HomeMy WebLinkAboutMiscellaneous - 106 BOSTON STREET 4/30/2018 (2) 106 BOSTON STREET
210/107.B-0041-0000.0
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CONSTRUCTION APPROVAL
Has plan review fee been paid: NO Permit#
Plan Approval: Date: I/Wo _ Approved by:
Designer: 60 I?'kI �7U1� �° Plan Date:
Conditions: i
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Water Supply: Town Well
Well Permit: Driller:
Well Tests: Chemical Date Approved
Bacteria I Date Approved
Bacteria II Date Approved
Plumbing Sign-Off: Wiring Sign-off:
Comments:
Form "U" Approval: Approval to Issue: YES NO
Date Issued By:
Conditions:
Final Approval:
All Permits Paid? YES NO
Well Construction Approval? YES NO
Septic System Construction Approval? YES NO
Certification? YES NO
Other? YES NO
Any Variance Needed? CE S) NO
FINAL BOARD OF HEALTH APPROVAL:
DATE:
APPROVED BY:
SEPTIC SYSTEM INSTALLATION
CONDITIONS:
Is the installer licensed? YES. NO
Type of Construction: REW <JEPAIR
New Construction: Certified Plot Plan Review YES NO
Floor Plan Review YES NO
Conditions of Approval from Form U YES NO
Issuance of DWC permit: NO
DWC Permit Paid? YES NO
DWC Permit# Installer:
Begin Inspection: YES NO
Excavation Inspection-
Needed: l:��,���,g J b I�. 1 ��� 1.-�FrM, '✓�.�,J S� �—
Passed: By:
Construction Inspection: �(
Needed: pe 6e, C ^���� - ►e� — f /l �J
As Built Plan Satisfactory: ( ,
1-ye: l/
Approval of Backfill: Date: By:
Final Grading Approval: Date: U'�✓ By:
Final Construction Approval: Date: �M\b�By: :x-
Certificate of Compliance: Approval: Date:
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AS ESI LT PLAN
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MERRIMACK ENGINEERING SERVICES, INC.
PROFESSIONAL ENGINEERS • LAND SURVEYORS • PLANNERS
60 PARK STREET • ANDOVER. MASSACHUSETTS 01610 or TEL (617)475-3555, 373.5721
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BOARD OF HEALTH ra11V "RD0FfffirACjjj 4.01,NORTH ANDOVER, MASS. 0184
APPLICATION FOR SOIL TESTS FMAY08 2001
DATE:
LOCATION OF SOIL TESTS: 1
Assessor's map& parcel number._ 1 0 7 0 � 41
OWNER: V►q,l A H 1.-LW 1?i' TEL.
ADDRESS: 12C�
ENGINEER: HE12 "AGI ftj6l U INTEL. NO.:
CERTIFIED SOIL EVALUATOR:
ded use o land. residential subdivision, single family home, commercial
Repair testi Undeveloped lot testing
N. onservation Commission Approval:
THE FOLLOWING MUST BE INCLUDED WITH THIS FORM:
1. Proof of land ownership (Tax bill, deed, or letter from owner permitting
tests)
2. Plot plan
3. Fee of 1275.QO per lot for new construction. This covers the minimum two deep holes
and two percolation tests required for each disposal area. Fee of$75.00 per lot for
repairs or upgrade.
GENERAL INFORMATION
1. Only Certified Soil Evaluators may perform deep hole inspections.
2. Only Mass. Registered Sanitarians and Professional Engineers can design septic
plans.
3. At least two deep holes and two percolation tests are required for each septic system
disposal area.
4. Repairs require at least two deep holes and at least one percolation test, at the
discretion of the BOH representative.
5. Full payment will be required for all additional tests within two weeks of testing.
6. Within 45 days of testing, a scaled plan (no smaller than 1"-100') shall be submitted to
the Board of Health showing the location of all tests (including aborted tests).
7. Within 60 days of testing-ea'valuation forms shall be su r
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PLATING: BOARD APPriOVAI.
LAV; T REQUFRED ,
PL1iMNG 'Win OF
PL. of= L.0-r $
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Of Am
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o� CHARLES
Dov z M.A.
v MARTIN
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APPLICATION FOR SEWAGE DISPOSAL INSTALLATION
t HEALTH DEPARTMENT - NORTH ANDOVER, MASS.
I hereby make application for permit for a sewage disposal installation at
20 &t7t - I will install this system in ac-
cordance with all the laws of the Commonwealth of Massachusetts and regulations of
the Board of Health of the Town of North Andover.
Further, I will construct the house sewer of bell and spigot pipe, the minimum
diameter being 4 inches, and will maintain a minimum grade of 1/ until 10 feet pre-
ceding the septic tank, where the grade shall not exceed 2%. I will install a con-
crete septic tank of / d�- � in size. A manhole (s) permitting easy cleaning
will be provided with removable cover (s) of iron or concrete within 12 inches of
the ground surface. I will provide subsurface disposal field with 4 inch perforated
or open jointed pipe and laid in a series of trenches, the bottom of which will pro-
vide a minimum of /f?-0 lineal (square) feet of effective absorption area.
The pipes will be laid on a 6 inch layer of washed gravel or crushed stone ranging
in size from 3/4 to 1-1/2 inches (dia. ) and the pipes will be surrounded by similar
material to a height of 2 inches above the crown of the pipe. The joints of these
pipes will be protected from clogging and before filling the trench, 2 inches of
gravel or stone 1/8" to 1/4" (dia. ) will be placed over the course gravel or stone.
The disposal field will be installed at a grade of 4 to 6 inches/100 feet. No single
tile line will exceed 100 feet in length and in any case, two lines of tile will be
installed. A minimum of 6 feet will be maintained between the center lines of the
disposal field trenches and the average depth of trench shall not exceed 36 inches.
No part of the installation will be less than 100 feet from any private water supply,
25 feet from any stream, 20 feet from any dwelling or 10 feet from any property line.
I further agree not to cover any portion of this installation until approved by the
inspection officer, as provided below, and to incorporate any additional requirements
that may be attached to the permit. Plot Plans must be submitted with application.
DATE C - -7/
Signature of Applicant
I hereby issue the above permit for the Board of Health of the Town of North
Andover, Massachusetts.
DATE -/
Signature of Health Agent
I have inspected the uncovered system indicated above and find everything done
as described
DATE 10 3- 0 7
Signature of Ins ting Officer
Percolation Test
Garbage Grinder "'�
BOARD OF HEALTH
��. TOWN OF NORTH ANDOVER, MASS.
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1. NAME J,, DATE
2. ADDRESSJP 5-",4C4wT 7�a,- qa Q SnA Sr LOT NO.
3. NO. OF BEDROOMS 3 DEN YES GOL-
4.
GARBAGE GRINDER YES NO
5. SHOW DIMENSIONS OF HOUSE
6. SHOW DISTANCES OF HOUSE TO ALL PROPERTY LINES
7. SHOW DIMENSIONS OF LOT
8. SHOW LOCATION AND SIZE OF SEPTIC TANK OR CESSPOOL
9. NOTE LOCATION AND DISTANCE OF WELL FROM SEWERAGE SYSTEM
10. SHOW LOCATION OF BROOKS, STREAMS, DITCHES, LEDGE OUTCROP, ETC.N°""E
11. SHOW DISTANCE OF SEPTIC TANK OR CESSPOOL FROM HOUSE
NOTE. LOCAL REGULATIONS SHOULD BE READ CAREFULLY.
•�.s
BOARD OF HEALTH OF NORTH ANDOVER, MASSACHUSETTS
SEWAGE DISPOSAL
DATE
NAME OF APPLICANT WJlliam Houde
LOCATION Lot #8 Boston St.
Address of lot no.
BUILDING: Dwelling X Other
SYSTEM: New X Repair
GENERAL DESCRIPTION OF LAND high
SUBSOIL: Clay Gravel Sand X Clay
PERCOLATION TEST 5 minutes per inch.
MINIMUM INSTALLATION RECOMMENDATIONS
CONCRETE SEPTIC TANK 1=000 gallon capacity.
LEACH FIELD 180 lineal feet of drain pipe.
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William J. Dr oll, Engineer
Board of Heal
Town of North Andover, Massachusetts Form No. 1
/ NORTH BOARD OF HEALTH
0 19-
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APPLICATION FOR SITE TESTING/INSPECTION
21 pOAATED PPP (y .
�SSACHUS�S
Applicant
NAME ADDRESS TELEPHONE
Site Location
Engineer
NAME ADDRESS TELEPHONE
Test/Inspection Date and Time
CHAIRMAN,BOARD OF HEALTH
Fee Test No.
S.S. Permit No. D.W.C. No. C.C. Date Plbg. Permit No.
Frnstaller.
Q rL�v t Owner's Name: L*10 ref f rll U
l: TI-��D'� "r(, t-f Address: D(p [�d�
Tel . _S 49!3-Z"New(SM) Repair
Date: (i- -e9 Wetlands �tzone11 SoilSymbol SOil Iqame_6jh& Soil Class
Deep Observation Hole Logs
Elevation Depth Soil Horizon Soil Te=ture Soil Color Soil Mottling % Gravel,Stones,etc:
Ar
42; to Y 104 VOVF"
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Date 0e:':: �1 Percolation Tests
Observation Hole
Depth of Perc ( tt
Start Pre-soak
Time at 12"
Time at 9"
Time at 6"
Time(9"-6")
Rate Min/Inch I
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TOWN OF NORTH ANDOVER o:°;�«•.° "o°�
HEALTH DEPARTMENT
27 CHARLES STREET
NORTH ANDOVER, MASSACHUSETTS 01845 "s•�_�tt
SACHUS
Sandra.Starr Telephone(978)688-9540
Public Health Director FAX(978)688-9542
August 6,2001
Bill Dufresne
Merrimack Engineering Services
66 Park Street
Andover,MA 01810
Re: 106 Boston Street
Dear Mr.Dufresne:
This letter comes as notification of technical deficiencies on the proposed septic plan repair dated 7/9/01: These
deficiencies are as follows:
The profile is not drawn to scale. (310 CMR 15.220(4)(o)and N.A. 8.02C).W i
The septic tank detail is out of date. (3 10 CMR 15.226& 15.227)
Please note that a re-submittal fee for these deficiencies shall not be necessary.
Sincerely,
Sandra Starr,RS.,C.H.O.
Public Health Director
Cc: Homeowner
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MERRIMACK ENGINEERING SERVICES, INC.
PROFESSIONAL ENGINEERS 0 LAND SURVEYORS • PLANNERS
66 PARK STREET•ANDOVER,MASSACHUSETTS 01810•TEL(978)475-3555,373-5721 •FAX(978)475.1448•E-MAIL:merreng@aol.com
TO: North Andover Board of Health
FROM: Bill Dufresne/Merrimack Engineering
DATE:
a
1 9 2CO
RE: 10(2 00 5To- rl) cc I
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OWNER(NAME& ADDRESS) Nr2
IJo� -,kit�-
Members of the Board:
An upgrade sewage disposal system plan dated: has been
submitted for the above referenced site. Pursuant to Title 5, and the North Andover
Board of Health Regulations, Local upgrade approval and/or variances are being sought
from the following sections.
1) L..u A. F�a- 0FFr5 C �� �w'I` �►u�r—� r�� t-v � �
2) tom. Q► I C t 7 '100-;?F 7 190 5F (4T9r�c
3)
Please consider these requests for approval on your earliest available meeting agenda.
We respectfully request your consideration of these matters.
Very truly yours,
MERRIMACK ENGINEERING SERVICES
F
William Dufresne
cd
Town of North Andover NORTH
. O
Office of the Health Department
Community Development and Services Division x
27 Charles Street °�~~'�• ` "
North Andover, Massachusetts 01845 SACHUSE
Sandra Starr Telephone(978)688-9540
Health Director Fax(978)688-9542
August 21, 2001
Bill Dufresne
Merrimack Engineering
66 Park Street
Andover, MA 01810
Re: 106 Boston Street
Dear Bill:
This is to notify you that the revised plans dated 8/13/01 for 106 Boston Street have been
approved.
If you have any questions, please do not hesitate to call the Board of Health Office at
978-688-9540.
Sincerely,
Sandra Starr, R.S., C.H.O.
Health Director
SS/smc
cc: Houde
File
BOARD OF APPEALS 688-9541 BUILDING 688-9545 CONSERVATION 688-9530 NURSE 688-9543 PLANTN NG 688-9535
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Sep-20-01 09: 29A P.02
BOARD OF HEALTH
NORTH ANDOVER, MA 0)$45
978-688-9540
APPLICATION FOR IIiSPOSAL WORKS CONSTRUCTION P'iJRMIT
DATE:_ D 1 CURRENT INSTAIA,ER'S LiC E,VSF# //
LOCATION: , 1,01/a Z,
LIC'PNSED INS AI,L 1J
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CHECK (;W, IV
RC.1?AIR: V11-
4-
IF
`lf-Ifs NV'W CONSTUCT. ;-BUILT.
$!60_00 Fcc Attached,
Foundation As-Built?
Floor Plans?
Approval
tor tl�O
BOARD OF yFgLTF,—
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2 X001'
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Sep-20-01 09:29A Jin ,4 P.02
BOARD OF HEALTH
NORTH AN DOVER, MA 01845
978-68S-9540
APPLICATION FOR DISPOSAL WORKS CONSTRUCTION PERMIT
DATE: af) D j (-:IJRRENT' IINSTAI,i,F,R'S I,IC'I:NSE# rI
L0CATI 0N: f6 OS -0n S7— IVB I__tJl/ -
LICFNS2) I,,S,'IAI,,LEI :_Jy (2 W ,°r t x 0 o
51t=NATCHECK
REPAIR: NEW CONSTRUCTION:
IF NI+,W CONSTUC'TION, PLEASE ATTACH FOUNDATION AS-BUILT.
Administrative Use Only
$160-00 Uee Attached'? IN o
Foutldatior, As-Iluilt? Yes No
Floor Nam? No
Approval � Date-
t? NF 0RT7_-A-1 -
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TOWN OF NORTH ANDOV=ER E DISPOSAL SYSTEM
INSTALLATION CERTIFICATION
The undersigned hereby certify that the Sewage Disposal System( ) constructed;
( ,repaired;
located at 104, F�00T._Vo
was installed in conformance with the North Andover Board of Health approved plan,
System Design Permit# , dated ' with an approved design
flow of W gallons per day. The materials used were in conformance with those
specified on the approved plan; the system was installed in accordance with the
provisions of 310 CMR 15.000, Title 5 and local regulations, and the final grading agrees
substantially with the approved plan. All work is accurately represented on the As-built
which has been submitted to the Board of Health.
Bed inspection date:
Engineer Representative
Final inspection date: '7id —01
Engineer Representative
Installer: Lic.#:`Q'/Date: / le
Design Fin ineer: mak_ Date: / Z`j
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AS PREPARED FORKORAVOSNo.37762 D
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DATE:
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MERRIMACK ENGINEERING SERVICES, INC.
PROFESSIONAL ENGINEERS • LAND SURVEYORS • PLANNERS
66 PARK STREET • ANDOVER. MASSACHUSETTS 01614 l TEL (617 as-MM. 3M5nl
Town of North Andover, Massachusetts Form No.2
f MORTh BOARD OF HEALTH
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DESIGN APPROVAL FOR
: ss,C"U SOIL ABSORPTION SEWAGE DISPOSAL SYSTEM
• Applicant-z)J�'►� _ � Q Test No, maz
Site Location_ /d IDQST��j
Reference Plans and Specs.�L)/—
ENGINEER DESIGN DATE
: Permission is granted for an individual soil absorption sewage disposal system to be installed
in accordance with regulations of Board of Health. --
76—,Z�
CHAIRMAN,BOARD OF HEALTH
Fee_Ll'o Site System Permit No. 114g,6_ '
DALTON & BARON
v ATTORNEYS AT LAW
68 Main Street
PO Box 608
Andover, MA.01810
Charles F. Dalton,Jr. Telephone(978)470-1320
Allan L.Baron Facsimile(978)470-3346
Susan T. Dalton
April 5, 2002
William J. Gillen
Susan J. Gillen
106 Boston Road
North Andover, MA 01845
RE: Confirmatory Deed from William Houde to William Gillen
Dear William and Susan:
Please be advised that this law firm represents William A. Houde and Linda M. Houde in connection with their Title V
escrow with First Essex Bank.
It has come to the attention of Mr. Houde that in order for the Title V Certificate of Compliance to be issued by the Town
of North Andover, that they require a paragraph in the deed relative to the fact the owners of the property will not add any
additional rooms to the dwelling without first tying into the Town's sewer system.
At the time that the conveyance was made to you, it was unknown by the Houde's that North Andover had this
requirement.
In order for the Houde's now to obtain the Certificate for your property and for them to then receive back their escrow
held through the bank, this deed will need to be executed.
I would urge you to contact your legal advisor relative fa'this atter before executing and returning the document to this
office.
.I would be happy to answer any questions relative to this matter b"you or your representative.
Sincerely,
` 11 Baron
ALB/amb
Cc: Attorneys Russell &Bernard;
Sandra Starr, RS, Agent; and -
William A. Houde
A:\Letter-gillen.doc
Confirmatory Deed
We, William A. Houde and Linda M. Houde, of 37 Cole's Way, Atkinson, New Hampshire,
03811 in consideration paid of Three Hundred Forty-Four Thousand and 00/100 Dollars
($344,000.00) grant to William J.' Gillen and Susan J. Gillen, HUSBAND AND WIFE AS
TENANTS BY THE ENTIRETY of 106 Boston Street,North Andover, Massachusetts, 01845
With QUITCLAIM COVENANTS
A certain parcel of land situated in North Andover, and being shown as Lot 8 on a plan of land
entitled: "Plan of Lot #8 Owned by Frances O. Goodhue, North Andover, Mass." Dated April
1971 which plan is recorded in the North Essex Registry of Deeds as Plan #6396, said premises
being substantially bounded and described as follows:
WESTERLY , by the Easterly line of Boston Street, 150 feet;
NORTHERLY by Lot 7, 285 feet;
NORTHEASTERLY by land of Bernard Power, 203.58 feet; and
SOUTHERLY by land of Frances O. Goodhue, 339.79 feet.
Containing 53,831 square feet, more or less, all as shown on said plan.
Pursuant to the Town of North Andover Health Department Ruling, the grantees, their successors
and/or assigns shall not add any additional rooms to the dwelling as it exists at present without
first tying the dwelling into the Town's sewer.
The purpose of this Confirmatory Deed being to include the above restriction in the deed
dated September 21, 2001 and recorded on September 21, 2001 at Book 6378, Page 2 of the
Essex North Registry of Deeds.
Being the same premises conveyed to us by deed of Frances O. Goodhue dated May 13, 1971
and recorded in Essex North Registry of Deeds at Book 1170, Page 800.
Executed as a sealed instrument this day of April, 2002.
William A. Houde Linda M. Houde
i
Tommonwtaltll of An,i,inr4usttto.
Essex, ss:
On this day of April, 2002, before me personally appeared William A. Houde and
Linda M. Houde, to me known to be the person(s) described in and who executed the forgoing
instrument, and acknowledged that he/she/they executed the same as his/her/their free act and
deed.
(Seal)
Notary Republic
My Commission Expires:
:ORl H AtVL�ii ��—,
RD OF HFALTH
DALTON & BARON
ATTORNEYS AT LAW WAR 2
68 Main Street L a �-- -
PO Box 608
Andover,MA.01810 '
Charles F.Dalton,Jr.
470-1320 Telephone(978)
Allan L. Baron Facsimile(978)
470-3346
Susan T.Dalton
March 25, 2002
Sandra Starr, RS, Agent
27 Charles Street
North Andover, MA 01845
RE: William A. Houde / William J. Gillen
106 Boston Street, North Andover, MA 01845
Dear Ms. Starr:
Please be advised that Dalton & Baron represents William Houde in connection with a Title V
compliance issue with the Town of North Andover. Mr. Houde has informed me that as part
of his Real Estate Closing on September 21, 2001, certain funds were escrowed for purposes
of Title V Compliance.
He informs us that it is his belief the Town of North Andover is requiring a restriction in his
Deed, which has already been granted and accepted by William J. Gillen and Susan J. Gillen as
part of the September 21, 2001 closing, that no further bedrooms be constructed without the
homeowners first tying into Town Sewer.
He has asked this office to facilitate the contacting of the buyer, lender and preparation of a
Confirmatory Deed.
Before this office commences that work, I would ask that your departments aid in supplying to
this office a written requirement from the town for this condition to be included in the Deed.
Mr. Houde presently is unable to provide us with a plan and/or any letter from the town
evidencing this requirement.
I am sure that I will have to provide such written information to the lender and/or borrower for
them to consider which to them is an unanticipated change in the terms of the conveyance.
AALetter-starr.doc
Jy�NN
DALTON & BARON
ATTORNEYS AT LAW 2
Should you have any questions relative to this matter, I would be happy to discuss the s ri
with you.
Sincerely,
\. X
Allan : Baron
Cc: William Houde .,
ALB/amb
AALetter-starr.doc
NOTICE OF VARIANCE / DEED RESTRICTION
Pursuant to 310 CMR 15.000 Title 5, and as a condition of the North Andover Board of Health
Disposal Works Construction Permit Approval, notice is hereby given that real estate located at
106 Boston Street, North Andover, Massachusetts, (a/k/a Assessor's Map 107 B / Block 41) as ,--;
described in a deed from William A. Houde and Linda M. Houde to William J. Gillen and Susan
J. Gillen, dated September 21, 2001 and recorded in the Essex North County Registry of Deeds
in Book 6378, Page 2, is the subject of a variance from the town of North Andover Minimum
Reouirements for the Subsurface Disposal of Sanitlaq Sewage A1.05 and C9.Oi (4). Said
variance limits the number of bedrooms at this dwelling to those existing as of 1/1/02. Existing
rooms may in certain cases be enlarged but the total number of rooms shall remain the same
unless a building permit is issued by the Town of North Andover which may necessitate an
upgrading of the current system or a connection to the municipal sewer, if available. This
variance is within the jurisdiction of the North Andover Board of Health.
Signed and {l
sealed this I Y ay Of /9•;i olyr , 2002.
i
r illiamXGillen Susan J. G111
Essex, ss Date: 2002
Then personally appeared the above-named William J. Gillen and Susan J. Gillen and
acknowledged the foregoing instrument to be their free act and deed, before me.
ESSEX NORTH REGISTRY OF DEEDS MWY C, �•
LAWRENCE, MASS. � Notary Public:
A TRUE COPY: ATTEST: My Commission E7*
re
X 705
J71If CFiELL E.l�ifl�EA
AW
6,jmY �
REGISTER OR DEEP,
- Octobe
r 7,2005
T(;JJ-,d OF k0RTH -!Q6,
BOARD OF PF..P.JH—
DALTON & BARON k
ATTORNEYS AT LAW 2 8 LC2
68 Main Street
PO Box 608
Andover,MA.01810
Charles F.Dalton,Jr. Telephone(978)470-1320
Allan L.Baron Facsimile(978)470-3346
Susan T.Dalton
August 27, 2002
Town of North Andover, Office of the Conservation Department
Community Development and Services Division, Health Department
Attn.: Brian J. LaGrasse, Health Inspector
27 Charles Street
North Andover
Via Facsimile and Mail
RE: 106 Boston Street, North Andover, Massachusetts
Dear Mr. LaGrasse:
Relative to the above captioned matter, I am enclosing for your review a proposed Notice of
Variance/Deed Restriction, which contains some compromised language.
If this form is agreeable to the Town of North d er, I would appreciate a telephone call or a
short fax indicating such and I will work with the o and new owner to have this executed,
recorded and returned to the Town of North Ando r, fo with.
f cerely,
1 Baron
Enclosures
ALB/amb
Cc: Mitchell T. Kroner, Esq.
3 Cannon Hill Road Extension
Groveland, MA 01834
AA Letter-lagrasse.doc
NOTICE OF VARIANCE / DEED RESTRICTION
Pursuant to 310 CMR 15.000 Title 5, and as a condition of the North Andover Board of Health
Disposal Works Construction Permit Approval, notice is hereby given that real estate located at
106 Boston Road, North Andover, Massachusetts, (a/k/a Assessor's Map / Lot
as described in a deed from William A. Houde and Linda M. Houde to William J.
Gillen and Susan J. Gillen, dated September 21, 2001 and recorded in the Essex North County
Registry of Deeds in Book 6378, Page 2, and as Document# , is the subject of a
variance from the town of North Andover Minimum Requirements for the Subsurface Disposal
of Sanitary Sewage A1.05 and C9.01 (4). Said variance limits the number of bedrooms at this
dwelling to those existing as of 1/1/02. Existing rooms may in certain cases be enlarged but the
total number of rooms shall remain the same unless a building permit is issued by the Town of
North Andover which may necessitate an upgrading of the current system or a connection to the
municipal sewer, if available. This variance is within the jurisdiction of the North Andover
Board of Health.
Signed and sealed this day of , 2002.
William J. Gillen Susan J. Gillen
(1 MAMIONV EACOM (AIT MA00.P1TRIWE&SO
Essex, ss Date: —52002
Then personally appeared the above-named William J. Gillen and Susan J. Gillen and
acknowledged the foregoing instrument to be their free act and deed, before me.
Notary Public:
My Commission Expires:
pop.RIJ OF HEALTH
DALTON & BARON
ATTORNEYS AT LAW JUL 5 2002
68 Main Street �—•-�-----
PO Box 608 J
Andover,MA.01810
Charles F.Dalton,Jr. Telephone(978)470-1320
Allan L.Baron Facsimile(978)470-3346
Susan T.Dalton
July 3, 2002
Brian J. LaGrasse, Health Inspector
Town of North Andover, Office of the Conservation Department
Community Development and Services Division, Health Department
27 Charles Street
North Andover, MA 01845
RE: 106 Boston Street,North Andover,Massachusetts
Dear Mr. LaGrasse:
This is a follow up of your May 8, 2002 memorandum to my office. Since then I have been in
contact with the attorney for the new owners of 106 Boston Street relative to the requirement that
a Notice of Variance/Deed Restriction be recorded.
Although the current owners would agree to sign a Deed Restriction limiting the number of
bedrooms at the dwelling to those existing as of the date of the variance, they take issue with
limiting themselves to increasing the sizes of other rooms within the dwelling or limiting their
ability to add additional non-bedrooms to the property.
I would ask that you consider agreeing to a deed restriction limited to the number of bedrooms as
a compromise to this situation. I would suggest a compromise in this situation only due to the
fact no party to this transaction had notice of the restriction requirement prior to closing. The
plan approval did not include the condition nor did any written document contain such condition.
If your department is unable to agree to this compromise, then I would appreciate you contacting
my office to advise how this office may obtain a certified copy of the notes taken of the August
23, 2001 Board of Health Meeting which according to your memo to this office included the
specific language as to the variances issued and the s ecific conditions that need to be contained
in the Deed.
Thank you for your cooperation in this matter thus ar and\your anticipated cooperation in an
effort to resolve this issue in a fair manner to all parties.
Si erely,
11 ar
ALB/amb
CC: William Houde
Mitchell E. Kroner, Esquire
AALetter-lagrasse.doc
Town of North Andover rORTp
Office of the Conservation Department
Community Development and Services Division
Health Department '� n•�`
AiO
27 Charles Street 4�SACNus�`
Sandra Starr North Andover,Massachusetts 01845 Telephone(978)688-9540
Health Director Fax(978)688-9542
MEMORANDUM
TO: Allan L.Baron,Esq.
FROM: Brian J.LaGrasse,Health Inspector
RE: Deed Restriction for 106 Boston Street
DATE: May 8,2002
The Board of Health at the August 23,2001 meeting unanimously,voted to approve the septic design
plans proposed for 106 Boston Street The Board issued variances for the proposed septic system,
including a variance for the size of the leach field from 900 square feet to 750 square feet The Board
issued this variance under the condition that a deed restriction would be placed on the subject property
to limit the number of bedrooms to three and that no more rooms are to be added prior to a Certificate of
Compliance is issued.
Please call me if you have any questions,commeti or concerns.
Since ly,
r
46-r).LaGrasse
Health Inspector
cc: Sandra Starr,Health Director
File
BOARD OF APPEALS 688-9541 BUILDING 688-9545 CONSERVATION 688-9530 HEALTH 688-9540 PLANNING 688-9535
OA NORT�74 u lJ ! .
. O
Town of North Andover
HEALTH DEPARTMENT
,S'sACHUStS
CHECK#: _JLC DATE:
LOCATION: ��(�O d� ✓'
H/O NAME: -��i?_.
CONTRACTOR NAME:
Type of Permit or License: (Check box)
❑ Animal $
❑ Body Art Establishment $
❑ Body Art Practitioner $
❑ Dumpster $
❑ Food Service-Type: $
❑ Funeral Directors $
❑ Massage Establishment $
❑ Massage Practice $
❑ Offal(Septic)Hauler $
❑ Recreational Camp $
❑ Sun tanning $
❑ Swimming Pool $
❑ Tobacco $
❑ Trash/Solid Waste Hauler $
❑ Well Construction $
SEPTIC Systems:
❑ Septic-Soil Testing $
❑ Septic-Design Approval $
❑ Septic Disposal Works Construction(DWC) $
❑ Septic Disposal Works Installers(DWI) $
❑ Title 5 Inspector $
:tle 5 Report $-5y,
❑ Other. (Indicate) $
Health Agent Initials
White-Applicant Yellow-Health Pink-Treasurer
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form Not for Voluntary Assessments J/�i,/a�
106 Boston Rd.
Property Address
Susan Gillen -
Owner Owner's Name
information is North Andover MA _ 01845 9-17-09
required for state Zip Code Date of Inspection
every page. CityfTown
.:his form. Inspection forms may not be altered in any
it the end of the form.
Important: REC E I'VE b
When filling out
forms on the
computer,use
only the tab ke! SEP 2 8 2009
to move your
cursor-do not TOWN OF NORTH ANDOVER
use the return HEALTH DEPARTMENT
key.� -----------
VQ
MA 01950
StateZip Code ----
870
License Number
B. Certification
I certify that I have personally inspected the sewage disposal system at this address and that the
information reported below is true, accurate and complete as of the time of the inspection. The inspection
was performed based on my training and experience in the proper function and maintenance of on site
sewage disposal systems. I am a DEP approved system inspector pursuant to Section 15.340 of
Title 5(310 CMR 15.000),The system:
® Passes ❑ Conditionally Passes F-1Fails
❑ Needs Further Evaluation by,the Local Approving Authority
_7-20-09
Inspect s Signature Date
The system inspector shall submit a copy of this inspection report to the Approving Authority(Board
of Health or DEP)within 30 days of completing this inspection. If the system is a shared system or
has a design flow of 10,000 gpd or greater,the inspector and the system owner shall submit the
report to the appropriate regional office of the DEP. The original should be sent to the system owner
and copies sent to the buyer, if applicable, and the approving authority.
""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,
f
,
t
Commonwealth of Massachusetts /.
Title 5 Official Inspection Foirm .
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
�- 106 Boston Rd.
Property Address
Susan Gillen
Owner Owners Name
information isNorth Andover MA 01845 9-17-09
required for — State _ Zip Code Date of Inspection
every page. Cityrl'own
Inspection results must be submitted on this form. Inspection forms may not be altered in any
way.Please see completeness checklist at the end of the form.
Important: A. General Information RECEIVED
When filling out
forms on the
computer,use 1. Inspector:
only the tab key SEP 2 8 2009
to move your Benjamin C. Osgood,
cursor-do not Name of Inspector TOWN OF NORTH ANDOVER
use the return HEALTH DEPARTMENT
key. none —_---------
Company Name
VQ 224 High Street, Apt 1 --
M � Company Address
MA _ 01950
Newburyport State Zip Code
nam t� Citylrown - -----
978-255-2261 _ 870
Telephone Number License Number
B. Certification
I certify that I have personally inspected the sewage disposal system at this address and that the
information reported below is true, accurate and complete as of the time of the inspection. The inspection
was performed based on my training and experience in the proper function and maintenance of on site
sewage disposal systems. I am a DEP approved system inspector pursuant to Section 15.340 of
Title 5(310 CMR 15.000).The system:
® Passes ❑ Conditionally Passes ❑ Fails
❑ Needs Further Evaluation by:the Local Approving Authority
_ 7-20-09
Inspect s Signature Date
The system inspector shall submit a copy of this inspection report to the Approving Authority(Board
of Health or DEP)within 30 days of completing this inspection. If the system is a shared system or
has a design flow of 10,000 gpd or greater,the inspector and the system owner shall submit the
report to the appropriate regional office of the DEP. The original should be sent to the system owner
and copies sent to the buyer, if applicable, and the approving authority.
""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.
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
106 Boston Rd.
Property Address
Susan Gillen
Owner Owner's Name
information is North Andover MA 01845 9-17-09
required for -
every page. Citylrown State Zip Code Date of Inspection
B. Certification (cont.)
Inspection Summary: Check A,B,C,D or E I 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.
Check the box for"yes", "no"or"not determined" (Y, N, ND)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.
0 Y ❑ N ❑ ND (Explain below):
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System form-Not for Voluntary Assessments
106 Boston Rd. — – --
Property Address
Susan Gillen
Owner Owner's Name
information is North Andover MA_ 01845 9-17-09
required for State Zip Code Date of Inspection
every page. Cityrrown
B. Certification (cont.)
B) System Conditionally Passes (cont.):
Observation of sewage backup or break out or high static water level in the distribution box due
❑ m will
to broken or obstructed pipe(s)or due to a broken, settled or uneven distribution box. System
pass inspection if(with approval of Board of Health):
❑ broken pipe(s)are replaced ❑ Y ❑ N ❑ ND (Explain below):
❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below):
❑ distribution box is leveled or replaced ❑ Y ❑ N ❑ ND (Explain below):
❑ 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 ❑ Y ❑ N ❑ ND (Explain below):
❑ obstruction is removed ❑ Y ❑ N ❑ ND(Explain below):
C) Further Evaluation is Required by the Board of Health:
❑ Conditions exist which require further evaluation by the Board of Health in order to determine if
the system is failing to protect public health, safety or the environment.
1. System will pass unless Board of Health determines in accordance with 310 CMR
15.303(1)(b)that the system is not functioning in a manner which will protect public health,
safety and the environment:
❑ Cesspool or privy is within 50 feet of a surface water
❑ Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh
Commonwealth of Massachusetts
Title 5 official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
106 Boston Rd. —
Property Address
Susan Gillen
Owner Owner's Name
information is
required for North Andover MA 01845 9-17-09
every page. Cityrrown State Zip Code Date of Inspection
B. Certification (cont.)
2. System will fail unless the Board of Health(and Public Water Supplier,if any)
determines that the system is functioning in a manner that protects the public health,
safety and environment:
❑ The system has a septic tank and soil absorption system (SAS)and the SAS is within
100 feet of a surface water supply or tributary to a surface water supply.
❑ The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water
supply.
❑ The system has a septic tank and SAS and the SAS is within 50 feet of a private water
supply well.
❑ The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or
more from a private water supply well".
Method used to determine distance:
**This system passes if the well water analysis, performed at a DEP certified laboratory, for coliform
bacteria indicates absent 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:
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
El ®
or clogged SAS or cesspool
❑ ® Liquid depth in cesspool is less than 6"below invert or available volume is less
than '/2 day flow
Commonwealth of Massachusetts
Title 5 official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
106 Boston Rd.
Property Address
Susan Gillen
Owner Owner's Name
information is
required for North Andover MA 01845 9-17-09
every page. Cityfrown State Zip Code Date of Inspection
B. Certification (cont.)
Yes No
❑ ® Required pumping more than 4 times in the last year NOT due to clogged or
obstructed pipe(s). Number of times pumped:
❑ 0 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 fecal coliform bacteria indicates absent 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
and chain of custody must be attached to this form.)
❑ ® The system is a cesspool serving a facility with a design flow of 2000gpd-
10,000gpd.
❑ ® The system fails. I have determined that one or more of the above failure
criteria exist as described in 310 CMR 15.303, therefore the system fails. The
system owner should contact the Board of Health to determine what will be
necessary to correct the failure.
E) Large Systems: To be considered a large system the system must serve a facility with a
design flow of 10,000 gpd to 15,000 gpd.
For large systems, you must indicate either"yes"or"no"to each of the following, in addition to the
questions in Section D.
Yes No
i
❑ ® the system is within 400 feet of a surface drinking water supply
❑ 0 the system is within 200 feet of a tributary to a surface drinking water supply
❑ ® the system is located in a nitrogen sensitive area (interim Wellhead Protection
Area—IWPA)or a mapped Zone 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.
Commonwealth of Massachusetts
Title 5 official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
106 Boston Rd.
Property Address
Susan Gillen
Owner Owner's Name
information is North Andover MA 01845 9-17-09 _
required for
every page. City/TownState Zip Code Date of inspection
C. Checklist
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 t1.
wo 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?,
El ® 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?❑ Y
® ❑ 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 and location of the Soil Absorption System(SAS)on the site has
been determined based on:
i
❑ ® Existing information. For example, a plan at the Board of Health.
El ® Determined in the field (if any of the failure criteria related to Part C is at issue
approximation of distance is unacceptable)1310 CMR 15.302(5)]
I
D. System Information
Residential Flow Conditions:
.. 3
Number of bedrooms(design): 3 Number of bedrooms(actual):
DESIGN flow based on 310 CMR 15.203(for example: 110 gpd x#of bedrooms):
330
Commonwealth of Massachusetts
Title 5 official Inspection Form
Subsurface Sewage Disposal System Form Not for Voluntary Assessments
106 Boston Rd.
Property Address
Susan Gillen
Owner Owner's Name
information is
required for North Andover MA 01845 9-17-09
every page. Citylrown : State Zip Code Date of Inspection
D. System Information
Description:
5
4
Number of current residents:
Does residence have a garbage grinder? ❑ Yes ® No
Is laundry on a separate sewage system?[if yes separate inspection required] ❑ Yes ® No
Laundry system inspected? ❑ Yes Z . No
Seasonal use? ❑ Yes ® No
Water meter readings, if available(last 2 years usage(gpd)):
Detail:
Sump pump? ❑ Yes ® No
Last date of occupancy: current _
Date
CommerciaUlndustrial Flow Conditions:
Type of Establishment: -- --
Design flow(based on 310 CMR 15.203): Gallons per day(9pd)
Basis of design flow(seats/persons/sq.ft., etc.): —
Grease trap present? ❑ Yes ❑ No
Industrial waste holding tank present? ❑ Yes ❑ No
Non-sanitary waste discharged to the Title 5 system? ❑ Yes ❑ No
Water meter readings, if available: -- -
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
106 Boston Rd. —
Property Address
Susan Gillen
Owner Owners Name
information is
required for North Andover MA 01845 9-17-09
every page. Cityrrown State Zip Code Date of Inspection
D. System Information (cont.)
Last date of occupancy/use: Date
Other(describe below):
i
General information
Pumping Records:
Source of information: 9-0!9
p�(21 aa1A
Was system pumped as part of the inspection? ❑ Yes ® No
If yes, volume pumped: gaga
lIons
How was quantity pumped determined?
Reason for pumping: --
Type of System:
® Septic tank, distribution box, soil absorption system
❑ Single cesspool
El 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) and a copy of latest
inspection of the I/A system by system operator under contract
❑ Tight tank. Attach a copy of the DEP approval.
❑ Other(describe):
Commonwealth of Massachusetts
Title 5 official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
b� 106 Boston Rd.
Property Address
Susan Gillen
Owner Owner's Name
information is
required for North Andover MA 01845 9-17-09
--
every page. Cityrrown State Zip Code Date of Inspection
D. System Information (cont.)
Approximate age of all components, date installed (if known)and source of information:
Built 2001er as built.drawings
p s 9
Were sewage odors detected when arriving at the site? ❑ Yes ® No
Building Sewer(locate on site plan):
1.5
Depth below grade: feet
Material of construction:
{�cast iron ❑40 PVC ❑ other(explain): --
Distance from private water supply well or suction line: eeA
Comments (on condition of joints, venting, evidence of leakage, etc.):
Pipe not visible Under concrete floor slab
Septic Tank(locate on site plan):
1.5
Depth below grade: feet
Material of construction:
e ne other(explain)
i ® concrete [J metal F1 fiberglass ❑ poly polyethylene ❑
If tank is metal, list age: years
Is age confirmed by a Certificate of Compliance? (attach a copy of certificate) ❑ Yes ❑ No
1500 Gallons
Dimensions: — —
Sludge depth: --
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
106 Boston Rd.
Property Address
Susan Gillen
Owner Owner's Name
information is North Andover MA 01845 9-17-09
required for —
every page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
Septic Tank(cont.)
Distance from top of sludge to bottom of outlet tee or baffle
30"
Scum thickness <1
8,s
Distance from top of scum to top of outlet tee or baffle
Distance from bottom of scum to bottom of outlet tee or baffle
12"
How were dimensions determined? Measure Stick
Comments(on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity,
liquid levels as related to outlet invert, evidence of leakage, etc.):
Tank in good condition. Outlet tee in good condition.
Grease Trap(locate on site plan):
Depth below grade: feet
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: Date —^
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
'~ 106 Boston Rd.
Property Address
Susan Gillen
Owner Owner's Name
information is
required for North Andover MA 01845 9-17-09
every page. Cityrrown State Zip Code Date of Inspection
D. System Information (cont.)
Comments(on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity,
liquid levels as related to outlet inveit, evidence of leakage, etc.):
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 per day
Alarm present: ❑ Yes ❑ No
Alarm level: Alarm in working order: ❑ Yes ❑ No
Date of last pumping: Date
Comments(condition of alarm and float switches, etc.):
*Attach copy of current pumping contract(required). Is copy attached? ❑ Yes ❑ No
N Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
106 Boston Rd.
Property Address
Susan Gillen
Owner Owner's Name
information is North Andover MA 01845 9-17-09
required for --
every page. Cityfrown State Zip Code Date of Inspection
D. System Information (cont.)
Distribution Box(if present must be opened)(locate on site plan):
Depth of liquid level above outlet invert
00
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.):
Box in good condition. Distribution equal. No evidence of leakage in or out.
Pump Chamber(locate on site plan):
Pumps in working order: ❑ Yes ❑ No
Alarms in working order: ❑ Yes ❑ No
Comments(note condition of pump chamber, condition of pumps and appurtenances,etc.):
Soil Absorption System(SAS) (locate on site plan, excavation not required):
If SAS not located, explain why:
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Forth -Not for Voluntary Assessments
106 Boston Rd.
Property Address
Susan Gillen
Owner Owner's Name
information is
required for North Andover MA _ 01845 9-17-09
every page. Cityrrown . State Zip Code Date of Inspection
D. System Information (cont.)
Type:
❑ leaching pits number: ---
❑
leaching chambers number:
❑ leaching galleries number:
❑ leaching trenches number, length:
® leaching fields number, dimensions: 1 - 15'x 50'
❑ 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.):
Area of leach field looks normal. No evidence of ponding, damp soil, or unusual vegetation.
Cesspools (cesspool must be pumped as part of inspection) (locate on site plan):
Number and configuration —
Depth—top of liquid to inlet invert -- ---
Depth of solids layer —
Depth of scum layer — --
Dimensions of cesspool —
Materials of construction ---
Indication of groundwater inflow 0 Yes ❑ No
Commonwealth of Massachusetts
Title 5 Official Inspection Form
i;
'Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
106 Boston Rd. _
Property Address
Susan Gillen
Owner Owner's Name
information is
required for North Andover MA 01845 9-17-09
every page. Citylrown state Zip Code Date of Inspection
D. System Information (cont.)
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.):
' Commonwealth of Massachusetts
Title 5 Official. Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
106 Boston Rd.
Property Address
Susan Gillen
Owner Owner's Name
information is
required for North Andover MA 01845 9-17-09
every page. Citylrown State Zip Code Date of Inspection
D. System Information (cont.)
Sketch Of Sewage Disposal System: Provide a view 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. Check one of the boxes below:
® hand-sketch in the area below
❑ drawing attached separately
pt��A++ eES
/}-iAut� tZs
f3-TAMIL SIR
g f.Dt3ax �o,S
CJI
g �}
I
C
i
�Ja 4ibN lZ c�
' Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
106 Boston Rd. _
Property Address
Susan Gillen
Owner Owner's Name
information is
required for North Andover MA 01845 9-17-09
every page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
Site Exam:
® Check Slope
® Surface water
® Check cellar
® Shallow wells
Estimated depth to high ground water: 4
feet
Please indicate all methods used to determine the high ground water elevation:
® Obtained from system design plans on record
If checked, date of design plan reviewed:
Date
❑ 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:
sgs maps
You must describe how you established the high ground water elevation:
Soil maps indicate water>6.0 feet below old existing grade.
System built 3 feet above ground water.
Before filing this Inspection Report, please see Report Completeness Checklist on next page.
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
106 Boston Rd.
Property Address
Susan Gillen
Owner Owner's Name
information is
required for North Andover MA 01845 9-17-09
every page. Cityrrown State Zip Code Date of Inspection
E. Report Completeness Checklist
® Inspection Summary:A, B, C, D, or E checked
® Inspection Summary D (System Failure Criteria Applicable to All Systems) completed
® System Information—Estimated depth to high groundwater
® Sketch of Sewage Disposal System either drawn on page 15 or attached in separate file
Town of North Andover o� Vjo of"��.
Office of the Health Department
Community Development and Services Division
27 Charles Street '. ...-•
North Andover,Massachusetts 01845 �4ssNrto
Hwwu
Sandra Starr Telephone(978)688-9540
Public Health Director Fax(978)688-9542
TOWN OF NORTH ANDOVER
BOARD OF HEALTH
CERTIFICATE OF COMPLIANCE
DATE OF COMPLIANCE
1"IM2
This is to certify that
the individual subsurface disposal system
constructed () or repaired (X)
by
J.W. Watson
at
106 Boston Street
has been installed in accordance with the provisions of Title V of the State Sanitary Code and with the
North Andover Board of Health regulations.
The Issuance of this certificate shall not be construed as a guarantee that the system will function
satisfactorily.
7
"Brian J. LaGrasse
Board of Health Inspector
BOARD OF APPEALS 688-9541 BUILDING 688-9545 CONSERVATION 688-9530 HEALTH 688-9540 PLANNING 688-9535
Town of-North Andover, Massachusetts Form"O.3 I
NORTH BOARD OF HEALTH
Qf"'G. '6. ll .
3? r. ., Q
c
f 9
�''�•,r.o��`� DISPOSAL WORKS CONSTRUCTION PERMIT
9SgACHUSEt
Applicant
-
NAME ADDRESS TELEPHONE
Site Location1:54!517
Permission is hereby granted to Construct ( ) or Repair ( an Individual Soil Absorption
Sewage Disposal System as shown on the Design Approval S.S. No.���.
CffXTRMAN—,BOARD OF HEALTH
Fee D.W.C. No. � �
Flus
i
Sep-24-01 10:02A P.02
INSTALLLIf PROJF("I'MANA(;FMFN'i'OBL1(:ATN?NS
A,c the: North Andover licensed installer tc)r tilt C4')rtstrLICtion of the nCl7ti4 system for the
property at 0 to bS To tJ' S T relativc to the application
ctf
)JO-dated 9-, for phim., byQ trn�ck�911*.and
with revisions dated -
1 under�tand the following Obligation, for manng.c li-lunt of this project.:
1. As theo in.miller i rm obligated to call For imy and all inspections. If homeowncr. Contractor.
project rtiang.cr, or tiny Cather person Milt assoc:iale-d with my Cclrttdlany schr.dtlles a11 111, Ction
and the system is not ready then dent Iwo shall be applicable,
2. As Ihc 1ristallcr I am required to hiivv the necessary work completed prior to the applicable
irr�pccticlns as indicated belOW. I understand that n.questing an impecllun, without
c )rrtp1v ion of the items in accordance with Tile 5 and chit Huard of Health Re.piltitions ntay
result ill a$50,00 fine being levied against my cornpany.
:lj &,unm of Bed - generally first inspection miless there is a rctainins wli which AloLld he drone
first. Inst;allcr must reclnrGr the ilispcction hit docs not hove to he present.
h) Fimil insp,ctic>n — ivrtginccr must first do their inspection li>r c.lovat 0111,. tics, ctc As-huilt i,r
vocklt OK from cnginccr rnusr. he suhrnittad It; 130ntrd Of Health, titter which instalLr c,ills ti)r
itt.4Pcctioll time. tnshtllrr roust he Present feu this inspection. With pump }steer ,111 electrical
work must he ready and r.hte tocol jsc pump to work and alarm to function.
c,, Final Grade— insu'dicr Meld request inspe.rtion Wheel all grading, is complete, L]ocs ntlt tlavc to be
on,,itc.
3_ As the installer I understand that per.,on,.s or companies nrlt assoCi,ite(l witl-, my company may
not perforin the work required by my company to completethe irslulkition of [he ;yoem
icdentificd in the attached application fur installation: I further Understand that work by others
uttliccnsad Ic; insttlll septic systerrls in Nurlh Andover can constitute reasons for clenial of Iho
,dein, rind/ur revocation rn• ;usdlC:rlSion of my license:. in the 'fc.lwn of North ,And(-rvc:r plus
�,igmficant fines to all persons involved,
4. As that Installer I understand Owl I must be on site during thc: pc.rtormance of the following
cronsutiction:steps:
a) Jklicumirlation that the )roPul eltwjtuirl Cel 111C C."Xi 'IJ011 har;hee?n 1'e,lwlted.
b) Inspection of tlic sand and stunt to b_ used.
I;inal !nspcction by Board W.Hclidth stnft"
(l) Installilriim Cil limk, 04ox, Piflcs, stone; vent, pump ch trnhcr, retaining w;;ll itnd uthcr
co mluncrits
5. As the installcrr I Understand that I am ;olcl•r rctiPonsible, for the inaallstiun of the system as
per the: ;ipprovc:d plans. No insmictions, by ihc, homeowner, general cowr,tc!or, or any other
pc.i—mmis shall absolve me cit this oblig.ition.
U i rsigned Licens, .'eplic Instiller
Dispo;;al Works Ce7ltstrttctinn Pc:rrtrit . .
M
Lt C4-4L-
N&M Job number 1770/
TOWN OF NORTH ANDOVER
INSPECTION CHECKLIST FOR SEPTIC SYSTEMS
Site: ►` G/ N_, ; �-
Final Date:
Installer: 1,)Q r AV 4
-j�c� •�' t� /F� f d' � . . " `, -I :. n i'.�_ � 0 1'Tb•1J�-cJ
a e es o
A. Bottom of Bed
1. Excavation to proper depth
2. With trenches,sides of excavation are beneath B horizon
3. Edge of excavation specified distance from foundation,etc.
Comments: (Use back of sheet for diagrams.)
B. Retaining Wall
1. Wall height and width as specified
2. Waterproofed
3. Wall minimum 10'to leaching facility
4. Wall meets specifications of plan
Comments:
C. Building Sewer
1. Pipe diameter minimum 4"
2. Schedule 40 pipe
3. Inlet to tank cemented
4. Slope minimum 0.01 or 1/8"per foot minimum
5. Pipe properly set on compact firm base
6. Pipe laid on continuous grade in straight line
7. Cleanouts precede all change in alignment and grade
8. Manholes at any 90°change„
9. 10'minimum offset to water line
Comments:
D. Septic Tank
1. Level
2. 1,500 gal minimum
3. Gas baffle present on outlet
4. Manhole to w/in 6"of grade
5. Manholes over center and each tee
6. 3-20"manholes
7. Outlet line cemented
8. 2"—3"drop from inlet to outlet
9. Pipe set
10. Compact base with 6"of 3/4"crushed stone under tank
11. Tank is watertight
12. Tees 12"off side of tank
N&M Job number 1770/
..
Comments: Date
Yes No Initials
E. Pump Chamber
1. If separate from tank,compact base with 6"of stone underneath
2. Minimum 2"pipe to d-box if gravity system
3. 20"access manhole
4. Tank level
5. Watertight
6. Tank size agrees with plan specification ,.
7. Manhole to grade
8. Check valve and bleeder hole present
9. Alarm in building on separate circuit
10. Alarm functions
11. Manual operating switch
12. Pump delivers liquid to d-box
Comments:
F. Distribution Box
1. D-box level �L
2. Minimum 0.1 T'(2")drop from inlet to outlet
3. Minimum 6"sump
4. Outlet pipes show equal distribution. �`--
5. Compact base with 6"of stone beneaih box — `-
6. Box is watertight
7. All lines cemented with hydraulic cement �-
8. Schedule pipe
9. First 2' from box laid level
Comments:
,r 7W ev
11,71 f
G. Soil Absorption system
1. All stone double-washed—3/a"— 1 '/2"
tr
-pea stone _ lrc> 1
Bucket test done? ,`,i
2. Minimum 2"of pea stone above distribution lines {'�, t L p r v
3. Minimum 6"stone beneath pipe
4. Distribution lines capped or connected together `./ j es;"'-'' r
5. Toe of slope stops minimum 5' from edge of property;
5a. if not,then swale.
Comments:
/Zr7 / S ro„r c 11 v i S T/G L N � �rs�✓� L. /.v 3,�
a�� c16,119
N&M Job number 1770/
Date Yes No Initials
H. Leach Trenches
1. Minimum 2 trenches
2. Length of trenches agrees with plan. (Max. length 100')
3. Width of trenches agrees with plan—Minimum 2';maximum—4'.
4. Vent present if>50 feet or specified
5. Minimum distance between trenches 10'
6. Pipe slope minimum 0.005 or 6"per 100'
7. Depth of trenches below outlet invert minimum of 6".
8. Pipes set on stable base.
Comments:
r-
I. Leach Field
1. Maximum length of field 100'
2. Pipe slope minimum 0.005 or 6"per 100'
3. Separation between pipes 6'maximum
4. Pipes connected at end&vent end raised
5. Separation between adjacent fields 10'minimum
6. Pipes set-on stable base
7. Maximum 4' separation from edge of field to first line
8. Minimum two distribution lines
Comments:
J. Leaching Pits
I. Minimum inlet pipe 4"
2. Pits of concrete
3. Sidewall between 12"and 48"wide
4. Access manholes on each pit
5. Pipes cemented with hydraulic cement
6.
Comments:
K. Final Grade
1. Slope over soil absorption system minimum 0.02
2. All system components covered by at least 9"soil
3. Cover soil free of stones larger than 6"
4. Grading slopes away from dwelling
5. No areas over system that may pond
6. Grading meets 3:1 slope
7. Minimum of 9" of fill graded over system