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HomeMy WebLinkAboutBuilding Permit #Exception - 332 CAMPBELL ROAD 4/9/2013 %40RT11 q BUILDING PERMIT6�AL TOWN OF NORTH ANDOVER ° w 0 APPLICATION FOR PLAN EXAMINATION - . ea 'Permit N0: Date Received Date Issued: �9SS�CMUS�� IMPORTANT: Applicant must complete all items on this page LOCATION_ J?� Print PROPERTY OWNER Rs3_6 O brl n pp Print MAP NO: PARCEL:U�ZONING DISTRICT: Historic District yes Machine Shop Village yes Cano� TYPE OF IMPROVEMENT PROPOSED USE Residential Non- Residential ❑ New Building VOne family BYAddition/-De-J k ❑ Two or more family ❑ Industrial ❑Alteration No. of units: ❑ Commercial ❑ Repair, replacement ❑AssessorY Bldg ❑ Others: ❑ Demolition ❑ Other ❑ Septic ❑Well ❑ Floodplain ❑ Wetlands ❑ Watershed District ❑ Water/Sewer MAn Cz R n R_sk1 16' L4,", 1"d 1znm L f�0,X (d I � CJk ADO �in�. lx2j inn, D� �Ybt��C' h@WL�CY n�\t16�'tltnS` 2 1 k�o 5' rul�,JJ a � dea�rpl't8n Identification Please Type or Print Clearly) OWNER: Name: o r,60_() Phone: Address: 3 of Gd`^hv9J 1 V`&a O d 4tS- CONTRACTOR Name: Phone: 7(F ftAf :2j4 cl,-1 -SU qk)9 2_ Address: ,/f l3�i-_ Paalig 0 S 1�rhT�rov /-9m- 0 "S-0— Supervisor's "01— Supervisor's Construction License:CS T Exp. Date: / Home Improvement License: Exp. Date: /L/3 OS-0 Lly/�� ARCHITECT/ENGINEER Phone: Address: Reg. No. FEE SCHEDULE:BOLDING PERMIT:$12.00 PER$1000.00 OF THE TOTAL ESTIMATED COST BASED ON$125.00 PER S.F. Total Project Cost: $ ugo Q�t FEE: $ Check No.: Receipt No.: NOTE: Persons contracting with u egistered contractors do not have access t the ua anty fund 17 - - - ,Signature of Agent/Owner Signature of contracto i a Plans Submitted ❑ Plans Waived ❑ Certified Plot Plan ❑ Stamped Plans ❑ ` TYPE OF SEWERAGE DISPOSAL Public Sewer ❑ Swimmin Tanning/MassageBody Art ❑�.. gPools El Well ❑ Tobacco Sales ❑ Food Packaging/Sales ❑ Private(septic tank,etc. ❑ permanent Dumpster on Site ❑ THE FOLLOWING SECTIONS FOR OFFICE USE ONLY INTERDEPARTMENTAL SIGN OFF - U FORM DATE REJECTED DATE APPROVED PLANNING & DEVELOPMENT ❑ ❑ COMMENTS NSERVATION Reviewed on Si nature k ,� Tbo COMMENTS CX/-J- � � ` s �H- EALTH Reviewed onSi nature —Y/4t- 1 COMMENTS ZoningB I' Board of Appeals: Variance, Petition No: Zoning Decision/receipt submitted yes Planning Board Decision: Comments Conservation Decision: Comments I .Wa$er& Sewer Connection/Signature& Date Driveway Permit DPW Towp- Engineer: Signature: Located 384 Osgood Street FIRE ®EPARTI4lIsa9T = Temp Dumpster on site fres no Located at 124:Main Street . Fire Depamerf signatureldate COMMENTS MORTGAGE INSPECTION PLAN City/Town N-A©WV\A A��oyEfa ,MA Date: Scale: Owner: Buyer. Deed Ref. \\S2 `2r�-i Plan No. Drawn per City/Town of e Assessors Map • V \�(9 j I Q` �k L • i � o To: I hereby certify that the above Mortgage Inspection Plan was prepared for use in connection with a new Mortgage and is not intended or represented to be a property line or land survey.It cannot be used for establishing fence, hedge, walls or building lilies. No responsibility is extended to the land owner,occupant or buyer.The location of the original building(s)as shown hereat was in compliance with the local applicable zoning bylaws in effect when constructed,with respect to horizontal dimensional requirements,to lot lines or is exempt from violation enforcement action tinder Mass G.L. Title VII,Chap.40A,Sec.7,unless otherwise shown herein.Subject buildino(s)lies in a flood zone designated Zone: X and shown on FIRM Map Conununity-Panel# 25oog Dated: Job No. JCD,INCORPORATED,LAND USE DEVELOPMENT CONSULTANTS 4 AUTUMN LANE,METHUEN,MA U 1844-3177 978-683-9932 i i FILE# 07 i A II SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: O..ner: Date of Inspection: f SKETCH OF SEWAGE DISPOSAL SYSTEM: include ties to at least two permanent references landmarks or benchmarks locate all wells within 100' (locate where public water supply comes into house) i 110 47 i I I j I I I I I -T 3 2- h h r I Vio (revised 04/2S/97)� page 9 of 10 „.,�..,,,.....,�w....,�.s ..,.,�...--.tea. All cig I I ' FILE# // 'f 107 Forest St. Middleton,MA 01949 (508) 774-2772 SEPTIC & DRAIN SERVICE _ _ i niORTH AT13-o -%RC► Or-HEALTH i I � o SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PROPERTY OWNER'S NAME:__ PROPERTY ADDRESS: .32 Ca—mo-hetll (/L ADDRESS OF OWNER:_... (if different) DATE OF INSPECTION: ��• ®7• NAME OF INSPECTOR: •THE PROFESSIONAL EXPERTS IN THE SEPTIC AND DRAIN INDUSTRY • ' I FILE# 11 O7 q8�--- 10'I Forest St. Middleton,MA 01949 (508) 774-2772 SEPTIC & DRAIN SERVICE SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION Property Address: 33 Z 0-a , �„�t� Address of Owner: Date of Inspection: //, q 7 � ,9 �( (If different) Name of Inspector: Phvi4 � rl_llj I am a DEP app rov d system inspect pursuant to Section 15.340 of Title 5 (310 CMR 15.000) Company Name: !"y' %O"ee lic Mailing Address: /V"JT-- Y" r' Telephone Number: 478•-771/9790 � P 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 inspection. The inspection was performed based on my training and experience in the proper function and maintenance of on-site sewage disposal systems. The system: Passes _ Conditionally Passes ',eeds Funher Evaluation By the Local Approving AuthoriN Fads Inspector's Signature: Date: // The Svstem Inspector shall submit a copy of this inspection report to the Approving Authority within thirty (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 Department of Environmental Protection. The original should be sent to the system owner and copies sent to the buyer, if applicable, and the approving authority. INSPECTION SUMMARY: Check 8, C, or D: A) SYSTEM PASSES: I have not found any information which indicates that the system violates any of the failure criteria as defined in 310 CMR 15.303. V Any failure criteria not evaluated are indicato below. 1. , / COMMENTS: p/1/ 1WA 1?l' j� �(�/� VV B) SY EM CONDITIONALLY PASSES: /Vy One or mores stem components as described in the "Conditional Pass section n eedlto be replaced or repaired. The system, upon completion of the replacement or repair, as approved by the Board of Health, will pass. I Indicate yes, no, or not determined (Y, N, or ND). Describe basis of determination in all instarices. If"not determined", explain why not. _ The septic tank is metal, unless the owner or operator has provided the system inspector with a copy of a Cenificate of Compliance (attached) indicating that the tank was installed within twenty (20) years prior to the date of the inspection; or the septic tank, whether or not metal, is cracked, structurally unsound, shows substantial infiltration or exfiltration, or tank failure is imminent. The system will pass inspection if the existing septic tank is replaced with a conforming septic tank as approved by the Board of Health. (revised 04/25/97) Pago 1 of 10 DEP on the World WPde Web http./Avww magnet.state ma.us/der Printed on Recycied Pacer FILE# SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: 33Z �� /` 40/ Mel X14 Owner: ��Q' 7— (1 r Date of Inspe6n:��� ii•o7- /6 Bj SYSTEM CONDITIONALLY PASSES !continued Sewage backup or breakout or high static water level observed in the distribution box is due to broken or obstructed pipe(s) or due to a broken, settled or uneven distribution box. The system will pass inspection if(with approval of the Board of Health). Describe observations: broken pipe(s) are replaced obstruction is removed distribution box is levelled or replaced _ The system required pumping more than four 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 odstruction is removed Cj 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 protea the public health, safery and the environment. I 1) SYSTEM WILL PASS UNLESS BOARD OF HEALTH DETERMINES THAT THE SYSTEM IS NOT FUNCTIONING IN A MANNER ti WH H WILL PROTECT THE PUBLIC HEALTH AND SAFETY AND THE ENVIRONMENT: 77 Cesspool or privy is within 50 feet of a surface water i"-a Cesspool or pri%)- 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 APPROPRIATE) DETERMINES THAT THE SYSTEM IS FUNCTIONING IN A MANNER THAT PROTECTS THE PUBLIC HEALTH AND SAFETY AND THE ENVIRONMENT: The system has a septic tank and soil absorption system (SAS) and the SAS is within 100 feet to a surface water supply or tributary to a surface water supply. The system has a septic tank and soil absorption system and the SAS is within a Zone I of a public water supoly'well. The system has a septic tank and soil absorption system and the SAS is within 50 feet of a private water supply well. The system has a septic tank and soil absorption system and the SAS is less than 100 feet but 50 feet or more from a private water supply well, unless a well water analysis 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. Method used to determine distance (approximation not valid). 3) OTHER i t (revised 04/25/97) Page 2 of 20 FILE# SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION. FORM PART A CERTIFICATION (continued) Propertv Address: /O Owner: /�� r �'� �/ Date of Inspection: DJ SYSTEM FAILS: //•d7, Yo , mus; indicate ether "Yes" or "No' as to each of the following: I have determined that the system violates one or more of the following failure criteria as defined in 310 CMR 15.303. The oas for this determination is identified below. The Board of Health should be contacted to-determine what will be necessary to come--, the failure. Yes No _ Backup of sewage into facility or system component due to an overloaded or clogged SAS or cesspool. Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS c• cesspool. Static liquid level in the distribution boa 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 1/2 day flov.. Required pumping more than 4 times'in the last year NOT due to clogged or.obstructed pipes;. Number of times pumped _. _ Any portion of the Soil Absorption System, cesspool or privy is below the high groundwater elevation. _ Am• porton of a cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. Any porton of a cesspool or prey is within a Zone I of a public well. An,..- porton of a cesspool or privy is within 50 feet of a private water supph well. Anv porton of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water supply well with r-o acceptable water quality analysis. If the well has been analyzed to be acceptable, attach copy of well water analysis fo, coliform bacteria, volatile organic compounds, ammonia nitrogen and nitrate nitrogen. E] LARGE SYSTEM FAILS: You must indicate either "Yes" or "No" as to each of the following: The following criteria apply to large systems in addition to the criteria above: The system serves a facility with a design flow of 10,000 g gpd or greater (large System) and the system is a significant threat to public health and safety and the environment because one or more of the following conditions exist: 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 iArea-IWPA) or a mapped Zone II of a public water supply well) I The owner or operator of any such system shall bring the system and facility into full compliance with the groundwater treatment program requirements of 314 CMR 5.00 and 6.00. Please consult the local regional office of the Department for further information. (revised 0{/25/97) Page 3 of 10 FILE# 07 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST Property Address: 3'32 a/dUGI� r Owner: Q Date of Inspection: //•07, Check if the following have been done: You must indicate either "Yes" or 'No" as to each of the following: Ye;~. No Pumping information was provided by the owner, occupant, or Board of Health. _ None of the system components have been pumped for at least two weeks and the system has been receiving normal flow rates during that period. Large volumes of water have not been introduced into the system recently or as part of this inspection. X As built plans have been obtained and examined. Note if they are not available with N;q. _ The facilih or dwelling was inspected for signs of sewage back-up. _ The system does not receive non-sanitary or industrial waste flow. _ The site %%as inspected for signs of breakout. _ All system components, excluding the Soil Absorption System, have been located on the site. '�•. _ The septic tank manholes were uncovered, opened, and the interior of the septic tank was inspected for condition of baffles or tees, material of construction, dimensions, depth of liquid, depth of sludge, depth of scum. The size and location of the Soil Absorption System on the site has been determined based on: The faciliry owner land occupants, if different from owner were provided with information on the proper maintenance of Sub-Surface Disposal Svstem. I Existing information. Ex. Plan at B.O.H. I Determined in the field (if anv of the failure criteria related to Part C is at issue, approximation of distance is unacceptable) [15.302311b1] i i j (revised 04/25/97) Page 4 of 10 FILE# 1 O' �T SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION PropertN Address:�3Z Owner: Date of Inspection((( 7 FLOW CONDITIONS RESIDENTIAL:21,E Design tiow J� g.p. ,1bedroom for S.A.S. Number of bedrooms: Number of current residents:� Garbage g,c der (yes or no!: Laundry co--ected to system es or no,:�S Seasonal use !yes or no): j Water meter readings, if available (last two (2) year usage (gpd): We, 30 �rvrvi S, f Sump Pump Ives or no):_fj . I Last date of occupant}•:—� �1/P/��y COMMERCIAUINDUSTRIAL• {ype of establishment._ o Design flow._gallonsrda\ Grease trap present: (ves or no Industria! \taste Holding Tank present: ties or no) ton-sanitary waste discharged to the Tale 5 system: lyes or no) 1%ater meter readings, if available Last pate of o cupanc-v OTHER: (Describe Last date of occupancv GENERAL INFORMATION PUMPING RECORDS and source of information a� System pumped as part of inspect�on: or no)_ If yes, volume pumped: zOoallonsJ(,� Reason for pumpingfj 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) VA Technology etc. Copy of up to date contract? Other APPROXIMATE AGE of all Components, date installed (if known) and source of information: 1273 Sewage odors detected when arriving at the site: (yes or no)1VO I (revised 04/25/97) Dago 5 of 10 qq FILE# SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) I Property Address: Owner: Date of Inspection: �� i BUILDING SEWER: (Locate on site plan) Depth below grade: !� Material of construction: —�Cast iron _40 PVC _other (explain) Distance fromprivate water supply well or suction Ir-t O P Diameter Y 'r Comments: (condition of joints, venting vi ence of leakage etc) SEPTIC TANK:41T (locate on site plan) 'Depth below grade: Material of construction:Yzoncrete _metal _Fiberglass '_Polyethylene _other(explain). If tank is metal, list age _ Is age confirmed by Certificate of Compliance _(Yes/No; Dimensions: �X� JVCe Sludge depth- Distance epth Distance from top of sludge to bottom of outlet tee or baffle: Scum thickness, Distance from top of scum to top of outlet tee or baffle: Distance from bottom of scum to booffutlet tee r baffle:_ How dimensions wnoere determined: Ul/ Comments: (recommendation for pumping, condition of let and o tlet tees or baffle , degih of Ii ui .level in relation outlet invert, tructura / integrity, evid ce of le�ge, etc.) /�/0- `S'/N GO GREASE TRAP:_L4/0 (locate on site plan) � I 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: i (recommendation for pumping, condition of inlet and outlet tees or baffles, depth of liquid level in relation to outlet invert, structural integrity, evidence of leakage, etc. (revised 04/25/97) Pago 6 of 10 i FILE# SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) PropemAddress:33ZL �*/ 0" �tJ� Datee of v � of Inspection: ` i/a7 yr TIGHT OR HOLDING TANK: "Tank must be pumped prior to, or at time, of inspection) (locate on site plan; Depth below grade: /vU Material of construction: _concrete _metal _Fiberglass _Polyethylene _other(explain) Dimensions: Capaciry gallons Design f)o"-: gallons%da% Alarm level. Alarm in working order _ Yes; No Date of previous pumping -Comments: (condition of inlet tee. condition of alarm and float switches, etc.) I I I DISTRIBUTION BOX:�ClS• (locate on site plan: �l ►�x►6 ��m�N�ovcs Depth of liquid level above outlet imert. Comments: 77T��� (note if level and distribution is equal,'evidence of slide carryove a 'denye�(leaks e i too R out of box, etc.) at� o d PUMP CHAMBER:j4—/(:9 (locate on site plan) Pumps in working order: (Yes or Not Alarms in working order (Yes or No, Comments: (note condition of pump chamber, condition ofum s and P P appurtenances, etc.) i. I; i I I; (revised 04/23/97) Paye 7 of 30 I �I FILE# //0T ell SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: Q � � /)N���y�• Owner: ��jj�� /_ / •v �l Yc� Date of Inoft n?:too SOIL ABSORPTION SYSTEM (SAS): (locate on site plan, if possible; exca tion not required, but may be approximated by non-intrusive methods) If not determined to be present, explain: Type: v leaching pits, number: ,(� leaching chambers, number:/"",� leaching galleries, number:-r4/ 49 leaching trenches, number,length: leaching fields, number, dimensions: overflow cesspool, number Alternative system: Name of Technology: o Comments: (note condition of soil, signs of hydraulic filur , level of pondir} , co dition of vegetation, e c d u�Z zioo/ i CESSPOOLS: _ (locate on site plan) U 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 (cesspool must be pumped as part of inspection) 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.) (revised 0{/25/97) Page 8 of 10 Y FILE# SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: ONner: fr�j��G!"l1'C�'� Date of Inspection: SKETCH OF SEWAGE DISPOSAL SYSTEM: include ties to at least two permanent references landmarks or benchmarks locate all wells within 100' (Locate where public water supply comes into house) yr Vol (40 C 11 i 4 -7-1 32--' •vv/ / /OV \ x-50 (revised 04/2S/97) Page 9 of 10 _7 • FILE# // 07 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: Owner. Date of Inspection: L� ii.07- �� Depth to Groundwater Feet Please indicate all the methods used to determine High Groundwater Elevation: Obtained from Design Plans on record Observation of Site (Abuning property, observation hole, basement sump etc.) Determine it from local conditions Check with local Board of health Check FEMA maps a heck pumping records Check local excavators, installers Use USGS Data Describe in your own words how you established the High Groundwater Elevation. (Must be completed) ij , All" A0 (revised 04/2S/97) Paye 10 of 10