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HomeMy WebLinkAboutMiscellaneous - 1193 GREAT POND ROAD 4/30/2018 (2) 1193 GREAT POND ROAD Road 21.0/103.0-0010-OOD0.0 t C Date A-t,....1...:.....Z NORTH °tt •'"° TOWN OF NORTH ANDOVER p PERMIT FOR WIRING �sSAcmU This certifies that . .......6e./.G ....... has permission to perform ........ ....... td ..U..'........... wiring in the building of...... ! � �.. '( / .. ............................ ............... .North Andover,Mass. Fee/ZPd......... Lic.No... 1...t � . .................................... ......... ELECTRICAL INSPECTOR r Check # — 10866 ti y - Commonwealth of Massachusetts Official Use only - a Department of Fire Services BOARD OF FIRE PREVENTION REGULATIONS Occupancy and Fee Checked [Rev.1/07] (leave blank APPLICATION FOR PERMIT TO PERFORM ELECTRICAL WORK All work to be performed in accordance with the Massachusetts Electrical Code C), 27 CMR 12.00 i (PLEA SEPRINT)NINKOR TYPEALL INFOAWTION) Date: City or Town of. NORTH ANDOVER �\ To the Inspector of Wires: By this application the undersigned gives notice of his or her intention to perform the electrical work described below. Location(Street&Number)-In R (3. Owner or Tenant Telephone No. Owner's Address Is this permit in conjunction with a building permit? Yes No ❑ (Check Appropriate Box) Purpose of Building Utility Authorization No. Existing Service S900 Amps / '4Volts Overhead E] Undgrd❑ No.of Meters New Service Amps / Volts Overhead❑ Undgrd❑ No.of Meters Number of Feeders and Ampacity ! /�FSaTt Location and Nature of Proposed Electrical Work: com letion o the ollowfn table m be waived by the Inspector o Wires. No.of Recessed Luminaires No.of Ceil.-Susp.(Paddle)Fans 1140.01 Total Transformers KVA No.of Luminaire Outlets No.of Hot Tubs Generators KVA V No.of Luminaires fSwimmingroo l Above ❑ In- ❑ o.o mergency Lighting rnd. nd. BatteryUnits No.of Receptacle Outlets of Oil Burners FIRE ALARMS No.of hones No.of Switches No.of Detection and =� No.of Gas Burners Initiating Devices No.of Ranges No.of Air Cond. Tootal No.of Alerting Devices No.of Waste Disposers Heat Pump Number Tons ' KW No.of Self-Contained Totals: `_..___ ._.._....._._......_.__...._..._......._. Detection/Alerting Devices No.of Dishwashers I Space/Area Heating KWLocal❑Munieln-_ ❑ Other Connection No.of Dryers Heating Appliances , SecuritySystems:Y• No.of Water No.of No,of Devices or E uivalent Heaters �' Data Wiring: Si s Ballasts ts No.of Devices or Equivalent No.Hydromassage Bathtubs No.of Motors Total HP Telecommunications Wiring: it OTHER: No.of Devices or E uivale Attach additional detail if desired,or as required by the Inspector of Wires. Estimated Value of Electrical Work: (When required by municipal policy.) Work to Start: Inspections to be requested in accordance with MEC Rule 10,and upon completion. INSURANCE:COVERAGE: Unless waived by the owner,no permit for the performance of electrical work may issue unless the licensee provides proof of liability insurance including"completed operation"coverage or its substantial equivalent. The undersigned certifies that such coverage is in force,and has exhibited proof of same to the permit issuing office. CHECK ONE: INSURANCE ❑ BOND ❑ OTHER ❑ (Specify:) I certify,under the pains and penalties ofperjrcry,that the information on this application is true and covj lete. FIRM NAME: '7118 (Q�^i-e.�itg (ul te-A coge LIC.NO.: - ?j Licensee: IIKE 4, Signature 4 LIC.NO.:, . (Ifapplicable,enter`exempt"i e license number line.) Bus.Tel.No. 7�'Sti"�y2 Address: '7 til/ e+ a cc ,..e Q i►J�/v pay *per MAlt.Tel.No.: .G.L c.147,s.57-61,security work requires Department ofPublic Safety"S"License: Lie.No. OWNER'S INSURANCE WAIVER: I am aware that the Licensee does not have the liability insurancecoverage normally required by law. By my signature below,I hereby waive this requirement. I am the(check one)❑owner El owner's agent. Owner/Agent Signature Telephone No. PERMIT FEE: G d . Y ._. • J1�JL:(YJ�V��J.1JL�.CJ..i..i i{®� ,�/Jl.ia%aVJS.r.Vi1J��•.���+i".^�� ._ ""O'g CT�foz�: waited--[ 1 �e-xnspect#on�equzxed'($�0.00)�� ) spectoxs' -a= )Its axn )Its: " _ C N R•1 � S. (]:WpWore Signatux'e no kin it!als) Date Passecl L[L.K p'ailecl--j ate-inspection required($50.00)•-[ � luspeetoxs'comments: Ot (JCxispectoWpignahwe-no Wiials) 'On A01 3.'CTieID:OR GRODM I NSTACTZO: �'assetl--j ) biled-j ate-iuspectioxt xequkea($60.00)-j ] ` Inspectors'coxa acts: b. Cimpectoxs},Signature•-noidtfals) Date 4 INSOPECITON— 'V�f!CE: D&AM,CAlD-RD N A±ONAl i C-S 1 :: KAM: Passed-- Re znspection.xequfred($50.00)- Inspectbxs'eoname�fs: (fnspectors'ffigaature-1io initials) bate 'Re Inspection required($50.00)•-[ aspectors'coMm.ents: . �1�spectoxs' ignatuxe••no initials) Date D 0OP TA(9,5.AM TO DE MMED QlJT ANDIEFT ON RITE M TM.APXA TO 3E MSTECTED ISNOT .A CCESSISZE A".A.RE URRECTION Off`$50,00INTO 13E CDfA�GED. . M The Commonwealth of Massachusetts 02 Department of IndustriglAccidents Office of Investigations 600 Washington Street Boston,MA 02111 www.mass gov1dia Workers' Compensation Insurance Affidavit:Builders/Contractors/Electriciansfplumbers Applicant Information Please Print Legibly Name(Business/Organization/Individual): ,a—rQ�c I.i Ckr Address: `7 14,l l veesa v Q, - City/State/Zip: SNI V - e g ZNg Phone#: 9 7 3-- -T3 Are you an employer?Check the appropriate box: Type of project(required): I.[911—am a employer with 1i 4. ❑ I am a general contractor and I 6. ❑New construction employees(full and/or part-time).* have hired the sub-contractors 2.F1 am a sole proprietor or partner- listed on the attached sheet. 7• ❑Remodeling ship and'have no employees These sub-contractors have S. ❑Demolition working for me in any capacity. workers'comp.insurance. g, El Building addition [No workers'comp.insurance 5. El We are a corporation and its required.] officers have exercised their 10.❑Electrical repairs or additions 3.❑ 1 am a homeowner doing all work right of exemption per MGL 11.❑Plumbing repairs or additions myself.[No workers'comp. c. 152,§1(4),and we have no 12.❑Roof repairs insurance required.]i employees.[No workers' comp.insurance required.] 13.❑Other !Any applicant that checks box#1 must also fill out the section below showing their workers'compensation policy information. I Homeowners who submit this affidavit indicating they aie doing all work and then hire outside contractors must submit anew affidavit indicating such. tContractors that check this box must attached an additional sheet showing the name of the sub-contractors and their workers'comp.policy information. lam an employer that is providing workers'compensation insurance for my employees Below is the policy and job site information. Insurance Company Name:. magAa'-_ 194b-14- Policy 94b.xPPolicy#or Self-ins.Lic.#: //r`b '76�'-& 1 Expiration Date: / Job Site Address: 1/�,� C 6ti &N-D 6) City/State/Zip: / _04&4a ✓ Attach a copy of the workers'compensation policy declaration page(showing the policy number and expiration date). Failure to secure coverage as required.under Section 25A of MGL c.152 can lead to the imposition of criminal penalties of a fine up to$1,500.00 and/or one-year imprisonment,as well as civil penalties in the form of a STOP WORK ORDER and a fine of up to$250.00 a day against the violator. Be advised that a copy of this statement maybe forwarded to the Office of Investigations of the DIA.for insurance coverage verification. Ido hereby cero under the pains andpenalties ofperjury drat the information provided above is true and correct. - Signature:h/";Z)r— Date: 64/ad/ — Phone#: Official use only. Do not write in this area,to be completed by city or town official City or Town: Permit/License# Issuing Authority(circle one): 1.Board of Health 2.Building Department 3.CitylTown Clerk 4.Electrical Inspector 5.Plumbing Inspector 6.Other - - - Contact Person: Phone#: i Information and Instructions Massachusetts General Laws chapter 152 requires all employers to provide workers'compensation for their employees. Pursuant to this statute,an employee is defined as"...every person in the service of another under any contract of hire, express or implied,oral or written." An employer is defined as"an individual,partnership,association,corporation or other legal entity,or any two or more of the foregoing engaged in a j oint enterprise,and including the legal representatives of a deceased employer,or the receiver or trustee of an individual,partnership,association or other legal entity,employing employees. However the owner of a dwelling house having not more than three apartments and who resides therein,or the occupant of the dwelling house of another who employs persons to do maintenance,construction or repair work on such dwelling house or on the grounds or building appurtenant thereto shall not because of such employment be deemed to be an employer." MGL chapter 152,§25C(6)also states that"every state or local licensing agency shall withhold the issuance or renewal of a license or permit to operate a business or to construct buildings in the commonwealth for any applicant who has not produced-acceptable evidence of compliance with the insurance coverage required" Additionally,MGL chapter 152,§25C(7)states"Neither the commonwealth nor any of its political subdivisions shall enter into any contract for the performance of public work until acceptable evidence of compliance with the insurance requirements of this chapter have been presented to the contracting authority." Applicants Please fill out the workers'compensation affidavit completely,by checking the boxes that apply to your situation and,if necessary,supply sub-contractors)name(s),address(es)and phone number(s)along with their certificate(s)of insurance. Limited Liability Companies(LLC)or Limited Liability Partnerships(LLP)with no employees other than the members or partners,are not required to carry workers'compensation insurance. Man LLC or LLP does have employees,a policy is required. Be advised that this affidavit maybe submitted to the Department of Industrial Accidents for confirmation of insurance coverage. ,Also be sure to sign and date the affidavit. The affidavit should be retumed to the city or town that the application for the permit or license is being requested,not the Department of Industrial Accidents. Should you have any questions regarding the law or if you are required to obtain a workers' compensation policy,please call the Department at the number listed below. Self-insured companies should enter their self-insurance license number on the appropriate line. 1 City or Town Officials Please be sure that the affidavit is complete and printed legibly. The Department has provided a space at the bottom of the affidavit for you to fill out in the event the Office of Investigations has to contact you regarding the applicant. Please be sure to fill in the permit/license number which will be used as a reference number. In addition,an applicant that must submit multiple permit/license applications in any given year,need only submit one affidavit indicating current policy information(if necessary)and under"Job Site Address"the applicant should write"all locations in (city or town)"A copy of the affidavit that has been officially stamped or marked by the city or town may be provided to the applicant as proof that a valid affidavit is on file for:future permits or licenses. A new affidavit must be filled out each year.Where a home owner or citizen-is obtaining a license or perniit not related to any business or commercial venture (i.e.a dog license or permit to burn leaves etc.)said person is NOT required to complete this affidavit. The Office of Investigations would like to thank you in advance for your cooperation and should you have any questions, please do not hesitate to give us a call. The Department's address,telephone and fax number: Tho CoMyAonwealth of massarhusotts Depa ent ofZndusidat Awidents Office of Iavestigatious 600 Washiugtoa Strout Boston,MA,021 It TQL#617-727-4900 eat 406 or 1-877,MA.SSAFE Revised 5-26-05 Fax#617-727-7749 www.mass.gov/dia e�j e� + :COMMONWEALTH OF MASSACHUSETTS CONTROL# H®'71 5 2 2 5 IMPORTANT ` ELECTRICIANS If this license is lost or destroyed, notify your Board at the: REGISTERED MASTER ELECTRICIAN. Division oT Professional Licensure, 1000 Washington St., ISSUES THE ABOVE LICENSE TO l ! Suite 710, Boston,MA 02118-6100. If your name or address shown is changed, notify your board f B ELECTRICAL SERVICES of correct name or address to insure proper mailing of next M I C H A E L J L A N G L 0 I S < j Renewal Application. Always refer to your license number. r 7 H I L L V I E W DR This license is subject to the provisions of the General Laws Imo' as amended_It is a personal privilege,and must not be loaned M E T H U.E N or assigned to any other person. Keep this license on your MA 0 18 4 4 2 6 9.3 person or pasted as required by law. l HAS 16719 A 07/3.1.113 F38f122.9� t �'• ILNI,-o i,,LO bL+•.UHI I y f EATURES I 4 suoneio a ; P d IIV 6uolt�yaelap ua�il Plod rJ;` _L#+ Q Z Z 4 `' ,COMMONWEALTH OF MASSACHUSETTS .r coNTIRO IMPORTANT ' ' • ° • y our Board at)rd •° notit Y ton :LECTRICIANS s license is lost or destroy sure, 1000 WashingAS A REG JOURnIf th NEYMAN ELECTRICIADivision oQ ProfessMA®21ri$•6100. ISSUES THE ABOVE LICENSE TO Suite 7i0, Boston, notify your shownro er mailing oMICHAEL J tf your Warne or addrddress to insure pis epr license nuLANGL0ISof correct name o Always refer to youRenewal Application• revisions of the Genera7HILLVIEW DR nwlege,and must not be This license Is subje ersonal p license ohJ ° as amended. It is a pother person. Keep thisM E T H UE N or assigned to any re aired by law. HA5 . I1 A 0 person Dr posted as I P��es 31934 E �"i ,►NG THiS DOG LIMEN E4 p SOURtTY R 07/31/13 88023.0 ' " 1 tNHANC • ° ° } °c l I� I' i I. 1 1 l . I ACOR®, CERTIFICATE OF LIABILITY INSURANCE r0MMIDDfYM)ATE( 10/ 5/2011 PRODUCER 781.729.8770 FAX 781.729.0053 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION John A. Pierce Insurance Agency, Inc ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE 934 Main St. HOLDER.THIS CERTIFICATE DOES NOT AMEND,EXTEND OR Winchester, MA 01890-1994 ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. -- INSURERS AFFORDING COVERAGE PIAiC# INSURED TCB Electrical Services Inc INSURERA: The Travelers Indemnity-co 59 7 Hillview Dr INSURERS: Traverlers Property Cas Inc Co 36161 Methuen, MA 01844-2693 INSURER C: INSURER D: 1N_SURER E: COVERAGES THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED.NOTWITHSTANDING ANY REQUIREMENT,TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE MAY BE ISSUED OR MAY PERTAIN,THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS,EXCLUSIONS AND CONDITIONS OF SUCH POLICIES.AGGREGATE LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS, ILTRAD N TYPE OF INSURANCE POLICY NUMBER POLICY EFFECTIVE POLICY EXPIRATION DATE MMIDDIYYYY DATE MMIDD/YYYY LIMITS GENERAL LIABILITY ISFCUP3A461548IND 07/01/2011 07/01/2012 EACH OCCURRENCE $ 11000,000 COMMERCIAL GENERAL LIABILITY PREMISES EaEOccccur encs $ 300,000 CLAIMS MADE ®OCCUR MED EXP(Any one person) $ 5,000 A X ' PERSONAL&ADV INJURY $ 11000,000 GENERAL AGGREGATE_ $ 21000,000 GEN'L AGGREGATE LIMIT APPLIES PER: PRODUCTS-COMP/OP AGG $ 2,000,000 X POLICY PRO- JECT LOC AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT ANY AUTO (Ea accident) $ ALL OWNED AUTOS BODILY INJURY $ SCHEDULED AUTOS (Per person) HIRED AUTOS BODILY INJURY $ NON-OWNED AUTOS (Per accident) PROPERTY DAMAGE $ (Per accident) GARAGE LIABILITY AUTO ONLY-EA ACCIDENT $ ANY AUTO OTHER THAN EA ACC $ AUTO ONLY: AGG $ EXCESS/UMBRELLA LIABILITY I6803A458882ACJ11 07/01/2011 07/01/2012 EACH OCCURRENCE $ 1,000,000 OCCUR CLAIMS MADE AGGREGATE $ B $ 1,000,000 1 DEDUCTIBLE X RETENTION $ 5,000 -- - WORKERS COMPENSATION WC STA U $ - DTH- b AND EMPLOYERS'LIABILITY TORY LIMITS ER ANY PROPRIETORIPARTNERIEXECUTIVE Ya E.L.EACH ACCIDENT $ OFFICER/MEMBER EXCLUDED? (Mandatory In NH) If yes,describe under E.L.DISEASE-EA EMPLOYEE $ SPECIAL PROVISIONS below OTHER E.L.DISEASE-POLICY LIMIT $ DESCRIPTION OF OPERATIONS/LOCATIONS!VEHICLES/EXCLUSIONS ADDED BY ENDORSEMENT/SPECIAL PROVISIONS CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF,THE ISSUING INSURER WILL ENDEAVOR TO MAIL 10 DAYS WRITTEN NOTICE TO THE CERTIFICATE HOLDER NAMED TO THE LEFT,BUT FAILURE TO DO SO SHALL Dakota Partners Inc IMPOSE NO OBLIGATION OR LIABILITY OF ANY KIND UPON THE INSURER,ITS AGENTS OR 1264 Main St REPRESENTATIVES. Waltham , MA 02451 AUTHORIZED REPRESENTATIVE Kevin Pierce ACORD 25{2009/01) ©1988-2009 ACORP CORPORATION, MVed. o are The ACORD name and to re ' g glstere�t marks of ACOR© Town of Noah Andover Office of the Building Department''' Community Development and Services Division 27 Charles street North Andover,Massachusetts 01845 'a�,cMus D.Robert Niicefta Telephone(978)688-9545 Building Commissioner Fax(978)688-9542 August 23 2002 Jack Murphy,President Ft 1e- Murphy Construction Company `1 a e -{� N� 1t9 3 P.O. Box 1510 11 � 3 h t` d `r.* 9.06)*- Newburyport,Ma 01950 Iva[to RE: Certificate(s)of Occupancy Building Permit 194-Building"A" Budding Permit 194-Building`B" 9 o t4 a o Brooks School z Dear Mr. Murphy: 3 2 8 1 am in receipt of your August 2&FAX correspondence on the_above referenced subject. Dae to conditions beyond your control,(waiting delivery of gas logs),the building l department will extend the temporary occupancy permits for the 4—Faculty Units for (60)sixty days from August 25,2002,as shown, on the enclosed occupancy permit copies. Yours truly, D. Robert Nicetta Building Commissioner Enclosures: CoP ies--CofO#194 8t 195 (Temporary) FAX: (978)-463-36945 BOARD OF APPEALS 6M9541 BUILDING 688-9545 CONSERVATION 68&9530 HEALTH 688-9540 PLANNING 688-9535 Town of North Andover F HORTM , OFFICE OF ' °°e COMMUNITY DEVELOPMENT AND SERVICES 27 Charles Street WILLIAM J. SCOTT North Andover, Massachusetts 01845 �gSsgcHUs��e Director (978)688-9531 Fax (978)688-9542 March 31, 1999 Brooks School 1160 Great Pond Road North Andover,MA 01845 RE: Letter of Noncompliance -Notice of Septic System Failure— 1135 & 1193 GPR Dear Property Owner: The North Andover Health Department has received and reviewed the Title 5 Inspection Report that was generated from the inspection of your septic system on December 3, 1998. Your inspector has determined that your septic system is failing to protect public health or the environment according to Title 5 of the State Sanitary Code. You are hereby required to retain the services of a Massachusetts licensed professional engineer (P.E.)or Massachusetts registered sanitation(R.S.)to design a new septic system In compliance with Title 5 and North Andover Board of Health regulations or take steps to be advised that because you are in the town hook up to municipal sewer. Please Watershed, you have one year from the inspection date to complete the necessary work. It is recommended that the septic tank be pumped periodically until a solution to the problem is achieved. The Board thanks you for your willingness to help protect the environment,the ground water and public health. Please do not hesitate to call the Health Department office at the number below if you have any questions. Sincerely, Sandra Starr,R.S. Health Administrator Encl. P.E. list Hauler list Cc: File Watershed Council BOARD OF APPEALS 688-9541 BUILDING 688-9545 CONSERVATION 688-9530 HEALTH 688-9540 PLANNING 688-9535 TOWN OF NORTH APP' ; BOARD OF HEALTr, DEC 14 1998 CU11'IMON1,NLALTII uF �r1ASSACHUSETTS EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS US DEPARTMENT OF ENVIRONMENTAL PROTECTION------ ONE ROTECTIO - ONE WINTER STREET, BOSTON MA 02108 (617) 292.5500 TRUDY COXE Secretary ARGEO PAUL CELLUCCI DAVID B. STRUHS Governor Commissioner SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION Pry Adreu: 1193 Great Pond Rd. Name of ow Brooks School Address of Owner: 11 res on Road, No. Andover, MA 0181' Date of Inspection: 12/03/98 Name of.Inspector:(Please Print) John Carr I am a DEP appitoved system inspector pursuant to Section 15.340 of Title 5 1310 CMR 15.000) Company Name: hamey Cont.- g. , Inc. Mailing Address: Knoll Road�_Methuen,_MA 01844 Telephone Number: 76$ 61�_'__Kq _ UL 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: 12/11/98 The System Insp shall submit a copy of this inspection report to the Approving Authority(Board of Health or DEP)within thirty (30)days of completing t ' spection. 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 subm' a report to the appropriate regional office of the Department of Environmental Protection. The.original should be sent to the system owner and copies sent to the buyer,if applicable, and the approving authority. NOTES AND COMMENTS bistribution box is under water, ground water 6"-81' below surface, but no evidence of breakout. i revised 9/2/98 Ndke r or It A i�Printed on Recycled Paper • SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PARI A CERTIFICATION(continued) Property Address: 1193 Great Pond Road owner_ �Mbl �91chool te Daof Inspection: // 33 INSPECTION SUMMARY: Chock A, B, C. o/ D: A. SYSTEM PARSES: NIA 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: N/A 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 pumping more than four times a year due to broken or obstructed pipe(s). The system will pass inspection if(with approval of the Board of Health): broken pipe(s) are replaced obstruction is removed revised 9/2/98 Page 2of11 SUBSURFACE SEW AGE DISPOSAL SYSTEM INSPECTION FORM . PART A CERTIFICATION(correnued) Property Address: 1193 Great Pond Road OVMW: B1r�365/9�hool Dste of C. FURTHER EVALUATION IS REQUIRED BY THE BOARD OF HEALTH: N/A 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. 11 SYSTEM WILL PASS UNLESS BOARD OF HEALTH DETERMINES IN ACCORDANCE WITH 310 CMR 15.303 11)(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 1 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 .4. revised 9/2/98 Page 3oru SUBSURFACE SEW,ME DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address: 1193 Great Pond Road Owner: Brnk3 School Date of Inspecfion: �� D. SYSTEM FAILS: You must indicate either "Yes" or"No" to each of the following: YeS 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 X _ Backup of sewage into facility or system component due to an overloaded or clogged SAS or cesspool. _ _X Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool. X Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool. N/A_ Liquid depth in cesspool is less than 6" below invert or available volume is less than 1/2 day flow. X Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number of times pumped_. _X Any portion of the Soil Absorption System, cesspool or privy is below the high groundwater elevation. N/A_ Any portion of a cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. N/A_ Any portion of a cesspool or privy is within a Zone I of a public well. _ N/A_ Any portion of a cesspool or privy is within 50 feet of a private water supply well. -� N/A _ _ Any portion of a cesspool or privy is less-then 100 feet but greater than 50 feet from a private caster 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: N/A 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 of a tributary to a surface drinking water supply r 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 16.304(2). Please consult the local regional office of the Department for further information. revised 9/2/98 Page 4of11 , i SUBSURFACE SEW AGE DISPOSAL SYSTEM INSPECTION FORM PAH7 B CHECKLIST Property Address: 1193 Great Pond Road Owrwr: Br k chool Date of hupection: 129839 Check if the following have been done:You must indicate either "Yes" or "No" as to each of the following: Yes No X _ Pumping information was provided by the owner, occupant, or Board of Health. X None of the system components have been pumped for at least two weeks and the system hes been receiving""mal flow rates during that period. Large volumes of water have not been introduced into the system recently or as part of this inspection. — N/A— As built plans have been obtained and examined. Note if they are not available with NIA. X _ The facility or dwelling was inspected for signs of sewage back-up. X _ The system does not receive non-sanitary or industrial waste flow. X _ The site was inspected for signs of breakout. X All system components, excluding the Soil Absorption System, have been located on the site. _ X The septic tank manholes were uncovered,opened, and the interior of the septic tank was inspected for condition of baffles or tees, material of construction, dimensions,depth of liquid, depth of sludge, depth of scum. The size and location of the Soil Absorption System on the site has been determined based on: X _ Existing information. For example, Plan at B.O.H. X _ Determined in the field(if any of the failure criteria related to Part C is at issue,approximation of distance is unacceptable) (15.302(3)(b)1 _ X The facility owner(and occupants, if different from owner) were provided with information on the proper maintenance of SubSurface Disposal Systems. revised 9/2/98 page sorii SUBSURFACE SEW,IGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION Property Address: 1193 Great Pond Road Owner: Brooks- School Dace of Inspection: 12/03/98 FLOW CONDITIONS RESIDENTIAL: Design flow: g.p.d./bedroom. Number of bedrooms(design): Number of bedrooms(actual):4 Total DESIGN flow 9 Number of current residents: 2 Garbage grinder lyes or no): no Laundry(separate system) (yes or no): no_, It yes, separate inspection required Laundry system inspected lyes or no) no Seasonal use lyes or no):no Water meter readings.if available(last two year's usage(gpd): 250 )?pd Sump Pump lyes or no): no Last date of occupancy: occupied COMMERCIAL/INDUSTRIAL: N/A Type of establishment: Design flow: qpd ( Based on 15.203) Basis of design flow_ Grease trap present: lyes or no)_ Industrial Waste Holding Tank present: lyes or no)_ Non-sanitary waste discharged to the Title 5 system: lyes 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: None System pumped as part of inspection: lyes or no) no If yes, volume pumped: gallons Reason for pumping: TYPE OF SYSTEM X Septic tank/distribution box/soil absorption system Single cesspool Overflow cesspool Privy Shared system lyes 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 information. 40 + ,years w Sewage odors detected when arriving at the site: (yes or no) no revised 9/2/98 Page 6orn SUBSURFACE SEW 4GE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(conti ied) Property Address: 1193 Great Pond Road Owner: Pool Date of Inspection: C BUILDING SEWER: (Locate on site plan) Depth below grade: 1811 Material of construction, X cast iron_40 PVC_other(explain) Distance fro �py private water supply well or suction line Diameter 4 1 Comments: (condition of joints, venting, evidence of leakage,etc.) good SEPTIC TANK:_ (locate on site plan) Depth below grade: 21 X Material of construction:_concrete_metal_Fiberglass _Polyethylene_other(explain) If tank is metal,list age_ Is age confirmed by Certificate of Compliance_ (Yes/No) Dimensions: unknown Sludge depth: not checked Distance from top of sludge to bottom of outlet tee or baffle: not checked Scum thickness: not checked Distance from top of scum to top of outlet tee or baffle: not checked Distance from bottom of scum to bottom of outlet tee or baffle: not checked How dimensions were determined: not determined 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.) _ liquid leel above invert of outgoing pipe in septic tank GREASE TRAP: none (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: frecommendation 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.) i revised 9/2/98 Page 7ofII �J SUBSURFACE SEW AGE DISPOSAL SYSTEM INSPECTION FORM PARI C SYSTEM INFORMATION(confirmed) Property Address: 1193 Great Pond Road Owner: Brooks School Date of Inspection: 12/03/98 TIGHT OR HOLDING TANK (Tank must be pumped prior to, or at time of, inspection) (locate an site plan) Depth below grade:_ Material of construction:_concrete_metal_Fiberglass_Polyethylene_other(ezplain) 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: 'See comments Comments: (note if level and ditribution is equal, evidence of solids carryover, evidence of leakage into or out of box, etc.) Tstrubution box under water PUMP CHAMBER: N/A (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 P2ge8of11 SUBSURFACE SENT WE DISPOSAL SYSTEM INSPECTION FORM PAH'I C SYSTEM INFORMATION(contiraiedl Property Address: 1193 Great Pond Road Owner: Brooks School Date of Inspection: 12/03/98 SOIL ABSORPTION SYSTEM(SAS):_ (locate on site plan, if possible: excavation not required,location may be approximated by non-intrusive methods) It not located, explain: System failed, S.A.S. was not located 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 ydrauli failure, lev f onding damp soil, condition of vegetation, tc.) G�roM water �'�-911 below surface in robe holes but' no sign of Breakout CESSPOOLS:_ A (locate on site plan) Number and configuration: Depth-top of liquid to inlet invert: Depth of solids layer:. �j 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.) PRP/Y:_VA (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 9ortl s�, SUBSURFACE SEW%GE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION Icorrtioued) Property Address: 1193 Great Pond Road Owner` Bfooks School Date of Inspection: 2/63/98 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) 62, I _ r- - _ revised 9/2/98 Page 10arll . r SUBSURFACE SEW,WE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continuedC Projxw"Address: 1193 Great Pond Road Owner: Brooks School Date of Inspection: 12/03/98 NRCS Report name 6411 Type_ Typical depth to groundwater_ _ USGS Date website visited Observation Wells checked Groundwater depth: Shallow____.__.,_ _--Moderate __Deep_ SITE EXAM Slope yes Surface water no Check Cellar yes Shallow wells none Estimated Depth to Groundwater •5'Feet Please indicate all the methods used to determine High Groundwater Elevation: Obtained from Design Plans on record x Observed Site (Abutting property, observation hole, basement sump etc.) probe holes X 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) Probe holes in vicinity of leaching area and Observation of water level above "D" box. . _ revised 9/2/98 page itorit SEPTIC SYSTEM INSPECTION FORM ADDRESS h93 g-lzjolcS STEVCN5 DATE INSPECTED -,-C),o-sdA� PROPERLY FUNCTIONING? V N WEATHER C©NDITIONS COMMENTS : WATER QUAL i T Y TES Eb ? 'RESULTS? DYE TEST PERFORMED? Y N DATE? SKETCH: Brooks Stevens, LLl 1193 Great Pend :Rd. APPLICATION FOR SEWAGE DISPOSAL INSTALLATION HEALTH DEPARTP.WT—NORTH AI4DOVER, MASS. I hereby make application for a permit for a sewage disposal installation at 1123 Great Pond Rd. . I will install this system in accordance 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 minimgm diameter being L, inches,, and will maintain a minimum grade of 1% until 10 feet preceding the septic tank,, where the grade shall, not exceed 2%. I will install a concrete septic tank of 1000 gal, in size. A manhole (s) permitting easy cleaning will be provided with removable cover (s) of iron or concrete within 32 inches of the ground surface. I will provide subsurface disposal field with open jointed bell and spigot Ackron pipe at least 4 inches in diameter and laid in a series of trenches, the bottom of which will provide a minimum of 200 lineal (pjlV ) 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 courseravel or stone. The disposal field will. be installed at a grade of 4 to 6 inches/100 feet. No single the line will exceed 100 feet in length and in any case, two lines of the 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 in- stallation 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 furtherr agree not to cover any Portion of this installation_untll. apnroved' 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. iP,�* 2 ft, trenches DATE 442A2 Signature of Applicant I hereby issue the above permit for the Board of Health of the Town of North Andover, Massachusetts. DATE 4/2/59 Signature of Health Agent I have inspected the uncovered system indicated above and find everything done as described. DATE �A �... .� -U �') Jt Signature of speating Officer Percolation Test 3 min. Sandy-gravel Garbage Grinder a r J April 2, 1959 Miss Mary Sheridan R. N. Health Agent . Board of Health North Andover, Mass. Dear Miss Sheridan; An examination was made as requested in order to determine the suitability of the soil for the subsurface disposal of sewage on the proposed Great Pond Road building site of Brooks Stevens III. The subsoil in the area was sandy gravel content and a 3-minute percolation test was conducted. The land in general is high. It is recommended that a 1,000 gallon concrete septic tank be installed together with 200 lineal feet of drain pipe in a 210" trench. Very truly yo , William J. riscoll BOARD OF HEADTIi CXi%,r1v1.G c,4bS OWN OF NORrfll ANDOVER, Ws. 20 fro }taco TEP7'K'A �' --- Sb 7 zM vr--)S' "-rs-e V 1. NAME DATE � 2. ADDRESS 1.9.a •G.: �•��Vto V- p,,,;,tL� r� • LOT N0. TEL.VI-s t-724Z 3. NO. OF BEDROOMS .�. DEN YES NO. 4. GARBAGE GRINDER. YES NO. . �: . 7c�- 5, SHOW DIi,ENS IONS OF HOUSE b. SHOW DISTANCES OF HOUSE TO ALL PROPERTY LINES 7. SHOW DI1,20SIONS OF LOT 8. SHOW LOCATION AND SIZE OF SEPTIC TANK OR CESSPOOL g. NOTE LOCATION AIM DISTANCE OF WELL FROM SEWERAGE SYSTEM 10. SHal LOCATION OF BROOKS, STREAKS, DITCHES, LEDGE OUTCROP, ETC. 11. SHOW DISTANCE OF SEPTIC TANK OR CESSPOOL FROM HOUSE NOTE: LOCAL REGULATIONS SHOULD BE READ CAREFULLY.