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HomeMy WebLinkAboutMiscellaneous - 550 WINTER STREET 4/30/2018 (2)_N O D z O -1 O m w ; N Cf) OM O m O m v r, N Commonwealth of Massachusetts City/Town of System Pumping Record r 3 V 0�1 Form 4 TOWN OF NORTH ANDovr:R DEP has provided this form for use by local Boards of Health.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 Locatio a ig front �ho, eft / Right rear of house, Left / right side of house, Left / Right side of building, Left / Right front of building, Left / Right rear of building, Under deck Address Cityrrown 2. System Owner: Name Address (if different from location) Cityrrown B. Pumping Record 1. Date of Pumping 3. Type of.system: ❑ State po'-' f - e) A - -C)� C --, � Zip Code State �� �r ^i� de Telephone Number �o Date 2. Quantity Pumped: Gallons Cesspool(s) Septic Tank ❑ Tight Tank ❑ Other (describe): 4. Effluent Tee Filter present? ❑ Yes If yes, was it cleaned? ❑ Yes ❑ No 5. Condition of lyjtce_ NV�� 6. System Pumped By: Neil Bateson Name Bateson Enterprises Inc Company 7. Locati re -co tents were disposed: L,S.j? Lowell Waste Water F5821 Vehicle License Number ()-- ( 1?— 4 Date t5form4.doc• 06103 System Pumping Record • Page 1 of 1 ", T, Commonwealth of Massachusetts Map -Block -Lot 104.A0082 ----------------------- p Board of Health Permit No ry North Andover BHP -2009-0705 n ----------------------- FEE "sic w� $125.00 ----------------------- DISPOSAL WORKS CONSTRUCTION PERMIT Permission is hereby granted Todd Bateson to (Repair -OUTLET TEE ONLY) an Individual Sewage Disposal System. at No 550 WINTER STREET ---------------------------------------------------------------------------------------------------------------------------------------------------------- as shown on the application for Disposal Works Construction Permit No. BHP -2009-070 Dated November 18, 2009 Issued On: Nov -24-2009 --------------------------------------- ----------------------------------------------------------------- Board of Health I t ,AORTH Commonwealth of Massachusetts Map -Block -Lot a 1.."to ',.a�{pa 104.A0082 ----------------------- _ Board of Health Permit No BHP -2009-0705 A ; North Andover ----------------------- �, b.'« P.I. FEE $125.00 F.I. DISPOSAL WORKS CONSTRUCTION PERMIT Permission is hereby granted Todd Bateson to (Repair -OUTLET TEE ONLY) an Individual Sewage Disposal System. at No 550 WINTER STREET ---------------------------------------------------------------------------------------------------------------------------------------------------------- as shown on the application for Disposal Works Construction Permit No. BHP -2009-070 Dated -__November_ 18,-2009 ------------------------ --------------------------------------- Issued On: Nov -24-2009 Board of Health at "4 TR +� Commonwealth of Massachusetts Map -Block -Lot c s, `<e bit104 _AO082 ,. Board of Health North Andover CERTIFICATE OF COMPLIANCE ACM THIS � THIS IS TO CERTIFY, That the Individual Sewage Disposal System (Repair -OUTLET TEE ONLY) by ---Todd Bateson ----------------------------------------------------------- - ---- —-------------------------------- ------ Installer at No 550 WINTER 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 -2009-070 Dated November 18 2009 ----------------------------------------------------------------- Printed On: Nov -24-2009 Board of Health I L 42b-2 4 NORiN , r 3r �.. .. •. oL N p Town of North Andover HEALTH DEPARTMENT 1SS�CNUSt� CHECK #:�/' DATE: 111110 / LOCATION: ;7-6-0 l J H/O NAME:ii�l!'P/'/�/� CONTRACTOR NAME: Type of Permit or License: (Check box) i ❑ Animal $ ❑ Body Art Establishment $ ❑ 4 Body Art Practitioner $ j ❑ 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 eptic Disposal Works Construction (DWC) ❑ Septic Disposal Works Installers (DWI) $ ❑ Title 5 Inspector $ ❑ Title 5 Report $ ❑ Other: (Indicate) $ I Health Agent Initials White - Applicant Yellow - Health Pink - Treasurer on.,Application for Septic Disposal System A Construction Permit -TOWN OF ORTH ANDOVER. MA 01845 Important When filling out forms on the computer, use only the tab key to move your cursor - do not use the return key. ILEI Application is hereby made for a permit to: ❑ Construct a new on-site sewage disposal system* I1 -I6 —o7 TODAY'S DATE $ 250,00 Full Repair $125.00 - Component ❑ Repair or replace an existing on-site sewage disposal system* O'iepair or replace an existing system component — What? ®, A. Facility Information J:5-© Address or Lot # Cityrrown wf4-t sf 1q"jd V.-22 RECEIVED, TOWN OF NORTH ANDOVER HEALTH rim ENT 2.- TYPE OF SEPTIC 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. Name J iSC� lit/ /�► �<.d' S� Address (if different from above City/Town State Tap Code Telephone Number 3. Installer Information 1 Name Na i r V , r�.• u uu i`L:,..�.<y .,.b. Address Andover, MA 01810 Cityfrown State Zip Code 1 7Y Ss'� 5— a:'7C2 3 Telephone Number (Cell Phone # if possible please) 4. Desi ner Info✓ atio Name Name of Company Address Cdyfrown State Zip Code Telephone Number (Best # to Reach) Application for Disposal System Construction Permit - Page 1 of 2 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 Locatio . o/ Rig front of Nous Left/ Right rear of house, Left/ right side of house, Left / Right side of building, Left / Right uilding, Left / Right rear of building, Under deck Address Cityrrown State 2. System Owner. ~� � a` Name r Address (if different from location) Citylrown B. Pumping Record 1. Date of Pumping 3. Type of system. ❑ ❑ Other (describe): Zip Code State( � "'�� ZiCode Telephone Number Cz —t-3. A=� Date 2. Quantity Pumped: gallons ' Cesspool(s) Er Septic Tank ❑ Tight Tank 4. Effluent Tee Filter present? ❑ Yes No If yes, was it cleaned? ❑ Yes ❑ No: 5. Condition of 6. System Pumped By. 7. Neil Bateson F5821 � Name Vehicle License Number Bateson Enterprises Inc' Company to ` `� contents were disposed: Lowell Waste Water Date poVER H 1AEP�TN CEP��M�N? t5form4.doc• 06/03 System Pumping Record • Page 1 of 1 Application for Septic Disposal System (Construction Permit -TOWN OF NORTH ANDOVER, MA 01845 PAGE 2OF2 A. Facility Information continued.... 5. Type of Building: esidential Dwelling or ❑Commercial B. Agreement TODAY'S DATE $ 250.00 - Full Repair $125.00 - Component 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 bjWhis Board of Health. Name Date Approved By: Application DisapT)roved for dof Health Representative) Date following reasons: For Office Use Only: I Fee Attached. Yes 1/ 2. Project Manager Obligation Form Attached.P Yes 3. Pump System? Ifso; Attach copy ofElectrical Permit Yes 4. Foundation As -Built. (new construction ronly): Yes (Same scale as approved plan) 5. Floor Plans? (new construction only): Yes_ No No No No No Application for Disposal System Construction Permit • Page 2 of 2 SEPTIC SYSTEM INSTALLER PROJECT MANAGEMENT OBLIGATIONS As the North Andover licensed installer for the construction for the septic system for the property at: , so 14/1-4 (Address of septic system) , n For plans by Relative to the application of�y^�-c� (Installer's name) And dated Dated /` —4 (, — O f(To ay s ate) With revisioi I understand the following obligations for management of this project: 1. As the installer, I am obligated to obtain all permits and Board of Health approved plans p or 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 hree shall, be applicable. 3." As the installer, I am required to have the necessary work completed prior to the applicable inspections as indicated below. I understand that requesting- an inspection, without completion of the items in accordance with Title 5 and the Board of Health Regulations may result in a $50.00 fine being. levied against me and/or my company a. Bottom of Bed — Generally, this is the first (15) inspection unless .there is a retaining wall, which should be done.first. The installer must request the inspection but does not have to be present. b. Final Construction Inspection — Engineer must first do thein inspection for elevations, ties, etc. As -built of verbal OK (or e-mail to: healthdept t@townofnorthandover.com) from the engineer must be submitted to the Board of Health, after which installer calls for an inspection time. Installer must be present for this inspection. With a pump system, all electrical work must be ready and able to cause pump to work and: alarm to function. „ c. Final Grade — Installer must request inspection when all grading is complete. Installer does not have to be on-site. 4.11 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 susl2ension 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 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 staffor 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. FINAL GRADE INSPECTION Date: Address: ❑ LOAMED? Owl ❑ SEEDED? or ❑ COVER PER PLAN? Othe : -� TOWN OF ISI SYSTEM PUMPING RECO DATE: V& 05 SYSTEM OWNER & ADDRESS SEP - 7 2005 TOHEA�TF NORTH H DEPARTT�T ANDOVER SYSTEM LOCATION (example: left front of house) If�'F �*awt o� house DATE OF PUMPING: ` (t — 0 S QUANTITY PUMPED: 1000 GALLONS CESSPOOL: NO YES SEPTIC TANK: NO YES NATURE OF SERVICE: ROUTINE EMERGENCY OBSERVATIONS: GOOD CONDITION HEAVY GREASE ROOTS EXCESSIVE SOLIDS SOLIDS CARRYOVER FULL TO COVER BAFFLES IN PLACE LEACHFIELD RUNBACK FLOODED OTHER (EXPLAIN) SYSTEM PUMPED BY: Bateson Enterprises, Inc. COMMENTS: CONTENTS TRANSFERRED TO: G.L.S.D Lowell Waste Town of North Andover o AO pTN Community Development and Services Division Office of the Health Department y 400 O5000D STREET North Andover, Massachusetts 01845 � SAruUSE� Susan Y. Sawyer, REHS/ RS Public Health Director Date: April 8, 2005 Address: 550 Winter Street, North Andover, MA 01845 Re: Application for: Jane Broderick Dear: Ms. Broderick, (978) 688-9540 - Phone (978) 688-8476 - Fax Your application for addition/remodel at 550 Winter Street has been reviewed by the Health Department. The application was denied on, April 8, 2005 for the following reasons: 1. X Missing information 2. X Passing Title 5 inspection of septic system required I D Location of structure not acceptable 4. D Undersized septic system To address the problem(s}: If #1 is checked, please supply: a. Floor plan of existing and proposed addition - all rooms b. Certified plot plan showing house, septic system and proposed project in scale If #2 is checked: a. Have the septic system inspected by a certified Title 5 inspector to determine the size of the system and whether it is operating properly: If #3 is checked: a. Relocate the project If #4 is checked: a. Provide additional information proving that the existing septic system meets current capacity requirements. Please consult an engineer to determine the flow capacity of the septic system. Please feel free to call the Health Office at 978-688-9540 with any questions you may have. Sincerely, ZLi Mi Kele E. Grant Cc: Building Department File BOARD OF APPEALS 688-9541 BUILDING 688-9545 CONSERVATION 688-9530 NURSE 688-9543 PLANNING 688-9535 > i�e, KO U ,e . R �� qC jQ oZ v AV IAS Gh w 1 FORM U - LOT RELEASE FORM f INSTRUCTIONS: This form is used to verifythat all necessary ssary 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 SECTIO APPLICANT JCS.n a° C e C 1 �,k PHONE 792 4/,F7 LOCATION: Assessors Map Number—i A PARCEL SUBDIVISION LOT (3) STREET V f �l i L ST. NUMBER J` -SO OFFICIAL USE ONL A DATE REJECTED � IAT�� n ,..� .. _ f A� n � i, � , e v LP. „ .l a .e' � C__••� . TOWN PLANNER DATE APPROVED DATE REJECTED COMMENTS FOOD INSPECTOR -HEALTH DATE APPROVED DATE REJECTED r acr 1 IG imarCG I UK-MrAL r K DATE APPROVED DATE REJECTED! fQ PUBLIC WORKS - SEWER/WATER CONNECTIONS DRIVEWAY PERMIT FIRE DEPARTMENT RECEIVED BY BUILDING INSPECTOR DATE Rovl@W W7 jm SECTION 4 - WORKERS COMPENSATION W�� Compensation Insunnca affidavit must be a of the isauanca of the buildin rt• in the denial Attwc led Yes .......0 No ....... 13 r 152 6 2546) — -A e.awn;�ned with thus ap,$!"tion. Failure to provide flus of 5i ad affidavd Work d►eckat owe SECTION 5 Desctl tion otYro ❑ Repair{s) ❑ Alterations(s) ❑ Addition ❑ New COnstructton ❑ Existing Building Accessory Bldg. ❑ pemolition ❑ Other ❑ Specify Brief Description of Proposed W°rk SECTION 6 - ESTIMATED CONSTRUCTION f -UN 1 M OFRICIAL USI Estimated Cost (Dollar) to be Item C leted b 't a licant , (a) Building Permit Fee 1, Building 'A 3 Multi Tier (b) Estimated Total Cost of 2 Electrical Cion Building Permit fee (a) x (b) 3 Plumb 4 Mechanical HVAC 5 Fire Protection Check Number 6 Total 1+2+3+4+5 SECTION 7a OWNER AU oORIZAnRO PPLIES FORING To BE COMWLETED PEMT Hereby-authorizeby this My be f, in all matters five to work sutho� i Si a of Owner ER/AUTHORIZED AGENT DECI as Owner/Authorized Agent of subject property to act on permit application. , �" D Tlata SE ION 7b OWN Agent of subject ,as Owner/Authorized Ag I, Hereby declare application are true and accurate, to the best of my knowledge property that the statements and information on the foregoing and belief Print Name Date Si lure of Owner/. ent SIZE NO.OF STORIES 3 BASEMENT OR SLAB 1 2' SIZE OF FLOOR 1BFRS SPAN ,zaNSIONS OF SILLS OF FW i1 PRIAL OF - TOWN OF NORTH ANDOVER BUILDING DEPARTMENT APPL► TION TO CONSTRUCT REP RENOVATE, OR DEMOLISH A ONE OR TWO FAMILY DWELLING BUR DING PERMIT NUMBER: DATE ISSUED- SSUED:SIGNAUR: SIGN : - Building Commissioneffl2gWor of Buildings Date SECTION 1- SITE INFORMATION 1.1 Property Address: /- 7,41orMap e 1.2 Assessors Map and Parcel Number: mumber Parcel Number 1.3 Zoning Information: Zoning DidriR Proposed Use 1.4 Property Dimensions: Lel Area F $ 1.6 BUILDING SETBACKS ft Front Yard Side Yard Rear Yard Required Required Provided Required Provided 1.7 Water S%v* NULLCA0. 34) 1.3. Flood Zone Infermation: zow outside F ❑ Pnblic ❑ Private ❑ lood Zane 1.8 Sewerage Disposal System: trtaaicipat ❑ a site Disposai System ❑ A SECTION 2 -PROPERTY OWNERSiiIP/AUTHORIZED AGENT ' Inti !Ct: Y23 P.IO 2.1 Owner of Record )) Name (Print) Address for Service: Signature Telephone 2.2 Owder of Record: Name Print Address for Service: Signature Telephone SECTION 3 - CONSTRUCTION SERVICES 3.1 Licensed Construction Supervisor: Licensed Construction Supervisor: Address Signature Telephone Not Applicable 0 License Number Expiration Date 3.2 Registered Home Improvement Contractor Not Applicable 0 Company Name Registration Number Address Expiration Date Signature Telephone Town of North Andover Community Development and Services Division Office of the Health Department 400 OSGOOD STREET North Andover, Massachusetts 01845 Susan Y. Sawyer, REHS/RS Public Health Director Date: April 8, 2005 Address: 550 Winter Street, North Andover, MA 01845 Re: Application for: Jane Broderick Dear. Ms. Broderick, (978) 688-9540 - Phone (978) 688-8476 - Fax Your application for addition/remodel at 550 Winter Street has been reviewed by the Health Department. The application was denied on, April 8, 2005 for the following reasons: 1. X Missing information 2. X Passing Title 5 inspection of septic system required 3. ® Location of structure not acceptable 4. 0 Undersized septic system To address the Rmblem(s): If #1 is checked, please supply: a. Floor plan of existing and proposed addition - all rooms b. Certified plot plan showing house, septic system and proposed project in scale If #2 is checked: a. Have the septic system inspected by a certified Title 5 inspector to determine the size of the system and whether it is operating properly: If #3 is checked: a. Relocate the project If #4 is checked: a. Provide additional information proving that the existing septic system meets current capacity requirements. Please consult an engineer to determine the flow capacity of the septic system. Please feel free to call the Health Office at 978-688-9540 with any questions you may have. Sincerely, Michele E. Grant Cc: Building Department File BOARD OF APPEALS 688-9541 BUILDING 688-9545 CONSERVATION 688-9530 NURSE 688-9543 PLANNING 688-9535 TOWN OF NORTH ANDOVER SYSTEM PUMPING RECORD 1�7rocicnck j 5) w iv�T� oeT SYSTEM LOCATION (example: left front of house) �440A—b kovs-e,— DATE OF PUMPING: ii) -A-D , QUANTITY PUMPEDf C)on _ CESSPOOL: NO YYES SEPTIC TANK: NO NATURE OF SERVICE: ROUTINE EMERGENCY OBSERVATIONS: GOOD CONDITION HEAVY GREASE ROOTS EXCESSIVE SOLIDS SOLIDS CARRYOVER SYSTEM PUMPED BY: COMMENTS: GALLONS YES -Z FULL TO COVER BAFFLES IN PLACE LEACHFIELD RUNBACK FLOODED OTHER (EXPLAIN) CONTENTS TRANSFERRED TO: ' System Owner ('01111tionweffilth of Massachusetts P. 4 System Pumping,Repord System Location Date of Pumping: � �G' �'�! / Quantity Pumped Cesspool: No . Yes H Septic Tank: No System Pumped by: velre44rt Fit&,?paea License # Contents transferrred to : Greater Lawrence Sanitary District Date: Inspector- la -j gallons Yes T��v;� OF,>!Of3TH ANJO�/ER/ """40 Or HEALTH commonwealth of Massachusells Massachusetts System @u"n ing-Recorcl Syaleni Owlier Ial2te of !'unipilq Cesspool. No — Yes Syslem Location .I0 Quantity Yumped: % z) gallons Seplic Tank: No [ .] Yes 074�- Sysleiu Iltimped by: varejeo giflrrr frija License # CcrtlteUs lrasfe red to . lice sanitary District _ Dale: Inspector: – Commonwealth of Massachusetts City/Town of System Pumping Record Form 4 DEP has provided this form for use by local Boards of Healt information must be substantially the same as that provided local Board of Health to determine the form they use. The S the local Board of Health or other approving authority. RECEIVED AUG 1 1 2009 terms �; �Wped but the i orm, check with your i Pumping Record must be submitted to A. Facility Information 1. System Location: Left side of house, Right side of hous , Left froht of hs Right front of house, Left rear of house, Right rear of house. Address ✓,-r- — City/Town 2. System Owner: Name Address (if different from location) Cityrrown B. Pumping Record 1. Date of Pumping 3. Type of system: ❑ State Zip Code State6o1 S- q,,j > ✓ e Telephone Number Date Cesspool(s) ❑ Other (describe): 4. Effluent Tee Filter present? ❑ Yes to 5. Condition of System: 6. System Pumped By: Neil Bateson 7 t5form4.doc• 06/03 — 2. Quantity Pumped Septic Tank Gallons ❑ Tight Tank If yes, was it cleaned? ❑ Yes ❑ No 6 V\1 Name Vehicle License Number F5821 Bateson Enterprises Inc Company Location where contents were disposed: System Pumping Record a Page 1 of 1 -:f Commonwealth of Massachusetts RECEIVED City/Town of System Pumping Record AUG - 6 2007 Jr Form 4 TOWN vf• tdORl H ANDOVER r• HEALTH DEPARTMENT 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 fora, 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 ming out 1. System Locati n: forms on the computer, use only the tab key AddressL7�.1 v ' (ice y V to move your cursor - do not City/Town State Zip Code use the return key. 2. System Owner: r P Name Address (if different from location) CitylTown State Zip Code as -- Telephone Number B. Pumping Record 1. Date of Pumping Date L. Quantity Pumped: Gallons 3. Type of system: ❑ Cesspool(s) _U -Septic Tank ❑ Tight Tank ❑ Other (describe): 4. Effluent Tee Filter present? ❑ Yes No If yes, was it cleaned? ❑ Yes ❑ No 5. Condition of System: ['n' ' Vim. v `�J 6. Systems Pu,Jfnr�2By: 9v Name Vehicle License Number Company 7. Hauler contents Date t5form4.doc• 06/03 System Pumping Record • Page 1 of 1 I