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;77
Date Received
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-ZONING DISTRICT
100 Year Structure
Historic District
Machine Shop Village
yes 1:,�6
yes �b
yes
TYPE OF IMPROVEMENT
FJROPOSED USE
Residential
Non- Residential
0 New Building
0 One family
11 Addition
El Two or more family
0 Industrial
D Alteration
No. of units:
11 Commercial
0 Repair, replacement
0 Assessory Bldg
"*M Others:
El Demolition
0 Other
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0 Septic 1, 0 Well
0 Ploodplain El Wetlands
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OWNER: Name: -
Address:
Contraclor ame:
Email:
Address:
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Supervisor's Construction License: Exp. Date:
Home Improvement License- NVO \ n�'Z Exp. Date: �k)l )U I
ARCH ITECT/ENGI NEER Phone:
Address: Reg. No.
FEE SCHEDULE: BULDING PERMIT. $12.00 PER $1000.00 OF THE TOTAL ESTIMATED COST BASED ON $125.00 PER S.F.
Total Project Cost: $ FEE: $ 4RO
Check No.: Receipt No.:
NOTE: Persons. contrq7t'btg witk i(nregiytvred contractors do not have aCZeX to t1rf gyara)q&�*nd
Certified Plot PlaN Stamped Plans
Plans Submitted Plans Waived 11
[T TYPE OF SEWERAGE DISPOSAL
c Sewe
Public Sewer Tanning/Massage/Body Art F1 Swfium'ng Pool'
wen El Tobacco Sales 11 Food Packaging/gales El
Private (septic tank, etc. Pennanent Dumpster on Site El
THE FOLLOWING SECTIONS FOR OFFICE USE ONLY
INTERDEPARTMENTAL SIGN OFF - U FORM
PLANNING & DEVELOPMEN . T Reviewed On �J22,1001� Signatur
xCOMMENTS
-
CONSERVATION
COMMENTS
HEALTH
CGMMENTS_,
Reviewed on 6
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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
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Town of North Andover
4Y*1 HEALTH DEPARTMENT
CHU
CHECK#: DATE:
LOCATION: �7� —0, ; vzz-/�,
H/0 NAME:
CONTRACTOR UME:
TYRe of P rmit or License:r(Check box)
0 Animal $
0 Body Art Establishment $
0 Body Art Practitioner $
0 Dumpster $
0 Food Service - Type.-- $
0 Funeral Directors $
0 Massage Establishment $
0 Massage Practice $
0 Offal (Septic) Hauler $
0 Recreational Camp $
0 Sun tanning $
0 Swimming Pool $
0 Tobacco $
0 TrasWSolid Waste Hauler $-
0 Well Construction $
SEP77C Sustems:
0 Septic — Soil Testing $
0 Septic — Design Approval $-
0 Septic Disposal Works Construction (DWC) $
0 Septic Disposal Works Installers (DWl)
L�itle -
Ti _ �5spector $
i itle 5
tle 5 Report
0 Other (Indicate) $ -;T77
Health Agent Initials
White - Applicant Yellow - Health Pink - Treasurer
XFMTY Connect Page I ot I
XFINITY Connect jhcurrier@comcasLne
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t5insp.doc-2010.doc - re: 272 BRIDGES LANE,, NORTH ANDOVEk MA 01845
From : Pamela DelleChiaie <pdelledi@townofnorthandover.oDm> Ri, Sep 09, 201102:42 PM
Subject: tSinsp.doc-2010.doc - re: 272 BRIDGES LANE, NORTH ANDOVER, MA 01845 1 attachment
To :jhcurrier@comcast.net <jhcur7ier@comcast.net>
Cc: Susan Sawyer <ssawyer@townofnorthandover.com>
To: James H. Currier
J's Septic & Drain
1341 Forest Street
Middleton, MA 01949
978-774-6685
Hi Jay,
The Title 5 Form that you submitted to me is out of date. I need you to resubmit the Title 5 report for 272 Bridges Lane, North Andover on the
attached form that was revised in Nov. 2010. Once I receive this, it will be passed in for review. I will hold your check until I receive the
revised one. You may scan and email the revised copy to me to process more quickly, but I do need the original sent via regular mail as well. If
you have any questions, please call me. Thank you.
Pamela DelleChiaie
Departmental Assistant I Community Development I Health Department
Town of North Andover
i600, Osgood Street I Bldg 2o I Suite 2-36
North Andover, MA oi845
91 Office - 978-688-9540
I Fax - 97"88-8476
EmDl Email -p ellechiaie_@M%kn_oMQMkr
1!;[Qv—er.com
-t Website http� www.townofnodt[-qRdQvqw-mJf-age-sJi—n(;[ez(
"flVe cpa see thepede of our fife ijIve are too bvsyfor_�,mM on t4epebbks under ourfeeL "--A -%myIngies
Please note 'the Massachusetts Secretary of State's office has determined that most emails to and from municipal offices and officials are public records. For
more information please refer to: http:il/kvwii.,-zec.state.ma.us/pre/preidx.htm.
Please consider the environment before printing this email.
---- -------
t5linsp.doc-2010.doc
318 KB
Z/-//
SEP 1 a Z011
r
TOWN OF NORTH ANDOVER
L..HEALTH -DEPARTMENT
.51469&xim7-1 9/11/2011
Owner
information i's
required for
every page.
A
.1 - . k
Commonwealth of Massachusetts
SEPTIC & DRAIN
Title 5 Official Inspection Form "s 131 Forest Street
MIDDLETON, MA 01949
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments (978) 774-6686-
272 BRIDGES LANE, NO. ANDOVER, MA 01845
Property Address
LINDA HIBBS
Owner's Name
NO.ANDOVER
C4/Town
MA 01945 8/31/11 Cj
State Zip Code Date of Inspection
Inspection results must be submitted on this form. Inspection forms may not be altered in any
way. Please see completeness checklist at the end of the form.
Important:
A. General Information
When filling out
forms on the
computer, use
1 Inspector:
only the tab key
to move your
JAMES H. CURRIER 11
cursor - do not
use the return
Name of Inspector
key.
Ts SEPTIC & DRAIN
Company Name
131 FOREST ST.
Company Address
MIDDLETON
City/Town
.978-774-6685
Telephone Number
B. Certification
t5ins - 11/10
9 toil
ri AN
jvvr,4 OF tivim w
HEALTH D�E%�PAIZ��W
MA
State
License Number
01949
Zip Code
I certify that I have personally inspected the sewage disposal system at this address and that the
information reported below is true, accurate and complete as of the time of the inspection. The inspection
was performed based on my training and experience in the proper function and maintenance of on site
sewage disposal systems. I am a DEP approved system inspector pursuant to Section 16.340 of
Title 5 (310 CMR 15.000). The system:
2 Passes El Conditionally Passes F� Fails
El Needs Further Evaluation by the Local Approving Authority
8/31/11
ctor
tn.. ) 's Sign urte: Date
T T i.,
hh.e system inspector shall submit a copy of this inspection report to the Approving Authority (Board
of Health or DEP) within 30 days of Completing this inspection. If the system is a shared system or
has a design flow of 10,000 gpd or greater, the inspector and the system owner shall submit the
report to the appropriate regional office of the DEP. The original should be sent to the system owner
and copies sent to the buyer, if applicable, and the approving authority.
****This report only describes conditions at the time of inspection and under the conditions of use
at that time. This inspection does not address how the system will perform in the future under
the same or different conditions of use.
Title 5 Official inspection Form: Subsurface Sewage Disposal System - Page 1 of I
(C\
'Commonwealth of Massachusetts
J's SEPTIC & DRAIN
Title 5 Official Inspection
Form
131 Forest Street
MIDDLETON A 01949
Subsurface Sewage Disposal System Form - Not for Voluntary
(978) 7�4�
Assessments 6685
272 BRIDGES LANE, NO. ANDOVER, MA 01845
Property Address
LINDA HIBBS
Owner
Owner's Name
information is
required for
NO.ANDOVER MA
01945
8/31/11
every page.
Cityrrown State
Zip Code
Date of Inspection
B. Certification (cont.)
Inspection Summary: Check A,B,C,D or E / always complete all of Section D
A) System Passes:
I have not found any information which indicates that any of the failure criteria described
in 310 CMR 15.303 or in 310 CMR 15.304 exist. Any failure criteria not evaluated are
indicated below.
Comments:
SYSTEM WORKING PROPERLY.
B) System Conditionally Passes:
El one or ore systemGomponents as described in the "Conditional Pass" section need to be
replaced %depaired. The system, upon completion of th placement or repair, as approved by
the Board of ealth, will pass.
Check the box for "ye�, "no" or "not determined" (Y, N, for the following statements. If "not
m'
determined," please ex in.
The septic tank is metal an ver 20 years old* the septic tank (whether metal or not) is
11 0 xfill
structurally unsound, exh%it s stant I al /ration or tank failure is imminent. System
I s i infilt ion or exfilt
will pass inspection if the \existing nk is re aced with a complying septic tank as approved by the
Board of Health.
* A metal septic tank will pass inspey6on if`&�is structurally sound, not leaking and if a Certificate of
Compliance indicating that the tar)K is less thallo years old is available.
El Y F1 N 0 ND (Explain below)':
t5ins. 11/10 Title 5 Official Inspection Form: Subsurface Sewage Disposal System - Page 2 of 2
Owner
information is
required for
every page.
'Commonwealth of Massachusetts J's SEPTIC & DRAIN
131 Forest Street
Title 5 Official Inspection Form MIDDLETON
(978) 7� MA 01949
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 4-6685
272 BRIDGES L
Property Address
LINDA HIBBS
Owner's Name
NO.ANDOVER
NO. ANDOVER, MA 01845
Cityrrown
B. Certification (cont.)
B) System Conditionally Passes (cont.):
MA 01945 8/31/11
State Zip Code Date of Inspection
F� Obkrvation of sewage backup or break out or high static water level in the distribution box due
to broNn or obstructed pipe(s) or due to a broken, settled or uneven distribution box. System will
pass ins*Gtion if (with approval of Board of Health):
El brok pipe(s) are replaced El Y El N71ND (Explain below):
obstructi is removed El Y ED] N El ND (Explain below):
distri\ibution b is leveled or replaced El Y N n ND (Explain below):
El The system required pumping more tt* 4 times a year due to broken or obstructed pipe(s). The
system will pass inspection if (with f the Board of Health):
El broken pipe(s) are replac�",� F1 Y 0 N El ND (Explain below):
F� obstruction is rem
Y El N El ND (Explain below):
C) Further Eval ion is Required by the Board of Health:
urt er Eval at
d to
Conditions xist which require further evaluation by the Board of Health \'order to determine if
the syste is failing to protect public health, safety or the environment.
1. Sy em will pass unless Board of Health determines in accordance 310 CMR
w
15.3 (1)(b) tha I t the system is not functioning in a manner which will prot tpublichealth,
sai /and txhfe environment:
Cesspool or privy is within 50 feet of a surface water
El Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt ma
t5ins - 11/10 Title 5 Official inspeddon FDrm: Subsurface Sewage Dispusal System - Page 3
`�,k
2. System v I fail unless the Board of Health (and Public Water Supplier, if any)
determines thah�he system is functioning in a manner that protects the public health,
safety and envirolqnent: I/
El The system h a septic tank and soil absorption system (
100 feet of a su ce water supply or tributary to a surface
The system has a ic tank and SAS and the SAS is wit
supply.
El The system has a septi tank and SAS and the
supply well.
El The system has a septic tank and \SS and the S
1 714"
more from a private water supply wel
(at r s
Method used to determine distance:
" This system passes if the well water anWsis, per
coliform bacteria indicates absent and tV presence
to or less than 5 ppm, provided th her failure
be attached to this form. a�r
3. Other:
D) System Failure Criteria Applicable to All Systems:
AS>4nd the SAS is within
-,s
w r upply.
n a Zone 1 of a public water
within 50 feet of a private water
less than 100 feet but 50 feet or
at a DEP certified laboratory, for fecal
ionia nitrogen and nitrate nitrogen is equal
are triggered. A copy of the analysis must
You must indicate "Yes" or "No" to each of the following for all inspections:
Yes No
El ED Backup of sewage into facility or system component due to overloaded or
clogged SAS or cesspool
El 0 Discharge or ponding of effluent to the surface of the ground or surface waters
due to an overloaded or clogged SAS or cesspool
El N Static liquid level in the distribution box above outlet invert due to an overloaded
or clogged SAS or cesspool
El o 0 Liquid depth in cesspool is less than 6" below invert or available volume is less
than 1/2day flow
t5ins - 11110 Title 5 Official Inspection Form: Subsurface Sewage Disposal System - Page 4 of 4
J's SEPTIC & DRAIN
'Commonwealth of Massachusetts
13 1 Forest Street
Title 5 Official Inspection
Form
MIDDLETON, MA 01949
(978) 774-6685
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
272 BRIDGES LANE, NO. ANDOVER, MA 01845
Property Address
LINDA HIBBS
Owner
Owner's Name
information is
required for
NO.ANDOVER MA
01945
8/31/11
every page.
cityrrown state
Zip Code
Date of Inspection
B. Certification (cont.)
`�,k
2. System v I fail unless the Board of Health (and Public Water Supplier, if any)
determines thah�he system is functioning in a manner that protects the public health,
safety and envirolqnent: I/
El The system h a septic tank and soil absorption system (
100 feet of a su ce water supply or tributary to a surface
The system has a ic tank and SAS and the SAS is wit
supply.
El The system has a septi tank and SAS and the
supply well.
El The system has a septic tank and \SS and the S
1 714"
more from a private water supply wel
(at r s
Method used to determine distance:
" This system passes if the well water anWsis, per
coliform bacteria indicates absent and tV presence
to or less than 5 ppm, provided th her failure
be attached to this form. a�r
3. Other:
D) System Failure Criteria Applicable to All Systems:
AS>4nd the SAS is within
-,s
w r upply.
n a Zone 1 of a public water
within 50 feet of a private water
less than 100 feet but 50 feet or
at a DEP certified laboratory, for fecal
ionia nitrogen and nitrate nitrogen is equal
are triggered. A copy of the analysis must
You must indicate "Yes" or "No" to each of the following for all inspections:
Yes No
El ED Backup of sewage into facility or system component due to overloaded or
clogged SAS or cesspool
El 0 Discharge or ponding of effluent to the surface of the ground or surface waters
due to an overloaded or clogged SAS or cesspool
El N Static liquid level in the distribution box above outlet invert due to an overloaded
or clogged SAS or cesspool
El o 0 Liquid depth in cesspool is less than 6" below invert or available volume is less
than 1/2day flow
t5ins - 11110 Title 5 Official Inspection Form: Subsurface Sewage Disposal System - Page 4 of 4
)CHNITY Connect
Page I of I
xFINITY Connect jhcurrier@comcasLne
+ Font Size -
.......... . ...
t5insp.doc-2010.doc - re: 272 BRIDGES LANE,, NORTH ANDOVER, MA 01845
From: Pamela DelleChiaie <pdellech@townofnorthandover.com>
Subject: t5irksp.doc-2010.doc - re: 272 BRIDGES LANE, NORTH ANDOVER, MA 01845
To :jhcurrier@comcastnet <jhc:urTier@comcast.net>
Cc: Susan Sawyer <ssawyer@tDwnofnorthandover.com>
To; James H. Currier
J's Septic & Drain
1341 Forest Street
Middleton, MA 01949
978-774-6685
Fri, Sep 09, 201102:42 PM
,L, 1 attachment
Hi Jay,
The Title 5 Form that you submitted to me is out of date. I need you to resubmit the Title 5 report for 272 Bridges Lane, North Andover on the
attached form that was revised in Nov. 2010. Once I receive this, it will be passed in for review. I will hold your check until I receive the
revised one. You may scan and email the revised copy to me to process more quickly, but I do need the original sent via regular mail as well. If
you have any questions, please call me. Thank you,
Pamela DelleChiaie
Departmental Assistant I Community Development I Health Department
Tokvn of North Andover
i600 Osgood Street I Bldg 2o I Suite 2-36
North Andover, MA oi845
T-, Office - 978-688-954o
I Fax - 97"88-8476
EZ -11 Email - pae AlecN aletomnohiort-hanclover.com
-t Website ft: www.townofhorft49Qver.mm
]Page5l n
h -ft
TVe cepp never seeshe pauk oftur fife ifte are too 11,W15Yfoalsing On ffie pehbks under ourfica, -..Inymons
---- ------ -
Please note the Massachusetts Secretary of State's office has determined that most emaills to and from municipal offices and officials are public records. For
more information please refer to: http:,I/xvww.sec,,--ta�te.ma.us/pre/preidx.htm.
Please consider the environment before printing this email.
t5insp.doc-2010.doc
Ef 318 KB
------- -- -
-11
'r
SEP 10 Z011
TOWN OF NORTH ANDOVER
p7.
al P*OOV
51469&xim7-1
9/11/2011
Commonwealth of Massachusetts I's SEPTIC & DRAIN
Title 5 Official Inspection Form 13 1 Forest Street
MIDDLETON, MA 01949
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments (978) 774-66PJ5
272 BRIDGES LANE, NO. ANDOVER, MA 01845
Property Address
LINDA HIBBS
Owner Owner's Name
information i's NO.ANDOVER MA 01945 8/31/11
required for
every page. Cirtyfrown state Zip Code Date of Inspection
Inspection results must be submitted on this form. Inspection forms may not be altered in any
way. Please see completeness checklist at the end of the form.
important:
When filling out
forms on the
computer, use
only the tab key
to move your
cursor - do not
use the return
key.
M
A. General Information
1. Inspector:
JAMES H. CURRIER 11
Name of Inspector
J's SEPTIC & DRAIN
Company Name
131 FOREST ST.
Company Address
MIDDLETON
City/Town
978-774-6685
MA
State
sp. 19 W1
HEALTH DEPARTMENT
Telephone Number License Number
B. Certification
01949
Zip Code
I certify that I have per-sonally inspected the sewage disposal system at this address and that the
information reported below is true, accurate and complete as of the time of the inspection. The inspection
was performed based on my training and experience in the proper function and maintenance of on site
sewage disposal systems. I am a DEP approved system inspector pursuant to Section 15.340 of
Title 5 (310 CMR 15.000). The system:
0 Passes [] Conditionally Passes E] Fails
F� Needs Further Evaluation by the Local Approving Authority
8/31/11
/;otor's Sign Ore Date
Thh',e system inspector shall submit a copy of this inspection report to the Approving Authority (Board
of Health or DEP) within 30 days of completing this inspection. If the system is a shared system or
has a design flow of 10,000 gpd or greater, the inspector and the system owner shall submit the
report to the appropriate regional office of the DEP. The original should be sent to the system owner
and copies sent to the buyer, if applicable, and the approving authority.
****This report only describes conditions at the time of inspection and under the conditions of use
at that time. This inspection does not address how the system will perform in the future under
the same or different conditions of use.
t5ins- 11/10 Title 5 Official Inspection Form: Subsurface Sewage Disposal System - Page I of I
Q
Owner
information is
required for
every page.
'Commonwealth of Massachusetts J's SEPTIC & DRAIN
131 Forest Street
Title 5 Official Inspection Form MIDDLETON, MA 01949
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments (978) 774-6685
272 BRIDGES LANE, NO. ANDOVER, MA 01845
Property Address
LINDA HIBBS
Owner's Name
NO.ANDOVER
c4from
B. Certification (cont.)
MA n I QA -r%
8/31/11
State Zip Code Date of Inspection
Inspection Summary: Check A,B,C,D or E / always complete all of Section D
A) System Passes:
1 have not found any information which indicates that any of the failure criteria described
in 310 CMR 15.303 or in 310 CMR 15.304 exist. Any failure criteria not evaluated are
indicated below.
Comments:
SYSTEM WORKING PROPERLY.
B) System Conditionally Passes:
El one or ore system components as described in the "Conditional Pass" section need to be
replaced %depaired. The system, upon completion of th placement or repair, as approved by
the Board of ealth, will pass.
Check the box for "yd`�, "no" or "not determined" (Y, for the following statements. If "not
determined," please exNin.
The septic tank is metal an.�
erS2 ars old*?1"tle septic tank (whether metal or not) is
0 ye'
S ;t 1111
inf
ri
ilt I
structurally unsound, exhib antia or exfillration or tank failure is imminent, System
"I�
will pass inspection if the existing nk is ed with a complying septic tank as approved by the
Board of Health.
* A metal septic tank will pass inspeydon Wit �rs structurally sound, not leaking and if a Certificate of
Compliance indicating that the tar)K is less thaNO years old is available.
F-1 Y El N [Z ND (Explain below)':
t5ins - 11/10 Title 5 Official Inspection Form: Subsurface Sewage Disposal System - Page 2 of 2
Owner
information is
required for
every page.
'Commonwealth of Massachusetts Js SEPTIC & DRAIN
131 Forest Street
Title 5 Official Inspection Form MIDDLETON, MA 01949
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments (978) 774-6685
272 BRIDGES LANE, NO. ANDOVER, MA 01845
Property Address
LINDA HIBBS
Owner's Name
NO.ANDOVER MA 01945 8/31/11
Cityrrown State Zip Code Date of Inspection
B. Certification (cont.)
B) System Conditionally Passes (cont.):
El Obkrvation of sewage backup or break out or high static water level in the distribution box due
to broks'n or obstructed pipe(s) or due to a broken, settled or uneven distribution box. System will
pass in nction if (with approval of Board of Health):
brok pipe(s) are replaced El Y F
E-1 N ND (Explain below):
obstructi is removed 0 Y E]XN 0 ND (Explain below):
I
El distri\ibution b is leveled or replaced [:] Y N 7EEJ IND (Explain below):
The system required pumping more t 4 times a year due to broken or obstructed pipe(s). The
system will pass inspection if (with a p al of the Board of Health):
0 broken pipe(s) are replac5l El Y El N El ND (Explain below):
El obstruction is
El Y El N El ND (Explain below):
C) Further Eval tion is Required by the Board of Health:
't er Eva' a
Conditions xist which require further evaluation by the Board of Health * order to determine if
thesyste is failing to protect public health, safety or the environme\nt.
1. Sy ern will pass unless Board of Health determines in accordance 'th310CMR
III p
15.3 /(1)(b) that the system is not functioning in a manner which will prot tpublichealth,
saf and the environment:
Cesspool or privy is within 50 feet of a surface water
Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt
t5ins - 11/10 Title 5 Officiai InSpeCtlDn Form: Subsurface Sewage Disposal System - Page 3
Owner
information is
required for
every page.
'Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
272 BRIDGES LANE, NO. ANDOVER, MA 01845
Property Address
LINDA HIBBS
J's SEPTIC & DRAIN
131 Forest Street
MIDDLETON, MA 01949
(978) 774-6685
Owner's Name
NO.ANDOVER MA 01945 8/31/11
cftyfrovm State Zip Code Date of Inspection
B. Certification (cont.)
2. System M�l fail unless the Board of Health (and Public Water Supplier, if any)
determines thA�he system is functioning in a manner that protects the public health,
safety and envirdNiment: 11�
El The system h, a septi tank and soil absorption system
N e w act
100 feet of a i um c er supply or tributary to a surface
The system ha 1c tank and SAS and the SAS is wit
supply.
El The system has a septi tank and SAS and the
supply well.
El The system has a septic tank and \SS and the S
more from a private water supply wel
Method used to determine distance:
This system passes if the well water anWsis, Pei
coliform bacteria indicates absent and tW , presence
to or less than 5 ppm, provided that n ther failure
be attached to this form. �r
3. Other:
D) System Failure Criteria Applicable to All Systems:
A"nd the SAS is within
oler supply.
n a Zone 1 of a public water
within 50 feet of a private water
less than 100 feet but 50 feet or
at a DEP certified laboratory, for fecal
tonia nitrogen and nitrate nitrogen is equal
are triggered. A copy of the analysis must
You must indicate "Yes" or "No" to each of the following for all inspections:
Yes No
El 0 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 overioaded or clogged SAS or cesspool
El z Static liquid level in the distribution box above outlet invert due to an overloaded
or clogged SAS or cesspool
El o 0 Liquid depth in cesspool is less than 6" below invert or available volume is less
than '/2dav flow
t5ins- 11/10 Title 5 Official Inspection Farm: Subsurface Sewage Disposal System - Page 4 of 4
Owner
information is
required for
every page.
'Commonwealth of Massachusetts J's SEPTIC & DRAIN
13 1 Forest Street
MIDDLETON, MA 01949
Title 5 Official Inspection Form (978) 774-6685
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
272 BRIDGES LANE, NO. ANDOVER, MA 01845
Property Address
LINDA HIBBS
Owners Name
NO.ANDOVER
cityfrown
MA 01945 8/31/11
State Zip code Date of Inspection
B. Certification (cont.)
Yes No
El
El 0
Required pumping more than 4 times in the last year NOT due to clogged or
El
obstructed pipe(s). Number of times pumped:
F1
Any portion of the SAS, cesspool or privy is below high ground water elevation.
E] E]
Any portion of cesspool or privy is within 100 feet of a surface water supply or
tributary to a surface water supply.
El El
Any portion of a cesspool or privy is within a Zone I of a public well.
E] Aj�
Any portion of a cesspool or privy is within 50 feet of a private water supply
well.
El El #
Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet
from a private water supply well with no acceptable water quality analysis. [This
system passes if the well water analysis, performed at a DEP certified
laboratory, for fecal coliform bacteria indicates absent and the presence
of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm,
provided that no other failure criteria are triggered. A copy of the analysis
and chain of custody must be attached to this form.]
The system is a cesspool serving a facility with a design flow of 2000gpd-
1 0,000gpd.
El z The system fails. I have determined that one or more of the above failure
criteria exist as described in 310 CMR 15.303, therefore the system fails. The
system owner should contact the Board of Health to deterTnine what will be
necessary to correct the failure.
E) Large Systems: To be copidered a large system the s t must serve a facility with a
design flow of 10,000 gpd IR 16,000 gpd. Y7
For large systems, you must
questions in Section D.
Yes
No
El
El
the system is
n
El
the system is
E-]
El
the syste S
;PPP`A
Area —
either"yes" or"nXto each of the following, in addition to the
feet of a surface drinking water supply
n 20Neet of a tributary to a surface drinking water supply
located in a n)kogen sensitive area (interim Wellhead Protection
or a mapped ZhQe 11 of a public water supply well
If you have answered "ye IvIto any question in Secti 'n �!he System is considered a significant threat,
0 rt
or answered "yes" in SeAion D above the large system a failed. The owner or operator of any large
i ' a'
�Eorf k1
system considered a $fgnificant threat under Section ai under Section D shall upgrade the
r 0
lw b�
system in aGcorda* with 310 CMR 15.304. The system owner ould contact the appropriate
regional office of)fie Department.
t5ins - 11/10 1-1/ Tibe 5 Official inspection Form: Subsurface Sewage Disposal System - Page 5 of 5
<C\
'Commonwealth of Massachusetts
0 El
J's SEPTIC & DRAIN
131 Forest Street
El 0
Title 5 Official Inspection
Form
MIDDLETON, MA 01949
(978) 774-6685
El 0
Subsurface Sewage Disposal System Form - Not for Voluntary
Assessments
this inspection?
272 BRIDGES LANE, NO. ANDOVER, MA 01845
Were as built plans of the system obtained and examined? (if they were not
available note as N/A)
Property Address
Was the facility or dwelling inspected for signs of sewage back up?
M El
Was the site inspected for signs of break out?
LINDA HIBBS
Were all system components, excluding the SAS, located on site?
Owner
Owner's Name
inspected for the condition of the baffles or tees, material of construction,
inforrnation is
required for
NO.ANDOVER MA
01945
8/31/11
every page.
Cityrrown State
Zip Code
Date of Inspection
been determined based on:
C. Checklist
Existing information. For example, a plan at the Board of Health.
El Z
Check if the following have been done. You must indicate "yes" or "no" as to each of the following:
Yes No
0 El
Pumping information was provided by the owner, occupant, or Board of Health
El 0
Were any of the system components pumped out in the previous two weeks?
0 El
Has the system received normal flows in the previous two week period?
El 0
Have large volumes of water been introduced to the system recently or as part of
this inspection?
0 El
Were as built plans of the system obtained and examined? (if they were not
available note as N/A)
Z El
Was the facility or dwelling inspected for signs of sewage back up?
M El
Was the site inspected for signs of break out?
z n
Were all system components, excluding the SAS, located on site?
Were the septic tank manholes uncovered, opened, and the interior of the tank
inspected for the condition of the baffles or tees, material of construction,
dimensions, depth of liquid, depth of sludge and depth of scum?
• El
Was the facility owner (and occupants if different from owner) provided with
information on the proper maintenance of subsurface sewage disposal systems?
The size and location of the Soil Absorption System (SAS) on the site has
been determined based on:
• El
Existing information. For example, a plan at the Board of Health.
El Z
Determined in the field (if any of the failure criteria related to Part C is at issue
approximation of distance is unacceptable) [310 CMR 15.302(5)]
D. System Information
Residential Flow Conditions:
Number of bedrooms (design): 4 Number of bedrooms (actual):
Ira
DESIGN flow based on 310 CMR 15.203 (for example: 44-0 gpd x # of bedrooms):
A
son r.pn
t5ins - 11/10 Title 5 Official Inspection Form: Subsurface Sewage Disposal System - Page 6 of 6
Owner
inforrnation is
required for
every page.
'Commonwealth of Massachusetts J's SEPTIC & DRAIN
131 Forest Street
Title 5 Official Inspection Form MIDDLETON, MA 01949
(978) 774-6685
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
272 BRIDGES LANE, NO. ANDOVER, MA 01845
perty Address
LINDA HIBBS
Omer's Name
NO.ANDOVER MA 01945 8/31/11
City/Town State Zip Code Date of Inspection
D. System Information
Descdption:
150 GPD X 4 BEDROOMS
Number of current residents:
Does residence have a garbage grinder? 0 Yes CK No
Is laundry on a separate sewage system? [if yes separate inspection required] 0 Yes 0 No
Laundry system inspected? WIA El Yes No
Seasonaluse? F1 Yes No
Water meter readings, if available (last 2 years usage (gpd)): 230.55 GPD
Detail:
2 YR. USEAGE = 225 UNITS X 748 (GALLONS) DIVIDED BY 730.
Sump pump?
Last date of occupancy:
Flow Conditions:
Type of Establishmen
Design flow (based on 310
Basis of design flow (seats/p
Grease trap present?
Industrial waste holding tank
Non -sanitary waste dischargi
Water meter readings, - /ava
15.203):
.ft., etc.):
the Title 5 system?
Gallons per day (gpd)
Z Yes [:1 No
CURRENT
Date
EJ
Yes
El
No
F1
Yes
El
No
0
Yes
0
No
t5ins - 11/10 <_1 Tvtle 5 Official Inspection Form: Subs5rface Sewage Disposal System - Page 7 of 7
*Commonwealth of Massachusetts J's SEPTIC & DRAIN
13 1 Forest Street
11IDLETON, MA 01949
Title 5 Official Insi3ection Form (978) 774-6685
Subsurface Sewage Disposal System Forrn - Not for Voluntary Assessments
272 BRIDGES LANE, NO. ANDOVER, MA 01845
Property Address
LINDA HIBBS
Owner
information is
required for
every page.
Owner's Name
NO.ANDOVER MA 01945 8/31111
Cityrrown State Zip Code Date of Inspection
D. System Information (cont.)
Last date of oGcupancy/use:
Other (describe below):
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:
Date
OWNER - LPD 2010
gallons
Type of System:
0 Septic tank, distribution box, soil absorption system
El Single cesspool
El Overflow cesspool
1:1 Privy
El Yes Z No
El Shared system (yes or no) (if yes, attach previous inspection records, if any)
Innovative/Altemative technology. Attach a copy of the current operation and
maintenance contract (to be obtained from system owner) and a copy of latest
inspection of the I/A system by system operator under contract
El Tight tank. Attach a copy of the DEP approval.
F-1 Other (describe):
t5ins- 11110 Title 5 Official Inspection Form: Subsurface Sewage Disposal System - Page 8 of 8
J's SEPTIC & DRAIN
'Commonwealth of Massachusetts 131 Forest Street
MIDDLETON, MA 01949
Title 5 Official Inspection Form 1918) 774-66a5
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
272 BRIDGES LANE, NO. ANDOVER, MA 01845
Property Address
LINDA HIBBS
Owner Owners Name
information is
required for NO.ANDOVER MA 01945 8/31/11
every page. c4frown State Zip Code Date of inspection
D. System Information (cont.)
Approximate age of all components, date installed (if known) and source of information:
PLANS DATED 3/1/1985
Were sewage odors detected when arriving at the site?
Building Sewer (locate on site plan):
Depth below grade:
Material of construction:
0 Gast iron n 40 PVC other (explain):
Distance from private water supply well or suction line:
1911
feet
N/A - PUBLIC WATER
feet
Comments (on condition of joints, venting, evidence of leakage, etc.):
PLUMBING IN GOOD CONDITION.
Septic Tank (locate on site plan):
Depth below grade:
Material of construction:
0 concrete El metal
If tank is metal, list age:
El fiberglass
21'
feet
[I polyethylene El other (explain)
years
Is age confirmed by a Certificate of Compliance? (attach a Gopy of certificate) El Yes El No
Dimensions: 1500 GAL, - 10' 6" X 5' 8"
Sludge depth:
N
t5ins - 1 Ill 0 Title 5 Official Inspection Form: Subsurface Sewage Disposal System - Page 9 of 9
'Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
272 BRIDGES LANE, NO. ANDOVER, MA 01845
Property Address
LINDA HIBBS
Owner
information is
required for
every page.
t5ins - 11/10
Owner's Name
NO.ANDOVER
Cityfrown
J's SEPTIC & DRAIN
131 Forest Street
MIDDLETON, MA 01949
(978) 774-6685
MA 01945 8/31/11
state Zip Code Date of Inspection
D. System Information (cont.)
Septic Tank (Gont.)
Distance from top of sludge to bottom of outlet tee or baffle 2511
Scum thickness 311-411
Distance from top of scum to top of outlet tee or baffle 511- 6"
Distance from bottom Of SGUM to bottom of outlet tee or baff le 14"
How were dimensions determined? SLUDGE JUDGE
Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity,
liquid levels as related to outlet invert, evidence of leakage, etc.):
INLET & OUTLET TEES IN PLACE, LIQUID LEVEL CORRECT, TANK IN GOOD CONDITION,
OWNER SCHEDULED PUMPOUT.
Grease 1�
Depth below
Material of c
0 concrete
(locate on site plan):
Dimensions:
Scum thickness
Distance from top of
Distance from bottor
Date of last D� Zinc
metal 0 fiberqlAss El polyethylene F] other (explain). -
7_710 top of outlet e
of scum to bottom = or baffle
Date
Title 5 Official Inspection FormSubsurfacL Sewage Disposal System - Page 10 of 10
J's SEPTIC & DRAIN
'Commonwealth of Massachusetts 131 Forest Street
MIDDLETON, MA 01949
(978) 774-6695
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
272 BRIDGES LANE, NO. ANDOVER, MA 01845
Property Address
LINDA HIBBS
Owner
information is
required for
every page.
Owner's Name
NO.ANDOVER
MA 01945
Cityrrown State Zip Code Date of Inspection
D. System Information (cont.)
Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity,
'4uid levels as related to outlet invert, evidence of leakage, etc.):
8/31/11
Tight or Holding Ta (tank must be pumped at time of inspection) (locate on Xe plan):
Depth below grade:
Material of construction:
El concrete 0 metal
Dimensions:
Capacity:
Design Flow:
Alarm present:
Alarm level:
Date of last pumping:
Comments (condition of
El fiber -glass tZpolyethylene [I other (explain):
gall s per day
s
E %Ye El No
Alarm in
Date
and float switches, etG.):
order: F1 Yes 0 No
* Att4eh copy of current pumping contract (required). Is copy att ached? El Yes [I No
t5ins - 11/10 Title 5 Official Inspection Form: Subsurface Sewage Disposal System - Page 11 of 11
'Commonwealth of Massachusetts
J Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
272 BRIDGES LANE, NO. ANDOVER, MA 01845
Property Address
LINDA HIBBS
Owner
information is
required for
every page.
J's. SEPTIC & DRAIN
13 1 Forest street
MIDDLETON, MA 01949
(978) 774-6685
Owner's Name
NO.ANDOVER MA 01945 8/31/11
cityrrown State Zip Code Date of Inspection
D. System Information (cont.)
Distribution Box (if present must be opened) (locate on site plan):
Depth of liquid level above outlet invert
N
Comments (note if box is level and distribution to outlets equal, any evidence of solids carryover, any
evidence of leakage into or out of box, etc.):
D -BOX 1'7" (ONE FOOD, SEVEN INCHES) BELOW GRADE, BOX IN GOOD CONDITION, NO
EVIDENCE OF CARRYOVER, LIQUID LEVEL CORRECT.
Pump Chamber (locate on site plan):
Pumps in working order:
Z
Yes
El
No
Alarms in working order:
0
Yes
n
No
Comments (note condition of pump chamber, condition of pumps and appurtenances, etc.):
PUMP PLUMBING IN GOOD CONDITION, PUMP & ALARM IN GOOD WORKING ORDER.
Soil Absorption System (SAS) (locate on site plan, excavation not required):
If SAS not located, explain why:
t5ins - 11110 Title 5 Official Inspection Form: Subsurface Sewage Disposal System - Page 12 of 12
'Commonwealth of Massachusetts
J's SEPTIC & DRAIN
131 Forest Street
Title 5 Official Inspection Form MIDDLETON, MA 01949
(978) 774-6685
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
272 BRIDGES LANE, NO. ANDOVER, MA 01845
Property Address
LINDA HIBBS
Owner
information is
required for
every page.
t5ins - 11/10
Omer's Name
NO.ANDOVER
Cityrrown
D. System Information (cont.)
State Zip Code
8/31/11
Date of Inspection
Type:
0
leaching pits
number:
leaching chambers
number:
leaching galleries
number:
leaching trenches
number, length:
leaching fields
number, dimensions:
El
overflow cesspool
number:
n
innovative/alternative system
ONE - 20'X 60'
Type/name of technology:
Comments (note condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of
vegetation, etc.):
SOILS GOOD, NO SIGNS OF HYDRAULIC FAILURE, VEGETATION NORMAL.
Cesspools (
Number and
must be pumped as part of inspection) (locate on site plan):
Depth — top of liquid to Is
Depth of solids layer
Depth of scum layer
Dimensions of cesspool
Materials of construction
Indication of
invert
inflow El Yes [_1 No
Tide 5 Official Inspection Form: Subsurface Sewage Disposal System - Page 13 of 13
Owner
information is
required for
every page.
'Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
272 BRIDGES LANE, NO. ANDOVER, MA 01845
Property Address
LINDA HIBBS
Owner's Name
NO.ANDOVER
MA 01945 8/31/11
Cityrrown State Zip Code Date of Inspection
J's SEPTIC & DRAIN
131 Forest Street
MIDDLETON, MA 01949
(978) 774-6685
D. System Information (cont.)
C ents (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation,
et�o.m
Privy (locate on site pla
Materials of construction:
Dimensions
Depth of solids N
Comments (note condition /ooil, signs
etc.):
failure, level of ponding, condition of vegetation,
t5ins- 11/10 Title 5 Official Inspection Form: Subsurface Sewage Disposal System - Page 14 of 14
J'S'73P
I'Z QJ�N
r e
DLE
Commonwealth of Massachusetts
Ml
(9�a�
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
272 BRIDGES LANE, NO. ANDOVER, MA 01845
Property Address
LINDA HIBBS
Owner Owner's Name
information is
required for NO.ANDOVER MA 01945 8/31/11
every page. City/ rown State Zip Code Date of inspection
D. System Information (cont.)
Sketch Of Sewage Disposal System: Provide a view of the sewage disposal system, including ties to
at least two permanent reference landmarks or benchmarks. Locate all wells within 100 feet. Locate
where public water supply enters the building. Check one of the boxes below:
El hand -sketch in the area below
N drawing attached separately
t5ins - 11110 Trde 5 Official Inspection Form: Subsurface Sewage Disposal System - Page 15 of 15
J'S SEPTIC & DRAIN
131 Forest Street
MIDDLETON, MA 01949
(978) 774-6685
vj �j
411
Ir
-U
all
lrj
'iN 1-4
rV.1
�-v
'Commonwealth of Massachusetts J'S SEPTIC & DRAIN
13 1 F6rest street
MIDDLETON, MA 01949
Title 5 Official Inspection Form (978) 774-6685
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
272 BRIDGES LANE, NO. ANDOVER, MA 01845
Property Address
LINDA HIBBS
Owner Owner's Name
information is
required for NO.ANDOVER MA 01945 8/31/11
every page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
Site Exam:
F�
Check Slope
D
Surface water
F�
Check cellar
0
Shallow wells
Estimated depth to high ground water:
71611
feet
Please indicate all methods used to determine the high ground water elevation:
0
01
Obtained from system design plans on record
If checked, date of design plan reviewed:
PLAN DATED 3/1/1985
Date
Observed site (abutting property/observation hole within 150 feet of SAS)
Checked with local Board of Health - explain:
El Checked with local excavators, installers - (attach documentation)
11 Accessed USGS database - explain:
You must describe how you established the high ground water elevation:
TEST PIT DATA ON FILE WITH BoH. TEST PITS PERFORMED 5/9/1984.
Before filing this Inspection Report, please see Report Completeness Checklist on next page.
t5ins- 11110 Title 5 Official Inspection Form: Subsurface Sewage Disposal System - Page 16 of 16
<t
Commonwealth of Massachusetts J's SEPTIC & DRAIN
13 1 Forest Street
'Amn Title 5 Official Inspection Form MIDDLETON, MA 01949
(978) 774-6685
V, VV u's V, sposa ysten, unn - Not or Volunta mssessmenLS
272 BRIDGES LANE, NO. ANDOVER, MA 01845
Property Address
LINDA HIBBS
Owner Owners Name
information is
required for NO.ANDOVER MA 01945 8/31/11
every page. Cityfrown State Zip Code Date of Inspection
E. Report Completeness Checklist
Inspection Summary: A, B, C, D, or E checked
inspection Summary D (System Failure Criteria Applicable to All Systems) completed
System information — Estimated depth to high groundwater
Sketch of Sewage Disposal System either drawn on page 15 or attached in separate file
tsins. 11/10 Title 5 Official Inspeabon FOTM: Subsurface Sewage Disposal Systern - Page 17 of 17
Sawyer, Susan
From:
Sawyer, Susan
Sent:
Friday, August 12, 20113:15 PIVI
To:
'sfinn021 @hotmail.com'
Cc:
DelleChiaie, Pamela
Subject:
proposed addition
Hello Shaun,
I pulled your file, reviewed your request and find that you fall into this category noted below in blue. Though almost
illegible, I find on your initial plan that the system was built for four bedrooms at 150 gallons per day, which is greater
than the 110 gallons currently used for calculations. Hence, you have a system that was designed for 600 gallons per
day.
Simply you have a system big enough for a 5 bedroom or maximum 11 room house (550/gpd). This does not include
bathrooms, foyers, halls etc. Your current proposal shows that you will be at the maximum of 11 rooms. This is allowed
by Title V and will not result in needing any septic system upgrade. (if the bonus storage room is desired in the future for
additional living space, this will result in triggering additional review. )
If you submit a building permit application, the Health Department will require a Title V inspection be done on the
system, and be submitted, showing that the system is in good working condition. A list of Title V licensed installers can
be found at this link.
http://www.townofnorthandover.com/Pages/NAndoverMA Health/permitsandregs
I hope this answers the majority of your questions.
Thank you for doing this research ahead of time and giving us the opportunity to assist you in your goals.
A copy of this correspondence will be placed in the file.
Susan
DEP interpretation:
"design flows ... An existing septic system is "grandfathered" into the design flow that it was built for as noted on the
DSCP, consistent with 310 CIVIR 15.204. If a system was built for a three-bedroom dwelling under a then -existing local
bylaw that required 200 gpd/bedroorn as identified on the DSCP and the local bylaw now adheres to T5 flows, the
existing system's capacity is 600 gpd. As long as facilities with aggregate design flow of 600 gpd or less are connected to
the system, the requirements for new construction have not been triggered."
Sa6aa Sawyet
Yub& Neafth Ohed"
16CC (96goad Stwd
JRUg 2C, unit 2-36
Nodh andooft, Ata 01845
e#ke 978 688-9540
fax 978 688-8476
All email messages and attached content sent from and to this email account are public
records unless qualified as an exemption under the
[ http://www.sec.state.ma.us/pre/`preidx.htm ]Massachusetts Public Records Law.
Town of North Andover
Health Department
1600 Osgood Street, bldg 20, Suite 2-36
North Andover MA 01845
Dear Susan Y. Sawyer, Health Director:
Please find attached preliminary schematic drawings for a potential addition at 272
Bridges Lane. The homeowners, Mr. and Mrs. Hibbs, are my in-laws (my wife's
parents). My wife and I are reviewing the possibility building an in-law master -suite
onto the house.
As you will see, the existing home has four (4) bedrooms. We intend on turning one
of the existing bedrooms into a series of closets, thus, we intend on maintaining four
(4) bedrooms. We also will maintain one (1) shared kitchen. We hope that this
meets with the existing plan so that no changes to the septic system is required,
however, we are contacting the Health Department to confirm.
Your time and assistance are greatly appreciated. Please contact me with any
questions, comments, or directions at either:
Cell: 617-777-1084
Email: sfinnUlftotmail.com
Respectfully,
Shaun Finn
272 Bridges Lane
North Andover MA 01845
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6mmunity Development and Services D ivision
27 Charles Street
North Andover, Massachusetts 01845
Susan Y. Sawyer, REHS/RS
Public Health Director
TOWN OF NORTH ANDOVER
BOARD OF HEALTH
CERTFICATE OF COMPLLA.NCE
DATE OF COMMANCE
August 25, 2003
This is to certify that
the in dividual, subsurface disposal system
constructed ( )
...... or
repaired'(X)
Im*.Replacement
by
William Sawyer
at
272 Bridges Lane
North Andover, MA 01845
has been installed in accordance with the provisions of Title V of the State Sanitary Code and with the
North Andover Board of Health regulations.
The Issuance of this certificate shall not be construed as a guarantee that the system will function.
sa
./fa oril
Brian J. LaGrasse
Health Inspector
BOARD OF APPEALS 688-9541 BUILDING 688-9545 CONSERVATION 688-9s3O i-rEALTH688-9540 PLANNING 688-9535
1
Town of North Andover 0* ORT
Office of the Health Department
Community Development and Services Division
27 Charles Street
North Andover, Massachusetts 01845
Susan Y. Sawyer, REHS/RS
Public Health Director
Telephone (978) �688-9540
Fax (978) 688-9542
TOWN OF NORTH ANDOVER
BOARD OF HEALTH
CERTIFICATE OF COMPLIANCE
DATE OF COMPLIANCE
August 25, 2003
I
This is to certify that
the individual subsurface disposal system
constructed ( ) repaired (X)
by
William Sawyer
at
272 Bridges Lane
North Andover, MA 01845
has been installed in accordance with the provisions of Title V of the State Sanitary Code and with the
North Andover Board of Health regulations.
The Issuance of this certificate shall not be construed as a guarantee that the system will function
satisfactorily.
Ar' n . LaGrasse
ealth Inspector
BOARD OF APPEALS 688-9541 BUILDING 688-9545 CONSERVATION 688-9530 HEALTH 688-9540 PLANNING 688-9535
Town of North Andover ORT
Office of the Health Department
Community Development and Services Division
27 Charles Street
'Art. oo�
North Andover, Massachusetts 01845 so%c S
Susan Y. Sawyer, REHS/RS
Public Health Director
Telephone (978) 688-9540
Fax (978) 688-9542
TOWN OF NORTH ANDOVER
BOARD OF HEALTH
CERTIFICATE OF COMPLIANCE
DATE OF COMPLIANCE
August 25, 2003
This is to certify that
the individual subsurface disposal system
constructed
or
repaired (X)
Tank Replacement OnI
by
William Sawyer
at
272 Bridges Lane
North Andover, MA 01845
has been installed in accordance with th,e provisions of Title V of the State Sanitary Code and with the
North Andover Board of Health regulations.
The Issuance of this certificate shall not be construed as a guarantee that the system will function
il
satisfai4 ri,
of
Brian J. LaGrasse
Health Inspector
BOARD OF APPEALS 688-9541 BUILDfNG688-9545 CONSERVATION 688-9530 BEALTH688-9540 PLANNING 688-9535
272 BRIDGES LANE
Proiect Detail
q"\4/) JS -2004-0062
Printed On: Fri Jul 18, 2003
Department Status
GeoTMS Module: Status File No. Comments: LCDate:
Board of Health GREEN FLAG BHJ-2003-0067 7/2/03 - Wed. - DWC Permit signed off for tank only. Faxed to William Sawyer at 603-772-
7552.--p.d.
7/l/03 - Tues. - Application and check recieved for DWC. Processed and put in for signoff. For
replacement of septic tank—p.d.
Permit History
Type: Permit No: Issue Date Status Work Category Project No: Description of Work:
Septic System BHP -2003-0152 Jul -02-2003 Open JS -2004-0062
GeoTMS@ 2003 Des Lauriers Municipal Solutions, Inc. Page I of 1
Excavators
Inc.
P.O. Box 405
EXETER, NH 03833-0405
MA FIELD OFFICE (978) 685-5113
To: Linda Hibbs
272 Bridges Ln.
North Andover, MA 01845
[Purchase Order Number Pate Ordered
7, Y
091nib
Terms ....... Notes,
ON RECEIPT
Invoice
Invoice No. Invoice Date
60000667- '-' 0 9/ 0-2- -/0 3
PAGE I
Date Shipped Payment Due Salesperson
09/62M' 00�43 IN TS�
Reference Description Amount
REPLACE SUPTLUT;VNk 3,600.00
Work completed:
I - Permit
2- Pump & crush existing tank
,3- Remove crushed tank & excess fill
.4- Supply & install 1500 gal. tank
5- Regrade, rake, & hydroseed all disturbed areas
6- Supply I -1 /2 loads of screened loam
7- Raise & supply cover for pump tank
ESTIMATE = $3,800.00
LESS DISCOUNT * 200.00
(Discount for being the most understanding
customer I have worked for! Thank You!)
0—
hdl'
Message
Thank you for your business!
SubTotal
Sales Tax
Ship -ping
TOTAL 3,600,00
,40RTH
CHU
Applicant
Town of North Andover, Massachusetts
RnARD nF HFAI TH
Fiji FAQ40dilro,64
DISPOSAL WORKS CONSTRUCTION PERMIT
F.,,,, N.. 3
Site Location
Permission is hereby granted to Construct ( ) or Repair (&-ra"'n' Individual Soil Absorption
Sewage Disposal System as shown on the Design Approval S.S. No.
7-A(14' J-111�4
CHAI RMAN, BOARD OF HEALTH
Fe D.W.C. No.
L11
VA S . d r 7". V 7, /Yw
TOWN OF NORTH ANDOVE
BOARD OF HEALTH 7,
Location -
Permit # &,It� S—
Food Service $
Retail Food $
Limited Retail $
Seasonal $
Disposal Works Installers $
Disposal Works Construction
Soil Testing $
Design Approval Permit $
Dumpster Permit $
Burial Permit $
swimming Pool Permit $
Animal Permit $
Recreational Camp Permit $
Well Construction Permit $
Funeral Directors Permit $
Massage Establishment License $
Massage Practice License $
Suntanning Establishment $
Offal/Trash Hauler $
Other $
6971
Health Agent
White - Applicant Yellow - Dept. Pink - Treasurer
L
TEMN OF NO�T� ANDOVE
BOARD OF HEALTH
Location
permit
Food service
Retail Food
Limited Retail
seasonal
Disposal Works Installers $
+-; on "/ �/� �,
Disposal Works Construc
Soil Testing
Design Approval Permit $ ------
,,,�nster Permit $
rACH FOUNDATION AS -BUILT.
Burial Permit $
Swimming P001 Permit $
Animal Permit
Recreational Camp Permit $ ------
Well cons I truction Permit $
Funeral Directors Permit $
Massage Establishment License $
Massage Practice License $
Suntanning Establishment $
$
offal/Trash Hauler
2003
�VORKS CONSTRUCTION PERMIT.
INSTALLER'S LICENSE#
�Qakl�
TELEPHONE# c(-2'3 - '2>0'7 6
NSTRUCTION:
other
6M
Health Agent
APPlicant YellOw - Dept* Pink - Treasurer
-ite
Use Only
No
No
No
Date:
Town of North Andover, Massachusetts Form No. 3
kORTH BOARD OF HEALTH
DISPOSAL WORKS CONSTRUCTION PERMIT
ACHU
Applicant//'-'X/e0
NAME ADDRESS TELEPHONE
Site Location-ao
Permission is hereby granted to Construct or Repair (4-Ya"'n' Individual Soil Absorption
Sewage Disposal System as shown on the Design Approval S.S. No.
1-hllve J/V1-Y
CHXIRMAN, BOARD OF HEALTH
F ee D.W.C. No.
HP Fax K1220xi
Last Transaction
Date Time TVe
Jul 2 1:39pm Fax Sent
Identification
816037727552
Log for
NORTH ANDOVER
9786889542
Jul 02 2003 1:40prn
Duration PaZe5 Result
1:19 1 OK
BOARD,OF HEALTH
No.Andover� Mass.
APPR"
Provideid:
;_ J'B'
Title V
Reg 2.5
SUBSURFACE DISPOSAL D=GN CHECK LIST 72
1 +4 IOT
MNIKJ
DISAPPRMED DATE
Reasonst
'��5 C -/O /
The submitted plan must show as a minimum:
a) the lot to be served-areasdimensions lot #.,abutters
b location aad log deep obskvation Mes-distance to ties
c location and results percolation testa -distance to ties
dj design calculations & calculations showing required leaching area
(a) location and dimensions of system -including L-Werve area
(f) existing and proposed contours
(g) location any vet areas -Athin IDO I of sewage disposal system'or
disclaimer -check wetlands mapping
(h) surface and subsurface drains within 100 1 of sewage disposal
system or disclaimer
(i) location any drainage easements within 1W I of sewage disposal
system or disclaimr-Planfiing Board files
(J) knova sources of water supply within 2001 of sewage disposal
system or disclaimer
(k) location of any. 1proposed well to serve lot -1001 from leaching facilit
(1) location of water lines on property -101 from leaching ftcilitT
(m) location of benchmark
(n) driveways
(o) garbage disposals
no to be used in construction
(q) profile of system -elevations of basement, plumb, pipes septic tank,
distribution box inlets and outletss distribution field piping and
other elevations
(r) maximum ground water elevation in area sewage disposal system
(a) plan mst be prepared by a Professional &4glneer,or other
professional authorized by law to prepare such. plans
Reg 6 Septic Tanks
(a) capacities-i5o;6 or flows water table, teesp depth of teess
access., punping
(b) cleenout
(c) lo, from cellar van or inground sulmming pool
i --Id) 251 from subsurface drains
Reg 10.2 7 Distribution - Boxes
(a) ilope greater Um 0.08
Reg 10.4 4b) sum
I
BO &rd o f H a al th -
North An4ovexM�De.
APPROVED DATE
OK
1,
)9_9
k 0- . 3 1 _'
10 ;1 (1�11
ID
smmc s13TEH
DL)FLr,O-fFOF INSTALTATICK COCK LIST
DI SUPR UM DATS
Reauonst to+E5
LOVJ' 22 B)7�2��S
WTIN OK ML
8. No Garbage Disposal
9. -711 al Grading Inspection
10. Barricading Covered System
3-1. As Built Submitted
a. Lot Location
b. Dimensions of System
CO Location with Regard -to, Pere Test
d " 'Elevations
e.* Water Table
T- -FO DV410 &Cj�: )VrC) e- J4
I -L_ PvMP61eJC5 7
�C
w4� vor,4� 10c.A -ro
1.
Distance To: 0 6,� -- OX4 7 -(04 1 i - k /0 5 1)OA -
a.
Wetlands
b.
c..
Drains
wen U45 IvUrt OF lf67 OF wk!p
2.
Wat LoAF-1' -1 � _(O T
sr Une ation
XA6��p TO /VLe5prA P(�Kl 51\)ge SY5
3.
No
-VC Pipe
. 01,4-teA -rHOU "MM, U " WL)5C, - k I- 5H OUP.
4.
Sel: 1A c Tank
W - 1�1' _i& 45
7ees lean Out Covers
a.
b.
�-_Lenffik'e
.1ement Pipe to Tank On Both Sides of Tank
Distribution Box
a.
Covert) & Boic - No Cracks
b.
All Lines'Flowing Equal Amounts
c.
No Back Flow
6.
L each nel4 or Trench
a.
Dix�ensions
b.
Stone Depth
c..
Capped Ends'
etan Double -Washed Stone
7.
Le tch Pits -
a.
Di=!�nsions
b.
Stone Depth
e..
Sp- sh Pads
d,
e.
reycs
Cment Pipe to Pit Both sides
fo
olean Double Washed Stone
8. No Garbage Disposal
9. -711 al Grading Inspection
10. Barricading Covered System
3-1. As Built Submitted
a. Lot Location
b. Dimensions of System
CO Location with Regard -to, Pere Test
d " 'Elevations
e.* Water Table
T- -FO DV410 &Cj�: )VrC) e- J4
I -L_ PvMP61eJC5 7
�C