HomeMy WebLinkAboutMiscellaneous - 58 PHEASANT BROOK ROAD 4/30/2018 (2) 58 Pheasant Brook Road
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MAP ' # L
} LOT # <
PARCEL # STREET
. " ' �O.NSTRUCTI_Q.N_A.PPROVA.L,
HAS PLAN REVIEW FEE .BEEN PAID? /� YES NU
PLAN APPROVAL: DATE PP. BY__,4
DESIGNER: I /1151142U:581-145466-12PLAN DA-FE. =—t
CONDITIONSQeIMAJ6
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WATER SUPPLY: TOWN WELL
WELL PERMIT DRILLER
WELL TESTS: '--- CHEMICAL DATE AFPROVEU.____—
BACTERIA I Tufa I E_ (II PRUVEU.
BACTERIA II~ DATE APPFtUVEll
COMMENTS:
FORM U APPROVAL: 1p o2G� APPROVAL TO ISSUE- YES NO
�1 D
DATE ISSUED—A---l- .a/ BY
CONDITIONS:
FINAL APPROVAL: .
ALL PERMITS PAID YES NO
WELL CONSTRUCTION APPROVAL YES NU
SEPTIC SYSTEM CONSTRUCTION APPROVAL ES NO
OTHER Y -S NU
ANY VARIANCE NEEDED ES NO
FINAL BOARD OF HEALTH APPROVAL: DA"TE: A_;V
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L\ Commonwealth of Massachusetts IVED
CitylTown of '`13 2015
System Pumping Record NORTH ANDOVER' ` �'
MAIN r c NORTH ANDOVER
Form 4
HLP,L I H DEPARTMENT
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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 within 14 days from the pumping date in
accordance with 310 CMR 15.351.
A. Facility information
Important:
When ruling out 1. System Location: K
forms on the Aa�-Uqkv-ILcomputer,use -f .-
only the tab key Addre /��� h
to move your __' �1 rd.P V_ .- A ._
cursor-do not _._..-_.._...... ...........
use the return
Cily[Town Stale Zip Code
key. 2 System Owr)er:
"'Imo! cc I' .C.V,. -
Name a
Address(if different from location)
CityrTown State Zip Code '
Telephone Number
B. Pumping Record �----�
1. Date of Pumping —-._. _----__-.. ....... Quantity Pu ed:
D
ate
Cations
3. Type of system: ❑ Cesspool(s) tic Tank ❑ Ig
Tank ❑ Grease Trap
❑ Other(describe):
4. Effluent Tee Filter present? aYeese �t�lo�t�'TRes, was it cleaned? s ❑ No
5. Condition of System: 40 S Pprte, St
Bradt a_®1835
6. System Pumped By: `978) 374-2382
Wind River Environmental
Name I63 Western Ave. VehiclJUL c nse Number
Company
7. Location where contents were disposed:
Signature of Hauler Date
Signature of Receiving Facility Date
15form4.doc•03106 System Pumping Record•Page I of 1
Commonwealth of Massachusetts
City/Town of
System Pumping Record NORTH ANDOVER
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 within 14 days from the pumping date in
accordance with 310 CMR 15.351. ��LrRKEIVEE)
A. Facility Information JUN _ 4 `4011
Important:
When filling out 1. System Location: TOWN OF NQRTH ANDOVER
forms on the ��,., �,� HEALTH DEPARTMENT
computer,use -. �a`�`JG nk---v oy-
only the tab key Address
to move your
— /11_. - v _ . - -
cursor-do not .Cily/Town State Zip Code
use the return
key. 2 System Owner-,
r
Name
Address(if different from location)
-------..._. ._._.
City/Town State f_ fZip Code
q_ 's- ----
Telephone Number
B. Pumping Record
5��1 ►� 6_off - -
1. Date of Pumping pate - 2. Quantity Pumped: 1
Gallons
3. Type of system: ❑ Cesspool(s) [,43 Septic Tank ❑ Tight Tank ❑ Grease Trap
❑ Other(describe):
4. Effluent Tee Filter present? 0 Yes ❑ No If yes, was it cleaned? ,6 Yes ❑ No
5. Condition of System:
6. System Pumped By:
�Namle Vehicle License Number
Company
7. Location where contents were disposed:
G.L.S.D. _
Signature of Hauler ���r���' �. � Date
Signature of Receiving Facility ----------_ -- _- Date -- --�-------- ------�--'-_—-_
t5form4.doc•03!06 System Pumping Record•Pa e
1 o
f 1
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Commonwealth of Massachusetts
City/Town of
System Pumping Record NORTH ANDOVER
Form 4
y 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 within 14 days from the pumping date in
accordance with 310 CMR 15.351.
A. Facility information
Important:
When filling out 1. System Location:
forms on the `��
computer,use
only the tab key Address
to move your
cursor-do not
-- Slate Zip Code
use the return Cilyrrown
key. Z. System Owner:
Name---- —--. ...__ ---- -- -
Address(if diKerent from loca(ion)
City/Town
State Zip Code
Telephone Number —.
B. Pumping Record
1. Date of Pumping Date , ` 2 Quantity Pumped: Gallons
�
3. Type of system: ❑ Cesspool(s) l� Septic Tank ❑ Tight Tank ❑ Grease Trap
❑ Other(describe):
4. Effluent Tee Filter present? [] fes ❑ No If yes, was it eleanedg [ ^es ❑ No
5. Condition of System:
o%
RrM ANa
6. System Pumped By: fpWN Or NQEppFtfMENT
- N +{ Vehicle,License Number
Name HG�Vpirl l�ll WV V t --_Y
-- --40 S Porter St
Company pp��
7. Location where contents were dispoBdford, iV�ai 01 40y
-2382—
Signature
2382 -Signature of Hauler Date
-----------�...—_...--- ---- -------- --
Signature of Receiving f=acility Date
15form4.doc•03!06 System Pumping Record•Page t of t
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TOWN OF NORTH ANDOVER
BOARD OF HEALTH
CERTIFICATE OF COMPLIANCE
DATE OF COMPLIANCE:
5/19/00
This is to certify that
the individual subsurface disposal system
constructed (X) or repaired ()
by
Dave Maynard
at
Lot 2A(58)Pheasant Brook Road
has been installed in accordance with the provisions of Title V of the State Sanitary Code
and with the North Andover Board of Health regulations.
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.z
NOR71y BOARD OF HEALTH
O�tt`•D I•1�O � ��
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DESIGN APPROVAL FOR
SS�C14U SOIL ABSORPTION SEWAGE DISPOSAL SYSTEM
Applicant 12O6 /%E65.IAM Test No.
Site Location_ ,or
Reference Plans and Specs. � �5����SE� l0�✓��70
ENGINEER DESIGN
-
Permission is granted for an individual soil absorption sewage disposal system to be installed
in accordance with regulations of Board of Health.
HAI RMA ,BOARD OF HEALTH
Fee LZ Site System Permit No. 162,3
TOWN OF NORTH ANDOVER SEWAGE DISPOSAL SYSTEM
INSTALLATION CERTIFICATION
The undersigned hereby certify that the Sewage Disposal System constructed-
repaired; /
by:._:
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located at e bZA
was,installed.in conformance with the North Andover Board of Health approved plan;.
System Desi gan.Pe. it /Ov? dated Z;—3 - tivit7 an approved design
flow of..- gallons per day. The materials used were in conformance with those
speciued on.the approved plan; the system was installed in accordance with the provisions
of 310 CTMR 15.000, Title 5 and local regulations, and the final grading agrees
substantially with the approved plan. All work is accurately ^r rated a t As-built
which has been submitted to the Board of Health.
Bed inspection date:
Engine Repre e^ ive
Final inspection date: 5
n e-r ReoresentatlV
Installers< Lic.m: 119Date: L.�_=
Design Engineer: Date: -5--
SYS�.ef, -
AS-BUILT CHECKLIST
(� LOT NUMBER, STREET NAME
ASSESSORS MAP &PARCEL NUMBER
LOT LINES &LOCATION OF DWELLINGS
LOCATIONS & DIMENSIONS OF SYSTEM,
INCLUDING RESERVE
IES TO LOT LINES &DWELLING, WELLS
f a. FROM SEPTIC TANK
b. FROM LEACH AREA
LOCATIONS OF DEEP HOLES &PERC
TESTS
ELEVATIONS OF DISPOSAL SYSTEM
V TOP OF FDN ELEVATION
LOCATIONS OF WELLS, DRAINS, WATERCOURSES
WITHIN 150' OF SYSTEM
LOCATION OF WATER, GAS, ELECTRIC LINES, CABLE
DISTANCES FROM CORNERS OF HOUSE TO CENTER OF
TANK&D-BOX
ORIGINAL STAMP & SIGNATURE
IMPERVIOUS AREAS - DRIVEWAYS, ETC.
1/ NORTH ARROW
LOCATION&ELEVATIONS OF BENCHMARK USED
Town of North Andover °F 4,ORTH
OFFICE OF �� °•° °
COMMUNITY DEVELOPMENT AND SERVICES p
30 School Street
North Andover,Massachusetts 01845
WILLIAM J. SCOTT SSACHuse
Director
June 25, 1998
Christiansen & Sergi
160 Summer Street
Haverhill, MA 01830
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RE: Lot 2 Evergreen Estates
Dear Phil:
This letter is to inform you that the proposed septic plan for Lot 2 Pheasant
Brook Road has been approved.
If you have any questions, please do not hesitate to call the Board of
Health office at the number below.
Sincerely,
'76/ZZZT
Sandra Starr, R.S.
Health Administrator
i
cc: Wm. Scott, Dir. CD&S
DECM
File
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BOARD OF APPEALS 688-9541 BUILDING 688-9545 CONSERVATION 688-9530 HEALTH 688-9540 PLANNING 688-9535
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APPLICATION FOR DISPOSAL WORKS CONSTRUCTION PERMIT
DATE: - — CURRENT INSTALLER'S LICENSE#
LOCATION: 4,ot ""?_
LICENSED INSTALLER: z7/ty/v�
SIGNATURE: TELEPHONE# �,63
CHECK ONE:
REPAIR: NEW CONSTRUCTION: E/
IF NEW CONSTUCTION, PLEASE ATTACH FOUNDATION AS-BUILT.
Administrative Use Only
$75.00 Fee Attached? Yes—Z No
Foundation As-Built? Yes No
Floor Plans? Yes No
Approval ���� Date: 9
TOWN OF NORTH ANDOVER/
SOARD OF HEALTH
SEP
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F.Ty5il I a t-� 3 7
r Town of North Andover, Massachusetts Form No.3
$• 0R7M BOARD OF HEALTHig
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DISPOSAL WORKS CONSTRUCTION PERMIT
SSACHUSES .
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Applicant
NAME ) ADDRESS TELEPHONE
Site Location
Permission is hereby granted to Construct (-,ror Repair ( ) an Individual Soil Absorption
Sewage Disposal System as shown on the Design Approval S.S. No. /Daj
CHAIRMAN,BOARD OF HEALTH
Fee—1� D.W.C. No.
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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***********************
i
�. APPLICANT `-' DERE PHONE 3o1- s�p
I
LOCATION: Assessor's Map Number /0(06 W7 �0 PARCEL
SUBDIVISION v�R6Rc r✓ LOT (S) c3g
STREET 7HEASaf-T '3/3L01< ST. NUMBER
**************OFFICIAL USE ONLY***********************************
b ,
RECO D IONS OF TO
AGENTS:
F
CO ERVAf ION ADMINI§TRATOb DATE APPROVED
DATE REJECTED
COMMENTS (/}�
TOWN PLANNER DATE/APPROVED
I . DATE REJECTED
COMMENTS
FOOD INSP TOR-HEALTH DATE APPROVED
/ DATE REJECTED
�✓ P ICI ECTOR-HEAL H DATE APPROVED _2
DATE REJECTED
COMMENTS
PUBLIC WORKS -SEWERIWATER CONNECTIONS
DRIVEWAY PERMIT •
FIRE DEPARTMENT
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RECEIVED BY BUILDING INSPECTOR DATE
SEPTIC PLAN SUBMITTALS
LOCATION:- �- (A
NEW PLANS: YES $60.00/Plan
REVISED PLAN : YES $25.00/Plan 1C103-)
DATE: Ci
DESIGN ENGINEER: i—
When the submission is all in place, route to the Health Secretary
NORTH ANDOVER BOARD OF HEALTH
DESIGN REVIEW REPORT
DATE
FEE: D PERMIT # A!Z" DATE RECEIVED
APPLICANT ( M65S1N/3 MAP � �� PARCEL
ADDRESS LOT # _ STREET # - ✓
ENG. ^�'� STREETl-77695PXJi 8eoo,r ZD
ENGINEER' S ADD. l l
PLAN DATE */ Lg/�I� REV. DATE
CONDITIONS OF APPROVAL
APPROVED DISAPPROVED
REASONS FOR DISAPPROVAL:
or
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✓� , M(S5 i�G �I�S �I�
oX /o cilx
Town of North Andover f AORTpf
OFFICE OF 3�o`st e s 6A, L
COMMUNITY DEVELOPMENT AND SERVICES
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30 School Street
WILLIAM J. SCOTT 4 North Andover,Massachusetts 01845 �9SSACH�s�t�h
Director
June 1, 1998
Mr. Phil Christiansen
Christiansen& Sergi
160 Summer Street
Haverhill, MA 01830
Re: 2A Pheasant Brook Road
Dear Phil:
This is to inform you that the proposed plans for the site referenced above have been
disapproved for the following reasons:
1) No benchmark within 75 feet of septic system. (3 10 CMR 15.220(q))
2) Missing gas baffle. (3 10 CMR 15.227)
3) Missing 2' level statement for D-Box. (310 CMR 15.232(c))
4) Missing vent. (310 CMR 15.251)
If you have any questions, please do not hesitate to call the Board of Health Office at the
number below.
Sincerely,
Sandra Starr, R.S.
Health Administrator
SS/cjp
cc: William Scott, Director, P&CD
Bob.Messina
File
BOARD OF APPEALS 688-9541 BUILDING 688-9545 CONSERVATION 688-9530 HEALTH 688-9540 PLANNING 688-9535
SEPTIC PLAN SUBMITTALS
LOCATION: 0
NEW PLANS: YES $60.00/Plan
REVISED PLANS: YES $25.00/Plan ✓�
DATE:
DESIGN ENGINEER: �s
When the submission is all in place, route to the Health Secretary
1
FORM U - LOT RELEASE FORM
INSTRUCTIONS: This form is used to verify that all necessary
approvals/permits from Boards and Departments having jurisdiction
have been obtained. This does not relieve the applicant and/or
landowner from compliance with any applicable local or state law,
regulations or requirements.
****************Applicant fills out this section********.*********
APPLICANT: Phone
LOCATION: Assessor' s Map Number. Parcel-
Subdivisions� /� er5 .Lot(s) �
Street 4!� St. Number
Use Only************************
RECOMMENDATIONS OF TOWN AGENTS
Date Approved
Conservation Administrator Date .Rejected
Comments
Date Approved
Town. Planner Date Rejected
Comments
Date Approved
Food Insp t ealth Date Rejected
AJV
Date Approved
Septic Inspe or-Health Date Rejected
Comments
Public Works - sewer/water connections
driveway permit
Fire Department
Received by Building Inspector Date
,`
1
��
CHRISTIANSEN & SERGI, INC.
PROFESSIONAL ENGINEERS AND LAND SURVEYORS
160 SUMMER STREET HAVERHILL, MASSACHUSETTS 01830 (508)373-0310 FAX: (508)372-3960
June 13, 1996 _
TOWN OF NORTH ANDOVER/
BOARD OF HEALTH
Ms. Sandra Starr
North Andover Board of Health
120 Main Street . —8 1996
North Andover, MA 01845
Re: Lot 2A Pheasant Brook Road(Evergreen Estates Subdivision)
Dear Ms. Starr:
Due to changes made to the lot lines of Lots 1, 2, and 3 (now IA, 2A, and 3A) at Evergreen
Estates, it was necessary to make some revisions to the previously approved septic system design for
Lot 2. The changes are related to the lot line changes and will not effect the construction of the
proposed primary leaching area. A summary of the changes is as follows.
1. The lot line between Lots 2 and 3 was moved farther away from the proposed leaching
area on Lot 2. As a result of this, the grading easement show on the previous plan is no longer
required.
2. The reserve area has been reconfigured to accommodate the lot line change between
Lots 2 and 3.
3. The foundation drain outlet has been relocated to accommodate the lot line change
between Lots 1 and 2.
4. The fill specification notes have been updated to comply with the interim changes in the
Title 5 specifications.
Enclosed are 3 copies of the revised Septic System Design for Lot 2A. Please contact me if you
have questions regarding this design.
e* G.
Yours,
hristiansen
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FORM C
APPLICATION FOR APPROVAL OF DEFINITIVE PLC
NORTH ANDOVER
January 17 - �9 95
To the Planning Board of the Town of North Andover:
The undersigned, being the applicant as defined under Chapter 41, Section
81 L, for approval of a proposed subdivision shown on a plan entitled
Definitive Subdivision Plan "Evergreen Estates" located in No_rrh Andover
by Christiansen & Sergi , Inc . dated December 28 . 1994
being land bounded as follows:Northerly bt Com of MA , land of Steer and Fried ;
easterly by land of Fried , Deadder , Rough , Green , Galeassi , Yourre , Mateja ,
clam skr.-, Rftd Faf- Farr and
�-,
Com of MA ; westerly by Com of MA,.
hereby submits said plan as a DEFINITIVE plan in accordance with the Rules and
Regulationsof the North Andover Planning Board and makes application to -the
for approval of said plan.
�� PP
1087 314
Title Reference: North Essex Deeds, Book 2901 , Page 13 ; or
Certificate of Title No. , Registration Book , page ; or
Other:
Said plan has(x) has not( ) evolved from a preliminary plan submitted to
the Board of A u O 2A.—Ig -► and approved (with modifications) ( )
disapproved (X) on Oct 4 , 1994
The undersigned hereby applies for the approval of said DEFINITIVE plan
by the Board, and in furtherance thereof hereby agrees to abide by the Board's
:Rules and Regulations. The undersigned hereby further covenants and agrees
with the Town of North Andover, upon approval of said DEFINITIVE plan by the
Board:
1. To install utilities in accordance with the rules and regulations of the
Planning Board, the Public Works Department, the Highway Surveyor, the
Board of Health, and all general as well as zoning by—laws of said Town,
as are applicable to the instai?ation of utilities within the limits of
ways and streets;
2. To complete and construct the streets or ways and other improvements shown
thereon in accordance with Sections Iv and V of the Rules and Regulations
of the Planning Board and the approved DEFINITIVE plan, profiles and cross
sections of the same. Saidlan rofiles cross sections and construction
P � profiles,
specifications are specifically, by .-reference, incorporated herein and made
a part of this application. This application and the covenants and agree—
ments herein shall.be binding upon all heirs, executors, administrators,
successors, grantees of the whole or part of said land, and assigns of the
undersigned; and
3. To complete the aforesaid installations and construction within two (2)
years from the date hereof.
Received by Town Clerk: ��-
Date: Signature of Applicant
Messina Development Corp . , 805 Winter St .
Time: North Andover , MA 01845
Signature: Address
Notice to APPLIUANI/'I I CLERK and Certification of A .on of Planning Board
on Definitive Subdivi'z�lon Plan entitled: ,
0
Evergreen Estates
By: Christiansen & Sergi dated ❑PcPmhPr �u 19 g4
The North Andover Planning Board has voted to APPROVE said plan, subject to the
following conditions:
1. That the record owners of the subject land forthwith execute and record
a "covenant running with the land", or otherwise provide security for the con-
struction of ways and the installation of municipal services within said sub-
division, all as provided by G.L. c. 41, S. 81-U.
2. That all such construction and installations shall in all respects
conform to the governing rules and regulations of this Board.
3. That, as required by the North Andover Board of Health in its report to
this Board, no building or other structure shall be built or placed upon Lots
No. as shown on said Plan without the prior
consent of said Board of Health.
4. 'Other .conditions:
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See attached o�
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In the event that no appeal shalt have been taken from said approval within
twenty days from this date, the North Andover Planning Board will forthwith
thereafter endorse its formal approval upon said plan.
The North Andover Planning Board has DISAPPROVED said plan, for the following
reasons:
NORTH ANDOVER PLANNING BOARD I'
Date: [august 15, 1995 By: A� I/ -M'1�
Josepi, V. Mahoney, Chairman
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a. A complete set of signed plans, a, copy of the Planning ,,
Board decision, and a copy of the Conservation Commission ±:
Order of Condition must be on file at the Division of
Public Works prior to issuance of permits for connections
to utilities. The subdivision construction and
installation shall in all respects conform to the rules
and regulations and specifications of the Division of
Public Works.
b. All site erosion control measures required to protect off
site properties from the effects of work on the lot
proposed to be released must be in place. The Town
Planning Staff shall determine whether the applicant has
satisfied the requirements of this provision prior to
each lot release and shall report to the Planning Board
prior to a vote to release said lot.
c. The applicant must submit a lot release FORM J to the
Planning Board for signature.
d. A Performance Security (Roadway Bond) in an amount to be
determined by the Planning Board, upon the recommendation
of the Department of Public Works, shall be posted to
ensure completion of the work in accordance with the
Plans approved as part of this conditional approval. The
bond must be in the form of a check made out to the Town
of North Andover. This check will then be placed in an
interest bearing escrow account held by the Town. Items
covered by the Bond may include, but shall not be limited
to:
i. as-built drawings
ii. sewers and utilities
iii. roadway construction and. maintenance
iv. lot and site erosion control
V. site screening and street trees
vi. drainage facilities
vii. site restoration
viii.final site cleanup
e. Three (3) complete copies of the endorsed and recorded
plans and two (2) certified copies of the recorded
subdivision approval, Covenant (FORM I) , Right of Way
easements, and FORM M must be submitted to the Town
Planner as proof of filing.
4 . Prior to a FORM U verification for an individual lot, the
following information is required by the Planning Department:
a. All lots must be approved by the Board of Health. The
Board of Health has determined that Lots 6, 9 , 12, 13 ,
and 21 cannot be used for building sites without injury
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to the public health without further testing. No
building or structure shall be placed upon these lots
without consent by the Board of Health.
b. Due to the large amount of rock on the site which may
interfere with the amount of parent material available
for leaching, the Board of Health will require that the
leaching area for each lot be completely excavated to
insure that there is the requisite four feet of parent
material present throughout the entire location proposed
for the leaching area.
C. The applicant must submit to the Town Planner proof that
the FORM J referred to in Condition 3 (c) above, was filed
with the Registry of Deeds office.
d. A plot plan for the lot in question must be submitted,
which includes all of the following:
i. location of the structure,
ii. location of the driveways,
iii. location of the septic systems if applicable,
iv. location of all water and sewer lines,
V. location of wetlands and any site improvements
required under a NACC order of condition,
Vi. any grading called for on the lot,
vii. all required zoning setbacks,
viii. location of any drainage, utility and other
easements.
e. All appropriate erosion control measures for the lot
shall be in place. Final determination of appropriate
measures shall be made by the Planning Board or Staff.
f. All catch basins shall be protected. and maintained with
hay bales to prevent siltation into the drain lines
during construction.
g. The lot in question shall be staked in the field. The
location of any major departures from the plan must be
shown. The Town Planner shall verify this information.
h. Lot numbers, visible from the roadways must be posted on
all lots.
5 . Prior to a Certificate of Occupancy being requested for an
individual lot, the following shall be required:
a. A stop sign must be placed at end of Pheasant Brook Road
where it intersects with Salem Street.
b. A driveway easement across Lot 22 must be granted to Ian
5
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N° 2228 2 8 Date....31
i,NORT"'1
4L TOWN OF NORTH ANDOVER
p PERMIT FOR WIRING
s � s
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,sSACMUS�
This certifies that ......................11 .....
............. .. .. . ......................................
(� ....,
s" has permission to perform ..... ,�..`...................... ...........................................
wiring in the building of...................................................................................
North And ov f✓M s.
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- Fee...&Z).,(J.A.J.. Lic.No.............. .....���... �....
EGTRICAI,INSPECTOR
WHITE: Applicant CANARY: Building Dept. PINK:Treasurer
TBE 00MV0 W LTH0FMASS4QWJ S OMUse only
DEPARTMEVfOFPUBLICS4= Permit No. D r_�
BOARD 0FFREPREVFAW0NRWUT4TT0ASV7CMR 120
V Occupancy&Fees Checked
A
PPLICATIONFOR PERMIT TTO PEUORMELECI'RICAL 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) Dat (�
Town of North Andover To the In ector of Wires:
The undersigned applies for a permit to perform the electrical w rk described below.
elo.
Location(Street&Number)
Owner or Tenant
Owner's Address
Is this permit in conjunction with a building permit: Yes No a (Check Appropriate Box)
Purpose of Building Utility Authorization No.
Existing Service Amps Volts OverheadUnderground ( No.of Meters
New Service Amps Volts OrveOiead Underground "� No.of Meters
Number of Feeders and Ampacity
Location and Nature of Proposed Electrical Work t
.of Lighting Outlets No.of Hot Tubs o.of Transformers Total
�+ KVA
No.of Lighting Fixtures S ing Pool pove Below Generators KVA
un�l ound
o.of Receptacle Outlets o.of Oil Burners No.of Emergency Lighting Battery Units
A*..
No.of Switch Outlets §�
No.of Gas Burners
No.of Ranges No.of Air Cond:'*A Total FIRE ALARMS No.of Zones
Ton
No.of Disposals SNo.of Heatf Total Total No.of Detection and
Pumps Tons KW Initiating Devices
No.of Dishwashers Space ASW eating KW No.of Sounding Devices
' No.of Self Contained
Detection/Sounding Devices
No.of Dryers Heiting6evices KW Local a Municipal a Other
Connections
No.of Water Heaters KW Na.of No.of
S' Bailasis
0i No.Hydro Massage Tubs o.of Motors Total HP
v
ATHE '
UmraneCo►aa�Ptrls�art regtmartar� COWALaws
1hawaamtLiabildyhstaaioe6d ;'Compke CovmWoritssrbstar5alegtrivalat YES a NO
Ihaw AhT»tWdva6dproofofsarlet�d' YES NO r7 IfjouhasedniQedYES,plrmrdc*theWofwmagebydmiagthe
a BO o a ftmespeffy)
Eviatim D.*
F=r kdVahredUeChMlWait S
WakiDStart h ipmimDEWRewested Rah Faral
Sigred MJWTre i cfpeijtay.
FIRM NAME LioaseNa
Lica�sae sig>taane Licer>seNo
BtsimTd.No.
°
dim m_....�_,__ At Tel Na
OWNER'SIIVSURANCEWANER;lama"mthattheLmwdmnAtheisrraxeccheaFaritssistartiale*im3karturegtmedbyM Ccrt dLa&
aoddratmysgrratiaecnihispwmappficmmv4 i�mthismgi'ertem(Please check one) Owner MAgent aTelephone No. PERMITFEE 2LJJ
+v..a. yr Lv.tiiv!lVVr:K
SYSTEM PUMPING REPORT
NAME OF PUMPING COMPANY U REPORT FOR MONTH OF
CONTENTS CONDITRiN
OWNERS GALLONS *H G TRANSFERRED OF
DATE ADDRESS NAME PUMPED C D S TO SYSTEM
� ��3 �oa S8 ���.asarl� �hn �Y1c.Co�z,�uc iso ► � 6� �
7�y
.. ! 1. 2002
1
&ter-
* C = Ces pool D = Drywell = Septic Tan}: G = rease Tra H = olding Tank
Commonwealth of&assaqbusetts . #F G " VED
City/Town of
a. System Pumping Recor / NOV 10 2009
Form 4
TOWN OF NORTH ANDOVER
H LTM D P T ENT
DEP has provided this form for use by local Boards of Health. Other form ;
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 within 14 days from the pumping date in
accordance with 310 CMR 15.351.
A. Facility Information
Important:
When filling out 1. System Location:
forms on the
computer,use V NctGSCA A-11 9000 K (2
only the tab key Address /� _
to move your &AacA6[!r"1- A
cursor-do not City/Town State Zip Code
use the return
key. 2. System Owner:
Name
Address(if different from location)
City/Town StateG€� Zip Code
Telephone Number
B. Pumping Record
1. Date of Pumping Date 2. Quantity Pumped: Gallons
3. Type of system: ❑ Cesspool(s) �eptic Tank ❑ Tight Tank ❑ Grease Trap
❑ Other(describe):
4. Effluent Tee Filter present? Efly'es ❑ No If yes, was it cleaned? FT'*Yes ❑ No
5. Condition of System:
6. System Pumped By:
Namett � ii Vehicle License Number
Ujtvta 'ver
Company
7. Location where contents were disposed: G.L.S,®
Lawrene MA.
cSignature of Hauler Date
Signature of Receiving Facility Date
t5form4.doc•03/06' System Pumping Record•Page 1 of 1
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Commonwealth of Massachusetts
city/Town of
System Pumping Record NORTH ANDOVER
Form 4
DEP has provided this form for use by lat:ai Boards of Health. other forms may be used,but the
e same as that provided here. Before using this form,Check with your
information must be substantially th
local Board of Health to determine the form they use.The System Pumping Record must be submitted to
the to.at Board of Health or other approving authority within 14 days from t �pE+�-EIVED
'4171
accordance with 310 CMR 15.351. (;
A. Facility information JUN •► 201Z
TOWN OF NORTH ANDOVER
When fining out Y
Important: 1 system Location: HEALTH DEPARTMENT
forms on the -
computer,use — --�---�
onty the tab Key Address
to move your /IJ .-
cursor•do not "-+ ---' - State Zip Code
use the return
Cityfrawn
key. 2. System Owner,
IL Ar Marne
Address{if Cif(erent iron EdCation) '
_ State —., ._... Zip Go
Teleplronk+NurnbOr _.
B. Pumping Record
.. �{.� Z. Quantity Pumped' Gallons
1. Date of Pumping Date
3. Type of system: 0 Cesspool S) optic Tank ❑ Tight Tank D Grease Trap
❑ Other(describe),
4. Effluent Tee Filter present? ❑ No If yes, was it cleaned? Yes ❑ No
5. Condition of Sy tem:
6. System Pumped By'.
Nattte Ve�iGe License Number
company
7. Location where contents were disposed: QLID.
Sigr�atute of t-tauler----_.� .._�. . ._ ..,.s, ... .__ --•- [)ate..,_.__.. ... . __ ....,� .�—._•� ,
System Pumping Record•Page t of f
1510mt4.doc•03106