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HomeMy WebLinkAboutMiscellaneous - 143 PHEASANT BROOK ROAD 4/30/2018 (3) I i 143 Pheasant Brook Road r �l�g� 4 v �j- > x � r }f•T .. I✓ ,G� Y ,n s..• s�r.Y?J vt rr 4x Xi� l..d".:, a,3 MAP # r :+� , LOT: # PARCEL # REE �ONSTRUCTIQ.N A.PPROV _. HAS PLAN REVIEW FEE .DEEN PAID? E NO PLAN APPROVAL: DATE - APP. BY d/l -447�� DESIGNER: PLAN DATE. CONDITIONS WATER SUPPLY: TOWN WELL WELL PERMIT DRILLER, WELL TESTS: ��- CHEMICAL DALE APPROVED BAC' IA I DA I E flPPRUVED BACTERIA II DATE APPROVED COMMENTS: i i FORM U APPROVAL: APPROVAL 1*0 ISSUE YES NU�� DATE ISSUED vim! Y� BY CONDITIONS: FINAL APPROVAL: - ALL PERMITS PAID YES NO WELL CONSTRUCTION APPROVAL YES NU SEPTIC SYSTEM CONSTRUCTION APPROVAL YES NO OTHER YES NU ANY VARIANCE NEEDED YES NU FINAL BOARD OF HEALTH APPROVAL: DATE:.... BY: /a-> J 1 ,•=;��~'�i` ' ' �E.��G�SY�•C�L"1_�.NSSfl4L.AZI QLvI .,'Ir• •�i, i• \. .r. '.• � ,.zj. , a:-'.�r .^..l r a, r:� ,.. \ t a 1 � 1 1. ']. . IS,THE' INSTALLER LICENSED? `yrc YE5 NO ` :TYPE OF CONSTRUCTION: ? " NE REPAIR ;. _ r ::NEW• CONSTRUCTION: CERTIFIED PLOT PLAN ,•REVIEW -���� NO CONDITIONS OF..APPROVALYES NO (FROM FORM U) - .ISSUANCEOFDWC PERMIT _ ` YES NO DWC PERMIT ' NO. - INSTALLER: Z-V ill _ BEGIN INSPECTION .EXCAVATION . INSPECTION: _ " NEEDED: SASSEDBY CONSTRUCTION INSPECTION= NEEDED: = AS BUILT PLAN SATISFACTORY: YES: _ - APPROVAL TO BACKFILL: DATE: r� - BY FINAL . GRADING APPROVAL: DATE % HY1 FINAL CONSTRUCTION APPROVAL: DATE: BY All t17. _ Town of North Andover, Massachusetts Form No. 1 NORTH BOARD OF HEALTH 32Oy<ZLED 0 Ley 19 o sr . A rO APPLICATION FOR SITE TESTING/INSPECTION ��SSAC HUs���h Applicant— Y"AP Z a. _,,1 ;2,-, NAME ADDRESS TELEPHONE Site Location 41-- A'-e Engineer NAME ADDRESS TELEPHONE Test/Inspection Date and Time CHAIRMAN,BOARD OF HEALTH Fee Test No. 7//�� p S.S. Permit No. 777 D.W.C. No. C.C. Date Plbg. Permit No. Town of North Andover, Massachusetts Form No. 1 NORTHq• BOARD OF HEALTH 01 QED ,64 'Y0 r' 19 .1 .) OL O � t� APPLICATION FOR SITE TESTING/INSPECTION �9SSacHusE��y Applicant NAME .� ADDRESS TELEPHONE Site Location Engineer t NAME ADDRESS TELEPHONE Test/Inspection Date and Time CHAIRMAN,BOARD OF HEALTH Fee `�� Test No. 6' { { A! Mr S.S. Permit No. 777 D.W.C. No. C.C. Date Plbg. Permit No. MAP AND PARCEL '-0—'t4 ADDI V / OWNER ��-' J a> SIZE OF LOT IN SQUARE FEET #BEDROOMS SEPTIC SYSTEM LOCATION S�� 16&1,7f`1 (For example,FRONT YARD SOUTHEAST CORNER) FINAL GRADING DATE Z AS BUILT T PLAN IN FILE? � INSTALLER �• ���� �Q�U'� DWC PERMIT DATE c7 — CERTIFICATE OF COMPLIANCE DATE a /� ENGINEER �sG/itIt•�J�� �' ^,tom APPLICATION FOR DISPOSAL WORKS CONSTRUCTION PERMIT DATE: ,15�_ ,� q— V) CURRENT INSTALLER'S LICENSE# LOCATION: Zo T everq fe_e Let Lff LICENSED INSTA LER: n /J 4 '' ►� e r�2Ci SIGNATURE: . LEPHONE# le— n C 3�� / 1 CHECK O i REPAIR: NEW CONSTRUCTION: IF,NEW CONSTUCTION, PLEASE ATTACH FOUNDATION AS-BUILT. a- Administrat've Use Only $75.00 Fee Attached? Yes No Foundation As-Built? Yes No Approval Date: i Town of North Andover, Massachusetts Form No. 3 NORTH BOARD OF HEALTH r OL 19 �-- ~ O A • ♦; c° -.«at::r:`,'ten�'* o0 h DISPOSAL WORKS CONSTRUCTION PERMIT • ,S`SACMUSE� Applicant ME ADDRESS pp TELEPHONE Site Location C-0-F tA)-211 QAJ 11 -/I,, f Permission is hereby granted to Construct ("4/or Repair ( ) an Individual Soil Absorption* Sewage Disposal System as shown on the Design Approval S.S. No. CHAIRMAN, BOARD OF HEALTH T5- a� Fee 5 Q V D.W.C. No. 94 I77 Form No.4 Town of North Andover, Massachusetts BOARD OF HEALTH AuTust 22 19 97 CERTIFICATE OF COMPLIANCE This is to certify that the Individual Soil Absorption Sewage Disposal System constructed (X ) or repaired ( ) by John DiVincenzo INSTALLER at Lot 7, #143 PheaSANT Brook Road SITE LOCATION has been installed in accordance with Board of Health Regulations as described in the Design Approval Site System Permit No. 777 dated June 25 19 96 The issuance of this certificate shall not be construed as a guarantee that the system will 'function satisfactorily. BOARD OF HEAL y. 1 FORM C APPLICATION FOR APPROVAL OF DEFINITIVE PLC E `'``A`'OWN N CI.rRK � NQRTH ANDOYER January 1719 95 ` JAN To the Planning Board of the Town of North Andover: The undersigned, being the applicant as defined under Chapter 41, Section 81—L, for approval of a proposed subdivision shown on a plan entitled Definitive Subdivision Plan "Evergreen Estates" located in Norrh Andover by Christiansen & Sergi , Inc : dated December 28 , 1994 being land bounded as follows:Northerly bt Com of MAL land of Steer and Fried ; easterly by land of Fried , eadde,r , Rough , Green , Galeassi , Yourre , Mateia , rRi " s Al ^alter end Daa-i s-rSalem 9ri Parr Farr and Com of MA ; westerly by Com of MA.. hereby submits said plan as a DEFINITIVE plan in accordance with the Rules and Regulations of 'the North Andover Planning Board and makes application to -the Board for approval of said plan. 1087 314 Title Reference: North Essex Deeds, Book 2901 Page 13 ; or Certificate of Title No. , Registration Book , page ; or Other: Said plan has( has not( ) evolved from a preliminary plan submitted to the Board of Aury 24 19 94 and approved (with modifications) ( ) disapproved (X on Oct 4 , 1994 The undersigned hereby applies for the approval of said DEFINITIVE plan by the Board, and in furtherance thereof hereby agrees to abide by the Board's :Rules and Regulations. The undersigned hereby further covenants and agrees crith the Town of North Andover, upon approval of said DEF' `INITIVE plan by the Board: 1. To install utilities in accordance utth the rules and regulations of the Planning Board, the Public Works Department, the Highway Surveyor, the Board of Health, and all general as well as zoning by—laws of said Town, as are applicable to the installation of utilities within the limits of ways and streets; 2. To complete and construct the streets or Kays and other improvements shown thereon in accordance with Sections Iv and V of the Rules and Regulations of the Planning Board and the approved DEFINITIVE plan, profiles and cross sections of the same. Said plan, profiles, cross sections and construction specifications are specifically, by .-reference, incorporated herein and made a part of this application. This application and the covenants and agree— ments herein shall be binding upon all heirs, executors, administrators, successors, grantees of the whole or part of said land, and assigns of the undersigned; and 3. To complete the aforesaid installations and construction within two (2) years from the date hereof. Received by Town Clerk: r`. Date: Signature of Applicant Messina Development Corp . , 805 Winter St . Time: 1,1orth Andover , MA 01845 Signature: Address • :iQ. �iu it r/r�:j;., Notice to AP?UUANf/'I V CLERK and Certification of A .on of rlanning Board on Definitive Subdivi.,ion Plan entitled: Evergreen Estates By: Christiansen & Sergii_ dated DPrP,,,hP, ;u19 94 The North Andover Planning Board has voted to APPROVE said plan, subject to the following conditions: 1. That the record owners of the subject land forthwith execute and record a "covenant running with the land", or otherwise provide security for the con- struction of ways and the installation of municipal services within said sub- division, all as provided by G.L. c. 41, S. 81-U. 2. That all such construction and installations shall in all respects conform to the governing rules and regulations of this Board. 3. That, as required by the North Andover Board of Health in its report to this Board, no building or other structure shall be built or placed upon Lots No. as shown on said Plan without the prior consent of said Board of Health. 4. 'Other .conditions: T :L� Z :0 See attached o =r+grnm rr} yam„ .'mac Lr_ c.r In the event that no appeal shall have been taken from said approval within twenty days from this date, the North Andover Planning Board will forthwith thereafter endorse its formal approval upon said plan. The North Andover Planning Board has DISAPPROVED said plan, for the following reasons: NORTH ANDOVER PLANNIM BOARD Au us � i995 B3''t 15 Date: g Jose P i, V. Mahoney, Charman I .l a. A complete set of signed plans, a copy of the Planning Board decision, and a copy of the Conservation Commission Order of Condition must be on file at the Division of Public Works prior to issuance of permits for connections to utilities. The subdivision construction and installation shall in all respects conform to the rules and regulations and specifications of the Division of Public Works. b. All site erosion control measures required to protect off site properties from the effects of work on the lot proposed to be released must be in place. The Town Planning Staff shall determine whether the applicant has satisfied the requirements of this provision prior to each lot release and shall report to the Planning Board prior to a vote to release said lot. C. The applicant must submit a lot release FORM J to the Planning Board for signature. d. A Performance Security (Roadway Bond) in an amount to be determined by the Planning Board uponon the recommendation of the Department of Public Works, shall be posted to ensure completion of the work in accordance with the Plans approved as part of this conditional approval. The bond must be in the form of a check made out to the Town of North Andover. This check will then be placed in an interest bearing escrow account held by the Town. Items i q coy may covered b the Bond include, but shall not be limited Y to: i. as-built drawings ii. sewers and utilities iii. roadway construction and maintenance iv. lot and site erosion control V. site screening and street trees vi. drainage facilities vii. site restoration viii. final site cleanup e. Three (3) complete copies of the endorsed and recorded plans and two (2) certified copies of the recorded subdivision approval, Covenant (FORM I) , Right of Way easements, and FORM M must be submitted to the Town Planner as proof of filing. 4 . Prior to a FORM 0 verification for an individual lot, the following information is required by the Planning Department: a. All lots must be approved by the Board of Health. The Board of Health has determined that Lots 6, 9, 12, 13 , and 21 cannot be used for building sites without injury 4 _. I 1 r to the public health without further testing. No building or structure shall be placed upon these lots without consent by the Board of Health. b. Due to the large amount of rock on the site which may interfere with the amount of parent material available for leaching, the Board of Health will require that the leaching area for each lot be completely excavated to insure that there is the requisite four feet of parent material present throughout the entire location proposed for the leaching area. C. The applicant must submit to the Town Planner proof that the FORM J referred to in Condition 3 (c) above, was filed with the Registry of Deeds office. d. A plot plan for the lot in question must be submitted, which includes all of the following: i. location of the structure, ii. location of the driveways, iii. location of the septic systems if applicable, iv. location of all water and sewer lines, V. location of wetlands and any site improvements required under a NACC order of condition, vi. any grading called for on the lot, vii. all required zoning setbacks, viii. location of any drainage, utility and other easements. e. All appropriate erosion control measures for the lot shall be in place. Final determination of appropriate measures shall be made by the Planning Board or Staff. f. All catch basins shall be protected and maintained with hay bales to prevent siltation into the drain lines during construction. g. The lot in question shall be staked in the field. The location of any major departures from the plan must be shown. The Town Planner shall verify this information. h. Lot numbers, visible from the roadways must be posted on all lots. 5 . Prior to a Certificate of Occupancy being requested for an individual lot, the following shall be required: a. A stop sign must be placed at end of Pheasant Brook Road where it intersects with Salem Street. b. A driveway easement across Lot 22 must be granted to Ian 5 CHRISTIANSEN & SERGI, INC. PROFESSIONAL ENGINEERS AND LAND SURVEYORS 160 SUMMER STREET HAVERHILL, MASSACHUSETTS 01830 (508)373-0310 FAX: (508)372-3960 February 20, 1996 Ms. Sandra Starr North Andover Board of Health 146 Main Street No. Andover, MA 01, 845 RE: Lot 7, Everc3 ,-een Estates - Dear Sandy: Thank you fo:- your review of Lot 7 , Evergreen Estates, dated February 7 , 1996. I have made all of the changes you requested except the note regarding we-_lands. The wetlands flag C-10 is 120 feet } from the system; ..herefore, note 10 which was added, had to state that there aren't any wetlands within 100 feet rather than 150 feet as you requested. Offsite wetlands are greater than 150 feet from the system. F Sin f, el ur , `Ph' lp G. Christiansen PGC;lc TOWNBGk�F 1-AINDOVER/ i 22 05 , DATE Sheet of BOARD OF HEALTH TOWN OF NORTH ANDOVER SUBSURFACE DISPOSAL DESIGN REVIEW FEE (�'� PERMIT # rl7 / DATE RECEIVED Ilqg� APPLICANT --506 /1E55/A.&,4 ASSESSOR'S MAP ADDRESS PARCEL # LOT # 17 STREET ENGINEER OJ-11'2l5Ti 4`U SE,CU ADDRESS / J PLAN DATE -le)//�s- REVISION DATE CONDITIONS OF APPROVAL: APPROVED DISAPPROVED /Uo ��ti/G. TO 0 evuiuj)u>/4/ %G���•S O/�/ S% G' OGUAVCO 4,�9-40 CV I I Town of North Andover NaRT►. i f 1 OFFICE OF COMMUNITY DEVELOPMENT AND SERVICES p I * S 1e x I 146 Main Street North Andover, Massachusetts 01845 9SSgc►+US (508) 688-9533 February 7, 1996 Christiansen & Sergi 160 Summer Street Haverhill MA 01830 Re: #7 Pheasant Brook Dear Phil: This is to inform you that the proposed plans for the site referenced above have been disapproved for the following reasons: 1) Elevations of perc tests missing. 2) No manhole to grade on tank. 3) Bottom of system only 4 .5 feet to groundwater, not 5 feet as required for 2 minutes perc rate. 4) Any wetlands on state-owned land within 150 feet of system? Please show or state. 5) 4 inches of peastone required. 6) What is basement elevation? If you have any questions, please do not hesitate to call the Board of Health Office at the number below. I ' Sincerely, i Sandra Starr, R.S. Health Administrator SS/cjp BOARD OF APPEALS 688-9541 BUILDING 688-9545 CONSERVATION 688-9530 HEALTH 688-9540 PLANNING 688-9535 Julie Partin D.Robert Nicetta Michael Howard Sandra Starr Kathleen Bradley Colwell i PLAN REVIEW CHECKLIST ADDRESS h�­V5,91U7_ CO3/-_ ENGINEER GENERAL 3 COPIES ' STAMP L��� LOCUS NORTH ARROW v SCALE CONTOURS'--- PROFILE SECTION BENCHMARK kAo SOIL & PERCS L___ ELEVATIONS WETS. DISCLAIMER WELLS & WETS WATERSHED?Jz/ DRIVEWAY C--'-_(Elev) WATER LINE &�-' FDN DRAIN SCH40 v-- TESTS CURRENT? y SOIL EVAL _`3, SEPTIC TANK MIN 1500G L/ . 17 INVERT DROP GARB. GRINDER(+200% EDF) 25 ' TO CELLARt-" MANHOLE A--" ELEV GW # COMPS. D-BOIL SIZE # LINES FIRST 2 ' LEVEL STATEMENT INLET - OUTLET J,�,?.77 = / (2" OR . 17 FT) TEE REQD?A_/0 LEACHING MIN 660 GPD? RES I ? Z� RESERVE AREA 4 FROM PRIMARY. 20 SLOPED 100 ' TO WETLANDS 100 ' TO WELLS (-� 4 ' TO S.H.GW=i A1_1, M/IN 35 ' TO FND & INTRCPTR DRAINS L,"'�"325 ' TO SURFACE H2O SUPP ' PERM. SOIL BELOW FACILITY 12" COVER &-----FILL? if above natural elev; 10 ' if below) BREAKOUT MET? ---- TRENCHES MIN 660 gpd SLOPE (min . 005 or 6"/1001 ) SIDEWALL DIST. 3X EFF. W OR D (MIN 61 ) RESERVE BETWEEN TRENCHES? IN FILL? MUST BE 10 ' MIN. 4" PEA STONE? VENT? (>3 ' COVER; LINES >501 ) BOT + SIDE X LDNG = TOT (L x W x #) (DxLx2x#) (G/ft2) Copyright© 1995 by S.L.Starr i PITS MIN 660 LEACHING MIN 1 (13 'x16 ' ) PIT MANHOLE/PIT GW MIN 4 ' BELOW BOTTOM EXC 2x EFF W OR D 12"-48" STONE BOT + SIDE x LOAD = TOTAL (L x W x ##) (2x(L+W)xD x ##) (G/ft2) CHAMBERS MIN 660 LEACHING GW MIN 4" BELOW COVER >3 FT - VENT MANHOLES 12"-48" STONE SPLASH PADS SLOPE .005 BED/TRENCH (Bed max. 60 ' X 601 ) MIN 13 ' X 16 ' PIT BOT + SIDE X LOAD = TOTAL (L x W x ##) (2 x (L+W)xD x ##) (G/ft2) FIELDS V MIN 660 GPDV` 900 ft2 BED GW MIN401 BELOW BOTTOM OF FIELD j PIPE ENDS JOINED? l/ 4" PEA STONE? DIST LINE SLOPE .005? i >31COVER-VENT SCH 40 MIN 12" COVER RATE /0/7)/-- LDG X 660 = X TOTALcI066=466 G/ft2 REQ'D (ft2) LXW DOSING TANKS AND PUMPS DIMENSIONS X X = PUMP CAPACITY 9Pm L W D Vol . DISCHARGE SIZE DISCHARGE� C GE RATE DISCHARGE TIME Spm MANHOLES TO GRADE ALARM SEP. CIRC. GW (Min. 1 ' below inlet) HWL LWL CHECK VALVE BLEEDER HOLE MANUAL OP. SWITCH Copyright 0 1995 by S.L. Starr i FORM U - VERIFICATIOv 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************* *** APP=hCANT: 'Phone LOCATION: Assessor' s Map. Number Parcel Subdivision ��l�C� �� p-/-n . .Lct,(s) Street ;t'� �)&4z, � St.. Number ** fiC1a1 Use r RECOMMENDA ONS OF WN AGENTS : l 1 : Date Approved Conrvation. Administrator Date Rejected Comments (,L/� ZICC �� ' n : t Date Approved .3 , own PlannerDate ,_ejected Comments Date, Approved Food Inspector-Health Date Rejected /tz� / Date Approved �l�� i Septic Inspector-Health Date Rejected h Comments ' Public Works =--mer/water connections. lug I ✓ i J ` l --err % permit l '�L �^ l 1 '/F Lre Department Received by Building Inspector Date , c FORM U -- VERIFICATION 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***************** CA APPLICANT: �y1 Phone - b �b/ LOCATION: Assessor' s Map Number Parcel SubdivisionLot(s) Kr Street C 1`Gf 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 Food Inspector-Health Date Rejected /Qin w Date A roved 8 A Se tic Ins ector-Healt PP h P P Date Rejected Comments Public .','Works sewer water connections driveway permit Fire Department Received by Building Inspector Date CHRISTIANSEN & SERGI, INC. PROFESSIONAL ENGINEERS AND LAND SURVEYORS 160 SUMMER STREET HAVERHILL, MASSACHUSETTS 01830 (508)373-0310 FAX: (508)372-3960 TOW BOARD OF 'AANDT OVV / June 17, 1996 E , g Ms. Sandra Starr North Andover Board of Health 120 Main Street North Andover, MA 01845 Re: Lot 7 Pheasant Brook Road (Evergreen Estates Subdivision) Dear Ms. Starr: On behalf of Mr. Charles Lamarca, the prospective buyer of Lot 7 Evergreen Estates, I submit to you the enclosed modified septic system design. The modifications made to the plan are as follows: 1. The placement of Mr. Lamorca's house footprint on the plan. 2. The slight rotation of the primary and reserve leaching areas away from the proposed driveway. 3. The revision of the profile of the septic system to reflect the changes in the septic tank and pipe locations. Enclosed are 3 copies of the revised Septic System Design for Lot 7. Please contact me if you have any questions regarding these modifications. V ghristiansen P ' CHRISTIANSEN & SERGI, INC. PROFESSIONAL ENGINEERS AND LAND SURVEYORS 160 SUMMER STREET HAVERHILL, MASSACHUSETTS 01830 (508)373-0310 FAX: (508)372-3960 January 4, 1996 NDO��R� TORN 0 u"J" B0f FiD OF Ms. Sandra Starr North Andover Board of Health �9 146 Main Street A No. Andover, MA 01845 RE: Lot 7 , Evergreen Estates Dear Sandy: Attached are revised plans for Lot 7 Evergreen Estates. The plans have been revised using new Title 5 and your recommendations from the first submittal. Very& ul you , hil ' .' G. Christiansen PGC;lc t NORT►1 1 BOARD OF HEALTH O D # s 120 MAIN STREET TEL. 682-6483 7 pD4.TfD•TP"�y 9SSACHUSEt NORTH ANDOVER, MASS. 01845 Ext23 November 28, 1995 Christiansen & Sergi 160 Summer Street Haverhill, MA 01830 Re: Lot #7 Pheasant Brook Dear Phil: This is to inform you that the proposed plans for the site referenced above have been disapproved for the following reasons: 1) Trenches not 10 feet apart. (N.A. 17 . 03) Also, distance between trenches not specified on either site plan or cross section Please also address reserve. 2) Slope of SAS lines not specified. 3) Please add north arrow on site plan. 4) What is map & parcel? I Please remove cross hatching showing top and subsoil removal that is above existing grade. If you have any questions, please do not hesitate to call the Board of Health Office at (508)688-9540. Sincerely, Sandra Starr, R.S. Health Administrator SS/cjp NORTH ANDOVER BOARD OF HEALTH DESIGN REVIEW REPORT FEE: ` [Oy PERMIT ## � DATE RECEIVED APPLICANT `�%J�O �55%�/� MAP PARCEL ADDRESS �A, fQ,U DD IJC�� LOT # ENG. STREET ADDRESS levo Suti1 M/,e c'3 i PLAN DATE REV. DATE CONDITIONS OF APPROVAL APPRPV�Dl DISAPPROVED REASONS FOk' bISAPPROVAL: t, ,Z&Ai CM�s Nor 161 1,9P�,�7-, (A), 19 - i 7 a Oj R E -9 AD ID ec-5 5 -;v,_& L G 19 5 3 . f35� D/J �O/2T-l'' L�•c�/2Gtc� nA) �GG�A5C= ��MOv�' G�O55 � �ich���G S��d�vi,U6 7-0 I!!!! 111 ��1 ��� 1 1 11 11111111111111111 i� 31 I!1 i�'"'!• '��i 1 11111 11 1 11111 A 11 �� � _ 1111111111111 111! 11 1 1� E7! ����, 1111111111111111 1 11 N 1� w 1 4 X11 �, '��� 11111 111 i 111 1 1 l PLAN REVIEW CHECKLIST i ADDRESS �7 ENGINEER GENERAL 3 COPIES ✓/ STAMP t/ LOCUS `' NORTH ARROW --- SCALE 1---� CONTOURS L� PROFILE SECTION BENCHMARK SOIL & PERC INFO ELEVATIONS WETS. DISCLAIM � WELLS & pf a0�HAFAti'M TOWNg�aD 4F No........................ ................r. THE COMMONWEALTH OF MASSACHUSET S BOARD OF HEALTH ld W&. ...............OF..t ®t'T1`1....... QD(1 2 . .-.....-.......... Appliratiutt for Bilivillial Marks (fouBtrtt tort Permit Application is hereby made for a Permit to Construct X or Repair ( ) an Individual Sewage Disposal System at: ........... .........l ro ee-�zc/ �O t� • C!�` re ... f ------ ------ ., /�. ocatioo-Address or .•--.-.---••----•--•-•-- �✓�&'`- .....!Q Zl t1 o» ----- f.................... 1 ..... 2!� ..o.. W Address a ................................................................................................. Installer dies... �;� � -�-A�••' Type of Building Address V C�[ Size Lot......--•---.....••--...---feet Dwelling— No. of Bedrooms..........;1................................Expansion Attic ( ) Garbage Grinder ( ) a Other—Type of Building ------------- No. of.persons.......---....-_- --.... Showers g ----��-�--���•- ( ) — Cafeteria ( ) Other fixtures ------------------------------------- WW Design Flow..... ................... ..................gallons per person per day. Total dailyy flow.---------.6.4. .®-------------------gallons. W x Septic Tank—Liquid ca acit / ----.-gallons Length./#. `6---- Diameter................ Depth-f5- Disposal Trench--No. .......... Width .... Total Length....GTotal leaching area----7,9?9...... �sq..i-�. ft. Seepage Pit No---------------------- Diameter..---..----..--..... Depth below inlet...---.............. Total leaching area...................sq. ft. z Other Distribution box,(v) Dosing tank ( ) , aPercolation Test Results Performed byl/lS. '�i✓ jpp_____-.-_ - Date-... /� Aj- __71_1.�pS Test Pit No. I-----9.......minutes per inch Depth of Test Pit. /.Q .( Depth to ground water--�1D (�t//ti.-. Test Pit No. 2...s12.---..--minutes per incl„ Depth of °i I 1 p "j-est,Prt._.-.,��.--.... Depth to ground water-�S//1NT.'�s® p; 0 ------------------ -----------------------------•------•--•-•----•• ----•--•---•--••-•--- -- -----•-•----•--•--------•---........_............. Description of Soil.........F/A&.- 591.2?dy--.1��1! r. JR/" 1�'�lrr�r --- o ...Ic'a, .1.......--- .......................... U •--••-----•--•----•................4......-- ------•---•----•-•-----•-------•--•-•----•-•••----•---•----------••----•--•-•------•----•---.- x ---------------------•------•------------------------------- --------------------------------------------------- U Nature of Repairs or Alterations—Answer when applicable............................ ...................... - Aggree--•-m-•-ent n-t--....----•--------------•--------------------- - The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of TITLE 5 of the State Sanitary Code— The undersigned further agrees not to place the system in operation until a Certificate of Compliance has been issued by the board of health. i Signed..................................... Application Approved B Date PP PP Y ----------•--------•----------•-- ........................................ � Application Disapproved for the following reasons: Da te -.-.--•--•------------------------------------------------------------------------------------ ... ...........•-----...---•--•---•----•----•---•---•----•-------------- --- Date Permit No.. --•----•-...... Issued Date