Loading...
HomeMy WebLinkAboutMiscellaneous - 61 WHITE BIRCH LANE 4/30/2018 (2)s.Y (3-- N _O Q 0 0 0 0 0 rn 2 m m W X z m W a i MAP # LOT #__.__.�__.__.-.____. PARCEL # STREET LJy_.L...... CONSTRUCT I.ON_-.APPROVAL HAS PLAN REVIEW FEE BEEN PAID? YES NO PLAN APPROVAL: DATE lle6 APP. BYC612-- DESIGNER: 612--DESIGNER: � f/.C��Sy�.J/L'��/� PLAN DATE._W/z,3 CONDITIONS- WATER ONDITIONS WATER SUPPLY: TOWN - WELL WELL PERMIT DRILLER._..._.__----..._....__._..___ ._...._.---_._._.................. WELL TESTS: CHEMICAL DALE BACTERIA I DALE E1E=NRUVED BACTERIA II DALE (IPPRUVED__. COMMENTS��o�P�,g�,C�i�L Cr7�556e V4 FORM U APPROVAL: APPROVAL 1'0 ISSUE _ES NO DATE ISSUED ---- CONDITIONS: FINAL APPROVAL:. --� ALL PERMITS PAID NO Y� WELL CONSTRUCTION APPROVAL NO SEPTIC SYSTEM CONSTRUCTION APPROVAL . J(�E NO OTHER YES NO ANY VARIANCE NEEDED FINAL BOARD OF HEALTH APPROVAL: ANO YES DA i" E : !U4z lq... B Y :.. i O y 096 `9 O y •s 1� Ci ml� 4;�cn 2 riq— v `L6ZS O y q r` CvVAV 0 .la rr,,,, H ]7 vJ�� �_� y y O O O O O '11 -11 y 2y O°OtinOj ° ° r'1 UD r rn yZOR� y y y czO vJ m`C Z y y n n Z LI h�h � tZt^^� vJ O �p Z r vJ nl� p V v v N v ° C �clJ NJ N o6 Li tp �INa N3 to i'rrIn�j r.i 2 O A v Cn Oo O 2�oZ o� '(t' v v �" TOWN OF NORTH ANDOVER •'` APPLICATION FOR PLAN EXAMINATION Permit N0: Date Received Date Issued: IMPORTANT: Applicant must complete all items on this page LOCATION G(/ A 1'74-G &;I- c-4 L 2`!'eni • lANaloyC'r _ Print PROPERTY OWNER l d d d f .i i i) 1 I o 10 e r Unit # Print MAP N0: PARCEL: ZONING DISTRICT: Historic District yes <9 Machine Shop Village yes (ED 100 year-old structure yes 9 TYPE OF IMPROVEMENT PROPOSED USE Residential Non- Residential ❑ New Building O'One family ❑ Addition ❑ Two or more family ❑ Industrial 14,Alteration No. of units: ❑ Commercial ❑ Repair, replacement ❑ Assessory Bldg ❑ Others: ❑ Demolition ❑ Other 'WHns opauiV;r 11 jWatershe�lDls ct� ;_°�� cSptyi 77 DESCRIPTION OF WORK TO BE YE1{.UMNIED: .1 75�2'C t zi t * P � Gr � .S 7�i b'�G e — S7`2 iru/zy aL'.-a,►A d - Nd yC�,�, 7`� /5t /I�y G . ?-x6,se`s d- ma,o l ��t t,AJ&d � 4 /ft -p--' kH « w z�l� a �` 1Y ' a L /A ;dc -5 — 7-w6 &21, awS -L 17S -A? (Identification Please Type or Print Clearly) OWNER: Name: To A lkp cr Phone: i 79- S -'17-1Y6 Address: 6 / I</4 ??4c S %.-o a•, c r(1- �vea- CONTRACTOR Name: &/2 Phone: -27 9- 46 Y- 00Y7 Address: /G 1� -00 c� rd d cS � i lltv-� c1� rLle. aiTs� l Supervisor's Construction License:- C S O n 3 r /3 Exp. Date:. Home Improvement License: t CJJ_ q Y 3 Exp. Date: 7' M A p4-c9,i+Ceti The ARCHITECT/ENGINEER TC 2 h n C 14 Phone: - J 7 S- L16 S- a t G 3 Address: 0- A I f reel S1-. _�u � fc 3o 06qv,,yo. Reg. No. S7 Sq / d l�doi FEE SCHEDULE: BULDING PERMIT: $12.00 PER $9000.00 OF THE TOTAL ESTIMATED COSTBASED ON $925.00 PER S.F. Total Project Cost: $ �(3 0 0 � FEE: $ Check No.: Receipt No.: NOTE: Persons contracting with unregistered contractors do not have access to the guaranty fund �Signatu"reofrAgent/.Qwner� _ .Sgriafure_ofcontractor - :4 � I f Plans Submitted ❑ Plans Waived ❑ Certified Plot Plan ❑ Stamped Plans ©' TYPE OF SEWERAGE DISPOSAL Public Sewer ❑ Tanning/Massage/Body Art ❑ Swimming Pools ❑ Well ❑ Tobacco Sales ❑ Food Packaging/Sales ❑ Private (septic tank, etc. Permanent Dumpster on Site ❑ THE FOLLOWING SECTIONS FOR OFFICE USE ONLY INTERDEPARTMENTAL SIGN OFF - U FORM PLANNING & DEVELOPMENT COMMENTS DATE REJECTED 01 DATE APPROVED CONSERVATION Reviewed on Signature COMMENTS HEALTH COMMENTS Reviewed k, <ti E IR -1 6 C i,"' y r" vim-- 1'-%- Cn— le_� - 62 l� Zoning Board of Appeals: Variance, Petition No:. Zoning Decision/receipt submitted yes Planning Board Decision: Conservation Decision: Comments Comm Water & Sewer Connection/Signature & Date Driveway Permit DPW Town Engineer: Signature: Located 384 Osgood Street FIRE DEPARTMENT - Temp Duinpster on site yes no Located at 124 Main Street Fire Department signature/date COMMENTS Owner information is required for every page. Important: When filling out forms on the computer, use only the tab key to move your cursor - do not use the return key. tab Comrhonwpalth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 61 White Birch Lane Property Address Anne Marie Towne Owner's Name North Andover MA 01845 11/15/2008 City/Town State Zip Code Date of Inspection Inspection results must be submitted on this form. Inspection forms may not be altered in any way. A. General Information 1. Inspector: Pat Leclerc Name of Inspector AP Title 5 Inspections Company Name 668 South Main Street Company Address Bradford City/Town (978) 662-5111 Telephone Number B. Certification MA State N/A License Number 01835 Zip Code I certify that I have personally inspected the sewage disposal system at this address and that the information reported below is true, accurate and complete as of the time of the inspection. The inspection was performed based on my training and experience in the proper function and maintenance of on site sewage disposal systems. I am a DEP approved system inspector pursuant to Section 15.340 of Title 5 (310 CMR 15.000). The system: ® Passes ❑ Conditionally Passes ❑ Fails ❑ Needs Further Evalu ion by the Local Approving Authority November 16, 2008 Ins ector's Signature Date The system inspector shall submit a copy of this inspection report to the Approving Authority (Board of Health or DEP) within 30 days of completing this inspection. If the system 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. ****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. Towne - DEP INSPECTION FORM.doc • 08/06 Title 5 Official Inspection Form: Subsurface Sewage Disposal System • Page 1 of 15 Owner information is required for every page. Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 61 White Birch Lane Property Address Anne Marie Towne Owner's Name North Andover MA 01845 11/15/2008 City/Town State Zip Code Date of Inspection B. Certification (cont.) Inspection Summary: Check A,B,C,D or E / always complete all of Section D A) System Passes: ® I have not found any information which indicates that any of the failure criteria described in 310 CMR 15.303 or in 310 CMR 15.304 exist. Any failure criteria not evaluated are indicated below. Comments: B) System Conditionally Passes: ❑ One or more system components as described in the "Conditional Pass" section need to be replaced or repaired. The system, upon completion of the replacement or repair, as approved by the Board of Health, will pass. Answer yes, no or not determined (Y, N, ND) in the ❑ for the following statements. If "not determined," please explain. ❑ The septic tank is metal and over 20 years old* or the septic tank (whether metal or not) is structurally unsound, exhibits substantial infiltration or exfiltration or tank failure is imminent. System will pass inspection if the existing tank is replaced with a complying septic tank as approved by the Board of Health. * A metal septic tank will pass inspection if it is structurally sound, not leaking and if a Certificate of Compliance indicating that the tank is less than 20 years old is available. ND Explain: ❑ Observation of sewage backup or break out or high static water level in the distribution box due to broken or obstructed pipe(s) or due to a broken, settled or uneven distribution box. System will pass inspection if (with approval of Board of Health): 0 0 broken pipe(s) are replaced obstruction is removed Towne - DEP INSPECTION FORM.doc • 06/06 Title 5 Official Inspection Form: Subsurface Sewage Disposal System - Page 2 of 15 Owner information is required for every page. Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 61 White Birch Lane Property Address Anne Marie Towne Owner's Name North Andover MA 01845 City/Town State Zip Code B. Certification (cont.) B) System Conditionally Passes (cont.): ❑ distribution box is leveled or replaced ND Explain: 11/15/2008 Date of Inspection ❑ 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: C) Further Evaluation is Required by the Board of Health: ❑ Conditions exist which require further evaluation by the Board of Health in order to determine if the system is failing to protect public health, safety or the environment. 1. System will pass unless Board of Health determines in accordance with 310 CMR 15.303(1)(b) that the system is not functioning in a manner which will protect public health, safety and the environment: ❑ Cesspool or privy is within 50 feet of a surface water ❑ Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh 2. System will fail unless the Board of Health (and Public Water Supplier, if any) determines that the system is functioning in a manner that protects the public health, safety and environment: ❑ The system has a septic tank and soil absorption system (SAS) and the SAS is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water supply. ❑ The system has a septic tank and SAS and the SAS is within 50 feet of a private water supply well. Towne - DEP INSPECTION FORM.doc • 08106 Title 5 Official Inspection Form: Subsurface Sewage Disposal System • Page 3 of 15 Owner information is required for every page. Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 61 White Birch Lane Property Address Anne Marie Towne Owner's Name North Andover MA 01845 City/Town State Zip Code B. Certification (cont.) C) Further Evaluation is Required by the Board of Health (cont.): 11/15/2008 Date of Inspection ❑ 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 indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis must be attached to this form. 3. Other: D) System Failure Criteria Applicable to All Systems: You must indicate "Yes" or "No" to each of the following for all inspections: Yes No ❑ ® Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool ❑ ® Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool ❑ ® Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool ❑ ® Liquid depth in cesspool is less than 6" below invert or available volume is less than 1/z day flow ❑ N Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number of times pumped: ❑ ® Any portion of the SAS, cesspool or privy is below high ground water elevation. ❑ ® Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. Towne - DEP INSPECTION FORM.doc • 08106 Title 5 Official Inspection Form: Subsurface Sewage Disposal System • Page 4 of 15 Commonwealth of Massachusetts - Title 5 Official Inspection Fo Subsurface Sewage Disposal System Form - Not for Voluntary 61 White Birch Lane Property Address Anne Marie Towne Owner Owner's Name information is required for North Andover MA 0184 every page. City/Town State Zip Co B. Certification (cont.) D) System Failure Criteria Applicable to All Systems (cont.): Yes No ❑ ® Any portion of a cesspool or privy is within a Zone 1 of a public well. ❑ ® Any portion of a cesspool or privy is within 50 feet of a private water supply well. ❑ ® Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality analysis. [This system passes if the well water analysis, performed at a DEP certified laboratory, for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis and chain of custody must be attached to this form.] ❑ ® The system is a cesspool serving a facility with a design flow of 2000gpd- 10,000gpd. ❑ ® The system fails. I have determined that one or more of the above failure criteria exist as described in 310 CMR 15.303, therefore the system fails. The system owner should contact the Board of Health to determine what will be necessary to correct the failure. E) Large Systems: To be considered a large system the system must serve a facility with a design flow of 10,000 gpd to 15,000 gpd. For large systems, you must indicate either "yes" or "no" to each of the following, in addition to the questions in Section D. Yes No rm ❑ Assessments ❑ ❑ 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 5 11/15/2008 de Date of Inspection Yes No ❑ ® Any portion of a cesspool or privy is within a Zone 1 of a public well. ❑ ® Any portion of a cesspool or privy is within 50 feet of a private water supply well. ❑ ® Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality analysis. [This system passes if the well water analysis, performed at a DEP certified laboratory, for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis and chain of custody must be attached to this form.] ❑ ® The system is a cesspool serving a facility with a design flow of 2000gpd- 10,000gpd. ❑ ® The system fails. I have determined that one or more of the above failure criteria exist as described in 310 CMR 15.303, therefore the system fails. The system owner should contact the Board of Health to determine what will be necessary to correct the failure. E) Large Systems: To be considered a large system the system must serve a facility with a design flow of 10,000 gpd to 15,000 gpd. For large systems, you must indicate either "yes" or "no" to each of the following, in addition to the questions in Section D. Yes No ❑ ❑ the system is within 400 feet of a surface drinking water supply ❑ ❑ the system is within 200 feet of a tributary to a surface drinking water supply ❑ ❑ the system is located in a nitrogen sensitive area (Interim Wellhead Protection Area — IWPA) or a mapped Zone II of a public water supply well If you have answered "yes" to any question in Section E the system is considered a significant threat, or answered "yes" in Section D above the large system has failed. The owner or operator of any large system considered a significant threat under Section E or failed under Section D shall upgrade the system in accordance with 310 CMR 15.304. The system owner should contact the appropriate regional office of the Department. Towne - DEP INSPECTION FORM.doc • 08/06 Title 5 Official Inspection Form: Subsurface Sewage Disposal System • Page 5 of 15 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments �M 61 White Birch Lane Property Address j Anne Marie Towne Owner information is required for every page. Owner's Name North Andover City/Town C. Checklist RAA AA 0 AL 11/15/2008 Date of Inspection Check if the following have been done. You must indicate "yes" or "no" as to each of the following: Yes No ❑ ® Pumping information was provided by the owner, occupant, or Board of Health ❑ ® Were any of the system components pumped out in the previous two weeks? ❑ ® Has the system received normal flows in the previous two week period? ❑ ® Have large volumes of water been introduced to the system recently or as part of this inspection? ® ❑ Were as built plans of the system obtained and examined? (If they were not available note as N/A) ® ❑ Was the facility or dwelling inspected for signs of sewage back up? ® ❑ Was the site inspected for signs of break out? ® ❑ Were all system components, excluding the SAS, located on site? ® ❑ Were the septic tank manholes uncovered, opened, and the interior of the tank inspected for the condition of the baffles or tees, material of construction, dimensions, depth of liquid, depth of sludge and depth of scum? ® ❑ Was the facility owner (and occupants if different from owner) provided with information on the proper maintenance of subsurface sewage disposal systems? The size and location of the Soil Absorption System (SAS) on the site has been determined based on: ® ❑ Existing information. For example, a plan at the Board of Health. ® ❑ Determined in the field (if any of the failure criteria related to Part C is at issue approximation of distance is unacceptable) [310 CMR 15.302(5)] Towne - DEP INSPECTION FORM.doc • 08106 Title 5 Official Inspection Form: Subsurface Sewage Disposal System • Page 6 of 15 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 01 61 White Birch Lane Property Address Anne Marie Towne Owner Owner's Name information is required for North Andover MA 01845 11/15/2008 every page. City/Town State Zip Code Date of Inspection D. System Information Residential Flow Conditions: Number of bedrooms (design): 4 Number of bedrooms (actual): 4 DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x # of bedrooms): 440 Number of current residents: 0 Does residence have a garbage grinder? ❑ Yes ® No Is laundry on a separate sewage system? [if yes separate inspection required] ❑ Yes ® No Laundry system inspected? ❑ Yes ❑ No Seasonal use? ❑ Yes ® No Water meter readings, if available last 2 ears usage d 9 ( Y 9 (gpd)): 288,306 394.0 gpd gal or Sump pump? ❑ Yes ® No Last date of occupancy: 10/15/08Date Commercial/Industrial Flow Conditions: Type of Establishment: N/A Design flow (based on 310 CMR 15.203): N/AGallons per day (gpd) Basis of design flow (seats/persons/sq.ft., etc.): N/A Grease trap present? ❑ Yes ❑ No Industrial waste holding tank present? ❑ Yes ❑ No Non -sanitary waste discharged to the Title 5 system? ❑ Yes ❑ No Water meter readings, if available: N/A Last date of occupancy/use: N/A Date Other (describe): N/A Towne - DEP INSPECTION FORM.doc • 08106 Title 5 Official Inspection Form: Subsurface Sewage Disposal System - Page 7 of 15 Commonwealth of Massachusetts - Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 61 White Birch Lane Property Address Anne Marie Towne Owner Owner's Name information is required for North Andover MA 01845 every page. City/Town State Zip Code D. System Information (cont.) General Information Pumping Records: Source of information: Was system pumped as part of the inspection? If yes, volume pumped: How was quantity pumped determined? Reason for pumping: No i)umpinq records 1500 gallons gallons Tank measurents 11/15/2008 Date of Inspection ® Yes ❑ No To inspect inlet and outlet Tees/Baffles Type of System: ® Septic tank, distribution box, soil absorption system ❑ Single cesspool ❑ Overflow cesspool ❑ Privy ❑ Shared system (yes or no) (if yes, attach previous inspection records, if any) ❑ Innovative/Alternative technology. Attach a copy of the current operation and maintenance contract (to be obtained from system owner) ❑ Tight tank. Attach a copy of the DEP approval. ❑ Other (describe): Approximate age of all components, date installed (if known) and source of information: Svstem installed in 1994. Were sewage odors detected when arriving at the site? ❑ Yes ® No Towne - DEP INSPECTION FORM.doc • 08106 Title 5 Oficial Inspection Form: Subsurface Sewage Disposal System • Page 8 of 15 Commonwealth of Massachusetts . Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments M ,•y'' 61 White Birch Lane Property Address Anne Marie Towne Owner Owner's Name information is required for North Andover MA 01845 every page. City/Town State Zip Code 11/15/2008 Date of Inspection D. System Information (cont.) Building Sewer (locate on site plan): Depth below grade: 3.0 feetfeet Material of construction: ❑ cast iron ® 40 PVC ❑ other (explain): Distance from private water supply well or suction line: feet Comments (on condition of joints, venting, evidence of leakage, etc.): Septic Tank (locate on site plan): Depth below grade: Material of construction: ® concrete ❑ metal 1.7 feet ❑ fiberglass ❑ polyethylene ❑ other (explain) If tank is metal, list age: years Is age confirmed by a Certificate of Compliance? (attach a copy of certificate) ❑ Yes ❑ No -------------------------------------------------------------------------------------------------------------------------- Dimensions: Sludge depth: Distance from top of sludge to bottom of outlet tee or baffle 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 How were dimensions determined? 8.0'X 5.16'X 6.0' 12 inches thick 18 inches 9 inches 3 inches 14 inches Tape measured Towne - DEP INSPECTION FORM.doc • 08/06 Title 5 Official Inspection Form: Subsurface Sewage Disposal System • Page 9 of 15 Commonwealth of Massachusetts - Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments GM ,•'' 61 White Birch Lane Property Address Anne Marie Towne Owner Owner's Name information is required for North Andover MA 01845 every page. City/Town State Zip Code 11/15/2008 Date of Inspection D. System Information (cont.) Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): During the pumping of the tank, no evidence was found that any infiltration is occurring. The inlet and outlet tees/baffles were inspected and found to be in good condition. The structural integrity of the tank and tees/baffles were qood. Grease Trap (locate on site plan): Depth below grade: N/A feet Material of construction: ❑ concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other (explain): N/A Dimensions: N/A Scum thickness N/A Distance from top of scum to top of outlet tee or baffle N/A Distance from bottom of scum to bottom of outlet tee or baffle N/A Date of last pumping: N/A Date Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): N/A Tight or Holding Tank (tank must be pumped at time of inspection) (locate on site plan): Depth below grade: N/A Material of construction: ❑ concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other (explain): N/A Towne - DEP INSPECTION FORM.doc • 08/06 Title 5 Official Inspection Form: Subsurface Sewage Disposal System - Page 10 of 15 Commonwealth of Massachusetts W � Title 5 Official Inspection F rm 0 Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 61 White Birch Lane Property Address Anne Marie Towne Owner Owner's Name information is required for North Andover MA 01845 every page. City/Town State Zip Code D. System Information (cont.) Tight or Holding Tank (cont.) Dimensions: Capacity: Design Flow: Alarm present: Alarm level: N/A Date of last um in N/A 11/15/2008 Date of Inspection N/A gallons N/A gallons per day ❑ Yes ❑ No Alarm in working order: ❑ Yes ❑ No N/A F p gJ Date Comments (condition of alarm and float switches, etc.): N/A * Attach copy of current pumping contract (required). Is copy attached? ❑ Yes ❑ No Distribution Box (if present must be opened) (locate on site plan): Depth of liquid level above outlet invert 0 Comments (note if box is level and distribution to outlets equal, any evidence of solids carryover, any evidence of leakage into or out of box, etc.): The distribution box was level and distribution to outlets was equal. There was no evidence of leakage into or out of D -Box. Pipes in and out of D -Box were in good condition. Water was introduced to septic tank and flow to each pipe was even. Some carry-over and D -box was pumped. Pump Chamber (locate on site plan): Pumps in working order: Alarms in working order: ❑ Yes ❑ No ❑ Yes ❑ No Towne - DEP INSPECTION FORM.doc - 08/06 Title 5 Official Inspection Form: Subsurface Sewage Disposal System • Page 11 of 15 Commonwealth of Massachusetts 4 y Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments �M 61 White Birch Lane Property Address Anne Marie Towne Owner Owner's Name information is required for North Andover MA 01845 11/15/2008 every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Comments (note condition of pump chamber, condition of pumps and appurtenances, etc.): N/A Soil Absorption System (SAS) (locate on site plan, excavation not required): If SAS not located, explain why: Type: ❑ leaching pits number: ❑ leaching chambers number: ❑ leaching galleries number: ❑ leaching trenches number, length: ® leaching fields 1,20'X50' 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 condition was good. No odors detected and no signs of hydraulic failure. The vegetation condition was normal. Towne - DEP INSPECTION FORM.doc • 08/06 Title 5 Official Inspection Form: Subsurface Sewage Disposal System • Page 12 of 15 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 61 White Birch Lane Property Address Anne Marie Towne Owner information is required for every page. Owner's Name North Andover City/Town State Zip Code 11/15/2008 Date of Inspection D. System Information (cont.) Cesspools (cesspool must be pumped as part of inspection) (locate on site plan): Number and configuration N/A Depth — top of liquid to inlet invert N/A Depth of solids layer N/A Depth of scum layer N/A Dimensions of cesspool N/A Materials of construction N/A Indication of groundwater inflow ❑ Yes ❑ No Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): N/A Privy (locate on site plan): Materials of construction: N/A Dimensions N/A Depth of solids N/A Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): N/A Towne - DEP INSPECTION FORM.doc • 08/06 Titie 5 Official Inspection Form: Subsurface Sewage Disposal System • Page 13 of 15 I - Commonwealth of Massachusetts w W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 61 White Birch Lane Property Address Anne Marie Towne Owner information is required for every page. Owner's Name North Andover City/Town D. System Information (cont.) MA 01845 State Zip Code 11/15/2008 Date of Inspection Sketch Of Sewage Disposal System: Provide a sketch of the sewage disposal system including ties to at least two permanent reference landmarks or benchmarks. Locate all wells within 100 feet. Locate where public water supply enters the building. Towne - DEP INSPECTION FORM.doc • 08/06 47.4' E MW Title 5 Official Inspection Form: Subsurface Sewage Disposal System - Page 14 of 15 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments °M 61 White Birch Lane Property Address Anne Marie Towne Owner information is required for every page. Owner's Name North Andover MA 01845 City/Town State Zip Code D. System Information (cont.) Site Exam: ® Check Slope ® Surface water ® Check cellar ❑ Shallow wells Estimated de th to round water• 11/15/2008 Date of Inspection 4 feet below bottom of SAS V g feet Please indicate all methods used to determine the high ground water elevation: // FOR ■❑ Obtained from system design plans on record If checked date of desi n Ian reviewed 1994 ' g p Date Observed site (abutting property/observation hole within 150 feet of SAS) Checked with local Board of Health - explain: ❑ Checked with local excavators, installers - (attach documentation) ❑ Accessed USGS database - explain: You must describe how you established the high ground water elevation: The high ground water elevation was determined to be 4 feet below soil absorption system. This information was obtained from the Plan of Subsurface Disposal System. Towne - DEP INSPECTION FORM.doc • 08/06 Title 5 Official Inspection Form: Subsurface Sewage Disposal System • Page 15 of 15 1'of 11. COMMONWEALTH OF MASSACHUSETTS ' EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS DEPARTMENT OF ENVIRONMENTAL PROTECTION TITLE 5 OFFICIAL INSPECTION FORM- NOT FOR VOLUNTARY ASSESSMENT SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM PART A CERTIFICATION R E C E I CERTIFICATION STATEMENT I certify that I have personally inspected the sewage disposal system at this address and that the information reported below is true, accurate and complete as of the time of the inspection. The inspection was performed based on my training and experience in the proper function and maintenance of the on site sewage disposal systems. I am a DEP approved system inspector pursuant to Section 15340 of Title 5 (310 CMR 15.000). The system: Inspector's Signature: Passes Conditionally Passes Needs Further Evaluation by the Local Approving Authority Fails % o,h The system inspection 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. C � 4 2006 Property Address: 61 Whitebirch Lane, North Andover, MA 01845 LHWE Owner's Name: Anne Marie Towne , �vU�{i'H ANDO�EF2 N DEPARTMENT Owner's Address: 61 Whitebirch Lane, North Andover, MA 01845 Date of Inspection: November 6, 2006 Name of Inspector: (please print) Benjamin C. Osgood, Jr. Certified Title 5 Inspector Company Name: New England Engineering Services Inc. Mailing Address: 1600 Osgood Street Building 20 Suite 2-64, North Andover, MA 01845 Telephone Number: 978-686-1768 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 the on site sewage disposal systems. I am a DEP approved system inspector pursuant to Section 15340 of Title 5 (310 CMR 15.000). The system: Inspector's Signature: Passes Conditionally Passes Needs Further Evaluation by the Local Approving Authority Fails % o,h The system inspection 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. 2of11 OFFICIAL INSPECTION FORM — NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: 61 Whitebirch Lane, North Andover, MA 01845 Owner's Name: Anne Marie Towne Date of Inspection: November 6, 2006 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: &02— One or more system components as described in the "Conditional Pass" section need to be replaced or repaired. The system, upon completion of the replacement or repair, as approved by the Board of Health, will pass. Answer yes, no or not determined (Y,N,ND) in the for the following statements. If "not determined" please explain. The septic tank is metal and over 20 years old* or the septic tank (whether metal or not) is structurally unsound, exhibits substantial infiltration or exfiltration or tank failure is imminent. System will pass inspection if the existing tank is replaced with a complying septic tank as approved by the Board of Health. *A metal septic tank will pass inspection if it is structurally sound, not leaking and if a Certificate of Compliance indicating that the tank is less than 20 years old is available. ND explain: Observation of sewage backup or break out or high static water level in the distribution box due to broken or obstructed pipe(s) or due to a broken, settled or uneven distribution box. System will pass inspection if (with approval of Board of Health): Broken pipe(s) are replaced Obstruction is removed Distribution box is leveled or replaced ND explain: The system required pumping more than 4 times a year due to broken or obstructed pipe(s). The system will pass inspection if (with approval of the Board of Health): Broken pipe(s) are replaced Obstruction is removed ND explain_ 3of11 OFFICIAL INSPECTION FORM — NOT FOR VOLUNTARY ASSESSMENT SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: 61 Whitebirch Lane, North Andover, MA 01845 Owner's Name: Anne Marie Towne Date of Inspection: November 6, 2006 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 (SAS) Soil Absorption System and the (SAS) and the SAS is within 100 feet of a surface water supply or tributary to a surface water supply. The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water supply. The system has a septic tank and 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 organize 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 5ppm, provided that no other failure criteria are triggered. A copy of the analysis must be attached to this form. 3. Other: 4of11 OFFICIAL INSPECTION FORM — NOT FOR VOLUNTARY ASSESSMENT SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: 61 Whitebirch Lane, North Andover, MA 01845 Owner's Name: Anne Marie Towne Date of Inspection: November 6, 2006 D. System Criteria applicable to all systems: You must indicate "yes or No" to each of the following for all inspections: Yes No Q✓ Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool ✓ Discharge or ponding of effluent to the surface of the ground or surface waters due to an overload or clogged SAS or cesspool. a/ Static liquid level in the distribution box above outlet invert due to an overload or clogged SAS or cesspool ✓ Liquid depth in cesspool is less than 6" below invert or available volume is less than'/2 day flow Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number of times pumped Any Portion of the SAS, cesspool or privy is below high ground water elevation. ^� Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply Any portion of a cesspool or privy is within a Zone 1 of a public well. ? Any portion of a cesspool or privy is within 50 feet of a private water supply well. Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality analysis. ( this system passes if the well water analysis, performed at a DEP certified laboratory for coliform bacteria and volatile organic compounds indicates that the well is free from pollution from that facility and the presence of ammonia nitrogen and nitrogen is equal to or less than 5ppm, provided that no other failure criteria are triggered. A copy of the analysis must be attached to this form.) 1(Yes/No) The system fails. I have determined that one or more of the above failure criteria exist as described in 310 CMR 15.303, therefore the system fails. The system owner should contact the Board of Health to determine what will be necessary to correct the failure. E. 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 4ndicate either "yes" or "no" to each of the following: (The follows criteria apply to large systems in addition to the criteria above) Yes No The system is wiihin 400 feet of a surface drinkin ater supply The system is within 200 feet o€a tribut to a surface drinking water supply The system is located in;;�� sensiti rea (Interim Wellhead Protection Area — IWPA) or a mapped Zone II of a public water supply If you answered "yes" to any que titin in Section E the system is considered significant threat, or answered "yes" in Section D above the large system has failed. We 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. 1 , 5of1'1 OFFICIAL INSPECTION FORM — NOT FOR VOLUNTARY ASSESSMENT SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST Property Address: 61 Whitebirch Lane, North Andover, MA 01845 Owner's Name: Anne Marie Towne Date of Inspection: November 6, 2006 Check if the following have been done. You must indicate "yes" or "no" as to each of the following: Yes No ✓ Pumping information was provided by the owner, occupant, or Board of Health Qjr Were any of the system components pumped out in the previous two weeks-? Has the system received normal flows in the previous two week period ? a/ Have large volumes of water been introduced to the system recently or as part of an inspection ? V, Were as built plans of the system obtained and examined? (If they were not available note as N/A) •/- Was the facility or dwelling inspected for signs of sewage back up ? Was the site inspected for sign of break out? Were all system components, excluding the SAS, located on site? Were all the septic tank manholes uncovered, opened, and the interior of the tank inspected for the condition of the baffles or tees, material of construction, dimensions, depth of liquid, depth of sludge and depth of scum? Was the facility owner ( and occupants if difference from owner) provided with information on the proper maintenance of the subsurface sewage disposal systems? The size and location of the Soil Absorption System (SAS) on the site has been determined based on: Yes No V1_Existing information. For example, a plan at the Board of Health. Determined in the field (if any of the failure criteria related to Part C is at issue approximation of distance is unacceptable) [3 10 CMR 15.302(3)(b)] .6 of 11 OFFICIAL INSPECTION FORM — NOT FOR VOLUNTARY ASSESSMENT SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION Property Address: 61 Whitebirch Lane, North Andover, MA 01845 Owner's Name: Anne Marie Towne Date of Inspection: November 6, 2006 FLOW CONDITIONS RESIDENTIAL Number of bedrooms (design) � Number of bedrooms (actual): DESIGN flow based in 310 CMR 15.203 ( for example: 110 gpd x # of bedrooms) C 6- 0 C Y r> Number of current residents:/ Does residence have a garbage grinder (yes or no): Is laundry on a separate sewage system (yes or no):&I Q [if yes separate inspection required] Laundry system inspected ( yes or no): Seasonal use: (yes or no): N ,% Water meter readings, if available (last 2 years usage (gpd): 0,.) Sump Pump (yes or no): ll, FRS C�^ , Grip t 'v4 C'` Last date of occupancy 6',,.� ; �eyCC' c�. a r� 2 t?�S 70 GJc'2 r0 6�,_p A� lD i �' 2S COMMERCIAL/INDUSTRIAL Type of establishment: Design flow (based on 310 CMR 15.203): gpd Basis of design flow (seats/persons/sqft, 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: r, t2— Was Was system pumped as part of the inspection (yes or no): If yes, volume pumped: gallons — How was quantity pumped determined? Reason for pumping: TYPE OF SYSTEM Septic tank, distribution box, soil absorption system Single cesspool Overflow cesspool Privy Shared system (yes or no) (if yes, attach previous inspection records, if any) Innovative/Alternative technology. Attach a copy of the current operation and maintenance contract (to be obtained from system owner) Tight tank Attached a copy of the DEP approval Other (describe): Approximate age of all components, date installed (if known) and source of information: Were sewage odors detected wen arriving at the site (yes or no): ffO 7of11 OFFICIAL INSPECTION FORM — NOT FOR VOLUNTARY ASSESSMENT SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: 61 Whitebirch Lane, North Andover, MA 01845 Owner's Name: Anne Marie Towne Date of Inspection: November 6, 2006 BUILDING SEWER (locate on site plan) Depth below grade: ?0 Materials of construction: cast iron .G 40 PVC_other (explain) Distance from private water supply well or suction line: Comments (on condition of joints, venting, evidence of leakage, etc.): E.7' rC---- LJo 1C.-> Cv,-> t:) tAL i-#4sr- +�t� -7- SEPTIC -r SEPTIC TANK: (locate on site plan) Depth below grade: 24 Material of construction: 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: 1.<-0 PJ S Sludge depth: <c Distance from top of sludge to bottom of outlet tee or baffle: 351" Scum thickness:2 ei— Distance from top of scum to top of outlet tee or baffle:5 ,r Distance from bottom of scum to bottom of outlet tee or baffle /Z" How were dimensions determined: 4<--o9 .= izc �-nc ►t.. . Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): i tlt: i�. ttir Cs C � .� CUti D , 0 0,-- 5=C/t tiC3 puc GREASE TRAP:311,(locate on site plan) Depth below grade Materials 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 sludge 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. 8of11 OFFICIAL INSPECTION FORM — NOT FOR VOLUNTARY ASSESSMENT SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: 61 Whitebirch Lane, North Andover, MA 01845 Owner's Name: Anne Marie Towne Date of Inspection: November 6, 2006 TIGHT OR HOLDING TANK: Alb+ (tank must be pumped at time of inspection)(locate on site plan) Depth below grade: Materials 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: (if present must be opened)(locate on site plan) Depth of liquid level above outlet invert: 0 Comments ( note if box is level and distribution to outlets equal, any evidnence of solids carryover, any evidence of leakage into or out of box, etc.): 1�,.;A i-./ 0-y-, G0L<DIT) 6 v. R.j2.t"Li G— 'moi i,y' %: i? -i d u (i„ - e, /= 6-1244 0L'4" _ t, P— C -Q, t'iL S -*i - 5 - PUMP PUMP CHAMBER: ,,v a4- (locate on sire plan) Pumps in working order (yes or no) Alarms in working order (yes or no) Comments (note condition of pump chamber, condition of pumps and appurtenances, etc.): ,9of11 OFFICIAL INSPECTION FORM — NOT FOR VOLUNTARY ASSESSMENT SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: 61 Whitebirch Lane, North Andover, MA 01845 Owner's Name: Anne Marie Towne Date of Inspection: November 6, 2006 SOIL ABSORPTION SYSTEM (SAS): (locate on site plan, excavation not required If SAS not located explain why TYPE leaching pits number leaching chambers, number leaching galleries number a leaching trenches, number in length z- — ip Z c Ai E" t tt t S leaching fields, 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) Oi -(Zf /4 C1 r— I -A C,- t HC -3 J� D 0 tAJ Alco /L dt c ZV c t, v,y e'rt CCom.' t i PC N 3Z> eN>ry> DH•+A ? Si?rG t?2 i'NJ �,,�.tFL �?C .-e ' 22-2D . CESSPOOLS: (cesspool must be pumped as part of inspection) (locate on site plan) Number and configuration: Depth — top of liquid to inlet invert: Depth of solids layer: Depth of scum layer: Dimensions of cesspool: Materials of Construction: Indication of groundwater inflow (yes or no): Comments(note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): PRIVY: �r (locate on site plan) Material of construction: Dimensions: Depth of solids: Comments (note condition of soil signs of hydraulic failure, level of ponding, condition of vegetation, etc. I . 10 of '11 OFFICIAL INSPECTION FORM — NOT FOR VOLUNTARY ASSESSMENT SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: 61 Whitebirch Lane, North Andover, MA 01845 Owner's Name: Anne Marie Towne Date of Inspection: November 6, 2006 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. ti T M DtST--Ar,3Cc5 i H -7,5- Z -' 7 ,SZ<< 3^ (- D ' 2 61- (.5 11 ofII OFFICIAL INSPECTION FORM — NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: 61 Whitebirch Lane, North Andover, MA 01845 Owner's Name: Anne Marie Towne Date of Inspection: November 6, 2006 SITE EXAM Slope Surface water Check cellar Shallow wells Estimated depth to ground water ��feet Please indicate (check) all methods used to determine the high ground water elevation: 4 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 excavator, installers — (attach documentation) Accessed USGS database -explain: You must describe how you established the high ground water elevation: � 4 bTL .M L.S. 4", 6(,.t�l S 6 D G f� F � � l L-Dw f4-ZC-- 4- & tiw D ,,L -u 0E (1 ri M_0. C'. kS cam- �1 SYST t rti f>Cs*,uc ^c D L' , A—$z),,c %-A-117" NORTN 0 y F . ,SSACHU`'E� V "t Form No. 3 Town of North Andover, Massachusetts BOARD OF HEALTH t j) 19 DISPOSAL WORKS CONSTRUCTION PERMIT Applicant ADDRESS NAME TELEPHONE t6 � Site Location��- Permission is hereby granted to Constructor Repair ( ) an Individual Soil Absorption Sewage Disposal System as shown on the Design Approval S.S. No. CHAIRMAN, BOARD OF HEALTH D.W.C. No. Co �_— Fee DATE IVD ✓• Sheet of BOARD OF HEALTH TOWN OF NORTH ANDOVER SUBSURFACE DISPO/SAL DESIGN REVIEW PERMIT # DATE RECEIVED/0 r APPLICANT /�i C�%G�iY/ ASSESSOR'S MAP ADDRESS ENGINEER PARCEL # LOT # _ STREET ADDRESS PLAN DATE (Jl . /� , /�I REVISION DATE CONDITIONS OF APPROVAL: APPROVED DISAPPROVED /1/057- -�� )9 XT /-9, pORTIf , P ♦i • e�. f 1P CHusE� Town of North Andover, Massachusetts BOARD OF HEALTH DESIGN APPROVAL FOR SOIL ABSORPTION SEWAGE DISPOSAL SYSTEM Form No. 2 Applicant Jlm eel r--ONI Test No. Site Location �D7" u5- Reference Plans and Specs. C/,/,e/j7aok6e�4/ ENGINEER DESIGN DATE Permission is granted for an individual soil absorption sewage disposal system to be installed in accordance with regulations of Board of Health. 411 - Fee -60 4: � fay CHAIRMAN, BOARD OF HEALTH Site System Permit No. c/,a 4' 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: Sc� "� C���-� �/7 C Phone LOCATION: Assessor's Map Number Subdivision ✓�r) dl Street /AL J1 IleZ. Parcel Lot (s) St. Number ************************Official Use Only*******************f**** =conservation F TOWN AGENTS: Date Approved nistrator Date Rejected Comments Town Planner Comments Food Inspector -Health Z'tA—I/Z Septic Inspector -Health Comments Public Works - sewerjwater connections - driveway permit Fire Department Date Approved Date Rejected Date Approved Date Rejected Date Approved_ Date Rejected Received by Building Inspector Date C7 O z Cf) m m D O z v ii rm O syOQ y = \► aoa" CO) O CD CD p 1 o yD a c Mia y •� Z " =-o O o .0M3cm CD y - � d CD aim o y mN ? CD'L CD i CD _ o o 'O O Q po C° CD C7 Z CO) O = "i C=L SO O O �a o < cDto H fl. y CD y M CCL OD CL co CDS -_- � CD y to S _ y y � _ O CD CD (00 O n CD O CD f C=D trip v CDCD rm CD CD CC CD � CD CACD -o CD z rn Z Q -IO �+ oo_d� O O �' �•• Nil '-'• C D 1.+ � y O CD bo ZC O cp C/' 0 G r It :3o=4 m UQ x o w C G �f � , r-' ?r AGi G 7? n 7o w G o G C o C z � M d .7 - � y Z O Q C" d z CD 3 d It 'A ri O C CD ►s FOUNDATION LOCATION PLAN CUENT: SCOTT CONSTRUCTION THIS CERTIFICATION IS MADE AND UMITED TO THE ABOVE CUNT. LOCATION: NORTH ANDOV£R,MA. SCALE:1 "=40' DATE:6/7/94 CHRISTIANSEN &SERGI PROUNfESSll�A, 160 SUMMER Sr. NAYERHILL.MA. 01630 TEL 308-373-0310 Q 1994 BY CHRISTIANSEN & SERGI /NC OT 4 I CERTIFY THAT THE PRIMARY STRUCTURE SHOWN CONFORMS TD THE HORIZONTAL SETBACK REOULREMENTS OF THE LOCAL APPLICABLE ZONING SY-LAWS IN EFFECT WHEN CONSTRUCTED. (THIS CERTIFICATION DOES NOT CONSIDER ANY OTHER RESTRICTIONS SUCH AS COVD"MMWETLANDS.EASEMENM ORDERS OF CONDMONSAETC.) THIS DRAWING SHALL NOT BE USED BY THE CLIENT FOR ANY PURPOSE OTHER THAN THAT OUTLINED ABOYE.EXCEPT WITH THE wmn7EN PERW/SSION OF CHRISmUSEN t SERA ANG FURTHERMORE THIS DRAWING IS THE COPYRIGHTED PROPERTY OF CHNSILWSEN 3 SERC/ INC. AND ANY LAMUTHOR/Z£D USE IS PROHl8llEDLCHR/STIANSEN & SERGI TAKES NO RESPONSIBILITY MR THE UNAUTHORIZED LOSE OF THIS DRAWING OR ANY INFOR- MATION CONTAINED HEREOF BASED ON SCALED DATA ONLY THE PRIMARY STRUCTURE SHOWN IS NOT LOCATED IN A FLOOD HAZARD ZONE AS SHOWN ON FEMA FLOW INSURANCE RATE MAR ?Om DA7r.612103 DWG.NO.:93067016