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Miscellaneous - 207 FARNUM STREET 4/30/2018 (2)
R � NAP # LOT - ----- i7aAAA,�� S4 - PARCEL # STHEET____ CONSTRUCTIONAPPRO HAS PLAN REVIEW FEE BEEN PAID? - ~o�7 NO PLAN APPROVAL: DATE__________ APP. BYi.��-/5c���2Y_-' DESIGNER: PLAN CONDITIONS .............. WATER SUPPLY: COWN WELL WELL PERMIT WELL ES BACT IA I DME U|l4{UVED BACTERIA I DA|E APPKUVEU_......... _ COMMENTS: FORM U APPROVAL:11 PPROVAL DATE ISSUED By CONDITIONS: FINAL APPROVAL: ALL PERMITS PAID UU / / WELL CONSTRUCTION APPROVA YES NU / SEPTIC SYSTEM CONSTRUCTION APPRUVAL OTHER YES HU / ' ANY VA8ZANCE NEEDED YES / FINAL BOARD OF HEALTH APPROVAL: DA\E: -_�� �*_��� BY: � �� . ':ISSUANCE OF DWC PERMIT o. ';'DWC PERMIT N BEGIN INSPECTION YE5 0: ..% EXCAVATION .INSPECTION : 4!i rv, PASSED 'CONSTRUCTION INSPECTION: AS BUILT PLAN SATISFACTORY: PLAN REVIEW APPROVAL NEEDED: IS THE INSTALLER LICENSED? NLW REPAIR YES No :TYPE OF CONSTRUCTION: YES 41 - CONSTRUCTION: CERTIFIED PLOT .,,NEW CONDITIONS OF FROM FORM U) ':ISSUANCE OF DWC PERMIT o. ';'DWC PERMIT N BEGIN INSPECTION YE5 0: ..% EXCAVATION .INSPECTION : 4!i rv, PASSED 'CONSTRUCTION INSPECTION: AS BUILT PLAN SATISFACTORY: PLAN REVIEW APPROVAL NEEDED: PL6 INSTALLER: IA4& L B Y NEEDED: BY APPROVAL TO BACKFILL: DATE FINAL GRADING APPROVAL: DATE --By. FINAL CONSTRUCTION APPROVAL: DATE: YES~~ NO NLW REPAIR YES No YES NO YES No PL6 INSTALLER: IA4& L B Y NEEDED: BY APPROVAL TO BACKFILL: DATE FINAL GRADING APPROVAL: DATE --By. FINAL CONSTRUCTION APPROVAL: DATE: Permit No#: Date Issued: LOCATION r BUILDING PERMIT Vactl(]� TOWN OF NORTH ANDOVER Sol, APPLICATION FOR PLAN EXAMINATION I Date Received 0"ATEP �gssACHuSE��y IMPORTANT: Applicant must complete all items on this Daize PROPERTY Print � 100 Year MAP 10_�PARCEL.,_� ZONING DISTRICT: J yes i st ri ct yes Shop Villade yes TYPE OF IMPROVEMENT PROPOSED USE Residential Non- Residential 0 New Building fine family AAddition 0 Two or more family 0 Industrial 0 Alteration No. of units: D Commercial [I Repair, replacement El Assessory Bldg 0 Others: El Demolition 0 Other Septic llwlel[ b1Qpdplain D Wetlands 11 Weitersh6d'Distriot 0 Water/Sewer DESCRIPTION OF WORK r lPERFORMED: C? + J (-'aq l ` Identification -ease Type or Print Clearly OWNER: Name: A7_ --G AA 041� Phone: Address: ��(7 T:�vand rl\ , IU(-jp—A kAl_ \re -z nlA-, Coritractot'Name,. Phone: $ , p Visor'5,Qonstruc-tlionLicense:. Exp. Oat, ARCHITECT/ENGINEER 5'1 4hl W&one: 11)63. KF 9_ %�6 Address: J�6 ko� Q �h2'g,PReg. No. g(02 FEE SCHEDULE: BULDING PERMIT. $12.00 PER $1000.00 OF THE TOTAL ESTIMATED COST BASED ON $125.00 PER S.F. Total Project Cost: $ FEE: $ Check No.: Receipt No.: NOTE: Persons contracting wit registered contractors do not have access to the guaranty d r re of A _,wrier 61gn gent/u Plans Submitted ❑ Plans Waived. ❑ Certified Plot Plan ❑ Stamped Plans ❑ TYPE OF SEWERAGE DISPOSAL Public Sewer ❑ Tanning/MassageBody Art ❑ Swimming Pools ❑ Well ❑ Tobacco Sales ❑ Food Packaging/Sales ❑ Private (septic tank, etc. Permanent Dumpster on Site ❑ THE FOLLOWING SECTIONS FOR OFFICE USE ONLY INTERDEPARTMENTAL SIGN OFF - U FORM NTNG & DEVELOPMENT COMMENTS C�TSNSERVATION COMMENTS V\..p tai HEALTH Reviewed o v7 At1IK -- Reviewed On (. C��14 Signature_ drtv-�, 1zrt Iojt.�v�---- Reviewed on Signature' CJ -A 0 0, 12 zx� �irnnnfi ird/ ///I/ l / Zoning Board of Appeals: Variance, Petition No: Zoning Decision/receipt submitted yes Planning Board Decision: Comments Conservation Decision: Comments Water & Sewer Connection/signature & Date Driveway Permit DPW Town Engineer: Signature: iFIR�E `DEPARTMENT Temp D;umpster on site, yes _ __ 3no� �� �_ �� _ ocated Osgood Street RireQDepartment signatpre/date_�� _ `0 0 0 0 0 0 Issued for Foundation Permit: 10\22\15 1D$ Project Name: Mixon Residence Addition !� e Silverwatch Architects, LLC AppPrepared Foc Tom Mixon xxx Architecture' Entreering- Design' Land Planning xxx Pro ect Address: Nm Pamvm t oaa L �NMa Adover, Messechuttlts 755 LmaaMerry RosaWlMam, NewHamgnke 07087 Sheet Title: MainFloorPlanSA-58-15 Q uj J m uoNliN woJL :JOA PMOwd s>>a;!y»b y�Iennian]!s � uonaa !ppV uap!sa-d aox!EN :au1r�,� .N »afoad jI%ZZ%ol :u.Lw?d uouapuno:j to3 pants] 4- 0 0 u 0 0 Fri MOFT�{ • Town of North Andover 'a'•o,,,,, .: HEALTH DEPARTMEr CMU`+�� CHECK #: —— DATE: LOCATION: t9 0 I �_ s H/O NAME: CONTRACTOR NAME: 6954 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 Sustems: ❑ Septic - Soil Testing $ ❑ Septic - Design Approval $ ❑ Septic Disposal Works Construction (DWC) $ ❑ Septic Disposal Works Installers (DWI) $ ❑ Title 5 Inspector $ UU L Title 5 Report $ ❑ Other: (Indicate) $ P Health Agent Initials White - Applicant Yellow - Health Pink - Treasurer Owner information is required for every page. Commonwealth of Massachusetts +E,ED 3 Title 5 Official Inspection Form JUL 010014 Subsurface Sewage Disposal System Form - Not for Voluntary Assessments TOWN OF NO T N 01 207 FARNUM STREET _HEALTH D -y Property Address SARA WEISS .111 Owner's Name N. ANDOVER City/Town MA 01845 06/26/14 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 A. General Information filling out forms on the computer, use only the tab 1. Inspector: key to move your cursor - do not John J. Soucy use the return Name of Inspector key. Soucy's Sewer Service, Inc. Company Name 78 North Broadway Company Address rem 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 ❑ Ne s Fu er Evaluation by the Local Approving Authority Signature 06/26/14 Date Thk(system inspector shall submit ecopy 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 • 3/13 Title 5 Official Inspection Form: Subsurface Sewage Disposal System • Page 1 of 17 Commonwealth of Massachusetts N W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments °wM 207 FARNUM STREET Property Address SARA WEISS Owner Owner's Name nforma quire tifo is every on equired foN. ANDOVER MA 01845 06/26/ page. City/Town State Zip Code Date of B. Certification (cont.) Inspection Summary: Check A,B,C,D or E /always complete all of Section D i re 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 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 - 3/13 Title 5 Official Inspection Form: Subsurface Sewage Disposal System • Page 2 of 17 14 Inspection 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 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 - 3/13 Title 5 Official Inspection Form: Subsurface Sewage Disposal System • Page 2 of 17 I L I Owner information is required for every page. Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 207 FARNUM STREET Property Address SARA WEISS Owner's Name N.ANDOVER City/Town B. Certification (cont.) nnn m par, ALMV I -1p I,Uuv 06/26/14 Date of Inspection ❑ 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 ❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below): ❑ 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 • 3/13 Title 5 Official Inspection Form: Subsurface Sewage Disposal System • Page 3 of 17 IL',,, Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments ,M 207 FARNUM STREET Property Address SARA WEISS Owner Owner's Name information is required for every N. ANDOVER MA 01845 06/26/14 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: 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 ❑ ® 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 t5ins • 3/13 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 207 FARNUM STREET Property Address SARA WEISS Owner Owner's Name nforma quire tifo is every on equired foN. ANDOVER MA 01845 06/26/14 page. City/Town State 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: El ® Any portion of the SAS, cesspool or privy is below high ground water elevation. El® Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. El® Any portion of a cesspool or privy is within a Zone 1 of a public well. F1® Any portion of a cesspool or privy is within 50 feet of a private water supply well. El® 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.] i re ❑ ® 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 • 3/13 Title 5 Official Inspection Form: Subsurface Sewage Disposal System • Page 5 of 17 M IW Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 207 FARNUM STREET Property Address SARA WEISS Owner Owner's Name information is N. ANDOVER required for every page. City/Town C. Checklist KAA r)IQAr^ 06/26/14 Date of Inspection 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)] D. System Information Residential Flow Conditions: Number of bedrooms (design . 3 Number of bedrooms (actual): 3 DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x # of bedrooms): 330 t5ins • 3/13 Title 5 Official Inspection Form: Subsurface Sewage Disposal System • Page 6 of 17 t Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments ;M 207 FARNUM STREET Property Address SARA WEISS Owner Owner's Name information is N. ANDOVER required for every page. City/Town D. System Information Description: Number of current residents: A A A ^A M A X 06/26/14 Date of Inspection 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)): Detail: See Attached Sump pump? ❑ Yes ® No Last date of occupancy: Current 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 • 3/13 Title 5 official Inspection Form: Subsurface Sewage Disposal System • Page 7 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments ,M 207 FARNUM STREET Property Address SARA WEISS Owner Owner's Name information is N. ANDOVER required for every page. City/Town D. System Information (cont.) Last date of occupancy/use: Other (describe below): Pumping Records: Source of information: MA 01845 06/26/14 State Zip Code Date of Inspection CURRENT Date General Information Was system pumped as part of the inspection? If yes, volume pumped: How was quantity pumped determined? Reason for pumping: Type of System: Soucv's Sewer Service 1500 gallons Maintenance and Inspection ® Septic tank, distribution box, soil absorption system ❑ Single cesspool ❑ Yes ® No ❑ 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): t5ins - 3/13 Title 5 Official Inspection Form: Subsurface Sewage Disposal System • Page 8 of 17 .<L\, Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments �M 207 FARNUM STREET Property Address SARA WEISS Owner Owner's Name information is N. ANDOVER required for every page. City/Town State Zip Code 06/26/14 Date of Inspection D. System Information (cont.) Approximate age of all components, date installed (if known) and source of information: 1993 (21 YEARS) Were sewage odors detected when arriving at the site? ❑ Yes ® No Building Sewer (locate on site plan): 40" AT TANK Depth below grade: feet Material of construction: ❑ cast iron ® 40 PVC ❑ other (explain): Distance from private water supply well or suction line: n/a feet Comments (on condition of joints, venting, evidence of leakage, etc.): Septic Tank (locate on site plan): Depth below grade: Material of construction: ® concrete ❑ metal 15" feet ❑ fiberglass ❑ polyethylene ❑ other (explain) If tank is metal, list age: years Is age confirmed by a Certificate of Compliance? (attach a copy of certificate) Dimensions: 101511 X 61611 Sludge depth: 211 ❑ Yes ❑ No t5ins • 3/13 Title 5 Official Inspection Form: Subsurface Sewage Disposal System - Page 9 of 17 .TIN Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 207 FARNUM STREET Property Address SARA WEISS Owner Owner's Name information is N. ANDOVER required for every page. City/Town D. System Information (cont.) State Zip Code Septic Tank (cont.) Distance from top of sludge to bottom of outlet tee or baffle 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 38" 0" 7" 14" 06/26/14 Date of Inspection 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.): PUMP TANK IN 2015 AND NOTE THE CONDITION OF THE SOLIDS. Grease Trap (locate on site plan): Depth below grade: Material of construction: ❑ concrete ❑ metal Dimensions: feet ❑ fiberglass ❑ polyethylene ❑ other (explain): 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: t5ins • 3(13 Date Title 5 Official Inspection Form: Subsurface Sewage Disposal System • Page 10 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form o Subsurface Sewage Disposal System Form - Not for Voluntary Assessments M 207 FARNUM STREET Property Address SARA WEISS Owner Owner's Name information is N. ANDOVER required for every page. City/Town MA 01845 06/26/14 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.): ALL BAFFELS ARE GOOD. TANK IS NOT LEAKING AND STRUCTURALLY SOUND. 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 l5ins • 3/13 Title 5 Official Inspection Form: Subsurface Sewage Disposal System - Page 11 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 207 FARNUM STREET Property Address SARA WEISS Owner Owner's Name information is N. ANDOVER required for every page. Cityfrown D. System Information (cont.) MA 01845 06/26/14 State Zip Code Date of Inspection 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.): "D" BOX REPLACED PRIOR TO INSPECTION. SEE PERMIT 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.): * 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 - 3/13 Title 5 Official Inspection Form: Subsurface Sewage Disposal System - Page 12 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments �M 207 FARNUM STREET Property Address SARA WEISS Owner Owner's Name information is N. ANDOVER required for every page. City/Town MA 01845 06/26/14 State Zip Code Date of Inspection D. System Information (cont.) Type: ❑ leaching pits number: ❑ leaching chambers number: ❑ leaching galleries number: ® leaching trenches number, length: (4) 3- X 50' ❑ 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.): NO SIGNS OF HYDRAULIC FAILURE 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 Depth of scum layer Dimensions of cesspool Materials of construction Indication of groundwater inflow ❑ Yes ❑ No t5ins • 3/13 Title 5 Official Inspection Form: Subsurface Sewage Disposal System • Page 13 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 207 FARNUM STREET Property Address SARA WEISS Owner Owner's Name information is required for every N. ANDOVER MA 01845 06/26/14 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 • 3/13 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 207 FARNUM STREET Property Address SARA WEISS Owner Owner's Name information is N. ANDOVER required for every page. City/Town MA 01845 State Zip Code 06/26/14 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 R drawing attached separately t5ins - 3/13 Title 5 Official Inspection Form: Subsurface Sewage Disposal System • Page 15 of 17 •� Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments ;M 207 FARNUM STREET Property Address SARA WEISS Owner Owner's Name information is required for every N. ANDOVER MA 01845 06/26/14 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Site Exam: ® Check Slope ® Surface water ® Check cellar ❑ Shallow wells E t' t d d th t hh r nd t r• 72" s ima a ep o ig g ou wa e . feet Please indicate all methods used to determine the high ground water elevation: ❑ Obtained from system design plans on record In If checked, date of design plan reviewed: 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 LOWER PORTION APPROXIMATELY 50' DOWN GRADIENT OF SYSTEM. 4' NO WATER Before filing this Inspection Report, please see Report Completeness Checklist on next page. t5ins • 3/13 Title 5 Official Inspection Form: Subsurface Sewage Disposal System • Page 16 of 17 Summary Record Card generated on 6/17/2014 3:55:33 PM by Karen Hanlon ), .4, L'61e -k J ,). , C�J'Y��I� Town of North Andover Tax Map # 210-107.A-0052-0000.0 Parcel Id 17878 207 FARNUM STREET SCHWALM, MARK WEISS, SARA 207 FARNUM STREET N. ANDOVER, MA 01845 Class 101 Single Family Property Type 1 Residential Zoning2 1 Residential Zoning3 1 Residential Size Total 1.01 Acres FY 2014 UB Mailina Index Name/Address SCHWALM, MARK WEISS, SARA 207 FARNUM STREET N. ANDOVER, MA 01845 UB Account Maint. Account No Cycle Bldg id. 14131.0 - 207 FARNUM STREET 2100113 02 Cycle 02 UB Services Maint. Account No. 2100113 Service Code MISCFEE ADMIN FEE WTR WATER UB Meter Maintenance Account No. 2100113 Serial No Status 33530356 a Active Date Reading 5/5/2014 198 2/3/2014 190 10/31/2013 183 8/1/2013 172 51112013 166 2/7/2013 159 10/30/2012 150 8/2/2012 141 5/2/2012 132 2/2/2012 126 11/1/2011 118 8/1/2011 107 5/2/2011 99 2/4/2011 90 11/1/2010 81 8/2/2010 68 5/3/2010 56 2/1/2010 45 11/2/2009 35 8/3/2009 23 5/6/2009 8 3/9/2009 0 2/2/2009 428 11/3/2008 410 MSG 36% 8/1/2008 392 MSG 15% Type Loan Number Active/Inact. From Payor Occupant Name Active/Inactive Last Billing Date 6/3/2014 Active Rate Charge Multiplier/Users 0.635/8 7.82 1/ 01 ALL METER SIZE 30.40 /1 Until Location Brand Type Size YTD Cons ERT HH b Badger w Water 0.63 0.63 190 Code Consumption Posted Date Variance a Actual 8 6/12/2014 19% a Actual 7 3/17/2014 -39% a Actual 11 12/20/2013 85% a Actual 6 9/18/2013 -23% a Actual 7 6/18/2013 -6% a Actual 9 3/13/2013 -11% a Actual 9 12/1312012 3% a Actual 9 9/26/2012 47% a Actual 6 6/20/2012 -22% a Actual 8 3/14/2012 -28% a Actual 11 12/15/2011 36% a Actual 8 9/14/2011 15% a Actual 9 6/13/2011 9% a Actual 9 3115/2011 -34% a Actual 13 12/13/2010 8% a Actual 12 9/13/2010 9% a Actual 11 619/2010 10% a Actual 10 3/11/2010 -17% a Actual 12 12/11/2009 -22% a Actual 15 9/11/2009 22% a Actual 8 6/16/2009 0% n New Meter 0 6/16/2009 0% m Manual estimate 18 3/16/2009 3% m Manual estimate 18 12/10/2008 -2% m Manual estimate 18 9/12/2008 22% Stewart's Septic Service U Andover Septic U Stratham Hill Septic U Roto -Ram : a (978) 372-7471 (978) 475-2593 (603) 772-5548 (978) 452-9022 58 South KimbaU Sftetj Bradford , MA 01835 D� PAY FROM THIS BILL Customer Name: -0 Reg. Nature of Service U N/C U Reg. Maint. Service Locatiorr Q Emergency Phone., Septic Tank Pumping and Cleaning U Day 0 Nigh, "Done the Right Way" ," Silting Address,Not Responsible for Covers F-6 rno-n 5�— or Irrigation Systems CitiILA /*m 11 z) ZIP: E3 I IS 44 1 AIL Special Instructions /a—cornpleted U Incompleted Reason: Per AM!PM Services Rendered Vacuum Pumping 0 1 Drain Cleaning Septic Tank X1ood 000nnsdition C1 Main twineCQ\0ryweII eechfield Runback 0 Toilet Bowl * Leech Pit / overflow 0 Riding High 13 Kitchen Sink * D -Box (liquid level) 0 Bathtub / Shower * Pump Chamber 0 Full to Cover U Vanity * Grease Trap Q Excessive Solids 0 Floor Drain * Catch Basin Top / Bottom Q vent * Portable Toilet 0 Use No Powdered Soap D Suer Jet * Other U Heavy Grease Cl Other Oty: U Roots rootage, Size: 0 Suggest Electric C3 Under 1000 gallons 0 1000 gallons 1500 gallons Rootering 0 2000 gations 0 3000 gallons 0 400 lions U Van Called Q 5000 gallons U Other 0 Other fisc. • Digging Charge U BackhoeeU Inspection • Location hr, U consultion U Cwtifloation: P/F • Service Call U Estimate Reason: • Labor U Portable Toilet Rental Q Pump Repair • Waiting Time U Baffle U Repair Digging Charge Is Per Driver U Chemical Treatment Discretion U Other Deso C) ........... . Recommendations Terms of Payment Parts 00 Vacuum Pumping Drain Cleaning Yr. —Month Yr. Month N Elm* -in 5 DAYS Tae is Terms & Conditions Q Cash U Check U Credit _D�_coun I Tota 1. Not responsibte for damage beyond curb line. 3, 1.511/6 per month Wil be charged to accounts past due, 2. Ali complaints shall be reported within 48 hours. 4. The purchaser slims to pay all cost of collection, Customer Signature Serviceman Commerce f N S U R A N C E - April 15, 2015 The Commerce Insurance Company'"' Citation Insurance Companyw 11 Gore Road, Webster, Massachusetts 01570 508.949.15001 www.commerceinsurance.com BUILDING COMMISSIONER or INSPECTOR OF BUILDINGS TOWN/CITY HALL NORTH ANDOVER MA 01845 Board of Health or Board of Selectmen Town/City Hall RE: Our Insured: THOMAS MIXON / PATRICIA EVERTON Property Address: 207 FARNUM STREET Policy#: BGHTQH Date of Loss: 02/23/2015 File#: JYVN30-HRKPA4 Claim has been made involving loss, damage, or destruction of the above captioned property which may exceed $1,000, or cause Massachusetts General Laws, Chapter 143, Section 6 to be applicable. If any notice under Massachusetts General Laws, Chapter 139, Section 3B is appropriate, please direct it to my attention. Please reference the above captioned insured, location, policy number, date of loss, and file number on any correspondence. THERESA KALISZEWSKI Telephone: (508)949-1500 Ext: 11535 Clm Representative II, Subrogation Toll Free: 1-800-221-1605, Ext: 11535 On this date, I cause copies of this notice to be sent to the persons indicated above, at the address above, by first class mail. April 15, 2015 DAMAGE CAUSED BY ICE MATER BATH, GUEST BED/BATHROOM, AND CLOSET C/WALLS CIC 254 (Rev. 4/95) MAIL I75 OF NOR7y qti SSA C HUs PUBLIC HEALTH DEPARTMENT Town of North Andover Coirununity Development Division CERTIFICATE OF COMPLIANCE As of: 6/26/14 This is to certify that the individual subsurface disposal system received a SATISFACTORY INSPECTION of the: Complete Repair of D -Box By: John Soucy At: 207 Farnum Street Map 107.A Lot 0052 North Andover, MA 01845 of this certipo#e shall qbt be construed as a guarantee that the system will function satisfactorily. Grant Public Health Agent 1600 Osgood Street, North Andover, Massachusetts 01845 Phone 978.688.9540 Fax 978.688.8476 Web www.townofnorthandover.com i North Andover Health Department Community Development Division ONSITE WASTEWATER SYSTEM CONSTRUCTION NOTES LOCATION INFORMATION ADDRESS: 207 Farnum St. INSTALLER: John Soucy DESIGNER: PLAN DATE: BOH APPROVAL DATE ON PLAN: MAP: 107.A LOT: 0052 INSPECTIONS INSPECTION: 6/26/14 D -Box DATE OF BED BOTTOM INSPECTION: DATE OF FINAL CONSTRUCTION INSPECTION: DATE OF FINAL GRADE INSPECTION: SITE CONDITIONS ❑ Contractor reports any changes to design plan ❑ Existing septic tank properly abandoned ❑ Internal plumbing all to one building sewer ❑ Topography not appreciably altered Comments: SEPTIC TANK ❑ Building sewer in continuous grade, on compacted firm base ❑ Cleanouts per plan ❑ Bottom of tank hole has 6" stone base ❑ Weep hole plugged ❑ 1500 gallon tank has been installed H-10 loading ❑ Monolithic tank construction ❑ Water tightness of tank has been achieved by visual testing ❑ Inlet tee installed, centered under access port Comments: PUMP CHAMBER Comments: CONTROLPANEL Comments: DISTRIBUTION -BOX ❑ Outlet tee installed, centered under access port (gas baffle/effluent filter) ❑ inch cover to within 6" of finish grade installed over one access port ❑ Hydraulic cement around inlet & outlet ❑ Bottom of tank hole has 6" stone base ❑ Weep hole plugged ❑ 1500 gallon Pump Chamber installed ❑ H-10 loading ❑ Monolithic tank construction ❑ Inlet tee installed, centered under access port ❑ Pump(s) installed on stable base ❑ Alarm float working ❑ Pump On/Off floats working ❑ Separate on/off floats ❑ Drain hole in pressure line ❑ cover at final grade installed over pump access port ❑ Water tightness of tank has been achieved by testing ❑ Hydraulic cement around inlet & outlet ❑ Alarm & Pump are on separate circuits ❑ Alarm sounds when float is tripped ❑ Location of control panel: basement ❑ Alarm signal located inside: basement X Installed on stable stone base X H-20 D -Box X Inlet tee (if pumped or >0.08'/foot) X Hydraulic cement around inlet & outlets X Observed even distribution X Speed levelers provided (not required) X Schedule 40 PVC Pipe Comments: D -box is 3'4" deep Commonwealth of Massachusetts BOARD OF HEALTH North Andover Map -Block -Lot 107.A0052 --------------------- Permit No BHP -2014-0670 --------------------- FEE $125.00 --------------------- DISPOSAL WORKS CONSTRUCTION PERMIT Permission is hereby granted John -Soucy----------------------------------------------- to (Repair) an Individual Sewage Disposal System.'" AA at No 207 FARNUM STREET ------------------------------------------------- as shown on the application for Disposal Works Construction Permit No. BHP -2014-067 Dated June 24, 2014 ----------------------- ----------------------------- BOARD 'i�1L T Issued On: Jun -24-2014 �i ❑ Dumpster 6864 Of NORTH ,� $ • Town of North Andover ❑ Massage Establishment '�'•�.; :o :: �' HEALTH DEPARTMENT ,ssACHU5t4 ❑ Massage Practice +, �j CHECK #: —�-�— DATE: � 1 I LOCATION: r ❑ Recreational Camp H/O NAME: JA ) O I �C_) ❑ Sun tanning CONTRACTOR NAME: ,I ❑ Swimming Pool $ ❑ Tobacco $ 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 $ �[' Gv Septic Disposal Works Construction (DWC) $�, ��T Septic Disposal Works Installers (DWI) $ ❑ Title 5 Inspector $ ❑ Title 5 Report $ ❑ Other. (Indicate) $ 10 Health Agent Initials White - Applicant Yellow - Health Pink - Treasurer T "9 Application for Septic Disposal System �J6&+ :Construction Permit - TOWN OF TODAY'S DATE �r $ 250.00 — Full Repair R_NORTH ANDOVER, MA 01845 $125.00 -Component Important: Application is hereby made for a permit to: When filling out ❑ Construct a new on-site sewage disposal system* forms on the computer, use ❑ Repair or replace an existing on-site sewage disposal system* only the tab key DISTRIBUTION BOX H-20 to move your ❑■ Repair or replace an existing system component —What.? cursor - do not use the return key. A. Facility Information 207 FARNUM STREET raf Address or Lot # N.ANDOVER City/Town 2.- *TYPE OF SEPTIC SYSTEM*: ❑ Pump ❑■ Gravity (choose one) ***If pump system, attach copy of electrical permit to application*** ■❑ Conventional System (pipe and stone system) ❑ Infiltrator or Biodiffuser (Gravel -Less) (Attach a copy of you ce ific�at or ,) III ilk type f system. F-1PressureDistribution S.A.S. (No D -Box) (Attach Draft Ma ntenance Agreement) ❑ Pressure Dosed (D -Box Present) S.A.S. I JUN 2 4 Z014 2. Owner Information TOWN OF NUR IH ANDOVER HEALTH t)EPARTMENT SARA WEISS Name 207 FARNUM STREET Address (if different from above) N. ANDOVER MA 01845 City/Town State Zip Code 617-335-8196 Telephone Number 3. Installer Information JOHN SOUCY SOUCY SEWER SERVICE INC Name Name of Company 78 N. BROADWAY Address SALEM NH 03079 City/Town State Zip Code 603-898-9339 Telephone Number (Cell Phone # if possible please) 4. Designer Information N/A Name Name of Company Address City/Town State Zip Code Telephone Number (Best # to Reach) Application for Disposal System Construction Permit • Page 1 of 2 4-W ;,NApplication for Septic Disposal System Construction Permit -TOWN OF ORTH ANDOVER. MA 01845 PAGE 2 OF 2 A. Facility Information continued.... 5. Type of Building: XResidential Dwelling or ❑Commercial B. Agreement 6/23/14 TODAY'S DATE $ 250.00 - Full Repair $125.00 - Component The undersigned agrees to ensure the construction and maintenance of the afore -described on-site sewage disposal system in accordance with the provisions of Title 5 of the Environ a Code, as well as the Local Subsurface Disposal Regulations for the Town of North dov ,and not to lace the system in operation until Certificate of Compliance has beer issued v this Boa f Health. 1 ame Date Application Approved By: oard of Health Representative) 1,, Z," -t 1 v Name /oved Date plication Disapp r the following reasons: For Office Use Only: 1. Fee Attached. Yes No 2. Project Manager Obligation Form Attached. Yes No .3 Pump S sv tem? Ifso, Attach coiZ,v ofElectrical Permit Yes No 4. Foundation As -Built? (new construction ronly). (Same scale as approved plan) Yes No 5. F1oorPlans? (new construction only). Yes No Application for Disposal System Construction Permit • Page 2 of 2 LaT 3A / CERT/FY THAT THE OFFSETS SHOWN COMPLY WITH THEZON/NG SY LAWS OF No, 4.Nc0veQ, MA. WHEN BUIL T. CERTIFIED FOUNDA TION PLAN LOCATED /N N0. ANboye&' r-�A. SCALE /"= 40' DATE : (- l tH Scott L. G/IesR.L.5 0 11-1 113 50 Deer Meadow Road North Andover, Mass. LOT Z -A 43, 3AB S.F. � EKIST_ SND = Tvwr?a�Z3 40 -33"- 23', 6Ae-anr�-n for z NQu� Iuspee-T&D -"4LS DtS ply S`iS�M aaD 1VK-'V -cam Cm,a t-<-rkt*4 AuD F+uAL�zW�1uG kas BES I&l Vic- CVppV,� VV11"k -C{{E �ESIG►JE�S 1WEV4r A►SD�t� ISR � t)4-jeb c'cyaroRl'�-� T4e R-I►1.) tvz, I ; -EA9 UM sT OFFSETS SHOWN ARE FOR THE USE OF THE SU/L DING /NSPEC TOR ONL Y AND SUCH USE IS FOR THE DETERMINATION OF ZON/NG CONFORMITY OR NON- CONFORM/TY WHEN CONSTRUCTED. i gs.gcJjt_'P gL-G-V/aT,o�.JS 1N TNOK` 13637' CuT "rA -W K' . Iti! � D'�K • 170' 011D ,t �, •,t.Z.lg33c' ,1 1 41-Q' : lie 4:22 Fj -a? x Commonwealth of Massachusetts City/Town of No andover System Pumping Record Form 4 L � 2,013 DEP has provided this form for use by local Boards of Health. Other forms may be used, but the information must be substantially the same as that provided here. Before using this form, check with your local Board of Health to determine the form they use. The System Pumping Record must be submitted to the local Board of Health or other approving authority within 14 days from the pumping date in accordance with 310 CM 15.351. Citylrown Ma State State Telephone Number B. Pumping Record f % 1. Date of Pumping Date 2. Quantity Pumped: 3. Type of system: ❑ Cesspool(s) �epfic Tank -❑ Tight Tank Zip Code Zip Code allons ❑ Grease Trap ❑ Other (describe): 4. Effluent Tee Filter present? ❑ Yes ['laO If yes, was it cleaned? ❑ Yes ❑ No 5. Condition of S :llzl'\ �c2� o>— 6. System Pumped_By Z — �\ Name Vehicle License Number Stewart's Septic Service Company 7. Location where contents were disposed: Stewart's Pre-treatment Plant, 20 So. Mill Bradford, Ma 01835 Date Date t5form4.doc• 03/06 System Pumping Record - Page 1 of 1 A. Facility Information Important: When filling out forms 1. System Location: on the computer, use only the tab 207 Farnum St _ key to move your Address cursor - do not No Andover use the return City/Town key. 2. System Owner: Wiess Name renon Address (if different from location) Citylrown Ma State State Telephone Number B. Pumping Record f % 1. Date of Pumping Date 2. Quantity Pumped: 3. Type of system: ❑ Cesspool(s) �epfic Tank -❑ Tight Tank Zip Code Zip Code allons ❑ Grease Trap ❑ Other (describe): 4. Effluent Tee Filter present? ❑ Yes ['laO If yes, was it cleaned? ❑ Yes ❑ No 5. Condition of S :llzl'\ �c2� o>— 6. System Pumped_By Z — �\ Name Vehicle License Number Stewart's Septic Service Company 7. Location where contents were disposed: Stewart's Pre-treatment Plant, 20 So. Mill Bradford, Ma 01835 Date Date t5form4.doc• 03/06 System Pumping Record - Page 1 of 1 (1) 0) CL Q) E 0 c 70 m t c 0 N E E 0 u C: 0 0 Q) Zn C: 0 U E m O m 8 0 E 0 G w 0 m H 0 a L 7 a L Q% .� iJ _ o EC Q) = 0 U,�.1 m o �i Q 1 a� f H o a U O Im W Z Q) E 0 c 70 m t c 0 N E E 0 u C: 0 0 Q) Zn C: 0 U E m O m .,t"::'sj� s�:,%w�''rrrrr:i'.•�1"k1��'i�Ji:T1Sr�•fi'�:`��:. '��ot RECEIVED DEC 0 6 2005 (()WN U} AUKI'It �N Ov, :17HEALTH DEPWN OF NORTH RTME�NTERI UA I't SY"T' "4 PIJMPIN(U RF_C C)KL. al' �7 j e� �sC ?qQ. rvKl 0), 3�RYICe: xUV'rlNc .. _ . en�tKul.n� . U'd l VA YA*nQNJ. KZAYDY 0UAoouor3a " YVU. fv t'iivrx B+�C&9$YYB 301,1p$ •"••, l Eir4CKJ'1C1.0 KUN6�t'ti, .. PLOOD�D �ot,ro c�x�YOY�A"" omeR •�xPtr,11N �uNI•�NI'� fX,•1Nyr�xKbU 11' . a:. FORM U - LOT RELEASE FORM 6. ..,_.. ,t INSTRUCT IONS: This farm is used to verify that all necessary approvals/permits from - Boards and Departments having jurisdiction have been obtained. This does not relieve applicable lic- • the applicant and/or landowner from compliance with any a pp or requirements. *AF FLIC ANT FILLS OUT THIS APPLICANT PHCNE LOCATION: Assessors flap Number 7 T PAFCE_ SUEDIVISION LOT (S) STRE.'-, ," R �%M S� S 7. NUINIEER a ©� OFFICIAL USE ONLY RECOMMENDATIONS OF TOWN AGENTS: Im nLs. o N S t Q S-4 V, td V, CONSERVATION ADMINISTRATOR DATE APPROVED DATE REJECTED COMMENTS TOWN PLANNER DATE APPROVED DATE REJECTED COMMENTS FOOD INSPECTOR -HEALTH DATE.APPROVED DATE REJECTED SE?TIC INSPECTOR -HEALTH DATE APPROVED L �a DATE REJECTED COMMENTS PUELIC WORKS - SEWER/WATER CONNECTIONS DRIVEWAY PERMIT FIRE DEPARTMENT RECEIVED i?Y EUILDING iNSPECTOR DATE Revised 919; im TOWN OF NORTH ANDOVER SYSTEM PUMPING RECORD DATE:d Z OL cVCrnw. ADDRESS aD7 (-- S SYSTEM LOCATION (example: left front of house) DATE OF PUMPING; 7 QUANT�TyUMPEDGALLONS CESSPOOL: NO �� YES ._.__ SEPTIC TANK: NO --_____ YES �— NATURE OF SERVICE: ROUTINE — 4 EMERGENCY OBSERVATIONS: GOOD CONDITION HEAVY GREASE ROOTS ---- EXCESSIVE SOLIDS SOLIDS CARRYOVER SYSTEM PUMPED BY: ,OMMENTS: ONTENTS TRANSFERRED TO: FULL TO COVER BAFFLES IN PLACE LEACHFIELD RUNBACK FLOODED ----- OTHER (EXPLAIN) 170 ARGEO PAUL CELLUCCI Governor COMMONWEALTH OF MASSACHUSETTS EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS DEPARTMENT OF ENVIRONMENTAL PROTECTION ONE WINTER STREET, BOSTON NIA 02108 (617) 292-5500 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A $) /� 7 �'A (u S r r CERTIFICATION Q 7 Property Address: \} )1. f`i o # IV�) Name of Owner ods,, /J ,Q f 0 q f Address of Owner: Date of Inspection: Sim 01,4 Name of Inspector: (Please Print) j.) 1 am a DEP approved system inspector pursuant to Section 15.340 of Title 5 (310 CMR 15.000) Company Name: �} / ! b©U r H �' !�► fr C Mailing Address: 4/` !'�,%�/�— 0',4 r Telephone Number: 37 -L —z 'i 'i TRUDY CORE Secretary DAVID B. STRUHS Commissioner CERTIFICATION STATEMENT I certify that I have personally inspected the sewage disposal system at this address and that the information reported below is true, accurate and complete as of the time of inspection. The inspection was performed based on my training and experience in the proper function and maintenance of on-site sewage disposal systems. The system: XPasses _ Conditionally Passes _ Needs FurtKer Evaluation By the Local Approving Authority _ Fails Inspector's Signature: %.� Date: The System Inspector shall submit a copy of this inspection report to the Approving Authority (Board of Health or DEP)within thirty (30) days of completing this inspection. If the system is a shared system or has a design flow of 10,000 gpd or greater, the inspector and the system owner shall submit the report to the appropriate regional office of the Department of Environmental Protection. The original should be sent to the system owner and copies sent to the buyer, if applicable, and the approving authority. NOTES AND COMMENTS revised 9/2/98 Page 1 of 11 0�s6 Premed on Recycled Paper T(3ih/N OF tiORTHI All®OL 80—ARD If E:S01999 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) 01 7 ITI� 'roperty`Aadress: Jwner: (% Date of Inspection: . INSPECTION SUMMARY: Check A, B, C, or D: A. QSYSTEM PASSES: t I have not found any information which indicates that any of the failure conditions described in 310 CMR 15.303 exist. Any failure criteria not evaluated are indicated below. COMMENTS: B. SYSTEM CONDITIONALLY PASSES: One or more system components as described in the "Conditional Pass" section need to be replaced or repaired. The system, upon f completion of the replacement or repair, as approved by the ^Board of Health, will pass. Indicate yes, no, or not determined (Y, N, or ND). Describe basis of determination in all instances. If "not determined", explain why not. The septic tank is metal, unless the owner or operator has provided the system inspector with a copy of a Certificate of Compliance (attached) indicating that the tank was installed within twenty (20) years prior to the date of the inspection; or the septic tank, whether or not metal, is cracked, structurally unsound, shows substantial infiltration or exfiltration, or tank failure is imminent. The system will pass inspection if the existing septic tank is replaced with a complying septic tank as approved by the Board of Health. Sewage backup or breakout or high static water level observed in the distribution box is due to broken or obstructed pipe(s) or due to a broken, settled or uneven distribution box. The system will pass inspection if (with approval of the Board of Health). broken pipe(s) are replaced obstruction is removed distribution box is levelled or replaced The system required pumping more than four times a year due to broken or obstructed pipe(s). The system will pass inspection if (with approval of the Board of Health): broken pipe(s) are replaced obstruction is removed revised 9/2/98 Page 2 of 11 0 0 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) ` 6,7 7 s. Property Address: Owner: j,� l•.' ��` l! �— C.� Date of Inspection: f C. FURTHER EVALUATION IS REQUIRED BY THE BOARD OF HEALTH: . Conditions exist which require further evaluation by the Board of Aealth in order to determine if the system is failing to protect the public Health, safety and the environment. 1) SYSTEM WILL PASS UNLESS BOARD OF HEALTH DETERMINES IN ACCORDANCE WITH 310 CMR 15.303 (1)(b) THAT THE SYSTEM IS NOT FUNCTIONING IN A MANNER WHICH WILL PROTECT THE PUBLIC HEALTH AND SAFETY AND THE ENVIRONMENT: Cesspool or privy is within 50 feet of surface water Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh. g 2) SYSTEM WILL FAIL UNLESS THE BOARD OF HEALTH (AND PUBLIC WATER SUPPLIER, IF ANY) DETERMINES THAT THE SYSTEM IS FUNCTIONING IN A MANNER THAT PROTECTS THE PUBLIC HEALTH AND SAFETY AND THE ENVIRONMENT: The system has a septic tank and soil absorption system (SAS) and the SAS is within 100 feet of a surface water supply or tributary to a surface water supply. _ The system has a septic tank and soil absorption system and the SAS is within a Zone I of a public water supply well. The system has a septic tank and soil absorption system and the SAS is within 50 feet of a private water supply well. The system has a septic tank and soil absorption system and the SAS is less than 100 feet but 50 feet or more from a private water supply well, unless a well water analysis for coliform bacteria and volatile organic compounds indicates that the well is free from pollution from that facility and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm. Method used to determine distance (approximation not valid). 3) OTHER revised 9/2/98 Page 3 of 11 a .w SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) . r7 Property Address: 7 Date of Inspection: D. SYSTEM FAILS: You must indicate either "Yes" or "No" to each of the following: 1 have determined that one or more of the following failure conditions exist as described in 310 CMR 15.303. The basis for this determination is identified below. The Board of Health should be contacted to determine what will be necessary to correct the failure. Yes No Backup of sewage into facility or system component due to an overloaded or clogged SAS or cesspool. Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool. 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. Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number of times pumped _. Any portion of the Soil Absorption System, cesspool or privy is below the high groundwater e4evation. Any portion of a cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. Any portion of a cesspool or privy is within a Zone I of a public well. _ Any portion of a cesspool or privy is within 50 feet of a private water supply well. Any portion of a cesspool or privy is less -than 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality analysis. If the well has been analyzed to be acceptable, attach copy of well water analysis for coliform bacteria, volatile organic compounds, ammonia nitrogen and nitrate nitrogen. E. LARGE SYSTEM FAILS: You must indicate either "Yes" or "No" to each of the following: The following criteria apply to large systems in addition to the criteria above: The system serves a facility with a design flow of 10,000 gpd or greater (Large System) and the system is a significant threat to public health and safety and the environment because one or more of the following conditions exist: Yes No the system is within 400'feet of"a surface"drinking water supply the system is within 200 feet of a tributary to a surface drinking water supply the system is located in a nitrogen sensitive area (Interim Wellhead Protection Area - IWPA) or a mapped Zone II of a public water supply well) The owner or operator of any such system shall upgrade the system in accordance with 310 CMR 15.304(2). Please consult the local regional office of the Department for further information. revised 9/2/98 Page 4orti SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST Property Address: r,9 Owner: ✓ it !� /t� `7 l Date of Inspection: .�- Check if the following have been done: You must indicate either "Yes" or "No" as to each of the following: Yes No Pumping information was provided by the owner, occupant, or Board of Health. _ None of the system components have been pumped for at least two weeks and -the system has been receiving normal flow rates during that period. Large volumes of water have not been introduced into the system recently or as part of this inspection. As built plans have been obtained and examined. Note if they are not available with N/A. The facility or dwelling was inspected for signsd.of s$wage.Kack-uq. - _w The system does not receive non -sanitary or industrial waste flow. The site was inspected for signs of breakout. All system components, excluding the Soil Absorption System, have been located on the site. The septic tank manholes were uncovered, opened, and the interior of the septic tank was inspected for condition of baffles or tees, material of construction, dimensions, depth of liquid, depth of sludge, depth of scum. The size and location of the Soil Absorption System on the site has been determined based on: Existing information. For example, Plan at B.O.H. Determined in the field (if any of the failure criteria related to Part C is at issue, approximation of distance is unacceptable) (15.302(3)(b)1 The facility owner (and occupants, if different from owner) were provided with information on the proper. maintenance -of SubSurface Disposal Systems. r —r . revised 9/2/98 Page 5of11 Iroperty Address: Owner: Date of Inspection: RESIDENTIAL: SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION FLOW CONDITIONS Design flow: g.p.d./bedro Number.of bedrooms (design): Q Number of bedrooms (actual):_ Total DESIGN flow Number of current residents: Garbage grinder lyes or no):__Ha J Laundry (separate system) (yes or no): )Vylf yes, separate -inspection required Laundry system inspected (yes or no) #A Seasonal use (yes or no): /jV Water meter readings, if available (last two year's usage (gpd):' Sump Pump lyes or no):--1kfV Last date of occupancy:--- (7, -P_ COMMERCIALIINDUSTRIAL: H. t ? Type of establishment: f� t'l Design flow: qpd ( Based on 15.203) Basis of design flow Grease trap present: (yes or no)_ Industrial Waste Holding Tank present: (yes or no)_ Non -sanitary waste discharged to the Title 5 system: (yes or no)_ Water meter readings, if available: Last date of occupancy: OTHER: (Describe) Last date of occupancy: GENERAL INFORMATION PUMPING RECORDS and source of information:P} System pumped as part of inspe tion: (yes or no) If yes, volume pumped:gallons Reason for pumping,: TYPE OF-YSTEM Septic tank/distribution box/soil absorption system Single cesspool Overflow cesspool Privy Shared system lyes or no) (if yes, attach previous inspection records, if any) I/A Technology etc. Attach copy of up to date operation and maintenance contract Tight Tank Copy of DEP.Approval Other r' L APPROXIMATE AGE of all components, date installed Of known) and source of information: CSS Yy - Sewage odors detected when arriving at the site: (yes or no)f4 revised 9/2/98 Page 6of11 t SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (contirwed) 'roperty Address: Owner: Date of Inspection: BUILDING SEWER: (Locate on site plan) Depth below grade: /" Material of construction: _ cast iron L"o 40 PVC _ other (explain) Distance from prj late water supply well or suction line Diameter _(� Comments: (condition of joints, venting, evidence of leakage, -etc.) SEPTIC TANK:_ t/.42) (locate on site plan) Depth below grade: Material of construction _concrete _metal _Fiberglass _Polyethylene _other(explain) If tank is metal, list age _ Is age confirmed by certificate or uompnance _ IYesrnol Dimensions: �o `"'�` Sludge depth: 4 4� Distance from top of sludge to bottom of outlet tee or baffle: Scum thickness: /I a-- " j Distance from top of scum to top of outlet tee or baffle: i "r Distance from bottom of scum to bottom of outlet tee or baffle: % How dimensions were determined: 6,11 5 f %C 'omments: (recommendation for pumping, condition of inlet and outlet tees or baffles, depth of liquid level in relation to outlet invert, structural integrity, evidence of leakage, etc.) -4-1 - )Yf J -f / ( i / r GREASE TRAP: (locate on site plan) Depth below grade:_ Material of construction: _concrete _metal _Fiberglass _Polyethylene _other(explain) Dimensions: Scum thickness: Distance from top of scum to top of outlet tee or baffle: b Distance from bottom of scum to bottom of outlet tee or baffle: Date of last pumping: Comments: (recommendation for pumping, condition of inlet and outlet tees or baffles, depth of liquid level in relation to outlet invert, structural integrity, evidence of leakage, etc.) revised 9/2/98 Page 7of11 I +r SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) 'roperty Address: Owner: Date of Inspection: TIGHT OR HOLDING TANKN(Tank must be pumped prior to, or 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/day Alarm present Alarm level: Alarm in working order: Yes _ No_ Date of previous pumping: !y Comments:';c r ,l (condition of inlet tee, condition of alarm and floattswitches, etc.) DISTRIBUTION BOX: (locate on site plan) Depth of liquid level above outlet invert! Y `� Comments: (note if level and distribution is equal, evidence of solids carryover, evidence of leakage into or out of box, etc.) , U V'z'C'e, S' .ice G41 PUMP CHAMBER:_ I HX (locate on site plan) Pumps in working order: (Yes or No) Alarms in working order (Yes or No) Comments: (note condition of pump chamber, condition of pumps and appurtenances, etc.) revised 9/2/98 Page 8ofII w SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (corKinupd), `roperty Address: Date of Inspection: SOIL ABSORPTION SYSTEM (SAS): /Ps' (locate on site plan, if possible; excavation not required, location may be approximated by non -intrusive methods) If not located, explain: Type leaching pits, number:_ leaching chambers, number:_ r leaching galleries, number:_ /f leaching trenches, number, length: leaching fields, number, dimensions: overflow cesspool, number:_ Alternative system: `s Name of Technolggy:;a Comments: (note condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of vegetation, etc.) ,L/U 5 / "a .E / e-7 YQ ✓Z 4 r -12 t C /r— /G G/ )'2 --c CESSPOOLS: _ y( (locate on site plan) Number and configuration: Depth -top of liquid to inlet invert: Depth of solids layer: )epth of scum layer: Dimensions of cesspool: Materials of construction: Indication of groundwater: inflow (cesspool must be pumped as part of inspection) Comments: (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.) PRIVY: (locate on site plan) Materials of construction: Dimensions: Depth of solids: Comments: (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.) revised 9/2/98 Page 9of11 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) f� 'jropertyAddress: cr4 )wner: Date of Inspection: SKETCH OF SEWAGE DISPOSAL SYSTEM: include ties to at least two permanent reference landmarks or benchmarks locate all wells within 100' (Locate where public water supply comes into house) 4 revised 9/2/98 Page 10 of 11 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) operty Address: iJ J �" ? �/v sc r . Jwner: ! / 7 Date of Inspection: ri 2 U f U NRCS Report name Soil Type_ Typical depth to groundwater USGS Date website visited Observation Wells checked Groundwater depth: Shallow Moderate Deep SITE EXAM Slope Surface water Check Cellar Shallow wells i Estimated Depth to Groundwater"` I Feet Please indicate all the methods used to determine High Groundwater Elevation: Obtained from Design Plans on record N \ Observed Site (Abutting property, observation hole, basement sump etc.) Determined from local conditions Checked with local Board of health Checked FEMA Maps Checked pumping records Checked local excavators, installers Used USGS Data Describe how you established the High Groundwater Elevation. (Must be completed) revised 9/2/98 Page 11 of 11 ' s"x a r •_ � _ __ x�" *.� & +Fi. ji�� w`�,^'}� t t - t t -s _ , ' ; 3 �' �. �� '' s `r /� .. x �`4 4 t��.K,l ti• �' ,� aK r� :s ]+ ' � t-� t . . '� t r,_ ' '��'{ += �• i „X.� xi{2� � ;z yx •'zr'4'".as'` r°nq"„ ( ,� a <- y �` ' .''tu" � m ' `I 3"'f rt i., fi7 •x. �- 71., rt t J e +�. v e Yf4 4kF 'r•. . +::r �,c�r.� +,�� Y�. .t�`'�6{.F""'.n .r+"'' � sR ra i, ,� s "� E f _ yxiI �".'i. �„tSY+'�Ssa'.'�.cL ,ir:. an. \fir .s. o.. eoK'+ �'..i.t?• � -`. � �.,:4tx -kk,� '. }esu t Y� i+i,aa 04 0001. f' a _, 'S Y _ '� � v.�:r .}S i't � �i,'�`y�"' •'"4. �..r •'moi i. - _r _:t' . t Y fi L Vii.'} �' n%?•L�r�f}'r*`i- ..� aF „ h.,+�"�' t r y f 3 f -5 F 4 F _• a ��+i. ^y �� � � a• � � `z � 4 y, C• �1�k~��i'.f �M. 3{,�n�Y - 5 y}, �s • ,>y Gt .. cJ `%� N`I:,j.Cyi'J "'` y � ..i�x .X .�' y � � A # 1 Y ,� .. yy_ ✓ T - �N•'.� �_r��t'eh � a��' i' "K Y'. � � Y' S •i' ¢�¢'N _f+�4y (Y11 �v.4'e,i.. `�- ,Yi2r.M,43"i�fi r _ !:, •e' i" Y .r"''`Y +� J�y 4}a' -r Com' ,1 Y�r'2 ff: f� q � 3 � �J t •i.` h lC"r `' ...;flo.S 'a iA Si F..1 Y .:i ... . t...4M'Y(7rF.1'1q ��lC:'. �..r •F'AT yam/ oe t ''r .l "t t NORTN 1 O 4 f ,SSACHUSEt Town of North Andover, Massachusetts BOARD OF HEALTH Form No. 3 1,90 G <�3 199",5 5 DISPOSAL WORKS CONSTRUCTION PERMIT Applicant D1 -)v&- 11%1-) y1v1eb NAME ADDRESS TELEPHONE Site Location /-�%— Permission is hereby granted to Construct (' or Repair ( ) an Individual Soil Absorption Sewage Disposal System as shown on the Design Approval S.S. No. 1-5j— -541 Fee '1�90 -- CHAIRMAN, BOARD OF HEALTH D. W.C. No. <�-0 3 Teti U� ST AS -BUILT CHECK LIST and .FINAL INSPECTION Proposed Elevations As -Built Elevation House C�g 198 � Tank IN /Q 7,3`7 / 9 - 97 Tank OUT /97, 1 ¢ /9wl, 73 D -box IN / Q 7, oq / 16, 7e) D -box OUT /96,9a /qL/O,` Trench Inverts Line 1 /9�•6 D /C��,/ — /g(, /( Line 2 M. 40 1913, Line 3 l qG, 7 Line 4. /gD 4d — /88 s Bottom of Exc. Stone OK? !� D -box checked? Pipes cemented? U. I Oce lon��6 7 �/ 1 0. Date TOWN OF NORTH ANDOVER I Certificate of Occupancy $ Building/Frame Permit Fee $ Foundation Permit Fee $ Other Permit Fee Sewer Connection Fee $ �/4—Water Connection Fee $ TOTAL II ng I s ctor Div. Public Works ivw" rLtuvivLxL &.. APP00va(_ CONSERVATION COMMISSION CONSERVATION ADMIN. DEPARTMENT OF PUBLIC WORKS DRIVEWAY PERMIT 69;49R/WATER CONNECTIONS FIRE DEPT. /401--e RECEIVED BY BUILDING INSPECTION DATE 211 PHONE 6F3 --Y77 NE DATE APPROVED DATE REJECTED DATE APPROVED DATE REJECTED DATE APPROVEDZ DA"r1 RF..IECTI?I1 - ..�.�_. RON �IXGJ � -� 000 This form shall be signed by the agents of the Planning and Health hoards, the Conservation Commission prior to the issuance of any building permlts for the subject lot. This form shall not releive the applicant from the compliance of any applicable Town requirement or Bylaw. VI `O CD O O CL r O � Q �. D� "O O 2 O CD CLQ `e CD O 0• u• CL O to CD CD CD P.* CD Cr 3 CA n� C O C4 E 0 CD O �a CD CDa y. CD CO) 0 0 CD 0 e CD 10 I •� ItJ .t9 r c 5 CSD 110 N W CL CD CD C-) ®N CCl) d Cl) m n z - S -O H © o = — CD N T ffin .q� = cD-wCD m '. y CD O N O OCD W CD = m S+ n, rn _ = CD CA -n-� Q= o, _ '® to o o c :urc y-. � . W O CD :® Com" c CO) CL �2 �• o= S co O N ` O n At CD cm 0 CD s03 CO)Im C. DJ O C o < _• n a _. N d CD Cfl ► : N ;.... CO) co -'� CD �j d N lb CD r-/ p C �\ CD 0. `AAC� N z ^� s e ;25 777:7- rt 7� g In UQ cn (((\\\\ cn 0 rt 0 C� 1 O 11 V� r� Samuel F. McCormack Co., Inc. A11%1 M)N. INDEVENDENT NSURANa AONSTIRS Insurance Adjusters and Appraisers AD1U$TERS � s" � 3 X41 a DATE: 11/15/93 Town of N. Andover Board of Health N. Andover, MA 01810 RE: ASSURED: LOSS LOCATION: POLICY NO.: OUR FILE NO: Gentlemen: ABRUZZIO, Dean & Jana 207 2A Farnum St., N. Andover, MA HOA 5730062 93-2096 Claim has been made involving loss, damage or destruction of the above -captioned property, which may either exceed $1,000.00 or cause Massachusetts General Laws, Chapter 143, Section 6 to be applicable. If any notice under Massachusetts General Laws, Chapter 139, Section 3B is appropriate, please direct it to the attention of this writer and include a reference to the above -captioned insured, location, policy number, date of loss and claim or file number. Thank you for your anticipated cooperation. Very truly yours, Paul A. Dionne Adjuster cc: Building Inspector 222 Forbes Road ■ Suite 304 ■ Braintree, MA 02184 (617) 843-1222 ■ MA WATS 800-972-5399 ■ FAX(617)849-8191 Town of North Andover, Massachusetts Form No. 1 )RTH BOARD OF HEALTH-"\ c0 6 A 'u;, `1 19 L APPLICATION FOR SITE TESTING/INSPECTION Test/Inspection Date and Time Fee CHAIRMAN, BOARD OF HEALTH Test No. S.S. Permit No.`J/10 D.W.C. No�C.C. Date Plbg. Permit No. ��6 Applicant NAME ADDRESS TELEPHONE Site Location, Engineer =`+1�',tr�..� 1-t. .+ �U NAME ADDRESS TELEPHONE Test/Inspection Date and Time Fee CHAIRMAN, BOARD OF HEALTH Test No. S.S. Permit No.`J/10 D.W.C. No�C.C. Date Plbg. Permit No. ��6 of i n 3 }, a• ap-ttM �� rf G1 ; arm �f'L`t;yt,• r "r ' T s.. '19 All ?c.Y � �.^�` 44L ti �"` �,aP� �pJ vx +�'u� `, i•Q% eas.. t ,t t J i' R i t On Cie Q Q arx x ae �- i y0— W 41 Q^rin r r dw - 2 !: I 'X ✓� tr� t � R a: Ya Yrs. N to 44! W co Y 3 FA .� .�3T J< 4 Y# -• .s a� fli.z �� iS � 2 =� x."'t d f�4 Fri - I IQ fix s?' "` + s t 0 �"=� - �,• ri, �,. ��� 4 L.r-e'- � r �h � � 4 ClIx The Commonwealth of Massachusetts Department of IndustrialAccidents a ..- : °-, A. r tl I Congress Street, Suite 100 Boston, AM 021192017 www mass.gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers. TO BE FILED WITH THE PERMITTING AUTHORITY. Name (Business/Organization/Individual): Address City/State/Zip: of C, 0A d k4o� e Are you an employer? Check the appropriate box: I xd 1. F-1 I am a employer with employees (full and/or part-time).* 2. ❑ I am a sole proprietor or partnership and have no employees working for me in any capacity. [No workers' comp. insurance required.] 3I am a homeowner doing all work myself. [No workers' comp. insurance required.] t 4. El I am a homeowner and will be hiring contractors to conduct all work on my property. I will ensure that all contractors either have workers' compensation insurance or are sole proprietors with no employees. 5. ❑ I am a general contractor and I have hired the sub -contractors listed on the attached sheet. These sub -contractors have employees and have workers' comp. insurance.$ 6.❑ We are a corporation and its officers. have exercised their right of exemption per MGL c. 152, §1(4), and we have no. employees. [No workers' comp. insurance required.] Type of project (required): 7. ❑ New construction 8. 0 Remodeling 9. ❑ Demolition 10 Building addition 11. F1 Electrical repairs or additions 12. ❑ Plumbing repairs or additions 13. ❑ Roof repairs 14. ❑ Other *Any applicant that checks box #1 must also fill out the section below showing their workers' compensation policy information. t Homeowners who submif 'this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such. #Contractors that check this box must attached an additional sheet showing the name of the sub -contractors and state whether or not those entities have employees. if the sub -contractors have employees,' they must provide their workers' comp. policy number. I am an employer that is providing workers' compensation insurance for my employees.' Below is the policy and job site information. Insurance Company Name: Policy # or Self -ins. Lie. Expiration Date: Job Site Address: City/State/Zip: Attach a copy of the workers' compensation policy declaration page (showing the policy number and expiration date). Failure to secure coverage as required under MGL c. 152, §25A is a criminal violation punishable by 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. A copy of this statement may be forwarded to the Office of Investigations of the DIA for insurance I do hereby ert' y u44& -the arns a penalties of perjury that the information provided above is t ue and correct. i f� Ci¢nnfiirP t Date: � N -1, /Clet t phd/r, 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 filt out the workers' compensation affidavit completely, by checking the boxes that apply to your situation and, if necessary, supply sub -contractors) name(s), address(es) and phone number(s) along with their certificate(s) of insurance. Limited Liability Companies (LLC) or Limited Liability Partnerships (LLP) with no employees other than the members or partners, are not required to carry workers' compensation insurance. 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 of the affidavit for you to fill out in the event the Office of Investigations has to contact you regarding the applicant. Please be sure to fill in the permit/license number which will be used as a reference number. In addition, an applicant that must submit multiple permit/license applications in any given year, need only submit one affidavit indicating current policy information (if necessary) and under "Job Site Address" the applicant should write "all locations in (city or town)." A copy of the affidavit that has been officially stamped or marked by the city or town may be provided to the applicant as proof that a valid affidavit is on file for future permits or licenses. A new affidavit must be filled out each year. Where a home owner or citizen is obtaining a license or permit not related to any business or commercial venture (i.e. a dog license or permit to burn leaves etc.) said person is NOT required to complete this affidavit. The Department's address, telephone and fax number: The Commonwealth of Massachusetts Department of Industrial Accidents 1 Congress Street, Suite 100 Boston, MA 02114-2017 Tel. # 617-727-4900 ext. 7406 or 1-877-MASSAFE Fax # 617-727-7749 Revised 02-23-15 www.mass.gov/dia 004 2n, 2•, we oal- 0 -?Z •' toof 2� '1;pDy cv•� �a1� iI VIP L oov tQy _ D �i Ifl I �+�- ._.__ I� tc. c 040 �• .pe h Id 4,(, Nv AMICK 2n, 2•, we ' �.}p,'+yh.Fx a* l: - � ��? r Y. ""a � zs -'a�ixih t. K..� � y� -eQ i t�,.,:-4+�.3�.'.ti+� .:xds; bs�ac. `F�;4h't �°^�°�+13�°t'--•;''x 7 �`,� �7+'?T'y�+e�^%. !`�}e �'-�'"-p`� - `y'+. � Lb6 i R C ' '.... > -� - > b is °Re^�' .L Y ?4 �� y-- F �•° ! 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