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HomeMy WebLinkAboutMiscellaneous - 24 DEER MEADOW ROAD 4/30/20189-1 I r l 1.0 %.) Date .,.r-?..1�A. \.p........ TOWN OF NORTH ANDOVER PERMIT FOR PLUMBING This certifies that .� Y,.........J.......1-., .A c�i....................................................... . has permission to perform .... !^� +` ° ........... .. plumbing in the buildings of ........ ..... P..4?tj.,.n........................................ . at ..; :H........P.- -c...........".Q :1� .............. North Andover, Mass. Fee3ll — Lic_ No. )vW7, Check # �-i n P,f ......................................... PLUMBING INSPECTOR P TYPE OR PRINT CLEARLY CG MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK CITY[.North Andover MA DATE 02129116 .. PERMIT # JOBSITE ADDRESS 24 Deer Meadow OWNER'S NAME Merrimack Construction Grou OWNER ADDRESS TEL �� FAX OCCUPANCY TYPE COMMERCIAL -1 EDUCATIONAL NEW: El RENOVATION: El REPLACEMENT: FIXTURES 1 FLOOR— BSM 1 BATHTUB W CROSS CONNECTION DEVICE ............................... DEDICATED SPECIAL WASTE SYSTEM ................................. DEDICATED GAS/OIL/SAND SYSTEM m DEDICATED GREASE SYSTEM DEDICATED GRAY WATER SYSTEM DEDICATED WATER RECYCLE SYSTEM DISHWASHER =1 DRINKING FOUNTAIN FOOD DISPOSER FLOOR / AREA DRAIN INTERCEPTOR (INTERIOR) all KITCHEN SINK LAVATORY ROOF DRAIN ;SHOWER STALL "SERVICE / MOP SINK TOILET URINAL WASHING MACHINE CONNECTION 1 . WATER HEATER ALL TYPES WATER PIPING ............... _..... OTHER 2 1 3 1 4 1 5 1 6 1 7 1 8 RESIDENTIAL PLANS SUBMITTED: YES [j NO[] INSURANCE COVERAGE: I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL Ch. 142. YES NO IF YOU CHECKED YES, PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW LIABILITY INSURANCE POLICY [] OTHER TYPE OF INDEMNITY [] BOND El OWNER'S INSURANCE WAIVER: I am aware that the licensee does not have the insurance coverage required by Chapter 142 of the Massachusetts General Laws, and that my signature on this permit application waives this requirement. CHECK ONE ONLY: OWNER Ej AGENT SIGNATURE OF OWNER OR AGENT I hereby certify that all of the details and information I have submitted or entered regarding this application are true and accurate to the best of my knowledge and that all plumbing work and installations performed under the permit issued for this application will be in compliance with all Pertinent provision of the Massachusetts State Plumbing Code and Chapter 142 of the General Laws. PLUMBER'S NAME Chris Milot LICENSE # 15062 7[/t •r�SIGNATURE MP jP0 CORPORATION # 2981 PARTNERSHIP# LLC# COMPANY NAME Chris Milot Plumbing and Heatin , Inc. ADDRESS X23 Glendale Ave. CITY I Tyngsboro STATE = ZIP 01879 TEL 987-649-2277 FAX978-649-6755 CELL 978-846-3799 „ EMAIL cmilotplumbing05@msn.comg� j 60 N r� Q &A (�- \ vo U 3-27- L( Date ...... ...�..`... \ �P .............................. TOWN OF NORTH ANDOVER PERMIT FOR GAS INSTALLATION r� �n,2 This certifies that ...( ivl 0�- ........................................................................... �...................... has permission �for gas installation ...........�`........................... in the buildings of ....!�.. � .........' .m r' ' t � '� , � ...............� ................................................................................... at ... i-1......... Pr" H eG JI, —3 ., North Andover, Mass. Fee ...W.-) ....'.... Lic. No. ......... ............ ......................................................... GASINSPECTOR Check # 111-111 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK -- . CITY I North Anover MA DATE [2129/16 PERMIT # a: JOBSITE ADDRESS; 24 Deer Meadow, OWNER'S NAME .. errimack Construction Group OWNER ADDRESS ( TELx FAX TYPE OR OCCUPANCY TYPE COMMERCIAL EDUCATIONAL ? RESIDENTIALt-J PRINT CLEARLY NEW: I RENOVATION: l REPLACEMENT: Ll PLANS SUBMITTED: YESO NO APPLIANCES 1 FLOORS BSM 1 2 3 4 5 6 7 8 '9, 10 11 12 13 14 BOILER' BOOSTER «„ CONVERSION BURNER m.=,., _.. _7 -1 COOK STOVE_- DIRECT VENT HEATER' DRYER FIREPLACE FRYOLATOR ..' i w. F., _ 4. M FURNACE GENERATOR GRILLEi _moi. INFRARED HEATER m LABORATORY COCKS MAKEUP AIR UNIT OVEN�a� POOL HEATER _ _- ROOM I SPACE HEATER; ROOF TOP UNIT k TEST UNIT HEATER UNVENTED ROOM HEATER WATER HEATER rT- OTHER t i INSURANCE COVERAGE I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL. Ch. 142 YES NO, , I IF YOU CHECKED YES, PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW LIABILITY INSURANCE POLICY Lj OTHER TYPE INDEMNITY Lj BOND OWNER'S INSURANCE WAIVER: I am aware that the licensee does not have the insurance coverage required by Chapter 142 of the Massachusetts General Laws, and that my signature on this permit application waives this requirement. CHECK ONE ONLY: OWNER ( AGENT SIGNATURE OF OWNER OR AGENT I hereby certify that all of the details and information I have submitted or entered regarding this application are true and accurate to the best of my knowledge and that all plumbing work and installations performed under the permit issued for this application will be in compliance with all Pertinent provision of the Massachusetts State Plumbing Code and Chapter 142 of the General Laws. PLUMBER-GASFITTER NAME Chris MilotN �M-- LICENSE #115062 SIGNATURE MP [j MGF '_� JP D JGF LPGI D CORPORATION [J,,#2981yn PARTNERSHIP S#1 LLC # COMPANY NAME:i Chris Milot Plumbing and Heatin , Inc. ADDRESS 23 Glendale Ave. i CITY Tyngsboro STATE MA ZIP 10 879 „ TEL 978 649-2277 .................. ...... ............ FAX! 78-649-6755 CELL 978-846-3799 EMAILrmllotplumbing05@msn.com LQ-zt 6 c The Commonwealth of Massachusetts Runt Form. Department of Industrial Accidents Office of Investigations I Congress Street, Suite 100 Boston, MA 02114-2017 y . www.massgov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Naive (Business/Organization/Individual): C -Y7/4/) Address: Ci al 9 Phone #: q�f- C 0- 477 Are you an employer? Check the appropriate box: 1. Ef I am a employer with d 4• ❑ I am a general contractor and I employees (full and/or part-time).* have hired the sub -contractors 2. ❑ I am a sole proprietor or partner- listed on the attached sheet. ship and have no employees These sub -contractors have working for me in any capacity. employees and have workers' [No workers' comp, insurance comp. insurance.1 required.] 5. ❑ We are a corporation and its 3. ❑ 1 am a homeowner doing all work officers have exercised their myself. [No workers' comp. right of exemption per MGL insurance required.] t c. 152, §1(4), and we have no employees. [No workers' coma. insurance reouired.l Type of project (required): 6. New construction 7. ❑ Remodeling 8. ❑ Demolition 9. ❑ Building addition 10. ❑ Electrical repairs or additions 11. ❑ Plumbing repairs or additions 12.0 Roof repairs 13. ❑ Other 'Any applicant that checks box #I must also fill out the section below showing their workers' compensation policy information. t Homeowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such. :Contractors that check this box must attached an additional sheet showing the 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. /'I i _ Insurance Company Name: ��-11 / Policy # or Self -ins. Lic. #: GZ/� ��la Q Expiration Date: Job Site Address: E'Pi' City/State/Zip: _�d Q��y Iss Attach a copy of the workers' compens4ion policy declaration page (showing the policy number and expiration date). Failure to secure coverage as required under Section 25A of MGL c. 152 can lead to the imposition of criminal penalties of a fine up to $1,500.00 and/or one-year imprisonment, as well as civil penalties in the form of a STOP WORK ORDER and a fine of up to $250.00 a day against the violator. Be advised that a copy of this statement may be forwarded to the Office of Investigations of the DIA for insurance coverage verification. Ido hereby cern under the pains and penalties of perjury that the information provided above is true and correct 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 #: A r^/-1 i -s ria CHRIMIL-01 BBOYER CERTIFICATE OF LIABILITY INSURANCE OATE(MMIDD/YYYY) 6/25/2015 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S), AUTHORIZED REPRESENTATIVE OR PRODUCER, AND THE CERTIFICATE HOLDER. IMPORTANT: If the certificate holder is an ADDITIONAL INSURED, the policy(ies) must be endorsed. If SUBROGATION IS WAIVED, subject to the terms and conditions of the policy, certain policies may require an endorsement. A statement on this certificate does not confer rights to the certificate holder in lieu of such endorsement(s). PRODUCER Welsh 81 Parker Insurance Agency, Inc. / Hudson Office 131 Coolidge Street, Suite 160 Hudson, MA 01749 CONTACT NAME: PHONE A C No FAI: (978) 562-5652 FAC o):(978) 562-7120 E-MAIL ADDRESS: INSURER(S) AFFORDING COVERAGE NAIC # INSURED INSURER A: Merchants Mutual 23329 INSURER B: Chris Milot Plumbing and Heating Inc. 23 Glendale Ave Tyngsboro, MA 01879 INSURER C : INSURER D: INSURERE: X COMMERCIAL GENERAL LIABILITY INSURER F: RGYIJIVIY IYUIYIDCK: THIS IS TO CERTIFY THAT 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. LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. INSR LTR TYPE OF INSURANCE INSD WVD POLICY NUMBER P I E F MM/DD/WYY P LICY EXP MM/DDM YY LIMITS A X COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE $ 1,000,000 CLAIMS -MADE T OCCUR BOP1073669 06/28/2015 06/28/2016 DAMAGES Rocwrrence $ 500,000 MED EXP (Any one person) $ 15,00 PERSONAL & ADV INJURY $ Included GEN'L AGGREGATE LIMIT APPLIES PER: a PRO- F-] GENERAL AGGREGATE $ 2,000,000 PRODUCTS - COMP/OP AGG $ 2,000,000 POLICY LOC OTHER: $ AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT Ea accident $ 11000,000 BODILY INJURY (Per person) $ .A ANY AUTO MCA0000042 09/23/2014 09/23/2015 AUTOS X SCHEDULED BODILY INJURY Per accident $ ( ) AUTOS AUTOS X HIREDAUTOS X NON -OWNED OS PROPERTY DAMAGE $ Per accident UMBRELLA LIAR OCCUR EACH OCCURRENCE $ EXCESS LIAB CLAIMS -MADE AGGREGATE $ DED I I RETENTION $ $ WORKERS COMPENSATIONOTH- X I AND EMPLOYERS' LIABILITY Y / N STATUTE ER A ANY PROPRIETOR/PARTNER/EXECUTIVE OFFICER/MEMBER EXCLUDED? ❑ N / A CA1033640 06/30/2015 06/30/2016 E.L. EACH ACCIDENT $ 100,000 (Mandatory in NH) If yes, desuibe under E.L. DISEASE - EA EMPLOYEE $ 500,000 E.L. DISEASE - POLICY LIMIT $ 100,000 DESCRIPTION OF OPERATIONS below I DESCRIPTION OF OPERATIONS / LOCATIONS / VEHICLES (ACORD 101, Additional Remarks Schedule, may be attached if more space is required) 4 CK I Ir it,,R l C MULLICK rAmrc1I ATVIkl ©1988-2014 ACORD CORPORATION. All rights reserved. ACORD 26 (2014/01) The ACORD name and logo are registered marks of ACORD SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE Town of North Andover THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN 1600 Osgood Street ACCORDANCE WITH THE POLICY PROVISIONS. North Andover, MA 01845 AUTHORIZED REPRESENTATIVE 0- ©1988-2014 ACORD CORPORATION. All rights reserved. ACORD 26 (2014/01) The ACORD name and logo are registered marks of ACORD April 12, 2016 Chris Shanahan Merrimack Construction Group 1 Westech Dr. Unit 1 Tyngsboro, MA 018791 RE: 24 Deer Meadow Rd. - Wall Removal Review North Andover, MA 01845 (DEI Project No. D3502) Dear Chris: Per your request we visited the above referenced site on April 1, 2016 to review the adequacy of several LVL beams that had been installed after the removal of sections of the center bearing wall, and a portion of the rear wall between the first and second floors. We also reviewed LVL's that were installed after the removal of sections of the center bearing wall between the second floor and the attic. After our review we submitted structural correctives via email on April 7, 2016 and subsequently re -visited the site on April 12, 2016 to view the completed work. Based on our site observations, follow-up conversations, and photos submitted on April 7h, it is our professional opinion that the LVL's have been designed & installed properly and in general accordance with the intent of our issued correctives. Please note that we did not review other aspects of the timber framing. Our review was limited to the LVL engineered timber beams, support posts, and supporting foundations. We trust this letter meets your needs at this time. Feel free to call if there are any questions. Very truly, DAIGLE ENGINEERS INC. 7jf ��%,✓� Pcs s�c.,g Jonathan M. Longchamp, PE, SECB (ext. 117) Principal/ President j7ongchamp4@laigleengineers.com JML/map Daigle Engineers, Inc. 1 East River Place Methuen, MAO 1844-3818 978 682 1748 978 682 6421 fax www.daigleengineers.com JONATHAN M. , 'yG\ LONGCHA" STRUCTURAL No. s58l7 11 t1,61STO Over 33 Years in Business - Est. 1979 DEI ♦ 4/12/16 ♦ D3502L041216.dmx ♦ Page I of 1 21�nks4 i,,JC qr� u3so��a- PUBLIC HEALTH DEPARTMENT Town of North Andover Community and Economic Development Division CERTIFICATE OF COMPLIANCE As of: 11/30/16 This is to certify that the individual subsurface disposal system received a SATISFACTORY INSPECTION of the: Replacement of an On -Site Sewage Disposal System By: Dean Dynan At: 24 Deer Meadow Road Map 104B Lot 68 N r over,�MA 01845 of tiiis certificate s t c trued as a guarantee t t the system will function satisfactorily. C '� Michele Grant Public Health Agent 120 Main St., North Andover, Massachusetts 01845 Phone 978.688.9540 Fax 978.688.9542 Web www.northandoverma.gov North Andover Health Department Community and Economic Development Division ONSITE WASTEWATER SYSTEM CONSTRUCTION NOTES LOCATION INFORMATION ADDRESS: 24 Deer Meadow MAP: 104B LOT: 68 INSTALLER: Dean Dynan DESIGNER: Cornerstone Land Consultants PLAN DATE: 4/26/16, rev. 5/9/16 BOH APPROVAL DATE ON PLAN: 5/12/16 INSPECTIONS TANK INSPECTION: 7/8/16,7/13/16 DATE OF BED BOTTOM INSPECTION: 7/13/16 DATE OF FINAL CONSTRUCTION INSPECTION: 8/18/16 DATE OF FINAL GRADE INSPECTION: u�t- b SITE CONDITIONS Comments: SEPTIC TANK N/A Contractor reports any changes to design plan X .Existing septic tank properly abandoned. ® Internal plumbing all to one building sewer ® Topography not appreciably altered ❑ Building sewer in continuous grade, on compacted firm base ® Cleanouts per plan X 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 ® Outlet tee installed, centered under access port (effluent filter) ® 24" inch cover to finish grade installed over inlet and outlet access ports ® Neoprene boots around inlet & outlet Comments: 7/8/16 tank and pump chambers not set on 6" of stone. Spoke to engineer, must be set on 6" stone and be re -inspected (B. LaGrasse). 7/13/16 re -inspected and stone base ok (B. LaGrasse) Pump chamber Dean installed 2 float system. I spoke to the engineer and they will change it out to a 3 float system. Please check (M.G.) PUMP CHAMBER X Bottom of tank hole has 6" stone base ® Weep hole plugged ® 1000 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 ® 24" cover at final grade installed over pump access port ® Water tightness of tank has been achieved by Visual testing ® Neoprene boots around inlet & outlet Comments: 8/18/16 — Pump test needs to be completed when installer confirms the electrical work is completed and water is in pump chamber. Installer will leave D -box accessible for pump test (I. Rowe) CONTROLPANEL ❑ Alarm & Pump are on separate circuits ❑ Alarm sounds when float is tripped ® Location of control panel: outside of house on back deck ❑ Alarm signal located inside: basement Comments: 8/18/16 — Control panel needs to be inspected at time of pump chamber inspection (I. Rowe) DISTRIBUTION -BOX ® Installed on stable stone base ® H-20 D -Box ® Inlet tee (if pumped or >0.08'/foot) ® Hydraulic cement around inlet & outlets ❑ Observed even distribution N/A Speed levelers provided (not required) ® Schedule 40 PVC Pipe Comments: 8/18/16 - Equal distribution needs to be inspected at time of pump chamber inspection (I. Rowe) SOIL ABSORPTION SYSTEM (General) X Bottom of SAS excavated down to C soil layer, as provided on plan X Size of SAS excavated as per plan ® Title 5 sand installed, if specified on plan N/A 40 Mil HDPE barrier installed ® Laterals installed and ends connected to header (and vented if impervious material above) ® Elevations of laterals and chambers installed as on approved plan N�Retaining wall (boulder / concrete / timber/ block) Final cover as per plan Comments: FINAL GRADE Loamed Seeded L� Cover per plan Comments: DOCUMENTS NEEDED R( Certification of Installation Form submitted By engineer and signed and dated by Engineer and installer ❑ As -Built Plan BM = 98.95 HR = 7.31 HI = 106.26 SYSTEM ELEVATIONS ROD ELEVATION AS -BLT INVERT ELEV DESIGN INVERT ELEV Benchmark Building Sewer OUT 5.89 100.07 101.25 Septic Tank IN 7.38 98.53 100.57 Septic Tank OUT 7.78 98.13 100.32 Pump Chamber IN 7.81 98.10 100.28 Pump Chamber OUT 2" 7.52 98.57 100.03 Distribution Box IN 2" 2.24 103.85 103.89 Distribution Box OUT 4" 2.22 103.69 103.73 Lateral 1 TOP 2.22/2.51 Lateral 1 INVERT 103.69 / 103.40 103.73 /103.50 Lateral 2 TOP 2.52/2.86 Lateral 2 INVERT 103.39 / 103.05 103.23 / 103.00 Lateral 3 TOP 3.19/3.48 Lateral 3 INVERT 102.72 / /102.43 102.73 / 102.50 Lateral 4 TOP 3.60/3.95 Lateral 4 INVERT 102.31 / 101.96 102.23 / 102.00 CRITICAL SETBACK DISTANCES Mark those distances checked in the field against the design plan and regulatory setback 1 Suction line 222(2) 2 100 feet is a minimum acceptable distance and no variance is allowed for a lesser distance (NA 5.02). 3 As defined in 310 CMR 10.55, 10.32, 10.54, and 10.30, respectively, pursuant to 15.211(3), also by NA wetland bylaws Tank SAS Sewer ® Property line 10 10 -- ® Cellar wall 10 20 -- ® Inground pool 10 20 -- ® Slab foundation 10 10 -- ® Deck, on footings, etc 5 10 -- Waterline 10 10 101 ® Private drinking well 75 1002 50 ® Irrigation well 75 100 ® Surface Water 25 50 ® Bordering Vegetated Wetland , Salt Marsh, Inland / Coastal Bank3 75 100 ® Wetlands bordering surface water supply or trib. (in Watershed) 150 150 ® Trib. to surface water supply 325 325 ® Public well 400 400 ® Interim Wellhead Prot. Area ® Reservoirs 400 400 ® Drains (wat. supply/trib.) 50 100 ® Drains (intercept g.w.) 25 50 ® Drains (Other) Foundation 10 (5) 20 (10) ® Drywells 20 25 1 Suction line 222(2) 2 100 feet is a minimum acceptable distance and no variance is allowed for a lesser distance (NA 5.02). 3 As defined in 310 CMR 10.55, 10.32, 10.54, and 10.30, respectively, pursuant to 15.211(3), also by NA wetland bylaws PUBLIC HEALTH DEPARTMENT Community Development Division TOWN OF NORTH ANDOVER SEPTIC DISPOSAL SYSTEM — INSTALLATION CERTIFICATION The undersigned hereby certify that the Sewage Disposal System (4onstructed; ( ) repaired; v (Print Name) Located at: (Installation Address) Was installed in conformance with the North Andover Board of Health approved plan, originally dated 2L and last revised on Sj I with a design flow of 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. CMR 15.000, regulations, and the final grading agrees substantially with the approved plan. All work is the As -built which has been submitted to the Board of Health. Bottom of Bed Inspection Date: And — Print Name Final Construction Inspection Date: lLt5mNa-7 H M. LjiA And — Print Name Installer: (Signature) Engineer:)�C. (Signature) Date: ly represented on (Signature) And — Print Name Date: J h A - p5h,tNw<k , And — Print Name 1600 Osgood Street, North Andover, Massachusetts 01845 Phone 978.688.9540 Fax 978.688.8476 Web http://www.northandoverma.gov p1ORTH m o � 5 allSSacH�s���c PUBLIC HEATH DEPARTMENT Community D. velopment Division E TOWN OF NORTH ANDOVER 1 SEPTIC DISPOSAL SYSTEM — INSTALLATION CERTIFICATION k The undersigned hereby certify that the Sewage Disposal System (4onstructed; () repaired; 0 (Print Name) t Located at: (Installation Address) Was installed in conformance with the North Andover Board of Health approved plan, originally dated I _ and last revised on 4p , with a design flow of E 4q0 gallons per day. The mate approved plan; the system was, installed in accordance regulations, and the final grading agrees substantially i the As -built which has been submitted to the Board of Bottom of Bed Inspection Date: _ ILt=e.iP.> T &A. LA+JiA And — Print Name Final Construction Inspection Date; 29 vo ��ss L- tTA J4( L4t4 i A And — Print Namg used were in conformance with those specified on the i the provisions of 310. CMR 15.000, T' and local the approved plan. All work is acc rately represented on And — Print Name f Date: �.1h�������� 1600 Osgood Street, North;Ando, Phone 978.688.9540 Fax 978.688:8476 t ° s ° And — Print Name Massachusetts 01845 Web http://www.northandoverma.goV To of North Andover — - AS -BUILT CHECKLIST 1) All changes to the design plan have been reflected and noted on the as -built plan 2) " -bui as a suita inch = 40 feet or fewer for plot plans) 3) = Street.A fires ssessor - a a Lot Number 4) Lot Lines and Location of Dwellings served by the system 5) I'/ 4ations evations and Dimensions of As -built s em components, including reserve (if applicable) 6)all tank openings, db , andlea�h re rom dwelling or Permanent Structure k distances are shown on the as -built plan from system components to: Subsurface, interceptor & foundation drains Catch basins Property lines Dwellings or other structures Private water supply or irrigation wills Watercourses or wetlands J 8) / Locations of Wells, Drains, Wetland Resource Areas within 150 feet of system 9) Location of water, gas, electric lines, cable, control panel (if applicable) 10) _ Location of Structures within 6 Inches of Finished Grade / 11) _zoriginal Stamp & Signature 12) '✓ Location and holder of any easements which could impact the system 13) Impervious Areas; Driveways, etc 14) North Arrow 15) -/Location & Elevation of Benchmark used 16 STATEMENT ON PLAN NA 5.3 ( ) a. "I certify the locations, elevations, ties, cover material; exposed component covers etc., shown on this as -built substantially agree with the approved plan and have determined that the breakout elevations, if applicable, have been met." Signature of Designer Date b. "If a STUCTURAL WALL IS PRESENT M 4.9) a Letter or statement on the as -built indicating the wall -was, or was not, constructed in accordance with the intended design and any manufacturer's specifications." Signature of Designer Revised 3/17/15 Date 24 Deer Meadow Road - Tank/ Pump Chamber Pics 7/7/16 Page 1 of 4 °r► : ,J _.ems. r..• r.«-,�a_._.�,�.-—r_...� Page 2 of 4 0 0 24 Deer Meadow Road - Tank/ Pump Chamber Pics 7/7/16 0 Page 3 of 4 24 Deer Meadow Road - Tank/ Pump Chamber Pics 7/ 7/16 Page 4 of 4 Commonwealth of Massachusetts Map -Block -Lot 104.60068 BOARD OF HEALTH --- ------------------- Permit No North Andover BHP -2016-0196 ----------------------- FEE $350.00 ----------------------- DISPOSAL WORKS CONSTRUCTION PERMIT Permission is hereby granted DeanDy--nan---------------------------------------------------------- -------------------------------- to (Upgrade) an Individual Sewage Disposal System. atNo -24 DEER MEADOW -ROAD --------------------------------------------------------------------------------------------------------- --------------- -- as shown on the application for Disposal Works Construction Permit No. BHP -2016-019 Dated- June 06, 2016 --------------- r^ - ------------- Issued On: Jun -06-2016 $OARS O�F�A JT -------------------------------------------------------------------------------- i • •. Application for Septic Disposal System 61611��- TdDAY'S'DATE Construction Permit -TOWN OF $350.00 - Full Repair NORTH ANDOVER, MA 01845 $175.00 - 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 e�91epair or replace an existing on-site sewage disposal system* only the tab key to move your ❑ Repair or replace an existing system component— What? cursor - do not use the return A. ciliity Information F l�j key. / Dey- Address or Lot # tab City/Town 2.- *TYPE OF SEPTIC SYSTEM*: ➢ ❑ Pump ❑ Gravity (choose one) ***If pumps stem, attach copy of electrical permit to application*** ➢ conventional System (pipe and stone system) ➢ ❑ Infiltrator or Biodiffuser (Gravel -Less) (Attach a copy of your certification to install this type of system.) ➢ ❑ Pressure Distribution S.A.S. (No D -Box) ➢ ❑ Pressure Dosed (D -Box Present) S.A.S. ' ➢ ❑ Does the system require an effluent filter? Ye No If yes, does plan specify make and model of filter? YES = (no further info. needed) NO = (installer must specify brramend off filter before DWC ls ance) 1T/fiat is the Make? �Q (. 0d- What is the Model. 2. Owner Information N <-41 Ct Address (if different from a ove) City/Town State Zip Cede M�16"oro(jd Act Email address 1 Telephone Number 3. Installer Information �.+'� me Name of Company' i- 1G' P so Address �0'C.: City/Town State(� % Zip Code Telephone Number (Cell Phone # if75ossible please) 4. Designer Information Com , Co" si 1i44T R ket V) fh r-e.W-41 6Name. /' Name of Company / Mn Oa C7 dress City/Town State Zip Code Telephone Number (Best # to Reach) Application for Disposal System Construction Permit • Page 1 of 2 rApplication for Septic Disposal System 6167 �6 Construction Permit - TOWN OF TO AY'S DATE $350.00 - Full Repair NORTH ANDOVER, MA 01845 $175.00 - Component PAGE 2OF2 A. Facility Information continued.... 5. Type of Building: Pasidential Dwelling or ❑Commercial B. Agreement 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 Environmental Code, as well as the Local Subsurface Disposal Regulations for the Town of North Andover. 1 understand that until a final Certificate of Compliance has been issued by thipgS, rd of Healfh, tailed system is not approved. Z7 Name Dat of Health Representative Date Application Disapprov5d for the following reasons: For Office Use Only: 1. Fee Attached. Yes No 2. Project Manager Ohligation Form Attached.? Yes No 3. Pump S sy tem? If so, Attach coQV of Electrical Permit Yes No Applicantreceived copy of "Electrical Inspection Notes for Septic Systems" es No Handout? 4. Reviewed approvalletter, all paperwork received? Yes No MISSIng.- 5. Foundation As -Built? (new construction only): (Same scale as approved plan) Yes No 6. Floor Plans? (new construction only): Yes No Application for Disposal System Construction Permit • Page 2 of 2 SEPTIC SYSTEM INSTALLER PROJECT MANAGEMENT OBLIGATIONS As the North Andover licensed installer for the construction for the septic system for the property at: ag 09 �^ r /lI (Address of septic system) For plans byy Nh Ul S^ le jj��(Engineer) Relative to the application of Oexzzf,, D uf�'�C.�--� (Installer's name) And dated1,14C- I�ngma to Dated azi!2 l o ay s ate With revisions dated (Last revised date) 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 manager, 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 Title 5 and the Board of Health Regulations may result in a $50.00 fine being levied against me and/or My companT. a. Bottom of Bed — Generally, this is the first (V5 inspection unless there is a retaining wall, which should be done first. The installer must request the inspection but does not have to be present. b. Final Construction Inspection — Engineer must first do their inspection for elevations, ties, etc. As -built of verbal OK (or e-mail to: healthdeptgtownofnorthandover.com) from the engineer must be submitted to the Board of Health, after which installer calls for an inspection time. Installer must be present for this inspection. With a 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. Installer does not have to be on-site. 4. As the installer, I understand that only I may perform the work (other than simple excavation) and I am required to complete the installation of the system identified in the attached application for installation. I further understand that work done by others unlicensed to install sebtic 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 construction steps: 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 annroved plans. No instructions by the homeowner. general contractor. or anv other t)ersons shall absolve me of this obligation. Undersigned Licensed Septic Installer: l I e6li �cFh (Name —Print) (Today's Date) Pame— ign 9/1/2016 Town of North Andover Mail - 24 Deer Meadow Rd, North Andover NORTI AN Massachus�s,w., Michele Grant <mgrant@northandoverma.gov> 24 Deer Meadow Rd, North Andover 1 message Ken Lania <Ken@comerstoneland.net> Thu, Sep 1, 2016 at 11:57 AM To: Michele Grant <mgrant@northandoverma.gov> Good morning Michelle, hope all is well. I wanted to email you a copy of these items so that you knew they were complete. It is my understanding the Dean Dynan will be calling or may have already called to receive final inspection for the above referenced property's completed septic installation. I have attached the Installation Certification and the As -Built Plan of the system for your review. I plan to provide these items in their original form to the Owner so that they can be delivered to your office once Dean Dynan signs the Installation Certification. Thanks for working with us on this project to get it completed. Any questions or issues, please don't hesitate to call me on the cell at (978) 835-0102. Kenneth M. Lania, E.I.T. Senior Project Manager ken@cornerstoneland.net CORNERSTONE Land Associates Civil Engineers I General Contractors 61 Main Street - P.O. Box 657 Pepperell, MA 01463 (978) 433-8100 2 attachments SDS Installation Certification 082916.pdf 586K in 9572 -082616 -C -1-E ndorsed. pdf 2448K https:Hm ai l.google.com/mai I/ca/u/0/?ui=2&ik=d4458df3d9&view=pt&search=i nbox&th=156e678043adO4df&sim l=156e678043ad04df 1/1 8/19/2016 Town of North Andover Mail - RE: 24 Deer Meadow NOPITI'l ANDOVER Massachusis Lisa Hadge <Ihadge@northandoverma.gov> RE: 24 Deer Meadow 1 message Isaac Rowe <irowe@millriverconsulting.com> Thu, Aug 18, 2016 at 4:24 PM To: Lisa Hadge <Ihadge@northandoverma.gov>, Brian Lagrasse <blagrasse@northandoverma.gov> Cc: Pam Lally <plally@millriverconsulting.com>, Isaac Rowe <irowe@millriverconsulting.com> Brian/Lisa, Attached is the final inspection form for the above referenced property. The inspection was completed today. See my comments under the pump chamber, control panel and D -box sections. The final pump inspection still needs to be completed. I am guessing Brian/Michele will do this inspection but if not we can help out. I told the installer to contact the Health Dept. when he was ready. Please let me know if you have any questions. Thanks, Isaac M. Rowe, R.S. Project Manager Mill River Consulting 6 Sargent Street Gloucester, MA 01930-2719 Phone: 978-282-0014 ext.804 Fax: 978-282-1318 irowe millriverconsulting.com www.miliriverconsulting.com From: Lisa Hadge [ma iIto: Ihadge@northandoverma.gov] Sent: Thursday, August 18, 2016 10:22 AM To: Isaac Rowe Subject: 24 Deer Meadow https:Hmail.google.com/mail/u/0/?ui=2&ik=46857787dO&view=pt&search=inbox&type=l 568ea329c898521&th=1569f5339344f244&siml=1569f533934... 1/2 Page 1 of 1 Date: July 20, 2016 20956 This is an e -permit. To learn more, scan this barcode or visit northandoverma.viewpointcloud.com/#/records/20956 t en TOWN OF NORTH ANDOVER PERMIT FOR WIRING [� This certifies that Jamie C Gendreau has permission to perform fix service and wire septic wiring in the buildings of TAORMINA, BARBARA at 24 DEER MEADOW ROAD, North Andover, Mass. Lic. No. 39197 httns://northandoverTna.viewDointcloud.com/ 7/27/2016 North Andover Health Department Community and Economic Development Division May 12, 2016 Christopher Shanahan 15 Maplewood Road Tyngsborough, MA 01879 Re: Subsurface Sewage Disposal System Plan for 24 Deer Meadow Rd. (Map 104B, Lot 68) Dear Mr. Shanahan: The proposed wastewater system design plan for the above site dated April 26, 2016 with a final revision date of May 9, 2016 and received on May 11, 2016 has been approved. The design plan has been approved for use in the construction of an upgrade on-site septic system for a 440 GPD, 4 -bedroom (9 -room maximum) home utilizing a pump chamber and leaching trench system. This design plan approval is valid until May 12, 2019. 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, the designer and the Town of North Andover. In the event an imminent health problem, such as sewage backup into the dwelling is occurring, the North Andover Board of Health may reduce the time period for which this plan is valid. This approval is also subject to the following conditions: 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)); Page 1 of 2 North Andover Health Department, 1600 Osgood Street, Suite 2035, North Andover, MA 01845 Phone: 978.688.9540 Fax: 978.688.8476 24 Deer Meadow Road May 12, 2016 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, Zoning Board, Planning Board, Building Inspector, 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. Please feel free to contact the office with any questions you may have. We look forward to working with you to obtain a wastewater treatment and dispersal system which will be in compliance with all regulations and assure protection of public health and the environment of North Andover. Sine y, 10 rian J. LaGrasse, CEHT Director of Public Health Encl. Installers list cc: John A. Visniewski, Cornerstone Land Consultants File Page 2 of 2 North Andover Health Department, 1600 Osgood Street, Suite 2035, North Andover, MA 01845 Phone: 978.688.9540 Fax: 978.688.8476 ', CORNE STON - hand Consultants, Inc. Civil Engineering • Land Surveying • Land Planning 61 Main Street • P.O. Box 657 • Pepperell, MA 01463 Phone: 978-433-8100 • Fax: 978-433-8125 May 9, 2016 Brian J. LaGrasse, CEHT Director of Public Health North Andover Health Department 1600 Osgood Street — Suite 2035 North Andover, MA 01845 RE: Sewerage Disposal System Upgrade 24 Deer Meadow Road Map 104B Lot 210 Mr. LaGrasse, On behalf of our client, Christopher Shanahan, Cornerstone Land Consultants, Inc. (CLC) is completing this letter in response to the Disapproval Letter dated May 6, 2016 that has been received by our office in regards to the above mentioned property. CLC has reviewed the letter and revised the plan as requested. The following are CLC's responses (Bold Normal) to North Andover Health Department's comments (Italic). 1. Please indicate the names of the abutters from the most recent tax map. / The names of the direct abutters have been added to the SDS Plan. 2. Please indicate the name and address of the current owner and applicant, if they are different. / The name and address of the current owner has been added to the SDS 1 Plan under General Notes 2. 3. Please remove reference to solid and perforated piping materials other than Schedule 40 PVC. All references to other piping materials have been removed. 4. Please provide lot area. The Lot Area has been added to the SDS Plan. 5. Please provide dimensions from components to property lines. The dimensions from the components to the property lines have been added to the SDS Plan. ,/ 6. Please indicate the distribution box is to be H-20 loading. Page 2 of 3 The Distribution Box Detail Note 3 indicates H-20 loading. -/ 7. Please provide a cross section of the proposed leaching facility. J A cross section of the leaching facility has been added to the SDS Plan. 8. Please provide a statement identifying whether the property is within or not within the Lake Cochichwick watershed. The statement identifying that the property is outside of the Lake Cochichwick/watershed has been added to the SDS Plan under General Notes 10. 9. Please provide the elevation/location statement as described in Section 3.2 of the North Andover Board of Health regulations. The statement of elevation/location has been added to the SDS Plan under General Notes 19. ✓ 10. Please indicate that the proposed septic tank and pump chamber shall be monolithic tanks. The details for the septic tank and pump chamber have been revised and specified as monolithic tanks. ✓ 11. Please specify means for abandonment of the existing system. The means for abandonment has been added to the General Notes 17. 12. Please specify that annual maintenance is required for the effluent filter. The requirement for annual maintenance has been added to the General Notes 18. 13. Please indicate the pipes exiting the distribution box are to be set level for the first two feet. The Distribution Box Detail Note 6 indicates that the pipes are to be set level for the first two feet. ✓ 14. Please clarify what appears to be a discrepancy between the Leach Facility Detail which indicates 17" stone depth and Calculations which indicates an 18" stone depth. The Leach Facility Detail has been corrected to indicate an 18" stone depth. 15. Please revise reference to Groton Board Health in Pump and Chamber Notes. The reference has been removed. CORNERSTONE Land Consultants, Inc. www.cornerstoneland.net Pepperell, MA • (978) 433-8100 Page 3 of 3 It is our opinion, that with this letter and the accompanying revised SDS Plan, all items for disapproval have been resolved and corrected. Should you have any questions or require additional inform please don't Hesitate to contact us in our Pepperell, MA office. Very truly yours, Kenneth M. Lania, E.I.T. Senior Project Manager Cc: Chris Shanahan file CORNERSTONE Land Consultants, Inc. www.cornerstoneland.net Pepperell, MA • (978) 433-8100 North Andover Health Department (ommunity and Economic Development Division May 6, 2016 Cornerstone Land Consultants, Inc. 61 Main Street PO Box 657 Pepperell, MA 01463 Re: 24 Dear Meadow Road (Map 104B, Lot 210) Dear Sir or Madam: The proposed wastewater system design plan for the above site dated April 26, 2016 and received on May 4, 2016 has been reviewed. Unfortunately, the plan cannot be approved until the following items are corrected. The specific section in Title 5: 310 CMR 15.000, or North Andover regulation that is not met by this design follows each item. 1. Please indicate the names of the abutters from the most recent tax map (NA 3.2). 2. Please indicate the name and address of the current owner and applicant, if they are different (NA 3.2) 3. Please remove reference to solid and perforated piping materials other than Schedule 40 PVC (NA 3.2) 4. Please provide lot area (NA 3.2) 5. Please provide dimensions from components to property lines (NA 3.2) 6. Please indicate the distribution box is to be H-20 loading (NA 3.2) 7. Please provide a cross section of the proposed leaching facility (NA 3.2) 8. Please provide a statement identifying whether the property is within or not within the Lake Cochichwick watershed (NA 3.2). 9. Please provide the elevation/location statement as described in Section 3.2 of the North Andover Board of Health regulations 10. Please indicate that the proposed septic tank and pump chamber shall be monolithic tanks (NA 3.2). 11. Please specify means for abandonment of the existing system (15.354 and NA 3.2) 12. Please specify that annual maintenance is required for the effluent filter (15.227(7)) Page 1 of 2 North Andover Health Department, 1600 Osgood Street, Suite 2035, North Andover, MA 01845 Phone: 978.688.9540 Fax: 978.688.8476 13. Please indicate the pipes exiting the distribution box are to be set level for the first two feet (I 5.232(3)(b)) 14. Please clarify what appears to be a discrepancy between the Leach Facility Detail which indicates 17" stone depth and Calculations which indicates an 18" stone depth 15. Please revise reference to Groton Board of Health in Pump and Chamber Notes In addition, while not a reason for disapproval, the following observations might be useful: a. You may wish to consider proposing the electrical splice box to be located outside the pump chamber riser b. You may wish to re -consider the necessity of a guide rail for use with a residential pumping system of this nature Please feel free to contact the office or Mill River Consulting at 978-282-0014 with any questions you may have. We look forward to working with you to obtain a wastewater treatment and dispersal system which will be in compliance with all regulations and assure protection of public health and the environment of North Andover. Sincerely, B an J. L Grasse, C T Director of Public Health cc: Chris Shanahan File Page 2 of 2 North Andover Health Department, 1600 Osgood Street, Suite 2035, North Andover, MA 01845 Phone: 978.688.9540 Fax: 978.688.8476 From: Dan Ottenheimer[mailto:dano@millriverconsultin4.com] Sent: Friday, May 06, 2016 4:29 PM To: 'Brian LaGrasse' (blagrasse@northandoverma.gov); Michele Grant (mgrant@northandoverma.gov); Lisa Hadge (Ihadge@northandoverma.gov) Cc: 'Isaac Rowe'(irowe@millriverconsulting.com); Pam Lally(plally@millriverconsulting.com) Subject: Plan Review, 24 Deer Meadow Road Attached please find the plan review disapproval letter we have prepared for 24 Deer Meadow Road. Most of the items of concern seem to be that they did not follow the design standards in the North Andover regulations. Overall it is a solid design plan. You will see a note in red regarding submitting a plan with a wet stamp. Since we only got a PDF version we are not aware if your office got a paper copy with a stamp. If you did, please delete this note. Also since we had no stamp we did not have an individual at Cornerstone to address the letter to so made it generic. Thanks, Dan Daniel Ottenheimer, President Mill River Consulting, Inc. 6 Sargent Street Gloucester, MA 01930-2719 978-282-0014 x 802 www.millriverconsulting.com dano@millriverconsulting.com Member: Massachusetts Association of Onsite Wastewater Professionals, Massachusetts Environmental Health Association, Cape Ann Chamber of Commerce, New England Water Environment Association pAq..V...a. �"'w6moVv4 �"vS113Sf1HOVSSdW'M3AO4NtlH1210N MIR-F.OW-ewi0*W"*0 -d%-L59 me'oe-n9reu t9 ti n'enuU4 J1{ „04emsSP43Oa MOOV3W a33a '£E 101 Z N eulW Wwn-6-,A--souc�-a91-0QM i1 ' as 'sjuu} u :80:1MavdUd we sA !n S z m p s �i e- d o w 3NO.LsHaNHOD 4 a`°Z ro . � W31SAS IVSOdSla 39vmas � N 19 iN �oX4 $n�ac `;e W� QC p Vbp U� NaN cZ+ r5 $ E(S 3 �i' v1 U s c'S rF 6gg o E v �m co K_ Z. Fp'Q` M' 4I 'Z v 6.0 a tK:{:.�.. g y S$ Qq c X � r W N� ' k �£ �2 v �5 O . _r �LU 2�£ Wm � wo6 W 3B LLS Z fis Q wU S o n0 ZA w w F 0 a 0 z cwi i w e 8 � �€ Q '^+:,.,...- LL W, < � P g d'�n9 Z.. NP v n ro I:fi$ ci_ 8 �_eS rn ° V iy w' w n00 � t oe -0-C .T.. o r i. t i 3S i .. : ,� v.� �✓i 1 �, 1 J p Z PIF rn o c o s s���gaaaaaaas �os� W I 111,11 y y y p wF44 11 A a $Iy5� g>:$>t O LLinNh w N 1 a W U N TOWN OF NORTH ANDOVER Office of COMMUNITY DEVELOPMENT AND SERVICES HEALTH DEPARTMENT 1600 OSGOOD STREET; SUITE 2035 NORTH ANDOVER, MASSACHUSETTS 01845 978.688.9540 - Phone 978.688.8476- FAX E-MAIL: healthdept@northandovenna.gov WEBSITE: http://www.northandoverma.gov SEPTIC PLAN SUBMITTAL FORM Date of Submission: 05/02/16 RECEIVED MAY U 3 2016 Site Location: 24 Deer Meadow Road, North Andover, MA TOWN OF NORTH ANDOVER Cornerstone Land Consultants, Inc. HEALTH DEPARTMENT Engineer:, New Plans? Yes X $275/Plan Check # 1094 (includes 1St submission and one re- 1 review only) Revised Plans?Yes $125/Plan Check # Site Evaluation Forms Included? Yes X Local Upgrade Form Included? Yes X Telephone #: (978) 835-0102 E-mail: ken@cornerstoneland.net Homeowner Chris Shanahan Name: OFFICE USE ONLY No No Fax #: When the subm' sion is complete (including check): ➢ V Date stamp plans and letter ➢ Complete and attach Receipt ➢ Copy File; Forward to Consultant ➢ Enter on Log Sheet and Database s c0 IT O T" O) r a 00 CU 2 O m LL m Q U) F a� 0 0 U a N c a Ug O o M to 0 N L N L � OL Via' a) m cn a) 4- v N L L c •N O� z wa U) cc r c 0 •� u t E N £ i >+ (1) C (n a) } a) m :m Q 0 a U 0 = i a) N � f E m U Z 'E Z ffo U) M } } ❑ ❑ m v c 0 m O Cl. w � O N 00 U _ O a) > w m _c c_ L L a) E m Z ca E O Z 3 0 a) m ❑ m m E E Z O Z E 0 Z O Q D 0) CL c C13 m 2 w O c } O Z U m U) o El® CL N 'co m U () Z Z > O ❑ >, n _O a) C O d O Z c >, S. 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Important: When filling out forms A. Site Information on the computer, use only the tab Chris Shanahan key to move your Owner Name cursor - do not 24 Deer Meadow Road use the return key. Street Address or Lot # North Andover Q City/Town Kenneth Lania, CLC Contact Person (if different from Owner) B. Test Results Observation Hole # Depth of Perc Start Pre -Soak End Pre -Soak Time at 12" Time at 9" Time at 6" Time (9"-6") Rate (Min./Inch) MA 01845 State Zip Code (978) 835-0102 Telephone Number 03/31/16 12:30pm Date Time Date Time TP#4 50" 12:54 1:09 pm 1:10 pm 1:46 2:41 pm 55 min. 19 min/in Test Passed: ® Test Passed: ❑ Test Failed: ❑ Test Failed: ❑ Kenneth M. Lania Test Performed By: Isaac, North Andover Board of Health Witnessed By: Comments: t5form12.doc• 06/03 Perc Test • Page 1 of 1 TOWN OF NORTH ANDOVER Office of COMMUNITY DEVELOPMENT AND SERVICES HEALTH DEPARTMENT 1600 OSGOOD STREET; SUITE 2035 NORTH ANDOVER, MASSACHUSETTS 01845 978.688.9540 - Phone RECEIVED 978.688.8476 - FAX healthdept@northandoverma.gov MAR 2 5 2016 www.northandoverma.gov SOWN OF NORTH ANDOVER APPLICATION FOR SOIL TESTS HEALTH DEPARTMENT DATE: J `%� I (o MAP & PARCEL: Ivo. `J mat LOCATION OF SOIL TESTS: OWNER: N -ft -l5 MAA -t,1 Contact #: 7-- 92J APPLICANT: l AAZAS Contact #: (9-7&) %517_7 q2( ADDRESS: -ZA ENGINEER: l A SI(�11= L� fJ%� I Contact #: a?� ��SIS - 0 62— CERTIFIED Z CERTIFIED SOIL EVALUATOR: V, 1 LA -!J i A_ Ste. i 3 l l Intended Use of Land: Residential Subdivision Single Family Home Commercial Is This: Repair Testing: Undeveloped Lot Testing; Upgrade for Addition:_ In the Lake Cochichewick Watershed? Yes THE FOLLOWING MUST BE INCLUDED WITH THIS FORM No ➢ Proof of land ownership (Tax bill, or letter from owner permitting test) ➢ 8.5" x 11 " Plot plan & Location of Testing (please indicate test nit sites on the plan) ➢ Fee of $585.00 per lot for new construction. This covers the minimum two deep holes and two percolation tests required for each disposal area. Fee of4$ 40.00 per lot for repairs or upgrades. GENERAL INFORMATION ➢ Only Certified Soil Evaluators may perform deep hole inspections. ➢ Only Mass. Registered Sanitarians and Professional Engineers can design septic plans. ➢ At least two deep holes and two percolation tests are required for each septic system disposal area. ➢ Repairs require at least two deep holes and at least one percolation test, at the discretion of the BOH representative. ➢ Full payment will be required for all additional tests within two weeks of testing. ➢ Within 45 days of testing, a scaled plan (no smaller than 1"-100') shall be submitted to the Board of Health showing the location of all tests (including aborted tests). ➢ Within 60 days of testing soil evaluation forms shall be submitted. Please Do Not Write Below This Line N.A. Conservation Commission Approval ate: 1 Signature of Conservation Agent. Oz u.1 e - Date back to Health Department: (stamp in): I lk ^ k�z 91 rl -"WIT 1,4 IF lk ^ ELEVA-r 1 ON!5. I NV PIPE OUT OF H5E AS E5UILT Ute- S U lz P -Ar a D I t� P05A1.-. 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