HomeMy WebLinkAboutBuilding Permit #Exception - 74 WILLOW RIDGE ROAD 6/14/2014Permit NO:_
Date Issued:
TOWN OF NORTH AND . OVER
�APPILICATION FOR PLAN EXAMINATION
Date Received
IMPORTANT: Applicant must complete all items on this page
LOCATION
rint.
R
PROPERTY OWNE
'Print 100 Year Old Structure
MAP NO: PARCEL: ZONING DISTRICT: Historic District
Machine Shop Villa
yes no
yes no
ves no
TYPE OF IMPROVEMENT.
PROPOSED USE
Residential
Non- Residential
New Building
0 One family
D AcLdition
El Two or more family
11 Industrial
R*Alteration
No. of units:
0 Commercial
D Repair, replacement
El Assessory Bldg
El Others:
11 Demolition
11 Other
El 1. Septic 0 . Well
D Floodplain El Wetlands
El Watershed bistrict
D Water/Sewer
111F.RCRIPTION OF WORK TO BE PERFORMED:
A,�� r\Dt=-L �N� &
Identification Please Type or Print Clearly)
OWNER: Name: Phone:
Address:
CONTRACTOR Name: P-h—one-
Address:
Supervisor's Construction License: Exp. Date:
Home Improvem(
icense:
-.xp. Date:
ARCH ITECT/ENGI NEER Phon
Address: Reg. No.
FEE SCHEDULE: BULDING PERMIT., $12.00 PER $1000.00 OF THE TOTAL ESTIMATED COSTBASED ON $125.00 PER S.F.
Total Project Cost: $
FEE: $
Check No.: Receipt No.:
NOTE: Persons contracting with unregistered contra tors do not have access to the guarantyfund
Sig ature of contractor
Plans Submitted Li Plans Waived Certified Plot Plan Stamped Plans
"Pla n s� Waived .:,'-.-.Certified Plot Plan El Stamped Plans El
J.OPE�0"EWERAGEDISPOSAL
Public Sewer
Tanning/Massage/Body Art
Swimming Pools
�Weil El .
Tobacco Sales El
Food Packaging/Sales
Private,,(,septic tanl�, -etc-
_P z' a ster o 'Site El
ermjadht �Dtmp n�,
THE -FOLLOWING SECTIONS FOWOFFICE USE ONLY
INTERDEPARTMENTAL SIGN OFF - U FORM
�-APPROVED
.,:....,DATE, REJECTED, DATE
?LANNING & DEVELOPMEN 'T El
COMMENTS
.CONSERVATION Reviewed on Si..qnature
COMMENTS
HEALTH
COMMENT%"
Reviewed on
Zoning Board of Appeals: Variance, Petition No:– —Zoning Decision/receipt submitted yes
Planning Board Decision: Comme
Conservation Decision: :Comments
Water & Sewer Connection Permit
DPW Tovyo Engineer: Signature:
Located 384 US900C
kkE UtP.AKTW�AT. 7Tem,p Dumpster on site yes no
Located -at 12'4 Street
-Fire Depairti-nevit-sic
inatut0dato"
COM'MENTS
z�areet
V\",
\7--
SOIL PROFILE & PERCOLATION TEST DATA
A c.� e,, - N Lot No.
Town/City�� o . & S t r e e t azzxYCW'."-1V111')
Loc./Subdiv. 4,:4 Ae lan Owner
P
Investigator/ -60-., Observer
SOIL PROFILES -DATE
2.. 3. 4.
Elev.- Elev. Elev. ;-;-Elev�__
0 1%
01 0 0 ------------- I"
1
2
3
4
.J5
,6
7
8
9
10
Benchmark
Elevation
1
2
3
4
5
6
7
8
9
10
1
2
3
4
5
6
7
8
9
10
Location
Da.tum
Percolation Tests -Date
Pit Number 2 3 4 5
Start Saturation -
Soalc-Mins.
Start Test Time
Drop of 311 -Time
Drop of 611 -Time
Mins.lst 3"Drop
M;_ 1 A
Notes & Sketches on Back Frank C. Gelinas & Associates, North And.
Commonwealth of Massachusetts
City/Town of North Andover
System Pumping Record
Form 4
RECEIVED
FEB 15 2013
TOWN OF NORTH ANDOVER
HEALTH DEPARTMENT
DEP has provided this form for use by local Boards of Health. Other forms may be used, but the
information must be substantially the same as that provided here. Before using this form, check with your
local Board of Health to determine the form they use. The System Pumping Record must be submitted to
the local Board of Health or other approving authority within 14 days from the pumping date in
accordance with 310 CIVIR 15.351.
A. Facility Information
Important: When
filling out forms
on the computer,
use only the tab
key to move your
cursor - do not
use the return
key.
2
System Location:
-79
Address
North Andover
Ma 01845
City/Town
State Zip Code
System Owner:
Urn
mnk��, .
Name
Address (if different from location)
City/Town State Zip Code
Telephone Number
B. Pumping Record I
1. Date of Pumping 2. Quantity Pumped:
Date Gallons
3. Type of system: F-1 Cesspool(s) E/Septic Tank Ej Tight Tank El Grease Trap
F-1 Other (describe):
4. Effluent Tee Filter present? El Yes VI No If yes, was it cleaned? El Yes [I No
5. Condition of System: G
�Ij
6.. S stem Pumped By:
Vehicle License Number
Stewart's Septic Service
Company
7. Location where contents were disposed:
'1-S;T art's Pre-trea�ment Tant, 20 So. Mill Bradford, Ma 01835
re of
Signature of-Rzce6ving Facility
Date
Date
t5form4.doc- 03/06 System Pumping Record - Page 1 of 1
Commonwealth of Massachusetts
City/Town of No.Andover
System Pumping Record
Form 4
DEP has provided this form for use by local Boards of Health. Other forms may be used, but the
information must be substantially the same as that provided here. Before using this form, check with your
local Board of Health to determine the form they use. The System Pumping Record must be submitted to
the local Board of Health or other approving authority within 14 days from the pumping date in
accordance with 310 CIVIR 15.351.
6. System Pumped By:
N—ame
Stewart's Septic Service
Company
Vehicle License Number
contents were disposed:
aatment Plant, 20 So. Mill Bradford, Ma 01835
Signature of Hauler
Signature of Receiving Facility
Date
Date
t5form4.doc- 03/06 System Pumping Record - Page 1 of 1
A. Facility Information
Important:
When filling out
1 . System Location*
forms on the
r7z-1 lot
computer, use
C.
only the tab key
Address
1
to move your
--/Ma
No.Andover
01886
cursor - do not
use the return
City/Town
State
Zip Code
key.
2. System Owner:
RECEIVED
t�Q
//?C 6? -5
F7
- -An
Name
-0 Lult-
Address (if different from location)
TOWN OF NORTH ANLjUvr-
HEALTH DEPARTMENT'
City/Town
State
Zip Code
Telephone Number
B. Pumping Record
1 . Date of Pumping Date 2.
Quantity Pumped:
Gallons
3. Type of system: Cesspool(s) Septic
Tank E] Tight Tank
E] Grease Trap
F-1 Other (describe):
4. Effluent Tee Filter present? El Yes 0 No
If yes, was it cleaned?
El Yes El No
5. Condition of System: (11
60�:��j
6. System Pumped By:
N—ame
Stewart's Septic Service
Company
Vehicle License Number
contents were disposed:
aatment Plant, 20 So. Mill Bradford, Ma 01835
Signature of Hauler
Signature of Receiving Facility
Date
Date
t5form4.doc- 03/06 System Pumping Record - Page 1 of 1
Commonwealth of Massachusetts
City/Town of No. Andover
System Pumping Record
Form 4
DEP has provided this form for use by local Boards of Health. Other forms may be used, but the
information must be substantially the same as that provided here. Before using this form, check with your
local Board of Health to determine the form they use. The System Pumping Record must be submitted to
the local Board of Health or other approving authority within 14 days from the pumping date in
accordance with 310 CMR 15.351.
r1AY '10 H11
TOWN OF NORTH ANDOVER
HEALTH DEPARTMENT
Important:
When filling out
forms on the
computer, use
only the tab key
to move your
cursor - do not
use the return
key.
A. Facility Information
1. System Location:
74 willow Ridge Rd
Address
No. Andover
Ma
01845
City/Town State Zip Code
2. System Owner:
Mcginnis
Name
Address (if different from location)
City/Town
B. Pumping Record
1. Date of Pumping
3. Type of system:
F� Other (describe)
4/15/11
Date
El Cesspool(s)
State
Telephone Number
— 2. Quantity Pumped:
0 Septic Tank El Tight Tank
4. Effluent Tee Filter present? Ej Yes D No
5. Condition of System:
Good Condition
6. (zys+nm Pumped By:
Ujo,he-&( �Shoto
Name
Stewart's SeDtic Service
Company
7. Locati n where co te s were disposed:
rts Pre-trealt2l, Plant. 20 So. Mill
of
Signature of
Zip Code
1000
Gallons
El Grease Trap
If yes, was it cleaned? E] Yes E] No
Vehicle License Number
Ma 01835
Date 41
Date
t5form4.doc- 03/06 System Pumping Record - Page 1 of I
-C-\ Commonwealth of Massachusetts
City/Town of NORTH ANDOVER, MASSACHUSETTS
System Pumping Record NOV 14 2007
Form 4
,IANDOVER
DEP has provided this form for use by local Boards of He A.?TMENT I Record must
be submitted to the local Board of Health or other approving authority.
A. Facility Information
Important:
When filling out 1 , System Location:
forms on the
computer, use
only the tab key Address
to move your Q - Q\,\ a ace, V); I �fl"s
cursor - do not City/Town stalte Zip C6de
use the return
key. " 2. System Owner:
v4k"D Fu M N) C' i'YN n i
Name
Address (if different from location)
City/Town state Zip Code
q I q — to
Telephone Number
B. Pumping Record
1. Date of Pumping
3. Type of system: El
[-j Other (describe):
2. Quantity Pumped
Date
Cesspool(s) Ef Septic Tank
4. Effluent Tee Filter present? [] Yes ef No
5. Condition of System:
60
6. Sy,%em Pumped By:
Ullwr- rob�m -�b LG Pp- - AJH -
We 0 fv* I Ce Vehicle License Number
M�'k C(A Etabz' "�J"
Company I F
7. Location where contents were disposed:
!(360
Gallons
E] Tight Tank
If yes, was it cleaned? [I Yes 0 No
T-1 Gl-," 1) 1?
Signature of Hauler Date
http://www.mass.gov/dep/water/approvals/t5forms.htm#inspect
t5form4.doc- 06103 System Pumping Record - Page 1 of 1
1P,
TOWN OF NORTH ANDOVER
SYSTEM PUMPING RECORD
DATE:
SYSTEM OWNER DDRESS
SYSTEM LOCATION
(example: left front of house)
DATE OF PUMPING: QUANTITY PUMPED GALLONS
CESSPOOL: NO / YES SEPTIC TANK: NO YES
NATURE OF SERVICE: ROUTINE �/ EMERGENCY
OBSERVATIONS:
GOOD CONDITION
HEAVY GREASE
ROOTS
EXCESSIVE SOLIDS
SOLIDS CARRYOVER
S 'A STEM PUMPED BY:
COMMENTS:
CONTENTS TRANSFERRED TO:
FULL TO COVER
BAFFLES IN PLACE
LEACHFIELD RUNBACK
FLOODED
OTHER (EXPLAIN)
TO:
FROM:
NORTH ANDOVER, MASS No 19 7
BOARD OF HEALTH
DESIGN ENGINEER
Re: Soil Absorption Sewage
System Inspection
This is to certify that I have inspected the construction of the said disposal system at
14// 4, P I d 6 C k 0( ' North Andover, Mass.
SITE LOCATION
The grades and construction are as specified in my plans and specifications dated
PWA
A
'54
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