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HomeMy WebLinkAboutMiscellaneous - 1000 TURNPIKE STREET 4/30/2018o m 2886 Date .. 4./ NORTM °f'"'°:•'"� TOWN OF NORTH ANDOVER p PERMIT FOR WIRING 40 ........ This certifies that ....L:. !.......r....� �'� - ........ � r ............................................................... has permission to perform ..... .' ...... ................................. wring in the buildingof - — ................ ................................ .................... ............ � at............................................................................... , North Andover, Mass. Fee .... ................. Lic. No.........................�� .......................................... . ..... ELECTRICAL INSPECTOR Check # WHITE: Applicant CANARY: Building Dept. PINK: Treasurer 49N TRECOM110A7J'E4LTHOFMASS4CHUSE 7S Office Use only C ' / DEPARMENTOFPUBLICS4FE7Y Permit No. BOARDOFFIREPREYEMONRWMTIOAN5270MR12:00 W Occupancy & Fees Checked UVAPPUCATTONFOR PERMIT TO PERFORMELECIRICAL WORK ALL WORK TO BE PERFORMED IN ACCORDANCE WITH THE MASSACHUSSTS ELECTRICAL CODE, Si% CMR 12:00 © (PLEASE PRINT IN INK OR TYPE ALL INFORMATION) Dat_ q Town of North Andover The undersigned applies for a permit to perform the electrical work described below. Location (Street 6 Owner or Tenant Owner's Address To the Inspector of Wires: Is this permit in conjunction with a building permit: Purpose of Building Existing Service % Ampszp// ��'Volts New Service Amps / Volts Number of Feeders and Ampacity Location and Nature of Proposed Electrical Work Yes(�N'o (Check Appropriate Box) Utility Authorization No. Overhead 12rundergr6und a No. of Meters Overhead M Underground No. of Meters �No. of Li ti Outlets No. of Hot Tubs o. of Transformers Total KVA No. Lighting Fixtures Swimming Pool Above Below Generators KVA 2-1 andground No. of Receptacle Outlets No. of Oil Burners No. of Emergency Lighting Battery Units No. of Switch Outlets No. of Gas Burners FIRE ALARMS No. of Zones No. of Ranges No. of Air Cond. Total Tons No. of Detection and Nu^of Disposals No. of Heat Total Total Pumps Tons KW Initiating Devices No. of Sounding Devices No. of Dishwashers Space Area Heating KW No. of Self Contained Detection/Sounding Devices Local Municipal Other No. of Dryers Heating Devices KW a Connections a No. of Water Heaters KW No. of No. of Signs Bailasis No. Hydro Massage Tubs / No. of Motors Total HP v A IrnuarloeCO R»artt9DtheregtmanalS&Vb%adxsftG==Laws Iha%eaa=tLabtldyhmxa=PolrynidgCat� i ('.mwdWcrits le#valatt YES NO s lha%ehnftdmfilproofof=x1odrOl� YES MM ffjouha%ecltedWYES,pleasemdc*theWofoomWbydmkffigthe bcx EViratim Date J VahteofE6drical Wcdc $ WotklnShRt /Jr j1 � J kgxe rD*Rapa;Wd Rao .4LkZ � Fatal FIRMNAME ` 0 C it r v ��3 J rr LicEt9ee "/% �`? �- �, Lit�eNo BusirXSSTCLNa �eL OWNFR'SWSURANCEWANER;Iamm=thatthel=iw t vel $�eitt�rane " orirsst lar�alec�rivaiati#as ewCorrallaws airad,Affys ,mftpm-&mvmi%mftrecienn. (Please check one) Owner Agents Telephone No. PERMIT FEE $ TBF09M10NW LTH0FMAS'�CHV'�77N Office Use only DEPARTMEWOFPUBLICS4MY Permit No. BOARD OFFIREPREIVEIVTIONREGULMOAN527CMR120 --' Occupancy & Fees Checked APPLICATION FOR PERMIT TO PERFORM ELECTRICAL WORK ALL WORK TO BE PERFORMED IN ACCORDANCE WITH THE MASSACHUSs rs ELECTRICAL CODE, 527 CMR 12:00 I ` (PLEASE PRINT IN INK OR TYPE ALL INFORMATION) DatO2- O Town of North Andover To the Inspector of Wires: The undersigned applies for a permit to perform the electrical work described below. Location (Street & Number)JL , �Q Owner or Tenant Owner's Address Is this permit in conjunction with a building permit: Yes No (Check Appropria t Purpose of Building ,= " Utility Authorization No. Existing Service ® 0 Amps% / VA o Overhead `Underground No. of Meters -- New Service Amps / Vo s Overhead= Undewound No. of Meters Number of Feeders and Ampacity _�- Location and Nature of Proposed Electrical o k V/,r f No. ofLiahtina Outlets . of Hot Tu ;l / _ of Tran rmers Total Fixtures No. of Receptacle Outlets No. of Switch Outlets No. of Ranges No of Disposals No. of Dishwashers t No. of Dryers No. of Water Heaters KW No. Hydro Massage Tubs OTHER 6 hisutaneCo Ptttsuarittheragtme I hmeaWWr1 L abk PGky h I have sttbmA�d valid pit�of� io the C WSURANCE d BOND KVA of Eri#rgency Lighting Battery Units No. of , f Total FIRE A RMS No. of Zones ffnd. f',a, Tons No. o at ✓/ Total Total o. of etection and um s�� Tons KW • is g Devices Spa Heating ` KW f No. of ounding Devices elf Contained Dete ion/Sounding Devices HIcei KW Local Municipal Other s Connections o. of Arlo Total HP I i Laws Corr fete o►a"ageorilsakstar>baleWiv� YES NO M YES i Ifjxuhmedte WYE.'S,pleaseudic*the Wcfout Wbydockfftgthe animR (Pleaespe* ExExi-atirn Die Va9a ofE1ectri -A Wcrk WotkiDStart �� / L hWocfionD*Ragtl,*'d Rwgjt Ia>da�ieP��albesofpajtay _ j� FRM P P. FIRM NAME �,! /? Li== JQ% i r, P /'�C 1 4W Signane 26 OWNER'SII,SURANCEWANER,I.amawat dAtheLieeae �einsxanet ragetress>bs r�ialec�rivaia�as GerteralLaws aaddvtmysig e,on tpanitappficmmwai%e;ftragtmenat (Please check one) OwnerID . Agent o� dem Telephone No. PERMIT FEE $ U -�� Location M/T p, //,- No. �— r Date�t� i TOWN OF NORTH ANDOVER Certificate of Occupancy $ sCMUs Building/Frame Permit Fee $ C.3,^ Foundation Permit Fee $ Other Permit Fee $ TOTAL $ Check #145 9 Building lh-pector 1.1 Property Address: 1.2 Assessors Map and Parcel Number: 2.1 Owner of Record syGu/ rr�i eta l� %VMpI'�� 100(0 d'L- Name (Print) Address for Service Signature Telephone " Map umber Iii,Parcel Number Signature Y Telephone 1.3 Zoning Information: SECTION 3 - CONSTRUCTION SERVICES 1.4 Property Dimensions: 3.1 Licensed Construction Supervisor: Not Applicable ❑ Licensed Construction Supervisor: Zoning District Proposed Use License Number Lot Areas Frontage ft 1.6 BUILDING SETBACKS ft Front Yard Side Yard Rear Yard Required Provide RegWred Provided ReqWred Provided 0 Crdd irl 5 1441` Q aur1C k j Company Name 1.7 Water Supply M.G.L.C.40. 54) 1.5. Flood Zone Information: 1.8 Sewerage Disposal System: Public ❑ Private 0 ' Zone Outside Flood Zone 0 Municipal ❑ On Site Disposal System 0 SECTION 2 - PROPERTY OWNERSIIIP/AUTHORIZED AGENT 2.1 Owner of Record syGu/ rr�i eta l� %VMpI'�� c�Z�^ Name (Print) Address for Service Signature Telephone 2.2 Owner of Record: Name Print .s Address for Service: Signature Y Telephone SECTION 3 - CONSTRUCTION SERVICES 3.1 Licensed Construction Supervisor: Not Applicable ❑ Licensed Construction Supervisor: 04e6 Z License Number l / n�� ��. ���/ �� '�v Address �$ Z Expiration Date U / Signature Telephone 3.2 Registered Home Imprrovemeent Contractor Not Applicable 0 0 Crdd irl 5 1441` Q aur1C k j Company Name Registration Number Expiration Date /zy 4A &V / Address I p 9 %�— / J" Signature Telephone M M X z O Q� 1V 1V 6 0 O z M 90 O ic r M�pp _r z A Y/ Alop SECTION 4 - WORKERS COMPENSATION (M.G.L C 152 § 25c(6) Workers Compensation Insurance affidavit must be completed and submitted with this application. Failure to provide this affidavit will result in the denial of the issuance of the building permit. Signed affidavit Attached Yes ..... bkr No ....... ❑ SECTION 5 Description of Proposed Work check all applicable) New Construction ❑ Existing Building ❑ Repair(s) ❑ Alterations(s) ❑ Addition Accessory Bldg. ❑ Demolition ❑ Other ❑ Specify Brief Description of Proposed Work: Ca �,1'zLrvc t— k /(p 1 TL n rec)m 44th & n )6mr-i@ fah D1 P.r• Ag ern tt i SECTION 6 - ESTIMATED CONSTRUCTION COSTS Item Estimated Cost (Dollar) to be Completed by permit a2plicant OFA IC1i�L USE O1�ILY 1. Building � (a) Building Permit Fee Multiplier 2 Electrical 5000 (b) Estimated Total Cost of Construction 3 Plumbing Building Permit fee (a) X (b) F 4 Mechanical HVAC 5 Fire Protection —� 6 Total 1+2+3+4+5 7""s—coo Check Number SECTION 7a OWNER AUTHORIZATION TO BE COMPLETED WHEN OWNERS AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT I, as Owner/Authorized Agent of subject property Hereby authorize to act on My behalf, in all matters relative to work authorized by this building permit application. Signature of Owner Date SECTION 7b OWNER/AUTHORIZED AGENT DECLARATION a— L.- r- as Owner/Authorized Agent of subject property Hereby declare that the statements and information on the foregoing application are true and accurate, to the best of my kno kedge and belief TQ,4 P'-- 19- 144-- BUY' Print Name Signature of Owner/A ent Date wai NO. OF STORIES SIZE X /b BASEMENT OR SLAB T SIZE OF FLOOR T&IBERS IsT ZX) 2 2ND 3 SPAN DIMENSIONS OF SILLS DIMENSIONS OF POSTS DIMENSIONS OF GIRDERS Z - j HEIGHT OF FOUNDATION Av THICKNESS SIZE OF FOOTING ' 4111S Q vG Q}; X MATERIAL OF CHIMNEY &J4 IS BUILDING ON SOLID OR FILLED LAND -Sbl Im IS BUILDING CONNECTED TO NATURAL GAS LINE .f/ o� y 0 0 c � 0 N a CL _ L LL fp Q •, m � d o C +. C �NmJ NUJ o�� 3ooU UQ ,sod � w Q dim aQ)c' Qj b r- QooQ L m R aa� Zoe C/) FORM - U - LOT RELEASE FORM INSTRUCTIONS: This form is used to verify that all -necessary approval/ permits from Boards and Departments having jurisdiction have been obtained. This does not relieve the applicant and or landowner from compliance with any applicable requirements. APPLICANT Z-� e. Lc Fl e e✓ PHONE 24,5- ASSESSORS js ASSESSORS MAP NUMB/ER -107C, LOT NUMBER Z D SUBDIVISION LOT NUMBER STREET %yrn p/' !-e d'6 - STREET NUMBER /D 00 �.......................... OFFICIAL USE ONLY.4 RECOI\N4ENDATIONS OF TOWN AGENTS v �1 DATE APPROVED 1406 CON ERVATION ADMINISTRATOR DAT REJECTED DATE APPROVED TOWN PLANNER DATE REJECTED_ DATE APPROVED FOOD INSPECTORFTHS DATE REJECTED �=L%�=✓ V ATE APPROVED SEPTIC INSPECTOR - HEALTH / /1 DATE REJECTED 4R 1 e X104) PUBLIC WORKS - SEWER / WATER CONNECTIONS DRIVEWAY PERMIT DATE APPROVED FIRE DEPARTMENT DATE REJECTED COMMENTS RECEIVED BY BUILDING INSPECTOR i NEW ENGLAND ENGINEERING SERVICES, INC 60 BEECHWOOD DRIVE NORTH ANDOVER, MA 01845 100b TURNPIK SyT�REPT �. ?� �---- END OF TRENCH }� e DECK 1000 GALLON SEPTIC TANK SEPTIC SYSTEM LOCATION PLAN 1000 TURNPIKE STREET NORTH ANDOVER, MASS SCALE: 1"- 20' BOARD OF BUILDING REGULAT€ONS !24License: CONSTRUCTION SUPERVISOR Number: CS 048827 —_ Birthdate: 08/28/1963 Expires: 08/28/2001 Tr. na: 4185 Restricted To: 00 ROBERT A LAFLEUR 123 LAFAYETTE ST LOWELL, MA 01854 Administr-.tor ` I 2 r i CONTRACTOR w xR fati��i'F€fQi ROBOT A LAFLEM ROBERT A, LMFFLEJnh } Lrcac`i' tAVAYETTE E - AOAR vis 'TOR MEL". #A 01854 � ti 41 The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations Boston, Mass. 02111. Workers' Compensation Insurance Affidavit Please Print Name: Location: City Phone am a homeowner performing all work myself. aI am a sole proprietor and have no one working in any capacity (� I am an employer providing workers' compensation for my employees working on this job. Company name: 6�cJ% %�Jn� !�' "0 i` P.(J'/a✓1 C,� Address 1-4&1 LlLe 2- ` City %t a- jI Mi1' 0/0-5-4 Phone Insurance Co. ee•Tb�a - '4LAyor f Policy # WC 79'3Z?(? Company name: Address City Phone # Insurance Co. Policy # Failure to secure coverage as required under Section 25A or MGL 152 can lead to the imposition of criminal penalties of a fine up to $1,500.00 and/or one years' imprisonment as well as civil penalties in the form of a STOP WORK ORDER and a fine of ($100.00) a day against me. I understand that a copy of this statement may be forwarded to the Office of Investigations of the DIA for coverage verification. I do herby certify under the pains and penalties of perjury that the information provided above is true and correct_ Signatur -r Date 4F • ZG - all Print name 2a,� 44 1-/ Phone # '99&9 .?Zls Official use only do not write in this area to be completed by city or town official' C Building Dept ❑Check if immediate response is required Building Dept p Licensing Board F1 Selectman's Office Contact person:_ Phone #. F-1 Health Department F-1 Other FORM WORKMAN'S COMPENSATION Town of North Andover o� Na TH 6 o Building Department o M 27 Charles Street North Andover Massachusetts 01845 Z .^ (978) 688-9545 Fax (978) 688-9542 Q�4 "`�`"w • "� �dSn ATeo PY DEBRIS DISPOSAL FORM In accordance with the provisions. of MGL c 40 s 54, and a condition of Building permit .# the debris resulting from the work shall be disposed of in a properly licensed solid waste disposal facility as defined by MGL cl 1, s150a. The debris will be disposed of in /at: Facility location Signature of Applicant ,9 - Date -Date NOTE: A demolition permit from the Town of North Andover must be obtained for this project through the Office of the Building Inspector. MR. Andir �]AfwMAMLAM- Prefessi0i Professional Building & Remodeling, On time, On Budget, or We'll Pay You, Guaranteed in Writing AGREEMENT FOR SERVICES This Agreement, along with the attached plans and specifications (if applicable), is the entire Agreement, and replaces any prior agreements. Date of this Agreement: September 16, 2000 Name of Salesperson: Robert A. LaFleur Description of work to be completed: Sunroom addition. See attatched specifications. Limitations on work to be completed: Any items of work or services not specifically provided for in this Agreement are excluded. This excludes, but is not limited to, any unspecified alterations to existing structures or disposal of unrelated existing materials on site. Client name and address: Mr. & Mrs. Paul Pierog, 1000 Turnpike St., N. Andover, MA 01845 978-685-1007 Job Location: Same Price of specified work to be completed: $40,536.00 Payment Terms: $5000.00 due upon execution of Agreement for Services. Equal payments of $6,800.00 beginning on start date and continuing weekly thereafter for a total of five weeks. Balance of $1,536.00 due upon completion. Completion: Work shall be deemed complete when all stated services have been initially completed. It is understood that routine "punch -list" and repair items are beyond the scope of completion and are covered under builder's warranty obligations. Builder is not responsible for delays incurred due to the actions or inactions of city/town officials, strikes, Acts of God, unfulfilled customer obligations or other delays beyond our control with regard to this agreement. Work will commence on or about October 3, 2000 and be completed within six weeks of start date. A 48 hour notice will be given prior to actual contract start date. Building Professionals will incur a penalty of $100.00 per business day starting on the 36th business day after start date and continuing to completion of job. Additional work: Any alteration or deviation from above specifications involving extra costs, will be executed only upon written orders, and will become an extra charge over and above the amount specified above. Insurance: Owner to carry fire, tornado, and other necessary insurance upon above work. Public Liability Insurance and Workmen's Compensation Insurance on above work to be taken out by Building Professionals. Notice: All home improvement contractors and subcontractors shall be registered and any inquiries about a contractor or subcontractor relating to a registration should be directed to: Director, Home Improvement Contractor Registration, One Ashburton Place, Room 1301, Boston, MA 02108, Tel. (617) 727-8598. Your cancellation rights: Subject to the provisions of MGL c.93, s.48; MGL c. 140D, s.10 or MGL c.255D s.14, as may be applicable, the owner may cancel this contract within three business days of the date the contract was signed. Warranty: Building Professionals warrants its work and the product(s) used therein against defects in materials and workmanship for a period of one year from the date on the Invoice for final payment. During the warranty period, Building Professionals will, at its option, either repair or replace products or workmanship which prove to be defective. This warranty shall not apply to defects or damage resulting from improper or inadequate maintenance by the customer, customer supplied products, unauthorized modification or misuse, damage incurred as a result of Acts of God or Civil Strife. The warranty set forth above is exclusive and no other warranty, whether written or oral, is expressed or implied. Building Professionals specifically disclaims the implied warranties or merchantability and fitness for a particular purpose. MCLS # 048827 HICR # 117932 FEIN # 04-3407556 123 LAFAYETTE ST. LOWELL, MA 01854 978-970-3215 Owner's Rights: You are dealing with a registered Home Improvement Contractor and are entitled to certain rights under the provisions of 780 CMR Wand MGL c. 142A. Liens: There are NO liens or security interests on the residence listed above as a consequence of this contract. Final Payment: If final payment is not received within 30 days of completion, the owner shall be responsible for all court costs and other costs incurred by the contractor, in attempting to collect final payment. Permits: All necessary construction -related permits will be obtained by the contractor or its subcontractors. Any owner who secures a construction -related permit on their own, shall be excluded from access to the Guaranty Fund. Unregistered contractors: Any owner who deals with an unregistered contractor will be excluded from access to the Guaranty Fund. Building Officials: Any additional costs incurred by the contractor as a result of decisions made by building officials will be the responsibility of the homeowner. The cost of the additional work will be calculated as follows: Material cost plus an hourly rate of $30.00/man hr., plus a reasonable mark-up for profit and overhead. Arbitration: The contractor and the homeowner hereby mutually agree in advance that in the event the contractor has a dispute concerning this contract, the contractor 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 MGL c.142A. Owners Name(s) Date LaFleur Date NOTICE: The signatures of the parties above apply only to the agreement of the parties to alternate dispute resolution initiated by the contractor. The owner may initiate alternative dispute resolution even where this section is not signed separately by the parties. All work to be completed in a good and workmanlike manner. All changes shall be indicated on this Agreement, plans and specifications (if applicable) and initialed by both parties. The above prices, specifications and conditions are satisfactory and are hereby accepted by all parties. Building Professionals is authorized to perform the work as specified. Payment will be made as outlined above. Owners Name(s) Date Contractor, Robert A. LaFleur Date Building Professionals Proposal - Specifications 123 Lafayette St. Lowell, 01854 NAME/ADDRESS Mr. Paul Pierog 1000 Turnpike St. No. Andover, MA 01845 DATE Proposal # l 1/12/2000 I 2000008 PROJECT Sunroom DESCRIPTION QTY UOM LAB/MAT/OTH Building Permit 1 EA OTH 15 YD. dumpster 1 EA OTH Pour continuous concrete footings 10" deep x 20" wide with #4 5 LF LAB rebar 2'-0" o.c. Dig out by hand to a depth of 4'-0", install 12" diameter sonotube, 5 EA LAB j pour concrete, and backfill. 12" x 4' sonotube, ready mix concrete, anchor bolts, and post 5 EA MAT anchors for pier footings. Install 6x6 wood suppport posts up to 8' high. 5 EA LAB 6x6 pressure treated support post up to 8' 5 EA MAT Pour 6" thick exterior concrete slab on grade. 35 SF LAB 6" thick exterior concrete slab on grade. 35 SF MAT Install double 2x12 built up wood beam. 36 LF LAB Double 2x12 kd spf #2 & btr. wood beam 36 LF MAT (above includes extra beam for hot tub) Install 4mil poly vapor barrier and cover with 4" of 3/4" crushed 1 EA LAB/MAT stone. Install 2x12 floor joists 16" o.c., including joist hangers, headers, 224 SF LAB bridging, and fasteners. 2x12 KD SPF #2&BTR. floor joists 16" o.c., including joist 224 SF MAT hangers, headers, bridging, and fasteners. Install 3/4" t&g subfloor. 224 SF LAB 13/4" OSB t&g subfloor, including fasteners and glue. 224 SF MAT Install 1/2" 4x8 under floor sheathing. 224 SF LAB 1/2" cdx fir plywood 4x8 sheathing including fasteners. 224 SF MAT Construct bearing wood stud wall consisting of 2x6 kd spf studs 472 SF LAB 16" o.c., double top plates, single sole plate, doortwindow headers per code. Bearing wood stud wall consisting of 2x6 kd spf studs 16" o.c., 472 SF MAT double top plates, single sole plate, door/window headers per code. install 112" 4x8 wall sheathing. 516 SF LAB 1/2" cdx fir plywood 4x8 sheathing including fasteners. 516 SF MAT Paae 1 TOTAL Building Professionals 123 Lafayette St. Lowell, 01854 NAME/ADDRESS Mr. Paul Pierog 1000 Turnpike St. No. Andover, MA 01845 Proposal - Specifications DATE Proposal # 1/12/2000 2000008 PROJECT Sunroom DESCRIPTION QTY UOM LAB/MAT/OTH (Above framing includes framing around hot tub) Install 2x10 roof rafters 16" o.c., with 2x12 ridge board and collar 336 SF LAB ties. 2x10 roof rafters 16" o.c. with 1/2" cdx fir plywood roof sheathing. 336 SF MAT 2x6 kd spf collar ties 16" o.c. 96 SF MAT Install 2x6 kd spf ceiling joists/collar ties 16" o.c. 84 SF LAB Install 1/2" roof sheathing. 336 SF LAB j 1/2" cdx fir roof plywood 336 SF MAT Install #2 primed pine fascia/rake/frieze board up to 1x12 56 LF LAB #2 primed pine fascia/rake/frieze board up to lx12 56 LF MAT Install fascia/rake trim moulding (flat/crown/bed) 56 LF LAB Fascia/Rake trim (crown/bedillat) moulding up to 21/2" width 56 LF MAT 25 yr_ 2501b.3 -tab fiberglass roof shingles, 8" galvanized drip edge 400 SF MAT and roof nails. Install 25 year 250 lb. 3 -tab fiberglass roof shingles and 8" 336 SF LAB galvanized metal drip edge along rakes and eaves. 7-12 pitch Windows 1 PKG LAB/MAT 3-024 casements, white, screens, HP glass, grille, and hardware I -C34 casement, white, screens, HP glass, grille, and hardware I-CTC2 circle top, white, HP glass, grille, and interior trim 12- Velux VS304 venting skylight, screen, Low "E" glass, operating irod FWG6068 Andersen patio door upcharge (N/C) 1 EA LAB/MAT Install 18" cedar shakes with 8 1/2" exposure, using 5d galvanized 350 SF LAB box nails. 18" red cedar shakes with 8 1/2" exposure including 5d galvanized 400 SF MAT box nails Extend heat to new room addition. 1 EA LAB/MAT Install/relocate duplex receptacles per code, white or ivory. 8 EA LAB/MAT Install 6" recessed can fixture with black baffle and white trim. 4 EA LAB/MAT Includes dimmer or toggle switch(es) Install ceiling fanlight including dimmer switch, wall speed 1 EA LABIMAT control, and circuit. TOTAL ,f-4 N_ Paue 2 Building 'Professionals A 123 Lafayette St. Lowell, 01854 NAME/ADDRESS Mr. Paul Pierog 1000 Turnpike St. No. Andover, MA 01845 Proposal - Specifications DATE Proposal # 1/12/2000 2000008 PROJECT Sunroom DESCRIPTION QTY UOM LAB/MAT/OTH Ceiling fanlight allowance $175.00 1 EA MAT Install phone jack. 1 EA LAB/MAT Install cable jack 1 EA LAB/MAT Ground Fault Circuit Interrupter outlet including dedicated 2 EA LAB/MAT iInstall circuit. Install outdoor fixture with switch 1 EA LAB/MAT Outdoor fixture allowance $100.00 1 EA MAT Install r] 9 kraft faced insulation 728 SF LAB Rl 9 x ] 5 krall faced fiberglass insulation 728 SF MAT (Above insulation includes insulation around hot tub) Install R30 kraft faced insulation. 280 SF LAB R30 x 15 kraft faced insulation 280 SF MAT Install 1/2" blueboard 764 SF LAB/MAT Install skim coat plaster finish over blueboard 764 SF LAB/MAT Install pre -finished 25/32" x 2 1/4" T&G solid oak flooring. 224 SF LAB 3/4" X 2 1/4" prefinished oak flooring 224 SF MAT 3 1/2" pine clamshell, ranch or colonial baseboard. 60 LF MAT Install 1/2" pine clamshell, ranch or colonial baseboard. 60 LF LAB Trim existing window with 2 1/2" casing, apron, stool cap, and 7 EA LAB extension jambs as needed. 2 1/2" casing, stool, apron, and ext. jamb for existing window 7 EA MAT TOTAL Jj -t Paae 3 b N a 1 b N a CD o�co)� rw p °'moo °000 fnD� rim r -d m � xvccf Ooh. ; N wham?,- o m co T O 4 2 00 4t to O• W � N fit b N a co ° z -11 co —a O N N N Q OO � N cep 4 Vl cog'o ' r,r- m to A v OD 00 � (D wrwamar Ncnomco O _ 0, m .TSI A (o�D ` y O w O/ N y /%?-0 CD tm2 CD/ )§�}§�� �aM4� CD /2\« E�2 00 Cb N(31 % o « �C, e ¢ f, } § # ■ � f co /J/kƒ� ¥ 02 ƒ g k c -R,3ƒ �¢( k o §)E§%$n 'O'D4/CD » � §302#%0 2 �m��•. e cnI £ ) D w # •O yjk �,!voq-q A / \ r m 2 D / � ƒ ƒ CD J (/s r q o ƒ�§ o k ƒ/ ■kƒ - § & %/��ok CO\w\Q% » i { ca N3 4c 0 Q / 2 mom,• k 2l n 2 D q & \ � sE 5,m �« On I 2`§ ,i , m 2 D / � ƒ ƒ CD J q o ƒ�§ o k ƒ/ ■kƒ %/��ok CO\w\Q% D ca N3 4c 2 mom,• k 2l n 2 (� \ � § f % % { k ( k) a ƒ ( O z 0 a 0 M 0 V m e o C2 C H ' � C C.3 V Q, C ea y�0 > , E a _ = CD o K O`Ec O: V O ; ci� m c m �O W oO cm • c ti C :o IDLo o�WE r ff. m w�Z O' t :o`er a c Q o mc .o _ ® :mw3 N C* +- D W OC r� NJ ��is GO "EL= C= w ®'vs O cm CO3 d CD O� J _ l0 � y 'O O I-- r �®.�m S T O Cm CO2 O O— ECDco m m 3� L m O Q CL cma CO2 s -a Q 'c. o,C? c Z 5 CL C.3 y � c c— �� C c — H D U) w w Ccw U) O o w U) aS. cn U a z w w G U ctl w" W 00 a a nG '� w W a w W a w ci w O H ` 0 w Ctl x ZW w a4 z CO o cn 0 V m e o C2 C H ' � C C.3 V Q, C ea y�0 > , E a _ = CD o K O`Ec O: V O ; ci� m c m �O W oO cm • c ti C :o IDLo o�WE r ff. m w�Z O' t :o`er a c Q o mc .o _ ® :mw3 N C* +- D W OC r� NJ ��is GO "EL= C= w ®'vs O cm CO3 d CD O� J _ l0 � y 'O O I-- r �®.�m S T O Cm CO2 O O— ECDco m m 3� L m O Q CL cma CO2 s -a Q 'c. o,C? c Z 5 CL C.3 y � c c— �� C c — H D U) w w Ccw U) TOWN OF NORTH ANDOVER BUILDING DEPARTMENT APPLICATION TO CONSTRUCT REPAI RENOVATE, OR DEMOLISH A ONE OR TWO FAMILY DWELLING BUILDING PERMIT NUMBER: DATE ISSUED: SIGNATURE: 'U /C Building Commissioner/1or of Buildings Date SECTION 1- SITE INFORMATION I 1.1 Property Address: 1.2� Assessors Map and Parcel Number: 2.1 Owner of Record b ul f'i ely q, 1,00o %-urna,)ee CIL--'i ' �� U 2.2 Owner of Record: Name Print Address for Service: Q ' Map umber Parcel Number 3.1 Licensed Construction Supervisor: 1.3 Zoning Information: Licensed Construction Supervisor: 1.4 Property Dimensions: License Number d • S3 206 • `7U fi Zoning District Proposed Use 3.2 Registered Home Improvement Contractor Lot Area Frontage ft 1.6 BUILDING SETBACKS ft Company Name- ame Registration Number Front Yard Side Yard Rear Yard R •red Provide RegWred Provided Required Provided v 1.7 Water Supply M.G.L.C.40. 54) 1.5. Flood Zone Information: 1.8 Sewerage Disposal System: Public 0 Private ❑ Zone Outside Flood Zone 0 Municipal ❑ On Site Disposal System 0 SECTION 2 - PROPERTY OWNERSHIP/AUTHORIZED AGENT 2.1 Owner of Record b ul f'i ely q, Name (Print) Address for Service Signature Telephone 2.2 Owner of Record: Name Print Address for Service: Signature Tele hone SECTION 3 - CONSTRUCTION SERVICES 3.1 Licensed Construction Supervisor: Not Applicable ❑ Licensed Construction Supervisor: 0480 Z7 License Number lz? 14Lve `/ �� Address '�7 • ! �� Expiration Date Signature Telephone 3.2 Registered Home Improvement Contractor Not Applicable ❑ / `�% �•-l� Company Name- ame Registration Number l014 � �.C'c �1G l0 J r�' ���/ � �' 12& Address �— Expiration Date Signature Telephone SECTION 4 - WORKERS COMPENSATION (NLG.L. C 152 § 25c(6) Workers Compensation Insurance affidavit must be completed and submitted with this application. Failure to provide this at in the denial of the issuance of the building permit. Si ned affidavit Attached Yes ..... No ....... 0 SECTION 5 Description of Proposed Work check all applicable) New Construction ❑ Existing Building ❑ Repair(s) ❑ Alterations(s) ❑ Addition 4; Accessory Bldg. ❑ Demolition ❑ Other ❑ Specify Brief Des�c}ription of Proposed Work: t J '16ro`le- an Di er- '406'19!-P I SECTION 6 - ESTIMATED CONSTRUCTION COSTS I will result Item Estimated Cost (Dollar) to be O�CIAL O� USl�`�NK Completed b permit a licant ✓ 1. Building (a) Building Permit Fee 20 D®(J Multiplier 2 Electrical (b) Estimated Total Cost of Y000 f7U Construction 3 Plumbing Building Permit fee (a) X (b) 4 Mechanical (HVAC) -- 5 Fire Protection 6 Total 1+2+3+4+5 ?�S�Q?p Check Number SECTION 7a OWNER AUTHORIZATION TO BE COMPLETED WHEN OWNERS AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT I, , as Owner/Authorized Agent of subject property Hereby authorize to act on My behalf, in all matters relative to work authorized by this building permit application. Signature of Owner Date SECTION 7b OWNER/AUTHORIZED AGENT DECLARATION L. &-& (2-. as Owner/Authorized Agent of subject property Hereby declare that the statements and information on the foregoing application are true and accurate, to the best of my knowledge and belief Print Name i- Za Si afore of Owner/A ent Date NO. OF STORIES SIZE X /b BASEMENT OR SLAB RD SIZE OF FLOOR TINIBERS 1 ZX ) 2 2 3 SPAN / M ENSIONS OF SILLS v T DIN ENSIONS OF POSTS DM ENSIONS OF GIRDERS 'Z - J Z HEIGHT OF FOUNDATION Aw THICKNESS SIZE OF FOOTING l sa -VO,6L X MATERIAL OF CHDdNEY /} IS BUILDING ON SOLID OR FILLED LAND -Z4IA IS BUILDING CONNECTED TO NATURAL GAS LINE di n IJ n !l LL 0 z 0 0 w F - z cn 0 0' C/) 0 W. z H w .01 Z LL 0 C) Z M 'U" 0. 0 .0 w w;U 17 w LU CL => W of w 0 �Z OF(D'— z '0 0 0 ul fl _j LLJ -i 0 0 Z,o ul D Ix. 1-- 04 Cj Cl LU Z c < CD Lul i. LL 0 O CL LL 0 Z 0 w 0 U) Z U) .0. CL 0 U) F- Lu. a. Z W wil W z LL 0 0 U)! Zi -i -0 . . . W. 93 O 04 p UJ fl, N 0. �.w LLI Cl) w co c): >: �1 0 2 w <Io mi Z' iLLI 1 C) U) IX F-- LU 0- Z' LL .0 : LL 0� z 0, Z) z z . LL. < w Of W! LU. 7 0 LL. 4- CL z >- 0'0 U) w z ce 0 0 CL LL F-: z. 0 w Of 0 .0 CL) Lu io. z LLI -a. W C-4 ID: Town of North Andover Office of the Health Department Community Development and Services Division William J. Scott, Division Director 27 Charles Street Sandra Starr North Andover, Massachusetts 01845 Health Director February 2, 2001 Paul Pierog 1000 Turnpike Street North Andover, MA 01845 Dear Mr. Pierog, Telephone (978) 688-9540 Fax(978)688-9542 This letter comes in response to the receipt of your passing Title V and of my personal observations made of your septic tank. According to the inspector, Ben Osgood, your subsurface absorption system passed a Title V inspection. Unlike the previous inspector, however, Mr. Osgood found that the Outlet "T" of the septic tank had eroded and was nonfunctional. Had this item not been identified, it was clear that in a matter of time, solids from your tank would have entered the leaching area causing irreparable damage. Mr. Osgood replaced the outlet "T" and I observed that replacement item. The only item of outstanding concern is the half moon shaped access hole in the top of the tank. The existing cement cover cannot be reinserted due to the "T" location; therefore there is an open area. It is important that a cover be found that will properly seal' the access hole. Leaving a portion open is of concern because of the escape of methane and other noxious gases that could cause serious odors. Also, because you won't be able to properly bury the tank, dirt and other items could easily fall into it. This could also harm your system. I seriously advise you to find a suitable cover for your septic tank; which could be easily removed when the tank is pumped. Lastly, please be advised that the older septic systems are not designed to last forever. The average life span of a system is between 30 and 40 years. The information gathered by this process concerning your septic systems size, location and age indicate that it is likely towards that end of it's life. As the cost of replacement systems is quite high, it is important that you be aware of these facts. It is unfortunate that sanitary sewer is not yet available to you as the Board of Health believes that sewer is the best method of sewage disposal. Best of luck with your endeavors. I was sorry for your delay in your plans, but Mr. Osgood's inspection report made it clear that our concerns were valid. Pleases don't hesitate to call my office if you have any questions regarding this correspondence.. Sincerel �--� an Ford, R.S. Health Inspector BOARD OF APPEALS 688-9541 BUILDING 688-9545 CONSERVATION 688-9530 HEALTH 688-9540 PLANNING 688-9535 t ' Town of North Andover Office of the Health Department Community Development and Services Division William J. Scott, Division Director 27 Charles Street Sandra Starr North Andover, Massachusetts 01845 Health Director November 22, 2000 Paul Pierog 1000 Turnpike Street North Andover, MA 01845 Re: Title V Report Dear Mr. Pierog: Telephone (978) 688-9540 Fax(978)688-9542 The Health Department has received the second septic inspection report concerning your system at 1000 Turnpike Street, North Andover. The previous letter sent to you from the Health Department identified deficiencies in the initial report. This correspondence is in regards to both reports. Although some of the information missing has been included in the new version there still remain some concerns. 1) Our records show that the septic tank was pumped of 1200 gallons on September 30, 2000 and your inspection was four days later. Part "B" check list shows that all pumping information was provided and yet the very next question indicates that the system was not pumped in the previous two weeks. This pumping report was confirmed and unfortunately this information invalidates the entire report done on October 4, 2000 as well as the November 15, 2000 report. 2) The second report indicates the date of the inspection as 11-15-00 and yet the information appears to be the same as the first as the 10-4-00 report. I believe that the reports have been incorporated. Any old information should be marked with the previous date for clarification. Page 7, sludge depth was 6" on one report and 4" on the other, however all other information was identical. Even though there is a slight discrepancy, this indicates that this was based on the 10/4/2000 inspection. 3) Although, the inspector indicated on page 10 that "the exact size and type of leaching area cannot be determined without excavating the entire back yard, which is beyond the scope and intent of a title 5 Inspection Report", it is not beyond the ability of this office to require. Sandy Starr, the Health Director indicated this when she sent you a letter on September 28, 2000. 4) The description on page 11 is very vague. The term "local conditions" does not provide enough detail. BOARD OF APPEALS 688-9541 BUILDING 688-9545 CONSERVATION 688-9530 I-IEALTH 688-9540 PLANNING 688-9535 As this system is quite old our concern is that if the system is nonconforming and possibly undersized at its present use, you may be looking at a repair in the near future. You as the homeowner need to know these facts and even though a passing Title V inspection is not a guarantee, it is our responsibility to see that you are properly informed as the law requires. In light of these findings, I have once again contacted Claire Golden of DEP. She also felt that there remain outstanding concerns. I am sorry that these problems are putting off your home improvement project, however, the Health Department must be sure that the information provided by the licensed inspector is accurate. Additional Notes: I contacted Mr. Sibelski personally this morning, (Nov. 22, 2000) and he confirmed that the tank information was based on the inspection done on October 4, 2000. He also indicated that he was unaware of the pumping on September 30, 2000. This information requires this office to mark the Title V invalid. To move this matter forward quickly, I told Mr. Sibelski that I would meet him at your home as soon as possible to observe. another inspection. Unfortunately, he will be out of town for two weeks. Please contact me if you choose to use another inspector. I stress that to help facilitate this matter I am requesting to be notified prior to the inspection. Following the above events I also spoke with your son in law about these problems. He indicated that it was he who had pumped the tank -prior _to .the inspection. I explained the problem with that action and how we could move forward from here. He stated that he would contact me prior to doing another inspection so that I could be present. I hope that this information has been communicated satisfactorily, however, please feel free to contact me if you have any questions. Thank you. Sincer sanFord, R. . Health Inspector Cc: Edward Sibeleski Claire Golden, DEP file 0 FORM. - U - LOT RELEASE FORM INSTRUCTIONS: This form is used to verify that all -necessary approval /permits from Boards and Departments having jurisdiction have been obtained. This does not relieve the applicant. and or landowner from compliance with any applicable requirements. APPLICANT ZA e eyr PHONEz/s 5 ASSESSORS MAP NUMBER /U7 G LOT NUMBER SUBDIVISION - Ml LOT NUMBER STREET r-np)l Ice ci$ STREET NUMBER /DUD OFFICIAL USE ONLY RECOMMENDATIONS OF TOWN AGENTS i.r■■i...................................................................... 5�"� DATE APPROVED 0 ( � CON VATION ADMINISTRATOR TOWN PLANNER COMMENTS _ DATE -REJECTED DATE APPROVED DATE REJECTED DATE APPROVED FOOD INSPECTOR_ ` DATE REJECTED �c7 - HEALTH ATE APPROVED. / DATE REJECTED PUBLIC WORKS — SEWER / WATER CONNECTIONS DRIVEWAY PERMIT FIRE DEPARTMENT DATE APPROVED DATE REJECTED M COMMENTS i RECEIVED BY BUILDING INSPECTOR ,.. , a 5�K'Ryo r1 NEW ENGLAND ENGINEERING SERVICES, INC 60 BEECHWOOD DRIVE NORTH ANDOVER, MA 01845 1006 TIJR DECK END OF TRENCH 1000 GALLON SEPTIC TANK SEPTIC SYSTEM LOCATION PLAN 1000 TURNPIKE STREET NORTH ANDOVER, MASS SCALE: I"= 20' CP27(��rJ fTLr s Wit COMMONWEALTH OF:MASSACHUSETTS EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS DEPARTMENT OF ENVIRONMENTAL PROTECTION TITLE 5 OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM PART A CERTIFICATION Property Address: /Dap TtJ lZ AjP 1,J E .5T2Er ,Lllo 12T71, HAv oo oC, 2 Owner's Name: 022I- P Owner's Address: l o0o Zv�11J PlJd E ST)ZC c i ,, TCVVn r H ANDOVER/ R HEALTH �ALTH Date of Inspection: —IA/ 5 �o Name of Inspector: (please print) Re,t,•SR M jA1 C— 016 -00i> -::7-1z `�� 3 l I Company Name: Alr-i10 F -/V 6-" nr D FM6-1N EL ►Zi N (r t Mailing Address: _L, o R 0/Z t1 L IV04171' AA) v o LJG-YL ' ,.y►i9 Telephone Number: 9 7 R - 1,06 - f -7(.,9 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 15340 of Title 5 (310 CMR 15.000). The system: 3Z )sasses Conditionally Passes Needs Further Evaluation by the Local Approving Authority Fails Inspector's Signature: f�= Date: zaAdoo 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 gffice of the DEP. The original should be sent t§ the system owner and copies sent to the buyer, if applicable, and the approving authority. Notes and Comments *"*This report only describes conditions at the time of inspectiot 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 1 „"�, , : �--•..w«+wi.w•Mia.-.�y Page 2 of 11"4'nr: OFFICIAL INSPECTION FORM — NOT FOR VOLUNTARY ASSESSMI�NTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM ' ' PART A CERTIFICATION (continued) PROPERTY ADDRESS: 1000 Turnpike Street North Andover, MA OWNER: Taal Pierog DATE OF INSPECTION: 12/5/00 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: B. System Conditionally 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 inspeetion 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 Qr break out or high static water level in the distribution box due to,'broken or ' obstructed pipe(s) or due .tot a -broken, settled or uneven distribution box. System will pass inspection if (W', ith. r' approval of Board, of Health):. broken pipe(s) are replaced obstruction is removed distribution box is leveled or replaced i i r 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): ' broken pipe(s) are replaced j obstruction is removed I I ND explain: Title 5 Inspection Form 6/15/2000 2 Page.5 of 11 • � � • OFFICIAL INSPECTION FORM NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A ' (''ERTIFICATION (continued) ROPERTY ADDRESS: 1000 Turnpike Street North Andover, MA OWNER: Paul Pierog DATE OF INSPECTION: 12/5/00 C. Further Evaluation ii 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 fa g to protect public health, safety or the environment. 1. Sy in will pass -unless Board of health determines in accordance with 31 MR.,15.303(1)(b) that the syste is not: functioning in a manner which will protect public health, fety and the -environment: _ Cessp 1 or privy is within 50 feet of a surface water Cesspoo privy is within 50 feet of a bordering vegetated tland or a salt marsh 2. System 'will Lail unless the Boar f health ( d Public Water.Supplier, if any) determines that the system is functioning in a manner that tec he public health, safety and environment: _ The system has a septic tank and s ab rption system (SAS) and the SAS is within 100 feet of a surface water supply or tributary to urface r supply. The system has a septic and SAS and the is within a Zone 1 of a public water supply. _ The system has a se c tank and SAS and the SAS is 'thin 50 feet of a private water supply well. The system has septic tank and SAS and,the SAS is less 100 feet but 50 feet or more from a private water sup well's*. Method used to determine distance "This syste passes if the well water analysis, performed at a DEP certi laboratory, for coliform bacteria volatile. organic compounds indicates that the well is freg from po tion from:that facility and r the pre nce of ammonia nitrogen and nitrate nitrogen is equal to or'less than 5 p provided that no other r � fail a criteria-.are:triggered. A 1copy of the analysis must be attached to this form. i 1 3. Other: Title 5 Inspection Form 6/15/2000 3 Page 4 of 11 OFFICIAL INSPECTION FORM — NO SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM ' PART A ' CERTIFICATION (continued) ROPERTY ADDRESS: 1000 Turnpike Street North Andover, MA OWNER: Paul Pierog DATE OF INSPECTION: 12/5/00 D. System Failure Criteria applicable to all systems: You must indicate `Yes" or "no" to each of the following for all inspections: 'Yes No Backup.of sewage into facility or system component due to overloaded or clogged SAS or cesspool 1( Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged -SAS of 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 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 1 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 faciliy 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.] (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. ). arge Systems:, , To be c ered a large system the system must serve a facility with a design flow of , 00 gpd to 15,060 gpd• You must indicate e r `yes" or `bo" to each of the following: (The following criteria ap to large systems in addition to the criteria ab yes no the system is within 400 feet of a s ce drinkin ater supply the system is within 200 feet of a tnbu to a acd drinking water supply _ the system is located in a . gen sensitive area (Interim lhead Protection Area — IWPA) or a mapped Zone II of a public w supply well I � 1 If you have answere es". to any question in Section E the system is considered a si scant threat, or answered "yes" in Sectio above the large system has failed. The owner or Is of any larges considered a significant eat under Section E or failed under Section D shall upgrade the system in accordanc ith 310 CMR 15.3 a system owner should contact the appropriate regional office of the Department. Title 5 Inspection Form 6/15/2000 4 i Page 5 of 11 OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMErjTS SUBStfRFACE `SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST ROPERTY ADDRESS: 1000 Turnpike Street i North Andover, MA OWNER: Paul Pierog DATE OF INSPECTION: 12/5/00 - I Check if the following have been done. You must indicate "yes" or "no" as to each of the following: Yes/ No V _ 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) 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 ? 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 an4 location of the ,$oil Absorption System (SAS) on the site has been determined based on: Yes no � Existing information.1 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 approximatioij of distance is unacceptable) [31d CMR 15.302(3)(b)] Title 5 Inspection Form 6/15/2000 5 '•�4 Page 6 of 11 i`Aq . OFFICIAL INSPECTION FORM — NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM-INSPECTIONFORM PART C; SYSTEM INFORMATION ROPERTY ADDRESS: 1000 Turnpike Street North Andover, MA OWNER: Paul Pierog i DATE OF INSPECTION: 12/5/00 r ,OW CONDMONS RESIDENTIAL Number of bedrooms (design):..- Number of bedrooms (actual): DESIGN flow; based on 310 CMR 15.203 (for example: 1110 gpd x # of bedrooms): Number of current residents: 3 Does residence have a garbage grinder (yes or no): f j� Is laundry on a separate sewage system (yes or no): &D [if yes separate inspection required] Laundry system inspected (yes or no): — Seasonal use: (yes or no): _ALD Water meter readings, if available (last 2 years usage (gpd)): Sump pump (yes or no): Last date of occupancy: Co k-Zc2 E COMIVIERCIAL/INDUSTRIAL Type of establishment: Design flow (based on 310 CMR 15,203): I;pd Basis of design flow (seats/persons/sgf ,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: 5 ,CPf& A B i= A acD, Was system pumped as part of 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): 3EPI7 4 1W V K tj f li S I.0 SLC LEi9 L11 Approximate age of all components, date installed (if known) and source of information: 9,5 ± 4 en 2S fc-e- o, -y .N t: 2 Were sewage odors detected when arriving at the site (yes or no): " Title 5 Inspection Form 6/15/2000 6 Page 7 of.l l OFFICIAL INSPECTION FORM — NOT FOR VOLUNTARY ASSESSMENTS''` SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C ' SYSTEM INFORMATION (continued) ROPERTY ADDRESS: 1000 Turnpike Street North Andover, MA — i '• OWNER: Paul Pierog — DATE OF INSPECTION: 12/5/00 BUILDING SEWER (locate on site plan) Depth below grade: 2 14E� Materials of construction: cast iron 40 PVC _other (explain): . Distance from private water supply well or suction line: 44& Comments (on condition of joints, venting, evidence of leakage, etc.): hoo lis 6-00 \7> n1 9As C- nil AJ—1 SEPTIC TANK: _ (locate on site plan) Depth below grade: I z" Material of construction: _concrete _metal _fiberglass polyethylene _other(explain) If tankis metal list age: _ Is age confirmed by a Certificate of Compliance; (yes or no): _ (attach a copy of certificate) Dimensions: 0o 6 -7 -AL- t-4 ti 5 - Sludge depth: O 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 bottom of outlet tee or baffle: -- How were dimensions determined: .41 EA.svPtE S77 C 0" ;Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels . as related to outlet invert, evidence of leakage, etd.): TA -N) 1Jk 1 - 01K C a 1UP 17 0 nJ R ECC Nt G N o. n� s %?q .4 T v .�,� C' Sc M D _PUC ovs L. FIT Vii% 0a-0 13HFFLR: ,s 6:32 1n/r: SCH (40 PUL TZ -:c 11vsTAuxP ins FAff7 - vi 1)` /Nsr�t=� !CREASE TRAP."ocate on site plan) , Depth below grade: Material of construction: concrete _metal fiberglass _polyethylene _other Dimensions: r { 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.): Title 5 Inspection Form 6/15/2000 7 • t �t-rr 4 Page 8 of 11ia:��y� • �,iJ . OFFICIAL INSPECTION FORM NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) PROPERTY ADDRESS: 1000 Turnpike Street Nortel Andover, MA OWNER: Paul Pierog DATE OF INSPECTION: 12/5/00 TIGHT or HOLDING TANK: AA (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.): i DISTRIBUTION BOX: NA (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.): PUMP CHAMBER: (locate on site plan) Pumps in working order (yes or no): Alarms in!working order (yes or no): Comments (note condition of pump chamber, condition otpumps and appuoenances, etc.): i . 1 i Title 5 Inspection Form 6/15/2000 8 Page 9 of 11:; OFFICIAL INSPECTION FORM.— NOT FOR VOLUNTARY ASSESSMENTS SUBSYJRFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM It I PART C SYSTEM INFORMATION (continued) PROPERTY ADDRESS: 1000 Turnpike Street North, Andover, MA OWNER: Paul Pierog _ DATE OF INSPECTION: 12/5/00 SOIL ABSORPTION SYSTEM (SAS): (locateonsite plan, excavation not required) If SAS not located explain why: Type leaching pits, number: leaching chambers, number: leaching galleries, number: u/ leaching trenches, number, length: / T2 Fav f N 4 W 1 O t 1 leaching fields, number, dimensions: overflow cesspool, number: innovative/alternative system Type/name of technology: m Coments (note con4ition of soil, signs of hydraulic failure, level of ponding, damp so}l, condition of vegetation, etc.): 14 e E4 OF 14CAJr/7 cuts Xo4AA A1. IVO P(A) 61pim P xy 1t_ 0 IZ o nl v sv AL- v Ezj-'-ze-no Al 3,:>TT0M c J-EOCIA P1 Per PIcFFTIF s THra-T 147-C-12 1S no i P&A -)'D' L P ou�L CESSPOOLS: LL (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): Pommeno (note condition of soil, signs of hydraulic failure, level jof;pondWg, condition of vegetation, etc.): PRIVY: W14 (locate on site plan). i Materials of construction: Dimensions: Depth of solids: Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): Title 5 Inspection Form 6/15/2000 9 ' 7 �t.,.h r..[� ii ✓fir -J. r +'"+r 'v� Page 10 of 11'� t: OFFICIAL INSPECTION FORM — NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE ]DISPOSAL SYSTEM INSPECTION FORM l PART C SYSTEM INFORMATION (continued) PROPERTY ADDRESS: 1000 Turnpike Street i North Andover, MA — OWNER: Paul Pierog DATE OF INSPECTION: 12/5/00 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. Tj RN PI ue a eo Title 5 Inspection Form 6/15/2000 10 V Page 11 of 1 �� ` r, feta r•:- OFFICIAL INSPECTION FORM = NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE -SEWAGE DISPOSAL SYSTEM INSPECTION FORM i PART C, CVCT1I,M INFORMATION (continued) PROPERTY ADDRESS: 1000 Turnpike Street North Andover, MA OWNER: Paul Pierog i DATEOF INSPECTION: 12/5/00 SITE EXAM Slope Surface water Check cellar Shallow wells Estimated depth to ground water L-/ feet Please indicate (check) all methods used to determine the high ground water elevation: Obtained from system design plans on record - If checked, date of design plan reviewed: x Observed site (abutting property/observation hole within 150 feet of SAS) Checked with local Board of Health -explain: Checked with local excavators, installers- (attach documentation) Accessed USGS database -explain: You must describe how you established the high ground water elevation: C- CSZ 4 C'oe C, c_ - a ii ! a 6",'e l.. _ _ _ [ , . c..n I S •1 .L. z L i -T Title 5 Inspection Form 6/15/2000 11 Y' NEW ENGLAND ENGINEERING SERVICES, INC 60 BEECHWOOD DRIVE NORTH ANDOVER, MA 01845 SEPTIC TANK SEPTIC SYSTEM LOCATION PLAN 1000 TURNPIKE STREET NORTH ANDOVER, MASS DECK g ccq C�27Fi�r� rr�r s SCALE: 1" = 20' FORM 4 - SYSTEM PUM ING RECORD Commonwealth of Massachusetts /l0 - /I A;-j)ovzv- , Massachusetts System Pumping Record vstem weer c System Location ! Sf /V Type: Emergency ❑ Routine Cesspool: No ❑ Yes ❑ Scptic Tank: No ❑ Yes �I Date of Pumping: ,3 Quantity Pumped: (Vo _ gallons S�'stem Pumped by (Company): Nit����� rS S `('�`c Permit Contents transferred to: Contents disposed at: Date` Pumper Signature r t� Condition. of system/other comments: f { FC P DFP APPROVED FORM - 12/07/9S 7 � y� ej Ft' �i�,� COMMONWEALTH OF MASSACHUSETTS = EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS DEPARTMENT OF ENVIRONMENTAL PROTECTION TITLE 5 OFFICIAL INSPECTION FORM — NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM PART A CERTIFICATION l Property Address: 1000 i c/iPiy�°�'�1E 6T /1/D, AriDayE,Q � iyiA, Owner's Name: fl -90L O/ E eoCT Owner's Address: loco 7-o1,?1z .'ooIrE /4,0, "9—/Jay /;i R Date of Inspection: // - /.5'- 2 coo Name of Inspector: (please print) cow/a Q0 S, ZGeC,'s Company Name: Zd,' If0 :5/"a-4 " Mailing Address: FO °'k `i eo S/sLEG 4,/ /!/N, 03���% Telephone Number: / - goo-.Sod-SSo`i' Vill-/ i� l '� CERTIFICATION STATEMENT I certif;, that 1 have personally inspected the sewage disposal system at this address and that the information reported below is rrue, 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. 1 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: ac 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 oricinal should be sent to the system owner and copies sent to the buyer, if applicable, and the approving authority. Mores and Comments ALTHOUGH THIS REPORT MAY BE DEEMED RELIABLE, NO WARRANTIES OR GUARANTIES ARE EXPRESSED OR IMPLIED. ****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 I ..r Page 2 of 1 I OFFICIAL INSPECTION FORM — NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Propert) Address: /o ic) Owner: f' --.—i 6,,,,r Date of Inspection: //Z/S--00 Inspection Summary: Check A,B,C,D or E / ALWAYS complete all of Section D A. System Passes: l/ 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: B. System Conditionally 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. V 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 (\N ith approval of Board of Health): broken pipe(s) are replaced obstruction is removed distribution box is leveled or replaced ND explain: IV 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): ND explain. broken pipe(s) are replaced obstruction is removed Page 3 of I 1 OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: /0 of > Owner: Date of Inspection: 00 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 s}stem is failing to protect public health, safety or the environment. 1. Sss"tem ss ill 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 seater supple \s ell _ 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 bactc is 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 1 I OFFICIAL INSPECTION FORM — NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: ZO60 Owner: Date of Inspection: D. System Failure Criteria applicable to all systems: You must indicate "yes" or "no" to each of the following for all inspections: Yes No _ Backup of sewage into facility or system component due to 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 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 '/2 day flow 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. IThis 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 cop), of the analysis must be attached to this forma (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 o\�ner 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 (I_nterim Wellhead Protection Area — IW -PA) or a mapped Zone 11 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 I I OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST Property Address: Ov o .w , Owner: Date of Inspection: 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 ? I,"' 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) 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 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 ? Yes no The e size and location of the Soil Absorption System (SAS) on the site has been determined based on. 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)] 5 Page 6 of 1 1 OFFICIAL INSPECTION FORM — NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION Property Address: /duD Owner: �t / Date of Inspection: //—/S --c 0 FLOW CONDITIONS RESIDENTIAL Number of bedrooms (design): Number of bedrooms (actual): 3 DESIGN flow based on 310 CMR 15.203 (for example: 1 10 gpd x # of bedrooms): Number of current residents: Does residence have a garbage grinder (yes or no): /vo Is laundr� on a separate sewage system (yes or no):[if yes separate inspection required] Laundry system inspected (yes or no): Seasonal use: (yes or no): 4-0 Water meter readings, if available (last 2 years usage (gpd)): Sump pump (yes or no): P10 Last date of occupancy: // —/S-- Ox) COMM ERCIAL/INDUSTRIA L 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: Was system pumped as pan of the inspection (yes or no): rye' If yes, volume pumped: gallons -- How was quantity pumped determined? Reason for Pumping: TSEOF SYSTEM Septic tank, disefibution beyi, soil absorption system _ Single cesspool _ Overflow cesspool _ Privy _ Shared system (yes or no) (if yes, attach previous inspection records, if any) _ Innovative/Alternative technology. Attach a copy of the current operation and maintenance contract (to be obtained from system owner) _ Tight tank _ Attach a copy of the DEP approval Other (describe): Approximate age of all components, date installed (if known) and source of information: Were sewage odors detected when arriving at the site (yes or no): /lici Page 7 of I I OFFICIAL INSPECTION FORM — NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: /o v0 ! . A11- I aL Owner: Date of Inspection: //— — Zr0 BUILDING SEWER (locate on site plan) Depth below grade: 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: _ (locate on site plan) Depth below grade: %2 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: � X 5— Sludge Sludge depth: `r`" Distance from top of sludge to bottom of outlet tee or baffle: F 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: 5 - How How ��ere dimensions determined: %moi Comments (on pumping recommendations, inlet and outlet tee or baffle condition. structural integrit\, liquid levels as related to outlet invert, evidence of leakage, etc.): 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 bottortt of outlet tee or baffle: Date of last pumping: Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrit), liquid levels as related to outlet invert, evidence of leakage, etc.): Page 8 of 1 1 OFFICIAL INSPECTION FORM — NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: %ovD Owner: Date of Inspection: 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 Boat 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. anv evidence of leakage into or out of box, etc.): p -- d,,r .1 P „ _ �14— PUMP CHAMBER: (locate on site plan) Pumps in working order (yes or no): Alarms i,; •.vorking order (yes or no): Comments (note condition of pump chamber, condition of pumps and appurtenances, etc.): Page 9 of 1 1 OFFICIAL INSPECTION FORM — NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: /off_ o Owner: Date of Inspection: S—oo SOIL ABSORPTION SYSTEM (SAS): (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: P6!, /® 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.): 06y 5o, 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 lay er. Dimensions of cesspool: Materials of construction: Indication of groundwater inflow (yes or no): Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc ). PRIVY: (locate on site plan) Materials of construction: Dimensions: Depth of solids: Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.) Page 10 of 1 I OFFICIAL INSPECTION FORM — NOT FOR VOLUNTARY ASSESSME',"TS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: A)00 Owner: Date of Inspection: // /5 —no SKETCH OF SEWAGE DISPOSAL SYSTEM Provide a sketch of the seg+age 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 0 RT lid UGQ.R Sc FPr'C ra •�!T T S z 9 Page 11 of 1 1 OFFICIAL INSPECTION FORM — NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: /c; of) Owner: ' Date of Inspection: SITE EXAM Slope Surface water Check cellar Shallow wells Estimated depth to ground water �' feet Please indicate (check) all methods used to determine the high ground water elevation: -I btained from system design plans on record - If checked, date of design plan reviewed: /71 site (abutting property/observation hole within 150 feet of SAS) Checked with local Board of Health -explain: 1,'�'�Checked with local excavators, installers- (attach documentation) Accessed USGS database -explain: You must escribe hovi y established the high ground water elevation: Z�' � ° � �� ��� - 3z � �.� �, k t Page 10 of I I. OFFICIAL INSPECTION FORM — NOT FOR VOLUNTARY ASSESSMENT SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORR,I PART C SYSTEM INFORMATION (continued) Property Address: /vcQ �& _ Owner: i Date of Inspection: 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 buildin-. R ��o RT lid 60 9-' V E c. IT S0,07,,'c IT ,L, ,�, FORM - U - LOT RELEASE FORM INSTRUCTIONS: This form is used to verify that allnecessary approval/ permits from Boards and Departments having jurisdiction have been obtained. This does not relieve the applicant and or landowner from compliance with any applicable requirements. APPLICANT Z-� e Lr, F1 eve-' PHONE gV - 990` 2 2,/Jf' ASSESSORS MAP NUMBER /D % G LOT NUMBER Z D SUBDIVISION LOT NUMBER STREET f vr'n pl' !te C6 - STREET NUMBER /D 00 �.......................... OFFICIAL USE ONLY.,:: • ::... 1. X�� RECONOAENDATIONS OF TOWN AGENTS DATE APPROVED /&O-N�SERVATTON ADMINISTRATOR DATE REJECTED CONO&XI S TOWN PLANNER COMMENTS FOOD INSPECTOR - TH SEPTIC INSPECTOR n \ -HEALTH DATE APPROVED DATE REJECTED DATE APPROVED DATE REJECTED DATE APPROVED DATE REJECTED COMMENTS% / % Z - /A) P6-C7C 7-104 PUBLIC WORKS - SEWER / WATER CONNECTIONS DRIVEWAY PERMIT DATE APPROVED FIRE DEPARTMENT DATE REJECTED CONSENTS RECEIVED BY BUILDING INSPECTOR DATE 5tinrc96ni t. .the bMa �g `logia techwsh ori plan tr t e a h requirements constructed.., FORM 4 - SYSTEM PUNTPLNIG RECORD Commonwealth of Massachusetts DAG , 9 / j -� ill Do Massachusetts --System Pumping Record ystem Owner System Location n s L tino��t� ovf i34, V U Cr ��,w �j�t s r / 1 P /V -19V v�� 05' 1007 Tvpe: Emergency ❑ Routine _9 - Cesspool: No ❑ Yes ❑ SLptic Tank: No ❑ Yes duantity Pumped: allons Date of Pumping: l 1'G —L'Q P ' `'`"` - — Svstem Pumped by (Company): "/ fie /� �S S �P!A Permit Contents transferred -to: Contents disposed at: L Date "` Pumper Signature Condition of systen-/other comments: (9 Uvd1 Cc,� kiDEP APPROVED FOR.N • 12/07/95 FORM 4 - SYSTEM PUM LNG RECORD Commonwealth of Massachusetts N -A tivouck', , Massachusetts Svstem Pumping Record System Owner System ocation l t f�iL)Q '! vv,k("1c N,-�N ve-" T -,,-pe: Emergency ❑ Routine Er Cesspool: No ❑ Yes ❑ Scptic Tank: No ❑ Yes Date of Pumping: /�" 30 ou Quantit-v Pumped:rj �O _ gallons S% -stem Pumped by (Company): r(��2��Cr5 s`('�`o Permit Contents transferred to: Contents disposed at: L,wAC1+&tc<1 v Date Pumper Signature Condition of system/other comments: iaDFP APPROVED FORM - 12/07/95 s �7 G• --o sr i��� ' TOWN OF NORTH ANDOVER OFFICE OF COMMUNITY DEVELOPMENT AND SERVICES 27 CHARLES STREET NORTH ANDOVER, MASSACHUSETTS 01845 Sandra Starr, Health Director October 30, 2000 Paul Pierog 1000 Turnpike Street North Andover, MA 01845 Re: Title V Report Dear Mr. Pierog: Telephone (978) 688-9540 FAX (978) 688-9542 This correspondence is in regards to your application for a sunroom addition to your home. Health Department personnel reviewed the Title V report on 1000 Turnpike Street, dated October 4, 2000 and have found the following deficiencies. 1) The as -built sketch found on page 10 of 11 does not meet the minimum requirements. The sketch should include an accurate depiction of the existing home as well as the complete lay out of the septic system. This as -built does not show any distinguishable benchmarks, identifiable ties or the location of leaching area. 2) There is no information about the distribution box. Page 8 of 11 is blank. The location, function and condition of the d -box remain unknown. 3) The soil absorption system information is incomplete. Page 9 of 11 has. not been properly filled in. The type of leaching system remains unknown; pits, chambers trenches etc. 4) Finally, the form used for the Title V submission is not the correct version. All State inspectors have been sent the newly revised form. All Title V's must be on the new form. Please be advised that this Title V Report is not acceptable. A copy of this letter is being sent to your inspector as well. Approval of your application for the addition cannot be issued until all the requirements are met. Once the Title V, including the as -built, is properly completed, please be sure that you submit a drawing that includes the septic system location in relation to the addition so that proper distances may be determined. 0 Please contact the Health Department if you have any additional questions. Sincerely S an Ford, R. S. v C Health Inspector Cc: Edward Sibeleski Claire Golden, DEP file NOR*M Town Of North Andover Community Development & Services William J. Scott 27 Charles Street Director "9- North Andover, Massachusetts 01845 (9781688-9531 ��SSACHUS S Fax 978-688-9542 September 28, 2000 Sincerely, Sandra Starr, R.S., C.H.O. Health Director Paul Pierog Board of 1000 Turnpike Street Appeals North Andover, MA 01845 (978) 688-9541 Re: Application for sunroom addition Building Department (978) 688-9545 Dear Mr. Pierog: Your contractor called questioning the need for a Title 5 inspection of your septic Conservation Department system. When any addition is being built onto a house served by a septic system (978) 688-9530 the Health Department must review the request and ascertain whether the se P q p system will be compromised by the addition. We must answer questions such as: Health • Will the addition be too close to the septic system? Department • Is the septic stem functioning properly? (978) 688-9540 • Is the leach area large enough for possible additional flow? • Are there any violations of 310 CMR 15.000? Public Health Nurse In order to do that we must review the existing information in our files. (978) 688-9543 Unfortunately, in the file for 1000 Turnpike Street there are only some pumping reports. We consequently cannot answer any of the necessary questions and Planning approve the project. Therefor it is necessary to inspect the septic system to gather Department (978) 688-9535 the information. A licensed septic inspector hired by the homeowner does the inspection. If you have difficulty locating a licensed inspector, please feel free to call the Health Department at 978-688-9540 for assistance. Sincerely, Sandra Starr, R.S., C.H.O. Health Director O)IIIItlom enith of hlnssnchusells a I ^______I , Massddlusetts Sysle��� i'u�n its Record sy01e111 Olveteipt ex�03 — - 1)nle of 1'u11gpilig: (q, l ~C Cesspool: No 11'I" ties .� 9yMoll LocAliort jrc-r-�-u �- Y\ ? -tte-5+ 6 tpialitity rultq►ed: fa�) goilulle Septic Imik: No [I Yes wl- Syslem Pumped by: Fdredent 5ferevIijej Llcellse # Ct�rfleitls Itansleirred la : t3rhtlNlr LittNte C� hahlttltY Ulltfttta DOW Inspeeiur: Cw i of �laa�nrl�uiell� Massachusetts .�'IlL.L[lllllLtljl'-j' t ' Sj�ie�mratcnn 5j'iicui LUU1155 � 2� (P . i Vlld�llll!' IoUiNlltcll I�0 Uate dr r������i�� I 1 Yr: U spoil toot (.easi�uult h�� � . a{ es Lactose M 5�•sk�i1 1 u��y�rJ b� . �5� Cu�Nrnls.Irausle�rrJ Ic+: �,.. � • 1 �JOI.c iilSpeClot ' ystem Owner FOR 14 - SYSTEM PL71PL\G RECORD Commonwealth of Massachusetts , Massachuse &stem Pumping Record o9 �1A/1 )W BOARD 0 HEkLl MAY 3 1 1995 (M:�3rC�sv� Date of Pumping: C -) C -)Quantity Pumped: f0'—gallons Cesspool: No Yes ❑ Septic Tank: No ❑ Yes System Pumped by- � License #: . P Contents transferred to: - Date Inspector Town of North Andover Office of the Health Department Community Development and Services Division William J. Scott, Division Director 27 Charles Street Sandra Starr North Andover, Massachusetts 01845 Health Director February 2, 2001 Paul Pierog 1000 Turnpike Street North Andover, MA 01845 Dear Mr. Pierog, Telephone (978) 688-9540 Fax (978) 688-9542 This letter comes in response to the receipt of your passing Title V and of my personal observations made of your septic tank. According to the inspector, Ben Osgood, your subsurface absorption system passed a Title V inspection. Unlike the previous inspector, however, Mr. Osgood found that the Outlet "T" of the septic tank had eroded and was nonfunctional. Had this item not been identified, it was clear that in a matter of time, solids from your tank would have entered the leaching area causing irreparable damage. Mr. Osgood replaced the outlet "T" and I observed that replacement item. The only item of outstanding concern is the half moon shaped access hole in the top of the tank. The existing cement cover cannot be reinserted due to the "T" location; therefore there is an open area. It is important that a cover be found that will properly seal the access hole. Leaving a portion open is of concern because of the escape of methane and other noxious gases that could cause serious odors. Also, because you won't be able to properly bury the tank, dirt and other items could easily fail into it. This could also harm your system. I seriously advise you to find a suitable cover for your septic tank; which could be easily removed when the tank is pumped. Lastly, please be advised that the older septic systems are not designed to last forever. The average life span of a system is between 30 and 40 years. The information gathered by this process concerning your septic systems size, location.and age indicate that it is likely towards that end of it's life. As the cost of replacement systems is quite high, it is important that you be aware of these facts. It is unfortunate that sanitary sewer is not yet available to you as the Board of Health believes that sewer is the best method of sewage disposal. Best of luck with your endeavors. I was sorry for your delay in your plans, but Mr. Osgood's inspection report made it clear that our concerns were valid. Pleases don't hesitate to call my office if you have any questions regarding this correspondence. Sincerel �-- an Ford, R. S. Health Inspector BOARD OF APPEALS 688-9541 BUILDING 688-9545 CONSERVATION 688-9530 HEALTH 688-9540 PLANNING 688-9535 NpR`'" Town Of North Andover a Community Development & Services William J. Scott 16. 27 Charles Street Director North Andover, Massachusetts 01845 (978) 688-9531 Waw .cw Fax 978.688-9542 September 28, 2000 Sincerely, .�ataj �Ilt,ck; Sandra Starr, R.S., C.H.O. Health Director Paul Pierog Board of 1000 Turnpike Street Appeals North Andover, MA 01845 (978) 688-9541 Re: Application for sunroom addition Building Department (978) 688-9545 Dear Mr. Pierog: Your contractor called questioning the need for a Title 5 inspection of your septic DepaConservation system. When any addition is being built onto a house served by a septic system (978) 88-9ment (978) 688-9530 the Health Department must review the request and ascertain whether the septic P q p system will be compromised by the addition. We must answer questions such as: Health • Will the addition be too close to the septic system? Department . Is the septic stem functioning properly? t p� Y g p P Y (978) 688-9540 . Is the leach area large enough for possible additional flow? • Are there any violations of 310 CMR 15.000? Public Health Nurse In order to do that we must review the existing information in our files. (978) 688-9543 Unfortunately, in the file for 1000 Turnpike Street there are only some pumping reports. We consequently cannot answer any of the necessary questions and Planning approve the project. Therefor it is necessary to inspect the septic system to gather Department (978) 688-9535 the information. A licensed septic inspector hired by the homeowner does the inspection. If you have difficulty locating a licensed inspector, please feel free to call the Health Department at 978-688-9540 for assistance. Sincerely, .�ataj �Ilt,ck; Sandra Starr, R.S., C.H.O. Health Director NOR*►+ Town Of North Andover p St�ao ya'�y Community Development & Services William J. sc°rr 27 Charles Street Director North Andover, Massachusetts 01845 (978) 688-9531 �9SSwc►+u �� Fax 978-688-9542 September 28, 2000 Sincerely, Sandra Starr, R.S., C.H.O. Health Director Paul Pierog Board of 1000 Turnpike Street Appeals North Andover, MA 01.845 (978) 688-9541 Re: Application for sunroom addition Building Department Dear Mr. Pierog: (978) 688-9545 Your contractor called questioning the need for a Title 5 inspection of your septic DepaConservation mem system. When any addition is being built onto a house served by a septic system (9781688-9530 (978) the Health Department must review the request and ascertain whether the septic P q P system will be compromised by the addition. We must answer questions such as: Health • Will the addition be too close to the septic system? Department • Is the septic stem functioning properly?, •, (978) 688-9540 • Is the leach area large enough for possible additional flow? • Are there any violations of 310 CMR 15.000? Public Health Nurse In order to do that we must review the existing information in our files. (978) 688-9543 Unfortunately, in the file for 1000 Turnpike Street there are only some pumping reports. We consequently cannot answer any of the necessary questions and Planning approve the project. Therefor it is necessary to inspect the septic system to gather Department (978) 688-9535 the information. A licensed septic inspector hired by the homeowner does the inspection. If you have difficulty locating a licensed inspector, please feel free to call the Health Department at 978-688-9540 for assistance. Sincerely, Sandra Starr, R.S., C.H.O. Health Director COMMONWEALTH OF MASSACHUSETTS EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS DEPARTMENT OF ENVIRONMENTAL PROTECTION ONE WINTER STREET, BOSTON MA 02108 (617) 292-5500 TRUDY COKE Secretary ARGEO PAUL CELLUCCI DAVID B. STRUHS Governor Commissioner SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION Property Address: % Obt? 7`iJR/►��°.'Nf S%, Name of Owner �r9oL �•'t /QOG /V d, '4'VV#V 'Q i M,67, Address of Owner: / od o T ✓ ,y F, 'sr F= S T_ Date of Inspection: %O •- f- UO 4' 0. '0^''004'C rQi '-syr Name of Inspector: (Please Print) EOWIi40 S.:BEC�:.Sf I am a DEP approved system inspector pursuant to Section 15.340 of Title 5 (310 CMR 15.000) Company Name: EDcvi3R0 S.dF-e- / -' r`wz r Mailing Address: %e, a'X /,SAO , Si4 cC•Zl i, %t! H_ O Pd�q 1, I1 Telephone Number: /-606- CERTIFICATION -606-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 _ Needs Further Evaluation By the Local Approving Authority Fails Inspector's Signature: ` Date: O� The System Inspector shall submit a copy of this inspection report to the Approving Authority (Board of Health or DEP)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 tovre system owner and copies sent to the buyer, if applicable, and the approving authority. NOTES AND COMMENTS ALTHOUGH THIS REPORT MAY BE DEEMED RELIABLE, NC WARRANTIES UR GUARANTIES ARE EXPRESSED OR IMkIIED. Xj V11, N rs v A ]. V 1 � f ,V, k ),t P revised 9.'2/98 Pagelorn A �� Printed on Recycled Paper � V 1 a SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: l O D d l U `V/V p• !1 C 5l , W A Owner: pA0i- 10 i`2 Ra6- Date of Inspection: / 6? — �>--0 0 INSPECTION SUMMARY: Check A, B, C, or D: A. SYSTEM PASSES: I have not found any information which indicates that any of the failure conditions described in 310 CMR 15.303 exist. Any failure criteria not evaluated are indicated below. COMMENTS: B. SYSTEM CONDITIONALLY 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. Indicate yes, no, or not determined (Y, N, or ND). Describe basis of determination in all instances. 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 Certificate 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 complying septic tank as approved by the Board of Health. 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). broken pipe(s) are replaced obstruction is removed distribution box is levelled or replaced The system required pumping7nore than four times a year due to broken or obstructed pipe(s). The system wilt - res -3 -inspection if (with approval of the Board of Health): broken pipe(s) are replaced obstruction is removed revised 9/2/98 Page 2of11 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: / ° 6P j cu R'✓ o, Ott ST ^'' /���avcR� •mom, Owner: /nflvt Date of Inspection: 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 the public health, safety and 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 THE PUBLIC HEALTH.AND SAFETY AND THE ENVIRONMENT. Cesspool or privy is within 50 feet of 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 AND SAFETY AND THE 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 soil absorption system and the SAS is within a Zone I of a public water supply 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 revised 9/2/98 Page 3ofII SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Prrww ry Ad&Ps_%- /000 r d Rw /7,-4r<_ ST rr�v, y daa�r­/Y Owner: 10,Adi- /" /•L /', o v Date of Inspection: /0--`) 00 D. SYSTEM FAILS: You must indicate either "Yes" or "No" to each of the following: I have determined that one or more of the following failure conditions exist as described in 310 CMR 15.303. The basis for this determination is identified below. The Board of Health should be contacted to determine what will be necessary to correct the failure Yes No Backup of sewage into fecilityorsystem component- due tto an overloaded ori 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 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 1/2 day flow. 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 Soil Absorption System, cesspool or privy is below the high groundwater elevation. Any portion of a 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. If the well has been analyzed to be acceptable, attach copy of well water analysis for -coliform bacteria, volatile organic -compounds, ammonia nitrogen and nitrate nitrogen. E. LARGE SYSTEM FAILS: 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: The system serves a facility with a design flow of 10,000 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 -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) The owner or operator of any such system shall upgrade the system in accordance with 310 CMR 15.304(2). Please consult the local regional office of the Department for further information. revised 9/2/98 Page 4ofII SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST Property Address: / v o 0 7-u Rn. A'KC T7, ry o. oe;z ev'A o vCR owner: PAVI, prc Rob Date of Inspection: /0-2-00 Check if the following have been done: You must Indicate either "Yes" or "No" as to each of the following: Yes No Pumping information was provided by the owner, occupant, or Board of Health. None of the system�compoaents haw,baan ptrrnped4oc-atleest two weeks sn&tbe system hasbeease'ceivi igwwsaaal flow rates during that period. Large volumes of water have not been introduced into the system recently or as part of this inspection. 'As built plans have been obtained and examined. Note if they are not available with NIA. The facility or dwelling was inspected for signs of sewage back-up. The system does not receive non -sanitary or industrial waste flow. The site was 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 orrthe site has been determined based on: Existing information. For example, Plan at B.O.H. Determined in the field (if any of the failure criteria related to Part C is at issue, approximation of distance is unacceptable) 11 5.302(3)(b)) The facility owner (and.occypants.Jf diffaraW from.owaer)..were. pravided.with informatiomon.tha.4rapw waintuuuw.&^t SubSurface Disposal Systems. revised 9/2/98 Page 5of11 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION Property Address: / o Cho T U Rti 14� 6f G S T . n r. �,, � e ✓� � �,3 Owner: /0/h,L /O/*G/Cd(7 Date of Inspection: /D -�--ao FLOW CONDITIONS accinFUTnA 1 . Design flow: g. p. d./bedroom. Number of bedrooms (design):_ Number of bedrooms (actual)y2 Total DESIGN flow Number of current residents: Garbage grinder (yes or no): V0 Laundry (separate system) (yes or no):/bO; If yes, separate inspection required Laundry system inspected yes or no) Seasonal use (yes or(q):_ Water meter readings, if available (last two year's usage (gpd): C� O i C 7- gEAQriYlr Sump Pump (yes o n Last date of occupbncy/O _7LOi, COMMERCIAL/INDUSTRIAL: Type of establishment: Design flow: qpd 1 Based on 15.203) Basis of design flow 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: OTHER: (Describe) Last date of occupancy: GENERAL INFORMATION PUMPING RECORDS and source of information: System pumped as part of inspection: (yes or If yes, volume pumped: gallons Reason for pumping: TYPE OF SYSTEM Septic tank/distribution box/soil absorption system Single cesspool Overflow cesspool Privy Shared sys+e?n (yes or no) (if yes, attach previous inspection records, if any) I/A Technology etc. Attach copy of up to date operation and maintenance contract Tight Tank Copy of DEP Approval Other APPROXIMATE AGE of all components, date installed{if known) -and source of,Wormation: - 2S -zfe C`_✓•yGx Sewage odors detected when arriving at the site: (yes ora— revised rna_ revised 9/2/98 Page 6or11 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: / o o O 7 V -V F', "vr E 3r, rv0 . Owner: 10,',1R,6 - Date of Inspection: BUILDING SEWER: (Locate on site plan) Depth below grade: Material of construction: _ cast iron _ 40 PVC _ other (explain) Distance from private water supply well or suction line Diameter Comments: (condition of joints, venting, evidence of leakage, -etc.) SEPTIC TANK:_ (locate on site plan) Depth below grade: Material of construction: _concrete _metal _Fiberglass _Polyethylene _other(explain) If tank is fnetal, list age — .Is.age-confirmed by Certificate of Compliance (Yes/No) _ Q!A X �/Q FICA Dimensions: Sludge depth: (p41 Distance from top of sludge to bottom of outlet tee or baffle:_ � -- ti Scum thickness:_ � IL Distance from top of scum to top of outlet tee or baffler J Distance from bottom of scum to bottom of outlet tee or baffle � ✓ 7/-c Sf� How dimensions were determined: Comments: (recommendation for pumping, condition of inlet and outlet tees or -baffles, depth of liquid level in relation to outlet invert, structuraHntegrity, evidence of leakage, etc.) 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: (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 9/2/98 Page 7of11 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (contirxwed) Property Address: /D a a i v AT, LCA S'T, /Y d, /� r,0o Owner: // e/L Date of Inspection: /v.-7—coo TIGHT OR HOLDING TANK: (Tank must be pumped prior to, or 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 Alarm level: Alarm in working order: Yes _ No_ Date of previous pumping: Comments: (condition of inlet tee, condition of alarm and float switches, etc.) DISTRIBUTION BOX: (locate on site plan) Depth of liquid level above outlet invert: Comments: (note if level and distribution is equal, evidence of solids carryover, evidence of leakage into or out of box, etc.) _ PUMP CHAMBER:_ (locate on site plan) Pumps in working order: (Yes or No) Alarms in working order (Yes or No) Comments: (note condition of pump chamber, condition of pumps and appurtenances, etc.) revised 9/2/98 Page 8of11 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: / 0 v O TU�P�v iJ.! r F $ , w o . Owner: I0/j201- /01"ER6 (52 Date of Inspection: /a-i—OJ SOIL ABSORPTION SYSTEM (SAS): (locate on site plan, if possible; excavation not required, location may be approximated by non -intrusive methods) If not located, explain: Type leaching pits, number:_ leaching chambers, number:_ leaching galleries, number:_ leaching trenches, number, length: leaching, fields, number, dimensions: overflow cesspool, number:_ Alternative system: Name of Technology: Comments: (note condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of vegetation, etc.) DA V So/L CESSPOOLS: _ (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 (cesspool must be pumped as part of inspection) Comments: (note condition of soil, signs of hydraulic failure, level of ponding, condition of•vegetation, etc.) 0 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 9/2/98 Page 9of11 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (contirvied) Property Address: % 0 6141 T llif'/L /T C S % . N o, 1�2,'.Vo '✓ Owner: Date of Inspection: SKETCH OF SEWAGE DISPOSAL SYSTEM: include ties to at least two permanent reference landmarks or benchmarks locate all wells within 100' (Locate where public water supply comes into house) revised 9,'2/98 Page 10 of II M SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: ! o " ° ?44 / Owner: 6�"4- Date of Inspection: /O NRCS Report name Soil Type_ Typical depth to groundwater USGS Date website visited Observation Wells checked Groundwater depth: Shallow Moderate ` Deep SITE EXAM Slope Surface water Check Cellar Shallow wells Estimated Depth to Groundwater 3 Feet Please indicate all the methods used to determine High Groundwater Elevation: Obtained from Design Plans on record Observed.Site (Abutting property, observation hole, basement sump etc.) Determined from local conditions Checked with local Board of health Checked FEMA Maps Checked pumping records Checked local excavators, installers Used USGS Data Describe how you established the High Groundwater Elevation. (Must be completed) ,�_ O C, 19 L (2 o v Pig l—I'VI✓S revised 9/2/98 Page 11 of 11 In w LLm9 LL 0 LLI �cal z U) 0 Uj 0. o CL LLI I. - C . n LL Z LLI LU 0 LL 0 ZO Z' WL Z 0 'U 3: lir 10 Lmu cL- 0. l w0 :W cn 0: co m IU =Iuj co OIL �co ISI ago 0 U-) C�l t iia a: Lu. LL 01W LU o 1 Z U)0:=0 F- LLI I Lu Jill W co Lu 0 Lu: >- 6, U. F— cl: 0 - �z w co m z c>n. : I LL, 0 P 0�& co: mic. Q CM 0 T- H LLJ Lu Lu to > OCL: w 0 Lu Z, -j o w LU CD IL o -U W= CL Z ;01 w F - C4 V Z /l I 0 . - _-- --'_ -- - -- - - --�_ � - zm O wcn v� Y o�O I p�oo, � CD Pp 0 O ii Pwa.aa zLL { wl. w F'000 � a►-�-f- I �an.a (n xw 0 U)�"� -- > 0 d w w J Q o 0 o U 0 O 0 0 Q 0 a w C7 C Ci c= 0 o al I 1 =z ? I w Q LL a w F- F- I i zZ U YWW 0O U) ZaU)i E U D Z z L) z F- aF-�L Q a co a T w w w Fw- z �0 CD 0 1 Q0 Z Y Z I l l ��i�Q�� 01 �I .IE Qw��il� z ��I I II II IIS I ! II�IIII�� l I�I�I o w F-NNN 00 C') 00 Q N I � /l i I z� III ; II i Ow �U) i N ;! z 04 O LL LU mi O I i F 1l W I z W F wI F- I I LL O O N J J j .I w w ! z 0 o F- l IJIJ '~! � w I III! r i wwlvl EL EL I I I FjOf w w I I } p pI =1> Qo0 LL ol ao; al a l C9�r I C')QI aI w I I U- la Z � =�ZCIL I� I Wiol w cn I 3: Zl o'Y O!O It}n Q z U>it i I � ~' z OI ! Ui I i F- o o a I I I I I j Z ' I I 1 I U) "Ilk1_ w , �I bi z w w ! ( j O z Z'O oo Z l �I W a z I G. z z _O a J i ! IIS I r I I I ! } ~ Q N N 1p I I I I I 10 q JOHNSON BORENSTEIN, LLC ATTORNEYS AT LAW 12 Chestnut Street Andover, MA 01810-3706 Tel: 978-475-4488 Fax: 978-475-6703 www.jbllclaw.com don@jbllclaw.com August 23, 2011 North Andover Zoning Board ATTN: Angela Ciofolo 1600 Osgood Street Building 20, Suite 2-36 North Andover, MA 01845 Mark B. Johnson (MA, NH, Dc) Donald F. Borenstein (MA, ME, NH) Kristine M. Sheehy (MA) Denise A. Brogna (MA, CA, NH) Kathryn M. Morin (MA, NH, ME) Lorri Gill COVitZ (MA) Leslie C. Carey (MA, RI) Michael A. Klass (MA, NH) Re: Applicant: Orchard Village LLC Property: 1001 and L-2 Turnpike Street Original Filing Date:. February 28, 2007 Decision Date: June 24, 2008 (filed with Town Clerk on 7/2/08) Amended Decision Date: December 9 2008 Dear Ms. Ciofolo: Paralegals Karen L. Bussell Danielle R. Corey Melanie J. O'Connell Lianne Patenaude Enclosed please find a recorded copy of the Form J Lot Release Form for release of 7 additional building lots (Lots 7, 9, 11, 12, 16, 20 & 26), and the water pump station lot (Lot 33) with regard to the above -referenced matter. Very truly yours, JOHNSON & BORENSTEIN, LLC Donald F. Borenstein DFB/mbf Enclosure Cc: Orchard Village, LLC A im ek..Rlf nd Count Registry FORM J LOT RELEASE FORM The undersigned being a majority of the Zoning Board of Appeals of the Town of North Andover, MA ("Board"), acting as the North Andover Planning Board in its capacity as the Comprehensive Permit granting authority under G.L. c. 40B, §§ 21-23, hereby certify that the requirements for work on the ground called for by the Comprehensive Permit dated June 24, 2008, recorded in the Essex North District Registry of Deeds in Book 11427, Page 192, as affected by an Amendment to Comprehensive Permit dated December 9, 2008, recorded in Book 11427, Page 214, and respectively registered as Documents Nos. 101303 and 101304 on Certificate of Title 16291 and, as shown on a Definitive Subdivision Plan entitled, "Definitive Subdivision Plan for Orchard Village in North Andover, MA" prepared by Christiansen and Sergi, dated April 2, 2009, last revised June 9, 2009, and filed with the Land Registration Office of the Land Court as Plan No. 18083E ("Definitive Subdivision Plan"), have been completed to the satisfaction of the Zoning Board of Appeals as to the following enumerated lots shown on said Definitive Subdivision Plan, and that a performance guarantee satisfactory to the Board, in the form of a letter of credit, has been posted by the developer with the Board pursuant to Mass.Gen.Laws c. 41, s. 81U, and said lots are hereby released from the restrictions as to sale and building specified thereon and released from the Form I Covenant dated August 13, 2009, registered as document number 99463 and as document number 99465. Lots designated on said Definitive Subdivision Plan and released hereby are as follows: Lot 7, Lot 9, Lot 11, Lot 12, Lot 16, Lot 20, Lot 26, and Lot 33 Of ing Board of Appeals ' Town of North Andover i, true Copy of Land Court DOouWlent 'o i '� Certifiicatel, COMMONWEALTH OF MASSACHUSETTS Essex County, ss: � ks'- 2011 Then personally appeared. �-e�fh who proved to me through satisfactory evidence of identificat' n, which was ©� photographic identification with signature issued by a federal or state governmental agency, ❑ oath or affirmation of a credible witness, ❑ personal knowledge of the undersigned, the above-named member of the Zoning Board of Appeals of the Town of North Andover, MA, and acknowledged the foregoing instrument to be the free act and deed of said Zoning Board of Appeals acting as the North Andover Planning Board in its capacity as the Comprehensive Permit granting authority under G.L. c.40B, §§ 21-23, before me, DANIELLE V* REED Notary Public: Notary Public UfCO MMONwenLrH of MassAeHu � My Commission Expires: My Commission Expires May 30, 2014