HomeMy WebLinkAboutMiscellaneous - 333 CANDLESTICK ROAD 4/30/2018r 1
4
MAP
PARCEL #
LOT #
* ......... . ....
Zg,L
STREET :27
CONSTRUCT
,eel HAS PLAN REVIEW FEE BEEN PAID? 9D NO
PLAN APPROVAL: DATE- /044 - - - APP.
DESIGNERi PLAN DR-rE_--*Zi
4-77�
CONDITIONS. ql3o
WATER SUPPLY: WELL
WELL PERMIT DRILLER
WELL TESTS: CHEMICAL DATE APPROVED
BACTERIA I DATE APPROVED..... . ... ......... ...... . . . .
BACTERIA II DATE
COMMENTS:
FORM U APPROVAL: APPROVAL TO ISSUE YES NO
DATE ISSUED----Z%Z
CONDITIONS:
•. .. . .... .. . ..................... ......... ......
FINAL APPROVAL:
ALL PERMITS PAID YES NO
WELL CONSTRUCTION APPROVAL 4P NO
SEPTIC SYSTEM CONSTRUCTION APPROVAL <Zjgg> NO
OTHER YES NO
ANY VARIANCE NEEDED
FINAL BOARD OF HEALTH APPROVAL:
YES NO
DATE:. .,
(
IS THE INSTALLER LICENSED? YES NO
TYPE OF CONSTRUCTION: NEW REPAIR
NEW CONSTRUCTION: CERTIFIED PLOT PLAN REVIEW YES NO
CONDITIONS OF APPROVAL YES NO
(FROM FORM U)
ISSUANCE OF DWC PERMIT NO
DWC PERMIT NO.__.____INSTALLER..-�B, !__11�9z�
BEGIN INSPECTION
6;Z1 0:
EXCAVATION INSPECTION: NEEDED:
.............
PASSED
. ....................
BY
.
CONSTRUCTION INSPECTION:
NEEDED:
.... . ..... .......... ..... ............ . ..... . ......... .
............. .............
. .. .. . ..... . . .. . .......... ........... ... ................ ........ ...............
AS BUILT PLAN SATISFACTORY:
.
................. . ....... . .............. . ... .....
............. . .... ........ . ..
............ ....... ... . ......... ........
APPROVAL TO BACKFILL: DATE:
-- fU 71-9-Z
-BY..._..__..._...._
.........
FINAL GRADING APPROVAL: DATE.
BY
& A
40.
.......... ....... ...... .....
FINAL CONSTRUCTION APPROVAL:
DATE: BY
This certifies that .. [ X . e- Z --.'X? n -r ?- J..........
has permission to perform .? �. �- �. ,..................
wiring in the building of ...... S �. Et . ................
at ..:,f . .%/ -�. j// -S17. P. /..... , N rth Andover, Mass.
Fe& 77"1..... Lic. No. .�1� 1 ... �
/r
ELECTRICAL INSPECTOR
Check
11279
Commonwealth of Massachusetts
Department of Fire Services
BOARD OF FIRE PREVENTION REGULATIONS
Official Use Only
Permit No. 112- 79
Occupancy and Fee Checked
[Rev. 1/071 (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 ININK OR TYPE ALL J NFORIVIATI0A9 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)3� �j AcG 2cp
Owner or Tenant a sx a Telephone No.
Owner's Address( ttA
Is this permit in conjunction with a building permit? Yes ❑ No (Check Appropriate ]Box)
Purpose of Building Utility Authorization N
Existing Service -Z C42 Amps l Z,-/ L {Volts Overhead ❑ Undgrd Authorization
of Meters
New Service Amps / Volts Overhead ❑ Undgrd ❑ No. of Meters
Number of Feeders and Ampacity
Location and Nature of Proposed Electrical Work: -X-AS;� It
Completion of the following table maybe waived by the Inspector of Wires.
No. of Recessed Luminaires
No. of Cel Susp. (Paddle) Fans
No. of Total
Transformers KVA
No. of Luminaire Outlets
No. of Hot Tubs
Generators KVA '20
No. of Luminaires
Swimming Pool Above ❑ In- Elo.
rnd. rnd.
o a mer cy Lighting
Battery Units
No. of Receptacle Outlets
No. of Oil Burners
FIRE ALARMS
No. of Zones
No. of Switches
No. of Gas Burners
No. of Detection and
Initiating Devices
No. of Ranges
g
No. of Air Cond. Total
Tons
No. of Alerting Devices
g
No. of Waste Disposers
Heat Pump
Totals:
Number
� *......................................................
Tons
KW
No. of Self -Contained
Detection/Alerting Devices
No. of Dishwashers
Space/Area Heating KW
Local ❑ Municipal ❑ Other
Connection
No. of Dryers
Heating Appliances KW
Security Systems:''
No. of Devices or Equivalent
No. of Water KW
Heaters
No. of No. of
Signs Ballasts
Data Wiring:
No. of Devices or Equivalent
No. Hydromassage Bathtubs
No. of Motors Total HP
Telecommunications Wiring:
No. of Devices or Equivalent
OTHER:
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: /Z - �f—/Z. 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, acrtde the pains and penalties ofperjuty, that the information on this application is true and complete.
FIRM NAM N / �c s/�C LIC. NO.:A9-06
Licensee• Signature I. h7c LIC. NO.: Z
(If appl' abl , e er `exempt in the license number line.) Bus. Tel. No:
Addre %30d Alt. Tel. No.: SV 3z 6- yo
*Per M. .L c. 147, s. 57-61, security work requires Department of Public Safety " '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 PERMIT FEE. $
Signature Telephone No.
❑ 2012 Massachusetts Electrical Code Amendments 527 CMR 12.00 § Rule 8: In accordance with the provisions of M.G.L. c. 143, § 3L, the
permit application form to provide notice of installation of wiring shall be uniform throughout the Commonwealth, and applications shall be filed
on the prescribed form. After a permit application has been accepted by an Inspector of Wires appointed pursuant to M. G.L c. 166, § 32, an
electrical permit shall be issued to the person, firm or corporation stated on the permit application. Such entity shall be responsible for the
notification of completion of the work as required in M.G.L. c. 143, § K.
Permits shall.be limited as to the time of ongoing construction activity, and may be deemed by the Inspector of Wires abandoned and invalid if he
or she has determined that the authorized work has not commenced or has not progressed during the preceding 12 -month period. Upon written
application, an extension of time for completion of work shall be permitted for reasonable cause. A permit shall be terminated upon the written
request of either the owner or the installing entity stated on the permit application.
❑ The Permit Extension Act was created by Section 173 of Chapter 240 of the Acts of 2010 and extended by Sections 74 and 75 of Chapter 238 of
the Acts of 2012. The purpose of this act is to promote job growth and long-term economic recovery and the Permit Extension Act furthers this
purpose by establishing an automatic four-year extension to certain permits and licenses concerning the use or development of real property. With
limited exceptions, the Act automatically extends, for four years beyond its otherwise applicable expiration date, any permit or approval that was
"in effect or existence" during the qualifying period beginning on August 15, 2008 and extending through August 15, 2012.
❑ Rule 8 — Permit/Date Closed: ** Note: Reapply for new permit ❑
❑ Permit Extension Act — Permit/Date Closed:
----- 11%
Trench Inspection
Pass
Failed
Re- Inspection Required ($.) ❑
Inspectors Comments:
Inspectors Signature:
Date:
SERVICE INSPECTION:
Pass M
Failed 0
Re- Inspection Required ($.) ❑
Inspectors Comments: .
Inspectors Signature:
Date:
PARTIAL ROUGH INSPECTION:
Pass 0
Failed
Re- Inspection Required ($.) ❑
Inspectors Comments:
Inspectors Signature:
Date:
ROUGH INSPECTION:
Pass M
Failed 0
Re- Inspection Required ($.) ❑
Inspectors Comments:
Inspectors Signature:
Date:
FINAL SPECTION:
Pass'49NFailed
0
Re- Inspection. Required ($.) ❑
Inspectors Comments:
Inspectors Signature:
Date:
DEB WEINHOLD ... TOWN OF MERRIMAC, MA. .......dweinhold@townofinerrimac.com
The Commonwealth of Massachusetts
Department of Industrial Accidents
Office of Investigations
600 Washington Street
Boston, MA 02111
,Y www.mass.gov/dia
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers
Applicant Information Please Print Legibly
Name (Business/Organizati6n/Individual): /�/ g
Address:
City/State/Zip:
- STVgi-3z-leoY& c C— r,
Phone #:_ 91,4- s75 z 51�6P6 - oWc.,,
Are
am a employer with
4. ❑ I am a general contractor and I
_
employees (full and/or part-time).*
have hired the sub -contractors
2. ❑ I am a sole proprietor or partner-
listed on the attached sheet. #
ship and have no employees
These sub -contractors have
working for me in any capacity.
workers' comp. insurance.
[No workers' comp. insurance
5. ElWe are a corporation and its
required.]
officers have exercised their
3. ❑ I Am a homeowner doing all work
right of exemption per MGL
myself. [No workers' comp.
c. 152, § 1(4), and we have no
insurance required.] f
employees. [No workers'
comp. insurance required.]
Type of project (required):
6. ❑ New construction
7. ❑ Remodeling
8. ❑ Demolition
9. ❑ Building addition
10.0 Electrical repairs or additions
11.❑ Plumbing repairs or additions
12.❑ Roof repairs
13.❑ Other
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.
am an employer that is providing workers' compensation insurance for my employees. Below is the policy and job site
!formation.
isurance Company Name:
olicy # or Self -ins. Lic. f'- —3 S Expiration Date:
)b Site Address:3 lelk� City/State/Zip:_ /L IdAlDalff
.ttach a copy of the workers' compensation policy declaration page (showing the policy number and expiration date).
Edlure to secure coverage as required under Section 25A of MGL c. 152 can lead to the imposition of criminal penalties of a
ne 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
up to $250.00 a day against the violator. Be advised that a copy of this statement may be forwarded to the Office of
tvestigations of the DIA for insurance coverage verification.
do hereby ce 1 under the pains and penalties of perjury that the information provided above is true and correct.
f/,
Are y u an employer? Check the appropriate box:
1.
Official ztse 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 #:
a
Information and Instructions
Massachusetts General Laws chapter 152 requires all employers to provide workers' compensation for their employees.
Pursuant to this statute, an employee is defined as "...every person in the service of another under any contract of hire,
express or implied, oral or written."
An employer is defined as "an individual, partnership, association, corporation or other legal entity, or any two or more
of the foregoing engaged in a joint enterprise, and including the legal representatives of a deceased employer, or the
receiver or trustee of an individual, partnership, association or other legal entity, employing employees. However the
owner of a dwelling house having not more than three apartments and who resides therein, or the occupant of the
dwelling house of another who employs persons to do maintenance, construction or repair work on such dwelling house
or on the grounds or building appurtenant thereto shall not because of such employment be deemed to be an employer."
MGL chapter 152, §25C(6) also states that "every state or local licensing agency shall withhold the issuance or
renewal of a license or permit to operate a business or to construct buildings in the commonwealth for any
applicant who has not produced acceptable evidence of compliance with the insurance coverage required."
Additionally, MGL chapter 152, §25C(7) states "Neither the commonwealth nor any of its political subdivisions shall
enter into any contract for the performance of public work until acceptable evidence of compliance with the insurance
requirements of this chapter have been presented to the contracting authority."
Applicants
Please fill out the workers' compensation affidavit completely, by checking the boxes that apply to your situation and, if
necessary, supply sub-contractor(s) name(s), address(es) and phone number(s) along with their certificate(s) of
insurance. Limited Liability Companies (LLC) or Limited Liability Partnerships (LLP) with no employees other than the
members or partners, are not required to carry workers' compensation insurance. If an LLC or LLP does have
employees, a policy is required. Be advised that this affidavit may be submitted to the Department of Industrial
Accidents for confirmation of insurance coverage. Also be sure to sign and date the affidavit. The affidavit should
be returned to the city or town that the application for the permit or license is being requested, not the Department of
Industrial Accidents. Should you have any questions regarding the law or if you are required to obtain a workers'
compensation policy, please call the Department at the number listed below. Self-insured companies should enter their
self-insurance license number on the appropriate line.
City or Town Officials
Please be sure that the affidavit is complete and printed legibly. The Department has provided a space at the bottom
of the affidavit for you to fill out in the event the Office of Investigations has to contact you regarding the applicant.
Please be sure to fill in the permit/license number which will be used as a reference number. In addition, an applicant
that must submit multiple permit/license applications in any given year, need only submit one affidavit indicating current
policy information (if necessary) and under "Job Site Address" the applicant should write "all locations in (city or
town)." A copy of the affidavit that has been officially stamped or marked by the city of town may be provided to the
applicant as proof that a valid affidavit is on file for future permits or licenses. A new affidavit must be filled out each
year. Where a home owner or citizen is obtaining a license or permit not related to any business or commercial venture
(i.e. a dog license or permit to bum leaves etc.) said person is NOT required to complete this affidavit.
The Office of Investigations would like to thank you in advance for your cooperation and should you have any questions,
please do not hesitate to give us a call.
The Department's address, telephone and fax number:
The Commonwealth of Massachusetts
Department of Industrial Accidents
Office of Investigations
600 Washington Street
Boston, MA 02111
Tel. # 617-7274900 ext 406 or 1.877-MASSAFE
Fax # 617-727-7749
evised 5 -26 -OS www.mass.gov/dia
Commonwealth of Massachusetts
City/Town of
System Pumping Record
Form 4
RrEC
JUN t b 2014,
YOM Of rel h ANDOVM
WL -Ah .. _
DEP has provided this form for use-, by local Boards of Health. Other forms may be'used, but the
information must be substantially the same as that provided here. Before using.this form, check with your
local Board of Health to determine the form they use. The System Pumping Record must be submitted to
the local Board of Health or other approving authority.
A. Facility Information
1. System Location: Left / Right front of house, LeRIQof house Left / right side of house, Left /
Right side of building, Left / Right front of building, Left / Right rear of building, Under deck
Address
3-S
City/Town
2. System Owner.
Name
State
i(ws6w (,(
Address (if different from location)
Citylrown
B Pumping Record
1. Date of Pumping
3. Type of system: ❑
Date
Cesspool(s)
Trp Code
State � ' / � G de
Telephone Number L
— 2. Quanti Pumped
eptic Tank
l
Gallons
❑ Tight Tank
❑ Other (describe):
4. Effluent Tee Filter present? ❑ Yes No If yes, was it cleaned? ❑ Yes ❑ No:
5. Condition of System:
6. System Pumped By:
Neil Bateson F5821
Name Vehicle License Number
Bateson Enterprises Inc
Company
7.
t5fbrm4.doca 06/03 System Pumping Record • Page 1 of 1
51
Commonwealth of Massachusetts
City/Town of
System Pumping Record
Form 4
DEP has provided this form for use by local Boards of Health. The System Pumping Record must
be submitted to the local Board of -Health or other approving authority. .
A. Facility Information
Important:
When fining out 1. System Location -
forms the
computer. use
only the tab key Address
to move your
cursor - do not
use the return Cityrrown State Zip Code
key.
2. System Owner:-
1
Name JUL_ 8 2006,
Address (if different from location) TOt�� r
r�N JF' j` r.t-ri Nb
OVE
Cityrrown St Q Zip Code
Telephone Number
B. Pumping Record
1. Date. of Pumping Date 2- Quantity` Pumped:
Gallons
I Type of system: ❑ Cesspool(s) Septic Tank ❑ Tight:Tank
❑ Other (describe):
4. Effluent Tee Filter present? ❑ Yes ❑ No if yes, was it cleaned? ❑ Yes ❑ No
5. Condition of System:
6. SysteV PN d B
Name- I-� r Vehicle License Number -
Company -- .
7.
Locatioprwhere contents .wer isposed:
11
Date
http://www.mass.gov/dep/Waterlapprovalt,/t5forms.htm#inspect
tr)fnrmd Mr- r IMI
System Pumping Record • Page 1 of 1
Important:
When filling out
forms on the
computer, use
only the tab key
to move your
cursor - do not
use the return
,key
YQ
ILEI
Commonwealth of Massachusetts RECENf
City/Town of
System Pumping Record SEP 16
2008
Form 4 TOWN OF NORTH ANDOVER
HEALTH DEPARTMENT
DEP has provided this form for use by local Boards of Healt . other forms may be used, but the
information must be substantially the same as that provided here. Before using this form, check with your
local Board of Health to determine the form they use. The System Pumping Record must be submitted to
the local Board of Health or other approving authority.
A. Facility Information
1. System Location:
Address
Cityfrown
2. System Owner.
Name
Address (if different from location)
City/Town
B. Pumping Record
1. Date of Pumping
CA
State Zip Code
State ^� � qde
Telephone Number `� �/7
Date 2. Quantity Pumped:
Gallons
3. Type of system: ❑ Cesspool(s) eptic Tank ❑ Tight Tank
❑ Other (describe): ,_,
4. Effluent Tee Filter present? El Yes .lIvo If yes, was it cleaned? ❑ Yes ❑ No
5. ConditRon o� k��
6. SysteP . �
Name y Vehicle License Number
Company
7. Location ere contents were osed:
Date
t5form4.doc• 06/03 System Pumping Record . Page 1 of 1
TOWN OF NORTH ANDOVER
SYSTEM PUMPING RECORD
DATE: 0 l
OWNER & ADDRESS
c( -SQ
:Z,-55 ccvjt5+�cy,
(example: left front of house)
d��
DATE OF PUMPING: I Q " t O QUANTITY PUMPED 15 Da GALLONS
CESSPOOL: NO • YES SEPTIC TANK: NO YES
-Z-
NATURE OF SERVICE: ROUTINE ZEMERGENCY
OBSERVATIONS:
GOOD CONDITION
HEAVY GREASE
ROOTS
EXCESSIVE SOLIDS
SOLIDS CARRYOVER
SYSTEM PUMPED BY:
FULL TO COVER
BAFFLES IN PLACE
LEACHFIELD RUNBACK
FLOODED
OTHER (EXPLAIN)
COMMENTS:
r;
CONTENTS TRANSFERRED TO: (` ' �5— �� ---
0
ul
O
Oh
E)
iO
TIT
O
n
O
31
O
cd
-1
a
rpt
0
D
-h
P,
D
p'
a
m
;y
a
a
a
0
1
I
o
rt
��o
OD
mm
eP3
0
ul
O
Oh
E)
R
SEPTIC & DRAIN SERVICE
107 FOREST STREET; MIDDLETON, MA 01949
(978) 774-2772
FORM 4 - SYSTEM PUMPING RECORD
COMMONWEALTH OF MASSACHUSETTS
An ���jy �,� , MASSACHUSETTS
SYSTEM PUMPING RECORD
SYSTEM OWNER: m ck c s t l SYSTEM LOCATION: Zo C /'� C� G C 61
�� n c y f
Cc��c� � S
33-� air
9 7S-'79 7
'lU Detc k uylde-
L'c./ b,r /-n�uIc1.
c,vtC� `YcSS
DATE OF PUMPING: Z " � � QUANTITY PUMPED: 1 5 U
GALLONS
CESSPOOL: NO F-1 YES = SEPTIC TANK: NO = YES
EE -
SYSTEM PUMPED BY: CURRIER SEPTIC & DRAIN SERVICE
CONTENTS TRANSFERRED TO: 9- S -D
DATE: ��l 7 INSPECTOR:AEALTa
�P�ir� P
- - 91999
'C
C O
CACD
n
n Z CO)
CDo-o
CL r o�
c
cm � c
CZ CO)
nco -0
O
v CD
a%NC o
CD
Sr
CD 0 CD
C CD y.
CD
d O_ CO)
I
to CD
F v
CO) O
'O Z
CD
a C.**
oCD
INCCD0
R
0
0
W
O
_
to
0
C
n
Co
to
c+
0
N
C
0
tz
N
H
W5 -0a =
_ z
�• fA C CD
cr N
=am0 m c", O
to CD O. 0, �. =
H _ _
=r C N T
® o. 5 d W02
O CS N G y
a O
O Cm% CD
CD;;
2
CD
O
z 5. ;'
CD V
CD N
CDM
7 C-)= '%L
0 0
C,
O1 N
CL. Co. Q
tX3 _ Q
CD
m CO)
CO)
m CD :`
CD w4
C=
.CD
. �:
o
CD0:G
N
.0CD
O
C � r
.CD
t
oay� ^
'
o C
� m
r
C O :
O
= CD
h
0 � 7
PVI rD z
G
w < G
�'
G
y T 0 C '�
w
O p
MO\
y�a.
C x
CAZ
►-�
►nj
�
` r4
n
�
Er
�
H
�,
H
HO
� � •O
N
w
y
0
9
AS
&b4-coe..
-BUILT
R
S.TH-H,
3z13-
�-gox
�'tiD T'iZ 411- L
eq, Z '
E)u
►, ,, , ,
E- D PIP
3S D'
I
1=.xi sT"
GEAcl�liva
.i cN -�-
(-T�l R) m
tr t
1-f r- cTf -P / Cron) F\ j TWA -r LOE NAVE
ILISPF �'. IE -!j
THE -:7 eoLlrtVl.)GTiD.0 '>F= TILS
ACCoRMOCF i.t),T-I RAW"'I%f'zr�iCtiln)(S
AS APPccivL-J FOP- 7-M..1 RY '-MF
r6 t,dd OF U 0 (? T F-} A U DDV-1�("L. P EAC.T)} UF.P
I
AS - Buti-7-
y�TJ o.0 s
IG3, lea
J-I''(� go -H,40 Rvc, luv
ovTre, E l�,o,93q
►, ,, , ,
ere- ID - o)< T 11�oo,76
I I rI rt rr I r
vr
ol e L -Box
scm--40 poor Pv if
tiJv (2 tucr�T' =
IL 11 ,, ,�
�I 8 fNa z-aL I Go. 0i
"("T2*?
-rP.-�W2 : I
1uzerTv*-S 160,3C)
W1 077 s,>=
/� p�E>L� io�f Po�FD
P A 9EM E.,LIT-
L_
Ex 1 s 1'i>uG
1tiL•F; D,
•F-jq3,49 - _ 106.01
2.14" .22
Ex I s i ••
0-0(lc• D -Box
FXIs-.
I SDU CA1_. coL1C,
SE P71C 'rAkl1:-
AS- BUILT PLAN
OF
SUBSURFACE DISPOSAL SYSTEM
LOCATED IN
KIDRTH AUDOVER, HA\ss.
AS PREPARED FOR- "
TH d M A S LAUDAH I .� RaOERT
DAL.EY
DATE: (fie I o BER 1 1982 8 CIVIL aa
SCALE:
LOT 23 GA lUtC-E l n, AMAL
e � G T :5 i cl -7
MERRIMACK ENGINEERING SERVICES, INC.
PROFESSIONAL ENGINEERS • LAND SURVEYORS • PLANNERS:
66 PARK STREET 0 ANDOVER, MASSACHUSETTS 01810 0 TEL. (508) 475 3555, 373.5721
14
&b4, eoe.
S.T. N►.H,
� - )ox
EIuQ 7'2�Z
� But
A
3� 3
3S o'
l-W(a6.Le
C,A)JDXlE -r 1 c V.
AS BUILT PLAN
OF
ST,
'c. D-Wx
Ex i sT:
Soo C,�1�, Col1�.
�EPT1C ?'Aum
SUBSURFACE DISPOSAL SYSTEM
LOCATED IN
KIO RTH AU DOVER, M ASS .
AS PREPARED FOR_
THOMAS LAUDAM I
DATE: OCI d BER ) , I qq?
SCALE: l" 140"
GAUtg-r ST i CK ROAD
MERRIMACK ENGINEERING SERVICES, INC.
PROFESSIONAL ENGINEERS • LAND SURVEYORS • PLANNERS:
66 PARK STREET 0 ANDOVER, MASSACHUSETTS 01810 • TEL. (508) 475-3555, 373.5721
vP 0ibn l.(2-� ErmZ)
l,uv, (-,9-FbbT�,j
�!L/, 3' Woe -Z. WVrs-
i-1"(� 9C14-40 RVC. Ikcv
OL;r6 f. -r 16o, 93q
/Go,7(
►, �� �, �, ��
0ur?-v b -Box 1(0., Sr
�►"� SO4.40 We-' P,V.,f.1uv
e r,uxr-r2+*±
fND -rTZOL = /Go ,of
►� ., ,,
„ c �D -r9-,l--2.=. /X0,03
lwermws 140-3c)
Fc -0 -r-*,3 =1 0,1(
l-W(a6.Le
C,A)JDXlE -r 1 c V.
AS BUILT PLAN
OF
ST,
'c. D-Wx
Ex i sT:
Soo C,�1�, Col1�.
�EPT1C ?'Aum
SUBSURFACE DISPOSAL SYSTEM
LOCATED IN
KIO RTH AU DOVER, M ASS .
AS PREPARED FOR_
THOMAS LAUDAM I
DATE: OCI d BER ) , I qq?
SCALE: l" 140"
GAUtg-r ST i CK ROAD
MERRIMACK ENGINEERING SERVICES, INC.
PROFESSIONAL ENGINEERS • LAND SURVEYORS • PLANNERS:
66 PARK STREET 0 ANDOVER, MASSACHUSETTS 01810 • TEL. (508) 475-3555, 373.5721
Z . ,�(5 CAMP LE 577c,(tj-
AS -BUILT CHECK LIST
and
FINAL INSPECTION
Proposed Elevations
House //�, 7S
Tank IN /6 % /Zj
Tank OUT /,� 0.85
D -box IN
D -box OUT
Trench Inverts
Line 1 /d 0.
Line 2
Line 3
Line 4
Bottom of Exc. /S9 a
Stone OK? D -box checked?
As -Built Elevation
/'/A/1 3�e,
1,61,15-
Tank
61/S
/w/o• 9
�Z/
/6 6-_3j /U/, -00.0s
Pipes cemented?
,(/O YLi,�O✓NO �7T/ON COCATi�V Fi@O�
A.v /NJ'rA91►7G.VT StiL�vEy
F1.e FLQ1D-
PLA/,t/
/I
�ETEA/T/per/ Po.,/2�
E/1671.1 7—
......
Lo 7-
7,0 77
-7,077 S, F?`
T. F. EGEv.
` Exi,ST/n/G
=/1,9.73 t
` ' .I
1616.01-1
<.9.c/2 E257 l t eO,47D
S HEREBY CE PT/FY TO TyE" TITLE /NS6,WO.P ANS /, L, or l c z .4N
TO THE BA V Y
7W,47-
Ile
W,4T/le LOT .4S S/fO/Yt/ ANO T/IiOT /T ODES LO.f/FOPiY1 /N
,wrw T.�/E rvzew OF.A/O, ANGQ✓6e ealvlwG PEGvGAT/OvS
REGA20/NG SETBAC,<S FROM ST-PEETS E LOT G/✓ES. /✓pETJ�/ /�ti�o�E�, /%�qs�
-r F(/.r>/S�E.P CE.PT/FY T/fi4T T.Y/S O!s'ELL/N6 /S LVOT /
L/1L%4TE0 1,W r, 6- FE FL000 11114Z.4.P0 APES. -r— OiPA`✓N FO,P
�Sf1awN o/V FfiH Yl . /Ty /o.4NEL '" / yO�rl
2500%5 ooioB .9s �1-9ri�,4N!
>/% 9Z Ala.
GATE / ¢� /
aFSS�
�qNa ti.�cQ'
7�/S PLAN Fo,�► ��,ePOSES -NOT FD,P
BO!/,VO,Pyi pETE.PY!/N T/O.t! Bo�ivo-4.es- /,vFo,P,,�- �EP•P/�1.�IGY E-,fiGif/EE,P�.(/G SE.Pv/lES
qT/O�/ T.4.rE.y F,POiY/ E'X/STi.EjG .PECoeas. 6� �'-4.P,(� ST,PEET
A�/ODYE�P, �/,4SS,4C,r/vSETTS O/8/O
FORM U - IAT RELEASE FORM
INSTRUCTIONS: This form is used to verify that all necessary
approvals/permits from Boards and Departments having jurisdiction
have been obtained. This does not relieve the applicant and/or
landowner from compliance with any applicable local or state law,
regulations or requirements.
**************J**Applicant(�fills out this section*****************
APPLICANT: two r, �,Q Y'� c> c c �r�o 1���� Phone
LOCATION: Assessor's Map Number Parcel
Subdivision Lot (s) a�
Street J. St. Number—'3
************************Official Use Only************************
RECO DATIONS OF TOWN AGENTS:
Date Approved log
Conservation Administrator Date Rejected
Comments
1
Town Planner
Date Approved % • ZO •1112..
Date Rejected
Comments
Health Agent
Date Approved
Date Rejected
Comments
Public Works --water connections �i�S�' �/?7
- driveway permit
Fire Department G`
Received by Building Inspector
�ff�
Z
Date
FOIUI U
TOWN OF NORTH ANDOVER
LOT RELEASE FORM
SUBDIVISION J /fes /�
ASSESSORS MAP — IQZ A
SUBDIVISION LOT(S) 3
PERMANENT ADDRESS,(ASSI NED BY D.P.W.
.STREET fj1�v�LC s"Tie jNE —
APPLICANT PHONE cS -
��f Ss 7 7
DATE OF APPLICATION
TOWN USE BELOW THIS LINE
PLANNING 0ARD
TOWN PLANN
CONSERVATION_CObalISSION
UUAbERVATION ADMIN.
BOARD OF HEAL
ITAI,3�kAN � 60/?19S
DEPARTMENT OF PUBLIC WORKS
DRIVEWAY PERMIT ,�9nt,w-? Urr
R/WATER CONNECTIONS �1
FIRE DEPT. X
RECEIVED BY BUILDING INSPECTION
DATE
DATE APPROVED -�
DATE REJECTED
DATE APPROVED
DATE REJECTED
DA'T'E APPROVED
DATE REJEC'T'ED
This form shall be signed by the agents of the' -Planning and Health Boards,
the Conservation Commission prior to the issuance of any building permits
for the subject lot. This form shall not releive the applicant from the
compliance of any applicable Town requirement or Bylaw.
N
!
j i
I,
'
I
I
_
3
-
I
N
NoI�TM Au pnue)� I MA ,,
E ��P�i Cgti T_ JG-T�Op Z,
FCD D WELL- APPROVED Df -i
S S __ 5t�T1 c 5y sl �,� -PE� T
�PPRavev APRzvul,06 Aurho►?iTy
PLAnJ D�Si G�vCI� iV�UC �v�51eA�
Pz4�v R4 -Tc -47 47
D 15A PPRU VEp
IA -1 E (o -� - 1- Tam t S w �� _ av► 1��1 �ro�.
R4SoNS = 2, Il /G k4,VVV) perk.
�'—Z`f--(,-�ti �Nt4n l -c h7GL"/
.DwL SrPr(C SYSTEM 1 -AJ SiA 1.t,ATIOAJ
(Q5P6-�-rlo0 P1 PE Ff2,()^-\ Ho
A PPRWED Q/JTC
Dl sk pt'1 0\j6p
Dare -
Q 1-/�5S 0 RAIL -
1 -0 T/J r Ll Pry 55 `D Po) L.
APPi�>)JA)G �vT�to(�1-ry
1 NsTioucR
FML A PPI�)VAL
w',� APPRa ll, 13 u iNog` ► /
TOWN OF � • AJ&LC.0
SYSTEM PUMPING RECORD
DATE:
SYSTEM OWNER & ADDRESS
JA4v ska I
� c
-320 �
3
SYSTEM LOCATION
(example: left front of house)
,(It ') U b a -A � 6 U S -e -
DATE OF PUMPING: QUANTITY PUMPED :O C� GALLONS
CESSPOOL: NO YES SEPTIC TANK: NO YES
NATURE OF SERVICE: ROUTINE EMERGENCY
OBSERVATIONS:
GOOD CONDITION
HEAVY GREASE
ROOTS
EXCESSIVE SOLIDS
SOLIDS CARRYOVER
FULL TO COVER
BAFFLES IN PLACE
LEACHFIELD RUNBACK
FLOODED
OTHER(EXPLAIlN)
SYSTEM PUMPED BY: Bateson Enterprises, Inc.
COMMENTS:
CONTENTS TRANSFERRED TO:
THE PROFE6610NAL EXPERTS
IN THE SEPTIC AND
DRAIN INDUSTRY
system UvMer
4 - SYSTEM PUNITING RECORD
Coriunbnwealth Of Massachusetts
'Date of Pumping: /� .�� ��
Cesspool: iso Yes "D
System Pumped bv:
t
. BGG" �/. f �r,E°
ystern Location
Qua.n gallons
Septic Tank: No ❑ y 0.
es'll-i
. ......... . I ................ . .. ..... I ........ ............................. I .......
Contents -transferred to:
Date -Inspector
License, 9: ...................................
I
13
&'\ Commonwealth of Massachusetts
City/Town of AUG 1 3 2007
System Pumping Record
TOWN OF
Form 4 HEALTH DEPARTMENT
M
Important:
When filling out
forms on the
computer, use
only the tab key
to move your
cursor - do not
use the return
key.
� ISI
ILEI
DEP has provided this form for use by local Boards of Health. Other forms may be used, but the
information must be substantially the same as that provided here. Before using this form, check with your
local Board of Health to determine the form they use. The System Pumping Record must be submitted to
the local Board of Health or other approving authority.
A. Facility Information
1. System Locati
C -D zc- clo—)
Address 2;aa /j1 p4I J ���
Citylrown State Zip Code
2. System Owner: C'X-A
Name jVj� L
Address (if different from location)
Cityrrown
State Zip Code
Telephone Number
B. Pumping Record
1. Date of Pumping Date 2. Quantity Pumped:
�CD Q—�
Gallons
3. Type of system: - ❑ Cesspool(s) eptic Tank ❑ Tight Tank
❑ Other (describe): /"
4. Effluent Tee Filter present? El Yes l -No If yes, was it cleaned? ❑ Yes ❑ No
5. Condition o�Systeff
6. Syste u ped By:
Name Vehicle License Number
Company
7. Location ere co tents Qp dis os d:
of
Date
t5form4.doc• 06103 System Pumping Record • Page 1 of 1
Commonwealth of Massachusetts
City/Town of
System Pumping Record
Form 4 OCT 3 0 2009
M
DEP has provided this form for use by local Boards of Health 5t'o'nr��oF#ng � ayA ,!ebut the
information must be, substantially the same as that provided reefartasi�g'tfi s check with your
local Board of Health tQ determine the form they use. The System Pumping Record must be submitted to
the local Board of Health or --other approving authority.
A. Facility Information
1. System Location: Left side of house, Right side of house, Left front of house, Right front of house,
Left rear of hour , Mght oof rear of building. Right rear of building.
Address 7?� v ` v b
City/rown State
2. System Owner:
Name
Address (if different from location)
City/Town
B. Pumping Record
1. Date of Pumping
3. Type of system: ❑
Zip Code
S11!?�7_,_�Zip Code
Telephone Number
l o-� --OD(
Date 2. Quantity Pumped:
Gallons
Cesspool(s) Septic Tank ❑ Tight Tank
❑ Other (describe):
4. Effluent Tee Filter present? ❑ Yes eNo
5. Condition of System:
elf *J�.
6. System Pumped By:
Neil Bateson
Name
Bateson Enterprises Inc
Company
If yes, was it cleaned? ❑ Yes ❑ No
k'2'U'k � '_�
7. Loca re contents were disposed:
Lowell Waste Water
F5821
Vehicle License Number
V. -
Signature of Hauler Daffi
t5form4.doc• 06/03 System Pumping Record . Page 1 of 1
Commonwealth of Massachusetts
City/Town of
° System Pumping Record POEO 14 2010
^M Form 4
TOWN CR NC 9YU "he
DEP has provided this form for use by local Boards of Health. Otl6eti�4Nrelilr`b�u� the
information must be substantially the same as that provided here. Before using Ismer , eck with your
local Board of Health to determine the form they use. The System Pumping Record must be submitted to
the local Board of Health or other approving authority.
A. Facility Information
1. Syste cation: Left front of house, right front of house, left side of house, right side of hou eft
(�!ar of a fight rear of house, left side of building, right rear of building, under deck.
739 'It-� Nc 'v 2 `. GAII—�
Cityrrown State Zip Code
2. System Owner:�n�"
Name
Address (if different from location)
City/Town
B. Pumping Record
1. Date of Pumping
3. Type of system: ❑
❑ Other (describe):
State ff`� 7 Code
C (.7
Telephone Number
Date 2. Quantity Pumped:
Cesspool(s) eptic Tank
4. Effluent Tee Filter present? ❑ Yes D— T--
5. Condition of System:
6. System Pumped By:
Neil J. Bateson
Name
Bateson Enterprises Inc.
Company
7. Locatjqp,%v4re contents were disposed:
.S.D
Signature of
/2-9��
Gallons
❑ Tight Tank
If yes, was it cleaned? ❑ Yes ❑ No
F5821
Vehicle License Number
Date
C) -&-ice
t5form4.doc• 06/03 System Pumping Record • Page 1 of 1
Commonwealth of Massachusetts
City/Town of
System Pumping Record
Form 4
JUN 102013
DEP has provided this form for usel by local Boards of Health. Oth4ga
f3r ut e
information must be substantially the same as that provided here. Before using.this form, c eck with your
local Board of Health to determine the form they use. The System Pumping Record must be submitted to
the local Board of Health or other approving authority.
A. Facility Information
1. System Location: Left / Right front of hous<W Right ear of ho eft /right side of house, Left /
Right side of building, Left / Right front of building, Left / Right rear of building, Under deck
Address
City/Town State
2. System Owner.
Address (if different from location)
Zip Code
City/Town State Zip Code
Telephone Number
B. Pumping Record
1. Date of Pumping Date 1 ' 2 Quantity Pumped: 5f
Gallons
3. Type of system: ❑ Cesspool(s) Septic Tank ❑ Tight Tank
❑ Other (describe):
4. Effluent Tee Filter present? ❑ Yes
5. Condition of System:
✓AII
6. System Pumped By.-
Neil
y:Neil Bateson
Name
Bateson Entemnses Inc
Company
7. Location where contents were disposed:
No If yes, was it cleaned?. ❑ Yes ❑ No.
Waste Water
t-e%.e
F5821
Vehicle License Number
S -3i- I
Date
t5form4.doc• 06103 System Pumping Record • Page 1 of 1