspool must be pumped as part of inspection)(locate on site plan)
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 I I
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Property Address: —1 Scoff Circle —
— North Andover—
Owner: Kingswood _
Date of iinspection: 7/27/2005
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.
• to 1 = 121
• to 2 = 16'
• to 3 = 20'5'
• to Drop Bc
B to 1 = 20'51
B to 2 = 23'51
B to 3 = 271
B to Drop Bc
C to Pit# 1 =
C to Pit# 2 =
C toPit#3=
D to Pit# 1 =
D to Pit # 2 =
D to Pit # 3 =
Page 11 of 11
OFFICIAL INSPECTION FORM — NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Property Address: —1 Scoff Circle —
North Andover—
Owner: Kingswoo�_
Date of linspection: 7/27/2005
SnT EXAM
Slope
Surface water
Check cellar
Shallow wells
Estimated depth to ground water — 41 —
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: 6/22/1978
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 ENTE"RISES, INC.
Excavating -Water.& Sewer Lines -Septic Systems & Pumping Service
I I I Argilla Road Andover, Mass. 0 18 10
Title 5 Inspection Report
Property Address: I Scott Circle, North Andover
Owner: Kingswood
Date of Inspection: 7/27/2005
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 fin-ther
operation of your current septic system.
Neil J. Bateson
Bateson Enterprises, Inc.
23-69
am
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41
IT
'� CHUS
Applicant____,��
NAME
tl�n " ", A
X10
Q,
lt'� IV "i
0
Town of North Andover, Massachusett;
BOARD OF HEALTH
Form No. 3
DISPOSAL WORKS CONSTRUCTION PERMIT
Site Location U7) -�- -#
[oil]
Permission is hereby granted to Construct rl,�or Repair an Individual Soil Absorption
Sewage Disposal System as shown on the Design Approval S.S. No.
CHAIRMAN, BOARD OF HEAFT—H--
Fee D.W.C. No. -(2�
23-69
k \ ,
CERTIFIED FOUAIDA TION PLAN
LOCATEDIN M.4NDOVER-MA,
SCALE: /".= 4 0' DATE: 71oqlQ C�
Scott L. GlIes R L. 5 00
50 Deer Aleadow Road
North Andover, Mass.
51.72 037 31'
8903"
L OT JA.
2. 0 ACRES
q , I I ff
EXISTING
'-X
FOUNDATION
THIS BUILDING IS NO IN A
FLOOD HAZARD ZONE
TO CO-OPERATIVE BANK OF CONCOHjJ2,
AND ITS TITLE INSURERS.
1501 7-0
LOT LINE
150' TO SCOTT CIRCLE
I CERTIFY THAT OFFSE TS SHO WAI A 1?,E- FOR THE USE
THE OFFSETS OF THE SUIL DING 111ISPEC Tol? olvL Y
SHO WAI COMPLY A NO SUCH USE IS FOR THE
WITH THEZOWAIG DETERIVINATION OFZOAIIAIG
BY LAWS OF CONFORMITY OR A10AI-COWFORMITY
-NQ4A1VDQVFR "A
WHEN COWSTRUCTED.
WHI-111 BLAL T
7houtenday ocaeoratolryr 9wo.
66 LITTLETON ROAD WESTFORD, MA 01886
Report Number: C-wps-12329
client:
Wilmington Pump Supply Inc.
P.O. Box 517
Wilmington, MA 01887
Sample Taken By: WPS Staff
(508) 692-8395 FAX (508) 692-0023 1 -800 -649 -TEST
Report Date: June 16, 1994
Sample Taken At:
David Dickerson
Lot 3 Scott Circle
N.Andover,Mass.
On: June 14,1994
CERTIFICATE OF ANALYSIS
L;A7N,4 "7.
TEST PARAMETER:
EPA Max
RESULTS
UNITS
Total Coliform (P)
0
0
Per 100ml
Total Plate Count
Not
Spec.
260
per 10 ml
calcium
No
Limit
28.1
Mg/L
Copper (S)
1.3
<0.02
Mg/L
Iron (S)
0.3
# 0.093
Mg/L
magnesium
No
Limit
5.3
Mg/L
Manganese (S)
0.05
0.03
mg/L
sodium
20
13.2
mg/L
Potassium (S)
No
Limit
0.5
mg/L
Alkalinity (S)
Not
Spec.
86.5
mg/L
Ammonia
Not
Spec.
<0.03
mg/L
chloride (s)
250
12.3
mg/L
chlorine (total)
0.7
<0.02
mg/L
Color (S)
15
# 25
CPU
conductivity
No
Limit
222
umhos/cm
Hardness
No
Limit
92
mg/L
Nitrates(as N)(P)
10
0.05
mg/L
Nitrites(as N)
1
<0.01
mg/L
pH (S)
6.5-8.5
7.8
SU
odor (S)
3
0
TON
Sulphates (S)
250
23
mg/L
Turbidity
5
2.4
NTU
sediment
pos/neg
neg
NT=Not Tested, #=Value Exceeds EPA STD, TNTC=Too Numerous to Count
*=Background Bacteria Noted, "=EPA Advisory Limit
—Exceeds EPA Advisory Limit
(P)=Primary EPA Standard, (S)=Secondary EPA standard (may affect
aesthetics of drinking.water i.e. taste, color, etc.)
This water sample, as tested, is considered SAFE to drink according
to EPA guidelines. However, one or more of the parameters exceeds
EPA secondary standards as indicated by the (#) sign.
Massachusetts State Certified Michael P. Carlson, for
Testing Laboratory #MA048 Thorstensen Laboratory Inc.
BOARD OF HEALTH
120 MAIN STREET TEL. 682-6483
NORTH ANDOVER, MASS. 01845 Ext. 32
June 10, 1994
Mrs. Cheryl Dickerson
1 Scotts Circle
North Andover, MA 01845
Re: Lot #3 Scotts Circle
Dear Mrs. Dickerson:
This is to certify that permission is granted for an
individual soil absorption sewage disposal system to be installed
at Lot #3 Scotts Circle in accordance with regulations of Board
of Health. Please see the attached copy of the North Andover
Board of Health Design Approval for Soil Absorption Sewage
Disposal System Permit.
If you have any questions in reference to this matter,
please do not hesitate to call the Board of Health Office at the
number above.
S incerely,
Sandra Starr, R.S.
Health Administrator
SS/cjp
4
1 o
-�A
Town of North Andover, Massachusetts Form No. 2
BOARD OF HEALTH
+
DESIGN APPROVAL FOR
CMUS SOIL ABSORPTION SEWAGE DISPOSAL SYSTEM
Applicant_ ch�L Test No-
r
Site Location
Reference Plans and S
Permission is granted for an individual soil absorption sewage disposal system to be installed
in accordance with regulations of Board of Health.
FeeLaL,
CHAIRMAN, BOARD OF HEALTH
Site System Permit No. G6,�,
INN,
-XVA
WA
'0 't'
-k
NUMBER FEE
403 THE COMMONWEALTH OF MASSACHUSETTS $25.00
TOWN... of ....... XQRTH ANDO R ................................
................. ....................... RE
This is to Certify that ......... Viexa..Wall ... C-ompaay ------------------------------------------------------------
NAME
253 Andover Street, Georgetown, MA 01833
...........................................................................................................................................................................
ADDRESS
IS HEREBY GRANTED A LICENSE
For .......... �qell .... D.r.i.1 1 i.n-g ... Permit for Lot #3 Scotts Circle
........ .. .. .. ....... .. ...............................................................................................................
............................. ...............................................................................
This license is granted in conformity with the Stat
Oj
'Ites
expires .... December ... 31-p ---- 1.9-9.4 .......... 8 oner
�10e I A . . i
.................................. 19 ... 9-4
FORM 433 HOBBS & WARREN. INC.
..... ....................................
,,s relating thereto, and
.A. - -
DATE
44
BOARD OF HEALTH
TOWN OF NORTH ANDOVE
Sheet of
FEE
SUBSURFACE
PERMIT
DISPOSAL DESIGN
REVIEW
RECEIVED
#
DATE
APPLICANT
ASSESSOR'S
MAP
ADDRESS
ENGINEER 5C-027- 6166-,5:,
ADDRESS
PARCEL #
LOT #
STREET
PLAN DATE REVISION DATE
CONDITIONS OF APPROVAL:
APPROVED
DISAPPROVED
0 60 7
17-
X'Z /9
06 4- --DP-R1A1P66- -7:�eOAJ &07- ;-'
PLAN REVIEW CHECKLIST
- / <---> 3C-0 -17'
ADDRESS 3,4 oco 7,1- 0 -//1 -,6; -/4 -ENGINEER
GENERAL
3 COPIES STAMP LOCUS NORTH ARROW SCALE
CONTOURS 4-"- PROFILE t-� SECTION BENCHMARK SOIL &
PERC INFO ELEVATIONS -- WETS. DISCLAIMER WELLS &
WETLANDS WATERSHED?,4X0 DRIVEWAY 4---(Elev) WATER LINE
FDN DRAIN SCH40 TESTS CURRENT?—/994-
SEPTIC TANK
MIN 150OG .17 INVERT DROP GARB. GRINDER/6 (+200% EDF)
25' TO CELLAR --/ MANHOLE TO GRADE -- ELEV GW
D -BOX
SIZE # LINES FIRST 2' LEVEL STATEMENT
INLET OUTLET /,;t3 3 = (2" OR .17 FT) TEE REQ'D?
LEACHING
MIN 660 GPD7 t/ RESERVE AREA 4--�4' FROM PRIMARY? ---�2% SLOPE
100' TO WETLANDS �,� 1001 TO WELLS 4' TO S.H.GW Ll�
35' TO FND & INTRCPTR DRAINS 325' TO SURFACE H20 SUPP
41 PERM. SOIL BELOW FACILITY MIN 12" COVER FILL?_ (251
if above natural elev; 101if below) BREAKOUT MET?
TRENCHES
MIN 660 gpd L--� SLOPE (min .005 or 611/1001) L-11-�31COVER?-VENT
SIDEWALL DIST. 2X EFF. W OR D (MIN 61)L--- IS RESERVE BETWEEN
TRENCHES? L��IN FILL? L----------'MAUST BE 101 MIN� z--��411 PEA STONE.
BOT 3gO. X LDNG :30 + SIDE -/,,/o) X LDNG TOT 7,70
(L x W x #) (G/ft2) (DxLx2x#) (G/ft2)
Copyright 0 1993 by S.L. Starr
0 5ec 7
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Applicant
Town of North Andover, Massachusetts
BOARD OF HEALTH
Form No. 1
YrLa� 114 19-91
APPLICATION FOR SITE TESTING/INSPECTION
Site Location ()DT-,* 2D 5clot�
Engineer
Test/inspection Date and Time
S U�D
Fee IS7) *
CHAI RMAN, BOARD OF HEALTH
Test No. U.1-1
S.S. Permit No.-D.W.C. No.--------C.C. Date-Plbg. Permit No.
Town of North Andover, Massachusetts Form No.1
BOARD OF HEALTH
19-
7T�
APPLICATION FOR SITE TESTING/INSPECTION
V
Applicant
NAME ADDRESS TELEPHONE
Site Location
Engineer
NAME ADDRESS TELEPHONE
Test/Inspection Date and Time
Fee—
CHAI RMAN, BOARD OF HEALTH
Test No. �1
S.S. Permit No.-D.W.C. No. C.C. Date-Plbg. Permit No
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BK199 1
2 & r Builders , T40.
a corporation duly established under the laws of Massachusetts
and having its usuid plate of businen at 35 Center Street
ideration of
of Burlingtong Middlesex County. Massachusetts. In consi
Three Hundred Fifty Thousand ($350l000.00) Dollars
granta to David D. Dickerson and Cheryl C. DickeraOn, husband & wife,
as tenants by the entirety,
of 1 Scott Circle, North Andover, Es3ex County, Massachusetts,
with qutUlahn rvcrn3u13
the land in North Andover, Essex County, Massachusetts
A certain parcel of land situated on the Northerly side of Forest
Street in North Andover, Essex County, MA, and shown on a definitive
Plan of Land entitled, 'Whippq�will Park, North Andover* Mass.6j
Owner, E&F Builders' ' Inc. j Engineer* Nysten -Engineering A Asaoc.0
and recorded with the Essex North District Registry of Deedi as Plan
No. 7842 and being more particularly bounded and described as followat
Beginn ing at the Southwesterly corner of said premises at an iron
pin at the Northerly line of Forest Street;
Thence running Northeasterly by land now or formerly of New England
Power Company, 677.40 feet to a point;
Thence turning and running Northeasterly by land of said New England
Power Company 683.83 feet to an iron -pin at land now or formerly
of Daniel E. flogan;
Thence turning and running Southwesterly by land of said Daniel E.
Mogan and a stone wall by five courses measuring 152.04 feet, 93.14
feet, 127.'86 feet, '39.69 feet, and 51.72 feet* to a point at land
now or formerly of ELF Builders# Inc.;
Thence running Southwesterly by land of said ELF Builders, Inc.#
and said stone wall, by 5 courses measuring 37.31 feet, 32 feet,
57.03 feet, 150.44 feet, and 43.20 feet to a drill hole at land now
or formerly of Morris F. and Ruby Rabb3:
Thence turning and'running Northwesterly by said land of Morris r.
and Ruby Rabbs 11.33 feet to a drill hole at land now or formerly
of George D. and Dorothea Miller:
Thence running Northwesterly by said land of George D. and Dorothea
Miller 335.96 feet to an iron pin;
Then . ce turning and running Southwesterly by said land of George D.
and Dorothea Miller and a stone wall 272.00 feet to a drill hole
at the mortherly line of said Forest Street;
Thence turning and running Northwesterly by the Northerly line of
said Forest Street and said stone wall by two courses measuring 32.85
feet and 57.15 feet to an iron pin and the point of beginning.
Containing Lots 1, 2, 3, and Scott Circle, all according to said
Plan.
I
W
6
B K 19 9 1
Sai�d premises are conveyed subject to and with the benefit of all
easements# restrictions, covenants# conditions and reservations of
record, if any# and as shown on said Plan No. 7842 insofar as the
same are now in force and applicable.
.PC = Tmcdxxx Xtot X)M M XsVhVb�&-'(Y-)tV rt* -x W Usua L -am am M M%Ydip
idmiri1x, ft=r%bxrx RRA x:1:0)M); x znz1xr*=rxb2�x xtX=zat& zzxx= =xz= VAWtXAXZX
Rr;iztr.Tx x)fx ftmzlzx i= 2mmix
fjorxmzttzritTxxmxxxC*rtilf,;—Ix 3DfxjVztaxxxxxr3fttxwtt=x"&cZM291=Xy
ViX ftXJIZX i=:B]D]DkX 11"DX X FM]gXX i ftr
Being the same premises conveyed to the Grantor by deed of even date
and recorded immediately prior hereto
Ja tvitums 11hrrrof the uid E & F Builders, -r4C.
hs3 caused its corporate seal to be hereto affixed and theac presenta to be signed, acknowledged and
delivered in its name and behalf by V. Scott Follansbee
It& PrPsident and hereto duly authorized, this
dsy of Treasurer La the year one thousand nine hundred and
6i,TnW`&n21z-. p esence of
Z
by v. Scott Follansbee, President
Re;enald L. Marden and Treasurer of E 4 F Builders
Olt Q:=CUMa V( M-zath-aus
Essex 06. June 21 1985
Ilea personally appeared the above named V. Scott Follansbee, President and
Trcasurer of E & F Builders, Inc.
and atknowledpd tho foregoing iwtrument to be the frft act and deed of %XX
E F Builders, Inc.
before
Reg d L. Marden
NO(MV Pkuic
.7 0 S*
June 16 89
My vorrunission expires
Reco,_�And June 21,1905 at 3:36PM #13074
WVO'l
-7 . ....
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3
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BOARD OF HEALTH
120 MAIN STREET
NORTH ANDOVER, MASS. 01845
Cheryl Dickerson
1 Scott Circle
No. Andover, MA 01845
Dear Mrs. Dickerson:
TEL. 682-6483
Ext. 32
June 30, 1993
This is to notify you that at their recent meeting on June
24 the Board of Health voted to grant you an extension on the
approved septic design plans for Lot 3 Scott Circle. The
extension has been granted to July 1994.
Sincerely,
Sandra Starr
Health Agent
cc: Karen Nelson
File
Cheryl Dickersoll
6,
-74
All,
ckeryl Dickerson
Al
-74
11
[v
iff"m
79
91 -7�
60? eE(7
e5��� " /��,
( o, e� -3,50 �
Town of North Andover, Massachusetts Form No.2
01 'AOR1,11 BOARD OF HEALTH
o Ck
49
DESIGN APPROVAL FOR
SACHUS* SOIL ABSORPTION SEWAGE DISPOSAL SYSTEM
Applicant--*'-- U Test No
Site Location
-, t
Reference Plans and Specs.--...Ne�.)�
ENGINEER DFUGN n ATI:
Permission is granted for an individual soil absorption sewage disposal system to be installed
in accordance with regulations of Board of Health.
4. &�Tqo,;eo e",
F.C.U&o4z CHAIRMA1q,W8Z0F HEALTH
kAw-- eAWNee -.Cr--e -
T&U.,cr COO_ Lzx 1L. p Rq-
'V,�,Lo"e �
Fee 0,
Site System Permit No.
.
. . . . . . . . . . . . . . . .
.
, 14
7
DATE -__P/
Sheet I of
BO ZQ OF HEALTH
TOWN OF NORTH ANDOVER
SUBS )ESIGN REVIEW
FEE (zo PERMIT #
DATE RECEIVED
APPLICANT
ADDRESS ��Tl-
431�>ouelz/ �AA
ENGINEER
ADDRESS 44�7
PLAN DATE
CONDITIONS OF APPROVAL:
APPROVED >�
DISAPPROVED
ASSESSOR'S MAP
PARCEL #
LOT #
STREET
REVISION DATE
t -z::) a-
��)
wc-��
C>tA L07
k- -e-,o & D t
.aM
L-�/60 QfLe 1-i I-
F--
BOARD OF HEALTH
120 MAIN STREET TEL. 682-6483
NORTH ANDOVER, MASS. 01845 Ext. 32 or 52
July 2, 1991
Mrs. Cheryl Dickerson
1 Scott Circle
North Andover, MA 01845
Re: Scott Circle
Dear Mrs. Dickerson:
This of f ice is in receipt of septic plans f or lots 2 and 3
Scott Circle. A review fee of $60.00 per lot must be submitted
to the Board of Health along with the sets of plans.
Any application for plan approval shall be accompanied by
this fee to be considered a complete application. Please advise
that no review will proceed until the required fees are paid.
Thank you for Your anticipated cooperation in this matter.
MJR/cjp
sincerely,
Health Agent
FORM L
REFERRAL FORM
Preliminary Plan
Definitive Subdivision TAC)C:�X�iCCOOOC)
Special Permit
Site Plan Review
Sup't/Highway, Utilities & Operations
Director of Engineering & Administration
Fire Chief
Conservation Commission
Inspector of Buildings
Board of Health
Police Chief
Planning Board
ppor
C,rck.)
North Andover, Massachusetts
3ua(D- -1-4 -, 19 0-�z
A Public Hearing has been scheduled for p.m ' on , I k n -e- ', qq'-�
to discuss these plans. (Preliminary plans do not neel public hearings.)
May we have your comments and recommendations concerning these plans
no later than 2-0,.
Thank you,
6ruqtft-jot��ArA Lk --
Clerk, Planning Office
6
BOARD OF HEALTH
120 MAIN STREET
NORTH ANDOVER, MASS. 01845
Lot #3 Scoff - Chervl.Dicl��-- n:
TEL. 682-6483
Ext. 32
The Board received a letter f rom Cheryl Dickerson requesting an
extension on the approval of a septic design for Lot #3 Scott
Circle which is due to expire in July 1993.
On a motion by Mr. Osgood
unanimously P seconded by Dr. Rizza, the Board voted
1994. to grant an one (1) year extension which will be July
Minutes: June 24, 1993