HomeMy WebLinkAboutMiscellaneous - 250 BARKER STREET 4/30/2018Date.��1.......191.1......4 ................
TOWN OF NORTH ANDOVER
PERMIT FOR WIRING
0U "-n 14 1 1
This certifies that
C-
has permission to perform
................ .............. ..............................................................
wiffng in the building of
at N Andover, Mass.
91
.......... A rth
Fee
6-1
-A
J.'........... Lic. No. . .....
AL INSPECTOR
Check it
Commonwealth of Massachusetts
Department of Fire Services
BOARD OF FIRE PREVENTION REGULATIONS
Official Use Only
Permit No. 12.P2-0
Occupancy and Fee Checked
[Rev- 1/071 (leave blank
APPLICATION FOR PERMIT TO PERFORM ELECTRICAL WORK
All work to be performed in accordance with the Massachusetts Electrical Code C), 527 MR 12.00
(PLEASE PRINT IN NK OR TYPE ALL INFORMATION) Date: 1 g�Y
City or Town of: NORTH ANDOVER To the Inspector of Wires:
By this application the undersigned gives notice of his or her intention to perform the electrical work described below.
Location (Street & Number)
Owner or Tenant ��,�_ �''�Z _ Telephone No. WY- 00,79- VS1�',
Owner's Address S4wt
Is this permit in conjunction with a building permit? Yes ❑ No ® (Check Appropriate Box)
Purpose of Building Utility Authorization No.
- Existing Service Amps / Volts
0
Oki
New Service
Amps / Volts
Number of Feeders and Ampacity
Location and Nature of Proposed Electrical Work:
Overhead ❑ Undgrd ❑
Overhead ❑ Undgrd ❑
No. of Meters
No. of Meters
Completion of the following table may be waived by the Inspector of Wires.
No. of Recessed LuminairesNo.
d
of Ceil: Susp. (Paddle) Fans
No. of Total
Transformers KVA
No. of Luminaire Outlets
No. of Hot Tubs
Generators KVA
No. of Luminaires
SwimmingPool Above ❑ In- r-,
rnd. grnd.
o. o Emergency ig ting
Battery Units
No. of Receptacle Outlets g
No. of Oil Burners
FIRE ALARMS
No. of Zones
No. of Switches L/
7
No. of Gas Burners
No. of Detection and
Initiating Devices
No. of Ranges
No. of Air Cond. Total
Tons
No. of Alerting Devices
No. of Waste Disposers
Heat Pump
Totals:
Number
--
Tons
""' ' "''
M.
'"'""''" "
No. of Self -Contained
Detection/Alerting Devices
No. of Dishwashers
Space/Area Heating KW
Local ❑ Municipal ❑ Other
Connection
No. of Dryers
Heating Appliances KW
Security Systems:*
No. of Devices or Equivalent
No. of Water KW
Heaters
No. of No. of
Signs Ballasts
Data Wiring:
No. of Devices or Equivalent
f1No. Hydromassage Bathtubs
No. of Motors Total HP
Telecommunications Wiring:
No. of Devices or Equivalent
OTHER:
Attach additional detail if desired or as required by the Inspector of Wires.
Estimated Value ofEle4rical Work: S-, CM70 (When required by municipal policy.)
Work to Start: ?/ (% Inspections to be requested in accordance with MEC Rule 10, and upon completion.
INSURANCE COVERAGE: Unless waived by the owner, no permit for the performance of electrical work may issue unless
the licensee provides proof of liability insurance including "completed operation" coverage or its substantial equivalent. The
undersigned certifies that such coverage is in force, and has exhibited proof of same to the permit issuing office.
CHECK ONE: INSURANCE [N BOND ❑ OTHER ❑ (Specify:)
I certify, ander the ai sand penalties of penury, tJzat the inforn2ation on this application is true and complete.
FIRM NAME: - � Ci `Z L, L C) LIC. NO.: 1M (Q ? y
Licensee: Rn v,/j Signatur LIC. NO.: 3-(\
(Ifapplicable, enter "exempt"
in the, licen� number line) Bus. Tel. No.- 3 y - 97(3
Address: 126q Betwtt� Smav� Qf C 3[103
Alt. Tel. No.: "I £fill -60
*Per M.G.L c. 147, s. 57-61, security work requires Department of Public Safety "S" License: Lic. No.
OWNER'S INSURANCE WAIVER: I am aware that the Licensee does not have the liability insurance coverage normally
required by law. By my signature below, I hereby waive this requirement. I am the (check one) ❑ owner ❑ owner's agent.
Owner/Agent PERMIT FEE: $
Signature Telephone No.
❑ 2012 Massachusetts Electrical Code Amendments 527 CMR 12.00 § Rule 8: In accordance -with the provisions of M.G.L. c. 143, § 3L, the 1
permit application form to provide notice of installation of wiring shall be uniform throughout the Commonwealth, and applications shall be filed �r
on the prescribed form. After a permit application has been accepted by an Inspector of Wires appointed pursuant to M. G.L c. 166, § 32, an
electrical permit shall be issued to the person, firm or corporation stated on the permit application. Such entity shall be responsible for the
notification of completion of the work as required in M.G.L. c. 143, § 3L.
Permits shall.be limited as to the time of ongoing construction activity, and may be deemed by the Inspector of Wires abandoned and invalid if he
or she has determined that the authorized work has not commenced or has not progressed during the preceding 12 -month period. Upon written
application, an extension of time for completion of work shall be permitted for reasonable cause. A permit shall be terminated upon the written
request of either the owner or the installing entity stated on the permit application.
❑ The Permit Extension Act was created by Section 173 of Chapter 240 of the Acts of 2010 and extended by Sections 74 and 75 of Chapter 238 of
the Acts of 2012. The purpose of this act is to promote job growth and long-term economic recovery and the Permit Extension Act furthers this
purpose by establishing an automatic four-year extension to certain permits and licenses concerning the use or development of real property. With
limited exceptions, the Act automatically extends, for four years beyond its otherwise applicable expiration date, any permit or approval that was
"in effect or existence' during the qualifying period beginning on August 15, 2008 and extending through August 15, 2012.
❑ Rule 8—Permit/Date Closed: *** Note: Reapply for new permit ❑
❑ Permit Extension Act — Permit/Date Closed:
Trench Inspection
Pass M
Failed
Re- Inspection Required ($.) ❑
Inspectors Comments:
Inspectors Signature:
Date:
SERVICE INSPECTION:
Pass 1fl
Failed
Re- Inspection Required ($.) ❑
Inspectors Comments:
F�
Inspectors Signature:
Date:
PARTIAL ROUGH INSPECTION:
Pass M
Failed
Re- Inspection Required ($.) ❑
Inspectors Comments:
Inspectors Signature:
Date:
ROUGH INSPECTION:
Pass(< M
Failed
Re- Inspection Required ($.) ❑
Inspectors Comments:
Inspectors Signature:
Date:
FINAL INSPECTION:
Pass IN V
Failed 0
Re- Inspection Required ($.) ❑
Inspectors Com en s:
�.-
Inspectors Signature:
Date:
DEB WEINHOLD ... TOWN OF MERRIMAC, MA. .......dweinhold@townofinerrimac.com
{ The Commonwealth of Massachusetts
Department of IndustrialAccidents
Office of Investigations
U1 600 Washington Street
Boston, MA 02111
www.mass gov/dia
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers
Applicant Information Please Print Lep-ibly
Name (Business/Organization/Individual):ct) a
Address: coq
City/Stat0-3/0,3 Phone #: &3 4,PY, - -7 970
Are you an employer? Check the appropriate box:
1. I am a employer with o20
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.
workers' comp. insurance.
[No workers' comp. insurance
5. ❑ We are a corporation and its
required.]
officers have exercised their
3. ❑ 1 am a homeowner doing all work
right of exemption per MGL
myself. [No workers' comp.
c. 152, § 1(4), and we have no
insurance required.] t
employees. [No workers'
comp. insurance required.]
Type of project (required):
6. New construction
7. ❑ Remodeling
8. ❑ Demolition
9. ❑ Building addition
10. ❑ Electrical repairs or additions
I L ❑ Plumbing repairs or additions
12. ❑ Roof repairs
13.❑ Other
*Any applicant that checks box#1 must also fill out the section below showing their workers' compensation policy information.
I Homeowners who submit this affidavit indicating they a're doing all work and then hire outside contractors must submit a new affidavit indicating such.
tContractors that check this box must attached an additional sheet showing the name of the sub -contractors and their workers' comp. policy information.
lam an employer that is providing workers' compensation insurance for my employees. Below is the policy and joh site
information. peer(e_�,
Insurance Company Name:. S �r--
Policy # or Self -ins. Lic. #: (3K S ss-��J jm Expiration Date: J
Job Site Address: ;sb �4t'etf' S� City/State/Zip: 0-) �a+ `
Attach a copy of the workers' compensation policy declaration page (showing the policy number and expiration date).
Failure to secure coverage as required under Section 25A of MGL c. 152 can lead to the imposition of criminal penalties of a
fine up to $1,500.00 and/or one=year imprisonment, as well as civil penalties in the form of a STOP WORK ORDER and a fine
of up to $250.00 a day against the violator. Be advised that a copy of this statement may be forwarded to the Office of
Investigations of the DIA for insurance coverage verification.
Ido herehjyfFerto undeeiepains andpKas ofperjury that the informationprovided abpve is true and correct.
v
Phone #: �3 6 - 7-2 ?o I
Official use only. Do not write in this area, to he 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. PIumbing Inspector
6. Other - - -
Contact Person: Phone #:
,/ 1
e? ,
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 ofpublic work until acceptable evidence of compliance with the insurance
requirements of this chapter have been presented to the contracting authority."
Applicants
Please fill out the workers' compensation affidavit completely, by checking the boxes that apply to your situation and, if
necessary, supply sub -contractors) name(s), address(es) and phone mumber(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 maybe 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 Office of Investigations would like to thank you in advance for your cooperation and should you have any questions;
please do not hesitate to give us a call.
The Department's address, telephone and fax number:
The Commonw-alth of Massachweits
Department of Industrial Accidents
Office of I11yestigations
600 Wasbington Street
Boston, SIA 021.1.1
TO, # 617-727-4900ext. 406 or 1-877:MASSAFE
Revised 5-26-05 Fax # 617-727.7749
wwmass.govfdaia
Commonwealth of Massachusetts
North Andover, Massachusetts
System Pumping Record
System Owner & Address:
Dave Stone
250 Barker Street
North Andover, Ma 01845
Location of system: Front
Date of Pumping: December 21, 2010
Type of system: Septic
Gallons Pumped: 1500 gallons
System Pumped by:
Service Pumping & Drain Co., Inc.
S Hallberg Park
North Reading, Ma
License #: BHP -2010-0359,0373,0374,0375,0376,0377,0378
Contents transferred to: Greater Lawrence Sanitary District
JAN -6 2011
TOWN OF NORTH ANDOVER
HEALTH DEPARTMENT
Date: December 21, 2010 Pumping Technician: MW
This is PROPRIETARY and CONFIDENTIAL information that may
be used only by the Board of Health for regulatory purposes
f
NEW ENGLAND ENGINEERING SERVICES
INC
May 20, 1999
North Andover Board of Health
Town Hall Annex
27 Charles Street
North Andover, MA 01845
RE: TITLE V REPORT: 250 Barker Street, North Andover
Enclosed is a copy of the Title V report for the above referenced property. The systemap sses our
inspection.
If there are any questions please call me at my office, 686-1768.
Yours truly,
�0
1�71
Benjamin C. Osgood Jr., .I.T.
President
33 WALKER ROAD -SUITE 23- NORTH ANDOVER, MA 01845 - (978) 686-1768- (888)359-7645- FAX (978) 685-1099
k9iCOMMONWEALTH OF MASSACHUSETTS
EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS
DEPARTMENT OF ENVIRONMENTAL PROTECTION
ONE WINTER STREET, BOSTON MA 02108 (617) 292-5500
r TRUDY COXE
Secretary
ARGEO PAUL CELLUCCI DAVID B. STRUHS
Governor Commissioner
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICA71ON
Property Address: eJz` "i� Name of Owner �� s i
AJ fl.��� �� .uoa Address of owner: A4 Fc�2 LkM ST- � N.
Date of Inspection: �� qct
Name of Inspector: (Please Print) Benjamin C. Osgood, Jr
1 am a DEP approved system inspector pursuant to Section 15.340 of Title 5 (310 CMR 15.000)
Company Name: New England Engineering Services Inc.
MaiTingAddress: 33 Walker Rd. , Sui rp 23, Nnrth Andover, MA 01845
Telephone Number: 978-686-1768
CERTIFICATION STATEMENT
I certify that I have personally inspected the sewage disposal system at this address and that the information reported below is true. accurate
and complete as of the time of inspection. The inspection was performed based on my training and experience in the proper function and
maintenance of on-site sewage disposal systems. The system:
/Passes
Conditionally Passes
Needs Further Evaluation By the Local Approving Authority
Fails
Inspectors Signature: & UDate: 5 1 '3
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 otEnvironmental Protection. The original should be sent to-"
system owner and copies sent to the buyer, if applicable, and the approving authority.
NOTES AND COMMENTS
revised 9/2/98 Page IofII
01 Primed on Recycled Paper
f
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION fcontinued)
Property Address: �: �� (� c: R k S [ l ' , A ti� c4
Owner: ; N
Date of Inspection:
INSPECTION SUMMARY: Check A, B, C, or D:
A. SYSTEM PASSES:
VSY1 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
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-Tnom than fourtfines a yeardue to broken or obstrtmcted pipe(s). The system wHI pass'w
inspection if (with approval of the Board of Health): - - -
broken pipe(s) are replaced
obstruction is removed
revised 9/2/98 Page 2or11
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION (continued)
Property Address: SL'
Owner:
Date of Inspection:
j-1Ll r
C. FURTHER EVALUATION IS REQUIRED BY THE BOARD OF HEALTH:
Conditions exist which require further evaluation by the Board of Health in order to determine if the system is failing to protect the
public health, safety and the environment.
1) SYSTEM WILL PASS UNLESS BOARD OF HEALTH DETERMINES W ACCORDANCE WITH 310.CMR 15.303 (1)(b) THAT THE SYSTEM
IS NOT FUNCTIONING IN A MANNER WHICH -WILL PROTECT THE PUBLIC EIEALTIiAND SAFETY ANQ THE ENIOBONMEIiLT:
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.
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 3ofII
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION (continued)
Property Address: rz r5 c°rc ST.
.
Owner: '
Date of Inspection: qci
D. SYSTEM FAILS: I
You must indicate either "Yes" or "No" to each of the following:
I 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 intoiecilir"r-system component- due tto an overloaded orvbggedSAS or•cesspod. y--"
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 elevation.
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 -o€ ib(►tary-tee eurfeoa•drinkiwg•avaw-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 inforWation.
revised 9/2/98 Page 4of11
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART B
CHECKLIST
Property Address: a 62" 13
Owner: i, I
Date of Inspection:� sT
q Cl
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 compoaants.hawabwn puwgwd4ar--AJaast two Lvaaks aa&the-system 11as6aaosacaiwwg araasa! flow
rates during that period. Large volumes of water have not been introduced into the system recently or as part of this
,,1 n inspection.
/v fl As built plans have been obtained and examined. Note if they are not available with N/A.
The facility or dwelling was inspected for signs of sewage back-up.
J _ 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 orrthe 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)
115.302(3)(b))
V - _ The facility owner (and.oc pLaats,if different iafntmatioann.the proper inionanao.of
SubSurface Disposal Systems.
revised 9/2/98 Page5ortl
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION
Property Address: V3 Q 2 K cam-
Owner:
Date of Inspecgon:
FLOW CONDITIONS
RESIDENTIAL:
Design flow: i bit, g.p.d./bedroom.
Number of bedrooms (design): Number of bedrooms (actual):
Total DESIGN flow kwO
Number of current residents.. -Z --
Garbage grinder (yes or no):-&
Laundry (separate system) (yes or no):AEL: If yes, s eparate inspection.required
Laundry system inspected (yes or no)
Seasonal use (yes or no) -AQ
Water meter readings, if available (last two year's usage (gpd): wC
Sump Pump (yes or no):
Last date of occupancy: Z2 ctq
COMM ERCIAL/INDUSTRIAL:
Type of establishment:
Design flow: apd ( 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 info?nation:
n/e�2e2 ey*t 91
System pumped as part of inspection: (yes or no)�ej
If yes, volume pumped: gallons
Reason for pumping:pec ek- 6 c-
TYPE OF SYSTEM
_ Septic tank/distribution box/soil absorption system
Single cesspool
Overflow cesspool
Privy
Shared system (yes or no) (if yes, attach previous inspection records, if any)
I/A Technology etc. Attach copy of up to date operation and maintenance contract
Tight Tank Copy of DEP Approval
Other 1L
APPROXIMATE AGE of all components, date installed{if known) -end source oftinfonnation:
Sewage odors detected when arriving at the site: (yes or no) A
revised 9/2/98 Page 6of11
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Property Address:
Owner:
Date of Inspection: " !>T
I I.
BUILDING SEWER:
(Locate on site plan)
Depth below grade:
Material of construction: _ cast iron /40 PVC _ other (explain)
Distance from private water supply well or suction line -4o'
Diameter N'�
Comments: (condition of joints, venting, evident ,of t""ge, etc.) I
SEPTIC TANK:_
(locate on site plan)
Depth below grade:
Material of construction: Zconcrete _metal _Fiberglass _Polyethylene _other(explain)
If tank is fetal, list age _ Is.age-confirmed by Certificate of Compliance _ (Yes/No)
Dimensions: 15-00 ✓i s
Sludge depth: [7', �� �'� riz+ CAC c css�, �iie
Distance from top of sludge to bottom of outlet tee orbaffle: _ k Scum thickness: 2" C ��t:f«` � ,- ,N ` _
Distance from top of scum to top of outlet tee or baffle:_
Distance from bottom of scum to bottom of outlet tee or baffler
How dimensions were determined: MCc+S .-- 5_pe K..
Comments:
(recommendation for pumping, condition of inlet and outlet tees or -baffles, depth of liquid level in relation to
evidence of leakage, etc.) i IA.' ..•v �r J.v c
invert, structureFintegrity,
4-. 1 —
GREASE TRAP: N ft
(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:
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
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Property Address: , 5c, g a 2 K c" .ti, . tj ;ti -0�
Owner. go }-1 N LO N �1Q-
Date of Inspection: S
TIGHT OR HOLDING TANK:_1C-EL- (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:
Comments:
(condition of inlet tee, condition of alarm and float switches, etc.)
DISTRIBUTION BOX:_
(locate on site plan)
Depth of liquid level above outlet invert: 13� •.Ick' )^ J� 1 c� c
Comments:
(note if level and distribution is equal, evidence of solids carryover, evidence of leakage)nto or out of box, etc.),
PUMP CHAMBER:.AL4
(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 P2ge8Of11
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
property Address: '2 6-C g 2KC'; S"i N Hti
Owner: ^� D Q,1
`
Date of Inspection:
SOIL ABSORPTION SYSTEM (SAS):_
(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:_
leaching galleries, number:_
leaching trenches, number, length:
leaching fields, number, dimensions: I CI E L• 0
overflow cesspool, number:_
Alternative system:
Name of Technology:
Comments:
(note condition of soil, signs of hy`dr, ulic failure, level of pond, g, damp soil, condition of vegetation, etc.) l j
eye Hyl- \le\� "c, U' CT -".7 cx//. yltt Kii J`C k/1 IL% 1C��i V1
�kn.,,• 4�in —0
CESSPOOLS: 1v f
(locate on site plan)
Number and configuration:
Depth -top of liquid to inlet invert:
Depth of solids layer:
Depth of scum layer:
Dimensions of cesspool:
Materials of construction:
Indication of groundwater:
inflow (cesspool must be pumped as part of inspection)
Comments:
(note condition of soil, signs of hydraulic failure, level of pending, condition of -vegetation, etc.) _—
PRIvY:
(locate on site plan)
Materjals 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)
Property Address: a 5o pj Ft (L y- uz- S i
Owner: -So Fk ni L. v v
Date of Inspection:
I
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)
revised 9/2/98 Page 10 of 11
IoN
ON
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Property Address: '� 5 C �j r1 K /\,'
Owner:
N 1 .. "' D Cit,.,'
Date of kmgmction:
I 5'(✓I �1c1 i
NRCS Reportname L>&j S�r-uev — 5sc x /Vt/}s.rf C.
Soil Type_ r
Typical depth to groundwater
USGS Date website visited
Observation Wells checked
Groundwater depth: Shallow Moderate X Deep
SITE EXAM Slope
Surface water .N
Check Cellar ti�� p rz. 2
Shallow wells
Estimated Depth to Groundwater Feet
Please indicate all the methods used to determine High Groundwater Elevation:
4- Obtained from Design Plans on record
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) n
`�_ li s. S.0 5. t% e.1� ntl. Ce1(rS �•✓c _C C� �• j b ije� �Gw l�it`� E� Ru '.s
5 7 GL �(�✓C. C��CY N �(�1��1c� Cj %
z� ���•�.� Tri-� •���- «k s��„-, r��
�2. b
revised 9/2/98 Page itottl
■Wi`'`t x4 �'rjt�.�+�'��."�"�'p'•r��
�I
'v,
I
i
v�
GC 4RD OP 115(o -PI
Nal�Th /j&) 1 MA,
� T
V PU C41v I
w oi2rLy ff3 be
SS � SLP(IG SYST�,c.�
I D UJEc,L
vest< -A
Flax) pin�
D154PPR6UEp CovvlBID k)5
R�4SoNS
D SGPT I sy5� E st 1 k ► sj;O LLATI OAJ
cX4V4 cow )AAP6:6i IoAj MIC - SSS [] 1;41L-
i SPFcrion) Fl FE Fiot-\ t-+ jL)6& -Fo T/J 0 K Ll Pry S< 1�] t=�►�
IATL Za 2 /SpPr vrn�G �1�r+1o��,1y �i'
+4��IT�DIJA(, W51:6 jjti5 (lp A jy)
DISAPMOVCID DA i C
FItiAL /JPPNpVAL D,oTC
J�- APPj�t vJ6 i v ;Hard y
BOARD OF HEALTH
Town of North Andover,Mass. 19 g
it
# �a Date
APPLICATION FOR WELL & PUMP PERMIT
Application is hereby made for permit to drill a well (_.). Application is
made to install (_) a pump system.
ar!✓ # �....
Location: Address G � S Lot
Owner �J D
U/ S% Address �Te1
�L'�fNod /7 �'L° .�o3
Well Contractor km O _&/-��/y1�i Tel.
W AddressO9�
e � (9 �
Pump Contractor \ U jrp,S Address S (�Je '/, Al Tel.
WELL CONTRACTOR (To be completed at time of pump test)
Type of Well 1 Yrr sy7 Well used for DOYy%B� T"/
Size of. Casing
Diameter of Well
i
Depth of Bed Rock_ Depth th casing into Bed Rock
�� Q
Was Seal Tested? Yes ( ) No (_) Date.of Testing
Depth .-o-f Ue-l:l — � -� Well Ended in What. Material kt/Ve .
S l a t✓
Depth to Water_ Delivers Gals.Per Min. for 4 hours
Drawdown feet after pumping __hours•at GPM
Date of Completion
Si Cure We Contr r
,J n
PUMP INSTALLER (To be• f•ilicd in' before installation)
Li s
Size & Name Pump a /+u -U _i'YI_�Q S!�J ��- _Pump Type Used Ol2le./ S
X720 L.
Water Pump Delivers—?—Size of Tank _GPM _
Pipe Material Used in Well: Cast Iron (_) Crnl.vani.zed (_) Plastic N,
Well Pit (_) or Pitless.Adapter
Was sleeve used to protect pipe? Yes (_) NO V) Type or Name Well Seal^
n - ,
Date
j
DateWater analysis.report• submitted to Board�eal'th
Date release given tD owner of record & Bldg. Insp
Health Inspector
3 Department of -Environmental Management/Division of Water Resources
a sb WATEI`�WELL COMPLETION REPORT
WELL LOCATIONsr.
�ael<_e
GEOGRAPHIC DESCRIPTION
Address—iso
/V do iVe
/VD.,
N S ci W of
(feet) (circle)
City/Town SVA. r�Y1
do VIE
r
Well owner
(road)
Address
N S E W of
/I d rn _ i V
�r M I,
f
(mi. in tenthsl (circle)
intersect. w/
(road)
Board of Health permit: yes 11 no ❑
WELL USE
WELL DATA
Domestic A Public ❑
Industrial ❑
Total well depth ,47 ft.
Monitoring [IOther
Depth to bedrock ft.
Water -bearing rock/ unconsolidated material:
In 1
Method drilled-�Q %a
,
i T/
Date drilled X 7
CASING
Type/ % Sre
Length,W—ft. Dia(.I.D.)__&_in..
Length into bedrock 16 ft.
Description
Water•bearing zones:
1) From .31q_6 To
2) From To
3) From To
Gravel pack well: dia.
Protective well seal:
Screen: dia.
Grout -[3 Other Slot* length—from—to—
PUMP
ength from_toPUMP TEST
Static water level below land surface1-2 ft. Date
Drawdown ft, after pumping _0— Amin. at gprn
How measured Recovery ft. after hr. min.
LOG of FORMATIONS ] COMMENTS
G
i
Driller, yTD��� l7 1j4 US r [�
Mass. Registration #
Firm.71S�N
Address g4
, /
City/Town �,[!f! t n�ti a� j /i/
"n OF KAETH COPY
r
LOT 1-
(D 2) 3 8 3
(02)383 Sq R
107,
EXIST.
WELL
EXISTING
SEPTIC TAV4K-
W/F MRR(DUK.
?-93-33
C
EXISTING
FOUND.
TO GL' 105.118
GAR IACER
MICHAEL J. -'RflSATI DAT
AS BUILT SEWAGE DISPOSAL
iRADES
ELEVATION
TO TOP OF PIPE
DWELLING:
--
TANK IN:
96.15
TANK 0 UT:
95.7E
D- BOX IN:
94-18
D -BOX OUT: A 93.98
MARCHIONDA & ASSOC.. lNC.
B 93.98
ENGINEERING AND PLAIIIII14G CONSULTANTS
C 93.98
80 kAPLF. STREET R F. D. 18
D .93.98
END OF DISTRIBUTION
LW& A
9 3.4 8
B
93.48
C
93A8
- D
93,48
MICHAEL J. -'RflSATI DAT
AS BUILT SEWAGE DISPOSAL
.f
SYSTEM PLAN
a
IN NORTH ANDOVER, MA.
9
AS PREPARED FOR JOHN LUMCGU 1Sr
SCALE 1"-50' DATE OCT 19139
r
MARCHIONDA & ASSOC.. lNC.
ENGINEERING AND PLAIIIII14G CONSULTANTS
80 kAPLF. STREET R F. D. 18
STONEIIAU, )MASS. 02100 )JANCHMTER 1111 03103
(817) 438-8121 (803) 43.1-8725
Jo
Y.
S, '�s / o�y
0
lb
D 1ST
Ir
'.
341:24'
fl
,
THIS IS TO CERTIFY THAT I HAVE WSPECTED
THE CONSTRUCTION OF THE SAID DISPOSAL
;
SYSTEM LOCATED AT LOT
I, BARtE , RDS
NORTH ANDOVER, MA. THE
GRADES AREAS
SPECIFIED IN THE PLANS
AND SPECIFICATIONS
DATED10� JkB . m R IONDA' -ASSOC'
MICHAEL J. -'RflSATI DAT
AS BUILT SEWAGE DISPOSAL
.f
SYSTEM PLAN
a
IN NORTH ANDOVER, MA.
AS PREPARED FOR JOHN LUMCGU 1Sr
SCALE 1"-50' DATE OCT 19139
MARCHIONDA & ASSOC.. lNC.
ENGINEERING AND PLAIIIII14G CONSULTANTS
80 kAPLF. STREET R F. D. 18
STONEIIAU, )MASS. 02100 )JANCHMTER 1111 03103
(817) 438-8121 (803) 43.1-8725
N1F T�RROt: K
ELEVATION
TO TOP OF PIPE
DWELLING:
--
TANK IN:
96.15
TANK OUT:
95.70
D— BOX IN:
94-18
D—BOX OUT: A 93.98
B 93.98
C 93.98
D .93.98
END OF DISTRIBUTION
LtNllr A
9 3-48
B
93.48
C
93.48
D
93.48
34`1, Gq" _ 1
"THIS IS TO CERTIFY THAT I HAVE INSPECTED
THE CONSTRUCTION OF THE SAID DISPOSAL
SYSTEM LOCATED AT LOT I, BARKER R0
NORTH ANDOVER, MA. THE GRADES AREAS
SPECIFIED IN THE PLANS AND SPECIFICATIONS
DATED 10 BY. MAR IONDA Assaf'
In
MICHAEL J. `"RflSATI DAT
AS BUILT SEWAGE DISPOSAL
SYSTEM PLAN
IN NORTH ANDOVIR, Mit-11.
AS PREPARED FOR JOHN LUIJDou iST-
SCA.LE 1"=50' DATE OCT 1989
AIARCTIIONDA & ASSOC., INC,
ENGINEERING AND PLANNING CONSULTANTS
80 LWLF, STREET R F. D. 18
STONEHAV, MASS. 0?_180 WANCHMTER 1r11 03103
(817) 438-8121 (803) 434-8725
LOT 1
(o2j383 Sc� F+.
I oil '
EX IST.
WF -(-L
EXISTING
GEMC TAWK
N/F TERRx..K
293,33'
EXISTING
FOUND.
TOP EL -10 W
'3\ I
Nig
GAP, I/\ER
ELEVATION
TO TOP OF PIPE
DWELLING:
--
TANK IN:
96.15
TANK 0 UT:
95.76
D- BOX IN:
94-18
D -BOX OUT: A 93.98
B 93.98
C 93.98
D .93.98
END OF DISTRIBUTION
LLL: A
9 3.48
B
93.48
C
93.48
D
93.48
34.24'
THIS IS TO CERTIFY THAT I HAVE INSPECTED
THE CONSTRUCTION OF THE SAID DISPOSAL
SYSTEM LOCATED AT IAT I, BARKER RD.,
NORTH ANDOVER, MA. THE GRADES ARE AS
SPECIFIED IN THE PLANS AND SPECIFICATIONS
DATED BY MAR IntIDA ASSOC!
.... I
MICHAEL J. "ROSATI DAT
AS BUIL;r SEWAGE DISPOSAL
SYSTEM PLAN
IN NORTH ANDOVER, tyro.
AS PREPARED FOR JOHN LUMDOU IST
SCALE 1"=50' DATE DCT 1989
MARCHIONDA & ASSOC., INC.
ENGINEERING AND PLANIII14G CONSULTANTS
80 i(APLE STREET R F.D. 18
STONEHAII, 11AS3. 0?180 IJANCHMTER Nit 03103
(817) 438-8121 (803) 43.1-8725