Loading...
The URL can be used to link to this page
Your browser does not support the video tag.
Home
My WebLink
About
Building Permit #235-13 - 207 BOXFORD STREET 9/24/2012
AORT11 BUILDING PERMIT TOWN OF NORTH ANDOVER APPLICATION FOR PLAN EXAMINATION * ,� Permit NO: 3 Date Received X14'°Rwreo►° 4`� �SSACHUS�� Date Issued: ol 110-RTANT:Applicant must complete all items on this page ,1 A, O w? �Cw2 - y n w . �.. - Pnnt { MAP NO PARCEL.6�ZONING�DISTRICT:. . _ Historic.Di' tidt yes -- - `Machine Shop Village,, }.ye TYPE OF IMPROVEMENT PROPOSED USE Res' Non- Residential New Building r One family Addition re family Industrial No. of units: Commercial Repair, replaceme Assessory Bldg Others: Demo ition Other x Sepfict WeU: floodplain . 1N.etlarids V1latersfied0st�ict. _ Water/Seweri . DESCRIPTION F WORK TO BE PREFORMED: Identification Please Type or Print Clearly) OWNER: Name: Phone:Gi 7�P� FP- ` Yd Address: -Z-0-1 s d C®NTRACTQR Name': . �°�/,.I/M.._Ail e g7p n 2-( �.2s Ald�,essH'S"` Supervisor',s,Constructibn,License 3Home�Improvement�Lic _ - . ARCHITECT/ENGINEER Phone: Address: Reg. No. FEE SCHEDULE:BULDING PERMIT:$92.00 PER$9000.00 OF THE TOTAL ESTIMATED COST BASED ON$925.00 PER S.F. Total Project Cost: $ ` —"" FEE: $ Check No.: �' S� Receipt No.: NOTE: Persons contracting with unregistered contractors do not have access to the guaranty fund Signature of Agent/Ov►ine 4'�i"Signature:of contractor 4.41 Location 2no-74- i 4o)( 21---1 No. � � � � Date � r • - TOWN OF NORTH ANDOVER • Certificate of Occupancy $ a Building/Frame Permit Fee � 7 � Foundation Permit Fee Other Permit Fee $ TOTAL $ Check#� 25740 Building Inspector Plans Submitted Plans Waived Certified Plot Plan Stamped Plans TYPE OF SEWERAGE DISPOSAL Public Sewer Tanning/Massage/Body Art Swimming Pools Well Tobacco Sales Food Packaging/Sales Private(septic tank,etc. Permanent Dumpster on Site V THE FOLLOWING SECTIONS FOR OFFICE USE ONLY INTERDEPARTMENTAL SIGN OFF - U FORM DATE REJECTED DATE APPROVED PLANNING & DEVELOPMENT COMMENTS CONSERVATION Reviewed on Signature COMMENTS HEALTH Reviewed on Signature COMMENTS Zoning Board of Appeals: Variance, Petition No: Zoning Decision/receipt submitted yes r t t~{Planning Board Decision: Comments ' Conservation Decision: Comments Water & Sewer Connection/Signature&Date Driveway Permit DPW Town Engineer: Signature: Located 384 Osgood Street FIRE DEPARTMENT -Temp'Dumpster on site: -yes i .L6cated;atw124 Macri Street �. , F' 4 ire Department signature/date. � _ ,.-. ... - : : , _.,.�. _ _ COMMENTS... ; .. Dimension Number of Stories: Total square feet of floor area, based on Exterior dimensions. Total land area, sq. ft.: ELECTRICAL: Movement of Meter location, mast or service drop requires approval of Electrical Inspector Yes No DANGER ZONE LITERATURE: Yes No MGL Chapter 166 Section 21A—F and G min.$100-$1000 fine NOTES and DATA— (For department use) ❑ Notified for pickup - Date Doc.Building Permit Revised 2008 Building Department The following is a list of the required forms to be filled out for the appropriate permit to be obtained. Roofing, Siding, Interior Rehabilitation Permits ❑ Building Permit Application ❑ Workers Comp Affidavit ❑ Photo Copy Of H.I.C. And/Or C.S.L. Licenses ❑ Copy of Contract ❑ Floor Plan Or Proposed Interior Work ❑ Engineering Affidavits for Engineered products NOTE: All dumpster permits require sign off from Fire Department prior to issuance of Bldg Permit Addition Or Decks ❑ Building Permit Application ❑ Certified Surveyed Plot Plan ❑ Workers Comp Affidavit ❑ Photo Copy of H.I.C. And C.S.L. Licenses ❑ Copy Of Contract ❑ Floor/Crossection/Elevation Plan Of Proposed Work With Sprinkler Plan And Hydraulic Calculations (If Applicable) ❑ Mass check Energy Compliance Report (If Applicable) ❑ Engineering Affidavits for Engineered products NOTE: All dumpster permits require sign off from Fire Department prior to issuance of Bldg Permit New Construction (Single and Two Family) ❑ Building Permit Application ❑ Certified Proposed Plot Plan ❑ Photo of H.I.C. And C.S.L. Licenses ❑ Workers Comp Affidavit ❑ Two Sets of Building Plans (One To Be Returned) to Include Sprinkler Plan And Hydraulic Calculations (If Applicable) ❑ Copy of Contract ❑ Mass check Energy Compliance Report ❑ Engineering Affidavits for Engineered products MOTE: All dumpster permits require sign off from Fire Department prior to issuance of Bldg Permit In all cases if a variance or special permit was required the Town Clerks office must stamp the decision from the Board of Appeals that the appeal period is over. The applicant must then get this recorded at the Registry of Deeds. One copy and proof of recording must be submitted with the building application Doc:INSPECTIONAL SERVICES DEPARTMENT:BPFORM07 Revised 2.2008 NORTH Town of E 1, Andover O - No. - i/ o `AK9h ver, Mass, COC"IC"l WIC A3, " y1' S U BOARD OF HEALTH Food/Kitchen PERMIT T LD LAS Septic System THIS CERTIFIES.THAT OW...... .1.. 4 !!�........... ....................' BUILDING INSPECTOR ........... ............ ........... . Foundation has permission to erect ............. ............ buildings on ....�+� .. .. .. .... .s�.................. Rough to be occupied as ................ .... .........��..........w .�.... ................ ..................... Chimney provided that the person accepting thi permit shall in every respect conform to the terms of the application Final on file in this office, and to the provisions of the Codes and By-Laws relating to the Inspection,Alteration and Construction of Buildings in the Town of North Andover. _ PLUMBING INSPECTOR VIOLATION of the Zoning or Building Regulations Voids this Permit. Rough _ Final PERMIT EXPIRES IN 6 MONTHS ELECTRICAL INSPECTOR UNLESS CONSTRUCT RTS Rough Service ......... .............................................. Final BUILDING INSPECTOR GAS INSPECTOR Occupancy Permit Required to Occupy Building Rough Display in a Conspicuous Place on the Premises — Do Not Remove Final No-Lathing or Dry Wall To Be. Done FIRE DEPARTMENT Until Inspected and Approved by the Building Inspector. Burner Street No. Smoke Det. SEE REVERSE SIDE The Commonwealth of Massachusetts - =---- kf Department of Industrial Accidents Office of Investigations t 600 Washington Street Boston, MA 02111 •.�•: : ��.�: � .: www.mass. ov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Tease Print Legibly Name(Business/Organization/Individual): A 00t y) A&l0 Moog s LL0_ Address: qS Pomb•-_ s�0 City/State/Zip: ��-/ry_g4 t Hij Qi g ,4 JL_ Phone#: u5-�7a s 5 Are you an employer?Check the appropriate box: Type of project(required): 1.D-fam a employer with '?—s 4. ❑ I am a general contractor and 1 6. ❑New construction employees(full and/or part-time).* have hired the sub-contractors 2.❑ I am a solero rietor or partner- listed on the attached sheet. 7. F-1Remodeling P P ship and have no employees These sub-contractors have g, [demolition workingfor me in an capacity. employees and have workers' Y9. E]Building addition r [No workers' comp. insurance comp. insurance.# required.] 5. ❑ We are a corporation and its 10.E]Electrical repairs or additions 3.❑ I am a homeowner doing all work officers have exercised their 11.❑Plumbing repairs or additions myself. [No workers' comp. right of exemption per MGL 12.❑Roof repairs insurance required.]t c. 152, §1(4),and we have no employees. [No workers' 13.❑ Other comp. insurance required.] *Any applicant that checks box#1 must also fill out the section below showing their workers'compensation policy information. t Homeowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such. $Contractors that check this box must attached an additional sheet showing the name of the sub-contractors and state whether or not those entities have employees. If the sub-contractors have employees,they must provide their workers'comp.policy number. I ane an employer that is providing workers'compensation insurance for my employees. Below is tlee policy and job site information. Insurance Company Name: H jD LQJP Q-s SAi S Cfn Policy#or Self-ins.Lic.#: 00 8 2.(-_0 l g a!g_ Expiration Date: -7 Job Site Address: City/State/Zip: Attach a copy of the workerscompensation policy declaration page(showing the policy number and expiration date). Failure to secure coverage as required under Section 25A of MGL c. 152 can lead to the imposition of criminal penalties of a fine up to$1,500.00 and/or one-year imprisonment,as well as civil penalties in the form of a STOP WORK ORDER and a fine of up to$250.00 a day against the violator. Be advised that a copy of this statement may be forwarded to the Office of Investigations of the DIA for insurance coverage verification. I do hereby certify under the pains and penalties of perjury that the information provided above is true and correct. �/ Signature: Date: ,/s-�---" -- Phone#• 1 ZCS-`74 Official use only. Do not write in this area,to be completed by city or town official City or Town: Permit/License# Issuing Authority(circle one): 1.Board of Health 2.Building Department 3.City/Town Clerk 4.Electrical Inspector 5.Plumbing Inspector 6.Other Contact Person: Phone#: =DATEDIYYYY) CERTIFICATE ®F LIABILITY INSURANCE THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER.THIS CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S), AUTHORIZED REPRESENTATIVE OR PRODUCER,AND THE CERTIFICATE HOLDER. IMPORTANT: If the certificate holder is an ADDITIONAL INSURED,the polis (les)must be endorsed. If SUBROGATION IS WAIVED,subject to the terms and conditions of the policy,certain policies may require an endorsement. A statement on this certificate does not confer rights to the certificate holder in lieu of such.endorsement(s). ONTACT DorolhyA.Cerled,CIC,RPLU PRODUCER NAME: Fred C.Church,Inc. PHONE 978 322727 1 FAX (978)454.1865 41 Wellman Slreel C o Ext)! AIC No Lowell,MA 01 B51 E-MAIL dcorle�ff_)lredcchurch.com (800)225-1865 ADDRESS: IN59RER1S AFFORDING COVERAGE NAIC q Citizens Insurance Company of America 31534 INSURER A: 22292 Hanover Usurance Company INSURED INSURER 8: 22306 New England Window&Door LLC Massachusalis Bay Insurance INSURER C: 13083 45 Fondi Road INSURER D'. New Harrohire Employers Insurance Company Haverhill,MA 01832-1302 INSURER E: INSURER F: COVERAGES CERTIFICATE NUMBER:22446 REVISION NUMBER: THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TOTHE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED. NOTWITHSTANDING ANY REQUIREMENT,TERM OR CONDITION OF ANY CONTRACT DR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE MAY BE ISSUED OR MAY PERTAIN, THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS, EXCLUSIONS AND CONDITIONS OF SUCH POLICIES.LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. ILTR ADDL SOUR POLICY EFF POLICY EXP LIMITS TYPE OF INSURANCE POLICY NUMBER MWDDIYYYY MMIDDIYYYY EACH OCCURRENCE $ 1,000,000 GENERAL LIABILITY DAMA E TO RENTED 100,000 X COMMERCIAL GENERAL LIABILITY I PREMISES Ea occurrence $ � MED EXP(Any one person) $ 10,000 CLAIMS-MADE El OCCUR ZBN8161407 71112012 I 711/2013 PERSONAL 8 ADV INJURY $ 1,000,000 A GENERAL AGGREGATE S 2.000,000 PRODUCTS-COMPIOPAGG $ 2.000,000 GEN'L AGGREGATE LIMIT APPLIES PER: $ 17 POLICY X PRO- X LOC EOMaBINEDISINGLE LIMIT $ 1,000,000 AUTOMOBILE LIABILITY BODILY INJURY(Per person) $ X ANY AUTO C ALL OWNEDSCHEDULED ADN8162169 7/112012 71112013 BODILY INJURY(Per accident) S AUTOS AUTOS PROPERTY DAMAGE Is NON-OWNED Per accident _ HIRED AUTOS AUTOS S X EACH OCCURRENCE $ 9,000,0,0 X UMBRELLA LIAR OCCUR 9,000,000 B EXCESS LAB CLAIMS-MADE UHN8167305 71112012 711!2013 AGGREGATE $ 8 DED RETENTION$ X WC STATU• OTH- WORXERS COMPENSATION I TORY LIMITS AND EMPLOYERS'LIABILITY 500,000 ANY PROPRIETORIPARTNERIEKECUTiVE Y� NIA 000082601825 71112012 7(112013 E.L.EACH ACCIDENT $ D OFFICERIMEMBER EXCLUDED7 500,000 (Mandatory In NH) E.L.DISEASE-EA EMPLOYE S If yes,describe under E.L.DISEASE•POLICY LIMIT S 500,000 DESCRIPTION OF OPERATIONS below DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES(Attach ACORD 101,Additional Remarks Schedule,If more space Is required) Proof of Insurance CERTIFICATE HOLDER CANCELLATION New England UUindow&Door LLC 45 Fendi Road SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE Haverhill,MA 01830 THE EXPIRATICN DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE U'VITH THE POLICY PROVISIONS. AUTHORIZED REPRESENTATIVE d0 d P Client kZtjov Mst a 22446 Cert Holder# 19976 0 1983-2010 ACORD CORPORATION. All rights reserved. ACORD 25(2010106) The ACORD name and logo are registered marks of ACORD �. ✓�ze aaav�nn�ur�ealf� 1Y'i,� u-,X aeez Office of:Consumer Affa'e; Y 3osii,e;s Regulation OI'►rIE IMPROVEMENT CONTRACTOR s t�F /• Reg istranor r69774 Ex rataGrl Type; P 11/2!20,1.3, Supplement ii PELLAWINDOINS�AND;;DOfORS ,` f WILLIAM NICHGLS 45 FONDI RD. HAVERHILL, AAA 01.832 Undc.secretary 13�ra�'tl.rrf, iilali�i-41' 1+_aafrta'i,rr.� y'ra;l��t;a;ati,+a"i , ConsirU'C"tlOi3 '�L.1J 1"Ji30i.;.I 1CB't7SF 9 License: CS 89853 WILLIAM R NJCHOLS N;n' '''"b " ,x 57 PEARTREE RDS` --4,€ � + HAVERHILL, MAO �—�— ----- ` ......... E— 10/26/2012 4529 f 1 l� _Q1 Contract s Detailed Pella Windows&Doors Sales Rep Name: Scott,Jennifer ® HIC#129774/Tax ID#26-1413183 45 Fondi Road Sales Rep Phone: 978-373-2500 Haverhill,MA 01832 Sales Rep Fax: Phone: (978)373-2500 Fax: (978)373-7274 Sales Rep E-Mail: ScottJA@PellaBoston.com Customer Information Project/Delivery Address Order Information Lisa Winslow LWinslow,Lisa,North Andover,MA1152021 Quote Name: 1 window 207 Boxford St 207 Boxford St Order Number: 741 JS0036 NORTH ANDOVER,MA 01845-3225 Lot# Quote Number: 4085897 Day Phone: (978)6897440 North Andover,MA 01845-3225 Order Type: installed Sales Mobile Phone: County: Essex Payment Terms: Deposit/C.O.D. Fax Number: Tax Code: MA TAX 6.25 E-Mail J6_4N e S t': ( n ✓U. ( 0, P7 Quoted Date: 9/11/2012 Great Plains#: Customer Number: 1006213338 Customer Account: 1001803342 Une# location: Attributes. 10 None Assigned Delivery/Setup-Delivery/Setup City For more information regarding the finishing,maintenance,service and warranty of all PellaOi)products,visit the Pella®website at www.pelia.com M4M.A. cif,rnnl^ 0-#-4 n + i + 0., t ..r G A Customer:Lisa Winslow Project Name: Winslow,Lisa,North Andover,MAI 152021 Order Number: 741JS0036 Quote Number:4085897 Jne# Location: Attributes 5 bedroom ProLine,Double Hung Fixed,59 X 49.25,White,3.11/16" City 1 1:Nonstandard Size Fixed Double Hung PK& Frame Size: 59 X 49 1/4 530 General Information: Clad,None Exterior Color I Finish: Standard EnduraCiad,White Interior Color!Finish: Prefinished White Interior _ Glass: insulated Low E Advanced Argon Gas Grille: None, Viewed From Exterior Wrapping Information: Foldout Fins,Factory Applied,3-11116"Factory Applied,Perimeter Length=217",Glazing Pressure=45. Frame Size:59"X 49.25" inal Wall Depth:3-11116" 3rd Story and Above-r301`t To Top Of Window- Install Charge(per unit) Qty 1 Exterior WreplCap for PI.Exterior Wrap/Cap For Complete Pocket Install Qty 1 PI_Complets•Pella Complete Pocket Qty 1 Jae# Location Attributes 771 !0 10 pct September Rebate-September Rebate City 1 .ine# Location: Attributes ?5 urgency dollars September Rebate-September Rebate City 1 For more information regarding the finishing,maintenance,service and warranty of all Pella®products,visit the Pella@ website at www.pelia.com DAM-4 01110n+o r ., n.f�;1 r 0— 1) ,.f s Customer:Lisa Winslow Project Name: Winslow,Lisa,North Andover,MA1152021 Order Number. 741JS0036 Quote Number:4085897 Thank You For Purchasing Pella@ Products 'ELLA WARRANTY: elle products are covered by Pella's limited warranties in effect at the time of sale.All applicable product warranties are incorporated into and become a part of this contract. lease see the warranties for complete details,taking special note of the two important notice sections regarding installation of Pella products and proper management of moisture ,ithin the wall system.Neither Pella Corporation nor Pella Windows&Doors will be bound by any other warranty unless specifically set out in this contract. However,Pella 'orporation will not be liable for branch warranties which create obligations in addition to or obligations which are inconsistent with Pella written warranties. leer opening(egress)information does not take into consideration the addition of a Rolsereen[or any other accessory]to the product.You should consult your local building code r entire your Pella products meet local egress requirements. er the manufacturer's limited warranty,unfinished mahogany exterior windows and doors must be finished upon receipt prior to installing and refinished annually,thereafter. 'ariations in wood grain,color,texture or natural characteristics are not covered under the limited warranty. 3roject Checklist Review (installed Orders Only) tgf,Qre the Installation the Homeowner agrees to dg the MIgwina: )btain Condo Association Approval )btain Historic Approval temove existing shutters and awnings temove air conditioners temove existing shades,drapes,window treatments,wall hangings,and personal belongings love furniture at least 3 feet away from work area 'ie or cut back trees.bushes and shrubs in the work area ,rrange to have alarm system and doorbells disconnected ,rrange to have any plumbing and electrical repairs or changes made by appropriate licensed contractor 'rovide a door handle and lockset for entry door if Pella handle and lockset is not purchased. Iefore the Instaliat€on Pella awes to do the following: )btain Building Permit(When required) 'refinish products when purchased in contract ►wring thgjnstsilation the Homeowner agrees to do the foliowing: ,eep pets safely away from work area ,eep children safely away from work area Jlow Pella Installer room to work safely within your home luring the Inal3ll2118 Ag€ges tg d91hAJQL1QMd= )eliver and unload products purchased per contract 'lace and remove drop cloths in work area then vacuum,and remove all debris at end of day temove existing product,including storm windows,and dispose of it unless otherwise specified istall all products using method specified in contract per Pella Installation Instructions For more information regarding the finishing,maintenance,service and warranty of all Pella(&products,visit the Pella®website at www.pelia.com n.:..b..l..., nf4 ..l G Customer:Lisa Winslow Project Name: Winslow,Lisa,North Andover,MA1152021 Order Number: 741JS0036 Quote Number: 4085897 replace interior and/or exterior trim only if purchased Purchased,install exterior primed pine wood trim or Composite.Composite will be unfinished. Purchased,install interior trim matching wood window finish or White trim for Impervia and Encompass (stall non-Pella entry door lockset provided by you.Pella is not responsible for it's quality or performance after the Installation the Home9Mp2f IaM2A LQ do the following: :e available for completion and sign off to verify all products purchased are in working order ;einstall existing shutters and awnings ;e-install existing shades,drapes,window treatments,wall hangings,and reposition furniture ,mange to have alarm system and doorbells reinstalled ;einstall air conditioners remove stickers from product and save for energy rebate and tax purposes Vash all interior&exterior glass surfaces ill nail holes and joints on interior trim if windows are to be stained(after staining) :lean up exterior casing issues due to storm window removal if full wrap or new exterior trim is not purchased JProject Checklist has been reviewed er ramal Product Only Addendum has been reviewed ustomer initial ;redit Card Account#: Last 4 Digits 'expiration Date: O / l L! ;harge final payment to same account ;Upon substantial completion) ustomer initial For more information regarding the finishing,maintenance,service and warranty of all Pella®products,visit the Pella®website at www.pella.com I Customer:Lisa Winslow Project Name: Winsiow,Lisa,North And0ver,MA1152021 Order Number: 741JS0036 Quote Number:4085897 ,Project Checklist has been reviewed Customer Name (Please print) Pella Sales Rep Name (Please print) Order Totals Taxable Subtotal $486.01 Cu omer Signature Is Sales p Signature Sales Tax @ 6.25% $30.3 Non-taxable Subtotal $606.00 Total $1,122.39 Data 2f Date /2 //Z D, ! Deposit Received $561.19 Amount Due $561.20 Cr dit Card Approval Signature For more information regarding the finishing,maintenance,service and warranty of all Pella®products,visit the Pella®website at www.pella.com DRnEaann Q.+IUnV) rn f—M Dona F of �. NOTICE OF CANCELLATION Customer N ame: VV �n s li v.j (Please print Date of transaction: You may cancel this transaction,without any penalty or obligation,within three business days from the above date. If you cancel,any property traded in,any payments made by you under the agreement, and any negotiable instrument executed by you will be returned within ten business days following receipt by the seller of your cancellation notice,and any security interest arising out of the transaction will be cancelled. If you cancel,you must make available to the seller at your residence,in substantially as good condition as when received,any goods delivered to you under this agreement;or you may if you wish,comply with the instructions of the seller regarding the return shipment of the goods at the seller's expense and risk. If you do make the goods available to the seller and the seller does not pick them up within twenty days of the date of your notice of cancellation,you may retain or dispose of the goods without any further obligation.If you fail to make the goods available to the seller,or if you agree to return the goods to the seller and fail to do so,then you remain liable for performance of all obligations under the contract. To cancel this transaction,mail or deliver a signed and dated copy of this cancellation notice or any other written notice,or send a telegram to Pella Windows and Doors, at 45 Foidi Rd.,Haverhill.MA 01832 not later than midnight of �(three business days from the date of transaction above). I hereby cancel this transaction. (Date) (Buyer's signature) DISPUTES Job Name���A C�\ILl Dae 3 THE CONTRACTOR AND THE HOMEOWNER HEREBY MUTUALLY AGREE IN ADVANCE THAT IN THE EVENT PELLA HAS A DISPUTE CONCERNING THIS CONTRACT,PELLA MAY SUBMIT SUCH DISPUTE TO A PRIVATE ARBITRATION SERVICE WHICH HAS BEEN APPROVED BY THE SECRETARY OF THE EXECUTIVE OFFICE OF CONSUMER AFFAIRS AND BUSINESS REGULATIONS AND THE CONSUMER SHALL BE REQUIRED TO SUBMIT TO SUCH ARBITRATION AS PROVIDED IN M.G.L.c. 142A Contractor Homeowner NOTICE:THE SIGNATURE OF THE PARTIES ABOVE APPLY ONLY TO THE AGREEMENT OF THE PARTIES TO ALTERNATIVE DISPUTE SETTLEMENT INITIATED BY THE CONTRACTOR. THE OWNER MAY INITIATE ALTERNATIVE DISPUTE RESOLUTION EVEN WHERE THIS SECTION IS NOT SEPARATELY SIGNED BY THE PARTIES. 211 BOXFORD STREET L J 21011060000.0 {{{ y F I i i I 4 1 J r K Lot & Street All � c� ��✓e Map/Parcel dX f CONSTRUCTION APPROVAL Has plan review fee been paid: YES NO Permit# Plan Approval: Date: Approved by: l Designer: oyf/&4 Plan Date: Z h?q//;,oc � Conditions: C6/(JG,@7,!� OVA Water Supply: Town We Well Permit: Driller: Well Tests: Chemical Date Approved Bacteria I Date Approved _ Bacteria II Date Approved Plumbing Sign-Off: Wiring Sign-off: Comments: Form "U" Approval: Approval to Issue: YES NO Date Issued By: Conditions: Final Approval: All Permits Paid? YES NO Well Construction Approval? YES NO Septic System Construction Approval? YES NO Certification? YES NO Other? YES NO Any Variance Needed? YES NO FINAL BOARD OF HEALTH APPROVAL: DATE: APPROVED BY: i I r SEPTIC SYSTEM INSTALLATION CONDITIONS: F i Is the installer licensed? YES NO Type of Construction: NEW REPAIR New Construction: Certified Plot Plan Review YES NO Floor Plan Review YES NO Conditions of Approval from Form U YES NO Issuance of DWC permit: YES NO DWC Permit Paid? YES NO DWC Permit# Installer: Begin Inspection: YES NO Excavation Inspection: Needed: / S �1 Passed: By: Construction Inspection: Needed: As Built Plan Satisfactory: YES: Approval of Backfill: Date: By: Final Grading Approval: Date: By: Final Construction Approval: Date: By: Certificate of Compliance: Approval: Date: MAP # 1 D(oo- LOT #—_6 _ PARCEL # 3 STREET �Q�,IS�R.U��x QN�.PPROVA�. .ArP HAS PLAN REVIEW FEE BEEN PAID? YES . NO PLAN APPROVAL: DATE 9y APP. DESIGNER: �/���'�0'4 PLAN DATE, P!*A) �sg CONDITIONS WATER SUPPLY: TOWN WELL '•'' WELL RERMIT .s DRILLER WELL TESTS: CHEMICAL DATE APPROVED_?/- BACTERIA BACTERIA I DATE APPROVED,.•,._II DATE APPROVED___ , 4 . COMMEN, S: • ' 0 to,, FORM U ARRROVALa APPROVAL TO ISSUE NO DATE ISSUED �i -BY— CONDITIONS: YCONDITIONSa • FINAL APPROVAL: ALL PERMITS PAID YE NO WELL CONSTRUCTION APPROVAL YES NO SEPTIC SYSTEM CONSTRUCTION APPROVAL S NO OTHER YES NO ANY VARIANCE NEEDED YES 20: FINAL BOARD OF HEALTH APPROVAL: DATES BY __ It � t SEPT Y C__ _Y_SZE1__I IS THE INSTALLER LICENSED? YES NO ,t �':!' exp r' , TYPE OF CONSTRUCTION: REPAIR ;NEW CONSTRUCTION: CERTIFIED PLOT PLAN REVIEW ES ICU CONDITIONS OF APPROVAL IJO (FROM FORM U) ISSUANCE OF DWC PERMIT YES NO �� INSTALLER:.- uo� DWC PERMIT NO. J ._ BEGIN INSPECTION 6)0 : ' EXCAVATION . INSPECTION: NEEDED: 141 .VES PASSED ��� BY . . CONSTRUCTION INSPECTION? NEEDED t _.__.._._....._...__—_...........__ ' 'i•' I Jl F ' �S t 3 OK ell t AS BUILT PLAN SATISFACTORY: �..•.° ' ': ..� APPROVAL. TO BACKFILL: DATE: _--.— FINAL GRADING APPROVAL: DATE sY.___�_—__�___._ _ { FINAL CONSTRUCTION APPROVAL: DATE:__ _BY_ __ wc 5 ',y i INSTALLER PROJECT MANAGEMENT OBLIGATIONS As the North Andover licensed installer for the construction of the septic system for the property at o�/� ��12r� S+ relative to the application of reln etl datefor plans by e,/ SSOCand dated 11 (v d with revisions datedYC/ 0� I understand the following obligations for management of this project: 1. As the installer I am obligated to call for any and all inspections. If homeowner, contractor, project manger, or any other person not associated with my company schedules an inspection and the system is not ready then item two shall be applicable. 2. As the installer I am required to have the necessary work completed prior to the applicable inspections as indicated below. I understand that requesting an inspection, without completion of the items in accordance with Tile 5 and the Board of Health Regulations may result in a$50.00 fine.being levied against my company. a) Bottom of Bed - generally first inspection unless there is a retaining wall which should be done fust. Installer must request the inspection but does not have to be present. b) Final inspection — Engineer must first do their inspection for elevations, ties, etc. As-built or verbal OK from engineer must be submitted to Board of Health, after which installer calls for inspection time. Installer must be present for this inspection. With pump system all electrical work must be ready and able to cause pump to work and alarm to function. c) Final Grade—Installer must request inspection when all grading is complete. Does not have to be on site. 3. As the installer I understand that persons or companies not associated with my company may not perform the work required by my company to complete the installation of the system identified in the attached application for installation. I further understand that work by others unlicensed to install septic systems in North Andover can constitute reasons for denial of the system, and/or revocation or suspension of my license in the Town of North Andover plus significant fines to all persons involved. 4. As the Installer I understand that I must be on site during the performance of the following construction steps: a) Determination that the proper elevation of the excavation has been reached. b) Inspection of the sand and stone to be used. c) Final inspection by Board of Health staff. d) Installation of tank, D-box, pipes, stone, vent, pump chamber, retaining wall and other components. 5. As the installer I understand that I am solely responsible for the installation of the system as per the approved plans. No instructions by the homeowner, general contractor, or any other persons shall absolve me of this obligation. Undersi nse Septic al r Date: 2 6 Dispo Wor/sZonstruction Permit# �ai� AS-BUILT CIIECKLIST LOT NUMBER, STREET NAME ASSESSORS MAP &PARCEL NUMBER LOT LINES & LOCATION OF DWELLINGS LOCATIONS & DIMENSIONS OF SYSTEM, INCLUDING RESERVE TIES TO LOT LINES &DWELLING, WELLS a. FROM SEPTIC TANK b. FROM LEACH AREA LOCATIONS OF DEEP HOLES &PERC TESTS ELEVATIONS OF DISPOSAL SYSTEM TOP OF FDN ELEVATION _= LOCATIONS OF WELLS DRAINS WATERCOURSES WITHIN 150' OF SYSTEM LOCATION OF WATER, GAS, ELECTRIC LINES, CABLE DISTANCES FROM CORNERS OF HOUSE TO CENTER OF TANK&D-BOX 4 ORIGINAL STAMP & SIGNATURE IMPERVIOUS AREAS - DRIVEWAYS, ETC. y NORTH ARROW LOCATION&ELEVATIONS OF BENCHMARK USED I N&M Job number 1770/ :�, 6t TOWN OF NORTH ANDOVER INSPECTION CHECKLIST FOR SEPTIC SYSTEMS Site: Z- t> o Final Date: Installer: Tel: Gl7 — 5-92- - + 5W2. i Date Yes No Initials A. Bottom of Bed 1. Excavation to proper depth 2. With trenches,sides of excavation are beneath B horizon 3. Edge of excavation specified distance from foundation,etc. Comments: (Use back of sheet for diagrams.) i i B. Retaining Wall 1. Wall height an"th-asspecified 2. Waterpr ed 3. Wa mimum 10'to lea g facility 4. all meets specifi Kris of plan C eats: i I C. Building Sewer 1. Pipe diameter minimum 4" ✓ �,,� 2. Schedule 40 pipe h 3. Inlet to tank cemented .�- 4. Slope minimum 0.01 or 1/8"per foot minimum 5. Pipe properly set on compact firm base d+ 6. Pipe laid on continuous grade in straight line 6� 7. Cleanouts precede all change in alignment and grade *^'` 8. Manholes at any 90°change 9. 10'minimum-offset to water line Comments.- D. omments.D. Septic Tank 1. Level /` 2. 1,500 gal minimum 3. Gas baffle present on outlet 4. Manhole to Win 6"of grade i✓/I 9�� 5. Manholes over center and each tee OK/ 6. 3-20"manholes 7. Outlet line cemented 8. 2"—3"drop from inlet to outlet 9. Pipe set e� 10. Compact base with 6"of 3/a"crushed stone under tank ..r- 11. Tank is watertight 12. Tees 12"off side of tank �� N&M Job number 1770/ r Comments: Date Yes No Initials E. Pump Chamber I. If separate from tank,compact base with 6" .f`,1--"-`stone underneath 2. Minimum 2"pipe to d-box if gravity 3. 20"access manhole 4. Tank level 5. Watertight 6. Tank size agrees i plan specification 7. Mainhole to gr a 8. Check valyWand bleeder hole present r- 9. Alarm-if building on separate circ- 10. Alarm functions 11. Manual operating switc 12. Pump delivers liquid to d-box w Comments: F. Distribution Box 1. D-box level �,,,� 2. Minimum 0.1 T'(2")drop from inlet to outlet let _— 3. Minimum 6"sump 4. Outlet pipes show equal distribution 5. Compact base with 6"of stone beneaih boxr---- 6. Box is watertight 7. All lines cemented with hydraulic cement 8. Schedule 40 pipe y 9. First 2'from box laid level Comments: G. Soil Absorption system '5--/SQ/p j r 1. All stone double-washed—%"— 1 '/z" �Zpo"J �p pea stone Bucket test done? 2. Minimum 2"of pea stone above distribution lines ��J 3. Minimum 6"stone beneath pipe 4. Distribution lines capped ort�connected together 5. Toe of slope stops minimum 5'-Gin ofproperty, 5a. if not, then swale. Comments: r>o V IJP P-,ar-- i N&M Job number 1770/ Date Yes No Initials H. Leach Trenches I. Minimum 2 trenches , 2. Length of trenches agrees plan. (Max. length 1001) 3. Width of trenches agges with plan Minimum 2';maximum—4'. 4. Vent present if eet or specified 5. Minimums ance between trenches 10' 6. Pipe sI ' minimum 0.005 or 6' per-if 0' 7. Dept1 of trenches belowout�letruivert minimum of 6 8. Pipes set on stable base. Comments: �. I. Leach Field ,rl3R/�J 'Z•r ��� I. Maximum length of field 100' G� 4 2. Pipe slope minimum 0.005 or 6"per 100' 3. Separation between pipes 6'maximum �^ 4. Pipes connected at end&vent end raised 5. Separation between adjacent fields 10'minimum 16. Pipes set on stable base , 7• Maximum 4' separation from edge of field to first line 8. Minimum two distribution lines Comments: I Leaching Pits 1. Minimum inlet pipe 4" �_- 2. Pits of concrete I Sidewall between�-12"and 48"wide �- 4. Access manh es on each pit 5. Pipes c m rated with hydraulic cement 6. Comments: K. Final Grade 1. Slope over soil absorption system minimum 0.02 2. All system components covered by at least 9"soil 3. Cover soil free of stones larger than 6" 4. Grading slopes away from dwelling 5. No areas over system that may pond 6. Grading meets 3:1 slope 7. Minimum of 9"of fill graded over system III NOONAN & Mc DOWELL, INC. 25 Bridge Street, Suite 6, Billerica, MA 01821-1023 Voice(978) 667-9736 Fax (978) 671-9565 Email: nm(a,netwa�com Date: January 15, 2002 /�� 1 is-OF NORTH�'itV4J iJV u BOASD OF HEA0 H i Town of North Andover JAN 2 2 2 Office of the Health Department Community Development and Services Division 27 Charles Street North Andover, MA 01845 RE: Subsurface Sewage Disposal System Plan Review, 1770/064 211 Boxford Street Assessors Map 106 A, Lot 254 Dear Members of the Board, Please be advised that Noonan &McDowell, Inc. has reviewed the plan dated November 6, 2001 by O'Neill Associates. It is our opinion that the proposed design will meet the requirements of Title 5 and the North Andover Board of Health`By-Laws"if the following is addressed: 1) Provide a smaller scale of legal boundaries of lot. 220 (4)(a) 2) Provide setbacks to property line from leaching area. 3) Provide location of water line and state either pressure or suction. 4) Provide a note stating existence of surface water supplies within 400',public wells within 250' and private wells within 150 ft of leaching area. 220 (4) 5) An inground pool/spa have setback requirements of 10 ft to septic tank and 20 ft to leaching field. Please review setbacks and show. 6) The breakout grade for the beginning of the leaching system is 86.68. Revise grading as necessary. 7) Specify water tight joints (mortared) at septic tank and D-Box. 8) Provide 6 in. of stone beneath septic tank and D-Box. 221 (2) Land Surveyors Civil Engineers Environmental Planners 9) Provide elevations and pipe lengths in profile. Check slope between septic tank and D- Box, and house to septic tank. 10)Show in profile and label first 2 ft. set level for outlets of D-Box. 11)Provide end connection of leaching lines. Do not allow cross flow. NA 15.01 12)Reserve area shall be 4 ft. from primary area. NA 9.04 13)Dimension primary on plan view. 14)Were the reserve area is located uphill of the primary. Please provide design grades for leaching system to ensure compliance with vertical offset requirements. Respectfully, John L. Noonan,P.L.S.-P.E. G:office/forms/211 Boxford.doc Land Surveyors Civil Engineers Environmental Planners 2 Town of North Andover F µOR7Ft Office of the Health Department A Community Development and Services Division 27 Charles Street "'' North Andover, Massachusetts 01845 "SS,CNUS�` Sandra Starr Telephone (978)688-9540 Health Director Fax (978)688-9542 March 22, 2002 Michael O'Neil O'Neill Associates 234 Park Street North Reading, MA 01864 Re: 211 Boxford Street Dear Mr. O'Neill: This is to notify you that the plans dated November 6, 2001 and revised on January 29, 2002 for the upgrade of the septic system at 211 Boxford Street have been approved with the condition that NO CONCRETE is placed over the building sewer line to the septic tank. This line must be accessible to enable possible work in the future. Please submit a letter or brief plan signed by the property owner to show that the decking in that area has been.altered to allow accessibility. If you have any questions,please do not hesitate to call the Board of Health Office at 978-688-9540. Sincerely, Sandra Starr, R.S., C.H.O. Health Director cc: Cronin Building File BOARD OF APPEALS 688-9541 BUILDING 688-9545 CONSERVATION 688-9530 NURSE 688-9543 PLANNING 688-9535. i O'Neill Associates Civil Engineers and Land Surveyors 234 Park Street North Reading,MA 01864 (978)664-8141 Fax(978)664-8142 Email:oneill.eng@verizon.net F—TOWN*_0F N—ORTH—ANDOVER/ November 1, 2002 BOARD OF H'TH Town of North Andover Board of Health 27 Charles Street North Andover, MA 01845 Attention: Sandra Starr,R.S., C.H.O. Health Director RE: 211 Boxford Street Dear Ms. Starr: I am in receipt of your letter dated October 25, 2002 regarding the deficiencies and disapproval of the as-built plan that was submitted on behalf of the above-referenced property. I have forwarded this information to my client and am awaiting a response from him. In the future, would you kindly address any and all future correspondence to Mr. Michael Cronin on this matter with a copy to us. If you have any questions with regard to the enclosed,please feel free to contact me. Very truly yours, O'Neill Associates Michael G. O'Neill, P.P.E. TOWN OF NORTH ANDOVER f Nowsh HEALTH DEPARTMENT 27 CHARLES STREET NORTH ANDOVER, MASSACHUSETTS 01845CH SgACHUSE'� Sandra Starr Telephone(978)688-9540 Public Health Director FAX(978)688-9542 October G5, 2.002 Michael O'Neill O'Neill Associates 234 Park Street North Reading, MA 01864 RG: 1 B___r_r r.1 I UXEUI{.'! St. Dear Mr. O'Neill: This letter comes to inform you that the as-built pian_ for the repaired septic system at 211 Boxford Street has deficiencies and cannot be approved. Please address the following problems and submit a new as-built plan so that a Certificate of Compliance can be issued for the property. Enclosed is a blank copy of North Andover's As-built Checklist for future reference. • Missing lot lines with relationship to dwelling, wells, septic tare and leach area; • Missing locations of deep holes and percolation tests; • Locations of wells, drains, and watercourses;within 150' of the system.; • Location of water, gas,electric and cable lines; • Original stamp and signature; • Impervious areas including driveways. Should you have anyuestions, please call the Health Depa! !!went at 978-688-!9'540, Monday through Friday between the hours of 8:30 and 4:30. Sincerely, Sandra Starr, 1 f' H 10" Health Director Cc: Homeowner File O'Neill Associates Civil Engineers and Land Surveyors 234 Park Street North Reading,MA 01864 (978)664-8141 Fax(978)664-8142 Email: oneillm@ziplink.net November 27, 2001 Town of North Andover 27 Charles Street North Andover, MA 01845 Attention: Sandra Starr,Agent Board of Health Re: Mike Cronin 211 Boxford Street O'Neill File#00-166 Dear Ms. Starr: Enclosed herewith please find our check#3679 in the amount of$100.00. On November 19, 2001 we hand-delivered the plans and permit application, together with a check in the amount of$60.00 to the Board of Health for filing. However, the $60.00 fee was the incorrect amount. Therefore, we are forwarding the additional amount owed for the filing of the permit at this time. Thank you for bringing this to our attention. If you have any additional questions with regard to the enclosed, please feel free to contact us. Very truly yours, O'Neill Associates s \ Michael G. O'Neill, P.P.E. Enclosure as stated BOARD OF HEALTH TOVVfV of r�oRrH A!`1C?0�" �/ NORTH ANDOVER, MA 01845 BOARD OF HEALTH 978-688-9540 AUG 2 0 2001, APPLICATION FOR SOIL TESTS DATE: a- -Lk - p t MAP & PARCEL: _��6 A ®Z S-4-. LOCATION OF SOIL TESTS: Call• Uz. OWNER: TEL. NO.: -79.1 • cj 5 3`} ADDRESS: 2 �t3ox�oczl� ����c cvo�z;H a►�1���Jc�� ` �`{�l ENGINEER: d a s�oc-tv-Te-s TEL.NO.: '17 a -- , .64- e 141 CERTIFIED SOIL EVALUATOR: Intended Use of Land: Residential Subdivision Single Family Home Commercial Is This: / Repair Testing: y Undeveloped lot testing: In the Lake Cochichewick Watershed? Yes No THE FOLLOWING MUST BE INCLUDED WITH THIS FORM 1. Proof of land ownership (Tax bill, or letter from owner permitting test) 2. Plot plan & Location of Testing 3. Fee of$275.00 per lot for new construction. This covers imum two deep holes an two percolation tests required for each disposal area. Fee of M--—0-707per lot for repairs oC u rades. GENERAL INFORMATION 1. Only Certified Soil Evaluators may perform deep hole inspections. 2. Only Mass. Registered Sanitarians and Professional Engineers can design septic plans. 3. At least two deep holes and two percolation tests are required for each septic system disposal area. Repairs require at least two deep holes and at least one percolation test,at the discretion of the BOH representative. 5. Full payment will be required for all additional tests within two weeks of testing. 6. Within 45 days of testing, a scaled plan(no smaller than 1"-100') shall be submitted to the Board of Health showing the location of all tests (including aborted tests). 7. Within 60 days of testing soil evaluation forms shall be submitted. Please Do Not Write Below This Line N.A. Conservation Commission Approval: Date Received: Check Amount: Check Date: -DETACH HERE- • - - - DETACH HERE . . • . . DETACH HERE • - - - - DETACH HERE DETACH HERE - - - - - DETACH HERE- SEE REVERSE SIDE FOR IMPORTANT INFORMATION Interest at the rate of 14 per annum will 1856 RE accrue on overdue payments from the duel Y �4R 2U( REAE ESTATE date until payment is made. 1st Half 2nd Half Prelm7nary TaX $ 2 104 18 Taxes 1,052.09 1,052.09 Assmnts 0.00 0.00 1st Payment Due $ 1,052;09 AUGIST Ol, 2001 . CRONIN, MICHAEL J 2nd payment Due $ �052Q9 NOVEMBER 1, 2001 mNlt wUue aA05 09 Loc: 211 BOXFORD STREET Parcel Id: 106.A 0254 0000.0 This form approved by the Commissioner of Revenue -DETACH HERE- - - - - DETACH HERE - - - - - DETACH HERE - - - - - DETACH HERE - - - - - DETACH HERE - - - - - DETACH HERE- 2002 QUARTERLY REAL ESTATE MAKE PAYMENTS TO THE COMMONWEALTH OF MASSACHUSETTS BILL NUMBER 1856 RE TOWN OF 'NORTH ANDOVER TOWN OF NORTH ANDOVER Loc: 211 BOXFORD STREET P. O. BOX 124 OFFICE OF THE COLLECTOR OF TAXES Map: 106.A NO ANDOVER, MA 01845 Tax Amount Block: 0254 M.-F. 8:30-4:30, ,8/1 TO 7:30 PM 1st 1,052.09 Lot: 0000.0 TAX 688-9550/ASSR :688=9566 Deed/Legal : 5189 198 Land Area: 6.06 (ac) Your Preliminary Tax for the Fiscal Year 2002 beginning July 01,2001 and ending June 30, 2002 on the Real Estate described is as follows: CRONIN, MICHAEL J JULIE A CRONIN 211 BOXFORD STREET Amount due by AOGUST01, 2001 NORTH ANDOVER MA 01845 Prelitm�ria;y Tax Due;:$ ,t52; 09 111111 INI IIIII Ilill 111111111111111111111111111111 Illi 1111111111111111111111111111111 Iill 11111111111111 �,a-4-...a. 1Srs�_._ :� ... t :.- ",'_`a.S..r__. .,<,s1.L..s.•;;__ - ,:.:.,. �, - ._ �F, ,y`y+• -t;. 5� .......... t�iai" i.Y+lk k e , FORM 11 - SOIL EVALUATOR FORM K Page 1 of 3 a No. Date: IZ 7 10f Commonwealth of Massachusetts tJar` k Ann wi-r- , Massachusetts Soil Suitabilitv Assessment for On-site Sewage Di'sosal . • Performed By: .. 1��........... ohrerv ........ ............................. Date: -- Witnessed By: ....... Lawae Addms or 2l �jox�or-c� �I-ree,� o.-M-5 maw' 0 icJ� C r��;� LA/ Aftus.Ld To, * ea /��' New Construction ❑ Repair L`� Office Review Published Soil Survey Available: No ❑ Yes ❑ Year Published ................. Publication ScaleAli : .....`..:. Soil Map Unit _..... Drainage Class ..:. Soil Limitations .....- Surficial Geologic Report Available: No 2 Yes ❑ Year Published Publication Scale Geologic Material (Map Unit) ...................................................................... Landform .............................................................................................. Flood Insurance Rate Map: Above 500ear flood boundary No ❑Yes Y �Y 2/ Within 500 year flood boundary No LJYes ❑ Within 100 year flood boundary No U✓Yes ❑ Wetland Area: National Wetland Inventory Map(map unit) Wetlands Conservancy Program Map(map unit) .........' ................._................................___._......... __.... Current Water Resource Conditions(USGS): Month C Range :Above Normal [ Normal — Below Normah ~-, Other References Reviewed: DQ AMWVW FORM•UMM FORM 11 - SOIL EVALUATOR FORM Page 2 of 3 Location Address or Lot No. <s„ On-site Review '! Dee Date: Hole Number I 9 Time: Weather 1� 1 A(Y)::...:/::... :. Location (Identify on site plan) Land Use ...::.::.� w.. ..:_,...,.. .. . Slope (961 1v Surface Stones '_::.... . .. Landform ... ... ............. .. ..... . . a Position on landscape (sketch on the back) Distances from: Open Water Body")2.oc> feet Drainage way 7Z)�-::> feet Possible Wet Area >I 00 feet Property Line lO feet ' Drinking Water Well 71=KD feet Other ;b DEEP OBSERVATION HOLE LOG* " Depth from Soil Horizon Soil Texture Soil Calor Soil Other Surface(Inches) (USDA) (Munsell) Mottling (Structure,Stones,Boulders,Consistency, % Gravel) 7 �5 Cl ,a>,,LS 10,tAl 6e-, r""le yZZ (Z >� to YR5+1 Gr, L,,O' e i �rl- i j. Panntt Material(geologic) OspQneoBedr+ock: DenM to Groundwater Standing Waw in the Hole: Weeping from Pit Face: Estitrbd SsesorW Haigh Ground Water: Q �� DO A"aovm t+01M-UMI" -'�;i�'s_.y...s,,::.e�:;.:� -=` . .:.. -=— - �'::<' .,._..��<�. _,. ;..1. .3ckv,e i�c_s'..�.�-��r:^sr'r :-t,y,�tv ....,-?y .L•3_ti� �` .x,�O'1S�"v�ase=as.`�a✓ FORM 11 - SOEL EVALUATOR FORM Page 3 of 3 Location Address -or Lot No. Determination for Seasonal High Water Table Method Used: ❑ Depth observed standing in observation hole................... inches ❑ Depth weeping from side of observation hole........... inches epth to soil mottles 190 inches Ground water adjustment ................... feet Index Well Number ................. Reading Date ....... . Index well level . Adjustment factor .................. Adjusted ground water level ...:............................ .. ............ Depth of Naturally Occurring Pervious Material Does at least four feet of naturally occurring pervious material exist in all areas observed throughout the area proposed for the soil absorption system? If not, what is the depth of naturally occurring pervious material? Certification I certify that on /� (date) I have passed the soil evaluator examination approved by the ep rtmant of Environmental Protection and that the above analysis was performed by me consistent with the required'training, expertise and experience described in 310 CMR 15.017. 3" 3. Signature. Date >t f/ 0o ArMvm roLM-UMM FORM 11 - SOIL EVALUATOR FORM V` Page 2 of 3 ry Location Address or Lot No. On-site Review a. Deep Hole Numbe;-TPLZ Date:j/�� Time: Weather Location (identify on site plan) - :..:: Land Use . Slope M �:�.� Surface Stones Vegetation :.:..::::::. �. ...,. . Landform ...:.:.:.:_�...�,...�...,:... _. .. . ....... - Position on landscape (sketch on the back) . Distances from: Open Water Body ?1� feet Drainage way 7Z5 feet Possible Wet Area 71-2- feet Property Line ',p feet Drinking Water feet Other DEEP OBSERVATION HOLE LOG Depth from Soil Horizon Soil Texture Soil Color Soil Other Surface(Inches) (USDA) (Munsell) Mottling (Structure,Stones,Boulders,Consistency, % t' Gravel) 47 - A6 '0Y,z-/Z 1515 5�, tlF�SL 10,fP11l& -7 g wz VF5L v /6 Sv9,/ 13Z CZ, ro�j� Erz .Parent Material(geologic! OepdntoBdrodc 7 i Depth to Gtoundwam Standing Water in the Hole: -- Weeping from Pit Face: Estimated Seasonal No Ground Water: DQ A>rMMM IF019M-12MIM FORM 11 - SOIL EVALUATOR FORM t` Page 3 of 3 Location Address pr Lot No. 'Locd Determination for Seasonal High Water Table Method Used: ❑ Depth observed standing in observation hole................::. inches ❑ Depth weeping from side of observation hole................ inches epth to soil mottles I )2, inches ❑ Ground water adjustment ................... feet Index Well Number ................. Reading Date ...._.... Index well level . Adjustment factor .................. Adjusted ground water level ... ................. ........... ........... Deoth of Naturally Occurring Pervious Material Does at least four feet of naturally occurring pervious material exist in all ar as observed throughout the area proposed for the soil absorption system? If not, what is the depth of naturally occurring pervious material? Certification I certify that on (date) I have passed the soil evaluator examination approved by the Depdrtment of Environmental Protection and that the above analysis was performed by me consistent with the required*training, expertise and experience described in 310 CMR 15.017. Signature. Date l7--/7/-:7/ cQ Arraovm FORM-umM FORM 12 - PERCOLATION TEST Location Address or Lot No. COMMONWEALTH OF MASSACHUSETTS Massachusetts Percolation Test` Date: o�/��j/®% Time: t Observation Hole # Depth of Perc io4n �o w n Start Pre-soak tt� End Pre-soak Time at 12" , 2r_1) Time at 9" Time at 6" Time (9"-6") lm,n 4E> scz, Rate Min./Inch 1=)4 2 * Minimum of 1 percolation test must be performed in both the primary area AND reserve ar . Site Passed Site Failed ❑ ............................................................................................................................................................... Performed BY: f n jdk ah w \ar Witnessed By: Y - Comments: DPP APPROVED FORM•12/17/93 .J tJl . 111 • I 111 - �_ I.. J'' I •. 11) • G I1_ IIF _ ItJ III t"Y -• O III �_ I<t• (1 O ( I _ I•- I- v1 _ 11.1 I 7 Q �J LL (IJ _ eeeeelneleellleelleeeeeeeleeelM eleellelleeeleeelelleeleelleeleel . 1111111111111111111111111111111111 11 1111111// 111111111111111111111 1 11111 11 111111111111111111111 .. � . 1111111 11 11111111111 1111111111 ���i�� �` 11111111111111111111111 1111111111 �! � �, 1111111111111111111111111111111111 1111111111111111111111111111111111 � , ,, � 1111111111111111111111111 1/1111/1 �` 1111111111111111111111111 111111 r� 1111/1111 111111111111111111111111 1111111/1 111111111111111111111111 1111111 1/1111111/ 111111111111111 .. � � :. 1111111 11 111111 111111111111111 1/111111 11 111111111111111 111111 . Inllllll 11111111111111111 111111 ' 11111111 111111111111111111111111 1111111 111111111111111111111111 . 1111111 1111111111111111111111111 -' 1111111111 11111/11 111111111111 111111�1l11 �1�!�1111� ; 11111111111 ��� 111111111�I�IIIilA�1����111111111111 ���� : 1111® 1111 �i11111�1f�i�11!li�ll©1111 ; �� 11111 loll 11111111111111111111111 �� ecce eneeeeeeeeeeeeeeeeeeeeeeeeee a, ecce eeeeeeeeeeeeeeeeeeeeeeeeeeeee eeee eeeeeeeeeeeeeeeeeeeeeeeeeeeee eeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeee eeeeeeeeeeeeeeeeeeeee m eeeeeeee eeeeeeeeeeeeee eeeeeeeeee - .� � _ : eeee e eeeeeeeeeeeeeee eeeeeeeeee . e� � een a eeeeeeeeeeeeeeeeeeeeeeeeee eeeeeeeeeeeeeeeeeee 11 Ell nu�eue � eeeeeeeeeeeeeeeee eeeeeeeeeeeeee eeeeeeeeeeeeeeeneeeeeeeeeee'eeeee ; �� a eeeeeeeee eeeeeeeeeeeeeeeeeeeeeeee �� eeeeeeeee eeeeeeeeeeeeeeeeeeeeeee :` �■■�� � eeeeeeee eeeeeee eeeeeeeeeeeeeee . �� � eeeeeeeee eeeeee Ell 1111 eeeeeeeeeee eeeeeneeeeeeeeeeeeeeee eeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeee - � . : eeeeeeeeeeeeneeneeeueeeeeeeeee' eeeeeee e eeeeeeeeeeeeeeeeeeeeeeee eeeeeee e eeeeeeeeeeeeeeeeeeeeeeee - - eeeeeeeeeeeeeeeeeeeee ee�eeeeeeeee nen■ eeeeee�Aeeee�eeeeee �e�eeeeeeeee ��� _ , - eeeeeeeee�e�ee�eeee����eee�e�eeeee eeee®®eeee eeee eeeeeeeeeeoeeee ��■ eeeeeeeeeEll eeee�eeEll leeeeeEll A I COMMONWEALTH OF MASSACHUSETTS W EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS i d DEPARTMENT OF ENVIRONMENTAL PROTECTION r O''M 5V 0v TITLE 5 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM PART A // CERTIFICATION Property Address: 21 1 T6 A4y J S+ree r Owner's Name• MIC api Croviir\ Owner's Address: Same Date of Inspection: 0.SS •60 Name of Inspector: (please print)Ld W&rd (L1 S2tnv10.0 r-R Company Name: Mailing Address: 15 C Pt Ond ion k Telephone Number: -5b3 3 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 Fails Inspector's Signature: Date: 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. �f Notes and Comments �� s-� r l��U O� bay 5k 6U `J V)-e PYO\.t 1 At ****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. Title 5 Inspection Form 6/15/2000 page l i Page 2 of I 1 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address: /211 tX r&j 1 + 4n 0,I 2 f Owner: rcj Date of Inspection: ) D. 2-3 •0 0 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: e Conditionally B System Con o y 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): brokenpipe(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: Owner: M I Ct-'Ae Cr0 Date of Inspection: 1 D• 21.0 U 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 1 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 I 1 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address: 12 1 O In�O�f r Owner yn Date of Inspection: I O. ,Z 7 •Dp D. System Failure Criteria applicable to all systems: You must indicate"yes"or"no"to each of the following for all inspections: Yes No V Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool y Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool ✓ Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool Liquid depth in cesspool is less than 6"below invert or available volume is less than '/z day flow v Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s).Number of times pumped Any portion of the SAS,cesspool or privy is below high ground water elevation. Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. Any portion of a cesspool or privy is within a Zone I of a public well. Any portion of a cesspool or privy is within 50 feet of a private water supply well. ✓ 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 `1 are triggered.A copy of the analysis must be attached to this forma V (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 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B 1 CHECKLIST Property Address: 2[( a Yct Owner: lC tv� Date of Inspection: IO •2-3 •D U Check if the following have been done.You must indicate"yes"or"no"as to each of the following: Yes No Pumping information was provided by the owner,occupant,or Board of Health Were any of the system components pumped out in the previous two weeks? Has the system received normal flows in the previous two week period? Have large volumes of water been introduced to the system recently or as part of this inspection? Were as built plans of the system obtained and examined?(If they were not available note as N/A) v _ Was the facility or dwelling inspected for signs of sewage back up? _ Was the site inspected for signs of break out? Were all system components,excluding the SAS, located on site? v _ 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? ✓ _ 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 Existing information. For example,a plan at the Board of Health. 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)] I Page 6 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION Property Address: 'z11 O vl o\t Pr Owner Date of Inspection: 10-23 -06 FLOW CONDITIONS RESIDENTIAL Number of bedrooms(design): 4— Number of bedrooms(actual): DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): Number of current residents: E Does residence have a garbage grinder(yes or no):9-0 Is laundry on a separate sewage system(yes or no):j4o [if yes separate inspection required] Laundry system inspected(yes or no):[O Seasonal use: (yes or no):8 0 Water meter readings, if available(last 2 years usage(gpd)): Sump pump(yes or no): j I Last date of occupancy:eKu r I oecc#18 COMMERCIAL/INDUSTRIAL 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: OTHER(describe): GENERAL INFORMATION Pumping Records Source of information: 01 n gd- Was system pumped as part Alof the inspection(yes or no): If yes,volume pumped: gallons--How was quantity pumped determined? Reason for pumping: TYPE OF SYSTEM 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 component? dat installed(if known)and spurce of information: 5" R1M �jq S'_ Lr 1 h �jrI V1G 6 T" Were sewage odors detected when arriving at the site(yes or 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: 21 OgD fc Vl P'r Owner: ) f,oni(/\ Date of Inspection: 1O- 0 U BUILDING SEWER(locate on site plan) Depth below grade: 3 � Materials of construction:_cast iron / 40 PVC_other(explain): Distance from private water supply well or suction line: Comments(on condition of joints,venting,evidence of leakage,etc.): SEPTIC TANK:v(locate on site plan) Depth below grade: 12 ' // Material of construction: 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: 3C Q Sludge depth: Distance from top of sludge to bottom of outlet tee or baffle: Scum thickness:I— i Distance from top of scum to top of outlet tee or baffle:— I N Distance from bottom of scum to bottom of outlet tee or baffle: How were dimensions determined: vyi e S L e.a Comments(on pumping recommendations, inlet and outlet tee or baffle condition,structural integrity, liquid levels as related to outlet invert,evidence of leakage,etc.): 570 b4i,c —l—a ok s(a011 I� �� to Z�W'� t C� 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: ` C sf Owner• Date of Inspection: t O •23 -o U 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: V (if present must be opened)(locate on site plan) Depth of liquid level above outlet invert: 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.): c e P 1 c�tAc-e o l cl s trr a ge r PUMP CHAMBER: (locate on site plan) Pumps in working order(yes or no): Alanns in working order(yes or no): Comments(note condition of pump chamber,condition of pumps and appurtenances,etc.): 1 , Page 9 of I 1 Page OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEMt INFORMATION(continued) Property Address: C a S e r' Owner: (N Date of Inspection:jp• Q3 •p p SOIL ABSORPTION SYSTEM(SAS): v/ (locate on site plan,excavation not required) If SAS not located explain why: Type leaching pits,number: leaching chambers,number: 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.): rb e v ��e>nc� cz� i�� �2 �r hoy►���.� or sa ra-l�� so,I s 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 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.): y Page 10 of 1 I OFFICIAL INSPECTION FORM—NOT FOR VOLUNR A ESSM NTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INS E TI NFO PART C SYSTEM INFORMATION(continued) Property Address: 1( dpc dS ee {— P Owner: kC'rf'a1i11 h i Date of Inspection:j p-2 -66 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. VENT LEACH FIELD i � I 102�� ' 36.3' DIST. B 0 X ��b. tx W/ INLET T W WELL OUSE 0 16. 3 1500 GALLON SEPTIC TANK Page 11 of 11 R VOLUNTARY ASSESSMENTS OFFICIAL INSPECTION FORM—NOT FOR SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) I Property Address: 54V,ee 11' Owner h i✓\ Date of Inspection: )Q- 23 SITE EXAM Slope Surface water Check cellar Shallow wells Estimated depth to ground water '>4- feet Please indicate(check)all methods used to determine the high ground water elevation: i Obtained from system design plans on record-If checked,date of design plan reviewed: 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 ou established the high round water elev on: �bs�rya- nom kole /I- Cie, ' I l`1 I I I I HEREBY CERTIFY THAT THE SUBSURFACE SEPTIC DISPOSAL SYSTEM HAS BEEN CONSTRUCTED IN GENERAL CONFORMANCE WITH THE APPROVED PLAN LISTED BELOW. CERTIFICATION IS FOR THE HORIZONTAL AND VERTICAL LOCATION OF SYSTEM COMPONENTS AS SHOWN ONLY. 1500g SEPTIC TANK 4" SCH40 ., TITLE: SUBSURFACE SEPTIC DISPOSAL SYSTEM UPGRADE PVC (TYP.) DECK `r 211 BOXFORD STREET 4" SCH40 l^�` NORTH ANDOVER, MASSACHUSETTS PVC (TYP.) 6.1% DISPOSAL FIELD 25'x 36' 4 PREPARED BY: O'NEILL ASSOCIATES lA0 56.6' =' - ` , , p - DATE: DATE: NOVEMBER 6, 2001 - REVISED TO APRIL 9, 2002 / a 2 1 2 2 S roRy r�...iy Ur ,�11Fl11t FOOD Q 20ARD OF r_...A�7I- #211 J ��,. N Q -r Michael O'Neill, P 6 OUTLET 137• ::- r_� f ,,, 4�>:u DISTRIBUTION BOX SCHEDULE OF INVERTS PROPOSED -AS-BUILT PROPOSED INVERT @ FOUNDATION EL.=88.50 EL.=90.36 / SEPTIC TANK INVERT (IN) EL.=87.50 EL.=86.91 SEPTIC TANK INVERT (OUT) EL.=87.25 EL.=86.64 EXISTING DOMESTIC DISTRIBUTION BOX INVERT IN) EL.=86.45 EL.=86.46 WELL DISTRIBUTION BOX INVERT OUT-L1) EL.=86.28 EL.=86.31 W 6 DISTRIBUTION BOX INVERT OUT-L2) - EL.=86.32 O DISTRIBUTION BOX INVERT PLAN DISTRIBUTION BOX crjINVERT (OUT-L4) - EL.=86.31 co NOT TO SCALE DISTRIBUTION BOX INVERT (OUT-L5) - EL.=86.31 Q DISPOSAL FIELD INVERTSTART-L1) EL.=86.18 EL.=86.20 DISPOSAL FIELD INVERT (START-L2) - EL.=86.20 z DISPOSAL FIELD INVERT START-0 - EL.=86.23 c DISPOSAL FIELD INVERT START-L4 EL.=86.22 DISPOSAL FIELD INVERT STARTL-5 - EL.=86.22 DISPOSAL FIELD INVERTEND-L1 EL.=86.00 EL.=86.01 a DISPOSAL FIELD INVERT (END- L2� - EL.=86.01 DISPOSAL FIELD INVERT END-L3 - EL.=86.02 C) DISPOSAL FIELD INVERT END-L4 - EL.=86.02 DISPOSAL FIELD INVERT END-L5 - EL.=86.02 AS-BUILT TIES POINT N0. A B NOTE: AS-BUILT FIELD MEASUREMENTS TAKEN 5-29-02 , FIELD BOOK 107, PAGES 63-64 N 1 58.0' 54.6' 2 65.2' 61.1' I O 'NEILL ASSOCIATES 0 0 BENCHMARKS (ASSUMED DATUM) 3 78.4' 71.8' Civil Engineers and Land Surveyors NO. DESCRIPTION ELEVATION 4 90.6' 86.0' IN 234 Park Street 3 L, BM#1 RT, CNR. BOTTOM STEP 99.45 5 74.3' 65.1' North Reading, MA 01864 BM#2 TOP EX. FDN. (SE CNR.) 95.38 6 105.2' 90.7' �1M OF MqSUBSURFACE SEPTIC SYSTEM C) t� d 0 7 118.8� 107.8 +! mlFWEL�r�� CD AS BUILT `° VEIL. Z. 211 BOXFORD STREET G No.27818 �� A �cIVIE NORTH ANDOVER, MASSACHUSETT � S � �`�TE ASSESSORS MAP 106A PARCEL 0254 300166ASB.DWG 'v�1•' � MAY 29, 2002 0 I HEREBY CERTIFY THAT THE SUBSURFACE SEPTIC DISPOSAL SYSTEM HAS BEEN CONSTRUCTED IN GENERAL CONFORMANCE WITH THE APPROVED PLAN LISTED BELOW. CERTIFICATION IS FOR THE HORIZONTAL AND VERTICAL LOCATION OF SYSTEM COMPONENTS AS SHOWN ONLY. 1500g SEPTIC TANK 4" SCH40 � - TITLE: SUBSURFACE SEPTIC DISPOSAL SYSTEM UPGRADE PVC (TYP.) A frll 211 BOXFORD STREET 4" SCH40 DECK �`•�' NORTH ANDOVER, MASSACHUSETTS G c PVC (TYP.) g.1% 2J'X 36' 4 r - '[ DISPOSAL FIELD - :• PREPARED BY: O NEILL ASSOCIATES �/ 56.6' r° 0 2 ,l. _,_ / ^�,' - ST p DATE: 2 DATE: NOVEMBER 6, 2001 _- REVISED TO APRIL 9, 2002 WOOS Y BOARC 21, r- , r Michael O'Neill, P.E. o / 6 OUTLET 137' - 7 DISTRIBUTION } SCHEDULE LE OF INVERT ��- "" S PROPOSED AS-BUILT C �w''_^L:" ..�.___ PROPOSED INVERT Ccs FOUNDATION EL.=88.50 EL.=90.36 / SEPTIC TANK INVERT (IN) EL.=87.50 EL.=86.91 SEPTIC TANK INVERT (OUT) EL.=87.25 EL.=86.64 EXISTING DOMESTIC DISTRIBUTION BOX INVERT (IN) EL.=86.45 EL.=86.46 WELL DISTRIBUTION BOX INVERT ((OUT-L1) EL.=86.28 EL.=86.31 6 DISTRIBUTION BOX INVERT (OUT-L2) - EL.=86.32 DISTRIBUTION BOX INVERT O PLAN DISTRIBUTION BOX INVERT (OUT-L4) - EL.=86.31 U m NOT TO SCALE DISTRIBUTION BOX INVERT (OUT-L5) - EL.=86.31 DISPOSAL FIELD INVERT START-L1) EL.=86.18 EL.=86.20 _ DISPOSAL FIELD INVERT (START-L2) - EL.=86.20 6 DISPOSAL FIELD INVERT START-L3 - EL.=86.23 DISPOSAL FIELD INVERT START-L4 EL.=86.22 DISPOSAL FIELD INVERT STARTL-5 - EL.=86.22 DISPOSAL FIELD INVERT (END-L1) EL.=86.00 EL.=86.01 DISPOSAL FIELD INVERT Q DISPOSAL FIELD INVERT _ EL.=86.01 �END-END-L2) 0 EL.-86.02 N DISPOSAL FIELD INVERT END-L4 EL.=86.02 DISPOSAL FIELD INVERT END-L5 - EL.=86.02 AS-BUILT TIES C POINT NO. A B NOTE: AS-BUILT FIELD MEASUREMENTS TAKEN 5-29-02 0 FIELD BOOK 107, PAGES 63-64 N 1 58.0' 54.6' 2 10 65'2° 61.1° 1 0 "NEILL ASSOCIATES 7 BENCHMARKS (ASSUMED DATUM) 3 78.4' 71.8' Civil Engineers and Land Surveyors NO. DESCRIPTION ELEVATION 4 90.6' 86.0' 234 Park Street s BM#1 RT. CNR. BOTTOM STEP 99.45 5 74.3' 65.1' North Reading, MA 01864 CD BM#2 TOP EX. FDN. (SE CNR.) 95.38 6 105.2' 90.7' SUBSURFACE SEPTIC SYSTEM ti1� of cl 7 118.8' 107.8' o�� Mlc .�r��� AS-BUILT w "No a i 211 BOXFORD STREET A clvl��o NORTH ANDOVER, MASSACHUSETTS "(ST ASSESSORS ASSESSORS MAP 106A PARCEL 0254 300166ASB.DWG MAY 29, 2002 Town of North Andover, Massachusetts Form No. 1 NORTH qti BOARD OF HEALTH L � ` ,LES 16 Sc yet 16 0 �O °� :w,.�>m APPLICATION FOR SITE TESTING/INSPECTION ��SSACH�S��.9 Applicant i nz de'-= 9n- NAME ADDRESS TELEPHONE Site Location Engineer 0/VG/�� :`- 979'J�4�141AII NAME ADDRESS p TELEPHONE Test/Inspection Date and Time - �?' /l. -Vow le) r� CHAIRMAN,BOARD OF HEALTH Fee / Test No. 16 t i S.S. Permit No. D.W.C. No. C.C. Date Plbg. Permit No. e Town of North Andover, Massachusetts Form No.2 NORTh BOARD OF HEALTH , o ,. p DESIGN APPROVAL FOR ,SSACHUSOIL ABSORPTION SEWAGE DISPOSAL SYSTEM 1 Applicant_ / / �C �LL�. �1��/f��/� Test No. Site Location ��� 0 '6 Sl , Reference Plans and Specsl �IKG C/GL- dd0l W li�tllby ENGINEER DESIGN DATE i Permission is granted for an individual soil absorption sewage disposal system to be installed in accordance with regulations of Board of Health. CHATAMAN,BOARD OF HEALTH P / f Fee Ito 0 Site System Permit No. C/lJf ti s z Form No.3 Town of North Andover, Massachusetts BOARD OF HEALTHt,IQ� NORTH . O<t1`aD Ia' 3? e�4. -.. OL O p �aD ^'q' DISPOSAL WORKS CONSTRUCTION PERMIT (J�l 1 ^� TELEPH NE Applicant NAME ADDRESS Site Location 211 1,eI - tion or Repair ( an Individual Soil Absorption hereby ranted to Construct ( ) 1 '' c� _ Permission Is he Y g roval S.S. No. Sewage Disposal System as shown on the Design APP 4 CHAIRMAN,BOA OF AL H r D.W.C. No. Fee `