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Miscellaneous - 32 OLYMPIC LANE 4/30/2018
/ 32 OLYMPIC LANE 210/106.B-0109-0000.0 Date..................... ......... NORTp °f t"`°:•�"° TOWN OF NORTH ANDOVER p PERMIT FOR WIRING �31 _ • �,SSACMUSE� f / This certifies that ... -.............. y '?............................................. has permission to perform r. ...... ................................ . ...:......... wiring in the building of....: ............ f................................ � F ........................................... .North Andover,,Mass. F ' QE�L�EC4MICALI / .. -"' Fe�-'�?................ Lic.Nor. �l9,?1.............. sl�:�.r .f � INSPECTO Check # ,d 86L, 2 Commonwealth of Massachusetts Official Use only iw l Department of Fire Services Permit No. Occupancy and Fee Checked _" BOARD OF FIRE PREVENTION REGULATIONS [Rev. 1/07] (leave blank) APPLICATION FOR PERMIT TO PERFORM ELECTRICAL WORK All work to be performed in accordance with the Massachusetts Electrical Code(MEC),527 CMR 12.00 (PLEASE PRINT IN INK OR TYPE ALL INFORMATION) Date: t J / , Ctpp� City or Town of: NORTH ANDOVER To the Inspector of Wires: By this application the undersigned gives notice of his or her intention to perform the electrical work described below. Location(Street& Number) .2- D t L LAIQ Owner or Tenant M9 14 Telephone No. Owner's Address s Is this permit in conjunction with a building permit? Yes No ❑ (Check Appropriate Box) Purpose of Building 0.S l t elyc t Utility Authorization No. Existing Service Amps / Volts Overhead ❑ Undgrd ❑ No.of Meters New Service Amps / Volts Overhead ❑ Undgrd ❑ No.of Meters Number of Feeders and Ampacity Location and Nature of Proposed Electrical Work: �lr��5 6 AAX-s A2'W1X,.q4t &-SS eA CtT�s >< .DLtAe lr lac. Completion of the following table may be waived by the Inspector of Wires. No.of Recessed Luminaires No.of Ceil.-Susp.(Paddle)Fans No.of Total Transformers KVA No.of Luminaire Outlets No.of Hot Tubs Generators KVA No.of Luminaires Swimming Pool Above ❑ In- ❑ o.o Emergency Lighting Crnd. grnd. Battery Units No.of Receptacle Outlets 6 No.of Oil Burners FIRE ALARMS No.of Zones Y No. of Switches No. of Gas BurnersNo.of Detection and f Initiating Devices No.of Ranges No.of Air Cond. Total No.of Alerting Devices Tons g Heat Pump Number Tons KW No.o Self-Contained No.of Waste Disposers Totals: Detection/Alerting Devices No.of Dishwashers Space/Area Heating KW Local❑ CoMunicipal cho ❑ Other Connection No.of Dryers Heating Appliances Kms, Security Systems:* No.of Devices or Equivalent No.o Water KW No.o No.o Data Wiring: Heaters Si ns Ballasts No.of Devices or Equivalent No. Hydromassage Bathtubs No.of Motors Total HP Telecommunications Wiring: No.of Devices or Equivalent OTHER: �1L5 crt 1i,-eer- Attach additional detail if desired, or as required by the Inspector of Wires. Estimated Value of Electrical Work: (When required by municipal policy.) Work to Start: Inspections to be requested in accordance with MEC Rule 10,and upon completion. INSURANCE COVERAGE: Unless waived by the owner,no permit for the performance of electrical work may issue unless the licensee provides proof of liability insurance including"completed operation"coverage or its substantial equivalent. The undersigned certifies that such coverage is in force,and has exhibited proof of same to the permit issuing office. CHECK ONE: INSURANCE ❑ BOND ❑ OTHER ❑ (Specify:) I certify,under th ;ahpiand enalties of p rj ry,that the information on this application is true and complete. FIRM NAME: i Jl- h1A)iK)— LIC. NO.: Licensee: JO/V/-V1114. Signatur LIC. NO.:4--9,7 (If applicabe,/�"ter "e en pt"in the license nu bei l� e.). Bus.Tel. No.:7 - 7 Address: }N•� kML l � /� Of Alt.Tel.No.: - Jr *Per M.G.L c. 147, s. 57-61, security work requires Department of Public Safety "S" License: Lic.No. OWNER'S INSURANCE WAIVER: I am aware that the Licensee does not have the liability insurance coverage normally required by law. By my signature below, I hereby waive this requirement. I am the(check one)❑ owner ❑ owner's agent. Owner/Agent SignaturTelephone No. PERMIT FEE. &2C,5_, Y' The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations ' a 600 Washington Street Boston, MA 02111 www mass gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Le ibl Name(Business/Organization/Individual): Address: Q.O. 'Reg.. (S City/State/Zip: No _ &wye ` kvO Phone#: -7 r/—�W— 75-0-- Are you an employer?Check the appropriate box: Type of project(required): 1.❑ I am a employer with 4. ❑ I am a general contractor and I 6. ❑New construction employees(full and/or part-time).* have hired the sub-contractors 2.Fr-1 am a sole proprietor or partner- listed on the attached sheet. * 7. [Remodeling ship and have no employees These sub-contractors have 8. ❑ Demolition working for me in any capacity. workers' comp.insurance. 9. ❑ Building addition [No workers' comp. insurance 5. ❑ We are a corporation and its required.] officers have exercised their 10.[�]'�lectrical repairs or additions 3.❑ I am a homeowner doing all work right of exemption per MGL 11.❑Plumbing repairs or additions myself. [No workers' comp. c. 152, X1(4),and we have no 12.❑Roof repairs insurance required.] t employees. [No workers' 13.❑ Other comp. insurance required.] *Any applicant that checks box#1 must also fill out the section below showing their workers'compensation policy information. Homeowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such. Contractors that check this box must attached an additional sheet showing the name of the sub-contractors and their workers'comp.policy information. I am an employer that is providing workers'compensation insurance for my employees. Below is the policy and job site information. Insurance Company Name: Policy#or Self-ins. Lic.#: Expiration Date: Job Site Address: City/State/Zip: Attach a copy of the workers'compensation policy declaration page(showing the policy number and expiration date). Failure to secure coverage as required under Section 25A of MGL c. 152 can lead to the imposition of criminal penalties of a fine up to$1,500.00 and/or one-year imprisonment,as well as civil penalties in the form of a STOP WORK ORDER and a fine of up to$250.00 a day against the violator. Be advised that a copy of this statement may be forwarded to the Office of Investigations of the DIA for insurance coverage verification. I do hereby r 'y un er a pai an a lti s of perjury that the information provided above iis' true and correct. Signature r Date: /Lt 1 g a/ Phone#: Official use only. Do not write in this area,to be completed by city or town official. City or Town: Permit/License# Issuing Authority(circle one): 1.Board of Health 2.Building Department 3.City/Town Clerk 4.Electrical Inspector 5.Plumbing Inspector 6.Other Contact Person: Phone#: Date.7/!'' .... .. I NORTIy °f 0? ` TOWN OF NORTH ANDOVER ' PERMIT FOR GAS INSTALLATION no••"`Sh j+ SACHUS This certifies that .�l?. �`.. .'.'.A . . . . . . . . . . . . . . . . . . . . has permission for gas 'nstallation . ! . . F.�. . . . . . . . . . . in the buildings of . ..J . . . . . . . . . . . . . . . . . . . . at . 3 2. �. . -�`. . . . . . . . , North Andover, Mass. Fee.3U'".-. Lic. No.. Y-. ?./.t. . . . . . . . .� . . . . . . GAS INSPECTOR " Check# 2 �� 7 � 6736 MASSACHUSETTS UNIFORM APPLICATON FOR PERMIT TO DO GAS (Type or print) NORTH ANDOVER, MASSACHUSETTS Date Building Loc',ations 01,,Y�YAC L, AJ '�7-7 Permit# Amount S Owner's Name cAv,4 /uA vG� New r/_L-" Renovation Replacement D Plans Submitted ❑ ' s� zw w �c rn �' U a a w cc a ° Z x �' Z aF m .H. " oa w < C z z&0 z p F w o z w 94 QQ > z z o z w -� w � a < e o o w o � o � k3RD . ASEMENT 3 `� -� U C > p o°. Fw„ O M ENT FLOOR FLOOR FLOORFLOORLOORLOORLOOR.LOOR (Print or type) Name L f. C ��G Check one: Certificate 1pstalli g Company �orp. Address U Partner. business 7ejephone E]n Firm/Co. Name of.Licensed Plumber'or Gas Fitter — �Ti�/ FINSURANCECOVERAGE t liability Insurance,policy or it's substantial equivalent. Check oneYes ecked yes,please indi a type coverage by checking theappropriate box. No�nce policy [-� Other type of indemnity El Bond 13 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. Signature of Owner or Owner's Agent Check one: er gen 1 herebAgent y certify that all of the details and information I have submitted(or enOt red) in i applications a and accurate t best of my knowledge and that all plumbing work and installations pe o u der Permit Issued for this application will to in the compliance with all pertinent provisions of the Massachusetts State apter.142 of the General Laws. 4 By: ignatur f 'censed Plumber Or Gas Fitter Title Plumb r City/Town.; 1 Gas Fitter ,eSe i iumbe 13 Master APPROVED(OFFICE USE ONLY) 0 Journeyman 1 .. Date.. ��?1 � ... .... NORTH Of .ao ,tiO 3? �` TOWN OF NOR, ANDOVER O � 9 /' • PERMIT FOR O`AS INSTALLATION SACMUSE� This certifies that . . �L �.'. has permission for gas installation . . .4���.(. . . l Td'. . . . . . . . . in the buildings of . . �- .�.: �'S .l. . . . . . . . . . . . . . . . . . . . . at . . . . . . . . . . . .. North Andover, Mass. Fee. . .. . . Lic. No.. ?. ! `. . . . . .�. . . .� "�"_:�,j-�... . . . 'GAS INSPECTOR Check# 2 `/ ! l 633 MASSACHUSETTS UN mRM APPucATON FOR PERMIT TO DO GAS Fi' UNG (Type or print) Date Z7' C� NORTH ANDOVER, MASSACHUSETTS l / . Building Locations J ( _j �l , 0 Permit# G 3 5 ?c Owner's Name C4 Amount$ New Ej,- Renovation Replacement Plans Submitted a CA zzw � m C �, H w a� c o -D as $ z G �' a U w v, z dFd a o `� > QW C7 F Z Q ?. W a W C F I'll Z' w w F m Z p 1- > � 3 C C7 .a U rg > O SUB-BATE M ENT BASEM ENT 1ST. FLOOR +� 2ND . FLOOR 3RD . FLOOR 4TH . FLOGR 5TH . FLOOR 6TH . FLOOR 7TH . FLOOR HE4:4— IST FLOOR (Print or type) / Check once: Certific Name_ at ,[�s g Company /f%Fti / C- �- /)7?1/ p1 e e I Address bolLV- S A� 6(116 Z ,i , 4-2 11Partner. Busmess Telephone p7 1 Firm Co. Name of Licensed Plumber'or Gas Fitter ��ZI j= r INSURANCE COVERAGE Check one: I have a current liability Insurance,policy or it's substantial equivalent. Yes NoO If you have checked ves,please indicate he.type coverage by checking the appropriate box. Liability insurance policy � Other type of indemnity 1:1 Bond 13 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: Signature of Owner or Owner's Agent Owner 13 Agent 13 1 hereby certify that all of the details and information 1 have submitted(or entered)in above application are true and accurate to the best of my knowledge and that all plumbing work and installations performe nder Permit Issued for this application will be in compliance with all pertinent provisions of the Massachusetts State G and apter 142 of the General Laws. I By: Si ature sed PI as Fitter Title Plumbe f City/Town, Gas Fitter Ice m er aster _ APPROVED(OFFICE USE ONLY) [3 Journeyman s L/ Date..... oTM 1ti TOWN OF NORTH ANDOVER p PERMIT FOR WIRING CHU`�� This certifies that ................................... ...................................................... has permission to perform ...... / — S v� Arm Z ... ................................................... ....... wiring in the building of.................r 4........vL............0 ........................ at................. ... ..... -.!.�!� orth Andover,Mass. Fee.... s .:... Lic.No.J.:7..3 2:.i�......... .....- .. .........:12 f ELE&RICAL INSPECTOR Check # 8065 Official use only Commonwealth of Massachusetts Department of Fire Services Permit No. � Occupancy and Fee Checked BOARD OF FIRE PREVENTION REGULATIONS Rev. 1/07] leave blank APPLICATION FOR PERMIT TO PERFORM ELECTRICAL WORK All work to be performed in accordance with the Massachusetts Electrical Code(MEC), 27 CMR 12.00 (PLEASE PRINT IN INK OR TYPE ALL INFORMATION) Date: City or Town of: NORTH ANDOVER To the Inspector of Wires: By this application the undersigned gives notice of his or her intention to perform the electrical work described below. Location(Street&Number) Owner or Tenant �l���rvlr ky�Ug Telephone No. Owner's Address Is this permit in conjunction with a building permit? Yes e No ❑ (Check Appropriate Box) Purpose of Building ,S`j/� �-t /1� Utility Authorization No. r N Existing Service ,90a Amps Volts Overhead [JUndgrd LDNo.of Meters / New Service Amps ! Volts Overhead❑ Undgrd ❑ No.o eters Number of Feeders and Ampacity Location and Nature of Proposed Electrical Work: -7'- + Completion o the ollowin table mgX be waived by the Ins ector of Wires. No.of Recessed Luminaires No.of Ceil:Susp.(Paddle)Fans No.of Total Transformers KVA No.of Luminaire Outlets No. of Tubs-.-_.-... Generators KVA No.of Luminaires Swimming Pool Above'❑ In- ❑ o.o mergency Lighting rnd. Battery Units No.of Receptacle Outlets No.of Oil Burne FIRE ALARMS No.of Zones No.of Switches o.of Gas Burners o.of Detection and Initiating Devices No.of Ranges No.of Air Cond. Total No.of Alerting Devices Tons g No.of Waste Disposers eat Pum _ um-_r _ons ______ o.o Self-Contained Totals: - "-' Detection/Alerting Devices No.of Dishwashers Space/Area Heating KWLocal 1:1 untctpa ❑ Other Connection No.of Dryers Heating Appliances KW SecuritySystems:* Na of Devices or Equivalent No.of Water KW o.of No.of Data Wiring: Heaters Signs Ballasts No.of Devices or Equivalent No.Hydromassage Bathtubs No.of Motors Total HP Telecommunications iring:No.of Devices or Equivalent OTHER: Attach additional detail if desired or as required by the Inspector of Wires. Estimated Value of Electrical Work: (When required by municipal policy.) Work to Start: Inspections to be requested in accordance with MEC Rule 10,and upon completion. INSURANCE COVERAGE: Unless waived by the owner,no permit for the performance of electrical work may issue unless the licensee provides proof of liability insurance including"completed operation"coverage or its substantial equivalent. The undersigned certifies that such coverage is in force,and has exhibited proof of same to the permit issuing office. CHECK ONE: INSURANCE 0-`BOND ❑ OTHER ❑ (Specify:) I certify,under the pains and penaltles of perjury,that the information on this application is true and complete. FIRM NAME: LIC.NO.: -de— Licensee: _�=1 /r /Li.�k/.!' Signature LIC.NO.: (If applicable,enter "exempt"in the license number line.) Bus.Tel.No.o Address: SD`" /�1/ �'/l�/Li� 4/9.%t Alt.Tel.No.:2,P/ *Per M.G.L c. 147,s.57-61,security work requires Department of Public Safety"S"License: Lic.No. OWNER'S INSURANCE WAIVER: I am aware that the Licensee does not have the liability insurance coverage normally required by law. By my signature below,I hereby waive this requirement. I am the(check one)E]owner El owner's Owner/Agent aa.._..�.._., m.. ....4,._..sT., I PF.R7177T FF.F.�- .R ®�o.� �',d�-.✓/ ,�ti ,©aa/ �-Qa���.r�.�-a�� Gvi.� .,�...-G /3o�C �'oa/ .ems.-� +��.�s,�.- 1 `A Date...........................1� f NORT►, TOWN OF NORTH ANDOVER p PERMIT FOR WIRING �O�•r.n I".C9 ACNUS� - This certifies that ....... .l:............................................ ................................ has permission to perform ..............`... ? wiring in the building of... - '*!- ............. .................................. J at.,�,,7... ........... .. .. ....... ,North Andover,Mass. Fee.. ..'....... ic. o .�a .. ..................... j ELECTRICAL INSPECTOR Check # 1-111� ' 290 THECOADIONWEALTHOFMASSACHUSETlS Office Use only DEPAR A19VTOFPUX1CSAF0 Perndt No. BOARDOFFIREPR1;VVEVHONRWULAHONS527CM12M 8���d Occupancy&Fees Checked APPLICATIONFOR PERAET TO PERFORMELECTRICAL WORK ALL WORK TO BE PERFORMED IN ACCORDANCE WITH THE MASSACHt1SSTS ELECTRICAL CODE,527 CMR 12:00 (PLEASE PRINT IN INK OR TYPE ALL INFORMATION) Date 0 Town of North Andover , To the Inspector of Wires: The undersigned applies for a permit to perform the electrical work descried below. Location(Street&Number) � Owner or Tenant (Gt Gr ✓l4�1 G� Owner's AddressG� Is this permit in conjunction with a building permit: Yes No r--J (Check Appropriate Box) Purpose of Building Utility Authorization No. Existing Service �4 Amps�Volts Overhead M Underground No. of Meters New Service Amps / Volts Overhead rI Underground No.of Meters Number of Feeders and Ampacity Location and Nature of Proposed Electrical Work No.of Lighting Outlets No.of Hot Tubs No.of Transformers Total KVA No.of Lighting Fixtures Swimming Pool Above Below Generators KVA round ground , No.of Receptacle Outlets D No.of Oil Burners No.of Emergency Lighting Battery Units No.of Switch Outlets No.of Gas Burners No.of Ranges No.of Air Cond. Total FIRE ALARMS No.of Zones Tons No.of Disposals No.of Heat Total Total No.of Detection and Pumps Tons KW Initiating Devices No.of Dishwashers Space Area Heating KW Np,,of Sounding Devices Na'of Self Contained Des&;• tiOWSounding Devices No&f Dryers Heating Devices KW Local Municipal Other Connections No.of Water Heaters KW No.of No.of Signs Bailasis No.Hydro Massage Tubs No.of Motors Total HP THER• umceCort?rage Pamml to the tequuementsofMassacln>S%CeneralLaws aNeaamentLiability kn ancePblicyinchackigCompl�e�awnsCoverageoritssubstantialeytuvalent YES ED NO awabmittadvandproofofsametotheOffm YES IfyouhnNeclieckedW-S,pka9eirldic&tbetypeofeo by Dcking the appfTmte box S'URANCE r✓� BOND r7 OTHER F-1 ftase Spa*) �—� Expilatimrate Estimated Valle of sect ical Wodc$ -`oStatt InspearonDateRegt Rough Final r)W,!xlerTr anatties cf MNO,ME Liomse-No. tsee �t� /-C%UU Signattue LieffiseNo � F / BushssTelNo A1tTe1NO. Na'S INSURANCEWAIVER,I am awatethat drLice w does nothave theirlstuar=o0vmgeoritsabstanbal egtuvalent as tzquiredbyNlassachusettsGenetal Laws that my sig mwm cn this penmt application waives this mqaffmr It ;ase check one) Owner ® Agent ® Telephone No. PERIMIT FEE lgna ure ol Owner 3777677- W The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations Boston; Mass. 02111 Workers'Compensation insurance Affidavit Name Please Print Name: Location: City Phone # I am a homeowner performing all work myself. I am a sole proprietor and have no one working in any capacity aI am an employer providing workers' compensation for my employees working on this job. Company name: Address City: Phone# Insurance.Co. Policv# Company name: Address ,.. City: Phone#: 4 A Insurance Co. Policv# ' Failure to secure coverage as required under Section 25A or MGL 152 can lead to the imposition of criminal penalties of,a fine up to$1,500.00 and/or one years'imprisonment-as well_as_civic penattiesin2hefnrm-ofa_STOP WORKORDER..and_a.fine_of.(.$1DO..OD)atiayagainst.me. understand that a copy of this statement may be forwarded to the Office of Investigations of the DIA for coverage verification. f do hereby certify under the pains and penalties of penury that the information provided above is true and correct. Signature Date Print name -Phone# Official use only do not write in this area to be completed by city or town official' City or Town Permit/Licensing E3 Building Dept ❑Check if immediate response is required Q Licensing Board p Selectman's Office Contact person: Phone#: Health Department Other Date.f� " o` TOWN OF NORTH ANDOVER p PERMIT FOR PLUMBING s �+ • �7 0, a SSA�MUS� moi' This certifies that . . . .,�I�H. e�. . . . ?!�. A/. . . . . . . . . . . . . . . . . . . . has permission to perform . . . H.. . . . . . . . . . . . . . . . plumbing in the buildings of . A H . . . . . . . . . . . . . . . . at . . .3.? . . .C_:.0 r. : . : L ti . . . . . . .,,Horth Andover, Mass. Fee . . . . Lic,No.`A. .'.. .'. . . . . . . . . . . . . . .... .T. .--�_. . . . . . . /PLUMBING INSPECTOR Check # / 6u7v MASSACHUSETTS UNIFORM APPLICATION FOR PERMIT TO DO PLUMBIN (Type or print) a NORTH ANDOVER,MASSACHUSETTS Date UJ 27 o L/ Building Location C C dd• Owners Name !/vI C. �i�(J /(0 Permit# &0") Amount Type of Occupancy New Renovation ReplacementEl Plans Submitted Yes No y FIXTURES ' S�IiS1VlC M%MENII 151:FLOCR / ZD FLOQR �FLOCR 4II31HIf. SII3 FLOOR 6II3 FLOOR 7M FLOOR SIH 1+ItaE2 (Print or type) �/� Check one: Installing Company Name I /M o r G� e� n Corp. Certificate Address �Q r S IJ Partner. ,• Business Telep one ca^fig - (�b-�j, �� Finn/Co. Name of Licensed Plumber: Insurance Coverage: Indicate,the,type of insurance coverage by checking the appropriate box: Liability insurance policyEr Other type of indemnity Bond El ❑ Insurance Waiver: I,the undersigned,have been made aware that the licensee of this application does not have any one of the above three insurance Signature O er El Agent ❑ I hereby certify that all of the details and i formation I have bmitted(or tered0abp lication are true andaccurate to the best of my knowledge and that all plumbin work and i tions perfo ed undd for this application will be in compliance with all pertinent provisions of the ach tts Stat ing C 142 of the General Laws. By: Signarure oT License/FlumoeC.7 Type of Plumb' g License Title /�113tl / City/Town lcense i um er " Master Journeyman APPROVED(OFFICE USE ONLY Location No. Date .a �oRTM TOWN OF NORTH ANDOVER c 1' s Certificate of Occupancy $ Building/Frame Permit Fee $ swcHus Foundation Permit Fee $ Other Permit Fee $ TOTAL $ ?� Check # Ave? 17146 Building Ins p or TOWN OF NORTH ANDOVER BUILDING DEPARTMENT APPLICATION TO CONSTRUCT REPAIR,RENOVATE, OR DEMOLISH A ONE OR TWO FAMILY DWELLING ""M 09440W W-04 BUILDING PERMIT NUMBER: DATE ISSUED: /� Q SIGNATURE: ZL2 Building Commissioiderfitor of Buildings Date z SECTION 1-SITE INFORMATION I 0 1.1 Property Address: 1.2 Assessors Map and Parcel Number: l�LVM 42 c �a & Map Number Parcel Number r 1.3 Zoning Information: 1.4 Property Dimensions: 43,'48 S.f• 1 1 o' 4-s - Zoning District Proposed Use Lot Areas Frontage ft 1.6 BUILDING SETBACKS ft Front Yard Side Yard Rear Yard Required Provide Required Provided Required Provided 04-0 3o,A 1.7 Water Supply M.G.L.C.40. 54) 1.5. Flood Zane Information: 1.8 Sewerage Disposal System: Public ❑ Private ❑ Zane Outside Flood Zane 0 Municipal ❑ On Site Disposal System [� SECTION 2-PROPERTY OWNERSHIP/AUTHORIZED AGENT m 2.1 Owner of Record Uj Name t) Address for Service ra Signature Telephone 2.2 Owner of Record------- Name ecor Name Print Address for Service: Signature Telephone SECTION 3-CONSTRUCTION SERVICES 90 3.1 Licensed Construction Supervisor: Not Applicable ❑ Licensed Con truction Supervisor: o/F/ License Number mn Address �&-y2 G-a6rSV Expiration Date Si nature Telephone 3.2 Registered Home Improvement Contractor Not Applicable ❑ Company Name // /8J7-�c�aw.�3Ei?/�/ Nl/'11cZ /�r�clore� h%<� O/��G r < Registration Number Address A L /� - !��— /y cozy � /�'7� /�G-�� Exp ri Uon Dae ^ Si nature Telephone Y+ SECTION 4-WORKERS COMPENSATION(NLG.L C 152 § 25c(6) Workers Compensation Insurance affidavit must be completed and submitted with this application. Failure to provide this affidavit will result in the denial of the issuance of the building permit. Signed affidavit Attached Yes....... No.......❑ SECTION 5 DesciA tion of P o osed Work check all applicable New Construction ❑ Existing Building ❑ Repair(s) ❑ Alterations(s) Addition Accessory Bldg. ❑ Demolition ❑ Other ❑ Specify Brief Description of Proposed Work: CaNVE2 % Ex�s//� �c/tC- To 1/ SEA TGh' ()Lyc n s1K / 1E C PZ 11lCilyc - ,¢ 7- %a SECTION 6-ESTIMATED CONSTRUCTION COSTS Item Estimated Cost(Dollar)to be ti OFFICIAL USE ONLY Completed by permit applicant 1. Building (a) Building Permit Fee Multiplier 2 Electrical / G (b) Estimated Total Cost of Construction 3 Plumbing dao o Building Permit fee(a)x (b) 4 Mechanical HVAC n/ )7 �- 5 Fire Protection 6 Total 1+2+3+4+5Y,3,066,_ Check Number SECTION 7a OWNER AUTHORIZATION TO BE COMPLETED WHEN OWNERS AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT I, /3 61t-"if rt X.4 v A v A o H ` wne Authorized Agent of subject property Hereby authorize to act on Y g If,in s lathy ork authorized by this building permit application. 3����i i afore of e Date SECTION 776THORIZED AGENT DECLARATION I, C n �y K as Owner/ �orizedAgentsubject property Hereby declare that the statements and information on the foregoing application are true and accurate,to the best of my knowledge E and belief / 5 rN e-6 Print Name / Signature of Owner/Agent Date NO.OF STORIES SIZE % .S6 ASC,1i -&; BASEMENT OR SLAB s E SIZE OF FLOOR TIMBERS 1 a io 2ND 3RD SPAN ` " a ,G. DIMENSIONS OF SILLS DMIENSIONS OF POSTS A/ . DIMENSIONS OF GIRDERS zi HEIGHT OF FOUNDATION,--_.4 ae - s rr✓cN -d THICKNESS /Q " SIZE OF FOOTING X MATERIAL OF CHIMNEY ti a IS BUILDING ON SOLID OR FILLED LAND IS BUILDING CONNECTED TO NATURAL GAS LINE FORM - U - LOT RELEASE FORM 3 5�s,o.•'� �o n�h C/e Li r\ n o.vN40 k/u, 4,0-A INSTRUCTIONS: This form is used to verify that all-necessary approval/permits from Boards and Departments having jurisdiction have been obtained. This does not relieve the applicant and or landowner from compliance with any applicable requirements. e.maa■mm..mwm...-■aWON.ww.wmw-....sae..........amamowns sm.asaswmmmm..msaswa0V r7 APPLICANT V Al A,'-- PHONE ASSESSORS MAP NUMBER LOT NUMBER SUBDIVISION LOT NUMBER STREET D - Lln a%c STREET NUMBER $swaps �swam a Sam■OWE OFFICIAL USE ONLY ...aam•sa..m■■..■........mmm■w...........■mw................................ RECOMMENDATIONS OF TOWN AGENTS E Now DATE APPROVED !S y �U CONSERVATION ADNf NBOR f/ DATE REJECTED CON%4E-NTS W eL onAn 2 /d0/-pro ,,I. 1=0-6ej tJar k 1 DATE APPROVED TOWN PLANNER DATE REJECTED COhfl\4ENTS DATE APPROVED FOOD INSPECTOR-HEALTH DATE REJECTED_ S DATE APPROVED 3 I O SEMC INSPECTOR-HEALTH C q� DATE REJECTED COMyIENTS JZ���c�5' IL k cl t'JK-'-i C, PUBLIC WORKS—SEWER/WATER CONNECTIONS DRIVEWAY PERMIT DATE APPROVED FIRE DEPARTMENT DATE REJECTED COMMENTS RECEIVED BY BUILDING INSPECTOR DATE C The Commonwealth of Massachusetts Department of Industrial Accidents A ce of/nvesfigations Boston, Mass. 02111 Workers`Compensaabon:/nsuranceAfl�idavit Name Please Print Name: Location: City Phone # aI am a homeowner performing.all work myself. 1 am a sole proprietor and have no one working in any capacity . 1 am an employer Provkkxj vworkers!conipei for mYywoWees/ �►9 om#ft Jam. C.ompany name: C� r� ,��� ��,�y &C,O Address QW, Insurance Co. �—ic Zala s2 Polict►.# c-e U X -S d CbFnpM name. , 6ddr+ trmsura e.:Co. - F?c r* -- Fa to seeu►eooMFage as reor JNWL 952 CiMesetjlato. arwar ane yewe Safbesams afaS=*1 J es�gf t10 �c�ry� undwstand that a eMy of Div staternent rmW ba forwarded to the Oft&W b�gatfons ai the t�tA for fabvesage lcaher bycmW-undaraapainsand ft#)pro~abmeisbv&a dcv#n t Signakim -Pae Pnnt name yrn c:•o C U/h K- r lb 3J� //�'�7 l/J E�� Onk at Ilse only dD not wr2e in Oft anaa tD be compieted by city a town dfivar 0C,hmk,W'Rnme&atennpormeismgu ed q s contact persom Phone#. p Heaffh Dq; Other North Andover Building Department Tel: 978-688-9545 DEBRIS DISPOSAL FORM In accordance with the provision of MGL c 40 S 54, a condition of Building Permit Number is that the debris resulting from this work shall-be disposed of in a properly licensed solid waste disposal facility as defined by MGL c11, S150A. The debris will be disposed of in: (Location of Facility) Signature of Permit Applicant � G Date NOTE: Demolition permit from the Town of North Andover must be obtained for this project through the Office of the Building Inspector . PROPOSAL PROPOSAL NO; m` SHEET NO. DATE Ve, PROPOSAL SUBMITTED TO: WORK TO.BE PERFORMED AT: �tAME ADDRI8 �. ADDRESS- 0V DATE OF PLANS N y.e PHONE NO. ARCHITECT We hereby propose to furnrsf the materials and perfoTmi e labor necessary for f}a completion of S Ems` crc:rf�, - rs� o.: a C,. { P Al f W f}f0&WV I At Aof tirz. r h � A-f-J .c YH CJ , .- r ` lec, -r- s : r T. i d � .w.s `[ r e -}- All material is guaranteed to be as specified, .and the above work to be performed in accordance,with the drawings and specifi- cations submitted for above work and completed in at substantial workmanlike manner for the sum of , - Dollars ($ 45�7!, 'VGO, with payments to be made as.follows. Respectfully submitted Any alteration or deviation from above specifications involving extra costs will be executed only upon written order, and will become an extra charge Per over and above the estimate. All agreements contingent upon strikes, ac- cidents,or delays beyond our control. Note—This proposal may be withdrawn' by us if not accepted within days. ACaPTAN E C}P PROPOSAL The above prices-, specifications and conditions are satisfactorland are hereby accepted: You are authorized oto do the work as specified. Payments will be made as outlined above. Signature Date Signature 381850 MADE IN PROPOSAL MADE IN USAA -��," .. . ✓die 1Ja7n�naru�reall! ���� BOARD OF BUILDING REGULATIONS License: CONSTRUCTION SUPERVISOR i i Number: CS 033592 Birthdate 11/16/1938 } Expires: 11116/2005 Tr.no: 9770.0 x Restrlc'tek 00 i RAYMOND A GAUTHIER { 18 STRAWBERRY HILL RD ANDOVER, MA 01810 Administrator Board of Building Regulations and Standards lug HOME IMPRdVEMENT CONTRACTOR Registration: 104458 Expiration: 7/14/2004 Type: Individual RAYMOND A.GAUTHI,ER Raymond Gauthier i 18 Strawberry Hill Roads i Andover,MA 01840 Administrator ' x � �ORT►y T01111111111i,;M' ® ? Andover O V No. Al C odover, Mass. y� > LA COCMICMEWICK S RATED V BOARD OF HEALTH PERM .IT T D Food/Kitchen Septic System THIS CERTIFIES THAT � �/�Q N � BUILDING INSPECTOR .......................... ......... ....................... .............................................................. Foundation I , has permission to erect.....�.�.... .�.............. bui m s on �/M .../.. ... ,� �.............. Rough ��I t. � I�/ �' �// �� ��� �N �.Z40� � Chimney to be occupied as................./ .................................................. ..r 3 S y d•................ . . . provided that the person accep ing this permit shall in every respect conform to the terms of the application on file in Final this office, and tc the provisions of the Codes and By-Laws relating to the Inspection, Alteration and Construction of Buildings in the Town of North Andover. 1,J y SS*JV Ap09,,eA PLUMBING INSPECTOR VIOLATION of the Zoning or Building Regulations Voids this Permit. /10lp Rough Final PERMIT' EXPIRES IN 6 MONTHS " UNLESS CONSTRUCTION STARTS ELECTRICAL INSPECTORRough od 44—oft. .............................. Service ....... . ...., BUILDING INSPECTOR Final Occupancy Permit Required to Occupy Building GAS INSPECTOR Display in a Conspicuous Place on the Premises — Do Not Remove RoughFinal No Lathing or Dry Wall To Be Done FIRE DEPARTMENT Until Inspected and Approved by the Building Inspector. Burner Street No. SEE REVERSE SIDE Smoke Det. ! —4,4--i PROP. GA2 J ell let a 13 ol.119O,B ' o o) 9,8 9,9 � 'r A"f •4� IT ~ _ , Y ,£1 Y ' o } 4„6.9 4,A1,4 01,11 Mot--£,1 9,11 —4,06 OhZ r f f_ 04 Ce,) a- lr r�r a, 6 0, 0 4' C,lwc fz � I .3 J��S ii nl r Ftr a, A _ siC,•�si• �r A i ,�n C mnlC•� SQA � '�—�� / ' i o; GA R. • yb� ti r-rel. Co Z�xtw xis t I I I ' I I Sol- 10 I I I �2 DGi G raEi cw 74 04y,n icL t tin C Q'uA �n� Ir 3/q' X tO" I/fRst+- t IV I At i UL $9rlc i v � �Z y W 9-A ANSI wxTi2 P,�TE ins 16'<< o,c r 5 � . k Q • �1 J I d y�. pncl. S'It"Isle ,v F T bd CAIP k sld, W. E0-1 / TY f. C{.pUl It 01 I I 1 i ' L.E FT El.ev• -Town of North Andover Project: Building Department ,,OR7H O64f1.t0 ,�1•yO 27 CHARLES ST 978-688-9545 * x Inc/ � / "o " * GICI1 7'`"d x �9SSACiiUSEt,(`' APPLICANT: �o,v,q �cQ F�ti o cch is a RE: /'Yk D DATE: to—Q,3 —0 3 Title of Plans and Documents: Please be advised that after review of your Application and Plans that your Application is DENIED for the following reasons: Plan RevieW The plans and documentation submitted have the following inadequacies: 1.Information Is not provided,2.Requires additional information, 3.Information requires more clarification 4. Information is incorrect. 5.All of the above. 1 Foundation Plan 12 Plumbing Plans 2 Subsurface investigation 13 Certified Plot Plan with proposed structure l 3 Construction Plans 14 116 Affidavit 4 Mechanical Plans and or details 15 Plans Stamped by proper discipline 5 Electrical Plans and or details 16 1 Framing Plan 6 Fire Sprinkler and Alarm Plan 17 Roofing Plan 7 Footing Plan 18 Plans to scale 8 Utilities 19 Site Plan 9 Water Supply 20 Sewage Disposal 10 Waste Disposal 21 Driveway Entry App. DPW 11 ADA and or ABBA requirements 22 Other: Administration The documentation submitted has the following inadequacies: 1.Information is not provided.2.Requires additional information. 3.-Inform tion requires more clarification.4. Information is incorrect.5.All of the above. # I # 1 Water Fee 5 State Builders License 2 Sewer Fee 6 Workman's Compensation 3 Building Permit Fee 7 Homeowners Improvement Registration 4 Building Permit Application 8 Homeowners Exemption Form 9 Other: The above review and attached explanation of such is based on the plans and information submitted. No definitive review and or advice shall be based on verbal explanations by the applicant nor shall such verbal explanations by the applicant serve to provide definitive answers to the above reasons for DENIAL. Any inaccuracies,misleading information or other subsequent changes to the information submitted by the applicant shall be grounds for this review to be voided at the discretion of the Building Department. The attached document titled"Plan Review Narrative"shall be attached hereto and incorporated herein by reference. The building department will retain all plans and documentation for the above file.You must file a new building permit applica' 'n form and begin th�ng process. ilding Department Official Signature Application Received � 1 Application Denied (v' 3 --ef:) 3 If faxed: # Date Sent Referral recommended: Fire Health Police Zoninq Board Conservation Department of Public Works Planning Historical Commission cc: Heidi Griffin Revised 9\97jm Plan Review Narrative The following narrative is provided to further explain the reasons for denial for the permit for the property indicated on the reverse side: 4 10 IOZ/64,4-'D n M c s USS � e. d coo 10,4 4/v//00d bLI / 0lyvs ON C2 7� cu�j is Gvll S-- �Y J� vr,v—a/ � UN vyk�r�o�- TOWN OF NORTH ANDOVER BUILDING DEPARTMENT APPLICATION TO CONSTRUCT REPAIR,RENOVATE, OR DEMOLISH A ONE OR TWO FAMILY DWELLING r Oft -' BUILDING PERMIT NUMBER. DATE ISSUED. rn SIGNATURE: Building Commissioner/I for of Buildings Date Z SECTION 1-SITE INFORMATION O 1.1 Property Address: 1.2 Assessors Map and Parcel Number: tom Map Number Parcel Number 1.3 Zoning Information: 1.4 Property Dimensions: Zoning District Proposed Use Lot Areas Fromm e ft 1.6 BUILDING SETBACKS ft Front Yard Side Yard Rear Yard Required Provide Required Provided Re red Provided v 1.7 Water Supply M.GL.C.40. 54) 1.5. Flood Zone Information: 1.8 Sewerage Disposal System: Public ❑ Private ❑ Zone Outside Flood Zone 0 Municipal ❑ On Site Disposal System 0 SECTION 2-PROPERTY OWNERSHIP/AUTHORIZED AGENT rn 2.1 Owner of Record Name(Print) Address for Service Signature Telephone 2.2 Owner of Record: Name Print Address for Service: 0 Z M Signature Telephone 90 SECTION 3-CONSTRUCTION SERVICES 3.1 Licensed Construction Supervisor: Not Applicable ❑ �� Licensed Construction Supervisor: C �j l-S 1 � �� O License Number \c- mn lAdd—rJs , Expiration Date Sig ature Telephone r 3.2 Registered Home Improvement Contractor Not Applicable ❑ v Company Name rn Registration Number r rre � Expiration Date ^Z Sign'ature Tele one v/ SECTION 4-WORKERS COMPENSATION(M.G.L C 152 § 25c(6) Workers Compensation Insurance affidavit must be completed and submitted with this application. Failure to provide this affidavit will result in the denial of the issuance of the buildin rmit. Signed affidavit Attached Yes....... No.......❑ SECTION 5 Description of Proposed Work check allapplicable) New Construction p/ Existing Building ❑ Repair(s) ❑ Alterations(s) ❑ Addition ❑ Accessory Bldg. ❑ Demolition ❑ Other ❑ Specify Brief Description of Proposed Work: SECTION 6-ESTIMATED CONSTRUCTION COSTS Item Estimated Cost(Dollar)to be OFFICIAL USE ONLY Completed by permit applicant 1. Building (a) Building Permit Fee Multiplier 2 Electrical (b) Estimated Total Cost of Construction 3 Plumbing Building Permit fee(.e) X (@) 4 Mechanical HVAC 5 Fire Protection 6 Total 1+2+3+4+5 Check Number SECTION 7a OWNER AUTHORIZATION TO BE COMPLETED WHEN OWNERS AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT I, as Owner/Authorized Agent of subject property Hereby authorize to act on My behalf,in all matters relative to work authorized by this building permit application. Signature of Owner Date SECTION 7b OWNER/AUTHORIZED AGENT DECLARATION I, as Owner/Authorized Agent of subject property Hereby declare that the statements and information on the foregoing application are true and accurate,to the best of my knowledge and belief Print Name Si ature of Owner/A ent Date NO. OF STORIES SIZE BASEMENT OR SLAB RD SIZE OF FLOOR TIMBERS 1 2 3 SPAN DIMENSIONS OF SILLS DIMENSIONS OF POSTS DIMENSIONS OF GIRDERS HEIGHT OF FOUNDATION THICKNESS SIZE OF FOOTING X MATERIAL OF CHIMNEY IS BUILDING ON SOLID OR FILLED LAND IS BUILDING CONNECTED TO NATURAL GAS LINE 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 APPLICANT RCS[ ��'006—c 1-1,119go PHONE LOCATION: Assessor's Map Number PARCEL SUBDIVISION LOT(S) STREETI_(2 )( � _ � � �C, ST. NUMBER ************************************OFFICIAL USE ONLY**/************* ** ** ***** * ** RECO ENDATIONS OFT WN AGENTS: CONSERVATION ADMINISTRAT DATE APPROVED iG d3 DATE REJECTED COMMENTS TOWN PLANNER DATE APPROVED DATE REJECTED COMMENTS FOOD INSPECTOR-HEALTH DATE APPROVED � � DATE REJECTED S S TIC INSPECTOR-HEALTH DATE APPROVED (, DATE REJECTED COMMENTS � ( It, �- donC• Ran $& a rK PUBLIC WORKS-SEWER/WATER CC U,t,�a- .n bar: �'►�s J y DRIVEWAY PERMIT ('P- FIRE DEPARTMENT ,Q,nd e RECEIVED BY BUILDING INSPECTOR_ .Eo ? ATE Revised 9W jm M � North Andover Building Department Tel: 978-688-9545 DEBRIS DISPOSAL FORM In accordance with the provision of MGL c 40 S 54, a condition of Building Permit Number is that the debris resulting from this work shall be disposed of in a properly licensed solid waste disposal facility as defined by MGL c11, S150A.. The debris will be disposed of in: NJ ati n f Fac' i ) t Signature f Permit Applicant Date NOTE: Demolition permit from the Town of North Andover must be obtained for this project through.the Office of the Building inspector u The Commonwealth of Massachusetts , Department of Industrial Accidents Office of Investigations Boston, Mass. 02111 S,1b Workers'Compensation Insurance Affidavit Name Please Print Name: U N A iln 6 7(7- Location: City r\-) Phone # aI am a homeowner performing all work myself. dI am a sole proprietor and have no one working in any capacity I am an employer providing workers'compensation for my employees working on this job. Company name: Address City: Phone# Insurance.Co. Policv# Company name: Address City: Phone#: Insurance Co. Policy# Failure to secure coverage as required under Section 25A or MGL 152 can lead to the imposition of criminal penalties of.a fine up to$1,5oo.00 and/or one;hat nso t_as welLas_ altiesin-the.fin-fASTOP-W-ORKORDFR..and..a fine.9f_($111o.>0)-atlayigaias#me I understate c of is tatement y forwarded to the Office of Investigations of the DIA for coverage verification. do herebynder 1 ins and o ury at the information provided above is true and corrLec/t Signature Date 7 j -�" 'G� Print name Phone# Official use only do not write in this area to be completed by city or town official' City or Town Permit/Licensing Building Dept []Check if immediate response is required 0 Licensing Board p Selectman's Office Contact person: Phone#. Ij Health Department Other , � � �.craduc/saelld BOARD OF BUILDING REGUWONS License:.CONSTRUCTiON SUPERVdOR' Number CSl 077344 f Y' r Birth f Q7123/1,967 cpiresr 07'123/2004 Tr.no: 77344 1 Restricted To:='•00, ; 4 j RONALD E FINOCCHIgRO JR { ,5►,(NATER STREET "'*'. ' ' 1845 . Administrator,..:. YER, MA q & 7144 Customer Name:2>','(. Address: CARPENTRY City/State/Zip: 65 Water Street Phone Number: L/ 6 Job No. No. Andover, MA 01845 978-794-2446 LJ Kitchen & Bath Install ❑ Builders Change ❑ Other �scrti�nri�e 7otl 1 ' X -1-7 C'4J ' apo GG yo . (Ida return of rnateruils after�'Q days In�tt ted items and spec:al vrrlers are nvt returrurbl,t Suul, Deperzt iS :111e "aacirbt Balaric Cust�ignatu a Date ��' 11� Carpentry Representative Date Comments: * Payment is to be made as follows: ❑ 50% Deposit/50% on receipt White-Customer Yellow-Office 32 Olympic Lane No.Andover,,MA.01845 14x28 Kitchen Addition 1- Permits for new work, Permits for dumpster, Permit for dig safe . 2- All work will be conducted to local building codes . 3- DEMO . A. Remove existing screen in porch . B. Remove exterior siding in addition location . C. Remove existing kitchen area . D. Cut through exterior wall into new addition. 4- Concrete footings for new addition @ 48"x10" 5- CONSTRUCTION. A. 14x21'10" Full basement foundation 10" walls $4,300.00 B. 3 10"x48" sona tubes footings to carry support beam. C. Floor construction 2x10 floor joist in foundation area. D. 3/4" t-g plywood for sub - floor with construction glue . E. Pressure treated 1/2" plywood for under addition . F. WALL CONSTRUCTION. G. 2x4 k.d for wall frame @ 16" o.c. H. 1/2" cdx fur plywood for wall sheating . I. 2x8 k.d. for window and door headers . J. 1/2" blue-board with plaster finish inside . K. ROOF CONSTRUTION. L. Roof frame for a snow zone 2 a shed type roof system w/ 2 gable ends for windows. M. Roof frame constructed of 2x10 @ 16" o.c. N. 5/8" cdx plywood for roof sheating . 0. 30 year roof shingle to match existing house . P. Install ridge vent and soffit vents . Q. Ceiling frame constructed of 2x8 k.d. 16" o.c. R. 1/2" blue-board with plaster finish. S. Exterior siding primed cedar clap boards to match existing house . T. Exterior trim to match existing house . WINDOWS , Not decided by home-owner , labor to install only . DOORS, labor only. Cut -through . All cut throughs openings will be supported with L.V.L beams . KITCHEN CABINETS , install only by plans supplied by home-owner . ✓ . i I I PLUMBING PRICE NOT INCLUDED. ELECTRICAL PRICE NOT INCLUDED. The contract above may be subject to change according local building department . Excavating cost $2,100.00 Total cost of kitchen bump out $40,000.00 Payment Schedule as follows : $ 12,000.00 Deposit to start job . $ 9,800.00 to start framing segment $ 8,100.00 to start plastering segment $ 5,300.00 to start interior trim and kitchen install . $ 2,400.00 punch list segment . $2,400.00 completion of job . Thank you Ron Finocchiaro ,Jr R&M CARPENTRY � o r ero hj� a m o { , SEPTICSYSTE(.j__�NS v:ALLA,TIC7N j • IS THE INSTALLER LICENSED? YES NO W - TYPE OF CONSTRUCTION: NEW F�EPAI t,;; •' NEW CONSTRUCTION: CERTIFIED PLOT hL_AN REVIEW Yh5 NU CONDITIONS OF APPROVAL YES 140 ' T (FROM FORM U) ISSUANCE OF DWC PERMIT YES NO ''t '' V� INSTALLER __ :••: , • DWC PERMIT N0. BEGIN INSPECTION CY ED NO: �'Y!'�;;l;. •;. : ^': . - _ EXCAVATION NEEDED: PASSED 7•l Cz BY - -- CONSTRUCTION INSPECTION: NEEDED:-_,-_,__ AS BUILT PLAN SATISFA ___.__..___...._._____._...-..._._...._.._.-------.__......__-_-�•-- j(6}l¢,, 1111 ,.•f ... V YES: ---------------------_ -- APPROVAL TO BACKFILL: DATE:�JJ __.-@Y--_-- ` FINAL . GRADING APPROVAL: DATE--%,��� BY _ ---- ----_ __ ril FINAL CONSTRUCTION APPROVAL: DAIE: .BY_,O` /4.JL7�__ __- -- • ZZ b Vit, : •, • . r + P � ��� /,��� ��,�, �� � 3 �� ��� � � � ���� � t a� • ` '� � 4 R • Si'gTTED I • • PUBLIC HEALTH DEPARTMENT Town of North Andover Community Development Division CERTIFICATE OF COMPLIANCE As of: 6/22/16 This is to certify that the individual subsurface disposal system received a SATISFACTORY INSPECTION of the: Full Repair of an On-Site Sewage Disposal System By: Todd Bateson At: 32 Olympic Lane Map 106B Lot 109 North Andover, MA 01845 The I an oft ' rtific to shall not be construed as a guarantee that the system will function satisfactorily. Xrian J. aGrasse, CEHT Director of Public Health 1600 Osgood Street,North Andover,Massachusetts 01845 Phone 978.688.9540 Fax 978.688.8476 Web www.townofnorthandover.com Commonwealth of Massachusetts II I W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments ,M 32 OLYMPIC LANE h, Property Address TRACEY KAVANAUGH Owner Owner's Name information is Q 3f required for every N. ANDOVER MA 01845 08/20/15 page. City/Town State Zip Code Date of Inspection Inspection results must be submitted on this form. Inspection forms may not be altered in any way. Please see completeness checklist at the end of the form. Important:When A. General Information filling out forms on the computer, RECEIVED use only the tab 1. Inspector: �V key to move your AUG 31 cursor-do not John J. Soucy 2 0 1 5 use the return Name of Inspector key. TOWN OF NORTH ANDOVER Soucy's Sewer Service Inc. HEALTH DEPARTMENT raa Company Name 78 North Broadway Company Address ,eru� Salem NH 03079 City/Town State Zip Code 603-898-9339 13397 Telephone Number License Number B. Certification 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: ❑ Pas ❑ Conditionally Passes ® Fails eeds F rther Evaluation by the Local Approving Authority 9C1 08/20/15 nspect Signature Date The ystem inspector shall submit 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•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 1 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments M 32 OLYMPIC LANE Property Address TRACEY KAVANAUGH Owner Owner's Name information is required for every N. ANDOVER MA 01845 08/20/15 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: ❑ 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. ❑ Y ❑ N ❑ ND (Explain below): t5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 2 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 32 OLYMPIC LANE Property Address TRACEY KAVANAUGH Owner Owner's Name information is required for every N. ANDOVER MA 01845 08/20/15 page. City/Town State Zip Code Date of Inspection B. Certification (cont.) ❑ Pump Chamber pumps/alarms not operational. System will pass with Board of Health approval if pumps/alarms are repaired. B) System Conditionally Passes (cont.): ❑ 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): ❑ broken pipe(s) are replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below): ❑ distribution box is leveled or replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ 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): ❑ broken pipe(s) are replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below): 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 public health, safety or the environment. 1. System will pass unless Board of Health determines in accordance with 310 CMR 15.303(1)(b)that the system is not functioning in a manner which will protect public health, safety and the environment: j ❑ 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 t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 3 of 17 I Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments wM 32 OLYMPIC LANE Property Address TRACEY KAVANAUGH Owner Owner's Name information is required for every N. ANDOVER MA 01845 08/20/15 page. City/Town State Zip Code Date of Inspection B. Certification (cont.) 2. System will fail unless the Board of Health (and Public Water Supplier, if any) determines that the system is functioning in a manner that protects the public health, safety and environment: ❑ The system has a septic tank and soil absorption system (SAS)and the SAS is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water supply. ❑ The system has a septic tank and SAS and the SAS is within 50 feet of a private water supply well. ❑ 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: 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 ❑ ® 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 El ® Liquid depth in cesspool is less than 6" below invert or available volume is less than '/day flow I t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 4 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments °wM 32 OLYMPIC LANE Property Address TRACEY KAVANAUGH Owner Owner's Name information is N. ANDOVER MA 01845 08/20/15 required for every page. City/Town State Zip Code Date of Inspection B. Certification (cont.) Yes No ❑ ® 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 SAS, cesspool or privy is below high ground water elevation. ❑ ® Any portion of 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 1 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. [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- 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 ❑ ❑ 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 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 W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 32 OLYMPIC LANE Property Address TRACEY KAVANAUGH Owner Owner's Name information is required for every N. ANDOVER MA 01845 08/20/15 page. City/Town 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 ® ❑ Pumping information was provided by the owner, occupant, or Board of Health ❑ ® 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? ❑ ® 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) ® ❑ Was the facility or dwelling inspected for signs of sewage back up? ® ❑ Was the site inspected for signs of break out? ® ❑ Were all system components, excluding the SAS, located on site? ® ❑ Were the septic tank manholes uncovered, opened, and the interior of the tank inspected for the condition of the baffles or tees, material of construction, dimensions, depth of liquid, depth of sludge and depth of scum? ® ❑ 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: ® ❑ 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): 5 Number of bedrooms (actual): 5 DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): 550 t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 6 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments ;M 32 OLYMPIC LANE Property Address TRACEY KAVANAUGH Owner Owner's Name information is required for every N. ANDOVER MA 01845 08/20/15 page. Cityrrown State Zip Code Date of Inspection 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 ❑ Yes ® No information in this report.) Laundry system inspected? ❑ Yes ❑ No Seasonal use? ❑ Yes ® No Water meter readings, if available(last 2 years usage(gpd)): Detail: SEE ATTACHED Sump pump? ❑ Yes ® No Last date of occupancy: CURRENT 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? ❑ Yes ❑ No Industrial waste holding tank present? ❑ Yes ❑ No Non-sanitary waste discharged to the Title 5 system? ❑ Yes ❑ No Water meter readings, if available: t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 7 of 17 Commonwealth of Massachusetts _ W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 32 OLYMPIC LANE Property Address TRACEY KAVANAUGH Owner Owner's Name information is required for every N. ANDOVER MA 01845 08/20/15 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Last date of occupancy/use: CURRENT Date Other(describe below): General Information Pumping Records: Source of information: Soucy's Sewer Service Inc Was system pumped as part of the inspection? ❑ Yes ® No If yes, volume pumped: gallons How was quantity pumped determined? Reason for pumping: Type of System: ® Septic tank, distribution box, soil absorption system ❑ Single cesspool ❑ Overflow cesspool ❑ Privy ❑ Shared system (yes or no) (if yes, attach previous inspection records, if any) ❑ 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 ❑ Tight tank. Attach a copy of the DEP approval. ❑ Other(describe): t5ins•3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 8 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments ° M 32 OLYMPIC LANE Property Address TRACEY KAVANAUGH Owner Owner's Name information is required for every N. ANDOVER MA 01845 08/20/15 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Approximate age of all components, date installed (if known) and source of information: 1992 Were sewage odors detected when arriving at the site? ❑ Yes ® No Building Sewer(locate on site plan): Depth below grade: feet Material of construction: ❑ cast iron ®40 PVC ❑ other(explain): Distance from private water supply well or suction line: feet Comments (on condition of joints, venting, evidence of leakage, etc.): Septic Tank(locate on site plan): Depth below grade: feet Material of construction: ® concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain) If tank is metal, list age: years Is age confirmed by a Certificate of Compliance? (attach a copy of certificate) ❑ Yes ❑ No Dimensions: 9'X 5' Sludge depth: 3 t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 9 of 17 Commonwealth of Massachusetts v Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 32 OLYMPIC LANE Property Address TRACEY KAVANAUGH Owner Owner's Name information is required for every N. ANDOVER MA 01845 08/20/15 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 37" Scum thickness 2" Distance from top of scum to top of outlet tee or baffle 5" Distance from bottom of scum to bottom of outlet tee or baffle 14" How were dimensions determined? TAPE AND SLUDGE TOOL Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): OUTLET BAFFEL IS IN NEED OF NEW PVC TEE. I Grease Trap (locate on site plan): Depth below grade: feet Material of construction: ❑ concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain): Dimensions: Scum thickness Distance from top of scum to top of outlet tee or baffle Distance from bottom of scum to bottom of outlet tee or baffle Date of last pumping: Date t5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 10 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 32 OLYMPIC LANE Property Address TRACEY KAVANAUGH Owner Owner's Name information is required for every N. ANDOVER MA 01845 08/20/15 page. Citylrown 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: ❑ concrete ❑ metal ❑fiberglass ❑ polyethylene ❑ other(explain): Dimensions: Capacity: gallons Design Flow: gallons per day Alarm present: ❑ Yes ❑ No Alarm level: Alarm in working order: ❑ Yes ❑ No Date of last pumping: Date Comments (condition of alarm and float switches, etc.): *Attach copy of current pumping contract(required). Is copy attached? ❑ Yes ❑ No t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 11 of 17 I Commonwealth of Massachusetts - Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments ° M 32 OLYMPIC LANE Property Address TRACEY KAVANAUGH Owner Owner's Name information is required for every N. ANDOVER MA 01845 08/20/15 page. Cityfrown 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" NEEDS REPLACEMENT Pump Chamber(locate on site plan): Pumps in working order: ❑ Yes ❑ No* Alarms in working order: ❑ Yes ❑ 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 Title 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 °M 32 OLYMPIC LANE Property Address TRACEY KAVANAUGH Owner Owner's Name information is required for every N. ANDOVER MA 01845 08/20/15 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Type: ® leaching pits number: (3) 5'X 8' EA ❑ leaching chambers number: ❑ leaching galleries number: ❑ leaching trenches number, length: ❑ leaching fields number, dimensions: ❑ overflow cesspool number: ❑ 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.): DRYWELI-41 IS FULL TO CAPACITY AND RUNNING BACK. DRYWELL#2 IS NOT RECEIVING ANY FLOW DUE TO A CRUSHED PIPE. DRYWELL#3 HAS LESS THAN HALF AVAILABLE CAPACITY( 12" STATIC LEVEL ) 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 ❑ Yes ❑ No t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 13 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments wM 32 OLYMPIC LANE Property Address TRACEY KAVANAUGH Owner Owner's Name information is required for every N. ANDOVER MA 01845 08/20/15 page. City/Town 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.): t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 14 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 32 OLYMPIC LANE Property Address TRACEY KAVANAUGH Owner Owner's Name information is required for every N. ANDOVER MA 01845 08/20/15 Y page. Cit /Town 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: ❑ hand-sketch in the area below ❑ drawing attached separately — (l 'BOY D 144- 12 Q (CJ, t _ _ blui ` i i 15ins•3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 15 of 17 Commonwealth of Massachusetts _ W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments °M 32 OLYMPIC LANE Property Address TRACEY KAVANAUGH Owner Owner's Name information is required for every N. ANDOVER MA 01845 08/20/15 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Site Exam: ® Check Slope ❑ Surface water ❑ Check cellar ❑ Shallow wells Estimated depth to high ground water: 5'feet Please indicate all methods used to determine the high ground water elevation: ❑ Obtained from system design plans on record If checked, date of design plan reviewed: Date ❑ Observed site (abutting property/observation hole within 150 feet of SAS) ❑ Checked with local Board of Health -explain: ❑ Checked with local excavators, installers-(attach documentation) ❑ Accessed USGS database -explain: You must describe how you established the high ground water elevation: DUG HOLE WITH AUGER IN LOW DROP OFF AREA, APPROXIMATELY 30' FROM DRYWELL#3 Before filing this Inspection Report, please see Report Completeness Checklist on next page. t5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 16 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 32 OLYMPIC LANE Property Address TRACEY KAVANAUGH Owner Owner's Name information is required for every N. ANDOVER MA 01845 08/20/15 page. Citylrown State Zip Code Date of Inspection E. Report Completeness Checklist ❑ Inspection Summary: A, B, C, D, or E checked ❑ Inspection Summary D (System Failure Criteria Applicable to All Systems) completed ❑ System Information— Estimated depth to high groundwater ❑ Sketch of Sewage Disposal System either drawn on page 15 or attached in separate file t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 17 of 17 nN�R C C UB 04A/CS/UBS/L 886 TOWN OF NORTH ANDOVER c INAL N0: 008 CONSUMER METER F/M DATE: ®9/73/99. TIME: 09:38:45 t- 88 B@-© FER USON ARK _, oe ter No: 001 Bev Mtr/8: N 000 Book: 17 Pa e.32 OLYMPIC nnector: ] Digits: ] Dim Cd: A] Muitipiier78Meter Flg: [es: Cd: ] Units: ] Arb S: ] m Pipe Size; ] Len: ] Type; 00 8@/ 0/0000 Inst: 00/80/0000 Cnct: 08/00/0000 Disc: 00/00/0000 Cd: 8j Cd: ] Mt Code: ] Met Loc: 8 TRI 8 In/Out:Cur: 3�0 A Prev: e a8: @82'53@3/26/1999 To: 3079 E 2nd Prev: 30S@ R [2]: 00/.08/0 Cns Cr:04/1S/1999 Cur2: Prev2: -First - - --------- ConsempkMon informth Bill: ation. --User_-_-__................. 12 Billing Months -----[g] I------ Last 12 Billing Months -_ _ }.� 1999 1A 12/1997 29£I 06/1946 -- __[4] a 1999 29E 49/1997 42A1 83/1996 22E 12/1994 27A z 1998 �29E 06/-1997 19A 12/1995 28A 69/1994 lift x 1998 . 22A 03/1997 19AI 09/1995 30A @6/1994 7A a 1948 29E 12/1996 32A1 86/1995 29A 03/1994 23A 28A �snr 1998 28E 09/1996 b3A� 03/1995 12/1993 Fi St 12 Total- 3 2 19A 09/1993 . 31A 5 �' > to Enter New Meter Number L s 2 To al: 2 9 <M>odify. <D>elete or <N>ext ^�s- r �-23 !-ICS O O r 4YTCi.FDl�a . RECEIVED JUN 13 2016 r TOWN OF NORTH ANDOVER HEALTH DEPARTMENT PUBLIC HEALTH DEPARTMENT Community Development Division TOWN OF NORTH ANDOVER SEPTIC DISPOSAL SYSTEM—INSTALLATION CERTIFICATION The undersigned hereby certify that the Sewage Disposal Systeme constructed;( )repaired; ed/ /�,�� By: pori aAfv� 3�(Print���e/)�/y� � Located at: /�� p (Installation Address) Was installed in conformance with the North Andover Board of ealth approved plan, originally dated �� ( J and last revised on 3 with a design flow of gallons per day. The materials used were in conformance with those specified on the approved plan;the system was installed in accordance with the provisions of 310.CMR 15.000,Title 5 and local regulations,and the final grading agrees substantially with the approved plan.All work is accurately represented on the As-built which has been submitted to the Board of Health. Bottom of Bed Inspection Date. TO t i ' �� l / Engine presentat a(Signature) 19 And—Print Name �/ Final Construction Inspection Date: 6 !� It 0SIMI r Eng' eer present, ve - gnature) VPO And—Print Name Installer: (Signature) Date: S. Al And—PrinTame Engineer: (Signature) TOWDate: a And—Print Name 1600 Osgood Street, North Andover, Massachusetts 01845 Phone 978.688.9540 Fax 978.688.8476 Web http://www.northandoverma.gov • SF'TT '➢'jOle . • North Andover Health Department Community and Economic Development Division ONSITE WASTEWATER SYSTEM CONSTRUCTION NOTES LOCATION INFORMATION ADDRESS: 32 Olympic Lane MAP: 106.6 LOT: 0109 INSTALLER: Todd Bateson DESIGNER: Jack Sullivan PLAN DATE: 112/11/15, revised 3/31/16 BOH APPROVAL DATE ON PLAN: 4/24/16 INSPECTIONS TANK INSPECTION: 5/25/16 DATE OF BED BOTTOM INSPECTION: 5/25/16 DATE OF FINAL CONSTRUCTION INSPECTION: 6/2/16 DATE OF FINAL GRADE INSPECTION: `� I SITE CONDITIONS N/A Contractor reports any changes to design plan X !Existing septic tank properly abandoned: ® Internal plumbing all to one building sewer ® Topography not appreciably altered Comments: SEPTIC TANK X Building sewer in continuous grade, on compacted firm base X Cleanouts per plan X Bottom of tank hole has 6" stone base X Weep hole plugged X 1500 gallon tank has been installed H-10 loading X Monolithic tank construction X Water tightness of tank has been achieved by visual testing X Inlet tee installed, centered under access port X Outlet tee installed, centered under access port (gas baffle/effluent filter) ® 24" inch cover to finish grade installed over outlet access port X Neoprene boots around inlet & outlet Comments: rubber gaskets in place DISTRIBUTION-BOX ® Installed on stable stone base ® H-20 D-Box N/A Inlet tee (if pumped or >0.08'/foot) ® Hydraulic cement around inlet & outlets ® Observed even distribution ® Speed levelers provided (not required) ® Schedule 40 PVC Pipe SOIL ABSORPTION SYSTEM (Gravel-less Chambers) ® Brand and Model of Chamber: Standard Quick 4 Low Profile Infiltrator Chambers ® Number of chambers per row: 13 ® Number of rows (trenches): 9 Comments: Total Chambers = 117 FINAL GRADE Loamed Seeded Cover per plan Comments: DOCUMENTS NEEDED Certification of Installation Form submitted By engineer and signed and dated by Engineer and installer As-Built Plan BM = 104.85 HR = 3.42 HI = 108.30 SYSTEM ELEVATIONS ROD AS-BLT INVERT DESIGN INVERT ELEVATION ELEV ELEV Benchmark Building Sewer OUT 6.59 101.36 100.9 Septic Tank IN 6.67 101.28 100.58 Septic Tank OUT 6.92 101.03 100.33 Distribution Box IN 8.74 99.21 99.22 Distribution Box OUT 8.92 99.03 99.05 Lateral 1-9 TOP 9.00 Lateral 1-9 INVERT 98.95 98.95 Top of Chamber Bottom of Bed/Chamberl 9.60 98.70 98.70 i CRITICAL SETBACK DISTANCES Mark those distances checked in the field against the design plan and regulatory setback 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 1002 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 1 Suction line 222(2) 2 100 feet is a minimum acceptable distance and no variance is allowed for a lesser distance(NA 5.02). 3 As defined in 310 CMR 10.55, 10.32, 10.54,and 10.30,respectively,pursuant to 15.211(3),also by NA wetland bylaws Map-Block-Lot Commonwealth of Massachusetts 106.80109 BOARD OF HEALTH Permit No North Andover BHP-2016-0154 ----------------------- FEE $350.00 ----------------------- DISPOSAL WORKS CONSTRUCTION PERMIT Permission is hereby granted Todd B-ateson - - - - ----------------------------------------------------------------------------------------- to(Upgrade)an Individual Sewage Disposal System. at No 32 OLYMPIC LANE as shown on the application for Disposal Works Construction Permit No. BHP-2016-015,,E Dated May 13,2016 -- ----------------------- T -------------------- • � Issued On:May-13-2016 BOARD OF HEALTH r i I 1 scsz. Application for Septic Disposal System TODAY'S DATE Construction Permit - TOWN OF $250'.00—full Repair NORTH ANDOVER, MA 01845 $925.00-Component Important: Application is hereby made for a permit to: When filling out ❑Construct a new on-site sewage disposal system* foims on the- computer,use Mj1epair or replace an existing on-site sewage disposal system* only the tab key to move your ❑Repair or replace an existing system component—What? cursor-do not use the return A. Facility Information key. �30� &9/yM Q►L .4-, - Address or Lot# asRECENED city/rown ol o MAY 13 2016 2:*TYPE OF SEPTIC SYSTEM*: ► ���.� > ❑Pump ravity(choose one) TOWN OF NORTH ANDOVER —if pump system,attach copy of electrical permit to application"* HEALTH DEPARTMENT > ❑Conventional System(pipe and stone system) > Rfnfiltrator or Biodiffuser(Gravel-Less)(Attach a copy of your certification to install this type of system.) > ❑Pressure Distribution S.A.S.(No D-Box) > ❑Pressure Dosed(D-Box Present)S.A.S. > ❑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 D WC issuance) What is the Make? What is themodail 2. Owner Information ?Mame Address(if different from above) s-ys— Cityrrown State Zip Code 9'78' S's ti-/sa Telephone Number 3. Installer Information 11 Name Name of CompaENTERPRISES,INC. I 11 ARGILLA ROAD ANDUIER nn vT Address Cityrrown State �I Zip Code 3 Telephone Number(Cell Phone#if possible please) 4. Desi.aner Information Name Name of Company VAN caL�- Address �> © �a�C �oo 1444 City/Town WD 6 u.t ✓ State Zip Code rr /-- 9-4 6(y Telephone Number(Best#to Reach) Application for Disposal System Construction Permit•Page 1 of 2 Applicaffoh.•for Septic Disposal :System 13_l ♦N� 3 •.�I � •e� ' TODAY'S DATE Construction -Permit = TOW -OF 'ORTH_ANDOVER, MA 01845 $.250.00-Full Repair ~ 4C $125.00.-C $125.00.-Component �ss PAGE 2 OF 2 A. Facility-Information continued.... S. Type*of Building; esidential Dwelling or[]Commercial B. Agreement 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, and not to place the system In operation until a Certlflcate of Compliance has been Issued by Is Board of Health. Name Date AppGc,ation App v d� : (Board of Health Representative) Name Date Ap Iication Disapproved.for the following reasons: For Of fee Use Only I. ''Fee Attached? Yes V _ No 2.- ProjectMariager Obligation Form Attacbed.� Yes No 3.: BM L&YCM--? Ifso)Aff-acb=V ! trr I P it„ Yes NO 4. FoundatlonAs Bu&R(hew construction-ronly (Same scale as a ro ed lan No PP Y P ) . .5 FloorPLms?(hew construction'only): Y.es No Applfcatton{orpispOsal.System:OonMMcflon Permft Page 2 of 2 5EP'k`IC > IN"�'� ROf BaCT ?�•GPMT-PBLIGATIPM As Ow N91thAndovericoaaetlawaa£or4tho t&mftgcdQft fps theeept c systM jar thelaolletty'4Rt �[ T lte7atit►e to (rhudws , asa dated / d—) _�s-- Dated With Milk=&W wWnA dw) I understand the following oftestiom fat in gcmcut of this grojeca i. As the iasb&4 I wm.obligsted ip abmiasffpec�and'Bosrd of filth appsvv d l�s�oa fafoaeipcfm3ittiu site 3. 1!s flie h3diltw.I spay gndaSa: I£Lameamn ' o�herpataoa natira�oe:Fsted�tt►y . �.� '� manAget,az map item tseashus st�pllatbie. P Oa and the systeta is not dp,thci� Ad iu�-x'sm fah"t wrya c,c ed-pz*to the.ap iddlcitedbgbm, QA r alraYa b�•dari" (I` p :theme �rpccag ,which 4!�' �>sts��v� ��eii���es•not bave to be presar�t•. _ 6. tfnla16�forTO tkvosts;-tom,ctc. • o Ox"(at e__msfl•tw egfry the a ider must ba#ubmitaed to c. ofHss�, for eii tune.' irmu3t he � #b c �'64 ge tt a -ben dy and sWe to- t asst rogtu mepecaoaIl gffidin is rP : IQstnllca Boca not 4. As-the iastallg"I tpq d that oily 3~ p p orm f1c'� trl6a�r e )anct 1 ria catplets the�jnsts�Irttt of tl�e� .b i ire#ht iostiitatioa ' �g�iired 5.. Ab tha3mplller;•I ttsaii ,I nm3� •Cs •pce•rf the CC!M . r JR DsraCm.�IaQ�thrrt.t&�p�erd(evnd��� Qil.�'+6CC�!s�e�c�eat- _ b, �d9 COQ Qfti�'rBYt'!d add QC�b bG UWd Cr rAWAwpwdba�BO Q( jGtjl��lftf'Gl COItBQ t�, b. As the issri �.lpaacAft 'rs .,lt drit Z��t,G�,� • G=Md D bA*wk11 �s�wnrftMMrtiM �a ' QOyirRg 7•�t Uaderdteesed Sapcic.I� .• _: (tpc I3itte �.� l& /G LED" • SF'�T 7� • North Andover Health Department Community and Economic Development Division April 27, 2016 Tracey Kavanagh 32 Olympic Lane North Andover, MA 01845 Re: Subsurface Sewage Disposal System Plan for 32 Olympic Lane (Map 10613,Lot 109) Dear Ms. Kavanagh: The proposed wastewater system design plan for the above site dated December 1, 2015 with a final revision date of March 31, 2016 and received on April 1, 2016 has been approved. The design plan has been approved for use in the construction of a new on-site septic system for a 4-bedroom(max 9-room)home utilizing a Quick 4 Plus Standard LP Infiltrator Chamber system. This design plan approval is valid until April 27, 2018. 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. In the event an imminent health problem, such as sewage backup into the dwelling is occurring,the North Andover Board of Health may reduce the time period for which this plan is valid. At a regularly scheduled meeting of the Board of Health,this plan received the following approvals by the members. Local Upgrade Approval: • To reduce the separation distance from the soil absorption system to the estimated seasonal high ground water table from 4' to 3' Page 1 of 2 North Andover Health Department, 1600 Osgood Street, Suite 2035, North Andover, MA 01845 Phone: 978.688.9540 Fax: 978.688.8476 32 Olympic Lane April 27, 2016 This approval is also subject to the following conditions: 1. 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(1)) 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 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. Sincerely, Michele Grant Health Inspector Encl. Installers list cc: John D. Sullivan, III File Page 2 of 2 North Andover Health Department, 1600 Osgood Street, Suite 2035, North Andover, MA 01845 Phone: 978.688.9540 Fax: 978.688.8476 4/4/2016 Town of North Andover Mail-Re:32 Olympic Lane-Request for Local Upgrade Approval FORTH ANDOVER Massachuse8s i Lisa Hadge <lhadge@northandoverma.gov> Re: 32 Olympic Lane - Request for Local Upgrade Approval 1 message Jack Sullivan <jacksu1153@comcast.net> Fri, Apr 1, 2016 at 2:53 PM To: "Hadge, Lisa" <Ihadge@northandoverma.gov>, 'Rowe, Isaac" <irowe@millriverconsulting.com> Cc: "Grant, Michele" <mgrant@northandoverma.gov>, Tracey<tpkav@comcast.net> Lisa and Michele, Please accept this email as a formal request to appear before the North Andover Board of Health on April 26, 2016 for a Local Upgrade Approval relative to the above property. The Local Upgrade Request is: 1) To allow.a three (3) foot vertical separation between the bottom of the infiltrator units and the seasonal high groundwater table (4 feet required). The perc rate for the soil condition is 42 minutes per inch. The owner/applicant is requesting this reduction in separation to allow the elimination of a pump chamber and also to reduce the construction cost of the system. The original design for this project had a pump chamber and prices from contractors were coming in 40k-50k due to the difficulty in accessing the backyard. By reducing the groundwater separation, the system can now function as a gravity system and there will be 1 foot less of septic sand required throughout the leaching field area which should provide more competitive pricing to replace the failed system. Thank you Jack Sullivan, PE 781-854-8644 From: "Jack Sullivan" <jacksuI153@comcast.net> To: "Lisa Hadge" <Ihadge@northandoverma.gov>, "Isaac Rowe" <irowe@millriverconsulting.com> Cc: "Michele Grant" <mgrant@northandoverma.gov>, "Tracey" <tpkav@comcast.net> Sent: Friday, April 1, 2016 2:45:44 PM Subject: Re: 32 Olympic Lane - Forms for Owners Signature Attached are the completed Form 9A - Local Upgrade Approval Form and the Infiltrator Certification which both will need to be signed by the homeowner. Tracey...can you review/sign page 4 of the Form 9A and sign the Infiltrator Certification form once you review the materials I provided to you. You can mail the signed materials to: hftps:Hmail.google.com/mail/ca/u/O/?ui=2&ik=46857787dO&view=pt&search=inbox&th=153d32c388a75ca7&siml=153d32c388a75ca7 1/5 4/1/2016 Town of North Andover Mail-Re:32 Olympic Lane-Revised Plans and letter Nop ' ANDLisa Hadge <lhadge@northandoverma.gov> Massachus ttts Re: 32 Olympic Lane - Revised Plans and letter 1 message Jack Sullivan <jacksu1153@comcast.net> Fri, Apr 1, 2016 at 10:36 AM To: "Hadge, Lisa" <lhadge@northandoverma.gov> Cc: "Grant, Michele" <mgrant@northandoverma.gov>, Tracey<tpkav@comcast.net> Lisa + Michele, I have revised the septic plans (attached) and a sample of the letter to be signed by the homeowner. I will be mailing the check for the plan review and plan copies to your office over the weekend. If you can forward to Isaac that would be great. With this design I need a Local Upgrade Approval to reduce the groundwater separation from 4 feet to 3 feet...this is being requested to avoid a pump system which would drive up the installation cost. also had to eliminate the pipe/stone system....this forced a pump system (even with a 1 foot GW reduction)-so I had to eliminate this type of leaching field and go with an infiltrator field. I did show a conventional trench system design/layout to show compliance. Have a good weekend. Tracey..you these plans to get some preliminary feedback on price...I made on typo correction on Sheet 2. You will receive my materials on monday. Jack Sullivan 781-854-8644 From: "Lisa Hadge" <Ihadge@northandoverma.gov> To: "Jack Sullivan" <jacksu1153@comcast.net> Cc: "Michele Grant" <mgrant@northandoverma.gov> Sent: Monday, March 28, 2016 3:49:55 PM Subject: 32 Olympic Lane Hi Jack, Attached is the disapproval letter for 32 Olympic Lane. Plan review resubmissions are $125.00. Please submit the fee with the new revised plans. Also, please read below for Mill River's comments: https://mail.google.com/mail/ca/u/0/?ui=2&ik=46857787dO&view=pt&search=inbox&th=153d2417abfdOefd&siml=153d2417abfdOefd 1/3 March 31,2016 RECEIVE® APR 1 1 2016 Town of North Andover TOWN OF NORTH ANDOVER Board of Health HEALTH DEPARTMENT 1600 Osgood Street North Andover,MA 01845 Re: 32 Olympic Lane,North Andover Infiltrator Units Owner Certification for Septic Upgrade As owner of the above property I certif that: L have been provided a copy of the Title 5 IIA technology Approval, the Owner's Manual, and the Operation and Maintenance Manual., and the Owner agrees to comply with all terms and conditions 2. for Systems installed under a Remedial Use Approval, the owner agrees to fulfill his responsibilities to provide written notification of the Approval to any new Owner, as required by 310 CMR 15.287(5), 3. if the design does not provide for the use of garbage grinders, the restriction is understood and accepted; and 4. whether or not covered by a warranty, the System Owner understands the requirement to repair, replace, modem or take any other action as required by the Department or the LAA, if the Department or the LAA determines the System to be failing to protect public health and safety and the environment., as defined in 310 CMR 15.303. Very my Yours, Tracey Ka<121Ld,h i RECEIVED Commonwealth of Alappachuse APR 1 1 2016 Cityrrown ofOP 4 Form 9A - Application for Local Upgrade AT t"AVND VER 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. Form 9A is to be submitted to the Local Board of Health for the upgrade of a failed or nonconforming septic system with a design flow of less than 10,000 gpd,where full compliance,as defined in 310 CMR 15.404(1),is not feasible. System upgrades that cannot be performed in accordance with 310 CMR 15.404 and 15.405,or in full compliance with the requirements of 310 CMR 15.000,require a variance pursuant to 310 CMR 15.410 through 15.415_ NOTE Local upgrade approval shall not be granted for an upgrade proposal that includes the addition of a new design flow to a cesspool or privy,or the addition of a new design flow above the existing approved capacity of an on-site system constructed in accordance with either the 1978 Code or 310 CMR 15.000. A. Facility Information Important When filling out 1. Facility Name andA dress: forms on the computer,use only the tab key Name to move your yl'!3'�► cursor-do not SUeet Address use the return gipode key. A%, AW -Cifyfrown State 2_ Owner Name and Address(if different from above): ,i Name Street Address Crtyfrown State Zip Code Telephone Number 3. Type of Facility(check all that apply): Residential ❑ Institutional ❑ Commercial ❑ School 4. Describe Facility: t ` f- 5. Type of Existing System: Privy ❑ Cesspool(s) Xconventionat ❑ Other(describe below): 6. Type of soil absorption system(trenches,chambers,leach field,pits,etc): t5form9a.doc-rev_7106 Application for Local Upgrade Approval,Page i of 4 S Commonwealth f Massachusetts X Ci /Town of k& Form 3A - Appl,cation for Local Upgrade Approval 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. A. Facility Information (Continued) 7. Design Flow per 310 CMR 15.2133: Design flow of existing system: YV6 gpa Design flow of proposed upgraded system qyn 9pd t Design flow of facility: B. Proposed Upgrade of System 1. Proposed upgrade is(check one): El Voluntary D Required by order,letter,etc.(attach copy) Required following inspection pursuant to 310 CMR 15.301: Y/2v date o irupectia 2. Describe the proposed upgrade to the system: 1 ,-- - a � � f€� A .. -4�/ xior � ' io t 3. Local Upgrade Approval is requested for(check all that apply): Reduction in setback(s)–describe reductions: Reduction in SAS area of up to 25%. sas size,sq.ft. %reduction Reduction in separation between the SAS and high groundwater: Separation reduction — Percolation rate minfnct; Depth to groundwater t5forin9a.doc•rev.7/06 Application for Local Upgrade Approval,Page 2 of 4 A Commonwealth o M chose -- City/Town of o 7 Y' Form 9A - Application for Local Upgrade Approval DEP has provided this form for use by local Boards of Health.Other forts may be used,but the information must be substantially the same as that provider!here_Before using this form,check with your local Board of Health to determine the form they use. B. Proposed Upgrade of System (continued) ❑ Relocation of water supply well(explain): Q Reduction of 12-inch separation between inlet and outlet tees and high groundwater El Use of only one deep hole in proposed disposal area Q Use of a sieve analysis as a substitute for a perc test ❑ Other requirements of 310 CMR 15.000 that cannot be met—describe and specify sections of the Code: If the proposed upgrade involves a reduction in the required separation between the bottom of the soil absorption system and the high groundwater elevation,an Approved Soil Evaluator must determine the high groundwater elevation pursuant to 310 CMR 15.4050)(h)(1)_ The soil evaluator must be a member or agent of the local approving authority. High grqundw, e lua� n determd by:' / luator's _m or riot — --- (tY�" p j i nature 9 Date evaluation G. Explanation Explain why full compliance,as defined in 310 CMR 15:404(1), is not feasible. (Each.section must be completed) !. An upgraded system infull com ian 310 CMR 15. not feasible 2. An alternative system pproved p rsuan.t,l:o 3 0,-PMR 5 3 to 15288 is not feasible: t5form9a.doc•rev.7/06 Application for Local Upgrade Approval,pprovat^Page 3 of 4 I Commonwealth of M aches - City/Town of /�' Meor Form 9A -- ticationpp Local Upgrade Approval DEP has provided this form for use by focal 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. C. Explana#ion (continued) 3. A shared system is not feasible: Af i v 4_ Connection to a public sewer is no asible: AML46 irk T ��2 ' 5_ The Application for Local upgrade Approval must be accompanied by all of the following(check the appropriate boxes): Application for Disposal System Construction Permit Complete plans and specifications Site evaluation forms ❑ A list of abutters affected by reduced setbacks to private water supply wells or property lines. Provide proof that affected abutters have been notified pursuant to 310 CMR 15.405(2). ❑ Other(List): D. Certification "I,the facility owner,certify under penalty of law that this document and all attachments,to the best of my knowledge and belief,are true,accurate,and complete.l am aware that there may be significant consequences for submitting false information,including,but not limited to,penalties or fine and/or imprisonmen r deliberate violations." Facilityls en re Date ill Print Name � Name of Preparer �� Date I !I ��� } Preparer's address ,/rovrn — StatelZtP Code Telephone---- V � t5form9a.doc.rev.7/06 Application for Local upgrade Approval,Page 4 of 4 Sullivan Engineering Group, LLC Civil Engineers&Land Development Consultants April 1, 2016 Town of North Andover Health Department 1600 Osgood Street, Suite 2035 RECEIVED North Andover,MA 10845 ANS U4 2016 vX 76YD Re: 32 Olympic Lane, North Andover TOWN OF NORTH ANDOVER Revised Septic Plan HEALTH DEPARTMENT Board of Health; Enclosed are three(3)copies of the revised Septic Upgrade Plans for the above site. I have also enclosed a check for$125.00 for the resubmission review of the septic plans. Under separate cover the homeowner will submit a signed Local Upgrade Approval Form 9A and regarding the infiltrator units. If you have any questions or comments please feel free to contact me. Very Tr Yours, ck S ' an, PE P.O. Box 2004 Woburn,MA 01888 (781)854-8644 a mail:jacksul153@comcast.net • • North Andover Health Department (ommunity and Economic Development Division March 28, 2016 John D. Sullivan, III P.E. Sullivan Engineering Group,LLC P.O. Box 2004 Woburn,MA 01888 Re: Subsurface Sewaze Disposal System Plan for 32 Olympic Lane(Map 106B,Lot 109) Dear Mr. Sullivan: The proposed wastewater system design plan for the above site dated December 1,2015,revised on March 25, 2016 and received on March 25,2016 has been reviewed. Unfortunately,the plan cannot be approved until the following items are corrected. The specific section in Title 5: 310 CMR 15.000, or North Andover regulation that is not met by this design follows each item where applicable. Since the Micro FAST system is proposed as secondary treatment unit the"Standard Conditions for Secondary Treatment Units Approved for Remedial Use"will apply. Please provide the following as required by the approval conditions Section H(9): An effluent pressure distribution system, designed in accordance with Department guidance, shall be installed for Secondary Treatment Units that have been issued Remedial Use Approval and for which there is: a) a reduction in the effective leaching area greater than 25116, as allowed under LUA ; and/or b) a reduction in the depth to groundwater greater than 1 foot, as allowed under LUA Section H(10): a) The record drawings, approved by the LAA, must clearly indicate an area for the best feasible replacement system that could be installed in the event that the proposed Alternative Soil Absorption System fails or it is determined that it is not capable of providing equivalent environmental protection; Page 1 of 2 North Andover Health Department, 1600 Osgood Street, Suite 2035, North Andover, MA 01845 Phone: 978.688.9540 Fax: 978.688.8476 Section H(20): c) a certification, signed by the Owner of record for the property to be served by the Technology, stating that the property Owner: i. has been provided a copy of the Approval, the Owner's Manual, and the Operation and Maintenance Manual, and the Owner agrees to comply with all terms and conditions,- ii. onditions;ii. has been informed of all the Owner's estimated costs associated with the operation including, when applicable:power consumption, maintenance, sampling, record keeping, reporting, and equipment replacement; iii. understands the requirement for a service contract; iv. agrees to fulfill his responsibilities to provide a Deed Notice as required by 310 CMR 15.287(10 and the Approval); V. agrees to fulfill his responsibilities to provide written notification of the Approval to any new Owner, as required by 310 CMR 15.287(5); vi. if the design does not provide for the use of garbage grinders, the restriction is understood and accepted; and vii. whether or not covered by a warranty, the System Owner understands the requirement to repair, replace, modify or take any other action as required by the Department or the local Approving Authority, if the Department or the local Approving Authority determines the Alternative System is not capable of meeting the performance standards. 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. n erely, c Michele Grant Health Inspector cc: Tracey Kavanagh File Page 2 of 2 North Andover Health Department, 1600 Osgood Street, Suite 2035, North Andover, MA 01845 Phone: 978.688.9540 Fax: 978.688.8476 3/28/2016 Town of North Andover Mail-RE:32 Olympic Lane-Revised Septic Plans and materials NORTH ANDOVER Lisa Hadge <Ihadge@northandove rma.gov> Massachusetts J RE: 32 Olympic Lane - Revised Septic Plans and materials 1 message Isaac Rowe <irowe@millriverconsulting.com> Mon, Mar 28, 2016 at 3:30 PM To: Lisa Hadge <Ihadge@northandoverma.gov>, Pam Lally <plally@millriverconsulting.com> Cc: Michele Grant<mgrant@northandoverma.gov>, Isaac Rowe <irowe@millriverconsulting.com> Lisa/Michele, Attached is the disapproval letter for revised plan review for the above referenced property. He redesigned the system to incorporate a FAST system which has specific requirements. Also it is a little confusing but there is a 5 bedroom house with 9 rooms total.Therefore the design plan has calculated the design flow correctly per Title 5 for a 4 bedroom design. Please let me know if you have any questions. Thanks, Isaac M. Rowe, R.S. Project Manager Mill River Consulting 6 Sargent Street Gloucester, MA 01930-2719 Phone: 978-282-0014 ext.804 Fax:978-282-1318 irowe millriverconsulting.com www.millriverconsulting.com From: Lisa Hadge [ma i Ito:Ihadge@northandoverma.gov] https://mail.goog le.com/mail/ca/u/O/?ui=2&ik=46857787dO&view=pt&search=inbox&th=153beb4a6412b87a&siml=153beb4a6412b87a 1/4 Sullivan Engineering Group, LLC Civil Engineers&Land Development Consultants March 25,2016 Town of North Andover Health Department 1600 Osgood Street, Suite 2035 North Andover,MA 10845 RECEIVED Re: 32 Olympic Lane, North Andover MAR 2 8 2016 Revised Septic Plan TOWN OF NORTH ANDOVER Board of Health; HEALTH DEPARTMENT Enclosed are three(3)copies of the revised Septic Upgrade Plans for the above site. The changes made to the plan reflect comments in a 12/22/2015 letter from Mill River Consulting and reflect the need to revise the plan to provide a cost-effective system based on expensive quotes for the previous system. One change to the plan, in a positive direction,is a Micro FAST unit is proposed in the 2 compartment septic tank. By adding the FAST system,the owner is allowed to take a reduction in groundwater separation and a 50%field reduction based on DEP"Standard Conditions for Secondary Treatment Units Approved for Remedial Use"with a latest revision date of March 20, 2015_ The following is a response to Mill River's comments(Mill River comment is in standard text and response is in italics). All comments were addressed. 1. The names of abutters from the most recent tax map are required (NA 3.2). Names of abutters and Tax Map/Parcel have been added 2. A scaled profile of the system is required (NA 3.2). The scaled profile has been added on Sheet 2 3. Show all wetland resource areas within 150' of the proposed system or provide a note indicating wetland resource areas are not present. The soil test application depicted a wetland resource area at the nmthem portion of the lot. A note has been added on Sheet I within the Site Plan stating no known wetlands are within 150 feet Of any septic components. 4. On sheet 1 of 2,the cetiification for the Infiltrator Chamber system is not required for this design. This certification was removed 5. A test pit log or indication of the ledge present in TH-3 should be added to the design pian. A note has been added at the location of TH-3 that ledge was encountered within 12"of grade 6. On sheet 1 of 2, a finished spot elevation should be added to the distribution box location to ensure the 9" of minimum cover material requirement is met A spot grade has been added on Sheet I and the min.finished grade is noted on the system profile 7. On sheet 2 of 2,the proposed inlet elevation of the pump chamber is not indicated. The pump chamber has been eliminated. 8. On sheet 2 of 2,the pump chamber detail indicates the inconect float heights in inches based on the proposed elevations. The pump chamber has been eliminated P.O. Box 2004 Woburn,MA 01888 (781)854-8644 e-mail:jacksu1153@comcast.net 9. Indicate the proposed soil horizons to be removed beneath the leach field area. This will ensure the installer removes the proper horizons prior to installing the Title 5 sand. This has been shown and indicated n the system profile on Sheet 2 10. The top elevation ofthe proposed impervious barrier should meet the breakout requirement for the higher end of the leach field or as needed. The proposed top of the banier elevation (100.55') is the breakout at-thc-low end-ofthe-leach-ficid. No barrier is required now....it has been eliminated from the design Under separate cover,the owner will be providing certification relating to conditions with the MicroFAST unit. The unsigned letter has been attached to demonstrate the pending certification. If you have any questions or comments please feel free to contact me. Vey Truly ours, J n, PE P.O. Box 2004 Woburn,MA 01888 (781)854-8644 e-mail:jacksu1153@comcast.net Sullivan Engineering Group, LLC Civil Engineers&Land Development Consultants March 25,2016 Town of North Andover Health Dept. 1600 Osgood Street, Suite 2035 RECEIVED North Andover,MA 01845 MAR 2 8 'L016 Re: Owner Certification—Alternative Technology TOWN OF NORTH ANDOVER 32 Olympic Lane,North Andover HEALTH DEPARTMENT To Whom It May Concern: I certify that the following conditions relative to the Micro FAST alternative technology: 1. has been provided a copy of the Title 5 IIA technology Approval, the Owner's Manual, and the Operation and Maintenance Manual, and the Owner agrees to comply with all terms and conditions: 2. for Systems installed under a Remedial Use Approval, the owner agrees to fulfill his responsibilities to provide written notification of the Approval to any new Owner, as required by 310 CMR 15.287(5); 3. if the design does not provide for the use of garbage grinders, the restriction is understood and accepted; and 4. whether or not covered by a warranty, the System Owner understands the requirement to repair, replace, modem or take any other action as required by the Department or the LAA, if the Department or the LAA determines the System to be failing to protect public health and safety and the environment, as defined in 310 CMR 15.303. Owner Name: Owner Signature: Date: P.O.Box 2004 Woburn,MA 01888 (781)854-8644 e-mail:jacksu1153@comcast.net 6/22/2016 Town of North Andover Mail-Re:32 Olympic Lane-Reivised Septic Plans and materials NORTH ANDOVER Massachus6tts Lisa Hadge<Ihadge@northandoverma.gov> Re: 32 Olympic Lane - Reivised Septic Plans and materials 1 message Jack Sullivan <jacksu 1153@comcast.net> Fri, Mar 25, 2016 at 3:27 PM To: Lisa Hadge <lhadge@townofnorthandover.com> Cc: Michele Grant<MGrant@townofnorthandover.com>, tpkav@comcast.net Michele & Lisa, I just mailed out the revised plans (3 sets) and cover letter for plan changes made based on the denial letter dated 12/22/2015 from Mill River Consulting to your office. I wanted to attached electronic copies of materials for your records and review as well. The owner had received pricing on the previous plan (which had a pump chamber) and she was getting prices between 40k-50k. Therefore, my revisions not only reflect all of Mill River's comments but I added a MicroFAST unit to the septic tank to allow a reduction in groundwater separation and 50% field reduction size (by right...see my cover letter). I had talked with Issac about this a few months back. I am hoping by eliminating the pump chamber and the sand fill required at the soil absorption field that the homeowner will get much better pricing on the system. All other aspects of the design, including the type of soil absorption field are the same as the previous submittal. All changes and additions to the plan set have been made on the design plan and are clearly identified in the cover letter. If you have any questions please feel free to email or call me. Jack Sullivan, PE 781-854-8644 From: "Lisa Hadge" <lhadge@townofnorthandover.com> To: "Jack Sullivan" <jacksu1153@comcast.net> Cc: "Michele Grant" <MGrant@townofnorthandover.com>, tpkav@comcast.net Sent: Tuesday, December 22, 2015 9:49:56 AM Subject: 32 Olympic Lane Good Morning, Attached you will find the disapproval letter for 32 Olympic Lane. -----Original Message----- From: noreply@townofnorthandover.com [ma iIto:nore ply@townofnorthand over.com] Sent: Tuesday, December 22, 2015 10:05 AM To: Hadge, Lisa Subject: Message from "ComDev-Health-Ricoh" This E-mail was sent from "ComDev-Health-Ricoh" (Aficio MP C3002). Scan Date: 12.22.2015 10:04:36 (-0500) Queries to: noreply@townofnorthandover.com https://mail.google.com/mail/ca/u/0/?ui=2&ik=46857787dO&view=pt&q=32%20olympic%201ane°/`20soil°/a20testing&qs=true&search=query&th=153af3... 1/2 6/22/2016 Town of North Andover Mail-Re:32 Olympic Lane-Reivised Septic Plans and materials Please note: As of January 11, 2016, all Town Hall offices, except Assessor and Veterans Services, will be temporarily moving to 1600 Osgood Street, Suite 2043. All email messages and attached content sent from and to this email account are public records unless qualified as an exemption under the Massachusetts Public Records Law. Visit us online at www.townofnorthandover.com Social Networks twitter.com/north andover www.facebook.com/northandoverma 4 attachments an Cover letter to BOH.pdf 24K an Owner certification.pdf 17K in Septic_Sheetl.pdf 175K in Septic_Sheet2.pdf 277K https://ma i l.goog le.com/mail/ca/u/0/?u i=2&i k=46857787d 0&view=pt&q=32%20olym pi c°/a201a ne%20soi l°/a20testing&qs=true&search=query&th=153af3... 2/2 I • S�.�TCED'1� • q1P North Andover Health Department (ommunity and Economic Development Division December 22, 2015 John D. Sullivan, III P.E. Sullivan Engineering Group, LLC P.O. Box 2004 Woburn, MA 01888 Re: Subsurface Sewage Disposal System Plan for 32 Olympic Lane (Map 106B, Lot 109) Dear Mr. Sullivan: The proposed wastewater system design plan for the above site dated December 1, 2015 and received on December 10, 2015 has been reviewed. Unfortunately, the plan cannot be approved until the following items are corrected. The specific section in Title 5: 310 CMR 15.000, or North Andover regulation that is not met by this design follows each item where applicable. 1. The names of abutters from the most recent tax map are required (NA 3.2). 2. A scaled profile of the system is required (NA 3.2). 3. Show all wetland resource areas within 150' of the proposed system or provide a note indicating wetland resource areas are not present. The soil test application depicted a wetland resource area at the northern portion of the lot. 4. On sheet 1 of 2, the certification for the Infiltrator Chamber system is not required for this design. 5. A test pit log or indication of the ledge present in TH-3 should be added to the design plan. 6. On sheet 1 of 2, a finished spot elevation should be added to the distribution box location to ensure the 9" of minimum cover material requirement is met. 7. On sheet 2 of 2,the proposed inlet elevation of the pump chamber is not indicated. 8. On sheet 2 of 2,the pump chamber detail indicates the incorrect float heights in inches based on the proposed elevations. 9. Indicate the proposed soil horizons to be removed beneath the leach field area. This will ensure the installer removes the proper horizons prior to installing the Title 5 sand. Page 1 of 2 North Andover Health Department, 1600 Osgood Street, Suite 2035, North Andover, MA 01845 Phone: 978.688.9540 Fax: 978.688.8476 i 10. The top elevation of the proposed impervious barrier should meet the breakout requirement for the higher end of the leach field or as needed. The proposed top of the barrier elevation (100.55') is the breakout at the low end of the leach field. Although not a reason for disapproval you may wish to consider the following: 11. On sheet 1 of 2,the test pits should be graphically depicted close to the approximate size and orientation as excavated. The graphic representation should be shown as a rectangle instead of a circle. 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. Sincerely, Michele Grant Health Inspector cc: Tracey Kavanagh File Page 2 of 2 North Andover Health Department, 1600 Osgood Street, Suite 2035, North Andover, MA 01845 Phone: 978.688.9540 Fax: 978.688.8476 TOWN OF NORTH ANDOVER Office of COMMUNITY DEVELOPMENT AND SERVICES HEALTH DEPARTMENT "�f'a�►m.�°�> 1600 OSGOOD STREET; SUITE 2035 NORTH ANDOVER,MASSACHUSETTS 01845 978.688.9540—Phone Susan Y.Sawyer,REHS/RS 978.688.8476—FAX Public Health Director E-MAIL:healthdent@townofnorthandover.com WEBSITE:hgp://www.townofhordmdover.com SEPTIC PLAN SUBMITTAL FORM Date of Submission: Site Location: 52 o l y# ()(' I-Ar- jW Engineer: New Plans? Yes X $225/Plan Check# (includes 1St submission and one re- review only) Revised Plans?Yes $75/Plan Check# Site Evaluation Forms Included? Yes No Local Upgrade Form Included? Yes No -7 Telephone#: / Fax#: E-mail: jYW c('/-J Ua'3 e Y " Homeowner QA Name: rn v -4 _�_--DEC 0 9 2015� ��,,ro)'; A_ OFFICE USE ONLY OVER TOWN OF NORTH AND �F ,LTH DEPARTMENT When the sub -ssion is complete(including check): ➢ m Date stamp plans and letter ➢ Complete and attach Receipt ➢ _Copy File; Forward to Consultant ➢ Enter on Log Sheet and Database Commonwealth o Ma huse City /Town of �' Form 11 - Soil Suitability Assessment for On-Site Sewage Disposal a DEP has provided this form for use by on-site professionals and local Boards of Health. Other forms may be used, but the information must be substantially the same as provided here. Before using this form, check with your local Board of Health to determine the form they use. A. Facility Information 1. Facility Information DEC Q 9 2015 Tracey Kavanaugh ki0PTNANnOVER Owner Name y HEALTH DEPARTMENT 32 Olympic Lane Map/Lot: Map 106B Lot 109 Street Address North Andover _ _MA 01845 City/Town State Zip Code i B. Site Information 1. (Check one) New Construction ❑ Upgrade ® Repair ❑ 2. Published Soil Survey available? Yes ❑ No ® If yes: Year Published Publication Scale Soil Map Unit Soil Name Soil limitations j 3. Surficial Geological Report available? Yes ❑ No ® If yes: Year Published Publication Scale Map Unit Geologic Material Landform 4. Flood Rate Insurance Map: Above the 500 year flood boundary? Yes ® No ❑ Within the 100 year flood boundary? Yes ❑ No Within the 500 year flood boundary? Yes ❑ No ® Within a Velocity Zone? Yes ❑ No 5. Wetland Area: National Wetland Inventory Map Map Unit Name Wetlands Conservancy Program Map Map Unit Name DEP Form 11 Soil Suitability Assessment for On-Site Sewage Disposal • Page 1 of 7 Commonwealth of/ Mas ch e g City/Town of b �4 Form 11 - Soil Suitability Assessment for On-Site Sewage Disposal d 6. Current Water Resource Conditions (USGS) Range: Above Normal ❑ Normal ❑ Below Normal ❑ Month/Year 7. Other references reviewed: C. On-Site Review (minimum of two holes required at every proposed disposal area) Deep Observation Hole Number: 1 9/25/15 10:00 am. 70 degrees/clear Date Time Weather ' 1. Location Ground Elevation at Surface of Hole 100.0 (Assumed Datum) Location (Identify on Plan ) See Sheet 7 of 7 2. Land Use: Residential Few 0-2 (e.g.woodland,agricultural field,vacant lot,etc.) Surface Stones Slope(%) Grass Flat Vegetation Landform Position on landscape(attach sheet) 3. Distances from: Open Water Body >200_ Drainage Way>200 Possible Wet Area 180 +/- feet feet feet Property Line 50 Drinking Water Well >150 Other feet feet 4. Parent Material: Loamy Eolian Deposits Unsuitable Materials Present: Yes ❑ No If Yes: Disturbed Soil[] Fill Material❑ Impervious Layer(s) ❑ Weathered/Fractured Rock[] Bedrock❑ 5. Groundwater Observed: Yes ❑ No If Yes: Depth Weeping from Pit__n/a Depth Standing Water in Hole Estimated Depth to High Groundwater: Mottles at 52" (Elev=95.66') DEP Form 11 Soil Suitability Assessment for On-Site Sewage Disposal•Page 2 of 7 Commonwealth of acVu TM City/Town of z Form 11 - Soil Suitability Assessment for On-Site Sewage Disposal a Deep Observation Hole Number: 1 Soil Soil Matrix: Redoxlmorphlc Features Soil Coarse Fragments Soil Structure Soil Depth Horizon/ Color-Moist (mottles) Texture % by Volume Consistence Other (In) Layer (Munsell) (USDA) (Moist) Depth Color Percent Gravel Cobbles &Stones 0-10 FILL 10-14 A 10 YR 3/3 n/a FSL FINE 14-30 Bw 10 YR 6/8 n/a FSL FINE 30-100 C 2.5 Y 6/4 52" 70 SL Additional Notes No groundwater observed DEP Form 11 Soil Suitability Assessment for On-Site Sewage Disposal• Page 3 of 7 Commonwealth of Ma chi City/Town ofMOE Form 11 - SoilUltabilit Assessment for On-Site Sewage Disposal y 9 p Vi C. On-Site Review (Cont.) Deep Observation Hole Number: _2 9/25/15 10:00 Am. 70 degrees/clear Date Time Weather 1. Location Ground Elevation at Surface of Hole 99.7' (Assumed Datum) i Location (Identify on Plan ) See sketch plan on sheet 7 2. Land Use: Grassed Few _0-2 (e.g.woodland, agricultural field,vacant lot,etc.) Surface Stones Slope(%) Grass Flats !i Vegetation Landform Position on landscape(attach sheet) 3. Distances from: Open Water Body_>230_ Drainage Way_>200_ Possible Wet Area 190 +/- feet feet feet Property Line 30 Drinking Water Well >150 Other feet feet 4. Parent Material: Loamy Eolian Deposits Unsuitable Materials Present: Yes ❑ No If Yes: Disturbed Soil[] Fill Material❑ Impervious Layer(s) ❑ Weathered/Fractured Rock[:] Bedrock❑ 5. Groundwater Observed: Yes ❑ No j If Yes: Depth Weeping from Pit none Depth Standing Water in Hole none Estimated Depth to High Groundwater: 48" 95.70 inches elevation DEP Form 11 Soil Suitability Assessment for On-Site Sewage Disposal•Page 4 of 7 Commonwealth of Mas a �chusetts City/Town of T jaa oMW Form 11 - Soil iluitability Assessment for On-Site Sewage Disposal Deep Observation Hole Number:_2 Soil Soil Matrix: Redoximorphic Features Soil Coarse Fragments Soil Soil Depth Horizon/ Color-Moist (mottles) Texture %by Volume Structure Consistence Other (In.) Layer (Munsell) (USDA) (Moist) Depth Color Percent Gravel Cobbles &Stones 0-7 A 10 YR 3/3 n/a FSL FINE 7-30 Bw 10 YR 6/8 n/a FSL FINE 30-59 C1 2.5 Y 4/4 48" 50 Fine Sand 59-100 C2 2.5 Y 6/4 Additional Notes No groundwater weeping or standing DEP Foran 11 Soil Suitability Assessment for On-Site Sewage Disposal• Page 5 of 7 Commonwealth of Ma chu efts ,/j Q City/Town of Y'` ` Form 11 - S �Ie:ii ltabllit Assessment for On-Site Sewage Disposal Y 9 p a D. Determination of High Groundwater Elevation 1. Method used: ❑ Depth observed standing water in observation hole A. inches inches ❑ Depth weeping from side of observation hole A. B. inches inches ® Depth to soil redoximorphic features (mottles) A. _52_ B. _48" Inches inches ❑ Groundwater adjustment(USGS methodology) A. B. Inches inches 2. Index Well Number Reading Date Index Well Level Adjustment Factor Adjusted Groundwater Level E. Depth of Pervious Material 1. Depth of Naturally Occurring Pervious Material a. Does at least four feet of naturally occurring pervious material exist in all areas observed throughout the area proposed for the soil absorption system? Yes ® No ❑ b. If yes, at what depth was it observed? Upper boundary: 30 Lower boundary: 100 Inches inches F. Certification I certify that I haveApassetl ev ator examination*approved by the Department of Environmental Protection and that the above analysis was perfotent with the required training, expertise an experience described in 310 CMR 15.017. ;z /L !J Signature of Soil Eva to r Date4�7 -77� Jan III, P.E._ October 1995 Typed or Printed ame "Date of Soil Evaluator Exam ISsac Rowe_ Consultant to Town of N.Andover BOH Name of Board of Health Witness Board of Health DEP Form 11 Soil Suitability Assessment for On-Site Sewage Disposal•Page 6 of 7 DE 99x3 QPr ' Comm 99x8 TH-1 City/To' V. � Forr 99 TH-2 100x0 o/ O 99 99x97 Gr O 7 100x1 700x1 � 99�fi1 tOix xCXJOppc l01 ® �h A,) C4 103x05 ��^]03x11 101x3 1003 STOCKADE /� �O' ' 24' 3x04 FENCE O V 10. 1oox8 11 102x61 1010 fNGROUND p00L 103 0 102 4 10049 OTM-3 10 7 CONC pp 103 103 OL. Pq n0 o BIT CONC BRICK PATIO a 103x14 102x85 i 1 � RAMP DECK 1 EXISTING -- I 103x35 t4' 14' STONE RET" WALT_ i CAR GAR88 UNDER DECK 14" GAF% SLAB— 14• CONC 57.77 -� s 03x1 WAY EXISTING TGF'= 10488 2 STY WOOD 2 CAR STRUCTURE 0 GARAGE ' O F UNDER2 I❑ P� MEM 5 BEDROOM HOUSE r o FF=105.E4� i �� Lability Assessmant for On-Site:>ewage Disposal•Page 7 of 7 Commonwealth of Ma �sachus Cit Y 0/Town of /V g�� use Percolation Test Form 12 N 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. Important: When filling out A. Site Information forms on the computer,use Tracey Kavanagh only the tab key Owner Name to move your 32 Olympic Lane cursor-do not Street Address or Lot# use the return key. North Andover MA 01845 Cityrrown State Zip Code VQ Tracey Kavanagh 978-857-1521 Contact Person(if different from Owner) Telephone Number B. Test Results 9/25/15 10:00 a.m. Date Time Date Time Observation Hole# PT-1 Depth of Perc 40"-56" Start Pre-Soak 9.57 End Pre-Soak 10:12 Time at 12" 10:12 Time at 9" 11:20 Time at 6" 1:26 Time(9°-6") 126 Minutes Rate(Min./Inch) 42 MPI Test Passed: ® Test Passed: ❑ Test Failed: ❑ Test Failed: ❑ John D. Sullivan III, P.E. Test Performed By: Issac Rowe, Consultant for Town of North Andover BOH Witnessed By: Comments: t5fonn12.doc•06/03 Perc Test•Page 1 of 1 Commonwealth VoF Mch se City/Town of / �.,�� Form 11 - Soil Suitability ) kssment for On-Site Sewage Disposal DEP has provided this form for use by on-site professionals and local Boards of Health. Other forms may be used, but the information must be substantially the same as provided here. Before using this form, check with your local Board of Health to determine the form they use. A. Facility Information 1. Facility Information Tracey Kavanaugh Owner Name 32 Olympic Lane Map/Lot: Map 106B Lot 109 Street Address North Andover _MA 01845 City/Town State Zip Code B. Site Information 1. (Check one) New Construction ❑ Upgrade ® Repair ❑ 2. Published Soil Survey available? Yes ❑ No ® If yes: Year Published' Publication Scale Soil Map Unit Soil Name Soil limitations 3. Surficial Geological Report available? Yes ❑ No ® If yes: Year Published Publication Scale Map Unit Geologic Material Landform 4. Flood Rate Insurance Map: Above the 500 year flood boundary? Yes ® No ❑ Within the 100 year flood boundary? Yes ❑ No Z Within the 500 year flood boundary? Yes ❑ No ® Within a Velocity Zone? Yes ❑ No 5. Wetland Area: National Wetland Inventory Map Map Unit Name Wetlands Conservancy Program Map Map Unit Name DEP Form 11 Soil Suitability Assessment for On-Site Sewage Disposal- Page 1 of 7 Commonwealthof Mas, chusetts City/Town of /'I/6�`� /�`` A ` Form 11 - Soil Suitability Assessment for On-Site Sewage Disposal o- 6. Current Water Resource Conditions (USGS) Range: Above Normal ❑ Normal ❑ Below Normal ❑ MonthNear 7. Other references reviewed: C. On-Site Review (minimum of two holes required at every proposed disposal area) Deep Observation Hole Number: 1 9/25/15 10:00 am. 70 degrees/clear Date Time Weather 1. Location Ground Elevation at Surface of Hole_100.0 (Assumed Datum) Location (Identify on Plan ) See Sheet 7 of 7 2. Land Use: Residential Few 0-2 (e.g.woodland,agricultural field,vacant lot,etc,) Surface Stones Slope(%) Grass Flat Vegetation Landform Position on landscape(attach sheet) 3. Distances from: Open Water Body >200_ Drainage Way>200 Possible Wet Area 180 +/- feet feet feet Property Line 50 Drinking Water Well >150 Other feet feet 4. Parent Material: Loamy Eolian Deposits Unsuitable Materials Present: Yes ❑ No If Yes: Disturbed Soil[] Fill Material❑ Impervious Layer(s)❑ Weathered/Fractured Rock❑ Bedrock❑ 5. Groundwater Observed: Yes ❑ No If Yes: Depth Weeping from Pit__n/a Depth Standing Water in Hole Estimated Depth to High Groundwater: Mottles at 52" (Elev=95.66') DEP Form 11 Soil Suitability Assessment for On-Site Sewage Disposal- Page 2 of 7 Commonwealth Vorachus ,/t����City/Town of f�, ; Form 11 - Soil Suitability Assessment for On-Site Sewage Disposal p Deep Observation Hole Number: 1 Soil Soil Matrix: Redoximorphic Features Sol[ Coarse Fragments Soil Structure Soil Depth Horizon/ Color-Moist (mottles) Texture %by Volume Consistence Other (In.) Layer (Munsell) (USDA) (Moist) Depth Color Percent Gravel Cobbles &Stones 0-10 FILL 10-14 A 10 YR 3/3 n/a FSL FINE 14-30 Bw 10 YR 6/8 n/a FSL FINE 30-100 C 2.5 Y 6/4 52" 70 SL Additional Notes No groundwater observed DEP Form 11 Soil Suitability Assessment for On-Site Sewage Disposal• Page 3 of 7 Commonwealth of MhPcuse City/Town of MA ` Form 11 - Soil Suitabi ity Assessment for On-Site Sewage Disposal C. On-Site Review (Cont.) Deep Observation Hole Number: _2 9/25/15 10:00 Am. 70 degrees/clear Date Time Weather 1. Location Ground Elevation at Surface of Hole 99.7' (Assumed Datum) Location (Identify on Plan ) See sketch plan on sheet 7 2. Land Use: Grassed Few _0-2 (e.g.woodland,agricultural field,vacant lot,etc.) Surface Stones Slope(%) Grass Flats vegetation Landform Position on landscape(attach sheet) 3. Distances from: Open Water Body_>230_ Drainage Way_>200_ Possible Wet Area 190 +/- feet feet feet Property Line 30 Drinking Water Well >150 Other feet feet 4. Parent Material: Loamy Eolian Deposits Unsuitable Materials Present: Yes❑ No If Yes: Disturbed Soil[] Fill Material❑ Impervious Layer(s) ❑ Weathered/Fractured Rock❑ Bedrock[] 5. Groundwater Observed: Yes ❑ No ED If Yes: Depth Weeping from Pit none Depth Standing Water in Hole none Estimated.Depth to High Groundwater: 48" 95.70 Inches elevation DEP Form 11 Soil Suitability Assessment for On-Site Sewage Disposal•Page 4 of 7 Commonwealth of Ms chuset����� MONNER City/Town of Form I I - 66il Suitability Assessment for On-Site Sewage Disposal Y g p a Deep Observation Hole Number:_2 Soil Soil Matrix: Redoximorp'hic Features Soil Coarse Fragments Soil Soil Depth Horizon/ Color-Moist (mottles) Texture % by Volume Structure Consistence Other Depth (Munsell) (USDA) (Moist) Depth Color Percent Gravel Cobbles &Stones 0-7 A 10 YR 3/3 n/a FSL FINE III 7-30 Bw 10 YR 6/8 n/a FSL FINE 30-59 C1 2.5 Y 4/4 48" 50 Fine Sand 59-100 C2 2.5 Y 6/4 Additional Notes No groundwater weeping or standing DEP Form 11 Soil Suitability Assessment for On-Site Sewage Disposal-Page 5 of 7 Commonwealthof Ms chMe ul"j- City/Town of �` Form 11 - Soil Suitability Assessment for On-Site Sewage Disposal D. Determination of High Groundwater Elevation 1. Method used: ❑ Depth observed standing water in observation hole A. _ inches inches ❑ Depth weeping from side of observation hole A. B. inches inches ® Depth to soil redoximorphic features (mottles) A. _52_ B. 48" inches inches ❑ Groundwater adjustment(USGS methodology) A. B. inches inches 2. Index Well Number Reading Date Index Well Level Adjustment Factor Adjusted Groundwater Level E. Depth of Pervious Material 1. Depth of Naturally Occurring Pervious Material a. Does at least four feet of naturally occurring pervious material exist in all areas observed throughout the area proposed for the soil absorption system? Yes ® No❑ b. If yes, at what depth was it observed? Upper boundary: 30 Lower boundary: 100 inches inches F. Certification I certify that I have s ed t II evaluator examination*approved by the Department of Environmental Protection and that the above analysis was pert rm c tent with the required training, expertise and experience described in 310 CMR 15.017. Signature of it Ev or Date n D. Sullivan III, P.E._ October 1995 Typed or Printed Name of Soil Evaluator *Date of Soil Evaluator Exam lssac Rowe_ Consultant to Town of N.Andover BOH Name of Board of Health Witness Board of Health DEP Form 11 Soil Suitability Assessment for On-Site Sewage Disposal• Page 6 of 7 DE, 99x3 Comm- PT-1om ssxa TH-1 city/To ) �' k Forr ssx Q�TN-2 laoxo 0 9s 99x97 100x1 100x1 '• �� 9941 1014 h^ OOG70 >O 101 X 1003 p f' 103x05 01X3 a STOCKADE �Oh -� � 24' . FENCE O v 103 100.8 102x61 101aC1 INGROUND POOL 103 /�r.IT 102 .�1Doxs�TH-310 CONC P 103 103°OLI'AnoONC BRICK PATIOa103x14102ca13 �� �P DECK 104 EXISTING J 103x35 14' 14' ' STONE RET WALL_ 1 CAR GAR8B 04 UNDER DECK 14' GAR SLAB— 14' 97.77 � � CONC 10:x1 EWAY EXISTING TOF=- 104.88 2 STY WOOD 2 CAR STRUCTURE a. . GARAGE #32 POOL MECH UDDER 5 BEDROOM HOUSE ° FF=105.84-7 I ability Assessment for On-Site Sewage Disposal posal F'ag•7 of 7 Commonwealth of7M ssachy�� City/Town of 1VO T 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. Important: illing out When filling A. Site Information forms on the computer,use Tracey Kavanagh only the tab key Owner Name to move your 32 Olympic Lane cursor-do not Street Address or Lot# use the return key. North Andover MA 01845 6%' Cityrrown State Zip Code Li Tracey Kavanagh 978-857-1521 Contact Person(if different from Owner) Telephone Number B. Test Results 9/25/15 10:00 a.m. Date Time Date Time Observation Hole# PT-1 Depth of Perc 40"-56" Start Pre-Soak 9:57 End Pre-Soak 10:12 Time at 12" 10:12 Time at 9" 11:20 Time at 6° 1:26 Time(9"-6°) 126 Minutes Rate(Min./Inch) 42 MPI Test Passed: ® Test Passed: ❑ Test Failed: ❑ Test Failed: ❑ John D. Sullivan 111, P.E. Test Performed By: Issac Rowe, Consultant for Town of North Andover BOH Witnessed By: Comments: t5form12.doc-06/03 Perc Test•Page 1 of 1 I TOWN OF NORTH ANDOVER Office of COMMUNITY DEVELOPMENT AND SERVICES HEALTH DEPARTMENT = 1600 OS!VFMIMASSACITUSETTS TREET; SUITE 2035 NORTRIS01845 Susan Y.Sawyer,RENS,RS 0 � 4 J��b 978.688.9540—Phone Public Health Director N�RSN pVA 978.688.8476—FAX 10* �F p�pPRhealthdeptaa,townofnorthandover.com No-v www.townofnorthandover.com APPLICATION FOR SOIL TESTS J/ /) DATE: � 'r• "I `�-o I �� MAP MW 1 a s G4 �v f 1' I &PARCEL. LOCATION OF SOIL TESTS: 11649Y1990 loll-ewvw-�w OWNER: a C 11 Contact#: 7� APPLICANT:_ Contact#: ADDRESS: D \ rvL 7( c LYN I J, A - ENGINEER: O h n 6 A L�`,/C<,� Contact CERTIFIED SOIL EVALUATOR: vy�V f`✓ � � Intended Use of Land: Residential Subdivision t/Single Family Home Commercial Is This: Repair Testing: ti� Undeveloped Lot Testing: Upgrade for Addition: In the Lake Cochichewick Watershed? Yes No ✓ THE FOLLOWING MUST BE INCLUDED WITH THIS FORM Proof of land owners (Tax bi or letter from owner permitting test) J/➢ 8.5"x 11"Plot Plan& n o Testin lease indicate test aLgles on the lap Fee of$425.00 per lot for new construction. This covers two deep holes and two percolation tests required for each disposal area. Fee o $360.00 r lot for repairs or upgrades. GENERALINFOR ➢ 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 Signature of Conservation Agent.' gent: Date back to Health Department: (stamp in): s� M W� 1 `F""�'• ��", "'` �`"� 6 �—"' 62.0L,.A� 47 b-Dj 24 2' —'1KX' DRAIN GE EASEMENT f • f y LOT AREA- 43,748 S.F. � J\ IV b 3z All �� �� EXISTING � 7REELDOE L4'CH LINK \ E 6. FENCE 6'STOCKADE e E1OSDNG � STONE FENCE h C rim I�•^� TP ^ r Geo M STOCK FENCE ry• 7P +�OWU D POOL o 0 / CCNC o POM PA lT0 ,W OBIT CONC BRICK PA710 y EXISTING a� 1 STY � ROOFED ENCLOSED i WALL c t� , s7DNE r^+ REWALLI aK owe LIM mw mnf'-wase cAR pKe DBIT CONC RIVEWAY 6277 i 2 CAR 2 W=OW 39.9' i O C] i JIM i rr-,a6e� i i 32.4' aNn Ilm KN 83.8' 55543709"W L-39.55' 110.45' 285. 0 O L Y M P I C L A N E ft� --425) i � : i ---- -- _----- .. _ I Y4 r i Ld l_��-.�.�s�for �Ls .�' ii- i?�� -Z—►�� -- ��' 36-Jl _��-2 5Y j�3 �v3 ��c�► _ , ;l f% I F r BUILDING PERMIT E 0011Th TOWN OF NORTH ANDOVER 0 � 1" APPLICATION FOR PLAN EXAMINATION 0 Permit NO: Date Received_f�—� Date Issued: ` ,SS�CHUSE�� IMPORTANT Applicant must complete all items on this page Y 'f Kz LOCATi01� � L _ Pn T PI�Oi�T77 Y`OWNER _ hlla�iiie�I�op Ullage yes © . TYPE OF IMPROVEMENT PROPOSED USE Residenti Non- Residential New Building Addition Two or more family industrial Alteration No. of units: Commercial Repair, replacement Assessory Bldg Others: Demolition Other $epic � Well ,f .. � f r cipJa�ra � _, �etlandsr Watershed D�stnct 11�aterlSeuuer:; " �` �.. DESCRIPTION OF WO K TO BE PRE ORM +D: Identification Please T e or Print arly) ` OWNER: Name: ., , r F f Phone: Address e � �' - G�S - ?� 's C r Z.7i I _ y,,,h.13 s iy 'Cfll1��#�ACTOR Name � �, .� ph iik. =a Address j 1 a f t A�„ Supervisor's Construc#ion L'cense Ezot p Date Home Improvement License:'. Exp Date. ARCHITECT/ENGINEER ✓. Phone: Address: Reg. No. FEE SCHEDULE:BULDING PERMIT.$12.00 PER$1000.00 OF THE TOTAL ESTIMATED COST BASED ON $125.00 P PER S.F. Total Project Cost: $ FEE: $ Check No.: Receipt No.: NOTE: Persons contractin ered�c ntractors do not have access to the guaranty and Signature W_A e, p: - - 9 i nature_of contract , 9. CERTIFIED PLOT PLAN + LOCATED IN NORTH ANDOVER, MASS. SCALE.-l"=40' DATE:11/08/2007 Scott L. Giles R.P.L.S. ASSESSORS Frank. S. Giles R.P.L.S. MAP 106 8 LOT 109 50 Deer Meadow Road North Andover, Mass. 43,748 S.F. SUBDIVISION LOT 2 PROPOSED P? 29,+1- POOL 2�*, tiry N n, P/r PIT SEPTIC DECK�VO AREA TANK EXIST. HSE. O FND. #32 110,45' L=39.55' OLYMPIC LANE I CERTIFY THAT OFFSETS SHOWN ARE FOR THE USE THE OFFSETS OF THE BUILDING INSPECTOR ONLYU�� SHOWN COMPLY AND SUCH USE IS FOR THE WITH THE ZONING DETERMINATION OF ZONING3972 st�R�o BYLAWS OF CONFORMITY OR NON-CONFORMITY `��o�At L��0 � NORTH ANDOVER WHEN CONSTRUCTED. WHEN BUILT x 1F- M j Ke �,pcsfy�ff FO t U - LOT RELEASE FORM 3 ?o nGh C/-edr AO 0 AW, A./Ap J INSTRUCTIONS: This rm i used to verify that all necessary approval/permits from 3,,C7- Boards and Departments havin' 'uri` 'ction have been obtained. This does not relieve the l applicant and or landowner fr pliance with any applicable requirements. 1/■R...■i..■R..i'!.flilf/.fEt.fR■.■R..!■.i■■.../...Rf.f..i/R.•R-■.■■f■now■.Man ass APPLICANTG.y r�n ,�A v�►�/,�I�" PHONE ASSESSORS MAP NUMBER LOT NUMBER SUBDIVISION LOT NUMBER . STREET NUMBERSTREETi...ix" /.7 .s.:Ra.■ OFFICIAL USE ONLY .....................i..fa..iR.■af.............R.....................■...................was..Man RECOMMENDATIONS OF TOWN AGENTS ■i.t..f■... .... i■.■........1Li■■. ..i.. -....1■.i.■.■R..■■.....■..RR....■■.■...■ ' DATE APPROVED �O C NSERVATION ADMINIS OR r��&0.n A f DATE RESECTED CON%4ENTS W , > -pro/I iQfo!96,,5e J.tDor K s DATE APPROVED TOWN PLANNER DATE REJECTED COhflVIENTS DATE APPROVED FOOD INSPECTOR-HEALTH DATE REJECTED _ n S DATE APPROVED "t G J Q SEPTfC INSPECTOR-HEALTH DATE RESECTED guy S ;a C4 L)\ o�L PUBLIC WORKS-SEWER/WATER CONNECTIONS DRIVEWAY PERMIT DATE APPROVED FIRE DEPARTMENT DATE RESECTED COMMENTS RECEIVED BY BUILDING INSPECTOR DATE