HomeMy WebLinkAboutMiscellaneous - 29 NORTH CROSS ROAD 4/30/2018z
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PUBLIC HEALTH DEPARTMENT
Town of North Andover
Community and Economic Development Division
CERTIFICATE OF
COMPLIANCE
As of: July 27, 2017
This is to certify that the individual subsurface disposal system received a
SATISFACTORY INSPECTION of the:
New Construction of an
On -Site Sewage Disposal System
By: Peter R. Breen - Peter Breen Excavation
At: 29 North Cross Road
Map 38 Lot 187
North Andover, MA 01845
this cpA4,ficA, shall pot be construed as a guarantee that the system will function satisfactorily.
Michele Grant
Public Health Agent
120 Main St., North Andover, Massa chusetts 01845
Phone 978.688.9540 Fax 978.688.9542 Web www.northandoverma.gov
r"
North Andover Health Department
(ommunity and Economic Development Division
QNSITE WASTEWATER SYSTEM CONSTRUCTION NOTES
LOCATION INFORMATION
ADDRESS: 29 North Cross MAP: 38 LOT: 187
INSTALLER: Peter Breen
DESIGNER: Willams & Sparages — JJW
PLAN DATE.- 3/30/2017
BOH APPROVAL DATE ON PLAN: 4/25/2017
INSPECTIONS
TANK INSPECTION:
DATE OF BED BOTTOM INSPECTION:
DATE OF FINAL CONSTRUCTION INSPECTION: 07/07/2017
DATE OF FINAL GRADE INSPECTION:7/27/2017
SITE CONDITIONS
Comments:
SEPTIC TANK
N/A Contractor reports any changes to design plan
Z Existin septic tank properly abandoned
9
Z Internal plumbing all to one building sewer
Z Topography not appreciably altered
Building sewer in continuous grade, on
compacted firm base
N/A Cleanouts per plan
Z Bottom of tank hole has 6" stone base
Z Weep hole plugged
1500 gallon tank has been installed
H-10 loading
Z Monolithic tank construction
Z Water tightness of tank has been achieved by
visual testing
Z Inlet tee installed, centered under access port
Outlet tee installed, centered under access port
(gas baffle/effluent filter)
24" inch cover to within 6" of finish grade
installed over one access port
Hydraulic cement around inlet & outlet
Comments:
PUMP CHAMBER
F-1 Bottom of tank hole has 6" stone base
E] Weep hole plugged
1000 gallon Pump Chamber installed
H-10 loading
Monolithic tank construction
Inlet tee installed, centered under access port
Pump(s) installed on stable base
Alarm float working
Pump On/Off floats working
Separate on/off floats
Drain hole in pressure line
24" cover at final grade installed over pump
access port
Water tightness of tank has been achieved by
Visual testing
Hydraulic cement around inlet & outlet
Comments:
CONTROL PANEL
Z Alarm & Pump are on separate circuits
Z Alarm sounds when float is tripped
Z Location of control panel: basement
Z Alarm signal located inside: basement
Comments: 7/6/17 Did not see stone under pump tank - electrical inspector did
not check the electrical panel or 3 floats. However, they did not install a junction
box. Please check to make sure it is there, also panel and floats.
DISTRIBUTION -BOX
Z Installed on stable stone base
Z H-20 D -Box
Z Inlet tee (if pumped or >0.08'/foot)
Z Hydraulic cement around inlet & outlets
Z Observed even distribution
Z Speed levelers provided (not required)
Z Schedule 40 PVC Pipe
Comments: 2" x 4" coupling installed approximately 3' before D -Box... IR
SOIL ABSORPTION SYSTEM (General)
Bottom of SAS excavated down to C soil layer,
as provided on plan
Size of SAS excavated as per plan
Z Title 5 sand installed, if specified on plan
Z 40 Mil HDPE barrier installed
Z Laterals installed and ends connected to
header (and vented if impervious material
above)
Z Elevations of laterals and chambers installed as on
approved plan
N/A Retaining wall (boulder / concrete / timber/ block)
F-1 Final cover as per plan
Comments: 6/28/2017 Peter had no sand on sight during the inspection.
Have to re -inspect. The hole was 3' short on the length. Called the engineer and
asked him to confirm compliance if the hole dug 3'closer to the house. Closing
the distance approx. to house —from 61'to 58'. Greg will send an email.
SOIL ABSORPTION SYSTEM (Gravel -less Chambers)
F-1 Brand and Model of Chamber: Standard Quick
4 Infiltrator Chambers
Number of chambers per row:
Number of rows (trenches):
Comments: Total Chambers =
26'x 63'
FINAL GRADE
Loamed
Seeded
Z Cover per plan
Comments:
DOCUMENTS NEEDED
Certification of Installation Form submitted
By engineer and signed and dated by
Engineer and installer
F-1 As -Built Plan
32wx28
BM =
HR =
HI =
SYSTEM ELEVATIONS
ROD AS -BLT INVERT DESIGN INVERT
ELEVATION ELEV ELEV
Benchmark
Building Sewer OUT
Septic Tank IN
Septic Tank OUT
Pump Chamber IN
Pump Chamber OUT
Distribution Box IN
Distribution Box OUT
Lateral 1 TOP
Lateral 1 INVERT
Lateral 2 TOP
Lateral 2 INVERT
Lateral 3 TOP
Lateral 3 INVERT
Lateral 4 TOP
Lateral 4 INVERT
Lateral 5 TOP
Lateral 5 INVERT
Lateral 6 TOP
Lateral 6 INVERT
Top of Chamber
Bottom of Bed/Chamber
SKETCH PLAN
L!
CRITICAL SETBACK DISTANCES
Mark those distances checked in the field against the design plan and regulatory
setback
Suction line 222(2)
100 feet is a minimum acceptable distance and no vafiance is allowed for a lesser distance (NA 5.02).
3 As defined in 3 10 CMR 10.55, 10.32, 10.54, and 10.30, respectively, pursuant to 15.211(3), also by NA
wetland bylaws
Tank
SAS Sewer
Property line
10
10
Cellar wall
10
20
Inground pool
10
20
Slab foundation
10
10
Deck, on footings, etc
5
10 --
Waterline
10
10 101
Private drinking well
75
1001 50
Irrigation well
75
100
Surface Water
25
50
Bordering Vegetated Wetland
Salt Marsh, Inland / Coastal Bank3
75
100
Wetlands bordering surface
water supply or trib. (in Watershed)
150
150
Trib. to surface water supply
325
325
Public well
400
400
Interim Wellhead Prot. Area
Reservoirs
400
400
Drains (wat. supply/trib.)
50
100
Drains (intercept g.w.)
25
50
Drains (Other) Foundation
10(5)
20(10)
Drywells
20
25
Suction line 222(2)
100 feet is a minimum acceptable distance and no vafiance is allowed for a lesser distance (NA 5.02).
3 As defined in 3 10 CMR 10.55, 10.32, 10.54, and 10.30, respectively, pursuant to 15.211(3), also by NA
wetland bylaws
Important:
When filling out
forms on the
computer, use
only the tab key
to move your
cursor - do not
use the return
key.
40----h
Application for Septic Disposal System
Construction Permit -TOWN OF
NORTH ANDOVER, MA 01845
Application is hereby made for a permit to:
E] Construct a new on-site sewage disposal system*
ClApair or replace an existing on-site sewage disposal system*
[] Repair or replace an existing system component - What?
A. Facility Information
Address or Lot #
TOVIAY'S/ATE
$350.00 - Full Repair
$175.00 - Component
City/Town
,,IV.
2.- *TYPE OF SEPTIC SYSTEW:
> [g -Pump El Gravity (choose one)
***If pump system, attach copy of electrical permit to application—
> [:] Conventional System (pipe and stone system)
> E] Infiltrator or Biodiffuser (Gravel -Less) (Attach a copy of your certification to install this type of system.)
> F1 Pressure Distribution S.A.S. (No D -Box)
> E] Pressure Dosed (D -Box Present) S.A.S.
> El Does the system require an effluent filter? Yes No
If yes, does plan specify make and model of filter? YES = (no further info. needed)
NO = (installer must specify brand of filter before DWC issuance)
What is the Make?
2. Owner Information
Name
What is the Mode]P
/0' VW4--f
Address (if different from ove)
M
,5z- 9 Zv� n 5's
State Zip Code
0 - S � LA C� 0 0'7'
Email address Telephone Number
3. Installer Information
P6i-,-fx- (2- .
Name Name of Company
Address
City/Town State Zip Code
ct ?
Telephone Number (Cell Phone # if possible please)
4. Desiciner Information
L"L ArVA5,
Name
(
Address
(1,
City/Town
1 -
Name of Company
State
Zip Code
Telephone Number (Best # to Reach)
Application for Disposal System Construction Permit - Page 1 of 2
Applic tion for Septic Disposal System
- '_.WWdrA Construction Permit —TOWN OF
NORTH ANDOVER, MA 01845
PAGE 2 OF 2
A. Facility Information ccmtinued....
5. Type of uildincrm ntial Dwelling or MCornmercial
B. Agreement
TODAY'S DATE
$350.00 - Full Repair
$175.00 - Component
The undersigned agrees to ensure the construction and maintenance of the afore -described
on-site sewage disposal system in accordance with the provisions of Title 5 of the
Environmental Code, as well as the Local Subsurface Disposal Regulations for the Town of
North Andover. I understand that until a final Certificate of Compliance has been issued by
this Board of Health, the installed system is not approved.
Name Date
Application Disapproved for the following reasons:
For Office Use Only:
5. Foundation As -Built? (new construction only): Yes No
(Same scale as approvedplan)
6. Floor Plans? (new construction only): Yes No
Application for Disposal System Construction Permit - Page 2 of 2
1. Fee Attached?
Yes
No
2. Project Manager Obligation Form AttachedP
Yes
No
3. Pump Svs P If so, Attach cop lectrical Permit
x ofE
Yes
Nol
AppEcant xeceived copy of
"ElecLricalinspecdon Notes for Septic Systems"
Yes
No
Handoutp
4. Reviewed approval letter, affpaperworkreceived?
Yes
No
5. Foundation As -Built? (new construction only): Yes No
(Same scale as approvedplan)
6. Floor Plans? (new construction only): Yes No
Application for Disposal System Construction Permit - Page 2 of 2
SEPTIC SYSTEM INSTALLER PROJECT MANAGEMENT OBLIGATIONS
As the North Andover licensed installer for the construction for the septic system for the property at:
_;� -) /7 .0 ,- 7-1-�
(Address of septic system) For plans by
Relative to the application of '(2
(Installer's name) And dated
(Engineer)
(Uriginal date)
Dated M 6_2 a ?
I oday-s clAe) With revisions dated
(Last revised date)
I understand the following obligations for management of this project:
1. As the installer, I am obligated to obtain all permits and Board of Health approved plans pdor to
performing any work on a site. I must have the approved 121ans and the permit on site when any work is
being done.
2. As the installer, I must call for any and all inspections. If homeowner, contractor, project manager, or any
other person not associated with my company schedules an inspection and the system is not ready, then
item three shall be applicable.
3. As the installer, I am required to have the necessary work completed prior to the applicable inspections as
indicated below. I understand that requesting an inspection, without completion of the items in accordance
with Tide 5 and the Board of Health kegulations may result in a $50.00 fine being levied against me and/or
my =12MY_
a. Bottom of Bed — Generally, this is the first (V� inspection unless there is a retaining wan, which
should be done first. The installer must request the inspection but does not have to be present.
b. Final Construction Inspection — Engineer must first do their inspection for elevations, ties, etc.
As -built of verbal OK (or e-mail to: healthdel2t@townofnorthandover.com) from the engineer must
be submitted to the Board of Health, after which installer calls for an inspection time. Installer must
be present for this inspection. With a pump system, all electrical work must be ready and able to
cause pump to work and alarm to function.
c. Final Grade — Installer must request inspection when all grading is complete. Installer does not
have to be on-site.
4. As the installer, I understand that only I may perform the work (otber than simple excavation) and I am required
to complete the installation of the system identified in the attached application for installation. I further
understand that work done by others unlicensed to install septic systems in North Andover can constitute
reasons for denial of the system and/or revocation or suspension of my license to operate in the Town of
North Andover, siMificant fines to all persons involved are also possible.
5. As the installer, I understand that I must be on-site during the performance of the following construction
steps:
a. Determination that tbeproper elevation of the excavation has been reached.
b. Inspection of the sand and stone to be used.
c. Final inspection by Board of Health staff or consultant.
d. Installation of tank, D-Boxpi
pes, stone, vent, pump chamber, retaining wall and other
components.
6. As the installer. I understand that I am solel,
y responsible for the installation of the system as per the
approved 121ans. No instructions by the homeowner, general contractor, or any other persons shall absolve
me of this obligation.
Undersigned Licensed Septic Installer: (Today's Date)
L r7V
(Name — Print) (Name — Signed)
PUBLIC HEALTH DEPARTMENT
Community & Economi( Development
TOWN OF NORTH ANDOVER
SEPTIC DISPOSAL SYSTEM — INSTALLATION CERTIFICATION
The undersigned hereby certify that the Sewage Disposal System (616onstructed; repaired;
By: er- T_C-sr it- fsfr_Z�X'
(Print Name)
Located at: 99 /io./- 7-4 (f/'bS S lZ"C
(Installation Address)
Was installed in conformance with the North Andover Board of Health approved plan, originally dated
and last revised on
with a design flow of
gallons per day. The materials used were in conforinance with those specified on the
approved plan; the system was installed in accordance with the provisions of 3 10. CNM 15.000, Title 5 and local
regulations, and the final grading agrees substantially with the approved plan. All work is accurately represented on
t'
the As -built which has been submitted to the Board of Health.
Bottom of Bed Inspection Date:
Engineer Representative (Signature)
And — Print Name
Final Construction Inspection Date:
Engineer Representative (Signature)
And — Print Name
Installeri/ (Signature) Date:k7lA 6
A I % 0 /
And - Print Name
Engineer: (Signature) Date: 7 11 bjZ0f7
And - Print Name
120 Main Street, North Andover, Massachusetts 01845
Phone 978.688.9540 Fax 978.688.9542 Web http://www.northandoverma.gov
. t -7
,AORTH 850
Town of North Andover
HEALTH DEPARTMENT
SS S
., us
CHECK #: DATE:
LOCATION: 9 ��4/
H/ 0 NAME: A�na6o AG
CONTRACTOR NAME: "c—
Type
of Permit or License: (Check box)
0
Animal
$
•
Body Art Establishment
$
•
Body Art Practitioner
$
0
Dumpster
$
0
Food Service -
$
0
Funeral Directors
$
0
Massage Establishment
$
0
Massage Practice
$
0
Offal (Septic) Hauler
$
0
Recreational Camp
$
0
Sun tanning
$
0
Swimming Pool
$
•
Tobacco
$
•
Trash/Solid Waste Hauler
$-
•
Well Construction
$
SEP77C Systems
0
Septic - Soil Testing
$
0
Septic - Design Approval �3
$-
Septic Disposal Works Construction (DW0
$
0
Septic Disposal Works Installers (DWI)
$
0
Title 5 Inspector
$
0
Title 5 Report
$
0 Other (Indicate) $
A<th �gent Initials
White - Applicant Yellow - Health Pink - Treasurer
Town of North Andover — Selptic m - AS -BUILT CHECKLIST
1) 11 changes to the design plan have been reflected and noted on the as -built plan 5,
+0
2) As -built plan has a suitable scale; (1 inch = 40 feet or fewer for plot plans)
3) Street Address, Assessor's Map and Lot Number
4) t Lines and Location of Dwellings served by the system
�T �
5) Locations, Elevations and Dimensions of As -built system components, including reserve (if applicable)
6) -ITies'to all tank openings, d -box, and leach area from dwelling or Permanent Structure
Setback distances are shown on the as~built plan from system components to:
Subsurface, interceptor & foundation drains
Catch basins
Property lines
Dwellings or other structures
Private water supply or irrigation wells
Watercourses or wetlands
8) Locations of Wells Drains, Wetland Resource Areas within 150 feet of system
9) -Locatio of water, electric lines, cable, control panel (if applicable)
10) z Location of Structures within 6 Inches of Finished Grade
11) I -Original Stamp & Signature
7 ___
12) *-Location and holder of any easements which could impact the system
13) V_ Impervious Areas; Driveways, etc
14) -North Arrow
15) V. Location & Elevation of Benchmark used
16) _7STATEMENT ON PLAN (NA 5.3)
a. "I certify the locations, elevations, ties, cover material; exposed component covers etc.,
shown on this as -built substantially q,-ree with the approvedplan andhave determined that the
break out elevations, if applicableha ve been met "
Signature of Designer
Date
b. -"If a.STUCTURAL WALL ISFRESEAT (NA 4.9) a Letter or statement on the as -built indica
the wall - w; s or was not ructedin accordance with the intended d 1
__j, -, const Ls� andany
manufacturer's E�Jficafions. "
Signature of Designer
Date
As of: Tu esd ay, M a rch 17,
July 18, 2017
Brian LaGrasse, Health Director
North Andover Board of Health
120 Main Street
North Andover, MA 01845
Re: 29 North Cross Road - Septic As -Built
Dear Brian,
w I -
&WILLIAMS
SPARAGES
ENGINEERS . PLANNERS . SURVEYORS
S
Please find enclose two (1) original and (2) copies of the Septic System As -Built Plan for
the above referenced property.
I hereby certify that the system was installed in substantial compliance with the design
plan and field changes approved by the designer and Board of Health.
If you have any questions regarding this information please do not hesitate to contact
our office.
Sincerely,
WILLIAMS & SPARAGES, LLC
Greg J. Hochmuth, RS, PWS
Project Manager
cc: Richard Pandolfo
P&CF.IVED
313L 18 2017
J,O,VM CC -Ts ANDOAR
, t4Cg
189 North Main Street, Suite 101 9 Middleton, MA 01949 e Tel: (978) 539-8088 * www.wsengineers.com
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6/21/2017
NORTRANDOVER
Massachu 'tts
29 North Cross Road
1 message
Town of North Andover Mail - 29 North Cross Road
Gregory Hochmuth <ghochmuth@wsengineers.com>
To: Michele Grant <mgrant@northandoverma-gov>
Cc: Brian LaGrasse <blagrasse@northandoverma.gov>
Michele Grant <rngrant@northandoverrna.gov>
Wed, Jun 21, 2017 at 11:25 AM
Hi Michele, Please find attached a sketch plan showing the leach bed shifting towards the house 3 feet. I will swing by
later today to inspect the bed bottom once it is excavated. As discussed we will be sure to note the field change on the
As -Built as well. Have a good day, Greg
Greg J. Hochmuth, RS, PWS, CWS
'W�.o & WILLLAMS
SPARAGES
MWEM. KOV.M. wnllan
T
S
189 North Main Street, Suite 101
Middleton, MA 01949
(978) 539-8088 Office
(978) 590-6416 Cell
(978) 539-8200 Fax
www.wsengineers.com
We invite you to follow us on Facebook www.facebook.com/wsengineers
an 20170621112237.pdf
273K
https:Hmail.google.com/mail/calu/0/?ui=2&ik=d4458df3d9&view=pt&search=inbox&th=15ccb42828195873&siml=15ccb42828195873 1/1
Commonwealth of Massachusetts Map -Block -Lot
038.00187
------- ---
BOARD OF HEALTH Permit - No ---------
North Andover - BHP -2017-04 - 06 .
--------------- --
P.I. FEE
F.I. I
DISPOSAL WORKS CONSTRU-IfTfON'IPERMIT
Permission is hereby granted -Peter-Bre-en ----------------------- ----------------------------------------
$350.00
------------
to (Construct) an Individual Sewage Disposal System.
atNo, 29 NORTH CROSSROAD
-------------------------------------------------------------------------------------------------------------------------------
as shown on the application for Disposal Works Construction Permit No. -BII-P-2-0-1-7---040 --- Dated. - - May- 05-,- 2017 --------
-----------------------------------------------------------------
Issued On: May -05-2017 BOARD OF HEALTH
- ------------------------------------------------------------------------------
Map-Block-Lot
Commonwealth of Massachusetts
038.00187
BOARD OF HEALTH -----------------------
North Andover
CERTIFICATE OF COMPLIANCE
THIS IS TO CERTIFY That the Individual Sewage Disposal System s cty
Q6T— tru
-0
by Peter Breen
--------------------------------------------------------------------------------- ----- N -- ------------------------------------ --------
Installer
-- --------------------------------------------------
atNo, --2-9- NORTH- CRO -S -S RO-AD -------------------------------------------------
has been installed in accordance with the provisions of TITLE 5 of the State Environmental Code as described in the
application for Disposal Works Construction Permit No. -B-H-P-2-0-1-7---040-- Dated --- MM 0 5, 2 0 17 ........
-----------------------------------------------------------------
Printed On:,May-05-2017 BOARD OF HEALTH
---------------------------------------------------------
Commonwealth of Massachusetts Map -Block -Lot
038.00187
BOARD OF HEALTH --------------------
Permit No
North Andover - BHP -2 - 017-04 - 06 -
------- ------- --
FEE
-----------------------
DISPOSAL WORKS CONSTRUCTIONPltkMIT
Permission is hereby granted Peter Breen
---------------------------------------------------------------- -----------------------------------------------
to (Construct) an Individual Sewage Disposal System.
atNo--2-9- NORTH- CRO -S -S -RO-AD ------------------------------------------------------------------------------------------------------------
as shown on the application for Disposal Works Construction Permit No. BIIP-2017-040 Dated May 05, 2017
------------------------ -----------------------------
-------------------------------------------------
I ssued On: M ay -05-2017 BOARD OF HEALTH
North Andover Health Department
(ommunity and E(onomic Development Division
April 25, 2017
Richard Pandolfo
29 North Cross Road
North Andover, MA 0 1845
Re: Subsurface Sewage Disposal System Plan for 29 North Cross Road
(Map 38, Lot 187)
To Whom It May Concern:
The proposed wastewater system design plan for the above site dated September 30, 2016 with a
final revision date of March 30, 2017 and received on April 7, 2017 has been approved.
The design has been approved for use in the repair of an on-site septic system for a Five (5)
Bedroom (max I I -room) home utilizing a septic tank, pump chamber and leach field system.
This design plan approval is valid until April 25, 2020.
During this time, a licensed septic system installer must obtain a permit and complete this work,
and a Certificate of Compliance be endorsed by the installer, designer and the Town of North
Andover.
This approval is also subject to the following conditions:
If site conditions are found in the field to be different from those indicated on the
design plan and/or soil evaluation, the originally issued Disposal System Construction
Permit is void, installation shall stop, and the applicant shall reapply for a new
Disposal Systems Construction Permit (3 10 CMR 15.020(l)).
2. It is the responsibility of the applicant and/or the applicant's septic system designer,
septic system installer or other representative to ensure that all other state and
municipal requirements are met. These may include review by the Conservation
Commission, Zoning Board, Planning Board, Building Inspector, Plumbing Inspector
and/or Electrical Inspector. The issuance of a Disposal System Construction Permit
North Andover Health Department, 120 Main Street,
North Andover, MA 0 1845 Phone: 978.688.9540
Page 1 of 2
Fax: 978.688.8476
shall not construe and/or imply compliance with any of the aforementioned
requirements.
Please feel free to contact the office with any questions you may have. We look forward to
working with you to obtain a wastewater treatment and dispersal system which will be in
compliance with all regulations and assure protection of public health and the environment of
North Andover.
Si
rian J. LaGrasse, CEHT
irector of Public Health
Encl. Installers list
CC: Greg J. Hochmuth, R.S.
Williams & Sparages
189 North Main Street
Middleton, MA 01949
North Andover Health Department, 120 Main Street,
North Andover, MA 0 1845 Phone: 978.688.9540
Page 2 of 2
Fax: 978.688.8476
March 30, 2017
Brian LaGrasse, CEHT
Director of Public Health
North Andover Health Department
120 Main Street
North Andover, MA 0 1845
I
WILLIAMS
SPARAGES
ENGINEERS � PLANNERS . SURVEYORS
RECEIVED
S
APR 0 7 zu-j/
TOWN OF NORTH ANDOVER
HEALTH DEPARTMENT
Re: Revised Subsurface Sewage Disposal System Plan for 29 North Cross Road
(Assessors Map 38, Lot 187)
Dear Brian,
Thank you for meeting with me the other day to discuss the sanitary disposal system design for
29 North Cross Road. As you know, we were hired to design a new sanitary disposal system to
replace the existing system at the above referenced property. We designed a new system and
received an approval letter from your department that was dated February 2, 2017 approving a
design prepared by our office with a final revision date of November 30, 2016.
Upon receipt of the approval letter, the property owner noticed that the approval letter and septic
design that was approved was for a 4 bedroom dwelling. The November 30, 2016 design that
was prepared by our office was based on assessor's records that listed the dwelling as a 4
bedroom as well as the original design for the property which was also for a 4 bedroom dwelling.
According to the property owner the home has always had 5 bedrooms and he recently reached
out to the Assessor's office to have them correct the error.
It is important to note that the original design was based on 150 Gallons Per Bedroom which
resulted in a flow of 600 GPD which would have accommodated 5 bedrooms based on the
current design flow.
The November 30, 2016 design prepared by our office was oversized to show an 800 sf leach
bed instead of the 595 SF leach bed that could have been installed based on the loading rate and
current Board of Health design flow. We recommended oversizing the system to the property
owner because he had the room and we don't recommend installing a leaching facility that is less
than 800 sf in size. This is important to note because an 800 sf leach bed with the current design
flow and loading rate for the property can accommodate 5 bedrooms.
As discussed we have revised the design plan to show a 100% ftiture reserve area adjacent to the
proposed leach bed. We have also made the test pit symbol slightly longer to touch the reserve
area. The reality is that during the soil testing effort the test pits were longer than the test pit
symbol shown on the design plan.
189 North Main Street, Suite 101 & Middleton, MA 01949 * Tel: (978) 539-8088 9 www.wsengineers.com
AW
If you have any questions regarding this information or require anything additional please do not
hesitate to contact our office.
Sincerely,
WILLIAMS & SPARAGES, LLC
Greg J. Hochmuth, RS, PWS
Project Manager
cc: Richard Pandolofo
A.
7868
0
Town of North Andover
HEALTH DEPARTMENT
SA
CHECK DATE:
LOCATION: AV
H/ONAME: ldal-joloz7co
CONTRACTOR NAME: W; /&Lfo -5 �'J�zt-cqe5
TYRe
of Permit or License: (Check box)
•
Animal
$
•
Body Art Establishment
$
•
Body Art Practitioner
$
0
Dumpster
$
•
Food Service - Type:
$
•
Funeral Directors
$
•
Massage Establishment
$
•
Massage Practice
$
•
Offal (Septic) Hauler
$
•
Recreational Camp
$
0
Sun tanning
$-
•
Swimming Pool
$
•
Tobacco
$
•
Trash/Solid Waste Hauler
$-
•
Well Construction
$
SEPTIC Systems
0
Septic - Soil Testing
$
VSeptic
- Design Approw4- /e OiW
$ 5 -
0
Septic Disposal Works Construction (DWQ
$
0
Septic Disposal Works Installers (DW1)
$-
0
Title 5 Inspector
$
0
Title 5 Report
$-
0 Other (Indicate) $
r-;O�
He?�gent Initials
White - Applicant Yellow - Health Pink - Treasurer
November 3 0, 2016
Brian LaGrasse, CEHT
Director of Public Health
North Andover Health Department
120 Main Street
North Andover, MA 0 1845
I -
WILLIAMS
'W--04 & SPARAGES
ENGINEERS . PLANNERS . SURVEYORS
S
Re: Subsurface Sewage Disposal System Plan for 29 North Cross Road (Map 38, Lot 187)
Dear Brian,
Long time no see, I hope all is well. Congratulations on coming back to North Andover. We
don't do a ton of work in town that is BOH related but I'm sure we will cross paths soon.
Please find attached revised plans for 29 North Cross Road in response to your comments dated
November 14, 2016.
• The lot area was added to Sheet I of 3.
• We have added the ESHWT elevation to the plans and buoyancy calculations have been
provided.
We added the watershed note as requested.
• We made it clear that the pump chamber proposed is Monolithic.
• The brand and model number of the proposed effluent filter has been added to the plan as
well as the recommended maintenance schedule.
• The approximate location of the water service has been shown.
• The scale has been added to the system profile.
• The breakout elevation has been corrected in the cross section.
If you have any questions regarding this information or require anything additional please do not
hesitate to contact our office.
Sincerely,
WILLIAMS & SPARAGES, LLC
Greg J. Hochinuth, RS, PWS
Project Manager
cc: Richard Pandolofo
RECEIVED
ULU U 5 Z016
TOWN OF NUR i H ANiDOVER
HEALTH DEPARTMENT
189 North Main Street, Suite 101 * Middleton, MA 01949 9 Tel: (978) 539-8088 * www.wsengineers.com
North Andover Health Department
(ommunity and Economic Development Division
February 2, 2017
Richard Pandolfo
29 North Cross Road
North Andover, MA 0 1845
Re: Subsurface Sewage Disposal System Plan for 29 North Cross Road
(Map 38, Lot 187)
To Whom It May Concern:
The proposed wastewater system design plan for the above site dated September 30, 2016 with a
final revision date of November 30, 2016 and received on December 5, 2016 has been approved.
The design has been approved for use in the repair of an on-site septic system for a Four (4)
Bedroom (max 9 -room) home utilizing a pump chamber and leach field system. This design
plan approval is valid until February 2, 2020.
During this time, a licensed septic system installer must obtain a permit and complete this work,
and a Certificate of Compliance be endorsed by the installer, designer and the Town of North
Andover.
This approval is also subject to the following conditions:
If site conditions are found in the field to be different from those indicated on the
design plan and/or soil evaluation, the originally issued Disposal System Construction
Pen -nit is void, installation shall stop, and the applicant shall reapply for a new
Disposal Systems Construction Permit (3 10 CMR 15.020(l)).
2. It is the responsibility of the applicant and/or the applicant's septic system designer,
septic system installer or other representative to ensure that all other state and
municipal requirements are met. These may include review by the Conservation
Commission, Zoning Board, Planning Board, Building Inspector, Plumbing Inspector
and/or Electrical Inspector. The issuance of a Disposal System Construction Permit
Page I of 2
North Andover Health Department, 120 Main Street,
North Andover, MA 01845 Phone: 978.688.9540 Fax: 978.688.8476
shall not construe and/or imply compliance with any of the aforementioned
requirements.
Please feel free to contact the office with any questions you may have. We look forward to
working with you to obtain a wastewater treatment and dispersal system which will be in
compliance with all regulations and assure protection of public health and the environment of
North Andover.
incerely, 7
Brian J. LaGrasse, CEHT
birector of Public Health
Encl. Installers list
CC: Greg J. Hochmuth, R.S.
Williams & Sparages
189 North Main Street
Middleton, MA 0 1949
North Andover, MA 0 1845 Phone: 978.688.9540 Fax: 978.688.8476
North Andover Health Department
(ommunity and Economi( Development Division
November 14, 2016
Peter Blaisdell, Jr., P.E.
Williams & Sparages
191 South Main Street
Middleton, MA 0 1949
Re: Subsurface Sewage Disposal System Plan for 29 North Cross Road (Map 38, Lot 187)
Dear Mr. Blaisdell:
The proposed wastewater system design plan for the above site dated September 30, 2016 and
received on October 24, 2016 has been reviewed. Unfortunately, the plan cannot be approved
until the following items are corrected. The specific section in Title 5: 3 10 CMR 15.000, or
North Andover regulation that is not met by this design follows each item.
I . On sheet I of 3, the lot area was not depicted on the design plan (NA 3.2).
2. It appears that the bottom of the septic tank and pump chamber may be below the
ESHWT. Please determine the ESHWT elevation in the location of the proposed tanks
and provide buoyancy calculations if required (3 10 CMR 15.221(8)).
3. The watershed of Lake Chochichewick note was not depicted on the design plan (NA
3.2).
4. A monolithic pump chamber is required and should be clearly noted on the design plan to
assist the installer (NA 3.2).
5. Provide the DEP approved brand and model number of the proposed effluent filter and
also provide a note indicating the required annual maintenance (3 10 CMR 15.227(7)).
6. On sheet I of 3, the waterline was not shown on the design plan (3 10 CMR
15.220(4)(m)).
7. On sheet 2 of 3, the scale the System Profile was not provided (NA 3.2).
8. On sheet 2 of 3, in section A -A the breakout elevation is incorrect.
Page 1 of 2
North Andover Health Department, 120 Main Street,
North Andover, MA 0 1845 Phone: 978.688.9540 Fax: 978.688.8476
Please feel free to contact the office or Mill River Consulting at 978-282-0014 with any
questions you may have. We look forward to working with you to obtain a wastewater treatment
and dispersal system which will be in compliance with all regulations and assure protection of
public health and the environment of North Andover.
19/rian J. LaGrasse, CEHT
Director of Public Health
cc: Richard Pandolfo
File
Page 2 of 2
North Andover Health Department, 120 Main Street,
North Andover, MA 0 1845 Phone: 978.688.9540 Fax: 978.688.8476
__5
TOWN OF NORTH ANDOVER
Office of COMMUNITY. DEVELOPMENT AND SERVICES
HEALTH DEPARTMENT qW
1600 OSGOOD STREET; SUITE 2035
NORTH ANDOVER, MASSACHUSETTS 0 1845
978.688.9540 -Phone
978.688.8476 -FAX
E-MAIL: healthdept@northandoverma.gov
WEBSITE: hiLtp://www.northandoverma.yov
SEPTIC PLAN SUBMITTAL
FORM R E f."O" E I V I -: D
Date of Submission:— i0la, OCT 2 4 2016
TOWN OF NORTH ANDOVER
I I?
HEALTH DEPDAA P.TM7T
Site Location: Qq NO(ZO (,WS5 IZOAT)
Engineer: Wa-wr--\5 + SPN246C6 t',(-
NewPlans? Yes )C $275/Plan Check# (includes l't submission and one re-
review only)
Revised Plans?Yes $125/Plan Check #
Site Evaluation Forms Included? Yes X No
Local Upgrade Form Included? Yes No X
Telephone#: C971?) 53q -9-09-0 Fax #: 5-3-t - ��-aco
E-mail:— !�' 6A ml�A P -W 5 C A! W' -_r5 - COTA
A I 1_x
Homeowner
Name: PQPJAC,
OFFICE USE ONLY
When the sub * sion is complete (including check):
I
7 Date stamp plans and letter
Complete and attach Receipt
Copy File; Forward to Consultant
> Enter on Log Sheet and Database
FORM 1A — APPLICATION FOR DSCP
Fee:
COMMONWEALTH OF MASSACHUSETTS
Board of Health, City�own of tjo4 A rywyag — MA
APPLICATION FOR DISPOSAL SYSTEM CONSTRUCTION PERMIT
Application for a Permit to Construct ( ) Repair ()o Upgrade ( ) Abandon ( ) - �4 Complete System 0 Individual Components
Location of Facility: aq
a
Owner's Name:
f'�11-14A110 PANICALF0
Map/Parcel # or Address: N P Lot LEI
Address (if different):
Lot #:
Telephone#: ('979-) 'agzj-9005
Installer's Name or Company:
Designer's Name or Company: WILLIP-A-5 rSPArIZAciS LLC
Address:
ALddress- /69 tj r -M (0 �:,r sag f- tui ^to&r_m4
Telephone #:
Telephone #: (q-79-) 53+1C_019_.9
Type of Building: 5; kic- F&, -,I;, A Lot Size: -2g-0 sq. ft.
%J
Dwelling — No. of Bedrooms:
Other — Type of Building:
Other Fixtures:
Garbage Grinder( )
No. of Persons: — Showers( ),Cafeteria( )
Design Flow (min. required): //0 gpd/6CLlculated Deign Flow: qq(9 gpd Design Flow Provided 'NO gpd
Plan: Date: sa*"be-e sod,01,6 No. of Sheets: 3 Revision Date:
Title: pla, (�nrrm
Description of Soil(s):
Soil Evaluator Form No.: It Soil Evaluator: 6f!!4 U04""A sf,�ms Date of Evaluation:
LI) Lao i.,
NATURE OF REPAIRS OR ALTERATIONS (IF APPLICABLE): h4steU kvaj 11W.? rAt- (+�,o cQ,*rfPmv-,4.) -l"'Ar,
I mfj rplv% wa,-p c6—k-r cind 501 x 16 'ci 5od ak&.5�kle-n ctj,
Date Last Inspected: Date:
The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system in
accordance with the provisions of TITLE 5 of the Environmental Code and not to place the system in pera !2
& . t - %u I �11 i ul
Certificate of Compliance has been issued by the Board of Health. KaUlzl s—
Signed:
Application Approved By:
Application Disapproved for the Following Reasons:
Date: OCT 2 4 2016
Date: nr: �,InOTY A�.lnn\/ER
HEALTH DEPARDAENT
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�111_'V' 4
Commonwealth of Massachusetts
City/Town of
Percolation Test
Form 12
Percolation test results must be submitted with the Soil Suitability Assessment for On-site Sewage
Disposal. DEP has provided this form for use by local Boards of Health. Other forms may be used, but
the information must be substantially the same as that provided here. Before using this form, check with
the local Board of Health to determine the form they use.
A. Site Information
Acwa,o PANOACW
Owner Name
Q9 tjcar� CMS OoAr)
Street Address or Lot #
wA-W Atjwga CIO5
Citvrrown State Zip Code
Contact Person (if different from Owner)
B. Test Results
Observation Hole #
Depth of Perc
Start Pre -Soak
End Pre -Soak
Time at 12"
Time at 9"
Time at 6"
Time (9"-6")
Rate (Min./Inch)
67g) ��-Fv -gov.5
Telephone Nuffiber
16) 7:53 Afn
Date I 1111e Date
i6 -a (P-))
q -5 3 AO
/0: 0'F AM
Wog- A K\
10'114 A A
/0-.\ I AM
-7 M I 1'j
3 /"P
Test Passed: Test Passed:
Test Failed: Test Failed:
GAPEC, noc /At^-T'O S;F_ ;)9.)L5
Test Performed By:
_T s A A 6 fZ
Board of Health Witness
Comments:
Time
t5form12.doc- 08/15 Perc Test - Page 1 of 1
TOWN OF NORTH ANDOVER
Office of COMMUNITY DEVELOPMENT AND SERVICES
HEALTH DEPARTMENT
1600 OSGOOD STREET; SUITE 2035
NORTH ANDOVER, MASSACHUSETTS 0 1845
978.688.9540 - Phone
978.688.8476 - FAX
healthdept@northandoverma.g RE411VED
www.northandoverma.gov
APPLICATION FOR SOIL TESTS SEP 0 8 2016
OF NORTH ANDOVER
TOWN DEpARTMENT
DATE: C�% -Z17-01 MAP & PARCEL: HEALTH
LOCATION OF SOIL TESTS: �Aentr
OWNER: T);ck Contact#: —CJ76- 584-9kQ05"
APPLICANT: vic-t-, PDX4.0%�o Contact #:— C�*76— SQ)k - 9k00_1:j'
ADDRESS: - ZC1% N10r44--1 Rocs -A Oor*N &n&mmr3 i%A 0X6
ENGINEER: Gom 0026�y� Contact#:
j
CERTIFIED SOIL EVALUATOR: Gree, Moaw,,A� ss vV za-z.G
a
Intended Use of Land: Residential Subdivision Commercial
Is This: Repair Testing: Y, Undeveloped Lot Testing:_ Upgrade for Addition:_
In the Lake Cochichewick Watershed? Yes No x
THE FOLLOWING MUST BE INCLUDED WITH THIS FORM
Proof of land ownership (Tax bill, or letter from owner permitting test)
8.5"x 11 " Plot plan & Location of Testinz (please indicate test pit sites on the plan)
> Fee of $585.00 per lot for new construction. This covers the minimum two deep holes and
two percolation tests required for each disposal area. Fee of $440.00 per lot for repairs or upgrades.
GENERAL INFORMATION
> Only Certified Soil Evaluators may perform deep hole inspections.
> Only Mass. Registered Sanitarians and Professional Engineers can design septic plans.
> At least two deep holes and two percolation tests are required for each septic system disposal area.
> Repairs require at least two deep holes and at least one percolation test, at the discretion of the BOH
representative.
> Full payment will be required for all additional tests within two weeks of testing.
> Within 45 days of testing, a scaled plan (no smaller than 1"-100') shall be submitted to the Board of Health
showing the location of all tests (including aborted tests).
> Within 60 days of testing soil evaluation forms shall be submitted.
Please Do Not Write Below This Line
N.A. Conservation Commission Approval Date:
Signature of Conservation Agent: 6--4_
Date back to Health Department: (stamp in): k",^ N^, C;k-
rliprx 0
L'oemAzorN
ol� -Tiesir-
p; "
LOT 7
LOCUM,
r, , ,,,
APPROVAI.. UNDER SJODIVISION CONTROL
LAWS NOT REOUIRED.
—?- T- _y/o
PLANNING SURD
AT
t1b
ell
0
PARCELI V11
767 S.F
61
z 'p 1,
49 416 S.F
4 gF
tA 1. 134 AC.
L
1.0 t\
PARC 2 PARCEL 4
0
OT 5
LO LOT 5 A,
50 Is? S
q 6-, 9 S.F 50, 153S.F
i.o74 AC. I. 152 AC.
o
- ol 0-16
PARCEL 3
1,988 S.F
0.0456 AC.
0-
61�
ot,
4'
NorE.
PARCELS 18, 3 ARE NOT
INDIVIDUAL BUILDAB.LE PARCELS.
PARCELS I S 4 ARE TO BE DEEDED
TOGETHER AS LOT 5A.
PARCELS 2 8 3 ARE TO BE DEEDED
TOGETHER AS LOT 6A.
THIS PLAN is COMPILED FROM THE
SUBDIVISION PLAN OF LAND OF FRANCES
ESTATES FOR E.C.S. INC. NOV. 1984
REVISED JUNE 1985.
R-2 ZONING
NORTH CROSS RD. CURRENTLY UNDER
CONSTRUCTION WILL BECOME A PUBLIC
WAY UPON ACCEPTANCE BY THE TOWN.
N/F
ABBOTT REALTY
TRUST
L L-75.00'
.36
R= 164.6p cl
.15.0 '1
L- 11.48
0)
N/F
C�
AE, E.C-S, INC.
50' WIDTH C,
gn
t4 PRIVATE WAY CPOSS '9040
PLAN AND DUD ATLANTIC ENGINEERING, a. SURVEY
EFIERENCES RECORDED CONSULTANTS, NC
No. ESSEX REGISIM 33 W. MAIN ST. GEORGETOWN, MASS.
I CERTIFY THAT THIS PLAN HAS SEEN PREPARED IN
CONFORMANCE WITH THE RULES AND REGULATIONS OF
THE REGISTERS OF DEEDS.
CATE
RmwmREQ LAW
I of I I SCALE: 1--4d "a
ila , , .
M �4—
F'o"R,
COMPILED SUBDIVISION
PLAN OF LAND
IN
N. ANDOVER, AfASS-
E.C.S. INC.
OWNER: PO. BOX 177 PINEHURST, MA
DATE: 8/27/86
Subject to, and with the benogLt off all easements, restric-
tions and covenants of record, including without limitation the
Declaration of Restrictive Covenants dated September 30, 1996o
recorded with said Deeds in Rook 2317, Page !84.
The herein conveyance is not the conveyance of all or
'substantially all of the assets of the Grantor in the
Commonwealth of Massachusetts.
,,ANCELLEE
�m
DEED
National Real estate and Development Corp. a Rassaahusetto cor-
porations with an address at 17-21 Rogers Street, Gloucestarl
Massachusetts 01930 In consideration of Four Hundred rive
Thousand and no/100 Dollars ($405,000.00) grants to Richard J.
Pandolfo and Teresa M. Vandolfo, husband and wifer an tenant@ by
the entirety, of North Cross Road, Worth Andover, Posex
County, Massachusetts, grants with quitclaim covenants certain
land with the building and the improvements thereon known as and
located at North Cross Road, North Andavert Essex Countyp
Commonwealth of Massachusetts, being described as follows:
V
Lot 6A shown on a plan entitled "Compiled Subdivision Plan
of Land# North Andover, Mass., Owners E.C.S., Inc., POO. BOX
1770 pinehurst, MAP dated August 21, 1986 by Atlantic Engineering
a Survey Consultantuf Inc.0 recorded with ossex worth County.
Registry Of Deeds on September 30# 1906.as Instrument No. 3240)
and as Plan No. 10456, being bounded more particularly described
An followat
EASTERLY: by Nor th Cross Road as shown on said plan by two
lines, 75.00 feet and 15.00 fe0tt
NORTHWESTERLYt by Lot SA as shown an said plan by four lines,
55.00 feet, 60.oc feet. 170.58 feet and 151.67
SOUTHWESTERLYs by Rea street aq shown on said plan, 65.35 featr
and
SOUTHERLYs by Lot 7 or. shown on said plan, 392.51 feet.
Subject to, and with the benogLt off all easements, restric-
tions and covenants of record, including without limitation the
Declaration of Restrictive Covenants dated September 30, 1996o
recorded with said Deeds in Rook 2317, Page !84.
The herein conveyance is not the conveyance of all or
'substantially all of the assets of the Grantor in the
Commonwealth of Massachusetts.
,,ANCELLEE
�m
BR2581
FCC titlS rOfOCOACe See deeds of QnVironmentaL Control $yet*", 73
Inc. d t4d SOPURbOr 30# 1986# reaar4ed with said Deeds In Book
2317#':oge let jpd in book 2345, Page 296.
gaeouted under seat this _L_f_ day of August, 1987.
NATIONAL REAJ- ESTATE AND
DEVELOPHENT CORPORATION
Syl
Richi-rdJ. n o fo, I r eLdent
Jack A. Von oVaj It& Treasurer
COMKONKEALTH OF MASSACHUSBTTS
se 1987
Then personally appeared Richard j. PandoLfoaft&-gaeh-A.
Ve"telv President rgspeebWeays of National Real
EstAtO and DOVelopment. Corporation, a Mazaachusettm corporation,
and they acknowledged the foregoing to be the free act and deed
of said corporation, before me*
Notary Public
my Caraission expiress a>
DFK
NAT.DRED
Recorded Aug.51,1987 at 4&2FM #28019
K
TOWN OF NORTH ANDOVER
NORTH ANDOVER, MASSACHUSETTS 01845
ttoRTh
AC
Permit Number
Date Issued
Expiration Date
Jackie's Law — Perinit Application
Pursuant to G.L. c. 82A §1 and 520 CMR 7.00 et seq.(as amended)
THIS PERMIT MUST BE FULLY COMPLETED PRIOR TO CONSIDERATION
Name of Applicant ec�e-e— 66C��
Phone Cell
Street Address C) &D �t"
7Y 7
CitylTown
MA
ZIP
h/V AOL��
I '
� ot14'5
Name of Excavator (if different from applicant)
Phone Cell
Street Address
City/Town
MA
ZIP
Name of Owner(s) of Property
Phone Cell
,I/%X—
Street Address
r-rhL C -C)
City/Town
MA
Z
Fee Received No] �Y
Other Contact
Description, location and purpose of proposed trench:
Please describe the exact location of the proposed trench and its purpose (include a description of what is (or is intended) to
be laid in proposed trench (eg; pipes/cable lines etc..) Please use reverse side if additional space is needed.
-wjev,0--- -r.& - r,.� r C
Insurance Certificate
--z;20/!K K7
Name and Contact Information of Insurer:
e�.lf
Policy Expiration bate�
Dig Safe #: -�2
Name of Competent Person (as defined by 520 CMR 7.02):
Massachusetts Hoistini L&enie 4
t 7C91g)
License Grade:
Expiration Date:
BY SIGNING THIS FORM, THE APPLICANT, OWNER, AND EXCAVATOR ALL ACKNOWLEDGE
AND CERTIFY THAT THEY ARE FAMILIAR WITH, OR, BEFORE COMMENCEMENT OF THE
WORK� WILL BECOME FAMILIAR WITH, ALL LAWS AND REGULATIONS APPLICABLE TO
WORK PROPOSED, INCLUDING OSHA REGULATIONS, G.L, c. 82A, 520 CMR 7.00 et seq., AND ANY
APPLICABLE MUNICIPAL ORDINANCES, BY-LAWS AND REGULATIONS AND THEY COVENANT
AND AGREE THAT ALL WORK DONE UNDER THE PERMIT ISSUED FOR SUCH WORK WILL
COMPLY THEREWITH IN ALL RESPECTS AND WITH THE CONDITIONS SET FORTH BELOW.
THE UNDERSIGNED OWNER AUTHORIZES THE APPLICANT TO APPLY FOR THE PERMIT AND
THE EXCAVATOR TO UNDERTAKE SUCH WORK ON THE PROPERTY OF THE OWNER, AND
ALSO, FOR THE DURATION OF CONSTRUCTION, AUTHORIZE S PERSONS DULY APPOINTED BY
THE MUNICIPALITY TO ENTER UPON THE PROPERTY TO MONITOR AND INSPECT THE WORK
FOR CONFORMITY WITH THE CONDITIONS ATTACHED HERETO AND THE LAWS AND
REGULATIONS GOVERING SUCH WORK.
THE UNDERSIGNED APPLICANT, OWNER AND EXCAVATOR AGREE JOINTLY AND SEVERALLY
TO REIMBURSE THE MUNICIPALITY FOR ANY AND ALL COSTS AND EXPENSES INCURRED BY
THE MUNICIPALITY IN CONNECTION WITH THIS PERMIT AND THE WORK CONDUCTED
THEREUNDER, INCLUDING BUT NOT LIMITED TO ENFORCING THE REQUIREMENTS OF STATE
LAW AND CONDITIONS OF THIS PERMIT, INSPECTIONS MADE TO ASSURE COMPLIANCE
THEREWITH, AND MEASURES TAKEN BY THE MUNICIPALITY TO PROTECT THE PUBLIC
WHERE THE APPLICANT OWNER OR EXCAVATOR HAS FAILED TO COMPLY THEREWITH
INCLUDING POLICE DETAILS AND OTHER REMEDIAL MEASURES DEEMED NECESSARY BY
THE MUNICIPALITY.
THE UNDERSIGNED APPLICANT, OWNER AND EXCAVATOR AGREE JOINTLY AND SEVERALLY
TO DEFEND, INDEMNIFY, AND HOLD HARMLESS THE MUNICIPALITY AND ALL OF ITS AGENTS
AND EMPLOYEES FROM ANY AND ALL LIABILITY, CAUSES OR ACTION, COSTS, AND EXPENSES
RESULTING FROM OR ARISING OUT OF ANY INJURY, DEATH, LOSS, OR DAMAGE TO ANY
PERSON OR PROPERTY DURING THE WORK CONDUCTED UNDER T141S PERMIT.
APPLICANT SIGNATURE'
a -K_ DATE
EXCAVATOR SIGNATURE (IF DIFFERENT)
DATE
OWNER'S SIGNATURE (IF DIFFERENT)
DATE:
2 1 P a g e
7/6 '-
DATE(Mmmoryyyyj
Acimbp CERTIFICATE OF LIABILITY INSURANCE I S/12/1
- 11%� H TIE
THIS CERTIFICATE IS ISSUED AS A mATrER OF wroRmAnoN ONLY AND coNFERS NO RIGHTS UPON T E CERTIFICA HOLDER THIS
CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMENDt EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES
BELOW. THS CERTIFICATE OF INSURANCE DOES NOT CONSTMJTE A CONTRACT BETWEEN THE ISSUING INSURER�S), AUTHORIZED
REPRESENTATIVE OR PRODUCEP, AND THE CFRTIF;CATE HOLDER.
-FM-pORTANT.- If the c@rdfIca1w holder is an ADDITIONAL INSURED, the policy(les) must be endomd. if SU WAIVED, subject to
the terms and conditions af the policy, certain policies my require an endorsement A staipment an this certificate does not conier rights to Me
certificate holder in lieu *f such andorsemengs). ZUNTACT JEL Paltonovich
PRODUCER NAME- Pau —
M.P. Roberts Insurance Agancy PHONE 1 Ngn (978) 683-3147
I&A N, Rt)- (9710 683-80.7.3
1060 Ongood Street E
A S: pau1a@m1Drobatt;8insur&nce-c0m
North Andover, MA 01845 INSURE 5 ArFORDING COVFRAGE
=+, L16Vdn
INSURIM
PETER BREE14 EXCAVATING INC
A/0 TRAV3:S & TIM CONSTRUCTION
770 BOXFORD STREET
NORTH ANDOVER, MA 01845
OVERAGES CERTIFICATE N UMBER: mr-Voolum MWIVIOrm. -
THIS 15 TO CERTIFY THAT THP- POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD
INDIQATED. NOTWTH67FANONG ANY REQUIREMENT, TERm OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WIT H RESPECT TO WHICH THIS
CERTIFICATE MAY BE ISSUED OR MAY PERTAIN, THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS,
EXCLUSIONS ANDCONDITIONS 05SUCH POUCIE$. LNITS SHOWN MAY HAVE BEEN REDUCEO BY PAIDCLAIMIS.
1,:M�Ff J,MR�X.OW,j LIMITS
A GENERAL UASILrry
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�701 CLAIMS-MAD6 lil OWUR
AGGRGGATELIMITAPPLIESKR:
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CESCRIPTION OPOPERATION$ I LOCATIONS IVEMCLES (Anm:h ACORD IM, AMMurud RqFrPrk% Schadula, Ifmorespace I8Mqwr90)
PAX# 978-689-8740/978-794-1625
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ACORD 25 (2010105) The AGORD naMe and logo are registered marks of AGORD
Phone: Fax: E -Mail-
- I I
SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE
THE EXRRATION DATE THEREOF, NOTICE WILL ME DELIVERED IN
CRUSADER PAPER 100
ACCORDANCE WITH THE POLCY PROVISIONS.
350 SOLT ROAD
AUTHDROM REMESENTATW
NORTH ANDOVER, Mh 01845
I
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w 'I moo -AU 1w JL%%.6Pr%Lj s�wr%vwmm FTVFN. Mq111!jF1wTwV1Awvwu-
ACORD 25 (2010105) The AGORD naMe and logo are registered marks of AGORD
Phone: Fax: E -Mail-
- I I
CONDITIONS AND REQUIREMENTS PURSUANT TO G.L.C.82A AND 520 CMR 7.00 et seq.
(as amended)
By Signing the application, the applicant understands and agrees to comply with the following:
No trench may be excavated unless the requirements of sections 40 through 40D of chapter 82, and any
accompanying regulations, have been met and this permit is invalid unless and until said requirements
have been complied with by the excavator applying for the permit including, but not limited to, the
establishment of a valid excavation number with the underground plant damage prevention system as
said system is defined in section 76D of chapter 164 (DIG SAFE);
Trenches may pose a significant health and safety hazard. Pursuant to Section I of Chapter 82 of the
General Laws, an excavator shall not leave any open trench unattended without first making every
reasonable effort to eliminate any recognized safety hazard that may exist as a result of leaving said
open trench unattended. Excavators should consult regulations promulgated by the Department of
Public Safety in order to familiarize themselves with the recognized safety hazards associated with
excavations and open trenches and the procedures required or recommended by said department in
order to make every reasonable effort to eliminate said safety hazards which may include covering,
barricading or otherwise protecting open trenches from accidental entry,
Persons engaging in any in any trenching operation shall familiarize themselves with the federal safety
standards promulgated by the Occupational Safety and Health Administration on excavations: 29 CFR
1926.650 et.seq., entitled Subpart P "Excavations".
iv.
Excavators engaging in any trenching operation who utilize hoisting or other mechanical equipment
subject to chapter 146 shall only employ individuals licensed to operate said equipment by the
Department of Public Safety pursuant to said chapter and this permit must be presented to said licensed
operator before any excavation is commenced;
vi.
By applying for, accepting and signing this permit, the applicant hereby attests to the following: (1) that
they have read and understands the regulations promulgated by the Department of Public Safety with
regard to construction related excavations and trench safety; (2) that he has read and understands the
federal safety standards promulgated by the Occupational Safety and Health Administration on
excavations: 29 CMR 1926.650 etseq., entitled Subpart P"Excavations" as well as any other
excavation requirements established by this municipality; and (3) that he is aware of and has, with
regard to the proposed trench excavation on private property or proposed excavation of a city or town
public way that forms the basis of the permit application, complied with the requirements of sections 40-
40D of chapter 82A.
This permit shall be posted in plain view on the site of the trench.
For additional information please visit the Department of Public Safety's website at www.mass.gov/di2s
3 1 P a g e
0
i
(�
0
13
File No.
-273
(To be provided by DEOE)
North Anlover
City/1 own
Commonwealth
of Massachusetts ECS Inc.
Applicant __gL_
Order of Conditions
Massachusetts Wetlands Protection Act
G JL. c. 131 9.§40
under--- the* Town o -r-.. y1a ;.Chapte. A-*'&' B"
a.nd f North Andove B w r 3.5
Nort--h Andover Conservation Commission
From
T
I ECS - Inc
1) . 0 !Name of t�p)lcant)
Box,
Pi-Tiehurst, 11"Li� 01866
Address
Address
same
(Name of property owner)
This Order!s issued and delivered as.follows:
(date)
0 lby hand delivery to applicant or representative on
17"s: Afhust 239 1985 (date)
:0 by certified mail, return r ested o
t .7, of N
Fr� te
s Es 0
_ITIC7 q 6f� Rea Sf-r,-et
Francis Estat--(--
This project Is locate
orth Essex
The property Is recorded at the Registry of
25-1
Boo Page
Certificate (if registered)
The Notice of Intent for this project was filed on. -May 2 1 1985 (date)
The public hearing was closed on Jiily 24, 1985 (date)
Findings
NACC has reviewed the above -referenced Notice of
The
Intent and plans and has held a public'hearing on the project. Based or'the information available to the
atthistime,the- NACC has determined that
ts In accordance with'
the area on which the proposed work is to be done is significant t,., the iollowing Interes
the Presumptions of Significance set forth in the regulatJons for each X-na Subject to Protection Under the
Act (check as appropriate)-.
135 Public water supply 5t6rm damage prevention
Qd Private water supply CZ Prev.ention of pollution'
Ca Ground water supply 0 Land containing shellfish
0 Flood control 0 FisherieA
PLANNNG BOARD
-IV
PD
9
00
;4
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North Andover BoArd of Assessors Public Access
Tot
.... 1p
CHUS
Click Seal To Return
Search for Parcels
Search for Sales
Summary
Residence
Detached Structure
Condo
Commercial
Page I of I
North Andover Board of Assessors
MM.
7ZIProperty Record Card
Parcel ID :210/038.0-0187-0000.0 FY:2013 Community: North Andover
SKETCH
Click on Sketch to Enlarge
PHOTO
Click on Photo to
29 NORTH CROSS ROAD
as
Location: 29 NORTH CROSS ROAD
Owner Name: PANDOLFO, RICHARD J
TERESE M PANDOLFO
Owner Address: 29 NORTH CROSS ROAD
City: NORTH ANDOVER State: MA Zip: 01845
Neighborhood: 7 - 7 Land Area: 1.00 acres
Use Code: 101-SNGL-FAM-RES Total Finished Area: 3935 sqft
ASSESSMENTS CURRENTYEAR. PREVIOUS YEAR
Total Value: 751,300 699,100
Building Value: 516,000 473,500
Land Value: 235,300 225,600
Market Land Value: 235,300
Chapter Land Value:
http://csc-ma.us/PROPAPP/display.do?linkld=2252332&town=NandoverPubAcc 10/22/2013
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Phone: 978-632-2660
JAMES A. TRUDEAU
Adjustment Service Inc.
P. 0. Box 7
Fax: 978-632-2662
Gardner, AM 01440
claimsAtrud auad*.com
Notice of Casualty Loss of Buildini!
Under Massachusetts General Laws, Chapter 139, Section 3B
March 4, 2015
)Building Inspector
120 Main Street
North Andover, MA 0 1845
Board of Health
120 Main Street
North Andover, MA 01845
Fire Department
Dept. of Records
124 Main Street
North Andover, MA 0 1845
Insured:
Richard Pandolfo
Loss Location:
29 North Cross Road, North Andover, MA 01845
Insurance Company:
The Concord Group Ins. Companies
Policy No.:
TBA
Date of Loss:
March 2,2015
File Number:
15-13007
Claim Number-
0001154257
Type of Loss:
Ice Dam
Claim has been made involving loss, damage, or destruction of the above captioned property, which may either
exceed $1,000.00 or cause "Mass. Gen. Laws, Chapter 143, Section 6" to be applicable. If any notice under "Mass.
Gen. Laws, Chapter 139, Section 3B" is appropriate, please direct it to the writer and include a reference to the
captioned insured, location, policy number, date of loss, and file or claim number.
Claim has been made involving loss, damage or destruction of the above -captioned property, which may
exceed $5000. If any notice under Massachusetts General Laws, Chapter 175, Section 97A is appropriate,
please direct it to the attention of this writer and include a reference to the above -captioned insured,
location, policy number, date of loss and claim number.
On this date, I cause copies of this notice to be sent to the person(s) named above at the address indicated by first
class mail.
Sincerely.
Joshua M. Trudeati
Claims Adjuster
P
P
11 r,), 2 2, 5
Date.. 129 .......
TOWN OF NORTH ANDOVER
PERMIT FOR PLUMBING
d I
This certifies that .... .... L�.- 6k, e,
.. ...... . .... ..... ..... ..... ..........................................................
2- ............ \
has permission to perform ......... CA J-;�, S�.SW� V
. �O
............................. f ....... . .....
plumbing in the buildings of....
D....................................................................................
..... . ......... North Andover, Mass.
.... RV
Fee.4 .'P-.... Lic. No. I . .................................................................................
PLUMBING INSPECTOR
I Check # � 0\0
610 �7, 3 ('01 — I q r, t 0 Vd I I
P
TYPE OR
PRINT
CLEARLY
MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK
CITY[_ MA DATE e /I
PERMIT#
JOBSITE ADDRESS L 7 'V OWN ER'S NAMErTzT/_2_)2;) VA17901r6
_j_
. ..... . .. . .........
OWNER ADDRESS TELL
FAX
OCCUPANCY TYPE COMMERCIAL ED EDUCATIONAL RESIDENTIAL
NEW: RENOVATION4.11 REPLACEMENT: E]
FIXTURES —1 FLOOR- 8SM
BATHTUB
CROSS CONNECTION DEVICE
DEDICATED SPECIAL WASTE SYSTEM
DEDICATED GAS/OIL/SAND SYSTEM
DEDICATED GREASE SYSTEM
DEDICATED GRAY WATER SYSTEM
DEDICATED WATER RECYCLE SYSTEM
DISHWASHER
DRINKING FOUNTAIN
---------- ----
FOOD DISPOSER
FLOOR /AREA DRAIN
INTERCEPTOR (INTERIOR)
KITCHEN SINK
LAVATORY
ROOF DRAIN
SHOWER STALL
......... .
SERVICE / MOP SINK
TOILET
URINAL
WASHING MACHINE CONNECTION
WATER HEATER ALL TYPES
.... . ..........
WATER PIPING
OTHER
PLANS SUBMITTED: YES 0 N00 .
INSURANCE COVERAGE:
I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL Ch. 142. YE4 NO
IF YOU CHECKED YES, PLEASE INDICAT
CYNE TYPE OF -COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW
LIABILITY INSURANCE POLI OTHER TYPE OF INDEMNITY [] BOND [_
OWNER'S INSURANCE WAIVER: I am aware that the licensee does not have the insurance coverage required by Chapter 142 of the
Massachusetts General Laws, and that my signature on this permit application waives this requirement.
SIGNATURE OF OWNER OR AGENT
I hereb cert; +k + 11 — -
CHECK ONE ONLY: OWNER El AGENT [I
I ly a a e deLails and imornriation I have submitted or entered regarding this application are true ccurate to t best of y knowledge
and that all plumbing work and installations performed under the permit issued for this application will n e n r ion of the
Massachusetts State Plumbing Code and Chapter 142 of the General Laws.
PLUMBER'S NAME[ LICENSE# FL-- SIGNATURE"
3�
M ip CORPORATION0#1
L LLC E]#
P4.
COMPANY NAME RESSI
ADD
C I TY STATE ZIP TEL
FAX CELL :50.1121 EMAIL .... . ------ . ...... Y, AV,]
LM
,71
Zs
a
4
4
.11 ��OMMONWEALTH OF MASSACHUSETTS
P. LUMBERS AND GASFITTERS
LICEN.S.ED AS A MASTER PLUMBER
ISSUES THE ABOVE LICENSE TO:
GLENN M MCCABE
POORFARM ROAD
DERRY
NH 03038-420Z�A
13562 05/01/14 187425
N b.
milli��
The Commonwealth ofMassachusetts
Department of IndustrialAccidints
Office of Investigations
600 Washington Street
Boston, MA 02111
www.mass.gov1dia
Workers' Compensation Insurance Affidavit: Buflders/ContractorsfElectriciansfPlumbers
Applicant Information Please Print Leeib
ividual):.
NaMe (Business/Organization/Ind A,(
Address: e d
CitylState/Zip:_0C06Z Phone 0
Are you an employer? Check the appropriate box:
LEI I am a employer with
4. El I am a general contractor and I
employees (fall and/or part-time).
have hired the sub -contractors
2 1 am a sole proprietor or partner-
Aship
listed on the attached sheet I
and'have no employees
These sub -contractors have
working for me in any capacity.
workers' comp. insurance.
[No workers' comp. Wurauce
5. El We are a corporation and its
required.]
officers have exercised their
3. [:11 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. 0 New con.struction
7. E] Remodeling
8. F1 Demolition
9. E] Building addition
10. n Electrical repairs or additions
1111 Plumbing repairs or additions
12. 0 Roofrepairs
13.[i Other
*Any applicant that checks box #1 must also fill out the section below showing their workers' compensation policy information.
T Homeowners who submit this affidavit indicating they tiie 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 isproviding workers'compensation insurancefor my employees. Below is thepolley andjoh site
information.
Insurance Company
Policy # or Self -ins. Lie. ff;
Expiration Date:
Job Site Address: City/State/Zip:
Attach a copy of the workers' compensationpolicy declaration page (showing the policy number and expiration date)
Failure to secure coverage as requiredunder 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
ofup 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.
I do hereby certjp,�WiVe 1"Ins rden7al ofperjury that the information provided above ' true nd correct.
Signature: Date:
Phone#: n
Official use only. Do not write in this area, to be completed by city or town ofji-cial.
City or Town:
Permit/License
Issuing Authority (circle one):
1. Board of Health 2. Building Department 3. City/Town Clerk 4. Electrical Inspector 5. Plumbing Inspector
6. Other
Contact Person: Phone
Information and Instrnctions
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 ofhire,-
express or implied, oral or written."
An employei is defined as "an individual, partnership, association, corporation or other legal entity, or any two or more
of the foregoing engaged in ajoint 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 apartaients 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 requ.ired."
Additionally, MGL chapter 152, §25C(7) states "Neither the commonwealth nor any of its political subdivisions shall
enter into any contract for the performance of public work until acceptable evidence of compliance with the insurance
requirements of this chapter have been presented to the contracting authority."
Applicants
Please fill out the workers' compensation affidavit completely, by checking ffic boxes that apply to your situation and, if
necessary, supply sub-contractor(s) name(s), address(es) and phone number(s) along with their certificate(s) of
insurance. Limited Liability Companies (LLQ or Limited Liability Partnerships (LLP) with no employees other than the
members or partners, are not required to carry workers' compensation insurance. If an LLC or LLP does have
employees, a policy is required. Be advised that this affidavit may be submitted to the Department of Industrial
Accidents for confirm�ation 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, reed 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 Riture permits or licenses. A new affidavit must be fille ' d 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 bum 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 Commonwealth of Ma s s a c -h- u s et ts
Dopartment of Industrial Accidents
Office of havestigations
600 Washington Street
Boston,MA02111
Tel, # 617-727-4900 ext 406 or 1-877-MASSAFE
Revised 5-26-05 Fax # 617-727-7749
--wWw-mass.gov/dia
............
Date .... .....
TOWN OF NORTH ANDOVER
PERMIT FOR WIRING
This certifies that ....... ....... ........ r .........
.................................................
r -e vv,, J -.-C
has permission to perform .... ...............................................................
wiring in the building of ........ .................................................................
at
...... ......................................................... . Andover
!S ,Nyrth lass.
.................
1,ee .... ...................... Lic. No ........
Check* -7656 ELEcT tot
IbI I Z11-3
Commonwealth of Massachusetts
MW Baw si Department of Fire Services
BOARD OF FIRE PREVENTION REGULATIONS
Official Use Only
Permit No. I k � M
Occupancy and Fee Checked
[Rev. 11071 (leave blank)
APPLICATION FOR PERMIT TO PERFORM ELECTRICAL WORK
All work to be performed in accordance with the Massachusetts Electrical Code (NEC), 527 CMR 12.00
(PLEASEYRTATINMK OR TYPE ALL MFORIkLMOA9 Date: za -2 V—
Z,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 rk described below.
Location (Street & Number) r---2eJ" 1149 '1-1// Z*gs( 0<70, 7 0,a --;9;D
Owner or Tenant Telephone No.
Owner's Address
Is this permit in conjunction with a building permit?
Purpose of Building
Existing Service _ Amps Volts
New Service Amps Volts
Number of Feeders and Ampacity
Location and Nature of Proposed Electrical Work:
Yes [ZK No F1 (Check Appropriate Box)
Utility Authorization No.
OverheadF] Undgrd [J No. of Meters
OverbeadF] Undgrd D No. of Meters
Completion ofthe followinR table may be waived by the Inspector of Wires.
No. of Recessed Luminaires
No. of Ceil.-Susp. (Paddle) Fans
No. o Total
Transformers KVA
No. of Luminaire Outlets
No. of Hot Tubs
Generators KVA
No. of Luminaires
Swimming Pool Above o In-
grnd. grnd. El
N-o.-OTEmergency Lighting
Battery Units
No. of Receptacle Outlets
No. of Oil Burners
FIRE ALARMS
INo. of Zones
No. of Switches
No. of Gas Burners
No. of Detection and
Initiating Devices
No. of Ranges
Total
No. of Air Cond. Tons
No. of Alerting Devices
No. of Waste Disposers
Heat Pump
Totals:
..........
No. of Self -Contained
Detection/Alerting Devices
No. of Dishwashers
Space/Area Heating KW
Local E] Municippl El 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
No. Hydromassage Bathtubs
No. of Motors Total HP
Telecommunications Wiring:
No. of Devices or Equivalent
OTHER:
-4 ttach additional detail if desired, or as requ !red by the Inspector of Rres.
Estimated Value of Electrical Work: (When required by municipal policy.)
Work to Start: Inspections to be requested in accordance with NIEC 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 operation7' 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.
CMCK ONE: INSURANCE [I BONDE] OTBEREI (Specify:)
I certify, under thepains andp nalties ofperjury, that the information on this application is true and complete.
FIRM NAME: LIC. NO.: Z�<4p;z 7
Licensee: Shmature LTC. NO.:
(If applicable, enter "exempt" in the license number line) Bus. Tel. No.:
_;Z e� �-W, Z,/ aw- z� -, -) / j�f
Address: <- A:7� o . Alt. Tel. No.:
*Per M.G.L c. 147's. 5'[-6l,-sejurity work fequires Departmefit of Public Safety "S' License: Lic. No.
OWNER'S INSURANCE WArVER: I am aware that the Licensee does not have the liability insurance coverage normally
er's agent.
required by law. By my signature below, I hereby waive this requirement. I am the (check one) [I owner El own
Owner/Agent
Signature Telephone No._ PkRMIT FEE.- $
9%
<1
K\
2012 Massachusetts Electrical Code Amendments 527 CMR 12.00 § Rule 8: In accordance -with the provisions of M.G.L. c. 143, § 3L, the
permit application form to provide notice of installation of wiring shall be uniform throughout the Commonwealth, and applications shall be filed
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.
0 Rule 8 — Permit/Date Closed: Note: Reapply for new permit 0
El Permit Extension Act — Permit/Date Closed:
Trench Inspection
Pass R1
Failed
Re- Inspection Required ($.) 0
Inspectors Comments:
Inspectors Signature:
Date:
SERV ICE INSPECTION:
I Pass Im
Failed
Re- Inspection Required 0
linspectors Comments:
Inspectors Signature:
Date:
irAMIAL ROUGH MSPECTION:
IPass N
Failed
Re- Inspection Required 0
I nspectors Comments:
Inspectors Signature:
Date:
ROUGH INSPR�CWN:
11
Pass
Failed
Re- Inspection Required 0
- I
Inspectors Comments:
4114
A
�/ 1
-_ /3
Inspectors Signature:
U
Date:
FINAL INSPECTMN:
Pass M V
Failed
Re- Inspection Required El
Inspectors Comm��
A
I Inspectors Si n:ature:
Date:
DEB WEINHOLD ... TOWN OF MERRIMAC, MA . ....... dweinhold@townofmerrimac.com
IS11-
1K The Commonwealth ofMassachusetis
Department ofIndustrialAccidihts
Office Of Investigations
600 Washington Street
Boston, MA 02111
www.mass.gov1dia
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers
Name (Business/Organization/Individual):
-Address:
City/State/Zip;
e_�I_Yq
0,4hone
Are you an employer? Check the appropriate box:
1. F1 I am a employer with
4. El I am a general contractor and I
employees (fall and/or part-ti-rne).*
have hired the sub -contractors
2. �a�i a sole proprietor or partner-
listed on the attached sheet. I
ship and'have no employees
These sub -contractors have
working for me in any capacity.
workers' comp. insurance.
[No workers' comp. insurance
5. El 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. F1 New con.struction
7. P(Remodeling
8. 0 Demolition
9. E] Building addition
10. Electrical repairs or additions
11. Plumbing repairs or additions
12.n Roof repairs
13.[i 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 aire doing all work and then hire outside contractors must submit anew 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 isproviding workers'compensadon insuranceformy employees. Below is thepolley andjob site
information.
Insurance Company Name;
Policy # or Self -ins. Lic.
Expiration Date;
Job Site Address: C tate/Zip:
f ity/S
Attach a copy of the workers' compensation -policy declaration page (showing the policy number and expiration date).
Failure to secure coverage as requiredunder 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, a's 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 ffie DIA for insurance coverage verification.
I do hereby certify under th e pains andpenalties ofperfury th at th e information provided above is true and correct.
Sienature: Date: —c>2
Phone#:
Official use only. Do not write in this area, to he completed by city or town official.
City or Town:
Permit/License 0
Issuing Authority (circle one):
1. Board of Health 2. Building Department 3. City/Town Clerk 4. Electrical Inspector 5. Plumbing Lispector
6. Other
Contact Person:
Phone
Information and Instructions
Massachusetts General Laws chapter 152 requires all employers to provide workers' compensation for their employees.
Pursuant to this statute, an employee is defined as "...every person in the service of another under any contract ofhire,-
express or implied, oral or written."
An employeiis defined as "an individual, partnership, association, corporation or other legal entity, or any two or more
of the foregoing engaged in ajoint 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-contractor(s) name(s), address(es) and phone number(s) along with their certificate(s) of
insurance. Limited Liability Companies (LLQ or Limited Liability Partnerships (LLP) with no employees other than the
members or partners, are not required to carry workers' compensation insurance. If an LLC or LLP does have
employees, a policy is. required. Be advised that this affidavit may be submitted to the Department of Industrial
Accidents for confirmation of insurance coverage. Also be sure to sign and date the affidavit. The affidavit should
be returned to the city or town that the application for the permit or license is being requested, not the Department of
Industrial Accidents. Should you have any questions regarding the law or if you are required to obtain a workers'
compensation policy, please call the Department at the number listed below. Self-insured companies should enter their
self-insurance license number on the appropriate line.
City or Town Officials
Please be sure that the affidavit is complete and printed legibly. The Department has provided a space at the bottom
of the affidavit for you to fill out in the, event the Office of Investigations has to contact you regarding the applicant.
Please be sure to fill in the permit/license number which will be used as a reference number. In addition, an applicant
that must submit multiple permit/license applications in any given year, need only submit one affidavit indicating current
policy information (if necessary) and under "Job Site Address"' the applicant should write "all locations in -(City or
town)." A copy of the affidavit that has been officially stamped or marked by the city or town may be provided to the
applicant as proof that a valid affidavit is'on file for future permits or licenses. A new affidavit must be fined 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 p* ermit to bum leaves etc.) said person is NOT required to complete this affidavit.
The Office of Investigations would Eke 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 ajid fax number:
The Commormealth of Massachusetts
Departramt of Industrial Accidents
Office of favestigations,
600 WasWngtoa Sjre�t
Boston, MA 021 It
TO. 9 617-7-27-4900 oxt 406 or 1-877,7MASSAFE
Revised 5-26-05 Fax # 617-727-7749
__WWWjUasS.gQVaa
M
I
Date....
... ............... ..
TOWN OF NORTH ANDOVER
PERMIT FOR WIRING
This certifies that ...................... A ... L) 7 ................................................
...... .... .......
has permission to perform ............ 5 .... :5'v�' .........
wiring in the building of .............. fi-'2-1VDC 1-/- 0
......................................................................
at ....... ........ North Andover, Mass.
... .... 2. �-, �i ��-i � - &-ri.cTo1v
Fee. Lic. No.e��IrO
Check # LI U (I
9061
<�\, (fommonweafik ol Ma,acLetb Official Use Oni�
0M . . Permit No.
Occupancy and Fee Checked
BOARD OF FIRE PREVENTION REGULATIONS [Rev.1/07]
APPLICATION FOR PERMIT TO PERFORM ELECTRICAL WORK
All work to be performed 'in accordance %%ith die Massachus,-ns Electrical Code (MEC). 5n27X.,fR 12.00
(PL EASf PR[,VT I. -V IVK OR T) TEA LL 1WORAL4 TIOJV) Date: ) / --� /0 2
. City or Town of: 4� A�2)�,e— To the Inspec(or of TVires.-
By this application the undersigned gives not' of1iisorher-11 t . n to perform the electrical work described below.
Location (Street & Number) c,,,v, Z X
OwnerorTeriant Telephone No.
O,,vner's'Address
Is this permit in -conjunction N�ith a buildin permit? Yes r No Y\ I (Check Appropriate Box)
Purpose of Building
Existing Service Amps Volts
New Service Amps Volts
Number o, Feeders arid Arripacity
Location and Nature of Proposed Electrical Work:�
Utility Authorization No.
OverheaclF� Unclard F No. of iMeters
Overhead UndgrdE] No. of Meters
6
Completion of the followine table mov be %vaived bv the Insoector of H'ires.
No. of Recessed Luminaires
NNo. of Ceil.-Susp.-(Paddle) Fans
No. of Total
Transformers KVA
No. of Luminaire Outlets
No. of Hot Tubs
Generators KVA
No. of Luminaires
Above In-
Swimming Pool - F�
-rnd. arnd.
No. ot �-mergency Liahi[InZ
Battery Units
No. of Receptacle Outlets
No. of Oil Burners
FIRE ALARj'YIS
I No. of Zones
No. of Switches
No. of Gas Burners
No. of Detection and
Initiatin2 Devices
No. of Ranges
Total
No. of Air Cond. Tons
No. of Aler-ting Devices
No. of Waste Disposers
Heat Pump
Totals:
I .
1-9.n.s.
I. . I
K W
............
IN 0. of Seif-Contained
Detection/Aler-tina Devices
No. of Dishwashers
Space/Are2 Heating KW
n
Local D Municipal n 11 Other
Connectio
No. of Drye . rs
Heating Appliances KW
Security Systems:*
No. of bevices or Equivalent
No. of Water
Heaters KW
No. of No. of
Signs Ballasts
Data Wirin-:
No. of D'evices or Equivalent
No. Hydrornassage Bathtubs
No. of Motors Total HP
Telecommunications Wiring:
No. of Devices or Equivalent
OTHER: 'k- -7 off Ire
Attach additional detail if desired, or as required by the Inspector of JVires.
Estimated Value of Electrical'W&k: 4/,!,/
.k, (When required by municipal policy.)
Work to Start: Inspections to be requested in accorclancewith NEC Rule 10, and upon completion.
INSURAN,CE COVERACE: Unless walved by the owner, no permit for the performance of electrical work may issue unless
the licen§�.e provides proof of liability insurance including "completed operation" coverage or its substantial equivalent. The
undersi2ned certifies that such coverage is in force, and has exhibited proof of same to the permit issuing office.
CHECKONE: INSURANCF [Z BOND [] OTHER 0 (Specify:) Self Insured
I certify, under thepains andpenallies ofperjury, that the i rmation on this application is true and complete.
FIRMNAME: A -DT Security Services L I C. N 0.:
Licensee: Mark A. Brophy __.Sign2tu e LIC. NO.: C-45
�Ifopplicable, enter "exempt - in the license number line.) Bus.Tel.No.: 603-594-S928
Address: 18 Clinton Dr�ve Hollis, NH Alt. Tel. No.:
*Per M.G.L. c. 147, s. 57-61, security work requires Department of Public Safety "S" License: Lic. Nlo. 00953
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 11 owner's agen .
Owner/Agent — g) I
Si -nature Telephone No.
EpEgm:,E FEE: S
p i I y 6, �jy �"f' a .'V -j 'Pj.j
s c CS C/I U 1.0 c SI) s 6 L s
o 9 9. o z o (I o o 1�" H o H
I- s 3 s 8 0 W. I L
d S H � C) �2 V ��VH
3 A 3 S A 11 �.A 1 J. (I V 3 'A.i
01 3SH3:)Il CHI FIOSSI
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siii snH)VSSVH'J-0'Hl�V]MNoWNQ3
13,
d'L L L :Oi 'J
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CSIGG00 00
Ai3zws onend -40
... . ....... . ...... .... ........
6\107. L 700
U0, ;0 80W�qo Puic ldl,3:)oj joj dal dgn>i
Ll 'Ji
�j J�/
z9ozo 'V'N 'oc)o�e'�rox
-zis Al-tdoug V'>D(VK
00 :01 POPU150
:,Oz//-O/Zo :sa-jfdx�3 Ec
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Pd �O ;UGW�JedG(] . . . . . .
0
Dat
TOWN OF NO
PERMIT FOR GAS INSTALLATION
This certifies that ........
has permission for gas. installation .........
in the buildings of . . ........... ........................
at ........................... '—., North Andover, Mass.
Fee,;.:��-.�� Lic. No:'���57.. ..... ...........
Check# ?c� GAS INSSECIT�6
5890
rMIS Sri
7j -
I la R -
C9
MASSACHUSETTS UNIFORM APPLICATION FOR PERMIT TO DO GASFITTING
(Print or Type)
NORTH ANDOVER Mass. Date 1/31
Building Location 29 N CROSS RD
Owner Tel# 978 682 9831
2007 Permit #
Owner's Name TERESE PANDOLFO
Type of Occupancy RESIDENTIAL
NewFv-1 RenovationF-1 ReplacementF-1 Plan Submitted: Ye[] No[:]
FIXTURES
W Installing Company Name Eastern Propane & Oil, Inc
Address 131 Water Street
Danvers, MA 01923
Business Telephone # 800-322-6628
Name of Licensed Plumber or Gas Fitter
Check one: Certificate
Fv]Corporation
F]Partnership
F]Firm/Co.
INSURANCE COVERAGE:
have a, cu liability insurance policy or its substantial equivalent which meets the requirements of MGL Ch. 142.
, -s' No 11
Y
f you have c�ecked yes, please indicate the type coverage by checking the appropriate box.
A liability insurance policy F-11 Other type of indemnity 11 Bond 0
OWNER'S INSURANCE WAIVER: I am aware that the licensee does not have the insurance coverage required by Chapter 142 of the
Mass. General Laws, and that my signature on this permit application waives this requirement.
Check one:
Owner 11 Agent 11
Signature of Owner or Owner's Agent
I hereby certify that all of the details and information I have submitted (or entered) in above application are true and accurate to the best of my
knowledge and that all plumbing work and installations performed under the permit issued for this ap tio ill be in compliance with all
)ertinent provisions of the Massachusetts State Gas Code and Chapter 142 of the General ws.
By_ Type of License: 657
- -Plumber Signature Af Li1,EMse0o*r11umber or Gas Fitter
Title %.AGas fitter
- -Master License abeK,?
City/Town - -Journeyman
APPROVED (OFFICE USE ONLY)
Aqs,161�ry or To-wi
-'I— -
>
z
w
OD
6
0 ce 0
C:, cn
C, cn
8
o
(D
PUBLIC HEALTH DEPARTMENT
Town of North Andover
Community Development Division
CERTIFICATE OF
COMPLIANCE
As of.- 7/31/2015
This is to certify that the individual subsurface disposal system received a
SATISFACTORY INSPECTION of the:
Repair of D -Box and Outlet Tee
By: Todd Bateson
At:
40 North Cross Rd.
Map 038.0 Lot 0183
North Andover, MA 01845
'\t be construed as a guarantee that the system will function satisfactorily.
The 15kance of this certi!1-Te"sQ1 no
Michele Grant
V
Public Health Agent
1600 Osgood Street, North Andover, Massa(husetts 01845
Phone 978.688.9540 Fax 978.688.8476 Web www.townofnorthandover.(om
North Andover Health Department
(ommunity and Economic Development Division
ONSITE WASTEWATER SYSTEM CONSTRUCTION NOTES
LOCATION INFORMATION
ADDRESS: 40 North Cross Rd.
INSTALLER: Todd Bateson
DESIGNER:
PLAN DATE:
BOH APPROVAL DATE ON PLAN:
MAP: 038.0 LOT: 0183
INSPECTIONS
Outlet T and D -Box:
DATE OF BED BOTTOM INS�
DATE OF FINAL CONSTRUCTION INSPECTION:
DATE OF FINAL GRADE INSPECTION:
SITE CONDITIONS
Comments:
SEPTIC TANK
Contractor reports any changes to design plan
' Existing septic tank properly abandoned,
Internal plumbing all to one bu ilding sewer
Topography not appreciably altered
F1 Building sewer in continuous grade, on
compacted firm base
El Cleanouts per plan
El Bottom of tank hole has 6" stone base
El Weep hole plugged
El 1500 gallon tank has been installed
H-10 loading
El Monolithic tank construction
El Water tightness of tank has been achieved by
visual testing
Inlet tee installed, centered under access port
F-1 Outlet tee installed, centered under access port
(gas baffle/effluent filter)
El inch cover to within 6" of finish grade
installed over one access port
F-1 Hydraulic cement around inlet & outlet
Comments:
PUMP CHAMBER
F-1 Bottom of tank hole has 6" stone base
Weep hole plugged
F-1 1500 gallon Pump Chamber installed
F-1 H-10 loading
F-1 Monolithic tank construction
F-1 Inlet tee installed, centered under access port
E] Pump(s) installed on stable base
F-1 Alarm float working
F-1 Pump On/Off floats working
F-1 Separate on/off floats
F-1 Drain hole in pressure line
El cover at final grade installed over pump
access port
Ej Water tightness of tank has been achieved by
testing
Hydraulic cement around inlet & outlet
Comments:
CONTROLPANEL
E] Alarm & Pump are on separate circuits
El Alarm sounds when float is tripped
F-1 Location of control panel: basement
0 Alarm signal located inside: basement
Comments:
DISTRIBUTION -BOX
F-1 installed on stable stone base
R H-20 D -Box
El inlet tee (if pumped or >0.08'/foot)
0 Hydraulic cement around inlet & outlets
Fj Observed even distribution
El Speed levelers provided (not required)
F-1 Schedule 40 PVC Pipe
Comments:
N-1
Ax
#a Ai
, 4--c
All
NI
AL
04
ly
Loh,
14,
Ou
Commonwealth of Massachusetts Map -Block -Lot
038.00183
-----------------------
BOARD OF HEALTH Permit No
BHP -2015-0324
North Andover -----------------------
P.I. FEE
$125.00
F.I. -----------------------
DISPOSAL WORKS CONSTRUCTION PERMIT
Pennission is hereby granted Todd -Bate -son -------------------------------------------------------------- ------------
to (Repair) an Individual Sewage Disposal System.
atNo 40 NORTH CROSSROAD ta- 17kt ------------------------------------------
a-A
as shown on the application for Disposal Works Construction Permit No. 2 Dated, July 30, 2015
I=- I e -------------------
------------------------------------------
Issued On: Jul -30-2015 BOARD OF HEALTH
---------------------------------------------------------------------------------- ---
Important
When filling out
forms on the
computer, use
only the tab key
to move your
cursor - do not
use the return
key.
VQ
I&Aq,
Application for Septic Disposal System
Construction Permit -TOWN OF
NORTH ANDOVER. MA 01845
Construct a new on-site sewage disposal system*
[] Repair or replace an existing on-site sewage disposal system*
21(e-Wir or replace an eidsting system component - What?
A. Facility Information 'Ife A1,9 \__11k
�7 - a-,_9 - / ---
TODAY S DATE
$ 250.00 - Full Repair
$125.00 - Component
RECEIVED
Add s or Lot # un '40 7015
V t.
N9,
CityfTow
TOWN OF NORTH ANDOVER
jiEkLTH DEPARTMENT
2, *TYPE OF SEPW SYSTEW:
> [] Pump JE -Gravity (choose one)
—lfjoumE_sy qm, attach copy of electrical permit to applicafion�
> L!!rConventional System (pipe and stone system) tron to instaff this type of system.)
> 0 Infiltrator or Biodiffuser (Gravel -Less) (Attach a copy of your certifica
> 0 Pressure Distribution S.A-S. (No D -Box)
> F1 Pressure Dosed (D -Box Present) SJLS.
> 0 Does the system require an effluent filter? Yes Nq__
If yes, does plan specify make and model of filter? YES = (no further info. needed)
NO = (installer must specify brand of filter before DWC issuance)
What is the Make?
2. Owner Information
,k,d
Address (if different from above
Ziiii-rown
3. Installer Information
-_ 1-1 ILZ9 101-.e
Name
Wha t is t he Mo dc 9
Address
,4 V-ZjL_ /,L14
Ztd_y_/Town
4. U0S1_Q
Name
Address
Cityfrown
— 0 C Y -Y5
State Zip Code
7 7
Telephone Number
Name of
BATMONENTERPRI-sEs,
1TI —ARGILLA ROAD'
ANDOVERMA01810
_§ �te�� Zip Code
Telephone Number (Cell Phone #if possible pleasID)
Name of Company
state
Zip Code
Ye-lephone Number (Best # to Reach)
Application for Disposal System Construction Permit - Page 1 of 2
Applicati-oh.for Septic Disposal ..S.y F7 - 3 01
stem
TODAYS DAM
Monstruction -Permit' TOWN
A -ORTH ANDOVER, MA 01845 $.250.00 " Full Repair
$125.00.- Component
PAGE 2 OF 2
A. Facility. Information continued....
6. Type* of Buildin-g: 2ffe--s-ldential Dwelling or E30ornmercial
B. Agreement
The undersigned agrees to ensur ' e the construction and maintenance of the afore-dei6fibed
on-slte sewage disposal sYstem In accordance with the provisions of Title 5 of the
Environmental Code, as well as the Local Subsurf6ce Disposal Regulations for the Town of
North Andover, and not to place the system lh operation until a Certfflcate Of Compliance has
been Issued b this Board of Health.
Name —6a—te
P r6ved B 0 epresentatIve)
-30
Date
Application Ditapproved.. for the following reasons:
For Office Use
I.
Fee Amazed?:
Yes
No
2.-
ProjectMgd2ger oh,&g2don Form Attached?
yis
No .
3.:
&M -D 17sqjAff-0ChCQQ M P
NO
4.
Fbundado.& As -Built? (new Construction -ronly).-
yes
.
1,qffM.- a.-af.-
. —
NO
A F1oorPLws?(neWC0jjS
tru C tio n o n No
I 1)1�potai �'Y.Stee.n--.C:6n*Uc(1 on Permn Page 2 Of 2
ISOM
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Owner
information is
required for
every page.
Important:
When filling out
forms on the
computer, use
only the tab key
to move your
cursor - do not
use the return
key -
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
40 North Cross Road
Property Address
Edward O'Toole
Owner's Name
North Andover
Cityrrown
MA 01845
§-t—ate -Zip Code
7/31/2015
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.
A. General Information
1. Inspector:
Neil J. Bateson
Name of Inspector
Bateson Enterprises Inc.
Company Name
111 Argilla Road
Company Address
Andover
Cityfrown
978-475-4786
Telephone Number
B. Certification
MA 01810
State Zip Code
S115
License Number
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 6 (310 CMR 15.000). The system:
Z Passes E] Conditionally Passes El Fails
Needs urther Evaluation by the Local Approving Authority
AS In AW
I TOM, Cc' NORTH ANDOVER
LzAb �)Lll ��� 7/31/2015 HEALTH DEPARTMENT
Inspecdt r, Sijnature Date
The 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 - 3113 Title 5 Official Inspection Form: Subsurface Sewage Disposal System - Page I of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
40 North Cross Road
Property Address
Edward O'Toole
Owner Owners Name
information is
required for North Andover MA 01845 7/31/2015
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:
Z 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:
After permit from B.O.H., install new outlet tee with gas baffle in septic tank & new d -box, septic
system now passes Title 5 inspection.
B) System Conditionally Passes:
F1 one or more system components as described in the "Conditional Pass" section need to be
replaced or repaired. The system, upon completion of the replacement or repair, as approved by
the Board of Health, will pass.
Check the box for "yes", "no" or"not determined" (Y, N, ND) forthe following statements. If "not
determined," please explain.
The septic tank is metal and over 20 years old* or the septic tank (whether metal or not) is
structurally unsound, exhibits substantial infiltration or exfiltration or tank failure is imminent. System
will pass inspection if the existing tank is replaced with a complying septic tank as approved by the
Board of Health.
* A metal septic tank will pass inspection if it is structurally sound, not leaking and if a Certificate of
Compliance indicating that the tank is less than 20 years old is available.
EI Y El N [I ND (Explain below):
t5ins - 3113 Title 5 Official Inspection Form: Subsurface Sewage Disposal System - Page 2 of 17
<t\ Commonwealth of Massachusetts
Title 5 Official Inspection Form AUG 0 3 2015
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
TOWN OF NORTH ANDOVER
40 North Cross Road. HEALTH DEPARTMENT
Property Address
Edward O'Toole
Owner
information i's
required for
every page.
Important:
When filling out
forms on the
computer, use
only the tab key
to move your
cursor - do not
use the return
key.
dl ---h
111101"
Owners Name
North Andover
City/Town
MA 01845
State Zip Code
7/23/2015
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.
A. General Information
1. Inspector:
Neil J. Bateson
Name of Inspector
Bateson Enterprises Inc.
Company Name
111 Arailla Road
Company Address
Andover MA
Cityrrown State
978-475-4786 S115
Telephone Number
B. Certification
License Number
01810
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 expedence 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:
F-1 Passes Z Conditionally Passes El Fails
El Neqds Further Evaluation by the Local Approving Authority
7/23/2015
ln*e�cto& Signhitre Date
The 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 - 3113 Title 5 Official Inspection Form: Subsurface Sewage Disposal System - Page 1 of 17
Owner
information is
required for
every page.
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
40 North Cross Road
Property Address
Edward O'Toole*
Owner's Name
North Andover MA 01845 7/23/2015
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:
El I have not found any information which indicates that any of the failure criteria described
in 310 CMR 15.303 or in 310 CMR 15.304 exist. Any failure criteria not evaluated are
indicated below.
Comments:
B) System Conditionally Passes:
one or more system components as described in the "Conditional Pass" section need to be
replaced or repaired. The system, upon completion of the replacement or repair, as approved by
the Board of Health, will pass.
Check the box for "yes", "no" or "not determined" (Y, N, ND) for the following statements. If "not
determined," please explain.
The septic tank is, metal and over 20 years old* or the septic tank (whether metal or not) is
structurally unsound, exhibits substantial infiltration or exfiltration or tank failure is imminent. System
will pass inspection if the existing tank is replaced with a complying septic tank as approved by the
Board of Health.
* A metal septic tank will pass inspection if it is structurally sound, not leaking and if a Certificate of
Compliance indicating that the tank is less than 20 years old is available.
El Y 0 N El ND (Explain below):
t5ins - 3113 ritle 5 Official Inspection Form: Subsurface Sewage Disposal System - Page 2 of 17
Owner
information is
required for
every page.
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
40 North Cross Road
Property Address
Edward O'Toole
Owner's Name
North Andover
Cityrrown
B. Certification (cont.)
MA 01845 7/2312015
State Zip Code Date of Inspection
Pump Chamber pumps/alarms not operational. System will pass with Board of Health approval if
pumps/alarms are repaired.
B) System Conditionally Passes (cont.):
El Observation of sewage backup or break out or high static water level in the distribution box due
to broken or obstructed pipe(s) or due to a broken, settled or uneven distribution box. System will
pass inspection if (with approval of Board of Health):
El broken pipe(s) are replaced El Y Z N El ND (Explain below):
R obstruction is removed El Y 0 N El ND (Explain below):
n distribution box is leveled or replaced F-1 Y Z N [I ND (Explain below):
F1 The system required pumping more than 4 times a year due to broken or obstructed pipe(s). The
system will pass inspection if (with approval of the Board of Health):
0 broken pipe(s) are replaced El Y Z N El ND (Explain below):
El obstruction is removed El Y 0 N [I ND (Explain below):
C) Further Evaluation is Required by the Board of Health:
El Conditions exist which require further evaluation by the Board of Health in order to determine if
the system is failing to protect public health, safety or the environment.
1. System will pass unless Board of Health determines in accordance with 310 CMR
15.303(l)(b) that the system is not functioning in a manner which will protect public health,
safety and the environment:
El 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 marsh
t5ins - 3113 -ritle 5 Official Inspection Form: Subsurface Sewage Disposal System - Page 3 of 17
Owner
information is
required for
every page.
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
40 North Cross Road
Property Address
Edward O'Toole
Owners Name
North Andover MA 01845 7/23/2015
Cityrrown State Zip Code Date of Inspection
B. Certification (cont.)
2. System will fall unless the Board of Health (and Public Water Supplier, if any)
determines that the system is functioning in a manner that protects the public health,
safety and environment:
E] 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.
El The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water
supply.
F-1 The system has a septic tank and SAS and the SAS is within 50 feet of a private water
supply well.
El The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or
more from a private water supply well".
Method used to determine distance:
** This system passes if the well water analysis, performed at a DEP certified laboratory, for fecal
coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal
to or less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis must
be attached to this form.
3. Other:
Outlet baffle in septic tank & d -box needs to be replaced.
D) System Failure Criteria Applicable to All Systems:
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
El N 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 N Liquid depth in cesspool is less than 6" below invert or available volume is less
than Y2day flow
t5ins - 3/13 Title 5 Official Inspection Form: Subsurface Sewage Disposal System - Page 4 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
40 North Cross Road
Property Address
Edward O'Toole
Owner Owners Name
information is
required for North Andover MA 01845 7/23/2015
every page. Cityrrown State Zip Code Date of Inspection
B. Certification (cont.)
Yes No
El 0 The system is a cesspool serving a facility with a design flow of 2000gpd-
10,000gpd.
The system fails. I have determined that one or more of the above failure
criteria exist as described in 310 CMR 15.303, therefore the system fails. The
system owner should contact the Board of Health to determine what will be
necessary to correct the failure.
E) Large Systems: To be considered a large system the system must serve a facility with a
design flow of 10,000 gpd to 15,000 gpd.
For large systems, you must indicate either "yes" or "no" to each of the following, in addition to the
questions in Section D.
Yes No
E-1 El the system is within 400 feet of a surface drinking water supply
El El the system is within 200 feet of a tributary to a surface drinking water supply
the system is located in a nitrogen sensitive area (interim Wellhead Protection
Area — IWPA) or a mapped Zone 11 of a public water supply well
If you have answered "yes" to any question in Section E the system is considered a significant threat,
or answered "yes" in Section D above the large system has failed. The owner or operator of any large
system considered a significant threat under Section E or failed under Section D shall upgrade the
system in accordance with 310 CMR 15.304. The system owner should contact the appropriate
regional office of the Department.
t5ins - 3/13 Title 5 Official Inspection Form: Subsurface Sewage Disposal System - Page 5 of 17
Required pumping more than 4 times in the last year NOT due to clogged or
obstructed pipe(s). Number of times pumped:
El 0
Any portion of the SAS, cesspool or privy is below high ground water elevation.
El 0
Any portion of cesspool or privy is within 100 feet of a surface water supply or
tributary to a surface water supply.
El M
Any portion of a cesspool or privy is within a Zone 1 of a public well.
El 0
Any portion of a cesspool or privy is within 50 feet of a private water supply
well.
D E
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.]
El 0 The system is a cesspool serving a facility with a design flow of 2000gpd-
10,000gpd.
The system fails. I have determined that one or more of the above failure
criteria exist as described in 310 CMR 15.303, therefore the system fails. The
system owner should contact the Board of Health to determine what will be
necessary to correct the failure.
E) Large Systems: To be considered a large system the system must serve a facility with a
design flow of 10,000 gpd to 15,000 gpd.
For large systems, you must indicate either "yes" or "no" to each of the following, in addition to the
questions in Section D.
Yes No
E-1 El the system is within 400 feet of a surface drinking water supply
El El the system is within 200 feet of a tributary to a surface drinking water supply
the system is located in a nitrogen sensitive area (interim Wellhead Protection
Area — IWPA) or a mapped Zone 11 of a public water supply well
If you have answered "yes" to any question in Section E the system is considered a significant threat,
or answered "yes" in Section D above the large system has failed. The owner or operator of any large
system considered a significant threat under Section E or failed under Section D shall upgrade the
system in accordance with 310 CMR 15.304. The system owner should contact the appropriate
regional office of the Department.
t5ins - 3/13 Title 5 Official Inspection Form: Subsurface Sewage Disposal System - Page 5 of 17
Commonwealth of Massachusetts
itle 5 c a nspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
40 North Cross Road
Property Address
Edward O'Toole
Owner Owner's Name
information is
required for North Andover MA 01845 7/23/2015
every page. Cityrrown State Zip Code Date of Inspection
C. Checklist
Check if the following have been done. You must indicate "yes" or "no" as to each of the following:
Yes No
D. System Information
Residential Flow Conditions:
Number of bedrooms (design): 4 Number of bedrooms (actual): 4
DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x # of bedrooms): 600
t5ins - 3/13 Title 5 Official Inspection Form: Subsurface Sewage Disposal System - Page 6 of V
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?
Has the system received normal flows in the previous two week period?
El E
Have large volumes of water been introduced to the system recently or as part of
this inspection?
Were as built plans of the system obtained and examined? (If they were not
available note as N/A)
2 El
Was the facility or dwelling inspected for signs of sewage back up?
Z El
Was the site inspected for signs of break out?
0 El
Were all system components, excluding the SAS, located on site?
0 E]
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?
0 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:
E] 0
Existing information. For example, a plan at the Board of Health.
Determined in the field (if any of the failure criteria related to Part C is at issue
approximation of distance is unacceptable) [310 CMR 15.302(5)]
D. System Information
Residential Flow Conditions:
Number of bedrooms (design): 4 Number of bedrooms (actual): 4
DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x # of bedrooms): 600
t5ins - 3/13 Title 5 Official Inspection Form: Subsurface Sewage Disposal System - Page 6 of V
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
40 North Cross Road
Property Address
Edward O'Toole
Owner Owners Name
Yes
E]
No
El
information is
required for North Andover MA 01845 7/23/2015
F1
No
D
Yes
every page. CityfTown State Zip Code Date of Inspection
No
D. System Information
Description:
Number of current residents:
2
Does residence have a garbage grinder?
Yes
No
Is laundry on a separate sewage system? (Include laundry system inspection
El
Yes
0
No
information in this report.)
Laundry system inspected?
D
Yes
R
No
Seasonaluse?
El
Yes
2]
No
Water meter readings, if available (last 2 years usage (gpd)):
Yes
Detail:
Sump pump?
0
Yes
El
No
Last date of occupancy:
Current
Date
Commerciallindustrial Flow Conditions:
Type of Establishment:
Design flow (based on 310 CMR 15.203):
Basis of design flow (seats/persons/sq.ft., etc.):
Grease trap present?
Industrial waste holding tank present?
Non -sanitary waste discharged to the Title 5 system?
Water meter readings, if available:
Gallons per day (gpd)
El
Yes
E]
No
El
Yes
F1
No
D
Yes
[]
No
t5ins - 3113 ritle 5 Official Inspection Form: Subsurface Sewage Disposal System - Page 7 of 17
I
'<L\ Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
40 North Cross Road
Owner
information is
required for
every page.
Property Address
Edward O'Toole
Owners Name
North Andover
Cityrrown
D. System Information (cont.)
Last date of occupancy/use:
Other (describe below):
Pumping Records:
Source of information:
MA 01845 7/23/2015
State Zip Code Date of Inspection
Date
General Information
Was system pumped as part of the inspection?
If yes, volume pumped:
How was quantity pumped determined?
Unknown
gallons
10�01M
Reason for pumping:
Type of System:
Septic tank, distribution box, soil absorption system
El Single cesspool
El Overflow cesspool
El Privy
E] Shared system (yes or no) (if yes, attach previous inspection records, if any)
0 Innovative/Alternative technology. Attach a copy of the current operation and
maintenance contract (to be obtained from system owner) and a copy of latest
inspection of the I/A system by system operator under contract
El Tight tank. Attach a copy of the DEP approval.
El Other (describe):
t5ins - 3/13 Title 5 Official Inspection Form: Subsurface Sewage Disposal System - Page 8 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
40 North Cross Road
Property Address
Edward O'Toole
Owner
Owner's Name
information is
North Andover MA
required for
every page.
Cityrrown State
01845 7/23/2015
Zip Code Date of Inspection
D. System Information (cont.)
Approximate age of all components, date installed (if known) and source of information:
25 years old, 8/17/1990, as built plan
Were sewage odors detected when arriving at the site? El Yes 0 No
Building Sewer (locate on site plan):
Depth below grade: 1.6
feet
Material of construction:
E cast iron 0 40 PVC El other (explain):
Distance, from private water supply well or suction line: feet
Comments (on condition of joints, venting, evidence of leakage, etc.):
4" Cast iron out to septic tank, 3" PVC in house, no leaks visible
Septic, Tank (locate on site plan):
Depth below grade:
Material of construction:
concrete metal
E.
feet
El fiberglass El polyethylene ' [I other (explain)
If tank is metal, list age: years
Is age confirmed by a Certificate of Compliance? (attach a copy of certificate)
Dimensions: 10'x 5'x 4'
Sludge depth: 611
El Yes E] No
t5ins - 3/13 ritle 5 Official Inspection Form: Subsurface Sewage Disposal System - Page 9 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form Not for Voluntary Assessments
40 North Cross Road
PropertyAddress
Edward O'Toole
Owner Owner's Name
information is
required for North Andover MA 01845 7/23/2015
every page. City/Town State Zip'Code Date of Inspection
D. System Information (cont.)
Septic Tank (cont.)
Distance from top of sludge to bottom of outlet tee or baffle N/A
Scum thickness 3"
Distance from top of scum to top of outlet tee or baffle N/A =Outlet tee has hole at liquid
level
Distance from bottom of scum to bottom of outlet tee or baffle N/A
How were dimensions determined? Tape Measure
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 tee ok. Outlet tee has bad corrosion, holes in it & needs to be replaced. Depth of liquid at outlet
invert. No evidence of leakaqe.
Grease Trap (locate on site plan):
Depth below grade:
Material of construction:
0 concrete El metal El fiberglass
Dimensions:
Scum thickness
Distance from top of scum to top of outlet tee or baffle
Distance from bottom of scum to bottom of outlet tee or baffle
Date of last pumping:
t5ins - 3113
feet
El polyethylene El other (explain):
Date
Title 5 Official Inspection Form: Subsurface Sewage Disposal System - Page 10 of 17
Owner
information is
required for
every page.
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
40 North Cross Road
Property Address
Edward O'Toole
Owner's Name
North Andover MA 01845 7/23/2015
Cityrrown State Zip Code Date of Inspection
D. System Information (cont.)
Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity,
liquid levels as related to outlet invert, evidence of leakage, etc.):
Tight or Holding Tank (tank must be,pumped at time of inspection) (locate on site plan):
Depth below grade:
Material of construction:
El concrete El metal El fiberglass El polyethylene other (explain):
Dimensions:
Capacity:
Design Flow:
Alarm present:
Alarm level:
gallons
gallons per day
0 Yes El No
Alarm in working order: El Yes 0 No
Date of last pumping: Date
Comments (condition of alarm and float switches, etc.):
* Attach copy of current pumping contract (required). Is copy attached? EJ Yes El No
t5ins - 3/13 Title 5 Official Inspection Form: Subsurface Sewage Disposal System - Page 11 at 17
W g W� N
MIM
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
40 North Cross Road
Property Address
Edward O'Toole
Owner Owner's Name
information is North Andover MA 01845 7/23/2015
required for
every page. 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 0
Comments (note if box is level and distribution to outlets equal, any evidence of solids carryover, any
evidence of leakage into or out of box, etc.):
D -box cover broken, replaced it. D -box has corrosion, needs to be replaced. Evidence of
carryover. Evidence of leakage, has corrosion holes at liquid level.
Pump Chamber (locate on site plan):
Pumps in working order:
El Yes El No*
Alarms in working order: El Yes El No*
Comments (note condition of pump chamber, condition of pumps and appurtenances, etc.):
* If pumps or alarms are not in working order, system is a conditional pass.
Soil Absorption System (SAS) (locate on site plan, excavation not required):
If SAS not located, explain why:
t5ins - 3/13 'ritle 5 Official Inspection Form: Subsurface Sewage Disposal System - Page 12 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
40 North Cross Road
Property Address
Edward O'Toole
Owner Owner's Name
information is
required for North Andover MA 01845 7/23/2015
every page. Cit�frrown State Zip Code Date of Inspection
D. System Information (cont.)
Type:
El
leaching pits
number:
El
leaching chambers
number:
El
leaching galleries
number:
El
leaching trenches
number, length:
leaching fields
number, dimensions: 1 field 25'x 45'
overflow cesspool
number:
El
innovative/alternative system
Type/name of technology:
Comments (note condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of
vegetation, etc.):
Soil Ok. Vegetation ok. No sign of ponding
to surface.
Cesspools (cesspool must be pumped as part of inspection) (locate on site plan):
Number and configuration
Depth — top of liquid to inlet invert
Depth of solids layer
Depth of scum layer
Dimensions of cesspool
Materials of construction
Indication of groundwater inflow El Yes El No
t5ins - 3/13 'ritle 5 Official Inspection Form: Subsurface Sewage Disposal System - Page 13 of 17
Owner
information is
required for
every page.
15ins - 3/13
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
40 North Cross Road
Property Address
Edward O'Toole
Owner's Name
North Andover MA 01845 7/23/2015
CityfTown State Zip Code Date of Inspection
D. System Information (cont.)
Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation,
etc.):
Privy (locate on site plan):
Materials of construction:
Dimensions
Depth of solids
Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation,
etc.):
Title 5 Official Inspection Form: Subsurface Sewage Disposal System - Page 14 of 17
Owner
information is
required for
every page.
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
40 North Cross Road
Property Address
Edward O'Toole
Owner's Name
North Andover
MA 01845 7/2312015
cityrrown 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:
0 hand -sketch in the area below
El drawing attached separately
LA..,
A -A-0 1 -7-- "� 3 3 it
:-- 1(1,7 1 ( /I
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C
D - IS o,7, L4
t5ins - 3/13 Trtle 5 Official Inspection Form: Subsurface Sewage Disposal System - Page 15 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
40 North Cross Road
Property Address
Edward O'Toole
Owner Owners Name
information is
required for North Andover MA 01845
every page. CityrFown State Zip Code
D. System Information (cont.)
Site Exam: . -
7/2312015
Date of Inspection
Z Check Slope
Z Surface water
Check cellar
Shallow wells
Estimated depth to high ground water: 4
feet
Please indicate all methods used to determine the high ground water elevation:
ED Obtained from system design plans on record
I
If checked, date of design plan reviewed: 8/6/1987
Date
Observed site (abutting property/observation hole within 150 feet of SAS)
Checked with local Board of Health - explain:
Desion Dian
Checked with local excavators, installers - (attach documentation)
Accessed USGS database - explain:
You must describe how you established the high ground water elevation:
Test pit data on design plan.
Before filing this Inspection Report, please see Report Completeness Checklist on next page.
t5ins - 3/13 Title 5 Offidal Inspection Form: Subsurface Sewage Disposal System - Page 16 of 17
Owner
information is
required for
every page.
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
40 North Cross Road
Property Address
Edward O'Toole
Owners Name
North Andover
Cityrrown State Zip Code
E. Report Completeness Checklist
7/23/2015
Date of Inspection
Z inspection Summary: A, B, C, D, or E checked
Z inspection Summary D (System Failure Criteria Applicable to All Systems) completed
Z System information — Estimated depth to high groundwater
Z Sketch of Sewage Disposal System either drawn on page 15 or attached in separate file
t5ins - 3/13 Title 5 Official Inspection Form: Subsurface Sewage Disposal System - Page 17 of 17
Summary Record Card generated an 7113/2015 2:20:10 PM by Karen Hanlon Page I
6. Town of North Andover
Tax Map # 210-038.0-0183-0000.0
Parcel ld 13253
40 NORTH CROSS ROAD
O'TOOLE, EDWARD
40 NORTH CROSS
NORTH ANDOVER, MA
01845
Class 101 Single Family
ZonIng2 1 Residential
Size Total 1 Acres
FY 2015
Property Type
Zoning3
I Residential
1 Residential
UB Mailing Index
Name/Address
Type
Loan Number
Active/Inact. From
Until
O'TOOLE, EDWARD
Payor
40 NORTH CROSS
NORTH ANDOVER, MA
01845
UB Account Maint.
Account No
Cycle
Occupant
Name
Active/inactive
Bldg Id. 13988.0 - 40 NORTH CROSS ROAD
Last Billing Date 6/4/2015
2100548
02 Cycle 02
Active
UB Services Maint.
Account No. 2100548
Service Code
Rate
Charge
Multiplier/Users
MISCFEE ADMIN FEE
0.635/8
7.82
1/
WTR WATER
01 ALL METER SIZE
19.00
/1
UB Meter Maintenance
Account No. 2100548
Serial No Status
Location
Brand
Type Size
YTD Cons
36207120 a Active
ERT HH
b Badger
w Water 0.630.63
542
Date
Reading
Code
Consumption
Posted Date
Variance
5/7/2015
565
a Actual
5
6/22/2015
-35%
2/5/2015
560
a Actual
8
3/20/2015
-82%
11/3/2014
552
a Actual
43
12/15/2014
-36%
8/5/2014
509
a Actual
66
9/11/2014
1265%
519/2014
443
a Actual
5
6/12/2014
-23%
2/7/2014
438
a Actual
7
3/17/2014
-83%
11/1/2013
431
a Actual
38
12/26/2013
32%
8/5/2013
393
a Actual
31
9/18/2013
208%
5/2/2013
362
a Actual
9
6/18/2013
-20%
2/6/2013
353
a Actual
13
3/13/2013
-24%
10/31/2012
340
a Actual
15
12/13/2012
-75%
8/6/2012
325
a Actual
66
9/26/2012
579%
5/4/2012
259
a Actual
9
6/20/2012
-16%
2/7/2012
250
a Actual
12
3/14/2012
-30%
11/2/2011
238
a Actual
16
12/15/2011
-65%
8/4/2011
222
a Actual
47
9/14/2011
666%
5/4/2011
175
a Actual
6
6/13/2011
-65%
2/3/2011
169
a Actual
18
3/15/2011
-47%
1111/2010
151
a Actual
32
12/13/2010
-59%
8/5/2010
119
a Actual
81
9/13/2010
434%
5/5/2010
38
a Actual
15
6/9/2010
-47%
2/3/2010
23
a Actual
23
3/11/2010
-100%
11/21/2009
0
n New Meter
0
3/11/2010
-100%
11/21/2009
1092
r Replacement
0
3/11/2010
-100%
11/3/2009
1092
a Actual
21
12/11/2009
203%
8/5/2009
1071
a Actual
7
9/11/2009
-46%
5/6/2009
1064
a Actual
13
6/16/2009
229%
2/4/2009
1051
m Manual estimate
4
3/16/2009
-1%
MSG
Town of North Andover, Massachusetts
BOARD OF HEALTH
�'6 �6
APPLICATION FOR SITE TESTIN
Applican
Site Location
Form No. 1
19
Engineer NAME ADDRESS TELEPHONE
Test/inspection Date and Time
CHAIRMAN, BOARD OF HEALTH
Fee I'my tz 6?0 Test No.
-04� 1 d 6al
S.S.. FjjrmLt �Lo. D.W.C. Date-Plbg. Permit No.
Town of North Andover, Massachusetts
BOARD OF HEALTH
APPLICATION FOR SITE TESTING/INSPECTION
Form No.1
19
Applicant
NAME ADDRESS TELEPHONE
I A,6
Site Location
Engineer 1/1 1 9,1t,
NAME
Test/Inspection Date and Time
Fee
CHAIRMAN,, BOARD OF HEALTH
Test No.
S.S. Permit No.-D.W.C. No.-C.C. Date-Plbg. Permit No.
PATRICK J. DONOVAN ASSOCIATES, INC.
Claims and Loss Adjustments
P.O. BOX 110
WAKEFIELD, MA 01880
Tel. (781) 245-5540 - FAX (781) 245-7016
February 13, 2003
Building Commissioner
City or Town Hall
North Andover, MA 0 1845
Insured
: Edward A & Sandra C O'Toole
Property Address
: 40 North Cross Street, North Andover
Insurer
: Vesta/Shelby Insurance Company
Policy Number
: HM71408
Type of Loss
: Water Damage
Date of Loss
: 02108/03
Our File #
: WAP34468
MMO IQ",
Claim has been made involving loss, damage or destruction of the above -captioned
property, which may either exceed $1,000 or cause Mass. Gen. Laws, Chapter 143,
Section 6 ' to be applicable. If any notice under Mass. Gen. Laws, Chapter 139, Section
3B is appropriate, please direct it to the attention of the writer and include a reference to
the captioned Insured, location, policy number, date of loss and file number.
On this date, I caused copies of this notice to be sent to the persons named above at
the addresses indicated above by first class mail.
Vern Laws, Adjuster
VL/so
Insurance Adjustment Service, Inc.
936 Roosevelt Trail Unit 5
Windham, Maine 04062
207-892-0522
Fax 207-892-0526
UNDER MASSACHUSETTS GENERAL LAWS CHAPTER 139, SECTION 3B
TO: Board of Health/Building Inspector
RE: Insured: Edward OToole
Property Address: 40 North Cross Rd.
North Andover, MA
Date of Loss
Policy Number:
Type of Loss:
2/15/2011
File or Claim Number: 71989
Date: April 20, 2011
REC—E-I-V�En
MAY -o Z011
TOWN OF
_t��NO�RT�
HANDOVER
NT
Claim has been made involving loss, damage or destruction of the above captioned property, which may either
exceed $1,000.00 or cause Mass. Gen. Laws, Chapter 143, Section 6, to be applicable.
If any notice under Mass. Gen. Laws, Ch. 139, Sec. 38 is appropriate, please direct it to the attention of the
writer and include a reference to the captioned insured, locations, policy number, date of loss and claim or file
number.
Thank you for your cooperation.
Very Truly yours,
Matt Martin
Adjuster
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HAYERHILL MA.
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PLAN OF PROPOSED HOUSE LOCATION
LOT # 3 NORTH CROSS ROAD
NORTH ANDOVER, MA.
OWNER: EDWARD & SANDRA OITOOLE
CONTOUR -KEY
—EXISTING Z - Z_le
PROPO,SFD
Of DATE: MAY 14, 1990
SCALE: lit 401
OF
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LOT RAK ENGINEERWG
160 MAW STREET
L ERMLL MA.
North Andover
120 Main St.
No. Andover,
Dear Members:
BOARD OF HEALTH
120 MAIN STREET TEL: 682-6483
NORTH ANDOVER, MASS. 01845 Ext. 32 or 33
Planning Board
MA 01845
October 18, 1990
On October 16, 1990, 1 visited Lots 2 and 3 North Cross
Road. A substantial rain had fallen a few days before. On my
sitewalk, I found a considerable amount of ponded water was
present along the common property line of Lots 2 and 3. This
area is also adjacent to the septic systems for the lots.
Surface water ponds in this area are due to the damming
ef f ect of the height of the road way and the septic systems on
the two lots.
I am very concerned with this situation because the height
of the ponded water was at least as high as the elevation of the
leaching trenches installed on Lot 2. 1 am also concerned that
this situation will effect the function and longevity of the
septic system if not corrected.
I feel this problem could be easily resolved with the
installation of a flared end section and approximately 50 ft. of
pipe to be connected to the catch basin located in North Cross
Road. Unfortunately, the homeowners of Lots 2 and 3 have
indicated that they cannot afford this action and have some doubt
that this situation is their responsibility to correct.
The Board
this situation
jurisdiction or
Board has some
appreciate your
MJR/rel
of Health does not have authority to deal with
and I am not sure if your Board has any
authority to address this matter. However if the
mechanism for resolving this situation, I would
participation in resolving this matter.
Very truly y let
ichael . Rosati
Health Agent
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