The URL can be used to link to this page

Home My WebLink AboutMiscellaneous - 79 BROOKVIEW DRIVE 4/30/2018 (2)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. Commonwealth of Massachusetts Title 5 Official, Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 79 Brookview Drive Property Address Edward A. Cain Owners Name No Andover City/Town I� h5 Eu,sEr� -i'AGC '7 CI -4129 14 616- MA 01845 1/30/08 State Zip Code Date of Inspection 2-7-og G- et ,v Inspection results must be submitted on this form. Inspection forms may not be altered in any way. A. General Information 1. Inspector: Beniamin C. Osaood Jr Name of Inspector New England Engineering Services Inc. Company Name 1600 Osgood Street Suite 2-64 Company Address No. Andover MA 01845 City/Town State Zip Code 978-686-1768 Telephone Number B. Certification License Number 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: 0"Passes ❑ Conditionally Passes ❑ Fails ❑ Needs Further Evaluation by the Local Approving Authority I sp ce topic Signature Dat revtCn 2-?- 8 gG (� The system inspector sh`all'submit a copy of this inspection report to the Approving Au�lh`ority (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 • 08106 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 Fora Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 79 Brookview Drive Property Address Edward A. Cain Owner's Name No Andover MA 01845 1/30/08 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: Q 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): ❑ broken pipe(s) are replaced ❑ obstruction is removed TITLE 5 FORM 2007.DOC • 02/66 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 Fora Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 79 Brookview Drive Property Address Edward A. Cain Owner's Name No Andover MA 01845 1/30/08 City/Town State Zip Code Date of Inspection B. Certification (cont.) B) System Conditionally Passes (cont.): ❑ 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 IND 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 peptic 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 Ofriciai Inspection Form- Subsurface Se,. age Disposal System • Page 3 of 15 I Owner information is required for every page. Commonwealth of Massachusetts Title 5 official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 79 Brookview Drive Property Address Edward A. Cain Owner's Name No Andover MA 01845 1/30/08 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 ❑ [3-- Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool ❑ r Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool ❑ 2— 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 '/z day flow ❑ [�r 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. TITLE 5 FORM 2007 DOC • 08/06 - Title 5 Official Inspection Form. Subsurface Seeaage Disposal system • Page 4 of 15 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. ❑ [Q^ Any portion of a cesspool or privy is within 50 feet of a private water supply well. ❑ 0� 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.] ❑ r -,l The system is a cesspool serving a facility with a design flow of 2000gpd- t� 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. TITLE 5 FORIA 2007.DOC • 08,06 Title 5 Official Inspection Form: Subsurface Sevvaoe Disposal System - Page 5 of 15 Commonwealth of Massachusetts l — :L Title 5 Official Inspection Fora' V Subsurface Sewage Disposal System Form Not for Voluntary Assessments _mo(` 79 Brookview Drive Property Address _ Edward A. Cain Owner Owner's Name _ information is required for No Andover MA 01845 1 /30/08 _ every page. City/Town State Zip Code Date of Inspection 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. ❑ [Q^ Any portion of a cesspool or privy is within 50 feet of a private water supply well. ❑ 0� 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.] ❑ r -,l The system is a cesspool serving a facility with a design flow of 2000gpd- t� 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. TITLE 5 FORIA 2007.DOC • 08,06 Title 5 Official Inspection Form: Subsurface Sevvaoe Disposal System - Page 5 of 15 C. Checklist Check if the following have been done. You must indicate "yes" or "no" as to each of the following: Yes Commonwealth of Massachusetts a,�; - Title 5 Official Inspection Form ❑ ERT Were any of the system components pumped out in the previous two weeks? l N Subsurface Sewage Disposal System Form - Not for Voluntary Assessments Has the system received normal flows in the previous two week period? ❑ ❑> ` -.,. 79 Brookview Drive this inspection? Property Address ❑ Were as built plans of the system obtained and examined? (If they were not Edward A. Cain Owner Owners Name ❑ information is required for No Andover MA 01845 1/30/08 every page. City/Town State Zip Code Date of Inspection C. Checklist 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 ❑ ERT Were any of the system components pumped out in the previous two weeks? 52 ❑ 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? I��' ❑ 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 CIV"i? 15.302(5)] TITLE 5 FORM 2007.DOC • 08,106 Title 5 Ofcia! Inspection. Form: Subsurface Sewage Disposal System • Page 6 of 15 Commonwealth of Massachusetts Title 5 official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 79 Brookview Drive Property Address Edward A. Cain Owner Owner's Name information is required for No Andover MA 01845 1/30/08 every page. City/Town D. System Information State Zip Code Date of Inspection Residential Flow Conditions: Number of bedrooms (design): Number of bedrooms (actual): 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? Seasonal use? 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 occupancy/use: Other (describe): Gallons per day (gpd) Date Yes ( No ❑ Yes 1�7141, No ❑ Yes Z No ❑ Yes R] No ❑ Yes No Date ❑ Yes ❑ No ❑ Yes ❑ No ❑ Yes ❑ No TITLE 5 FORM 2007.DOC • 08106 Title 5 Official Inspection Form: Subsurface Sewage Disposal System • Pace 7 of 15 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments \VI 79 Brookview Drive Property Address Edward A. Cain _ Owner Owners Name information is required for No Andover MA 01845 1/30/08 every page. City/Town State Zip Code Date of Inspection 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: (3J tJ J �) T.A_ koyy1cb 'r'v� gallons Type of System: Septic tank, distribution box, soil absorption system ❑ Single cesspool ❑ Overflow cesspool ❑ Privy ❑ Yes No ❑ 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: 7_00 = -(?— Q Were sewage odors detected when arriving at the site? ❑ Yes 0 No TITLE 5 FORM 2007.000 • 08106 Title 5 Official Inspection Form Subsurface Se%vage Disposal System • Page 8 of 15 D. System Information (cont.) Building Sewer (locate on site plan): Depth below grade: feet Material of construction: ❑ cast iron [4 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: ❑-6bncrete ❑ metal I 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: % r v Sludge depth: ' ---- Distance from top of sludge to bottom of outlet tee or baffle r — ---- Scum thickness Distance from top of scum to top of outlet tee or baffle J -- Distance from bottom of scum to bottom of outlet tee or baffle How were dimensions determined? TITLE 5 FORM 2007.DOC • 08i06 Title 5 Official Inspection Form Subsurface Se'.aage Disposal Systen•, • Page 9 of 15 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 79 Brookview Drive _ Property Address Edward A. Cain Owner Owner s Name information is required for No Andover MA 01845 1/30/08 every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Building Sewer (locate on site plan): Depth below grade: feet Material of construction: ❑ cast iron [4 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: ❑-6bncrete ❑ metal I 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: % r v Sludge depth: ' ---- Distance from top of sludge to bottom of outlet tee or baffle r — ---- Scum thickness Distance from top of scum to top of outlet tee or baffle J -- Distance from bottom of scum to bottom of outlet tee or baffle How were dimensions determined? TITLE 5 FORM 2007.DOC • 08i06 Title 5 Official Inspection Form Subsurface Se'.aage Disposal Systen•, • Page 9 of 15 Commonwealth of Massachusetts ---i`- Title 5 ®fficial Irl�pection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 79 Brookview Drive _ Property Address Edward A. Cain Owner Owners Name information is required for No Andover MA 01845 1/30/08 — 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.): Grease Trap (locate on site plan): Depth below grade.- Material rade:Material of construction: ❑ concrete ❑ metal Dimensions: Scum thickness feet ❑ fiberglass ❑ polyethylene ❑ other (explain): 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 • 03/06 Title 5 Official Inseection Form, Subsurface Sewage Disoosal System • Page 10 of 15 Commonwealth of Massachusetts ,�--- 'Title 5 Official Inspection Form =i Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 79 Brookview Drive Property Address Edward A. Cain Owner Owner's Name information is required for No Andover MA 01845 1/30/08 every page. City/Town D. System Information (cont.) Tight or Hoping Tank (cont.) Dimensions: Capacity: Design Flow: Alarm present: Alarm level: Date of Inspection gallons gallons per day ❑ Yes ❑ No Alarm in working order: Date of last pumping: Date Comments (condition of alarm and float switches, etc.): ❑ Yes ❑ No Attach copy of current pumping contract (required). Is copy attached? ❑ Yes ❑ No Distribution Box (if present must be opened) (locate on site plan): t Depth of liquid level above outlet invert v 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.): _ ?J c Cil _ ,c i :fit C_f d�j1yG._.GZ: 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 Oficial Inspection Form: Subsurface Sev:age Disposal System • Page 11 of 15 Commonwealth of Massachusetts Title 5 Official Inspecti®n F®r N Subsurface Sewage Disposal System Form - Not for Voluntary Assessments \�. i 79 Brookview Drive _ Property Address Edward A. Cain Owner information is required for every page. Owner's Name No Andover MA 01845 1/30/08 City/Town State Zip Code Date of Inspection D. System Information (cont.) Comments (note condition of pump charnber, condition of pumps and appurtenances, etc.): Soil Absorption System (SAS) (locate on site plan, excavation not required): If SAS not located, explain why: Type i❑ leaching pits number: ❑ leaching chambers number: ❑ leaching galleries number: >r ®f 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.): Git.< G� -Qa ¢-.i =� i-t�: �. n -t � _ 1 >` c.? ..� � �'�ii , f;� G »-� , f 3 � VA C TITLE 5 FORM 2007.DOC • 08/06 Title 5 Oricial Inspection Form. Subsurface Sewage Disposal System - Page 12 of 15 Commonwealth of Massachusetts i_w, Title 5 Official Inspecti®n Form ,. i Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 79 Brookview Drive Property Address Edward A. Cain Owner Owner's Name information is required for No Andover MA 01845 1/30/08 every page. City/Town 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 FormSubsurface Sewage Disposal System • Pace 13 of 15 Owner information is required for every page. Commonwealth of Massachusetts Title 5 official Inspection Fora Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 79 Brookview Drive Property Address Edward A. Cain Owner's Name No Andover MA 01845 City/Town State Zip Code D. System Information (cont.) 1/30/08 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. z�I� 01ti6F-5 9 TITLE 5 FORM 2007.DOC • 08105 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 79 Brookview Drive D. System Information (cont.) Site Exam: FI Check Slope D --Surface water -vowZ [9 --Check cellar [2' -Shallow wells 1/30/08 Date of Inspection Estimated depth to ground water: feet 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: �/ +A� i '� P� __ _ _ �" S � ✓ b^� t.:�� /\ Ufa 'C-- �, �S -"l��j 4� c 1,J N TITLE 5 FORM 2007.DOC • 08106 Title 5 Oficial Inspection Form Subsurface Sewage Disposal System • Paye 15 of 15 Property Address Edward A. Cain Owner Owner's Name information is No Andover MA 01845 required for _ every page. City/Town State Zip Code D. System Information (cont.) Site Exam: FI Check Slope D --Surface water -vowZ [9 --Check cellar [2' -Shallow wells 1/30/08 Date of Inspection Estimated depth to ground water: feet 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: �/ +A� i '� P� __ _ _ �" S � ✓ b^� t.:�� /\ Ufa 'C-- �, �S -"l��j 4� c 1,J N TITLE 5 FORM 2007.DOC • 08106 Title 5 Oficial Inspection Form Subsurface Sewage Disposal System • Paye 15 of 15 w u j i a z 0 IL .. Na J u z 0 u Z ' 0 �O z o m O 'C 0 m u z . LU a m 0U. 0 cd s 3 5 i O ❑ 1i !� W o � cr Je 0 ° P � o � z W 0o a Z ' d �O z o m O 'C 0 o O u z . LU a m 0U. 0 cd s 3 5 i O ❑ 1i m W o � cr O 0 ° o 0 z W 0o a 4 '0 I A a L, S t o H D N W L Z m a pu S (u� i CL V< p 3 0< m u a O a L. U_ N 0 Z 0 Z 0 j Z F w H w i v JooZ O 0 0 � v � O W O W O W r i o Ax W LU j i a z 0 J u z 0 u< u e W p e J w D Z 0 0 O O � I ~ 7 0 Or n ,. 01 Z 0 u 0 Z Z 0 0 O W U Z m 0 F j m i u � Z O 1• : Z 2 Q U F- d �O z o J ' E-. O m . LU V1, 0U. LU cd s 3 0 z < Z O W IL 0 h < w 2 N o � OS w a ;.V W O, 0 W 0 m Z W f W Q z v z W ` R LL O Z i 2 C ►- r. U IL < Z m O J U < u W Z_ L L p < J k. j 0 m p IK J <0 m j i z 0 J u z 0 u< u e W p e J w D Z 0 0 O O � I ~ 7 0 Or n ,. 01 Z 0 u 0 Z Z 0 0 O W U Z m 0 F j m i u � o F L 0 m W W V M L L U W N ►c- u V W W u c L W < � e . LU V1, 0U. LU cd s 3 0 Z 0 O L) _ U = � ;.V Z 1 W 1C �- ❑ Z oo A a S t o - a: W W < o 0 it a pu S (u� i CL V< p 3 0< u a O a L. U_ N J a Z 0 Z 0 j Z F w H w i v JooZ O 0 0 C O W O W O W ^, Q i o i i i �� Q W O, 0 W 0 m Z W f W Q z v z W ` R LL O Z i 2 C ►- r. U IL < Z m O J U p O m J W m H L > W Q 0 r < J O F L 0 m W W V M L L U W N ►c- u V W W u c L W Z O< d Q S= W Q Q O m Z<< a Z ii a lzi a s a s 0 a.h0 'sxo07 ��f 01 O<=0< �t u o f TI I W II u Z Y Q = z m K 2 o W W V W" 0 ° iii o mh 1 �62- ZZ izci<" W vW - �.].,zs 0 <o�� O .00 0RZIZ 00 ZvW 1r1.1<.zs6oxh`00 i� Z Z 1�6 00 �'� �° dma� 00 zi v o 3 7 a> h m h h p u ' a 8�,� 00 f 0a m� WN WW u= Z a cr a 0 O o� Lulx a pupa 0 2 LL�0 Ooa _ m c ZEN Omu Z IL • m WOo. W OZM } i 0 IA u�S �. Gd j C'W X Din 0 �. 0+ u a. 6-A OWJJ �- W CL 0 ZZN 0< Ln V WZ� (n N �H17 10< F- J fi ,11111\ III -I1IIN TT7 TV _I I I �I1�I I N = 0 z o O z o A I I W W °` � T� Z _tr r> Z O< d Q S= W Q Q O m Z<< a Z ii a lzi a s a s 0 a.h0 'sxo07 ��f 01 O<=0< �t u o f TI I W II u Z Y Q = z m K 2 o W W V W" 0 ° iii o mh 1 �62- ZZ izci<" W vW - �.].,zs 0 <o�� O .00 0RZIZ 00 ZvW 1r1.1<.zs6oxh`00 i� Z Z 1�6 00 �'� �° dma� 00 zi v o 3 7 a> h m h h p u ' a 8�,� 00 f V 6 z 04 ON X u V% :U O vU CL gm m C Z ' Ecn CE a �•mo o 41 �` E S 04) p C O O O r CD C E N !O Ma N � � � r=" � �+� •ems'' o: pG aj Ca :mo ar CLC -2 o (n ycr- CD o< �_ W �...1 ts^ O 0 m IS z�o 0 ev o c i .0 Q h m C •S ;a o m WC A t -..O m H N =wC°C Z �m m •N O � om�s V2 n 4D o -0 = A y C J F- � CL IS m O cm CO2 O H O O �E m m 0 CD f� 3 O �CO O O e_wv o a E: cmac go O ++ cc C.3 .300 CL Oca CL C � � C.3 h O C C C _c d CO2 o FV w W a x a � uCE o a A o o p c ._C C a m a�' in a W o c x ca W x z c v .se vi V% :U O vU CL gm m C Z ' Ecn CE a �•mo o 41 �` E S 04) p C O O O r CD C E N !O Ma N � � � r=" � �+� •ems'' o: pG aj Ca :mo ar CLC -2 o (n ycr- CD o< �_ W �...1 ts^ O 0 m IS z�o 0 ev o c i .0 Q h m C •S ;a o m WC A t -..O m H N =wC°C Z �m m •N O � om�s V2 n 4D o -0 = A y C J F- � CL IS m O cm CO2 O H O O �E m m 0 CD f� 3 O �CO O O e_wv o a E: cmac go O ++ cc C.3 .300 CL Oca CL C � � C.3 h O C C C _c d CO2 FORM U - IAT RF.L n 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: Af do 61 o1v 6.410/e/ dom(S Phone h �`ng^bS� Q LOCATION: Ass=essor's Map Number �&4 tId Parcel 3 t 7 Subdivision Be601rU1c O fS74-Te S Lots) Street �Ca6 elle VC St. Numi:er Use REC229EIlDATI NS 0 OWN AGENTS: WAM Date Approved "nsdr-% at_ --n Ad--nistrat :r Date Re; ect=_d cc= er.t- /lam ,AAY-(,-k" d s u ) i14- fy L) !V- �-q-1 Date Approved C V Town P annex Date Re;eczed Cc=e: :_s Co ':.c.. Date Arnrove•d Date Re -J ec -=_-4 Date Apprcved la tea¢ Date Reject_d Wcr�:s - se.rer,'water connections - driveway periit Fire Denar--men,: ei� -7 "�u �� —� 7 Received by Building Insrector Data Growth Management Bylaw Exemption Statement Town of North Andover Building Department This form shall be used to assist the Building Department in their determination of exemptions under section 8.7.6 of the Town of North Andover Growth Management Bylaw. The building applicant shall provide all of the necessary information as requested below. Name of Applicant on Buildiag Pe it (below) Address of Property for Permit (below) fe,4 ,MapandParcel:w p6rposeof jpplication (check below) Phone N mber of A licant: ,,C Single Family _ Two Family If�'41 1 the undersigned applicant for the above property attest that the attached building permit for which this form is completed does comply with the EXEMPTION section 8.7.6 of the North Andover Growth �3 f� Management Bylaw. I also understand providing this form does not absolve me or any party to this permit from the requirements of obtaining other permits required prior to the issuance of the Building Permit. Further I understand that my interpretation of the EXEMPTION status is subject to review by the Building Department and is only officially accepted when the Building Permit is issued. Based on section 8.7.6 of the North Andover Growth Bylaw the above lot and the work as applied for on the above lot, in the building permit application and associated attachments, complies with one or more of the following sections as indicated by a check mark. This is an application for a building permit for the enlargement, restoration, or reconstruction of a dwelling in existence as of the effective date of this by-law, provided that no additional residential unit is created. e lot(s) were/was created prior to May 6, 1996 are exempt from the provisions of this Section 8.7 of the Zoning Bylaw. This application is for dwelling units for low and/or moderate income families or individuals, where all of the conditions of 8.7.6.care met and/or represents Dwelling units for senior residents, where occupancy of the units is restricted to senior persons through a properly executed and recorded deed restriction running with the land. For purposes of this Section "senior" shall mean persons over the age of 55. This application is a part of a development project which voluntarily agreed to a minimum 40% permanent reduction in density, (buildable lots), below the density, (buildable lots), permitted under zoning and feasible given the environmental conditions of the tract, with the surplus land equal to at least ten buildable acres and permanently designated as open space and/or farmland. The land to be preserved shall be protected from development by an Agricultural Preservation Restriction, Conservation Restriction, dedication to the Town, or other similar mechanism approved by the Planning Board that will ensure its protection. This application represents a tract of land existing and not held by a Developer in common ownership with an adjacent parcel on the effective date of this Section 8.7 shall receive a one-time exemption from the Planned Growth Rate and Development Scheduling provisions for the purpose of constructing one single family dwelling unit on the parcel. i This application represents a lot which is ready for building permits,(Le. all other permits from all other boards and commissions have been received and the project is in compliance with those permits), and the Development Schedule does not accommodate issuing a building permit in that Year, one building permit will be issued per Year per Development until such time as the Development Schedule accommodates issuing building permits. Applicant must supply approved form U with this EXEMPTION. Please provide any and all information that would assist the Building Department in making a determination that your application is allowed one or more of the above EXEMPTIONS. By signing below I attest to the accuracy allowed an EXEMPTION as cited above inaccurate information, or the checking knowledge or t, is grounds f�� refusal117 ature Lf Ownerdr'Authoria€, form must be attached to of the information provided and that the attached building permit Further I understand that the submittal of misleading and or off of an above item which does not comply, whether done to my �B' di ;Department to issue a Building Permit. A �d sigD35d the Attached Building Permit Dat f 7ermit upon application for such permit. C I g) The applicant must submit to the Town Planner a FORM M for all utilities and easements placed on the subdivision. The Board will sign the document and it must be recorded at the Essex North Registry of Deeds. h) All application fees must be paid in full and verified by the Town Planner.. i) The applicant must meet with the Town Planner in order to ensure that the plans conform with the Board's decision. A full set of final plans reflecting the changes outlined above, must be submitted to the Town Planner for review endorsement by the Planning Board, within ninety (90) days of filing the decision with the Town Clerk. j) The Subdivision and PRD Decision for this project must appear on the mylars. k) All documents shall be prepared at the expense of the applicant, as required by the Planning Board Rules and Regulations Governing the Subdivision of Land.. 2. Prior to any work on site: a) Three (3) complete copies of the endorsed and recorded plans and two (2) certified copies of the recorded subdivision approval, Covenant (FORM I), Right of Way easements, and FORM M must be submitted to the Town Planner as proof of filing. b) - All erosion control measures must be in place and reviewed by the Town Planner. 3.' Prior to any lots being released from the statutory t;ovenants: a) The applicant must comply with the Phased Development Bylaw, Section 4(2) of the Town of North Andover Zoning Bylaw. This project is exempt from Section 8.7 Growth Management as the preliminary plan was filed prior to May 6, 1996 and the definitive plan was submitted within seven months. However the exemption will only run for eight years from the date of the endorsement of the plans as set forth under Mass. Gen. Law. b) A complete set of signed plans, a copy of the Planning Board decision, and a copy of the Conservation Commission Order of Conditions must be on file at the Division of Public Works prior to issuance of permits for connections to utilities. The subdivision construction and installation shall in all respects conform to the rules and regulations and specifications of the Division of Public Works. C) All site erosion control measures required to protect off site properties from the effects of work on the lot proposed to be released must be in place. The Town Planning Staff shall determine whether the applicant has satisfied the requirements of this provision prior to each lot release and shall report to the Planning Board prior to a vote to release said lot. d) The applicant must submit a lot release FORM J to the Planning Board for signature. 2 I�I j Restricted To: 00 176'50 I 00 - None j IA - Masonry only 1G - 1 & Z Family Homes Failure to possess a current edition of the Massachusetts State Buiildingg Code is cause for revocation of ihis license. �` -. .... :: �17(! 1!'Ir7q 917lr illiCn'�✓1/ ��. /�i7:1.1l7!'l7 n.l�✓�J _ DEPARTMENT OF PUBLIC SAFETY 3 ") CONSTRUCTION SUPERVISOR LICENSE Number: Expires: Birthdate: CS 005693. 01/13/1998 01/13/1954 Restricted To: 00 DAVID A KINDRED 40 MARBLERIDGE RD POROX531 N ANDOVER, MA 01845 V � r C4 0 Z z o Q Q -) --� Q W 8W\" fn 't C q I U L �7 N O Q N \Q CIA m\9\0 x�dJ A 0 �00 � z Q ::3 x a_ )E in ILL V � r C4 0 Z z o Q Q -) --� Q W 8W\" fn 't C q I -u 9) °o Xmv o O r. Ulu 3 rg '' O� �'-r�l UU � USO U 4" O Qj rn o -U 7e: rno v% U �i 07 c w :77 U V �vsg m : LO a� 4v:3 X V (LY -m u- -u 9) °o Xmv o O r. Ulu 3 rg '' O� �'-r�l UU � USO U 4" O Qj rn o -U 7e: rno v% U it II II II II II II II II II II II II II II II II II II II II II -LI �i 07 c U V �vsg qC% U I U) U O UU U U7 m w 75 p IL E O U �� i LL U, U q to4[U _ �� ou it II II II II II II II II II II II II II II II II II II II II II -LI lu 0 J a i.0 Z w 0 L U N L Q� N O � � X to CA � Q- � ICl lL L r— O�� SD �QO .3 (L Y- M c m cc a o� 0 U } L �7 m N tR ` J � I -U pN�O U lU I ori Q ct) _� x =�� G;� N ti- m Q O O > x wx -� :3 tnq i� � tf �l°Oux UX u x LL Z W tow _ t!_ um d �Uito N B�� to ,�>_ O Ca �Qv tV to w iN V o o � m ri o� a o to F- am to m }wu to J touj FU u, a LL W q x �J P M e0 U tr to ' J v �Qma Illllli illlll� • V � �.. o 4 Sod mm „0l .� 14-1 —moo o ., 9-,03 U 4 VIPZ O £ 6ti o \ O FZ 8� w { 1 0 -C lIl .ri ,= .9-102 ,U—,t$G 0 O Q U } r O W O t4 tQ %U ro �, va Na D x dD W u (L iD u. .9-102 ,U—,t$G 0 O Q V I ", _ � 1 O O L J CIS � m Z O N J F U N w OBJX y.\qm N 1 1 X N O-%� d' X W �Jc:00 NZ ", _ � 1 O O J J Z O LL J F U N w OBJX r N N CIA X N O-%� d' 3:: LU Q fL ct) 2 O O J J Z O LL J F U N w OBJX r N w X N O-%� d' 3:: a _U } L M CIA T \s)m cz , C-4 \Q c� � Cd X -Wclo :3 x IL ): cn ui L ww�^ V JJ � <v cz cz �Lr . X fA 66 0 00 rQ ::3 .� fL :L fQ.l° 0 I U L Q� �7 i N O C- cfj C14 ( p0 ,�J <I O tlJ m Q � � O N \Q Z, i Y'IV IY X .9—,t (Z N to tQ Nrj y"^ -cAco x to)O O �MO ll l s V OL X: m LO 0 I .0—,9Z 7F of le C] Y2 1" 00 1 40 1J �11-0-1 "2—,z {i�Z o yV /V ( p0 ,�J C YV—/9 oo O I Z, i Y'IV IY X .9—,t O � I I >I a C� II N II C, I I °D o w6—,9 Y6—,9 0 If] LOx Q to U x in i`7 iD -C, ,I j7 N aI x I n DO p O fvl o 9- IE Y,Z LL C I }— I I o C` / LL_ C rD I Y9-,£ oll I u 3 C I I Oell c] x I I � `� U I Z t M U _c � 7�yt1) N 00 I I M I ol x 0 I to Lo I x a nl O O O O LO O '= N c 'I' _O II 0 N I rD ol .0—,9Z 7F „9 -,Ll ,A- L cn tl � cv O N %D C6 N X CfJ dJ O S �L- m i� „9 -,Ll ,A- s� V } L Cn N NtoVQ\Q O 0 X00 O' W �tJ LU % w O LL C�1 w m Op— � N O � 0 LL O e W= p N \Q w � � cMI1 co ,-� ® X fA CA O 000 � O cci m 11 O' W O LU % w O LL C�1 w Op— � O � 0 LL O e W= w � � � O L L N � � O O V Q O � n LL -1 N M � C o � TQC �Q} cn�Q LU w W6 U- _Q u lz (Y- C cX cv _U L �1 m N — � ONN-O to c6 � co � 0 OL f ca IT � C o � TQC �Q} cn�Q LU w W6 U- _Q u lz (Y- C cX cv Q) U } i_ C� � N 4 C-4 � 1 1 � vQ m m ., o �,00 W 2 o LU aLL,ui z c� p � Q w g �ul,- QC`� }� X10 �aLL'n W �a � W awO c�D.1y am ;Oz Q �Op= wX QU Q � W NO C(1 43 to g 0 V Q a j �QC� 2S°�p U m�X �0 a z�ui ��- }- �d�'r m\9 �' Z f - V Nip +- 1 1 1 1 1 o 0 LL � � z a • ii � IK � � m gfv 4 x do a � a °f o° w 0- a N 'u z w - ° � q�L U } M - wU o � 0 o UmA LU LU JZ �o- �� x ao= ;!) LL HO Iv Nfll MO 1" _ qo �O 0 �W°-0 VC fy fl� O LL E�loll LL W 10 as €ID JE O E gLn40 u°a°tLL d) PDQ 3 O r2 cr► 4 di .9 r' NJ U - VN wLe 0 ck= [�Q�N u— V Qr��f Fes - a "r o d p p (K p � rp in E aLL. 1L ci C� sr uj r LL ?S LIN Lu j ►= �h in Ul o wQ =-j7-o N In�K� a� U QQr UOjI X�, N�oO-. WQ ON�I%J LU N rJ�Wtb U-1 LL 0> eqZ W w cl i.4 4OQWN p zi :z do 'Q ��QWJ 15ou: UCQ Q N. a t_ 4 L w -A n V (0 �Vy9 Q— q (1!: x -(\Q' (V Q3� ` (� it _N xx3 f-- ' 1 1 1 1 1 1 (` r r 1 1 „O-,8 j-,4 �J N 11\ J n r- � �• CCI � Z O iii Q <t m AC. Q C'i DO O CJ �Q 9 X00 ICi ul n p0 -,Z2 �i- OL X: a- UI �.�- —I •� n 0 �'S- -rT—�, -r e e -�e-T n-e-7� a °�T--�-� I TFT 1 4. I I I o I 444 I I I iD a> I I �� C. 14'I -! I- LU a1� 1°'41 LI I J i l l I i*O 3 _azo q 1� I — a. a1 I 1 � � "3 U ►4 1 x sr tf �o I I I I A z 1 X A= Ej 40 C,I #- W X I• )N cj to 1= �1 I I I II �JOf" r� ID► �� .c � `J 4, I 1 -1 I__ :►- X q R i I I 1 i3 o rQ 1 ►;► I� a, I I I 1 �t�_a I Ito 3 3 S 0 1 4'4 1 L I I J -1 X 1 I I 51 q[ I I p•► E; ° a, 1 Ul 4 if o� a. �j =;t 9 UCD I I L l a 4'41---11 �i0 ,o� t o '-� I I I I I I'•1---I a� i I L J°'►I R 114' 1 1 p,► 1 41) r cti o 1 4.4 I X u� I- 14' 4 1 m I I I I I N 1 4' 1 `p r1a, $ 14.41 I I I Ip'►1 c'93w E I I I I I ►'►I 4'4 St m N 14.41 1 101 1 4 I C), y— `� isrs to 14' 4 1 I I I 1 1 1¢ca W 1 a IL mss w 1 f� d p p 0JI �US2��1 14.41 U Ra> 1 I I I v 1' Ic" LL oa w i-5 4 1 4'4 1 r. 1 I I I I D'► I i�� 14.1 I II I 1'•'lin I 4)Ts 0 1 4.11 11fxa 1 I I I I ID,►1 1 41 T— $m 14.41 1 LH •�►0x4� 14'41 111 I 1D,►I m a . au ocm 14.41 ir. 1 11 I 1.D U�gQv►-9 I I II I L6 .0 1 4'4 1 4. 1 I I I I I ►'► I 14.41 1 1 1 DI I I 1 1 1 I I D,► I 44 90) 9 4' I 1 1 1 I 1 ►�► 1 I s94�4� r 1II I w N 333 4' I Q 1>'' I �• ° ��- b I I I I I o 4iO_�o 14'41 I i� I 1D,►1 w di o IQL 14. 1 I I I I � ►'► I slitC-4 ID I ' I 1 11 I �D,el ,`a 4 --co, I 4 I a, L ��Q•N 460 09 9,gm4�� 1,•41 1 1p.►I 1 ' 3792 Date. A TOWN OF NORTH ANDOVER 8 co PERMIT FOR PLUMBING "' M This certifies that /C. -7.4—A /`/z... , o m has permission to perform .... ........... .., plumbing in the buildings of..?)/, at ,North Andover, Mass. Fee;:.V.... Lic. No/.01 5.!` .. .... PLUMBING INSPEC WHITE: Applicant CANARY: Building Dept. PINK: Treasurer MASSACHUSETTS UNIFORM APPLICATION FOR PERMIT TO DO PLUMBING :ype or print) NORTH ANDOVER, M SACHjdSETM Date duilding Locations 7 % �/4o/`C �j e iv �/ � `11�- Permit # 3 ?9 Z-- mount Owner's Name d opt C S New 12 Renovation � Replacement E] Plans Submitted 1/ (Print or type) / /J� j f _//� Check one: Certificate Installing Company Name 06 �/'- Ol/ f%' ❑ Corp. >� 9 / � c ❑ Address � X717 y r' C � �� Partner. Business Telephone q 7 - 3 % Finn/Co. Name of Licensed Plumber: X a1r;1-1-1 Z�l4 I/l� Insurance Coverage: Indicate th type of insurance coverage by checking the appropriate box: ❑ Liability insurance policy a Other type of indemnity ❑ Bond Insurance Waiver: I, the undersigned, have been mdde aware that the licensee of this application does not have any one of the above three insurance Signature Owner ❑ Agent ❑ I hereby certify that all of the details and information I have submitted (or entered) in above application are true and accurate to the best of my knowledge and that all plumbing work and i nsfor this application will be in compliance with all pertinent provisions of the Massac2 of the General Laws. By: I ot Licenseaum er Type of Plumb* n License Title License City/Townmer Master 0 Journeyman ❑ APPROVED (OFFICE USE ONLY ■■■ """ ••• 1' - (Print or type) / /J� j f _//� Check one: Certificate Installing Company Name 06 �/'- Ol/ f%' ❑ Corp. >� 9 / � c ❑ Address � X717 y r' C � �� Partner. Business Telephone q 7 - 3 % Finn/Co. Name of Licensed Plumber: X a1r;1-1-1 Z�l4 I/l� Insurance Coverage: Indicate th type of insurance coverage by checking the appropriate box: ❑ Liability insurance policy a Other type of indemnity ❑ Bond Insurance Waiver: I, the undersigned, have been mdde aware that the licensee of this application does not have any one of the above three insurance Signature Owner ❑ Agent ❑ I hereby certify that all of the details and information I have submitted (or entered) in above application are true and accurate to the best of my knowledge and that all plumbing work and i nsfor this application will be in compliance with all pertinent provisions of the Massac2 of the General Laws. By: I ot Licenseaum er Type of Plumb* n License Title License City/Townmer Master 0 Journeyman ❑ APPROVED (OFFICE USE ONLY ■■■ """ •••