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Home My WebLink AboutMiscellaneous - 650 FOREST STREET 4/30/2018 (3) �� c o, a _� � Massachusetts Department of Environmental Protection Bureau of Resource Protection - Wetlands DEP File Number. WPA Form 8B — Certificate of Compliance 242-1130 Massachusetts Wetlands Protection Act M.G.L. c. 131, §40 Provided by DEP A. Project Information Important: When filling out 1. This Certificate oomP f Compliance is issued to: forms on the Robert& Patricia Gohn computer, use Name only the tab key to move 650 Forest Street your cursor- Mailing Address do not use the North Andover MA. 01845 return key. City/Town State Zip Code Q2. This Certificate of Compliance is issued for work regulated by a final Order of Conditions issued to: James Wilhelm Name 4/16/02 242-1130 Dated DEP File Number 3. The project site is located at: 650 Forest StreetNorth Andover Street Address Cityrrown Map 105D Parcel 24 Assessors Map/Plat Number Parcel/Lot Number the final Order of Condition was recorded at the Registry of Deeds for: Robert& Patricia Gohn Property Owner(if different) Essex North 6797 290 County Book Page N/A Certificate 4. A site inspection was made in the presence of the applicant, or the applicant's agent, on: 5/10/04 Date B. Certification Check all that apply: ® Complete Certification: It is hereby certified that the work regulated by the above-referenced Order of Conditions has been satisfactorily completed. ❑ Partial Certification: It is hereby certified that only the following portions of work regulated by the above-referenced Order of Conditions have been satisfactorily completed.The project areas or work subject to this partial certification that have been completed and are released from this Order are: wpaform 8b.doc•rev.12/15/00 Page 1 of 3 Massachusetts Department of Environmental Protection Bureau of Resource Protection Wetlands DEP File Number. WPA Form 8B — Certificate of Compliance L11 Massachusetts Wetlands Protection Act M.G.L. c. 131, §40 242-1130 Provided by DEP B. Certification. (cont.) ❑ Invalid Order of Conditions: It is hereby certified that the work regulated by the above- referenced Order of Conditions never commenced. The Order of Conditions has lapsed and is therefore no longer valid. No future work subject to regulation under the Wetlands Protection Act may commence without filing a new Notice of Intent and receiving a new Order of Conditions. ® Ongoing Conditions: The following conditions of the Order shall continue: (Include any conditions contained in the Final Order, such as maintenance or monitoring, that should continue for a longer period). Condition Numbers: 62 C. Authorization Issued by: Y North Andover Conservation Commission Date 6f Iss ance This Certificate must be signed by a majority of the Conservation Commission a cop sent to the applicant and appropriate DEP Regional Office (See Appendix A). Signatures: �44 On Of flay a00 Y Day Month an Year before me personally appeared a-sstSCO'4 . Ha-5,5,?- to o me known to be the person described in and who executed the foregoing instrument and acknowledged that he/she executed the same as his/her free act and deed. 11111,wl, �' N ry Pubic My com DONNA M.WEDGE WTAWPUBW c�TM OF MAS OMSEM *Camm Ib*=AQ.7,2U wpaform 8b.doc-rev.12/15/00 age 2 of 3 Massachusetts Department of Environmental Protection Bureau of Resource Protection Wetlands DEP File Number: WPA Form 8B — Certificate of Compliance Massachusetts Wetlands Protection Act M.G.L. c. 131, 40 242-1130 Provided by DEP D. Recording Confirmation The applicant is responsible for ensuring that this Certificate of Compliance is recorded in the Registry of Deeds or the Land Court for the district in which the land is located. Detach on dotted line and submit to the Conservation Commission. --------------------------------------------------------------------------------------------------------------------------- To: North Andover Conservation Commission Please be advised that the Certificate of Compliance for the project at: 242-1130 Project Location DEP File Number Has been recorded at the Registry of Deeds of: County for: Property Owner and has been noted in the chain of title of the affected property on: Date Book Page If recorded land, the instrument number which identifies this transaction is: If registered land, the document number which identifies this transaction Document Number Signature of Applicant wpaform 8b.doe•rev.12/15/00 Page 3 of 3 y <' LlMassachusetts Department of Environmental Protection Bureau of Resource Protection - Wetlands WPA Appendix A - DEP Regional Addresses Massachusetts Wetlands Protection Act M.G.L. c. 131, §40 Mail transmittal forms and DEP payments,payable to Commonwealth of Massachusetts Department of Environmental Protection Box 4062 Boston, MA 02211 DEP Western Region Adams Colrain Hampden Monroe Pittsfield Tyringham 436 Dwight Street Agawam Conway Hancock Montague Plainfield Wales Alford Cummington Haffield Monterey Richmond Ware Suite 402 Amherst Dalton Hawley Montgomery Rowe Warwick Springfield, MA 01103 Ashfield Deerfield Heath Monson Russell Washington Phone:413-784-1100 Becket Easthampton Hinsdale Mount Washington Sandisfield Wendell Belchertown East Longmeadow Holland New Ashford Savoy Westfield Fax:413-784-1149 Bemardston Egremont Holyoke New Marlborough Sheffield Westhampton Blandford Erving Huntington New Salem Shelburne West Springfield Brimfield Florida Lanesborough North Adams Shutesbury West Stockbridge Buckland Gill Lee Northampton Southampton Whately Charlemont Goshen Lenox Northfield South Hadley Wilbraham Cheshire Granby Leverett Orange Southwick Williamsburg Chester Granville Leyden Otis Springfield Williamstown Chesterfield Great Barrington Longmeadow Palmer Stockbridge Windsor Chicopee Greenfield Ludlow Pelham Sunderland Worthington Clarksburg Hadley Middlefield Peru Tolland ti DEP Central Region Acton Charlton Hopkinton Millbury Rutland Uxbridge 627 Main Street Ashburnham Clinton Hubbardston Millville Shirley Warren Ashby Douglas .Hudson New Braintree Shrewsbury Webster Worcester,MA 01605 Athol Dudley Holliston Northborough Southborough Westborough Phone:508-792-7650 Auburn Dunstable Lancater Northbridge Southbridge West Boylston Fax:508-792-7621 Ayer East Brookfield . Leicester North Brookfield Spencer West Brookfield Barre FitchbGrg Leominster Oakham Sterling Westford TDD:508-767-2788 Bellingham Gardner Littleton Oxford Stow Westminster Berlin Grafton Lunenburg Paxton Sturbridge Winchendon Blackstone Groton Marlborough Pepperell Sutton Worcester Bolton Harvard Maynard Petersham Templeton Boxborough Hardwick Medway Phillipston Townsend Boylston Holden Mendon Princeton Tyngsborough Brookfield c Hopedale Milford Royalston Upton DEP Southeast Region Abington Dartmouth Freetown Mattapoisett Provincetown Tisbury 20 Riverside Drive Acushnet Dennis Gay Head Middleborough Raynham Truro Attleboro Dighton Gosnold Nantucket Rehoboth Wareham Lakeville,MA 02347 Avon Duxbury Halifax NewBedford Rochester Wellfleet Phone:508-946-2700 Barnstable Eastham Hanover North Attleborough Rockland West Bridgewater Fax:508-947-6557 Berkley East Bridgewater Hanson Norton Sandwich Westport Boume Easton Harwich Norwell Scituate West Tisbury TDD:508-946-2795 Brewster Edgartown Kingston Oak Bluffs Seekonk Whitman Bridgewater _ Fairhaven Lakeville Orleans Sharon Wrentham Brockton Fall River Mansfield Pembroke Somerset Yarmouth Carver Falmouth Marion Plainville Stoughton Chatham Foxborough Marshfield Plymouth Swansea Chilmark Franklin Mashpee Plymplon Taunton DEP Northeast Region Amesbury Chelmsford Hingham Merrimac Quincy Wakefield 205 Lowell Street Andover Chelsea Holbrook Methuen Randolph Walpole Arlington Cohasset Hull Middleton Reading Waltham Wilmington, MA 01887 Ashland Concord Ipswich Millis Revere Watertown Phone:978-661-7600 Bedford Danvers Lawrence Milton Rockport Wayland Fax: 978-661-7615 Belmont Dedham Lexington Nahant Rowley Wellesley Beverly Dover Lincoln Natick Salem Wenham TDD:978-661-7679 Billerica Dracut Lowell Needham Salisbury West Newbury Boston Essex Lynn Newbury Saugus Weston Boxford Everett Lynnfield Newburyport Sherborn Westwood Braintree Framingham Malden Newton Somerville Weymouth Brookline Georgetown Manchester-By-The-Sea Norfolk Stoneham Wilmington Burlington Gloucester Marblehead North Andover Sudbury Winchester Cambridge Groveland Medfield North Reading Swampscott Winthrop Canton Hamilton Medford Norwood Tewksbury Woburn Carlisle Haverhill Melrose Peabody Topsfield wpaform8b.doc•Appendix A•rev.5/12/04 Page 1 of 1 r' RECEIVED -C-N Commonwealth of Massachusetts Sip 2010 City/Town of System Pumping Record NORTH ANDOVwNOFNORTHANDOVER EALTti DEPARTMENT 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. A. Facility Information Important: When filling out 1. System Location: forms on there 7z- computer, �r use -- - --- - ---- ----- — --... -------only the tab key Address to move your ---- -- - �-- - ---- cursor-do not �` -- - - State Zip Code use the return City/Town key. 2. System Owner: Name ------ Address(if different from location) --- - — --- ------ — _—.- -State Zip Code Cityrrown 97,9 97-C- crus ---- Telephone Number B. Pumping Record 1. Date of Pumpingpate —� 2. Quantity Pumped: Gall,1- ons - -- 3. Type of system: ❑ Cesspool(s) eptic Tank ❑ Tight Tank El Grease Trap ❑ Other(describe): -- ---- 4. Effluent Tee Filter present? ❑ Yes ❑ No If yes, was it cleaned? ❑ Yes ❑ No 5. Condition of S stem: -- - --- ------.-- --------- - 6. System Pumped By: Name �� -- ---- ---- Vehi�le.LicenseNumber � ---------- Company 7. Location where contents were di§posed: Signature of Hauler �•rer �� IV3�. Date Signature of Receiving Facility Date t5form4.doc•03/06 System Pumping Record•Page 1 of 1 but the P has rovided this form, for use'by local Boards tit Health. Other'forms may beused. , �, check with your Vhw DEP p here.Before using this , information must be substantially this same as that:provided local Board of Health to determine the form h�+�g a kith n Systemhe d days from he Record pumping d Babe submitted'to the local Board of Health or other,approving In accordance with 310 CMR 15.351. A. Facility Information imporunt S tem Location: When ttig out �� fo(m5 an the - computer.use - ordy"lob key Address �,� D/8 to move Your _ .. - . . Zip Code cursor-do not ` d �GityRawn use'the return key, 2. System Owner.. Na V Code Cityrrowri ��7.2. --- rB hofte Number. B. [pumping Record L 6_7 -- 2, Quantity Pumped; 1'. Rate of Pumping Date 3. Type of system: ❑' Cesspool(s) piicTank ❑ Tight-Tank [ . Grease Trap ❑ Other(describe?: 4. Effluent Tee.'ritter present? ❑ Yes ❑ No if yes, was'it Gleaned? ❑ Yes. Q., No 5: Condition of System:: 6. System Pumped.By: VeF�tcte License.Numner Company 7. Location where contents were disposed: Sic�aluYeof Hauler.-- Qate Siynaiure,af Receiving FaEditY Date 5yslent Pumpirq.Reeord-Page t of 1 1516mWdoe-03105 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.proWfled here.Before n s ng this df form, cbeck submitted o local Board of Health to determine the form they use.The System pumping in date to The total Board of Health or other approving authority Within 14 days from the pumping accordance with 310 CMR 15.351. A.Fa inity information Impomunt g em Location When Ukq oat y forms an the �S Q 9rdl Zompuler,use Addressonly the tab key �,►— Io move yaw /�/� .. - - .. .,... 5 Zip Code cursor-do rrot CltyRown use the return key. 2. System Owner: Na address{iitliRere„tfromleealiony -- -- --_. - -- _ _- —._._---- - St81e — zip code City`rrown Telephone Number B.Pumping Record 2. Quantity Pumped: GO- 1. Date of Pumping bate 3. Type of system: ❑'cesspool(s) ticlank ❑ Tight Tank ❑ Grease Trap ❑ Other(describe): 4. Effluent Tee Filter present? ❑ Yes ❑ No it.yes,was it cleaned? ❑Yes [3,No 5. condition of System: _. .._ t. c /. .... 6. System Pumped By. _- ItiiGeLtcenaeNumber ase � company 7. Location Where contents were disposed: -•--.._.. .._...-._—._--.'101faQl�r` Signature of Receiving Fucikty — system Pumping Record•Page I of 1 ISfon rA.doe•03=