HomeMy WebLinkAboutMiscellaneous - 296 BOSTON STREET 4/30/2018 (2)co
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ASK
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MAP #
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PARCEL #
STREET
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HAS PLAN REVIEW FEE,DEEN PAID YES NO
q/
PLAN APPROVAL: DATE APP. BY
DESIGNER: 1,114 Y6,15
PLAN DwE:Z2:;�?,
CONDITIONS
WELL TESTS:
COMMENTS:
DRILLER
BACTERIA I,
BACTERIA Ii
DAIE APPROVED.---.----
DPJ�g flPPRUVED
DA TE APP
FORM U APPROVAL: APPROVAL 1*0 ISSUE YES NO
DATE ISSUED
CONDITIONS:
FINAL APPROVAL:
ALL PERMITS PAID YES NO
WELL CONSTRUCTION APPROVAL YES NO
SEPTIC SYSTEM CONSTRUCTION APPROVAL YES NO
OTHER YES NO
ANY VARIANCE NEEDED
YES NO
FINAL BOARD OF HEALTH APPROVAL: DATE: BY:
Commonwealth of Massachusetts
*City/Town of No. Andover
x
System Pumping Record
Form 4
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 your
local Board of Health to determine the form they use. The System Pumping Record must be submitted to
the local Board of Health or other approving authority within 14 days from the pumping date in
accordance with 310 CMR 15.351.
City/Town
Ma
01845
State Zip Code
IVIED
AUG -
TOWN OF NORTH ANDOVER
HEALTH DEPARTMENT
State Zip Code
Telephone Number
B. Pumping Record 7-27-11 /-S�
1. Date of Pumping Date 2. Quantity Pumped: Gallons
3. Type of system: El Cesspool(s) ej �Sepfic Tank F1 Tight Tank El Grease Trap
El Other (describe):
4. Effluent Tee Filter present? Ej Yes E:1 N o
5. Condition of System:
If yes, was it cleaned? 0 Yes E] No
6. 3ystem Pumpp��.'
04 a
Name Vehicle License Number
Stewart's Septic Service
Company
7. Location where contents were disposed:
$ftwaits-Pre-treatment Plant, 20 So. Mill Bradford, Ma 01835
-KhajjrLFdTHauler
Signature of Receiving FYX�it
.L� ...
-V
Date 2-27-11
Date
t5form4.doc- 03/06 System Pumping Record - Page 1 of 1
A. Facility Information
Important:
When filling out
1 . System Location:
forms on the
computer, use
296 Boston St
only the tab key
Address
to move your
No. Andover
cursor - do not
City/Town
use the return
key.
2. System Owner:
WQ
HArtford
Name
Address (if different from location)
City/Town
Ma
01845
State Zip Code
IVIED
AUG -
TOWN OF NORTH ANDOVER
HEALTH DEPARTMENT
State Zip Code
Telephone Number
B. Pumping Record 7-27-11 /-S�
1. Date of Pumping Date 2. Quantity Pumped: Gallons
3. Type of system: El Cesspool(s) ej �Sepfic Tank F1 Tight Tank El Grease Trap
El Other (describe):
4. Effluent Tee Filter present? Ej Yes E:1 N o
5. Condition of System:
If yes, was it cleaned? 0 Yes E] No
6. 3ystem Pumpp��.'
04 a
Name Vehicle License Number
Stewart's Septic Service
Company
7. Location where contents were disposed:
$ftwaits-Pre-treatment Plant, 20 So. Mill Bradford, Ma 01835
-KhajjrLFdTHauler
Signature of Receiving FYX�it
.L� ...
-V
Date 2-27-11
Date
t5form4.doc- 03/06 System Pumping Record - Page 1 of 1
0
I
Important
Men filling out
forms on the
computer, use
only the tab key
to move your
cursor - do not
use the return
key.
I TOWN OF NORTH ANDOVER
DEP has provided this form for use by local Boards of Health. h1dolim
I MpEjWeekd must
be, submitted to the local Board of Health or other approving authority.
A.. F.acility information
1. System Location:
(0
Address
Cityfrownv
2. System Owner:
-HQd4
Zip Code
Name
Address (if different from location)
City/Town State Zip Code
Felephone Number
B. Pumping Record
X
1. Date of Pumping d-ltl Xr 1 2. Quantity Pumped: ZeTn
Gallons
3.., Type of system: Cesspool(s) 29,"Septic Tank Tight Tank
Other (describe):
4. Effluent Tee Filter present? [] Yes E] No If �6',*Vvas it cleaned? 0 Yes F� No
5. Condition of System:
6. System Pu%edd By:_,().
e 7�e—hlde License Number
KCJ
-rompany
7. Location wAere contents were disposed:
oc� - C�"�Znvfrn n-1 I/ /'
Si$i#re of Hauler Date
http:/Mww.mass.gov/d4'pt-water/approvalstt5forms.htm#inspect
t5form4.doc- 06/03
System Pumping Record - Page I of 1
I
-C-\ Commonwealth of Massachusetts
CHUSETTS
City/Town of NORTH ANDOVER, MASSA
System Pumping Record
Form 4
DEP has provided this form for use by local Boards of Health TH -ftecord must
be submitted to the local Board of Health or other approving uth
A. Facility Information JUL 0 7 2008
Important;
When filling out
forms on the
computer, use
only the tab key
to move your
cursor - do not
use the return
key.
VQ
http://www
t5form4.doe- 06103
1. System.1-ocation:
City/Town
2. System Owner:
4;
Name
Address (if different from location)
City[Town
B. Pumping Record
TOWN OF NORTH ANDOVER
HEALTH DEPARTMENT
L
State
State
Telephone Number
Zip Code
Zip Code
1. Date of Pumping 2. Quantity Pumped:
Date Gallons
I Type of system: El Cesspoof(s) Septic Tank 0 Tight Tank
0 Other (detcribe):
4. Effluent Tee Filter present? E] Yes Q'/No If Yes, was it cleaned? [] Yes n No
5. Condition of System:
6. Sy4tern Pump" By:
e Vehicle' License Number
Company
7. Location where contents were disposed:
/'--1 , el -11- ;� -*. '
of Hauler
rms.htm#inspect
System Pumping Record - Page 1 of I
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BRADFORD, MA 01835
978-372-7471
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Owner
information is
required for
every page.
I
Commonwealth of Massachusetts *
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
296 Boston St
Property Address
Keith Regnante
Owner's Name
North Andover
City/Town
MA 01845
State Zip Code
5/29/2007
C, C
Date of Inspection
Inspection results must be submitted on this form. Inspection forms may not be altered in any
way.
Important:
A. General Information
When filling out
forms on the
computer, use
1 . Inspector:
only the tab key
to move your
Chad Jablonski
cursor - do not
Namo of Inspector
use the return
key.
Jablonski & Sons Inc.
do"�
Company Name
vt�=A
P.O. Box 8147
Company Address
Haverhill
City/Town
978-360-9358
Telephone Number
B. Certification
MA
01835
State Zip Code
Mass. DEP does not issue #'s at this time
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 15.340 of
Title 5 (310 CMR 15.000). The system:
Z Passes El Conditionally Passes F-1 Fails
M Needs Further Evaluation by the Local Approving Authority
re
Date
� lqle,7
The solep hspector shall submit a copy of this inspection report to the Approving Authority (Board
,y te
of U, o DEP) within 30 days of completing this inspection. It the system is a shared system or
h W7,5,q i�n 41-- M V) nr)r) —4 — m— — Ln in , �+— n�A +k —0 nm ^ k 4 +k
s e e L —ner shall o, e
H .... ... � "' -y-
report to the appropriate regional office of the DER The original shoulY�e—s'e"nt' 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.
Regnante, Keith 296 Boston St., N. And - 08/06 Title 5 Official inspection Form: Subsurface Sewage Disposal System - Page 1 of 15
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form Not for Voluntary Assessments
296 Boston St
Property Address
Keith Regnante
Owner Owner's Name
information is
required for North Andover MA 01845 5/29/2007
every page. City/Town 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:
1 have not found any information which indicates that any of the failure criteria described
in 310 CMR 15.303 or in 310 CMR 15.304 exist. Any failure criteria not evaluated are
indicated below.
Comments:
B) System Conditionally Passes:
El One or more system components as described in the "Conditional Pass" section need to be
replaced or repaired. The system, upon completion of the replacement or repair, as approved by
the Board of Health, will pass.
Answer yes, no or not determined (Y, N, ND) in the F� for the following statements. If "not
determined," please explain.
F-1 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 extiltration or tank failure is imminent.
System will pass inspection if the existing tank is replaced with a complying septic tank as
approved by the Board of Health.
* A metal septic tank will pass inspection if it is structurally sound, not leaking and if a Certificate
of Compliance indicating that the tank is less than 20 years old is available.
ND Explain:
D 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):
0
X
broken pipe(s) are replaced
obstruction is removed
Regnante. Keith 296 Boston St., N. And - 08/06 Title 5 Official Inspection Form: Subsurface Sewage Disposal System - Page 2 of 15
Owner
information is
required for
every page.
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
296 Boston St
Property Address
Keith Regnante
Owner's Name
North Andover MA 01845 5/29/2007
City/Town State Zip Code Date of Inspection
B. Certification (cont.)
B) System Conditionally Passes (cont.):
El distribution box is leveled or replaced
ND Explain:
The system required pumping more than 4 times a year due to broken or obstructed pipe(s). The
system will pass inspection if (with approval of the Board of Health):
[I broken pipe(s) are replaced
F1 obstruction is removed
ND Explain:
C) Further Evaluation is Required by the Board of Health:
E] 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:
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
2. Sustem will fail unless the Board of Health (and Public Water Supplier, if anyl
determines that the system is functioning in a manner that protects the public health,
safety and environment:
El 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.
F� The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water
supply.
El The system has a septic tank and SAS and the SAS is within 50 feet of a private water
supply well.
Regnante, Keith 296 Boston St.. N. And - 08/06 Title 5 Official Inspection Form: Subsurface Sewage Disposal System - Page 3 of 15
Owner
information is
required for
every page.
Commonwealth of Massachusetts
itle 5 fficial Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
296 Boston St
Property Address
Keith Regnante
Owner's Name
North Andover MA 01845 5/29/2007
City/Town State Zip Code Date of Inspection
B. Certification (cont.)
C) Further Evaluation is Required by the Board of Health (cont.):
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 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:
D) System Failure Criteria Applicable to All Systems:
You must indicate "Yes" or "No" to each of the following for all inspections:
Yes
No
Backup of sewage into facility or system component due to overloaded or
clogged SAS or cesspool
El
E
Discharge or ponding of effluent to the surface of the ground or surface waters
due to an overloaded or clogged SAS or cesspool
0
171
Static liquid level in the distribution box above outlet invert due to an overloaded
or clogged SAS or cesspool
El
E
Liquid depth in cesspool is less than 6" below invert or available volume is less
than 1/2day flow
EJ
E
Required pumping more than 4 times in the last year NOTdue to clogged or
obstructed pipe(s). Number of times pumped: _.
Any portion of the SAS, cesspool or privy is below high ground water elevation.
E]
E
Any portion of cesspool or privy is within 100 feet of a surface water supply or
tributary to a surface water supply.
Regnante, Keith 296 Boston St., N. And - 08/06
Title 5 Official Inspection Form: Subsurface Sewage Disposal System - Page 4 of 15
Owner
information is
required for
every page.
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
296 Boston St
Property Address
Keith Regnante
Owner's Name
North Andover MA 01845 5/29/2007
Cityfrown State Zip Code Date of Inspection
B. Certification (cont.)
D) System Failure Criteria Applicable to All Systems (cont.):
Yes No
El Z Any portion of a cesspool or privy is within a Zone 1 of a public well.
El Z Any portion of a cesspool or privy is within 50 feet of a private water supply well.
E] z Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet
from a private water supply well with no acceptable water quality analysis. [This
system passes if the well water analysis, performed at a DEP certified
laboratory, for fecal coliform bacteria indicates absent and the presence
of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm,
provided that no other failure criteria are triggered. A copy of the analysis
and chain of custody must be attached to this form.]
The system is a cesspool serving a facility with a design flow of 2000gpd-
1 0,000gpd.
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 f low 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] El the system is within 400 feet of a surface drinking water supply
El 0 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 — lWPA) 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.
Regnante, Keith 296 Boston St., N. And - 08/06 Title 5 Official Inspection Form: Subsuriace Sewage Disposal System - Page 5 of 15
Commonwealth of Massachusetts
Title 5 Official Inspection Form
W. Subsurface Sewage Disposal System Form Not for Voluntary Assessments
296 Boston St
C. Checklist
5/29/2007
Date of Inspection
Check if the following have been done. You must indicate "yes" or "no" as to each of the following:
Yes No
Z E]
Property Address
F� Z
Keith Regnante
Owner
Owner's Name
information is
required for
North Andover MA 01845
every page.
CityfTown State Zip Code
C. Checklist
5/29/2007
Date of Inspection
Check if the following have been done. You must indicate "yes" or "no" as to each of the following:
Yes No
Z E]
Pumping information was provided by the owner, occupant, or Board of Health
F� Z
were any of the system components pumped out in the previous two weeks?
Z F-1
Has the system received normal flows in the previous two week period?
1:1 Z
Have large volumes of water been introduced to the system recently or as part of
this inspection?
Z 1:1
Were as built plans of the system obtained and examined? (If they were not
available note as N/A)
Z 11
Was the facility or dwelling inspected for signs of sewage back up?
Z 1:1
Was the site inspected for signs of break out?
Z 1:1
Were all system components, excluding the SAS, located on site?
Z 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?
Z 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:
Z 1:1
Existing information. For example, a plan at the Board of Health.
El Z
Determined in the field (if any of the failure criteria related to Part C is at issue
approximation of distance is unacceptable) [310 CMR 15.302(5)]
Regnante, Keith 296 Boston St., N. And - 08/06 Title 5 Official Inspection Form: Subsurface Sewage Disposal System - Page 6 of 15
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
296 Boston St
D. System Information
Residential Flow Conditions:
01845 5/29/2007
Zip Code Date of Inspection
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): 440 gpd
Number of current residents: 4
Does residence have a garbage grinder? 0 Yes E No
Is laundry on a separate sewage system? [if yes separate inspection required] D Yes Z No
Laundry system inspected? Z Yes El No
Seasonaluse?
Property Address
No
Keith Regnante
Owner
Owner's Name
information is
required for
North Andover MA
every page.
City/Town State
D. System Information
Residential Flow Conditions:
01845 5/29/2007
Zip Code Date of Inspection
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): 440 gpd
Number of current residents: 4
Does residence have a garbage grinder? 0 Yes E No
Is laundry on a separate sewage system? [if yes separate inspection required] D Yes Z No
Laundry system inspected? Z Yes El No
Seasonaluse?
F� Yes Z
No
Water meter readings, it available (last 2 years usage (gpd)):
222 gpd w/o
summer mnths.
Sump pump?
El Yes Z
No
Last date of occupancy:
occupied
Date
Commercial/industrial Flow Conditions:
Type of Establishment:
Design flow (based on 310 CMR 15.203): Gallons per day (gpd)
Basis of design flow (seats/persons/sq.ft., etc.):
Grease trap present?
El Yes F-1
No
Industrial waste holding tank present?
El Yes F�
No
Non -sanitary waste discharaed to the Title 5 system?
Yes
No
Water meter readings, if available:
Last date of occupancy/use: Date
Other (describe):
Regnante, Keith 296 Boston St.. N. And - 08/06 Title 5 Official Inspection Form: Subsurface Sewage Disposal System - Page 7 of 15
Owner
information is
required for
every page.
Commonwealth of Massachusetts
Title 5 Off icial lhspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
296 Boston St
Property Address
Keith Regnante
Owner's Name
North Andover
CityfTown
D. System Information (cont.)
Pumping Records:
Source of information:
5/29/2007
State Zip Code Date of Inspection
General Information
Was system pumped as part of the inspection?
If yes, volume pumped:
How was quantity pumped determined?
Reason for pumping:
Type of System:
N. Andover BOH
El Yes 0 No
n/a
gallons
n/a
n/a
F� Privy
E] Shared system (yes or no) (if yes, attach previous inspection records, if any)
El Innovative/Alternative technology. Attach a copy of the current operation and
maintenance contract (to be obtained from system owner)
D Tight tank. Attach a copy of the DEP approval.
El Other (describe):
Approximate age of all components, date installed (if known� and source of information:
10 yrs, as -built plans approved 4/23/97
Were sewage odors detected when arriving at the site? El Yes Z No
Regnante. Keith 296 Boston St., N. And - 08/06 Title 5 Official Inspection Form: Subsurface Sewage Disposal System - Page 8 of 15
Septic tank, distribution box, soil absorption system
Single cesspool
Overflow cesspool
F� Privy
E] Shared system (yes or no) (if yes, attach previous inspection records, if any)
El Innovative/Alternative technology. Attach a copy of the current operation and
maintenance contract (to be obtained from system owner)
D Tight tank. Attach a copy of the DEP approval.
El Other (describe):
Approximate age of all components, date installed (if known� and source of information:
10 yrs, as -built plans approved 4/23/97
Were sewage odors detected when arriving at the site? El Yes Z No
Regnante. Keith 296 Boston St., N. And - 08/06 Title 5 Official Inspection Form: Subsurface Sewage Disposal System - Page 8 of 15
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
296 Boston St
D. System Information (cont.)
Building Sewer (locate on site plan):
Depth below grade:
f eet
Material of construction:
F-1 cast iron Z 40 PVC M other (explain):
Distance from private water supply well or suction line: n/a
f eet
Comments (on condition of joints, venting, evidence of leakage, etc.):
watertight at foundation, no evidence of back up or leaking
Septic Tank (locate on site plan):
Depth below grade: 3"
f eet
5/29/2007
Date of Inspection
Material of construction:
Z concrete El metal El fiberglass E] polyethylene other (explain)
If tank is metal, list age: n/a
years
Is age confirmed by a Certificate of Compliance? (attach a copy of certificate) El Yes El No
--------------------------------------------------------------------------------------------------------------------------
Dimensions: 10' x S8 x 68
Sludge depth: 3"
Distance from ton of shirige to bottom of outlet tee or bafflp +3'
Scum thickness minimal
Distance from top of Scum to top of outlet tee or baffle n/a
Distance from bottom of scum to bottom of outlet tee or baffle n/a
Tifin r, I; k + 14 +; L,
How were dimensions determined? klc;t I Ct V a U
Regnante. Keith 296 Boston St., N. And - 08/06 Title 5 Official Inspection Form: Subsurface Sewage Disposal System - Page 9 of 15
Property Address
Keith Regnante
Owner
Owner's Name
information is
required for
North Andover MA 01845
-�tate
every page.
City/Town Zip Code
D. System Information (cont.)
Building Sewer (locate on site plan):
Depth below grade:
f eet
Material of construction:
F-1 cast iron Z 40 PVC M other (explain):
Distance from private water supply well or suction line: n/a
f eet
Comments (on condition of joints, venting, evidence of leakage, etc.):
watertight at foundation, no evidence of back up or leaking
Septic Tank (locate on site plan):
Depth below grade: 3"
f eet
5/29/2007
Date of Inspection
Material of construction:
Z concrete El metal El fiberglass E] polyethylene other (explain)
If tank is metal, list age: n/a
years
Is age confirmed by a Certificate of Compliance? (attach a copy of certificate) El Yes El No
--------------------------------------------------------------------------------------------------------------------------
Dimensions: 10' x S8 x 68
Sludge depth: 3"
Distance from ton of shirige to bottom of outlet tee or bafflp +3'
Scum thickness minimal
Distance from top of Scum to top of outlet tee or baffle n/a
Distance from bottom of scum to bottom of outlet tee or baffle n/a
Tifin r, I; k + 14 +; L,
How were dimensions determined? klc;t I Ct V a U
Regnante. Keith 296 Boston St., N. And - 08/06 Title 5 Official Inspection Form: Subsurface Sewage Disposal System - Page 9 of 15
Commonwealth of Massachusetts
7 Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form Not for Voluntary Assessments
296 Boston St
Property Address
Keith Regnante
Owner Owner's Name
information is
required for North Andover MA 01845 5/29/2007
every page. City/Town
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.):
Tank pumped on 5/30/2007 as recommended. Some solid material in tee. Recommend home owner
installs Zabel filter with cast iron frame and cover to arade.
Grease Trap (locate on site plan):
Depth below grade:
Material of construction:
El concrete D metal El fiberglass
feet
El polyethylene E] other (explain):
Dimensions:
Scum thickness
Distance from top of scum to top of outlet tee or baffle
Distance from bottom of scum to bottom of outlet tee or baffle
Date of last pumping: Date
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 numppri i timp of in.sneCtion) flocca e on site plan) -
Depth below grade:
Material of construction:
El concrete F� metal El fiberglass polyethylene E] other (explain):
Regnante, Keith 296 Boston St.. N. And - 08/06 Title 5 Official Inspection Form: Subsurface Sewage Disposal System - Page 10 of 15
t\ Commonwealth of Massachusetts
4"N
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
296 Boston St
D. System Information (cont.)
Tight or Holding Tank (cont.)
Dimensions:
Capacity:
Design Flow:
Alarm present:
Alarm level:
gallons
5/29/2007
Date of Inspection
gallons per day
El Yes F� No
Alarm in working order:
Date of last pumping: Date
Comments (condition of alarm and float switches, etc.):
M Yes El No
* Attach copy of current pumping contract (required). Is copy attached? El Yes E] No
Distribution Box (if present must be opened) (locate on site plan):
Depth of liquid level above outlet invert Oil
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.):
Box was level and distributing equally. No sign of hydraulic failure. Some solid carryover, due to baby
wipes according to home owner.
Pump Chamber (locate on siteplan):
Pumps in working order:
Alarms in working order:
El
Hroperty Address
7
Keith Regnante
Owner
Owner's Name
information is
No
required for
North Andover MA 01845
every page.
City[Town State Zip Code
D. System Information (cont.)
Tight or Holding Tank (cont.)
Dimensions:
Capacity:
Design Flow:
Alarm present:
Alarm level:
gallons
5/29/2007
Date of Inspection
gallons per day
El Yes F� No
Alarm in working order:
Date of last pumping: Date
Comments (condition of alarm and float switches, etc.):
M Yes El No
* Attach copy of current pumping contract (required). Is copy attached? El Yes E] No
Distribution Box (if present must be opened) (locate on site plan):
Depth of liquid level above outlet invert Oil
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.):
Box was level and distributing equally. No sign of hydraulic failure. Some solid carryover, due to baby
wipes according to home owner.
Pump Chamber (locate on siteplan):
Pumps in working order:
Alarms in working order:
El
Yes
7
No
El
Yes
7
No
Regname, Keith 296 Boston St., N. And - 08/06 Title 5 Official Inspection Form: Subsurface Sewage Disposal System - Page 11 of 15
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
296 Boston St
01845 5/29/2007
Zip Code Date of Inspection
D. System Information (cont.)
Comments (note condition of pump chamber, condition of pumps and appurtenances, etc.):
Soil Absorption System (SAS) (locate on site plan, excavation not required):
If SAS not located, explain why:
Property Address
Keith Regnante
Owner
Owner's Name
information is
required for
North Andover MA
every page.
CityfTown State
01845 5/29/2007
Zip Code Date of Inspection
D. System Information (cont.)
Comments (note condition of pump chamber, condition of pumps and appurtenances, etc.):
Soil Absorption System (SAS) (locate on site plan, excavation not required):
If SAS not located, explain why:
Comments (note condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of
vegetation, etc.):
No evidence of hydraulic failure or ponding
Regname. Keith 296 Boston St., N. And - 08106 Title 5 Official Inspection Form: Subsurface Sewage Disposal System - Page 12 of 15
Type:
El
leaching pits
number:
11
leaching chambers
number:
El
leaching galleries
number:
0
leaching trenches
number, length: 3,60-
0
leaching fields
number, dimensions:
El
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.):
No evidence of hydraulic failure or ponding
Regname. Keith 296 Boston St., N. And - 08106 Title 5 Official Inspection Form: Subsurface Sewage Disposal System - Page 12 of 15
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form Not for Voluntary Assessments
296 Boston St
Property Address
Keith Regnante
Owner Owner's Name
information is
required for North Andover MA 01845 5/29/2007
every page. CityfTown
State Zip Code
Date of Inspection
D. System Information (cont.)
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 N o
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.):
Regname, Keith 296 Boston St., N. And - 08/06 Title 5 Official Inspection Form: Subsurface Sewage Disposal System - Page 13 of 15
n
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
296 Boston St
6
D. System Information (cont.)
5/29/2007
Date of Inspection
Sketch Of Sewage Disposal System: Provide a sketch 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.
T E5 A T 18.0 "'
P -�32-
7
.-D
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EAIT
Regnante, Keith 296 Boston St.. N. And - 08/06 Title 5 Ofticial Inspection Form: Subsurface Sewage Disposal System - Page 14 of 15
t-roperty AcIciress
Keith Regnante
Owner
Owner's Name
information is
required for
North Andover MA 01845
every page.
Cityrrown State Zip Code
6
D. System Information (cont.)
5/29/2007
Date of Inspection
Sketch Of Sewage Disposal System: Provide a sketch 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.
T E5 A T 18.0 "'
P -�32-
7
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Regnante, Keith 296 Boston St.. N. And - 08/06 Title 5 Ofticial Inspection Form: Subsurface Sewage Disposal System - Page 14 of 15
Owner
information is
required for
every page.
Commohwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
296 Boston St
Property Address
Keith Regnant
Owner's Name
North Andover
CityfTown
State
01845
Zip Code
5/29/2007
Date of Inspection
D. System Information (cont.)
Site Exam:
Z Check Slope
El Surface water
Check cellar
Shallow wells
Estimated depth to ground water: 42"
feet
Please indicate all methods used to determine the high ground water elevation:
z Obtained from system design plans on record
If checked, date of design plan reviewed. 11/19/96
Date
El Observed site (abutting property/observation hole within 150 feet of SAS)
El Checked with local Board of Health - explain:
11 Checked with local excavators, installers - (attach documentation)
El Accessed USGS database - explain:
You must describe how you established the high ground water elevation:
Plans approved by the N. Andover Health Department on 11/19/96. Perc Test dates 4/22/94, 8/4/95,
8/5/95
Regnante, Keith 296 Boston St., N. And - 08/06 Title 5 Official Inspection Form: Subsurface Sewage Disposal System - Page 15 of 15
Form No. 3
Town of North Andover, Massachusetts
,LoRTpj BOARD OF HEALTH 19
0
DISPOSAL WORKS CONSTRUCTION PERMIT
Applicant NA ME ADDRESS
60
Site Location
Permission is hereby granted to Construct,�-�®r Repair an Individual Soil Absorption .
Sewage Disposal System as shown on the Design Approval S.S. No.—
D. W.C. No.
Fee
APPLICATION FOR DISPOSAL WORKS CONSTRUCTION PERMIT
,!5. /
DATE:-//- 7b CURRENT INSTALLER'S LICENSE4
LOCATION: 7— *-5- 'ea's Rj,
LICENSED INSTALLER:_
SIGNATURE:
CHECK ONE:
REPAIR:
t"- 1 C2 ki /1 C /6<1 -e_ t -
ONE# �'/ -7 - Sj'�O
NEW CONSTRUCTION:
][F NEW CONSTUCTION, PLEASE ATTACH FOUNDATION AS -BUILT.
Administrative Use Only
$75.00 Fee Attached? Yes No
Foundation As -Built? Yes No—
Approval Date:
Town of North Andover, Massachusetts Form No.2
,t0RT#j BOARD OF HEALTH
n
AL —JQ
a_ DESIGN APPROVAL FOR
as CH SOIL ABSORPTION SEWAGE DISPOSAL SYSTEM
Applicant t��O� Test No
Site Location Lic;7- -*-!s - i i L4 aos6-y, '�z-:>"T-
Reference Plans and Specs. k U V—
ENGINEER DffIG
V
Permission is granted for an individual soil absorption sewage disposal system to be installed
in accordance with regulations of Board of Health.
-t fo
FeelDI----
CHAIRMAN, BOARD OF HEALTH
Site System Permit No. 2
LOT 6
co
CERTIFIED PLO'[PLAN
LOCATED IN NORTH ANDOVER, MA.
SCALE:1"= 40' DATE: 10/18/96
.Scoft L. Giles R.P.L.S.
Frank S. Giles
50 Deer Meadow Road
13
North Andover, Mass.
BOSTON STREET
LOT 5
83,082 S.F.
320'TO BOSTON S�.
-.4
Aj
0- 1�1 �
'"n
ILI
Alm,
1 CERTIFY THAT OFFSETS SHOWN ARE FOR THE USE
THE OFFSETS OF -1 HE BUILDING INSPECTOR ONLY
SHOWN COMPLY AND SUCH USE IS FOR THE
WITH THE ZONING DETERMINATION OF ZONING
BY LAWS OF CONFORMITY OR NON -CONFORMITY
NORTH ANDOVER WHEN CONSTRUCTED.
WHEN BUILT.
y,
....... ..... - - - - - - . . . . .
A,r
Ile . J- 7 �ff
I 1, 10
It
Af
'Y�f- *1,
11L# 4
Mg!
fk,4% W
--B65 7 -OA)
A,r
Ile . J- 7 �ff
I 1, 10
It
Af
'Y�f- *1,
11L# 4
Mg!
fk,4% W
-- ------- --
0
UA rE sy
SYSTEM,OWNER & AD06RFRU
v
,2
DATE OF PUMPING -
RECEIVED
VN OF NORTH ANDOVEF, SEP - 7 2004
TEM PUMPINQ RECORj) TOWN OF NOERTH ANDOVER
HEALTH D PARTf�ENT
TION
QUANTITY PUMPED:
CLSSPOOL: NO---____., � YES- SOPtic Tank. y ES
NATURE OF SERVICE: KouriNE- ERGENCY
UOSF-RVAMNS:
GWD CONDITION FULL'W COVEg
HEAVY ORE"E
ROOTS BAFFLES IN PLACE
LEACMELD RUNBACK
EXCESSIVE soLIpS ------ FLOODED
SOUD CARRyC)VER OTIfER EXPLAIN
pl%unprod by
COMWNTS,
CUN'TtNi's rKAN3ftMD'Fo
11
0 ,
L_K' E
Applicant
Town of North Andover, Massachusetts Form No.1
BOARD OF HEALTH
N -? 19 q1L
Y)" AD& ' -- I
APPLICATION FOR SITE TESTING/INSPECTION
NAME 0
Site Location ( --I-- "
Engineer AIC'4� ,
NAME
Test/l nspection Date and Time
Fee—
CHAIRMAN, BOARD OF HEALTH
TestNo. (0\9
S.S. Permit No.—D.W.C. No.—C.C. Date—Plbg. Permit No.
Town of North Andover, Massachusetts Form No.1
tAORTH BOARD OF HEALTH
0* 'q4,, I . i
,1 6 10 r
0 19 -
APPLICATION FOR SITE TESTING/INSPECTION
Applicant
NAME ADDRESS TELEPHONE
Site Location
Engineer
NAME ADDRESS TELEPHONE
Test/l nspection Date and Time
Fee
CHAIRMAN, BOARD OF HEALTH
Test No.
S.S. Permit No.-D.W.C. No. C.C. Date-Plbg. Permit No.
Town of North Andover Of tkoRTN -1 V
OFFICE OF t ,so " 16 0
COMMUNITY DEVELOPMENT AND SERVICES -:kamm . i . A "o
146 Main Street
U
North Andover, Massachusetts 0 1845 CHU
(508) 688-9533
December 7, 1995
Steve D'Urso
22 Lily Pond Road
Boxford, MA 01921
Re: Lot #5 Boston Street
Dear Steve:
This is to inform you that the proposed plans for the site
referenced above have been disapproved for the following reasons:
1) No benchmark.
2) No water line.
3) Is driveway there?
4) Tank outlet needs gas baffle.
5) No map & parcel number.
If you have any questions, please do not hesitate to call the Board
of Health Office at the number below.
sincerely,
Sandra Starr, R.S.
Health Administrator
SS/cjp
BOARD OF APPEALS 688-9541 BUILDING 688-9545 CONSERVATION 688-9530 HEALTH 688-9540 PLANNING 688-9535
Julie Parrino D. Robert Nicetta Mchael Howard Sandra Staff KatWeen Bradley Colwell
NORTH ANDOVER BOARD OF HEALTH
DESIGN REVIEW REPORT
FEE: �9/0 6 PERMIT # -�03 DATE RECEIVED /0� lz,�(*51
APPLICANT' -DO k) JQ J4 -/L):57 -Z)0 MAP PARCEL
ADDRESS
LOT #
1,3 -
ENG. �57Z,-Vkg- b I&Ie-SIO STREET. --250t:5,7-01-)
ADDRESS- ZI&LY TD -;E76
PLAN DATE 117-5- REV. DATE
CONDITIONS OF APPROVAL
APPROVED
REASONS FOR DISAPPROVAL:
/, ILJO
DISAPPROVED
C)6 -j;, IUO
16
6,45
AIC -
AJC>
PLAN REVIEW CHECKLIST
ADDRESS 4ir�- ENGINEER 's. b
GENERAL
3 COPIES Ll�� STAMP LOCUS L,""' NORTH ARROW SCALE
CONTOURS L,--' PROFILE L." SECTION BENCHMARK -h SOIL &
PERCS ELEVATIONSL,---� WETS. DISCLAIMER WELLS & WETS
WATERSHED?�/6 DRIVEWAY.7 (Elev) WATER LINE2!C"" FDN DRAIN
SCH40 TESTS CURRENT?- 19q I- SOIL EVAL 5 7-1-9,e)C
SEPTIC TANK
MIN 150OG L-""'.17 INVERT DROP GARB. GRINDER �/o (+200% EDF)
25' TO CELLAR MANHOLE ELEV
GW # COMPS.
D -BOX
SIZE # LINES FIRST 2' LEVEL STATEMENT
INLET QQ644- OUTLET,�06,4 17 (2" OR .17 FT) TEE REQ'D? AIC)
LEACHING
MIN 660 GPD? 6L, RESERVE AREA-� 4' FROM PRIMARY? 4� 2% SLOPE
100' TO WETLANDS C�-' 100' TO WELLS --"" 4' TO S.H.GW �-� (51>2M/IN)
35' TO FND & INTRCPTR DRAINS 325' TO SURFACE H20 SUPP
4' PERM. SOIL BELOW FACILITY MIN 12" COVER L"'�FILL?-�(25'
if above natural elev; 101if below) BREAKOUT MET? ---'
TRENCHES
MIN 660 gpdOr----' SLOPE (min .005 or 611/1001 ) C-""'-SIDEWALL DIST. 3X EFF.
W OR D (MIN 61 RESERVE BETWEEN TRENCHES? L,,'��IN FILL? &---'-�MUST
BE 10' MIN. L,�4- PEA STONE? 4,1-�VENT? 4,--' (>3' COVER; LINES >50'
BOT. il �() + SIDE ?6S- X LDNG '33 = TOT
(L x W x #) (DxLx2x#) (G/ft2)
Copyright 0 1995 by S.L. Starr
#
0
4 V
V(
PLAN REVIEW CHECKLIST
ADDRESS 4) 7-,5- ENGINEER , /// � - Yz-, �
GENERAL
3 COPIES STAMP LOCUS NORTH ARROW 4,--' SCALE
CONTOURS PROFILE SECTION L-� BENCHMARK
SOIL &
PERCS ELEVATIONS WETS. DISCLAIMER WELLS & WETS
WATERSHED? A10 DRIVEWAY
(Elev) WATER LINE FDN DRAIN
SCH40 1Y TESTS CURRENT? SOIL EVAL
SEPTIC TANK
MIN 150OG V,11' .17 INVERT DROP GARB. GRINDER-Ae�� 2 comps +200)
10 - TO FDN bl""� MANHOLE 0 "-/ ELEV - GW '-� # COMPS. / GB L---
D-BOX
SIZE # LINES 1�5 FIRST 2' LEVEL STATEMENT
INLET.V,"'Z� 167 - OUTLET 7 (211 OR .17 FT) TEE REQ - D? IZ/10
LEACHING
MIN 440 GPD?,k RESERVE AREA &,"-'�4' FROM PRIMARY?L"".'/ 2% SLOPE
7
100' TO WETLANDS(--' 100' TO WELLS el_ ---,4' TO S.H.Gw' (51>2M/IN)
20' TO FND & INTRCPTR DRAINS--' 400- TO SURFACE H20 SUPP
4' PERM. SOIL BELOW FACILITY Lf�"- MIN 12" COVER `-�FILL?
(15')
BREAKOUT MET?
TRENCHES
MIN 440 gpd
SLOPE (min .005 or 611/1001) SIDEWALL DIST. 3X EFF.
W OR D (MIN 6') RESERVE BETWEEN TRENCHES?��IN FILL? MUST
BE 101 MIN.L,��- 411 PEA STONE?Z VENT? L----- (>3' COVER; LINES >50')
BOT 7(64-6 + SIDE 7 X LDNG 1511 = TOT 4-3(�
(L x W x #) (DxLx2x#) (G/ft2)
13P- 3
Copyright 0 1996 by S.L. Starr
NORTH ANDOVER BOARD OF HEALTH
DESIGN REVIEW REPORT
FEE: PERMIT # DATE RECEIVED
z
APPLICANT j)O-�J 57-04) MAP PARCEL
L076
ADDRESS LOT # TREET #
—6—t,
ENG. 1-14 V<!55 S T R E E T --;50 6 re :577
ENG. ADDRESS '663 S7- IOA149,-�C-lefz�b O/ff �o
PLAN DATE Ao 171�76 REV. DATE
CONDITIONS OF APPROVAL
APPROVED
DISAPPROVED
REASONS FOR DISAPPROVAL:
A)
7-0,e 6 6 6 -.e,4
0
"91
C- I'q
- a -/V/ 4)
&-W t) Z-0 7' �3 �)17
OA) LOF M1,15T -I--
oo 7 � /.g,
ZV UV b 404 r Z;�Z
( IV - A. 4, ge,
LOCATION:
NEW PLANS: YES
REVISED PLANS:
DATE:
DESIGN ENGINEER:
SEPTIC PLAN SUBMITTALS
- C; S A
$60.00/Plan
$25.00/Plan X)1�1
U
When the submission is all in place, route to the Health Secretary
Town of North Andover
OFMCE OF
COMMUNITY DEVELOPMENT AND SERVICES
WILLIAM J. SCOTr
Director
November 4, 1996
Hayes Engineering
G. Rogerson
603 Salem Street
Wakefield, MA 0 18 80
Re: Lot 5 & 6 Boston Street
To Whom it May Concern:
146 Main Street
North Andover, Massachusetts 0 1845
This is to inform you that the proposed plans for the site referenced above have been
disapproved for the following reasons:
I . Insufficient leach area. Capacity only for 436 GPD instead of 440 GPD.
2. No foundation drain.
3. 2" of peastone instead of 4".
4. All piping to be sch. 40.
5. Material note I A shall meet specs of 3 10 CMR 15.25 5 (3).
6. No benchmark on lot 5 within 75 feet of leach area.
7. Cellar floor on lot 5 must be at least I foot above maximum groundwater
elevation - 200.5. (N.A. 4.20)
If you have any questions, please do not hesitate to call the Board of Health Office at the
number below.
Sincerely,
—". jl-&��/L)
Sandra Starr, R.S.,
Health Administrator
cc: D. Johnston
'10 ,
BOARD OF APPEALS 688-9541 BUILDING 688-9545 CONSERVATION 688-9530 HEALTH 688-9540 PLANNING 688-9535
to )c
v I L, -I-
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pe, pip" val�
ef- -T-0
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50 0 C4--(-
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/I mb. 5 p
5zo
to )c
v I L, -I-
-- 4�
TOWN OF NORTH ANDOVER
SYSTEM PUMPING RECORD
I)ATF:
��'STEM OWNER & ADDRESS
62?9& ��,7�Tn G-7�
/v, 41zl-ool�
SYSTEM LOCATION
(example: left front of house)
rf
D.,\TE OF PUMPING: O�–eZ. QUANTITY PUMPED //�—OdGALLONS
Cl'.S S I )OOL: NO JZYES SEPTIC TANK: NO Y E S
NATURE OF SERVICE: ROUTINE __ZEM ERG ENCY
()13.SERV.-,kTIONS:
GOOD CONDITION
HEAVY GREASE
ROOTS
EXCESSIVE SOLIDS
SOLIDS CARRYOVER
SY1.�,'TEM. PUMPED BY:
CONINI E N TS:
_jZFULL TO COVER .
BAFFLES IN PLACE
LEACHFIELD RUNBACK
FLOODED
OTHER (EXPLAIN)
C ONTE'NTS TRA N S F E IZ RE D TO:
CERTIFIED PLOT PLAN
LOCATED IN NORTH ANDOVER, MA.
SCALE: 1 "= 40' DATE: 10/18/96
Scoft L. Giles R.P.L.S.
Frank S. Giles
50 Deer Meadow Road
North Andover, Mass.
BOSTON STREET
177.41'
-4
(P
tp
0
tp
10'.
1`0
�-J
lvojg�;
Rm
I CERTIFY THAT
OFFSETS SHOWN ARE FOR THE USE
THE OFFSETS
OF THE BUILDING INSPECTOR ONLY
SHOWN COMPLY
LOT 6
83,082 S.F.
DETERMINATION OF ZONING
44/
BY LAWS OF
CONFORMITY OR NON -CONFORMITY
NORTH ANDOVER
WHEN BUILT.
WHEN CONSTRUCTED.
fAj
-4
(P
tp
0
tp
10'.
1`0
�-J
lvojg�;
Rm
I CERTIFY THAT
OFFSETS SHOWN ARE FOR THE USE
THE OFFSETS
OF THE BUILDING INSPECTOR ONLY
SHOWN COMPLY
AND SUCH USE IS FOR THE
WITH THE ZONING
DETERMINATION OF ZONING
BY LAWS OF
CONFORMITY OR NON -CONFORMITY
NORTH ANDOVER
WHEN BUILT.
WHEN CONSTRUCTED.