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HomeMy WebLinkAboutMiscellaneous - 73 CARLTON LANE 4/30/2018 (3)NORrM s o� ,�• a SSACMOs� TOWN OF NORTH ANDOVER PERMIT FOR PLUMBING This certifies that•`.......... • • • • • • • • • • • • • • has permission to perform ..... t -<.f•4, f/.f I.,. • .. • .. , ..... . plumbing in the buildings of .... (-f ...................... at ... 7.3. ( . I' ........... , North Andover, Mass. Fed. .. �.. Lic. No..�,1.j.'.�. Y: ....... ...w: !� ......... PLUMBINGG INSPECTOR Check #�� 7 8 50 9 MASSACHUSETTS UNIFORM APPLICATION FOR PERMIT TO DO PLUMBING k City/Town: /� ,�' //y�J "iI'I /�ilfl �' r , MA. Date: ;'—,3—/L,' Permit# Yd O Building Location: -? Cft.(r,� Owners Name: J7,qeSr Type of Occupancy: Commercial ❑ Educational ❑ Industrial ❑ Institutional ❑ ResidentialA New: [—]Alteration: ❑ Renovation: ❑ Replacement: Plans Submitted: Yes ❑ , No,j FIYTI 109:Q Installing Company Name: J O n Le 6k)V_ `Cj 6 Address: t'!• n\ acc, c k 4itv/Town: kn �,ei,57 State: IV, 14-, Business Tel:— 03) 200 " Q ?/ Fax: 02031 Name of Licensed Plumber: J—C) h c:necK Une only Gertlticate # ❑ Corporation ❑ Partnership ❑ Firm/Company INSURANCE COVERAGE: I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL. Ch. 142 Yes ❑ No Cl If you have checked Yes, please indicate the type of coverage by checking the appropriate box below. A liability insurance policy-- Other type of indemnity ❑ Bond ❑ OWNER'S INSURANCE WAIVER: I am aware that the licensee does not have the insurance coverage required by Chapter 142 of the Massachusetts General Laws, and that my signature on this permit application waives this requirement. Check One Only _Signature of Owner or Owner's Agent Owner ❑ Agent E] I hereby certify that all of the details and information I have submitted (or entered) regarding this application are true and accurate to the best of my Knowledge and that all'plumbing work and installations performed under the permit issued for this application will be in compliance with all Pertinent provision of the Massachusetts State Plumbing Code and Chapter 142 of the General Laws. By - Title City/Town APPROVED (OFFICE USE Type of License: ❑ Plumber >1Irhture o I sed Plumber-' Master ❑Journeyman Licen umber: l �� y� MMMMMMMMMMMMMMMMMMMMMMMMMMMM MMMMMMMMMMMMMMMMMMMMMMMMMMMM MMMMMMMMMMMMMMMMMMMMMMMMMMMM MMMMMMMMMMMMMMMMMMMMMMMMMMMM MMMMMMMMMMMMMMMMMMMMMMMMMM MMMMMMMMMMMMMMMMMMMMMMMMMMMM n�i�iiiiiiii�iiiiiiiiiiiiiiiii Installing Company Name: J O n Le 6k)V_ `Cj 6 Address: t'!• n\ acc, c k 4itv/Town: kn �,ei,57 State: IV, 14-, Business Tel:— 03) 200 " Q ?/ Fax: 02031 Name of Licensed Plumber: J—C) h c:necK Une only Gertlticate # ❑ Corporation ❑ Partnership ❑ Firm/Company INSURANCE COVERAGE: I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL. Ch. 142 Yes ❑ No Cl If you have checked Yes, please indicate the type of coverage by checking the appropriate box below. A liability insurance policy-- Other type of indemnity ❑ Bond ❑ OWNER'S INSURANCE WAIVER: I am aware that the licensee does not have the insurance coverage required by Chapter 142 of the Massachusetts General Laws, and that my signature on this permit application waives this requirement. Check One Only _Signature of Owner or Owner's Agent Owner ❑ Agent E] I hereby certify that all of the details and information I have submitted (or entered) regarding this application are true and accurate to the best of my Knowledge and that all'plumbing work and installations performed under the permit issued for this application will be in compliance with all Pertinent provision of the Massachusetts State Plumbing Code and Chapter 142 of the General Laws. 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WLP,IS.WT ArF0111I7EG s?Y TI IC )', WfJES C'CSC;N,Nf:G i RLST'E;:i TC; 9 I l Vi N! * LC!+: t't-RA![ 6,t A'' !fE 1550€iI" tlx'PEIPP I& sI;p W..CT TO AU f lit rKi?PgB, Fkt L.cSI•JfaS A.P 0 CONP4'1 K1NS Gf SUC'H P(5I,lC'?F,S. t•: fr.0-HATE UMIT$514WOJ fAY fWV'E.CW£M £.@LsU:'CU 5Y t',4t4 =:LAIF09. -., `T_- _._.r.._. .,_._....._ ._. .. ... _ .. .... ILTR haS - tIPP OF tP95UKgMC% Y4LiGY PTttf✓!CER Pb1IC'r'l"l'- `-. OATir j'dA79t1Ll+YY d:t1TE fl 4IR;�O'0411, LIMITS .... ^ _ _• . GENEUL LIAWPTY r--- AX' crMs=rJtt rr L -L+ Lr TriCE 5 i Ciflt3i)00 ClUfERALtiAPIlily IaQ05705 p5/16/Og i 05/16/10 ........FHEA9(Ieu,ej_ fa 50900 _. . VWX 2 ECT Ew (Any we pmc,*l 135000 _ . E t t`ERwob-Li ¢ e (sU wjurli I _ .._ a ; 100@fl0 3J Nf, L AG REGA i € I �i 2000000 q . ..� 1 tiv+Ii�PI I vcovoo � p :. 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NaRrM 3 f 6-1 Town of North Andover HEALTH DEPARTMENT cNu54 CHECK #:_ DATE: LOCATION: lowe-, H/O NAME: CONTRACTOR NAME: Tvve of Permit or License: (Check box) ❑ Animal $ ❑ Body Art Establishment $ ❑ Body Art Practitioner $ ❑ Dumpster $ ❑ Food Service - Type: $ ❑ Funeral Directors $ ❑ Massage Establishment $ ❑ Massage Practice $ ❑ Offal (Septic) Hauler $ ❑ Recreational Camp $ ❑ Sun tanning $ ❑ Swimming Pool $ ❑ Tobacco $ ❑ TrashlSolid Waste Hauler $ ❑ Well Construction $ SEPTIC Systems: ❑ Septic - Soil Testing $ ❑ Septic - Design Approval t $ ❑ Septic Disposal Works Construction (DWC) $ ❑ Septic Disposal Works Installers (DWI) $ ❑ Title 5 Inspector $ DIr�itle 5 Report $ `5 ' ❑ Other: (Indicate) $ Health Agent Initials'. White - Applicant Yellow - Health Pink - Treasurer 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 low Commonwealth of Massachusetts Title 5 Official Ins ect7ion Form p y�o`o8 Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 73 , r_ *1z L'ro N.) L- A m 6 - Property Address James & Patricia Thames Owner's Name No Andover MA 01845 2/22/08 Cityrrown 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: Benjamin C. Osgood, Jr Name of Inspector New England Engineering Services, Inc. Company Name 1600 Osaood Street Suite 2-64 Company Address No. Andover City/Town 978-686-1768 MA State Telephone Number License Number B. Certification 01845 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: E Passes ❑ Conditionally Passes ❑ Fails ❑ Needs Further Evaluation by the Local Approving Authority r spect s Signature Z -22-oS 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. TITLE 5 FORM 2007.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 73CAQA,T010 t--ANE- Property --ANCProperty Address James & Patricia Thames Owner's Name No Andover MA 01845 2/22/08 Cityrrown 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: ZY 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): ❑ broken pipe(s) are replaced ❑ obstruction is removed TITLE 5 FORM 2007.DOC • 08/06 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 73 L-A2LTC,N L,04 Property Address James & Patricia Thames Owner's Name No Andover MA 01845 City/Town State Zip Code B. Certification (cont.) B) System Conditionally Passes (cont.): ❑ distribution box is leveled or replaced ND Explain: 2/22/08 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. TITLE 5 FORM 2007.DOC • 08/06 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 73Ca?,L-TbIJ kANr Property Address James & Patricia Thames Owner's Name No Andover MA 01845 2/22/08 City/Town State Zip Code Date of Inspection B. Certification (cont.) C) Further Evaluation is Required by the Board of Health (cont.): ❑ 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 ❑ 53,,, Liquid depth in cesspool is less than 6" below invert or available volume is less than '/z day flow ❑ 0- Required pumping more than 4 times in the last year NOTdue 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. TITLE 5 FORM 2007.00C • 08/06 Title 5 Official Inspection Form: Subsurface Sewage Disposal System • Page 4 of 15 Commonwealth of Massachusetts w Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments Property Address James & Patricia Thames Owner Owner's Name information is required for No Andover MA 01845 every page. City/Town State Zip Code B. Certification (cont.) D) System Failure Criteria Applicable to All Systems (cont.): Yes No 2/22/08 Date of Inspection ❑ 2- 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.] ❑ 9. 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 ❑ Eg--- the system is within 400 feet of a surface drinking water supply ❑ P'- the system is within 200 feet of a tributary to a surface drinking water supply ❑ the system is located in a nitrogen sensitive area (Interim Wellhead Protection Area – IWPA) or a mapped Zone II of a public water supply well If you have answered "yes" to any question in Section E the system is considered a significant threat, or answered "yes" in Section D above the large system has failed. The owner or operator of any large system considered a significant threat under Section E or failed under Section D shall upgrade the system in accordance with 310 CMR 15.304. The system owner should contact the appropriate regional office of the Department. TITLE 5 FORM 2007.DOC - 08/06 Title 5 Official Inspection Form: Subsurface Sewage Disposal System • Page 5 of 15 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 73 G42 LTL'5 ti LrAtj M Property Address James & Patricia Thames Owner information is required for every page. Owner's Name No Andover MA 01845 City/Town State Zip Code C. Checklist 2/22/08 Date of Inspection Check if the following have been done. You must indicate "yes" or "no" as to each of the following: Yes No Was the site inspected for signs of break out? ❑ {_], - Pumping information was provided by the owner, occupant, or Board of Health El+lam ❑ 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? The size and location of the Soil Absorption System (SAS) on the site has been determined based on: E� ❑ Existing information. For example, a plan at the Board of Health. ❑ Q/ 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)] TITLE 5 FORM 2007.DOC • 08106 Title 5 Official Inspection Form: Subsurface Sewage Disposal System • Page 6 of 15 ❑ 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: E� ❑ Existing information. For example, a plan at the Board of Health. ❑ Q/ 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)] TITLE 5 FORM 2007.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 ° M 73 CAtZlUTc?!' LANs; Property Address James & Patricia Thames Owner information is required for every page. Owner's Name No Andover MA 01845 City/Town State Zip Code D. System Information 2/22/08 Date of Inspection Residential Flow Conditions: Number of bedrooms (design): Number of bedrooms (actual): 6 DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x # of bedrooms): Number of current residents: Does residence have a garbage grinder? Is laundry on a separate sewage system? [if yes separate inspection required] Laundry system inspected? Seasonaluse? Water meter readings, if available (last 2 years usage (gpd)): Sump pump? Last date of occupancy: Commercial/Industrial Flow Conditions: Type of Establishment: Design flow (based on 310 CMR 15.203): Basis of design flow (seats/persons/sq.ft., etc.): Grease trap present? Industrial waste holding tank present? Non -sanitary waste discharged to the Title 5 system? Water meter readings, if available: Last date of occupancyluse: Other (describe): ❑ Yes ❑ No ❑ Yes No ❑ Yes No ❑ Yes Y No 271 &-Pa 4 5?ei KL-tL s�ys�c,•1 ❑ Yes ® No ,'QcrcnT Date Gallons per day (gpd) ❑ Yes ❑ No ❑ Yes ❑ No ❑ Yes ❑ No Date TITLE 5 FORM 2007.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 '4M 73 GA'ZLMbN L.KWl Property Address James & Patricia Thames Owner information is required for every page. Owner's Name No Andover City/Town D. System Information (cont.) Pumping Records: State Zip Code General Information 2/22/08 Date of Inspection 1-3 Source of information: V �' IJ C1t� Was system pumped as part of the inspection?. ❑ Yes 0 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. Attach 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 when arriving at the site? ❑ Yes ❑ No TITLE 5 FORM 2007.DOC • 08/06 - Title 5 Official Inspection Form: Subsurface Sewage Disposal System • Page 8 of 15 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments ,M 73 'CWRLTorJ "N£ Property Address James & Patricia Thames Owner Owner's Name information is required for No Andover MA 01845 2/22/08 every page. CitylTown State Zip Code Date of Inspection D. System Information (cont.) Building Sewer (locate on site plan): �r Depth below grade: feet Material of construction: [R 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.): ?� L lr oo ICS b IL 1 N i3 fi's �Nt EN tt Septic Tank (locate on site plan): Depth below grade: 12 feet Material of construction: [K concrete ❑ metal ❑ 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? 1,_5 0 -� CSF u a ,., S M 1 As5-3 p P 90 C- K TITLE 5 FORM 2007.DOC • 08/06 Title 5 Oficial 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 M 73r_A4L_irotj L,AAjr Property Address James & Patricia Thames Owner Owner's Name information is required for No Andover MA 01845 2/22/08 every page. City/Town State Zip Code 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.): _f 04 K J AJ Goon cr�a �� o _ be tic �y L O'.T L' C-1- A206,1> ?i A2061> 4+s PA -14i- or rN s.>e c-11 kwj Grease Trap (locate on site plan): Depth below grade: feet Material of construction: ❑ concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other (explain): Dimensions: Scum thickness Distance from top of scum to top of outlet tee or baffle Distance from bottom of scum to bottom of outlet tee or baffle Date of last pumping: 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.): Tight or Holding Tank (tank must be pumped at time of inspection) (locate on site plan): Depth below grade: Material of construction: ❑ concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other. (explain): TITLE 5 FORM 2007.DOC - 08/06 Title 5 Official Inspection Form: Subsurface Sewage Disposal System • Page 10 of 15 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments ,M 73 CA R LTUO L-)Aou C Property Address James & Patricia Thames Owner Owner's Name information is required for No Andover MA 01845 2/22/08 every page. City[Town State Zip Code Date of Inspection D. System Information (cont.) Tight or Holding Tank (cont.) Dimensions: Capacity: gallons Design Flow: gallons per day Alarm present: ❑ Yes ❑ No Alarm level: Alarm in working order: ❑ Yes ❑ No Date of last pumping: Date Comments (condition of alarm and float switches, etc.): * 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 - Lme 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.): gJz r.aoe� c�..�•�iJn. Dl�i r-JOA6" FflJ.4L. ,�JJ c� n�Cc o� LchaKAG-C ln-j c 9- 1 C> 12- r 4 AIN o -1t--- 3 [S� fZ15e2 A08Eb 71D 3fLlN� CJvt2 r: $GGow �c f Ca�G� Pump Chamber (locate on site plan): Pumps in working order: Alarms in working order: ❑ Yes ❑ No ❑ Yes ❑ No TITLE 5 FORM 2007.DOC • 08/06 Title 5 Official Inspection Form: Subsurface Sewage Disposal System • Page 11 of 15 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments M 73 C_ARLTo" (,.ANC Property Address James & Patricia Thames Owner information is required for every page. Owner's .Name No Andover City/Town D. System Information (cont.) MA 01845 2/22/08 State Zip Code Date of Inspection Comments (note condition of pump chamber, condition of pumps and appurtenances, etc.): 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 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.): (to -Elf Oft- Lec- e k �j r LA �.., � �� E,7, i2 .� C -- R 1u cc-- -PCD "P (1.,e, � /.fir P 0,2 UN �A L U&A& N' TITLE 5 FORM 2007.DOC • 08/06 Title 5 Official Inspection Form: Subsurface Sewage Disposal System - Page 12 of 15 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments M 73 c,AeLTi�t-a LANE Property Address James & Patricia Thames Owner Owner's Name information is required for No Andover MA 01845 2/22/08 every page. Citylfown State Zip Code Date of Inspection D. System Information (cont.) 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 ❑ No Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): Privy (locate on site plan): Materials of construction: Dimensions Depth of solids Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): TITLE 5 FORM 2007.DOC - 08106 Title 5 Official Inspection Form: Subsurface Sewage Disposal System - Page 13 of 15 Commonwealth of Massachusetts u Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments �M 73 COOZ L -Tot-) L.A A.) Property Address James & Patricia Thames Owner Owner's Name information is required for No Andover MA 01845 2/22/08 every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 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. F, 3u` I 5 TITLE 5 FORM 2007.DOC • 08/06 Title 5 Official Inspection Form: Subsurface Sewage Disposal System • Page 14 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 73 .LAQL-'TOtJ I-Atut Property Address James & Patricia Thames Owner's Name No Andover City/Town D. System Information (cont.) Site Exam: ❑ Check Slope ❑ Surface water ❑ Check cellar ❑ Shallow wells Estimated depth to ground water: i i AaF 0Wtu �IN �Uuc 6 feet 2/22/08 Date of Inspection Please indicate all methods used to determine the high ground water elevation: ❑ Obtained from system design plans on record If checked, date of design plan reviewed: 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: e ? QAc. N D. L✓ 95 pq, Ila Ili G% w E rL-A J -9s TITLE 5 FORM 201 - 08/06 Title 5 Official Inspection Form: Subsurface Sewage Disposal System • Page 15 of 15 Important: When filling out forms on the computer, use only the tab key to move your cursor - do not use the return key. th 110 Massachusetts Department of Environmental Protection Bureau of Resource Protection - Wetlands WPA Form 8B — Certificate of Compliance Massachusetts Wetlands Protection Act M.G.L. c. 131, §40 A. Project Information 1. This Certificate of Compliance is issued to: Richard J. Byers, Attorney at Law Name 401 Andover Street Mailing Address North Andover City/Town MA State DEP File Number: p4foC 7A7_11r, rruwueu oy urr 01845 Zip Code 2. This Certificate of Compliance is issued for work regulated by a final Order of Conditions issued to: Desun Corporation Name December 21, 1982 Dated 3. The project site is located at: 73 Carlton Lane (Lot 28A) Street Address Map 106C Assessors Map/Plat Number 242-115 DEP File Number North Andover City/Town Parcel 20 Parcel/Lot Number the final Order of Condition was recorded at the Registry of Deeds for: Property Owner (if different) Essex North County Certificate 1652 Book 4. A site inspection was made in the presence of the applicant, or the applicant's agent, on: 2/24/08 Date B. Certification Check all that apply: W4� Uv ❑ 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: PCOC for 73 Carlton Lane (Lot 28A) only. wpaform 8b.doo • rev. 7/13104 Page 1 of 4 Massachusetts Department of Environmental Protection Bureau of Resource Protection - Wetlands DEP File Number: WPA Form 8B — Certificate of Compliance PC 0c, Massachusetts Wetlands Protection Act M.G.L. c. 131, §40 242-115 � iProvided 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: C. Authorization Issued by: North Andover Conservation Commission Date of Issuance This Certificate must be signed by a majority of the Conservation Commission and a copy sent to the applicant and appropriate DEP Regional Office (See Attachment). Sigr wpaform 8b.doc - rev. 7/13/04 _ Page 2 of 4 L11Massachusetts Department of Environmental Protection Bureau of Resource Protection - Wetlands WPA Form 8B — Certificate of Compliance Massachusetts Wetlands Protection Act M.G.L. c. 131, §40 C. Authorization (cont.) Notary Acknowledgement Commonwealth of Massachusetts County of On this Day 2 7 y -L, Essex North Of r Month before me, the undersigned Notary Public, personally appeared SC - o .�4 1'n SSC. Name of Document Signer proved to me through satisfactory evidence of identification, which was/were Massachusetts License Description of evidence of identification Year DEP File Number: nc 06 242-115 Provided by DEP to be the person whose name is signed on the preceding or attached document, and acknowledged to me that he/she signed it voluntarily for its stated purpose. As member of e" NOTARY PUBLIC COMMONWEALTH OF MASSACHUSETTS My Comm Expres Aug. 7, 2009 North Andover City/Town Place notary seal and/or any stamp above Conservation Commission -)w ignature of Notary Public Printed Name of Notary Public y J b)vC� My Commission xpires (Date) Sig'hature of Notary Public wpaform Bb.doc • rev. 7113/04 Page 3 of 4 Massachusetts Department of Environmental Protection L7Bureau of Resource Protection - Wetlands DEP File Number: WPA Form 8B — Certificate of Compliance Pc `°6 242-115 Massachusetts Wetlands Protection Act M.G.L. c. 131, §40 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: 73 Carlton Lane (Lot 28A) 242-115 Project Location DEP File Number Has been recorded at the Registry of Deeds of: Essex North 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 is: Document Number Signature of Applicant wpaform 8b.doc • rev. 7/13104 - Page 4 of 4 Massachusetts Department of Environmental Protection Bureau of Resource Protection - Wetlands 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 Suite 402 Alford Cumminglon Hatfield Monterey Richmond Ware 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 Fax: 413-784-1149 Belchertown East Longmeadow Holland New Ashford Savoy Westfield TDD: 617-574-6868 Bernardslon 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 DEP Southeast Region Chesterfield Great Barrington Longmeadow Palmer Stockbridge Windsor 20 Riverside Drive Chicopee Greenfield Ludlow Pelham Sunderland Worthington Lakeville, MA 02347 Clarksburg Hadley Middlefield Peru Tolland Wareham DEP Central Region Acton Charlton Hopkinton Millbury Rutland Uxbridge 627 Main Street Ashbumham Clinton Hubbardston Millville Shirley Warren Worcester, MA 01608 Ashby Athol Douglas Hudson New Braintree Shrewsbury Webster Ashland Dudley Holliston Northborough Southborough Westborough Phone: 508-792-7650 Auburn Dunstable Lancaster Northbridge Southbridge West Boylston Fax: 508-792-7621 Ayer East Brookfield Leicester North Brookfield Spencer West Brookfield TDD: 508-767-2788 Barre Fitchburg Leominster Oakham Sterling Westford TDD: 617-574-6868 Bellingham Gardner Littleton Oxford Stow Westminster - Berlin Grafton Lunenburg Paxton Sturbridge Winchendon Blackstone Groton Marlborough Pepperell Sutton Worcester Bolton Harvard Maynard Petersham Templeton Weymouth Boxborough Hardwick Medway Phillipston Townsend Wilmington Boylston Holden Mendon Princeton Tyngsborough Winchester Brookfield Hopedale Milford Royalston Upton Winthrop DEP Southeast Region Abington Dartmouth Freetown Mattapoisett Provincetown Tisbury 20 Riverside Drive Acushnet Dennis Gay Head Middleborough Raynham Truro Lakeville, MA 02347 Attleboro Dighton Gosnold Nantucket Rehoboth Wareham Avon Duxbury Halifax New Bedford 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 TDD: 508-946-2795 Boume Easton Harwich Norwell Scituate West Tisbury 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 Plympton Taunton DEP Northeast Region Amesbury Chelmsford Hingham Merrimac Quincy Wakefield 1 Winter Street Andover Chelsea Holbrook Methuen Randolph Walpole Boston, MA 02108 Arlington Cohasset Hull Middleton Reading Waltham Ashland Concord Ipswich Millis Revere Watertown Phone: 617-654-6500 Bedford Danvers Lawrence Milton Rockport Wayland Fax: 617-556-1049 Belmont Dedham Lexington Nahant Rowley Wellesley Beverly Dover Lincoln Natick Salem Wenham TDD: 617-574-6868 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 • DEP Addresses • rev. 2/22/08 Page 1 of 1