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HomeMy WebLinkAboutMiscellaneous - 42 WINDKIST FARM ROAD 4/30/2018 (2)A^ 71, MAP # LOT # 16 PARCEL # 3 STREET AA J --'J 5 / CONSTRUCTION APPROVAL HAS PLAN REVIEW FEE BEEN PAID? NO PLAN APPROVAL: DATE 7 / % APP. BY DESIGNER: /`1 ��j��"/��5� PLAN DATE- CONDITIONS ATE CONDITIONS 11 WATER SUPPLY WELL PERMIT_ WELL TESTS: .� WELL DRILLER CHENICALDATE APPROVED z BACTERIA DATE APPROVED BACTERIA II DATE APPROVED PLUMBING SIGNOFF. WIRING SIGNOFF COMMENTS: t FORM U APPROVAL: APPROVAL TO ISSUE� NO DATE ISSUED BY CONDITIONS: FINAL APPROVAL: -" ALL PERMITS PAID C YES NO WELL CONSTRUCTION APPROVAL SEPTIC SYSTEM CONSTRUCTION APPROVAL ��� NO OTHER YES NO ANY VARIANCE NEEDED YES Y� FINAL BOARD OF HEALTH APPROVAL: DATE: BY: SEPTIC SYSTEM INSTALLATION IS THE INSTALLER LICENSED? TYPE OF CONSTRUCTION: NEW CONSTRUCTION: CERTIFIED PLOT PLAN REVIEW CONDITIONS OF APPROVAL (FROM FORM U) ISSUANCE OF DWC PERMIT' DWC PERMIT PAID? v It YES NO �a::) REPAIR YES NO YES NO DWC PERMIT NO. INSTALLER: BEGIN INSPECTION YES NO: EXCAVATION INSPECTION: NEEDED: 1 - YES NO YES NO PASSED % BY � CONSTRUCTION INSPECTION: NEEDED: AS BUIr'LT PLAN SATISFACTORY: ,-YES: APPROVAL TO BACKFILL: DATE: o BY l FINAL GRADING APPROVAL: DATE FINAL CONSTRUCTION APPROVAL: DATE: 111,4�y '/ gg c.".... GtKIC1GA?fot,l 1b A L�1►ILlL.41.IN Of�f4E '5140'' 11�+GQ 14poy.L 2'�sK�iTeH, rT 1s A ZE,Ww 'opr4g �„w X 2.01 AW C I g vor 10J of Ti4k tri � i Nh yYSlr+ O Sex Q caHPos.1>`►� ry. AS BUILT PLAN SUBSURFACE DISPOSAL SYSTEM /77 �_/v Jo.7 LOCATEDIN Klo �-A �,4 D oV X12 , H -A _'17 / 1101'r D� t F v r—l. (ZP AS PREPARED FOR DATE: A SCALE: -T-L, 341999 MERRIMACK ENGINEERING SERVICES, INC. PROFESSIONAL ENGINEERS 0 LAND SURVEYORS • PLANNERS 66 PARK STREET • ANDOVW MASSACHUSE775 01410 4 TEL (617) 475-36S3. 373-5711 I r TOWN OF NORTH ANDOVER BOARD OF HEALTH CERTIFICATE OF COMPLIANCE DATE OF COMPLIANCE: 11/5/99 This is to certify that the individual subsurface disposal system constructed (X) or repaired ( ) by Ray Frazier at Lot 16 Windkist Farm Road has been installed in accordance with the provisions of Title V of the State Sanitary Code and with the North Andover Board of Health regulations as described in the Design Approval Site System Permit # 953 dated 7/15/97. The Issuance of this certificate shall not be construed as a guarantee that the system will function satisfactorily. Board of Health Inspector 10/29/99 09:10 1 G-28--1999 3: 2 1 Wt 1 5097740149 FROI } THE FRASER COMPANY TOWN OF NORTH AND+OVEIt SEWAGE DISPOSAL SYSTEM INSTALLATION CERTIFICATION The undersigned hereby certify that the Sewage Disposal System (instructed ( ) repaired: located at L PT was installed in conformance with the North And ver Board of'Health approved plan, System Design l?etmit # y,S3, dated `> flow of—:J-10o per day. The materials used were in conformance wwith an ith those design specifies on the approved plan; the system was installed in accordance with the p ovisions of 310 Cdvlt 13.OQ0, Title 5 and local regulations, and the substantially with the approved plats. All work is accuratelfinal Ors esented on the As - which has been submitted to the Board of Health, built Bed inspection date; Final inspection date: Engineer Representative hVneer Representative Installer: l Lic.#: Design E4neer: c�.. Date. Date: PAGE 01 F'. 2 7'C ,!M OF NORTH ANDOVER/ Pl^ ".SSD OF HEALTH Town of North Andover) Massachusetts of vaolt`rsf Form No BOARD OF HEALTH 0 -------- - I q__f2 DESIGN APPROVAL FOR ACH SS SOIL ABSORPTION SEWAGE DISPOSAL SYSTEM Applicant Test No Site Location eteren%,'flajq pecs. ENGINEER DESIGN `Permission j - Is: -granted fo an indiAd-uags6il- r in absorption sewage dis�6sa'l accordance with- system- to beinstalledf ons, 0. Board of"H�drtfi--­ re OF �HEALT�H�� —CHAIRMAN, 130A Fee, Site- . µ System Permit No. ER -L* w O O FM4 4 O > 1� H iar I/ oc L O a'o cr- L Cc CD g SS s Xz cD _ aD Cc CL COD cot tp CO O CD o Q r" O d Z jam' C*CD Q o y CD C O O 0 CD ti CL CD m m m '^ O �H h vJ y v C O 25 Of � _. m v L- o. 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X N5-'fC lv C'Effrl rr 7b rHd' Flo, ANDD%/ f -Z 6OLL71146 Pgl-r —rgArr -rN E- Fa JiJ09VIf tar.+7;Co o v riyEGOr Off .f.1VWW.4,410 7,-Wr/r PVWS CU✓.�G+Ci!/ !WrAl eV— Nv , APJCoV6X Z6wl va etesvt.irrws iAW44.C,01A4 C SG?AICorX '-�MW STrCErrS r 1 .1W7weW ryAr TN/S hquN D<cflOd CnUrt-O /N rwe- EAGr.IL Azowto W,714,Co 44pr.A. Syew" ejy ft 410 Mt/.v/Ty /AUAIC< '* ZSO�9S GOI�jC ...iVNE Z(R�I� �k f 4c �a a oeh . DOvvotY 9FG�S�P �Q�'�*, '� I Oav .�,r NOT FD.P .4r/041 7,-4&-E.V t'/JTZ G .C6rYi OS. �L O T �G Q�t/ /N I.lo�-rl ANr�©YES, F'fASS, i .LVODI'E�, .If�S.S.ilv!/SETTS O/B/D 0 77 3 p a D 0 Cul r p cv .x � D 0 ............... i ._............................... o o n 0 77 3 p a D 0 Cul r p cv L cD 3 oa � D 0 o o n ° D n c Or ZO o va' _ a c � 3 o � a o = P� � m y F cn D Z cr ull c 0 m o' 0 77 p D � r p 0 � D 0 cn ° D n Or ZO o c � 3 a O Z c m �» N 3 T O � 3 z 0 w FORM U - VERIFICATION FORM INSTRUCTIONS: This form is used to verify that all necessary approvals/permits from Boards and Departments having have been obtained. This does not relieve the appliantland/or tion landowner from compliance with any applicable local or state law, regulations or requirements. ****************Applicant fills out this section***************** APPLICANT: Lk Lz 6 Phone LOCATION: Assessor's Map Number �� i Parcel S5/ Subdivision • Lot(s) Street �C��l 5 %�� =�� St. Number 4- - **********jNSLTOZAGENTS: ****(ficial RECO onservation Administrator Comments Planner Comments Food Inspector -Health Septic Inspector -Health Comments/oma 'OK i :7'-e_✓ Use only************************ Date Approved Date Rejected Date Approved Date Rejected Date Approved Date Rejected Date Approved / 4 Date Rejected ,D& -,7e - Z, -,4 &-,7e- S/ �4 C LOQ % mss' Public Works - sewer/water connections i j C 7 - driveway permit 7,T -L-6 `� % 3� 97 Fire Department t lr&L (1ftvA J; Received by Buildingspector Date SEPTIC PLAN SUBMITTALS LOCATION: NEW PLANS: REVISED PLANS: YES $25.00/Plan DATE: � �46 DESIGN ENGINEER: eAel When the submission is all in place, route to the Health Secretary No. THE COMMONWEALTH OF MASSACHUSETTS FEE )BOARD OF HEALTH W/ v OF %U C4� 4_i APPLICATION FOR DISPOSAL SYSTEM CONSTRUCTION PERMIT Application for a Permit to Construct 0W Repair ( ) Upgrade ( ) Abandon ( ) - ❑ Complete System ❑ Individual Components lovi 11 i i WLocation A/P / �Ci� 77 Q0 Installer's Name Address Telephone R 4folon«P `j //ace pey CAa J�Qq 77 yO�wncrS amc ,6_dz� (o�Z ress _ - 2 Z Ph:lfd C��� Tcl hone q s f 14,4-7s cry 104 s' Mrju Designer's N X73 -f�3/ Address U Telephone # Type of Building: 1A1004 F7'QXi"i'y1 _ Dwelling — No. of Bedrooms Other — Ty�e of Building No. of persons Other fixtures Design Flow (min. required) 11 gpd Calculated design flow Plan: Date 61/0/'?7 Number of sheets 2 - Description of Soil(s) r, )y -SQn-iQ Soil Evaluator Form No./617 Name of Soil DESCRIPTION OF REPAIRS OR ALTERATION Lot Size S o Sq. feet Garbage Grinder ( ) Showers ( ), Cafeteria gpd Design flow provided 6> gpd Revision Date Date of E The undersigned agrees to install the above described Individual Sewage Disposal System in accordance with the provisions of TITLE 5 and fu r s of to ce the system in operation until a Certificate of Compliance has beear issued by the Board of Health. Signed Date Inspections FORM 1 - APPLICATION FOR DSCP DEP APPROVED FORM 5/96 No. THE COMMONWEALTH OF MASSACHUSETTS FEE BOARD OF HEALTH CERTIFICATE OF COMPLIANCE Description of Work: ❑ Individual Component(s) ❑ Complete System The undersigned hereby certify that the Sewage Disposal System; Constructed ( ), Repaired ( ), Upgraded ( ), Abandoned ( ) by: at has been installed in accordance with the provisions of 310 CMR 15.00 (Title 5) and the approved design plans/as-built plans relating to application No. dated . Approved Design Flow (gpd) Installer Designer: Inspector Date The issuance of this certificate shall not be construed as a guarantee that the system will function as designed. FORM 3 - CERTIFICATE OF COMPLIANCE DEP APPROVED FORM 5/96 No. THE COMMONWEALTH OF MASSACHUSETTS FEE BOARD OF HEALTH DISPOSAL SYSTEM CONSTRUCTION PERMIT Permission is hereby granted to Construct ( ) Repair ( ) Upgrade ( ) Abandon ( ) an individual sewage disposal system at as described in the application for Disposal System Construction Permit No. dated Provided: Construction shall be completed within three years of the date of this permit. All local conditions must be met. Date FORM 2 - DSCP FORM 1255 (REV 5/96) Board of Health DEP APPROVED FORM 5/96 H&W HOBBS& WARREN 'M PUBLISHERS - BOSTON FORM 11 - SU1L L v Page 1 of 3 Date: %9 No. Commonwealth of Massachusetts )V9 Y, % ��"�`�" , Massachusetts .. „ •�_L:�;�,t a ceoc.cment or E_�-site Sewage Di JU6� �7LLLLu-arYYvr - - I3 � J Date A Performed By: /.., . r�,5am Witnessed By: .�Cy�r.................... W , N.fne. Colo r %�l Aoe dM5T YI/�s Ad—'. aD1 %v 41/`� , ae__—.� a,,s�ryc �� T�iro� � 1/�d4�,uction fS Repair office Review Yes . Published Soil Survey Available: No ❑ d �— . f , /S' Soil Map Unit ���. Year Published �� y % .................. Publication Scalet .................. �CGi� ..Soil Limitations ...................................... ................... . Drainage Class Well d .... •...... ❑ 2--,yesSurficial Geologic Report Available: NPublication Scale Year Published .............................................. . Geologic Material (Map Unit).................................................................. ..... Landform...........�Y(,ti'►�. ........................................... Flood Insurance Rate Map: Above 500 year flood boundary No 'lJYes ❑ - 1/ Yes Within 500 year flood boundary No ❑ Within 100 year flood boundary No [;]'K es .......... Wetland Area: Ma ma unit) ................................................... P ... National Wetland Inventory P ............................................ Wetlands Conservancy Program Map (map unit) Current Water Resource Conditions (USGS): Month Range :Above Normal ❑Normal []Belch/ Normal 11 Other References Reviewed: DEP APPROVED FORM • 12/07/95 FORIM 11 - SOIL EVALUATOR FORM Pagc of Location Address or Lot No./&h1S On-site Review % Deep Hole Number jp'—'/ Date: b /13/�J�/ Location (identify on site plan) I P q7 /6 �1 Land -Use .. Slope (W) 3 Vegetation ak, G)k' lc Landform sl'U / n l "'l Position on landscape (sketch on the back) Distances from: Time: �' Weather 072Ld�� �OJ Surface Stones na Open Water Body feet Drainage way Possible Wet Area feet Property Line W II � feet Other feet feet Drinking Water e DEEP OBSERVATION HOLE _OG� Deoth from Soil Horizon Soil Texture Soil Color Soil Other ) (USDA) (Munseil) I Mottling (Structure, Stones. Boulders, Consistence, Surface (Inches°ro 0 8 A F S.� . �o v�43 S•� /o Ye (`l Mass%�� abs i �lL y 'i- L Nr ; Vt t-10 D DISPU Lr c r/ Depthto8edrock:^> 143 Parent Material (geologic! Depth to Groundwater: Standing Water in the Hole: �� Weeping from Pit Face: Estimated Seasonal High Ground Water: DEP APPROVED F0101 - 12107/95 rvr`.., L♦ Page ; of Location .-address or Lot No. 1 �� � � ' � Y� termination for Se Method Used. ie,h Mater nl Depth observed standing in observation hole inches Depth weeping from side of observation hole inches Depth to soil mottles inches ;round water adjustment feet index Wpli Number ............. Reading Date ................ Index well level Adjusted ground water level Adi.:stment actor J Depth o` Naturally Occurring Pervious Material Does at least four feet of naturally occurring ithe soil sous material exist m all areas observed throughout the area propose 7 141 not, what is the depth of naturally occurring pervious material? �eYiifl�^ti�" �er`ify that on %�%`� (date) I have sassed the soil evaluator exammGt�or apprcved by the Department of `:nvironmentaProtection ing e peruse and oX aenaonsi was performed by me consistent with the required aescribed in 310 CMR 1 x.017. i Signature !� ��C� Date T_J V DEP APPROVED FORA - 1:107M FORINT 11 - SOIL t VALUH1UN rvhiU Page Z'of 3 Location Address or Loti� o. f �0 ir1 S � r-4 va H CJ Mt to n i c tRy PHUPUJCU Ularuz— AT ,/ DepthtoBedrock: Parent Material -(geologic) , 1154 / Weeping from Pit Face: Death to Groundwater: Standing Water in the Hole: / Estimated Seasonal High Ground Water 7 DEP APPROVED FORM - 12107/95 On-site Review Z/ 1 I3 �� Time: :30 Weather fttcu� e Deep Hole Number Date: 71097_7-.1 Location (identify on site plan) Slope M) Surface Stones no Land. Use ... Vegetation Landform Or u m It ✓l Position on landscape (sketch on the back) Distances from: Open Water Body feet Drainage way feet Possible Wet Area feet Property Line feet Drinking Water Well feet Other DEEP OBSERVATION HOLE _OG* Deoth from Soil Horizon Soil Texture Soil Color Soil (USDA) (Munsell) Mottling Other (Structure, Stones. Boulders, Consistency, 4.0 Surface !Inches) 6-7 A4a siv'e F%0,h(� 7_23 a,sv�� Icy ,� Q s s% NMve� NICD H CJ Mt to n i c tRy PHUPUJCU Ularuz— AT ,/ DepthtoBedrock: Parent Material -(geologic) , 1154 / Weeping from Pit Face: Death to Groundwater: Standing Water in the Hole: / Estimated Seasonal High Ground Water 7 DEP APPROVED FORM - 12107/95 Location Address or Lot No. �ndtion Method Used: 1UrCJ�'1 11 ►�\/1L L � ►•... �..►• v.. • vim.•. • Page 3 of 3 ►o,h. Water Tab �J Depth observed standing in observation hole . Depth weeping from side of observation hole Depth to soil mottles v2 inches i = around water adjustment feet index Well Number ............... Adiustment factor ........... Reading Date .................. -inches inches Index well level Adjusted around water level Deoth o` Naturally Occurring Pervious Material Does at least four feet of naturally occurring -pervious material exist in all areas observed throughout the area proposed for the soil absorption system. -J If not, what is the depth of naturally occurring pervious material? ��riiil�,3tivr' - / certify that on. �� `� (date? I have passed the soil evaluator examinatior approved by the Department of EnvironmentaUPr� to ainin tion ane pertise and exp ove rienc, was performed by me consistent with ane rep 9. described in 310 CMR 1 x.017. , G� � `= Date .� �2 i � 7 Signature `" DEP APPROVED FOR.N1 - 13/07/95 FORM 1_2- PERCOLATION TEST Location Address or Lot No. 16., 61 16'97-- ✓ ce—d( COMMONWEALTH OF MASSACHUSETTS Al,Prdfd iJ'e , Massachusetts Percolation Test* Date: X113517 Time:, Observation Hole # `� _ / n Depth of Perc Start Pre-soak End Pre-soak Time at 12" Time at 9" Time at 6" l� Z too- Time (9"-6") Rate Min./Inch — -CA * Minimum of 1 oercolation test must be pperfcr—med in broil i the primary area AND reserve area. Site Passed R Site Failed ❑ ......................................................................................................................................__._......._......_. Performed By: Witnessed By: c5:2in'4t sx"� Comments: . DEP APPROVED FORM - 12/07/95 M `o gV6 ggkV APPLICATION FOR DISPOSAL WORKS CONSTRUCTION PERMIT DATE: C 2Z CURRENT INSTALLER'S LICENSE# LOCATION: GOT IC W IA)D l-1 S T -FST PT&S LICENSED INSTALLER: /7fiy /f4dry0 T F/;'RSErz 1T SIGNATURE:. TELEPHONE# 978 '774-9146 CHECK ONE: REPAIR: NEW CONSTRUCTION: IF NEW CONSTUCTION, PLEASE ATTACH FOUNDATION AS -BUILT. $75.00 Fee Attached? Foundation As -Built? Administrative Use Only Yes c/ No Yes:z// No Floor Plans? es_ No Approval Date: HEALTFf JUN 23 0