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Miscellaneous - 193 LACY STREET 4/30/2018
1 ' \ 1 - 193 LACY STREET ��r { 210/105.D-0060-0000.0 i � - I F I lu D �N� o UPC 14081 k* a - -a G (D gaov+aao.na Q 193 LACY STREET 210/105.D-0060-0000.0 i 6(142 Date.......7.- Y. • gORTM °f,«'° 410' TOWN OF NORTH ANDOVER 3r �.,� O� PERMIT FOR WIRING SACMUSE� This certifies that Seer C............................................ .... has permission to perform ........... ..............7 2 ..... wiring in the building of................ r� ... .... ' ... .................. < 3 LC .............. North Andover,Mass. at.....�....................... ...... ........ ........ Fee. ..: ^... Lic.No....� ............. ... ELECTRICAL INSPECTOR Check # �� r S-s 1l1C tLVLYlLYlVly rrl3Hl�!n V��rrt+•1�tLnv.usl�� �"""'/�L"`""� 1 DEPAR7A1UV1'0FPUBLICS4FE7Y Permit No. BOARD OFFMPREVEMONREGULATTONS 5V OR 12:Ob Occupancy&Fees Checked APPIICA71ONFOR PEI?Atff TO PERFORM ELECTRICAL WORK ALL WORK TO BE PERFORMED IN ACCORDANCE WITH THE MASSACHUSSTS ELECTRICAL CODE,527 CMR 12: 0t 0 '1�.� (PLEASE PRINT IN INK OR TYPE ALL INFORMATION) Town of North Andover To the Inspector of Wires: The undersignedapplies for a permit to perform the electrical work described below. Location(Street&Number) r` Owner or Tenant qj Owner's Address Is this permit in conjunctsith a building permit: Yes[—] No (Check Appropriate Box) Purpose of Building 171 -C' Lr Utility Authorization No. Existing Service lde�jQ Amp / O Volts OverheadUnderground No.of Meters / New Service Amps Volts Overhead =1 Underground Q No.of Meters Number of Feeders and Ampacity Location and Nature of Proposed Electrical Work /i iy . ll.�C � t✓rrx �?w!lO-r �� �/ �f��'�.7 No.of Lighting Outlets No.of Hot Tubs No.of Transformers Total KVA No.of Lighting Fixtures Swimming PoolAbove low Generators KVA round round No.of Receptacle Outlets No.of OU Burners No.of Emergency Lighting Batt Units No.of Switch Outlets No.of Gas Burners No.of Ranges No.of Air Cond. Total FIRE ALARMS No.of Zones Tons No.of Disposals No.of Heat total Total No.of Detection and Plumps Tons KW Initiating Devices No.of Dishwashers Space Area Heating KW No.of Sounding vices No.of Self Cont ned Detection/So ding Devices No.of Dryers Heating Devices KW Local Municipal Other Connections No.of Water Heaters KW No.of No.of Signs Bailasis No.Hydro Massage Tubs No.of Motors l Total HP i OTHER- IhneaameritLmWtyln==Fbkymdu&gCcnriee ComworitswbasifialeWivalat YEs NO IhavesibmWedvdklpwafof=woDdieOffm YES lfymha%ec rdedYES,plea9ei<r1;caet&gWof00%uaWby DANCE BOND OTS Esbm*dVakrdBXftrd Wak$ WodcbStart �� hspechcnDa1eRe4xe Rao rural Sigledurtdor&f ia�of ' FIRMNAME o LiwwNa .9/mss Iioasee /.�?� �c7Lt° s�gnal>ne L;oaseNo .0=1�/ '3 Bus=Tel Na 7,S Zo ��rl✓.C' i��S� .� /�7Pp AltTeINd. ,)WNElU'SINSURAN EWANER;Iama%mdxtdrLiowdoesmtlimedeirswa=camaWorAsabgm lepvaicitaste mWby GalaalIaws urddiatnry9g>�eon thispeQritapplirabonwaivesthi�regtarerrtalt (Please check one) Owner Agent Telephone No. PERMIT FEE$ signature of Owner or AgenT NORpH oEtt °D b�� ° he NORTH.ANDOVER BUILDING DEPARTMENT Eo c5 .x.600 Osgood Street �SSAcwus�'� North Andover Tel: 978-688-9545 Fax: 978688-9542 RMUMS FORM FOR TOWN CLERK DATE: / a 2)./a t>13 NA IE: mess i c� �1 at�i��r ADDRESS: L-a-N Ske , Q 04hy)d cw-cr , M d 1846 ZONING DISTRICT: TYPE OF BUSINESS: n� or btWryL+hq BUILDING LAYOUT PROVIDED: YES NO AVAFLABLE PARK1WG SP.ACES: .� ZONING BYLAW USAGE: S� NO ] DING INSPECTOR SICINATUM BUSINESS FORM FORTOWN CLERK i 2.40 Home Occupation(1989/32) An accessory use conducted within a dwelling by a resident who resides in the dwelling as his principal address, which is clearly secondary to the use-of the•building-for filing piuposes. Home occupations shall `incliide,'but not limited to the following uses; personal services such as fun fished by an artist or instructor, but not occupation involved with motor vehicle repairs, beauty parlors, animal kennels, or the conduct of retail business,or the manufacturing of goods,which impacts the residential nature of the neighborhood. 4. For use of a dwelling in any residential district or multi family district for a home occupation, the following conditions shall apply. a. Not more than a total of three (3) people may be employed in the home occupation, one of whom shall be the owrier of the home occupation and residing in said dwelling, b. The use is carried on strictly within the principal building; c. There shall be no exterior alterations, accessory buildings, or display which are not customary with residential buildings; - d. Not more than twenty five (25) percent of the existing gross floor area of the dwelling unit. so used, not to exceed one thousand (1000) square feet, is devoted to'such use. in connection with such use, there is to be kept no stock in trade, commodities or products which occupy space beyond these limits; e. There will be no display of goods or wares visible from the street; f. The building or premises occupied shall not be. rendered objectionable or detrimental to the residential.character of the neighborhood due to the exterior appearance, emission' of odor, gas, smoke, dust, noise, disturbance, or in any other way become objectionable or detrimental to any residential use within the neighborhood, g. Any such building shall include no features of design not customary in buildings for residential use. Signature Date Date....3...............t ........... TOWN OF NORTH ANDOVER PERMIT FOR WIRING 3 CHUS Et This certifies that ......... /V.......... .................... .11.............................................. has permission to perform ......4.5........ .................................... ....... ........ . wiring in the building of.........P ........................................................................ at...... .............. ....................................... . North Andover,Mass. Fee-3 ............ Lic.No..RZO/0.(..... Ic ?Ic INSPECTOR; Check # 10704 Q, Commonwealth ofl►'assachusetts Official Use Only a Department of Fire Services PermttNo. 1 77 6 BOARD OF FIRE PREVENTION REGULATIONSOccupancy and Fee Checked [Rev.1/071 (leave blank APPLICATION FOR PERMIT TO PERFORM ELECTRICAL WORK All work to be performed in accordance with the Massachusetts Electrical Code(NBCY 597 CMR 12.00 (PLEA SE PRINT IN MK ORTYPEALLINFORMATION) Date: Z City or Town of: NORTH ANDOVER To the In e or of Wires: By this application the undersigned ives notice of his or her intention to perform the electrical work described below. Location(Street&Number) Owner or Tenant Z�A(A � , S c� n t ,i-�.� E e Telephone No. R-,7f 6,F) j y Owner's Address I/yJ�' ��-1� 1� Is this permit in conjunction with a building permit? Yes No El (Check Appropriate Box) Purpose of Building Utility Authorization No. 5 Existing Servicol _ Amps l-�j/ Volts Overhe Undgrd❑ No.of Meters New Service Amps / Volts Overhead❑ Undgrd❑ No.of Meters d Number of Feeders and Ampacity Location and Nature of Proposed Electrical Work: AIL �� 1°ina O� Com letion o the ollon table m be warved b the Ins ector o Wires. No.of Recessed Luminaires No.of Ceil:Susp.(Paddle)Fans r of Total Transformers KVA $^ No.of Luminaire Outlets No.of Hot Tubs Generators KVA YV No.of Luminaires Swimming Pool Above ❑ In- ❑ o.o mergency ig mg rnd. rnd. Batter Units �. No.of Receptacle Outlets No.of Oil Burners FIRE ALARMS No.of Zones No.of Switches No.of Gas Burners No.of Detection and Initiating Devices No.of Ranges No.of Air Cond. Tonsl No.of Alerting Devices No.of Waste Disposers 1KW No.of Self-Contained Totals: Detection/Alertin Devices No,of Dishwashers Space/Area Heating KW Local❑ Municipal Connection ❑ Other No.of Dryers Heating Appliances KW Security Systems:*. No.of Water No.of Devices or E uivalent No.of No.of Heaters KW Data Wiring: Signs Ballasts No.of Devices orE uivalent No.Hydromassage Bathtubs No.of Motors Total HP Telecommunications Wiring: No.of Devices or E uivalent OTHER: Attach additional detail if desired,or as required by the Inspector of Wires. Estimated Value of Electrical Work: 5 (When required by municipal policy.) Work to Start: / Inspections to be requested in accordance oriance with MEC Rule 10,and upon completion. INSURANCE C RAGE: Unless waived by the owner,no permit for the performance of electrical work may issue unless the licensee provides proof of liability insurance including"completed operation"coverage or its substantial equivalent. The undersigned certifies that such coverage is in force,and has exhibited proof of same to the permit issuing office. CHECK ONE: INSURANCE BOND ❑ OTHER ❑ (Specify:) I certify,under thepains andpenalties ofperjury,that the information on this application is true and cor1tete. FIRM NAME: C i LIC.NO.:�" Licensee: Signature LIC.NO.: (If applicable,enter`exe t"in t:e license number line.) Bus.Tel.No. ? Address: G/ 'vim �A o ris�h *Per M.G.L c. 147,s.57-61,security work requires Department o Department Safety"S"License: Alt. 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. Owner/Agent Signature Telephone No. PERMIT.FEE.,$ ' ELECTRICAL PFRwffT NO, 11�T�PEC���TREP4�?�7C: _ E�EC'Jl'RYC.A]G 3t�I'S��+��'®�.-• � . � - x. 0. _S ' CTIO_N_'e Passel _ waited-•[ ) Ae-inspectzon zequzxe2f($50.OQ)~[ ] Inspecto s' amme�fs: - (Xnspeetoxs'Signa e-n #rsfzals) Date Z.PJNAC,I�7�PPC�'ZOI47c . Passed•-- Failed-j 3 Re-iuspeetimrequired($50.00)-C j Inspectors'c mtaents: (Cris&ctors'Pignature•-)ao• 'fials) Jute ' rI?a.-s MYR GROUND INgRECTXON. ed—[ ] S+ailed--C ) Reinspectiourequixed($50.00)-Cectors'comments: (Tuspectors}Signatuira-no Hfials) Date _ �.IN�PECTION--SE�t,Y�CE: DATE C.LI,E-D NA +ON'AL OP I : HAMM Passed—[ ) I'aiied- Ce-inspectionxequire[ { 50.00)- C ] Inspectors'eoxnmept�s: (iusp ectors'Signature•-io initials) Date 5.INS TELT ON•-OTMR, Passed--f I{ailed-[ )_ 'Re-insp ection xegufred($50.00)•-[ Inspectors'collam.eds: fir,spectors'signature oinitials} Date JD O OR TAGS.ARE TO BE T SLED OUT AND EEFT OST 19ITE M THE AR"A TO BE INSPECTED 18 NOT .A.CCESS BIE AND A RE WSPECTION OF L50.00IN TO 33E CHARGED. The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations 600 Washington Street Boston,MA 02111 www massgov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Legibly Name(Business/Organization/Individual): Address: GQPO6�L/fyV A� vc 5 `a City/State/Zip: < N4yAILIAI /J/_ /! o?f'�> Phone Are you an employer?Check the appropriate box: Type of project(required): bA 1 I am a employer with_�_ 4. ❑ I am a general contractor and I 6. ❑New construction employees(full and/or part-time).* have hired the sub-contractors 2.❑ I am a sole proprietor or partner- listed on the attached sheet. �• '�]Remodeling ship and'have no employees These sub-contractors have 8. ❑Demolition workingfor me in an capacity. workers' comp.insurance. 9 y p ty. ❑Building addition [No workers'comp.insurance 5. ❑ We are a corporation and its required.] officers have exercised their 10.❑Electrical repairs or additions 3.❑ I am a homeowner doing all work right of exemption per MGL I L❑Plumbing repairs or additions myself. [No workers' comp. c. 152,§1(4),and we have no 12.❑Roof repairs insurance required.]f employees.[No workers' 13.❑Other 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 aie 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 name of the sub-contractors and their workers'camp.policy information. I am an employer that is providing workers'compensation insurance for my employees. Below is thepolicy and job site information. Insurance Company Name:. _22!2�& dgnr� lb Policy#or Self-ins.Lic.#: La l� (�d y Z�' ff Wpq Expiration Date: S? 2.'7 avi s��1f.27•��lZ . Job Site Address: � -� ��C -S �� City/State/Zip: /J/J.�Of/ Attach a copy of the workers'compensation policy declaration page(showing the policy number and expiration date). Failure to secure coverage as requiredunder 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. n 'e er'u that the information provided above is true and correct. I do hereby certify uncle the and pe alts s ofperjury� ry f Simature: / Date: ��- Phone#: <�43 3V 7l 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 dwelling house of another who employs persons to do maintenance,construction or repair work on such dwelling house or on the grounds or building appurtenant thereto shall not because of such employment be deemed to be an employer." MGL chapter 152,§25C(6)also states that"every state or local licensing agency shall withhold the issuance or renewal of a license or permit to operate a business or to construct buildings in the commonwealth for any applicant who has not produced acceptable evidence of compliance with the insurance coverage required" Additionally,MGL chapter 152, §25C(7)states"Neither the commonwealth nor any of its political subdivisions shall enter into any contract for the performance of public work until acceptable evidence of compliance with the insurance requirements of this chapter have been presented to the contracting authority." Applicants Please fill out the workers'compensation affidavit completely,by checking the boxes that apply to your situation and,if necessary,supply sub-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 Please be sure that the affidavit is complete and printed legibly. The Department has provided a space at the bottom Y 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 bum leaves etc.)said person is NOT required to complete this affidavit. The Office of Investigations would like to thank you in advance for your cooperation and should you have any questions, please do not hesitate to give us a call. The Department's address,telephone and fax number: The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations 600 Washington Street Boston.,MA.02111 Tel,#617-727-4900 ext 406 or 1-877,7MASSAF& Revised 5-26-05 Fax#617-727-•7749 www.mass.gov1dia _ Date.....1...................../. �. r " 2768 F yOR71f E¢ Of t...o i•�h� TOWN OF NORTH ANDOVER P p — PERMIT FOR WIRING SSACHUSE� This certifies that ...... ...... . . . . ..... .. ..:.../.,.. .. ........ .... : .......... has permission to perform ...41Z ....,1 . . wiring in the buildi of... " 1. /�......�-- .......... t at.../. -- -- . - ....... .. ............:.............. ,North Andover,Mass. Fee..154eo . Lic.No./V.. 049L� 11634 19 15.00 RAIIr WHITE: Applicant CANARY: Building Dept. PINK:Treasurer GOLD: File Jim tluiv ylUly ryrf "1I U1'�rinarit,nv.ua i DEPARTAIE 1'OFPLIBIICSAFE7Y Permit No. 6aa 2% BOAMOFFMPREVFM ONREGULMONSS27Qtllel2.0 Occupancy&Fees Checked APPLICATION FOR PERMIT TO PERFORM ELECTRICAL WORK All.WORK TO BE PERFORMED IN ACCORDANCE WITH THE MASSACHUSSTS ELECTRICAL CODE,527 CMR 12:00 'LEASE PRINT IN INK OR TYPE ALL INFORMATION) Date own of North Andover To the Inspector of Wires: he undersigned applies for a permit to perform the electrical work described below. ocation(Street&Number) (. 1wner or Tenant r ``J + /�7 1wner's Address this permit in conjuncti ith a building permit: Yes No (Check Appropriate Box) urpose of Building J �G' Utility Authorization No. xisting Service 11 .- Amp J/0 Overhead Underground No.of Meters / lew Service AmpVolts Overhead Underground No.of Meters [umber of Feeders and Ampacity ocation and Nature of Proposed Electrical Work /i nG .�' />f�C t��-rt�c�?,.�XO-�- L?0,VgW No.of Lighting Outlets No.of Hot Tubs No.of Transformers Total KVA No.of lighting Fixtures Swimming Pool' Above low generators KVA round and No.of Receptacle Outlets No.of Oil Burners No.of Emergency Lighting Bar Units No.of Switch Outlets . No.of Gas Burners No.of Ranges No.of Air Cond. Total FIRE ALARMS No.of Zones Tons No.�posals No.of Heat /Total Total No.of Detection and Pum s . Tons KW Initiating Devices No.of Dishwashers Space Area Heating KW No.of Sounding:. vices No.of Self Con ed Detection/So ding Devices No.of Dryers Heating Devices KW Local Municipal Other Connections No.of Water Heaters KW No.of No.of Sims Bailasia No.Hydro Massage Tube No.of Motors Total HP THER• Ptttsuatt lD dE OWitanats�GaMal Laws acanatLiabl7Qyhtasaat� R ynr1XftCar pi&- crflsarrialequvaiat YES NO aibmaladvafidptodbfs0lWlDd Offs~YES lI'youhMdr&dYMplea9eitdraltsQlegpeofa NaVby the ILL�.���JJJ E D Esti n&dVaJXofElearita1Wadc$ IDSlat ?. �O 5' his XdMDaoeRegt Wed Rottgh l„//C� �'/�fL lith! ut�rTieR +Tfiesof IVgrIEo �l Lioa>,seNa /�f � � `1�C7C� Stgnattae Lioa�eNo / Busi�TRN6. /� f�C/�C %1l✓.C' i�. 5� /�i/.� 7f0 Alt Tel No. �1SURAI WAIVER;Iamaware!hattheLioa>.sedoesriothaletheiraaaloeamrWgritsmbtaFMaWh,,latasiag*edbyN GalealLaws my s�iglakae rn this merit applr�al waives d nx�aetnatt e check one) Owner Agent Telephone No. PERMIT FEE$ �. Signature of Owner or Agent I 9 c.- e--9 Ac- 41 - �• lit Ville ( ainnionwcaltll of Massar4itsl:tfil c>tt,,,. t ...Only Department of Public Safety Permit No._ �7 00 BOARD OF FIRE PREVENTION REGULATIONS 527 CMR 12:f'() ��W Occupancy !G I(q. t br r keel 3/90 (leave blank) APPLICATION FOR PERMIT TO PERFORM ELECTRICAL `YORK All work to be pertomwil in accordance with the Massachuwtfs fleruiral r„ , 'i1' CMR 12:00 (PLEASE PRINT IN INK OR TYPE ALL INFORMATION) 'Date City or Town of 6/c TH 14 Wago It the Impertnr of\^rim�- The undersigned aliplie, fora permit to perform the electrical work described below. Location (Street d Nomherl l q 3 L AC v S Owner or Tenant A,14TN y C/IJ/SrYl IA)C'Cle Owners Address S4 rl? Is this permit in coniunction with a building permit: Yes 0 No (Check Appropriate Box) Purpose of Building 1.1tility AutFhnri7alinn No. Existing Service Arnp% / volts nverheac(ll O Undgrd El No. of Meters New Service Amps / volts Overhead Undgrd ❑ No. of Meters Number of Feeders and Ampacity Location and Nature of Proposed Electrical Work 12,CP1-19C S � S f1E 101'AI. No. of Lighting Outlets No. of I•lot Tubs No. of Transformers KVA A veIn- l No. of Lighting Fisturrc SwimmingPool rnd. ❑ •rile). 0 f o-nerators KVA _ '4,+. of Emergency Ligbtim-, No. of Receptacle Outlets No, of Oil Burners lcittury Units No. of Switch Outlets No. of Gas Burners rlVF. ALARMS No. (if 7.one, Ir't' Nn. of Detection and No. of Ranges No. of Air Conditioners Ton, Initiating Devices Heat Total Int'l No. of Sounding Devi(r•, No.of Disposals No. of Pum s Tons KW _ N+,. of Self Contained _ I>rHrction/Sourxling l rrvi+r•, No. of Dishwashers Space/Area f Zeatin KW "wart r� local❑' Connection 001her No. Of Dryers Heating Devices KW No, of o. of 1,-%-/ Vo tage No. of Water Heaters KW Signs Ballasts Wiring No Hydro Massage Tubs No of Motor, Total HP OTHER: INSURANCE COVERAGE: Pursuant to the requirements of Massachttsttes General Laws I have a current Liability Insurance Policy including Completed Operations Coverage or if,;suh,tantinl+•rµtivalent. YES C1 NO I I !have mihmitted valid t,n,nf of same.to this office. YES U NO O If you have checked YES, please indicate the type. of coverage by checking the appropriate ben. INSURANCE [ENOND ❑ OTHER❑ (Please Specify) �N FiLE (Expiration Dahl Estimated Value of Electrical Work$ Work to Start Inspection Date Requested: Rough Final Signed under the penalties of perjury: FIRM NAME Philip A. Paglieranl LIC. NO. /9 y�/� E ec r ; r .Licensee Box 633R Sig LIC. NO. Address Atkin-,nn, N H 63811 Bus. Tel. No. _ 1-603-362-4065 Alt.Tel. No.66 OWNER'S INSURANCE WAIVER:I am aware that the Licenser does not have the insuranre rove-,.wr.or it,.uh,tantial equivalent a,required by Mas,arhusen, .General Laws,and that my signature on this permit application waives this requirement. Owner A)!+•nt (Please check one) Telephone No. PERhia rFF. Sy (Signature of Owner or Agent) ...,., ,.. :-'a.gsCvc�?"`�k �C-'6�':,r t .:"`•�:.L :;cr...nM^w. r ,. V{'a^_: s+. tee. - � . Location No. Date 1 TOWN OF NORTH ANDOVER vp M Certificate of Occupancy $ s� ^E Building/Frame Permit Fee $ AC MUS Foundation"Permit Fee $ Other Permit Fee $ TOTAL $ Check # � F r F �1 r k i t 17622 C Building Inspector i TOWN OF NORTH ANDOVER BUILDING DEPARTMENT APPLICATION TO CONSTRUCT REPAIR,RENOVATE, OR DEMOLISH A ONE OR TWO FAMILY DWELLING BUILDING PERMIT NUMBER. / DATE ISSUED: er 70 SIGNATURE: f aI Building Commissioner/I for of uildin Date 71 d Z SECTION 1-SITE INFORMATION O 1.1 Property Address: 1.2 Assessors Map and Parcel Number: 19 3 LC v �� Ovr� nap N� Parcel Number ki, AN Dojf-e-sz n 1.3 Zoning Information: 1.4 Property Dimensions: Zoning District Proposed Use Lot Area Fronts ft 1.6 BUILDING SETBACKS ft Front Yard Side Yard Rear Yard Required Provide R redProvided R red Provided v 1.7 Water Supply M.G.L.C.40. 34) 1.3. Flood Zone Information: 1.8 Sewerage Disposal System: Public ❑ Private p Zone Outside Flood Zone 0 Municipal 0 On Site Disposal System 0 V SECTION 2-PROPERTY OWNERSIIIPIAUTHORIZED AGENT J 1 M 2.1 Owner of Record Name(Print) Address for Service 0 Signature Telephone 2.2 Owner of Record: Mame Print Address for Service: Z M Si ature Telephone 90 SECTION 3-CONSTRUCTION SERVICES 3.1 Licensed Construction Supervisor: Not Applicable 0 Pe-T r-F, '?, - 1 A&E7(,-- Licensed Construction Supervisor: aO License Number `1gua-I srt�vUT S�- k/z lU !�167VA), Iyi�, a� ��s7 M Address S Expiration Date ic Signature Telephone r 3.2 Registered Home Improvement Contractor Not Applicable ❑ v Company Name Registration Number r 95 0465TW-r 5t`- V /tLCMj&jC-(t6P. tAK_ C9ga7 Address, 717, / Z Expiration Date /1 Signature Telephone Y� A SECTION 4-WORKERS COMPENSATION(M G.L C 152 § 25c(6) Workers Compensation Insurance affidavit must be completed and submitted with this application. Failure to provide this affidavit will result in the denial of the issuance of the building it. Signed affidavit Attached Yes.......❑ No.......0 SECTION 5 Description of Proposed Work check all applicable New Construction ❑ Existing Building ❑ Repair(s) ❑ Alterations(s). Addition 0 Accessory.Bldg. ❑ Demolition ❑ Other 0 Specify Brief Description of Proposed Work: a w �;T P ►p EFx t 5- ,6 "f'K i m A- &r- ST 4Z (NS U��TC� �F�.1 eFST�c2 —TH I IJ T AT/ pJEw TR I UA, 71 F"GUviz o f; c SECTION 6-ESTIMATED CONSTRUCTION COSTS Item Estimated Cost(Dollar)to be OFFICIAL USE ONLY Completed by permit applicant 1. Building O (a) Building Permit Fee C'-O Multiplier 2 Electrical (b) Estimated Total Cost of J 0'O Construction 3 Plumbing O Building Permit fee(a)X (b) 4 Mechanical HVAC 5 Fire Protection �p 6 Total 1+2+3+4+5 Check Number } ,a SECTION 7a OWNER AUTHO=XYION TO BE COMPLETED WHEN c OWNERS AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT .a 1, as Owner/Authorized Agent of subject property Hereby authorize to act on rte. My behalf,in all matters relative to work authorized by this building permit application. Signature of Owner Date SECTION 7b OWNER/AUTHORIZED AGENT DECLARATION 1, �GT�� '\ �Y^,Fa as OwnerCutho,:z:e d Agent f subject + property Hereby declare that the statements and information on the foregoing application are true and accurate,to the best of my knowledge and belief Pri am �OZ 7 Sr ature of Owner/Agent Date NO.OF STORIES SIZE BASEMENT OR SLAB SIZE OF FLOOR TINMERS iST2ND 3 SPAN DIMENSIONS OF SILLS DIMENSIONS OF POSTS DIMENSIONS OF GIRDERS HEIGHT OF FOUNDATION THICKNESS SIZE OF FOOTING X MATERIAL OF CHIMNEY IS BUILDING ON SOLID OR FILLED LAND IS BUILDING CONNECTED TO NATURAL GAS LINE NORTH o o over Or.r�.Ate. Y•'�`�� .it J No. over, Mass., 1Q- LA LA COCMICKEWICK V RATED BOARD OF HEALTH Food/Kitchen PERMIT T D Septic System BUILDING INSPECTOR THIS CERTIFIES THAT. .......'......................................... ............. .o.. ................ ..................... ........ Foundation has permission to erect........................................ buildings o ..� `-3 ..... trough to be occupied as.. chimney .. ... . .. . . . ... . ............ . .. . .. . . . ................ provided that the person accepting this permit shall in every respect conform to the terms of the application on file in Final this office, and to the provisions of the Codes and By-Laws relating to the Inspection, Alteration and Construction of Buildings in the Town of North Andover. PLUMBING INSPECTOR VIOLATION of the Zoning or Building Regulations Voids this Permit. Rough Final PERMIT EXPIRES IN 6 MONTHS UNLESS CONSTRUCTION STARTS - ELECTRICAL INSPECTOR D. Rough �4�1�!!!'1.....�!� ... Service BUILDIM INSPECTOR Final Occupancy Permit Required to Occupy Building GAS INSPECTOR Rough Display in a Conspicuous Place on the Premises — Do Not Remove Final No Lathing or Dry Wall To Be Done FIRE DEPARTMENT Until Inspected and Approved by the Building Inspector. Burner Street No. SEE REVERSE SIDE Smoke Det. PROPOSAL MAGEE BUILDERS, INC. 95 CHESTNUT STREET WILMINGTON, MA 01887 TELEPHONE (978) 668-4442 FAX (978) 657-6638 I June 7, 2004 Catherine Entsminger 193 Lacey Street N. Andover, MA 01845 Remove existing cabinets and tops, remove plaster ceiling and walls, insulate, new plaster ceiling and walls, wonder board floor for tile, tile floor installed (normal installation), new casings, new wood base and molding, crown molding. Electrical work according to Davies proposal. Plumbing: remove and replace sink and dishwasher, relocate ice maker. Allowances included in price: Paint allowance to be priced *Tile installation for diagonal or patterns is an additional charge. * Tile material to be supplied by others. Total cost $23,366.00 I Payments made as follows: 1/2 when work starts and balance on completion. All material is guaranteed to be as specified: All work to be completed in a workmanlike manner according to standard practices. Any alteration or deviation from above specifications involving extra costs will be executed only upon written orders, and will become an extra above the estimate. All agreements contingent upon strikes, accidents or delays beyond our and control. Owner to carry all necessary insurance requirements. our workers are fully covered by Workman's Compensation Insurance. Authorized Si nature 9 Note: This proposal may be withdrawn by us if not accepted within 30 days. Acceptance of Proposal: The above prices, specifications and conditions are satisfactory and are hereby accepted. You are authorized to do the work as specified. Payment will be made as outlined abov . Signature Date O Signature Date--;z - b j From. I homas Gregory Associates Ghiei Rossetti-I honlas Giegoiy Assoc I o. Magee 131,111ders Page: 22 Date. 3123/04 12.10:46 PM . CERTIFICATE OF LIABILITY INSURANCE OP ID DATE(MMfDDfYYYY) AcoRoMAGEE-1 03/23/04 PRODUCER THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE Thomas dregory Associates Inc. HOLDER.THIS CERTIFICATE DOES NOT AMEND,EXTEND OR 601 Edgewater Drive S235 ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. Wakefield MA 01880 Phone: 781-914-1000 Fax:781-246-2601 INSUR:::� FORDING COVERAGE NAIC# INSURED INSURER Acadia Insurance Magee Incorporated DBA IrasUPFP8 Citation Insurance Co. Magee Builders Ifd5l1PLRC Granite State Insurance Co. Magee Builders - 95 Chestnut Street IHSUPLPL1 Wilmington MA 01887 - - Irdsl.Ni Iz:_ COVERAGES THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED.NOTWITHSTANDING ANY REQUIREMENT,TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE MAY BE ISSUED OR MAY PERTAIN,THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS,EXCLUSIONS AND CONDITIONS OF SUCH POLICIES.AGGREGATE LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. -- --------- POLICY€FF�CTIVE POLICY EXPIVATION . LTR NSR TYPE OF INSURANCE POLICY NUMBER DATE(MMIDDfYY) - DATE(MMIDDIYY) LIMITS GENERAL LIABILITY EACH OCCLIRPF NCE - - $ 1000000 _ c=a;Ta-E m r,FTTTFn $2 50 0 0 0 A X COMMERCIAL GENERAL UABIUI f BOA0058430-13 01/01/04 01/01/05 rPFMISFS IFa ncculence) CLAIMS MADE D OCCUR NIEL,G%P(Any 0110 P01 son) $ 5000 FFRSORA.I,8 ADV INJUPi $ 1000000 GENERAL Arg;REGATE_ $2000000 GEIJ'L AGGREGATE UPAI1 APPLIES PER PRODUCTS-COMPIOP AGG $ 1000000 _- PRo _ POLICY JECT 1-QC AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT $ B ANfAUTO 02MMNY2338 12/17/03 12/17/04 IEaa°c'd�-11t) ALL OWNED AU105 H�uu v u1.nn+Y nw,nn) $ 250000 IPOr X SCHEDULED AIJTOS - X HIRED AUTOS BODIc;1N,NPY a 500000 (Pn, X NON OWNFO AUTOS r.P`FFr<TY DA.MAC+F $250000 GARAGE LIABILITY AUTO ONL Y_EA ACC1DFN`T $ OTHER rl!AN EA ACC $ ANY AUTO AV II-)ONLY AGG $ EXCESSIUMBRELLA LIABILITY EArH OC.CI PREP10E $ OCCUR n --I A.R,15 MADF A6GRFCATF $ __ $ a DEDUCTIBLE RETENTION $ $ WORKERS COMPENSATION AND X TO' , 111IITS ER C EMPLOYERS'LIABILITY WC7483144 01/01/04 01/01/05 EL EACHACCIDE•lT $ 100000 ANY PROPRIETOR/PARTNERIE ECUTIVE OFFICER/MEMBER EYCLUDED7 E L DISEASE-EA DMIPLOYEE $ 100000 If yes,describe under - E L.DISEASE-POLICY LIMIT $500000 - SPECIAL PROVISIONS below OTHER DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES 1 EXCLUSIONS ADDED BY ENDORSEMENT I SPECIAL PROVISIONS CERTIFICATE HOLDER CANCELLATION TOWHOMI SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF,THE ISSUING INSURER WILL ENDEAVOR TO MAIL DAYS WRITTEN NOTICE TO THE CERTIFICATE HOLDER NAMED TO THE LEFT.BUT FAILURE TO DO SO SHALL TO WHOM IT MAY CONCERN IMPOSE NO OBLIGATION OR LIABILITY OF ANY KIND UPON THE INSURER,ITS AGENTS OR REPRESENTATIVES. AUTHORIZED RESENTATI V 00e ACORD 25(2001108) ©ACORD CORPORATION 1988 This fax was sent with GFI's FAXmaker FAX Server-For more information,visit: hftp://www.gfi.com i CITY OF BOSTON [Ac'. No: 131867 9 BOARD OF` EXAMINERS MAYOR THOMAS M. MENINO THIS CffPfINE3 P ER.R, MACES,. . Is! E WQKKIUNDER PROVISIONS OF THE ACTS, OF'11 11:ICHAff M NDEO, BC :\� 4129/03- 4/29/04 Class of l Fid; Dab Issu d EA.6910 I BOARD OF EXAMINERS / ALEXANDER H MACLEOD AIA T F SCOTT DARLING III PATRICK TR1,CY ��ae fo�zmon.�veallli cl Board of Building Regulutidns and Stanrd3 HOME IMPROVEMENT CONTRACTOR _ X Registration: 113679 -= Expiration: 7/7/2005 Type: Private Corporation MAGEEINC PETER MAGEE 95 CHESTNUT ST ,� , �.E.i WILMINGTON, MA 01887 AdministraIlo. ti fie �anrinza�r.�vea� o��!�vaae�%ueP,l�a �Icense: BOARD OFf1jIMING REGULATIONS CONSTRUCTIbN SUPERVISOR F Number: CS ' 021816 ,i Irthdate: 08/15111989 Expires: 08/15/00.5 Tr. no: 1437 { f Restricted: PETER R•MAGEE 95 CHESTNUT STS, WILMINGTON, MA 018 Administrator I �s. r -f"oWrt- RACF s/nIK T►GT-our 6 lCuTG£R`i,S1Li � 8R_AD, ? 7 n2 t�iG ac/�' �," ►i it DISf}10W£C� "fs 1 we.71 I r i l Orn u� L �,' I , , civ E NS t '51 SH. s P14 /D SnT-0 „dO(3 vrRr�cor To DECK l; u ('�� I TIC & � ' ,r� De tj� Vil T ffN PLM I�f � SCALE I " I-Q APPROVED BY ` J„ DRAWN BY DATE LL 3 �'6 A15HINC-iH� PTSID�W,6 r DRAWING NUMBER d 14 Date. .'G".:—:.U`Y..... TOWN OF NORTH ANDOVER p PERMIT FOR WIRING SACMUSEt This certifies that ��......... ....... has permission to perform .................................................... 3 wiring in the building of..:f l—z.ez.e.�.A—;�� {/.................................... {at... 9 ..... .... , �- ...................... .North Andover,Mass. Fee............' ... Lic.No. ................ ..........:........................ ----:-,ELECTRICAL INSPECTOR Check # 5471 7BECOMMONWF+4L7HOFAIASS4CHUSE IS Office Use only / DEPARTA1E T0FPUBIICSAFM Permit No. 5V 7 BOARDOFFMPREVFI WONREGUTATTONSR7CMRlZO Occupancy&Fees Checked ` APPLICATTONFOR PERMIT TO PERF a RMELECTRICAL WORK ALL WORK TO BE PERFORMED IN ACCORDANCE WITH THE MASSACHU TS ELECTRICAL CODE,527 CMR 12:00 (PLEASE PRINT IN INK OR TYPE ALL INFORMATION) Date q �G Town of North Andover To the Inspector of Wires: The undersigned applies for a permit to perform the electrical work descri"e below. Location(Street&Number) 19L? L Cy ,/`/ Owner or Tenant Owner's Address Is this permit in conjunction with a building permit: Yes[No (Check Appropriate Box) Purpose of Building Utility Authorization No. Existing Service Amps/ olts Overhead -Underground No.of Meters New Service Amps Volts Overhead 1=1 Underground EZ3 No.of Meters Number of Feeders and Ampacity Location and Nature of Proposed Electrical Work-u//i�� No.of Lighting Outlets No.of Hot Tubs No.of Transformers Total KVA No.of Lighting Fixtures /D Swimming Pool Above Below Generators KVA round ground No.of Receptacle Outlets No.of Oil Burners No.of Emergency Lighting Battery Units No.of Switch Outlets / C7 No.of Gas Burners No.of Ranges /, tX� No.of Air Cond. Total FIRE ALARMS No.of Zones ( � Tons �+No.of Disposals / No.of Heat Total Total No.of Detection and --� Pumps Tons KW Initiating Devices \No.of Dishwashers Space Area Heating KW No.of Sounding Devices 1� No.of Self Contained Detection/Sounding Devices No.of Dryers Heating Devices KW Local Municipal Other Connections No.of Water Heaters KW No.of No.of Signs Bailasis No.Hydro Massage Tubs No.of Motors Total HP OTHER• IllstaanaeCovfrage.Plus<>atlt�thetagt>rterr�ertsofl�lassad>t»llst.,ala�alL3ws Ihaneac mentLiabkkm m=PblicyindudmgCompim ComxWoritsad awMegtrivalat YES NO Ila'r-eahniwdvandpoofofsam iDtheOffmYES CI lfymhat%edrdcedYES,pleasehkd *h NXDfoo.UWby INSURANCE LIJ BOND t71II-IQt a (Please Spa�y> G�/ii/ o�� Fxp'Qa6alDate oO a o Estitm>amdv O alueofl~7ednrelwak$ �3 Wotkmshut /c% kq)ocdmD*ReWesled Rwgh Final si wundArpbiakiesofpmw FUZMNAvE ,yi9d/E 1. Lioer�seNo. �d/�� Lic� side LiDa>seNo A _ BuskmTel.No. p ��� /!"OOi%o.-✓�%. G. /3a�raa� � r !� /�C� Alt Tel Na G/7J d/off OWNER'SINSURANCEWAIVER;IamawareMdieL=nsedDesnothavethemarmxcover eoritsabsalegtrivalartasmegtlrtedbyMassadmscmC=aalLaws and fhatmysigoahaeon drispeanitapphcatim waives dns ovitanaY (Please check one) Owner Agent a Telephone No. PERMIT FEE$ signature of Owner or Agent Commonwealth of Massachusetts W Title 5 Official Inspection Form cE`v�� Subsurface Sewage Disposal System Form - Not for Voluntary Assessments NOV 0 6 2017 193 Lacy Street TOWN OF NORTH ANDOVER Property Address HEALTH DEPS &A" Scott Stannard Owner Owner's Name information is required for every North Andover MA 01845 10/03/2017 State Zi Code Date of Inspection page. City/Town P P Inspection results must be submitted on this form. Inspection forms may not be altered in any way. Please see completeness checklist at the end of the form. Important:When A. General Information filling out forms on the computer, �C•� use only the tab 1. Inspector: (1 key to move your cursor-do not Robert Herrick use the return Name of Inspector key. Wind River Environmental r� Company Name 163 Western Avenue Company Address I Gloucester MA 01930 Cityrrown State Zip Code (978)282-7315 S1�:13 TVY Telephone Number License Number B. Certification I certify that I have personally inspected the sewage disposal system at this address and that the information reported below is true, accurate and complete as of the time of the inspection. The inspection was performed based on my training and experience in the proper function and maintenance of on site sewage disposal systems. I am a DEP approved system inspector pursuant to Section 15.340 of Title 5(310 CMR 15.000). The system: ® Passes ❑ Conditionally Passes ❑ Fails ❑ Needs Further Evaluation by the Local Approving Authority 10/03/2017 nspector's Signature Date The system inspector shall submit a copy of this inspection report to the Approving Authority(Board of Health or DEP)within 30 days of completing this inspection. If the system has a design flow of 10,000 gpd or greater, the inspector and the system owner shall submit the report to the appropriate regional office of the DEP. The original should be sent to the system owner and copies sent to the buyer, if applicable, and the approving authority. ****This report only describes conditions at the time of inspection and under the conditions of use at that time. This inspection does not address how the system will perform in the future under the same or different conditions of use. t5ins.doc•rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 1 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments M 193 Lacy Street Property Address Scott Stannard Owner Owner's Name information is North Andover MA 01845 10/03/2017 required for every page. City/Town State Zip Code Date of Inspection B. Certification (cont.) Inspection Summary: Check A,B,C,D or E/always complete all of Section D A) System Passes: ® I have not found any information which indicates that any of the failure criteria described in 310 CMR 15.303 or in 310 CMR 15.304 exist. Any failure criteria not evaluated are indicated below. Comments: System is in good working order. B) System Conditionally Passes: ❑ One or more system components as described in the "Conditional Pass" section need to be replaced or repaired. The system, upon completion of the replacement or repair, as approved by the Board of Health, will pass. Check the box for"yes", "no" or"not determined" (Y, N, ND)for the following statements. If"not determined," please explain. The septic tank is metal and over 20 years old*or the septic tank(whether metal or not) is structurally unsound, exhibits substantial infiltration or exfiltration or tank failure is imminent. System will pass inspection if the existing tank is replaced with a complying septic tank as approved by the Board of Health. *A metal septic tank will pass inspection if it is structurally sound, not leaking and if a Certificate of Compliance indicating that the tank is less than 20 years old is available. ❑ Y ❑ N ❑ ND (Explain below): t5ins.doc•rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 2 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form _ Subsurface Sewage Disposal System Form -Not for Voluntary Assessments M 193 Lacy Street Property Address Scott Stannard Owner Owner's Name information is required for every North Andover MA 01845 10/03/2017 page. City/Town State Zip Code Date of Inspection B. Certification (cont.) ❑ Pump Chamber pumps/alarms not operational. System will pass with Board of Health approval if pumps/alarms are repaired. B) System Conditionally Passes (cont.): ❑ Observation of sewage backup or break out or high static water level in the distribution box due to broken or obstructed pipe(s)or due to a broken, settled or uneven distribution box. System will pass inspection if(with approval of Board of Health): ❑ broken pipe(s)are replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below): ❑ distribution box is leveled or replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ The system required pumping more than 4 times a year due to broken or obstructed pipe(s). The system will pass inspection if(with approval of the Board of Health): ❑ broken pipe(s)are replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below): C) Further Evaluation is Required by the Board of Health: ❑ Conditions exist which require further evaluation by the Board of Health in order to determine if the system is failing to protect public health, safety or the environment. 1. System will pass unless Board of Health determines in accordance with 310 CMR 15.303(1)(b)that the system is not functioning in a manner which will protect public health, safety and the environment: ❑ Cesspool or privy is within 50 feet of a surface water ❑ Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh t5ins.doc-rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 3 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 193 Lacy Street i Property Address Scott Stannard Owner Owner's Name information is required for every North Andover MA 01845 10/03/2017 page. City/Town State Zip Code Date of Inspection B. Certification (cont.) 2. System will fail unless the Board of Health (and Public Water Supplier, if any) determines that the system is functioning in a manner that protects the public health, safety and environment: ❑ The system has a septic tank and soil absorption system (SAS)and the SAS is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water supply. ❑ The system has a septic tank and SAS and the SAS is within 50 feet of a private water supply well. ❑ The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or more from a private water supply well". Method used to determine distance: **This system passes if the well water analysis, performed at a DEP certified laboratory, for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis must be attached to this form. 3. Other: I D) System Failure Criteria Applicable to All Systems: You must indicate"Yes" or"No"to each of the following for all inspections: Yes No ❑ ® Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool ❑ ® Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool El ® Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool ❑ ® Liquid depth in cesspool is less than 6" below invert or available volume is less than '/2 day flow t5ins.doc•rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 4 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments °M 193 Lacy Street Property Address I Scott Stannard Owner Owner's Name information is required for every North Andover MA 01845 10/03/2017 page. City/Town State Zip Code Date of Inspection B. Certification (cont.) Yes No El ® 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 SAS, cesspool or privy is below high ground water elevation. ❑ ® Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ ® Any portion of a cesspool or privy is within a Zone 1 of a public well. ❑ ® Any portion of a cesspool or privy is within 50 feet of a private water supply well. ❑ ® Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality analysis. [This system passes if the well water analysis, performed at a DEP certified laboratory,for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis and chain of custody must be attached to this form.] ❑ ® The system is a cesspool serving a facility with a design flow of 2000gpd- 10,000gpd. ❑ ® The system fails. I have determined that one or more of the above failure criteria exist as described in 310 CMR 15.303, therefore the system fails. The system owner should contact the Board of Health to determine what will be necessary to correct the failure. E) Large Systems: To be considered a large system the system must serve a facility with a design flow of 10,000 gpd to 15,000 gpd. For large systems, you must indicate either"yes" or"no"to each of the following, in addition to the questions in Section D. Yes No ❑ ❑ 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 public water supply well If you have answered "yes" to any question in Section E the system is considered a significant threat, or answered "yes" in Section D above the large system has failed. The owner or operator of any large system considered a significant threat under Section E or failed under Section D shall upgrade the system in accordance with 310 CMR 15.304. The system owner should contact the appropriate regional office of the Department. t5ins.doc-rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 5 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments °M10 193 Lacy Street Property Address Scott Stannard Owner Owner's Name information is North Andover MA 01845 10/03/2017 required for every — page. Cityrrown State Zip Code Date of Inspection C. Checklist Check if the following have been done. You must indicate"yes" or"no" as to each of the following: Yes No ® ❑ Pumping information was provided by the owner, occupant, or Board of Health ❑ ® Were any of the system components pumped out in the previous two weeks? ® ❑ Has the system received normal flows in the previous two week period? E] ® Have large volumes of water been introduced to the system recently or as part of this inspection? ® ❑ Were as built plans of the system obtained and examined? (If they were not available note as N/A) ® ❑ Was the facility or dwelling inspected for signs of sewage back up? ® ❑ Was the site inspected for signs of break out? ® ❑ Were all system components, excluding the SAS, located on site? ® ❑ Were the septic tank manholes uncovered, opened, and the interior of the tank inspected for the condition of the baffles or tees, material of construction, dimensions, depth of liquid, depth of sludge and depth of scum? ® ❑ Was the facility owner(and occupants if different from owner) provided with information on the proper maintenance of subsurface sewage disposal systems? The size and location of the Soil Absorption System (SAS) on the site has been determined based on: ® ❑ Existing information. For example, a plan at the Board of Health. El ® Determined in the field (if any of the failure criteria related to Part C is at issue approximation of distance is unacceptable) [310 CMR 15.302(5)] D. System Information Residential Flow Conditions: Number of bedrooms (design): 4 Number of bedrooms (actual): 4 DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): 440 gpd t5ins.doc-rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 6 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments H 193 Lacy Street Property Address Scott Stannard Owner Owner's Name information is required for every North Andover MA 01845 10/03/2017 page. City/Town State Zip Code Date of Inspection D. System Information Description: This system is made up of a septic tank, pump chamber and distribution box and soil absorption system. Number of current residents: 2 ✓�� Does residence have a garbage grinder? ❑ Yes ® No Is laundry on a separate sewage system? (Include laundry system inspection ❑ Yes ® No information in this report.) Laundry system inspected? ❑ Yes ® No Seasonal use? ❑ Yes ® No Water meter readings, if available (last 2 years usage (gpd)): Well Water Detail: Sump pump? ❑ Yes ® No Last date of occupancy: Occupied Date Commercial/Industrial Flow Conditions: Type of Establishment: Design flow(based on 310 CMR 15.203): Gallons per day(gpd) Basis of design flow(seats/persons/sq.ft., etc.): Grease trap present? ❑ Yes ❑ No Industrial waste holding tank present? ❑ Yes ❑ No Non-sanitary waste discharged to the Title 5 system? ❑ Yes ❑ No Water meter readings, if available: t5ins.doc•rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 7 of 17 I i I Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments � M 193 Lacy Street Property Address Scott Stannard Owner Owner's Name information is North Andover MA 01845 10/03/2017 required for every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Last date of occupancy/use: Date Other(describe below): General Information Pumping Records: Source of information: Home Owner jWas system pumped as part of the inspection? ❑ Yes ® No If yes, volume pumped: gallons How was quantity pumped determined? Reason for pumping: Type of System: ® 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) ❑ Innovative/Alternative technology. Attach a copy of the current operation and maintenance contract(to be obtained from system owner)and a copy of latest inspection of the I/A system by system operator under contract IIS ❑ Tight tank. Attach a copy of the DEP approval. ® Other(describe): Pump chamber t5ins.doc•rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 8 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments ^M 193 Lacy Street Property Address Scott Stannard Owner Owner's Name information is North Andover MA 01845 10/03/2017 required for every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Approximate age of all components, date installed (if known)and source of information: 2005; Plans on File Were sewage odors detected when arriving at the site? ❑ Yes ® No Building Sewer(locate on site plan): Depth below grade: 2 feet Material of construction: ❑ cast iron ® 40 PVC ❑ other(explain): Distance from private water supply well or suction line: Over 100' feet Comments (on condition of joints, venting, evidence of leakage, etc.): All joints look to be solid. There are no signs of leakage and venting is through the building's sewer. Septic Tank(locate on site plan): 6 Depth below grade: feet Material of construction: ® concrete ❑ metal ❑fiberglass ❑ polyethylene ❑ other(explain) If tank is metal, list age: years Is age confirmed by a Certificate of Compliance? (attach a copy of certificate) ❑ Yes ❑ No Dimensions: 10'6"x 5'8"x 5'8" Sludge depth: 3 t5ins.doc-rev.6116 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 9 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form _ Subsurface Sewage Disposal System Form -Not for Voluntary Assessments M 193 Lacy Street Property Address Scott Stannard Owner Owner's Name information is required for every North Andover MA 01845 10/03/2017 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Septic Tank(cont.) Distance from top of sludge to bottom of outlet tee or baffle 31" Scum thickness 1 Distance from top of scum to top of outlet tee or baffle 6" Distance from bottom of scum to bottom of outlet tee or baffle 14" How were dimensions determined? Tape Measure & Sludge Judge Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): Recommend pumping yearly. The inlet and outlet baffles are solid. There are no signs of leakage and the liquid level is OK in relation to the inverts. Grease Trap (locate on site plan): Depth below grade: feet Material of construction: ❑ concrete ❑ metal ❑fiberglass ❑ polyethylene ❑ other(explain): Dimensions: Scum thickness Distance from top of scum to top of outlet tee or baffle Distance from bottom of scum to bottom of outlet tee or baffle Date of last pumping: Date t5ins.doc•rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 10 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments �M 193 Lacy Street Property Address Scott Stannard Owner Owner's Name information is required for every North Andover MA 01845 10/03/2017 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): Tight or Holding Tank(tank must be pumped at time of inspection)(locate on site plan): Depth below grade: Material of construction: ❑ concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain): Dimensions: Capacity: gallons Design Flow: gallons per day Alarm present: ❑ Yes ❑ No Alarm level: Alarm in working order: ❑ Yes ❑ No Date of last pumping: Date Comments (condition of alarm and float switches, etc.): Attach copy of current pumping contract(required). Is copy attached? ❑ Yes ❑ No t5ins.doc•rev.6116 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 11 of 17 Commonwealth of Massachusetts w Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments GSM 193 Lacy Street Property Address Scott Stannard Owner Owner's Name information is North Andover MA 01845 10/03/2017 required for every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Distribution Box(if present must be opened)(locate on site plan): Depth of liquid level above outlet invert 0 Comments (note if box is level and distribution to outlets equal, any evidence of solids carryover, any evidence of leakage into or out of box, etc.): The distribution box is solid. There are no signs of carryover or leakage in or out of the box. The liquid level is OK in relation to the inverts. Pump Chamber(locate on site plan): Pumps in working order: ® Yes ❑ No* Alarms in working order: ® Yes ❑ No* Comments (note condition of pump chamber, condition of pumps and appurtenances, etc.): The pump chamber was in good working condition at the time of inspection. * If pumps or alarms are not in working order, system is a conditional pass. Soil Absorption System (SAS)(locate on site plan, excavation not required): If SAS not located, explain why: t5ins.doc•rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 12 of 17 Commonwealth of Massachusetts w Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments /4M 193 Lacy Street Property Address Scott Stannard Owner Owner's Name information is North Andover MA 01845 10/03/2017 required for every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Type: ❑ leaching pits number: ® leaching chambers number: 36 ❑ leaching galleries number: ❑ leaching trenches number, length: ❑ leaching fields number, dimensions: ❑ overflow cesspool number: ❑ innovative/alternative system Type/name of technology: Comments (note condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of vegetation, etc.): The soil is dry and there are no signs of hydraulic failure or ponding. The vegetation is normal for the area. Cesspools (cesspool must be pumped as part of inspection)(locate on site plan): Number and configuration Depth—top of liquid to inlet invert Depth of solids layer P Y Depth of scum layer Dimensions of cesspool Materials of construction Indication of groundwater inflow ❑ Yes ❑ No t5ins.doc•rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 13 of 17 i Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments M 193 Lacy Street Property Address P Scott Stannard Owner Owner's Name information is North Andover MA 01845 10/03/2017 required for every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): Privy(locate on site plan): Materials of construction: Dimensions Depth of solids Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): t5ins.doc-rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 14 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments i; � "w 193 Lacy Street Property Address Scott Stannard - Owner Owner's Name information is North Andover MA 01845 10/03/2017 required for every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Sketch Of Sewage Disposal System: Provide a view of the sewage disposal system, including ties to at least two permanent reference landmarks or benchmarks. Locate all wells within 100 feet. Locate where public water supply enters the building. Check one of the boxes below: ❑ hand-sketch in the area below ® drawing attached separately 41--e 23,z ' A- 0 /;t•9. I #_,c 13-4 13`Z 13 Y Z 13 �X D I O v� t5ins.doc•rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 15 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 193 Lacy Street Property Address Scott Stannard Owner Owner's Name information is North Andover MA 01845 10/03/2017 required for every — page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Site Exam: ® Check Slope ® Surface water ® Check cellar ® Shallow wells Estimated depth to high ground water: 4 feet Please indicate all methods used to determine the high ground water elevation: ® Obtained from system design plans on record If checked, date of design plan reviewed: 2004 Date ❑ Observed site(abutting property/observation hole within 150 feet of SAS) ❑ Checked with local Board of Health -explain: ❑ Checked with local excavators, installers - (attach documentation) ❑ Accessed USGS database-explain: You must describe how you established the high ground water elevation: Obtained the estimated ground water using the 2004 design plan on record with the Board of Health. Before filing this Inspection Report, please see Report Completeness Checklist on next page. l5ins.doc•rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 16 of 17 Y Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments °M 193 Lacy Street Property Address Scott Stannard Owner Owner's Name information is required for every North Andover MA 01845 10/03/2017 page. City/Town State Zip Code Date of Inspection E. Report Completeness Checklist ® Inspection Summary: A, B, C, D, or E checked I ® Inspection Summary D (System Failure Criteria Applicable to All Systems) completed ® System Information— Estimated depth to high groundwater ® Sketch of Sewage Disposal System either drawn on page 15 or attached in separate file I t5ins.doc-rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 17 of 17 Of NORT e,h 8069 3?•'�j" n • OL s _`f Town of North Andover ,,,,, HEALTH DEPARTMENT ,SSACHU`+t� - CHECK#: //D DATE: LOCATION: _� C S H/O NAME: Sf o6q III r CONTRACTOR NAME: Type of Permit or License:(Check box) ❑ Animal $ ❑ Body Art Establishment $ ❑ Body Art Practitioner $ ❑ Dumpster $ ❑ Food Service-Type: $ ❑ Funeral Directors $ ❑ Massage Establishment $ ❑ Massage Practice $ ❑ Offal(Septic)Hauler $ ❑ Recreational Camp $ ❑ Sun tanning $ ❑ Swimming Pool $ ❑ Tobacco $ ❑ Trash/Solid Waste Hauler $ ❑ Well Construction $ SEPTIC Systems: ❑ Septic-Soil Testing $ ❑ Septic-Design Approval $ ❑ Septic Disposal Works Construction(DWC) $ ❑ Septic Disposal Works Installers(DWI) $ ❑ Title 5 Inspector $ ffTitle 5 Report # pasa $ 50- 13 5©—❑ Other:(Indicate) $ K��t� nth Agent Initials White-Applicant Yellow-Health Pink-Treasurer y r ♦ y Commonwealth of Massachusetts 7NORTHAND W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessmen TOWH °M 193 Lacy Street _ Property Address Jessica Plattner Owner Owner's Name y, information is MA 01845 10/09/13 required for every North Andover page. City/Town — State Zip Code Date of Inspection Inspection results must be submitted on this form. Inspection forms may not be altered in any way. Please see completeness checklist at the end of the form. Important:When filling out forms A. General Information on the computer, use only the tab 1. Inspector: key to move your cursor-do not John Soucy use the return Name of Inspector key. Soucy's Sewer Service r� Company Name 78 North Broadway Company Address r Salem NH 03079 City/Town State Zip Code 603-898-9339 13397 Telephone Number License Number B. Certification I certify that I have personally inspected the sewage disposal system at this address and that the information reported below is true, accurate and complete as of the time of the inspection. The inspection was performed based on my training and experience in the proper function and maintenance of on site sewage disposal systems. I am a DEP approved system inspector pursuant to Section 15.340 of Title 5 (310 CMR 15.000).The system: ® Passes ❑ Conditionally Passes ❑ Fails ❑ Needs Further Evaluation by the Local Approving Authority 10/09/13 pe or's Signature Date Th system inspector shall sub a copy of this inspection report to the Approving Authority (Board of Health or DEP)within 30 days of completing this inspection. If the system is a shared system or has a design flow of 10,000 gpd or greater, the inspector and the system owner shall submit the report to the appropriate regional office of the DEP. The original should be sent to the system owner and copies sent to the buyer, if applicable, and the approving authority. ****This report only describes conditions at the time of inspection and under the conditions of use at that time. This inspection does not address how the system will perform in the future under the same or different conditions of use. t5ins•09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 1 of 17 t, Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 193 Lacy Street Property Address Jessica Plattner Owner Owner's Name information is MA 01845 10/09/13 required for every North Andover 1 page. Cityrrown State Zip Code Date of Inspection B. Certification (cont.) Inspection Summary: Check A,B,C,D or E/always complete all of Section D A) System Passes: i ® I have not found any information which indicates that any of the failure criteria described in 310 CMR 15.303 or in 310 CMR 15.304 exist. Any failure criteria not evaluated are indicated below. Comments: i B) System Conditionally Passes: ❑ one or more system components as described in the"Conditional Pass" section need to be replaced or repaired. The system, upon completion of the replacement or repair, as approved by the Board of Health, will pass. Check the box for"yes", "no" or"not determined" (Y, N, ND) for the following statements. If"not determined," please explain. The septic tank is metal and over 20 years old' or the septic tank (whether metal or not) is structurally unsound, exhibits substantial infiltration or exfiltration or tank failure is imminent. System will pass inspection if the existing tank is replaced with a complying septic tank as approved by the Board of Health. *A metal septic tank will pass inspection if it is structurally sound, not leaking and if a Certificate of Compliance indicating that the tank is less than 20 years old is available. ❑ Y ❑ N ❑ ND (Explain below): t5ins•09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 2 of 17 Commonwealth of Massachusetts w Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments M 193 Lacy Street Property Address Jessica Plattner _ Owner Owner's Name information is MA 01845 10/09/13 required for every North Andover - page. City/Town State Zip Code Date of Inspection B. Certification (cont.) B) System Conditionally Passes (cont.): ❑ Observation of sewage backup or break out or high static water level in the distribution box due to broken or obstructed pipe(s) or due to a broken, settled or uneven distribution box. System will pass inspection if(with approval of Board of Health): ❑ broken pipe(s) are replaced ❑ Y ❑ N ❑ ND (Explain below): I ❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below): ❑ distribution box is leveled or replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ The system required pumping more than 4 times a year due to broken or obstructed pipe(s). The system will pass inspection if(with approval of the Board of Health): ❑ broken pipe(s) are replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below): C) Further Evaluation is Required by the Board of Health: ❑ Conditions exist which require further evaluation by the Board of Health in order to determine if the system is failing to protect public health, safety or the environment. 1. System will pass unless Board of Health determines in accordance with 310 CMR 15.303(1)(b)that the system is not functioning in a manner which will protect public health, t5ins-09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 3 of 17 L, Commonwealth of Massachusetts j W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 193 Lacy Street Property Address Jessica Plattner Owner Owner's Name information is MA 01845 10/09/13 required for every North Andover page. City/Town State Zip Code Date of Inspection 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 B. Certification (cont.) 2. System will fail unless the Board of Health and Public Water Supplier, if any) determines that the system is functioning in a manner that protects the public health, safety and environment: ❑ The system has a septic tank and soil absorption system (SAS) and the SAS is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water supply. ❑ The system has a septic tank and SAS and the SAS is within 50 feet of a private water supply well. ❑ The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or more from a private water supply well". Method used to determine distance: **This system passes if the well water analysis, performed at a DEP certified laboratory, for coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis must be attached to this form. 3. Other: D) System Failure Criteria Applicable to All Systems: You must indicate "Yes" or"No"to each of the following for all inspections: Yes No t5ins-09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 4 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form Not for Voluntary Assessments ,M 193 Lacy Street Property Address Jessica Plattner Owner Owner's Name information is MA 01845 10/09/13 required for every North Andover page. City/Town State Zip Code Date of Inspection ❑ ® Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool ❑ ® Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool ❑ ® Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool ❑ ® Liquid depth in cesspool is less than 6" below invert or available volume is less than 1/2 day flow B. Certification (cont.) Yes No El ® 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 SAS, cesspool or privy is below high ground water elevation. ❑ ® Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ ® Any portion of a cesspool or privy is within a Zone 1 of a public well. ❑ ® Any portion of a cesspool or privy is within 50 feet of a private water supply well. ❑ ® Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality analysis. [This system passes if the well water analysis, performed at a DEP certified laboratory,for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis and chain of custody must be attached to this form.] ❑ ® The system is a cesspool serving a facility with a design flow of 2000gpd- 10,000gpd. ❑ ® The system fails. I have determined that one or more of the above failure criteria exist as described in 310 CMR 15.303, therefore the system fails. The system owner should contact the Board of Health to determine what will be necessary to correct the failure. E) Large Systems: To be considered a large system the system must serve a facility with a design flow of 10,000 gpd to 15,000 gpd. For large systems, you must indicate either"yes"or"no"to each of the following, in addition to the questions in Section D. Yes No ❑ ❑ the system is within 400 feet of a surface drinking water supply t5ins•09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 5 of 17 t Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 193 Lacy Street Property Address Jessica Plattner Owner Owner's Name information is MA 01845 10/09/13 required for every North Andover page. CitylTown State Zip Code Date of Inspection ❑ ❑ the system is within 200 feet of a tributary to a surface drinking water supply El El Area system is located in a nitrogen sensitive area (Interim Wellhead Protection Area—IWPA) or a mapped Zone II of a public water supply well If you have answered "yes" to any question in Section E the system is considered a significant threat, or answered "yes" in Section D above the large system has failed. The owner or operator of any large system considered a significant threat under Section E or failed under Section D shall upgrade the system in accordance with 310 CMR 15.304. The system owner should contact the appropriate regional office of the Department. II C. Checklist Check if the following have been done. You must indicate"yes" or"no" as to each of the following: Yes No ® ❑ Pumping information was provided by the owner, occupant, or Board of Health ❑ ® Were any of the system components pumped out in the previous two weeks? ® ❑ Has the system received normal flows in the previous two week period? ❑ ® Have large volumes of water been introduced to the system recently or as part of this inspection? ® ❑ Were as built plans of.the system obtained and examined? (If they were not available note as N/A) ® ❑ Was the facility or dwelling inspected for signs of sewage back up? ® ❑ Was the site inspected for signs of break out? ® ❑ Were all system components, excluding the SAS, located on site? ® ❑ Were the septic tank manholes uncovered, opened, and the interior of the tank inspected for the condition of the baffles or tees, material of construction, dimensions, depth of liquid, depth of sludge and depth of scum? ® ❑ Was the facility owner(and occupants if different from owner) provided with information on the proper maintenance of subsurface sewage disposal systems? The size and location of the Soil Absorption System (SAS) on the site has been determined based on: ® ❑ Existing information. For example, a plan at the Board of Health. ® ❑ Determined in the field (if any of the failure criteria related to Part C is at issue approximation of distance is unacceptable) [310 CMR 15.302(5)] t5ins-09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 6 of 17 i Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments ^,^M 193 Lacy Street Property Address Jessica Plattner Owner Owner's Name information is MA 01845 10/09/13 required for every North Andover page. City/Town State Zip Code Date of Inspection D. System Information Residential Flow Conditions: Number of bedrooms (design): 4 Number of bedrooms (actual): 4 DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): 440 D. System Information Description: Number of current residents: 2 Does residence have a garbage grinder? ❑ Yes ® No Is laundry on a separate sewage system? [if yes separate inspection required] ❑ Yes ® No Laundry system inspected? ❑ Yes ® No Seasonaluse? ❑ Yes ® No Water meter readings, if available last 2 ears usage d Well 9 ( Y 9 (gP ))� Detail: Sump pump? ❑ Yes ® No Last date of occupancy: current Date Commercial/Industrial Flow Conditions: t5ins•09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 7 of 17 Commonwealth of Massachusetts w Title 5 Official Inspection Form Subsurface Sewage Disposal"System Form - Not for Voluntary Assessments 193 Lacy Street Property Address Jessica Plattner Owner Owner's Name information is MA 01845 10/09/13 required for every North Andover page. City/Town State Zip Code Date of Inspection Type of Establishment: N/A Design flow(based on 310 CMR 15.203): Gallons per day(gpd) I Basis of design flow (seats/persons/sq.ft., etc.): Grease trap present? ❑ Yes ❑ No Industrial waste holding tank present? ❑ Yes ❑ No Non-sanitary waste discharged to the Title 5 system? ❑ Yes ❑ No Water meter readings, if available: D. System Information (cont.) Last date of occupancy/use: Current Date Other(describe below): General Information Pumping Records: Source of information: Owner i Was system pumped as part of the inspection? ® Yes ❑ No If yes, volume pumped: 1500 gallons How was quantity pumped determined? gauge on truck Reason for pumping: Inspection Type of System: ® Septic tank, distribution box, soil absorption system ❑ Single cesspool t5ins•09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 8 of 17 Commonwealth of Massachusetts N W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments M 193 Lacy Street Property Address Jessica Plattner Owner Owner's Name information is MA 01845 10/09/13 required for every North Andover page. City/Town State Zip Code Date of Inspection ❑ Overflow cesspool ❑ Privy ❑ Shared system (yes or no) (if yes, attach previous inspection records, if any) ❑ Innovative/Alternative technology. Attach a copy of the current operation and maintenance contract(to be obtained from system owner) and a copy of latest inspection of the I/A system by system operator under contract ❑ Tight tank. Attach a copy of the DEP approval. ❑ Other(describe): D. System Information (cont.) Approximate age of all components, date installed (if known) and source of information: 12/2005 Were sewage odors detected when arriving at the site? ❑ Yes ® No Building Sewer(locate on site plan): 4 Depth below rade: p g feet Material of construction: ❑ cast iron ® 40 PVC ❑ other(explain): Distance from private water supply well or suction line. 100' feet Comments (on condition of joints, venting, evidence of leakage, etc.): Septic Tank(locate on site plan): 3' � Depth below grade: feet t5ins-09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 9 of 17 L i Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments ^M 193 Lacy Street Property Address Jessica Plattner _ Owner Owner's Name information is required for every North Andover MA 01845 10/09/13 page. City/Town State Zip Code Date of Inspection Material of construction: ® concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain) If tank is metal, list age: years Is age confirmed by a Certificate of Compliance? (attach a copy of certificate) ❑ Yes ❑ No Dimensions: Sludge depth: D. System Information (cont.) Septic Tank (cont.) Distance from top of sludge to bottom of outlet tee or baffle 38" Scum thickness 2" 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 14" How were dimensions determined? Tape and sludge tool Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): t5ins-09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 10 of 17I t Commonwealth of Massachusetts w Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 193 Lacy Street Property Address Jessica Plattner Owner Owner's Name information is MA 01845 10/09/13 required for every North Andover page. Cityfrown State Zip Code Date of Inspection Grease Trap (locate on site plan): Depth below rade: N/A I p g feet Material of construction: ❑ concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain): Dimensions: Scum thickness Distance from top of scum to top of outlet tee or baffle Distance from bottom of scum to bottom of outlet tee or baffle Date of last pumping: Date D. System Information (cont.) Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): Tight or Holding Tank(tank must be pumped at time of inspection) (locate on site plan): Depth below grade: N/A Material of construction.- F-1 onstruction:❑ concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain): Dimensions: Capacity: gallons t5ins-09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 11 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 193 Lacy Street Property Address Jessica Plattner Owner Owner's Name information is MA 01845 10/09/13 required for every North Andover page. Cityfrown State Zip Code Date of Inspection Design Flow: gallons per day Alarm present: ❑ Yes ❑ No Alarm level: Alarm in working order: ❑ Yes ❑ No Date of last pumping: Date Comments (condition of alarm and float switches, etc.): "Attach copy of current pumping contract(required). Is copy attached? ❑ Yes ❑ No D. System Information (cont.) Distribution Box (if present must be opened) (locate on site plan): Depth of liquid level above outlet invert 0 11 Comments (note if box is level and distribution to outlets equal, any evidence of solids carryover, any evidence of leakage into or out of box, etc.): Flow checked good. Pump Chamber(locate on site plan): Pumps in working order: ® Yes ❑ No t5ins•09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 12 of 17 <{ Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 0 193 Lacy Street Property Address Jessica Plattner Owner Owner's Name information is MA 01845 10/09/13 required for every North Andover page. City/Town State Zip Code Date of Inspection Alarms in working order: ® Yes ❑ No Comments (note condition of pump chamber, condition of pumps and appurtenances, etc.): Soil Absorption System (SAS) (locate on site plan, excavation not required): If SAS not located, explain why: I D. System Information (cont.) Type: ❑ leaching pits number: ® leaching chambers number: 36 ❑ leaching galleries number: ❑ leaching trenches number, length: ❑ leaching fields number, dimensions: ❑ overflow cesspool number: — ❑ innovative/alternative system Type/name of technology: — — -- Comments (note condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of vegetation, etc.): t5ins•09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 13 of 17 , t i, Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments M 193 Lacy Street Property Address Jessica Plattner Owner Owner's Name information is MA 01845 10/09/13 required for every North Andover page. City/Town State Zip Code Date of Inspection Cesspools (cesspool must be pumped as part of inspection) (locate on site plan): Number and configuration N/A 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 ❑ Yes ❑ No D. System Information (cont.) Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.)-. Privy (locate on site plan): Materials of construction: N/A Dimensions Depth of solids t5ins•09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 14 of 17 �• Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 193 Lacy Street Property Address Jessica Plattner Owner Owner's Name information is MA 01845 10/09/13 required for every North Andover page. City/Town State Zip Code Date of Inspection Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): i I I i D. System Information (cont.) Sketch Of Sewage Disposal System: Provide a view of the sewage disposal system, including ties to at least two permanent reference landmarks or benchmarks. Locate all wells within 100 feet. Locate where public water supply enters the building. Check one of the boxes below: ® hand-sketch in the area below El drawing attached separately Y t5ins•09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 15 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form - Subsurface Sewage Disposal System Form -Not for Voluntary Assessments w 193 Lacy Street Property Address Jessica Plattner Owner Owner's Name information is MA 01845 10/09/13 required for every North Andover page City/Town State- — Zip Code � 3 uw _ N ' t000,GWON pONOV1N�M i Y 1388 cY20X STYDO,,,C T¢ , TAX I �OOX-2 ' OIMWe%:TOP OF Q�L ROOp .. LtFN10Ul r NOTE:------- MP INSTALLE IIARNES YODEL SEE411P4PUP SPECIRED.DIN LIEll'OF „f j INVERT ELEVATIONS TANK IN127.50 1 28.00 TANK OUf 127.25 12 PIIYP W 12].IS 128.01 Gl '�i\�::5'�`i\}r`ui:•4�"":.::' PUMP OUT 126.00 D—BO%.W 23].50 133.24 � OUT1335, 133.2] "' A 1312 133.23 ejr ` B' 13]3 133.2) O C" °;.i'\����?, 0 .a:��.. �. ? 1}3.22 IJJ.23 ::.2; `:�:.. 33.2 D 1 . IJ3.23 \? E 133.22 133.23 :j,,,�;.\;:,:::•:�;:' 131VI F 1}3.21 et:,.�;`.•���\T�+�:: . BOTTOM Or BED132.70 193 IACX$TREE! ASSESSORS MAP 105D, PARCEL.811, 1.57 AC. � r h & B D. System Information (cont) Site Exam: ® Check Slope ® Surface water ® Check cellar ❑ Shallow wells Estimated depth to high ground water: 31 feet Please indicate all methods used to determine the high ground water elevation: t5ins-09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 16 of 17 `• Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 193 Lacy Street _ Property Address Jessica Plattner Owner Owner's Name information is MA 01845 10/09/13 required for every North Andover page. City/Town State Zip Code Date of Inspection ® Obtained from system design plans on record If checked, date of design plan reviewed: 09/20/2005 Date ® Observed site (abutting property/observation hole within 150 feet of SAS) ❑ Checked with local Board of Health - explain: ❑ Checked with local excavators, installers-(attach documentation) ❑ Accessed USGS database-explain: You must describe how you established the high ground water elevation: Dug hole with auger in low drop off area. Before filing this Inspection Report, please see Report Completeness Checklist on next page. E. Report Completeness Checklist ❑ Inspection Summary: A, B, C, D, or E checked ❑ Inspection Summary D (System Failure Criteria Applicable to All Systems) completed ❑ System Information— Estimated depth to high groundwater ❑ Sketch of Sewage Disposal System either drawn on page 15 or attached in separate file t5ins•09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 17 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection orm Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 193 Lacy Street____---. -- Property Address Kathy Entsminger Owner Owner's Name information is MA 01845 09/02/10 required for every North Andover _ — -— page. City/Town State Zip Code Date of Inspection Inspection results must be submitted on this form. Inspection forms may not be altered in any way. Please see completeness checklist at the end of the form. Important:Wher: &a. General Information .--- filling out forms 0.19C�IVE'D on the computer, C use only the tab 1. Inspector: key to move your r�^p �� �}D�� cursor-do not John Soucy/Shawn Brazel .. SE +s use the return Name of Inspector key. TOWN OF NORTH ANDOVER Souc 's Sewer Service L;4E.A.1-TH DEPARTMENT r� Company Name 78 North Broadway Company Address Salem _ NH 03079 City/Town State Zip Code 603-898-9339 '>�o r - — Telephone Number License Number B. Certification I certify that I have personally inspected the sewage disposal system at this address and that the information reported below is true, accurate and complete as of the time of the inspection. The inspection was performed based on my training and experience in the proper function and maintenance of on site sewage disposal systems. I am a DEP approved system inspector pursuant to Section 15.340 of Title 5 (310 CMR 15.000).The system: ® Passes ❑ Conditionally Passes ❑ Fails ❑ Needs Further Evaluation by the Local Approving Authority 09/02/10 O'ature Inspector's SDate The system inspector shall submit a copy of this inspection report to the Approving Authority (Board of Health or DEP)within 30 days of completing this inspection. If the system is a shared system or has a design flow of 10,000 gpd or greater, the inspector and the system owner shall submit the report to the appropriate regional office of the DEP. The original should be sent to the system owner and copies sent to the buyer, if applicable, and the approving authority. rit . ****This report only describes conditions at the time of inspection and under the conditions of use at that time.This inspection does not address how the system will perform in the future under the same or different conditions of use. Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 1 of 17 t5ins•09108 f Commonwealth of Massachusetts _ = W Title 5 Official Inspection Fora Subsurface Sewage Disposal System Form - Not for Voluntary Assessments M 193 Lacy Street _ _ --- Property Address Kathy Entsminger _ Owner Owner's Name information is MA 01845 09/02/10 required for every North Andover _ page. City/Town State Zip Code Date of Inspection B. Certification (cont.) Inspection Summary: Check A,B,C,D or E/always complete all of Section D A) System Passes: ® I have not found any information which indicates that any of the failure criteria described in 310 CMR 15.303 or in 310 CMR 15.304 exist. Any failure criteria not evaluated are indicated below. Comments: B) System Conditionally Passes: ❑ One or more system components as described in the "Conditional Pass" section need to be replaced or repaired. The system, upon completion of the replacement or repair, as approved by the Board of Health, will pass. Check the box for"yes", "no" or"not determined" (Y, N, ND) for the following statements. If"not determined," please explain. The septic tank is metal and over 20 years old* or the septic tank (whether metal or not) is structurally unsound, exhibits substantial infiltration or exfiltration or tank failure is imminent. System will pass inspection if the existingtank is laced with a complying septic tank as approved by the Board of P Health. *A metal septic tank will pass inspection if it is structurally sound, not leaking and if a Certificate of Compliance indicating that the tank is less than 20 years old is available. ❑ Y ❑ N ❑ ND (Explain below): Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 2 of 17 t5ins•09108 C Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments GSM 193 Lacy Street Property Address Kathy Entsminger Owner Owner's Name information is North Andover MA 01845 09/02/10 required for every - page. City/Town State Zip Code Date of Inspection B. Certification (cont.) B) System Conditionally Passes (cont.): ❑ Observation of sewage backup or break out or high static water level in the distribution box due to broken or obstructed pipe(s) or due to a broken, settled or uneven distribution box. System will pass inspection if(with approval of Board of Health): ❑ broken pipe(s) are replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below): ❑ distribution box is leveled or replaced ❑ Y ❑ N ❑ ND (Explain helow): ❑ The system required pumping more than 4 times a year due to broken or obstructed pipe(s). The system will pass inspection if(with approval of the Board of Health): ❑ broken pipe(s) are replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below): C) Further Evaluation is Required by the Board of Health: ❑ Conditions exist which require further evaluation by the Board of Health in order to determine if the system is failing to protect public health, safety or the environment. 1. System will pass unless Board of Health determines in accordance with 310 CMR 15.303(1)(b)that the system is not functioning in a manner which will protect public health, safety and the environment: ❑ Cesspool or privy is within 50 feet of a surface water ❑ Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh t5ins•09108 Title 5 Official Inspection Form:Subsurface Sewage Dispo—I System•Page 3 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 193 Lacy Street Property Address Kates Entsminger Owner Owner's Name information is required for every _North Andover _MA 01845 09/02/10_ _ page. City/Town State Zip Code Date of Inspection B. Certification (cont.) 2. System will fail unless the Board of Health (and Public Water Supplier, if any) determines that the system is functioning in a manner that protects the public health, safety and environment: ❑ The system has a septic tank and soil absorption system (SAS) and the SAS is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water supply. ❑ The system has a septic tank and SAS and the SAS is within 50 feet of a private water supply well. ❑ The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or more from a private water supply well". Method used to determine distance: This system passes if the well water analysis, performed at a DEP certified laboratory, for coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis must be attached to this form. 3. Other: I _ D) System Failure Criteria Applicable to All Systems: You must indicate "Yes" or"No"to each of the following for all inspections: Yes No El ® Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool ❑ ® Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool ❑ ® Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool El ® Liquid depth in cesspool is less than 6" below invert or available volume is less than '/z day flow t5ins•09/08 Title 5 Oficial Inspection Form:Subsurface Sewage Disposal System•Page 4 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments ° 193 Lacy Street - Froperty Address Kathy Entsminger -_ _. _ -, Owner Owner's Name information is North Andover _MA 01845 09/02/10 required for every ---- - page. City/Town Sttao te Zip Code Date of Inspection B. Certification (cont.) Yes No ❑ ® Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number of times pumped: ❑ ® Any portion of the SAS, cesspool or privy is below high ground water elevation. El Z Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ ® Any portion of a cesspool or privy is within a Zone 1 of a public well. ❑ ® Any portion of a cesspool or privy is within 50 feet of a private water supply well. ❑ ® Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality analysis. [This system passes if the well water analysis, performed at a DEP certified laboratory,for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis and chain of custody must be attached to this form.] ❑ ® The system is a cesspool serving a facility with a design flow of 2000gpd- 10,000gpd. ❑ ® The system fails. I have determined that one or more of the above failure criteria exist as described in 310 CMR 15.303, therefore the system fails. The system owner should contact the Board of Health to determine what will be necessary to correct the failure. E) Large Systems: To be considered a large system the system must serve a facility with a design flow of 10,000 gpd to 15,000 gpd. For large systems, you must indicate either"yes" or"no"to each of the following, in addition to the questions in Section D. Yes No ❑ ❑ 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 El ❑ 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 If you have answered "yes" to any question in Section E the system is considered a significant threat, or answered "yes" in Section D above the large system has failed. The owner or operator of any large system considered a significant threat under Section E or failed under Section D shall upgrade the system in accordance with 310 CMR 15.304. The system owner should contact the ap propriate e regional office of the Department. t5ins•09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 5 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 193 Lacy Street - Property Address Kathy Entsmin er Owner Owner's Name information is required for every North Andover MA 01845 09/02/10 -- page. City/Town State Zip Code Date of Inspection C. Checklist i Check if the following have been done. You must indicate"yes" or"no" as to each of the following: Yes No ® ❑ Pumping information was provided by the owner, occupant, or Bcard of Health ❑ ® Were any of the system components pumped out in the previous two weeks? ® ❑ Has the system received normal flows in the previous two week period? Have large volumes of water been introduced to the system recently or as part of ❑ ® this inspection? ® ❑ Were as built plans of the system obtained and examined? (If they were not available note as N/A) ® ❑ Was the facility or dwelling inspected for signs of sewage back up? ns of break out?® inspected for si❑ Was the site p g ® ❑ Were all system components, excluding the SAS, located on site? ® ❑ Were the septic tank manholes uncovered, opened, and the interior of the tank inspected for the condition of the baffles or tees, material of construction, dimensions, depth of liquid, depth of sludge and depth of scum? ® ❑ Was the facility owner(and occupants if different from owner) provided with information on the proper maintenance of subsurface sewage disposal systems? The size and location of the Soil Absorption System (SAS) on the site has been determined based on: ® ❑ Existing information. For example, a plan at the Board of Health. ® ❑ Determined in the field (if any of the failure criteria related to Part C is at issue approximation of distance is unacceptable) [310 CMR 15.302(5)] D. System Information Residential Flow Conditions: Number of bedrooms (design): 4 Number of bedrooms (actual): 4 DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): 440 t5ins•09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 6 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments M 193 Lacy Street Property Address Kathy Entsminger Owner Owner's Name information is required for every North Andover MA 01845 09/02/10 - — -- page. City/Town State Zip Code Date of Inspection D. System Information i Descnpt on: 4 I Number of current residents: Does residence have a garbage grinder? ® Yes ❑ No Is laundry on a separate sewage system? [if yes separate inspection required] ❑ Yes ® No Laundry system inspected? ❑ Yes ® No Seasonal use? ❑ Yes ® No Well Water meter readings, if available (last 2 years usage (gpd)): Detail: Recommend removal of garbage disposal _— I Sump pump? ❑ Yes ® No current Last date of occupancy: Date Commercial/Industrial Flow Conditions: � N/A Type of Establishment: Design flow(based on 310 CMR 15.203): Gallons per day(gpd) Basis of design flow(seats/persons/sq.ft., etc.): Grease trap present? ❑ Yes ❑ No Industrial waste holding tank present? Ll Yes ❑ No Non-sanitary waste discharged to the Title 5 system? ❑ Yes E] No Water meter readings, if available: t5ins•09108 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 7 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form Not for Voluntary Assessments ,M 193 Lacv Street — — — Property Address Kathy Entsminger _— —_— -- — - Owner Owner's Name information is North Andover MA 01845 _ 09/02/10 — required for every State Zip Code Date of Inspection page. City/Town D. System Information (cont.) Current — Last date of occupancy/use: Date Other(describe below): — General Information Pumping Records: Owner _ --- Source of information: -- Was system pumped as part of the inspection? Yes ❑ No 1500 If yes, volume pumped: gallons gauge on truck How was quantity pumped determined? — Inspection Reason for pumping: Type of System: ® 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) D Innovative/Alternative technology. Attach a copy of the current operation and maintenance contract(to be obtained from system owner) and a copy of latest inspection of the I/A system by system operator under contract ❑ Tight tank. Attach a copy of the DEP approval. ❑ Other(describe): Title 5 official Inspection Form:Subsurface Sewage Disposal system•Page 8 of 17 t5ins•09108 Commonwealth of Massachusetts w Title 5 Official Inspection Form Subsurface Sewage Disposal System Form Not for Voluntary Assessments M 193 Lacy Street Property Address Kathy Entsminger Owner Owner's Name information is North Andover MA 01845 09/02/10 required for every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Approximate age of all components, date installed (if known) and source of information. 12/2005 -- Were sewage odors detected when arriving at the site? ❑ Yes ® No Building Sewer(locate on site plan): i 4 Depth below grade: feet Material of construction: ❑ cast iron ® 40 PVC ❑ other(explain): — 100, — Distance from private water supply well or suction line: feet Comments (on condition of joints, venting, evidence of leakage, etc.): Septic Tank (locate on site plan): Depth below grade: feet I Material of construction: ® concrete ❑ metal ❑ fiberglass El polyethylene other(explain) If tank is metal, list age: years Is age confirmed by a Certificate of Compliance? (attach a copy of certificate) ❑ Yes ❑ No Dimensions: Sludge depth: Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 9 of 17 t5ins•09/08 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 193 LacY Street - - Property Address Kathy Entsminger Owner Owner's Name information is MA 01845 09/02/10 required for every North Andover page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Septic Tank (cont.) 38" Distance from top of sludge to bottom of outlet tee or baffle - 2" _ Scum thickness 8„ - Distance from top of scum to top of outlet tee or baffle 14" Distance from bottom of scum to bottom of outlet tee or baffle Tape and sludge tool How were dimensions determined? Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): Grease Trap (locate on site plan): N/A Depth below grade: feet Material of construction: ❑ concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain): Dimensions: Scum thickness Distance from top of scum to top of outlet tee or baffle — Distance from bottom of scum to bottom of outlet tee or baffle ---- Date of last pumping: Date Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 10 of 17 t5ins•09/08 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments o °M 193 Lacy Street Property Address Kathy Entsminger Owner Owner's Name information is required for every North Andover MA 01845 09/02/10 - - -- page City/Town State Zip Code Date of Inspection D. System Information (cont.) Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): Recommend removal of garbage disposal i Tight or Holding Tank (tank must be pumped at time of inspection) (locate on site plan): N/A _ Depth below grade: Material of construction: ❑ concrete ❑ metal ❑ fiberglass ❑ polyethylene L� other(explain): I Dimensions: Capacity: gallons Design Flow: gallons per day Alarm present: ❑ Yes ❑ No Alarm level: Alarm in working order: ❑ Yes ❑ No Date of last pumping: date Comments (condition of alarm and float switches, etc.): *Attach copy of current pumping contract(required). Is copy attached? ❑ Yes ❑ No Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 11 of 17 t5ins•09/08 Commonwealth of Massachusetts W Title 5 Official Inspection Form s� Subsurface Sewage Disposal System Form Not for Voluntary Assessments 193 Lacy Street Property Address Kathy Entsmincger. Owner Owner's Name information is North Andover MA 01845 09/02/10---- required 9/02/10 __required for every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Distribution Box (if present must be opened) (locate on site plan): 0" Depth of liquid level above outlet invert Comments (note if box is level and distribution to outlets equal, any evidence of solids carryover, any evidence of leakage into or out of box, etc.): Flow checked good, some deposits formed by garbage disposal. Pump Chamber(locate on site plan): Pumps in working order: ® Yes ❑ No Alarms in working order: ® Yes ❑ No Comments (note condition of pump chamber, condition of pumps and appurtenances, etc.): Soil Absorption System (SAS) (locate on site plan, excavation not required): If SAS not located, explain why: Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 12 of 17 t5ins•09108 I Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments ,.H 193 Lacy Street Property Address Kathy Entsminger — Owner Owner's Name information is North Andover MA 01845 _ 09/02il0 required for every — — page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Type: ❑ leaching pits number: 36 ® leaching chambers number: — ❑ leaching galleries number: ❑ leaching trenches number, length: ❑ leaching fields number, dimensions: ❑ overflow cesspool number: - ❑ innovative/alternative system Type/name of technology: Comments (note condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of vegetation, etc.): Cesspools (cesspool must be pumped as part of inspection) (locate on site plan): N/A 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 ❑ Yes ❑ No Title 5 official Inspection Form:Subsurface Sewage Disposal System•Page 13 of 17 t5ins•09/08 I Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 193 Lacy Street Property Address P Y Kathy Entsminger _ Owner Owner's Name information is North Andover MA 01845 — 09/02/10 required for every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.)-. I — Privy (locate on site plan): N/A Materials of construction: Dimensions Depth of solids Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 14 of 17 t5ins•09/08 Commonwealth of Massachusetts v ` Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 'w 193 Lacy Street Property Address Kathy Entsmin er — Owner Owner's Name information is North Andover MA 01845 09/02/10 required for every State Zip Code Date of Inspection page City/ own D. System Information (cont.) ' Sketch Of Sewage Disposal System: Provide a view of the sewage disposal system, including ties tc at least two permanent reference landmarks or benchmarks. Locate all wells within 100 feet. Locate where public water supply enters the building. Check one of the boxes below: ® hand-sketch in the area below ❑ drawing attached separately z O Oy .�--- 0000 m yOUz. VI Zc0 Xx TI�1➢D 8—I—1-1—1—i Cq �LG•(D� [iyj 'U ��' CD(n mu 7, ve 000000 ViAIJN c� 000Cz p dib N b ��ccnn C rD 07 C [+7 M t�7 l7 t+C7�C] (7 XX H �� ry D 7Jry� ......� K O m z y to co �' 9 [] OC p7 r 0 0o O to oON ro m �1 O� tnm c0iiim ern ,- VIII O mn OO NN 2P I D O � » i tJ 0 1 � I 1n0NV310 00 NOOT3 30—.40 401;MSYNHON: NNV1 OLLd3S SII OIH1nONOW NOTrv'J OOSI .l 00 -HOO X0a Ncunelwsl X38 d ,J HllTO 0M NOTNO OOOI f-H03 Y V V ONVs dD 11wn r Z-H00 r J t iN3A Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 15 of t5ins•09108 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 193 Lacy Street --- -- Property Address Kathy Entsminger _ Owner Owner's Name information is North Andover _MA 01845 09/02/10 required for every - State Zip Code Date of Inspection j page. City/Town D. System Information (cont.) Site Exam: ® Check Slope ® Surface water i ® Check cellar ❑ Shallow wells 3' Estimated depth to high ground water: feet Please indicate all methods used to determine the high ground water elevation: j ® Obtained from system design plans on record 09/20/2005 If checked, date of design plan reviewed: Date I ® Observed site (abutting property/observation hole within 150 feet of SAS) ❑ Checked with local Board of Health -explain: ❑ Checked with local excavators, installers-(attach documentation) ❑ Accessed USGS database -explain: You must describe how you established the high ground water elevation: j Dug hole with auger in low drop off area. Before filing this Inspection Report, please see Report Completeness Checklist on next page. Title 5 Official Inspection Form:Subsurface Sewage Disposai System•Page 16 of 17 t5ins•09/08 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 193 Lacy Street Property Address Kathy Entsminger - Owner Owner's Name information is _North Andover _MA 01845 09/02/10 required for every - page. City/Town State Zip Code Date of Inspection E. Report Completeness Checklist 2;lnspection Summary: A, B, C, D, or E checked ns ection Summary D (System Failure Criteria Applicable to All Systems) completed System Information— Estimated depth to high groundwater EZ/Sketch of Sewage Disposal System either drawn on page 15 or attached in separate file Title 5 Oficial Inspection Form:Subsurface Sewage Disposal System•Page 17 of 17 t5ins•09108 ,Wn of North Andover E N°RTH, Office of the Health Department Community Development and Services Division s ; 400 OSGOOD STREET North Andover,Massachusetts 01845CH SACNUS Susan Y. Sawver, RE.HS/RS 978.688.9540-Phone Public Health Director 978.688.8476-Fax Cw W 7j" IE O F COJK(p.,r r g SCE As of: December 29, 2005 This is to cert that the individual subsurface disposal system was a Fully Constructed y ,john Soucy At: 193 .Lacy Street North Andover, 9V3 01845 Ifas been installed in accordance with the provisions of Title v of the State Sanitary Code and with the North Andover Board of Yfeafth regulations. The Issuance of this certifi'cate shall not 6e construed as a guarantee that the system will function satisfactorily. 'Sus n T Sawyer, XMIQ,S (Public Yfealth Director BOARD 01-APPFAIS 688-9541 BUILDING 68&95.45 CONSii?RVATION 68$0530 IIEALT}t 68&9540 PLANNING 6880535 N OF NORTH ANDOVER - °t NORTh LRECEMWIle of OMivitNITY DEVELOPMENT AND SER-VICES HEALTH DEPARTMENT � 7 2005 400 OSGOOD STREETORTH ANDOVER, MASSACHUSETTS 01845 �sswcMuOF NORTH ANDOVER 978.688.9540-Phone DEPARTidIENT awyer–REEFtStft 978.688.8476–FAX Public Health Director E-MAIL:healthdept@atownofnorthandover.com WEBSITE:http://www.townofnorthandover.com TOWN OF NORTH ANDOVER SEPTIC DISPOSAL SYSTEM - INSTALLATION CERTIFICATION The undersigned hereby certify that the Sewage Disposal System ( ) constructed; �e) repaired; by o R IJ Sao (PrintName) located at t q S:;—(C,COE:i a 9_1W AAJ J> vL (Instalfation Address) was installed in conformance with the North Andover Board of Health approved plan, originally dated - _and last Revised on q L14 Nos , with a design flow of gyp gallons per day. The materials used were in conformance with those specified on the approved plan;the system was installed in accordance with the provisions of 310 OCMR 15.000, Title 5 and local regulations, and the final grading agrees substantially with the approved plan. All work is accurately represented on the As-built which has been submitted to the Board of Health. i Bed inspection date: ? Engi eer Represe tive(Signature) gchOs a�da JQ And-Print Name Final inspection date: 2-010 Engi eer Representative(Signature) And-Print N me Installer: (Signature) Date: 6SAM �c And-Print Name Engineer: Ar' (Signature) Date: cy 1240s— O And-Print Name -0 . 0 f DelleChiaie, Pamela From: amcbrearty@verizon.net Sent: Friday, September 09, 2005 12:21 PM To: DelleChiaie, Pamela; Sawyer, Susan; Grant, Michele Subject: Construction inspection 193 Lacy St 193Lacy Const. Insp.doc Hi All, Const. Inspection for 193 Lacy went well. Quite the mound in their backyard. Hopefully Soucy can grade it in well. Here is the const. report. (3-floats, BTW. . . ) 1 0- OWN OF NORTH ANDOVER O e Office of COMMUNITY DEVELOPMENT AND SERVICES �? HEALTH DEPARTMENT 400 OSGOOD STREET NORTH ANDOVER, MASSACHUSETTS 01845 $�SSgCH Susan Y. Sawyer,REHS/RS 978.688.9540—Phone Public Health Director 978.688.9542—FAX ADDRESS: 193 Lacy Street MAP:105D LOT: 8D INSTALLER: Soucy Septic DESIGNER: Milestone Engineering PLAN DATE: 9/14/04 (Rev. 4/16/2005) BOH APPROVAL DATE ON PLAN: 7/25/2005 DATE OF BED BOTTOM INSPECTION: DATE OF FINAL CONSTRUCTION INSPECTION: 9/9/2005 DATE OF FINAL GRADE INSPECTION: SITE CONDITIONS ❑Existing septic tank properly abandoned ®Internal plumbing all to one building sewer ❑Topography not appreciably altered Comments: SEPTIC TANK ❑ Bottom of tank hole has 6" stone base ❑ Weep hole plugged ® 1500 gallon tank has been installed H-10 loading Monolithic construction ❑ Water tightness of tank has been achieved (Visual or Vacuum Test or Water held for 24hrs) ® Inlet tee installed, centered under access port ® Outlet tee (gas baffle or effluent filter) installed, centered under access port ® 24" inch cover to within 6" of final grade installed over one access port, must be over outlet of tank if effluent filter is present ® Hydraulic cement around inlet & outlet Comments: 2-compartment mono tank, tees at inlet, outlet and compartment wall as required Page 1 of 3 TOWN OF NORTH ANDOVER O f NORTH ' Office of COMMUNITY DEVELOPMENT AND SERVICES HEALTH DEPARTMENT 400 OSGOOD STREET NORTH ANDOVER, MASSACHUSETTS 01845 �''Ss�CMUst�' Susan Y.Sawyer,REHS/RS 978.688.9540—Phone Public Health Director 978.688.9542—FAX PUMP CHAMBER ❑ Bottom of tank hole has 6" stone base ❑ Weep hole plugged ® 1000 gallon Pump Chamber installed H-10 loading Monolithic construction) ® Inlet tee installed, centered under access port ® Pump(s) installed on stable base ® Alarm float working ® Pump On/Off float working ® Drain hole in pressure line ® 24" inch cover to within 6" of final grade installed over pump access port ❑ Water tightness of tank has been achieved Visual testing ® Hydraulic cement around inlet & outlet Comments: 3 floats as called for in plan D-BOX ® Installed on stable stone base ® Inlet tee (if pumped or >0.08'/foot) ® Hydraulic cement around inlet & outlets ® Observed even distribution ❑ Speed levelers provided (not required) Comments: CONTROLPANEL ® Alarm & Pump are on separate circuits ® Alarm sounds when float is tripped ® Location of control panel: ❑ Rated for exterior if placed outside Comments: i Page 2 of 3 Q TOWN OF NORTH ANDOVER N°RTH Office of COMMUNITY DEVELOPMENT AND SERVICES HEALTH DEPARTMENT p woo fi 400 OSGOOD STREET NORTH ANDOVER,MASSACHUSETTS 01845 Susan Y.Sawyer,REHS/RS 978.688.9540-Phone Public Health Director 978.688.9542-FAX SOIL ABSORPTION SYSTEM ❑ Bottom of SAS excavated down to soil layer, as provided on plan ® Size of SAS excavated as per plan ® Title 5 sand installed, if specified on plan ® laterals installed and ends connected to header (and vented if impervious material above) ® Gravelless disposal systems: type, number and location as per plan ® Elevations of laterals installed as on approved plan ® 40 Mil HDPE barrier installed ❑ Final cover as per plan Comments: ,� - hn ra i n+o r 2q.s V�1C�,�h, �N.� I..Qx�r,� , aS� J(J QA - U-z jR. � o�V to SYSTEM ELEVATIONS Benchmark: 126.39 Rod at Benchmark: 7.89 Height of Instrument: 134.28 INVERT ON DESIGN PLAN INVERT ELEVATION Building Sewer OUT 129.70 129.03 Septic Tank IN 127.50 128.90 Septic Tank OUT 127.25 128.65 Pump Chamber IN 127.15 128.62 Pump Chamber OUT 126.90 128.49 Distribution Box IN 133.56 133.45 Distribution Box OUT 133.39 133.29 Manifold Lateral 1 HIGH 133.70 133.70 Lateral 1 LOW 133.70 133.70 Lateral 2 HIGH 133.70 133.70 Lateral 2 LOW 133.70 133.70 Lateral 3 HIGH 133.70 133.70 Lateral 3 LOW 133.70 133.70 Lateral 4 HIGH 133.70 133.70 Lateral 4 LOW 133.70 133.68 Lateral 5 HIGH 133.70 133.70 Lateral 5 LOW 133.70 133.70 Page 3 of 3 M�"rN Commonwealth of Massachusetts Map-Block-Lot c .• '% , y���i 105.D-0060-.. r ,* Board of Health PemiitNo BNP-2005-0269 North Andover ....-_ _..-__.. P.I. ._.__ _ FEE rs♦cwuE� F.I. $250.00 Disposal Works Construction Permit Permission is hereby granted Joh Solley _ to(Repair)an Individual Sewage Disposal System. at No 193 LACY STREET -___ ......-- ---------- ----- as shown on the application for Disposal Works Construction Permit No. BHP-2005-026 Dated August 29,2005 Issued On:Aug-29-2005 Board of Health TOWN OF NORTH ANDOVER /�. t gORTH 1 Office of COMMUNITY DEVELOPMENT AND SERVICES HEALTH DEPARTMENT 400 OSGOOD STREET NORTH ANDOVER, MASSACHUSETTS 01845 SACHUS 978.688.9540—Phone Susan Y.Sawyer,RENS/RS 978.688.9542—FAX Public Health Director healthdeptp_townofnorthandover.com-e-mail www.townofnorthandover.com-website APPLICATION FOR DISPOSAL WORKS CONSTRUCTION PERMIT DATE: 613 s-0 LOCATION: HOMEOWNERNAME: r LICENSED INSTALLER NAME: .J •.� A�6u� PLEASE PRINT SIGNATURE: Z& TELEPHONE# CHECK ONE FULL SYSTEM REPAIR:P/ 0(�2_50) COMPONENT REPAIR(indicate what parts): ($125) * NEW CONSTRUCTION: * If NEW CONSTRUCTION, please attach the Foundation As-Built Plan. $250.00 or$125 Fee Attached? Yes No Project Manager Obligation From Attached? Yes No Foundation As-Built? Yes No Floor Plans? Yes No Approval of Health Agent Date: Q S v 4. INSTALLER PROJECT MANAGEMENT OBLIGATIONS As the North Andover licensed installer for the construction of the septic system for the property at relative to the application ofdated $'—� �o for plans by� .(' ,and dated V' 111/611with revisions dated I understand the following obligations for management of this project: 1. As the installer I am obligated to obtain all permits and Board of Health approved plans prior to performing any work on a site. I must have the approved plans and the permit on site when any work is being done. 2. As the installer I must call for any and all inspections. If homeowner, contractor, project manger, or any other person not associated with my company schedules an inspection and the system is not ready then item three shall be applicable. 3. As the installer I am required to have the necessary work completed prior to the applicable inspections as indicated below. I understand that requesting an inspection, without completion of the items in accordance with Tile 5 and the Board of Health Regulations may result in a$50.00 fine being levied against my company. a) Bottom of Bed - generally first inspection unless there is a retaining wall which should be done first. Installer must request the inspection but does not have to be present. b) Final inspection — Engineer must first do their inspection for elevations, ties, etc. As-built or verbal OK from engineer must be submitted to Board of Health, after which installer calls for inspection time. Installer must be present for this inspection. With pump system all electrical work must be ready and able to cause pump to work and alarm to function. c) Final Grade—Installer must request inspection when all grading is complete. Does not have to be on site. 4. As the installer I understand that only I may perform the work (other than simple excavation) required to complete the installation of the system identified in the attached application for installation. I further understand that work by others unlicensed to install septic systems in North Andover can constitute reasons for denial of the system, and/or revocation or suspension of my license to operate in the Town of North Andover; significant fines to all persons involved are also possible. 5. As the Installer I understand that I must be on site during the performance of the following constructionsteps: a) Determination that the proper elevation of the excavation has been reached. b) Inspection of the sand and stone to be used. c) Final inspection by Board of Health staff or consultant. d) Installation of tank, D-box, pipes, stone, vent, pump chamber, retaining wall and other components. 6. As the installer I understand that I am solely responsible for the installation of the system as per the approved plans. No instructions by the homeowner, general contractor, or any other persons shall absolve me of this obligation. Undersi e Licensed Septi Installer Date: 't? L Dispo 1 Works Const ction P r it# 193 LACY STREET JS-2004-0981 Proiect Detail Report Printed On:Thu Oct 14,2004 Project Name: Septic GIS#: 6537 Project No: JS-2004-0981 Owner of Record ENTSMINGER,ARLEN R& f J40RTk Map: 105.13 Date Submitted: Apr-27-2004 1.93 LACY STREET } •` s Block: 0060 Status: Open NORTH ANDOVER,MA 01845 Lot: Work Category: Work Location: 193 LACY STREET Zoning: Proposed Use: District: *~'�i�•.r`"�, land Use: 101 Proposed Use Detail Subdivision SACKWU Description Soil Testing Comments: of Work: Department Status GcoTMS Module: Status File No. Comments: LCDatc: Board of Health GREEN FLAG BHJ-2004-0057 5/6/04-per Dan,Soil testing changed to 5/13/04 by the designer. 4/14/04-Application for Soil Tests received. Tests are scheduled with Mill stone Engineering for Thursday,May 6th @ 10:00 a.m. Permit History Type: Permit No: Issue Date Status Work Category Contractor Project No: Description of Work: Plan Review BHP-2004-0662 Oct-13-2004 DENIED JS-2004-0981 New Soil Testing-Repair BHP-2004-0357 PENDING JS-2004-0981 Soil Testing Inspection History f�, Inspection Type: Permit Type: Permit No: Insp Date: Status: Inspector: Project No: Comment: �J Soil Testing Repair Soil Testing-Repair BHP-2004-0357 May-06-2004 New Dan Ottenheimer JS-2004-0981 oeGeoTMS®2004 Des Lauriers Municipal Solutions,Inc. Page 1 of I (TOWN OF NORTH ANDOVER �./ gORTIy O�tt ,°V,'ti0 Office of COMMUNITY DEVELOPMENT AND SERVICES HEALTH D E l"AR TMENT 400 OSGOOD STREET •--;-- NORTH ANDOVER, MASSACHUSETTS 01845 ;'SS4CHU 978.688.9540—Phone Susan Y.Sawyer, REHS/RS 978.688.8476—FAX Public Health Director E-MAIL: healthdept@townofnorthandover.com WEBSITE:http://www.townofiiorthandover.com July 25, 2005 Arlen and Catherine Entsminger 193 Lacy Street North Andover, MA 01845 Re: Septic Design for 193 Lacy Street,May 105D,Lot 8D Dear Mr. And Mrs. Entsminger: The Health Department has received your letter releasing Milestone Engineering as the responsible engineer for the repair of your septic system at the address listed above. As the disapproval letter sent to you on April 25, 2005 indicates, there were a few minor issues that needed addressing on the plan prior to its approval. These issues were addressed in Mr. Osgood's letter of July 11, 2005. New England Engineering and Mr. Ben Osgood, is assuming the responsibility to oversee the installation of the septic system at your property. They will also be responsible for drawing up the final As-Built and will be signing off that the system has been installed per plan. Please be advised that this is highly unusual,however, Mr. Osgood is willing to assume this responsibility. The Health Department is appreciative of all you have been through to this point and in your regard and in the interest of public health the following decision was made to assist you in this process. The design has been approved for use in the construction of an upgrade onsite septic system. Generally, a new plan approval is valid for three years from the date of this letter and during this time a licensed septic system installer must obtain a permit and complete this work, and a Certificate of Compliance must be endorsed by the installer, designer and the Town of North Andover. The time period,for which this plan is valid, is reduced to two years from the date of a septic system inspection that did not meet the acceptable criteria in the state regulations. The 4-bedroom(9-room maximum) design has been approved for use in the construction of a replacement onsite septic system. 1. If site conditions are found in the field to be different from those indicated on the design plan and/or soil evaluation,the originally issued Disposal System Construction Permit is void, installation shall stop, and the applicant shall reapply for a new Disposal Systems Construction Permit(3 10 CMR 15.020(1)). 2. It is the responsibility of the applicant and/or the applicant's septic system designer, septic system installer or other representative to ensure that all other state and municipal requirements are met. These may include review by the Conservation Commission, b6ning Board, Planning Board, Building:.-60ector, Plumbing Inspector and/or Electrical Inspector. The issuance of a Disposal System Construction Permit shall not construe and/or imply compliance with any of the aforementioned requirements. 3. The installer should inform the electrician that will be installing the pump system that the electrical code requires that a shut off switch be installed within eyesight of the pump. Please have the electrician speak with the inspector before installation of the electrical box. 4. This system utilized infiltrator technology, please note that the septic installer must provide proof that Infiltrator has trained them on the installation of these chambers. In regards to the previous review: 5. The new engineer will be responsible to advise the installer the excavation of 6 inches into the parent soil, as is required for the bottom of excavation per the N. Andover Regulations. Please advise the installer of these local requirements 6. It is understood that trenches were not used due to site constraints. Please feel free to contact the office with any questions you may have. We look forward to working with you to obtain a septic system that will be in compliance with all regulations and assure protection of public health and the environment of North Andover. Sincerelv- Susan Sawyer. Public Health Director cc: New England Engineering I I i i, July 18,2005 RECEIVED Susan Sawyer JUL 2 U 2005 North Andover Board of Health 400 Osgood Street TOWN OF NOR-1 H ANDOVER North Andover,MA 01845 HEALTH DEPARTMENT Re: 193 Lacy Street,North Andover Septic System Repair Dear Ms. Sawyer: This letter is to inform you that we have released Milestone Engineering as the responsible Engineer for the repair of our septic system at 193 Lacy Street as they have gone out of business. We have employed New England Engineering Services as our new Engineer to assist in obtaining approval of the design originated by Milestone,monitor construction of the septic system and supply the as built plans and certifications. Sincerely, l Arlen R and Catherine L tsminger cc: Ben Osgood,New England Engineering Services I NEW ENGLAND ENGINEERING SERVICES - INC July 11, 2005 RECEIVED Susan Sawyer JUL 1 3 2005 North Andover Board of Health 400 Osgood Street TOVm,Ur NOR'TH'ANDOVER HEALTH DEPARTMENT North Andover, MA 01845 Re: 193 Lacy Street,North Andover Septic System repair Dear Susan: This letter is being written request that the Board of Health discuss the above referenced property at the next board of health meeting. The purpose of the discussion would be to determine how the owner can obtain approval of the septic system design plan which has been submitted. Due to the fact that the original design engineer has moved.to Florida and has not responded to repeated requests to correct deficiencies in the plans,the owner of the property has asked this office to assist in obtaining approval of the design,monitoring construction of the septic system, and to supply the as built plans and certifications. At this point in time three minor deficiencies have been noted in the design plan. It is the opinion of this office that the three items are minor and could be addressed as follows: 7. The pipe slopes are indicated on the plan. The slopes are meant to be continuous over the length of the pipe which would meet the requirement.As an added assurance the approval could condition that all pipes be at a continuous grade. 17. Trenches are the preferred method of Soil Absorption System construction,however in a repair situation leach fields are used to conserve space,keep the cost reasonable, and save trees. 18. The note regarding excavation 6"in to the C layer is missing and could be a condition of approval. In order to insure that these conditions of approval be enforced it could also be,a condition of permit issuance that the installer meet with the Board of Health representative in the Board of Health office with this engineer to review the conditions of approval and review the procedures that will be followed to insure that the.conditions are met. 60 BEECHWOOD DRIVE-NORTH ANDOVER,MA 01845-(978)686-1768-(888)359-7645-FAX(978)685-1099 4 I appreciate being afforded the opportunity to discuss this matter and thank you in advance for your cooperation. If you have any questions, or need additional information, please-do not hesitate to contact this office. Sincerely, RECEIVED � Cr v JUL 1 3 2005 Benjamin C. Osgood, Jr., P.E. TOWN c ER President HEA: t ivi NT CC: Arlen Entsminger Dellechiaie, Pamela From: health department[healthdept@townofnorthandover.com] Sent: Thursday, May 05, 2005 9:53 AM To: 'mail.milestone@verizon.net' Subject: 193 Lacy Street-Septic Plan Status Importance: High Mr. Soucy: Ms. Kathy Entsminger called this office this morning and stated that she has been unable to reach you to follow-up on some revisions and questions about the septic plan you submitted to our office on April 19, 2005. There were several comments regarding the plan dated September 14, 2005 and revised April 16, 2005. Items in question were 6.; 7; 17;and 18. Please call us at your earliest convenience to address these issues, as no one is responding to your voice mail, and the fax number is apparently not working. Thank you. gall R¢0aods, PaN004 DAIM0,0lflafa Health Department Assistant Town of North Andover 400 Osgood Street North Andover,MA o1845 978.688.9540-Phone 978.688.8476-Fax http://www.townofnorthandover.com healthdept@townofnorthandover.com Dellechiaie, Pamela.vcf 1 If" TOWN OF NORTH ANDOVER ORT"1 Office of COMMUNITY DEVELOPMENT AND SERVICES or-`° °�o0. HEALTH DEPARTMENT p 400 OSGOOD STREET " ° • ^'' NORTH ANDOVER, MASSACHUSETTS 01845 'ss�causp� 978.688.9540—Phone Susan Y.Sawyer,REHS/RS 978.688.9542—FAX Public Health Director E-MAIL:healthdept@Ltownofnortilaiidover.com WEBSITE: http://www.townofnorthandover.com April 25,2005 John A. Soucy,Civil Engineer Milestone Engineering Services,Inc. 50 Water Street,Mill#1 Suite 413 Newburyport,MA 01950 Re: Proposed Septic Design for 193 Lacy Street,Mal) 105D,Lot 8D Dear Mr.Soucy: The proposed septic system design plans for the above site dated September 14,2004 and revised April 16,2005 u b hone reviewed. Unfortunate] the tans cannot be approved at this time. I attempted to contact you y p have been e y, p pP P to discuss a few issues but was unable to do so.Please respond to the questions below so that we may move forward with this review.If additions or corrections are needed,please submit the revised plan with a response sheet that lists your comments or corrections to the questions and a check for$75 for a third review.Note that the numbers of the questions correlate to the original review. If you respond in this manner, it will enable my office to do a quick and thorough review. 6.The"covered porch"is 8 feet form the tank and 13 feet from the SAS. Is this porch on cement supports or does it have a full foundation?If on cement supports,please show them on the plan and indicate the distance from the closest support to the tanks and the SAS. If there is a full foundation,this structure does not meet the setbacks and adjustments to the components and field must be made. 7.Pipe laid on continuous grade.Please indicate where on the plan the note was added.Reviewer was unable to locate the note. 17.Trenches are to be used whenever possible.Please note the reason for not utilizing trenches or revise as needed. 18.The reviewer was unable to locate the note regarding excavation of 6 inches into the parent soil,as is required for the bottom of excavation per the N.Andover Regulations. 1 free to contact the office with an questions you may have. We look forward to working with you to Please fee ee Y q Y Y g obtain a replacement septic system,which will be in compliance with all regulations and assure protection of public health and the environment of Andover. Sincerely, u n Y. Sawyer,REHS/RS Public Health Director cc: Homeowner File o 50 Water Street,Mill 1,Suite 13 Voice(978)465-7776 Fax(978)465-5455 Milestone ' ' _ ' Services, Inc. Civil/Site and Environmental Engineering Land Development . Transmittal To: Ms. Susan Sawyer From: Jack Soucy Public Health Director CC: Date: April 18, 2005 193 Lacy Street, North Andover, MA j Re: Applicant-Kathy Entsminger 5 copies revised plan set. Enc: ❑ Urgent ❑ For Review ❑ Please Comment ❑ Please Respond ❑ Please Return • Comments: Please find enclosed 5 copies of our repair septic system plan dated revised 4/16/05 for the referenced site. The revisions correspond to your review letter dated 10/11/04. Do not hesitate to contact me should you have questions or comments regarding this matter. Thank you Jack T041805_STE0404SSawyer.jas.doc BOARD OF HEALTH MEET Page 1 of 3 i This is G o o g I e's cache of hftr)://www.townofne\klburv.ora/Boh/boh32105.htm as retrieved on Apr 19, 2005 17:44:43 GMT. G o o g I e's cache is the snapshot that we took of the page as we crawled the web. The page may have changed since that time. Click here for the current page without highlighting. This cached page may reference images which are no longer available. Click here for the cached,text only. To link to or bookmark this page, use the following url: http://www.google.com/search? q=cache:mCB3zFPwCKOJ:www.townofnewbury.org/Boh/boh32105.htm+milestone+engineering,+newburyport&hl=en&start=l Google is not affiliated with the authors of this page nor responsible for its content. These search terms have been highlighted: milestone engineering newburyport BOARD OF HEALTH MEETING MARCH 21, 2005 Chair Alba Gouldthorpe opened the meeting at 7:00 p.m. Elaine Byrne, Steve Fram, Debbie Rogers and Ginger Bacon were present. The minutes of the February 7th meeting were accepted as presented on a motion by Elaine Byrne, seconded by Steve Fram and voted unanimously. The next BOH meeting was scheduled for April 4th 12 Girard Way—Tom Petty addressed the Board regarding a proposed addition of approximately 82 sq/ft to a rear bedroom. Drawings and photos were submitted. Upon review the plans were approved on a motion by Steve Fram, seconded by Elaine Byrne and voted unanimously. 5-47th Street- Martha Taylor representing Jane LaBranche, owner,presented plans to raze and reconstruct a two-bedroom structure. No additional rooms are to added. The plans have been before the Conservation Commission and will be reviewed by the ZBA on April 14th. Upon review it was noted that an enforceable schedule had not been submitted and the proposal was tabled until later in the evening to allow the owner to complete and submit an enforceable schedule for signatures of the board. 82 Southern Blvd. —A proposal to remove flat roofs on either end of the house and construct pitched roofs to increase the interior size of the rooms on each end of the hours were discussed. Interior renovations will also take place with new windows, new kitchen and the relocation of the bedrooms to either end of the house.No additional rooms will be added. Plans of the existing structure and an enforceable schedule were not available. Steve Fram moved to continue this matter to the next meeting on April 4th to allow the homeowner time to collect the necessary forms and plans, seconded by Elaine Byrne and voted unanimously. 18 Temple Blvd. - Sandy Lepore, owner and Attorney Richard Nylen presented plans to raze and reconstruct a five room dwelling, no change in the number of bedrooms. The enforceable schedule has been recorded and the plans have been cleared by Conservation and DEP. Steve Fram moved to approve the plans as submitted, seconded by Elaine Byrne and voted unanimously. Joe Doyle, 20 Rolfe's Lane and Mark Audette, 18 Rolfe's Lane addressed the Board regarding the possibility of tying into Newburyport's sewer system in lieu of replacing failing septic systems. 22 and 23 Rolfe's Lane properties would also be included. These four houses would share the costs of running lines from the Harbor School area. Newburyport has asked for a letter from the BOH stating that the Town has no problem with this remedy. The board noted they would need assurance that the existing http://64.23 3.161.104/search?q=cache:mCB3 zFPwCKOJ:www.townofnewbury.org/Boh/boh... 5/5/2005 BOARD OF HEALTH MEET--7-31 Page 2 of 3 systems were properly disconnected,pumped and crushed or removed. Elaine suggested a letter be drafted approving the connection to Newburyport Sewer and requesting plans for closure. It was moved by Steve Fram, seconded by Elaine Byrne and voted unanimously to follow Elaine's suggestion. Approval must also be obtained from the DPW Director to cut and excavate the roadway. 5-47th Street was taken off the table on a motion by Elaine Byrne and seconded by Steve Fram. Jane LaBranch submitted a completed enforceable schedule for signatures which she will have recorded at the Registry of Deeds in Salem. Her request for renovation was approved as presented on a motion by Elaine Byrne, seconded by Steve Fram and voted unanimously. 178 Hay Street—Ben Osgood Jr. of New England Engineering presented plans for the repair of the septic system at this address. One Title 5 Variance was requested—to allow the use of a sieve analysis in lieu of a percolation test to determine the loading rate. The variance was granted on a motion by Steve Fram, seconded by Elaine Byrne and voted unanimously. Three local upgrade requests were also required— 1)reduce the offset distance between the leach bed and foundation wall from 20' to 10'; 2) reduce the offset distance between the septic tank and foundation wall from 10' to 7'; 3)reduce the offset distance between the leach bed and drinking water well from 100' to 62'. The upgrade requests and plans were approved as submitted on a motion by Steve Fram, seconded by Elaine Byrne and voted unanimously. J . r322Fruit Street—Jack Soucy of Milestone Engineering presented septic repair plans with one Title 5 iance request—to allow the use of a sieve analysis in lieu of a percolation test to determine the ding rate. The variance was approved on a motion by Steve Fram, seconded by Elaine Byrne and the ns were approved as submitted on a motion by Steve Fram, seconded by Elaine Byrne and voted animously. -Hanover Street—Millennium Engineering presented septic upgrade plans with the following local upgrade requests and Title 5 variances: o Reduce property line setback to septic tank from 10' to 4'7" o Reduce property line setback to Waterloo tank from 10' to 8'3 o Reduce property line setback to leach field from 10' to 8'8" o Reduce# of deep hole tests from 2 to 1 in area of leach field o Reduce groundwater separation to SAS from 4' to 3' o Reduce leach field size from 667 s/f to 337.5 s/f pursuant to remedial use approval for Waterloo o Use alternative to percolation testing in accordance with DEP policy Proof of notice to abutters was submitted. The plans with all upgrade requests and variances was approved as submitted on a motion by Steve Fram, seconded by Elaine Byrne and voted unanimously. Abby Gindele, Recycling Coordinator addressed the board regarding the composting site application and how best to compile the data needed. She also spoke about the "healthy lawn workshop" scheduled for April 3rd at the Firemen's Hall. A press release will be forwarded to the News. Abby and Kay Halloran will be on WNBP Tuesday, March 29th to promote this workshop.. Alan McIntosh from DEP was unable to attend this meeting and has been rescheduled for the next meeting on April 4th. Tim Leonard and Doug Packer will also be invited to review the proposed regulation on storm water discharge. http://64.23 3.161.104/search?q=cache:mCB3 zFPwCKOJ:www.townofnewbury.orgBoh/boh... 5/5/2005 BOARD OF HEALTH MEET�u Page 3 of 3 Deb advised that tobacco compliance checks will be completed by June 1 st. Brandon Rogers and Erica Searle have been hired to do the checks and they will be paid from a mini grant for this purpose. The disposal of dog feces at P.I. center was briefly discussed. A sign stating the law and fines will be posted at the center and the ACO will police the area for violators. A draft of the budget was reviewed and will be submitted to the Finance Committee for their consideration. The meeting was adjourned at 9:25 p.m. on a motion by Steve Fram, seconded by Elaine Byrne and voted unanimously. Respectfully submitted, Kathleen Sirois, Secretary I I http://64.23 3.161.104/search?q=cache:mCB3 zFPwCKOJ:www.townofnewbury.org/Boh/boh... 5/5/2005 C/7 Page 1 of 1 Dellechiaie, Pamela From: Dan Ottenheimer[info@millriverconsulting.com] Sent: Tuesday, October 12, 2004 3:55 PM To: amcbrearty@millriverconsulting.com; Lisa LaVasseur; 'Pamela Dellechiaie'; Susan Sawyer i Subject: plan reviews Sue and Pam, Attached please find the plan reviews for193 Lac Street and 247A Farnum Street. Please call or write if any questions. Dan Mill ►Wile ' consultingJ Daniel Ottenheimer, President Mill River Consulting Septic System Management Services 2 Blackburn Center Gloucester, MA 01930-2259 978-282-0014 or 1-800-377-3044 fax: 978-282-0012 www.millriverconsulting.com dano millriverconsulting.com 10/12/2004 i TOWN OF NORTH ANDOVER Office of COMMUNITY DEVELOPMENT AND SERVICES HEALTH DEPARTMENT WROW 27 CHARLES STREET "'+" � • � ' NORTH ANDOVER, MASSACHUSETTS 01845 'SS,CMust` Susan Y.Sawyer,REHS/RS 978.688.9540—Phone Public Health Director 978.688.9542—FAX October 11, 2004 r F e John A. Soucy, PE Milestone Engineering Services, Inc. 50 Water Street, Mill No.1, Suite No.13 Newburyport, MA 01950 . RE: 193 Lacy Street,Map 105D, Lot 8D,North Andover, MA Dear Mr. Soucy, The proposed septic system design plans for the above site dated September 14, 2004 and received on September 27, 2004 has been reviewed. Unfortunately, it cannot be approved until the following items are corrected. Each item is followed by the specific section in Title 5: 310 CMR 15.000, or North Andover regulations which is not met by this design. /01 1. Please provide abutters to the property (this may be completed on a separate sheet if desired) -NA 8.020). 3-''2. If there is no foundation drain, then please so indicate, otherwise its location and elevation must be stated. NA 8.02y The profile must be to scale. Also, lines depicting the existing and proposed grades should be shown running through the profile. -220(4)(o) &NA 8.02c 1!4. The following distances must be shown on the site plan: Septic tank,pump chamber, and SAS to dwelling and property lines. Only the SAS to property line distance is shown.—NA8.02z ✓5. Locations of water lines and subsurface utilities are needed. -220(4)(m) ,I 6. The following setback distances are not met: a. Septic tank and pump chamber to dwelling (10') ✓ b. SAS to cellar wall (20') c. Septic tank and pump chamber to deck(5') Please revise the design or submit appropriate variance or Local Upgrade Approval requests as appropriate. 7. Regarding the building sewer, the following notations are needed: a. Joints shall be watertight -222(3) & (4),NA 11.02 Pipe shall be laid on a compact, firm base -222(5) c. .Pipe shall be laid on a continuous grade, in a straight line -222(8) 8. Regarding the septic tank tees,the following must be specified: L/a. . 3" (min.) air space above the tees -227(4) ub`. ,�-Tees must extend 6" above the flow line -227(1) Z'Gas baffle needed on the final outlet tee -227(4) d. Tees must be on the center line of the septic tank. -227(1) vd'o9. Regarding the effluent filter: a. the name/type shall be noted on the manhole cover, and �ry b. a maintenance schedule must be specified. r Please specify the proper size (< 1-1/2") of stone that is to be used beneath the septic tank. —221(2) & 228(1). Please specify the proper size (3/4") of stone that is to be used beneath the pump chamber, per North Andover regulations. ✓i'2. A notation is required for a watertight septic tank, pump chamber, and d-box. -221(1) V113. It is not clear whether the top of the septic tank, pump chamber, leach area, and d-box are more than 36"below grade. Perhaps this will be clarified with a revised profile, otherwise please specify that the top of the tank and d-box are not to be more than 36" below grade. -221(7) s �1-4-.-' A detail of the d-box is needed demonstrating features specified in Title 5. 15. A notation is needed for a manual operating switch on the pump control panel.-NA 12.01 ,x,1.6:` The elevation of the percolation test is needed.-NA8.02n 17. Trenches are the disposal mechanism to be used whenever possible. Please use trenches or explain why they cannot be used. -240(6) & 254(1)(c) f" 18. , The excavation beneath the leach area must extend 6" into the natural soil. NA 9.02 9` The final grade over the SAS must slope at a minimum of 0.02ft/ft. -240(10) ,20,,;,- It appears that the surface water from elevations higher than the SAS will be directed over the SAS. Surface drainage should be directed away from the SAS. -240(11) &245(5) Please feel free to contact the office with any questions you may have. We look forward to working with you to obtain a septic system which will be in compliance with all regulations and assure protection of public health and the environment of North Andover. Sincerely, Ssan Y. Sawyer, REH /RS Public Health Director cc: Owner File 50 Water Street, Mitt#1, Suite#13 Newburyport, Massachusetts 01950 Voice (978)465-7776 1 ; T 0 N E Fax(978)465-5455 Civil/Site and Environmental Engineering Land Development and Permit Acquisition September 23,2004 Town of North Andover Health Department 27 Charles Street North Andover,MA 01845 RE: Mr./IMrs.Arlen Entsminger,Repair Subsurface Sewage Disposal Plan for 193 Lacy Street,North Andover,MA;Assessors Map 105D,Lot 60 Enclosed please find three copies of the above subject plan,one copy of the MDEP Form 11 and 12 Soil Suitability Assessment,a septic plan submittal form,and a partially completed Application for Disposal System Construction Perr- t.Also enclosed is a check for the review fee of$225.00. All of the above are being submitted to you for approval.Should the plan be required to go before the Board of Health,please let me know the date and time of the hearing as soon as possible.Please do not hesitate to contact me.should you have any questions or comments regarding any of the above. Y John ucy,Jr.P.E. SEP 2 7 2004 Vice rest t TOWN OF NORTH ANDOVER HEALTH DEPARTMENT Cc: Nft.. Arlen Entsminger, 193 Lacy Street,No.Andover,MA 01845 Enc: (3) SSDS Plans (1) Soil Suitability Assessmesrt (1) Disposal System Construction Permit Application (1) Septic Plan Submittal Form (1) Check for review fee Sep 22 04 03: 18p 978&9542 Py l _ N StmeFMEALTH GLWo P 2 7 2004 NORTH ANDOVER DEPARTMENT � _ � EE - - 55,tyusi-i E< i YES YES SUE EVALUAMN FO T—K -U NO wEBn YES Tambom : Fames C? S' ` - �'�� t }fir mumm- 1.F-X E us omL-Y &. 2- Cwt and acRawipt - 3 Fmwwdic 4 Rmfi—rr oa LogShad amd _�- -� NO. THE COMMONWEALTH OF MASSACHUSTS FEE BOARD OF HEALTH OF V-)o APPLICATION FOR DISPOSAL SYSTEM CONSTRUCTION PERMIT Application fora Permit to Construct ( ) Repair (Upgrade ( ) Abandon ( ) - ❑Complete System ❑Individual Components Location Owncr's Natnc Map/Parcel# /�,� � re C>� Lot It Telephone# Installer's Name Designer's Name Address Telephone It Telephone# Type of Building: Lot Size k%5 7 qtr T Dwelling—No.of Bedrooms V�QL Garbage Grinder (kj" Other—Type of Building No.of persons Showers ( ), Cafeteria ( ) Other fixtures Design Flow(min.required) ' _gpd Calculated design flow_gpd Design flow provided 5-2-2.9pd Plan: Date Wo Number of sheets � Revision Date i��G' Title '� 'iJ Or 'Q—VA--AL, be�t+ t)E: �S`"Z i y,� Description of Soil(s) Soil Evaluator Form No. Name of Soil valuator30W,� ate of Evaluation r ll�� \ 0i DESCRIPTION OF REPAIRS OR ALTERATIONS QQK), AM 33&—SZA&Y.4 SIEPU C AQK� GWS , \97 — rlp The undersigned agrees to install the above described Individual Sewage Disposal System in accordance with the provisions of TITLE 5 and further agrees not to place the system in operation until a Certificate of Compliance has been issued by the Board of Health. Signed Date Inspections FORM 1 - APPLICATION FOR DSCP DEP APPROVED FORM 5/96 �. 0 Q '? Calculation Sheet Milestone Engineering Services, Inc. Title : SSDS System Curve Calculation 50 Water Street, Mill No. 1, Suite No. 13 Project : STE0404- 193 Lacy Street, North Andover, MA Newburyport, MA 01950 By : JAS Purpose The purpose of this calculation is to determine the system performance curve of the the proposed pumped subsurface sewage disposal system.. Forcemain Description 2.00 Inch Internal Diameter SCH40 PVC Forcemain 140 Hazen-Williams C Value for forcemain friction loss 13 Total Forcemain Run (feet) Forcemain Fixtures Number Fixture Fixture K 1 Gate Valve(Full Open) 0.20 1 Swing Check Valve(Full Open) 2.50 1 Short-radius Elbow(r/Dia= 1.00) 0.90 1 Standard Tee(Out Side) 2.00 5.60 Total Fixture K Static losses 133.47 Centerline Forcemain Discharge End Elevation (feet) 123.52 All Pumps Off Elevation in Dose Chamber(feet) 9.95 Difference is Static Lift (feet) 2.50 Distal End Pressure Head (feet) 3.28 Pressure Distribution Network Head Loss(feet) Total Dynamic Head (Hazen-Williams Formula) Discharge Velocity Velocity Head Forcemain Fixture Static TDH (gpm) (fps) (ft) Headloss(ft) Headloss(ft) Headloss(ft) (ft) 20 2.04 0.13 0.1 0.7 13.2 14.1 40 4.09 0.52 0.5 2.9 13.2 16.6 60 6.13 1.17 1.0 6.5 13.2 20.7 100 10.21 3.24 2.5 18.2 13.2 33.9 40.0 - 35.0 - mu 0.035.030.0 c� = 25.0 - 20.0 E_ 15.0 a 10.0 0 5.0 - 0.0 20 40 60 100 Discharge Rate (gpm) 9/22/2004 Sheet 1 of 1 Commonwealth of Massachusetts i�oh City/Town of Form I 1 m Soil Suitability Assessment for Ole-Site Sewage Disposal w.J` DEP has provided this form for use by on-site professionals and local Boards of Health.Other forms may be used, but the information must be substantially the same as provided here. Before using this form, check with your local Board of Health to determine the form they use. A. Facility Information� ..._.._.._. .�..�.. 1, Facility Information Map/Lot— CLn Owner Name c��� Street Address ...... ........._.��,..-._..-.........,. .....,,........,,�•,,„�S,'_�.. Clty/Town State Zip Code B. Site Information 1, (Check one) New Construction ( Upgrade (] Repair 2. Published Boil Survey available? Yes Q No 0 If yes: _ y N5? A r\A ,�C)D Year Published Publication Scale Soil Map Unit Soil Name Sall limitations 3. Surficial Geological Report available? Yes [] No El If yes: Year Published Publication Scale Map Unit Geologic Material Landform 4. Flood Rate Insurance Map: Above the 500 year flood boundary? Yes Q No f3 Within the 100 year flood boundary? Yes ( No (� Within the 500 year flood boundary? Yes [3 No Within a Velocity Zone? Yes n No S. Wetland Area: National Wetland Inventory Map Map Unit Name Wetlands Conservancy Program Map �� Y 1�` _ ,?Z Map Unit Name DEP Form 11 Soli Suitability Assessment for On-Site Sewage Disposal o Page 1 of 7 Commonwealth of Massachusetts 1 City/Town of Form 'I I a Soil Suitability Assessment for On-Site Sewage Disposal 6. Current Water Resource Conditions(USGS) Range: Above Normal Normal Below Normal [] Month/YJ 7. Other references reviewed:_ �- _ __ _ ___..._._._._,._.__ _._...___---_.._.___�__ C. On-Site Review (minimum of two holes required at every proposed disposal area) Deep Observation Hole Number: Date Time WWeather 1. Location `M Ground Elevation at Surface of Hole_�Dto,5 4 L Location(Identify on Plan) 2. Land Use:__ �-�, _ _____----__�.�_ . �1t.1 a11!iC ___ (e.g.woodland,agricultural field,vacant tot,etc.) Surface Stones Slope(%) Vegetation Landform Position on landscape(attach sheet) 3, Distances from: Open Water Body Drainage Way_ � � Possible Wet Area �� 1.1►� u.` CC� J'C� O feet feet feet Property line Drinking Water Well �."_-jQ_ Other feet feet 4. Parent Material: ,% t _ Unsuitable Materials Present: YesE] Nog"', If Yes: Disturbed Soil© Fill MaterialEj Impervious Layer(s)[] Weathereffractured Rock[] Bedrock[] 5, Groundwater Observed: Yes Ed No If Yes: Depth Weeping from Pit :?`` _ Depth Standing Water in Hole Estimated Depth to High Groundwater: DEP Dorm 11 Soil Suitability Assessment for On-Site Sewage Disposal o Page 2 of 7 Commonwealth of Massachusetts , N , City/Town of Form I I - Soil Suitability Assessment for On-Site Sewage Disposal Inches elevation Deep Observation Hole Number;_____, _ __ Soil Soil Matrix: Redoximorphic Features Soli Coarse Fragments Soil Structure Soil Depth Horizon/ Color-Moist (mottles) Texture %by Volume Consistence Other (K) Layer (Munsell) (USDA) (Moist) Depth Calor Percent Gravel' Gobbles &Stones LS Mass;%1e_ r-%e-.b\e_ Additional,Notes _ t,� �=� � - 20`"______ DEF'Form I 1 Soil Suitability Assessment for On.-Site Sewage Disposal<Page 3 of 7 Commonwealth of Massachusetts City/Town of Form 1I - Scall Suitability Assessment for On-Site Sewage Disposal C. Ota-Site Review (Cont.) Deep Observation Hale Number: � �����a� _ CA Sp C' grvl Gate Time Weather 1. Location e�c\ 'o o eA 6y1 be.,�c.:.kNrrcar\C. Ground Elevation at Surface of Hole Location(Identify on.Plan ) 2. Land Use; (e.g.woodland,agricultural field,vacant lot,etc.) Surface Stones Slope V( eti landform Position on landscape(attach sheet) 3. Distances from; Open Water Body>-LQ� Drainage Way_!1 j Possible Wet Area feet _ �` feet feet Property Line-kP— Drinking Water Well _ Other NJM- L_._ w- feet feet 4. Parent Material; � �� _._ Unsuitable Materials Present; Yes ❑ No If Yes: Disturbed Soli❑ Fill Material(] Impervious Layer(s)Q Weathered/Fractured Flock() BedrockE O 5. Groundwater Observed: Yes ❑ No If Yes: Depth Weeping from Pit,�__,_,,,,_ Depth Standing Water in Hole Estimated Depth to High Groundwater: _ __� -5---- inohee elevation DEP Form 11 Sou Suitability Assessment for On-Site Sewage Disposal•Page 4 of 7 Commonwealth of Massachusetts City[Town of Form 11 - Soil Suitability Assessment for On-Site Sewage Disposal Cheep Observation Hole Number:_._._....._.-._ _ Soil Soil Matrix: Redoximorphic Features Soil Coarse Fragments Soil Soil Depth Horizon/ Color-Moist (mottles) Texture %by volume Structure Consistence other {ln.) layer (Munsell) (USDA) (Moist) O Depth Color percent Gravel Cobbles &Stones N G. lax vA W-qp, '1i$ 5 �� � Q Mar,• _ `—' ! 1( C� �.. '/"k Additional Nates_—___ -t —_____...___—__..__..___________--- _—____-_—___—__� DEP Form 9'i Soil Suitability Assessment for On-Site Sewage Disposal•Page 5 of 7 comwionwaath of ill assachusell's City/ own of or I I - Soil Suitability Assessment for On-Site Sewage Disposal Deap Obsorvation Hole Number Date Tinis Weather 1, Locationbe:�-'e'A_ Ground Elevation at Surface of Hole Location(Identify on Plan 2. Land Use., (e.g.woodland,agricultural(Maid,vacant lot,sto') Surface Stories slope N Vegetation Landform PosItion on landscape(attaoh ohoot) mm 3. Distancestrom: Open Water Cody,>12,g Drainage Way>_LC�Q PossibloWet Area feet feet Nat Property Line Drinking Water Well -j_:A, Other feet 4. Parent Material: UnsultableMaterials Present; Yeerl Nov If Yes; Disturbed Soil RlMateriel[] Impervious Layor(a)[—] Weathered/FraoturedRock[j- Bedrockfj 5, Groundwater ObsoNed: Yes [I No V If Yes: Depth Weeping from Pit Depth Standing Water In Hole Estimated Depth to High Groundwater; --- Inches elevation J)EP Form 99 Soil Suitability Assessment for on-site Sewage Disposal-Page 4 of'7" CotYtYi(toti@1 oalth of Massachusetts 6 City/Town of J Form I`fl - Soil Suitability Assessment forOn-Site Sewage Disposal Deep Observation Mole Number;_._ Soil I aril Matrix: Redoximorphle Features � Soil Coarse Frsirfin`R gill iii �� Depth Horizon/ Color-Moist (mottles) "texture %by Volume Structure Consistence other (In.) Layer (Munsell) (USDA) (Molmt) O Depth Cotear Percent �r�u�l Cobbles a stonea 1a \OIC �, lyt�vq Additional Notes DEP Form 11 Soil aultek)illty Assessment for on-Site Sewage Disposal Page 6 of 7 C\ Commonwealth of Massachusetts City/'Town of a 4 Form I 1 m Soil Suitability ,Assessment for On-Site Sewage Disposal 1 D. Determination of High Groundwater Elevation 1. Method used: Depth observed standing water in observation hole A. Inches Inches ❑' Depth weeping from side of observation hole A.__._._._ B. Inches inches (Depth to soil redoximorphic features (mottles) A,— _ B._ _ G. . -. 3(0 Inch s Inches is+acu (� Groundwater adjustment(USGS methodology) A. B. Inches inches 2, Index Well Number _ _ _ Heading Date___—__----.-...__.v._. Index Well level Adjustment Factor_ __ .__ Adjusted Groundwater Level __._.---—___--- Depth of Pervious Material 1. Depth of Naturally Occurring Pervious Material a. Does at least four feet of naturallyoccurring pervious material exist in all areas observed throughout the area posed for the soil absorption system? Yes 5 No❑ Ar *36 A 5 Z4\ b, if yes,at what depth was It observed? Upper boundary: _"�� _ Lower boundary: ? Inches Inches FCertification 1 certify that I hav sed the soil evaluator examination*approved by the Department of Environmental Protection and that the above s s pe me by me consist nt with the required training,expertise and experience described In 310 CMR 15.017, SI na re oil E� uatar ~- --____�._.._— Date 1�� � __ 1z ntasd Name of$o i Evaluator `Date of Salt Evaluator Exam _ ' , ? 2 .. - Name of Board of Health witness Board of Health Mote:This form must be submitted to the approving authority with Percolation Test Form 12 DEP Farm 91 Soil Suitability Assessment for On-Site Sewage Disposal Page 6 of 7 q� Commonwealth of Massachusetts 4 City/Town oV n of Form I I m Soil Suitability Assessment forOn-Site Sewage Disposal s, Use this shoot for fie '12414 � �, „.. . � � ACE ,, I yp/:1 4FiM tl IP (�y 4w. REMovp- °r/r "(I IN)(°r raj �o it -/0 IWp„ OiAxy. W O q ., n�..n� PRECAST MIMCO fE' mg, . ' `"� t BOX FIT CEM.CQNC � ,°MCJIJT° C, a�.. fit ` ,,C0RDAN(I, WI'F1�I ; 9�)CM 1,' / \ I 0 Commonwealth € f Massachusetts Cion of Percolation Test Form 12 Percolation test results must be submitter)with the Soil Suitability Assessment for On-site Sewage Disposal. DEF'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 the local Board of Health to determine the form they use. Invoft rt- s Site Infb ion VV`hen Ming out forrits on the cornguter,use anty the tab ley Owner Name '7 �--;-- to move your 1a%j Cursor-do Ila Street Address or Lot� usethe return key 1—Q—T►-�,� Cityrrow�n Sta e Zip Cade Contact Person(d different from Owner) Teiepfione Number B. Test Result MN`? Nate Tune Date e Observation Hole# � � 22 ti Depth of Pere 4`A Tom--g ' t Start Pre-Soak End Pre-Soak Time at 12' Time at 9" � Time at 6" '. AZim Time(9'-6-) ►'�1s� Rate(Min.finch) Test Passed: Test Passed: El Test Failed: Test Failed: Test FA-Wormed By. Vt{tnesssect By-- Comments: yComments: t5form12_do--0&103 Pere"fest-Page 1 of 1 DEP Bordering Vegetated Wetland (310 CMR 10.55) Delineation Field Form Applicant: Cathy Entsminer _ Prepared by: REQ Project location:t.acy St., North Andover DEP File#: Check all that apply: ❑ Vegetation alone presumed adequate BVW boundary: fill out section I only ® Vegetation and other indicators of hydrology used to delineate BVW boundary: fill out sections I and II ❑ Method other than dominance test used attach additional information Section I. Vegetation: Observation plot Number: Wet Transect nunlber:134Date of delineation:5/2 5/04 A. Sample layer and plant species B. Percent cover C. Percent D. Dominant Plant E. Wetland (by common name/scientific name) (or basal area) Dominance (yes or no) Indicator Category* Trees: Red maple/Acer rubrum 63.0 100 Yes *FAC Sapl: Red maple/Acer rubrum 20.5 100 Yes *FAC Shrub: Eastern white pine/Pinus strobus 20.5 40 Yes FACU Highbush blueberry/Vaccinlum corymbosum 20.5 40 Yes *FACW Swamp azalea/Rhododendron viscosum 10.5 20 Yes *013L Herbs: Cinnamon fern/Osmunda cinnamomea 38.0 39 Yes *FACW Skunk cabbage/Symplocarpus foetidus 38.0 39 Yes *0131- Canada mayflower/Malanthemum canadense 20.5 21 Yes FAC- Vine: O Fox grape/Vitis labrusca 10.5 100 Yes FACU Use an asterisk to mark wetland indicator plants: species listed in the Wetlands Protection Act(MGL c. 131,s.40);plants in the genus Sphagnum;plants listed as FAC, FAC+,FAC-,FACW,FACW+,or OBL;or plants with physiological or morphological adaptations.if any plants are identified as wetland indicator plants due to physiological or mo holo ical adaptations,describe the adaptation next to the asterisk. Vegetation conclusion: Number of dominant wetland indicator plants: 6 Number of dominant non-wetland plants: 3 Is the number of dominant wetland plants equal to or greater than the number of dominant non-wetland plants? ® yes ❑ no If vegetation alone is presumed adequate to delineate the BVW boundary,submit this form with the Request for Determination of Applicability or Notice of Intent MADEP;3/95 Section 11. Indicators of Hydrology Hydric Soil Interpretation Other Indicators of Hydrology: (check all that apply and describe) 1. Soil Survey 0 Site inundated: El Depth to free water in observation hole: Is there a published soil survey for this site? Yes ❑ water marks: Title/date: Essex County, Northern Part Map number: 27 M Drift lines: Soil type mapped: Me, Medisparists Hydric soil inclusions: M Sediment deposits: (7) Are field observations consistent with soil survey?Zyesnno Z Drainage patterns in BVW: Remarks: ❑ Oxidized rhizospheres: 2. Soil description Horizon Depth Matrix Color Mottles Color Z Water-stained leaves: 0 8-0 A 0-1 1 OYR 311 ❑ Recorded data(stream, lake, or tidal gauge; aerial photo,other):_ B 1-15 1 OYR 4/3 1 OYR 6/3 ❑ Other: Vegetation and Hydrology Conclusion Remarks Yes No 3. Other Histic epipedon Number of wetland indicator plants Z 0 >number of non-wetland indicator plants: Conclusion: Is soil hydric? Z yes F-1 no Wetland hydrology present: Z R Hydric soil present Other indicators of hydrology present: Sample location is in a BVW DEP Bordering Vegetated Wetland (310 CMR 10.55) Delineation Field Form Applicant: Cathy Entsmin er Prepared by: REC Project location.Lgcy t.. North Andover DEP File#: Check all that apply: ❑ Vegetation alone presumed adequate BVW boundary: fill out section I only ® Vegetation and other indicators of hydrology used to delineate BVW boundary: fill out sections I and II ❑ Method other than dominance test used attach additional information Section I. Vegetation: Observation plot Number: Up l Transect number:MDate of delineation:5/2 5/04 A. Sample layer and plant species B. Percent cover C. Percent D. Dominant Plant E. Wetland (by common name/scientific name) (or basal area) Dominance (yes or no) Indicator Category* Trees: Eastern white pine/Pinus strobus 63.0 86 Yes FACU Red maple/Acer rubrum 10.5 14 No *FAC Sapi: Eastern white pine/Pinus strobus 63.0 100 Yes FACU Shrubs:Tupelo/Nyssa sylvatica 10.5 12 No *FACW Eastern white pine/Pinus strobus 38.0 44 Yes FACU Honeysuckle/Lonicera taterica 38.0 44 Yes FACU Herbs: Canada mayflower/Maianthemum canadense 63.0 56 Yes FAC- Sarsaparilla/Aralia nudicaulis 38.0 44 Yes FACU White oak/Quercus alba 10.5 9 No FACU Vine: Fox grape/Vitis labrusca 38.0 100 Yes FACU Use an asterisk to mark wetland indicator plants: species listed in the Wetlands Protection.Act(MGL c. 131,s.40);plants in the genus Sphagnum;plants listed as FAC, FAC+,FAC-,FACW,FACW+,or OBL;or plants with physiological or morphological adaptations.If any plants are identified as wetland indicator plants due to physiological or morphological adaptations,describe the adaptation next to the asterisk. Vegetation conclusion: Number of dominant wetland indicator plants: o Number of dominant non-wetland plants: 7 Is the number of dominant wetland plants equal to or greater than the number of dominant non-wetland plants? ❑ yes ® no If vegetation alone Is presumed adequate to delineate the HVW boundary,submit this form with the Request for Determination ofApplicabllity or Notice of latent MADEP;3/95 Section II. Indicators of Hydrology Hydric Soil Interpretation Other Indicators of Hydrology: (check all that apply and describe) 1. Soil Survey ❑ Site inundated: ❑ Depth to free water in observation hole: _ Is there a published soil survey for this site? Yes ❑ Water marks: Title/date: Essex County, Northern Part Map number: 27 ❑ Drift lines: Soil type mapped: ShB, Scituate Hydric soil inclusions: Ridgebury,Whitman Sediment deposits: Are field observations consistent with soil survey?®yes❑no ❑ Drainage patterns in BVW: Remarks: ❑ Oxidized rhizospheres: 2. Soil description Horizon Depth Matrix Color Mottles Color ❑ Water-stained leaves: A 0-1 10YR 4/3 B 1-20+ 2.5Y 5/6 ❑ Recorded data(stream, lake, or tidal gauge; aerial photo, other):_ ❑ Other: Vegetation and Hydrology Conclusion Remarks Yes No 3. Other Number of wetland indicator plants ❑ >number of non-wetland indicator plants: Conclusion.: Is soil hydric? ❑ yes ®no Wetland hydrology present: ❑ Hydric soil present Other indicators of hydrology present: ❑ Sample location is in a BVW ❑ „ , r i i i k s / A t` $ s it n R y I Dc r L 1 11 or 1 i i ucz x-t uj uj:-trip nux a r,mnvuvtK P.c , (✓) 0 OF IMALTH I$y rte = AON FOR DATE' t� M"&]FARO.: LOCA tC €4F .�: l 9.3 t - .- OWMR �� d- CAfh�:2,:,► IM.iii€_: 6, S s. 8y0 3 ADDRESS: CERTHUD SOB.EVAL UA'I'Ct O ^► c, J , huended use of land: Residenfitat Subffivision siIA&WOOYHOM CommercW R TW �$ l�for�t t In the Lake Cod6dowkk WaftnAeV acs No TM Ft3I,I.UVW(G MM RR DjcLum f Wffn TRIS FORM: —f—Pred+af lmd swnmhip(T=b,de4 or lefter from owner p tests) —2.-- p1m Fee o€ _t10per tot t9wa leets at mqmmdfmc&*divosaarc& Fee of$30.a0 per h*fmmma s cw - Q—KNERAL�+ Tfft CK kk + 1 0*Cei Med Soft Evahatms m 2- 0*Whm Repocmd SmAnum and pmamamg Eugmeem cm deagm Ott 3_ At least tars deur holes and Im pemotafion tis ace ragmmd for=h s e s 4- pxpair,requkeat leaa wo dwp boles and at k2d oma test,at the dis c of ft BOH res. 5. FM p rymeat M be reyuimd fm all aMficmg usts vftjn tvm mss oftmfiB& 6_ 45 days ofg,a-sealed (9D s �i�-IW)&batt be sd miici to the Board ofHealth siw�ing of an terms Cid" aborW tuts). 7. mthin 6o dais of raring sM evabaadon firms shit be submitte& Please Do Not WrAe BeLawThis N.A AvpmW: I OF �: .. A ti I I i (YIA? 10 s t� I Lo z' 14 60 I g 3 (Acy s jam~ .42 a . ac ,.- �. -. a' 62 c /! % � r 167 I �r l 7 Lac 29 3 0CD Lo 46 31 a. i l i t n ,.;;� t ., a:; •'1 \>;.,,. > `•v: 'p'fo 1 "xv i'.. ',ar ...:r F ) �L .:.; -.•e -..� djr," 4Sr�.�lr e^ v^. t \ +,t oa ,r';� C 4 . gym• ``9�3 ;�+I: #� YY `� .. .•�� r'� �.'k- Cr+ r; L�V 1y\ ' a yk ,,. A sP,' a \ x :,•\,,,� .,y^ � y4�1� 1 �:.\ y," n�d T Y•, � .� '.A sa•. ty Il, .r. t_••, t � ,-ftY�,{ty'.VN 4�} 7'{;,. ,ry 4y -,t`l'� ,L'' V y '�^' 1 L \ c ,,YN �i r t { ilb t:; �w ,x a� ?•:1' Ci r,�. r :h :1 d .� y .y r+.a :it...; � r,.' ,�, it. 'rY>4v�-: 1 •r a i �' u _ ,r t �� ! .►c:? �� ;4,i. �,,s. \ ! r as it ;'" r ��f �""r4.0^� 1 >'�:, � .r.. 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"'y '"' 1 Cn.� w 7 u •P.h�i, y :1 'r j<. >• 'y r ,r :at .a4.. 4u '^4„ `�,,� ^`4w,..., 1 'tit� { y..y� •1 I �J\ :'''s7, �ky/ y 4MM�J. r �i � � � �"^y , Fd, 1 i :1 \ .1„ t y t ],. 41 f4 \ 1 1 y.� � •{�,� � `y , �,� d 1_I7 t z � tit st \ "�..'"",5 .� r "'."`""• �� .. in ',Me,yw",•°p'� t'�r 4 s\ \ .1411 �.. ,. \ :; ^ •^v �,""nw 44 Ar } •I l'� t 1 1 ��py �,}r J � ✓ FAL YEAR 2004 REAL ESTATE TAX BI1 12.597 TOWN OF NORTH ANDOVER OFFICE OF THE COLLECTOR OF TAXES - P.O.BOX 124 THE COMMONWEALTP OF MASSACHUSETTS I IIIIII VIII VIII VIII VIII VIII IIII II I NORTH ANDOVER,MA 01845 TOWN OF NORTH ANDOVER M-F 8:30-4:30 YY9 TAX 688-9550/ASSR 688-9566 Tax Unpaid Message Tax Map No: 210-105.13-0060-0000.0 IstInstalirnent Tax bills may be paid at our temporary location:400 Osgood Location: 193 LACY STREET 2nd Installment $ _ Street. Deed/Legal: Book 1340 Page 672 3rd Installment $ Land Area: 1.56 Ames 4th Installment $ 1,188.99 II 4TH PAYMENT REMITTANCE VOUCHER ENTSMINGER,ARLEN R Payment due by May 03, 2004 CATHERINE L ENTSMINGER 193 LACY STREET Amount Now Due : $ 1,188.99 NORTH ANDOVER, MA Based upon assessments as of Jan.0l.2003 your Real Estate tax for the fiscal year 01 845 commencing July 01,2003 and ending on June 30.2004 on the described property below is as fiilluws 00040929462004000000000000001125970200000000000000118899005 Detach Here Return top Voucher with Payment Detach Here Tax Map No : 210-105.13-0060-0000.0 FISCAL YEAR 2004 Property Location :193 LACY STREET REAL ESTATE TAX Deed/Legal: Book 1340 Page 672 Fiscal Year 2004 Tax $ 4,660.05 Land Area: 1.56 Acres Land Value: 4 147.7110 Bldg Value: S 200.000 Exempt value:S - Taxable Value S 387,700 Preliminary Tax : $ 2,282.05 Res.Value: S 347.7110 Residential Tax Rate for Fiscal Year 2004: S 11.76 - Comm.Value:S - Commercial Tax Rate tix Fiscal Year 2004: S 14.23 3rd Installment : $ 1,189.01 Fiscal Year 2004 Tax Description : Payment dde by March 01,2004 Tax: 55 Cpa: $ 100.70 4th Installment : $ 1,188.99 Betterments: $ - Payment due by May 03,2004 Liens: $ Tonal: Tax Paid : $ 3,471.06 . Abatement: $ - Interest as of $ - April 09,2004 Interest at the rate of 14%per annum will accrue on overdue payments from the due date until payment is made. Amount Now Due : $ 1,188.99 ABATEMENT APPLICATIONS MUST BE RECEIVED BY THE ASSESSOR'S OFFICE NO LATER THAN 03/01/2004 FISCAL YEAR 2004 REAL ESTATE,TAX BILL 12597 TOWN OF NORTH ANDOVER OFFICE OF THE COLLECTOR OF TAXES P.O.BOX 124 THE COMMONWEALTH OF MASSACHUSETTS I IIIIII VIII VIII(IIII(IIII(IIII 11111,11011NORTH ANDOVER,MA 01845 TOWN OF NORTH ANDOVER M-F 8:30-4:30 TAX 688-9550!ASSR 688-9566 Tax Unpai Message Tax Map No: 210-105.D-0060-0000.0 I st Insta Invent $ Tax bills may be paid at our temporary location:400 Osgood Location: 193 LACY STREET 2nd Installment $ Street. Deed/Legal: Book 1340 Page 672 3rd Installment $ Land Area: 1.56 Acres 4th Installment $ 1,188.99 4TH PAYMENT RECEIPT VOUCHER ENTSMINGER, ARLEN R CATHERINE L ENTSMINGER Payment due by May 03,2004 193 LACY STREET Amount Now Due : $ 1,188.99 { NORTH ANDOVER, MA Based upon assessments as ot'Jan.01.2003 your Real Estate tax for the fiscal vear 01845 commencing July 01.1003 and ending on.lune 30,2004 on the described property below is as follows: 00040929462004000000000000001125970200000000000000118899005 {ZA;w��• r,2cl�A fi. ^4t8ReL�-ti r .. '„>• :';3G 2c�� � �st+►cT l�s.Ag � Ip:oa 3Z• ` {•.�,,,.Q P,�,� ,i,u. St'Rltt SOAK$ ►ZI` �D:�� i Te I`- f` to B48° �iR�qri n I - em,Owe•j O MPJ�i4,u 1 2 41� 2,41 r • '� ,. SuatC. H_ ��r�E 9"_l0 �oSr•,r�l _?Oa c QAIV, 3 sem„41 wl PON 14 i i . 4�,. �1 � /���� ` � ',��� ~ I� �� ,'t"" �. �� � 7 ~ r~ *'-.y s ,..bdi�. . . _ r ^` t :'• *� - "` '.. ..t i � p: Y: ► Aw �'!• � _ .r, , ..`.I;�,..�'`�\iii, � � 'Oy 1 . 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