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MAP # LOT it __LQ
.... .......
PARCEL # STREET
CONSTRUCTION
HAS PLAN REVIEW FEE BEEN PAID? YES NO
. . .. ............
PLAN APPROVAL: DATE aAPP.
DESIGNER: PLAN DATE
CONDITIONS gi'-05,
. .... ....... . ...........
.......... ...........
WATER SUPPLY: WELL
WELL PERMIT DRILLER
WELL TESTS: \,CHEM I CAL UP I E APPRUVED .... . .........
BACTE�R I A I DAIE (11"PRUVED
I DAiE APPROVED
BACTERTI
COMMENTS:
FORM U APPROVAL: APPROVAL 1*0 ISSU.E (�ONU
DATE ISSUED
CONDITIONS:
FINAL APPROVAL:
ALL PERMITS PAID
WELL CONSTRUCTION APPROVAL
SEPTIC SYSTEM CONSTRUCTION APPROVAL
OTHER
ANY VARIANCE NEEDED
FINAL BOARD OF HEALTH RPPROVAL:
YES
YES
Y E S
YES
YES
[110
NU
NO
NU
ILI
DA I*E:. BY:
FINAL CONSTRUCTION APPROVAL: DATE:
IS THE INSTALLER LICENSED?
Y_G s
NO
TYPE, OF CONSTRUCTION:
REPnIR
CONSTRUCTION: CERTIFIED
PLOT PLnN REV I EW
yl- s
1,10
CONDITIONS
OF APPROVAL
YES
110
(FROM FORM
U)
.,ISSUANCE.OF.DWC PERMIT
YES
NO
DWC PERMIT NO.
INSTALLER:0, &A1h2k_-
BEGIN INSPECTION !��_�YENO:
EXCAVATIOWINSPECTION:
NEEDED:
PASSED,
By
'�CONSTRUCTION INSPECTION:
NEEDED:
AS BUILT PLAN SATISFACTORY:
APPROVAL- TO BACKFILL: DATE:
-
FINAL GRADING APPROVAL: DATE
BY
FINAL CONSTRUCTION APPROVAL: DATE:
Commonwealth of Massachusetts
CitylTown of North Andover
System Pumping Record
Form 4 U ; juttltA -but the
fi,%, used,
DEP has provided this form for use by local Boaras o, HealLI
information must be substantially the same as that provided re. Bef re using this form, check with your
local Board of Health to determine the form they use. The System Pumping Record must be submitted to
ing authority within 14 days from the pumpingdate in
the local Board of Health or other approv
accordance with 310 CMR 15-351.
A. Facility Information
Important When
,filling out forms
on the computer,
use only the tab
key to move your
cursor - do not
use the return
key.
2
System Location'.
Address
North Andover
Cityfrown
System owner:
Name
Addr;ss (if -d-rfferent from location)
Ma 01886
State TIP —Code
State
C. 0,dn
Telephone Number
B. Pumping Record
2. Quantity Pumped:
.1. Date of Pumping Date
3. Type of system: Cesspool(s) Septic Tank Tight Tank
F1 Other (describe):
4. Effluent Tee Filter present? F� Yes F� No
5. Condition of System:
6. System Pumped By
Zip Code
Gallons
El Grease Trap
lf.yes, was it cleaned? [] Yes [] No
Vehicle License Number
Name
Stewart's Septic Service
Company
7. Location where contents were disposed'.
Stewart's Pre-treatmiznf Plant 20 So. Mill Bradford, Ma 01835
ignature of Hauler Date
Signature of Receiving Facility Date
t5form4.doc- 03106
System Pumping Record - Page I ,
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Is form for 1A
use by local Boards of HeaI6. The gyvp� I nip rQg
-:'be submitted t* 'the of Health or other approving auth
0 Oocal'Board
�:.,k Foci lity.1 nforniatio n
fUlIng out'. 1,1:-.: Systom.Locatlon:*-�..
CQMPUter.`UsS'.�-1 �5
on� the tab key Address
to move your
do pot
the retum".1,...
Zp Pode
M` Qwner,
Name
Address (it dIfforent from locauon):.,
State
lephone Numb
M PIP 0 �.Req'o'rd....
p ng.�.�,
�0! o Pum' j* . t_ 2. Oua'nflty Pumped:
Gallon3
T Sys em 0 Cesspool(s)
ypQ 9 Z-1eptic Tank
El Tight Tank
�Oth
er (describe):
EMu:'en't Tee Filter Yes 17'N
If yes, was It cleaned? Yes N
0
ItI f, 8
on.o YO
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Vehicle Ucen*e Numb
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Oposed:
SWn
Date
UP '/d
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SYStem Pumping Record - Page 1 of i
Commonwealth of Massachusetts K9CEIVI-5-10
'V
r
City/Town of No.Andover
JUL 18 2011
System Pumping Record
TOWN OF NORr
t�MTMI�OWER
Form 4 LHEALTH HMO NT
DePARTMe
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 within 14 days from the pumping date in
accordance with 310 CMR 15.351.
Ma
State
State
Telephone Number
B. Pumping Record W
1. Date of Pumping Date 2. Quantity Pumped:
3. Type of system: El Cesspool(s) Septic Tank F Tight Tank
F-1 Other (describe):
01845
Zip Code
Zip Code
06
Gallons
El Grease Trap
4. Effluent Tee Filter present? D Yes El No If yes, was it cleaned? El Yes E] No
5. Condition of System:
6. "ym P d y:
lei rid 01C
Name- Vehicle License Number
Stewart's Septic Service
Company
7. Location where contents were disposed:
Stewart's Pre-treatmentP-kmli. 20 So. Mill Bradford. Ma 01835
Signature of Hauler
Signature of Receiving
Dat
Date
t5form4.doc- 03/06 System Pumping Record - Page 1 of 1
A. Facility Information
Important:
When filling out
1 . System Location:
forms on the
I
computer, use
only the tab key
Address
to move your
No.Andover
cursor - do not
City/Town
use the return
key.
2. System Owner:
f,.4Q
Name
Address (if different from location)
City/Town
Ma
State
State
Telephone Number
B. Pumping Record W
1. Date of Pumping Date 2. Quantity Pumped:
3. Type of system: El Cesspool(s) Septic Tank F Tight Tank
F-1 Other (describe):
01845
Zip Code
Zip Code
06
Gallons
El Grease Trap
4. Effluent Tee Filter present? D Yes El No If yes, was it cleaned? El Yes E] No
5. Condition of System:
6. "ym P d y:
lei rid 01C
Name- Vehicle License Number
Stewart's Septic Service
Company
7. Location where contents were disposed:
Stewart's Pre-treatmentP-kmli. 20 So. Mill Bradford. Ma 01835
Signature of Hauler
Signature of Receiving
Dat
Date
t5form4.doc- 03/06 System Pumping Record - Page 1 of 1
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UNITED STA TE S POSTAL SE ESS
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Print your name, address and ZIP Code here
N. ANDOVER BOARD OF HEALTH
120 MAIN STREET
N. ANDOVER, MA. 01845
% SENDER:
:9 - Complete items 1 and/or 2 for additional services.
I also wish to receive the
0 * Complete items 3, and 4a & b.
following services (for an extra (D
0 - Print your name and address on the reverse of this form so that we Can
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fee): >
(D return this card to you.
> - Attach this form to the front of the mailpiece, or on the back if space
1. El Addressee's Address
does not permit.
Write "Return Receipt Requested" on the mailpiece below the article number -I
2. 0 Restricted Delivery
The Return Receipt will show to whom the article was delivered and the date
C delivered.
Consult postmaster for fee. (D
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3. Article Addressed to:
4a. Article Number
P 844 208 131
CL
E Mr. George Henderson
4b. Service Type
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P 844 208 131
Certified Mail Receipt
No Insurance Coverage Provided
Do not use for International Mail
UMTM STAns
(See Reverse)
Sent to
George Henderson
Street & No.
280 Chandler Road
P.O., State & ZIP Code
Andover, MA 01810
Postage
Certified Fee
Special Delivery Fee
Restricted Delivery Fee
Return Receipt Showing
to Whom & Date Delivered
Return Receipt Showing to Whom,
Date, & Address of Delivery
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& Fees
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Postmark or Date
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Sent to
Grasso Construction
Street & No.
865 Turnpike Street
P.O., State & ZIP Code
North Andover, MA 0184,
Postage
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BOARD OF HEALTH
120 MAIN STREET
NORTH ANDOVER, MASS. 01845
George Henderson
280 Chandler Road
Andover, MA 01810
RE: Lot 6 Wintergreen Drive
Dear George,
TEL. 682-6483
Ext. 32
April 9, 1993
Certified Letter # P 844 208 131+
As we discussed by telephone earlier this week, because of
conditions in the proposed leach area at Lot 6 Wintergreen Drive
being different than what was stated in the plan, all work on the
septic system is to cease until you are notified otherwise by the
Board of Health.
Under the authority of 310 CMR 15.02(4) the Disposal Works
Construction Permit #620 for Lot 6 Wintergreen Drive, North
Andover is hereby revoked until this matter can be straightened
out.
If you have any questions, please do not hesitate to call
the office at 682-6483.
Sincerely,
Sandra Starr
Health Agent
cc: John Grasso
Phil Christiansen
Karen Nelson
132,
(Grxsj;6)
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 ndt relieve the applicant and/or
landowner from compliance with any applicable local or state law,
regulations or requirements.
****************Applicant fills out this section*****************
APPLICANT: Phone
LOCATION: Assessor's Map Number Parcel
Subdivision
i PR Lot (s)
Street St. Number
************************Official Use only************************
RECOMMENDATIONS OF TOWN AGENTS:
Date Approved
Conservation Administrator Date Rejected
Comments
Date Approved
Town Planner Date Rejected
Comments
H-e-aft�th A�gent����� Date Approved J -Z19 -1L
Date Rejected
Comments
.Public Works ----mwev�/water connections t ss&r��) 7/-"2
U
driveway pe rmit 14 ILOJ (,4J
Fire Department
Received by Building Inspector Date
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TO:
BOARD OF HEALTH
.. 120 MAIN STREET
NORTH ANDOVER, MASS. 01845
Christiensen & Sergi, Inc.
160 Summer --Street
Haverhill, MA 01830
,/ A
FROM:—Sandy Starr 2�' '�' J
RE: Lot 6 Wintergreen
Dear Phil:
TEL. 682-6483
Ext. 32
DATE: Sept. 9, 199.2
This is to inform you that the proposed septic design plans
for the above site dated Aug. 20, 1992 - have been
APPROVED.
If you have any questions about the next step in the
process, please call the Board of Health office.
APPROVED WITH THE FOLLOWING CONDITIONS:
DISAPPROVED FOR THE FOLLOWING REASONS:
1. Distances of system components to house required. (N.A. 6.03a -c)
2. Need benchmark in working area. (N.A. 6.04a)
3. Foundation drain requi3:ed. (N.A. 6.02v)
4. Need water supply to house. (N.A. 6.02q)
5. Wetlands disclaimer note required. (N.A. 6.02o)
6. Specifications & dimensions missing from end & longitudinal
views - ie. stone, chamber dimensions, manholes, splash pads,
layout, etc.
7. Need manhole to grade for septic tank. (310 CMR 15.06(12))
DATE
BOARD OF HEALTH
TOWN OF NORTH ANDOVER
SUBSURFACE DISPOSAL DESIGN REVIEW
Sheet of
FEE X60 PERMIT # DATE RECEIVED 8
APPLICANT -
ADDRESS
ENGINEER
ADDRESS
LAN DATE
CONDITIONS OF APPROVAL:
APPROVED
DISAPPROVED
ASSESSOR'S MAP
PARCEL #
LOT #
STREET #
REVISION DATE
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PLAN REVIEW CHECKLIST
ADDRESS ENGINEER.
GENERAL
3 COPIES STAMP LOCUS SCALE CONTOURS
PROFILE SECTION BENCHMARK ELEVATIONS SOIL
WELLS & WETLANDS
& PERC INFO WETS. DISCLAIMEV
WATERSHED? ffo DRIVEWAY_��' WATER LINE,
(Elevations)
DRAINS SCH40 SLOPE TESTS CURRENT?
SEPTIC TANK
MIN 1500G. t/ .17 INVERT DROP GARB. GRINDER_/16 (+200% EDF)
25' TO CELLAR_A/ MANHOLE TO GRADE, ELEV GW
D -BOX
SIZE
LINES
FIRST 2' LEVEL STATEMENT
INLET
OUTLET/47�
(211 OR .17 FT)
LEACHING
RESERVE AREA 4' FROM PRIMARY? 100' TO WETLANDS 2% SLOPE_
100' TO WELLS 325' TO SURFACE H20 SUPP 35' TO FND & INTRCPTR
DRAINS 41 TO S.H.GW 4' PERM. SOIL BELOW FACILITY MIN
12 " COVER
TRENCHES
MIN 660 gpd
FILL? _ (251 if above natural elevation; 101if below)
SLOPE (min .005 or 611/1001) >31 COVER? - VENT
SIDEWALL DIST. 2X EFF. W OR D (MIN 6') _ IS RESERVE BETWEEN
TRENCHES? IN FILL? MUST BE 10' MIN. 4" PEA STONE?
BOT X LDNG + SIDE X LDNG TOT
(L x W x (G/ft2 ) (DxLx2x#)
PITS
MIN 660 LEACHING '-� MIN 41 BELOW BOTTOM L,—" MANHOLE/PIT
EXCAV 2x EFF W OR D 12"-4811 STONE SURROUNDINGLI-�
7s
BOT IZ40 + SIDE x LOAD 3Z�1-
(L x W x T2 x (L+W) x D x
CHAMBERS
COVER >3 FT - VENT
FIELDS
MIN 900 ft2 LEACHING PERC RATE FASTER THAN 20M/IN GW MIN
41 BELOW BOTTOM OF FIELD PIPE ENDS JOINED W/NON-PERF. PIPE?
411 PEA STONE? DIST LINE SLOPE .005? >3' COVER - VENT
SCH 40 MIN 1211 COVER L x W = T x LDNG > DESIGN FLOW?
DOSING TANKS AND PUMPS
K"
DIMENSIONS8' /x x PUMP CAPACITY— --gpm
L W Vol.
DISCHARGE SIZE DISCHARGE RATE DISCHARGE TIME
gpm
MANHOLES TO GRADE ALARM SEP. CIRC.,.-- GW (Min. 11 below
inlet) HWL LWL)&.7 CHECK VALVE BLEEDER HOLE MANUAL
OP. SWITCH t-�
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