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Miscellaneous - 438 SUMMER STREET 4/30/2018
438 SUMMERS ET- y 210/107.A-0077-0000.0 4 I � r' r i i 438 SUMMER STREET 210/107.A-0077-0000.0 iI I -5 Date.... (,7_06 .... AORTH TOWN OF NORTH ANDOVER AL 3r •` ° PERMIT FOR WIRING ,SsACMUS c� This certifies that . .?R W, has permission to perform . ?' ............ ..... ....... ..:�'�' !.......................... wiring in the building of.... ...................... atR........., .....',;F77 . ... ,North Andover,Mass. Fee.. `""'.. Lic.No.� ......... .. ......... .............. . .......... ... y. ELECTRICAL INSPECTO `, Check # 62�? b �_- 6850 Commonwealth of Massachusetts Official Use Only Department of Fire Services Permit No. Occupancy and Fee Checked J ` BOARD OF FIRE PREVENTION REGULATIONS [Rev.9/05] (leave blank) APPLICATION FOR PERMIT TO PERFORM ELECTRICAL WORK All work to be performed in accordance with the Massachusetts Electrical Code(MEC),527 CMR 12.00 (PLEASE PRINT IN INK OR TYPE ALL INFORMATION) Date: City or Town of: " zr7 qpm-(/� To the Ins ect of Wires: By this application the undersigned gives notice of his or her intention to perform the electrical work described below. Location(Street&Number) XT— Owner .t;T— Owner or Tenant /2,51 3(Cx��_J A � -7— Telephone No. Owner's Address Is this permit in conjunction with a building permit? Yes ❑ No ©'(Check Appropriate Box) Purpose of Building �//jfzwe / Utility Authorization No. Existing Service /00 Amps /ZD /z YO Volts Overhead � Undgrd❑ No.of Meters ) New Service 26C Amps Z7,0 Volts Overhead E3— Undgrd ❑ No.of Meters _ Number of Feeders and Ampacity ` 1-19;7 Location and Nature of Proposed Electrical Work: .� �1n'lc�I+ Zej6 ,$AJr 02- 2262U!k K IJI Cp 7 64 bet:— Completion of the following table may be waived by the Inspector of Wires. No.of Recessed Luminaires No.of Ceil.-Susp.(Paddle)Fans No.of Total Transformers KVA `+ No.of Luminaire Outlets No.of Hot Tubs Generators KVA No.of Luminaires Swimming Pool Above ❑ In ❑ o.o Emergency Ligbiting rnd. rd. Batter Units No.of Receptacle Outlets No.of Oil Burners FIRE ALARMS No.of Zones No.of Switches No.of Gas Burners No.of Detection and Initiating Devices No.of Ranges No.of Air Cond. Total No.of Alerting Devices Tons g No.of Waste Disposers Heat Pump I Number I Tons KW No.of Self-Contained Totals: Detection/Alerting Devices No.of Dishwashers Space/Area Heating KW Local❑ Munic'pal ❑ Other Connection pp KW No.of Dryers HeatingAppliances Security Systems: No.of Devices or Equivalent No.of Water KW 0.0 No.of Data Wiring: Heaters Signs Ballasts No.of Devices or Equivalent No. Hydromassage Bathtubs No.of Motors Total HP Telecommunications Wiring: No.of Devices or Equivalent OTHER: �J Attach additional detail if desired, or as required by the Inspector of Wires. ' Estimated ValVoflect ical Work: (When required by municipal policy.) Work to Start: (�� Inspections to be requested in accordance with MEC Rule 10,and upon completion. INSURANCE RAGE: Unless waived by the owner,no permit for the performance of electrical work may issue unless the licensee provides proof of liability insurance including"completed operation"coverage or its substantial equivalent. The undersigned certifies that such cover e is in force,and has exhibited proof of same to the permit issuing office. CHECK ONE: INSURANCE OND ❑ OTHER ❑ (Specify:) I certify,under the pains and penalties of perjury,that the information on this application is true and complete. FIRM NAME: 122( 1!_IC--( S �l/lC LIC. NO.:6�'/Z 3/ Licensee: J6t_/= AM A-)-5 Signature LIC. NO.:4/--�;"%6Z (If applicable, enter "exempt"in the license number line.) Bus.Tel. No. 7ds/'zS8'9�6J Address: S'T c54(,161-19 PIA 11 Alt.Tel. No.: *Security System Contractor License required for this work; if applicable,enter the license number here: OWNER'S INSURANCE WAIVER: I am aware that the Licensee does not have the liability insurance coverage normally required by law. By my signature below, I hereby waive this requirement. 1 am the(check one)❑ owner ❑ owner's agent. Owner/Agent \I Signature Telephone No. PERMIT FEE. $ Location 1133 SO 441 11 r l r� No. 5,3 Date ypRTN TOWN OF NORTH ANDOVER A Certificate of Occupancy $ 4L I Building/Frame Permit Fee $ aS ��sswcH�sEt� Foundation Permit Fee $ Other Permit Fee $ Sewer Connection Fee $ Water Connection Fee $ TOTAL $ ✓1L /136(l '11P'� Building Inspector 13464 Div. Public Works i PERMIT NO. �� APPLICATION FOR PERMIT TO BUILD"""""" *NORTH ANDOVER, MA ., 11iAP NO. 1,07 LOT NO, 2. RECORD OF OWNERSIIIP DATE BOOK PAGE ZONESUB DIV. LOT NO. v LOCATION W3 V 'su m e r PURPOSE OF BUILDING l �( � T \� OWNER'SNAl11E e �N^V� �r r1C NO.OF STORIES' b �� SIZE OWNER'S ADDRESS Y 1 vA BASENIENTORSLAB ARCHITECT'S NAME l� SIZE OF FLOOR TMIBERS 2-)( 1 1 I 2ND 3RD BUILDER'S NAME -p.r � SPAN [4 I l l� DISTANCE TO NEAREST BUILDING DIMENSIONS OF SILLS DISTANCE FROM STREET DIMENSIONS OF POSTS DISTANCE FROM LOT LINES-SIDES REAR DIMENSIONS OF GIRDERS AREA OF LOT FRONTAGE HEIGHT OF FOUNDATION THICKNESS IS BUILDING NEW ���cJ SIZE OF FOOTING i D �yl -�Uk, X IS BUILDING ADDITION (/p S MATERIAL OF CHIMNEY IS BUILDING ALTERATION / IS BUILDING ON SOLID OR FILLED LAND WILL BUILDING CONFORM TO REQUIREMENTS OF CODE \f IS BUILDING CONNECTED TO TOWN NATER BOARD OF APPEALS ACTION,IF ANY IS BUILDING CONNECTED TO TOWN SEWER IS BUILDING CONNECTED TO NATURAL GAS LINE INSTUC HONS 3.PROPERTY INFORMATION LAND COST �� I t EST.BLDG.COST PAGE 1'SFILL OUT SECTIONS 1-3 `\ EST.BLDG.COST PER SQ. FT. v4 `3�o EST.BLDG.COST PER ROOM ELECTRIC METERS MUST BE ON OUTSIDE OF BUILDING SEPTIC PERM FT NO. cid ATTACHED GARAGES MUST CONFORM TO STATE FIRE REGULATIONS 4. APPROVED BY: PLANS MUST BE FILED AND APPROVED BY BUILDING INSPECTOR BUILDING INSPECTOR DATE FILED OWNERS TEL# (` l 8-GS2_'e)4-1a 1 CONTR.TELH (te7b- 35Z 0' l 0 l O \( CONTR.LIC# ��44q_G SIGNATURE OF OWNER OR AUTHO IZED AGENT FEE $ �V PERBITT GRANTED. l l 19 Revised 5/5/99 JM 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 or requirements. ******************APPLICANT FILLS OUT THIS SECTION. APPLICANT \� � PHONE ���" OLR(o LOCATION: Assessor's Map Number (0-1 PARCELq SUBDIVISION LOT (S) STREET SuYY1mec Z,)I-- ST. NUMBER 4-:39 ** ********** ** ********* **OFFICIAL USE ONLY************ *** ************* RECOMMENDATIONS OF TOWN AGENTS: �J CONSERVATION A MINISTRATOR DATE APPROVED 2Z Lt, DATE REJECTED I w COMMENTS ��� i TOWN PLANNER DATE APPROVED DATE REJECTED COMMENTS FOOD INSPECTOR-HEALTH DATE APPROVED DATE REJECTED SEP I PECTORAALTH DATE APPROVED 1Z z DATE REJECTED COMMENTS .� e S �! 5 ' PUBLIC WORKS -SEWERIWATER CONNECTIONS DRIVEWAY PERMIT FIRE DEPARTMENT RECEIVED BY BUILDING INSPECTOR DATE Revised 9197 jm e. y .� i� P,�'at x = a W,# i,t1?`li.1 i�;i. i a ;i:: a n. I, y t., r S y [ s - ,� S, t.�y f } i3r+ f' :t i"4.,-t F.:aK�3 a s }. .0 q + ! rr .. .. . r .I t .'r J .�i t.'t y t -.r,: !i1 n S;XF T : '3 1 7ill t --:a,l a s:§ra- Is r J-z t 7 S C., t a > ,�-r't, ". , o- r t. 11 r' 4 .t.;3i r;` S{..% u1S t } ' b Y 7 ?" t ! 'r ' o , I} .'.I c x t 2U s .a', f 1 •`"'l, } i 4.. it . 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'"�-J I LY ,O Omit',v y! A.i'',>At ^Y+ S'{ 7> s q: 7 a a' p_"i. p,.(.�'G'r l;''-�,A S - ,,.r t Q' ,I.LI Q� % ��7 a -;" ,.' •.,1 9 ,i ;.�M F< t}'1� , i' 4e;y.; r �,,,. ILL &�.J' 11°? 7.!': .. - 1. - - ' =�sr'•rQ�I t J� a i tl} I ' yf^! i�t W 133 a'it' ta: ,." (o-.� Ir,ft. , �Xj�i w*1.1 .y_. k'}. I.i J - % _ � .. -7 at ,§,r tt i inn ,5J§y } 4.,et;3� L-' f O.pi[O Q 'S r" f L ii - - c. f 1 j t Qt. I�1 .x.r �2.:Y.:.iY-' • w,�ar:;, ty.,t...,.{ xi i I.., I,..t,l :Y.t •. , M ORTGAGE SURVEY/PLOT' PLAN x' FOR BANK USE ONLY This Plan is based upon Public Records and existing physical evidence on the ground . ADDRESS: Z -JM6� !! ! KIDe-1l-4 - ' G t APPLICANT V_eVc ,� _ ,[V&uz,e W E, CALLA:WAN SOURCE: yfcm -F, Tf-EAT E_ t�FD ZC34 SCALE: CERTIFICATE I CERTIFY that the t L L,tQ RLGT.STRY shawn� hereon DEED. BIC. td:_ PG : �n(cZ4� i present Zoning of the2E"� of PLJUT And further, that the CERT. OF TITLE ( are): not located within a desig— ' `:':n`ated Flood Iiazard Zone . C.omm un i U y Panel No. 2 ja0">8--o� - Dai;ed �� 2 ► `Lone - .1-OFERT, Lp, q RODI;I3T G GOODW N R.L. S. � G;c�crrtn GOODWIN m 82 Central Street 117930 kY Andonr, Mass , <9^9FU(S7E�ln , • °;N OTE i7Y ROGER S. LeBLANC GENERAL CONTRACTOR CARPENTER*BUILDER (508) 352 - 8170 (SAS ZX-L- BallvJ9(15 -36 r � q . r North Andover Building Department Tel: 978-688-9545 DEBRIS DISPOSAL FORM In accordance with the provision of MGL c 40 S 54, a condition of Building Permit Number is that the debris resulting from this work shall be disposed of in a properly licensed solid waste disposal facility as defined by MGL c11, S150A. The debris will be disposed of in: �o t�. YYtxwS r' c��6,4 (Location of Facility) Signature of Permit Applicant -21 Date NOTE: Demolition permit from the Town of North Andover must be obtained for this project through the Office of the Building Inspector i I The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations \� W� Boston, Mass. 02111 vWorkers' Compensation Insurance Affidavit Name Pleaser Print Name Location: City f-/,V Phone # X71)- c I am a homeowner performing all work myself. ® I am a sole proprietor and have no one working in any capacity I am an employer providing workers' compensation for my employees working on this job. Comoanv name: Address Citv: Phone# Insurance Co. Policv# Companv name: - Address Citv: Phone# Insurance Co. Policv# Failure to secure coverage as required under Section 25A or MGL 152 can lead to the imposition of criminal penalties of a fine up to$1,500.00 and/or one years'imprisonment as well as civil penalties in the form of a STOP WORK ORDER and a fine of(3100.00)a day against me. I understand that a copy of this statement may be forwarded to the Office of Investigations of the DIA for coverage verification. do hereby certify uneams,and p tie e urs th t the information provided above is true and correct. Signature Date l �? Print name SnefL�lG", Phone# >-J52-76 ric r Official use only do not write in this area to be completed by city or town official' City or Town Permit/Licensing Building Dept ❑Check d immediate response is required Licensing Board Selectman's Office Contact person: Phone:: 11 Health Department ❑ Other w ♦ 1 y NORTFI ONNM of• • L p dover L No. �- p = l E dover, Mass., 1 COCHE G, ApRA 7 E D S 5` 7 BOARD OF HEALTH Food/Kitchen rE 11 M .1 I T U Septic System THIS CERTIFIES THAT....KWV1.A)..4P ... mPp.rkeev BUILDING INSPECTOR .. alb ►.4Au....................................... Foundation has permission to erect...1.419.14.1 . . . 1. P �.�!...... .................. buildings on ....�.�.&........�&.v.�..�r.�.......�..� - Rough to be occupied as..... ..P. .... ..C.It......o .....R .�.r...®. ... +►V Q'�V N�. Chimney . . . . . . ........... provided that the person accepting this permit shall in every respect conform to the terms-of the application on file in Final this office, and to the provisions of the Codes and By-Laws relating to the Inspection, Alteration and Construction of Buildings in the Town of North Andover. PLUMBING INSPECTOR VIOLATION of the Zoning or Building Regulations Voids this Permit. Rough ' to I PERMIT EXPIRES IN 6 MONTHS Final b4 UNLESS CONSTRUCTIONoiTARTS ELECTRICAL INSPECTOR Rough as ......................................... Service • BUILDING INSPECTOR Final Occupancy Permit Required to Occupy Building GAS INSPECTOR Display in a Conspicuous Place on the Premises — Do Not Remove RoughFinal No Lathing or Dry Wall To Be Done FIRE DEPARTMENT Until Inspected and Approved by the Building Inspector. Burner Street No. SEE REVERSE SIDE Smoke Det. Id i.r Ra. BMW=II 'Una MW III Nam IIIt %Anil 1 i,no- KIM -X Iowl,YQQ W"I �15 MAKI IIiitIV goo Ivisit iF 410*0 not 0 IIINot I"To" ITI vows& "I" -Amp Ir; IW goo kne Iit ns. lish, squ, ?p IT531 IItIIIInow,,,If Its oil x„_, y. ILI U-sh py- IIIISO Ina Irail HIM f"Nowl null of IIIIIlip IIIIL W fall�n PTA A, AMIN III "NINA,",.jaw IIAMHU1 t(;)N[3(j IIIcalms tII02 i ; lot QS I-AW IITILi IITIL4J'Man tIlong—AV ',,f}:IIIKNIq lot 11"Up"kY ,4 .IYN.Ito eg tII ;on IIOct.............. IIIIIII .. a_ _ ,. Location - ,=1 t+M'I f-er f No. /_ Date 42— TOWN 2 - TOWN OF NORTH ANDOVER „ Certificate of Occupancy $ * Building/Frame Permit Fee $ ss� Hus CHU ESQ Foundation Permit Fee $ Other Permit Fee $ Sewer Connection Fee $ Water C�onneon Fee, $ WW Building Inspec'tor a• Rs � s Colic Div. Public Works Location No. ° Date /y j2- i "ORTPI TOWN OF NORTH ANDOVER ! OA „ Certificate of Occupancy $ • ; * Building/Frame Permit Fee $ / Foundation Permit Fee $ sACMusE Other Permit Fee $ PAID -eMrk;$n c�,ion Fee $ Water Connection Fee $ TO�y4L � $ Building Inspector Div. Public Works PERlIIT N0. -149 APPLICATION FOR PERMIT TO BUILD - NORTH ANDOVER, MASS. I,/PA G E. 1 ` ✓�vIAP 4-40. LOT NO. 2 RECORD OF OWNERSHIP 'DATE (BOOK 'PAGE — ZONE I SUB DIV. LOT NO. LOCATION �f - PURPOSE OF BUILDING OWNER'S NAME ( NO. OF STORIES ZE OWNER'S ADDRES Ste'- BASEMENT OR SLAB ARCHITECT'S NAME SIZE OF FLOOR TIMBERS IST 2ND 3RD BUILDER'S NAME SPAN DISTANCE TO NEAREST BUILDING DIMENSIONS OF SILLS DISTANCE FROM STREET POSTS DISTANCE FROM LOT LINES—SIDES REAR GIRDERS AREA OF LOT FRONTAGE HEIGHT OF FOUNDATION THICKNESS IS BUILDING NEW SIZE OF FOOTING X IS BUILDING ADDITION MATERIAL OF CHIMNEY IS BUILDING ALTERATION - IS BUILDING ON SOLID OR FILLED LAND WILL BUILDING CONFORM TO REQUIREMENTS OF CODE IS BUILDING CONNECTED TO TOWN WATER BOARD OF APPEALS ACTION. IF ANY IS BUILDING CONNECTED TO TOWN SEWER IS BUILDING CONNECTED TO NATURAL GAS LINE INSTRUCTIONS 3 PROPERTY INFORMATION LAND COST SEE BOTH SIDES EST. BLDG. COST PAGE 1 FILL OUT SECTIONS 1 - 3 EST. BLDG. COST PER SQ. FT. FAAGE 2 FILL OUT SECTIONS 1 - 12 EST. BLDG. COST PER ROOM SEPTIC PERMIT NO. Et ECTRIC METEPS MUST BE ON OUTSIDE OF BUILDING 4 APPROVED BY t ATTACHED GARAGES MUST CONFORM TO STATE FIRE REGULATIONS PLANS MUST BE FILED/{AND APPROVED BY BUILDING INSPECTOR DATE FILED BOARD OF HEALTH T/UREA OOP.OWN OR A T JUZED AGENT FEE OWNER TEL.# PLANNING BOARD PERMIT GRANTED CONTR.TEL.# - $ / 19 L CONTR.LIC.# 'oe BOARD OF SELECTMEN [��.'{,•,, ( A -BUILDING INSPECTOR +�:.' Cil I .. I BUILDING RECORD 1 OCCUPANCY 12 , SINGLE FAMILY I I STORIES THIS SECTION MUST SHOW EXACT DIMENSIONS OF LOT AND DISTANCE FROM MULTI. FAMILY OFFICES LOT LINES AND EXACT DIMENSIONS OF BUILDINGS. WITH PORCHES. GA- APARTMENTS I RAGES. ETC. SUPERIMPOSED. THIS REPLACES PLOT PLAN. CONSTRUCTION 2 FOUNDATION —I 8 INTERIOR FINISH CONCRETE _ 3 1 2 13 CONCRETE BL'K. PINE _ BRICK OR STONE HARDW D PIERS PLASTER _ DRY WALL _ UNFIN. 3 BASEMENT AREA FULL FIN. B'M'TAREA _ Y. 1/7 '/ FIN. ATTIC AREA _ N_O B M T FIRE PLACES _ HEAD ROOM MODERN KITCHEN 4 WALLS I 9 FLOORS CLAPBOARDS B 1 2. 3 r DROP SIDING CONCRETE �_ WOOD SHINGLES EARTH _ ASPHALT SIDING HARD\r✓'D _ ASBESTOS SIDING COMMON VERT. SIDING ASPH. TILE _ STUCCO ON MASONRY STUCCO ON FRAME BRICK ON MASONRY ATTIC STIRS. & FLOOR I_ BRICK ON FRAME CONC. OR CINDER BILK. STONE ON MASONRY WIRING STONE ON FRAME _ SUPERIOR I_f POOR ± ADEQUATE I NONE 5 ROOF 10 PLUMBING GABLEHIP BATH 13BATH FIXE GAMBREL MANSARD TOILET RM. 12 FIX.) _ FLAT SHED WATER CLOSET _ ASPHALT SHINGLES LAVATORY WOOD SHINGES KITCHEN SINK SLATE NO PLUMBING _ TAR & GRAVEL STALL SHOWER _ ROLL ROOFING I MODERN FIXTURES _ TILE FLOOR TILE DADO 6 FRAMING II 11 HEATING WOOD JOIST PIPELESS FURNACE FORCED HOT AIR FURN. TIMBER BMS. &COLS. STEAM STEEL BMS. & COLS. HOT W'T'R OR VAPOR WOOD RAFTERS AIR CONDITIONING RADIANT H'T'G UNIT HEATERS 7 NO. OF ROOMS GAS OIL B'M'T 2nd _ ELECTRIC 1st 13rd NO HEATING �ATUI_.......__..— INA6 rLANNIMa CON ERVATION FINAL n over Town of orth ',��A No. 03�� a A'fEjyy.-_.. :_ � ��ISM 11" )RIVEohAndover, Mass., 19 �Z S`R a BOARD OF HEALTH LD MIT To U THIS CERTIFIES THAT........... . .... ........................... BUILDING INSPECTOR has permission to WM ... .. ...... buildings on ...4030... ••• Rough . �� Chimney tobe occupied as.......... �. .. .... ... Y........................................ Final provided that the person accepting this permit shall in every respect conform to the terms of the application on file in PLUMBING INSPECTOR this office,and to the provisions of the Codes and By-Laws relating to the Inspection,Alteration and Construction of Rough Buildings in the Town of North Andover. Final VIOLATION of the Zoning or Building Regulations Voids this Permit. 1 IN (3 M0111111-Is . ELECTRICAL INSPECTOR Rough M_� � I` ai.) .3 _�f� � ..�. . Service Final ....... . . .... ... . ...... ...................... BUILDING INSPECTOR GAS INSPECTOR Rough 'C1,1`,11!1 R OV14,1'01 !u 4vW!'up l! PlIfj(iNG -_..._._..._----- ----- — —--- - - ..-- - Final Display in a Conspicuous Place on the Premises FIRE DEPT. Do Not Remove Burner No Lathing to Be Done Until Inspected and Approved by Smoke Det. Building Inspector 14 I � t it 6 , P�1611. ilIIII ;� l' 14 .. u 9m;- N Y } _ ♦r iml�a Am 438 . , .� R�1 >a1.0 1 ..J`� iL1YYlL - ��� ■err cm VFMAi q r �.,���l��fOiL'•1e.>< � ei 'offf. ,j' 'i� 4",r, 1 , ' -1 C �. Y �,':i i � r. :e `•- ..J r. � �\\1` � pa.:� . . � �, y � `-�, 4 fii q� W /}�� -`.. _ � , .` _.._.� r !7ff. ` _ yx.+.a�.. `.l �� �r ::� hy� �' �� � '�,. --� ,�,ayl�- ..� yryY' � 4n.,f::�i'r �y Y 6 y 3tF-X ;:>'. .,.a-' ��'��_� 3 ��� {3'� �e; .r/'. ��' t �l '' �_�- +Y/ � Df L �.: � ��� �� } .� �1 r� i�S�.:;': 4 `. �" � .y, } - - F Y.� �y _ ��j7I}�Yt K�. e ,a�5 �� t �� -�. F 4' 1� �' .f S /9. ..a w.� 1 4 '��� �. �Q} C Location V SUv►? mr � � � No. � Date X).0 NORT►, TOWN OF NORTH ANDOVER p Certificate of Occupancy $ .¢ • : ; ; Building/Frame Permit Fee $ �sE<� Foundation Permit Fee $ M1 CH ---� o Other Permit Fee $ Sewer Connection Fee $ Water Connection Fee $ TOTAL $ t/ Building Inspector 132' 23 Div. Public Works PERMIT NO. 2 APPLICATION FOR PERMIT TO BUILD********N RTH ANDOVER, MA NIArNo. LOT NO. 2. RECORDOFOVNERSIID' v DATE BOOK PAGE ZONE , fa Still DIV. LOT NO. LOCATION �(J� Um n,er � PURPOSE OF BUILDING t �t �p,� � Ca c� s , ( Wt�vDouO/000r, Cl©s-.� cN OWNER'S N.ANIE Ji'eEK q ka v\ NO.OF STORIES SIZE OWNER'S ADDRESS 1}',� � e� - BASENIENT OR SL-All ARCIIITECT°S NANIE SIZE OF FLOOR TINIBERS ST 2ND 3`D BUILDER'S NAME e� (� SPAN DISTANCETO NEAREST BUILDING DIMENSIONS OF SILLS DISTANCE FROM STREET DIMENSIONS OF POSTS DISTANCE FROM LOT LINES-SIDES REAR DIMENSIONS OF GIRDERS AREA OF LOT FRONTAGE HEIGHT OF FOUNDATION THICKNESS IS BUILDING NEW SIZE OF FOOTING X IS BUILDING ADDITION MATERIAL OF CHIMNEY IS BIIILDIN ,I.TERATION LS BUILDING ON SOLID OR FILLED LAND WILL BUILDING CONFORM TO REQUIRENIENTS OF CODE IS BUILDING CONNECTED TO"TOWN NVATER Y e S BOARD OF APPEALS ACTION, IF ANY IS BUILDING CONNECTED TO TOWN SEWER IS BUILDING CONNECTED TO NATURAL GAS LINE INSTIIC"TIONS 3. PROPERTY INFORNIA"TION LAND COST EST. BLDG.COST PAGE I FILL.OUT SECTIONS 1-3 EST.BLDG.COST PER SQ. FT. EST. BLDG.COST PER ROOM ELECTR?C METERS NIUST BE ON OUTSIDE OF BUILDING SEPTIC PERMLf NO. 12 Al-I'ACIIED GARAGES NIUSTCONFORNI TO STATE FIRE REGIII-A"LIONS d. APPRON'FI)BY: PLANS MUST BE FILED AND APPROVED BV BUILDING INSPECTOR BUJIMING INSPECTOR DATE FII-F.D OWNERS TET.# CONTR.TELN ,3�j 8 Q SIGN:\HIRE OP((d)\VNF:R OR AUllIOIiIZE;U AGENT CONTRAK 202oG6 FEE $ Cl II.I.C.# 4�( �J G ( 2- ( 17 Jdv 1'E JUN IITCRANTE D Revised 5/5/99 JN The Commonwealth o Afassachusetts — ( Department of Industrial Accidents — MICS'd11RYe5tl9atlo17s = ; 600 Washington Street Boston, Mass. 02111 Workers' Compensation Insurance Affidavit r .n � CCLA-� aam -53T SujX FO"\. T 0 -- A 6 a R7.8-352-8174) I am a homeowner performing all work myself. [ am a sale proprietor and have no one working in any capacity I am an employer provldtng workers compensation for my employees working on this fob. Company name. address: city ohon #- insurance ca. 2olicy 4 I am a sole proprietor, general contractor, or homeowner(circle one) and have hired the contractors listed below who have the following workers' compensation polices: company name: address: citYr phone i#- insttrance Co. policy#. Company.namc: address: circ phonc insurance ca, policy" Failure to secure coverage as required under Scction 25A of NIGL 15:can lead to the imposition of criminal penaldes of a fine up to 51.500.00 and/or one yean' imprisonment as well as civil penalties in the form of:t STOP WORK ORDER and a fine of 5100.00 a day against me. 1 understaad that a copy of this statement may be forwarded to the Office of Investigations of the DIA for coverage verification. !do hereby ce un r th pmH` of perjury that the information provided above is true and correct Si Q amrc Date �yl� 1 Print nameSale(- I..C_B"s'e— Phone official use only da pat write in this area to be completed by city or town official city or town: permit license q fl BuDDepar--TmencCLicheck if immediate response is required [jSelCHecontact person: phone x: 170t (rc+uaa 3195 PJA) Town of North Andover NORTH OFECE OF Of thio ,e�tiO 3r 5` L r COMMVNI ITY DEVELOPMENT AND SERVICES x 27 Charles Street o 9 m North Andover, Massachusetts 01845 WILLIAM J. SCOTT SAC HU�� Director (978)688-9531 Fax (978) 688-9542 In accordance with the provisions of MCL c 40 S 54, a condition of Building Permit Number is that the debris resulting from this work shall be disposed of in a properly licensed solid waste disposal facility as defined by MCL c 11, S 150 A. The debris will be disposed of in: IN"\ Ct (Location of Facilifi�) ianature of Permit Applicant Date NOTE: Demolition permit from the Town.,,of North Andover must be obtained for this project through the Office of the Building Inspector BOARD OF APKALS 688-9541 KTtLDING 633-95.15 CONSEI VATION 683-9530 IiE.LTI-I 635-9540 PL.-NNING 68S-9535 t ✓ee Ua�rvma�zureaCCf, o. aro acute DEPARTMENT OF PUBLIC SAFETY CONSTRUCTION SUPERVISOR LICENSE Nuder, Expires. Birthdate CS 034445 04/20/2000 04/20/1951 � 1 — Res#ricted To: 00lU ROGER S. lE$LANC , p PO BOX 160 BOXFORD, MA 01921 t j f _ vx J. "HOME IMPROVEMENT CONTRACTORS REGISTRATION t: .. °Board of Building Regulations and Standards . One Ashburton Place -- Room 1301 . Boston , Massachusetts 02108 F . OME IMPROVEMENT CONTRACTOR ' agistration 111356 Expiration 12/17/00 ------ , Iy P e - DBA Tl,� P�.,�,nd/dr �✓Glaolua�rra HOME IMPROVEMENT CONTRACTOR Registration 111356 ROGER LEBLANC CARPENTRY I Type - D8A ROGER S LeBLANC Expiration 12/17/00. I • PO BOX--160/ 537 IPSWICH RD BOXFORD MA 01921 ROGER LEBLANC CARPENTRY ' I 'ROGER S. LeBLANC I �j, OX 160/ 537 IPSWICH RD ADMINISTRATOR BOXFORD MA 01921 _r5 IAORTbf Town of dover LE D 0�l - LIQ_ dover, Mays., COC HI E �DRATED P'? Cl BOARD OF HEALTH Food/Kitchen PE R' MIT T Septic System THIS CERTIFIES THAT....X BUILDING INSPECTOR ................................... Foundation -50'4 IS has permission to erect... . ......` ...............`O . ... buildings on ........... . .. VAN. kvf. ....... 4Rough to be occupied as....t .0..... ............:'4.........,............... ...t......® .( .......... o.............. r a��� 6f. eChimney provided that the person accepting this permit shall in every respect conform to the terms of the application on file in this office, and to the provisions of the Codes and By-Laws relating to the Inspection, Alteration and Construction of Final Buildings in the Town of North Andover. PLUMBING INSPECTOR VIOLATION of the Zoning or Building Regulations Voids this Permit. Rough PERMIT EXPIRES IN 6 MONTHS Final amok , i t UNLESS CONSTRUC ON ,T^ \R J ELECTRICAL INSPECTOR ................................................... Rough ...... ............. Service BUILDING INSPECTOR Final Occupancy Permit Required to Occupy Building GAS INSPECTOR Display in a Conspicuous Place on the Premises ® Do Not Remove Rough No Lathing or Dry Wall To Be Done Final Until Inspected and Approved by the Building Inspector. FIRE DEPARTMENT Burner Street No. SEE REVERSE SIDE Smoke Det. Date. � N�- 407 . R ' pORTH 01,<��•°;•.�,o� TOWN OF NORTH ANDOVER41 '. PERMIT FOR PLUMBING . , .. s$ACMUSE� t�: This certifies that ��. . .�1. 2 has permission to perform plumbing in the buildings of . . -.1 -.... . . . . . . . . . . . . . . at. .`.'f`j. . -cf— p}, , , , . ,, North And"over, Mass. Fee _. . . . .Lic. No?6W. . . . �^ . . J``r, . . . . . . . , / PLUMBINSfECTOR y v 07`09199I1 S:0AYplicant 45.WNAfffj j3uilding Dept. PINK:Treasurer 4 7 MASSACHUSETTS UNIFORM APPLICATION FOR PERMIT TO DO PLUMBING (Type or print) NORTH ANDOVER,MASSACHUSETTS 7� r (( �`+ ( Date Building Location 4'n- SlkyYti'YK�e-`' U ,Owners Name e ��I o C cxl a1 Nocv\ Permit# 4,071 Amount Type of Occupancy New Renovation Replacement ® Plans Submitted Yes ❑ No FIXTURES z Wo z a a C w F W@ Cn w Q w a x A x H w w fx a z Si RBM B�ASDE'i�[r F T ISE Ilan { r 2M FLOOR IM FLOOR 4IH i�'YOCR 5IIH7 HIM V 111 PL7.M 7IH HEM Slit HfM (Print or type) l I Check one: Certificate Installing Company Name c�Ok ti �q� q C E- °� I`t ❑ Corp. Address 1 Rax V-r-. Partner. Business T hone G1 15Firm/Co. Name of Licensed Plumber: Ok v, W Q Q Ce- Insurance Coverage: Indicate the type of insurance coverage by checking the appropriate box: Liability insurance policy 0— Other type of indemnity ❑ Bond Insurance Waiver: I,the undersigned,have been made aware that the licensee of this application does not have any one of the above three insurance Signature Owner ® Agent I hereby certify that all of the details and information I have submitted(or entered)in above application are true and accurate to the best of my knowledge and that all plumbing work and installations performed under Permit Issued for this application will be in compliance with all pertinent provisions of the Massac setts Sq Plutgbing Code and Chapter 142 of the General Laws. By: ; o icense um er T e 9f Plumbing License Title City/Town icense um er Master Journeyman APPROVED(OFFICE USE ONLY N2wry P/} Date.�.............................. N- 1 7 1 NORTH °7"� TOWN OF NORTH ANDOVER p PERMIT FOR WIRING C14 S This certifies that .,.'.-/..:/ �'� �-- -7,/ �- :. .......'........... has permission toperforin f I - —� ............................................................... wiring in the building.of...` -...... *'�-r.::`� .......................................... f ........ ,North Andover,Mass. N Fee7�—........ Lic.No/� ........... `f�: ... `. '.................. .. .. ELECTRICAL INSPECTOR WHITE:App i aant 13•�CANARY:Building Dentin PINK:Treasurer � MMOP��'EALTH0FM4-&SACH SS= Office Use only MAP DEPART E7YTOFPUBLICSAFM Permit No. �! 7 0FF2EPRU=0NREGUL4g6AS5270M 1210 Occupancy&Fees Che47 cked PARCEL PST TO PERFORM ELE=C L WORK ALL WORK TO BE PERFORMED IN ACCORDANCE WITH THE-MASSACHUSSTS ELECTRICAL CODE, 527 CMR 12:00 (PLEASE PRINT IN INK OR TYPE ALL INFORMATION) Date Town of North Andover To the Inspector of Wires: The undersigned applies for a permit to perform the electrical work described belo 2F�ORWA�RD Location (Street&Number) Owner or Tenant Owner's Address �? 'U � 'C Gr J*-i/n e—r �1 Is this permit in conjunction with a building permit: Yes=NO ® (Check Appropriate Box) Purpose of Building ��11—f awn ���� Utility Authorization No. w Existing Service ,Amps / Volts Overhead Underground No. of Meters New Service Amps / Volts Overhead ® Underground No. of Meters Number of Feeders and Ampacity A Location and Nature of Proposed Electrical Work Te—Ta-7-1 L1.�Sy�roanf No.3f Lighting Outlets No.or Hot Tubs No.of Transformers Total � KVA No.of Lighting Fixtures Swimming Pool Above Below Generators KVA and ground No.of Receptacle outlets j No.of Oil Btuners No.of Emergency Lighting Battery Units No.of Switch Outlets / No.of Gas Burners No.of Ranges No.of Air Cond. Total FIRE ALARMS No.of Zones Tons No.of Disposals No.'of Heat Total Total No.of Detection and Pumas Tons KW--- Initiating Devices No.of Dishwashers Space Area Heating KW No.of Sounding Devices No,of Self Contained Detection/Sounding Devices No.of Dryers Heating Devices KW Local Municipal ® Other Connections No,ef Water Heaters KW No.or No.of Signs Bailasis No.dydro Massage Tubs I No.of Motors Total HP OTHER Ir>Str�reCo.e'�Pt.astlax3ethezcsct�dnse�C>ens'alLaws I have att Ilabiliiy h Ply to Comma cr its ctrl aluvalerd YES ®� No Iha esutrtitted Yakpimfofsam iothe0ffim YES No � lfjcu hmedrzked YES,please the wSUR ANCE BOND ® UII� � peme ) Eju=Dan Egtma>ed Vahe �Work S Wick*OStsrt It tDaeR Ragh Final Signed U-'Ciatie Peres cfpq-ffy. FIRM NAME tJ uxnseel p—N�rG%/� S bt a-��� Sisnanae d �3 r'n U J' V ✓ C.' . cJ - Ai TeI_No. OWNER'S WAMHR,I am are t tte l r not Ixie the'amxa= a-z r>ra1 E4m'�x rued bvMasm� Cziesal Laws at�i thatmysier�aern ilrsp��p�t wares the t�t¢e�s. (Please check one) Owner Agent Telephone No. PER"rfTT FSE S .� 438 SUMMER STREET 210/107.A-0077-0000.0 - -- -- I Residential Property Record Card#1 of 1 Parcel Year:2018 PARCEL ID: 210/107.A-0077-0000.0 MAP 107.A BLOCK 0077 LOT 0000.0 PARCEL ADDRESS: 438 SUMMER STREET as of:6/29/2017 PARCEL INFORMATION Use-Code: 101 Sale Price: 490000 Book: 08441 Tax Class: T Sale Date: 12/3/2003 Page: 0052 Tot Fin Area: 2286 Sale Type: P Cert/Doc: Tot Land Area: 1.02 Sale Valid: Y Owner#1: BELANGER, DONALD R. Grantor: CALLAHAN, KEVIN Owner#2: C/O FAISALAHMED Address#1: 24 POWERS ROAD Inspect Date: 1/20/2012 Road Type: T Exempt-B/L%: 0/0 Address#2: Meas Date: 1/20/2012 Rd Condition: P Resid-B/L%: 100/100 ANDOVER MA 01810 Entrance: X Traffic: M Comm-B/L%: 0/0 Collect ID: RRC Water: Indust-B/L%: 0/0 Inspect Reas: C Sewer: Open Sp-B/L%: 0/0 RESIDENCE# 1 INFORMATION LAND INFORMATION Style: CL Tot Rooms: 8 Main Fn Area: 1480 Attic: N NBHD CODE: 6 NBHD CLASS: 6 ZONE: R2 St Y Seg Type Code Method Sq-Ft Acres Influ-1/2/3 Value Class Story Height: 2 Bedrooms: 3 Up Fn Area: 806 Bsmt Area: 1480 Roof: G Full Baths: 2 Add Fn Area: Fn Bsmt Area: 1 P 101 S 43560 1 100/ 213444 Ext Wall: BV Half Baths: 1 Unfin Area: Bsmt Grade: 2 R 101 A 0.02 100/ 152 Masonry Trim: Ext Bath Fix: Tot Fin Area: 2286 Foundation: CN Bath Qual: T RCNLD: 259574 Kitch Qual: M Eff Yr Built: 1979 Mkt Adj: Heat Type: HW Ext Kitch: Year Built: 1965 Sound Value: Fuel Type: G Grade: AG Cost Bldg: 259600 Fireplace: 1 Bsmt Gar Cap: 2 Condition: AG Att Str Val1: DETACHED STRUCTURE INFORMATION Central AC: N Bsmt Gar SF: Pct Complete: Att Str Val2: Str Unit Msr-1 Msr-2 E-YR-BIt Grade Cond %Good P/F/E/R Cost Class Att Gar SF: %Good P/F/E/R: /100/100/79 Porch Type Porch Area Porch Grade Factor P 96 W 224 VALUATION INFORMATION SKETCH 14 Current Total: 473200 Bldg: 259600 Land: 213600 MktLnd: 213600 Prior Tot: 473200 Bldg: 259600 Land: 213600 MktLnd: 213600 W 16 224 Sq.Ft. 16 PHOTO ------------------------------------------------- FUH 142-3 62 S�1Ft. FU/FM/B FM/B 744 Sq.Ft. 736 Sq.Ft. - 24 24 32 32 12 31ar . TR 8 96 Sq.Ft. 8 438 SUMMER STREET 23 12 �r SUPOM01 Lot& Street 32�- Ma /Parcel 16 714 CONSTRUCTION APPROVAL Has plan review fee been paid: YES NO Permit# Plan Approval: Date: /Z Approved by: Q Designer: _-F 0 S G 00 D, P Plan Date: R'13 Ak' Conditions: Water Supply: _ Well Well Permit: Driller: Well Tests: Chemical Date roved Bacteria I Date Approv Bacteria II Date Approved Plumbing Sign-Off: Wiring Sign-Off- Comments: ign-OffComments: Form "U"Approval: Approval to Issue: YES NO Floor Plans Date Issued By: Conditions: Final Approval: All Permits Paid? YES NO Well Construction Approval? YES NO Septic System Construction Approval? YES NO Certification? YES NO Other YES NO As Built YES NO ro G Any Variance Needed? NO _FINAL BOARD F EALTH APPROVAL: DATE: , APPROVED Y: r Y SEPTIC SYSTEM INSTALLATION Is the installer licensed? Type of Construction: NEW (REPAIR New Construction: Certified Plot Plan Review YES O Floor-Plan Review YES NO Conditions of Approval from Form U YES NO Issuance of DWC permit: S NO DWC Permit Paid? NO DWC Permit# `Q Installer: Jo1+k) S14ACJ DWC Date Begin Inspection: NO Excavation Inspection: Needed: Passed: r0 By: Construction Inspection: Needed: As Built Plan Satisfactory: �� NO Approval of Backfill: Date: /b By: 611 Final Grading Approval: Date: VIA 04 By. Final Construction Approval: Date: By: Certificate of Compliance: Approval: ,l Date: ec Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments ,ro1c "d ��cc 438 Summer Street Property Address Faisal Ahmed Owner Owner's Name information is required for every North Andover MA 01845 6-28-2017 page. City/Town State Zip Code 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. Important:When A. General Information filling out forms, on the computer, ` use only the tab 1. Inspector: key to move your cursor-do not Neil James Bateson use the return Name of Inspector key. Bateson Enterprises Inc. Company Name 111 Argilla Road Company Address Andover MA 01810 City/Town State Zip Code 978-475-4786 SI-15 Telephone Number License Number B. Certification 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 6-28-2017 Inspector's gnature 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 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.doc-rev.6116 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 1 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 438 Summer Street Property Address Faisal Ahmed Owner Owner's Name information is required for every North Andover MA 01845 6-28-2017 page. Citylrown 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: After permit from B.O.H., install new d-box, pump septic tank, inspection from B.O.H., septic system now passes Title 5 Inspection. 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 Boacd 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): t5ins.doc•rev.6116 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 2 of 17 Commonwealth of Massachusetts - Title 5 Official Inspection Form � 0 5 nil Subsurface Sewage Disposal System Form - Not forVoluntary Assessments li DOVER 100OF 1, �p ENT ,e M ' ''� 438 Summer Street HEAL-TMS Property Address Faisal Ahmed Owner Owner's Name information is North Andover MA 01845 6-26-2017 required for every page. City/Town State Zip Code 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. Important:When A. General Information filling out forms on the computer, use only the tab 1. Inspector: key to move your cursor-do not Neil J. Bateson use the return Name of Inspector key. Bateson Enterprises Inc. r Company Name r� 111 Argilla Road Company Address Andover MA 01810 City/Town State Zip Code 978-475-4786 SI-15 Telephone Number License Number B. Certification 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 6/26/2017 lnsobctorSignatt 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 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 ofnspectton anth under the conch 'ons�;o 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.doc•rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 1 of 17 Commonwealth of Massachusetts a Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 438 Summer Street Property Address Faisal Ahmed Owner Owner's Name information is required for every North Andover MA 01845 6-26-2017 page. 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): t5ins.doc•rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 2 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 438 Summer Street Property Address Faisal Ahmed Owner Owner's Name information is required for every North Andover MA 01845 6-26-2017 page. CitylTown 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.doc•rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 3 of 17 Commonwealth of.Massachusetts _ Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 438 Summer Street Property Address Faisal Ahmed Owner Owner's Name information is required for every North Andover MA 01845 6-26-2017 page. 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: 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 %day flow t5ins.doc-rev.6116 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 4 of 17 Commonwealth of Massachusetts a Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 438 Summer Street Property Address Faisal Ahmed Owner Owners Name information is required for every North Andover MA 01845 6-26-2017 page. City/Town 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. El ® 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.doc•rev.6116 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 5 of 17 Commonwealth of Massachusetts . Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 438 Summer Street Property Address Faisal Ahmed Owner Owner's Name Information is required for every North Andover MA 01845 6-26-2017 page. Cityrrown 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): 4 Number of bedrooms(actual): 4 DESIGN flow based on 310 CMR 15.203(for example: 110 gpd x#of bedrooms): 440 t5ins.doc-rev.6/16 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 438 Summer Street Property Address Faisal Ahmed Owner Owner's Name information is required for every North Andover MA 01845 6-26-2017 page. Cityrrown State Zip Code Date of Inspection D. System Information Description: Number of current residents: 0 Does residence have a garbage grinder? ❑ Yes ® No Is laundry on a separate sewage system? (Include laundry system inspection ❑ Yes ® No information in this report.) Laundry system inspected? ❑ Yes ❑ No Seasonaluse? ❑ Yes ® No Water meter readings, if available last 2 ears usage d Yes 9 ( Y 9 (gP ))� Detail: Sump pump? ❑ Yes ❑ No Last date of occupancy: Approx. twoyears ago 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.doc•rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 7 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form k 5o Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 438 Summer Street Property Address Faisal Ahmed Owner Owners Name information is North Andover MA 01845 6-26-2017 required for every page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Last date of occupancy/use: Date Other(describe below): General Information Pumping Records: Source of information: unknown Was system pumped as part of the inspection? ❑ Yes ❑ No If yes, volume pumped: 1500 gallons How was quantity pumped determined? Reason for pumping: 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.doc•rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 8 of 17 Commonwealth of Massachusetts lugTitle 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 438 Summer Street Property Address Faisal Ahmed Owner Owner's Name information is required for every North Andover MA 01845 6-26-2017 page. Cityfrown State Zip Code Date of Inspection D. System Information (cont.) Approximate age of all components, date installed (if known)and source of information: 19 years old, 10-27-1999, as built plan Were sewage odors detected when arriving at the site? ❑ Yes ® No Building Sewer(locate on site plan): Depth below grade: 1.3feet 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 through wall to septic tank, 3" PVC in house, no leaks visible Septic Tank(locate on site plan): Depth below grade: 0.3 feet Material of construction: ® concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain) If tank is metal, list age: years Is age confirmed by a Certificate of Compliance? (attach a copy of certificate) ❑ Yes ❑ No Dimensions: 10'x 5'x 4' 2" Sludge depth: t5ins.doc•rev.6116 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 438 Summer Street Property Address Faisal Ahmed Owner Owner's Name information is required for every North Andover MA 01845 6-26-2017 page. City/Town 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 31" Scum thickness 0" Distance from top of scum to top of outlet tee or baffle 8" Distance from bottom of scum to bottom of outlet tee or baffle 15" 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.): Inlet tee ok. Outlet tee ok. Depth of liquid at outlet invert. No evidence of leakage. Center cover has riser to grade. 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: t5ins.doc•rev.6/16 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 438 Summer Street Property Address Faisal Ahmed Owner Owner's Name information is North Andover MA 01845 6-26-2017 required for every page. Cityrrown 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.doc•rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 11 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form UV- 14 Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 438 Summer Street Property Address Faisal Ahmed Owner Owner's Name information is North Andover MA 01845 6-26-2017 required for every page. Cityfrown State Zip Code Date of Inspection D. System Information (cont.) Distribution Box(if present must be opened) (locate on site plan): Depth of liquid level above outlet invert 0 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 level &distribution equal. No evidence of leakage: Evidence of carryover. D-box badly corroded needs to be replaced. 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.doc•rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 12 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 438 Summer Street . Property Address Faisal Ahmed Owner Owner's Name information is required for every North Andover MA 01845 6-26-2017 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Type: ❑ leaching pits number: ❑ leaching chambers number: ❑ leaching galleries number: ❑ leaching trenches number, length: ® leaching fields number, dimensions: 1 field 20'x 45' ❑ 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. 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.doc•rev.6/16 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 438 Summer Street Property Address Faisal Ahmed Owner Owners Name information is required for every North Andover MA 01845 6-26-2017 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.doc•rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 14 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 438 Summer Street U19- Property Address Faisal Ahmed Owner Owners Name information is required for every North Andover MA 01845 6-26-2017 page. City/Town 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 lT` ex- A4-0 k Q � rZ L(6- .-5 L4 140 3 ' t5ins.doc•rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 15 of 17 Commonwealth of Massachusetts _ Tithe 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 438 Summer Street Property Address Faisal Ahmed Owner Owner's Name information is required for every North Andover MA 01845 6-26-2017 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: 3 feet Please indicate all methods used to determine the high ground water elevation: ® Obtained from system design plans on record 8-31-1998 If checked, date of design plan reviewed: Date ❑ Observed site (abutting property/observation hole within 150 feet of SAS) ® 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 design plan test pit data Before filing this Inspection Report, please see Report Completeness Checklist on next page. t5ins.doc-rev.6116 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 438 Summer Street Property Address Faisal Ahmed Owner Owner's Name information is required for every North Andover MA 01845 6-26-2017 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 t5ins.doc•rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 17 of 17 { Commonwealth of Massachusetts Clty/Town of . ° System Pumping-Record - Form 4 DEP has.provided this form for use-by local Boards of'Heaith. Other form's maybe'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 for(h they use.The System Pumping Record must be submitted to the local.Board of Health or other approving.authority. A. Facility. InforMM- ion 1. System Location: Lift/Right front of Pious%.- gh ear of , Left./right side of house, Left ® Right side of building, Left/Right front of bur r6g, Left/Right rear of building, Under deck Address K S S CRY/Town State - Zip code 2. System Owner. Name' DL G ' Address(if different from location) cityrrown Stater Zip Code Telephone Number .B. Pumping Record 1. Date of Pumping L ?� P 9 pat 2. Quantity Pumped: Gallons y 3. Type-of system: ❑ Cesspool(s) a-,156ptic Tank ❑ Tight.Tank ❑ Other(describe): 4. Effluent Tee Filter present? ❑ Yes Leo if yes,was it cleaned? ❑ Yes El Na 5. Condition of System: F -------------------- 6. System Pumped By: Neil'Bateson • F5821 Name Vehicle License Number Bateson Enterprises Inc Company 7. Location where contents-were disposed: Lowell Waste Water SignAtufe qf Hbul Date ` form4.doc 06/03 System Pumping Record•Page 1 of 1 Town of North Andover Tax Map # 210-107.A-0077-0000.0 Parcel Id 17902 438 SUMMER STREET FAISAL AHMED 24 POWERS ROAD ANDOVER MA 01810 Class 101 Single Family Property Type 1 Residential Zoning2 1 Residential Zoning3 1 Residential Size Total 1.0.Z-,Acres FY 209 7 UB Mailing Index Name/Address Type Loan Number Active/Inact. From Until FAISAL AHMED Owner 24 POWERS ROAD ANDOVER MA 01810 BELANGER, DONALD Previous Customer Inactive 6/9/2017 438 SUMMER STREET NORTH ANDOVER, MA 01845 UB Account Maint. Account No Cycle Occupant Name Active/Inactive Bldg Id. 14235.0-438 SUMMER STREET Last Billing Date 6/19/2017 2100231 02 Cycle 02 Active UB Services Maint. Account No.2100231 Service Code Rate Charge Multiplier/Users MISCFEE ADMIN FEE 0.635/8 7.82 1/ WTR WATER 01 ALL METER SIZE /1 UB Meter Maintenance Account No.2100231 Serial No Status Location Brand Type Size YTD Cons 16336283 a Active ERT METE METE w Water 0.63 0.63 384 Date Reading Code Consumption Posted Date Variance 5/2/2017 1225 a Actual, 0 6/26/2017 -100% 2/2/2017 1225 a Actual 0 3/14/2017 -100% 11/2/2016 1225 aActual 0 12/19/2016 -100% 8/3/2016 1225 a Actual 0 9/21/2016 -100% 5/4/2016 1225 aActual 0 6/21/2016 -100% 2/2/2016 1225 a Actual 0 3/28/2016 -100% 11/2/2015 1225 aActual 0 12/30/2015 -100% 8/4/2015 1225 a Actual 0 9/14/2015 -100% 5/5/2015 1225 a Actual 0 6/22/2015 -100% 2/3/2015 1225 a Actual 0 3/20/2015 -100% 11/3/2014 1225 aActual 0 12/15/2014 -100% 8/4/2014 1225 aActual 0 9/11/2014 -100% 5/5/2014 1226 a Actual 0 6/12/2014 -1000/0 2/4/2014 1225 a Actual 4 3/17/2014 -100% 10/31/2013 1221 aActual 0 12/20/2013 -100% 8/1/2013 1221 aActual 50 9)18%2013 -100% 5/6/2013 1171 a Actual 0 6/18/2013 "-"` ,-100% 2/7/2013 1171 a Actual 0 3/13/2013 =w 0Q% 10/30/2012 1171 a Actual 1 12/13/2012 -950191 8/3/2012 1170 a Actual 22 9/26/2012 24% 5/2/2012 1148 a Actual 17 6/20/2012 38% 2/3/2012 1131 a Actual 13 3/14/2012 1159% 11/1/2011 1118 aActual 1 12/15/2011 -75% 8/2/2011 1117 a Actual 4 9/14/2011 -70% 5/3/2011 1113 a Actual 13 6/13/2011 -36% 2/4/2011 1100 a Actual 22 3/15/2011 -13% i ;' NORTh 7931 { O Town of North Andover HEALTH DEPARTMENT $,cHust` CHECK#: DATE: LOCATION: y.3$ SUM H/O NAME: kne-Q1 CONTRACTOR NAME: AcL tk.5'0 0 TYRe 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 $ ❑ Trash/Solid Waste Hauler $ ❑ Well Construction $ SEPTIC Systems: ❑ Septic-Soil Testing $ ❑ Septic-Design Approval $ ❑ Septic Disposal Works Construction(DWC) $ ❑ Septic Disposal Works Installers(DWI) $ ❑ Title 5 Inspector $ yTitle 5 Report /110-5s5 $-50 -- 0 50❑ Other:(Indicate) $ Hea gent Initials White-Applicant Yellow-Health Pink-Treasurer • TgL'ED�j�- ' ORgj��'�g4 PUBLIC HEALTH DEPARTMENT Town of North Andover Community and Economic Development Division CERTIFICATE OF. COMPLIANCE As of: June 28, 2017 This is to certify that the individual subsurface disposal system received a SATISFACTORY INSPECTION of the: D-Box Repair of an On-Site Sewage Disposal System By: Bateson Enterprises At: 438 Summer Street . Map 107.A Lot 77 North Andover, MA 01845 ThOs uance of this c ' icat all not e construed as a guarantee that the system will function satisfactorily. ichele Grant Public Health Agent 120 Main St.,North Andover,Massachusetts 01845 Phone 978.688.9540 Fax 978.688.9542 Web www.northandoverma.gov ` Map-Block-Lot Commonwealth of Massachusetts 107.A0077 - - ---- ------ BOARD OF HEALTH - Permit No North Andover ------------------BHP-2017-0480 0 �. P.I. FEE F.I. $175.00 ----------------------- DISPOSAL WORKS CONSTRUCTION PERMIT Permission is hereby granted Bateson Enterprises -- N to (Repair)an IndividualSewageDisposal System. at No 43 8 SUMMER STREET %`N as shown on the application for Disposal Works Construction Permit No. BHP-2017-048 Dated June.27 2017 ---- F ------ Issued On: Jun-27-2017 •s "3 Commonwealth of Massachusetts Map-Block-Lot �-- . 107.Ao077 BOARD OF HEALTH ----------------------- North Andover ' CERTIFICATE OF COMPLIANCE THIS IS TO CERTIFY,That the Individual Sewage Disposal System (Repair) byBateson Enterprises � -- - ------ --------- ------------- - ---- ------ ------------------ ns`t�r� at No 438 SUMMER STREET ---------------------------------------------------------------------------------------- has been installed in accordance with the provisions of TITLE 5 of the State Environmental Code as described in the application for Disposal Works Construction Permit No. -BHP-2017-048- -- -- -- Dated---June_27,2017. ------ --------- - - ---- ---------------------------------------------------------------- Printed On: Jun-27-2017 BOARD OF HEALTH ---------------------------------------------------------- •,� � Commonwealth of Massachusetts Map-Block-Lot 107.A0077 . BOARD OF HEALTH ----------------------- Permit No North Andover BHP-2017-04-80 FEE $175.00 ----------------------- DISPOSAL WORKS CONSTRUCTION PERMIT Permission is hereby granted Bateson_Enterprises --------------- to(Repair)an Individual Sewage Disposal System. at No 438 SUMMER STREET as shown on the application for Disposal Works Construction Permit No. BHP-2017-048 Dated June 27,2017 ------------------------ ----------------------------- Issued On: Jun-27-2017 BOARD OF HEALTH • Commonwealth of Massachusetts Map-Block-Lot 1o7.Aoo77 �-`- '" ----------------------- BOARD OF HEALTH Permit No ' North Andover BHP-2017-0480 y P•I• FEE F.I. $175.00 �drlof.R* DISPOSAL WORKS CONSTRUCTION PERMIT Permission is hereby granted Bateson Enterprises-;_�,")� y---------------------------------------------------------------------- to(Repair)an Individual Sewage Disposal System. at No 4-38-SUMMER-STREET---- - - ------ --------------------------- ------------------------------------------ as shown on the application for Disposal Works Construction Permit No. 13HP-20177048 Dated—June 27,2017-------- ---------------------------------------------------------------- Issued On:Jun-27-,2017 BOARD OF HEALTH •.5s '�''�+' , Commonwealth of Massachusetts Map-Block-Lot 107.A0077 BOARD OF HEALTH ----------------------- North Andover CERTIFICATE OF COMPLIANCE THIS IS TO CERTIFY,That the Individual Sewage Disposal System (Repair) b Bateson Ente rises =" - y --------------- -- s---------------- ------------------------------------------ -- Installer �r^�-� at No 438 SUMMER STREET ,/� �"'('ata - - - -------------------------- -"=-.-"�---------------------- ------------------------------------------ has been installed in accordance with the provisions of TITL-Ea5 tof the State Environmental Code as described in the application for Disposal Works Construction Permit No. BIIP-2017-048 Dated___June_27,2017-___ _ ------------------------------------ Printed On:Jun-27-2017 BOARD OF HEALTH •..} °' 6' , Commonwealth of Massachusetts Map-Block-Lot 107.A0077 BOARD OF HEALTH Permit No North Andover BHP-2017-04-80 FEE $175.00 ---- ------------------ DISPOSAL WORKS COI`ISTRUCTION PERMIT Permission is hereby granted BatesoyyE erpris(A ----------------------------------------------------------------------------- to(Repair)an Individual Sewage Disposal Syst ./ at No -4-38-SUMMER-STREET -- - - ------------ ------- --------------------------------------------------------------------------------------------------------------------- as shown on the application for Disposal Works Construction Permit No. BHP-2017-048 Dated June 27,2017 ----------------------------------------------------------------- Issued On: Jun-27-2017 BOARD OF HEALTH WMO7921 nT� i°- `' - s • Town of North Andover HEALTH DEPARTMENT gsSACHU`+tt CHECK#: 0 DATE: LOCATION: 413 g ,Svc ¢/ a4 H/O NAME: ` CONTRACTOR NAME: /.a tez—on 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 $ ❑ Trash/Solid Waste Hauler $ ❑ Well Construction $ SEPTIC Systems: �r) ❑ Septic-Soil Testing $ ❑ Septic-Desi Approval ' �� $ Septic Disposal Works Construction(DWC) $ 7J- ❑ Septic Disposal Works Installers(DWI) $ ❑ Title 5 Inspector $ ❑ Title 5 Report $ ❑ Other:(Indicate) -_, $ Health Agent Initials White-Applicant Yellow-Health Pink-Treasurer r.r. j0b ' RareizA�` North Andover Health Department (ommunity and Economic Development Division ONSITE WASTEWATER SYSTEM CONSTRUCTION NOTES LOCATION INFORMATION ADDRESS: 438 Summer Street MAP: 107.A LOT: 0077 INSTALLER: Bateson DESIGNER: PLAN DATE: BOH APPROVAL DATE ON PLAN: INSPECTIONS — D Box 6/28/2017 TANK INSPECTION: - DATE OF BED BOTTOM INSPECTION: DATE OF FINAL CONSTRUCTION INSPECTION: DATE OF FINAL GRADE INSPECTION: SITE CONDITIONS ❑ Contractor reports any changes to design plan ® Existing septic tank properly abandoned] ❑ Internal plumbing all to one building sewer ❑ Topography not appreciably altered Comments: SEPTIC TANK ❑ Building sewer in continuous grade, on compacted firm base ❑ Cleanouts per plan ® Bottom of tank hole has 6" stone base ❑ Weep hole plugged ® 1500 gallon tank has been installed H-10 loading ❑ Monolithic tank construction ❑ Watertightness of tank has been achieved by visual testing ❑ Inlet tee installed, centered under access port ❑ 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 Comments: PUMP CHAMBER ❑ 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 Comments: CONTROL PANEL ❑ Alarm & Pump are on separate circuits ❑ Alarm sounds when float is tripped ❑ Location of control panel: basement ❑ Alarm signal located inside: basement Comments: DISTRIBUTION-BOX ® 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 Comments: A SOIL ABSORPTION SYSTEM (General) ❑ Bottom of SAS excavated down to C soil layer, as provided on plan ❑ Size of SAS excavated as per plan ❑ Title 5 sand installed, if specified on plan 40 Mil HDPE barrier installed ❑ Laterals installed and ends connected to header (and vented if impervious material above) ❑ Elevations of laterals and chambers installed as on approved plan ❑ Retaining wall (boulder/ concrete /timber/ block) ❑ Final cover as per plan Comments: SOIL ABSORPTION SYSTEM (Gravel-less Chambers) ❑ Brand and Model of Chamber: Standard Quick 4 Infiltrator Chambers ❑ Number of chambers per row: ❑ Number of rows (trenches): Comments: Total Chambers = FINAL GRADE ❑ Loamed ❑ Seeded ❑ Cover per plan Comments: DOCUMENTS NEEDED ❑ Certification of Installation Form submitted By engineer and signed and dated by Engineer and installer ❑ As-Built Plan i BM = HR = HI = SYSTEM ELEVATIONS ROD AS-BLT INVERT DESIGN INVERT ELEVATION ELEV ELEV Benchmark Building Sewer OUT Septic Tank IN Septic Tank OUT Pump Chamber IN Pump Chamber OUT Distribution Box IN Distribution Box OUT Lateral 1.TOP Lateral 1 INVERT Lateral 2 TOP Lateral 2 INVERT Lateral 3 TOP Lateral 3 INVERT Lateral 4 TOP Lateral 4 INVERT Lateral 5 TOP Lateral 5 INVERT Lateral 6 TOP Lateral 6 INVERT Top of Chamber Bottom of Bed/Chamber SKETCH PLAN CRITICAL SETBACK DISTANCES Mark those distances checked in the field against the design plan and regulatory setback Tank SAS Sewer ® Property line 10 10 -- ® Cellar wall 10 20 -- ® Inground pool 10 20 -- ® Slab foundation 10 10 -- ® Deck, on footings, etc 5 10 -- ® Waterline 10 10 101 ® Private drinking well 75 1002 50 ® Irrigation well 75 100 ® Surface Water 25 50 ® Bordering Vegetated Wetland , Salt Marsh, Inland/Coastal Banka 75 100 Wetlands bordering surface water supply or trib. (in.Watershed) 150 150 ® Trib. to surface water supply 325 325 ® Public well 400 400 ® Interim Wellhead Prot. Area ® Reservoirs 400 400 ® Drains (wat. supply/trib.) 50 100 ® Drains (intercept g.w.) 25 50 ® Drains (Other)Foundation 10(5) 20(10) ® Drywells 20 25 ' Suction line 222(2) 2 100 feet is a minimum acceptable distance and no variance is allowed for a lesser distance(NA 5.02). 3 As defined in 310 CMR 10.55, 10.32, 10.54, and 10.30,respectively,pursuant to 15.211(3),also by NA wetland bylaws F. �RAPEIi A�� North Andover Health Department [ommunity and Economic Development Division ONSITE WASTEWATER SYSTEM CONSTRUCTION NOTES LOCATION INFORMATION ADDRESS: 438 Summer Street MAP: 107.A LOT: 0077 INSTALLER: Bateson DESIGNER: PLAN DATE: BOH APPROVAL DATE ON PLAN: INSPECTIONS TANK INSPECTION: ao C DATE OF BED BOTTOM INSPECTION: DATE OF FINAL CONSTRUCTION INSPECTION: DATE OF FINAL GRADE INSPECTION:. ..�/ SITE CONDITIONS Contractor reports any changes to design plan Existing septic tank properly abandoned lot Internal plumbing all to one building sewer ❑ Topography not appreciably altered Comments: SEPTIC TANK ❑ Building sewer in continuous grade, on compacted firm base [ Cleanouts per plan [' Bottom of tank hole has 6" stone base Weep hole plugged 1500 gallon tank has been installed H-10 loading ❑ Monolithic tank construction ❑ Water tightness of tank has been achieved by visual testing ❑ Inlet tee installed, centered under access port ❑ 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 Comments: PUMP CHAMBER ❑ 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 Comments: CONTROL PANEL ❑ Alarm & Pump are,on separate circuits ❑ Alarm sounds when float is tripped ❑ Location of control panel: basement ❑ Alarm signal located inside: basement Comments: DISTRIBUTION-BOX 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 Comments: SOIL ABSORPTION SYSTEM (General) ❑ Bottom of SAS excavated down to C soil layer, as provided on plan ❑ Size of SAS excavated as per plan ❑ Title 5 sand installed, if specified on plan ❑ 40 Mil HDPE barrier installed ❑ Laterals installed and ends connected to header (and vented if impervious material above) ❑ Elevations of laterals and chambers installed as on approved plan ❑ Retaining wall (boulder/ concrete /timber/ block) ❑ Final cover as per plan Comments: SOIL ABSORPTION SYSTEM (Gravel-less Chambers) ❑ Brand and Model of Chamber: Standard Quick 4 Infiltrator Chambers ❑ Number of chambers per row: ❑ Number of rows (trenches): Comments: Total Chambers = FINAL GRADE ❑ Loamed ❑ Seeded ❑ Cover per plan Comments: DOCUMENTS NEEDED ❑ Certification of Installation Form submitted By engineer and signed and dated by Engineer and installer ❑ As-Built Plan BM = HR = HI = SYSTEM ELEVATIONS ROD AS-BLT INVERT DESIGN INVERT ELEVATION ELEV ELEV Benchmark Building Sewer OUT Septic Tank IN Septic Tank OUT Pump Chamber IN Pump Chamber OUT Distribution Box IN Distribution Box OUT Lateral 1 TOP Lateral 1 INVERT Lateral 2 TOP Lateral 2 INVERT Lateral 3 TOP Lateral 3 INVERT Lateral 4 TOP Lateral 4 INVERT Lateral 5 TOP Lateral 5 INVERT Lateral 6 TOP Lateral 6 INVERT Top of Chamber Bottom of Bed/Chamber SKETCH PLAN i. e� CRITICAL SETBACK DISTANCES Mark those distances checked in the field against the design plan and regulatory setback Tank SAS Sewer ® Property line 10 10 -- ® Cellar wall 10 20 -- ® Inground pool 10 20 -- ® Slab foundation 10 10 -- ® Deck, on footings, etc 5 10 -- Waterline 10 10 101 Private drinking well 75 1002 50 ® Irrigation well 75 100 ® Surface Water 25 50 ® Bordering Vegetated Wetland , Salt Marsh, Inland/Coastal Banka 75 100 ® Wetlands bordering surface water supply or trib. (in Watershed) 150 150 ® Trib. to surface water supply 325 325 ® Public well 400 400 ® Interim Wellhead Prot. Area ® Reservoirs 400 400 ® Drains (wat. supply/trib.) 50 100 ® Drains (intercept g.w.) 25 50 ® Drains (Other)Foundation 10(5) 20(10) ® Dr ells 20 25 Yw' ' Suction line 222(2) 2 100 feet is a minimum acceptable distance and no variance is allowed for a lesser distance(NA 5.02). s As defined in 310 CMR 10.55, 10.32, 10.54,and 10.30,respectively,pursuant to 15.211(3),also by NA wetland bylaws BATESON ENTERPRISES, INC. 111 Argilla Road ♦ Andover, MA 01810 Phone: (978) 475-1474 Fax: (978) 475-5451 June 27, 2017 Mr. Faisal Ahmed 438 Summer Street North Andover, MA 01 845 Dear Sir, A septic system inspection was performed at 438 Summer Street on Monday June 26, 2017. The system received a conditional pass. The D-Box needs to be replaced. A permit was pulled on Tuesday June 27"'. The repair work will be completed on June 29, 2017 and inspected by the North Andover Board of Health. Sincerely,/10/ " r. 1 G' Todd Bateson Town of North Andover, Massachusetts Form No. 1 p10RTF1 BOARD OF HEALTH q�� 5� b 0� d 19 * r APPLICATION FOR SITE TESTING/INSPECTION �9SSACHUS E��y Applicant N E ADDRESS TELEPHONE Site Location VT — Engineer Y2 ' C>7ee ?L NAME U ADDRESS TELEPHONE Test/Inspection Date and Time . //- CHAIRMAN-,BOARD OF HEALTH Fee lA.D Test No. S.S. Permit No. D.W.C. No. C.C. Date Plbg. Permit No. Town of North Andover, Massachusetts Form No. 1 ` NORTH A BOARD OF HEALTH O`�SLED 16�'YOL O 19 fid" yZ d r m� * APPLICATION FOR SITE TESTING/INSPECTION 79 AORATED SSacHus� -^ Applicant // `/ C.-N/� 7 NAME ADDRESS TELEPHONE Site Location Engineer 41',4Z d� NAME V /` ADDRESS TELEPHONE C Test/Inspection Date and Time f CHAIRMAN;BOARD OF HEALTH Fee /✓' ` Test No. t S.S. Permit No. D.W.C. No. C.C. Date Plbg. Permit No. FORM 11 - SOIL EVALUATOR FOR `x Page 1 No . Date:70/4 Commonwealth of Massachusetts n/o- �,Yz�o�-�Massachusetts of �uitabili, Assessment for On-site Sewaze Mom .r,G,�� Date: /;1/40/7W PerformedB ..................... .................... ............� .. . ......................................... ...................... . .. ............ ........._................. Witnessed By: ...✓d .. .............................. ............ ..... / (.acarian Addrus Or Owncr's Name. _Z:-5�- 7y Lot X ,?.`//✓� /� �y�� /�� Aches,and Tckphomrc a eW Construction ❑ Repair Office Review Published Soil Survey Available: No ❑ Yes Year Published �� ..... Publication Scale l� Soil Map Unit Drainage Class Soil Limitations .�D.-... ........ T/ ....... ......._..-......_..._.. Surficial Geologic Report Available: No R1 Yes ❑ Year Published _........ Publication Scale -_ Geologic Material (Map Unit) ..............................................._..._._...._. ................................................................................... Landform ............................................_.-.._.__... a Flood Insurance Rate Map: Above 500 year flood boundary No ❑Yes Within 500 year flood boundary No ❑Yes ❑ - Within 100 year flood boundary No ❑Yes ❑ Wetland Area: National Wetland Inventory Map (map unit) ......................._....... ......... Wetlands Conservancy Program Map (map unit) ......................................................................................... Current Water Resource Conditions (USGS): Month 41, 11Z Range :Above Normal ©Normal ❑Below Normal ❑ Other References Reviewed: DEP APPROVED FORM-12/07/95 FORM 11 - SOIL EVALUATOR FORM Page 2 of 3 Location Address or Lot NO. On-site Review. Deep Hole Number Date: . Time:./.��. Weather/,�Ji • .6 Location (identify on site plan) 7 � ....::., �..,.., .:..:. /...: ..,......... ...........:.:.. ... Land Use � r �'` � Slope (%) Surface Stones .—.,..:.... Vegetation , .. ... ..� .... ;� .:.,.:.: .:.: .....,..,. .. �.. . . .... ... .., __. Landform Position on landscape (sketch on the back) Distances from: //// Open Water Body��� feet Drainage way 7Uo feet Possible Wet Area feet Property Line ..�� feet Drinking Water Well/O,O feet Other . DEEP OBSERVATION HOLE LOG* Depth from Soil Horizon Soil Texture Soil Color Soil Other Surface(inches) (USDA) (Munsell) Mottling (Structure,Stones,Boulders, Consistency, % Gravel) —7 0 2 /X KNIMUM OF 2 HGEE9 RECUREU A I EVERY PROPOSED DISPOSAL AREA Parent Material(geologic) P7 l DepthtoBedrock: / ' ' -'��� Depth to Groundwater: Standing Water in the Hole: Weeping from Pit Face: _ Estimated Seasonal High Ground Water: DEP APPROVED FORM- 12/07/95 I i FORM 11 - SOIL EVALUATOR FORD) Page 2of3 Location Address or Lot No. On-site Review 11"'le Weather/�--�86 Deep Hole Number Z Date: Time:. Location (identify on site plan) 7, Z�� L � .....:....:_......:........:..........:.:.. ... Land Use .,.:. ��`" Vegetation Slope M Surface Stones . -..v.,:......... . n:. . . Landform , . l . .......... ........:.:. ..:... .. .. Position on landscape (sketch on the back) Distances from: Open Water Body feet Drainage way��O.: feet Possible Wet Area �3�. feet Property Line ...�� .. feet Drinking Water Well / feet Other. DEEP OBSERVATION HOLE LOG* Depth from Soil Horizon Soil Texture Soil Color Soil Other Surface (Inches) (USDA) (Munsel() Mottling (Structure,Stones,Boulders, Consistency, % Gravel -57 � � � --------'-MINIMUM OF THOLLS REQUInT-9rTvMvTT6F0nT DISPOSAL AREA Parent Material(geologic) i�l���`ff /l�f DepthtoBedroc k: De th to Groundwater: Standing Water in the Hole: Weeping from Pit Face. : _ _ Estimated Seasonal High Ground Water: DEP APPROVED FORM- 12/07/95 A s { FORM 11 - SOIL EVALUATOR rp12M.r. Page 2 of 3 n Address or Lot No. Location � On-site Review h Date: J/ Time:. Weater�lZ�..��e Deep Hole Number .. -� Location (identify on site plan) ... . __:..,..:.� A .�.. ��,GT....:...::._....:. ........:.. :........ Land Use b ��, 4 Slope (%) Surface Stones . Vegetation .C53. . ::..:.v:...:..:. .... . . Landform .-1:1. Position on landscape (sketch on the back) ..✓ �.:. Distances from: Open Water Body feet Drainage way _4 feet Possible Wet Area feet Property Line ... .. feet Drinking Water feet Other DEEP OBSERVATION HOLE LOG* Depth from Soil Horizon Soil Texture Soil Color Soil Other h (USDA) (Munsell) Mottling (Structure, Stones, Boulders, Consistency, % Surface(Inches) Gravel) -:_01/3 FMINIMUM OF 2 HOLES REQUIRED AT-EVERY PROPOSED DISPOSAL AREA Parent Material(geologic) _ ----LG ` DepthtoBedrock: Depth to Groundwater: Standing Water in the Hole: Weeping from Pit Face: Estimated Seasonal High Ground Water: -- DEP APPROVED FORM- t2/07/9S i ------ - ----------- ------- ---- - FORM t l - SOIL EVALUATOR F0 Page 3 of 3. Location Address or Lot No. Determination �for Seasonal High Water Table Method Used: ❑ Depth observed standing in observation hole inches ❑ Depth weeping from side of observation hole .. ...... .. inches M Depth to soil mottles v .v .... .... inches ❑ Ground water adjustment .................. feet Index Well Number .................. Reading Date ................... Index well level .............. Adjustment factor ................... Adjusted ground water level ........................................................ Depth of 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? If not, what is the depth of naturally occurring pervious material? Certification I certify that on (date) I have passed the soil evaluator examination approved by the D pa tment of Environmental Protection and that the above analysis was performed by me consistent with the required training, expertise and experience described in 310 CMR 15.017. Signature0,�VVW6�2��IDate DEP APPROVED FORM•12/07/95 Y Town of North Andover t HORTM OFFICE OF ?° '`" •'.goo COMMUNITY DEVELOPMENT AND SERVICES 30 School Street ` North Andover, Massachusetts 01845 ..•`�5 WILLIAM J. SCOTT SSS-ACH S Director OUTSIDE CONSULTANT ESCROW AGREEMENT NORTH ANDOVER BOARD OF HEALTH Agreement is made this 1Z= 6lyo (AL) ')5T between the Town of North Andover and of for Soil Tests, Plan review KNOW ALL men by these present that the Applicant hereby provides the Town of North Andover with a check in the sum of $ a- - a ) , to be deposited in an escrow account for the Town of North Andover and has deposited in an interest- bearing account as designated by the Town Treasurer to be expended by the North Andover Board of Health to insure payment to any outside consultant (s) for Soil Tests, Plan Review for the above referenced project . This agreement shall remain in full force and effect until the specified project has reached completion , Board of Health Chairman Applicant or Agent D- /z/?Jr// Date Date. SS " 53-7058/2113 c - NEW ENGLAND ENGINEERING SERVICES, INC. 887807675 V 33 WALKER.RD., STE. 23 -PH. 978-686-1768 -NORTH ANDOVER, MA-01845 DATE—.15i(/ o QRD R TH E ORDER OF Q Kal(A—ecl ,�- Five v ` V DOLLARS B I, r �a = IPSWICH SAVINGS BANK r'Aer •,� � ",,,,y IPSWICH,MASSACHUSETTS 01938- r * ME 0 - :"2 L. 13 7 0 5 8 7 i: 1 DATE: LOCATION: N INEE - E. G - Q'� BCH WITNESS: L�4 PERC0L/TION TLST EP T tH OF PERC TEST: _17 BOTTOM D ..1 c TIME OF SOAK: t_ � __ (At legis, 5 inutcs Icr-ig) e TIME AT12" C) TIME AT 9" P TIME ATEE" O\,'",NIGHT SOAK TIME S i �-, ^ DT`D N'=XT D,,Y SOAK: TIME AT DATE: -7 -` LOCATION: ENG E.-. � .---- -F--=-�-- - BOH WITNES& PERCOLATION TEST r _4 � BOT i OM DEPTH OF PERC TEST. �- TIME OF SOAK: _ `(��___ (At lea`; rninut s Icnc) TIME AT 12" TIME AT S" TIME AT F" �•��� OVE ,NIGHT S0 TIME S T NEn T D,4v SOAK. n i ea "i f7 InUi�S) c I ivl E ;=, i 2" T INIE T 9' TIME AT ��i FORM 11 - SOIL EVALUATOR Page 1 of No. Date:�0/� Commonwealth of Massachusetts Massachusetts of uitability Assessment for On-site Sewage Disposal Date: /_7/40/ Performed By: .........�,� �G,��.. . ......./�... �/ .�� `. �..... ....... � ............� .... .................................................... ........................................................ ............................... Witnessed By: ........ . ..�............... .............. ` ���4 ocaiian Addrut a Owner's Name. ^vi /`�—`� I Lot N Address.and Tekphone/ /,—/m. New construction ❑ Repair Office Review Published Soil Survey Available: No ❑ Yes �� ......... Publication Scale l���r Soil Map Unit Year Published .. �' '"' ' Soil Limitations /yl .-...r ���....... ........._....... Drainage Class ........ Surficial Geologic Report Available: No Q Yes ❑ Year Published Publication Scale �.W. Geologic Material (Map Unit) .. ........................................................._..-_._...._. Landform ........ ........_.-.._.._... Flood Insurance Rate Map: Above 500 year flood boundary No ❑Yes Within 500 year flood boundary No ❑Yes ❑ Within 100 year flood boundary No ❑Yes ❑ Wetland Area: - ..............................................-... National Wetland Inventory Map (map unit) .--•.• Wetlands Conservancy Program Map (map unit) _ . •.......•....••.....•.. Current Water Resource Conditions (USGS): Month t111NF Range :Above Normal ©Normal ❑Belcty Normal ❑ Other References Reviewed: DEP APPROVED FORM•12/07/95 FORM 11 - SOIL EVALUATOR FORM Page 2 of 3 Location Address or Lot No. On-site Review Deep Hole Number `� •... Date: . Time:./��.� Weather / . ,. Location (identify on site plan) �_ - f ...:.::...yc .:..,. /,:._.......:.,..................:.:.. ... y:. Land Use .- Slope (%) Surface Stones .— Vegetation , ; : ..... .. .... . . Landform Position on landscape (sketch on the back) . Distances from: ''// Open Water Body ca�O feet Drainage way 7` �a feet Possible Wet Area feet Property Line ..�� .. feet Drinking Water We10 li O feet Other .. DEEP OBSERVATION HOLE LOG* Depth from Soil Horizon Soil Texture Soil Color Soil Other Surface (Inches) (USDA) (Munsell) Mottling (Structure, Stones, Boulders, Consistency, % Gravel) 1 i� - �LES REQUiRE1174 T EVERY PROPOSED DISPOSAL AREA Parent Material(geologic) c�r�C,y� f` _ DepthtoBedrock: Depth to Groundwater: Standing Water in the Hole: Weeping from Pit Face: / Estimated Seasonal High Ground Water: •.-- DEP APPROVED FORhl- 12/07/95 FORM 11 - SOIL EVALUATOR FORM Page 2of3 Location Address or Lot No. �'� - /7 5;1v �'C1JjGx% t On-site Review Date: Time:.7 ' / Time:.1,�t"�Cr Weatherl��'/l---�8.6 Deep Hole Number .::. ... L Location (identify on site plan) w Land Use ..:,M.. - 1� Slope {%) Surface Stones Vegetation ` Landform , :.....:..:....... Position on landscape (sketch on the back) Distances from: '// Open Water Body �� feet Drainage way�". O. feet Possible Wet Area /�. feet Property Line feet Drinking Water Well 7/� feet Other . DEEP OBSERVATION HOLE LOG* Depth from Soil Horizon Soil Texture Soil Color Soil Other Surface (Inches) (USDA) (Munsell) Mottling (Structure,Stones,Boulders, Consistency, % Gravel) IVA (:P/ /lker Parent Material (geologic) DepthtoBedrock: . 9� Depth to Groundwater: Standing Water in the Hole: — Weeping from Pit Face:� Estimated Seasonal High Ground Water: -- DEP APPROVED FORM-12107/95 ' , FORM 11 - SOIL EVALUATOR FORA1 ; Page 2 of Location Address or Lot No. On-site Review �, Time:. e� Weather?, e Deep Hole Number Date:... � Location (identify on site plan) ..... :_......._...�� . .. ...,.:...::._.....:.......:................. Land Use ZDe94r � Slope M Surface Stones :.... ...... Vegetation Landform ....��%/ i� . .` /'C, .:.:.. .:. .:...:..........:.:. .::.:..:..:....:.. .: Position on landscape (sketch on the back) ..✓` � f j-' Distances from: Open Water Body feet Drainage way feet Possible Wet Area feet Property Line ... .. feet Drinking Water feet Other .. :......,,...:- DEEP OBSERVATION HOLE LOG* Depth from Soil Horizon Soil Texture Soil Color Soil Other Surface(Inches) (USDA) (Munsell) Mottling (Structure,Stones, Boulders, Consistency, % Gravel) 3 MINIMUM OF 2 H75LES RrOUM-M AT EVERY PROPOSED DISPOSAL AREA Parent Material(geologic) �_� 1----LC =�� DepthtoBedrock: - Depth to Groundwater: Standing Water in the Hole: Weeping from Pit Face: Estimated Seasonal High Ground Water: _..�— DEP APPROVED FORM- 12107/95 ._ FORM 11 - SOIL EVALUATOR Fop :h` ;rtLoPage 3 af,3:-,;'- Location cation Address or Lot No. Detennination for Seasonal High Water Table Method Used: ❑ Depth observed standing in observation hole......... inches ❑ Depth weeping from side of observation hole .......... ... inches ® Depth to soil mottles ..:...:....... .., inches ❑ Ground water adjustment .............I.... feet Index Well Number .................. Reading Date ................... Index well level .... ......... Adjustment factor ................... Adjusted ground water level ....................................................... Depth of Naturally Occurring Pervious Material Does at least four feet of naturally occurring pervious material exist in WI areas observed throughout the area proposed for the soil absorption system? S If not, what •is the depth of naturally occurring pervious material? Certification I certify that on -5-- (date) I have passed the soil evaluator examination approved by the D pa tment of Environmental Protection and that the above analysis was performed by me consistent with the required training, expertise and experience described in 310 CMR 15.017. Signature0,5VIwO7621 Date DEP APPROVED FORM-12/07/95 y \ N o�%01tw,.Nj s Page 1 of 5 9A-APPLICATION FOR LOCAL UPGRADE APPROVAL Commonwealth of Massachusetts North Andover, Massachusetts Application for Local Upgrade Approval Title 5, 310 CMR 15.000 DEP approved form required by 310 CMR 15.403(1) To be submitted to Local Approving Authority/Board of Health: For the upgrade of a failed or non-conforming system with a design flow of<10,000 gpd, where full compliance, as defined in 310•CMR 15.404(1), is not feasible. To be submitted to DEP: For the upgrade of a failed or non-conforming system with a design flow of 10,000 up to 15,000 gpd and/or for upgrade of state of federal facility, where full compliance, as defined in 310 CMF 15.404(1), is not feasible. NOTE: Local upgrade approval shall not be granted for an upgrade proposal that includes the addition of new design flow to a cesspool or privy or the addition of new design flow above the existing approved capacity of a system constructed in accordance with either the 1978 Code or 310 CMR 1.5/000. 1) Facility/System Owner: Name: ko mer Lc,CS��✓t — Address: y 3 b So r►- m c/1 RAJvo Qe&, nit.A Phone #: 970-6 ea ^4613 3 Address of facility: ya g s ,t,, s-h N', /4 �vvt-, n14 v1- 2) Applicant (if different from above) Name:- sa,,�� Address: Phone #: 3) Type of Facility: Residential Commercial School Institutional (Specify) y B.Q. S' c Page 2 of 5 4) Type of Existing System: _privy cesspool(s) 7Q conventional system other(describe) Type of soil absorption system (trenches, chambers, pits, etc.) Trc^c/4C'.-C 5) Design Flow Based on 310 CMR 15.203: a) Design flow of existing system - gpd Approved: des Approval date: ? no Why: b) Design flow of proposed upgraded system y90 gpd Why c) Design flow of facility y yo gpd 6) Proposed upgrade of existing system is: a) Voluntary required by order, letter, etc. (attach copy) _Required following inspection required by 31 CMR 15.301 (provide date inspection form was submitted to the approving authority) (date) b) Describe the proposed upgrade to the system: / 7-- ib a/�0,2 sa T Q nGt a,J 142C 6nllon hz.s 4 •� -a�Xi c 60- c) Which of the following are applicable to the proposed upgrade? Reduction of setback(s) (list setbacks to be reduced with proposed setback distances) Percolation rate of 30-60 minutes per inch (state actual perc rate) Up to 25% reduction in subsurface disposal area design requirements (state required& proposed size) Relocation of water supply well (identify well, describe relocation) Reduction of required separation between bottom of SAS & high groundwater(specify proposed reduction& perc rate) 2cd�ee- 13 �GY. nsj � � min�.rnc`i Page 3 of 5 Other requirements of 310 CMR 15.000 that cannot be met(specify sections of the code) System upgrades that cannot be performed in accordance with 31 CMR 15.404 & 15.405, or in full compliance with the requirements of 310 CMR 15.000, require a variance pursuant to 310 CMR 15.410-15.417. 7) If the proposed upgrade involves a reduction in the required separation between `the bottom of the soil absorption system and the high groundwater elevation,an Approved Soil Evaluator must determine the high ground water elevation pursuant to 310 CMR 15.405(1)(1)(1). The evaluator must be a member or agent of the local approving authority: Distance from soil absorption system to high groundwater 3 feet As determined by: i Evaluator's name: Evaluator's Signature: Date of evaluation: 8) Notice to Abutters: No application for upgrade approval in which the setback from property yli nes or a private water supply well is reduced shall be complete until the applicant has notified all abutters whose property 9or well is affected by certified at least ten days before the Board of Health meeting at which the upgrade approval will be on the agenda. Such notice shall include the date, time and place where the upgrade approval will be discussed. 'If the department is the approving authority, then such notice to abutters must be completed prior to the date of submission of the application to the department. The notices to abutters shall include a copy of the completed application form and shall reference the standards set forth in 310 CMR 15.402 through 15.405. Page 4 of 5 List of affected abutters: Abutter Name Date notified Address Abutter Name Date notified Address Abutter Name Date notified Address Abutter Name Date notified Address 9) Explain why full compliance, as defined in 310 CMR 15.404(1), is not feasible (each section must be completed): a) An upgraded system in full compliance with 310 CMR 15.000 is not feasible: a ,.0 �-•�Z, �01 1,141, -11r- V�n dl b) Annalternative system approved pursuant to 310 CMR 15.283-15.288 is not feasible. /& r al�a-PL ra S�.je s ow-e k .,. v'1`/ a cQ / foo em L"C M n gne � /Z, Cas� —� �4S/e-hn c) A shared system is not feasible. Cp ` 4 x d) Connection to a/sewer is not feasible. y/ 10 Ana application for a disposal pp p system construction permit, including all required attachments (e.g. plans & specifications, site evaluation forms), must accompany this application. Is the DSCP application attached? yes no Page 5 of 5 11) Certification "I, the facility owner, certify under penalty of law that this document and all attachments, to the best of my knowledge and belief, are true, accurate, and complete. I am aware that there may be significant consequences for submitting false information, including, but not limited to, penalties or fine and/or imprisonment for knowing violations." OaC7=Owner's Si e Date Ise,,'p&SA ',\ Print Name �Gn�Ana. ( S2120 S Fe) 9 8 Name of Preparer Date (, l76 S3 W a��t eil Ste:>� e3 W, A, jt� Telephone No. & Address of Preparer �tr4 pig�,S NOTE: Title 5, 310 CMR 15.403(4) requires the system owner or operator to submit to the Department a copy of the local upgrade approval upon issuance by the Board of Health and prior to commencement of construction. t Town of North Andover, Massachusetts BOARD OF HEALTH 19 DESIGN APPROVAL FOR SOIL ABSORPTION SEWAGE DISPOSAL SYSTEM Applicant 1 pp �- ��WLQ �, Test No: Site LocationT_� � Reference Plans and Specs. ENGINEER DESIGN DATE Permission is granted for an individual soil absoprtion sewage disposal system to be installed in accordance with regulations of the State and the Board of Health. BOARD OF HEALTH Fee l 2 60 Site System Permit No. 988 ` SEPTIC PLAN SUBMITTALS LOCATION: e{ 3 5/'2/tey TfreT' NEW PLANS: YE $125.00/Plan REVISED PLANS: S $ 45.00/Plan SITE EVALUATION FORMS INCLUDED: YES NO DATE: Of DESIGN ENGINEER: geAl 0S6Qci Ty- DATE rDATE TO CONSULTANT: When the submission is all in place, date stamp plans and route to Health. Town of North Andover f NORTH OFFICE OFF COMMUNITY DEVELOPMENT AND SERVICES 30 School Street North Andover. Massachusetts 0l 8.15 WILLIAM J. SCOTT SAC US Director September 2, 1998 Homer Leighton 438 Summer Street North Andover, MA 01845 Dear Mr. Leighton:. Enclosed please find a copy of the letter that serves as a notification of a granted variance to groundwater for the property referenced above. You should be aware that under 310 CMR 15.402 and 15..414 and 15.415,that because of this variance, any addition to your dwelling can only be made after approval of the North Andover Board of Health and the State Department of Environmental Protection. This notification should be kept with other official papers relating to your property and should be part of any transfer of title of the property. Sincerely, I Sandra Starr, R.S. Health Administrator i Cc: Building Dept. B. Osgood,Jr. File BOARD OF APPEALS 688-9541 BUILDING 688-9545 CONSERVATION 688-9530 HEALTH 688-9540 PLANNING 688-9535 i September 2, 1998 New England Engineering Ben Osgood,Jr. 33 Walker Road North Andover,MA 01845 Dear Mr. Osgood: This letter is to confirm that with the approved variance to 3 feet to groundwater granted on September 2, 1998 for the septic repair at 438 Summer Street,the proposed plans are approved. Please call the office at the number below if you have any questions. Sincerely, Sandra Starr,RS. Health Administrator Cc: H.Leighton File TOWN OF NORTH ANDOVER SYSTEM PUMPING RECORD DATE: — SYSTEM OWNER &ADDRESS SYSTEM LOCATION (example: left front of house) DATE OF PUMPING: — QUANTITY PUMPED �J ✓v GALLONS CESSPOOL: NO YES SEPTIC TANK: NO YES —Z- NATURE OF SERVICE: ROUTINE EMERGENCY OBSERVATIONS: GOOD CONDITION FULL TO COVER HEAVY GREASE BAFFLES IN PLACE ROOTS LEACHFIELD RUNBACK EXCESSIVE SOLIDS FLOODED SOLIDS CARRYOVER OTHER (EXPLAIN) SYSTEM PUMPED BY: &f'5-6 V-.— COMMENTS: /�COMMENTS: CONTENTS TRANSFERRED TO: - S r COMMONWEALTH OF MASSACHUSETTS z EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS u d DEPARTMENT OF ENVIRONMENTAL PROTECTION M s�° TITLE 5 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM PART A CERTIFICATION p Property Address:_438 Summer Street _North Andover_ Owner's Name:_Kevin Callahan_ Owner's Address:_438 Summer Street_ _North Andover,MA 01845 a -«- - ANDOVER/ Date of Inspection:6/9/2003_ t,r c,F7 OF H ALTH Name of Inspector:_Neil J.Bateson_ Company Name: Bateson Enterprises Inc._ JUN 2 0 2003 Mailing Address: 111 Argilla Road_ Andover Ma.01810 Telephone Number:J978)475-4786_ I CERTIFICATION STATEMENT I certify that I have personally inspected the sewage disposal system at this address and that the information reported below is true,accurate and complete as of the time of 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: X Passes Conditionally Passes Needs Further Evaluation by the Local Approving Authority JF y 4 Inspector's Signature: Date: _6/9/2003_ The system inspector shall su it 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. Notes and Comments ****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. I Page 2 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address:_438 Summer Street_ _North Andover— Owner:_Callahan Date of Inspection:_6/9/2003_ Inspection Summary: Check A,B,C,D or E/ALWAYS complete all of Section D A. System Passes: _X_ 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. Answer yes,no or not determined(Y,N,ND)in the 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. ND explain: 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 obstruction is removed distribution box is leveled or replaced ND explain: 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 obstruction is removed ND explain: Page 3 of 11 OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address:_438 Summer Street _North Andover— Owner:_Callahan_ Date of Inspection:_6/9/2003_ 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 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 coliform bacteria and volatile organic compounds indicates that the well is free from pollution from that facility and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm,provided that no other failure criteria are triggered.A copy of the analysis must be attached to this form. 3. Other: Page 4 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address:_438 Summer Street_ _North Andover— Owner:_Callahan_ Date of Inspection:_6/9/2003_ D. System Failure Criteria applicable to all systems: You must indicate"yes"or"no"to each of the following for all inspections: Yes No _No_ Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool _No_ Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool _No_ Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool _No_ Liquid depth in cesspool is less than 6"below invert or available volume is less than'/z day flow _No_ Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number of times pumped No Any portion of the SAS,cesspool or privy is below high ground water elevation. No Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. _No_ Any portion of a cesspool or privy is within a Zone 1 of a public well. _No Any portion of a cesspool or privy is within 50 feet of a private water supply well. —No— 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 coliform bacteria and volatile organic compounds indicates that the well is free from pollution from that facility and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm,provided that no other failure criteria are triggered.A copy of the analysis must be attached to this form.] No (Yes/No)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. Y 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. You must indicate either"yes"or`no"to each of the following: (The following criteria apply to large systems in addition to the criteria above) 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 R 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. Page 5 of 11 OFFICIAL INSPECTION FORM -NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST Property Address: 438 Summer Street _North Andover_ Owner:_Callahan_ Date of Inspection:_6/9/2003_ Check if the following have been done.You must indicate`yes"or"no"as to each of the following: Yes No Yes _ Pumping information was provided by the owner,occupant,or Board of Health No Were any of the system components pumped out in the previous two weeks? Yes _ Has the system received normal flows in the previous two week period? _No Have large volumes of water been introduced to the system recently or as part of this inspection? Yes _ Were as built plans of the system obtained and examined?(If they were not available note as N/A) Yes _ Was the facility or dwelling inspected for signs of sewage back up? Yes _ Was the site inspected for signs of break out? Yes _ Were all system components,excluding the SAS,located on site? _Yes_ _ 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? _Yes_ _ 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: Yes no _Yes_ _ Existing information.For example,a plan at the Board of Health. No Determined in the field(if any of the failure criteria related to Part C is at issue approximation of distance is unacceptable)[3 10 CMR 15.302(3)(b)] Page 6 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION Property Address:_438 Summer Street_ _North Andover— Owner:_Callahan_ Date of Inspection:_6/9/2003_ FLOW CONDITIONS RESIDENTIAL 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):_440_ Number of current residents:_4 Does residence have a garbage grinder(yes or no):_No_ Is laundry on a separate sewage system(yes or no):_No_ Laundry system inspected(yes or no): Seasonal use: (yes or no):_No Water meter readings: Yes_ Sump pump(yes or no): Yes,outside cellar by sliding door._ Last date of occupancy:— Current-COMMERCIAL/INDUSTRIAL Type of establishment: Design flow(based on 310 CMR 15.203): gpd Basis of design flow(seats/persons/sgft,etc.): Grease trap present(yes or no):_ Industrial waste holding tank present(yes or no):_ Non-sanitary waste discharged to the Title 5 system(yes or no): Water meter readings,if available: Last date of occupancy/use: OTHER(describe): GENERAL INFORMATION Pumping Records Source of information:_Pumped one month ago,owner_ Was system pumped as part of the inspection(yes or no): Yes_ If yes,volume pumped:_1500_gallons--How was quantity pumped determined?_Measured tank_ Reason for pumping:_Inspect tank&baffles TYPE OF SYSTEM X 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) _Tight tank _Attach a copy of the DEP approval _Other(describe): Approximate age of all components,date installed(if known)and source of information:_5 years old, 10/27/1998, As Built plan._ Were sewage odors detected when arriving at the site(yes or no):_No Page 7 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address:_438 Summer Street_ _North Andover— Owner:_Callahan_ Date of Inspection:_6/9/2003_ BUILDING SEWER locate on site plan)X ( P ) Depth below grade:_12"_ Materials of construction:—X—cast iron _X_40 PVC_other _ Distance from private water supply well or suction line: Comments(on condition of joints,venting,evidence of leakage,etc.):_4"PVC thru wall to septic tank. 4"Cast Iron in house.No leaks. SEPTIC TANK: X locate on site plan) Depth below grade:_1"_ Material of construction:—X—concrete_metal_fiberglass_polyethylene —tank If tank is metal list age:_ Is age confirmed by a Certificate of Compliance(yes or no):_(attach a copy of certificate) Dimensions:_10'x 5'x 4' Sludge depth:—0"_ Distance from top of sludge to bottom of outlet tee or baffle: 2711 _ Scum thickness:_011 _ Distance from top of scum to top of outlet tee or baffle:_811 _ Distance from bottom of scum to bottom of outlet tee or baffle:_15" How were dimensions determined:_Measured scum&sludge depth to tee length_ Comments(on pumping recommendations,inlet and outlet tee or baffle condition,structural integrity,liquid levels as related to outlet invert,evidence of leakage,etc.):_Pumped septic tank. Inlet tee ok.Outlet tee ok.Depth of liquid at outlet invert.No evidence of leakage._ GREASE TRAP: locate on site plan) _( P ) Depth below grade:_ 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: Comments(on pumping recommendations,inlet and outlet tee or baffle condition,structural integrity,liquid levels as related to outlet invert,evidence of leakage,etc.): I Page 8 of 11 OFFICIAL INSPECTION FORM —NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address:_438 Summer Street_ _North Andover— Owner:_Callahan_ Date of Inspection: 6/9/2003_ 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/day Alarm present(yes or no): Alarm level: Alarm in working order(yes or no): Date of last pumping: Comments(condition of alarm and float switches,etc.): DISTRIBUTION BOX: X (if present must be opened)(locate on site plan) Depth of liquid level above outlet invert:_0 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 level&distribution equal.No evidence of leakage. Evidence of carryover,Pumped d-box to clean._ PUMP CHAMBER: (locate on site plan) Pump in working order(yes or no):_ Alarms in working order(yes or no):_ Comments(note condition of pump chamber,condition of pumps and appurtenances,etc.):_ Page 9 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 438 Summer Street_ _North Andover- Owner:_Callahan_ Date of Inspection:6/9/2003_ SOIL ABSORPTION SYSTEM(SAS):_X (locate on site plan,excavation not required) If SAS not located :explain why: Y Type leaching pits,number:_ leaching chambers,number: leaching galleries,number: leaching trenches,number,length:_ _X_leaching fields,number,dimensions:_1 Field 20'x 451 _ 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.— 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 or no): 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.): • Page 10 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 438 Summer Street _North Andover— Owner:_Callahan_ Date of inspection:— SKETCH OF SEWAGE DISPOSAL SYSTEM Provide a sketch 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. Driveway Water Meter House A to Tank=38'9" AB A to D-Boz=74'7" B to Tank=37' Deck B to D-Boz=4516" Septic Tank D-Boz Page 11 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address:_438 Summer Street_ _North Andover_ Owner:_Callahan_ Date of Inspection: 6/9//2003 SITE EXAM Slope Surface water Check cellar Shallow wells Estimated depth to ground water 3_feet Please indicate(check)all methods used to determine the high ground water elevation: _X_Obtained from system design plans on record-If checked,date of design plan reviewed:_8/31/1998 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: You must describe how you established the high ground water elevation: Design Plan_ O O O ........... - "_.. _: - .:. - _ ''ni = :.______.,•_-_._._-_.:__ :_.'_..____,::_:_'_.� - `= :;':.__ -µ:Vi_:-.L'. __- _ _ _' 4.. .. . _ ._.4...._ .. . - - - - I- pg pi -r - -- _ - - _ - - - - = _ - = - ---- - -- - - - _ f �-fit.. .._ r��.Lt�:-::.,:1 = ";;�:.::. _ _ - -- -- 4JATER BILLING ACCOUNTS---------------------- 8K_ 15 PG- 21 ACCT #: 3150189000_0 _74AP: BLOCK: _ 01-4131000-0 U028 LOT: 0000.0 PRIOR ID 'Ti - `h�UuHook" 0 112:� -_-- CITY- N. AP, orrn�ct Iidit T•ernvnel - _ - = - = - T :: ;; ;_ _ .�" �w __ _:fir• PHONE q. - __-- - 's p cD 4JATER BILLING HIST RY 2100231-100231KEUIN METER q1 _ 2100231 -- 438 SUMMER ST ------------------ w FHOUSE q: li q CYCLE SERVICE PR R--CURRENT-Vs WATER SEWER FEES TOTAL �J ;SERVICE ADDRE� 1 2000-12 08/02/1999 974 994 20 54.60 0.00 0_00 54_60 2 2000-22 12/08/1999 994 78 84" 229.32 0.00 0.00 229.32 _: 5RATETABLE <R3 3 2000-32 Q3/09/2000 78 103 25 68.25 9_00 0.00 68.25; =� 57 z USE DISC. RATE 4 2000-42 05/18/2000 103 128 25 68_25 0_00 0.00 68.25' -. SPEC. HANDLING _ 5 200y-12 08/11/2000 128 158 30 81_90 0.00 11_00 92_90_;;-- x ! 6 2001-22 12/07/2000 0 23 127 346_71 0.00 11 .00 357_71 ;`: _ y (;METER lit I0: 7 2001-32 02/16/2001 23 46 23 62.79 0.00 11 .00 73.79 : i "`" d =METER R2 IO: 8 2001-42 05/18/2001 46 70 24 65.52 0_00 11,00 76.52" c 9 2002-22 12/05/2001 124 1B0 56 162.96 0_00 5.55 168.51:3- tri "OLD VALUE: 0910 2002-32 03/15/2002 180 205 25 63.99 0.00 5_55 69_54I= ry €11 2002-42 05/17/2002 205 226 21 52.99 0.09 5.55 58.54_ _._;._:__. 12 2002-12A 08/07/2001 70 124 54 171_46 0.00 5.55 177.01: _ •-ur'r� `- -' 13 2003-12 08/12/2002 226 269 43 135.00 0.00 5.97 140.97:r ` ; _ '1;14 2003-22 11/06/2002 269 301 32 93.20 0.80 5.97 99-17V - .15 2003-32 02/06/2003 301 328 27 72.78 0.00 5_97 78_75:- .' 16 2003-42 05/06/2003 328 354 26 70.40 0.00 5.97 76.37== ': :+: NeCwoEk " pa NeigE oIhoco)d REU I EW CHOICE q Dr <ENTER> MORE HISTORY: s; : - InbO ;Pi;: ItRVRS iXlRS::n =•T yeti;`10 .: CD 0 Tel: (978) 475-4786 Fax: (978) 475-5451 BATESON ENTERPRISES, INC. Excavating-Water.& Sewer Lines-Septic Systems&Pumping Service 111 Argilla Road Andover, Mass. 01810 Title 5 Inspection Report Property Address: 438 Summer Street, North Andover Owner: Callahan Date of Inspection: 6/9/2003 My report contained herein does not constitute a guarantee of future usage and the functionality of the existing septic system. Such report issued herewith is merely based upon my observations, and I hereby disclaim any further operation of your current septic system. Neil J. Bateson Bateson Enterprises, Inc. NEW ENGLAND ENGINEERING SERVICES INC August 11, 1998 M D.0F.ME1LTEa Sandra Starr, Administrator North Andover Board of health Osgood Street 4 R North Andover, MA 01845 Re: 438 Summer Street septic design Dear Sandra: Enclosed are the following documents.concerning the replacement septic system design at 438 Summer Street in North Andover. 1. 5 sets of design plans 2. 3 copies of soil evaluator sheets 3. 3 copies of local upgrade request forms 4. check for the approval fee. Please note that the local upgrade approval form needs to be signed by Susan Ford, the soil evaluator for the local approving authority. Also, I would like to have this item on the agenda for the next Board of Health meeting in order to have the local upgrade request considered by the Board of health. If you have any questions please do not hesitate to contact this office. Sincerely, � Benjafnm C. Osgood�Yr., EIT�� President 33 WALKER ROAD-SUITE 23-NORTH ANDOVER, MA 01845-(978)686-1768-(888)359-7645-FAX(978)685-1099 • a.s Page 1 of 5 9A-APPLICATION FOR LOCAL UPGRADE APPROVAL Commonwealth of Massachusetts North Andover, Massachusetts Application for Local UPgradeApproval Title 5, 310 CMR 15.000 DEP approved form required by 310 CMR 15.403(1) To be submitted to Local Approving Authority/Board of Health: For the upgrade of a failed or non-conforming system with a design flow of<10,000 gpd, where full compliance, as defined in 310-CMR 15.404(1), is not feasible. To be submitted to DEP: For the upgrade of a failed or non-conforming system with a design flow of 10,000 up to 15,000 gpd and/or for upgrade of state of federal facility, where full compliance, as defined in 310 CMF 15.404(1), is not feasible. NOTE: Local upgrade approval shall not be granted for an upgrade proposal that includes the addition of new design flow to a cesspool or privy or the addition of new design flow above the existing approved capacity of a system constructed in accordance with either the 1978 Code or 310 CMR 15/000. 1) Facility/System Owner: Name: Be ; t'lo mer I.e.C j�%�a A — Address: q 38 So»qm cA 5_1-1rJ. 4AJ vo oe e., nn.�! Phone#: 177&-6 88 -k6_8,1 3 Address of facility: ,�Ja vi.. /Vt V9, 2) Applicant (if different from above) Name-'- sca'V,C' Address: Phone#: 3) Type of Facility: Residential Commercial School Institutional (Specify) y Ae, 41, %c,se- s 9!5' Y Page 2 of 5 4) Type of Existing System: _privy cesspool(s) conventional system other(describe) Type of soil absorption system (trenches, chambers, pits, etc.) Tro v1G�►G� 5) Design Flow Based on 310 CMR 15.203: a) Design flow of existing system ? gpd Approved: ? yes Approval date: ? no Why: b) Design flow of proposed upgraded system yyo gpd Why c) Design flow of facility YYO gpd 6) Proposed upgrade of existing system is: a) Voluntary required by order, letter, etc. (attach copy) -_X--Required following inspection required by 31 CMR 15.301 (provide date inspection form was submitted to the approving authority) (date) b) Describe the proposed upgrade to the system: �1ption OV nct ne '0 -6�X� c. c) Which of the following are applicable to the proposed upgrade? Reduction of setback(s) (list setbacks to be reduced with proposed setback distances) Percolation rate of 30-60 minutes per inch(state actual perc rate) Up to 25% reduction in subsurface disposal area design requirements (state required& proposed size) Relocation of water supply well (identify well, describe relocation) Reduction of required separation between bottom of SAS & high groundwater(specify proposed reduction& perc rate) Page 3 of 5 Other requirements of 310 CMR 15.000 that cannot be met(specify sections of the code) System upgrades that cannot be performed in accordance with 31 CMR 15.404 & 15.405, or in full compliance with the requirements of 310 CMR 15.000, require a variance pursuant to 310 CMR 15.410-15.417.,. 7) If the proposed upgrade involves a reduction in the required separation between the bottom of the soil absorption system and the high groundwater elevation, an Approved Soil Evaluator must determine the high ground water elevation pursuant to 310 CMR 15.405(1)(1)(1). The evaluator must be a member or agent of the local approving authority: Distance from soil absorption system to high groundwater 3 feet As determined by: Evaluator's name: -!vsa.n c s ,-c T kS S Evaluator's Signature: Date of evaluation: 8) Notice to Abutters: No application for upgrade approval in which the setback from property lines or a private water supply well is reduced shall be complete until the applicant has notified all abutters whose property 9or well is affected by certified at least ten days before the Board of Health meeting at which the upgrade approval will be on the agenda. Such notice shall include the date, time and place where the upgrade approval will be discussed. :If the department is the approving authority, then such notice to abutters must be completed prior to the date of submission of the application to the department. The notices to abutters shall include a copy of the completed application form and shall reference the standards set forth in 310 CMR 15.402 through 15.405. J". Page 4 of 5 List of affected abutters: Abutter Name Date notified Address Abutter Name Date notified Address Abutter Name Date notified Address Abutter Name Date notified Address 9) Explain why full compliance, as defined in 310 CMR 15.404(1), is not feasible (each section must be completed): a) An upgraded system in full compliance with 310 CMR 15.000 is not feasible: w� ' b) An alternative//system[[ approved pursuant to 310 CMR 15.283-15.288 is not feasible. Lt 1k,,2-n r Aoe S 41 Kv�� w*// etc-OA 2790 r""vc GI !n 4. cos Y- Sys kw. c) A shared system is not feasible. /V-19 itil o. ` TT.r Gp d) Connection to a sewer is not feasible. 10) An application for a disposal system construction permit, including all required attachments (e.g. plans & specifications, site evaluation forms), must accompany this application. Is the DSCP application attached? yes no A 1 ' Page 5 of 5 11) Certification 1, the facility owner, certify under penalty of law that this document and all attachments, to the best of my knowledge and belief, are true, accurate, and complete. I am aware that there may be significant consequences for submitting false information, including, but not limited to, penalties or fine and/or imprisonment for knowing violations." c 6 Paco Owner's Si e Date Print game Name of Preparer Date e3 ., /, Telephone No. & Address of Preparer .t�ti4 NOTE: Title 5, 310 CMR 15.403(4) requires the system owner or operator to submit to the Department a copy of the local upgrade approval upon issuance by the Board of Health and prior to commencement of construction. Town of North AndoverHORTh OFFICE OF 3?°9 "'° '•.,40` COMMUNITY DEVELOPMENT AND SERVICES 30 School Street ; North Andover,Massachusetts 01845 WILLIAM J. SCOTT SSS^cHusE�� Director OUTSIDE CONSULTANT ESCROW AGREEMENT NORTH ANDOVER BOARD OF HEALTH Agreement is made this Z 4GtiV Dy UST between the Town of North Andover and of for Soil Tests, Plan Review e �9'3C �VIL4AW, �T . KNOW ALL men by these present that the Applicant hereby provides the Town of North Andover with a check in the sum of $ a, , 0-0 , to be deposited in an escrow account for the Town of North Andover and has deposited in an interest- bearing account as designated by the Town Treasurer to be expended by the North Andover Board of Health to insure payment to any outside consultant (s) for Soil Tests, Plan Review for the above referenced project . This agreement shall remain in full force and effect until the specified project has reached completion . Board of Health Chairman Applicant or Agent S'/z/, Date Date.. SS 53-7058/2113 n C NEW ENGLAND ENGINEERING SERVICES, INC. 887807676 G V 33 WALKER.RD.,-STE. 23 'PH. 978-686-1768 -NORTH ANDOVER, MA,01845 /J DATE PAY TO THE � "A ORDEROF �sYOftj hlv r/d'r�d -�e'L;rr Ve 1 u DOLLARSEI = IPSWICH SAVINGS BANK ,•4~ ..IPSWICH..MASSA CHUSEI73 01938 * tvti?Nto _77� B nr I. l F� r • ��45� 'J A-41 d k } k$ �s � 1 ��1 1111111 ,. A A f u ' - .� : � 1►�11 1111 1 � �` i :} 1111 1 1 s �` 11111 11111 1 1 _,� � „ y r Ni �, x. 11111 1 1 1114 5 r 111111 111 1 111111 �` �' � ' 111 1 111 111/1111/ � �`� 1111 1 111 1 1111 1111/11/ � ���� � �� w � gym,_s�, � r " z .;.,z ^.} r `"k •s'.`..' �. a first ,.yh �. - - f _- ��.:W .:: s t±: � �, fir_:y ar �,��-��c-. F ._•,�,.-.,� .�'1CeJ +,'+�'4r �' ; :xs :..L'`,."" �'��+.� ;Y,s ,{ � 1. � �"�::. cif '",+.{ ti%a_ :EA �.-� `<_r�`swW��°r�r? «srA.�.ye".z�',,:•;;,t�'.,'�"-w�' h=' � :�. -_< _. _ :.,.. _.,, k' ": ,� '�., ,�x :` ',"• - ::'F A� w.1q��i .w�u n �.ra `; "..` '°�.7. .;idw .""s1'�t'..:C ��[;...,;- a :.: � ,,.' ,.. ..,.. ,...•M ,..'. 'a.•x t,;_ :z '�.° \..;�'i; - 's` r x.�9. .w '. ....:... .. .:. .. .. ,.:. .r ".a ... .... ,j,. "'r'k r:v_..,.J, �Y.i 4n c•1:.. �L^ .Y'F '".'. p _ ...�,., -,._,.:.3 ,. ,. M1 ,. ..t .y.'•�,�_ ..:. ,... -�3 w. `.:.. -.�".'.'��v _ �`-�Y� '^'.'.'[Sl'Sii��4 1. :;t.. -� $'f .. .., .-r ... , ,. .-.,. -c,,.: �, -:,::t ,v^ _ .� .�,> :� .y;�ty�y-" ,..� .f.&.a t� �z•�:�• t .!"_t'�rs.,�� v?'s�•�' s ` FILE# '1:9 gA 107 Forest St.Middleton,MA �P�N - s (508) 774 2772 5 I SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PROPERTY OWNER'S NAME: 1..e i q k4c n PROPERTY ADDRESS: `f3Yf ADDRESS OF OWNER: (if different) DATE OF INSPECTION: 'J-un e 14 4 FI NAME OF INSPECTOR: J�h ory +S _T Ch'i!a S 10ARD 0C HE, 4 � r • THE PROFESSIONAL EXPERTS IN THE SEPTIC AND DRAIN INDUSTRY• } FILE # l� ���A SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION Property Address: '��8 Summer St N.A nA6\jer Address of Owner: Date of Inspection: g JU h Cr l�� (If different) Name of Inspector: I am a DEP approved system inspector pursuant to Section 15.340 of Title S (310 CMR 15.000) Company Name: :r�r s? IL + t 'l Y Mailing Address: In)-I /}- Telephone Number: Q7$ 7776/-2772 CERTIFICATION STATEMENT I cenify that I have personally inspectedthe sewage disposal system at this address and that the information reported below is true, accurate and complete as of the time of inspection. The inspection was performed based on my training and experience in the proper function and maintenance of on-site sewage disposal systems. The system: _ Passes Conditionally Passes reeds Further Evaluation By the local Approving Authority Fails Inspector's Signature: !i 61?;I r, Date: a9 The Svstem Inspector shall submit a copy of this inspection report to the Approving Authority within thirty (30) days of completing this inspection. If the system is a shared system or has a design flow of 10,000 gpd or greater, the inspector and the system owner shall submit the report to the appropriate regional office of the Department of Environmental Protection. The original should be sent to the system owner and copies sent to the buyer, if applicable, and the approving authority. INSPECTION SUMMARY: Check A, B, C, or D� A) SYSTEM PASSES: ZI have not found any information which indicates that the system violates any of the failure criteria as defined in 310 CMR 15.303. Any failure criteria not evaluated are indicated below. 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. Indicateyds,fno, or not determined.(Y, N, or ND). Describe basis of determination in all instances. If"not determined", explain why not. ., V The septic tank is metal, unless the owner or operator has provided the system inspector with a copy of a Certificate of " Compliance (attached) indicating that the tank was installed within twenty (20) years prior to the date of the inspection; or the septic tank, whether or not metal, is cracked, structurally unsound, shows substantial infiltration or exfiltration, or tank failure is imminent. The system will pass inspection if the existing septic tank is replaced with a conforming septic tank as approved by the Board of Health. (revised 04/25/97) Page 1 of 10 - - t - r FILEb SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) BJ SYSTEM CONDITIONALLY PASSES (continued) Sewage backup or breakout or high static water level observed in the distribution box is due to broken or obstructed pipe(s) or due to a broken, settled or uneven distribution box. The system will pass inspection if(with approval of the Board of Healt ). Describe observations: broken pipe(s) are replaced obstruction is removed ,( distribution box is levelled or replaced , The system required pumping more than four times a year due to broken or obstructed pipe(s). The system will pass inspection if(with approval of the Board of Health): broken pipe(s) are replaced obstruction is removed C) FURTHER EVALUATION IS REQUIRED BY THE BOARD OF HEALTH: r Conditions exist which require further evaluation b the Board f Y o Health in order to determine .ifh t e system is failing to protea the public health, safety and the environment. 1) SYSTEM WILL PASS UNLESS BOARD OF HEALTH DETERMINES THAT THE SYSTEM IS NOT FUNCTIONING C IONING IN A WHICH WILL PROTECT THE PUBLIC HEALTH AND SAFETY AND THE ENVIRONMENT: MANNER Cesspool or privy is within 50 feet of a surface water 84 Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh. 2) SYSTEM WILL FAIL UNLESS.THE BOARD OF HEALTH (AND PUBLIC WATER SUPPLIER, IF APPROPRIATE) DETERMINES THAT THE SYSTEM IS FUNCTIONING IN A MANNER THAT PROTECTS THE PUBLIC HEALTH AND SAFETY AND THE ENVIRONMENT: The system has a septic tank and soil absorption system (SAS) and the SAS is within 100 feet to a surface water si ;:: .:• tributary to a.surface water supply. The system has a septic tank and soil absorption system and the SAS is within a Zone I of a public water supply well. The t system has a septic tank and soil absorptions stem and the SAS ' w'Y (s rthm 50 feet ofriv a private water supply well. The system has a septic tank and soil absorption system and the SAS is less than 100 feet but 50 feet or more from a private water supply well, unless a well water analysis for coliform bacteria and volatile organic compounds indicates that the well is free from pollution from that facility and the presence of ammonia nitrogen and d nitrate nitrogen is equal less.than 5 ppm. Method used to determine distance g eq to or _ (approximation.not valid). 3) OTHER Ta JUN i I ' (revised 04/25/97) Pago 2 o1 10 FILE # SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) D) SYSTEM FAILS: Y u ust indicate either "Yes" or "No" as to each of the following: �� I have determined that the system violates one or more of the following failure criteria as defined in 310 CMR 15.303. The basis for this determination is identified below. The Board of Health should be contacted to determine what will be necessary to correct the failure. Yes o 7` Backup of sewage into facility or system component due to an overloaded or clogged SAS or cesspool. Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or J cesspool. J _ Static liquid level in the distribution boa 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 1/2 day flow. Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number of times pumped _. Any portion of the Soil Absorption System, cesspool or privy is below the high groundwater elevation•,. //�V"/+t Any ponion of a cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. IVA, Any ponion of a cesspool or privy is within a Zone I of a public well. AAAny portion of a cesspool or privy is within 50 feet of a private water supply well. Any ponion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality analysis. If the well has been analyzed to be acceptable, attach copy of well water analysis for coliiorm bacteria, volatile organic compounds, ammonia nitrogen and nitrate nitrogen. \E] LARGE SYSTEM FAILS: You must indicate either "Yes" /io ach of the following: The following criteria systems in addition to the criteria above: ,The system serves a faesi n flow of 10 000 r r8 gpd o g eater (Large System) and the system is a significant threat to ppblic health and safeironment because one or more of the following conditions exist: Yes No th/ste, is within 400 feet of a surface drinking water supply �fte 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) The owner or operator of any such sy tem shall bring the system and facility into full compliance with the groundwater treatment program requirements of 314 CMR 5.00 and 6.00 Please consult the local regional office of the Department for further information. (reviaod 04/25/97) page 3 of 10 r FILE # 6GO? ? ?A SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B. CHECKLIST Check if the following have been done: You must indicate either "Yes" or "No" as to each of the following: Ye; NO Pumping information was provided by the owner, occupant, or Board of Health. _ None of the system components have been pumped for at least two weeks and the system has been receiving normal flow rates during that period. Large volumes of water have not been introduced into the system recently or as pan of this inspection. As built plans have been obtained and examined. Note if they are not available with N/A. _ The facility or dwelling was inspected for signs of sewage back-up. _ The system does not receive non-sanitary or industrial waste flow. _ The site was inspected for signs of breakout. _ All system components, excluding the Soil Absorption System, have been located on the site. �'• _ The septic tank manholes were uncovered, opened, and the interior of the septic tank was inspected for condition of baffles or tees, material of construction, dimensions, depth of liquid, depth of sludge, depth of scum. The size and location of the Soil Absorption System on the site has been determined based on: _ The facility owner (and occupants, if different from owner) were provided with information on the proper maintenance of Sub-Surface Disposal System. _ Existing information. Ex. Plan at B.O.H. _ Determined in the field (if any of the failure criteria related to Pan C is at issue, approximation of distance is unacceptable) [15.302(3)(b)J 130AR7 C" r6 JUN I I (revimad 04/25/97) Page 4 of 20 _-_ _ FILE SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION RESIDENTIAL: .FLOW CONDITIONS Design flow: Z- D�g.p. ./bedroom,for S.A.S. Number of bedrooms: L Number of current residents: Garbage g,,: der (yes or no):-Y—O Laundry cor-ected to system (yes or no):� Seasonal use tyes or no):� V%Vater meter readings, if available (last two (2) year usage (gpd): Un9Va,1QYJ�L 7-1�ne lJ/�/%S C Sump Pump (ves or no): AO Last date of occupancv:A&Ie COMMERCIAUINDUSTRIAL• I,ype of establishment: Design flow: eallons/ ay Grea?- trap present: Ives r not_ Inaustn \Paste Holdi Tank oresent: ryes or no)_ ton-sanit waste d charged to the Title i system: tves or no)_ �%ater meter eadi s, if available Last pate of o: u� ncy: OTHER: ( escribe! Last dale of occuoancy. i GENERAL INFORMATION PUMPING RECORDS and source of info r ati n: t�r�wt,ornc r � O System pumped as pan of inspection: (yes or no) Q If yes, volume pumped: allons Reason for pumping TYPE OF SYSTEM —V' s Septic tank/distribution box/soil absorption system _ N Single cesspool Overflow cesspool Privy Shared system (yes or no) (if yes, attach previous inspection records, if any) VA Technology etc. Copy of up to date contract? Other APPROXIMATE AGE of all components, date installed (if known) and source of information: Jr' i Sewage odors detected when arriving at the site: (yes or no) TC, (revised 04/25/97) _�_ r- • I Page 5 of 10 ��. FILE # 66aq $A SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) BUILDING SEWER: (Locate on site plan) Depth below grade:-5/ Material of construction: cast iron _40 PVC _ other (explain) Distance from private water supply well or suction lir(. N Diameter Comments:'(condition/of joints, v nti g, a 'deuce of leakage, etc.) Al SEPTIC TANK::S (locate on site plan) Depth below grade: Material or construction: concrete _metal _Fiberglass _Polyethylene _other(explain) If tank is metal, Inst age = Is age confirmed by Certificate of Compliance —(Yes/No) Dimensions: L X WX . -'cy 1,n r t,L 2` /000 ctcl TO-A (� Sludge depth: �/ Distance from top of sludge to bottom of outlet tee or baffle: NA Scum thickness: Distance from top of scum to top of outlet tee or baffle:_ Distance from bottom of scum to bo= r2:)de utlet tee or baffle:_IVA How dimensions were determined: ruler. Comments: (recommendation for pumping, conclitiop of inlet and outlet tees or baffles, depth of liquid levein relation to outlet invert, struct ral integrity, evidence(of leakage,,etc.) a '-f'4 0,,0. J v r' OLpe- xa A sPil 0 7 V c t r l II7 i REASE TRAP: (lo a on site.plan) Depth be w grade: Material of cstruction: oncrete ,_metal _Fiberglass _Polyethylene _other(explain) Dimensions: Scum thickness: Distance from top scuNto top of outlet tee or baffle: Distance from om of scOT to bottom of outlet tee or baffle: Date of last pumping: Comments/` (recom7ndation for pumping, conditi of inlet and outlet tees or baffles, depth of liquid•level in relation to outlet invert,'structural integrity, evidence of leakage, etc.) (revised 04/25/97) Page 6 of 10 FILE 0 89?4 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) TI�HT OR HOLDING TANK:,-/Tank must be pumped prior to, or at time, of inspection) (locate\on site plan) Depth belo�w grade: Material of construction: _concrete _metal _Fiberglass _Polyethylene _other(explain) Dimensions: �C Capacit\-: \iallons Design flow:g o );aIlons/da\ Alarm level Alarm in working order_ Yes; _ No Date of previous pumping: Comments: (conditio of inlet tee, condition of alarm and float switches, etc.) 1�. e bet" r'a vte g DISTRIBUTION BOX: S �t�ehSfD)) Z1`Z X 1.3W (locate on site plan) Depth of liquid level above outlet invert: Comments: (note if level and distribution is equal,.evid nce of soli s carryover, evi nce o leakage into rout of bo etc.) -�o I r 2V2 czf l I i ri it E ere La ';16 Uer PULP CHAMBER: (locate,pn site plan) Pumps in wo'r ing or r: (Yes or No) Alarms in worki der (Yes or No) Comments: (note conditio /f purrmp chamber, condition of pumps and appurtenances, etc.) c - TOM N OF N0RTH R�!DO,7,�7% SOAR" t)= ;t�,*:T,4 JUN (revised 04/25/97) ��..� Page 7 of 10 LFILE # o0 9'PA SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) SOIL ABSORPTION SYSTEM (SAS): S (locate on site plan, if possible; excavation not required, but may be approximated by non-intrusive methods) If not determined to be ,resentexplain: �t� y p Type: leaching pits, number:_ leaching chambers, number: leaching galleries, number: leaching trenches, number, length: wC� l.�C�1 1r'P��I,t2s APPr°n �✓ �l� leaching fields, number, dimensions: overflow cesspool, number: Alternative system: Name of Technology: Comments: (note condition of soil, igns of hydraulic failure, level of pon g, con ition f veg i , etc.) t Q r�e i r- " ( s SPOOLS: �V (locate On site plan) Number and\configuration: Depth-top of T uid to inlet inven• Depth of solids er: Depth of scum laye Dimensions of cesspool; Materials of construction- Indication of groundw er: inflow (ces ool must\be pumped as part of inspection) Comments: (note co ition of soil, signs of hydraul\icfan level of ponding, condition of vegetation, etc.) P wy: (locate on site plan) Materials ot-ccinstruction: / Dimensions: Depth of solidi:.. Comments: (note condition of so( ,signs of hydraulic failure, level of ponding, condition of vegetation, etc.) (ravioad" 04/25/97) Page a of 10 FILE # 8 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) SKETCH OF SEWAGE DISPOSAL SYSTEM: include ties to at least two permanent references landmarks or benchmarks locate all wells within 100' (Locate where public water supply comes into house) 7 AN C A: FILE SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C , SYSTEM INFORMATION (contin ;ed) Depth to Groundwater Feet �P�YOX Please indicate all the methods used to determine High Groundwater Elevation: Obtained from Design Plans on record ✓ Observation of Site (Abutting property, observation hole, basement sump etc.) Determine it from local conditions Check with local Board of health Check FEMA maps Check pumping records Check local excavators, installers Use USGS Data Describe in your own words how you 7etaMblished he High Groundwater Elevation. (Must be complet d) e Ger ��s Q T 04rr�ale 00 1000' PI 7KV(9 to I"- 66' �� �� It 14 s -tet /1/0 SIS GtJi S S y k 70V-, OF ')!T' 3OAq C, JUN 1 1 ; (revised 04/25/97) Page 10 of 10 Aug-21-98 10:06A Paul D_ Turbide, PE/PLS 508-465-0313 P.04 August 21, 1998 Sandra Stats North Andover Board of Health Administrator Office of Community Development and Services 120 Main Street - North Andover,MA 01845 i RE: Title V review for 438-Summer Street - Dear Sandra, Enclosed find the"Checklist for North Andover Septic System Plans" for the above- mentioned site. The following is a list of all the`Problem' areas and deficiencies Port Engineering has found. h' Leat sttg Facility • Groundwater separation is less than the required 4'a variance and local upgrade approval has been requested. If the variance is granted then the plans need not be resubmitted. If you have any questions or comments please feel free to contact us. tncerely Paul D. Turbide,PEIPLS PODT ENGINEERING, Civil Engineers& Land Surveyors One Harris Street Newburyport,MA 01950 (978)465-8594 OFF sib r���� r►t / 'rf)ARD'(0' HEAL TH 9 1998 1 j TOWN OF NORTH ANDOV=RR SEWAGE DISPOSAL SYSTEM INSTALLATION CERTIFICATION The undersigned hereby certify that the Sewage Disposal System ( ) constructed; (Xrepaired-, by located at '�7� 3 ��ws ,�- p- ,57L was installed in conformance with the North Andover Board of Health approved plan, System Design Pen-nit#/pY , dated Sr ,�B 9� with an approved design flow of V1/0 gallons per day. The materials used were in conformance with those specified on the approved plan; the system was installed in accordance with the provisions of 310 CNIR 15.000, Title 5 and local regulations, and the final grading agrees substantially with the approved plan. All work is accurately represented on the As-built which has been submitted to the Board of Health. Bed inspection date: sp L9//� Final inspection date: { Installer.< G l � Lic. #: Date: Design Enginee i� L d w Date: l T/,t-4 APD �t .g• _ d 9� •..`;' .r, i•0. , I r '411" -iZ t' WEEKLY TIME SHEET COMMUNITY[ Department 5100 f Clock Number 25011 Department HE Employee# Susan Ford Employee's Si, Week Ending 10/30/99 i REGULAR HOURS Code *8108 8000 8103 *1 Comm. Admin. Direct I Support Mgt. Services RE { Projects Pe i Sunday ' Monday Tuesday Wednesday Thursday i NEW ENGLAND ENGINEERING SERVICES INC fd TCWP$®F 0 r car LTRs N(1V , � 1998 November 7, 1998 North Andover Board of health 27 Charles Street North Andover, MA 01845 RE: 438 Summer Street Dear Sandra: Enclosed are two copies of the as built plan and one copy of the designers certificate for the above referenced location. If you have any questions please do not hesitate to contact this office. Sincerely, Benjamin C. Osgood, Jr., EIT President 33 WALKER ROAD-SUITE 23-NORTH ANDOVER, MA 01845-(978)686-1768-(888)359-7645-FAX(978)685-1099 TOWN OF NORTH ANDOVER BOARD OF HEALTH CERTIFICATE OF COMPLIANCE DATE OF COMPLIANCE: 11/6/98 This is to certify that the individual subsurface disposal system constructed O or repaired ( X) by John Shaw III at 438 Summer Street 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 # 1046 dated 9/28/98. The Issuance of this certificate shall not be construed as a guarantee that the system will function satisfactorily. Board of Health Inspector Town of North Andover, Massachusetts Form No.3 e NORT/� BOARD OF HEALTH } t OC 1 9 ; - ��' �.,o..�' �• DISPOSAL WORKS CONSTRUCTION PERMIT } ,SSACMUSES L 4 � tr Applicant 1 , NA ADDRESS TELEPHONE wt Site Location 1 h Permission is hereby granted to Construct ( ') or Repair an Individual Soil Absorption Sewage Disposal System as shown on the Design Approval S.S. No. F r t CHAIRMAN, BOARD OF HEALTH Fee D.W.C. No. G t i r t tt �{ t , S t a 't t Sr tt rt� f tt "- .. :.. ..: .. .(....,... :.r. t s i i . - . : N t t t r t r • s f "> - APPLICATION FOR DISPOSAL WORKS CONSTRUCTION PERMIT DATE: y as Q� CURRENT INSTALLER'S LICENSE# LOCATION: 4/3 '5 LICENSED INSTALLER: �,� SIGNATURF<: � �� TELEPHONE# 1771-1 g0 '9 g CHECK ONE: REPAIR: 1// NEW CONSTRUCTION: IF NEW CONSTUCTION, PLEASE ATTACH FOUNDATION AS-BUILT. Administrative Use Only 75.00 Fee Attached? Yes No Foun tion As-Built? Yes No For Plans? Yes No Approval Date: :�3' &-N Commonwealth of Massachusetts REC I��® City/Town of MAY 2 9 2007 System Pumping Record yForm 4 TOWN OF NORTH AM OTER HEALTH DEPART 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 Important: When filling out 1. Syst m Location: forms on the computer,use only the tab key Address j ��-- to move your l�' cursor-do not City/Town State / Zip Code use the return key. 2. System Owner: Name Address(if different from location) City/Town State/° �C_59�Zip Code Telephone Number B. Pumping Record 5-2)4-07 1. Date of Pumping Date 2. Quantity Pumped: Gallons 3. Type of system: ❑ Cesspool(s) eptic Tank ❑ Tight Tank ❑ Other(describe): 4. Effluent Tee Filter present? ❑ Yes Vo If yes, was it cleaned? ❑ Yes ❑ No 5. Conditior}�of Sy� � ste " � W� 6. System u Name Vehicle License Number Company 7. Location re nteere ' osed: Signat cfWau)& Date t5form4.doc•06/03 System Pumping Record•Page 1 of 1 i TOWN OF SYSTEM PUMPING RECORD DATE: - ' MAY 2 2003 SYSTEM OWNER& ADDRESS SYSTEM LOCATION (example:left front of house) �j J ko uk� q 3 S uvv�-w�rr DATE OF PUMPING: QUANTITY PUMPED : GALLONS CESSPOOL. • NO V YES SEPTIC TANK: NO YES NATURE OF SERVICE: ROUTINE V EMERGENCY OBSERVATIONS: GOOD CONDITION FULL TO COVER HEAVY GREASE BAFFLES IN PLACE ROOTS LEACHFIELD RUNBACK EXCESSIVE SOLIDS FLOODED SOLIDS CARRYOVER OTHER(EXPLAIN SYSTEM PUMPED BY: Bateson Enterprises, Inc. COMMENTS: CONTENTS TRANSFERRED TO: 2 I i s TOWN OF NORTH ANDOVER SYSTEM PUMPING RECORD DATE: SYSTEM OWNER &ADDRESS SYSTEM LOCATION (example: left front of house) DATE OF PUMPING: 5— (—�t)bUANTITY PUMPED GALLONS CESSPOOL: NO YES SEPTIC TANK: NO YES NATURE OF SERVICE: ROUTINE EMERGENCY OBSERVATIONS: GOOD CONDITION FULL TO COVER HEAVY GREASE BAFFLES IN PLACE ROOTS LEACHFIELD RUNBACK EXCESSIVE SOLIDS FLOODED SOLIDS CARRYOVER OTHER (EXPLAIN) SYSTEM PUMPED BY: COMMENTS: TOWN OF NORTH ANDOVER77 CONTENTS TRANSFERRED TO: 14 ZQQI J PP C � � �8I `� firC Q it �2— CNo R 1Q r i t QSP O Findin q s ❑ u0 Appliedtion filed on; Hearing due on: I Decision due bu: "I 0 t� I , SII i Legal Notice TOWN OF NORTH ANDOVER BOARD OF APPEALS NOTICE c�No�'M �� Jufy 22,19i6 0 Notice Is hereby given o' �• �,. that the Board of Appeals F will give a hearing at the F Town Building, North An- • ^. ...L,_. .'' 4over, on Tuesday evening M J .'��' the 12 day of August, SAC H°g 1986,at 7:30 o'clock,to all parties-Interested in the ap- peal of Homer&Elizabeth Leighton requesting a varla- tion of Sec.7,Para 7.3 and Table 2 Bylaw so as to per• mit relief from the side lot line setback for future con- . veyance purposes on the premises, located at 438 Summer.St.. By Order of the Board of Appeals Frank Serlo, Jr., Chairman. Publish North Andover Citizen, July 24 &July 31, 1986. k21 Legal Notice TOWN OF NORTH ANDOVER BO,_ O OF APPEALS NOTICE H?RT duly 22,1986 3:°.�,;'��.;`•,'ot Notice is hereby given '° that the Board of Appeals • will give a hearing at the Town Building, North An- dover, on Tuesday evening the 12 day of August, ss^CH°5� 1986,at 7:30 o'clock,to all parties interested in the ap- peal of Homer&Elizabeth Leighton requesting a varia- tion of Sec.7,Para 7.3 and Table 2 Bylaw so as to per- mit relief from the side lot line setback for future con- veyance purposes on the ,premises, located at 438 Summer St.. By Order of the Board of Appeals Frank Serio, Jr., Chairman. Publish North Andover Citizen, July 24 &July 31, 1986. k21 vepartmentgivesthetown ureaoiuiy w hire another officer in . his place. Lustenberger was paid $20,78' in fiscal year 1985 until his r%irement. His retirement benefits will be figured on his length of service. The difference between being ruled "disabled" as to"retired"is significant to both Lustenberger and the town, ex- plained Selectman Chair Charles Salisbury., ! . "If he's injured in the line of duty he gets full compensation until he is retired or returns to work," Salisbury said. "If he's--injured outside of work he's not en- titled to.anything beyond sick leave. (As a disabled officer) he stays on as an in- active member of the police department holding a position t uthorized for an of- ficer." L O p { � ..i • (X/VAS,', sACNU3 t�« TOWN OF NORTH ANDOVER .MASSACHUSETTS BOARD OF APPEALS S Homer & E . Leighton 438 Summer St . N . Andover , MA 01845 Date: Jul -y 30 , 1986 Dear Applicant: Enclosed is a copy of the legal notice for your application before the Board of Appeals . Kindly submit $ 3 . 96, for the following: Filing Fee $ Paid Postage $ 3 . 96 ' r Your check must be made payable, to the Town of North Andover an-d- '_ may be sent to my attention at the Town Office Building, 120 Main Street , North Andover , Mass . 01845. Sincerely, BOARD OF APPEALS Audr W. Taylor, Clerk iA,4., Legal Notice' n w TOWN OF NORTH ANDOVER, - -BOARD OF APPEALS •, 4 01 Mo.TM 1h NOTICE July 22,1986, y, ? ; c Notice is hereby given that the Board of Appeals will give a hearing at the Town Building, North An • �s :.. •r dower, on Tuesday evening e `- + `• y1s.,...•��,� the 12 day of August, US 1986,at 7:30 o'clock,to all '11, parties interested in the ap- _, r M # peal of Homer$Elizabeth:Leighton requesting a varia • { tion of Sec..7,Para 7.3 and Table 2 Bylaw so as to per-., ,mit relief from the side,lot line.setback for future con- voyanee purposes,on the premises, located at 438 r�rk Summer St.. _ y ¢ , , 1 -=By Order.of.the Board of.Appeals ' �;Frank Serlo#J(.,Chairman: Publish North Andover Citizen,July 244 July 31, x k21 1986: • d S A�l` 1 y 1 a get , l i a. "444 a . ►►f aORTH'�f • ' ISSS ;��► 1S9• ,C` SACHU9�'i44 TOWN OF NORTH ANDOVER MASSACHUSETTS BOARD OF APPEALS NOTICE . . . J.uly. .22. . . . . .19. .86 Notice is hereby given that the Board of Appeals will give a hearing at the Town Building,North Andover,on . . .T u e.s.d a y e v.e n i n g. . . . . . the . . 12. day of .A u.g us t. . 198 6 , at.7:;.241ock, to all parties interested in the appeal of Homer & Elizabeth. -Le ighton_ requesting a variation of Sec..7 . .P a r a 7 . 3 of the Zoning By Law so as to permit. . . . . . . . .and. . . .Tabl. . . . .e. . .2. . . . . . . . . . . . . . relief from -the side lot line setback fo.r. `futu.re conveyance purposes . on the premises, located at. . 438 Summer- S t . . . . By Order of the Board of Appeals Frank Ser o , J: . , Chairman Publish in NA Citizen on July 24 July 31 , 1986 i R•N� DALi ;l? ii 3: ;r pL TOY.,, + K p NORI a.` Auc I �4 ;�Ss�cHoOVER us� r. .. TOWN OF NORTH ANDOVER MASSACHUSETTS BOARD OF APPEALS 4 August 14 , 1986 Mr. Daniel Long , Town Clerk Pe ti ti on #18-87 ,t 120 MainStreet Homer & E . Leighton North Andover , MA 01845 438 Summer St . Dear Mr . Long , The Board of Appeals held a public .hearing on August 12 , 1986 upon the application of Homer & E . Leighton requesting a variance from the requirements of Section 7 , Paragraph 7 . 3 and Table 2 of the Zoning ByLaws so as' to, permit relief from the side lot line setback for future conveyance purposes . The following members were present and voting : Frank Serio , Jr. , Chairman , Alfred Fri zel le , Vice-chairman , William Sullivan , Raymond Vivenzio and Anna. O ' Connor . The hearing was advertised in the North Andover Citizen on July 24 and July 31 , 1986 and all abutters were notified by regular mail . Motion made by Mr . William Sullivan and seconded by Alfred Frizelle to GRANT this petition as requested . The Board feels that a financial hardship could be created if the house were put up for sale and did not conform to zoning ordinance . Due to the large distances to structures on adjoining properties , there is, no detrimental effect to the neighhood by granting this: petition . r Sincerely , ran erii o, , , C arman BOARD OF APPEALS ^, ,:; •f� Post-it®Fax Note 7671 °ateap #oof .2� ,ZI r 4 f To From Co pt.. Co. ' /1/`f Phone# �/ / r-y Phone# Fax#� Fax# G . i t• ,4 p. n/' y x h TOWN Ct.r_RK `O � � z NORTH ANDOVER ] '• 1855 ;�C�' An N a 44 AM '86 � { TOWN OF NORTH ANDOVER MASSACHUSETTS Tw� - BOARD Of APPEALS 111%Y4# F 4� NOTICE OF DECISION, Homer & E . Leighton 438 Summer St .. f ' f{ N. Andover , MA 01845 Date . : . . . � k Aog'ust. .1,3 ,• . a.g86. . . . Petition No.. .'.1.8: .87. . . . . . . ... . . . . f $ tr• Date of Hearing. A.W g u s t• 12•,• 19 8 6 � ..` 'Horne r & E . Leighton 1 Petitwn of . . . . . . . . . . . . . . t Premises affected . . . 4.3 8 S.u m m e r St . . . . . . . . . . . . . . . .•. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . P F Referring to the above petition for a variation from the requirements of the . . .Sectio n 7 , , , •Rar.agr.a.ph. .7...3 . a.nd:.T.ab.te. .2 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . -s0 as to emit . . r.e.l.i.e.f. .f.rom. .the. .si.de. .lot . 1 i.ne. .set'back• for •future „r+4 pe •con:vey-an•ce . .p.urp.oses . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . After a public hearing given on the above date, the Board of Appeals voted to . .G R AN T.. : the .v a•r i a n c e. . . . . . . . . . . . . . . . . . . eX E(eEyX sYuXtHi Xti#X41 X XtXi 9MOR eft"w"9M OXON Ab"xq cKkIft"WOOMA)w thud wim""iby x The Board feels a financial hardship could be created if house put up i 4 for sale and did not conform to zoning ordinance . Due to the large distances to structures on adjoining properties , the Board feels there is no detrimental effect to the neighborhood . xf M L Signed - ' . . . .Fr•ank. •Se•rio•, • J•r ,.•,• .Ch.air.man�. ti Al•fre-d• Fri •z'el•1•e ,• Xice-char rman "ki fid.[-•'�.. ' - - . . . . . . . . .i-1 I-i-am. •S u-l.l i van. . . . . . . . . . . . - Raym'on d. N i.ven z i o. . . . . . . . . . . A.nna. .0.'.Con.no.r. . . . . . . . . . Board.of Appeals Received by Town Clerk: jp`r r D A N i I €. 8' NOPM-1 1 Fi?d OVER y� TOWN OF NORTH A MY6, IWe SETTS BOARD OF APPEALS APPLICATION FOR RELIEF FROM THE REOUIREMENTS OF THE ZONING ORDINANCE ApplicantHomer C. & Elizabeth^F. Leighton Address438 Summer St. ,, No.Andover, Ma. 1. Application is hereby made: a) For a variance from the requirements of Section 7 ParagraOh 7.3 and Table 2 of the Zoning By Laws . b) For a Special Permit under Section Paragraph of the- Zoning By Laws . A c) As a Party Aggrieved, for review of a decision made by the Building Inspector or other authority. 2. a ) Premises affected are land Xy and building(s )X_numbered 438 Summer Street . b) Premises affected are property with frontage on the North ( ) South ( )) East ( ) West ( ) side of Summer Street , and known as No. 438 Summer Street. c) Premises affected are in Zoning DistrictR-2 , and the premises affected have an area of 44,600 square feet and frontage of 150 —feet . 3. ownership e e a) Name and address of owner ( if joint ownership, give all names ) : Homer C. & Elizabeth F. Lei_&hton, 438 Summer St. ® No. Ando)Lgp,_� 01845 Date of Purchase December 21 . 1965previous Owner :..3 b) If applicant. is not owner, check his/her interest in the premises: Prospective Purchaser Lesee Other (explain) 44 Size of proposed building:� front; feet deep; H Height_. stories;_ a ) Approximate date of erection: _ Occupancy or use of each floor: c ) Type 0.1 ® Size of e i,„ [.i►lg xsuilding: 54.3 feet front;] «t .. tF: f!ea,ght.,., 2..�.. .stories;_,. ��4feet . . ) A�' r�r0XiP1 �� riz r rt Cif orect'on �) Oc�Purcyr use o! each floor : Residential . Type of construction: vd frame Prem""? rthere been a pr appeal , under zoning, on these P no t eco, when��...�.�«a a .1 7. Description of relief sought on this petition Relief from the side lot e line setback for future conveyance purposes. _ S. Deed recorded in the Registry of Deeds in Book 1051 Page 8 Land Court Certificate No. -Book Page The principal points upon which. I base my application are. as follows: (must be stated in detail ) 1 . Financial hardship in the event house cannot be sold because it does not co f orm to z ning ordinance, 2 A ... �xe to lar e distances o s urc urea on a oining proper es e e -1—S—ho e .r mens -effect a e nelghborhood. i' Agree to pay the filing fee, advertising in newspaper, and incidental expanses* h Signature Of Petitioner Every application for action by the Board shall be made on a form approved by the . Board. These forms shall be furnished by the Clerk upon request. Any communication purporting to be an application shall be treated as mere notice of intention to seek relief until such time asit is made on the official application form. All information called for by the form shall be furnished by the applicant in the manner therein prescribed. Every application shall be submitted with a list of "Parties In Interest" which list shall include the petitioner, abutters, owners of land directly opposite on any public or private street or way, and abutters to the abutters within three hundred feet (300° ) of the property line of the petitioner as they appear on the most recent applicable tax list, notwithstanding that the land of any such owner is located in another city or town, the Planning Board of the city or town, and the Planning Board of every abutting city or town. *Every application shall be submitted with an application charge cost in the amount of $25.00. In addition, the petitioner shall be ,responsible for any and all costs involved in bringing the petition before the Board. Such costs shall include mailing and publication; but are not necessarily limited to these. e Every application shall be submitted with a plan of land approved by the Board. No petition will be brought before the Board unless said plan has been submitted. Copies of the Board' s requirements regarding plans are 'Sf attached hereto or are available from the Board of Appeals upon request. LIST OF PARTIES IN INTEREST Name Address Charles Otis 456 Summer Ste . No. Andover, Ma, 01845 Richard J. and Judith A. Hillner 96 Farnum St. , No. Andover, Ma, 01845 John F. and Eileen P. Burns 110 Farnum St. , No. Andover, Ma. 01845 /Richard N. and Roberta A. Denault . 122 Farnum St. , No. Andover, Ma. 01845 Brothers of the order of the Hermits c/o Merrimack College of St. Augustine, Inc. Turnpike St. , No. Andover, Ma. 01845 /Francis X. Jr. and Dianna M. Dignam 414 Summer St. , No. Andover,, Ma, 01845 Nieholas M. and Jean, A. gzabat 437 Summer St. , NO. Andover` Ma. 01845 ?lWb (use additional sheets if necessary) .