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HomeMy WebLinkAboutMiscellaneous - 366 CANDLESTICK ROAD 4/30/2018u " ~~/ - ^ | � ' cq En N G� o . ) o � � ~~/ 46 z to, L +.:... MAP # LOT #I.�3�_._......... PARCEL # STREET. --.(2( n-( G'. .T/Cx...... Q c� CONSTR.UCT_ION __..APPr?OVA..L. HAS PLAN REVIEW FEE BEEN PAID? NO PLAN APPROVAL: y� DATEy_ APP. BY.._.._._- ..... ................................. ._ ._... DESIGNER: �CYj'�2 //�� PLAN . ........ COND I T I ONS d fI/L PIPLr S6#46 oR) 19 Dp ,T',G _ sous TExT/N670 $� D01Vf PT, IDR rt7 CO WATER SUPPLY: WELL PERMIT_ WELL TESTS: COMMENTS: T0�l1�1 WELL DRILLER CHEMICAL BACIERIA I BACTERIA II ....._.......................-......_........... __ .... DATE flPi-IRUVED Df -11E f11 -'DROVED DATE APPROVED FORM U APPROVAL: APPROVAL TO ISSUE E5 NO DATE ISSUED Z� CONDITIONS: FINAL APPROVAL: ALL PERMITS PAID NO WELL CONSTRUCTION APPROVAL YES NO SEPTIC SYSTEM CONSTRUCTION APPROVALYES tJ(.) OTHER YES NU ANY VARIANCE NEEDED YES �NU, FINAL BOARD OF HEALTH APPROVAL: DAZE:/� BY:l>" IS THE INSTALLER LICENSED? YES NO TYPE. OF CONSTRUCTION: NLW REPnIR NEW CONSTRUCTION: CERTIFIED PLOT PL -1N REVIEW „ CONDITIONS OF APPROVAL YES NO (FROM FORM U) ISSUANCE OF DWC PERMIT YES NO DWC PERMIT N0. �3 INSTALLER:_ / 1/l� BEG I N..INSPECTION YES. NO: . EXCAVATION.INSPECTION: NEEDED: —__— _•___._—__ PASSED BY ----- -- — -- . CONSTRUCTION INSPECTION: NEEDED= _--.._._,___.____.__......_.__.__.___._._.......__.___.___._.__ AS BUILT PLAN SATISFACTORY: (YS Sf_BY—_______.__._..._._.._—_______..______ APPROVAL TO BACKFILL: DATE: FINAL GRADING APPROVAL: DATE Vo A3 BY DATE:g19h�_BY`�. FINAL CONSTRUCTION APPROVAL: _ n Fire & Water — Cleanup & RestorationIm 978-688.2242 ® of Lawrence 603-893-9700 • SERVPRO 978-475-1199 SERVPRO® of Salem/Plaistow crQvPRe of The Andovers Rno-535-6322 LE, a Independently Owned and Operated Like it never even happened PUBLIC HEALTH DEPARTMENT Town of North Andover Community Development Division CERTIFICATE OF COMPLIANCE As of: 6/22/15 This is to certify that the individual subsurface disposal system received a SATISFACTORY INSPECTION of the: Complete Repair of Tank and D -Box By: James Boraczek At: 366 Candlestick Road Map 106.A Lot 0226 Yublic Health Agent er, MA 01845 a guarantee that the system will function satisfactorily. 1600 Osgood Street, North Andover, Massachusetts 01845 Phone 978.688.9540 fax 978.688.8476 Web www.townofnorthandover.com P 9'' North Andover Health Department (ommunity and Economic Development Division ONSITE WASTEWATER SYSTEM CONSTRUCTION NOTES LOCATION INFORMATION ADDRESS: 366 Candlestick Rd. MAP: 106.A LOT: 0226 INSTALLER: James Boraczek DESIGNER: PLAN DATE: BOH APPROVAL DATE ON PLAN: INSPECTIONS TANK INSPECTION: �� 1 DATE OF BED BOTTOM INS E ION: DATE OF FINAL CONSTRUCTION INSPECTION: DATE OF FINAL GRADE INSPECTION: SITE CONDITIONS VrEx-isting ontractor reports any changesto design plan septic tank properly_abandoned ❑ Internal plumbing all to one building sewer ❑ Topography not appreciably altered C meat (;:SEPTIC TANK ❑ Building sewer in continuous grade, on compacted firm base \. ❑ Cleanouts per plan Bottom of tank hole has 6" stone base �eep hole plugged 00 gallon tank has been installed 10 loading Q Monolithic tank construction ❑ ater tightness of tank has been achieved by visual testing Inlet tee installed, centered under access port Comments: PUMP CHAMBER Comments: CONTROLPANEL Comments: DISTRIBUTION -BOX Comments: ❑ Outlet tee installed, centered under access port (gas baffle/effluent filter) ❑ inch cover to within 6" of finish grade installed over one access port ❑ Hydraulic cement around inlet & outlet ❑ Bottom of tank hole has 6" stone base ❑ Weep hole plugged ❑ 1500 gallon Pump Chamber installed ❑ H-10 loading ❑ Monolithic tank construction ❑ Inlet tee installed, centered under access port ❑ Pump(s) installed on stable base ❑ Alarm float working ❑ Pump On/Off floats working ❑ Separate on/off floats ❑ Drain hole in pressure line ❑ cover at final grade installed over pump access port ❑ Water tightness of tank has been achieved by testing ❑ Hydraulic cement around inlet & outlet ❑ Alarm & Pump are on separate circuits ❑ Alarm sounds when float is tripped ❑ Location of control panel: basement ❑ Alarm signal located inside: basement ❑/ Installed on stable stone base ®/ H-20 D -Box Inlet tee (if pumped or >0.08'/foot) Hydraulic cement around inlet & outlets [� Observed even distribution Speed levelers provided (not required) Schedule 40 PVC Pipe •a19�1 A ! i � � +y � c f! �!t Y''yk', J i � h !• mss'" ' T !�`f•t i�"�'..t�' y, ,yr w.-'4 Iyi' • r ' t ��'� + t.. y � . c« � r � ,a��.. j•L`k. ,ya'�.,r.t / „ t 1 1.w' } •iET� . y .i.�.�. .�..` `�•q ��. _ �� . 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Commonwealth of Massachusetts Map -Block -Lot 106.A0226 BOARD OF HEALTH ----------------------- Permit No North Andover BHP -2015-0272 ----------------------- FEE $125.00 -=--------------------- DISPOSAL WORKS CONSTRUCTION PERMIT Permission is hereby granted James Boraczek to (Repair) an Individual Sewage Disposal System. at No 366 CANDLESTICK ROADk-gL47A as shown on the application for Disposal Works Construction Permit No. BHP -2015-027 Dated June 18, 2015 - - - ----------- --- --- ---------------- -� i UE- -n - /_— ---- Issued On: Jun -18-2015 BOARD OF HEAL •�<w., Application for Septic Disposal System Construction Permit - TOWN OF TODAY'S DATE NORTH ANDOVER, MA 01845 u" Repair $125.00 - C mponent Important: Application is hereby made for a permit to: When filling out ❑ Construct a new on-site sewage disposal system* forms on the computer, use ❑ Repair or replace an existing on-site sewage disposal system* only the tab key epair or replace an existing system component- What? ,4,VX 74- aoX to move your cursor - do not use the return A. Facility Information key. -?b4 CQf�y1/e SICK rab Address or Lot # " lel ISICity/Town 2.- *TYPE OF SEPTIC SYSTEM*: ➢ ❑ Pump D1,9ravity (choose one) ***If pump ystem, attach copy of electrical permit to application*** ➢ Conventional System (pipe and stone system) ➢ Infiltrator or Biodiffuser (Gravel-Less) (Attach a copy of your certification to install this type of system.) ➢ ❑ Pressure Distribution S.A.S. (No D-Box) ➢ ❑ Pressure Dosed (D-Box Present) S.A.S. ➢ ❑ Does the system require an effluent filter? Yes No If yes, does plan specify make and model of filter? YES = (no further info. needed) NO = (installer must specify brand of filter before DWC issuance) What is the Make? What is the Model. 2. Owner Information A.Sv 'EhL Ntfirne Sara! Address (if different from above) City/Town State Zip Code Email address Telephone Number 3. Installer Information _��>s /.Ylf'fjCL� �/f9C2e.Kf� Srp�� � �l`�✓ ANG Name Name of Company 31 IA-24 Dr Address A1M OA '&%/ B l City/Town I State Zip Code /--9 7t- v79-s2-36 Telephone Number (Cell Phone # if possible please) 4. Designer Information Name Name of Company Address City/Town State Zip Code Telephone Number (Best # to Reach) Application for Disposal System Construction Permit • Page 1 of 2 . �Kcraar Application for Septic Disposal System Construction Permit -TOWN OF TODAY'S DATE $ 250.00 - Full Repair NORTH ANDOVER, MA 01845 $125.00 - Component PAGE 2OF2 A. Facility Information continued.... 5. Type ofBuilding: C�esidential Dwelling or E]Commercial B. Agreement The undersigned agrees to ensure the construction and maintenance of the afore -described on-site sewage disposal system in accordance with the provisions of Title 5 of the Environmental Code, as well as the Local Subsurface Disposal Regulations for the Town of North Andover. I understand that until a final Certificate of Compliance has been issued by this Board of Health, the installed system is not approved. N e Date Application Approved By: (Board of Health Representative) Name Date Application Disapproved for the following reasons: For Office Use Only: 1. Fee Attached? Yes No 2. Project Manager Obligation Form Attached? Yes No 3. Pump System? If so, Attach copy ofElectrical Permit Yes No Applicant received copy of "Electrical Inspection Notes for Septic Systems" Yes No Handout? 4. Reviewed approval letter, all paperwork received? Yes No 5. Foundation As -Built? (new construction only): Yes No (Same scale as approved plan) 6. Floor Plans? (new construction only): Yes No Application for Disposal System Construction Permit • Page 2 of 2 SEPTIC SYSTEM INSTALLER PROJECT MANAGEMENT OBLIGATIONS As the North Andover licensed installer for the construction for the septic system for the property at: 366 CQAe)l(. (Address of septic system) //�� Relative to the application of �i!/�1rs /34/YrCL.1G (Installer's name) Dated o ay s ate For plans by And dated With revisions dated I understand the following obligations for management of this project: (Engineer) (Original ate (Last revised date) 1. As the installer, I am obligated to obtain all permits and Board of Health approved plans prior to performing any work on a site. I must have the approved plans and the permit on site when any work is being done. 2. As the installer, I must call for any and all inspections. If homeowner, contractor, project manager, or any other person not associated with my company schedules an inspection and the system is not ready, then item three shall be applicable. 3. As the installer, I am required to have the necessary work completed prior to the applicable inspections as indicated below. I understand that requesting an inspection, without completion of the items in accordance with Title 5 and the Board of Health Regulations may result in a $50.00 fine being levied against me and/or my company a. Bottom of Bed — Generally, this is the first (15) inspection unless there is a retaining wall, which should be done first. The installer must request the inspection but does not have to be present. b. Final Construction Inspection — Engineer must first do their inspection for elevations, ties, etc. As -built of verbal OK (or e-mail to: healthdept(c7�,townofnorthandover.com) from the engineer must be submitted to the Board of Health, after which installer calls for an inspection time. Installer must be present for this inspection. With a pump system, all electrical work must be ready and able to cause pump to work and alarm to function. c. Final Grade — Installer must request inspection when all grading is complete. Installer does not have to be on-site. 4. As the installer, I understand that only I may perform the work (other than simple excavation) and I am required to complete the installation of the system identified in the attached application for installation. I further understand that work done by others unlicensed to install septic systems in North Andover can constitute reasons for denial of the system and/or revocation or suspension of my license to operate in the Town of North Andover, significant fines to all persons involved are also possible. 5. As the installer, I understand that I must be on-site during the performance of the following construction steps: a. Determination that the proper elevation of the excavation has been reached. b. Inspection of the .sand and stone to be used. c. Final inspection by Board of Health staff or consultant. d. Installation of tank, D -Box, pipes, stone, vent, pump chamber, retaining wall and other components. 6. As the installer_ I understand that I am solely responsible for the installation of the system as per the approved plans. No instructions by the homeowner, General contractor, or anv other persons shall absolve me of this obligation. Undersigned Licensed Septic Installer: (Name — Print ame — Signe (Today's Date) (0 �S Mills 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. Commonwealth of Massachusetts r Title 5 Official Inspecti n Form R Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 366 Candlestick Road APR 2 7 2015 Property Address TOWN OF NORTH ANDOVER Joseph Elaz h,::,,L-iti :•EiVt i--"i;',4LNT Owner's Name North Andover Cityrrown MA 01845 State Zip Code 4/17/2015 Date of Inspection Inspection results must be submitted on this form. Inspection forms may not be altered in any way. Please see completeness checklist at the end of the form. A. General Information 1. Inspector: Neil J. Bateson Name of Inspector Bateson Enterprises Inc. Company Name 111 Argilla Road Company Address Andover Cityrrown 978-475-4786 Telephone Number B. Certification MA State S115 License Number 01810 Zip Code 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 ❑ Ne s urther Evaluation by the Local Approving Authority 4/17/2015 Inspector's Sighature 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 6 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 366 Candlestick Road Property Address Joseph Elaz Owner's Name North Andover MA 01845 4/17/2015 Cityrrown State Zip Code Date of Inspection B. Certification (cont.) Inspection Summary: Check A,B,C,D or E / always complete all of Section D A) System Passes: ❑ I have not found any information which indicates that any of the failure criteria described in 310 CMR 15.303 or in 310 CMR 15.304 exist. Any failure criteria not evaluated are indicated below. Comments: B) System Conditionally Passes: ® One or more system components as described in the "Conditional Pass" section need to be replaced or repaired. The system, upon completion of the replacement or repair, as approved by the Board of Health, will pass. Check the box for "yes", "no" or "not determined" (Y, N, ND) for the following statements. If "not determined," please explain. The septic tank is metal and over 20 years old* or the septic tank (whether metal or not) is structurally unsound, exhibits substantial infiltration or exfiltration or tank failure is imminent. System will pass inspection if the existing tank is replaced with a complying septic tank as approved by the Board of Health. * A metal septic tank will pass inspection if it is structurally sound, not leaking and. if a Certificate of Compliance indicating that the tank is less than 20 years old is available. ® Y ❑ N ❑ ND (Explain below): Tank leaking out, liquid 3" from outlet invert. l5ins • 3113 Title 5 Official Inspection Form: Subsurface Sewage Disposal System • Page 2 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 366 Candlestick Road Property Address Joseph Elaz Owner's Name North Andover MA 01845 4/17/2015 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): ❑ broken pipe(s) are replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below): ❑ distribution box is leveled or replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ The system required pumping more than 4 times a year due to broken or obstructed pipe(s). The system will pass inspection if (with approval of the Board of Health): ❑ broken pipe(s) are replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below): C) Further Evaluation is Required by the Board of Health: ❑ Conditions exist which require further evaluation by the Board of Health in order to determine if the system is failing to protect public health, safety or the environment. 1. System will pass unless Board of Health determines in accordance with 310 CMR 15.303(1)(b) that the system is not functioning in a manner which will protect public health,, safety and the environment: ❑ 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 MAL _= Owner information is required for every page. Commonwealth of Massachusetts Title 5 Official inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 366 Candlestick Road Property Address Joseph Elaz Owners Name North Andover MA 01845 4/17/2015 City/Town State Zip Code Date of Inspection B. Certification (cont.) 2. System will fail unless the Board of Health (and Public Water Supplier, if any) determines that the system is functioning in a manner that protects the public health, safety and environment: ❑ The system has a septic tank and soil absorption system (SAS) and the SAS is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water supply. ❑ The system has a septic tank and SAS and the SAS is within 50 feet of a private water supply well. ❑ The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or more from a private water supply well**. Method used to determine distance: ** This system passes if the well water analysis, performed at a DEP certified laboratory, for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis must be attached to this form. 3. Other: Septic tank & d -box needs to be replaced. 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 '/2 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 ° 366 Candlestick Road Property Address Joseph Elaz Owner Owner's Name information is required for North Andover MA 01845 4/17/2015 every page. Cityfrown State Zip Code Date of Inspection B. Certification (cont.) Yes No ❑ ® Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number of times pumped: ❑ ® Any portion of the SAS, cesspool or privy is below high ground water elevation. ❑ ® Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ ® Any portion of a cesspool or privy is within a Zone 1 of a public well. ❑ ® Any portion of a cesspool or privy is within 50 feet of a private water supply well. ❑ ® Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality analysis. [This system passes if the well water analysis, performed at a DEP certified laboratory, for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis and chain of custody must be attached to this form.] ❑ ® The system is a cesspool serving a facility with a design flow of 2000gpd- 10,000gpd. ❑ ® The system fails. I have determined that one or more of the above failure criteria exist as described in 310 CMR 15.303, therefore the system fails. The system owner should contact the Board of Health to determine what will be necessary to correct the failure. E) Large Systems: To be considered a large system the system must serve a facility with a design flow of 10,000 gpd to 15,000 gpd. For large systems, you must indicate either "yes" or "no" to each of the following, in addition to the questions in Section D. Yes No ❑ ❑ the system is within 400 feet of a surface drinking water supply ❑ ❑ the system is within 200 feet of a tributary to a surface drinking water supply ❑ ❑ the system is located in a nitrogen sensitive area (Interim Wellhead Protection Area IWPA) or a mapped Zone II of a public water supply well If you have answered "yes" to any question in Section E the system is considered a significant threat, or answered "yes" in Section D above the large system has failed. The owner or operator of any large system considered a significant threat under Section E or failed under Section D shall upgrade the system in accordance with 310 CMR 15.304. The system owner should contact the appropriate regional office of the Department. t5ins • 3/13 Title 5 Official Inspection Form: Subsurface Sewage Disposal System • Page 5 of 17 Owner information is required for every page. Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Forth - Not for Voluntary Assessments 366 Candlestick Road Property Address Joseph Elaz Owner's Name North Andover Cityrrown C. Checklist MA State n-11uAr; —F 4/17/2015 Date of Inspection 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): 4 Number of bedrooms (actual): 4 DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x # of bedrooms): 660 t5ins - 3113 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 r 366 Candlestick Road Property Address Joseph Elaz Owner Owner's Name information is required for North Andover MA 01845 4/17/2015 every page. Cityrrown State Zip Code Date of Inspection D. System Information Description: Number of current residents: Does residence have a garbage grinder? Is laundry on a separate sewage system? (Include laundry system inspection information in this report.) Laundry system inspected? Seasonaluse? Water meter readings, if available (last 2 years usage (gpd)): Detail: Sump pump? Last date of occupancy: Commercial/Industrial Flow Conditions: Type of Establishment: Design flow (based on 310 CMR 15.203): Basis of design flow (seats/persons/sq.ft., etc.): Grease trap present? Industrial waste holding tank present? Gallons per day (gpd) ❑ Yes ® No ❑ Yes ® No ❑ Yes ❑ No ❑ Yes ® No Yes ❑ Yes ® No Current Date ❑ Yes ❑ No ❑ Yes ❑ No Non -sanitary waste discharged to the Title 5 system? ❑ Yes ❑ No Water meter readings, if available: t5ins • 3113 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 '< 366 Candlestick Road Last date of occupancy/use: Other (describe below): Pumping Records: Source of information: un nwnAe General Information Was system pumped as part of the inspection? If yes, volume pumped: How was quantity pumped determined? Reason for pumping: Date Pumped 2013, owner 1200 gallons Measured tank Inspect tank & tees. 4/17/2015 Date of Inspection ® Yes ❑ No Type of System: ® Septic tank, distribution box, soil absorption system ❑ Single cesspool ❑ Overflow cesspool ❑ Privy ❑ Shared system (yes or no) (if yes, attach previous inspection records, if any) ❑ Innovative/Alternative technology. Attach a copy of the current operation and maintenance contract (to be obtained from system owner) and a copy of latest inspection of the I/A system by system operator under contract ❑ Tight tank. Attach a copy of the DEP approval. ❑ Other (describe): t5ins • 3113 Title 5 Official Inspection Form: Subsurface Sewage Disposal System •Page 8 of 17 Property Address Joseph Elaz Owner Owners Name information is North Andover required for every page. Cityfrown D. System Information (cont.) Last date of occupancy/use: Other (describe below): Pumping Records: Source of information: un nwnAe General Information Was system pumped as part of the inspection? If yes, volume pumped: How was quantity pumped determined? Reason for pumping: Date Pumped 2013, owner 1200 gallons Measured tank Inspect tank & tees. 4/17/2015 Date of Inspection ® Yes ❑ No Type of System: ® Septic tank, distribution box, soil absorption system ❑ Single cesspool ❑ Overflow cesspool ❑ Privy ❑ Shared system (yes or no) (if yes, attach previous inspection records, if any) ❑ Innovative/Alternative technology. Attach a copy of the current operation and maintenance contract (to be obtained from system owner) and a copy of latest inspection of the I/A system by system operator under contract ❑ Tight tank. Attach a copy of the DEP approval. ❑ Other (describe): t5ins • 3113 Title 5 Official Inspection Form: Subsurface Sewage Disposal System •Page 8 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 366 Candlestick Road 1 ,rte Property Address Joseph Elaz Owner Owner's Name information is required for North Andover every page. Citylrown D. System Information (cont.) MA 01845 4/17/2015 State Zip Code Date of Inspection Approximate age of all components, date installed (if known) and source of information: 22 years old, 5/25/1993, as built plan Were sewage odors detected when arriving at the site? Building Sewer (locate on site plan): Depth below grade: 18 feet Material of construction: ❑ cast iron ® 40 PVC ❑ other (explain): Distance from private water supply well or suction line: feet Comments (on condition of joints, venting, evidence of leakage, etc.): 4" PVC throuqh wall & 3" PVC in house, no leaks visible. Septic Tank (locate on site plan): Depth below grade: Material of construction: ® concrete ❑ metal .8 feet ❑ Yes ® No ❑ fiberglass ❑ polyethylene ❑ other (explain) If tank is metal, list age: years Is age confirmed by a Certificate of Compliance? (attach a copy of certificate) Dimensions: 10'x 5'x 4' Sludge depth: 11b ❑ Yes ❑ No t5ins • 3/13 Title 5 Official Inspection Form: Subsurface Sewage Disposal System •Page 9 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 366 Candlestick Road Property Address Joseph Elaz Owner Owner's Name information is North Andover MA 01845 4/17/2015 required for every page. Citylrown State Zip Code Date of Inspection D. System Information (cont.) Septic Tank (cont.) Distance from top of sludge to bottom of outlet tee or baffle Scum thickness Distance from top of scum to top of outlet tee or baffle N/A 411 N/A= Outlet tee has holes. Distance from bottom of scum to bottom of outlet tee or baffle N/A How were dimensions determined? Tape Measure Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): Liquid level in septic tank 3" from outlet invert. Evidence of leakage. Inlet tee ok. Outlet tee badly corroded & has holes in sides. Grease Trap (locate on site plan): Depth below grade: feet Material of construction: ❑ concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other (explain): Dimensions: Scum thickness Distance from top of scum to top of outlet tee or baffle Distance from bottom of scum to bottom of outlet tee or baffle Date of last pumping: Date t5ins • 3113 Title 5 Official Inspection Form: Subsurface Sewage Disposal System •Pape 10 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 366 Candlestick Road Property Address Joseph Elaz Owner's Name North Andover MA 01845 4/17/2015 Cityfrown State Zip Code Date of Inspection D. System Information (cont.) Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): Tight or Holding Tank (tank must be pumped at time of inspection) (locate on site plan): Depth below grade: Material of construction: ❑ concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other (explain): Dimensions: Capacity: gallons Design Flow: gallons per day Alarm present: ❑ Yes ❑ No Alarm level: Alarm in working order: ❑ Yes ❑ No Date of last pumping: Date Comments (condition of alarm and float switches, etc.): * Attach copy of current pumping contract (required). Is copy attached? ❑ Yes ❑ No t5ins • 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 366 Candlestick Road Property Address Joseph Elaz 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 -2 4/17/2015 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.): D -box badly corroded, Evidence of leakage. Liquid level 2" from outlet inverts Pump Chamber (locate on site plan): Pumps in working order: ❑ Yes ❑ No" Alarms in working order: ❑ Yes ❑ No* Comments (note condition of pump chamber, condition of pumps and appurtenances, etc.): * If pumps or alarms are not in working order, system is a conditional pass. Soil Absorption System (SAS) (locate on site plan, excavation not required): If SAS not located, explain why: t5ins • 3113 Title 5 Official Inspection Form: Subsurface Sewage Disposal System • Page 12 of 17 Type/name of technology: Comments (note condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of vegetation, etc.): Soil ok. Vegetation ok. No sign of ponding to surface J 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 Form: Subsurface Sewage Disposal System - Page 13 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 366 Candlestick Road Property Address Joseph Elaz Owner Owner's Name information is required for North Andover MA 01845 4/17/2015 every page. Citylrown State Zip Code Date of Inspection D. System Information (cont.) Type: ❑ leaching pits number: ❑ leaching chambers number: ❑ leaching galleries number: ® leaching trenches number, length: 2 trenches 35' long ❑ 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.): Soil ok. Vegetation ok. No sign of ponding to surface J 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 Form: Subsurface Sewage Disposal System - Page 13 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form 6 Subsurface Sewage Disposal System Form - Not for Voluntary Assessments "( 366 Candlestick Road Joseph Elaz Owner Owner's Name information is required for North Andover MA 01845 4/17/2015 every page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): Privy (locate on site plan): Materials of construction: Dimensions Depth of solids Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): t5ins • 3/13 Title 5 Official Inspection Form: Subsurface Sewage Disposal System • Page 14 of 17 Owner information is required for every page. Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 366 Candlestick Road Property Address Joseph Elaz Owners Name North Andover MA 01845 4/17/2015 Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Sketch Of Sewage Disposal System: Provide a view of the sewage disposal system, ,including ties to at least two permanent reference landmarks or benchmarks. Locate all wells within 100 feet. Locate where public water supply enters the building. Check one of the boxes below: ® hand -sketch in the area below ❑ drawing attached separately � a 0 �- F3 C t t5ins • 3113 Title 5 Official Inspection Form: Subsurface Sewage Disposal System • Page 15 of 17 Commonwealth of. Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 366 Candlestick Road Property Address Joseph Elaz Owner Owner's Name information is required for North Andover MA 01845 4/17/2015 every 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: 4 feet Please indicate all methods used to determine the high ground water elevation: ® Obtained from system design plans on record If checked, date of design plan reviewed: 4/18/1989 Date ❑ Observed site (abutting property/observation hole within 150 feet of SAS) N Checked with local Board of Health - explain: Design plan ❑ Checked with local excavators, installers - (attach documentation) ❑ Accessed USGS database - explain: You must describe how you established the high ground water elevation: As per test pit data on design plan , 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 Commonwealth of Massachusetts Title 5 official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary. Assessments °< 366 Candlestick Road Property Address Joseph Elaz Owner Owner's Name information is required for North Andover MA 01845 4/17/2015 every page. Cityrrown State Zip Code Date of Inspection E. Report Completeness Checklist ® Inspection Summary: A, B, C, D, or E checked ® Inspection Summary D (System Failure Criteria Applicable to All Systems) completed ® System Information — Estimated depth to high groundwater ® Sketch of Sewage Disposal System either drawn on page 15 or attached in separate file l5ins - 3/13 Title 5 Official Inspection Form: Subsurface Sewage.Disposal System - Page 17 of 17 Summary Record Card generated on 4/7/2015 1:03:43 PM by Karen Hanlon Town of North Andover Tax Map # 210-106.A-0226-0000.0 Parcel Id 17367 366 CANDLESTICK ROAD ELAZ, JOSEPH 366 CANDLESTICK RD N. ANDOVER, MA 01845 Page 1 Class 101 Single Family Property Type 1 Residential Zoning2 1 Residential Zoning3 1 Residential Size Total 2.14 Acres FY 2015 UB Mailina Index Name/Address Type Loan Number Active/Inact. From Until ELAZ, JOSEPH Payor 366 CANDLESTICK RD N. ANDOVER, MA 01845 UB Account Maint. Account No Cycle Occupant Name Active/Inactive Bldg Id. 17657.0.- 366 CANDLESTICK ROAD Last Billing Date 1/7/2015 3170327 03 Cycle 03 Active UB Services Maint. Account No. 3170327 Service Code Rate Charge Multiplier/Users MISCFEE ADMIN FEE 0.635/8 7.82 1/ WTR WATER 01 ALL METER SIZE 60.80 /1 UB Meter Maintenance Account No. 3170327 Serial No Status Location Brand Type Size YTD Cons 36388053 a Active ERT HH b Badger w Water 0.63 0.63 355 Date Reading Code Consumption Posted Date Variance 3/11/2015 353 a Actual 16 1% 12%11/2014 337 aActual 16 1/15/2015 16% 9/11/2014 321 aActual 14 10/15/2014 -13% 6/11/2014 307 aActual 16 7/16/2014 6% 3/11/2014 291 aActual 15 4/11/2014 -7% 12/10/2013 276 aActual 16 1/17/2014 -10% 9/11/2013 260 aActual 18 10/15/2013 20% 6/12/2013 242 a Actual 15 7/24/2013 -11% 3/13/2013 227 a Actual 17 4/22/2013 17% 12/11/2012 210 aActual 14 1/9/2013 -19% 9/13/2012 196 a Actual 18 10/15/2012 24% 6/12/2012 178 a Actual 14 7/16/2012 -10% 3/14/2012 164 a Actual 16 4/14/2012 12% 12/12/2011 148 aActual 14 1/17/2012 -21% 9/12%2011 134 a Actual 19 10/13/2011 5% 6/7/2011 115 a Actual 17 7/20/2011 4% 3/8/2011 98 a Actual 16 4/13/2011 1% 12/9/2010 82 aActual 16 1/12/2011 -54% 9/10/2010 66 a Actual 37 10/15/2010 35% 6/7/2010 29 a Actual 26 7/15/2010 73% 3/9/2010 3 a Actual 3 4/14/2010 -100% 2/19/2010 0 n New Meter 0 4/14/2010 -100% 2/19/2010 1469 r Replacement 21 4/14/2010 29% 12/8/2009 1448 aActual 20 1/12/2010 -6% 9/9/2009 1428 a Actual 22 10/15/2009 -6% 6%8/2009 1406 a Actual 22 7/20/2009 -1% 3/13/2009 1384 a Actual 24 4/29/2009 2% 12/9/2008 1360 aActual 23 1/20/2009 -30% 9/8/2008 1337 a Actual 34 10/10/2008 1% : �.. uommonweann oT massacnuseus City/Town of . System Pumping Record Form 4 DEP has provided this form for use>by local Boards of Health. Other forms may be'used, but the information• must be substantially the same as that provided here. Before using.this form, check with your local Board of Health to determine the form they use. The System Pumping Record must be submitted to the local Board of Health or other approving authority. A. Facility. Information 1. System Location: Left/ Right front of house, Righ ear of hous. Left/ right side of house, Left/ Right side of building, Left / Right front of building, Left / Righ rear o building, Under deck CityRown State Zip Code 2. System Owner. t Name' Address (if different from location) Cityrrown ' State ,a.I�r Zip Code - Telephone Number B. Pumping Record L4 1. Date of Pumping tate 2. Quantity Pumped: Gallons ,. 3. Typeof stem: sY . ❑ Cesspool(s) eptic Tank El Tight Tank ❑ 4. Other (describe): Effluent Tee Filter present? ❑ Yep No 5. Condition of stem: 6: System Pumped By: Neil, Bateson Name Bateson Enterprises Inc Company 7. Lo contents were disposed: La Lowell Waste Wg If yes, was it cleaned? 3 Q. F5821 Vehicle License Number nate ❑ Yes ❑No, t5form4.doc- 06/03 System Pumping Record • Page 1 of 7 or THOMAS E. NEVE ASSOCIATES, INC. :t Engineers - Land Surveyors - Land Use Planners 447 Boston Street US Route #1 TOPSFIELD, MASSACHUSETTS 01983 (508) 887.8586 FAX (508) 887-3480 TO SANpY STARK >3aARo OR= HE,aL_TH� NORTH ANpOVMR TD`NN HALL. iVORT1-1 A"DOVE.R MA > WE ARE SENDING YOU ❑ Attached ❑ Under separate cover via ❑ Shop drawings 5? Prints ❑ Plans ❑ Copy of letter ❑ Change order ❑ LIEUTEQ OF TRUMATUM DATE SEPT. ►B 1992 JOB NO. 305-Z- 18 ATTENTION SAIaoY TAr2 RE: 5Y5TEM DE ICG LOT lb C.Ar t>L_E,ST 1 C.14 ROAD T -o MAIrjTA10 THE 4' L3ET4JEEN THE qc>-rroM OF 51i'STEM AOD -1714E CsRoJNpv�/ATER Eac-oo►JTErZED. THE 5Y,5TEM poES MEET THE RE(rU L -,T10/05 the following items: ❑ Samples ❑ Specifications COPIES DATE NO. DESCRIPTION 4 No`-b'l-j REV AM%,. Lb, -y-1 5A-JITARY D15PogAL SYSTEM 1.0-r AS CAr1Ct_ESTIG.Ic ROAD TNOMA vE ASSot.i TES vP 10 ORDER T -o MAIrjTA10 THE 4' L3ET4JEEN THE qc>-rroM OF 51i'STEM AOD -1714E CsRoJNpv�/ATER Eac-oo►JTErZED. THE 5Y,5TEM poES MEET THE RE(rU L -,T10/05 An>p yJE Ho PE THAT 1(py WILL ISSOE. Aa APPR,oVaL So THAT THE 15VILDER MA`( C>ET STAMTED APJY OUESTIOOS OR PROBLEMS PL -.EAS& C.AL.L-, THAIJICYoJ FOR YoJR T-IRnnE 10 TN1S MATTER THESE ARE TRANSMITTED as checked below: JR For approval ❑ Approved as submitted ❑ For your use ❑ Approved as noted > ❑ As requested ❑ Returned for corrections ❑ For review and comment ❑ ❑ FOR BIDS DUE ❑ Resubmit copies for approval ❑ Submit copies for distribution ❑ Return corrected prints 19 ❑ PRINTS RETURNED AFTER LOAN TO US REMARKS DEAR SANDY : PLEASE FIND E►JG.LOSED -4 PRINTS of TI+E SEPTIC_ OESIGstJ POR LOT 16 C.AIJDLESTIG.IC RoAC DATED Nov. 6 1989 ^-)p REJISED To APRIL.. ZB L99Z. TL-iE SYSTEM WAs, eoi%_T vP 10 ORDER T -o MAIrjTA10 THE 4' L3ET4JEEN THE qc>-rroM OF 51i'STEM AOD -1714E CsRoJNpv�/ATER Eac-oo►JTErZED. THE 5Y,5TEM poES MEET THE RE(rU L -,T10/05 An>p yJE Ho PE THAT 1(py WILL ISSOE. Aa APPR,oVaL So THAT THE 15VILDER MA`( C>ET STAMTED APJY OUESTIOOS OR PROBLEMS PL -.EAS& C.AL.L-, THAIJICYoJ FOR YoJR T-IRnnE 10 TN1S MATTER S ►a C.HR L_`( COPY TO ' j1- - SIGNED: CQOM Moet PRODUCT 240-1n a Inc., cmron, Mm 01471. If enclosures are not as noted, kindly notify us at once. rg 7j D 0"73 poa!E,34J" MITlyr, A coo vi y No T rl. na. v w, 7. 1 0 Q Q27 vj nix Qfw. vow IV-- um"dju —A wm:�: win W A no; mil v 1 -i-T -V /4 H 1, i., -<,. -; -j To-_ rl. na. v w, 7. Town of North Andover, Massachusetts BOARD OF HEALTH DISPOSAL WORKS CONSTRUCTION PERMIT Site Location_ 21 /9 U 11/Uf. l E5 r/wi< Permission is hereby granted to Constructor Repair Sewage Disposal System as shown on the Design Approval S.S Fee lU ) an Individual Soil Absorption D.W.C. No. 61,3 > r , � co n / ^' 'CO R ® — J G © go 2 -. as f g r . . CL CD tA ® 0 .¢ 0 � . . % 0 g 0 0 / rn w 2 > C) o o 2 ƒ lu k -0. 0 0 E Acr x o . ° C)O 3:< .=rg m < . m , 0 . o D :3 / M 3 0 m Ln 2 / k > c tA z ° ® r r § z J k 0 nX § m g m 2 0 = r 2r. ° o 3 > . . ) 0 . . 2 . 0 _ . wl P m AS -BUILT CHECK LIST and FINAL INSPECTION Proposed Elevations As -Built Elevation ,,Zi2 House 6 9 Tank IN Tank OUT gQ /� l D -box IN 160,64 D -box OUT 160.1(4 Trench Inverts Line 1 166 -- /60 .O Line 2 /�©• l3- /meq• j3 Line 3 Line 4 Bottom of Exc. /fig -Z5 /!z Stone OK? D -box checked? Pipes cemented?-- FORM U - LOT RELEASE FORM INSTRUCTIONS: This form is used to verify that all necessary - approvals/permits from Boards and Departments having jurisdiction have been obtained. This does not relieve the applicant and/or landowner from compliance with any applicable local or state law, regulations or requirements. ****************Applicant fills out this section***************** APPLICANT• lf� /Ccs;° �� 7A-1 Phone LOCATION: Assessor's Map Number Parcel 9 J 7 -37y� Subdivision �2` '� �` ` e. Lot (s) l� Street "'��' S/' St. Number 13b(y ************************Official Use Only************************ RECOMMENDATIONS OF TOWN AGENTS: Date Approved Conservation Administrator Date Rejected Comments `,%l.)�� Approved t Date Town Planner Date Rejected Comments Date Approved Health Agent Date Rejected Comments VA-z1n1?t-10A1 a,- DFEP V1o1-Es ZiPio�? TG ANY '5S &I er_)V57RVC7-16N Clvea� �Fe 111 Public works -__,/water connections - driveway permit - hard wired smoke detector required permit to be pulled 11Fire Department hy electrician at. fire Deptprior--to inst lation Received by Building Inspector Date PLAN REVIEW CHECKLIST ADDRESS �� �� �Q/n l_ENGINEER GENERAL 3 COPIES C---' CONTOURS L/ PERC INFO c/ WETLANDS FDN DRAIN L, SEPTIC TANK MIN 1500G. STAMP �--� PROFILE -/ LOCUS 4/ NORTH ARROW ` SCALE L---= k�� SECTION V BENCHMARK No�r� SOIL & WETS. DISCLAIMER WELLS & ELEVATIONS ✓ WATERSHED? N SCH40_Y 25' TO CELLAR t-� D -BOX DRIVEWAY (Elev) WATER LINE TESTS CURRENT? d - /98 �e e - XY�er)51UV� 00 ��sflr�4 g,Uen.. .17 INVERT DROP MANHOLE TO GRADE GARB. GRINDER/fO (+200% EDF) ELEV GW SIZE # LINES FIRST 2' LEVEL STATEMENT_ INLET - OUTLET _ 716 (2" OR .17 FT) TEE REQ'D?410 LEACHING RESERVE AREA4/ 4' FROM PRIMARY? 100' TO WETLANDS � 2% SLOPE 100' TO WELLS 35' TO FND & INTRCPTR DRAINS C-� 4' TO S.H.GW L_— 325' TO SURFACE H2O SUPP L 4' PERM. SOIL BELOW FACILITY �-'- MIN 12!' COVER FILL?25'= f above natural elev; 101if below) BREAKOUT MET? t --- TRENCHES TRENCHES / / / MIN 660 gpd " SLOPE (min .005 or 6"/100')x/ >3' COVER? - VENT SIDEWALL DIST. 2X EFF. W OR D..(MIN 61) �� IS RESERVE BETWEEN TRENCHES?1IN FILL? / MUST BE 10' MIN. L-"�' 4" PEA STONE? --y BOT 7g0 X LDNG 'S + SIDE P -So X LDNG NO = TOT (L x W x #) (G/ft2) (DxLx2x#) DATE 30 42 Sheet of r BOARD OF HEALTH TOWN OF NORTH ANDOVER SUBSURFACE DISPOSAL DESIGN REVIEW FEE ��p PERMIT # . DATE RECEIVED 3 2G fL APPLICANT AV V ASSESSOR'S MAP ADDRESS PARCEL # LOT # A ENGINEER 1 f 6- STREET ADDRESS 447 liip B+oslaaJ 12p PLAN DATE 966 REVISION DATE CONDITIONS OF APPROVAL: APPROVED DISAPPROVED x Lvxc- -v j tv Q. 'DCt o. t t tX--56.I E A,T A o4 oti.L �11k �,Ac c -I � � Wn.��e.. �isv Tt �'l, �tZ,o., w Nl T'o