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Commonwealth of Massachusetts
Executive Office of Environmental Affairs -:
Deparifirnent of '
Environ r� .. al Protection rel
William F.Weld ?r'
Govemor
Trudy Coxe
iecrst.7,EDEA
David B. Struhs
Commissioner
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A '+
CE TIFICA�TML
I 'n
Property Address: Address of Owner:
L 3
Date of Inspection: (if different)
Name of Inspector: Q �V-\ Dw�
Company Name, Addres and Telephone Number: l
CERTIFICATION STATEMENT
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-sites age disposal systems. The s•stcm
Passes
— Conditionally Passes
Needs Furth Evaluation By the Local Approving Authority
Fails
Inspectors Signature: Date: `1131%
1 ? %
The System Inspector shall sub a copy of this in poet on repo to the Approving Authority within thirty (30) days of completing this
inspection. If the system is a s red system or has a de>igr; flog•, of 10,000 gpd or greater, the inspector and the system owner shall submit .
the repon to the appropriate regional office of the Depr{rtmen! of Environmental Protection.
The original should be sent to the system owner and co;) ,� ,.n; to the buyer, if applicable and the approving authority.
INSPECTION SUMMARY:
Check B, C, or D:
AJ SYSTEM PASSES:
/,/II have not found any information which indicates that the system violates any of the failure criteria as defined in 310 CMR 15.303.
Any failure criteria not evaluated are indicated below.
B) SYSTEM CONDITIONALLY PASSES:
One or more system components need to be replaced or repaired. The system, upon completion of the replacement or repair,
passes inspection.
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 an .
_ pct kis metal, cracked, structurall} unsound, shows substantial infiltration or exfiltration, or tank failure is
imminent. The system will pass inspection if the existing septic tank is replaced with a conforming septic tank as
approved by the Board of Health.
' (revised 8/15/95)
One Winter Street 0 Boston, Massachusatts 02108 • FAX(617) 556-1049 0 Telephone (617) 292-5500
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SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION (continued) '
Property Address:
Owner: CQ�I J GQNI �2 = /V �G1�✓�� `• ; ..�T;
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Date of Inspection:
B] SYSTEM CONDITIONALLY PASSES (continued)
Sewage backup or breakout or high static water level observed in the distribution box is due to broken or obstructed'
pipe(s) or due to a broken, settled or uneven distribution box. The system will pass inspection if(with approval of the
Board of Health):
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
C] FURTHER EVALUATION IS REQUIRED BY THE BOARD OF HEALTH:
Conditions exist which require further evaluation by the Board of Health in order to determine if the system is failing to protect the
public health, safety and the environment.
1) SYSTEM WILL PASS UNLESS BOARD of HEALTH DETERMINES 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 a surface water
Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh.
2) SYSTEM WILL FAIL UNLESS THE BOARD OF HEALTH (AND PUBLIC WATER SUPPLIER, IF APPROPRIATE) DETERMINES THAT
THE SYSTEM IS FUNCTIONING IN A MANNER THAT PROTECT THE PUBLIC HEALTH AND SAFETY AND THE
ENVIRONMENT:
The system has a septic tank Ina sol absorption system and is withii, 1J0 feei to a surface wzitei supe y of tributary to a
surface water supply.
The system has a septic tank and soil absorption system and is within a Zone I of a public water supply well.
The system has a septic tank and soil absorption system and is within 50 feet of a private water supply well.
The system has a septic tank and soil absorption system and is less than 100 feet but 50 feet or more from a private water .
supply well, unless a well waver 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.
D] SYSTEM FAILS:
I have determined that the system violates one or more of the following failure criteria as defined 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.
Backup of sewage into facility or system component due to an overloaded or clogged SAS or cesspool.
Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or
cesspool.
(revised 8/15/95) 2
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SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION (continued)
Property Address: 1 VY)GQ/l' ) (� ,
Owner: (� Yr
r,
Date of Inspection:
DJ SYSTEM FAILS (continued
Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool. r`
d ht
Liquid depth in cesspool is less than 6" below invert or available volume is less than 1/2 day flow,
s•'
Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). ,' i
Number of times pumped ..
Any portion of the Soil Absorption System, cesspool or privy is below the high groundwater elevation.
Any portion of a cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply.
Any portion of a cesspool or privy is within a Zone I of.a public well.
Any portion of a cesspool or privy is within 50 feet of a private water supply well. },.,•` •'.` :`
Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water supply well with no ;a'..
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.
El LARGE SYSTEM FAILS:
The following criteria•apply to large systems in addition to the criteria above:
The design flow of system is 10,000 gpd or greater (Large System) and the system is a significant threat to public health and safe s
and the environment because one or more of the following conditions exist:
the system is within 400 feet of a surface drinking water supply
the system is within 200 feet of a tributary to a surface drinking water supply
the system is located in a nitrogen sensitive area (Interim Wellhead Protection Area (IWPA) or a mapped Zone II of,a RS
public water supply well)
The owner or operator of any such system shall bring the system and facility into full compliance with the groundwater treatment program-,. ::_,, ;...
requirements of 314 CMR 5.00 and 6.00. Please consult the local regional office of the Department for further information. ^"
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(revised 8/15/95) 3 >3
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SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM ,
PART B
CHECKLIST
• .iron y- •,�
Property Address: jq/ �,�� �� . �-/(&%,,o Vo lam.
Owner:
Date of Inspection: + ;
Li S) �nz
Check if the foll ing have been done:
^..•.'�
Pumping information was requested of the owner, occupant, and Board of Health.
✓None of the system components have been pumped for at least two weeks and the system has been receiving normal flow rates
during that period. large volumes of water have not been introduced into the system recently or as part of this inspection.
/Asbuilt plans have been obtained and examined. Note if
they are not available with N/A.
The facility or dwelling was inspected for signs of sewage back-up.
she system does not receive non-sanitary or industrial waste flow
,�he site was inspected for signs of breakout.
/AI
systemAbsorption > '_•
.�[ y components, excluding the Soil
gSystem, have been located on the site.
The septic tank manholes were uncovered opened, and the interior s
of the septic tank was inspected ed for condition of bafles -,�_<:=�t•;..
t s, 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 existing information or t '•=::;;cl
a proximated by non-intrusive methods.
Y
The facility owner (and occupants, if different from owner) were provided with information on the proper maintenance of Sub-',"; ,^.;
Surface Disposal System, r-
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14,
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(revised 8/15/95) 4
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SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM `s
PART C
SYSTEM INFORMATION
Property Address: LJ �Gfl 1 CC,�tJ�/J '
Owner: tic— /V ( �"Vl(�
was
Date of Inspection: l 4► �'
RESIDENTIAL:
FLOW CONDITIONS
� x
Design flow: '—'eallons
Number of bedrooms:, {y
Number of current residents:
'Garbage grinder(yes or no):�/1�Oken S(iOLAO &C �� W'.0v—,D.
Laundry connected to system (yes or no):� .
Seasonal use (yes or no):__AZCC ?� i
Water meter readings, if available: Soz
Last date of occupancy: [ Lj V2ZV — <v
COMMERCIAUINDUSTRIAL•
Type of establishment:
Design flow: gallons/day
Grease trap present: (yes or no)_ +'�?
Industrial Waste Holding Tank present: (yes or no)_
Non-sanitary waste discharged to the Title 5 system: (yes or no)
Water meter readings, if available:
Last date of occupancy:
OTHER: (Describe) .�5`....
Last date of occupancy:
GENERAL INFORMATION
'1.d...,
PUMPING RECORDS and source of inf rmation:
S1,L)r �;
System pumped as part of inspection: ye o no)_
If yes, volume pumped. al n-;
Reason for pumping isn1G �t�� S ���tnn�p'Lff� r?✓Z �ksw
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TYPESYSTEM
Septic tank/distribution box/soil absorption system
Single cesspool
Overflow cesspool
Privy
Shared system (yes or no) (if yes, attach previous inspection records, if any)
Other (explain)
,.•.
APPROXIMATE AGE of all components, date installed (if known) and source of information: ,�"�i~^
(C kJ
Sewage odors detected when arriving
at the
(yes •r��,� :•-..•.
(revised 8/15/95) S
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SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C. ,
+ SYSTEM INFORMATION (continued)
'Property Address: �l I rrll G4t1 ( G
Owner: (X is
4;
Date of Inspection: �}
SEPTIC TANK•
-/
(locate on site plan)
Depth below grader
Material of construction:
concrete metal FRP other(explain) 'y�,, •
Dimensions: G-
Sludge depth;_,
y�
Distance from top ofPdge to bottom of outlet tee or baffler ••
Scum thickness:
3 �
Distance from top of scum to top of outlet tee or baffle: / f ��
Distance from bottom of scum to bottom of outlet tee or baffler
Comments:
(recommendation for pumping, condition of inlet and outlet tees or baffles, epth of liquid ev I in relation to outlet inxert uctural
integrity, evidence of leakage, etc.) / -4,A1 r� , C0:> "
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GREASE TRAP: /U
(locate on site plan)
Depth below grade: '
Material of construction: _concrete —metal —FRP —other(explain)
Dimensions:
Scum thickness:
Distance from top of scum to top of outlet tee or baffle:
Distance from bottom ni .rntm i- honor„ of ou!!e+ tee or bailie: '
Comments:
(recommendation for pumping, condition of inlet and outlet tees or baffles, depth of liquid level in relation to outlet invert, structural
integrity, evidence of leakage, etc.)
(revised 8115/95) 6
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SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C Ka
SYSTEM INFORMATION (continued)
Property Address: Manlalv-�
Owner:
Date of Inspection: Vz+ ,�,s'`•
TIGHT OR HOLDING TANK:�J l
(locate on site
e plan)
Depth below grade:
a .
Material of construction: _concrete _metal _FRP other(explain) '
Dimensions:
Capacity: gallons
Design flow: eallons/day
Alarm level:
Comments:
(condition of inlet tee, condition of alarm and float switches, etc.)
is
DISTRIBUTION BOX:
(locate on site plan)
Depth of liquid level above outlet invert: '
N I.
Comments:
(note if level and distrbut o:, i; equal, evidence o'>ohd> carr,over, evidence of leakage into or out of box etc.
S.
PUMP CHAMBER: �/`7
(locate on site plan)
Pumps in working order:(yes or no) ;; .
Comments:
'iy��Rrsg4:.
(note condition of pump chamber, condition ofum s and
P p appurtenances, etc.) '.}Z .:•,,....;f.
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(reviseda
8/15/95)
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SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
u,
PART C
SYSTEM INFORMATION (continued) 'aft
Property Address:
�Lj �(1�ctn laM OR, )0' tea-)
Owner:
Date of Inspection:
•iU
SOIL ABSORPTION SYSTEM (SAS): ,
(locate on site plan, if possible; excavation not required, but may be approximated by non-intrusive methods)
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If not determined to be present, explain
Type: / ;..
leaching pits, number: L1
leaching chambers, number:`
leaching galleries, number:
leaching trenches, number,length:
leaching fields, number, dimensions:
overflow cesspool, number:
Co ments: note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation,etc,) ot"K .
c
CESSPOOLS:
(locate on site plan)
Number and configuration:
Depth-top of liquid to inlet invert:
Depth of solids layer:
Depth of scum layer:
Dimensions of cesspool:
Materials of construction:
Indication of groundwater:
inflow (cesspool must be pumped as part of inspection)
Comments: (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.)
PRIVY:.LV f7
(locate on sit 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 8/15/95) 8
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SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C '1..
SYSTEM INFORMATION (continued) -;i^
Property Address: /�(Gt/✓� �2 n,� V
- ,Y {r
Owner:
Date of Inspection:
SKETCH OF SEWAGE DISPOSAL SYSTEM: .
include ties to at least two permanent references landmarks or benchmarks
locate all wells within 100'
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DEPTH
DEPTH TO GROUNDWATER 1
Depth to groundwater: feet 7j ,
method of determination or approximation:
(revised 8/15/95) 9 :`
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STEWART'S SEPTIC TANK SERVICE, INC.
47 RAILROAD STREET f
BRADFORD, MASSACHUSETTS 01830
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Telephone 372-7471
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BOARD OF HEALTH
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TOWN OF NORTH ANDOVER, MASS.
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1. NAME J�.,i c y G✓ j T, DATE zl-
2.
ADDRESS 14/1 G LOT N0. TEL.
3. NO. OF BEDROOMS DEN YES '� NO
4. GARBAGE GRINDER YES NO L/
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.
11. SHOW DISTANCE OF SEPTIC TANK OR CESSPOOL FROM HOUSE
NOTE: LOCAL REGULATIONS SHOULD BE READ CAREFULLY.
READING DATE j / J WATER & SEWER BILL
P„f�E$ENY. PREVIOUS
AMOUNTDESCRIPTION WATER RATE
a
MINIMUM
USAGE ...-I,r: n a
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USAGE PER 100'CI
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SEWER RATE
RETAIN FOR YOUR RECORDS .0SAG EPgk3fioaCl
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IF'PAID AFTER
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PRESENT' PREVIOUS
AMOUNT DESCRIPTION WATER RATE
MINIMUM
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RETAIN FOR YOUR RECORDS • ' �'• ,USAGE PER 100-CF
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SEWER RATES
RETURN THIS COPY WITH PAYN'.E fT .—• ]J�;i j USAGE PER 100 CF
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STEWART'S SEPTIC TANK SERVICE, INC.
47 RAILROAD STREET
BRADFORD, MASSACHUSETTS 01830
Telephone 372-7471
S?EWART
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Post-ItTm brand tax transmittal memo 7671 #of pages ► �--
To . n. From
Co. Co. O
Dept. Phone o '
Fax# ��
Hillside Acres
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Lot # 9
j APPLICATION FOR SEWAGE DISPOSAL INSTALLATION
HEALTH DEPARTMENT - NORTH ANDOVER, MASS.
I hereby make application for a permit for a sewage disposal installation at
Lot # 9, Hillside Acres . 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 1000 gala 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 200 lineal (dqCUM) 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
the 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
Signat&Iof Applicant
I hereby issue the above permit for the Board of Health of the Town of North
Andover, Massachusetts.
DATE
Sighature of Health Agent
I have inspected the uncovered system indicated above and find everything done
as described.
DATE
Signature o Inspecting Officer
Percolation Test 8min* Soil: Clay
Garbage Grinder-"_)U
• BOARD OF HEALTH
TOWN OF NORTH ANDOVER, MASS.
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1. NAME J,!'✓ 0llell �vtt . DATE
2. ADDRESS OT N0. TEL.
'01
3. NO. OF BEDROOMS te'�► DEN YES '� NO
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.
11. SHOW DISTANCE OF SEPTIC TANK OR CESSPOOL FROM HOUSE
NOTE: LOCAL REGULATIONS SHOULD BE READ CAREFULLY.
BOARD OF HEALTH OF NORTH ANDOVER, MASSACHUSETTS
SEWAGE DISPOSAL
DATE
NAME OF APPLICANT T. j. Reg ad ell ; ,,_Ta,_
LOCATION_ T.O:L 9, w, ll -,i(Ie Aures
Address of lot no.
BUILDING: Dwelling Other
SYSTEM: New Repair
GENERAL DESCRIPTION OF LAND R;
SUBSOIL: Clay_X GravelN� Sand____
PERCOLATION TEST g minutes per inch.
MINIMUM INSTALLATION RECOMMENDATIONS
CONCRETE SEPTIC TANK 1000 gallon capacity.
.LEACH FIELD 200 lineal feet of drain pipe.
William J. r scoll , Engin r
Board of Health
FORM U - LOT RELEASE FORM
INSTRUCTIONS: This form is used to verify that all necessary
approvals/permits from Boards and Departments having jurisdiction
have been obtained. This does not relieve the applicant and/or
landowner from compliance with any applicable local or state law,
regulations or requirements.
****************Applicant fills out this section*****************
APPLICANT: JO`)rl m.`�'�U�u S . �I,lr}S Phone 6 I--6L,q0
LOCATION: Assessor's Map Number Parcel
Subdivision Lot(s)
Street he, St. Number
************************Official Use Only************************
RECOMMENDATIONS OF TOWN AGENTS:
Date Approved
conservation Administrator
Date Rejected
Comments
Date Approved
Town Planner Date Rejected
Comments
Date Approved
Health Agent Date Rejected
Comments
Public Works - sewer/water connections
- driveway permit
Fire Department
Received by Building Inspector Date
d/F JAMES, O'BRIEIJ '
-�A'I I LTO E 5 d^jj
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of
LOT 95 .1 F'
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MORTGAGE INSPECTION PL/
B= .-MOM-00 C�-L�E�I
LOCATED IN
TO IoRT-o A0 utwF-
TN_E•- f�IJpovER- � �JMASSACHUSETTS
1 HEREBY CERTIFY THAT T HAVE EXAMINED THE PREMISES AND ALL EASEMENTS INSURERS
ENCROACHMENTS AND BUILDINGS ARE LOCATED ON THE GROUND AS SHOWN.
1 FURTHER CERTIFY THAT THE BUILDING SHOWN 00
TTHE
ZONING LAWS AND AMENDMENTS, I.I. (FRONT, SIOE 9 REAR YARD SETFORM BACK ONLY) OF 1 '
WHEN CONSTRUCTED, f FURTHER CERTIFY THAT THIS PROPERTY IS� NO, A�DO_VER
LOCATED IN THE ESTABLISHED FLOOo HAZARD AREA , l
NOTE 71115 CERTIFICATION IS BASED ON THE LOCATION OF SURVEY MARKERS OF OTHERS, AND
DOES NOT REPRESENT A PROPERTY SUR DEED
EXAMINATION OF THE RFrnnnc , SURVEY.
nn
FOR11 U
TOWN OF NORTH ANDOVER
LOT RELEASE FO1U1
SUBDIVISION
ASSESSORS MAP
SUBDIVISION LOT(S)
PERMANENT ADDRESS (ASSIGNED BY D.P.W.
/STREET
/APPLICANT PHONE
/DATE OF APPLICATION
TOWN USE BELOW THIS LINE
PLANNING BOARD
DATE APPROVED
TOWN PLANNER DATE REJECTED
CONSERVATION COMISSION
DATE APPROVED
CONSERVATION ADMIN. DATE REJECTED
BOARD OF HEALTH
DATE APPROVED /2 !7 �l
E T i I ARI DATE REJECTED
• /ACU /�vlr�l�iC.J�L.- /�b�S
DEPARTMENT OF PUBLIC WORKS
DRIVEWAY PERMIT
SEWER/WATER CONNECTIONS j{r1i�
FIRE DEPT.
RECEIVED BY BUILDING INSPECTION
DATE
This form shall be signed by the agents of the Planning and Health Boards,
the Conservation Commission prior to the issuance of any building permits
for the subject lot. This form shall not releive the applicant from the
compliance of any applicable Town requirement or Bylaw.
i
FORM U - LOT RELEASE FORM
INSTRUCTIONS: This form is used to verify that all necessary
approvals/permits from Boards and Departments having jurisdiction
have been obtained. This does not relieve the applicant and/or
landowner from compliance with any applicable local or state law,
regulations or requirements.
******\**Applicant fills out this section*****************
APPLICANT: 30 hVN M Z C- cC P- \ W O r�S Phone (o 0 c7
LOCATION: Assessor's Map Number Parcel
Subdivision Lot(s)
street /►') Y}JZ ) ft �J 1�-1�/ - St. Number
************************Official Use Only************************
ATIONS OF TOWN AGENTS:
1A 171?G r
Date Approved J
Conservation Administrator Date Rejected
Comments
Date Approved
Town Planner Date Rejected
Comments
/A ,
Health A ent Date Approved
g Date Rejected
Comments
Public Works - sewer/water connections
- driveway permit
Fire Department
Received by 'Building Inspector Date