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Home My WebLink AboutMiscellaneous - 52 NORTH CROSS ROAD 4/30/2018 52 NORTH CROSS ROAD / - 210/038.0-0184-0000.0 DAD II I MAP # - Sib LOT PARCEL # -1 j -1- STREET.___�__ ......_.._..._.__..___.....__._.________.._.._......... CONSTRUCTI-ON APPROVAL* HAS PLAN REVIEW FEE BEEN PAID? ES NO PLAN APPROVAL: DATE._.& � APP. BY,...._._._._____._..__.__-�._....__...__... DESIGNER: � i� PLAN DATE-------- CONDITIONS `1 _a 1 ? f -70C '-s7-�r-�� ....f fi r _ WATER SUPPLY: WELL WELL PERMIT�� DRILLER.___-..._._____..._.._..._._....... ......_....... WELL TESTS: CHEMICAL DATE APPROVED-------- BACTERIA I DATE APPROVED,..,,__.__...._..,_.._,.___._.-... BACTERIA II DATE APPROVED COMMENTS: FORM U APPROVAL: APPROVAL TO ISSf,UEE� YES NO DATE ISSUED__ CONDITIONS: FINAL APPROVAL: ALL PERMITS PAID ES NO WELL CONSTRUCTION APPROVAL F'��A� Y NO SEPTIC SYSTEM CONSTRUCTION APPROVAL YES NO OTHER S NO ANY VARIANCE NEEDED YES O FINAL BOARD OF HEALTH APPROVALS DATE:.,..# 'L SEpT I C__S_Y_�TEM_._�NSTALLAT I.ON IS THE INSTALLER LICENSED? YES NO TYPE OF CONSTRUCTION: NEW REPAIR NEW CONSTRUCTION: CERTIFIED PLOT PLAN REVIEW YES NO CONDITIONS OF APPROVAL YES NO r (FROM FORM U) ISSUANCE OF DWC PERMIT YES NO DWC PERMIT No. . 41INSTALLER:,..., —C— a�-r-o BEGIN INSPECTION YES EXCAVATION INSPECTIO,N�: NEEDED:_.__._.__.___....__...__....---_.._._...._._...—__--............ ..........................._............ i r 4,0 __..._ ...._ o ... PASSED �� BY__._____....._.__._._.._._.._._____.._..................... _._._..___.._._...._._._.______.__.._ CONSTRUCTION INSPECTION1 NEEDED: 11 f2 c- .. .......1' ........... � �rN�L GM>A►N� �IL- l��T�� . AS BUILT PLAN SATISFACTORY: YES:_____� !_"-__...__.___..._........._.._.._..___...___.__._._........._ _.___.._._. _....__._ _.._._. ..__...__....._.._............_.-..._._.......__..__---...._._...__ APPROVAL TO BACKFILL: DATE:_� ._ + FINAL GRADING APPROVAL: DATE____";"" '� BY._..._. ._ .... _... ::_.__.._. .._.._ FINAL CONSTRUCTION APPROVAL: DATE:.- BY Commonwealth of Massachusetts _ City/Town of . System Pumping-Record Form 4 DEP has provided this form for use by local Boards of Health. Other forms may be'used, but the information must be substantially the same as that provided here. Before using.this form,check with your local Board of Health to determine the form they use.The System Pumping Record must be submitted to the local Board of Health or other approving authority. A. Facility. Information 1. System Location: Left/Right front of Housoc f�t Ri ar f h , Left/right side of house, Left/ Right side of building, Left/Right front of bung, Left/ Ig rear of'building,buildin , Under deck Address City/Town State Rb i NE D 2. System Owner. JUN 01 2015 Name' TOWN OF NORTH ANDOVER HEALTH DEPARTMENT Address(if different from location) Cityrrown State Zi Code CD Telephone Number r a B. Pumping Rpcordo 1. Date of Pumping Date 2. Quantity Pumped: Gallons ..- 3. Type-of s stem: y- ❑ Cesspools) eptic Tank [3 Tight Tank ❑ Other(describe): 4. Effluent Tee Filter present? ❑ Yes L.3'4o If yes,was it cleaned? ❑ Yes ❑ No ' 5. Condition of s m: 6.. System Pumped By: Neil.Bateson F5821 Name Vehicle License Number Bateson Enterprises Inc- Company 7. Lol,ati - where contents were disposed: Cx L S'. Lowell Waste Water "' Ste f Sign Haul Nu Date t5form4.doc-06/03 System Pumping Record•Page 1 of 1 Date.... .... ............................. of�pT�'ti TOWN OF NORTH ANDOVER PERMIT FOR GAS INSTALLATION ;; Thiscertifies that .......... . L......44�wt�....... ................................................ has permission for gas inst lation ... ... ................................................. in the buildings of ............... . ......................................................................... at t) �,... ..... .'.. , North Andover, Mass. Fee... .t�. ...... Lic. No. . �3 1...... .'.....!..d....................................................... GAS INSPECTOR Check# ;' 2r";. � MASSACHUSETTS UNIFORM+LICATION FOR A PERMIT TO PERFORM GAS FITTING WORK CITY: t MA. DATE: l02 /s f PERMIT# JOBSITE ADDRESS: S aZ tUG7� kc AWNER'S NAME: �C�.�? 3 G OWNER ADDRESS:5d� /UbY{h TEL: 33q, VVQ . 3a�f3FAx: TYPE OR OCCUPANCY TYPE: COMMERCIAL F EDUCATIONAL ❑ RESIDENTIAL,f PRINT CLEARLY NEW:�] RENOVATION:❑ REPLA IEMENT:❑ PLANS SUBMITTED: YES❑ NO APPLIANCESZ FLOOR-4 Bsmt 1 2 31 4 1 5 6 7 8 9 10 11 12 13 14 BOILER BOOSTER CONVERSION BURNER COOK STOVE DIRECT VENT HEATER DRYER FIREPLACE /A Setla, FRYOLATOR FURNACE GENERATOR GRILLE INFRARED HEATER LABORATORY COCK MAKEUP AIR UNIT OVEN POOL HEATER ROOM/SPACE HEATER ROOF TOP UNIT TEST UNIT HEATER UNVENTED ROOM HEATER WATER HEATER i AT i INSURANCE COVERAGE — 1 have a current liabili insurance policy or its substantial equivalent which meets the requirements of MGL.Ch.142 YES UKN0 ❑ L If you have checked YES,,please indicate the type of coverage by checking the appropriate box below. LIABILITY INSURANCE POLICY [� OTHER TYPE INDEMNITY ❑ BOND ❑ OWNER'S INSURANCE WAIVER:I am aware that the licensee�oes not have the insurance coverage required by Chapter 142 of the. Massachusetts General Laws,and that my signature on this p6rmit application waives this requirement. _ 1 CHECK ONE ONLY: OWNER ❑ AGENT ❑ SIGNATURE OF OWNER OR AGENT I hereby certify that all of the details and information I have submitt�d(or entered)regarding this application are true and accurate to the best of my Knowledge and that all plumbing work and installations performed under the permit issued for this application will be in compliance all Pertinent provision of the Massachusetts State Plumbing Code and Chapter 1142 of the General Laws. Az�� PLUMBER/GASFITTER NAME:Mai- �I ,'&3 LICENSE#�J�S� IGNAT RE COMPANY NAME: ADDRESS:3i �pr�5i' ST CITY: STATE: L�• ► ZIP: 6t-C1149 FAX: �i)g 97 Y TEL: ��6"Z I S 3 CELL: 9 3 6- Z� S I13 EMAIL: MASTER[JOURNEYMAN❑ LP INSTALLER❑ CORPORATION I`_7# J�a� PARTNERSHIP❑# LLC i I Uepartmenti o fIndustrial Accidents ' Office oflnvestigations ' X !;;Street,Suite;100 Boston,MA 02114-2017 www.massgov/dia Workers' Compensation hisurance Af6avit: Builders/Contractors/Electricians/Plumbers Applicant Information I . Please Print Legibly Name(Business/Organization/individual): A C I JI C Q lfe,(� Address:��- � T— City/State/Zip: /n p,r�r� =�t�y� Phone#: ��X77�� ' Z 3 Are you an employer?Check the appropriate bog: Type of project(required): 1.2 I am a employer with .3 4. ❑ I am a general contractor and I employees(full and/or part-time).* havelhired the sub-contractors 6. ❑New construction 2.❑ 1 am a sole proprietor or partner- listed on the attached sheet. 7. [3 Remodeling ship and have no employees Thes,sub-contractors have g. E]Demolition working for me in any capacity. employees and have workers' I � 9. ❑Building addition [No workers' comp.insurance comp. insurance. 10. Electrical repairs or additions required] 5. ❑ We are a corporation and its ❑ P 3.❑ I am a homeowner doing all work officers have exercised their 11.❑Plumbing repairs or additions myself. [No workers' comp. rightlof exemption per MGL 12.❑Roof repairs insurance required]t c. 152, §1(4), and we have no employees. [No workers' 13.NfOther�� '�` .t-� comp. insurance required.] *Any applicant that checks box#1 must also fill out the section below showing their workers'compensation policy information. t Homeowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such. (Contractors that check this box must attached an additional sheet showing the name of the sub-contractors and state whether or not those entities have employees. If the sub-contractors have employees,they must provide their workers'comp.policy number. I am an employer that isproviding workers'compensation insurance for my employees Below is the policy and job site information. Insurance Company Name: J i Policy#or Self-ins.Lie.#: .� RAJ O CI 7 d Expiration Date: Job Site Address: �a /V 6111, ( DSS 90th City/State/Zip: OYyl1119626 11 0�l/7 d t � —I Attach a copy of the workers'compensation policy declaration page(showing the policy number and expiration date). Failure to secure coverage as required under Section 25A of MGL c. 152 can lead to the imposition of criminal penalties of a fine up to$1,500.00 and/or one-year imprisonment,as well as civil penalties in the form of a STOP WORK ORDER and a fine of up to$250.00 a day against the violator. Be advised that a copy of this statement may be forwarded to the Office of Investigations of the DIA for insurance coverage verification. Ido hereby certi under the gains and enalties o e!jug that the in ormation provided above is true and correct Date 102 . _- -- - - ^- -- --------------- Phone#: ,'' 9 7 ' R:3 66- Z f ; 3 Official use only. Do not write in this area,to be completed by city or town officiaL City or Town: j Permit/License# Issuing Authority(circle one): I 1.Board of Health 2.Building Department 3. Ci Town Clerk 4.Electrical Inspector 5.Plumbing Inspector 6.Other Contact Person: Phone#: i i Al A.- COMMONWEALTH OI= MASSACHUSETTS `~ l & BOARD OF MQ-17- I PLUMBR S � AND N GAS F i TT C 1 ERS ISSUES THE FOLLOWING LICENSE Y REGISTERED AS A PLUMBING CORP o _: tiN' •, ;Q � e.. MARK MAGN I F 1 Cdr } MAGNIFICO BROS PLBSHGT,GAS FITTI h ' � v 31 FORE-sr sr ,N MlDDLETON i Ma 01949-2015 3 21;6 ---_ _ 5/01/16 204666 "s,r - p. OQNWdLTH OF MASSACHUSETTS " �n t# BOARDr- --' s PLUMBERS AND GASFITTERS : ISSUES THE FOLLOWING LICENSE LICENSED AS A MASTER PLUMBER t { . MARK B MAGN 1 F I I 0 31 FOREST STREET z ;4100LETON �MA 01949-2015 135r-9 0.5/01/16 204667 -. CO-MMONWEA X OF MASSETTS S ,CHU .7., .-.. BOARD bF T PLUMBERS AND GASFITTERS ISSUES THi FOLLOWING LICENSE LICENSED AS A JOURNEYMAN PLUMBER r ftARK S MAGN I F I CO h ' F* 31 FOREST ST U rliI DVIL€TOIL MA 01949-2015 l r _- 25002 05/01/16 204668 • 1 Commonwealth of Massachusetts qi P-2 City/Town of System Pumping Record Form 4 DEP has provided this form for use,by local Boards of Health. Other forms may be'used, but the information must be substantially the same as that provided here. Before using.this form,check with your local Board of Health to determine the form they use.The System Pumping Record must be submitted to the local Board of Health or other approving authority. A. Facility Information 1. System Location: Left/Right front of hou Left/ ig rea�house)Left/right side of house, LeftRight side of building, Left/Right front of bui Ing, Leftuilding, Under deck Address �� ,��„ ► 1 - City/Town State Zip Code 2. System Owner. Name Address(if different from location) cdylrown -- Telephone Number B. Pumping Record 1. Date of Pumping2. Quan' Pum Date Gallons 3. Type of system: ❑ Cesspool(s) Q Sep�k ❑ Tight Tank ❑ Other(describe): 4. Effluent Tee Filter present? ❑ Ye. o If yes, was it cleaned? ❑ Yes ❑ No 5. Conditio of stem: 6. System Pumped By: Neil.Bateson F5821 Name Vehicle License Number RECEIVED Bateson Enterprises Inc Company r•� n 9.2013 7. 7�aL,S a contents were disposed: ww! L" �' Lowell Waste Water ` s = ' P4; /,4�T;4 r z m ruecnrr Sig Haul Date t51orm4.doc-06/03 System Pumping Record•Page 1 of 1 i Z Grafi Of 3 LOT Z ?s' 43, r.88 sFt Z � d- box LOT 3 3� '` _ nkc rjll� LOT 1 ,70;0 W//n""'/y .60 �F L `6.cio" DAVID cys R 160.00 A. WEBBER N No. 30757 oe FJ, �E0 STEa�� P��a �pN NO ( L ' SJ ✓�I_f �PT!-� Goss Qa. p/an red' 4.N.o.,e.o. p/. n0. 100/3 e//J75 ELEVATIONS description as - built �� I NV. PIPE OUT OF HSE. /69• f S E3 V I ' I LT I NV. PIPE INTO TANK ` I W PIPE OUT TAK 16657 INV. PIPE NTOODISTNBOX /68..5SUB U - SUS `FACE DISPOSAL INV. PIPE OUT OF DIST. BOX D// /6e.Y6 � �� I� INV.&/ 0w OF PIPE .4 / /108.28 0 2 IN Inv. 0i end o p/pe # 3 /x8.00 NO. ANDOI/ER , Am . Robe"-1 Loprele " #3 /6 7. 95 OR : N Scale : 1 =�� Date: Sept /3, /990 +� pipe nod /n From {ounda�ion �O RICHARD F KAMINSKI AND ASSOCIATES , INC. se tic dank P ENGINEERS ARCHITECT SURVEYORS - LAND PLANNERS NORTH ANDOVER , MASS G 0� 3� 8 L ®T 9 05, ¢3, 688 S.Ft 3 l7 � ,ate d- box /-Or 3 / f�, t .• sep��c 1O T 1 9� � / fang � T `�e�%nar"/4, P . `A OF 44 25.00 L =/25.CL;" b" DAM 'P'/6O.GU A. WEBBER �^ +� No. 30757 oQ /STERE P�`a IL SJ NORT/w CROSS RD. 2/an /-W E.N.P.R.D. /o% 17o. /oo15 e 11375 i ELEVATIONS description as - built I NV- PIPE OUT OF HSE. /6-9.5t *° " A S S U ! LT' INV. PIPE INTO TANK /69.0* �/ INV. PIPE OUT OF TANK 1166.757 S i 'L,j B • SURFACE DISPOSAL! S POSA L INV. PIPE INTO DIST. BOX /68.53 J � INV. PIPE OUTOFDIST. BOX O// 168.26 FPIPE / /� �6 SYSTEM I N v.e/bole o �# # 2 IDS MV.. o en 01',01,P& # 3 /68.00j NO. A POMER a MA . # 2 /68.// Robed L oPrel e Scale : =40 Date: Sep{ /3, /990 pipe r7o/ /n from - ounclalion �o RICHARD F KAMINSKI AND ASSOCIATES , INC. sepllc dank ENGINEERS - ARCHITECT - SURVEYORS - LAND PLANNERS NORTH ANDOVER , MASS North Andover Board of Assessors Public Access Page 1 of 1 poRtH TOWn of Worth AVK10Ver hoard.of Assessors 32 •... "�'^of P. - Property � Return to the Home page click on logo --""`1 Record Card Parcel ID:210/038.0-0184-0000.0 Community:North Andover SKETCH PHOTO New Search Click on Sketch to EnlargeClick on Photo to Enlarge Sales 1 Summary .; Residence Detached Structure Condo Commercial Comparable Sales 52 NORTH CROSS ROAD Location: 52 NORTH CROSS ROAD Owner Name: STATHOPOULOS,STEPHEN J LYDIA J JAMES Owner Address: 52 NORTH CROSS ROAD City:NORTH ANDOVER State:MA ZIP:01845 Neighborhood:7-7 Land Area: 1 acres Use Code: 101 -SNGL-FAM-RES Total Finished Area:2849 sgft ASSESSMENTS CURRENT YEAR PREVIOUS YEAR Total Value: 617,000 643,300 Building Value: 392,200 406,800 Land Value: 224,800 236,500 Market Land Value:224,800 Chapter Land Value: LATESTSALE Sale Price:295,000 Sale Date:04/29/1992 Arms Length Sale Code:L-NO- Grantor:FIRST COLONIAL REPOCESSN BANK Cert Doc: Book:03454 Page:0041 http://csc-ma.us/NandoverPubAcc/jsp/Home.jsp?Page=3&Linkld=1175782 8/22/2008 OE NO oRTN 1y i 342 Town of North Andover HEALTH DEPARTMENT ,sSACMUst� CHECK#: DA : LOCATION: H/O NAME: I CONTRACTOR NAME: 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: ❑ Septic-Soil Testing $ ❑ Septic-Design Approval $ \❑ Septic Disposal Works Construction(DWC) $ 7 Septic Disposal Works Installers(DWI) $ Title Inspector $ iZ tle 5 Report ' $ 0. er:(Indicate) $ Health Agent Initials 7licant Yellow-Health Pink- Treasi t Y COMMONWEALTH OF MASSACHUSETTS EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS M � d DEPARTMENT OF ENVIRONMENTAL PROTECTION Y� TITLE 5 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM PART A CERTIFICATION Property Address:_52 North Cross Road_ —North Andover_ Owner's Name:_Stephen Stathopoulos Owner's Address: 52 North Cross Road RECEIVED _North Andover,MA 01845_ Date of Inspection:_8/13/2008 AUG 18 2008 Name of Inspector:_Neil J.Bateson TOWN OF NORTH ANDOVER Company Name:_Bateson Enterprises Inc._ HEALTH DEPARTMENT Mailing Address:_111 Argilla Road_ _Andover,MA 01810_ Telephone Number:_(978)4754786_ 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: Passes _X_ Conditionally Passes eeds Further Evaluation by the Local Approving Authority i F Inspector's Signature: ✓. Date: 8/13/2008_ The system inspector shall submit a copy of this inspection report to the Approving Authority(Board of Health or DEP)within 30 days of completing this inspection.If the system is a shared system or has a design flow of 10,000 gpd or greater,the inspector and the system owner shall submit the report to the appropriate regional office of the DEP.The original should be sent to the system owner and copies sent to the buyer,if applicable,and the approving authority. 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. Title 5 Inspection Form 6/15/2000 page 1 Page 2ofII OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: 52 North Cross Road_ —North Andover_ Owner:_Stathopoulos_ Date of Inspection:_8/13/2008_ 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: X 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.Outlet tee in tank partially corroded off,needs replaced. N 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: N 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: N 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: Title 5 Inspection Form 6/15/2000 2 Page 3 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address:_52 North Cross Road_ — North Andover_ Owner:_Stathopoulos_ Date of Inspection:_8/13/2008_ 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 surf_ace 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: I I Title 5 Inspection Form 6/15/2000 3 L Page 4 of 1 l OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address: 52 North Cross Road- -North oad__North Andover_ Owner:_Stathopoulos— Date of Inspection:_8/13/2008_ D. System Failure Criteria applicable to all systems: You must indicate"yes"or"no"to each of the following for all inspections: — _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'/2 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 1.5.303,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. 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 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. Title 5 Inspection Form 6/15/2000 4 w Page 5 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST Property Address: 52 North Cross Road_ _North Andover_ Owner:_Stathopoulos_ Date of Inspection:_8/13/2008 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? _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.As built plan only. _Yes_ _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(3)(b)] Title 5 Inspection Form 6/15/2000 5 Page 6 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION Property Address: 52 North Cross Road- -North oad__North Andover_ Owner:_Stathopoulos_ Date of Inspection:_8/13/2008_ FLOW CONDITIONS RESIDENTIAL Number of bedrooms(design):_N/A_Number of bedrooms(actual):_4_ DESIGN flow based on 310 CMR 15.203 N/A_ Number of current residents:_3 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 reading:_Yes_ Sump pump(yes or no):_Yes_ Last date of occupancy:_Current_ COMMERCIAIA DUSTRIAL Type of establishment: Design flow(based on 310 CMR 15.203):_gpd Basis of design flow(seats/persons/sqf,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 July 29,2008,owner Was system pumped as part of the inspection(yes or no) –No– If No_ If yes,volume pumped: gallons--How was quantity pumped determined?_ Reason for pumping: _ 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_18Years old,9/13/1990, as built plan_ Were sewage odors detected when arriving at the site(yes or no):_No Title 5 Inspection Form 6/15/2000 6 Page 7 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 52 North Cross Road _North Andover_ Owner:_Stathopoulos_ Date of Inspection:_8/13/2008_ BUILDING SEWER_X_ (locate on site plan) Depth below grade: 36"_ Materials of construction: __ 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,3"PVC in house no leaks visible SEPTIC TANK: X Depth below grade:_2' Material of construction X concrete—metal_fiberglass_polyethylene _other(explain) 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: 27"_ 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: 21"_ How were dimensions determined:_ 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 partially corroded,needs replaced. Depth of liquid at outlet invert.No evidence of leakage._ GREASE TRAP:_(locate on site plan) 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.): Title 5 Inspection Form 6/15/2000 7 Page 8 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 52 North Cross Road _North Andover_ Owner:_Stathopoulos_ Date of Inspection:_8/13/2008_ 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_ Depth below grade _28"_ 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 cover cracked,replaced it.D-box level&distribution equal.No evidence of leakage.Evidence of carryover._ PUMP CHAMBER:_(locate on site plan) Pump in working order(yes or no):_ Alarm in working order(yes or no):_ Comments(note condition of pump chamber,condition of pumps and appurtenances,etc.): Title 5 Inspection Form 6/15/2000 8 Page 9 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 52 North Cross Road —North Andover_ Owner:_Stathopoulos Date of Inspection:_8/13/2008_ SOIL ABSORPTION SYSTEM(SAS):_X (locate on site plan,excavation not required) If SAS not located explain why: Type T Leaching pits,number: _ Leaching chambers,number: Leaching galleries,number: _X_Leaching trench,number,length: 3 trenches 50' long_ Leaching field,number,dimensions: Overflow cesspool,number: Innovative/alternative system Type/name of technology: Comments(note condition of soil,signs of hydraulic failure,level of ponding,damp soil,condition of vegetation, etc.):_Soil ok.Vegetation ok.No sign of ponding to surface._ CESSPOOLS: Number and configuration:— Depth—top of liquid to inlet invert: Depth of sludge 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.): Title 5 Inspection Form 6/15/2000 9 Page 10 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION Property Address:_52 North Cross Road —Andover— Owner: Andover_Owner:_Stathopoulos_ Date of Inspection:_8/13/2008_ 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 Garage House Water Meter ZA B Deck A to Tank=43'9" A to D-Box=53'2" Septic Tank B to Tank=38'2" B to D-Box=41'11" D-Box Title 5 Inspection Form 6/15/2000 10 Page 11 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 52 North Cross Road_ —North Andover_ Owner:_Stathopoulos_ Date of Inspection:_8/13/2008_ SITE EXAM Slope_No_ Surface water_No_ Check cellar _Yes_ Shallow wells No Estimated depth to ground water ?6'_ Please indicate(check)all methods used to determine the high ground water elevation: Obtained from system design plans on record-If checked,date of design plan reviewed: 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) _X_Accessed USGS database-explain: _Essex County Soil Map_ You must describe how you established the high ground water elevation:_Essex County Soil Map,Sheet#36 Charlton Soil,Water>6'deep._ Title 5 Inspection Form 6/15/2000 11 summary Record Card generated on 8/12/2008 2:23:45 PM by Karen Hanlon PageI Town of North Andover Tax Map # 210-038.0-0184-0000.0 • Parcel Id 13254 52 NORTH CROSS ROAD STATHOPOULOS, STEPHEN 52 NORTH CROSS ROAD NORTH ANDOVER, MA 01845 Class 101 Single Family Property Type 1 Residential Size Total 1 Acres FY 2009 -- UB Mailing Index Until Name/Address Type Loan Number Activellnact. From STATHOPOULOS,STEPHEN Payor 52 NORTH CROSS ROAD NORTH ANDOVER,MA 01845 UB Account Maint. Account No Cycle Occupant Name Activellnactive Bldg Id. 13990.0-52 NORTH CROSS ROAD Last Billing Date 6/11/2008 2100546 02 Cycle 02 Active UB Services Maint. Service Code Rate Charge Multiplier/Users MISCFEE ADMIN FEE 0.635/8 7.82 1/ WTR WATER 01 ALL METER SIZE 39.49 /1 UB Meter Maintenance Serial No Status Location Brand Type Size YTD Cons w Water 0.63 0.63 0 34765701 a Active ENC RT METE METE Date Reading Code Consumption Posted Date Variance 8/5/2008 3448 a Actual 84 672% 5/6/2008 3364 a Actual 11 6/18/2008 -16% 2/4/2008 3353 a Actual 13 3/14/2008 -79% 11/5/2007 3340 a Actual 63 1/15/2008 -29% 8/6/2007 3277 a Actual 89 9/14/2007 -100% 5/7/2007 3188 c Correction 0 6/22/2007 -100% 2/28/2007 3188 m Manual estimate 17 3/23/2007 -37% 11/3/2006 3171 a Actual 17 12/22/2006 -84% Trouble Code:03 8/21/2006 3154 a Actual 130 9/13/2006 821% Trouble Code:03 5/25/2006 3024 a Actual 17 6/20/2006 -8% 2/8/2006 3007 a Actual 16 3/13/2006 -80% 11/8/2005 2991 a Actual 77 12/14/2005 7% Trouble Code:03 8/10/2005 2914 a Actual 72 9/12/2005 -100% Trouble Code:03 5/12/2005 2842 a Actual 6/8/2005 -100% 2/15/2005 2842 m Manual estimate 20 3/15/2005 -57% MSG 11/17/2004 2822 m Manual estimate 50 12/17/2004 -54% 8/12/2004 2772 a Actual 96 9/20/2004 511% 5/19/2004 2676 a Actual 17 6/14/2004 -51% Trouble Code:03 2/17/2004 2659 a Actual 39 4/16/2004 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: 52 North Cross Road, North Andover Owner: Stathopoulos Date of Inspection: 8/13/2008 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. NORTil q Q �gIED ,6 to O O O cociiHiw¢« 1' �-0s PUBLIC HEALTH DEPARTMENT (ommunity Development Division CF TIFIC3T1F OF C0�441VGIAjrVCE As of: September 30, 2008 q-his is to cert that the individual su6surface disposal system received a SATISTACTORTINSTECTIONof the: Repair of the Outlet Tee By Todd Bateson At: 52 North Cross Wgad Map 038.0; Parcel 184 North Andover, wA 01845 The Issuance of this certificate shall not 6e construed as a guarantee that the system will function satisfactorily. n 2:Sawyer (PufficWealth(Director 1600 Osgood Street,North Andover,Massachusetts 01845 Phone 978.688.9540 Fax 978.688.8476 Web www.townofnorthandover.com 14ORTil q /6• "IO OL O i 1 Oy O LOCMIL�wKM 1' ��4°Rwrao ►Pa�y�(9 9SSAC PUBLIC HEALTH DEPARTMENT Community Development Division CERTI FIC.32'E Off' CO_1V1� 'GI.AXCE As of: September 30, 2008 This is to cert that the individuafsu6sut face dTsposaCsystem received a SAIISTAC7ORTINSTEMOX of the: Repair of the Outlet Tee Bv: J Todd Bateson At: 52 9Vorth Cross mad Wap 038.0; (I'arref184 North Andover, WA 01845 The Issuance of this certiftate shall not 6e construed as a guarantee that the system urill function satisfactorily. n 7 Sauryer (Pu61�c Yfealth Director 1600 Osgood Street,North Andover,Massachusetts 01845 Phone 978.688.9540 Fax 978.688.8476 Web www.townofnorthandover.com COMMONWEALTH OF MASSACHUSETTS EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS ry V DEPARTMENT OF ENVIRONMENTAL PROTECTION Y0 TITLE 5 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM PART A CERTIFICATION Property Address:_52 North Cross Road_ _North Andover_ FAUG 1' Owner's Name:_Stephen Stathopoulos Owner's Address: 52 North Cross Road _North Andover,MA 01845_ 6 L 008 Date of Inspection:_8/20/2008 TOWN OF N& :R Name of Inspector:_Neil J.Bateson HEALTH D& Company Name:_Bateson Enterprises Inc._ Mailing Address:_111 Argilla Road_ _Andover,MA 01810_ Telephone Number:_(978)475-4786_ 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: Passes Conditionally Passes Needs Further Evaluation by the Local Approving Authority Fails x- Inspector's Signature: 1 Date: 8/20/2008_ The system inspector shall submit a copy of this inspection report to the Approving Authority(Board of Health or DEP)within 30 days of completing this inspection.If the system is a shared system or has a design flow of 10,000 gpd or greater,the inspector and the system owner shall submit the report to the appropriate regional office of the DEP.The original should be sent to the system owner and copies sent to the buyer,if applicable,and the approving authority. Notes and Comments:After permit from Board Of Health,install new outlet tee with gas baffle,inspection from Board Of Health,septic system now passes Title 5 Inspection. ****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. Title 5 Inspection Form 6/15/2000 page 1 I` VtORTH q 0 �-TLaD .61b�0 �y ?, T OR4 COCNC Mt Kw`y7' T C3 SS4C HUS�� PUBLIC HEALTH DEPARTMENT Community Development Division C(F TI FIC,Arr(F OF C0�44('GIA5VCE As of: September 30, 2008 This is to cert that the individual subsurface disposafsystem received a SATISFACl7ORTINSTEC' ONof the. Repair of the Outlet Tee Bv: J Todd Bateson At. 52 9Vorth Cross mad Map 038.0; Parref184 North Andover, JKA 01845 The Issuance of this certificate shaff not 6e construed as a guarantee that the system wiff function satisfactorily. n T Sawyer P'u6ftc Yleafth Director 1600 Osgood Street,North Andover,Massachusetts 01845 Phone 978.688.9540 Fax 978.688.8476 Web www.townofnorthandover.com S • TOWN OF NORTH ANDOVER µoRrk Office of COMMUNITY DEVELOPMENT AND SERVICES 0r°4tit .o HEALTH DEPARTMENT 1600 OSGOOD STREET; Building 2-36 NORTH ANDOVER,MASSACHUSETTS 01845 �9ssNc Hu6ESih Susan Y. Sawyer,REHS/RS 978.688.9540—Phone Public Health Director 978.688.8476—FAX ONSITE WASTEWATER SYSTEM CONSTRUCTION NOTES LOCATION INFORMATION ADDRESS: Ja /2), MAP: LOT: INSTALLER:'o/,, C /l DESIGNER: PLAN DATE: BOH APPROVAL DATE ON PLAN: INSPECTIONS TANK INSPECTION: DATE OF BED BOTTOM INSPECTION: DATE OF FINAL CONSTRUCTION INSPECTION: DATE OF FINAL GRADE INSPECTION: SITE CONDITIONS ❑Existing septic tank properly abandoned ❑Internal plumbing all to one building sewer ❑Topography not appreciably altered Comments: SEPTIC TANK M � ❑ Bottom of tank hole has 6" stone base ❑ Weep hole plugged ❑ 1500 gallon tank has been installed H-10 loading Monolithic construction ❑ Water tightness of tank has been achieved (Visual or Vacuum Test or Water held for 24hrs) ❑ Inlet tee installed, centered under access port ❑ Outlet tee (gas baffle or effluent filter) installed, centered under access port ❑ 24" inch cover to within 6" of final grade installed over one access port, must be over outlet of tank if effluent filter is present ❑ Hydraulic cement around inlet & outlet Wastewater System Documentation—Feb 2006 Page 1 of 6 � s r TOWN OF NORTH ANDOVER f KORTH_q , Office of COMMUNITY DEVELOPMENT AND SERVICES 3�OZ.".° HEALTH DEPARTMENT A 1600 OSGOOD STREET;Building 2-36 If NORTH ANDOVER,MASSACHUSETTS 01845 KC HUSF Susan Y. Sawyer,REHS/RS 978.688.9540—Phone Public Health Director 978.688.8476—FAX Comments: PUMP CHAMBER ❑ Bottom of tank hole has 6" stone base ❑ Weep hole plugged ❑ Combo Tank installed. Size: ❑ 1000 gallon Pump Chamber installed H-10 loading Monolithic 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 ❑ 24" inch cover to within 6" of final grade installed over pump access port ❑ Water tightness of tank has been achieved Visual testing ❑ Hydraulic cement around inlet & outlet Comments: ADVANCED TREATMENT TECHNOLOGY ❑ Type of treatment device: ❑ Installed per manufacturers requirements ❑ All components working in accordance with manufacturer's requirements Comments: Wastewater System Documentation—Feb 2006 Page 2 of 6 NT. y` r (J� 3 4 L 2 = Town of North Andover HEALTH DEPARTMENT ,SSAC M15tt CHECK#: DATE: LOCATION: &A-6 S7 H/0 NAME: CONTRACTOR NAME: 701 61 ZZ �01Y 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: ❑ Septic-Soil Testing $ ❑ Sept�'c-Design Approval $ ZSeptic Disposal Works Construc 'o C) $ �� Z. 11 Septic Disposal or InstaF llers( WI) $ ❑ Title 5 Inspector $ ❑ Title 5 Report $ ❑ Other:(Indicate) $ • �t Health Agent Initials White-Applicant Yellow-Health Pink-Treasurer r ' E �oR* Commonwealth of Massachusetts Map-Block-Lot 038.0-0184- _ Board of Health ----------------------- Permit No s . BHP-2008-0175 North Andover ----------------------- P.I. FEE �SSAc►+u�t� F.I. $125.00 ----------------------- Disposal Works Construction Permit Permission is hereby granted Todd_Bateson ---------------------------------------------------------------------------------------------------- to(Repair)an Individual Sewage Disposal System. at No 52 NORTH CROSS ROAD as shown on the application for Disposal Works Construction Permit No. BHP-2008-017 Dated August 18,2008 ------------------------ --------------------------- Issued On:Aug-18-2008 Board of Health Commonwealth of Massachusetts Map-Block-Lot 038.0-0184- Board of Health ----------------------- North Andover b•-•�®••• Certificate of Compliance 1ss�tCHUSfi THIS IS TO CERTIFY,That the Individual Sewage Disposal System (Repair) by Todd Bateson Installer at No 52 NORTH CROSS ROAD 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-20087017 Dated___August 18,2008 Printed On: ----------------------------------------------------------------- Aug-15-2008 ----------------------- -------------------------- ---------------- ---- Board of Health "O°Tao- Application for Septic Disposal System —l-s-�� 3?°` � ''''•° °c TODAY'S DATE -Construction Permit — TOWN OF - •FAA' ORTH ANDOVER, MA 01845 $ 250.00—Full Repair Ano A� $125.00 -Component SS�CHUg Important: Application is hereby made for a permit to: When filling out ❑ Construct a new on-site sewage disposal system* forms on the computer,use ❑ Repair or replace an existing on-site sewage disposal system* only the tab key �� to move your [�epair or replace an existing system component—What? �� 1A� cursor-do not use the return A. Facility Information n ` key. s-k Ay&e` 0 5 S � Address or Lot# City/Town 2.-*TYPE OF PTIC SYSTEM*: ❑ Pump Gravity (choose one) ***If pump system, attach copy of electrical permit to application*** ❑ Conventional System (pipe and stone system) ❑ Infiltrator or Biodiffuser(Gravel-Less) (Attach a copy of your certification to install this type of system. ❑ Pressure Distribution S.A.S. (No D-Box)(Attach Draft Maintenance Agreement) ❑ Pressure Dosed (D-Box Present) S.A.S. 2. Owner Information �sf t �-► Name Address(if different from above) City,'Town State Zip Code e:7)13 Telephone Number 3. Installer Information �N �� .t-'��So� �� gym✓ �'� � � . Name Name Company Address A-4 City/Town State Zip Code Telephone Number(Cell Phone#if possible please) 4. Designer Information Name Name of Company Address City/Town State Zip Code Telephone Number(Best#to Reach) Application for Disposal System Construction Permit•Page 1 of 2 OR itApplication for Septic Disposal System ttNs, `AConstruction Permit — TOWN OF TODAY'S DATE $250.00—Full Repair •.,,�e,, ORTH ANDOVER, MA 01845 $125.00-Component PAGE 2OF2 A. Facility.Information continued.... 5. Type of Building: Residential Dwelling or❑Commercial B. Agreement The undersigned agrees to ensure the construction and maintenance of the afore-described on-site sewage disposal system in accordance with the provisions of Title 5 of the Environmental Code,as well as the Local Subsurface Disposal Regulations for the Town of North Andover, and not to place the system in operation until a Certificate of Compliance has been issued h is Board of Health. Name Date Application Approved By: (Board of Health Representative) Name Date Application Disapproved for the following reasons: For Office Use Only: I Fee Attached. Yes No 2. Project Manager Obligation Fotm Attached. Yes No I Pump Svstem? If so,Attach copy of Electtical Permit Yes No 4. Foundation As-Built. (new construction ronly). Yes No (Same scale as approved plan) 5. Floor Plans?(new construction only): Yes No Application for Disposal System Construction Permit•Page 2 of 2 f i SEPTIC SYSTEM INSTALLER PROJECT MANAGEMENT OBLIGATIONS As the North Andover licensed installer for the construction for the septic system for the property at: _s,a A41 11- ,, �d S5 15Y - (Address of septic system) For plans by ngine ) Relative to the application of 10 Ato i2>A-fAE1_'5oA✓ (Installer's name) And dated ' n ate Dated Dated 5-15-10e o ay s ate With revisions dated ast revi d date) I understand the followi� obligations for management of thisproject: 1. As the installer, I am obligated to obtain all permits and Board of Health approved plans prior to performing any work on a site. I must have the approved plans and the permit on site when any work is being done. 2. As the installer, I must call for any and all inspections. If homeowner, contractor,project manager, or any other person not associated with my company schedules an inspection and the system is not ready,then item three shall be applicable. 3. As the installer, I am required to have the necessary work completed prior to the applicable inspections as indicated below. I understand that reduesting an inspection,without completion of the items in accordance with Title 5 and the Board of Health Regulations may result in a$50.00 fine being levied against me and/or MY company a. Bottom of Bed—Generally, this is the first (1s) inspection unless there is a retaining wall,which should be done first. The installer must request the inspection but does not have to be present. b. Final Construction Inspection—Engineer must first do their inspection for elevations, ties, etc. As-built of verbal OK (or e-mail to: healthdept(ao,townofnorthandover.com) from the engineer must be submitted to the Board of Health, after which installer calls for an inspection time. Installer must bd present for this inspection. With a pump system, all electrical work must be ready and able to cause pump to work and alarm to function. c. Final Grade—Installer must request inspection when all grading is complete. Installer does not have to be on-site. 4. As the installer, I understand that only I may perform the work (other than simple excavation)and I am required to complete the installation of the system identified in the attached application for installation. I further understand that work done by others unlicensed to install septic systems in North Andover can constitute reasons for denial of the system and/or revocation or suspension of my license to operate in the Town of North Andover, significant fines to all persons involved are also possible. 5. As the installer, I understand that I must be on-site during the performance of the following construction steps: a. Determination that the proper elevation of the excavation has been reached. b. Inspection of the sand and stone to be used. c. Final inspection by Board ofHealth staff or consultant. d. Installation of tank, D-Box,pipes, stone, vent,pump chamber, retaining wall and other components. 6. As the installer, I understand that I am solely responsible for the installation of the system as per the approved plans. No instructions by the homeowner,general contractor, or any other persons shall absolve me of this obligation. Undersigned Licensed Septic Installer: (Today's��f e,��c/ (Today's Date) (Name—Print) a —Signed) Z rP") 4J \ Siff? r � 1 LOT 2 ?5� 43,C,68 S.Ft / �/ ••�reric�ee__ �� l tis d- box Q LOT 3 COT 1 .25.00 OF M�s� L=/?5..CIO ' DAVID cyG� �P=/60.q0 / A. L3 WEBBER H Ke. JG16- gs o ECISTtIL eaJ Plan rel' E.N.0.,2.0. P/ l70. /00/5 F//375 ELEVATIONS description as - built I NV. PIPE OUT OF HSE. /69.5 f " AS BUILT S INV. PIPE INTO TANK 165.Ot� f-1 INV. PIPE NTOODIST. BOX /66.-V SUB - SURFACE DISPOSAL INV. PIPE OUT OF DIST. BOX Q// /r1o6._?6 INeD /08./ KSYSTEM # 2 IN 117✓. oi en pipe # / /(8.00 NO. ANOot/ER , MA . Robt L oPret e " 3 _ /6 7. 95 FOR : er � M � Scale : 1 =40 Date: SePf 1g, /990 * pipe nol /n From {ounclollon to sevlle- �on�- RICHARD F KAMINSKI AND ASSOCIATES , INC. a i r 0 �t f l t q u 2� 2n i� a COMPLAINT NUMBER DATE: #24 MAY 6, 1993 COMPLAINTANT:TIM OULETTE CLOSE DATE: ADDRESS: DPW PHONE: OWNER: PHONE #: ADDRESS: 52 NORTH CROSS ROAD INSPECTION DATE: ORDER L DATE: COMPLAINT: LEACHATE COMING FROM SEPTIC SYSTEM ONTO 64 NORTH CROSS ACTION: Vj5/TEb �4 I • CeOSS J--17 (0a)4/ � A-DJd1�l/11V6 LOT 6601e5 FORM U - VERIFICATION FORM INSTRUCTIONS: This form is used to verify that all necessary approvals/permits from Boards and Departments having jurisdiction have been obtained. This does not relieve the applicant and/or landowner from compliance with any applicable local or state law, regulations or requirements. ****************Applicant fills out this section***************** APPLICANT: SYe V- Phone LOCATION: Assessor's Map Number Parcel Subdivision Lot(s) Street S No�C�� C �'=�S S /< �. St. Number Use Only************************ JRECDAONS O AGENTS: D/� T Date Approved L q Conservation Administrator Date Rejected Comments Date Approved Town Planner Date Rejected Comments Date Approved Food Inspector-Health Date Rejected Date Approved Septic Inspector-Health Date Rejected Comments //U GeouA)1> 1�00� Public Works - sewer/water connections - driveway permit Fire Department Received by Building Inspector Date G � b 10 h // ��:...fi•cncfies d- box Town of North Andover, MA Watershed Septic System Servicing Report qW Date: Homeowner: Ue umper : Stewart's Septic Tank Svc. Street Address: 47 Railroad St., Bradford Phone ��— 2 / Phone 508-372-7471 Nature of Service: Routine Emergency Observations: Good Condition . Full to Cover 40 Baffles in Place Y_Ks Leachfield Runback 40 Excessive Solids ,�/QS Heavy Grease Roots Other (Explain) " .icsvrizitiv of Pump septic tank Comments: This is not a septic certification. Should not be used to provide at closings. That is an additional fee. Page 1 of 1 DelleChiaie, Pamela From: Kimberly Brown [kbrown@neengineeringinc.com] Sent: Monday, July 28, 2008 1:25 PM To: DelleChiaie, Pamela Hi Pam, Can you check when you get a moments for an as-built for: 120 Cricket Lane - Dolben North Cross Road—Stachapoulos Thanks! Kim Kimberly Brown Office Manager New England Engineering Services, Inc. 1600 Osgood Street Suite 2-64 North Andover, MA 01845 978-686-1768 www.neengineeringinc.com No virus found in this outgoing message. Checked by AVG. Version: 7.5.524/Virus Database:270.5.6/1577-Release Date: 7/28/2008 6:55 AM 7/28/2008 1'17 UN iF 6'�7jxa C'17n1Y.1':••'(" �LI.':`V..v'ir:''`;•'.:!:S:i.• : e/, 17YSG;jrJ}Y +lj•fb• F.01 , ,t,!1�,;,d{.1,• y'F",Yj /r. , n'•. •`••-^.Y.i..� .-,�„�...�:.__...._ '' �:;d 5.. 7ir�rµ •�it{}'. �la!i.r,;.r. .,1. ,r•l4 yCi.,.' If:•:.,. {rT dJ Jr t' }? t„•.,itf iyr t ,�•�k. •�+.�4 `it �4b yr1��nYrli�Yd�1,' ,'r��J..�ir1,SJ/.�)!'LJIr�.11r;Yv7('r:�t`•,,I,L �.+�:�.,1:1.),' f�,.. 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Site � i t reference Plans and firers . � PCf171jS51Qr7 IS rarlt;'d lr�� +, ' .,-r i ' r; a , 1 d,�. t.a' ti i� h , pt ,r, 5 .ti,jQr d ti�,.;;.ai s�scem ire be InStalRGd r' in accordance With rep ,it ons of t1 n.#f� ,f Hca11+;. ez f J ci 1 • F H 0 T P T 7 1 E t4OTE t. D k T E S T F E F. 4 0 K 7 r, 2 .2 Z- 2' 4 SEP - 10 8 •{: :r + TO DATE // TIME C AM .6G' PM H FROM AREA CODE O OF NO. EXT. E M FAX# E s M s , E A m E SIGNED PHONED CALL ❑ RETURNED ❑ WANTS TO ❑ WAS IN ❑ AGILL AINALL ❑ UAGENT❑ BACK CALLSEE YOU 5 t e yU • r DATE INVOICE AMOUNT J, 53-160/113 i MURPHY CORPORATION P.O.BOX 86 LYNNFIELD, MA 019401723 C2 c _ w 19 PAY v �1 t dC) DOLLARS $ o O - THE ORDEROF =Mf company a11100 1 7 23II' 1:0 1 1 30 1604is 0 21.0 16 lootiBlin (D ix R, A1IDOVE ,,r SS GNUS D�P hai o !llod vidod e1hol :Ya( to Ch ! L ,u � •i OF N pF �, Facillry Informa,'on n Sys'am Owner (s V ' r. Pddra+J (IIQVIO(Inl rcvn lou Um 97,?– E3,'.P,umpin g 7,?B,:Pumping Regord -- 3. •Type al ayslam,� . r l �es5, �:.�-, ^oo!(s) Sapl.c^Term (describe): �. Etflrum Tao FNo(Prpsen? r �c.',' •r r'''.i '{�'f i.�,� 'tf' ' 1 Gag C��rd 7 yep -- ' ,� .�,•i�S✓.�r�..,.tir. ''o%I•• 14:x. -_ 1900 �yV�B71(I '0 'Ju,1,1 Tl �4r --- oca on '6' e�re��cor1(eril9�Were�c:5�^sa� me�sl.;ov/oa^Jwelar/approva�s/161orm9 — .o; Commonwealth of Massachusetts City/Town of �R19U.11WID a System Pumping Record Form 4a�9 ME DEP has provided this form for use by local Boards of Health. Ota(e.— Mthe information must be substantially the same as that provided hereL H' ck with your local Board of Health to determine the form they use. The System Pumping Record must be submitted to the local Board of Health or other approving authority. A. Facility Information 1. System Location: Left front of house, right front of house, left side of house, right side of hous , Le earouse right rear of house, left side of building, right rear of building, under deck. City/Town State Zip Code 2. System Owner: Name ' Address(if different from location) City/Town State Zip Code Telephone Number B. Pumping Record 1. Date of Pumping c � l 2QPumped: Date . Quantity umpe : Gallons 3. Type of system: ❑ Cesspool(s) eptic Tank ❑ Tight Tank ❑ Other(describe): 4. Effluent Tee Filter resent? Yes oo If p ❑ LAN es, was it cleaned? ❑ Yes ❑ No Y 5. Condition pff S stem: oVN- 6. System Pumped By: Neil J. Bateson F5821 Name Vehicle License Number Bateson Enterprises Inc. Company 7. Loca ' where contents were disposed: L.S. Lo II Waste r Signatur o a er Date` t5form4.doc•06/03 System Pumping Record•Page 1 of 1 Town of North Andover, Massachusetts Form No. 1 NORTH BOARD OF HEALTH 3 OrytS E° ,6gyaL 19 * - �b APPLICATION FOR SITE TESTING/INSPECTION 21 QORnrc° PP ,(y �SSACHUsti� 3g Applicant VV NAME ADDR�S,E�, TELEPHONE Site Location //WW�o Engineer NAME ADDRESS TELEPHONE Test/Inspection Date and Time r CHAIRMAN,-BOARD OF HEALTH Fee Test No. S.S. Permit No. D.W.C. No. ` � C.C. Date Plbg. Permit No. d