Loading...
HomeMy WebLinkAboutMiscellaneous - 35 EVERGREEN DRIVE 4/30/2018 (4)N ,, � I o I c>s w o O "1 SS � tl 1 pN 4 n� of U viii o aw z 3� o� a M t$ t c>s w o O "1 N A of U viii aw z 3� o� a M U t $� % d �~ _ 2. -�4 \ �. «©° e. �. � �■"c/ \Q\ § 2 2�^§¥2� � � Ow 2 Lr) § � M � • a sSS N 81 7QVw� y¢y} N O X51 O^ 0 O N o Ln z am Of ICS Uaa Onty . rtts Permit Na e rtL6llL Occupancy a Fee Owdcad�' BOARD OF FIRE PREVeMON REGULATIONS 527 COIR 12:00 nom° � . TION FOR PERMIT TO PERFORM ELECTRICAL "WORK All work to be performed in accordance with trio Massacausetts Etectricai Code. SZ7 CINR t 00 _ PLEASE PRINT IN INK OR TYPE ALL INFORMATION) Date (X* or Town of NORTH ANDOVER � ,, '4 To the Inspector of Wires: The udersigned applies for a-�permit ttt�o Perform the electrical work described below. Location (Street & Number) �/V� Owner or Tenant Cwner's Address S- �S 7T G�k Is .his permit in ccniunc:ion with a �_uilcmg =ermit- Yes No r (Check Appropriate Box) ?urpcse ct 3uiiCing 'r. Utility Authcnzation No. Existing Service Amos _1 Vcits Cverread '1 1 Uncgrna ❑ No. of Meters New Service Amps_J Va1ts Cv.ernead r UnCgmd Q No. of Meters Numcer of Feeders and Ampacity Location and Nature at Pr000sed E:ec .-.ca1 'Ncrx Total No. at Lgnttng Curets i No. ar -.:as i , No. or 7ransformers KVA. . Baa• :_cve�— n - No.. of !rgnt:ng = xtures ow'rr--:rg --c, _ -_-nc. _ Gar.eratcrs KVA o• No. at E:-ergency Lgnung No. of Receotac:e Cutlets No. at Cit turners i 3arery Units J No. sr Switch Cutlets No. ar Gas ?timers' ( FiF.E .AL -\RMS No. of Zones ozat No. at Detection ants j No. at Ranges i No. ar Air Canc. yrs I Initiating Cevtces I -leas ': tar utas No. at '-,isccsats NC.aT �+,�as –Ons :C'I I No. ar Sounding Devicas No. at matt Contatnec •_e,;:;. K'.Y � Dater:aniSouncing Cavtces Vo. of Disnwasners==acefArea . S ata T?I r — Munic:oai —Ctner No. at Orvers ea�-g Dev,ces I Connecnan No. or tie. ar I Low ':ctta(;e No. of Water Heaters KW i Signs 3a:las:s ✓/innc f No. 6ivcro Massage Tubs ! No. at Motors otai �iP I Alew tNS::RANCc CC VEPAGE. P rsuant to :na recc:refer.:s a aassacnasers yererat.taws _ I nave a current Liaatiity Insurance Policy :nc_c:rg -;_-r. etec Cceraacns Coverage or as sucs:antiat ea-utvatent. YES = NO t _ nave suamtttea vatic proof at same to :me C'cs. YE_NO = t ':cu :nave cnecxea YE:. ::tease inetcate trio type of coverage cv cnecxtng the aoorocnate pox. INSURANCE BCNO = OTHER = ,Please Scec:ty) (Exotranon Oates Esantatea Value of sectncal Warx S Worx to Start Insceccen Casa i;acuestee: Raugn Final S;gnea cancer the Penalties of penury: Q FIRM NAME Cb-A`'� I SI LIC. NO. ' L censee _ ✓ / = gnaturs LIC. NO. �) /}/1 .n �..�-{1�c� Sus. :e1. No. Actress �" �!�f`tel �! -,-iSW% �ly Ait. :el. No. CWNER S INSURANCE WAIVER: t am aware tnat �.e Lcer.see aces ret nave :rte insurance coverage or its suostannal egwvalent as '9- cutrea ny Massachusetts General Laws. ane that MY s:gr.ature on -.^.ts �errntt acpticl[ICn watves tnts requirement- Ow1/" � Agent . tP!eass cttecsc ons► d etecnorte No. PSSMIT FE S tSignattue of Owner Cr aSenq:03 - - 2+! N i 335 Date........4.. TOWN OF NORTH ANDOVER PERMIT FOR WIRING This certifies that ........ C).tiC t c 1Mr-t "` ......... C'.` t has permission to perform ..... ..... 5.. W /........................... �.. wiring in the building of ......�Aac-., .��.........�.h .!.`.(................................. R. ' N.... ....................... .North Andover, Mass. at j, ,5.........�.4.:�A� Fee..../J ........... Lic. No. A.70 7.............................................................. ELECTRICAL INSPECTOR CAW. / 7 •g Dept. 24 15. oo PAID WHITE: Applicant CA uil inPINK: Treasurer Owner information is required for every page. Important: When filling out forms on the computer, use only the tab key to move your cursor - do not use the return key. r� Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Asses: 35 Evergreen Drive Property Address Donna Armstrong Owner's Name North Andover MA 01845 Cityrrown State Zip Code 04-08-2017 Date of Inspection Inspection results must be submitted on this form. Inspection forms may not be altered any way. Please see completeness checklist at the end of the form. ,,v� A. General Information 1. Inspector: Benjamin C. Osgood, Jr. Name of Inspector none Company Name 157 Bluff Street Company Address Salem NH 03079 Cityrrown State Zip Code 978-435-1324 870 Telephone Number B. Certification License Number 4,fn5 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: ® Passes ❑ Conditionally Passes ❑ Fails ❑ Needs Further Evaluation by the Local Approving Authority Inspector's Si ature 04-10-2017 Date The system inspector shall submit a 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 • 3113 Title 5 Official Inspection Form: Subsurface Sewage Disposal System • Page 1 of 17 Owner information is required for every page. Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 35 Evergreen Drive Property Address Donna Armstrong Owner's Name North Andover Citylrown B. Certification (cont.) MA 01845 State Zip Code 04-08-2017 Date of Inspection 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): N/A t5ins • 3113 Title 5 Official Inspection Form: Subsurface Sewage Disposal System - Page 2 of 17 f Commonwealth of Massachusetts y Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments w 35 Evergreen Drive Property Address Donna Armstrong Owner Owner's Name information is required for every North Andover MA 01845 04-08-2017 page. Cityrrown 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): ❑ ❑ ❑ N/A broken pipe(s) are replaced ❑ Y obstruction is removed ❑ Y distribution box is leveled or replaced ❑ Y ❑ N ❑ N ❑ N ❑ ❑ ❑ ND (Explain below): ND (Explain below): 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): N/A 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: ❑ 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 Owner information is required for every page. Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 35 Evergreen Drive Property Address Donna Armstrong Owner's Name North Andover City/Town B. Certification (cont.) MA 01845 State Zip Code 04-08-2017 Date of Inspection 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 ❑ ® Liquid depth in cesspool is less than 6" below invert or available volume is less than %a day flow t5ins • 3113 Title 5 Official Inspection Form: Subsurface Sewage Disposal System • Page 4 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments GSM 35 Evergreen Drive Property Address Donna Armstrong Owner Owner's Name information is required for every North Andover MA 01845 04-08-2017 page. Cityrrown 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 Ttle 5 Official Inspection Form: Subsurface Sewage Disposal System • Page 5 of 17 Commonwealth of Massachusetts 4 Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 35 Evergreen Drive Property Address Donna Armstrong Owner Owner's Name information is reequiredquiredfor every North Andover MA 01845 04-08-2017 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 Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments M 35 Evergreen Drive Property Address Donna Armstrong Owner Owner's Name information is required for every North Andover MA 01845 04-08-2017 page. City/Town State Zip Code Date of Inspection D. System Information Description: 1,500 gallon septic tank, pump chamber, and 6 leach trenches Number of current residents: 3 Does residence have a garbage grinder? ❑ Yes Z 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: 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 Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments w,. 35 Everareen Drive Property Address Donna Armstrong Owner Owner's Name information is required for every North Andover MA 01845 04-08-2017 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Last date of occupancy/use: Other (describe below): General Information Pumping Records: Source of information: Was system pumped as part of the inspection? If yes, volume pumped: How was quantity pumped determined? Reason for pumping: Type of System: Date 2 to 3 years per owner gallons ® Septic tank, distribution box, soil absorption system ❑ Single cesspool ❑ Yes ® No ❑ Overflow cesspool ❑ Privy ❑ Shared system (yes or no) (if yes, attach previous inspection records, if any) ❑ Innovative/Altemative 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 - 3/13 Title 5 Official Inspection Form: Subsurface Sewage Disposal System - Page 8 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 35 Evergreen Drive Property Address Donna Armstrong Owner Owner's Name information is required for every North Andover MA 01845 04-08-2017 page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Approximate age of all components, date installed (if known) and source of information: Built in 1997 per BOH records Were sewage odors detected when arriving at the site? Building Sewer (locate on site plan): Depth below grade: Material of construction: ❑ cast iron ® 40 PVC ❑ other (explain): Distance from private water supply well or suction line: ❑ Yes ® No 3' feet N/A feet Comments (on condition of joints, venting, evidence of leakage, etc.): Pipe OK in basement. Septic Tank (locate on site plan): Depth below grade: Material of construction: ® concrete ❑ metal If tank is metal, list age: ❑ fiberglass 2.5' feet ❑ polyethylene ❑ other (explain) years Is age confirmed by a Certificate of Compliance? (attach a copy of certificate) ❑ Yes ❑ No Dimensions: 1,500 gallons Sludge depth: 2„ t5ins - 3113 Title 5 Official Inspection Form: Subsurface Sewage Disposal System • Page 9 of 17 Owner information is required for every page. t5ins • 3113 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 35 Evergreen Drive Property Address Donna Armstrong Owner's Name North Andover MA 01845 04-08-2017 City/Town State Zip Code D. System Information (cont.) Septic Tank (cont.) Distance from top of sludge to bottom of outlet tee or baffle Scum thickness Distance from top of scum to top of outlet tee or baffle Distance from bottom of scum to bottom of outlet tee or baffle How were dimensions determined? Date of Inspection Oal- 2" 2" 611 14" Measure stick Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): Tank in good condition. SCH 40 PVC tees in good condition. Riser to grade. Grease Trap (locate on site plan): Depth below grade: Material of construction: ❑ concrete ❑ metal Dimensions: Scum thickness feet ❑ fiberglass ❑ polyethylene ❑ other (explain): 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 Title 5 Official Inspection Form: Subsurface Sewage Disposal System - Page 10 of 17 Commonwealth of Massachusetts N Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments wM 35 Evergreen Drive Property Address Donna Armstrong Owner Owner's Name information is required for every North Andover MA 01845 04-08-2017 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: Design Flow: Alarm present: Alarm level: gallons gallons per day ❑ Yes ❑ No 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 - 3113 Title 5 Official Inspection Form: Subsurface Sewage Disposal System - Page 11 of 17 Owner information is required for every page. Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 35 Evergreen Drive Property Address Donna Armstrong Owner's Name North Andover Cityrrown D. System Information (cont.) MA 01845 State Zip Code Distribution Box (if present must be opened) (locate on site plan): Depth of liquid level above outlet invert 0 04-08-2017 Date of Inspection Comments (note if box is level and distribution to outlets equal, any evidence of solids carryover, any evidence of leakage into or out of box, etc.): Box in good condition. Liquid levels normal, no indication of leakage in or out. 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.): Pump and chamber look normal. Riser to grade. * 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 35 Evergreen Drive Property Address Donna Armstrong Owner Owner's Name information is required for every North Andover MA 01845 04-08-2017 page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Type: ❑ leaching pits number: ❑ leaching chambers number: ❑ leaching galleries number: ® leaching trenches number, length: 6 - 62' long trenches ❑ 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.): Leach pits clean and drv. 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 • 3113 Title 5 Official Inspection Forth: Subsurface Sewage Disposal System • Page 13 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form a Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 35 Evergreen Drive Property Address Donna Armstrong Owner Owner's Name information is required for every North Andover MA 01845 04-08-2017 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.): Title 5 Official Inspection Form: Subsurface Sewage Disposal System • Page 14 of 17 Owner information is required for every page. Commonwealth of Massachusetts Ville 5 official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 35 Evergreen Drive Property Address Donna Armstrong Owner's Name North Andover City/Town D. system Information (cont.) MA 01845 04-08-2017 State Zip Code Date of Inspection 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: t5ins - 3113 Title 5 Official Inspection Form: Subsurface Sewage Disposal System - Page 15 of 17 <C\\. Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 35 Evergreen Drive Property Address Donna Armstrong Owner Owner's Name information is required for every North Andover MA 01845 04-08-2017 page. Cityrrown 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: 21 feet Please indicate all methods used to determine the high ground water elevation: 0t 7 Obtained from system design plans on record If checked, date of design plan reviewed: 1997 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: Perched water table depth 24" below grade. System raised 4 ' above grade You must describe how you established the high ground water elevation: Soil evaluation done by this inspector in 1997. System constructed with bottom of stone 4' above seasonal high water table. Before filing this Inspection Report, please see Report Completeness Checklist on next page. t5ins - 3113 Title 5 Official Inspection Form: Subsurface Sewage Disposal System - Page 16 of 17 Owner information is required for every page. Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 35 Evergreen Drive Property Address Donna Armstrong Owner's Name North Andover MA 01845 04 08 2017 Cityrrown State E. Report Completeness Checklist ® Inspection Summary: A, B, C, D, or E checked Zip Code Date of Inspection ® 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 - 3113 Title 5 Official Inspection Form: Subsurface Sewage Disposal System • Page 17 of 17 7868 . . Town of North Andover �+�'•e,,.ae .: HEALTH DEPARTMENT ,SS�CMUStt CHECK #: 3 DATE: LOCATION: 3 e/' r H/O NAME: CONTRACTOR NAME: Ile Type of Permit or License: (Check box) $ ❑ Animal $ ❑ Body Art Establishment $ ❑ Body Art Practitioner $ ❑ Dumpster $ ❑ Food Service - Type: $ ❑ Funeral Directors $ ❑ Massage Establishment $ ❑ Massage Practice $ ❑ Offal (Septic) Hauler $ ❑ Recreational Camp $ ❑ Sun tanning $ ❑ Swimming Pool $ ❑ Tobacco $ ❑ TrashlSolid Waste Hauler $ ❑ Well Construction $ SEPTIC Sustems: ❑ .Septic - Soil Testing $ ❑ Septic - Design Approval $ ❑ Septic Disposal Works Construction (DWC) $ ❑ Septic Disposal Works Installers (DWI) $ Title 5 Inspector $ �❑j f, Title 5 Report SS $ ❑ Other: (Indicate) � -� -11Cd He --a- A Agent Initials White - Applicant Yellow - Health Pink - Treasurer J t f ' . t •iii 014tLOIIlII1DI mallII Qf Baolmew P� 00101111 tip oiir o. lip Erlim ntrat of public *ufrtg Occupancy L Fee Cheated BOARD OF FIRE PREVENTION REGULATIONS 527 CMR 12:00 Mo Maw t� APPLICATION FOR PERMIT TO PERFORM ELECT R1CAL WORK All work to be performed in accordance with the Massacnusetts Electrical Code, 527 CM (PLEASE PRINT IN INK OR TYPE ALL INFORMATION) IMA or Town of Date To the Inspector Of Wlrea: The udersigned applies for a permit t 1151erform the electrical work described below. Location (Street & Numbed Gv2� i��c�, ���c�p A_) Owner or Tenant Owner's Address Is this permit. in conjunction with a building permit: Yes. No /` o (Check Appropriate box) 0,0,0Purpose of Building �t '-),' Utility Authorization No. Existing Service 90U Amps�J 2-L Volts Overhead ' r—� Undgrnd L_ No. of motors ` a New-_ Amps J Vous'-' r Overnead _ Undgrno No. of Motors Number of Feeders and Ampacity Location and Nature of Proposed Electrical'NorK No. of Lt nbn 9 9 Outlets I No. of yat ' cs I Tow No. of Translormera /No. of Lignting Fixtures. Swimming PC.oi Aocve,— ,n- r_ '_ I KNA gyro — Srno Generators KVA o. of Recomacle Outlets 55 INo. of Oil corners % I ( No. of Emergency lighting Battery Units NO. of SwgGh Outlets �� I No. of Gas _•:rrers / No. DI Ranges / I No. Cl Air C,:r.c. "otai , FIRE ALARMS No. at Zones No. Deacuon of and 'cnS . Inifiaung Devices NO. of Disposals / I No.ol Heat TO:ai -oiai Pur -::s -ons 1<1',I No. of Sounding Devices I No. of Oianwssners I SoacerArea •+eatirq K`,Y No. or Self Contained i 0eieetionrSounain g Devices No. Of Dryers I Heating Cevices Kyr— L•ocat Mumcioal r�-Other ; Connection No. of Iqu it No. of Wafer Heaters G KW Signa °a - ilas:s Low voltage ; Winn g�j„ ie�on�e No. Hyoro Massage Tuos I No. of Moicrs oiai HP OTHER. INSURANCE COVERAGE. Pursuant :o the reouiremenis Jt t.tassaccLser.s ;eneral Laws 1 have,& current 1-401111y Insurance Policy incivaing Czr,c flet Ccerations Coverage or its have suOmtned valid proof of same to the Office. YES = v0 = subatan tial f ES -` NO _ I If you nave cnscxed YES, p(eaa�pntucste yN Cnecking the appraortate Dox. type of covertlge sy INSURANCE Z� aONO = OTHER = (Please Scac.1?) r Estimated Value f Xsc fe worst s y �-'L Work 10 Start I (f aolra]tgn pates . Insoec:ion Date :.accas:ec: Rougn I NO� / I lll�`J'Ti �v� Signed S+gned under the of perlury; FinalCJI (Anatha FIRM NAME Licensee� i�r� / N[: i(�/ S.5^&:lire c UC. NO. Address -_�Q /'i i_ ,_� / dTiilr<r1i fi%�% .,--'LIC.No. Bua. Ti. No.3 3G-L/i S OWNER'S INSURANCE WAIVER: 1 am aware Inat Ins I_:censee ^_fes not nave All. Tel. No. i me insurance coverage or its suoetanusl autre0 by Maaa&cnuseas General Laws. ane Inst my a+Qrial r on •.^•Va term& appncatipn wawa IMa ►egWremea. �tltvalem"►e. (Pies" cnecx onel• Y0 v Ag r_l ` ` iieenene !) No. ---_�..�'EFIMIT ( of m Agents FEE ! !/ N°.61 437 Date ...�A?/ TOWN OF NORTH ANDOVER PERMIT FOR WIRING S This certifies that �. v .. C t i cti i s �� .. has permission to perform ....%{...........(.l. �......`.............................................<' wiring the building of ..... ..Z .!........... TC;, P ... `.�..................... 6 ata) ...:................ . North Andover, Mass. 7n? Lic. No. f�... (................................................................... ELECTRICAL INSPECTOR G �t 0 /o y7 WHITE: Applicant CANARY: Building Dept. PINK: Treasurer