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HomeMy WebLinkAboutMiscellaneous - 34 FOSTER STREET 4/30/2018i 1� C y, Z MAR # LOT. # ti : PARCEL # STREET s�. - CONSTRUCTION A_PPROVAC HAS PLAN REVIEW FEE .BEEN PAID? ES NO PLAN APPROVAL: DATE APP. BY/LG_ ' DESIGNER:C, G �� PLAN DA-TE,�D \1 CONDITIONS WATER SUPPLY: �, TOWN WELL WELL PERMIT DRILLER WELL TESTS: CHEMICAL DALE APPROVED B TERIA I DALE fiPPRUVED BACTERI I DATE APPROVED COMMENTS: FORM U APPROVAL: APPROVAL 1-0 ISSUE YES NO DATE ISSUED BY CONDITIONS: FINAL APPROVAL:. ALL PERMITS PAID WELL CONSTRUCTION APPROVAL SEPTIC SYSTEM CONSTRUCTION APPROVAL OTHER ANY VARIANCE NEEDED FINAL BOARD OF HEALTH APPROVAL: YES NO YES NO YES NO YES NO YES NO DATE• IIY: 16-6, STEWART'S SEPTIC TANK SERVICE 47 RAILROAD STREET BRADFORD, Imo► 01835 978-372-7471 mNrH OF O G-�6 bei Q�v _1Uo A n rkyer t �a� �k y Oran L pd Pic lqne- 411-f- Oq It es Dr 76 Tum/Cei'�r-/),) q66 win 4f,- 5 f- ? t t3 %i-)l,P r c G�Mn Le r 57 �hqr pt) yrs Ponce )tdl. `'✓Y tci Cori iq.,. e lei 3 / n sem , --- 5A fro/ I'�oo loco t I� l� l ods, 160L.) 156,0 l�ae� �a d fo�3 16-6, STEWART'S SEPTIC TANK SERVICE 47 RAILROAD STREET BRADFORD, Imo► 01835 978-372-7471 mNrH OF O G-�6 bei Q�v _1Uo A n rkyer t �a� �k y Oran L pd Pic lqne- 411-f- Oq It es Dr 76 Tum/Cei'�r-/),) q66 win 4f,- 5 f- ? t t3 %i-)l,P r c G�Mn Le r 57 �hqr pt) yrs Ponce )tdl. `'✓Y tci Cori iq.,. e lei 3 / n sem , --- 5A fro/ I'�oo loco t I� l� l ods, 160L.) 156,0 l�ae� Date.. e/?J ��........ ,aORTIy TOWN OF NORTH ANDOVER PERMIT FOR GAS` INSTALLATION This certifies that . 5 -se t!��.../J i !P�iv ............ 11,, ��� i has permission for gas installation /✓26J�?i ... ! �?� +� ..... in the builld//ings of f�%f�v✓ ..1 ..V1v..+�'r�................. . at ... �.?.. !7 Sr ........., North A�} dover,ass. Fee.$?!' �? Lic. No.3G�,?:? . X, rc. L -..... GAS INSPECTOR Check # 7935 a" MASSACHUSETTS UNIFORM APPLICATION FOR PERMIT TO DO GAS FITTING City/Town: har � f`d(ltRr , MA. Date d Permit# J . Building Location: �% 'S �eR (n Owners Name: /rfi Hur /fie 1��1 Type of Occupancy: Commercial ❑ Educational ❑ Industrial ❑ Institutional ❑ Residential New: ❑ Alteration: Renovation: ❑ Replacement: ❑ Plans Submitted: Yes ❑ No ❑ OWNE WAIVER: I am aware that the licensee does not have the insurance coverage required by Chapter 142 of the a ,�r that my signature on this permit application waives this requirement. Cheek One Only Signature of Owner or Owner's A---� Owner Agent ❑ By checking this box ❑; I hereby certify that all of the details and information I have submitted (or entered) regarding this application are true and accurate to the best of my Knowledge and that all plumbing work and installations performed under the permit issued for this application will be in compliance with all Pertinent provision of the Massachusetts State Plumbing Code and Chapter 142 of the General Laws. By=USEONLYI Type of License: ❑ Plumber Title❑ Gas Fitter '❑ Master Citylrown❑Journeyman APPROVE❑ LP Installer Signature of Licensed Plumber/Gas Fitter License Number: 1 FIXTURES co i /0 W iY o:. Q U co m Q = N' m= 4 w w C) cA F O WJ V.4 w w - p Z cn � W Z p w m O Q ❑ H Cl O W F— ❑ W X ADO (►, w 1- Q Z w w w z m x w� a w H❑= v_ �aJ \ > W w z O J F— F— O Z J U' 2= m> O Z LL O W = W Z z F w W W a� U❑❑ I=i O C9 SUB BSMT. BASEMENT 1 FLOOR 2 FLOOR 3 FLOOR 4 FLOOR 5 FLOOR i 6 FLOOR i 7 FLOOR 8 FLOOR Installing Company Name: ) C f ("n T� i`b(V Check One Only Certificate # Address: `"l S City/Town:—ALV C/ 1` i �J State: � ❑ Corporation Business Tel: Vw/J % 1S3 Fax: El Partnership , Name of Licensed Plumber/Gas Fitter: StW ❑ Firm/Cor9pany INSURANCE COVERAGE: I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL. Ch. 142 Yes ❑ No If you have checked Yes, please indicate the type of coverage by checking the appropriate box below. A liability insurance policy ❑ Other type of indemnity ❑ Bond ❑ OWNE WAIVER: I am aware that the licensee does not have the insurance coverage required by Chapter 142 of the a ,�r that my signature on this permit application waives this requirement. Cheek One Only Signature of Owner or Owner's A---� Owner Agent ❑ By checking this box ❑; I hereby certify that all of the details and information I have submitted (or entered) regarding this application are true and accurate to the best of my Knowledge and that all plumbing work and installations performed under the permit issued for this application will be in compliance with all Pertinent provision of the Massachusetts State Plumbing Code and Chapter 142 of the General Laws. By=USEONLYI Type of License: ❑ Plumber Title❑ Gas Fitter '❑ Master Citylrown❑Journeyman APPROVE❑ LP Installer Signature of Licensed Plumber/Gas Fitter License Number: 1 The Commonwealth of Massachusetts Department oflndustrialAccidents Office of Invesfigationg 600 Washington Street Boston, AM 02111 Uwwwmass.gov1dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information please Print Leeibly Name (Business/organization/Individual):— �jt Is{ r) Address: City/State/Zip: Phone #: IiW • q 7�- 7;11 "o3 Are you an employer? Check the appropriate box: 1. ❑ I 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. t ship and have no employees These sub -contractors have working for me in any capacity, [No workers' comp. insurance workers' comp. insurance. 5. ❑ We are a corporation and its required.] 3111 am a homeowner doing all .officers have exercised their work myself. [No workers' comp. right of exemption per MGL c. 152, §1(4), and wehaveno insurance required.] t employees. [No workers' comp, insurance required j Type of project (required): 6• ❑ New construction 7. ❑ Remodeling 8. ❑ Demolition 9. ❑ Building addition 10. ❑ Electrical repairs or additions 1 L ❑ Plumbing repairs or additions 12.❑ Roofrepairs 13.❑ Other *Any applicant that checks box of must also fill out the section below showing their workers' compensation policy information. I 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. Lie. #: 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 ofMCL 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. Do' that a copy of this statement may be forwarded to the Office of Investigations of the DIA for insurance coverage verification. I do hereby certif under the pains and penalties ofperjury that the information provided above is true and correct. -'771 -- 1��► ; air "VIcrat use only. Do not write in this area, to be completed by city or town official. City or Town: Perruit/License # Issuing Authority (circle one): I. Board of Health 2. Building Department 3. City/Tpvm Clerk 4. Electrical Inspector 5. Plumbing Inspector 6. Other Contact Person: ' Phone #: w 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 apartinents and who resides therein, or the occupant of the dwelling house of another who employs persons to do maintenance, construction or repair work on such dwelling house or on the grounds or building appurtenant thereto shall not because of such employment be deemed to be an employer." MGL chapter 152, §25C(6) also states that "every state or local licensing agency shall'withhold the issuance -or renewal of a license or permit to operate a business or to construct buildings in the commonwealth for any applicant who has not produced acceptable evidence of compliance with the insurance coverage required." Additionally, MGL chapter 152, §25C(7) states "Neither the, commonwealth nor any of its political subdivisions shall enter into any contract for the performance ofpublic work until acceptable evidence of compliance with the insurance requirements of this chapter have been presented to the contracting authority." Applicants Please till out the workers; compensation affidavit completely, by checking the boxes nThat apply to your situation and, if ecessary, supply sub -contractors) name(s), addresses) and phone numbers) along with their certificates) 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 Iicense 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 (ifnecessary) and under "Job Site Address" the applicant should write "all locations in (city or town)." A copy of the affidavit that has been officially stamped or marked by the city or town may be provided to the applicant as proof that a valid affidavit is on file for future permits or licenses. A new affidavit must be 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 burn 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 co-mmontweaL,of Massaosetis Department of Zndmirial Accidents Office of Inves-igatioxns 600 Washington Street Boston; MA 0211 X Tel. # 1617-727-4900 ext 406 or 1-877-M-AS,S,AFE Revised 5-26-'05 Fax # 617•-727-7749 Www.mass.jz-ovldia. 9214 Date. J?!/. / /.. . TOWN OF NORTH ANDOVER PERMIT FOR PLUMBING This certifies that .,.��h..��.4.9.t1.. ........s has permission to perform ..A9CA" ,,fi(��i/..�9,K!../L,k....... r plumbing i the buildings of .. !?.�r.. /a l"qn! ......... at .. 3/i� ..�!'...0-- ................ . North Andover, ass. Fee. 4? !47S d. Lic. No.-? ��' lig ✓. h .... PLUMBING INSPECTOR Check #- A have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL. Ch.142 Yes ❑ No i If you have checked Yes, please indicate the type of coverage by checking the appropriate bo)t below. r. A liability Insurance policy ❑ Other type of indemnity ❑ Bond OWNER' RANCE WAIVER: l am aware that the licensee does not have the insurance coverage required by Chapter 142 of the Mass use G e a d-that my signature on this-permit application waives this requirement Che ne Only Owner [ Agent ❑ i n a of O ner or Owner's A ent By checking this box.[]; I hereby certify that all of the details and information 1 have submitted (or entered) regarding this application are true and accurate to the best of my Knowledge and that all plumbing work and installations performed under the permit issued for this application will be in compliance wit Il Pertinent provision of the Massachusetts State Plumbing Code and Chapter.142.of the General Laws. By%Z Type of-License: El Plumber ❑ Gas Fitter Tine ❑ Master Signature of Licensed Plumber/Gas fitter { - CityFrown []Journeyman License Number: &&PROVED (OFFICE USE ONLY) [ILP Installer _3 MASSACHUSETTS UNIFORM APPLICATION FOR PERMIT TO DO PLUMBING City/Town:_ MA. Date: a - Permit# Building Location:c{ Ff jP/ Owners Name: _.1r71 kr r°ILIiZ4 Type of occupancy: Commercial[] Educational ❑ Industrial ❑ Institutional ❑ Residential New: ❑ Alteration: O Renovation• ❑ Replacement ❑ Plans Submitted: Yes M No R FIXTURES DEDICATED L SYSTEMS z w o V) , W Z ~ _� Q i J U ~ L7 LU C Z Q.� z z Q ¢ W IU Ln Or. Lr a _Z Ln O U a Q � W d Y= ¢ N ¢ Z Lr O U W W _.! Z h ¢ W U 1-- Z =• F- U Z Q LL �' J ¢ Z W W a 0 w Q ¢ `—'� � O H O O O O 2 Z ,n Fj- w , 1 Ln w0 jF ¢ LLI L10 D O LL Z Lnn in F¢- 37 = F- -SUB U W Q Bsnnr. a 3 BASEMENT 1sT FLOOR 2ND FLOOR 3RD FLOOR 4T" FLOOR 5T" FLOOR 6T" FLOOR 7T" FLOOR 8T" FLOOR rr., F, V G r`t€ Insta liittg C-rri z:r,�,fka e: i7? e e i�+Se gj: _.. Address: q QS El Corporation City/town: AJ V State: �� �� El Partnership Business Tel �, 1 ' Q Fax: El Firm/Company Name of Licensed Plumber: INSURANCE COVERAGE; 1 have a current liability Insurance policy .or its substantial equivalent which meets the requirements of MGL. Ch. 142 Yes ❑ No ❑ If yo have checked Yes leas please indicate the. `, -type of coverage a e b 9 y checking the appropriate box below. A li ility insurance policy. ❑ Other t ype of indemnity ❑ ` Bond ❑ { OWNER'S INSURANCE WAIVER: lam aware that the licensee does not have the insurance coverage required by Chapter 142 of the Massachusetts General Laws, and that my signature on this permit application waives this requirement. Check One Only !i nature of Owner or Owner's Agent ®caner ❑ Agent ❑ hereby certify that all of the details and information I have submitted (or entered) regarding this application are true and accurate to the best of my Knowledge and that all plumbing t:ork and installations performed under the permit issued for this Pertinent provision of the Massachusetts application will be in com lia State Plumbing Code and Chapter 142 of the General Laws. p nce with all �r Type of License: — Ile Sign SI [$ Plumber g ture of Licensed Plumber 'PRO PROVED El Master 1 (OFFICE USE ONLY) [Journeyman License Number: r-&- - �(/� i The Commonwealth ofMassachusetts Department of-fndustrialAccidents Office oflnvestigations 600 Washington Street Boston, MA. 02111 www.massgov/dia Workers' Compensation Insurance Affidavit: Builders/ContractorsfElectricians/Plumbers Applicant Information Please Print Le�bly Name Address: q Shack City/State/Zip:h " t__ / / Phone #: Are you an employer? Check the appropriate box: L ❑ I am a employer with 4. ❑ I am a general contractor and I employees (full and/or part-time).* have hiredthe sub -contractors 2.0 t I am a sole proprietor or partner- listed on the attached sheget. t ship and have no employees These sub -contractors have working for me in any capacity. [No workers' comp. insurance workers' comp, insurance. 5. ❑ We aie a corporation and its required.] 3. ❑ I am a homeowner doing all work officers have exercised their right of exemption per MGL myself. [No workers' comp. c. 152, §j (4), and we have no insurance required.] t employees. [No workers' comp, insurance required.) Type of project (required): 6. ❑ New construction 7. ❑ Remodeling B. ❑ Demolition 9. [( Building addition 10. ❑ EIectrical 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. I T Homeowners who submitthis 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. lam an an employer that isproviding workers' compensation insurance for my employees Below is the policy and job site in Insurance Company Name: Policy # or Self -ins. Lie. #: Expiration Date: Job Site Address;_ �� A, I Cr S'i City/State/Zip: �U/T /, Attach a copy of the workers' compYdeclaratio n 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 maybe forwarded to the Office of Investigations of the DIA, for insurance coverage verification. Ido hereby certify der the pains and penalties ofperjury that the information provided above is true anti correct. Si nature; 7T %%% -�,q vifictai 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): I. Board of Health 2. Building Department 3. City/Toyvn Clerk 4. EIectrical Inspector 5. Plumbing Inspector 6 Other Contact Person: Phone #: I Date .1. 4*' / * �/....... . TOWN OF NORTH ANDOVER A PERMIT FOR GAS INSTALLATION This certifies that ./4! '..- ......... /� has permission for gas installation in the buildings of at /.O 4F ........ �. , North Andover, Mass. Fee. GAS INSPECTOR Check # 3,3 It 7865 MASSACHUSETTS UNIFORM APPLICATON FOR PERMIT TO DO GAS FITTING (Type or print) Date NORTH ANDOVER, MASSACHUSETTS <J / Building Locations (�j ��/ " -11— Permit # New Owner's Name ftAur Amount $ MI&V Renovation Replacement 1:1Plans Submitted ✓T�1-1 (Print or type)I (_ Check one: Certificate Installing Company Name 6 w Corp. AddressRMI l ' LJU' 1 Partner. Business I eleptionew 1 0 -1 U Firm/Co. Name of Licensed Plumber or Gas Fitter d w z o z a F x a w d w O U H v z 0 0.1 F W sF " O z � z ] o O F W W F n w Q w E n 0. CG G O �Tj x 0 > xQ 0 zO wx > z O O O o x w 3 A c7 Qx > OaxF SUB -BASEMENT B A S E M E N T 1ST. FLOOR 2ND. FLOOR 3RD. FLOOR 4TH. FLOOR H. FLOOR H. FLOOR H. FLOOR LT H. FLOOR (Print or type)I (_ Check one: Certificate Installing Company Name 6 w Corp. AddressRMI l ' LJU' 1 Partner. Business I eleptionew 1 0 -1 U Firm/Co. Name of Licensed Plumber or Gas Fitter d INSURANCE COVERAGE Check one: I have a current liability Insurance policy or it's substantial equivalent. Yes [:] No If you have checked Les, please indicate the type coverage by checking the appropriate box. Liability insurance policy ❑ Other type of indemnity ❑ Bond ❑ Owner's Insurance Waiver: I am aware that the licensee does not have the Insurance coverage required by Chapter 142 of the Mass. General ams, and �igi�{ure qn t ' permit application waives this requirement. (� at Jam/ Check one: Signature of Owner or Owner's Agent Owner 0 Agent I hereby certify that all of the details and information I have submitted (or entered) in above application are true and accurate to the best of my knowledge and that all plumbing work and installations performed under Permit Issued for this application will be in compliance with all pertinent provisions of the Massachusetts State Geode and Chapterj41)of the,�ienqyal Lay< 1 By: �� „ /f��p//� Signature of Licensed Plumber Or Gas Fitter Title f 0 Plumber City/Town M'Tas Fitter r icense um 5 e ❑ Master APPROVED (OFFICE USE ONLY) 1:1 Journeyman Name (Business/Organization/individual): fi Address: City/State/Zip: Phone 4: b t: � - Are you an employer? Check the appropriate box: The Commonwealth of Massachusetts Print Form -- --_ �: Department of Industrial Accidents 2. ❑ 1 am a sole proprietor or partner- Office of Investigations ship and have no employees I Congress Street, Suite 100 working for me in any capacity. Boston, MA 02114-2017 [No workers' comp, insurance www. mass.go v/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumhers licant Information please Print Legibly Name (Business/Organization/individual): fi Address: City/State/Zip: Phone 4: b t: � - Are you an employer? Check the appropriate box: 1. ® 1 am a employer with 'IC- :4, ❑ I am a general contractor and i employees (full and/or part-time).* have hired the sub -contractors 2. ❑ 1 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. employees and have workers' [No workers' comp, insurance comp. insurance.* required.] S. ❑ We are a corporation and its 3. ❑ I am a homeowner doing all work officers have exercised their myself. [No workers' comp. right of exemption per MGL insurance required.] + e. 152, § 1(4), and we have no employees. [No workers' comp. insurance required.l i --7ti�(-d Type of project (required): 6- ❑ New construction 1. ❑ Remodeling 8, ❑ Demolition 9. ❑ Building addition 10. ❑ Electrical repairs or additions 11.0 Plumbing repairs or additions 12.❑ Roof repairs 13.❑ Other 'Any applicant that checks box # I 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 state whether or not those entities have employees. If the sub -contractors have employees, they must provide their workers' comp. policy number. I ant an employer that is providing workers' compensation insurance for my employees. Below is the policy and job site information. a Insurance Company Name: it Ala -(02- na; Avt- —r i iJ r' rA-rr) 4 "L4'1i,:_ T� �4 / ✓u Policy # or Self -ins. Lic, #: �`% L c :, C� c ;,'L- (c' 1� Expiration Date: ��r j r.� / �: c v / ;L Job Site Address: tkw no Nur 0 City/State/Zip: 00 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 5250.00 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 insuranec coverage verification, I do hereby _ce}tap under the pains andeenalties ofperjury that the information provided above is true and correct, 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 I City/Town Clerk 4. Electrical Inspector 5. Plumbing Inspector 6. Other Contact Person: Phone #: z0'd Z2:TT TTOZ T2 130 0692868209:Xp3 SIO d3Wi'13 / SH9 N3W-lHd �l LL a -J c U E- L- ro 0 0 V) V) E 0 0 ru y n =f 0 Q E O o. a m 0 L a L m.-. CLi .f S � C U !C O 4 w C Z `n C cc O v ~ C _ O c C C c Q R C 7 U O C in Z E- L- ro 0 0 V) V) E 0 0 ru y n Form No. 4 Town of North Andover, Massachusetts BOARD OF HEALTH SPntPmher ? ti ,19 0.f CERTIFICATE OF COMPLIANCE This is to certify that the Individual Soil Absorption Sewage Disposal System constructed ( ) or repaired. ) by Ben Osgood, Jr INSTALLER at 34 Foster Street, North Andover, MA 01845 SITE LOCATION . has been installed in accordance with Board of Health Regulations as described in the Design Approval Site System Permit No. 858 datedAug -s 0, 19 96 The issuance of this certificate shall not be construed as a guarantee that the system will function satisfactorily. f ,AORT1/ O 4L A F no ,SSACMUSEt� Town of North Andover, Massachusetts BOARD OF HEALTH Form No. 2 DESIGN APPROVAL FOR SOIL ABSORPTION SEWAGE DISPOSAL SYSTEM Applicant LJ -1 < Test No. Site Location LOT 3 LA ST- , Reference Plans and Sp NGIN DESIGN Z Permission is granted for an individual soil absorption sewage disposal system to be installed in accordance with regulations of Board of Health. I Fee CHAIRMAN, BOARD OF HEALTH Site System Permit No. gs�� NEW ENGLAND ENGINEERING SERVICES INC Sept. 10, 1996 Attn.: Sandra Starr North Andover Board of Health Town Hall Annex North Andover, MA 01845 RE: 34 Foster Street, North Andover Dear Sandra: IIN�• �- R6ARu SEP � 0 Enclosed is a revised plan for 34 Foster Street. The plan addresses the comments in your letter dated Sept. 9, 1996 as follows. 1. The septic tank is 13 feet from the foundation wall, however the tank is below the level of the basement slab. Further, the property does not have a perimeter drain on this side of the house so the 13 feet should be acceptable. 2. Manholes have been shown on the design. 3. No action needed. 4. The design has been modified to show the reserve area 4 feet from the primary leaching area. 5. The design has been modified to show a separation distance of 10 feet between the trenches. 6. The owner will put a dead restriction on the property when he sells the home. 7. The error has been corrected. 8. If you look at the groundwater found at test pit # 1, which is further away from the large slope than the septic tank, you will see that the groundwater is at least 4 feet below the proposed bottom of the septic tank. I believe that a condition that stipulates that a test hole be done at the time of the tank installation would be sufficient to verify the groundwater elevation in the area of the tank. At that time, if the groundwater elevation is above the bottom of the tank, calculations can be done to insure that the tank will not float. I am sure this letter addresses all of your concerns and your quick review and approval of these changes would be greatly appreciated. Yours truly, Ben C. Osgood'Ir. 33 WALKER RD. - SUITE 22 - NORTH ANDOVER,. MA 01845 - (508) 686-1768 NORTH ANDOVER BOARD OF HEALTH DESIGN REVIEW REPORT FEE: PERMIT # DATE RECEIVED��6 APPLICANT MAP PARCEL ADDRESS �'� ,X o6rG� �5/ LOT # STREET # ENG. GN 0:5600b) J e STREET IZ:�057&5e— 5,17 ENG. ADDRESS_ 03 W1,C1,4e5e- PLAN DATE 8XFAP6 REV. DATE CONDITIONS OF APPROVAL APPROVED DISAPPROVED REASONS FOR DISAPPROVAL: Q /iiG 7Y1 r9 �tJ/SOL C S TD G 219,Dg CH 19-M C3 e7k. 5 1716 cvN o,v Fee Or- c 67 1 DD TD Gc>e�yL�D S — 19' Its. /' it/O7" V0 7 'b•eCSCJAds 04-7, 7W6;;e67 /6 19A) 4F440,e IA,) g• D D l� rf/� r�'t �3 &,e- 7-0 7-6-5 % -7-- 0,e 6,e�vU,u,S a-) APPLICATION FOR DISPOSAL WORKS CONSTRUCTION PERMIT DATE: CURRENT INSTALLER'S LICENSE# LOCATION: 31-/ S fit -54- LICENSED INSTALLER: SIGNATURE: o CHECK ONE: ONE#�M�3 — 5' `% d q REPAIR: V/" NEW CONSTRUCTION: IF NEW CONSTUCTION, PLEASE ATTACH FOUNDATION AS -BUILT. Administrative Use Only 75 00 F Attached? Yes $ Fee Attac ed . " No Foundation_ As -Built? Yes No � Approval �G� Date: z/ / A Town of North Andover, Massachusetts Form No.3 Olt AORTk BOARD OF HEALTH —19 Cl DISPOSAL WORKS CONSTRUCTION. PERMIT ACMUSE Applicant ��D NAW A RESSE�PHON E Site Location Permission is hereby granted to Construct ( ) or Repair ( ) an Individual Soil Absorption Sewage Disposal System as shown on the Design Approval S.S. No. AIRMAN, BOARD OF HEALTH Uvi Fee D.W.C. No. R, :L- i I VA UA`I'R. F01 .1 Pagc`2 of 3 0?1-s to ..Review Deep We Number a.te Time: Weathe �/1�- ... �. ��:2 v.aCi ;E'rr•�.��L,-`��- Jj',':.. - J;Jc (6/4) ? Surface Stones :. .. .., F nr'.�Ilon o (1,dw car.,'.r i,-rYc)h f).'i tri? M, cJ �*i .. :. .... .. , _k,,�y , ., 'f efl` !._i r a q e ,dray �`�;21'.- feet Po s ;jCs:2 W t 'A-- `c'a 'eel �'t'i JF i ; ` � `le .. feet DEEP OBSE V AON HOLE LOC- i t rn J; c Soil Other SU � ac e irl . S DA ; ( (Mur v`ottling (Structure, Stones, Boulders, Consistency, % �.. a �,_. _...._� .. _ .�1.•� w . _ _ Gravel) 1 .__� 13'Lt.S tw ir.;.... - 's".� iP�.` w'sy..�r-;•Ppi r� Y- _ y-y��... _ --. •,x 'L''i}. .�i�•3.v r{�. .I;'r l Fi -~l. ,4 E�i:+�}'t m. j ✓?vt"VJHIICi� 7U, ,.,`/! --- ry �.y _. �epthtC S-UrQciC. Pyr_ tt '1'st ,a4 auk .,�� - r-. c ^�r! ,4iaatee! ;?r,_actr , ' !.,, . ;'n the Hole:_� _ ,Ptae?ing from Pit Face: -- N(r F -,i" -?y �� Se so Ii I 6�Vater Table MethodU�sd: al- .?✓ .. r �i �.� n ing in observation hole.. inches ' I .. €Jepti 41E;, p;j i, riorn side; of observation hole.,,, ... inches ' i J �e:rti'! i(? sc�fl tt�stilp /� 'C�j,,. in Cle i 51dex. v �eii i !1^ii�� ;e;�, ing ,� I � index well level .......... ... ... t�C'ti�sfff?C,?nt fc-ic1c ?r t�a`�jUSted 47t"G. tUnd P'I��er i�`.1;;' l ��,Naturally iJCC,E r f � rvicus Mat' rte ial iJwr�rH•! �;4 ;. `��. -Clow �t. least-four:ert;01 n atUraliy' QCC r;ng pervious material ,exist.in all areas k t ¢ W' t ?.i r fi)�l l? tl Vis`"iG rM i E" me soli abl ,4.nrption system? If, not, V."11 � ?s the C'ep'th 0natt-i �iiy ocourring per `iouss material? l ry r<<iep; ti,�t on `f idat i -have passed •tie soil evaluator examination , ; prE�,<< 4 a:`, Its' rf€ a rt?vr;' Prote ;-Jo7'1 and that the above analysis " enar? ,iSiurit wit- til;.' rs'auired £mining, expertise and experience nlti x ll4:' A-PPRC)6i.ti f' /fila 12107/91 .{ II FORM 11 SOIL EVALUATOR FORM Page 2 of 3 DEEP 0M'3-E"'RVAT'10K! HOLE LOG i „.. DUARD OF H�-"H err/ r�:oo P4C?ifross or LU_ i\o. urf aCC' tip-N�f'S1 } I K)SDA i (".f+.tnc�!!: -, i ,'viotiling (Structure-, Stones, Boulders, Consistency, % Gravel) AUG /-01996 I -site Review 'SZ iii �j.✓� ° Or i') Hlc,ls N! ,j,.—nbe, / T'srne:. Weather Location {it),.,nt"tGr site pian,. `� .. a ,:. U!� 'Zr Z.rx� , r l)Ps M Surface Stones . I � i �� � . PG., ,iOr' con Ci`Gr (,)n t . back.) �!%� i.•ii 4�,f f/� �,+ {� 7jj '7 -i. t<61•• vrtl a10 .,.h(i! _"'ie'- `eet Drti ,•L; �; . r,_i :�.d feet . pews ea Tibia W Ai. s� r ,' Prra e tv Unf" , /2. feet i til` N1 fi^ r 4 rUir.+: s.,q ! ; 'c '�,i _J .. '.� ,. . Drinking 4e.Y,ale., Well ,. •_ � �„ feet .Otlie7 .. ,.. .... - DEEP 0M'3-E"'RVAT'10K! HOLE LOG i De -h r ni aril -(Ai xluro ' ( s6i: cn; ' Soil Other - urf aCC' tip-N�f'S1 } I K)SDA i (".f+.tnc�!!: -, i ,'viotiling (Structure-, Stones, Boulders, Consistency, % Gravel) il�rte&?/.48G 'SZ iii �j.✓� ° s i eWe I � i �� � . j I - !l'yf 3( It ....� �!%� i.•ii 4�,f f/� �,+ {� 7jj '7 i til` N1 fi^ r 4 rUir.+: s.,q ! ; 'c '�,i _J .. '.� ,. MEA .`N°�.}1 __.. to Bedrock• Je;� GI'C , cl.t .�,_ u.andirlct Wa,ar in th.,j Hole - Weeping from Pit Face: — (,a! High .,7 QUA u'.11J i.9 r',. M1 Vim:.A N;Ltiz:L'FQI'.^,S-!2x.9719 ORM 11 - S(>IL !;VALUATOR FORM Page 3 of 3 PRF rta_ c, t`3.J '.JL FJ :Vv /yy ��ybA dor Water.. Table areas#3ielz i 1✓cot;a observed standing in �i se: y tion hole .............. inches ;foal Lyry<� FRr {�,_ 1 ��mt. side uf.tobse a I'D In hole_,_ , .. inches D1;_Ai hill It;rtic c; �i �1� S1. yjny epdi g Date lhdex well. level ` t"' f'`'i • Adjusted ,f r ne w ;a i level { Y�m.r., �ral1r4 Qom' ur r it"a jai r vice ;;3. f %[ a T. er iCx iii iexist to all Jc'. ILS�rnareas of ;Lr d 41;r« uc;!{ �4 r.t iw °e a troo��;d for t o sold absorption systern' ! rev ;tib,. iS l,Fj ci s ►:! f r ur�.>l;f L�r.curnng pervious material? , 4_- S.; oassed the soil evaluator examination _ /�y:o��c' ,,p'r ce �.c �r r' f J.1 .1 lV 1 ava 6 4 t EP It. ti Vin; s+ �j �4al Protection and that the above analysis w oe actr+, Ll �, r I wr,siste ;� vv- Ute , is lirCGd training; expertise and experience -I C) C m f , : 7 1 . , r y �•r�' '4 / D l �} e C+ i� �.i i � _t ����f-C'��UC ` t a 4 P+ r .. ,.fd'.l . Ga1 \,•rV 3..,,� 145 FORM 11 - SOIL EVALUATOR FORM Page 1 of 3 _..._..__n� DaLpo con Irl mealt� ��' r��assachtasetts .2iassechusetts b�Q$e k,;!, h A �s,0 ssrhefit * 0n -site Sewage Dis�osat efGeiaS1 '............ a" : < ... !•aii� ��G� Date: r'i� ?tissed ,r � ..... ti �"� /t/ f%v2... / ................................. ,.Jl T .... . y LdJCon iUi.:.`C55 P` 1°._.. �• re ` r "�rw..« iJ. �_ •i %��tnC. L/ 4"LC'JCJ+...�' ��_E'+-% rl. C��f GC.� .4.x.2•:,. ifd -14' r ":�� �.'� 5— 'tublisj ed. Steil Suet t,'y ti',Ai.ab1c: "',p t_._! Year ub isi-lsd S,-" Soil Map Unit <' �. i-1 51i1 •• r�pQ �`.'...•, "'" .:`, �)t,e2 intli Sz, c..'Y . i r rv'C. r /7 'r" .�� -r-, 7�r r.,. maze Li sr „ t N..., , , .. , 6 ti t Et lal t,r s{ i i3S; �\iporl «''wvafl ;1b'lr No G..F,� T 1 `i L / _Jia rtiCasl? i lrwC'v�`7, lit-,£ tMIA; ,7y= .t - - . 11 00*1 1:s L idoe 11.4 4 Il/k aii. tt�dtt[;i Srll s?; .. bolln:ltrry ry`a"7 f .L.e-" Pry K `,Cl .� xdAi7 `J 1313 ..;..! ✓.n.L1f ....... .. .. .... ....... .:. ., ,.. u rce C,_ C ;c . a t i. s .. S', 1. �... , -.b1,.'..1�,�(.. .! _'�.�.�Vi1;.-.1. 'uY,�.t2�'4,1•Y�GI i:..�.'i�t.iiv` :�...I�.,. .._._i -� �,. I';rr'LtiC? S R v iL'1' I t L I NEW ENGLAND ENGINEERING SERVICES INC Aug. 19, 1996 Attn.: Sandra Starr North Andover Board of Health Town Hall Annex North Andover, MA 01845 Re: 34 Foster Street, North Andover Dear Sandra: Enclosed with this letter are the following: 1. 3 copies of the completed design for 34 Foster Street 2. 1 copy of the soil evaluator information for 34 Foster Street AUS 01996 I am providing this information to you so that this plan can be looked at by the Board of Health at Thursdays meeting. I had previously submitted a site plan with the request for the variance to the distance to a wetland. I was hoping that the site plan would be sufficient to ask for the distance variance, however you told me that I had to have the completed plan to you so therefore it is being submitted now. I would appreciate you reviewing this plan for the meeting and letting this plan be presented to the Board. Please keep in mind that this property is sold and a month delay in going to the Board will delay the sale another month. If you have any questions please do not hesitate to call. Yours truly, / "�;' C EVI Benjamin C. Osgood, Jr. 33 WALKER RD. - SUITE 22 - NORTH ANDOVER, MA 01845 - (508) 686-1768 SEPTIC PLAN SUBMITTALS LOCATION: ;' r o NEW PLANS: S REVISED PLANS: YES DATE: DESIGN ENGINEER: $60.00/Plan L --- $25.00/Plan When the submission is all in place, route to the Health Secretary NEW ENGLAND ENGINEERING SERVICES INC Aug. 12, 1996 North Andover Board of Health Town Hall Annex 120 Main Street North Andover, MA 01845 Re: 34 Foster Street variance request Dear Mr. Chairman: Please accept this letter as a request for a variance to the North Andover minimum requirements for the construction of a subsurface disposal system. The requested variance is to allow a subsurface disposal system to be constructed 58 feet from the wetlands at the rear of 34 Foster Street. The plan that has been submitted is not a completed subsurface disposal system design. It is understood that the granting of any variance would be subject to having an approved subsurface disposal design plan. I will be at your next Board of Health meeting to discuss this matter. Yours truly, ? (1' Benj C. Osgood Ji.' president 33 WALKER RD. - SUITE 22 - NORTH ANDOVER, MA 01845 - (508) 686-1768 i S7`P N REVIEW CHECKLIST ADDRESS to ENGINEER GENERAL SEPTIC TANK MIN 1500G t/ .17 INVERT DROP ✓ GARB. GRINDERY(2 comps +200) 25' TO FDN-0 MANHOLE ELEV GW # COMPS. GB D -BOX SIZE # LINES FIRST 2' LEVEL STATEMENT INLET �6^,c'l - OUTLET 9lf/l = -17 ( 2" OR .17 FT) TEE REQ' D? LEACHING \` MIN 660 GPD?/\ RESERVE AREA ----4' FROM PRIMARY?z 20 SLOPE 100' TO WETLANDS 100' TO WELLS ,� 4' TO S.H.GW (5'>2M/IN) �- A 35' TO FND & INTRCPTR DRAINSa/d�00' O SURFACE H2O SUPP 4' PERM. SOIL BELOW FACILITY t---. MIN 12" COVER`S FILL? (15') BREAKOUT MET? TRENCHES MIN 660 gpd SLOPE (min .005 or 6"/1001) - SIDEWALL DIST. 3X EFF. W OR D (MIN 6')�� RESERVE BETWEEN TRENCHES?e--' IN FILL? MUST BE 10' MIN. 4" PEA STONE? 1-�' VENT? (>3' COVER; LINES >501) BOT i_ + SIDE 7l X LDNG (G = TOT�`T✓ (L x W x #) (DxLx2xl) (G/ft2) Copyright 0 1995 by S.L. Starr 3 COPIESy STAMPy- LOCUS NORTH ARROW " SCALE CONTOURSy PROFILE L/ SECTION (-/- BENCHMARK `- ' SOIL & PERCS "_-- ELEVATIONS WETS. DISCLAIMER WELLS & WETS `f WATERSHED?,4/6) DRIVEWAY (Eley) WATER LINE FDN DRAIN SCH40�✓� TESTS CURRENT? ✓ SOIL EVAL'. %✓�/r,,�-.�f�i v SEPTIC TANK MIN 1500G t/ .17 INVERT DROP ✓ GARB. GRINDERY(2 comps +200) 25' TO FDN-0 MANHOLE ELEV GW # COMPS. GB D -BOX SIZE # LINES FIRST 2' LEVEL STATEMENT INLET �6^,c'l - OUTLET 9lf/l = -17 ( 2" OR .17 FT) TEE REQ' D? LEACHING \` MIN 660 GPD?/\ RESERVE AREA ----4' FROM PRIMARY?z 20 SLOPE 100' TO WETLANDS 100' TO WELLS ,� 4' TO S.H.GW (5'>2M/IN) �- A 35' TO FND & INTRCPTR DRAINSa/d�00' O SURFACE H2O SUPP 4' PERM. SOIL BELOW FACILITY t---. MIN 12" COVER`S FILL? (15') BREAKOUT MET? TRENCHES MIN 660 gpd SLOPE (min .005 or 6"/1001) - SIDEWALL DIST. 3X EFF. W OR D (MIN 6')�� RESERVE BETWEEN TRENCHES?e--' IN FILL? MUST BE 10' MIN. 4" PEA STONE? 1-�' VENT? (>3' COVER; LINES >501) BOT i_ + SIDE 7l X LDNG (G = TOT�`T✓ (L x W x #) (DxLx2xl) (G/ft2) Copyright 0 1995 by S.L. Starr PITS MIN 660 LEACHING MIN 1 (13'x16') PIT MANHOLE/PIT GW MIN 4' BELOW BOTTOM EXC 2x EFF W OR D 12"-48" STONE BOT (L x W x ##) CHAMBERS + SIDE x LOAD = TOTAL (2x(L+W)xD x #) (G/ft2) MIN 660 LEACHING GW MIN 4" BELOW COVER >3 FT - VENT MANHOLES 12"-48" STONE SPLASH PADS SLOPE .005 BED/TRENCH (Bed max. 60' X 60') MIN 13' X 16' PIT BOT + SIDE X LOAD = TOTAL (L x W x ##) (2 x (L+W)xD x ##) (G/ft2) FIELDS MIN 660 GPD 900 ft2 BED GW MIN 4' BELOW BOTTOM OF FIELD PIPE ENDS JOINED? 4" PEA STONE? DIST LINE SLOPE .005? >31COVER-VENT SCH 40 MIN 12" COVER RATE LDG X 660 = X = TOTAL G/ft2 REQ'D (ft2) LXW DOSING TANKS AND PUMPS DIMENSIONS—!Z�X �� , X_ %ZE = 4-63C PUMP CAPACITY 9Pm L W D Vol. A DISCHARGE SIZE_s��o . DISCHARGE RATE 114- DISCHARGE TIME 3 * r7, ru 9Pm MANHOLES TO GRADE `� ALARM SEP. CIRC./ GW (Min. 1' below inlet) HWL 8F 7 LWL �2LCHECK VALVE BLEEDER HOLE L-- MANUAL OP. SWITCH 1-� ENUF STORAGE? ✓-� Copyright 0 1995 by S.L. Starr Town of North Andover NORT„ OFFICE OF 1 o ` . o . �o ytt 6 OL COMMUNITY DEVELOPMENT AND SERVICES .1�� p 146 Main Street North Andover, Massachusetts 01845 WILLIAM J. SCOTTSSACHUSE r Director September 9, 1996 Ben Osgood, Jr. 33 Walker Road North Andover, MA 01845 Re: 34 Foster Street Dear Ben: - This is to inform you that the proposed plans for the site referenced above have been disapproved for the following reasons: 1. Septic tank not 25 feet from foundation. (Is there a foundation drain?) 2. No manholes to grade on tank chamber. Show on profile. 3. Variance received. 4. Reserve not 4 feet from primary leach area. 5. Distance between trenches not 10 feet minimum. 6. Deed restriction should be filed - 3 bedrooms only - unless connected to sewer. 7. There is an error in note#11. 8. Deep hole required in area of tank and pump chamber to test for groundwater. If you have any questions, please do not hesitate to call the Board of Health Office at the number below. Sincerely, Sandra Starr, R. S., Health Administrator SS/cjp BOARD OF APPEALS 688-9541 BUILDING 688-9545 CONSERVATION 688-9530 HEALTH 688-9540 PLANNINQ"f88-9535 NEW ENGLAND ENGINEERING SERVICES INC Aug. 12, 1996 North Andover Board of Health Town Hall Annex 120 Main Street North Andover, MA 01845 Re: 34 Foster Street variance request Dear Mr. Chairman: Please accept this letter as a request for a variance to the North Andover minimum requirements for the construction of a subsurface disposal system. The requested variance is to allow a subsurface disposal system to be constructed 58 feet from the wetlands at the rear of 34 Foster Street. The plan that has been submitted is not a completed subsurface disposal system design. It is understood that the granting of any variance would be subject to having an approved subsurface disposal design plan. I will be at your next Board of Health meeting to discuss this matter Yours truly, BenjZC"Osgood Jr. president 33 WALKER RD. - SUITE 22 - NORTH ANDOVER, MA 01845 - (508) 686-1768 Commonwealth of Massachusetts Executive Office of Environmental Affairs Department of Environmental Protech William F. Weld Governor Argeo Paul Celluccl U. Gammor R0, 0, CO MM SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION Property Address: TL��J ' `� ' A� r. V94_ Address of Owner. Date of Inspection,, ;r6-9 ' _ � ,., (If different) Nasse of Inspector iV 6 t '-S.��C�V� Company Name, Address and Telephone Number. BATESON ENTERPRISES, INC. TEL: (SOS) 475-1474 508 - y is - Ll q ec Excavating - Water & Sewer Lines - Septic Systems & Pumping Sery ce FAX: (508) 475-.5451 ��10 1 11 Argilla Road a Andover, Mass. 01810 CERTIFICATION STATEMENT I certify that I have personally inspected the sewage disposal system at this address and that the information reported below is true, accurate and complete as of the time of inspection. The inspection was performed based on my training and experience in the proper function and maintenance of on-site sewage disposal systems. The system: I B. Struhs Commissioner _ Passes Conditionally Passes Neecla. Further, Evaluation By the Local Approving Authority '7--.-4, Inspector's Signature: Date: The System Inspector shall Ac.opy this inspection report to the Approving Authority within thirty (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 Department of Environmental Protection. The original should be sent to the system owner and copies sent to the buyer, if applicable and the approving authority. INSPECTION SUMMARY: Check A, B, C, or D: A] SYSTEM PASSES: I have not found any information which indicates that the system violates any of the failure criteria as defined in 310 CMR 15.303. Any failure criteria not evaluated are indicated below. B] SYSTEM CONDITIONALLY PASSES: One or more system components need to be replaced or repaired. The system, upon completion of the replacement or repair, passes inspection. Indicate yea, no, or not determined (Y, N, or ND). Describe basis of determination in all instances. If ''not determined", explain why not) The septic tank is metal, cracked, structurally unsound, shows substantial infiltration or exfiltration, or tank failure is imminent. The system will pass inspection if the existing septic tank is replaced with a conforming septic tank as approved by the Board of Health. ,:, (revised 11/03/95) One Winter Street a Boston, Massachusetts 02108 a FAX (617) 556-1049 a Telephone (617) 292-5500 A J Pnnied on Recycled Paper v SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: Ll Fo^ teK— __fV *\ /�'�'�VQ-"C— Owner. Date of Inspection: Bl SYSTEM CONDITIONALLY PASSES (continued) Sewage backup or breakout or high static water level observed in the distribution box is due to broken or obstructed pipe(s) or due to a broken, settled or uneven distribution box. The system will pass inspection if (with approval of the Board of Health): broken pipe(s) are replaced obstruction is removed distribution box is levelled or replaced . The system required pumping more than four times a year due to broken or obstructed pipe(s).' The system will pass inspection if (with approval of the Boal of Health): broken pipe(s) are replaced obstruction is removed CI FURTHER EVALUATION IS REQUIRED BY THE BOARD OF HEALTH: Conditions exist which require further evaluation by the Board of Health in order to determine if the system is failing to protect the public health, safety and the environment. 1) SYSTEM WILL PASS UNLESS BOARD OF HEALTH DETERMINES THAT THE SYSTEM IS NOT FUNCTIONING IN A MANNER WHICH WILL PROTECT THE PUBLIC HEALTH AND SAFETY AND THE ENVIRONMENT: Cesspool or privy is within 50 feet of a surface water Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh. 2) SYSTEM WILL FAIL UNLESS THE BOARD OF HEALTH (AND PUBLIC WATER SUPPUER. IF APPROPRIATE) DETERMINES THAT THE SYSTEM 1S FUNCTIONING IN A MANNER THAT PROTECT THE PUBLIC HEALTH AND SAFETY AND THE ENVIRONMENT: The system has a septic tank and soil absorption system and is within 100 feet to a surface water supply or tributary to a surface water supply. The system has a septic tank and soil absorption system and is within a Zone I of a public water supply well. The system has a septic tank and soil absorption system and is within 50 feet of a private water supply well. The system has a septic tank and soil absorption system and is less than 100 feet but 50 feet or more from a private water supply well, unless a well water analysis for coliform bacteria and volatile organic compounds indicates that the well is free from pollution from that facility and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm. 3) OTHER (revised 11/03/95) 2 J SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: —I�� '� -' 'V , �VQ� Owner. �' . i_Li S2MQ� �' (Q�\ Y\Q W Date of Inspection: D) SYSTEM FAILS: 1/�= I have determined that the system violates one or more of the following failure criteria as defined in 310 CMR 15.303. The basis for this determination is identified below. The Board of Health should be contacted to determine what will be necessary to correct the failure. Backup of sewage into facility or system comvonettt due to an overloaded or clogged SAS or cesspool. Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or �cesspool. Ll Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool. ,t Liquid depth in cesspool is less than 6" below invert or available volume is less than 1/2 day flow. Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number of times pumped Any portion of the Soil Absorption System, cesspool or privy is below the high groundwater, elevation. — Any portion of a cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. Any portion of a cesspool or privy is within a Zone I of a public well. Any portion of a cesspool or privy is within 50 feet of a private water supply well. Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality analysis. If the well has been analyzed to be acceptable, attach copy of well water analysis for coliform bacteria, volatile organic compounds, ammonia nitrogen and nitrate nitrogen. ' E) LARGE SYSTEM FAILS: The following criteria apply to large syatems in addition to the criteria above: The system serves a facility with a design flow of 10,000 gpd or greater (Large System) and the system is a significant threat to public health and safety and the environment because one or more of the following conditions exist: 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 13 of a public water supply well) The owner or operator of any such system shall bring the system and facility into frill compliance with the groundwater treatment program requirements of 314 CMR 5.00 and 6.00. Please consult the local regional office of the Department for further information. (revised 11/03/95) 3 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST Property Address: 3 u -F�,Xp_, Owner. �U,6( xA4(2_ A -r_ -12t\ V\Q W Date of Inspection: Check if the folio ve been done 7one information was requested of the owner, occupant, and Board of Health.he system components have been pumped for at least two weeks and the system has been receiving normal flow rates �pp jjduring that period. Large volumes of water have not been introduced into the system recently or as part of this inspection. /l/A. b ' t plans have been obtained and examined. Note if they are not available with N/A. ��:_ The fac' 'ty or dwelling was inspected for signs of sewage back-up. _ hl/f a sy does not receive non -sanitary or industrial waste flow �AAIII =as inspected for signs of breakout. mponents, excluding the Soil Absorption System, have been located on the site. :::­_:�ptic tank manholes were uncovered, opened, and the interior of the septic tank was inspected for condition of baffles or tees, mail of construction, dimensions, depth of liquid, depth of sludge, depth of scum. _ The' a and location of the Soil Absorption System on the site has been determined based on existing information or appro ' ted by non -intrusive methods. _ The facility owner (and occupants, if different from owner) were provided with information on the proper maintenance of Sub - Surface Disposal System. (revised 11/03/95) 4 1% K SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C r SYSTEM INFORMATION Owner. Property Address: 3 (I 4 SA, ._V Q� Date of Inspection: �� � 1-e— %V'\Q FLOW CONDITIONS RESIDENTIAL: Design flow: 30 gallons Number of bedrooms: 3 Number of current residents: + Garbage grinder (yes or no):O Laundry connected toes or no):� Seasonal use (yea or nrtlro dL Water meter readings, if available: Last date of occupancy: CV V"AA� COM MERCIAL /INDUSTRIAL: Type of establishment: Design flow:_gallons/day Grease trap present: (yes or no)_ Industrial Waste Holding Tank present: (yes or no)_ Non -sanitary waste discharged to the Title 5 system: (yes or no),_, Water meter readings, if available: Last date of occupancy: OTHER: (Describe) Last date of occupancy: 6, So0cga,0 -% /36LcmS = a to q -J /clj GENERAL INFORMATION PUMPING RECORDS and source of information: YU ""D,& S',veAA- `, ^ S C um System ` Y pumped as part of ' pection: (yes or no) If yes, volume pumped: O ns 1 Reason for pumping: 11n�1 bO-QA- TVN4,� c1 VX QHS TYPE YSTEM 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) Other (explain) APPROXIMATE AGE of all components, date installed (if known) and source of information: ?& -AAS 00 0W A42X Sewage odors detected when arriving at the site: (yes or no) fjo (revised 11/03/95) 5 14 - Y f SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: W T: -A-� SQ : Q . Owner. tr\ �.�?`(2�lh0 W Date of Inspection: V SEPTIC TANK_V (locate on site plan) Depth below grade: 10 - Material of construction: _ ncrete _metal _FRP _other(explain) Dimensions: I -a Sludge depth: Va " Distance from top of sludge to bottom of outlet tee or baffle: P/A �0�r— Distance Scum thickness: toPI �.a.-d� Distance from top of scum to top of outlet tee or baffle: t`� 14 ( QO �' from bottom of scum to bottom of outlet tee or baffle: V/A Comments: (recommendation for pump conditi^on �of Wet and o tet tees or baffles, d pth of liq d le�vf 1 ' relatio to tlet invert, struc�tur .1 in evidence of leaka¢e, etc.) � �e��C" ��� 11i��-1 ��-le GREASE TRAF*Ir,), �J- �X �� �� 5 O'er. _ 'V , (locate on site plan) Depth below grade: Material of construction: _concrete _metal _FRP —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: Comments: (recommendation for pumping, condition of inlet and outlet tees or baffles, depth of liquid level in relation to outlet invert, structural integrity, evidence of leakage, etc.) (revised 11/03/95) e n SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) z Property Address `3 y Jt7SAQ� ��• �� � �- c Owner. Dat of Inspection: ` �9 P -Me- 166Y-No.A.7 TIGHT OR HOLDING TANK: V, (locate on site plan) Depth below grade: Material of construction: _concrete _metal _FRP _other(eaplain) - Dimensions: Capacity: gallons t Design flow: ¢allons/day Alarm level: Comments: (condition of inlet tee, condition of alarm and float switches, etc.) DISTRIBUTION BOX._✓ (locate on site plan) ' if Depth of liquid level above outlet invert: Comments: (note if level and distribution is eaual. evidence of solids P P CRAM (locate on site plan) �•1 Pumps in working order:(yes or no) Comments: (note condition of pump chamber, condition of pumps and appurtenances, etc.) (revised 11/03/95) 7 or out of bo:t_etc.) _ `�� ,+ SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FOAM PART C SYSTEM INFORMATION (continued) Property AaareaW 3 Owner. r 4 f Date of Inspection SOIL ABSORPTION SYSTEM (SAS)-- (locate SAS):v(locate on site plan, if possible; excavation not required, but may be approximated by non -intrusive methods) If not determined to be present, explain: Type: leaching pits, number:_ leaching chambers, number:_ leaching galleries, number: 1 leaching trenches, number, length: leaching fields, number, dimensions: overflow cesspool, number: CESSPOOLS: V� (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 (cesspool must be pumped as part of inspection) E Comments: (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.) PRIVY: V c7Ae— (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.) (revised 11/03/95) 8 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: Owner- Date wnerDate of Inspection: SKETCH OF SEWAGE DISPOSAL SYSTEM: include ties to at least two permanent references landmarks or benchmarks locate all wells within 100' r-- v0 k Sal �3 Ll DEPTH TO GROUNDWATER Depth to groundwater:i�Ltw (revised 11/03/95) 9 a 49 1;� 1 4;4 6_&4 l _J00-:7✓7LI MOO ---------- LZ I 49 1;� 1 4;4 System Owner 14-1LLQ Nth V✓ Commonwealth of Massachusetts Massachusetts System Pumping Record System Location 3.4 Fos -rep, ST. Nuz7-H ANv-,>cve2 o�- JUS Date of Pumping: 7— 76 Quantity Pumped: gallons Xmal: No Yes ❑ optic Tank: No ❑ Yes System Pumped by: 64&d" E &Vw6w License # Contents transferrred to : Greater Lawrence Sanitary District Date: Inspector: