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HomeMy WebLinkAboutMiscellaneous - 29 WHITE BIRCH LANE 4/30/2018O Location No. � Date �— woR*M TOWN OF NORTH ANDOVER Certificate of Occupancy $ *'1io ; : Building/Frame Permit Fee $ `— O sACMUs t� Foundation Per it Fee $ 0th r re It Fee $ �S • 0 G Sewer Connection Fee $ s 5 7314 Water Connection Fee $ �+�-- TOTAL $ Building Inspector Div. Public Works o;cation No. Date NaRTM TOWN OF NORTH ANDOVER YX3 Certificate of Occupancy $ . Building/Frame Permit Fee $ sACMUst Foundation Permit Fee $ ' Other Permit Fee $ Sewer Connection Fee $ �� 33$Water Connection Fee $ TOTAL $ Se¢ • `Building Inspector 050/9t o9a28 1,149.04 PAID 7264 Div. Public Works ' cation..2 Date * HpRTH . iP ,SSACNUstt s . 7A9 41— /,, TOWN OF NORTH ANDOVER Certificate of Occupancy $� Building/Frame Permit Fee $ Foundation Permit Fee $ G Other Permit Fee $ Sewer Connection Fee $ Water Connection Fee $ TOTAL C) /�$�d Building 0-1/15/'4 10:55 150.00 Inspector PAID Div. Public Works Location at G__ & i NO. Date y"�l HORTPI TOWN OF NORTH ANDOVER `A Certificate of Occupancy $ ON 0 Building/Frame Permit Fee $ o cNusEt Foundation Permit Fee $ .. 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This does not relieve the applicant and/or landowner from compliance with any applicable local or state law, regulations or requirements. ****************Applicant fills out this section***************** APPLICANT: EC C_QA, � �/% C Phone 77 V LOCATION: Assessor's Map /Number Parcel Subdivision li�� AC - Lot(s) Street --T,� �� �--� St. Number -�- ************************Official Use Only************************ RECOMMENDATIONS OF TOWN AGENTS: JL�ZA Date Approved Conservation dministrator Date Rejected Comments IlR tkttK&J1k Town Planner Comments Food Inspector -Health Septic Inspector -Health Comments Date Approved Q Date Rejected Date Approved Date Rejected Date Approved 4A - Date Rejected Public Works --B ywater connections A( - driveway permit c�v� C v Fire Department ` eceived b Building Inspector�l T (5T(l�Y' ��•` Date r�� AFR, 61994 „� , 21 1 y� fix. 1 �I I CT o S a � v 21 1 y� fix. 21 ULI II II \ ^1 \ \ \ \ x..,, , \\ loo\ lot- �y t loe- •�# / $-'- \ \ \ sae >� 1 I I s� 70 t i /,���\ �♦ \ �l I I�C � got ��, t=om \ ��— 4 £g~ \I�I�' i 1 \111 �r-10 ue' \otd•r•AoJ•oom iy IIf\\�- /la `\ or, 1 w 11 —r—" Tis Wo /iit. le \\ 11 I 1 �,le alM 1 I \I 414 _9 14 imQOR $i /00 - � , �� � � `✓ / � / \ / � 4 met �o °t° or / / ! 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NOT VALID UNTIL SIGNED BY LICENSEE AND OFFICIALLY a t., , ! ,{I NM}- r,• • STAMPED • OR • SIGNATURE OF THE COMM133bNE*�11�4 i t �": ! r ' j t; �, j •*� j 1;, . { .,'i4, ti I V jll INIAOV� �IflktlfUF&�_�INE' � I + • BIGHAIUREOf <5uC61�•1� + �I$ t +9r4t �W�+,&�+!�'e I t, �,�N�N EN• y pg r bft#ATION. I1 ��', • T1 pop. ._I. n tJTI I• ice.. •r I i_.: �� i •� i-4: t Cyt is 1 t P r 1111 .�'. MAY 231994 11 104-001 O 001 LOT 7 AREA=340075. F. 10.9' LOT 2 \ �EL.=1 55.0' \ \.O-- 10.9' °-� T eN� 39.5' 100.00' WHITE BIRCH LANE FOUNDATION LOCATION PLAN CLIENT. SCOTT CONSTRUCTION THIS CERTIFICATION IS MADE AND LIMITED TO THE ABOVE CLIENT. LOCATION. NORTH ANDOVER,MA. SCALE.1 "=40' DA TE. 5/20/94 CHRI S TIA NSEN SERGI PROFESSIONAL E O NEERS LAN160 SUMMER Sr. HAVERHILL.MA. 01830 TEL. 508-373-0310 © 1994 BY CHRISTIANSEN # SERGI INC I CERTIFY THAT THE PRIMARY STRUCTURE SHOWN CONFORMS TO THE HORIZONTAL SETBACK REOUIR£M£NTS OF THE LOCAL APPLICABLE ZONING BY-LAWS IN EFFECT WHEN CONSTRUCTED. (THIS CERTIFICATION DOES NOT CONSIDER ANY OTHER RESTRICTIONS SUCH AS COVENANTSWETLANDS,EASEMENTS ORDERS OF CONDITIONS,ETC.) THIS DRAWING SHALL NOT BE USED BY THE CLIENT FOR ANY PURPOSE OTHER THAN THAT OUTLINED ABOVE.fXCEPT WITH THE WRITTEN PERMISSION OF CHRISTIANSEN d: SERGI INC. FURTHERMORE THIS DRAWING 1S THE COPYRIGHTED PROPERTY OF CHRISTIANSEN & SERGI INC. AND ANY UNAUTHORIZED USE IS PROHIBITED.CHRIS77ANSEN & SERGI TAKES NO RESPONSIBILITY FOR THE UNAUTHORIZED USE OF THIS DRAWING OR ANY INFOR- MATION CONTAINED HEREON. BASED ON SCALED DATA ONLY THE PRIMARY STRUCTURE SHOWN IS NOT LOCATED IN A FLOOD HAZARD ZONE AS SHOWN ON FEMA FLOOD INSURANCE RATE MAP. i COMMUNITY NO.: 250098 0005C DATE -6/2/93 ` . s a �Kasg DWG. NO.: 93067016 z z T z D v_ y C •C CA C7 10 0 CD n Z y CD O 'O CL r OMM. C O ? C fl. _• y O C 0 CD CDCL o Q CD CD O CD C CD V; CL v y .o co D I v y O CD CD z o o CD0 dc CD O C• N O H •O = C4 WO W H C7 —C2 T CD '•Ti Z C oma. 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I I t) :(A ()I t CHIMNEY APPLICAHOIJ ANO I'E1311I• "Or,-/. :_, I r11; III I I11 •1'I r•d�nlll ,�I��ill� 1'�: r\i; ItiC; u'1111'.1.11': 11 i ti•1'; PI?ItrEl r. # 21 d —U LINER'S NAME: JILDER'S NAME: �� G� 1/% �'c,�• S lam' ISON' S NAME: CS j kSON' S ADDRESS: ! yy P ISON' S TELEPHONE: JERIAL OF CHIMNEY: 1TERIOR CHIMNEY: IMBER AND SIZE OF FLUES//..-) Y EXI ERIOR CHIMNLY: IICKNESS OF HEARTII: ' _._.... __.._.. cfvunn,ey aa O(AenCace can(anln to 4he u() .the curie and have -(uCe.3 cull( :gu,Catiow beell neeezved: TE: GNATURE OF MASON: :RMIT GRANTED: _ 'BERT NICETTA j 'ILDING INSPECTOR ; SPECTEO: -- :MARKS: - SULIU BLOCK REQUIItE'1) THIS PERMIT MUSF GE UISPLAYLU 014 111E FU1,11SLS It z c xxCLn i1 y Cr cm > z z° z o o m y z y amn EA H > > W m H cc y y > £ � 0n a � � C d z 'p � Z O d � z z o � v y C � CO) Cl)co Z y Cc) O -v CL r- Cl) fl. = CO) D co 'o O v CD CD ,c o CL Q CD n•F� CD '° C7 z CD O CD rj \/ 0 ani' _� ��G c m t" DO O CD y D < av y T z o �c I � y v O m 'v nCD O 3 CCD v n+ -v m rn Q -•1 w T Cl T1 rn r. rn r t� a O z O CD 0 0 co O CL cc C CD cc C d 0 O N C 0 a N N CTD z'• �r7'R- d z Q N C O S O CD R C') SCA CD 3 N _ ._•�ca .OiCD N T_ C aid m o O N G y o =rC� CD = CD -2 a o ,o cro .� o O CA Cf O CD co) a o �co CL o C C4F O O N CL 1 CD "3 N c lu N O. d �O' �� C W O. wCCD C'. 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F• L: N N 1 U, W K H v s W C I rt" C, ',5 C -� u z ` �. -a N ( w m � y C � V� N 4n z vx U W W U. z Lf z W L e IL .•L W N N < W U, W K H v s W C I rt" C, C u z ` N W N ( w m � y C � N 4n z vx U W W U. z Lf z W L e IL Li �! w CO 9-1 00_. N Q FORM U - LOT RELEASE FORM INSTRUCTIONS: This form is used to verify that all necessary approvals/permits from Boards and Departments having jurisdiction have been obtained. This does not relieve the applicant and/or landowner from'compliance with any applicable or requirements. *APPLICANT FILLS OUT THIS SECTION r APPLICANT �� l I`-� '� PHONE r CL -4q --WL t LOCATION: Assessor's Map Number 6 ". PARCEL_ SUBDIVISION l�e ,'�" `"" LOT (S) STREET �"" ���'ST. NUMBER Cl'* 1 USE ONLY*** RECOMMENDATIONS PF JOWN AGENTS: - CONSERVATION ADMINI$TRAtOR DATE APPROVED _ -,�i (-- Ll 6 DATE- REJECTED COMMENTS ✓VW A Jd-10' TOWN PLANNER DATE /APPROVED r1� DATE REJECTED COMMENTS FOOD INSP OR -HEALTH DATE APPROVED DATE REJECTED IN CTOR-HEAL H DATE APPROVED 3/ f DATE REJECTED COMMENTS;JCi _s,4 -,,4 - PUBLIC WORKS - SEWER/WATER CONNECTIONS DRIVEWAY PERMIT FIRE DEPARTMENT RECEIVED BY BUILDING INSPECTOR DATE fit- i 20 BLANCIIAR-D T?,D. • BURLINGITO-N, -rvTA 01803 T TEL {617) 272-3100 • FKX (617) 272 -GOOD 1 -KA GAr.-nt: �� XdANi,7,F� 6� �Mr9h',�N � �E,r �. Ix r) Piot -fr,06' T,c]CA1lIrom:Tr?—]��i%'riTit l� y'ift C/,T/�/� LI'A-1 ktM1l,I l5itr J�31�N !�'3 F \r \AfI(I T(= �-ti?may x?. cf=�•r.�z rr.�. 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I ►I � i►� � �a�li�!' �'Et IilY�j ��t � �� ��� �' i I PROPOSED — 50 WIDE) EXISTING I -I U � 297.86 F I I i �i• i 1 `` 1v;4 x:wi � •\ a�,d�; i S 89026116j1W CO) d C � CO)CD n Z CO) CL o 0, C CL �• y ato v o co CD o CL cr �d CD CD o CD ww _a C CD y� CD CL CD O CO) O I Cc CD S CA O 10 Z CD o CD 0 CD ���0 0 d 0 �• co < O co CO) U2 m C09 m o haC Z =r9 y _1 SRI-= = T !O C N C CO) O ^�S gym: CD O a _ = m N O O_ n o oy0- W =r :S CA c a _ aco '^ _?� VJ O m m N �r (A C� C h•r1 � H � • ' O Oy D1 H am: Q z � W a C36 19 m :� y �. (/) = H �O y _ A o rn 2 aC.) n0 CD = o o H CD � O CD CD CL JiM MA 7 , f 00i 0 O C o d � �'" �• �. rte., � b �'. � ►d to '�. �' =. Or p � R• 7 , f 00i 0 O C ay N S p om oo = = o z o m o m (D MAP # LOT PARCEL # STREET _ ._ .... ......—._....��/�-�- CONSTRUCTION APPROVAL HAS PLAN REVIEW FEE BEEN PAID? YES NO PLAN APPROVAL: DATE qq APP. DESIGNER: i5/�/���ST/�r'/VS � _ PLAN DATE._ I1 �3 _ CONDITIONS-36AXIV/29I,eZ M -3<5- .5&7 1/V WATER SUPPLY: TOWN WELL WELLPERMIT DRILLER_...._._.___.._..__._.._.__.._....._. __...._.._....._....._. _ . WELL TESTS: CHEMICAL DAIE APPRUVEU..._.___..___..__._.___. BACTERIA I DA I E f1F PRUVED BACTERIA II DATE (.IPPRUVEI)_______..___.__ COMMENTS: FORM U APPROVAL: APPROVAL I'D ISSU- �YES l U� DATE ISSUED By BY CONDITIONS: FINAL APPROVAL:. ALL PERMITS PAID YES NO WELL CONSTRUCTION APPROVAL YES NU SEPTIC SYSTEM CONSTRUCTION APPROVAL 5 ND OTHER -S NU ANY VARIANCE NEEDED YES NO FINAL BOARD OF HEALTH APPROVAL: DAT'E:_.,... ... ___.._ ._DY a • .. ' p.. .. TcT' t �T At Vim+•. r - .• �Er ' a a•t��J�`1..I.EI:I�Ik.Ny..1.�.4��lrh Q!.! ISTHE INSTALLER LICENSED? + �-/ NO TYPE OF CONSTRUCTION: ? REPAIR -. • ' : NEW CONSTRUCTION:, . , CERTIFIED PLOT PLAN , REVIEW Y NO r.: - CONDITIONS OF..APPROVAL ES NO r ; _ (FROM FORM U) ISSUANCE OF DWC PERMIT. YES NO •INSTALLER. • ,"�. t Y �p �i • ; DWC PERMIT N0. �L7jCL BEGININSPECTION YEP -NO ==:EXCAVATION. INSPECTION: :NEEDED: 7. ' PASSED BY =.-.:CONSTRUCTION INSPECTIONS NEEDED: AS BUILT PLAN SATISFACTORY: ' ' I APPROVAL. TO BACKFILL: DATE: % �• BY APPROVAL: DATE/ �/ R� BY ;FINAL .GRADING FINAL CONSTRUCTION APPROVAL: DATE: BY WHITE BIRCH LANE 5LOPE T (/50) X 150 - _ ........................... DE5I6N REI/.4T/ON AT ......... (TOP Of STONE) = ............... EXISTING ELoldr/ON 4r...... . REQU/eED %LL a ... ...............I.......... oEs1,�-N z oaltr ,JS &"/T INV PIPE OUT OF I-1041SE 130.78 150.63 INV P/PE INTO T,4NK 150.20 150.04 /NV. PIPE OUT OF TANK 141.95 149-87. INV PIPE INTO D. BOX. 149.90 !49.78 INV PIPE OUT 01`,0,30X 149.73 149.61 INV END OFP/PE MEN C11 1 2 149• 149.30 149.30 It it *3 INV BEG OF PIPE TRENCH __._ 149.25 49.6 GV�JTER EL El/.4 T10N 143.4 143.4 AVER40E STONE DEP7'1-/ ,47 PROBE NOTE.• 711/5 PLAN /5 /VDT .4 `.4,eP,4/VTY OF T1/E SYSTEM 311r.4 YE.R1.6' 4rION Of Tt/E LOCATION OF 711E EX/5T/1116 STPUCTURES. SYSTEM /N NORTH ANDOVER, MA. F0� SCOTT CONSTRUCT/ON 6C.4,1 -E.' 1" = 40' D4TE: 7/25/94 CyRI STI NSEN SE19C71, _INC. 1100 SUMMER STREET � HAVFRH/LL ,MASS. is LETTER OF TRANSN/WrTAL. North Andover Health Department 400 Osgood Street North Andover, NIA 01.845 978.688.9540 Phone 978.688.8476 - Fax healthdept�a`..townofnorthandover.com - E-mail www.townofnorthandover.com - Website NpRT1j 4 Ilk o16 <oc.ii[ 1W.CA a A C NUS�� {5 Page % of TO: DATE: COMPANY: FROM: Pamela DelleChiaie, Health Department Assistant Phone: RE: G� L Fax / �/ / ��X' Q 2e7 We are sending you: L7 Copy of Letter OPlans ther ill in below) These are transmitted as checked below: O=Requesiw od OForRewm and com-wd Mubmi 49 OFor Your Use dist OAsRequired ➢ OResubmit copiesfor OFarAppmW aPPiva copiesfor REMARKS: , COPY TO: COPY TO: SIGNED: - COPY TO: TRANSMISSION VERIFICATION REPORT TIME 02/1512006 14:32 NAME HEALTH FAX 9786888476 TEL 9786888476 SER.# 000B4J120960 DATE DIME 02115 13:57 FAX NO./NAME 817812380302 DURATION 00:00:38 PAGE(S) 02 RESULT OK MODE STANDARD ECM ' I j LOT z I. �v LOT 1 EAT. NOU No. X f a� i w j1 N0.205 o e wv.w -•y WHITE BIRCH LANE SLOPE IM0011MUENT (/50) X - /50 .. ........................... DES/GN EL EWT/ON AT ......... (TOP OF STONE) = ............... • . • ........... EX/ST/NO a0ldT/ON ,4T......... IMMIRE0 A&Z a ............................. f«v.�riorys DS/GN .4.sail/iT ,4S BU/ T /NV P/PE oar OF 1100E 130.78 150.63 INV P/PE INTO UNA< 150.20 150.04 INV. P/PE OUT OF TANK 149.95 149.87 INV PIPE INTO D. BOX. f49. 90 (49.76 INV P/PE OUT OF D. BOX 149.73 149.61 /NV END OFP/PE 7X£NCH* 1 149. 4 149. z Co 1417.30 INV BEG OF PIPE TRENCH 149.25 49.G Wi1TEk' i!FZ cl 4T/ON 143.4 143.4 AVEle.40S STONE DEPT'! QT P,e0BE SU,B -saend E a/5/pow SYSTEM /N NORTH ANDOVER M4. FOR SCOTT CONSTRUCT/ON - SCALE: P- 40' D4TE: 7125/94 T///S PL 4N /S N07,4 g14,ee.41VTY CNRI STIANSEN ER.GI , INC. OF T!/E SYSTEM BUT ,4 Vre1rX4T/ON 1G0 SUMMER STREET MvERH/LL . MA55. Of T#F LOUT/0N OF AT EY/57/N6 STRUCTURES. FORM U - LOT RELEASE FORM INSTRUCTIONS: This form is used to verify that all necessary approvals/permits frorta. Boards and Departments having jurisdiction have been obtained. This does not relieve'` the applicant and/or landowner from compliance with any applicable or requirements. APPLICANT FILLS OUT THIS SECTION APPLICANT S '� PHONE ° a T t —00 - LOCATION: Assessors Map Number t ,Y PARCEL_ SUBDIVISION C� ` 1'' ``-� LOT (S)_ STREET �""' ���� � � ` ' ST. NUMBER �� *********a***OFFICIAL USE ONLY*** RECOMMENDATIONS OF TOWN AGENTS: CONSERVATION ADMINI T � RATOR DATE APPROVED DATE -REJECTED COMMENTS TOWN PLANNER DATE APPROVED DATE REJECTED COMMENTS FOOD INSP OR -HEALTH DATE APPROVED J DATE REJECTED IN CTOR-HEAL H COMMENTS;�i /fid° U� 11 i��. ►� . DATE APPROVED DATE REJECTED a 4� PUBLIC WORKS - SEWERIWATER CONNECTIONS DRIVEWAY PERMIT FIRE DEPARTMENT RECEIVED BY BUILDING INSPECTOR DATE �y ,- WILLIAM F. WELD Governor ARGEO PAUL CELLUCCI Lt. Governor COMMONWEALTH OF MASSACHUSETTS EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS DEPARTMENT OF ENVIRONMENTAL PROTECTIOINS �; g ONE WINTER STREET. BOSTON, MA 02108 617-292-5500, TV" r' r. yltwY A c0XE Secretary ` DAVID"B"STRUHS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM Commissioner PART A CERTIFICATION Property Address: 29 White Birch Lane, N.AndoverAddM of Owner: Date of Inspection: 8 / 11 / 9 7 (if different) Name of Inspector: James W_ Wright, Jr. 1 am a -DEP approved system inspector pursuant to Section 15.340 of Title 5 (310 CMR 15.000) Company Name: R.J. Inspections Mailing Address: 1 0 --good St. , Methuen, MA 1844 Telephone Number: �r 875 9 CERTIFICATION STATEMENT I certify that I have personally inspected the sewage disposal system at this address and that the information reported below is true, accurate and complete as of the time of inspection. The inspection was performed based on my training and experience in the proper function and maintenance of on-site sewage disposal systems. The system: r ✓_ Passes _ Conditionally Passes _ t�a'e�ds Further Evaluation By the Local Approving Authority In Signature: Date: The System Ins shall submit copy of this inspection report to the Approving Authority within thirty (30) days of completing this inspection. If t system is a shared system or has a design flow of 10,000 gpd or greater, the inspector and the system owner shall submit the report to the appropriate regional office of the Department of Environmental Protection. The original should be sent to the system owner and copies sent to the buyer, if applicable, and the approving authority. INSPECTION SUMMARY: Check A, B, C, or 'D: A] SYSTEM PASSES: 1 have not found any information which indicates that the system violates any of the failure criteria as defined in 314 CMR 15.303. Any failure criteria not evaluated are indicated below. COMMENTS: B] SYSTEM CONDITIONALLY PASSES: One or more system components as described in the "Conditional Pass" section need to be replaced or repaired. The system, upon completion of the replacement or repair, as approved by the Board of Health, will pass. Indicate yes, no, or not determined (Y, N, or ND). Describe basis of determination in all instances. If "not determined", explain why not. The septic tank is metal, unless the owner_ or operator has provided the system inspector with a copy of a Certificate of Compliance (attached) indicating that the tank was installed within twenty (20) years prior to the date of the inspection; or the septic tank, whether or not metal, is cracked, structurally unsound, shows substantial infiltration or exfiltration, or tank failure is imminent. The system will pass inspection if the existing septic tank is replaced with a conforming septic tank as approved by the Board of Health. ;. (revised 04/25/97) Page 1 of 10 DEP on the World Wide Web: ht JMww.magnetstate.ma.uiVdep 6.7 Printed on Recycled Paper 0 G SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: 29 White Birch Lane, N. Andover, MA Owner: John Golden Date of Inspection: 8/11/97 BJ SYSTEM CONDITIONALLY PASSES (continued) Sewage backup or breakout or high static water level observed in the distribution box is due to broken or obstructed pipe(s) or due to a broken, settled or uneven distribution box. The system will pass inspection if (with approval of the Board of Health). Describe observations: broken pipe(s) are replaced obstruction is removed distribution box is levelled or replaced The system required pumping more than four times a year due to broken or obstructed pipe(s). The system will pass inspection if (with approval of the Board of Health): broken pipe(s) are replaced obstruction is removed C] FURTHER EVALUATION IS REQUIRED BY THE BOARD OF HEALTH: Conditions exist which require further evaluation by the Board of Health in order to determine if the system is failing to protect the public health, safety and the environment. 1) SYSTEM WILL PASS UNLESS BOARD OF HEALTH DETERMINES THAT THE SYSTEM IS NOT FUNCTIONING IN A MANNER WHICH WILL PROTECT THE PUBLIC HEALTH AND SAFETY AND THE ENVIRONMENT: Cesspool or privy is within 50 feet of a surface water Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh. 2) SYSTEM WILL FAIL UNLESS THE BOARD OF HEALTH (AND PUBLIC WATER SUPPLIER, IF APPROPRIATE) DETERMINES THAT THE SYSTEM IS FUNCTIONING IN A MANNER THAT PROTECTS THE PUBLIC HEALTH AND SAFETY AND THE ENVIRONMENT: The system has a septic tank and soil absorption system (SAS) and the SAS is within 100 feet to a surface water supply or tributary to a surface water supply. The system has a septic tank and -soil absorption system and the SAS is within a Zone I of a public water supply well. The system has a septic tank and soil absorption system and the SAS is within 50 feet of a private water supply well. The system has a septic tank and soil absorption system and the SAS is less than 100 feet but 50 feet or more from a private water supply well, unless a well water analysis for coliform bacteria and volatile organic compounds indicates that the well is free from pollution from that facility and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm. Method used to determine distance (approximation not valid). 3) OTHER (revised 04/25/97) Page 2 of 10 t � . -SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: 29 White Birch Lane, N. Andover, MA Owner: John Golden Date of Inspection: 8/11/97 D] SYSTEM FAILS: You must indicate ei;!,er "Yes or "No" as to each of the following: I have determined that the system violates one or more of the following failure criteria as defined in 310 CMR 15.303. The basis for this determination is identified below. The Board of Health should be contacted to determine what will be necessary to correct the failure. Yes No Backup of sewage into facility or system component due to an overloaded or clogged SAS or cesspool. Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool. Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool. Liquid depth in cesspool is less than 6" below invert or available volume is less than 1/2 day flow. Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number of times pumped _. Any portion of the Soil Absorption System, cesspool or privy is below the high groundwater elevation. Any portion of a cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. Any portion of a cesspool or privy is within a Zone I of a public well. Any portion of a cesspool or privy is within 50 feet of a private water supply well. Any portion of a cesspool or privy is less than 100 feet but greater than 50 .feet from a private water supply well with no acceptable water quality analysis. If the well has been analyzed to be acceptable, attach copy of well water analysis for coliform bacteria, volatile organic compounds, ammonia nitrogen and nitrate nitrogen. E] LARGE SYSTEM FAILS: You must indicate either "Yes" or "No" as to each of the following: The following criteria apply to large systems in addition to the criteria above: The system serves a facility with a design flow of 10,000 gpd or greater (Large System) and the system is a significant threat to public health and safety and the environment because one or more of the following conditions exist: Yes No the system is within 400 feet of a surface drinking water supply the system is within 200 feet of a tributary to a surface drinking water supply the system is located in a nitrogen sensitive area (Interim Wellhead Protection Area - IWPA) or a mapped Zone II of a public water supply well) The owner or operator of any such system shall bring the system and facility into full compliance with the groundwater treatment program requirements of 314 CMR 5.00 and 6.00. Please consult the local regional office of the Department for further information. (revised 04/25/97) Page 3 of 10 a SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST... Property Address: 29 White BIrch Lane, N. Andover, MA Owner: John Golden Date of Inspection: 8/11/97 Check if the following have been done: You must indicate either "Yes" or "No" as to each of the following: Yes No —/ o Pumping information was provided by the owner, occupant, or Board of Health. v — None of the system components have been pumped for at least two weeks and the system has been receiving normal — Y g flow rates during that period. Large volumes of water have not been introduced into the system recently or / as part of this inspection. As built plans have been obtained and examined. Note if they are not available with N/A. v — The facility or dwelling was inspected for signs of sewage back-up. The system does not receive non -sanitary or industrial waste flow. The site was inspected for signs of breakout. — All system components, excluding the Soil Absorption System, have been located on the site. — The septic tank manholes were uncovered, opened, and the interior of the septic tank was inspected for condition of baffles or tees, material of construction, dimensions, depth of liquid, depth of sludge, depth of scum. / The size and location of the Soil Absorption System on the site has been determined based .on: —/ — The facility owner (and occupants, if different from owner) were provided with information on the proper maintenance of Sub -Surface Disposal System. Existing information. Ex. Plan at B.O.H. — Determined in the field (if any of the failure criteria related.to Part C is at issue, approximation of distance is unacceptable) [I 5.302(3)(b)] (revised 04/25/971 page 4 of 10 c -- -- SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION Property Address: 29 White Birch lane, N.Andover, MA Owner: John Golden Date of Inspection: 8/11/97 FLOW CONDITIONS RESIDENTIAL: Design flow:t:.p.d. room for S.A.S. Number of bedrooms: Number of current resid nts:,..3 Garbage grinder (yes or no)" Laundry connected to system (yes or no):Y— Seasonal use (yes or no):_" qq Water meter readings, if available (last two (2) year usage (gpd): T'fS /2p/ Sump Pump (yes or no):,ev—d Last date of occupancy: COMMERCIAL/I N D USTRIA L: Type of establishment: Design flow:_gallons/day Grease trap present: (yes or no' Industrial WastAings, ngkaW Non-sanitary w Water meter reif Last date of occu OTHER: (Di Last date of present: (yes or no)_ to the Title 5 system: (yes or no)_ GENERAL INFORMATION PUMPING RECORDS and source of information: System pumped as part of inspection: (yes or no) If yes, volume pumped: gallons Reason for pumping: TYPE OF STEM Septic tank/distribution box/soil absorption system Single cesspool Overflow cesspool Privy Shared system (yes or no) (if yes, attach previous inspection records, if any) IIA Technology etc. Copy of up to date contract? Other APPROXIMATE AGE of all components, date installed (if known) and source of information: Sewage odors detected when arriving at the site: (yes or no) z!V-1,1 (revised 04/25/97) - Page 3 of 10 ----SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: 29 White Birch Lane, N. Andover, MA Owner: John Golden Date of Inspection: 8-/ 11 / 9 7 BUILDING SEWER: (Locate on site plan) Depth below grade: Material of construction: _ cast iron _ 40 PVC _ other (explain) Distance from private �rfateG� I or suction line Diameter Comments: (condition of oin , v sting, evidence of leakage, etc.) SEPTIC TANK:_ (locate on site plan) S/ Depth below grade:L � Material of construction: L<5 rete _metal _Fiberglass _Polyethylene —other(explain) If tank is metal, list age _ Is age confirmed by Certificate of Compliance — (Yes/No) Dimensions: Y, /0 Sludge depth:_ Distance from top of sludge to bottom of outlet tee or baffle:_ 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 affle: /3 , How dimensions were determined: 14,11 %/ Comments: (recommendation for pumping, condition of inlet and outlet tees or baffles, depth of liquid level ip relation to outlet invert, structural integrity, evidence of leakage, etc.) L�N�_/.✓ wo� /'d�'IJ�/%—/O� GREASE TRAP: (locate on site plan) Depth below grade: Material of construction: _concr9te _metal _Fiberglass _Polyethylene _other(explain) Dimensions: Scum thicknes Distance from top of ! Distance from bottom Date of last pumping: t of outlet tee or baffle: to bottom of outlet tee or baffle: Comments: (recommendation for pumping, condition of inlet and outlet tees or baffles, depth of liquid level in relation to outlet invert, structural integrity, evidence of leakage,, etc.) (rsvisod 04/25/97) -Page 6 of 10 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: 29 White Birch Lane, N.Andover, MA Owner: John Golden Date of Inspection: $/ 1 1/ 9 7 -.TIGHT OR HOLDING TANK: (Tank must be pumped prior to, or at time, of inspection) (locate on site plan) Depth below grade: Material of construction: _concrete _metal _Fiberglass _Polyethylene —other(explain) Dimensions: Capacity: gallons Design flow: to Alarm level: A m order _ Yes; _ No Date of previous pu ing: Comments: (condition of inlet tee, ndition of alarm and float switches, etc.) DISTRIBUTION BOX:_ (locate on site plan) Depth of liquid level above outlet invert:__/s�_ Comments: PUMP CHAMBER:_ (locate on site plan) Pumps in working order: (Yes or No) Alarms in working order (Yes or No) Comments: n / (note condition of pup c4� ndition of pumps and appurtenances, etc.) (revised 04/25/97) Page -7 of 10 SEWAGE DISPOSAL SYSTEM INSPECTION FORM - PART C - - - ---" SYSTEM INFORMATION (continued) Property Address: �29 .White Birch Lane, N. Andover, MA Owner: John Golden Date of Inspection: 8/ 11 9 7 _SOIL ABSORPTION_ SYSTEM (SAS):_ (locate on site plan, if possible; excavation not required, but may be approximated by non -intrusive methods) - If not determined to be present, explain: Type: leaching pits, number:_ leaching chambers, number:_ leaching galleries, number: r leaching trenches, number,length: leaching fields, number, dimensions: overflow cesspool, number: Alternative system: Name of Technology: Comments: (note condition of soil, signs of hydraulic failure level of ondin , condition of vegetation, etc.) . 111 C/ S/Lti 5 ril% a-,� /9 /ni r — " �- Z= if CESSPOOLS: (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 groundwat - inflow (cesspool mudbeu ped as part of inspection) Comments: (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.) PRIVY: (locate on site plan) 'Materials of constriction: Dimensions: . . Depth .of solids: Comments:- . - — Anote condition of soil;:-si 50. failure, level of ponding, condition of vegetation, etc.) _ _� rwiaad 04 -IS 971-- - -- page a of 10 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: 29 White BIrch Lane, N. Andover, MA Owner: John Golden Date of Inspection: 8/ 1 1/ 9 7 SKETCH OF SEWAGE DISPOSAL SYSTEM: include ties to at least two permanent references landmarks or benchmarks locate all wells within 100' (Locate where public water supply comes into house) (revised 04/25/97) Page 9 of 10 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: 29 White BIrch Lane, N.Andover, MA Owner: John Golden Date of Inspection: 8/11/97 Depth to Groundwater _ Feet Please indicate all the methods used to determine High Groundwater Elevation: ,Obtained from Design Plans on record Observation of Site (Abutting property, observation hole, basement sump etc.) Determine it from local conditions Check with local Board of health Check FEMA Maps Check pumping records Check local excavators, installers Use USGS Data Describe in your own words how you established the High Groundwater Elevation. Must be completed) Ll X (reviaad (14/25/97) Pago 10 of 10 PM PHONE AREA CODE NUMBER XTENSION MESSAGE — L CALL ACA{N �' Wr l GAME TO SEE YOU ' WANTS TO YOU SIGNED 1 ,SEE _ n1(' nn .TOPS FORM 4003 NOTES '.\., _ t ~-ii 3; t T ? 7,y A.\.1 �i 1'.��#Y , \ 1' i � 1 , i� �i ,�,. •. {t' - tl. l ,.\ 7_\\4'16+7�:7.',i-7� `?,tY R'•. �'•q\�Ak\ A7�., iW41y�4'\�S.�i�.�hv'�t s�>�'M.r4�IM.11h��e,�� T ^r_I{... '!,� � , j. i '�5 +♦ ;Y `'• Al tEl'q Fkl '�,'���i\i} �, 1`: \i �u�;�\aE T' �i ��\ .'•moi �.\, 4. V'stt/A,. t ti`•e �, i. r'. tile:+ \� :e '\ + \ •' \ k - � 1 1 �•Il ' '� 4 } T ,� `1 ,lrF �e a S �.� �' \. l l �.\ '2 � rl1 w 1 ,..� i ti �� �.}s �t y .� s"� ''S'��: `l}},T 1i// li`+�i�^�}'�i�,S'��iyj''g�1�Y•yI`ti�..lhe`,1 X slY`t;�_.. ,,. - - 1 4 { •pit''' f1`L .�; � +\Tia %'�1 1 , i :s T ,, , i3 '4 T ,AORTM 0c H A JF SSACHUSE Town of North Andover, Massachusetts BOARD OF HEALTH Form No.3 19 T_ DISPOSAL WORKS CONSTRUCTION PERMIT Applicant CV 1�` TELEPHONE NAME ADDRESS Site Location�d.�� Permission is hereby granted to Constructor Repair ( ) an Individual Soil Absorption Sewage Disposal System as shown on the Design Approval S.S. No. CHAIRMAN, BOARD OF HEALTH Fee D.W.C. No. 0 N -1-o4-000 w 0 LOT I N AREA=34007S. F. .o 0 10.9' LOT 2 \ �EL FN 55.0' \ 10.9' 39.5' 100.00' WH/ TE BIRCH LANE FOUNDATION LOCATION PLAN CLIENT. SCOTT CONSTRUCTION THIS CERTIFICATION IS MADE AND LIMITED TO THE ABOVE CLIENT. LOCATION: NORTH ANDOVER,MA. SCALE.1 "=40' DATE. 5/20/94 CHRI S TIA NSEN Q SERGI PRO LANDSURVEYORSEERS 160 SUMMER ST. HAVERHILL.MA. 01830 TEL. 508-373-0310 © 1994 BY CHRISTIANSEN & SERGI INC. I CERTIFY THAT THE PRIMARY STRUCTURE SHOWN CONFORMS TO THE HORIZONTAL SETBACK REOUIREM£NTS OF THE LOCAL APPLICABLE ZONING BY-LAWS IN EFFECT WHEN CONSTRUCTED. (THIS CERTIFICATION DOES NOT CONSIDER ANY OTHER RESTRICTIONS SUCH AS COVENANTS,WETLANDS,EASEMENTS, ORDERS OF CONDITIONS.ETC.) THIS DRAWING SHALL NOT BE USED BY THE CLIENT FOR ANY PURPOSE OTHER THAN THAT OUTLINED ABOVE,EXCEPT WITH THE WRITTEN PERMISSION OF CHRISTIANSEN & SERGI INC. FURTHERMORE THIS DRAWING IS THE COPYRIGHTED PROPERTY OF CHRISTIANSEN & SERGI INC. AND ANY UNAUTHORIZED USE IS PROHISITED.CHRISTIANSEN & SERGI TAKES NO RESPONSIBILITY FOR THE UNAUTHORIZED USE OF THIS DRAWING OR ANY INFOR- MATION CONTAINED HEREON. BASED ON SCALED DATA ONLY THE PRIMARY STRUCTURE SHOWN IS NOT LOCATED 1N A FLOOD HAZARD ZONE AS SHOWN ON FEMt FLOOD INSURANCE RATE MAP. i COMMUNITY NO.: 250098 0005C OATE. 612193 �11OF moo'% y :R�m, • , S s ' D WG. NO.: 93067016 FORM U - LOT RELEASE FORM INSTRUCTIONS: This form is used to verify that all necessary approvals/permits from Boards and Departments having jurisdiction have been obtained. This does not relieve the applicant and/or landowner from compliance with any applicable local or state law, regulations or requirements. ****************Applicant fills out this section***************** APPLICANT:-� i- > > �� �1 -1 /% Phone LOCATION: Assessor's Map Number Subdivision�- Parcel Lot (s) Street S t . Numb e r ************************Official Use RECOMMENDATIONS OF TOWN AGENTS: Conservation Administrator Comments Town Planner Comments Food Inspector -Health Septic Inspector -Health Comments Public Works - sewer/water connections - driveway permit Fire Department Received by Building Inspector �i Date Approved Date Rejected Date Approved Date Rejected Date Approved Date Rejected Date Approved Date Rejected Date Town of North Andover, Massachusetts Form No. 2 MOR*h BOARD OF HEALTH n U, .45 1 CA -3 DESIGN APPROVAL FOR s�cN� SOIL ABSORPTION SEWAGE DISPOSAL SYSTEM Applicant. illn C 9 el C-6AII Test No. Site Location GDT Reference Plans and IN Permission is granted for an individual soil absorption sewage disposal system to be installed in accordance with regulations of Board of Health. $ Fee G CHAIRMAN, BOARD OF HEALTH Site System Permit No. 6 4i— ',t`• is:�l �V. }i. �. �1♦ �\ 'Seim' 1i� \1�! t.b. .tr.(\�i `lY\t. l � - )r i ; t ; „ � ..i �. 7 . 1 t p �, . - � . •` 4 l .,, lll� �.� �\ :ice � l ' � }t . .',•_\.� ....'i. .[-. ivaiR' t �'. \�1sn}.e .. .e . l ��. :.� .ty'�\,\ ..Ci.�:,`?.. : d�L ,. t `;4t. •1_. i lk I BOARD OF HEALTH 120 MAIN STREET NORTH ANDOVER, MASS. 01845 Phil Christensen 160 Summer Street Haverhill, MA 01830 RE: Revision Fees on Lots #1, Dear Phil: - November 15, 1993 & 4 White Birch Lane TEL. 682-6483 Ext23 This is to notify you that your septic plans for Lots #1, 2, I 3, 4, 5, and 6 White Birch Lane have been rejected: Please see attached sheets outlining what is needed for approval. In addition, revision fees are required for Lot's # 1, 2, and 4 White Birch Lane. The fee for re -submittal is $25L00 per plan, which will total $75.00. Please make check payable to the Town of North Andover. If you have any questions, please do not hesitate to call the Health Office. Sincerely, iL I " Sandra Starr Health Agent SS/cjp • S r Z ol Sheet of BOARD OF HEALTH TOWN OF NORTH ANDOVER SUBSURFACE DISPOSAL DESIGN REVIEW FEE *'j, d PERMIT # APPLICANT J IM ADDRESS DATE RECEIVED IO/�/X ASSESSOR'S MAP PARCEL 4 LOT # STREET ENGINEER ADDRESS A�0 PLAN DATE fH06, /0, /YZ� REV151UN UA•t•r; CONDITIONS OF APPROVAL: APPROVED DISAPPROVED 1 C Nc # M A 2,if To 069, �D U/i/•D�T/O/V ���/�1l l �i� TANG -SET cc�E�N DATE• �V`� Sheet_ of BOARD OF HEALTH TOWN OF NORTH ANDOVER SUBSURFACE DISPOSAL DESIGN REVIEW D� FEECD PERMIT # DATE RECEIVED �� N APPLICANT JIM I M Qbc-6 (// ASSESSOR'S MAP ADDRESS PARCEL # LOT # I STREET # ENGINEER -P. Cfi/?I6T/f9AX5ZA1 ADDRESS Ada 5l 10M d 4 vee,? -/re c. PLAN DATE AUG• /D, /993 REVISION DATE CONDITIONS OF APPROVAL: APPROVED DISAPPROVED' 1 b � NGH n� A2,e To jE' SET //V° �oU/l/�/�'T/O/1I �D��f/IJ /�'I/5'S /�G • �/�