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Miscellaneous - 1577 SALEM STREET 4/30/2018 (2)
1577 SALEM STREET _ 210/106.B-00040000.0 �1 i t �I✓ MAP # LOT # PARCEL # STREET CONSTRUCTION APPRO-V • 1 HAS PLAN REVIEW FEE BEEN PAID? YES NO PLAN APPROVAL: DATE (51,31 IqI7 APP. BY Zdo/�y- u DESIGNER: �/}Ct'�/ ��/�-i/�/ PLAN DATE c_ h�&z CONDITIONS t, WAFER SUPPLY: TOWN WELL WELL PERMIT DRILLER WELL TESTS:'*, CHEMICAL DATE APPROVED B�'CTERIA I DATE APPROVED ~ BACTERIA II DATE APPROVED PLUMBING SIGNOFF `WIRING SIGNOFF COMMENTS: t - FORM U APPROVAL: APPROVAL TO ISSUE YES NO r' DATE ISSUED BY CONDITIONS: FINAL APPROVAL: ALL PERMITS PAID YES NO WELL CONSTRUCTION APPROVAL YES NO SEPTIC SYSTEM CONSTRUCTION APPROVAL YES NO OTHER YES NO ANY VARIANCE NEEDED YES NO FINAL BOARD OF HEALTH APPROVAL: DATE: BY: SEPTIC SYSTEM INSTALLATION IS THE INSTALLER LICENSED? YES NO TYPE OF CONSTRUCTION: ; NEW REPAIR NEW CONSTRUCTION: CERTIFIED PLOT PLAN REVIEW YES NO CONDITIONS OF APPROVAL YES NO (FROM FORM U) ISSUANCE OF DWC PERMIT 9:s) NO DWC PERMIT PAID? ES NO DWC PERMIT NO. 9�! INSTALLER:—pgTF,- , Ae�g d BEGIN INSPECTION �S T0: EX7-AVATION INSPECTION: NEEDED: r: PASSEDBY o CONSTRUCTION INSPECTION: NEEDED: r AS BUILT PLAN SATISFACTORY: APPROVAL tO BACKFILL: DATE: 7 7 BY z4��j FINAL GRADING APPROVAL: DATE �,//�7�9� BY C( FINAL CONSTRUCTION APPROVAL: DATE�/I lqr BY �J Date..A2-`� ��`�........... °� "" '•,~ TOWN OF NORTH ANDOVER ' 0 3a * * PERMIT FOR WIRING • 88�cHus� This certifies that .... , .(l!, ��1�(��t S� haspermission to perform ...ceiaon!;z...... ........ .! .................... M wiring in the building of........... ............ L� at ................� � .......... :.Q...r'1......�� :..........,North Andover,Mass. w ............ Fee.. .�,......��...........Lic.No � '"! .............................................................................. ELECTRICAL INsPEcToR Check# 11612 i X Commonwealth of Massachusetts Official Use only Department of Fire Services Permit No. Z-- f Occupancy and Fee Checked BOARD OF FIRE PREVENTION REGULATIONS [Rev. 1/07] leave blank APPLICATION FOR PERMIT TO PERFORM ELECTRICAL WORK All work to be performed in accordance with the Massachusetts Electrical Code(MEC),527 CMR 12.00 (PLEASE PRINT IN INK OR TYPE ALL INFORMATION) Date: 6--2 Af —,2o1-.z 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) Owner or Tenant \7—o r Telephone No. Owner's Address Is this permit in conjunction with a building permit? Yes ❑ No (Check Appropriate Box) Purpose of Building 5/" Utility Authorization No. Existing Service Amps / Volts Overhead ❑ Undgrd❑ No.of Meters j New Service Amps / Volts Overhead❑ Undgrd❑ No.of Meters / Number of Feeders and Ampacity Location and Nature of Proposed Electrical Work: �t„ S k-P /Zl r Y �1 n 42. Completion of the followingtable maybe waived b the Ins ector of Wires. No.of Total i No.of Recessed Luminaires No.of Cell:Susp.(Paddle)Fans Transformers KVA No.of Luminaire Outlets No.of Hot Tubs Generators KVO► s Above n- No.of Emergency Lighting S No.of Luminaires Swimming Pool nd. grnd. ❑ Batte Units No.of Receptacle Outlets No.of Oil Burners FIRE ALARMS I No.of Zones and No.of Switches No.of Gas Burners o.o eteng D Initiating Devices No.of Ranges No.of Air Cond. Tons TotNo.of Alerting Devices Heat Pump Number Tons KW No.oSelf-Contained No.of Waste Disposers Totals: ' Detection/Alerting Devices No.of Dishwashers Space/Area Heating KW Local ElCoumapa C1 Other uri yyuection No.of Dryers Heating Appliances KWSec No of Devices or Equivalent No.of Water , o.o No.o Data Wiring: Heaters Signs Ballasts No.of Devices or Equivalent No.Hydromassage Bathtubs No.of Motors Total HP Telecommunications No.of Devices or E avalent OTHER: 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 cove,71fe 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 andpenalties ofperjury,that the information on this application is true and complete- FIRM NAME: 0 19 LIC.NO.: Licensee:_PA LI, U-19A H S s,l Signature LIC.NO.: d2 (If applicable,enter"exempt"in the license number line) Bus.Tel.No.: 6- f7-6333 Address: Alt.Tel.No.: q71' 14 7Z�Z4�o 'Per M.G.L c. 147,s.57-61,security work requires Department of Public Safety"S"License: Lie.No. OWNER'S INSURANCE WAIVER: I am aware that the Licensee does not have the liability insurance coverage normally required by law. By my signature below,I hereby waive this requirement. I am the(check one)❑owner ❑owner's agent. Signature Telephone No. PERMIT FEE: $ '1 tt r .f �s . .. . • _ . �:y _ � / � . � _ . �_ � ,P: . s,. ,,, a � -i i ` � / � o y i. __ � F � �. _. _ t i i r i ,P 'i f . . ,. �. ... _. a �i. _ _ .. ... ., e s r .. � � - � .. _ P P P � ,� i' .. i P .z ._ �, r ;. -` � � D . c . i _. �i � t .. � . i *, i. _�. �. � t .. � � � �. i .. f it .. u - • r _ } I The Commonwealth of Massachusetts Department of Industrial Accidents -- Office of Investigations < 600 Washington Street Boston,MA 02111 www.mass.gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Legibly Name (Business/Organization/Individual): PIV H/GU Address: // So Ai cr Ir S? /4 tl . City/State/Zip:12/1/116 Phone#: 76` o Are you an employer?Check the appropriate box: Type of project(required): 1.❑ I am a employer with 4. ❑ I am a general contractor and I oyees(full and/or part-time).* have hired the sub-contractors 6. F-1 New construction 2. I am a sole proprietor or partner- listed on the attached sheet. 7. ❑ Remodeling ship and have no employees These sub-contractors have g. ❑ Demolition working for me in any capacity. employees and have workers' insurance.$ 9. ❑ Building addition [No workers comp.comp. insurance required.] 5. ❑ We are a corporation and its 10.rRflectrical repairs or additions officers have exercised their 11. Plumbing repairs or additions 3.❑ I am a homeowner doing all work ❑ g P myself. [No workers' comp. right of exemption per MGL 12.❑Roof repairs insurance required.] t c. 152, §1(4),and we have no 13.❑ Other employees. [No workers comp. insurance required.] *Any applicant that checks box#1 must also fill out the section below showing their workers'compensation policy information. t Homeowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such. $Contractors that check this box must attached an additional sheet showing the nam of the sub-contractors and state whether or not those entities have employees. If the sub-contractors have employees,they must provide their workers'comp.policy number. I am an employer that is providing workers'compensation insurance for my employees. Below is the policy and job site information. Insurance Company Name: Policy#or Self-ins.Lic.#: Expiration Date: Job Site Address: City/State/Zip: j 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 may be forwarded to the Office of Investigations of the DIA for insurance coverage verification. I do hereby certify under thepains andpenalties of perjury that the information provided above is true and correct Signature: Date: Phone#: 9>X _45__5_;7 _7G.d 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.City/Town Clerk 4.Electrical Inspector 5.Plumbing Inspector 6.Other Contact Person: Phone#: 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 joint 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 I 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." I 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-contractor(s)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. If an LLC or LLP does have employees, a policy is required. Be advised that this affidavit may be 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 returned 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. City or Town Officials I 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 permit 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. I I The Department's address,telephone and fax number: s The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations 600 Washington Street Boston,MA 02111. Tel. # 617-727-4900 ext 406 or 1-877-MASSA-FE Fax # 617-727-7749 Revised 11-22-06 www.mass.gov/dia 4 tVIMfJNWEALTkjI.MAS ACHUSE17S ` }}:: ' • OR . • `,= 7� a j;" ""F•ke�'M° itANfGUA.S A �4sE- CTRiCIA;N xr ° 'ISSUESTHE;�AB01Yt11CMSE1�? A SDA1i AADD.HNS0 ' iI1 SPNCRESTf AVE, _ xl * 1887Li I, Date..... ....................... NORT1{ pf t�.�o.•1� . 3: ea,�, •;- 's ppm TOWN OF NORTH ANDOVER PERMIT FOR WIRING SCMUSE� d This certifies that .............0/74.4 )........ /,�.S.Q'.?. .................. has permission to perform .. o :/?v[ F wiring in the building of......... U/2 f"C ................................................. at.........::57..7.... ....... ........................ . rth Andover,Mass. Fee�F .... Lic.No..IAL�-/. .................... ... ELE IC AL INSPE4 Check it 1 648 i Commonwealth of Massachusetts Official Use Only Department of Fire Services Permit No. I Occupancy and Fee Checked BOARD OF FIRE PREVENTION REGULATIONS [Rev. 1/07] leave blank APPLICATION FOR PERMIT TO PERFORM ELECTRICAL WORK All work to be performed in accordance with the Massachusetts Electrical Code(MEC),527 CMR 12.00 (PLEASE PRINT IN INK OR TYPE ALL INFORMATION) 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) / 7'7 —)G, /�Pn S Owner or Tenant f, r k'ice Telephone No. Owner's Address-- Is this permit in conjunction with a building permit? Yes ❑ �No ❑ (Check Appropriate Boz) Purpose of BuildingS,�/.� ,,,,;/�, }In•�, Utility Authorization No. 1,2 3S-;;Po SW Existing Service Amps1-2- /A rti7 Volts Overhead Q� Undgrd❑ No.of Meters i New Service pri a Amps 1,?_,; /;24 Volts Overhead[[�]� Undgrd❑ No.of Meters Number of Feeders and Ampacity Location and Nature of Proposed Electrical Work: Completion of the followinigtable may be waived by the Inspector of Wires. No.of Recessed Luminaires No.of Ceil.-Susp.(Paddle)Fans o.of Total Transformers KVA No.of Luminaire Outlets No.of Hot Tubs Generators KVA No.of Luminaires Swimming Pool Above ❑ n- ❑ 0.0 Emergency ig ng rnd. nd. Batte Units No.of Receptacle Outlets No.of Oil Burners FIRE ALARMS No.of Zones No.of Switches No.of Gas Burners No.o Detection and Initiatin Devices No.of Ranges No.of Air Cond. Toons No.of Alerting Devices No.of Waste Disposers eat Pump um er onsKW No.of Self-Contained Totals: Detection/Alerting Devices No.of Dishwashers Space/Area Heating KW Local❑ Municipal ❑ Other Connection st No.of Dryers Heating Appliances KW ecNo.of DevicyevZc s: No. es or Equivalent No.of Water KW No.o o.o Data Wiring: Heaters Signs Ballasts No.of Devices or E uivalent No.Hydromassage Bathtubs No.of Motors Total HP Telecommunications Wiring: No.of Devices or Equivalent OTHER: 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 SInspections 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 e BOND ❑ OTHER ❑ (Specify:) I certify,under the pains and penalties of perjury,that the information on this application is true and complete. FIRM NAME: LIC.NO.: Licensee.-'I'nyj-Y) fp hhl-'50Al Signature LIC.NO.: ^a (If applicable,enter"exempt"in the license number line.) Bus.Tel.No.; // Address: /I Sv tyc�r'S T /�U�' ZU I��i t rV�7`yWr —AM J /� 7 Alt.Tel.No. 5i'F K177 72,1101-6 *Per M.G.L c. 147,s.57-61,security work requires Depar6nent of Public Safety"S"License: Lic.No. OWNER'S INSURANCE WAIVER: I am aware that the Licensee does not have the liability insurance coverage normally required by law. By my signature below,I hereby waive this requirement. I am the(check one)❑owner ❑owner's a ent. Owner/Agent Signature Telephone No. PERMIT FEE.$ 4.. 1 . ' i ��� • .. . '�. �'�.) I I � _ �I ...� � :� � .. + i r ,, _. ' + ._ ���,,.A I: t. • i 1 .. . • • r • 't.. 'm t.' �I� _ .• �- _ .. ' �. - .� � ., ". � i J. 3: . .1• .r.� .. i .. ... _ " _ i - � is 7, - t The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations 600 Washington Street Boston, MA 02111 c 77 www.marssgov/dia . Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Annlicant Information Please Print Legibly Name(Business/Organization/Individual): Ui /i1U���tt1 Address: ,j/ Se• �/ AUef. RF City/State/Zip:� / 7�Z4� �Phone#:-- 2-7z Are you an employer?Check the appropriate box: Type of project(required): 1.[3 I am a employer with 4. ❑ 1 am a general contractor and I 6. ❑New construction employees(full and/or part-time).* have hire -contractors d the sub 2. II am a sole proprietor or partner- listed on the attached sheet.t 7• E]Remodeling ship and have no employees These sub-contractors have 8. ❑Demolition working for me in any capacity. workers' comp.insurance. 9. ❑Building addition [No workers'comp.insurance 5. ❑ We are a corporation and.its required.] officers have exercised eir 10. lectrical repairs or additions 3.F1 I am a homeowner doing all work right of exemption per MGL 1 I.❑ Plumbing repairs or additions myself.[No workers'comp. c. 152,§1(4),and we have no 12.E]Roof repairs insurance required.]t .employees. [No workers' 13.❑Other comp.insurance required.] *Any applicant that checks boz#1 must also fill out the section below showing their workers'compensation policy information. t Homeowners who submit this affidavit indicating they are doing all work and then him outside contractors must submit a new affidavit indicating such. $contractors that check this box must attached an additional sheet showing the name of the sub-contractors and their workers'comp.policy infvmtation. i I ant an employer that is providing workers'compensation insurance for nqr employees. Below is the polity and job site information. Insurance Company Name: Policy#or Self-ins. Lic.#: Expiration Date: Job Site Address: City/State/Zip: 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 may be forwarded to the Office of Investigations of the DIA for insurance coverage verification. I . I do hereby certify under the pains and penalties of perjury that the information provided above is true and correct i e: Date 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.City/Town Clerk 4.Electrical inspector 5.Plumbing inspector 6.Other Contact Person: Phone#: i '' „�•..ti ti,+/••'Y�)•v;Y'jLrq w.'.'.:Si•i'i+r y'Nie.`.,Iw.q L.F J.�.1Y.r;iS.i•�.r;�lL�; 4xvw"y3hy� rkYF:.r;.� �.t o,..•,.,,. t "' •�" ' RECEIVED ����•• DEC 0 f�)WN U}' NUK'I'ly 6 2005 VnI't Lo SY9'T-11\1 PIJMPINQ RPc`l�hl TOWN OF NORTH ANDOVER •' ssF�� HEALTH DEPARTMENT • i Y31'SM 0 !3R � �l7DR�SS _—•---__._._,_TS1�i,.s i.,.:�'-7'i;•;:�� ' • ....._....._..� ....... ..... ctoo, CSf I 7TI_0? ���.... .. ..�IJ�NT1rY PUMPE(` -".POOL; N� rvKu 01' 58xYlee; xUvrlN� Qv 4)sA YA,n(UNJ. ' 0000 CORZAt�01'!'IVN YtIU. (� l C7�r!c YY pygrti3g erU'Y U RDOT3'• " 40✓01X1.0 R V1v SOLCDC�IVtY9Y�� ONER•EXPLAIN ��Iv I'�N 1'y tx^rryr�K�U I't •,Y } zh 11/Df- �Nwver az. o- w »� � Main Sf T S SEPTIC TANK SERVICE 47 RAILROAD STREET Na/lh A nnov@i- BRADFORD, MA 01835 w.-m a l Lie. 15/-[ap NF 978-372-7471 �nS' X11 Lim # / -0 MONTH OF ( C C.r GW MONY REPORT FOR TMN OF DATE ADDRESS GALLONS pppgrNIS 0- d a x / 2a 8 i rrun Y-I l I P4-- . l rsc� 163 UJ in ld�e, 6 406 Q I Olhen55 02ir- 1-0 FU el 6 bod AY 15-3 7 f g r7c.. 15L HAUL LIC # 777 $100 1996 STEWART'S SEPTIC TANK SERVICE INST LIC # 659 $200 1996 47 RAILROAD STREET BRADFORD, MA 01835 508-372-7471 I May 3, 1996x,-; NO ANDOVER BOH TOWN HALL A R\IEX 120 MAIN STREET NO ANDOVER, MA 01845 PH# 508-682-6483 508-688-9540 ** � FAX 508-688-9556 Dear SIRS: The following is a list of properties that we pumped in your town. In accordance with TITLE V regulations, we are complying by sending you the following on a monthly basis, if need be. If we didn't pump, you will not be notified. I PUMP DATE ADDRESS GALMNS i 04-01-96 197 ABBOTT STREET 1,500 105 WINTERGREEN DRIVE 11000 04-02-96 A 42 OLYMPIC LANE 11000 04-04-96 A 71 PENNI LANE 11000 0 04-06-96 492 SHARPNER'S POND ROAD 11000 A 39 HAYMEADOW ROAD 1,500 04-08-96 498 WINTER STREET 11000 187 SOUTH BRADFORD 11000 04-09-96 A 495 REA STREET 11000 04-10-96 A 706 FOSTER STREEET 11000 04-11-96 A 83 CAMPBELL ROAD 11000 04-11-96 A 43 CHRISTIAN LANE M 1,500 04-12-96 7 HAYMEADOW ROAD 11000 1577 SALEM STREE`T7 11000 04-13-96 278 BARKER STREET 1,000 HEAVY 04-16-96 A 30 BREIS CIRCLE 11000 04-17-96 A 27 COACHMAN'S LANE 11000 04-18-96 369 HIGH PLAIN ROAD 11000 28. CEDAR LANE 11000 A 121 CAMPBELL ROAD 11000 04-19-96 A 160 BRIDALPATH LANE 2,200 04-20-96 A 200 RALEIGH TAVERN LANE 1,500 A 1 GARFIELD LANE 1,800 Zv cc-) Form No.4 Town of North Andover, Massachusetts BOARD OF HEALTH May 21—_-1917 CERTIFICATE OF COMPLIANCE ' This is to certify that the Individual Soil Absorption Sewage Disposal System constructed ( ) or repaired (X ) by Peter Breen INSTALLER at— 1577 Salem Street, North Andover, MA 01845 has been installed in accordance with Board of Health Regulations as described in the Design Approval Site System Permit No. 908 dated March 20 19 97 The issuance of this certificate shall not be construed as a guarantee that the system will function satisfactorily. � E : Town of North Andover, Massachusetts Form No.2 f MORTq BOARD OF HEALTH O•t �ao a,'60 F w DESIGN APPROVAL FOR HUS E�� SOIL ABSORPTION SEWAGE DISPOSAL SYSTEM • Applicant __ c % Test No. PP �v- Site Location Reference Plans and Specs._ • 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. CHAIRMAN,BOARD OF HEALTH Fee ��/ Site System Permit No. 2S APPLICATION FOR DISPOSAL WORKS CONSTRUCTION PERMIT DATE: C fL ` CURRENT INSTALLER'S LICENSE# f LOCATION: lS'- S, LICENSED INSTALLER: Pt ��%e r� SIGNATURE: �� `� ` TELEPHONE# 41 22 CHECK ONE: REPAIR: NEW CONSTRUCTION: IF NEW CONSTUCTION, PLEASE ATTACH FOUNDATION AS-BUILT. Admini'trative Use Only $75.00 Fee Attached? Yes No Foundation As-Built? Yes No Approval Date: Form No.3 Town of North Andover, Massachusetts BOARD OF HEALTH �] NORTH I 19 0�1.� D es,1•p OL O F P DISPOSAL WORKS CONSTRUCTION PERMIT ,SSACHUS Pn 1 �l /1 0 .Q/1^ i E`PH0NZF • Applicant � ADDRESS NAME Site Location : ranted to Construct ( ) or Repair ( `)"an Individual Soil Absorption Permission is hereby g n on the Design Approval S.S. No. ' Sewage Disposal System as show CHAIRMAN,BOARD OF HEALTH D.W.C. No. d Fee rf , i THOMAS E. NEVE ASSOCIATES, INC. ��44�� O� Engineers Land Surveyors Land Use Planners 447 Boston Street US #1 TOPSFIELD, MASSACHUSETTS 01983 (508) 887-8586 DATE 312 4/97 JOB NO11QO 7_7 FAX (508) 887-3480 ATTENTION SAtAr> STAiZR _ TO RE: Sro►+ys�y STARIZ 15-x'7 SA�..E.r�t.� '�', .� gOAStq> OF V-A EALTi->; 1Jot t h A,-%cLcvtr MA > WE ARE SENDING YOU Attached Elollo Under separate cover via � thelfing items: ❑ Shop drawings 1 Prints ❑ Plans ❑ Samples ❑ Specifications ❑ Copy of letter ❑ Change order ❑ COPIES DATE NO. DESCRIPTION 1Zs.v 5ANtTAR � iSl�OSAL. SyST'Gt� RQA%R Z- 3 Z4 9'7 t(oZ-7 Y E lra'z"7 SA�E.M S-rR1:lET THESE ARE TRANSMITTED as checked below: xFor approval ❑ Approved as submitted ❑ Resubmit copies for approval ❑ For your use ❑ Approved as noted ❑ Submit copies for distribution ❑ As requested ❑ Returned for corrections ❑ Return corrected prints ❑ For review and comment ❑ ❑ FORBIDS DUE 19 ❑ PRINTS RETURNED AFTER LOAN TO US REMARKS PEAR SAr4Ley Pleasp_ enc.loSeot z Pt-,r,+_5 of -t4-t wbo•c C'ej'etrcr-.tee cL s3 en . A S %_Oe 1-ad, od.:S coSstd Fri (3/Z 1) +V,e. floes, rO-I:Sedl -1c S1no'_j +wo e4,r,0'jtS -0 C3 V A ja o.,c. 0, t1nrL e-K-iS}►., _ CL- bcx Ck,-%cl -1.1,c a,+1,er lsg,r%A c f*1?-I ' 9-1--e 'S.0 24- 4-"1< 1yc.1 V-"Lve �.at rIt +Io e� S �{ [ or+�r ri,s ple rse i+e, -%,z- c,C% e r'C COPY TO JeJ CTre-er-i � 1 r�r• :,k l 1� RECYCLED PAPER: t �7�Contents:40%Pre-Consumer-10%Post-Consumer SIGNED: if enclosures are not as noted,kindly notify us at once. i i == SUSAN L. GREEN 2096 JEFFREY A. GREEN 1577 SALEM ST. PH. 508-681-8322 y G ( 53-235/113 '. NORTH ANDOVER, MA 01845 7 o��riss,Ds BAYBANK MIDDLESEX '�AIISQN- MASSACHUSETTS c+ ✓.,,. Iay4yrJ ` � 1:0113023571: & 29 .. 9775211' 69 Town of North Andover 40RTh OFFICE OF 3?0,.`<`•' ",foo` COMMUNITY DEVELOPMENT AND SERVICES p 146 Main Street i o9 1 North Andover,Massachusetts 01845 QOq�TED ""q5 WILLIAM J. SCOTT 9SSAcNuSEt Director March 21, 1997 Mr. Jeff Green 1577 Salem Street North Andover, MA 01845 Re: 1577 Salem Street Dear Mr. Green: This is to inform you that the proposed plans for the site referenced above have been approved. Before a Certificate of Compliance is issued the following is required: 1. Deed restriction limiting number of rooms to three (3). 2. Proof of well abandonment. If you have any questions, please do not hesitate to call the Health Office. Sincerely, Sandra Starr, R.S. Health Administrator S S/cjp cc: Neve BOARD OF APPEALS 688-9541 BUILDING 688-9545 CONSERVATION 688-9530 HEALTH 688-9540 PLANNING 688-9535 NORTH ANDOVER BOARD OF HEALTH l/ DESIGN REVIEW REPORT DATE FEE• Its, PERMIT # DATE RECEIVED APPLICANT_ )Cry C��. A� / MAP PARCEL ADDRESS J /6-7 % �f�G.�/'✓1 LOT #l_ STREET # f,577 ENG. JV SSTREET &YAQ1011 07,7- LIE ENGINEER' S ADD. J C� /T WGb `iTO� 0l 9� PLAN DATE / ///� 7 REV. DATE CONDITIONS OF APPROVAL APPROVED DISAPPROVED REASONS FOR DISAPPROVAL: IUaT�E ,e CT/!S / l 0 G A4 7'i/UG /JDl7D evan J p `� PLAN REVIEW CHECKLIST�j ADDRESS 177 �/ �M ENGINEER , /.r/G' GENERAL 3 COPIESc_� STAMP LOCUS NORTH ARROW SCALE CONTOURS L---- PROFILE �Sc SECTION �� BENCHMARK --- SOIL & PERCS ELEVATIONS WETS. DISCLAIMER L� WELLS & WETS WATERSHEDD?"/UCS DRIVEWAY Z---- /--'/ WATER LINE /--' FDN DRAIN �— M&P SCH40 41 TESTS CURRENT? SOIL EVAL_ Z) SEPTIC TANK MIN 1500G . 17 INVERT DROP _ GARB. GRINDER_NQ (2 comps +200) 10 ' TO FDN MANHOLE ELEV -- GW # COMPS I GB D-BOX SIZE # LINES FIRST 2 ' LEVEL STATEMENT INLET99. 9(,/ - OUTLET 07• T) (2" OR .17 FT) TEE REQ'D? VC&D LEACHING SGrlM N 440 GPD?X/_ RESERVE AREA 4 ' FROM PRIMARY? 2% SLOPE 100 ' TO WETLANDS 100 ' TOWELLS 4 ' TO S.H.GW Z" (5 ' >2M/IN) 20 ' TO FND & INTRCPTR DRAINS c-� 400 ' TO SURFACE H2O SUPP 4--- 4 ' PERM. SOIL BELOW FACILITY A�-- MIN 12" COVER� FILL? — (15 ' ) BREAKOUT MET? TRENCHES / MIN 440 gpd� SLOPE (min .005 or 6" )/100 ' ) SIDEWALL DIST. 3X EFF. W OR D (MIN 6 ` ) `' RESERVE BETWEEN TRENCHES?L/ IN FILL? — MUST BE 10 ' MIN. 4" PEA STONE? VENT? (>3 ' COVER; LINES >50 ' ) BOT + SIDE 1 ?�- = ��'Z ' X LDNG i� = TOT (L x W x ##) (DxLx2x##) (G/ft2) Copyright 0 1996 by S.L. Starr r Y <--vent Y D] 1t}' nnu CI no n�yUmWwawnYrlp . Ge�rrou�u X-FIC,TANK L.E ACN FIELD Ald -F blE Septic Comp ante, Inc affilliate of Thomas E. Neve Assoc., Inc. March 20, 1997 North Andover Board of Health 146 Main Street North Andover, MA 01845 Attn: Sandra Starr Re: Sanitary Disposal System Inspection 1577 Salem Street- Jeff Green Dear Ms. Starr: In accordance with the Commonwealth of Massachusetts, Department of Environmental Protection, State Environmental Code (Title V), 310 CMR 15.301, paragraph 7, please find attached a "Subsurface Sewage Disposal System Inspection Form" for your records. If you have any questions regarding this report or any of its contents, please do not hesitate to contact this office. We thank you, in advance, for your continued cooperation in these matters. Very truly yours, SEPTI5�141` NCE, IN C� Gtti Paul Cardone Certified Septic Inspector Attachment N.Andlet.sain • SYSTEM INSPECTORS • • SOIL EVALUATORS • • ENVIRONMENTAL ENGINEERS • 447 Old Boston Rd., US Route 1,Topsfield, MA 01983 Tel (508) 887-8586 Fax(508) 887-3480 ,E—Vent Y y �,,u,o�.uruY.we Geano SEPTIGTANK LEACHHELO s�ter7able Septic Compliance, Inc. affilliate of Thomas E. Neve Assoc., Inc.. SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION Property Address: 1577 Salem Street No.Andover,Ma.01845 Address of Owner: Jeff Green (if different) Date of Inspection: March 17, 1997 Name of Inspector: Paul Cardone Company Name, Septic Compliance,Inc. Address and 447 Old Boston Road,Topsfield,MA 01983 Telephone Number: (508)887-8586 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 XX Fails Inspector's Signature: Date: March 17, 1997 The System Inspector shall submit a copy of this inspection report to the Approving Authority within thirty (30) days of completing this inspection. If the system is a shared system or has a design flow of 10,000 gpd or greater, the inspector and the system owner shall submit the report to the appropriate regional office of the Department of Environmental Protection. The original should be sent to the system owner and copies sent to the buyer,if applicable and the approving authority. 1 • SYSTEM INSPECTORS • • SOIL EVALUATORS • • ENVIRONMENTAL ENGINEERS • 447 Old Boston Rd., US Route 1,Topsfield,MA 01983 Tel (508) 887-8586 Fax(508) 887-3480 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued)- Property Address: 1577 Salem Street No.Andover,Ma.01845 Owner: Jeff Green Date of Inspection: March 17, 1997 INSPECTION SUMMARY: Check A,B,C,or D: A) SYSTEM PASSES: I 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. The septic tank is metal,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 conforming septic.tank as approved by the Board of Health. X 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 leveled 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 2 i SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: 1577 Salem Street No.Andover,Ma.01845 Owner: Jeff Green Date of Inspection: March 17, 1997 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 THE BOARD OF HEALTH DETERMINES THAT THE SYSTEM IS NOT FUNCTIONING IN A MANNER THAT PROTECTS 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 PROTECTS THE PUBLIC HEALTH AND SAFETY AND THE ENVIRONMENT. The system has a septic tank and soil absorption system and is within 100 feet to a surface supply or tributary to a surface water supply. The system has a septic tank and soil absorption system and is within a Zone 1 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 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. 3 II i f SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: 1577 Salem Street No.Andover,Ma.01845 Owner: Jeff Green Date of Inspection: March 17, 1997 D) SYSTEM FAILS: XX 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 contact to determine what will be necessary to correct the failure. Y Backup of sewage into facility or system component due to an overloaded or clogged SAS or cesspool. N Discharge or ponding of effluent to the surface of the ground or surface water due to an overloaded or clogged SAS or cesspool. Y 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. N Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s) Number of Times Pumped Any portion of the Soil Absorption System,cesspool or privy is below the high groundwater N elevation. N Any portion of a cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. 4 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address: 1577 Salem Street No.Andover,Ma.01845 Owner: Jeff Green Date of Inspection: March 17, 1997 D) SYSTEM FAILS(continued) N Any portion of a cesspool or privy is within a Zone 1 of a public well. N Any portion of a cesspool or privy is within 50 feet of a private water supply well. N Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality analysis. If the well has been analyzed to be acceptable,attach copy of well water analysis for coliform bacteria,volatile organic compounds, ammonia nitrogen and nitrate nitrogen. E) LARGE SYSTEM FAILS: 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 safety and the environment because one or more of the following conditions exists: 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. Y �"Y g 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 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. 5 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST Property Address: 1577 Salem Street No.Andover,Ma.01845 Owner: Jeff Green Date of Inspection: March 17, 1997 Check if the following have been done: Y Pumping information was requested of the owner,occupant,and Board of Health. Y 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. N/A Asbuilt plans have been obtained and examined. Note if they are not available with N/A. Y The facility or dwelling was inspected for signs of sewage back-up. Y The system does not receive non-sanitary or industrial waste flow. Y The site was inspected for signs of breakout. Y All system components,excluding the Soil Absorption System,have been located on the site. Y 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. Y The size and location of the Soil Absorption System on the site has been determined based on existing information or approximated by non-intrusive methods. Y The facility owner land occupants(if different from owner)were provided with information on the proper maintenance of Subsurface Disposal System. 6 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION Property Address: 1577 Salem Street No.Andover,Ma.01845 Owner: Jeff Green Date of Inspection: March 17, 1997 FLOW CONDITIONS RESIDENTIAL Design flow: 330 gallons Number of bedrooms: 3 Number of current residents: 3 Garbage grinder(yes or no): no Laundry connected to system(yes or no): yes Seasonal use(yes or no): no Water meter readings,if available: Last date of occupancy: occupied COMMERCIAL/INDUSTRIAL: 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 V system(yes or no). Water meter readings,if available: Last date of occupancy: OTHER(Describe): Last date of occupancy: 7 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 1577 Salem Street No.Andover,Ma.01845 Owner: Jeff Green Date of Inspection: March 17, 1997 GENERAL INFORMATION PUMPING RECORDS and source of information: According to the owner the tank was pumped one year ago. System pumped as part of inspection(yes or no): yes If yes,volume pumped: 1,000 gallons Reason for pumping: To inspect the structural integrity of the tank,to check the baffles,and to check for leaks. TYPE OF SYSTEM XX Septic tank/distribution box/soil absorption system Single cesspool Overflow cesspool Privy Shared system(yes or not) [If yes,attach previous inspection records,if any] Other(explain) APPROXIMATE AGE of all components,date installed(if known)and source of information:Approx.twenty years of age.Owner told me. Sewage odors detected when arriving at the site(yes or no): no SEPTIC TANK: yes (locate on site plan) Depth below grade: 10 1/2" Material of construction: X concrete metal FRP Other(explain) 8 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: 1577 Salem Street No.Andover,Ma.01845 Owner: Jeff Green 1 Date of Inspection: March 7, 1997 7 Dimensions: diameter 93"height 56"invert 46" Sludge Depth: 3 Distance from top of sludge to bottom of outlet tee or baffle: 22" Scum thickness: 4" Distance from top of scum to top of outlet tee or baffle: 8" Distance from bottom of scum to bottom of outlet tee or baffle: 12" Comments: (recommendations 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.) Baffles were in tact and in good condition,structural integrity good,no evidence of leaks. GREASE TRAP: none (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 of scum to bottom of outlet tee or baffle: 9 i SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: 1577 Salem Street No.Andover,Ma.01845 Owner: Jeff Green Date of Inspection: March 17, 1997 Comments: (Recommendations 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.) TIGHT OR HOLDING TANK: none (locate on site plan) Depth below grade: Material of construction: Concrete Metal FRP Other(explain): Dimensions: Capacity: gallons Design flow: gallons/day Alarm level: Comments: (Condition of inlet tee,condition of alarm and float switches,etc.) DISTRIBUTION BOX: Yes (Locate on site plan) 10 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 1577 Salem Street No.Andover,Ma.01845 Owner: Jeff Green Date of Inspection: March 17, 1997 Depth of liquid level above outlet invert: The box was full of sludge. Comments: (Note if level and distribution is equal evidence of solids carryover,evidence of leakage into or out of box,etc.) The box was cracked yes yes PUMP CHAMBER: none/gravity (Locate on site plan) Pumps in working order(yes or no): Comments: (Note condition of pump chamber, condition of pumps and appurtenances, etc.) i SOIL ABSORPTION SYSTEM(SAS): yes (Locate on site plan,if possible;excavation not required,but may be approximated by non-intrusive methods) If not determined to be present, explain: I 11 j SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 1577 Salem Street No.Andover,Ma.01845 Owner:. Jeff Green Date of Inspection: March 1T, 1997 Type: Leaching pits,number: Leaching chambers,number: Leaching galleries,number: Leaching trenches,number,length: Leaching fields,number,dimensions: 1-field 20'x 40' Overflow cesspool,number: Comments: (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.) normal none none normal CESSPOOLS: none. (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): 12 s SUBSURFACE SEWAGE DISPOSAL.SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 1577 Salem Street No.Andover,Ma.01845 . Owner: Jeff Green Date of Inspection: March 17; 1997 Comments(Note condition of soil,signs of hydraulic failure,level of ponding,condition of vegetation,etc.): PRIVY: none (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.): 13 ♦ f SKETCH OF SEWAGE DISPOSAL SYSTEM: Include ties to at least two permanent references, landmarks or benchmarks. Locate all wells within 100'.. Ae 39 Cs,nC�� � V 0 X S L 0s � DEPTH TO GROUNDWATER Depth to groundwater: no water observed feet Method of determination or approximation: Two ten foot deep holes were done,and a soil evaluation was performed at the time of the title five inspection. The North Andover Board of Health was present(Susan Ford). 14 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART D CERTIFICATION Name of Inspector Paul Cardone Company Septic Compliance,Inc. Address 447 Boston Road,Topsfield,MA 01983 (508)887-8586 Certification Statement I certify that I have personally inspected the sewage disposal system at this address and that the information reported is true, accurate and complete as of the time of inspection. The inspection was performed and any recommendations regarding upgrade, maintenance and repair are consistent with my training and experience in the proper function and maintenance of on-site sewage disposal systems. Check one: I have not found any information which indicates that the system fails to adequately protect public health or the environment as defined.in 310 CMR 15.303. Any failure criteria not evaluated are as stated in the FAILURE CRITERIA section of this form. I have determined that the system fails to protect public health and the environment as defined in 310 CMR 15.303. The.basis for this determination is provided in the FAILURE CRITERIA section of this form. XX Inspector's Signature: Date: March 17, 1997 Copies to: Board of Health Buyer(if applicable)Approving authority: FORM 11 - SOIL EVALUATOR FORINI Page 1 of 3 No. Date: 3 ►g/9� Commonwealth of Massachusetts n►oRrN Awto+/01C , Massachusetts Soil SuitabiW Assessment,fior On-site ewa a DisDOSal Performed B Ste•re.n '[>' Urso Date: 3 i 39'7 �uS ar,......... ,. ............................................_. Witness y: .......................... .. . .............................................. o.Mr:rams. J r-f-F 4GrrzCf-1 LaUUM Aft=a �:.Vd iS"1"1 SmlcM St,rect S.Icm Sty. Nor+� A(-%A*ver > MA i New Construction ❑ Repair I so$ - Gir► - $3zz. Office Review Published Soil Survey Available: No Yes ❑ Ce.nt�� Year Published IgB.�-- Publication Scale I `►SZ...•... Soil Map Unit Drainage Class 0011 Dra:e+cA...... Soil Limitations .............................................................------...---.--- ........... 160 Surficial Geologic Report Available: No 9 Yes ❑ Year PublishedPublication Scale Geologic Material (Map Unit) ...........I..........._.....,._..___._ _.._ Landform ............................................._...._... Flood Insurance Rate Map: Above 500 year flood boundary No ❑Yes Within 500 year flood boundary No ©Yes Within 100 year flood boundary No ©Yes ❑ i Wetland Area: m ............_......_............._.._. _... . National Wetland Inventory Map( ap unit) ......................................................... Wetlands Conservancy Program Map(map unit) ...................................... _.... ................. i Current Water Resource Conditions(USGS): Month Range :Above Normal ❑Normal XBelcw Normal ❑ Other References Reviewed: DEP APPROVED FORM-12107195 FORM 11 - SOIL EVALUATOR FORM Page 2of3 Location Address or Lot No. 15,'7 50.1crr• Sfit-ee.�. On-site Review Deep Hole Number ::.:, '..::. Date:.,.3�9"? Time:... Weather Location (identify on site plan) -..Sed. P�. Land Use -..Rcs;dcn,.f;0,.1. Slope (%) $% Surface Stones .. ..too..-". . Vegetation . --.c►..�n ..::.......... ::.:.:...:: Landform ... .... Position on landscape (sketch on the back) Distances from: Open Water Body feet Drainage way feet Possible Wet Area 359". feet Property Line ... A.-O'. feet Drinking Water Well , 85. . feet Other . .:... .......::.::. :.n..:::.:.::.:. DEEP OBSERVATION HOLE =0G' Depth from Soil Horizon Soil Texture Soil Color Soil Other Surface(Inches) (USDA) (Munsell) Mottling (Structure.Stones,Boulders,Consistency, % Gravel) 1 (o - Z Co A Q F.3.t.r, t 0-f it 3/3 F.S.L. IcYR414 4�-►� 4 G C-o"'y Z.5vS/(" /Mwhsi"C/Fri'eblc s.ir. HOLES KhUU1 OPOSED DISPOSAL-AREA i l I l Parent Material(geologic) Depthw8edrock: Death to Groundwater: Standing Water in the Hole: POW-+Q Weeping from Pit Face: ryo^s Estimated Seasonal High Ground Water: fir+e ` DEP APPROVED FORM-12/07195 FORM 11 - SOIL LVALUATOR FORM Page 3 of 3 Location Address or Lot No. 15'1-7 Solar-% Strer-+ Determination for Seasonal High Water Table Method Used: ❑ Depth observed standing in observation hole................... inches ❑ Depth weeping from side of observation hole................. inches ❑ Depth to soil mottles ...:..... .:.�...: inches ❑ Ground water adjustment ................... feet Index Well Number .................. Reading Date ................... Index well level .................. Adjustment factor .................. Adjusted ground water level ........................................................ Depth of Naturally Occurrina Pervious Material Does at least four feet of naturally occurring pervious material exist in all areas observed throughout the area proposed for the soil absorption system? If not, what is the depth of naturally occurring pervious material? Certification I certify that on t 1/9 4- (date) -I have passed the soil evaluator examination approved by the Department of Environmental Protection and that the above analysis was performed by me consistent with the required training, expertise and experience described in 310 CMR 15.017. Si nature 31,919 7 9 ��_�.�-��°�Date DEP APPROVED FORM-12!07195 FORM z: -PERCOI;ATION TEST Location Address or Lot No. l�a'�'T Sa1e,..� Sttcct COMMONWEALTH OF MASSACHUSETTS Massachusetts Percolation Test' Date: 3/1 3 j 9-7' Time: t:ooP,� — 3:t?r.•. Observation Hole # 1 Depth of Pere , Start Pre-soak :0 4 Z : 1 Co End Pre-soak 9 Z.- 31 Time at 12" 1:19 Z , 31 Time at 9" Z Z 4- Z:4-7 Time at 6" 3: 1-7 Tif11e t9"-6"1 3 O M�r.1 Efate Min./inch No Groov► ► o rn/1 Minimum of 1 percolation test must be performed in both the primary area AND reserve area. Site Passed A Site Failed 0 Performed By: S��•,c n L7'V�"so Witnessed Comments: ... .___ .._.....,�_..._... . �. �...�� _..._.. _ ..�. . 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AM p S P FRO P AREA 60DE N EXT. E M 1 E S ., S G r� o E IGNED PHONED❑ BACK CALL RETURNED SEE YOU AGAIN ALL 0 WAS IN URGENT Town of North Andover, Massachusetts Form No. 1 NORTH BOARD OF HEALTH F 9A - Q ttLED 64/ 'YO 3? y� 6 Q� + 19 /�R .......... APPLICATION FOR SITE TESTING/INSPECTION /q ADRATED PPp��y SSAGHUS� Applicant �— NAME ADDRESS TELEPHONE Site Location Engineer — NAME ADDRESS TELEPHONE Test/I nspection Date and Time ��' I ' "e CHAIRMAN,BOARD OF HEALTH Fee Test No. "t S.S. Permit No. D.W.C. No. C.C. Date Plbg. Permit No. TO DATE TIME AM H FR 0 --� NO. d J (O ( V V N _ EXT. E nota L E ) 7 M s E s A Aj «-- C 0 Q01.2WIANED PHONED BACK CALL RNED S YOU �I WILL AGAIN ALL WAS IN URGENT �©V l ASS CIATE INC, January 24, 1997 Ms. Sandy Starr Board of Health 146 Main Street North Andover, MA 01845 Re: 1577 Salem Street- Green Residence Dear Sandy: We have been contracted by Jeff Green following an assessment of the system at the above- referenced lot and have been retained to do the repair of his system. The house is on the market, he wants to move and he asked that we expedite this work as soon as possible. If there is any opportunity for you to do the soil tests for this repair soon please schedule same and we will make sure one of our soil evaluators is available. We have enclosed the $75 application fee. We thank you in advance for your anticipated cooperation in this matter. Sincerely, THOMAS E. NEVE ASSOCIATES, INC. Thomas E. Neve, PE, PLS President, CEO TEN/km Enclosure - cc: Mr. Jeff Green #1627 GREEN.wPs • ENGINEERS • • LAND SURVEYORS • • LAND USE PLANNERS • 447 Old Boston Road U.S. Route #1 Topsfield, MA 01983 (508) 887-8586 FAX (508) 887-3480 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: A Phone LOCATION: Assessor's Map Number Parcel Subdivision Lot(s) Street �7GL�Gtnn �`F• St. Number 5-77 ************************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 Date Approved Se tic Ins ector-Health P Date Rejected P 7 Comments //)a Public Works - sewer/water connections - driveway permit Fire Department Received by Building Inspector Date TOWN OF NORTH ANDOVERa°� SYSTEM PUMPING R.ECO,R:D 5 2002 I ENl OWNER & ADDRESS SYSTEM LOCATION -- - kxamPle: Ief( front of housr) I OF PUMPINC: ; (QUANTITY PUM PCD %QW �SJ'UUL: NO _ YES SEPTICTANK : NO YES _ ATURE OF SERVICE: ROUTINE EMERCENCY .M! MRV \TIONS: CUOD CONDITION _ (FULL TO COVE';t HFAVY CREASE BAFFLLS IN HOOTS LEACHFIELD RUNUACK... CXCESSIVE SOLIDS FLOODED SOLIDS CARRYOVER O.�HER (EXPLAIN) �j I L,m PUM 1'1D (3Y: 71 � . U,1 ti1 rNTS: U � I !:'N I'J TIZANSFEIZIZLD TO. 6. use AI IDOVSR.- ( il SACHUS• ��•,� -., S TI .: ��pIR- Record' Twa'it. t� m Qf�V7y�'Y,�SYj1�`{V•,yyty{1�1 � �+)pg'i;u'::'' ■grRp.� /?per j .Z tit` •:l`.r,,a+ 'O ;"•1'�•,j�Yl�1;,+:1 t JY�Y•{•�v7J`,�.' tV'�LLTi!itl.!r,., R V EI Y ED •:I•. .,.{t;;..,y vY{` ''it�t; f�J' {'>tir7,:^:t' 1,+,, n. r1,t.•..Y':1r, .. . D7 t r'tl• 1;.,,"!•:•v•o-,�i'.:F, ,•'�.r •' �' .. E .,.has provlded Xhls form for use by local oard be subm!( ed to the.local'Board o(Health o (�H��aallh-N � system Pumping Recorri . r ther ►ov'In9 authority, r' s ..:A;. Facility Inforr tlon y. HEALTH DEPARTMENT IM J,,yvher,'Nung out. .1;. Systam l.ocatlon: only the tab key Address to move your:; Cl <.,. Stat '''•( y t.,y tiTtii''', ': '`''''r'��''!IIi'..;:.Y l• ,'..r; '1' :: �:1:;•' .. : e ' Zi Code ''Nil•' :J1Y'i.7.i�i r .S ,. ,, ••'}'; i; • `� .:,�',i::;Y '��.'i.' ,Y 'r Name •`� , r' Addfaas if • different et ( from•bcadon• : .' Ci4frown:.° State • Telephone Number e.9ord: V l' r hr /f�tq?.a1i41YTl'14t.,,. �•�.•• '�f ,.� Date of Pum .•.. ping ,Date 2. Quantity Pumped: t 3,.' :Typ9 9 Systerh ; ❑ Cesspools) optic Tank cions ;. :,:� ❑ Tight Tank fOther(descrlbej 4, Effluent Tee Rite(pro3ent? ❑ Yes If It 7, , yes, was cleaned? ❑ Yes ❑ N i •. ,l: ;,;^...,r;;i,.7 ,inY,N'��:+i;!S.itt {,.�tr...{ ,' .'i;:•`.' � .. AN 1Fs' yy•1 4•:V)'/:i�y{tr',(!.S:7T�ry ry;r%j'j.'hr 'IYY.•i•..4`',..} :" i ,.: iii l' +Na+os t' , r• • , ; Pum ed B �'.. . :,.... Via,,..„a•,�;y. �::.• .;.p, y' ' G ••;';:';`i..,,.+• +l ti',)•• r"'f.J 1'L 'Y , i,' +Y Y +l.L\ '{ Wn ,�,;r,.•<.:rti.rr �, ,,• '..tri :, .i,�.;.,f':,,,,;;,;'',:•_',,, Vehicle U N •v, y,• ,, x9�;J r � {' .0 ie umber , ::�� � ” r�•. iti�: .% 1 y'I�t,V4J•��� i y .I/"i y'� 1•?�. ,r,'.:,; ',i�; .r::►'Y Y�'rS'/,•. r:; yFD�iS1 , rq a•� 1; � 4/'�5.�,1ji•�. .•Y•J'• ., a: Y!i (;�Ir i riy'r'�'•Nj'fr1pAh��•C��i•.; ::�7,1. �i���'1�'�S"'• v .,I!� on.wfiere contents .ere di posed: � N:,':�' •"i,•�•'�i!�'�l::'v:!.':i.n;�.S�ra.," •':` ��l yip. (/(y,(�// � ' • :t• j, •t-,i1!f.i3•K'i;!�/ii,.F�PS;Mi't��i•.hT' :7C t,�.: '� r - ..-_ .,;: '•:,,;•/`:�>'1 :}•,f,;y'�;;?i;StQn� a ofHouler:iµ/'iirt''i't,,,',•:,.4:. 'thup:/Nri+w.ma33, ov/d8 Dale g P�water/app�ovajs/t5forms,htm#Inspect t5forrM,doa!o=3 „ 1 System Pumping Record Page i Commonwealth of Massachusetts City/Town of No.Andover System Pumping Record Form 4 DEP has provided this form for use by local Boards of Health. Other forms may be used, but the information must be substantially the same as that provided here. Before using this form, check with your local Board of Health to determine the form they use. The System Pumping Record must be submitted to the local Board of Health or other approving authority within 14 days from the pumping date in accordance with 310 CMR 15.351. A. Facility Information Important: When filling out 1. System Location: forms on the 1�� computer, use / only the tab key Address to move your No.Andover Ma Qia4-9. cursor-do not City/Town State ��� f :G use the return DO key. 2. System Own ,� JAN `i U 2412 Name TOWN OF NORTH ANDOVER HEALTH DEPARTMENT Address(if different from location) City/Town State Zip Code Telephone Number B. Pumping Record 1. Date of Pumpingp t _ _ I 2. Quantity Pumped: al 2. 3. Type of system: ❑ Cesspool(s) Septic Tank ❑ Tight Tank ❑ Grease Trap ❑ Other(describe): 4. Effluent Tee Filter present? ❑ YesNo If yes, was it cleaned? E] Yes E] No 5. Condition of System: , Syst umped Qy: Name Vehicle License Number tewart's Septic Service Company 7. Location where contents were disposed: Stewart's PN-treatment Plant, 20 So. Mill Bradford, Ma 01835 L rwid Signature ,f HUM Date Signaturof a ving Facility Date t5form4.doc•03/06 System Pumping Record•Page 1 of 1 t ro ,. sCM omonwealth.of Massachusetts City/"Fown of NORTH ANDOVER, MASSACHUSETTS System Pt;M Ing Record Form 4 DEP has provided this form for use by local Boards of Health. The System Pump`ng Record must be submitted to the local Board of Health or other approving authority. X Facility Information Important: When ti"out 1. System Location: -7 tomo on the omrn cputer use p nx only the tab key Address to move your cursor-do not Cfty[Town State Zip Code use the return key....• 2. System Owner. Name ILS► Address(if different from location) Clty/rown State Zip Code Telephone Number B. Pumping Record /060 2. Quantity Pumped:1. Date of Pumping ry p Gallons Date s. Tyre of s cesspools) Septic Tank ❑ Tight Tank system: ■ ❑ Other(describe): 4. Effluent Tee Filter present? ❑ Yes ❑ No If yes,was it cleaned? ❑ Yes ❑ No 5. Condition of System: 6. System Pumped By: Vehicle Ucense Number Company /lam 7. Location whArA contents were disposed: 0� 30 m Signs"of Hauler Date http://www.mass.gov/deptwater/approvalatt5forms.htm#insped t5form4.doo+06M System Pumping Record•Page t of 1 V-6 A,5w,;f ti�y Vi,::Pv 6t,U_al4 T,7 ALA Jo> .4z-il eD s '60.