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HomeMy WebLinkAboutMiscellaneous - 247 BRIDGES LANE 4/30/2018 (2)I MAP LOT # PARCEL # - - -------- STREET_ HAS PLAN REVIEW FEE BEEN PAIDdl ? PLAN APPROVAL: DATE 711-4- YES 019 NO APP. By DESIGNER: PLAN CONDITIONS WATER SUPP'L\Y: WELL PERMIT WELL TESTS: COMMENTS: WELL DRILLER .. .. .... .. ... CHEMICAL DALE APPRUVED BAC DO I E OPPRUVED BACTERIA II DATE APPROVED FORM U APPROVAL: APPROVAL J,u ISSUE -a NO DATE ISSUED le) BY . . .. . ........ . . CONDITIONS: FINAL APPROVAL:. ALL PERMITS PAID WELL CONSTRUCTION APPROVAL YES NO SEPTIC SYSTEM CONSTRUCTION APPROVALNO (��, OTHERNU YES NU ANY VARIANCE NEEDED FINAL BOARD OF HEALTH APPROVAL: YES NU D A 1"E -17¢ DY: BUILDING PERMIT TOWN OF NORTH ANDOVER APPLICATION FOR PLAN EXAMINATION Date Received ici �� LOCATION. �`i�- 0,z)r \ Ag eS WIZ d�$qS Print PROPERTY OWNER C���er ��� —t- Geva- lZ P VV\F G vzkL-1 J Print 100 Year Structure MAP l PARCEL: ZONING DISTRICT: Historic District yes yes Machine -Shop Village yes no no no TYPE OF IMPROVEMENT PROPOSED USE Residential Non- Residential ❑ New Building ❑ One family ❑ Addition ❑ Two or more family ❑ Industrial ❑ teration No. of units: ❑ Commercial Repair, replacement- ❑ Assessory Bldg ❑ Others: ❑ Demolition ❑ Other Septic' D Well ❑ "Floodplain O VVetlantls ,Vllatersfled District 0 Water/Sewer DESCRIPTION OF WORK TO BE PhK1-L)KMtu: (--e. -e kLLs h r,, - hM Wood Iy t y, Lac -lc- x a' 6'. Identification - Please Type or Print Clearly OWNER: Name: q c—L I V\/%` Phone.1 --�'5 cl,0 a- —1-6,;` Address. Contractor Name: Phone: Email: Address: Supervisor's Construction License: Home Improvement License: Exp. Date: Exp. Date: fit cy,r -Si I1""c" — "c"— 1_ A CHITECT/ENGINEERC \f\co�d �\&WA 5 + Phone: 3 3 _d Address: e 0 Su vv- v\,xtf (�;A ut"U 1Ac _Reg. No. - FEE SCHEDULE. BULDING PERMIT.• $92.00 PER $1000.00 OF THE TOTAL ESTIMATED COST BASED ON $925.00 PER S.F. Total Project Cost: $ FEE: $ Check No.: Receipt No.: NqTE: P r� sons eij�nF with unregistered contractors coo not have access to the gv" <19 nati ira of AaPnt/Owner __ S onatur� of rnnfirar. or y Plans Submitted ❑ Plans Waived ❑ Certified Plot Plan ❑ Stamped Plans ❑ TYPE OF SEWERAGE DISPOSAL Public Sewer ❑ Tanning/Massage/Body Art ❑ Swhnm"'g Pools ❑ Well ❑ Tobacco Sales ❑ Food Packaging/Sales ❑ Private (septic tank, etc. x Permanent Dwnpster on Site ❑ THE FOLLOWING SECTIONS FOR OFFICE USE ONLY INTERDEPARTMENTAL SIGN OFF m U FORM PLANNING & DEVELOPMENT Reviewed On � I� � 1� Signature_ jot COMMENTS_ keFPl tc r Pt-&— - ��t 5►7�t1 ����N CONSERVATION COMMENTS P�-n XHEALTH COMMENTS Reviewed Reviewed onlul N'ls Si nature 0 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: Located 384 Osgood Street FIRE DEPAkTMENT - Temp Dumpster onsite yes no Located at 124 Main Street Fire Department signature/date COMMENTS oI ®m Z Q J vt ST w,q Y LZ�YVoaT/O//,5 DES/�'iV ,4S !3U/LT OUT Of ,yOUS5 1 1 'IVV P/,4 INTO T.4Nk 'NV. P/PE OUT OF T,4N,� 'Nt/. P/PE /NTD D. BOA, NV P//'E OUT OF D. BOX NY. E!1%D t7.4-a/DC 1d 7 EL E' 4 T/ON T vE Z46Lc STONE" }EPr� ,4T PROBE COTE 7'�/.S PL 4N /S NOT ,4 1v,4lP2.41VTY OF 7I67 SYSTEM BUT ,4 P,E" IF/C,4T/ON OF 7 -1 -IF L OC.4l/ON OF T, -/E 67YI T sre�crU2Es. , 4S /L T E D/SAO ,�1L SYSTEM IN D d tJ C- rC. M4 FOle W le Ll A-1-7 3,44C.S- 7"7 - SCALE .• l � �` i o 4 TE.• CyR/5TIAIVSEN e sEfiGl , INC, &O SUMMER ST,'5EET -- 8AV55,yILL , MAss. U r Commonwealth of Massachusetts W ial Ins ection FogpI4 p _ oluntary Assessments S Subsurface Sewage gisposaf'System Form ins .pectlep results MUG #ae submitted on this feral Or On the e�;caai Tlt)q'6 anspectlon Form dated 6!1,5/2000. Ins action forms may not be altered in an wa I. RECEIVEDA. terdf�cattDfl Important: JUL 18 2016 When filling out 1. Property Information: forms on the `Z- Y'7 bt),c4 crs �,y computer, use HEALTH DEPA TMENT only the tab key Prppe Address to cursor edo not At a e ourG lS 1 ✓1 �1"I OYwnees N use the return &me- w L �\ key. .w Oy++ner s Address /140/Idtt'S� — � � �AMpr1yC�' State cityfTown Zip Code bate of inspection: rata 2. Inspector: u°t Ow -4 Leo 2�L -- Nof Inspector Company Name Ght+S40101 wl -- Company Address u �� City/Town State Zip Code WE- 3'71/- VW -3 Telephone Number Certification Statement: 1 certify that 1 have peisbnally Inspected the 'sewage dlspbsal 'system at itis ad'dres's and that the information reported below is true, accurate and complete as of the time of the Inspection. The inspection was perfbifhed based on my t�bining and expeMenbe in the ptbper functlbn and maintenance of on site sewage disposal systems. I am a DEP approved system inspector pursuant to Section 15.340 of Title b 131D -CMR is.nnb). The §ystem: Passes ❑ Conditionafly Passes {] Palls Vlnso�ens s further♦=�raluatlo by the Local{approvingfluthority Signature Date The system fnspectbr shall t:Ob�mii a copy bf this fnspect on..repbft tb the A'P'p fng Autho�itji (Board of Health or DEP):.within 30 days of completing this inspection: If the system is a shared system or fie§ A ntign mw brt ID'Dnn f'office pend the §yste'ii't OWhn r §hall 'subbml the report to the approprlate reglgna of.fhe DEP'. The original should be sent to the system owner and cb'ple §enttb tha bUyBp, if appllcAble;..iiid tPiBpppbVing aUthbtity. . "*"*This report only describes conditi.Qns atthe time of inspection and under the conditions of use at that time. This inspection does not..ad�dress how -the system will.perform in the future under the same or different conditions of use.' Till Offlci 1 trrspe'ctton FnTm' Subsurface Sewage otsposal systern'- ttitnsp.tfoc,- 1112004 e a Page Aof16 Commonwealth of Massachusetts q; Title 5 Official Inspection Form Not for Voluntary Assessments Subsurface Sewage Disposal System Form A. Certification �cnnt.) Z y7 PropertyAddress. 9W Zip Code City'fown State 5-31-- . o5- - Owner s Na a Date of Inspection Inspection Summary: Check A,B,C,D or E I always complete all of Section D A) System Passes: j I have not found any information which indicates that any of the failure criteria described in 310 GMR 16.303 or in 310 GMR 16.304 exist. Any failure criteria not evaluated -are indicated below. Comments: SWC -4., %s r,„ mod Cotc4 ► f r �t 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. Answer yes, no or not determined (Y, N, ND) in the ❑ for the following statements. If "not determined," pfease expfain. ❑ 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 exfiltratlon 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. ND Explain: t5insp.doc i t%wild Title b Official Inspection Form: Subsurface Sewage Disposal System Page 2 of 16 Commonwealth of Massachusetts Title 5 Oficial Inspection Form Not for Voluntary Assessments Subsurface Sewage Disposal System Form A. Certification �cnnt.) _ZeR ,dies 1-v Property Address /jA �i-ANrw� Clty/Town State Zip Code Owners Name Date of Inspection 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 ❑ distribution box is leveled or replaced ND Explain: ❑ The system required pumping more than 4 times a year due to broken or obstructed pipe(s). The system will pass in-speotion if (with approval of the Board of Health): ❑ broken pipe(s) are replaced ❑ obstruction is removed ND Explain: 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 Hoard Df Health determines in a-cvrdanoB with 310 CMR 15.303(1)(b) that the system is not functioning in a manner which will protect public health, safety and the envivonmtent: ❑ Oesspbbi of Privy is within 51D feet of a suiface wster ❑ Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh t5insp:doc • 1112004 Title 5 Official inspection frnrn: Subsurface Sewage Disposal System Page 3 of 16 Commonwealth of Massachusetts Title 5 official Inspection Form Not for Voluntary Assessments Subsurface Sewage Disposal System Form A. Certification �onnt.) Property Address Ca3/ ys" , , / 1 Stale Zip Code Cityrrown -- - Owner's Name Date of Inspection C) Further Evaluation is Required by the Board of Health (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 s-upply 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: ** TNs system passes if the well water analysis, performed at a DEP certified laboratory, 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, provided that no other failure criteria are triggered, A copy of the analysis must be attached to this form, 3. Other: t5lnsp.doc - 1112004 Title 5 Ufficiai inspection form: Subsurface Sewage Disposal Sysrem Page 4 of 16 Commonwealth of Massachusetts Title, -5 official Inspection Form Not for Voluntary Assessments Subsurface Sewage Disposal System Form A. Certification (cont.) ZH "7 Liv Property Address /4f* 4f N— NooJy ZipCode City/Town State V-3/-CyT Owner's Name Date of Inspection D) System Failure Criteria Applicable to All Systems: You must indicate "Yes" or "No" to each of the following for all inspections: Yes No Yes NO ❑ ❑ The system falls. 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. t5insp.doc 11/2fl(}4 Tine 5 Official inspection Form: Subsurface Sewage Disposal System Page 5 of 16 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 % 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 SAS, cesspool or privy is below high ground water elevation. Any portion of cesspool or privy Is within 100 feet of a surface water supply of El❑ tributary to a surface water -supply. ❑ ❑ Any portion of a cesspool or privy is within a Zone 1 of a public well. Any portion of a cesspool or privy is within 50 feet of a private water supply ❑ ❑ Cl❑ 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. his system passes If the well water analysis, performed at a DEP certified . laboratory, 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, provided that no other failure criteria are triggered, A copy of the analysis must be attached to this form.] Yes NO ❑ ❑ The system falls. 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. t5insp.doc 11/2fl(}4 Tine 5 Official inspection Form: Subsurface Sewage Disposal System Page 5 of 16 Commonwealth of Massachusetts Title 5 Official Inspection Form Not for Voluntary Assessments Subsurface Sewage Disposal System Form A. Certification (cont.) 2 y-7 dicid-e-s -- — Property Address V� ' " State Zip Code CitylTown S'-3/-oS C qA NI C�J�nf�1 Owners Name — J Date of Inspection E) Large Sy'stem's; To be cbnside'reda 1a"r9es0tem the syst'e'm Fti'0st serve a fiacilrty wrth a design flow of 10,000 gpd to 15,000 gpd. For large systems, you must indicate either'°yes" °no" to each of the following, in addition to the or 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» 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 upgrad�ethe system in accordance with 310 CMo R 15.304. The system owner should contact the app p a regional office of the Department. t5insp.doc 11064 Page b Offioial Inspection Form: Subsurface Sewage Disposal System Page 6 of 16 Commonwealth of Massachusetts Tile 5 or-r-cial inspection Form Not for Voluntary Assessments Subsurface Sewage Disposal System Form B. Checklist _ ZV7 Bary* 1-v Property Address Ci��ow�, State �c Owner's Date of Inspection v ir- ZlpCoT de 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? (x ❑ Were the septic tank manholes uncovered, opened, and the interior of the tank l— 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 mainte-narlce of subsurface sewage disposal $ysterr�s? The size and location of the Soil Absorption System (SAS) on the site hasi been determined based on: ❑ Existing information. For example, a plan at the Boars! of Health. ❑ Determined in the field (if any of the failure criteria related to Part C is at issue distance is unacceptable) (310 CMR 15.302(3)(b)) approximation of I�insp.doc 11%�t1i1d Title b CNficlal lnspeeion Form: Subsurface Sewage Disposal system Page 7 of t6 Commonwealth of Massachusetts 5 Oficial Inspection ection Fp Not for. Q untag y Assessments Subsurface Sewage Disposal System Form ic. System information 21 Property Address City/Tg#n Owner's Residential Flow Conditions: Number of bedrooms (design): y State Zip Code Date of Inspection Number of bedrooms (actual): 14© DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x # of bedrooms): Number of current residents: Does residence have a garbage grinder? Is laundry on a separate sewage system? [if yes separate inspection required] Laundry system inspected? Seasonal use? Water meter readings, if available (last 2 years usage (gpd)): Sump pump? Last date of occupancy: Commercial/Industrial Flow Conditions: Type of Establishment: Design flow (based on 310 CMR 15.203): Basis of design flow (seats/persons/sq-.ft•.•, ete,.3: Gfease trap present? irrdvstriai waste hotding tank present? N -on -sanitary waste discharged to the Titte 5 system? Vvater metsr res -dings, if avalt8bte:. Last date bf obbuOahbyMu : Other (describe): 'GMM Per d4 (§M) Date '�7 ❑ Yes No ❑ Yes No Yes ❑ No ❑ Yes,. No ❑ YeS'/ No CL--r/'CA4 0 ate ❑ Yes ❑ No ❑ Yes ❑ No ❑ Yes ❑ No 15insp.doc - 1112004 Titte 5 Officfai tnsp don Form: Subsurface Sewage Disposal System Page 8 of 16 Commonwealth of Massachusetts T%tle 5 OTTicial Inspection Form Not forVoluntary Assessments Subsurface Sewage Disposal System Form C. System Information (cont.) t 1 1 &1,dc3 L/ Property Address Cltyrrown State Zip Code ��y ,/�c S -3 lam' Owners Name Date of Inspection General Information Pumping Records: Source of information: Was system pumped as part of the inspection? If yes, volume pumped: How was quantity pumped determined? Reason for pumping: &0 1z Yes ❑ No /moo gallons f3'}Al�i 'ANt�. Type of System: Septic tank, distribution box, soil absorption system ❑ Single cesspool ❑ Overflow cesspool ❑ Privy ❑ Shared system (fires or no.) (if yes, attach {previous inspection records, if aRy) ❑ Innovative/Alternative technology. Attach a copy of the current operation and maintenance cbnt�aci (tb be bbiaihM fironi sysiefi owiieF) ❑ Tight tants, Attacb a Eppy of the D€f' aiaprovaf. Cl Other (desoribe): Approximate age of ail components, date installed (if known) and source of information: Were sewage odor's detected when btdving at tbi site? ❑ Yes / No t5insp.doc t IMN Tl'tle 8 Widal Inspection Form: Subsurface Sewage Disposal System Page 9 of 16 C. Sptem Information twnt.) 2V 13r►tes Cv Property Address P��� City/Town Owner's Name -� t5insp.doc • 11/2004 Building Sewer (locate on site plan): Depth below grade: . Material of construction: State Zip Code Date of inspection feet ❑ cast iron 7�40 PVC ❑ other (explain): f Distance from private water supply well or suction line: feet Comments (on condition of joints, venting, evidence of leakage, etc.): t'� S)� Ao F l,cgA Or Septic Tank (locate on site plan): //7— Depth below grade: feet Material of construction: concrete ❑ metal ❑-fiberglass ❑ polyethylene ❑ other (explain) If tank Is metal, list age: years is age confirmed by a Certificate of Compliance? (attach a copy of ❑ Yes ❑ No cer�lfiiraie) /0 %6 f 5S Dimensions: Sludge depth: Distance from top of sludge to bottom of outlet tee or baffle scum thtclmBss Dlstant;e from top of soum to top of outl-et tb-6 or baffio Distance ftbm boft h) of scum tb bottom of butlet tee of baifile Now were dimensions determined'? i 0 y�y S 1r �'1e4s� Title 5 Offictai fnspectton form: Subsurface Sewage Disposai System Page 10 of 16 Commonwealth of Massachusetts Title 5 official Inspection Form Not for Voluntary Assessments Subsurface Sewage Disposal System Form C. System Information (cont.) Property Address City own State Zip Code Date of Inspection — --- Owner's Name Comments (on pumping recommendations, inlet end nutlet tee or beffle condition, structural integrity liquid levels as related to outlet invert, evidence of leakage, etc.): t3A �� �Id fif��U� �'-�,r Cat,'A, ,� I�/c�'i✓� ��L �1--- - UtI MW V4lct 'T' ol< a Grease Trap (locate on site plan): Depth below grade: Material of construction: ❑ concrete ❑ metal ❑ fiberglass Dimensions: Scum thickness Distance from top of scum to top of outlet tee or baffle Distance from bottom of scum to bottom of outlet tee or baffle feet ❑ polyethylene ❑ other (explain) Date of last pumping: Date Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrit-y. liquidlevel's as relaled 16 661161 invert, evidence bf leakage, Tight or Holding Tank (tank must be pumped at time of inspection) (locate on site pfan): Depth below gra'd'e: Material of construction: ❑ concrete ❑ metal ❑ fiberglass ❑ Polyethylene ❑ other (explain, t5insp.doc , 11/2004 Titfe 5 OfficW inspection Form: Subsurface Sewage Disposal Sysrel Page I I of c. System information >-cont.) . Z (/7 B`►'d5le-i Property Address � �N povv Cityrrown Owners Name Tight or Holding Tank (cont,) Dimensions: Capacity: Design Flow: Alarm present: Alarm level: Date of last pumping: state zip code 5 -�lros Data of inspection gallons gallons per day ❑ Yes ❑ No Alarm in working order: ❑ Yes ❑ No Date Comments (condition of alarm and float switches, etc,): Distribution Box (if present must be opened) (locate on site plan): /Y C""/ Depth of liquid level above outlet invert Comments (note if box Is level and distribution to outlets equal, any evidence of solids carryover, any evi'd'ence by leakage Tnib or out of box, ego.) rr t U«Y 611le <ucry p�u^ �iP�t� n`t/ 1,C494 411f/If/ d�ticl� 1eRC,4 kv Cs D-Ik#( is P 6 -mJ 5611?5 'Pump ChamtreT> ocate ion site pian): Pumps tn workln� ordor: ❑Yes ❑ No Alarms in working order: ❑Yes ❑ No tNinsp.doc - 11120bd Title 5 official Inspection Form: subsurface Sewage Disposal System, Page 12 of 16 Commonwealth of Massachusetts Title 5 Official Inspection Form VEEP -law Not for Voluntary Assessments Subsurface Sewage Disposal System Form C. System Information (cont.) Property Address Citylrow / State Zip Code C011A/ �ie.gr�iA S�3ioS^ -- Owners Name Date of Inspection Comments (note condition of pump chamber, condition of pumps and appurtenances, etc.): Soil Absorption System (SAS) (locate on site plan, excavation not required): If SAS not located, explain why:, Type: ❑ leaching pits number: ❑ leaching chambers number: ❑ leaching galleries number: ( leaching trenches number, length: ❑ leaching fields number, dimensions: ❑ overflow cesspool number: Cl innovative/alternative system Type/name of technology: y— 22'7 Comments (note condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of vegetation, etc.): /` 5115h5 Z50"Al 7X/ t�insp.doc - 1!M64 Title b Official Inspection Form: Subsurface Sewage disposal System Page 13 of 16 +w'1 E uml 31� 0 oz CD CL CL z R aa..I —a i `l� • : c� X NNIE =a fl. a IA ES CD 0 r• u cm CD C CD ds CL � v Ol C d � N ►"" CO a m > Q -v C ~ cn .arctm � O O� 10, >Z o c Q o o uj Q CV' as c o W M Ci a, m = 3 LL m cc CD o"ui 'r - N O w E c��va, � u co o -mp C-13 a d •5; =:aca J = R H .O LLJ ►— .0 $ c.=... m CL Q In 0 O z O 0 y .CD L CL ^Q i C Q CO V _Q Cl - CA C O O cv .Q CO3 C 0 cc �C D 0 co Q L 0 Q O � MOFA* C O O J ..Q O CO z CDQ y C z 0 ryQ �uj V J z 0 CD J Q z T LU ' x .H oa � U o U ° �• �� o Q tJ z� u o (U w U) \ 7 O _C C w U w O G W O P4V) w w cco cn c uml 31� 0 oz CD CL CL z R aa..I —a i `l� • : c� X NNIE =a fl. a IA ES CD 0 r• u cm CD C CD ds CL � v Ol C d � N ►"" CO a m > Q -v C ~ cn .arctm � O O� 10, >Z o c Q o o uj Q CV' as c o W M Ci a, m = 3 LL m cc CD o"ui 'r - N O w E c��va, � u co o -mp C-13 a d •5; =:aca J = R H .O LLJ ►— .0 $ c.=... m CL Q In 0 O z O 0 y .CD L CL ^Q i C Q CO V _Q Cl - CA C O O cv .Q CO3 C 0 cc �C D 0 co Q L 0 Q O � MOFA* C O O J ..Q O CO z CDQ y C z 0 ryQ �uj V J z 0 CD J Q z T LU ':. '.� •r "� i`1..Y .t.• w ,.i ,.�. rye. , Town of North Andover, Massachusetts Form No. 3 BOARD OF HEALTH NORTNAL Oe<„eD e,�O 9C,- 3? el .i. ..,. •e OL O p �►''��:;:o:%�'` OIL DISPOSAL WORKS CONSTRUCTION PERMIT ,SSACHUSEt Applicant 1 I X Yeo NA ' ADDRESS TELEPHONE Site Location Permission is hereby granted to Construct x or Repair ( ) an Individual Soil Absorption Sewage Disposal System as shown on the Design Approval S.S. No. CHAIRMAN, BOARD OF HEALTH 1 4L) Fee D.W.C. No. PLAN REVIEW CHECKLIST ADDRESS -�� �G%ST��(�/��/ ENGINEER C2114/ST/✓?/V 5G%v GENERAL r� 3 COPIES STAMP LOCUS `� NORTH ARROW_LZ SCALE CONTOURS✓ PROFILE( SECTION -� BENCHMARK ✓ SOIL & PERC INFO i/ ELEVATIONS ✓ WETS. DISCLAIMER C✓ WELLS & WETLANDS./ WATERSHED?,,J/L DRIVEWAYS✓(Eley) WATER LINE c✓ FDN DRAIN I(0� SCH4 0.. 1✓ TESTS CURRENT? 9t- /q9r,7, SEPTIC TANK / MIN 150OG ✓ .17 INVERT DROP GARB. GRINDER A6 (+200% EDF) 25' TO CELLAR? MANHOLE TO GRADE ELEV- ✓ GW D -BOX SIZE T) -- % # LINESJ— FIRST 2' LEVEL STATEMENT INLET�c9 - OUTLET ��a�✓� _ "17 (2" OR .17 FT) TEE REQ'D? /(/U LEACHING / MIN 660 GPD? L/ RESERVE AREA(-,/ 4' FROM PRIMARY? ✓ 2% SLOPE 100' TO WETLANDS J` 100' TO WELLS 4' TO S.H.GW .� 35' TO FND & INTRCPTR DRAINS'2✓ 325' TO SURFACE H2O SUPP 4' PERM. SOIL BELOW FACILITY ✓ MIN 12" COVER `- FILL?(25' if above natural elev; 101if below) BREAKOUT MET? -� TRENCHES MIN 660 ✓ gpd SLOPE (min .005 or 611/1001) V >31COVER?-VENT -- SIDEWALL DIST. 2X EFF. W OR D (MIN 6')Y— IS RESERVE BETWEEN TRENCHES?" IN FILL? MUST BE 10' MIN. -- 4" PEA STONE? ✓ /1/0 BOT a,14 X LDNG� + q8 0 SIDE X LDNG -1)40= TOT 7& (L x W x #) (G/ft2) (DxLx2x#)G/ft2) /00 1 6 40v '700 7',!: 9 d 6) r INSTRU=ONS: This form is used to verify that all necessary approvals/permits from Boards and Departments having jurisdiction have been obtained. This does not relieve the applicant and/or landowner from compliance with any applicable local or state law, regulations or requirements. ****************Applicant fills out this ssection***************** APPLICANT: �0 LO�y /' f --C Q ✓& Phone LOCATION: Assessor's Map Number _ Parcel % Subdivision IL 5 Int% Lot(s) Street A- (k,40 --j r. St. Number Use Only********** *** ***** *** RECOIIM=ATIONS OF TOWN AGENTS: Conseriation Administrator • Comments Town Planned Comments Heal t:: Aaent Ccmments Public Works - sewer/water ccnnections - dr'_vewav per--it- F-4---- er-it Fir= Depar -me^. t Date Approved Date Rejected Date Arnroved10-2q7 Date Rejected Date Arrrcved C / Date Rejected Received Dv Buildina Inszec==r Data Town of North Andover, Massachusetts Form No. 2 NOR,ti BOARD OF HEALTH 19 qq`` o••.•e •,�� _ o � A « s '�--�►--•+F' DESIGN APPROVAL FOR CH SOIL ABSORPTION SEWAGE DISPOSAL SYSTEM Applicant \&k.� &AA11t Test No. Site Location Reference Plans and Specs. [).o^ � Qom► V ENGINEER DESIGN DATE Permission is granted for an individual soil absorption sewage disposal system to be installed in accordance with regulations of Board of Health. Fee CFTAIRMAN, BOARD OF HEALTH Site System Permit No. DATE dZA3 Sheet of BOARD OF HEALTH TOWN OF NORTH ANDOVER SUBSURFACE DISPO/SAL DESIGN REVIEW FEE PERMIT PERMIT # DATE RECEIVED APPLICANTlGGi9,e� . / ASSESSOR'S MAP ADDRESS ENGINEER �f/•�/sriA.ySA/ ADDRESS PARCEL # LOT # S' STREET V&r67" WA PLAN DATE ,2/c28/93 REVISION DATE CONDITIONS OF APPROVAL: APPROVED DISAPPROVED 2N® 1G,9rE '7P15 r-,Agvvc G --Z?ETw��.tJ 3r-:0 ox./ X14 7-10x!% 9 d Do2�s S ��P �,r ocrr T4 1fJ. �tiha �� SEG- /7-03 C4 / f ;e,--WG/`�ES w Irr -�Z 5- A�5 C�✓o� err 91,55 Appl Town of North Andover, Massachusetts Form No.e BOARD OF HEALTH r 'in 16 19 (� APPLICATION FOR SITE TESTING/INSPECTION Site Location L& -c- r- '�'5 g � - En ineer \% 1 NAME ADDRESS TELEPHONE Test/Inspection Date and Time MaA-0/'1 �� , 16t 9 tCHAIRMAN, BOARD OF HEALTH Fee� �Test No. ;— S.S. Permit No. D.W.C. No. C.C. Date Plbg. Permit No. O 0 11 uiE 0 +� +1 in w 14 -a H a o 0 � r 4J M Q 14 a a w aa) � t� 14 L W O -3 H U ^ Irl a) LL jEj O P (n a) A r -I ri V) N ` ro U 41 rl •rl 41 (a !J rl ,k 4 > r 4 r-1 4 U U A 1-) N x _, a) 10 �+ �+ o -H o .� :1a) (aU w ., U a� o O�� a) o ro� P 4-) (0 p 0) (n �© rl o o a) a 3 3 + +� aa a a) a a) $:;+- o N -4N o w a z (a o a) w rA ro r -I ro r -I (a In a) >4 a) a 0) r. a •r( 4-) z o a) a) H �4 C H .rl d-) U) rl a) r� a) En F +) ri •rl r•i it U ro M M C \ 4-) rl (o r ro -P -r-IN l O O C) + O 04 ri rl aJ a ro ." � ro � a) �d ri � a) ro(a (n In ro ri -P ro N v U o 41 � (a m (n -rl U) N -H -H U r -I C m m C (4-4 s O a) a a O w a) a rl a a) U) •,A A —1 0 O m a) A C] : W 3 to r 4 a) a a) 3 O P+ ro z ca z w m 0 +1 0 O 0 11 SCCD of HRL'i H WAG6P SS (- �PPi�ovEv D►SAPPRQ vEv R�SaNS V Sc� PPL7 ' .�qPc.� CQl`J I _ CRCSTwooJ R� � 0 oiEu.- ,5 PTic s Y STEAA vESIGAj C D,4rt' = AP WPJ6 /urlyoi?)Ty ��-- PC/J� D ta�vCt? 5[-�Or,j t�l�,v �,�T� 2-1Z=�� �AJ 10 1�6 c_C�' SaL T& -STS aF 3 -30) - X i 4/-P Tul2n/6�V- (T IUCOESTGo 1766P O'Y 2' Z . CESS TH411-) r_v I TO D �� Std I� Sy5TEN1 t�STAt�,Q"('�oti1 C- X4 V4 T1d/J )"SPEG ► O AJ 1`INAL 1IJS(�F.�TIOn� A PP�d�ED Mrc 0 f;45 S ❑ F41L- Ft PE Fg() /-\ t-tocYS-6 ry -F4 0 t� [ I PA S5 -0 R J L Q/JTC APPr)\)ING AUTHOr?�-ry ,l'l�lT,ol--),QL.L InlsPbc i (O^j5 (11=- may) DtSAPPIZo\jW Rj�6So NS FRAL APPIR)VAL M D 1-e- por APP13W V,)6 / M i Ha91 ice/ DATE 30 �Z Sheet l of I BOARD OF HEALTH TOWN OF NORTH ANDOVER SUBSURFACE DISPOSAL DESIGN REVIEW FEE � ` PERMIT # DATE RECEIVED APPLICANT '� �I I I�'CJ t ►� ASSESSOR'S MAP ADDRESS PARCEL # LOT # ENGINEER STREET ADDRESS -VIO}L 951( 0, b*jf0% PLAN DATE _ 41 0%11,% REVISION DATE v CONDITIONS OF APPROVAL: APPROVED DISAPPROVED 1)1 'J GO IAQ 1p-&t4Et�,) FsE To t ' 2) & _Q".AAr#.+" To 'IN0 (1) 4s1&rwa 'Tp ks Nwp , uQaKlAbj O ��,�, C71jr*zvor To t! � A OW - b►•t7 OX\l CG IR Q" %*D TO SjWA-'n 0lQ (lot0 .'S . t Xkk tJep R;&, Wa\\ Iw .'4ts -ot ,-T1ow Tra`C� we. -^r LAyo"c. c+.�i1 A 't, "C ��S �L �t�v wdy '�Ro�►o p '� IoTrv4 644A war 'By rn� Tv►2�;� ►a s't'n. c.'�vz.Orl.1t ey ll14t -Tb �� H GQ 0A 00 k»\\ Ktjcx Qltro,,o 2 t -T- Nacv2d.L:, e ,4A- F►oc L S4oOo 13c w. Vr t.a� 1 \ Y�% A s— � � *,I- rr I r- * moor': 1. -, k yrs- -m 00- REVIEW CON`1'INUED SHEET ?i OF A) Sow- Gt Cad Q•rco a -%A Ff:&Lr64*A -BY,- Fuo to c4 5erojeeti T46U` Ov'r c •* '�j i►yv ton of &JO$ or-- �. ,, �8E 'tic �C`o�� n- w SGlto fife i L�� ez, k,� V i� Or JUN -14-2005 03:55P FROM: TO:9786888476 P:1/2 • James Borsuck Boricuk's Septic and D;aiu • (478) 374-8803 PlIouc To. _� y �.. �,. , r Fax: From:` , 4 4 C" 1 � .. Date: Re: Pago$: . CC: © Urgent 0 For Review Q Please Commont Q please Reply 0 Please RecKle V 1 JUN -14-2005 03:56P FROM: TO:9786888476 Commonwealth of Massachusetts Title 5 Official Inspection Form Not for Voluntary Assessments Subsurfao Sewage Disposal System Form A. Certification (cont.) Z10 flridot.� l.V Property Address City/Town Qwner�.. C- rtl� ---,144 St8t0 Date of Inspection D) System Failure Criteria Applicable to All Systems; pr34/r tipcode P:2/2 You mus Indicato "Yes" or "No" to each of the following for all Inspections: Yes No Backup of sewage into facility or system component due to overlaad„j r), Clogged SAS or cesspool a Discharge or ponding of effluent to the surface of the ground or surface watt r,. due to an overloaded or Clogged SAS or cesspool ❑ Static liquid level in the distHbutlon box above outlet invert due to an overoajF,_ or clogged SAS or cesspool Q Et Ey liquid depth In cesspool is less than 6" below Invert or available volume i� les -3 then'/z day flow ❑ rlh W Requlrnd pumping more than 4 times In the last year NQr due to clogged ni ©batructvd pipe(&): Number of times pumpod; ❑ Any portion of the SAS, cesspool or privy is below high ground water eievi3ti()rj ❑ rpt x� Any portion of cesspool or privy is within 100 feet of a surface water supe.:, tributary to a surface water supply. ❑ 0� Any portion of a cesspool or privy is within a Zone 1 of a public well ❑ Any portion of a Cesspool or privy is within 50 feet of a private water well. C] Any portion of a cesspool or privy is less than 100 feet but greater Than 50 fGL! irom a private water supply well with no acceptable water quality analysis Crh is system passes If the well water analysis, performed at a DEP certified laboratory, for cQ11form 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, provided that no other failure criteria are triggered. A copy of the analysts must be attached to this form.) Yes No ❑ The system falls. I have determined that one or more of the above la lure criteria exist as described in 310 CMR 15.303, therefore the systern tails Tr,e system owner should contact the Board of Health to determine what w�II be necessary to Correct the failure. tainsp doc • t {12004 TWO 5 offciel inspoctiun fvrm: 5ubsurtsce Sewage Dispcm Sysrer Fuge 5 a' Town of North Andover, Massachusetts Form No. 1 NORTH BOARD OF HEALTH OL 1 i-• i r r 19 O APPLICATION FOR SITE TESTING/INSPECTION ApplicantNAME ADDRESS TELEPHONE Site Location -r r Engineer NAME ADDRESS TELEPHONE Test/Inspection Date and Time 1 CHAIRMAN, BOARD OF HEALTH Fee Test No. L S.S. Permit No. D.W.C. No. C.C. Date Plbg. Permit No. oe <ubml({ed to the local Board of Health otharua or rtealth, The System Pum In PProying authority, P A; Facility InforM tion �t Ing QVI Syscam Location, CnMNIIAt 19 1 , °M' 00 ltb koy Addre9� A0a;r�or . 4o flpl _� ,CItY(Town 'J'�,., .. l i+, rY .lrv.l`(I ', /.Irl•'% 11:. ' '''' '!..'r.l J,' � , '�`•' ,�, �,1 i' `fij!'I Ir �iV. r.t,.' /rr,. 1�1,` ,{�ilw�l�'1 Y, ., � ^ ' "iai' J' :J''' NilTll /V ?a• I.,. '1.ri 'j:g l l..1I..1. na Addrel� (If dltfewl rom'IocaUon) C�Y/T'ovm' �® .). "... .i.rl ��`f'�!I /u (.f .1 �'',.1;(.Ilt'.'.� '� 1'i •. 1.� „Y.1' I urn .plllgRegord zoN ,+ .,i(,.�>'V }��'Cdr.�:'!{?fn.n:lJ'�•'/,�'{i'i�eJ` q (}. of Pumpin9''' . _ Oate State -- 2p / Q Z— '1 $ olop�on Number 2, QuanUry Pumped TYpe 0M; , ❑ Cesspools) epcic Ten k I.j CiNQn4 ❑ Tight Tank ✓.lily �, t,', %�i'i'''?i�'ri1'P� vrrl �..0 fv ., Effluent Tee'Fl1le ' >r•,"•'r (•p(@sent?..❑ Yes o If es w Y as II ciaanad? ❑ Yes .. ''��"f:'i. •, '.�. ••f !�•n.�S/'�, ''IYrli IruJ( I: 1'•'/ _ 7, -,- on on.Q.�sY.�`. '', •'r x!117 yr •IrJ'i (:,il•l, J. L� L,il' , / .I,':L,,i \�+.r �-��� ..1 ;,�,,' •,I',1 w'?rl'jf�l`/j;r �,;.l�ij,;}J%.�,�}t�.,l,r ._._� nN'; 11 PUmpad 'i • �i v'A�'i�i ���:,.�� iµfM'flt A� \',�'�"�''�0d I�'��(�i 1��1�ji�'1r r;l'1,','.J, � . '...,/.,. ,i �'�,.1.'.r.,o.l 'rl � l.!•'.ffrJ� Ip' t<`�ly.V:�ly:'�(:(,': `' .. .3:7:1 Loca on where oo(1lenks'Were dl9posed; •� ��; ,;;%;i�•:ra., ,:Slpn�•lur� olHiule�, � �<.Y..,',.;.,,, , hr�� v,mass,goV/dap!waler/approya&/Worm5,hcm#ln9pact cx, 04A 3 VahlGe U(Wff NVmbar r w • Sys em Pumping Reccro c;;, i