HomeMy WebLinkAboutMiscellaneous - 80 PHEASANT BROOK ROAD 4/30/2018 (2).1
00
i
5
75
MAR # d ; .a LOT
STREET
PARCEL # P.�
- - POYES
OIV,STRUCTI.ON_A..-
HAS PLAN REVIEW FEE .BEEN PAID? NO
PLAN APPROVAL: DATE Q APP. BY-
DESIGNER:
YDESIGNER: /r�f57/�.US ��/ PLAN DACE.
CONDITIONS )CG4VA, 4l� �`�ST iy /3�G/� �� \ y, <,
WATER SUPPLY: OWN WELL
WELL PERMIT DRILLER._.`.-.---_._._.—._^ __._---...._._._._.._..
WELL TESTS: � CHEMICAL DALE AF'PRUVED._,____—.____
BAC, IIA I llA f E (1FhRUVEU
^\ �-
BACTERIA IDATE nPPROVED _
COMMENTS:
FORM U APPROVAL: APPROVAL TO ISSUE YES NU
DATE ISSUED BY --- — - --'- -... ---
CONDITIONS:
FINAL APPROVAL:
ALL PERMITS PAID YES NO
WELL CONSTRUCTION APPROVAL YE NU
SEPTIC SYSTEM CONSTRUCTION APPROVAL ES,,. NO
OTHER ES NU
ANY VARIANCE NEEDED
FINAL BOARD OF HEALTH APPROVAL:
YES NO
DR TE:.alIiOl ....DY:._ .
Commonwealth of Massachusetts
MM �e'��I�Bo►
City/Town of
System Pumping Record�'UN 2;0 2014
Form 4 TOWN OF NORTH ANDOVER
HEALTH DEPARTMENT
DEP has provided this form for use, -by local Boards of Health. Other forms may e ,
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.
A. Facility Information
1. System Location: Left / Right front of house, Leftfreer of house, Left / right side of house, Left /
Right side of building, Left / Right front of building, Left / Right rear of building, Under deck
Address
oVv&,N�O_A_� d_�� �� fY - 41-v�
City/Town State Zip Code
2. System Owner.
Name �--
t5fomm4.doc- 06/03
Address (if different from location)
City/Town State
vie
Telephone Number
- i
B. Pumping Record
1. Date of Pumping
3. Type of system: ❑
❑ Other (describe):
Date 2• Quantity Pumped: Gallons
Cesspool(s) Septic Tank ❑ Tight Tank
4. Effluent Tee Filter present? ❑Yes L,�f�o If yes, was it cleaned? ❑Yes ❑ No;
5. Condition of System:
6. System Pumped By.
Neil Bateson
Name
Bateson Enterprises Inc
Company
7. Location where contents were disposed:
F5821
Vehicle License Number
System Pumping Record • Page 1 of 1
Commonwealth of Massachusetts
City/Town of RECEIVED
System Pumping Record MAY 2 12008
g` Form 4
TOWN OF NORTH
�ANDOVER'
DEP has provided this form for use by local Boards of Health. Other forms I'�° Q ; dj NT
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.
A. Facility Information
Important:
When filling out 1. System Location, �� ��
fomes on the ��
computer, use
only the tab key Address `
to move your C "' a L
cursor - do not
use the return City/Town State Zip Code
key. 2 System Owner.
dL
vl=
Name
ISI Address (if different from location)
Citylrown Statel) Cade
S
Telephone Number
B. Pumping Record �-
1. Date of PumpingDate 2. Quantity Pumped: Gallons
3. Type of system: ❑ Cesspool(s)eptic Tank ❑ Tight Tank
❑ Other (describe):
4. Effluent Tee Filter present? ❑ Yes ❑—ffo If yes, was it cleaned? ❑ Yes ❑ No
5. Condition of System:
a /� � `CJu
6. System Pu By:
Name Vehicle License Number
C�1
Company
7.
con is disposed:
Date
t5form4.doc• 06/03 System Pumping Record < Page 1 of 1
Commonwealth of Massachusetts
"City/Town of NORTH ANDOVER MASSACHU uTS
System Pumping Record
Form 4
M
DEP has provided this form for use by local Boards of Health. The System Pumping Re�Q�,�d must
be submitted to the local Board of Health or other approving authority.
A. Facility Information
Important:
When filling out 1. System Location: j
forms the
computer, use
only the tab key Address
to move your
cursor - do not City/Town /A
use the return State Zip Code
key. '
2. System Owner:
Name
Address (if different from location)
City/Town
MAY 11 2006
OF NORTH ANDOVER
B. Pumpingl`i"�u�r�r. ivy.
1. Date of PumpingZ�
Date
$. Type of system: ❑ Cesspool(s)
❑ Other (describe):
State 9 A 6fc5Z;i
Telephone Number �p jr
2. Quantity Pumped: Ii5-z) b
Gallons
Septic Tank ❑ Tight Tank
4. Effluent Tee Filter present? ❑ Yes ❑ No If yes, was it cleaned? ❑ Yes ❑ No
5. Condition of System:
-- d C&�
6. System Pumped By: r,
Name
Company
7. Location where contents were disposed:
Signature of Ha er
http://www.mass.gov/dep/wat pprovaIs/t5forms.htm#inspect
t5form4.doc• 06/03
Date
License Number
System Pumping Record • Page 1 of 1
?�8 eli�stj%toz2�a��.cp?�
09?,5S.46 MS77S
DytrasA--t 4;19#& Satiety
BOARD OF FIRE PREVENTION REGULATIONS 527 CMR 12:00
APPLICATION FOR PERMIT TO
All work to be performed in accordance with the
(Please Print in ink or type all information)
Town of North Andover
The undersigned applies for a permit to perform the electrical
Location (Street &
Owner or Tenant 4:::�( &)n /if / — y
Owner's Address d/
Is this permit in conjunction with a building permit
Purpose of Building
Yes
Office Use
Only
Permit No_
Occupancy & Fee CheckedA6
PERFORM ELECTRICAL WORK
Massachusetts Electrical Code 527 R 12:
Date
To the I pector 6f Wires:
described below.
Existing ServiceAmps - voits
New Service Amps
Number of Feeders and Ampacity
Location and Nature of Proposed Electrical Work
I
No ❑ (Check Appropriate Box)
Authorization No. 0L-1
Overhead ❑ Undgmd ❑ No. of Meters
Overhead ❑ Undgmd [3'/ No. of Meters
OTHER:
INSURANCE COVERAGE. Pursuant to the requiremen6ts of Massachusetts General Laws
I have a current Liability Insurance Policy including Completed Operations Coverage or its substantial equivalent YES = NO =
haves Knitted valid proof of same to the Office YES= NO = .If _ u ave ch YES please indicate the e f rage by checking the appropriate box
U gbl. = BOND = OTHER = (Please Specify) �!�? �i�
(Expiration Date)
Estimated Value of Electrical Work$
Work to Start Inspection Date Resquested GC>r l/`/6Z Rough Final
Signed underthe Penaltiepegww
s o
FIRM NAME __ % sr L axl .e- Zli<l .4 tO 4,::4 LIC. NO.
Bus. Tel No.
Alt Tel. No.
does have the insurance coverage or its substantial equivalent as required by Massachusetts
1,w es this requirement. Owner Agent (Please Check one)
Telephone No. PERMIT FEE $
of Owner or Agent)
Total
No. of Light8ng Outlets
No. of Hot fuse
No. of Transformers KVA
Above C1
in 11No.
of Lighting Fixtures
Swimminq Pool rnd ❑
gmd ❑
Generators KVA
No. of Emergency Lighting
No. of Receptacles Outlets
No. of Oil Burners
Battery Units
No. of Switch Outlets
No of Gas Burners
FIRE ALARMS No. of Zone
No. of Detection and
Total
No. of Ranges
No of Air Cond
Tons
Initiating Devices
Heat Total Total
No. of Di oral
L
No. Pumps
Tons
KW
No. of Sounding Devices
No./ of Self Contained y�
No. of Dishwashers
`
Space/Area Heating
KW
Detection/Sounding Devices
❑ Municipal ❑ Other
No. of Dryers
Heating Devices
KW
Loca Connection
No. of
No. of
Low Voltage
No. of Water Heaters
KW
Signs
Bailases
Wiring
No. Hydro Massage Tuds
No. of Motors
Total HP
OTHER:
INSURANCE COVERAGE. Pursuant to the requiremen6ts of Massachusetts General Laws
I have a current Liability Insurance Policy including Completed Operations Coverage or its substantial equivalent YES = NO =
haves Knitted valid proof of same to the Office YES= NO = .If _ u ave ch YES please indicate the e f rage by checking the appropriate box
U gbl. = BOND = OTHER = (Please Specify) �!�? �i�
(Expiration Date)
Estimated Value of Electrical Work$
Work to Start Inspection Date Resquested GC>r l/`/6Z Rough Final
Signed underthe Penaltiepegww
s o
FIRM NAME __ % sr L axl .e- Zli<l .4 tO 4,::4 LIC. NO.
Bus. Tel No.
Alt Tel. No.
does have the insurance coverage or its substantial equivalent as required by Massachusetts
1,w es this requirement. Owner Agent (Please Check one)
Telephone No. PERMIT FEE $
of Owner or Agent)
TOWN OF NORTH ANDOVER
PERMIT FOR WIRING
Thiscertifies that .................... I .......................................................................
has permission' to perform s....... ................................
wiring in the building of...... 1.,� '., .. . ..................................................
at ........
— . ................ ......... North Andover, Mass.
Fee7:A/ Lic. Nom-ZZ-L'Z� ..............................................................
ELECTRICAL INSPECTOR
03/27/98 13:12 245.00 PAID
WHITE: Applicant CANARY: Building Dept. PINK: Treasurer
` CERTIFICATE OF USE &OCCUPANCY
Town of North Andover
Building Permit Number Date—
THIS
THIS CERTIFIES THAT
THE BUILDING LOCATED ON 600
MAYBE OCCUPIED AS IN ACCORDANCE
WITH THE PROVISIONS OF THE MASSACHUSETTS STATE BUILDING CODE AND
SUCH OTHER REGULATIONS AS MAY APPLY.
CERTIFICATE ISSUED TO
ADDRESS
tsuuctrng inspector
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INS' RUCTIONS
QRE•w' CONSTRUCTION
.The following fst.of, mandatory information required to obtain a Building
Permit foc,.,nevr construction. (single and two, family .
1 A completed Form U Verift.ca ion Form signed by all depts. and boards. Y
2 A blue Growth, Management R law Exemption Statement, filled out and signed.
3 A completed building permit application form in duplicate, and signed.
4 A plot plan of the property with a proposed building shown on the property with
proper set backs. "
5 If a variance was required , the decision from the Board of Appeals must be
stamped by the Town Clerks office that the twenty day appeal period is over and
recorded at the Registry of Deed& tier` copy must be submitted with application.
6 A copy of your Massachusetts Builders License. If you are a homeowner and want
to build your on home but subcontract the framing, a copy of the builders license /
must be submitted with the application.
7 Two full sets of building plans drawn to scale. ( one set will be returned )
8 No applications willbe accepted unless accompanied by all the proper documents.
Your. anticipated cooperation will expedite the building permit process.
Thank you.
J
cop
goh Imo' 1 C c4+A,
FORM U - VERIF'ICAT'ION 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*****************
44 OWVW��
APPLICANT: JdFtU t�. F-LEVR,l Phone _68- VSj- 9158 time
LOCATION: Assessor's Map Number �d B
Subdivision _ t -t 0,r^d'eeh �,64xtc-5
Street f 6a;sakt 9moic RgW
Parcel
Lots) ND.
St. Number
************************Official Use Only************************
Comments
q Cd_u�
Town Planner
Comments
Food Inspector -Health
Septic Inspector -Health
Comments
V Public Works - sewer/water connections
- driveway permit
Fire Department
Received by Building Inspector
M
Date Approved�-
Date Rejected
Date Approved
Date Rejected
Date Approved a�
Date Rejected
IVa
z
Y,3o —
Date
RE
ND77AT.IONS OF TOWN AGENTS:
AJI�
Date
Approved
r'
J '�
Conservation Administrator
Date
Refected
Comments
q Cd_u�
Town Planner
Comments
Food Inspector -Health
Septic Inspector -Health
Comments
V Public Works - sewer/water connections
- driveway permit
Fire Department
Received by Building Inspector
M
Date Approved�-
Date Rejected
Date Approved
Date Rejected
Date Approved a�
Date Rejected
IVa
z
Y,3o —
Date
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 Building Permit (below) Address of Property for Permit (below)
7jbIfK 1, FL EJRI _ FV�+� F��,I est{- -t �
Map and Parcel: Purpose of Application (check below)
PAone Ot mb_� _
f J p 'cant: �(, Single Family _ Two Family
I Itfe 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
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 iq 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
exist nce as of the effective date of this by-law, provided that no additional residential unit is created.
The lot(s) were/was created prior to May 6, 1996 are exempt from the provisions of this Section 8.7 of the Zoning
ByTTaw.
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.
This application represents a lot which is ready for building permits,(i.e. 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 of the information provided and that the attached building permit is
allowed an EXEMPTION as cited above. Further I understand that the submittal of misleading and or
inaccurate information, or the checking off of an above item which does not comply, whether done to my
knowledge or not, is grounds for refusal by the Building Department to issue a Building Permit.
����f7
ature o w r or Authorized AXent who signed theiAttached Building Permit Date
form must he attached to t Building Permit upon application for such permit.
rrJii
location:
city DI nhnne#f4mT Yscf-7l_J A
I am a homeowner performing all work myself.
I am a sole proprietor and have no one working in any capacity
the following workers' compensation polices:
one years' imprisonment as well as civil penalties in the form of a STOP WORK ORDER and a fine of $100.00 a day against me. I understand that a
copy of this statement may be forwarded to the Office of Investigations of the DIA for coverage verification.
I do hereby certify under the pains and penalties of perjury that the information provided above is true and correct
Signature Date/0-01?" fit
Print nameI%'Z Phone # l B� Yi -17 �71-- 9
official use only do not write in this area to be completed by city or town official
city or town: permittlicense # MBuilding Department
[]Licensing Board
C] check if immediate response is required (3Selectmen's Office
pHealth Department
contact person: phone #; ___]:]Other
(revised 3/95 P1A)
Information and Instructions
Massachusetts General Laws chapter 152 section 25 requires all employers to provide workers' compensation for their
employees. As quoted from the "law", an employee is defined as every person in the service of -another under any
contract of hire, -express or implied, oral or written.
An employer is defined as an individual, partnership, association, corporation or other legal entity, or any two or more of
the foregoing engaged in a joint enterprise, and including the legal representatives of a deceased employer, or the
receiver or trustee of an individual , partnership, association or other legal entity, employing employees. However the
owner of a dwelling house having not more than three apartments and who resides therein, or the occupant of the
dwelling house of another who employs persons to do maintenance, construction or repair work on such -dwelling house
or on the grounds or, building: appurtenant thereto shall not because of such employment be deemed to bean_ employer.
MGL chapter 152 section 25 also states that every state or local licensing agency shall withhold the issuance or
renewal of a Iicense or permit to operate a business or to construct buildings in the commonwealth for any
applicant who has not produced acceptable evidence of compliance with the insurance coverage required. _
Additionally, neither the commonwealth nor any of its political subdivisions shall enter into. any contract for the
performance of public work until acceptable evidence of compliance with the insurance requirements of this chapter have
been presented to the contracting authority. .
Applicants
Please fill in the workers' compensation affidavit completely, by checking the box that applies to your situation and
supplying company names, address and phone numbers as all affidavits may be submitted to the Department of
Industrial Accidents for confirmation of insurance coverage. Also be sure to sign and date the affidavit. The
affidavit should be returned to the city or town that the application for the permit or license is being requested,
not the Department of Industrial Accidents. Should you have any questions regarding the "law" or if you are required
to obtain a workers' compensation policy, please call the Department at the number listed below.
City or Towns
Please be sure that the affidavit is complete and printed legibly. The Department has provided a space at -the bottom of
the affidavit for you to fill out in the event the Office of Investigations has to contact you regarding the applicant. Please
be sure to fill in the permit/license number which will be used as a reference number. The affidavits may be returned to
the Department by mail or FAX unless other arrangements have been made.
The Office of Investigations would like to thank you in advance for you cooperation and should you have any questions,
please do not hesitate to give us a call.
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600 Washington Street
Boston, Ma. 02111
fax 4: (617) 727-7749
phone #: (617) 727-4900 ext. 406, 409 or 375
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Cow
DEPARTMENT MENT .
OF P J �_I; 'AF
TON P ETY
ONE ASHBUR
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BOSTON, MA 02.10E-1613
CONSTRUCTION SUPERVISOR LICENSE
CS Number: Expires:
Birthdate:
Restricted3TO: 00Ef20/199i DEJ20f?948
ROLANO
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INSURANCE COVERAGE:
1 have 4 current liabllty Insurance policy or Its substantial equivalent Check one
It YOU have checked yet, please indicate the Yes 6�� No ❑
type coverage by checking the appropriate box.
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Ype of Indemnity ❑ Bond ❑
OWNER'S INSURANCE WAIVER: I am aware aptthat the licensee d
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All oppf the details and War .Matlon I have submitted ( and Inor entered) In above application are W
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2 79 u Date ...5 ..........
f „oRTM , TOWN OF NORTH ANDOVER
9 PERMIT FOR GAS INSTALLATION
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This certifies that .. �! ........ I r ......................
has permission for gas installation ...rl. ......
in the buildings of
at ...? �.../.'/ r�.r.,>... ..%' '.�...., North Andover, Mass.
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GAS INSPECTOR
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MASSACHUSETTS UNIFORM APPLICATION:FOR PERMIT,!TO:DO'P1.UNI�B1, r
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NORTH ANDOVER ,Mass. ppj i-4 `. Date:' •6& -e3 -y
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Liability insurance policy Other type �.of indemnity [:] Bond
Insurance Waiver: I, the undersigned, have been made aware - that the licensee of
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Signature
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TOWN OF NORTH ANDOVER
SEWAGE DISPOSAL SYSTEM
INSTALLATION CERTIFICATION
The undersigned hereby certify that the Sewage Disposal Sem ( constructed; ( )repaired;
by �c�.--air_ Akyst-
located
c�
was installed in conformance with the North Andover Board of Health approved plan, System
Design Permit rt ,j datedy�Z_ -7 with an approved design flow of
gallons per day. The materials used were in conformance with those specified on the approved
P
plan; the system was installed in accordance with the provisions of 310 CMR 15.000, Title 5 and
local regulations, and the final grading agrees substantially with the approved plan. All work is
accurately represented on the As -built which has been submitted to the Board of Health.
Bed inspection date:
Final inspection date:
Installej
Design
e—p
Date:
Date: G
'$ 5083723960
APG
�pw� Ol v0RTH _ANDOVER
SE�V,aGE t?tSPOSAL SYSTEM
iNST.-kLi-AT1ON CEl2TfFIC.,TION
v .etn ; �cns�s�ted: r r�;ired:
��crecy _�-t1�• chat c.':t Sc��•a�e UisposJ S, s'
e undersiu►ec .
Y —�—
it
was :nst311ed :n .:enior:stlLe a'iL:. the \J[itt Zr1CC�'eT �i1atL of s{C31rh :iDpYCVe(. p1at1. -]�'STZTtI
-7 .with an approved desig-*t 3cw of yo
:aced � —� e ttTtl hose ;pecitieci �n he app
_ - ce:t'�'-`�c ?re•isionS of -10 {��1�'.=.JOU -,;de : and
i31,.ns per day he m3cenais uses .ve;e ;n centoRnOro ! .�:1 work s
plan. The ,yste'n'xas n�t;lled _-t ac:JT13 d �t':italch.
cul st:ca_. u;d the i:rai �adils� a es subs:snt:al.y wi h c.'te apprcyed F
local -e5 9 ._._
ac: 1cate..v 'epresenced on he .�s-l�ulit xili '.: has been ,ubm�tted
fed ,pec- L dare.
`-15181Ier:
�tSiL11 L
Date:
J {�
Date_ O
P02
f NORTh ,
t
F A
♦ off_ _ _ � }
,SSACHUSES
Applicant
Town of North Andover, Massachusetts Form No. 3
BOARD OF HEALTH q �,
l 19—��
DISPOSAL WORKS CONSTRUCTION PERMIT
e.c9✓ae /-/c"�erS 1Sz—ti
NAME / L y 61 AUUKt55 I tLtrhurvt
Site Location Leo- L -DA P ;3. !Z 14,:a-/— R'�--
Permission is hereby granted to Construct (>) or Repair ( ) an Individual Soil Absorption
Sewage Disposal System as shown on the Design Approval S.S. No.�
Fee
D.W.C. No. 166.S
H -
TOWN OF NORTH ANDOVER
SEWAGE DISPOSAL SYSTEM
INSTALLATION CERTIFICATION
The undersigned hereby certify that the Sewage Disposal System (constructed; ( ) repaired;
1 � `
located at
was installed in conformance with the. North Andover Board of Healthproved plan, System
Pe.e,_;l rja�G / 9/9,L
Design Permit,, � dated '�-z -z/-r 7 with an approved design flow of D
gallons per day. The materials used were in conformance with those specified on the approved
plan; the system was installed in -accordance with the provisions of 310 CMR 15.000, Title 5 and
local regulations, and the final grading agrees substantially with the approved plan. All work is
-accurately represented on the As -built which has been submitted to the Board of Health.
Installer:
Design Engineer:
Lic. #: Date:
Date:
Town of North Andover, Massachusetts Form No. 2
NOR7►, BOARD OF HEALTH
O.4•`ao �•',•`O 1 q
F w
P
i ;
♦ i i
DESIGN APPROVAL FOR
ass"C14p5SOIL ABSORPTION SEWAGE DISPOSAL SYSTEM
Applicant N I Test No.
Site Location q1.,.•r
Reference Plans and Specs. _LA A.
ENGINEER DESIGN I DATE
Permission is granted for an individual soil absorption sewage disposal system to be installed
in accordance with regulations of Board of Health.
CHAI RMAN,BOARD OF HEALTH
Fee V Site System Permit No. I
Town of North Andover, Massachusetts Form No. 3
NORTH
BOARD OF HEALTH
1
19
F p
DISPOSAL WORKS CONSTRUCTION PERMIT
,SSACHUSEt
Applicant 7-/ Ili 11)4L )r'.11-)
NAME ADDRESS TELEPHONE
Site Location �GT �VG,�C SEC—;CJ
Permission is hereby granted to Construct ( ) or Repair ( ) an Individual Soil, Absorption
Sewage Disposal System as shown on the Design Approval S.S. No. 9/-:C
Fee � 7.5
CHAIRMAN, BOARD OF HEALTH
D.W.C. No. c' ! :)-
APPLICATION FOR DISPOSAL WORKS CONSTRUCTION PERMIT
DATE: g CURRENT INSTALLER'S LICENSE#
LOCATION: -- �o Lien
LICENSED INSTALLER: ` 5 o h
SIGNATURE: —se— , TELEPHONE# L ° L -s- ffy 3 -
CHECK ONE:
REPAIR: NEW CONSTRUCTION: Z --
IF
- -IF NEW-CONSTUCTION, PLEASE ATTACH FOUNDATION AS -BUILT.
Administrative Use Only
$75.00 Fee Attached? Yes No
Foundation As -Built? Yes No
Floor Plans? Yes i No
Approval Date:
FORM U - VERIFICATION FORM
INSTRUCTIONS: This form is used to verify that all necessary
approvals/permits from Boards and Departments having jurisdiction
have been obtained. This does not relieve the applicant and/or
landowner from compliance with any applicable local or state law,
regulations or requirements.
****************Applicant fills out this section*****************
4V4APPLICANT: Jdl��( F. F�-EVRY .4�� 736o�og Worms
Phone �$- V5a- 915$ 44o4e
LOCATION: Assessor's Map Number �d B
Subdivision �� earareen �S�c�-tcs
Street f�GeuSc.,..t Brook Rtxc�
Parcel
Lots) N0. q
St. Number
************************Official Use Only************************
RE DATIONS OF TOWN AGENTS: /J
` Date Approved -5- 4-
Conservation Administrator Date Refected
Comments
Town Planner
Comments
Food Inspector -Health
Septic Inspector -Health
Comments
Public Works - sewer/water connections
- driveway permit
Fire Department
Date Approvedq-
Date Rejected
Date Approved
Date Rejected
Date Approved a�
Date Rejected
Received -by Building Inspector Date
NORTH ANDOVER BOARD OF HEALTH
DESIGN REVIEW REPORT
DATE jj
FEE: PERMIT # DATE RECEIVED
APPLICANT N1,9755,JIU4 Z%i� ? MAP PARCEL
ADDRESS
LOT # 4 STREET #
ENG. `� -``�" STREET�11z5�AA-)7- EAK
ENGINEER'S ADD. /,/a 6) �L�7r�1It� jr i"jai
PLAN DATE REV. DATE
CONDITIONS OF APPROVAL
APPROVED DISAPPROVED
REASONS FOR DISAPPROVAL:
/'Jo
/.eF�
MAP
Town of North Andover
OFFICE OF
COMMUNITY DEVELOPMENT AND SERVICES
WILLIAM J. SCOTT
Director
September 12, 1997
Christiansen & Sergi
160 Summer Street
Haverhill, MA 01830
30 School Street
North Andover, Massachusetts 01845
Re: Lot #4 Pheasant Brook Road
Dear Phil:
This is to inform you that the proposed plans for the site referenced above have been
disapproved for the following reasons:
1) No manhole within 6 inches of grade. (3 10 CMR 15.228(2))
2) Two feet after D -Box level statement missing. (3 10 CMR 15.232(c))
3) Please show area of ledge.
4) Map & Parcel missing. (N.A. 8.02a)
5) Site visit will be required before final approval with both primary and reserve.
If you have any questions, please do not hesitate to call the Board of Health Office at the
number below.
Sincerely,
Sandra Starr, R.S.
Health Administrator
SS/cjp
cc: William Scott, Director, P&CD
Bob -Messina
File_ S
CONSERVATION 688-9530 HEALTH 688-9540 PLANNING 688-9515
PLAN REVIEW CHECKLIST
ADDRESS O7'-¢ �DO ENGINEER
GENERAL
3 COPIES l/ STAMP C--'
/
LOCUS (/
NORTH ARROW
SCALE Ll--
S,C
Y oeMs
CONTOURS PROFILE t---'
SECTION
�� BENCHMARK C/
SOIL&
PERCS ELEVATIONS P'
WETS. DISCLAIMER WELLS
& WETS
WATERSHED? DRIVEWAY
L—( E1ev)
WATER LINE L---- FDN
DRAIN el,
SCH40 TESTS CURRENT? /q SOIL EVAL
SEPTIC TANK /
MIN 1500G L/ .17 INVERT DROP '`'' GARB. GRINDER EDF)
25' TO CELLAR V MANHOLE ELEV GW # COMPS./
D -BOX
SIZE # LINES FIRST 2' LEVEL STATEMNT�
INLET /� q,7% - OUTLET I 9, �pQ _ . / ( 2" OR .17 FT) TEE REQ' D?/(/0
LEACHING
MIN 660 GPD? V" RESERVE AREAL,-" 4' FROM PRIMARY? V" 20 SLOPE L�/
100' TO WETLANDS t/ 100' TO WELLSy 4' TO S.H.GW (5'>2M/IN)
35' TO FND & INTRCPTR DRAINS L,--'-3251 TO SURFACE H2O SUPP -�--
4' PERM. SOIL BELOW FACILITY( MIN 12" COVER FILL? (25'
if above natural elev; 101if below) BREAKOUT MET?
TRENCHES
MIN 660 gpd SLOPE (min .005 or 6"/1001) SIDEWALL DIST. 3X EFF.
W OR D (MIN 61) RESERVE BETWEEN TRENCHES? IN FILL? MUST
BE 10' MIN. 4" PEA STONE? VENT? (>3' COVER; LINES >50')
BOT + SIDE X LDNG = TOT
(L x W x #) (DxLx2x#) (G/ft2)
Copyright V 1995 by S.L. Starr
PITS
MIN 660 LEACHING MIN 1 (13'x16') PIT MANHOLE/PIT
GW MIN 4' BELOW BOTTOM EXC 2x EFF W OR D 12"-48" STONE
BOT + SIDE x LOAD = TOTAL
(L x W x #) (2x(L+W)xD x #) (G/ft2)
CHAMBERS
MIN 660 LEACHING GW MIN 4" BELOW COVER >3 FT - VENT
MANHOLES 12"-48" STONE SPLASH PADS SLOPE .005
BED/TRENCH (Bed max. 60' X 601) MIN 13' X 16' PIT
BOT + SIDE X LOAD = TOTAL
(L x W x #) (2 x (L+W)xD x #) (G/ft2)
FIELDS
MIN 660 GPD & 900 ft2 BED GW MIN 4' BELOW BOTTOM OF FIELD
PIPE ENDS JOINED? r/ 4" PEA STONE? DIST LINE SLOPE .005?y�
>31COVER-VENT SCH 40MIN 12" COVER // //
RATE /►XPi LDG X 660 = Old X '66= TOTAL LSO
G/ft2 REQ'D (ft2) LXW�-
!QQ
DOSING TANKS AND PUMPS
DIMENSIONS X X - PUMP CAPACITY 9Pm
L W D Vol.
DISCHARGE SIZE DISCHARGE RATE DISCHARGE TIME
9Pm
MANHOLES TO GRADE
inlet) HWL
OP. SWITCH
Copyright 0 1995 by S.L. Starr
ALARM SEP. CIRC. GW (Min. 1' below
LWL CHECK VALVE BLEEDER HOLE MANUAL
LOCATION: UD -r
NEW PLANS: YES
SEPTIC PLAN SUBMITTALS
T
REVISED PLANS: YES
DATE:
DESIGN ENGINEER
$60.00/Plan /
$25.00/Plan
When the submission is all in place, route to the Health Secretary
SEPTIC PLAN SUBMITTALS
LOCATION: L -07—`A P V Q-SQy7-t &Y -0C Ih 20( .
NEW PLANS: YES $60.00/Plan
REVISED PLANS: YES $25.00/Plan V
DATE:
DESIGN ENGINEER: CCOLY�-�
When the submission is all in place, route to the Health Secretary
CHRISTIANSEN & SERGI, INC.
PROFESSIONAL ENGINEERS AND LAND SURVEYORS SEP 2 2 1997 m°
160 SUMMER STREET HAVERHILL, MASSACHUSETTS 01830-6318 (508) 17n3t0-FAX-- 8) 372!39601
September.22, 1997
Ms. Sandra Starr
Health Administrator
30 School Street
North Andover, MA 01845
Dear Ms. Starr:
RE: Lot 4, Pheasant Brook Road
In response to your letter of September 12, enclosed are
copies of revised Septic System Plans incorporating all of
your comments.
If you have any additional questions, please do not hesitate
to call.
PGC; 1c
•
APPLICATION FOR DISPOSAL WORKS CONSTRUCTION PERMIT
DATE: 57— / -- 6�% CURRENT INSTALLER'S LICENSE#
LOCATION:
LICENSED INSTALLER:
SIGNATURE:
CHECK ONE:
i ' r,
TELEPHONE# 6,?
NEW CONSTRUCTION:
IF NEW CONSTUCTION, PLEASE ATTACH FOUNDATION AS -BUILT.
$75.00 Fee Attached?
Foundation As -Built?
Administrative Use Only
Yes / No
Yes No
Approval Date:
EPM CONTRACTING INC. -LAWRENCE SAVINGS BANK s
22 DALE STREET
ANDOVER, MA 01810 - 53-7143-2113
PAY TO
ORDER OF E sown cF nom (An �-
��vCx�tY
MEMO LOf '; 6 Eu a man n &(J'„')
ennn L l illi nn
$ r� �S: 00
417
a
0
0
a
DOLLARS
APPLICATION FOR DISPOSAL WORKS CONSTRUCTION PERMIT
DATE: 57— � '�? 7 CURRENT INSTALLER'S LICENSE#
LOCATION:
LICENSED INSTALLER:
SIGNATURE: 4z-
41,
TELEPHONE# 6,?
CHECK ONE:
REPAIR: NEW CONSTRUCTION:
IF NEW CONSTUCTION, PLEASE ATTACH FOUNDATION AS -BUILT.
$75.00 Fee Attached?
Foundation As -Built?
Administrative Use Only
Yes V No
Yes No
Approval —== � ��
Date:�`�<
P
TO
DATE
TIME AM
Pm
H
O
N
FROM
ivy- /�lnYl V 'G[�r r
NO.
y✓�r �✓
EX .
/G
OF / ✓ I7
E
nn
E
1�.. D L of
M
sle
4-11 cLJG
M
G
OE
SIGNED
PHONED ❑
CALL
RETURNED ❑
WANTSTO ❑
qFFYQlj
WILLCALI ❑
AMAIN
WAS IN
URGENT ❑
)r
it l 1
.� \
� � \ `'
�t `, tiT
'\ /�
1` �
♦\
R
Town of North Andover
OFFICE OF
COMMUNITY DEVELOPMENT AND SERVICES
146 Main Street
North Andover, Massachusetts 01845
WU LIAM J. SCOTT
Director
March 24, 1997
Mr. Roland A. Coulliard
D.E.C.M. Essex Inc.
660 Rogers Street
Lowell, MA 01852
Re: Septic testing - Evergreen Estates
Dear Mr. Coulliard,
�B
2 " inr.
I am writing to remind you that some of the lots in the Evergreen Estates subdivision require
additional septic testing prior to Building Permit issuance per the decision of the Planning
Board. I have had several applicants come into my office seeking a building permit who were
unaware of these conditions.
The leaching bed must be excavated on lots 4, 5, 19, and 20 before a building permit can be
issued. If the leaching bed has not been excavated, the applicant may choose to place a note on
the deed for the lot stating that the septic system must be installed, inspected and approved by the
Board of Health in accordance with all state and local regulations before construction of the
primary building is begun. This includes the pouring of foundation walls. A certified copy of the
recorded deed must be submitted to the Planning Department and Board of Health.
If you have any questions please do not hesitate to call me at 688-98535.
Very truly yours,
Kathleen Bradley Colwell
Town Planner
cc. W. Scott, Dir. CD&S
S. Starr, Health Adm.
BOARD OF APPEALS 688-9541 BUILDING 688-9545 CONSERVATION 688-9530 HEALTH 688-9540 PLANNING 688-9535
Lot#
Date Plans
Submitted
Date.
Plans
A ' roved
Date Form
"U" Sign Off
Notes:
IA
6/13/96
9/19/96
9/19/96 -SS
2A
6/13/96
1/9/96-
7/23/96
9/19/96 -SS
3A
2/20/96
4/2/96
8/5/96 -SS
4
3/25/96
5/28/96
see note 1
5
10/1/95
11/1/95
see note 1
6
8/30/96
9/3/96
9/3/96 -SS
7
6/17/96
6/25/96
8/5/96 -SS
8
4/1/96
4/15/96
8/5/96 -SS
9
9/20/96
9/27/96
9/27/96
see note 3- 9/26/96
10
2/28/96
4/2/96
8/5/96 -SS
11
2/29/96
4/2/96
8/5/96 -SS
12
9/18/96
9/20/96
9/20/96 -SS
13
9/18/96
9/27/96
9/27/96
see note 3 - 9/26/96
14
12/4/95
8/1/96
8/29/96 -SS
15A
1/31/95
3/19/96
8/5/96 -SS
16A
6/14/96
7/29/96
8/26/96 -SS
17
8/2/96
5/24/96
8/19/96 -SS
18
10/1/95
11/26/95
see note 1
19
12/19/95
2/6/96
see note 1
20
2/20/96
4/2/96
see note 1
21
9/20/96
9/27/96
9/27/96
see not 3 - 9/26/96
22
8/8/96
9/3/96
9/3/96
1 - Excavation needed
2 - Additional tests needed. Previous tests either did not pass or are incomplete.
3 - Plans require variance (s) from Board of Health.
TABLE #2
s»
FORM C .. .
APPLICATION FOR APPROVAL OF DEFIMT= PL �CE
OWs C►..r.RX
NORTH AH00YER
January 17 ^ c; 19 95
JAN `i t :<<,
To the Planning Board of the Town of Forth Andover:
The undersigned, being the applicant as defined under Chapter Lit, Section
81-L, for approval of a proposed subdivision shorn on a plan entitled
Definitive Subdivision Plan "Evergreen Estates" located in North Andover
by Christiansen & Sergi, Inc. dated December 28. 1994
being land bounded as follows: Northerly bt Com of MA, land of Steer and Fried;
easterly by land of Fried, Badder, Rough, Green, Galeassi, Yourre, Mateja.,
R; T„A1 L-Arn2,4 n a; g —SQ Tern- S4 �-r-a"4 P Farr and
Com of MA; westerly by Com of MA..
hereby submits said plan as a DEFINITIVE plan in accordance with the Rules and
Regulations of the North Andover Planning Board and makes application to -the
Board for approval of said plan.
1087 314
Title Reference: North Essex Deeds, Book 2901 , Page 13 ; or
Certificate of Title No. , Registration Book , page ; or
Other:
Said plan has(X) has not( ) evolved from a preliminary plan submitted to
the Board of A u ry 24 19 _9and approved (Kith modifications) ( )
disapproved (X on Oct 4 , 1994
.The undersigned hereby applies for the approval of said DEFINITIVE plan
by the Board, and in furtherance thereof hereby agrees to abide by the Board's
:Rules and Regulations. The undersigned hereby further covenants and agrees
with the Town of North Andover, upon approval of said DEFINITIVE plan by the
Board:
1. To install utilities in accordance with the rules and regulations of the
Planning Board, the Public Works Department, the Highway Surveyor, the
Board of Health, and all general as well as zoning by-laws of said Town.,
as are applicable to the installation of utilities within the limits of
ways and streets;
2. To complete and construct the streets or ways and other improvements shown
thereon in accordance with Sections Iv and V of the Rules and Regulations
of the Plamu ng Board and the approved DEFINITIVE plan, profiles and cross
sections of the sane. Said plan, profiles, cross sections and construction
specifications are specifically, by. -reference, incorporated herein and made
a part of this application. This application and the covenants and agree-
ments herein shall. be binding upon all heirs, executors, administrators,
successors, grantees of the whole or part of said land, and assigns of the
undersigned; and
3. To complete the aforesaid installations and construction within two (2)
years from the date hereof.
Received by Town Clerk:
Date: Signature of Applicant
Messina Development Corp., 805 Winter St.
Time: North Andover, MA 01845
Signature: Address
Gtr ..i. ,i a -"t.
Notice to APYL1UAW/T V CLERK and Certification of A .on or rlann=g Board .,
on Definitive Subdivioion Plan entitled: ,!
Evergreen -Estates
By: Christiansen & Sergi dated nPr pmF,ar 7,p 19 94
The North Andover Planning Board has voted to APPROVE said plan, subject to the
following conditions:
1. That the record owners of the subject land forthwith execute and record
a "covenant running with the land", or otherwise provide security for the con—
struction of ways and the installation of municipal services within said sub—
division, all as provided by G.L. c. 41t S. 81—U.
2. That all such construction and installations' shall in all respects
conform to the governing rules and regulations of this Board.
3. That, as required by the North Andover Board of Health in its report to
this Board, no building or other structure shall be built or placed upon Lots
No. as shown on said Plan without the prior
consent of said Board of Health.
4. 'Other.conditions:
Lr
See attached
r+*rrm
c.�
Lr
In the event that no appeal shall have been taken from said approval within
twenty days from this date, the North Andover Planning Board will forthwith
thereafter endorse its formal approval upon said plan.
The North Andover Planning Board has DISAPPROVED said plan, for the following
reasons:
Date: August 15, 1995
NORTH ANDOVER PLANNIM BOARD r
By:
r{�
Josepi, V. Mahoney, Chalrman
1
a. A complete set of signed plans, a, copy of the Planning
Board decision, and a copy of the Conservation Commission
Order of Condition must be on file at the Division of
Public Works prior to issuance of permits for connections
to utilities. The subdivision construction and
installation shall in all respects conform to the rules
and regulations and specifications of the Division of
Public Works.
b. All site erosion control measures required to protect off
site properties from the effects of work on the lot
proposed to be released must be in place. The Town
Planning Staff shall determine whether the applicant has
satisfied the requirements of this provision prior to
each lot release .and shall report to the Planning Board
prior to a vote to release said lot.
C. The applicant must submit a lot release FORM J to the
Planning Board for signature.
d. A Performance Security (Roadway Bond) in an amount to be
determined by the Planning Board, upon the recommendation
of the Department of Public Works, shall be posted to
ensure completion of the work in accordance with the
Plans approved as part of this conditional approval. The
bond must be in the form of a check made out to the Town
of North Andover. This check will then be placed in an
interest bearing escrow account held by the Town. Items
covered by the Bond may include, but shall not be limited
to:
i. as -built drawings
ii. sewers and utilities
iii. roadway construction and.maintenance
iv. lot and site erosion control
V. site screening and street trees
vi. drainage facilities
vii. site restoration
viii.final site cleanup
e. Three (3) complete copies of the endorsed and recorded
plans and two (2)_ certified copies of the recorded
subdivision approval, Covenant (FORM I), Right of Way
easements, and FORM M must be submitted to the Town
Planner as proof of filing.
4. Prior to a FORM U verification for an individual lot, the
following information is required by the Planning Department:
a. All lots must be approved by the Board of Health. The
Board of Health has determined that Lots 6, 9, 12, 13,
and 21 cannot be used for building sites without injury
4
0
to the public health without further testing. No
building or structure shall be placed upon these lots
without consent by the Board of Health.
b. Due to the large amount of rock on the site which may
interfere with the amount of parent material available
for leaching, the Board of Health will require that the
leaching area for each lot be completely excavated to
insure that there is the requisite four feet of parent
material present throughout the entire location proposed
for the leaching area.
C. The applicant must submit to the Town Planner proof that
the FORM J referred to in Condition 3 (c) above, was filed
with the Registry of Deeds office.
d. A plot plan for the lot in question must be submitted,
. which includes all of the following:
i.
location of
the structure,
ii.
location of
the driveways,
location of
the septic systems if applicable,
iv.
location of
all water and sewer lines,
V.
location of
wetlands and any site improvements
required under a NACC order of condition,
vi.
any grading
called for on the lot,
vii.
all required zoning setbacks,
viii.
location of
any drainage, utility and other
easements.
e. All appropriate erosion control measures for the lot
shall be in place. Final determination of appropriate
measures shall be made by the Planning Board or Staff.
f. All catch basins shall be protected and maintained with
hay bales to prevent siltation into the drain lines
during construction.
g. The lot in question shall be staked in the field. The
location of any major departures from the plan must be
shown. The Town Planner shall verify this information.
h. Lot numbers, visible from the roadways must be posted on
all lots.
Prior to a Certificate of Occupancy being requested for an
individual lot, the following shall be required:
a. A stop sign must be placed at end of Pheasant Brook Road
where it intersects with Salem Street.
b. A driveway easement across Lot 22 must be granted to Ian
5
P r
11
CHRISTIANSEN & SERGI, INC.
PROFESSIONAL ENGINEERS AND LAND SURVEYORS
160 SUMMER STREET HAVERHILL, MASSACHUSETTS 01830
March 25, 1996
Ms. Sandra Starr
North Andover Board of Health
120 Main Street
North Andover, MA 01845
Re: Lot 4 Pheasant Brook Road (Evergreen Estates Subdivision)
Dear Ms. Starr:
(508)373-0310 FAX: (508) 372-3960
Thank you for your February 12, 1996 comments regarding the Septic System Design for the
above referenced lot. I have the following responses to your reasons for disapproval.
1. The required Soil Evaluator forms are enclosed.
2. The septic tank has been raised to an elevation where it will have less than 1 foot of
cover and therefore does not require a manhole. See revised plan.
3. The elevations of the perc tests have been added to the plan.
Enclosed are 3 copies of the revised Septic System Design for Lot 4. Please contact me if you
have any other comments regarding this design.
V*G.
y ours,
Christainsen
a
FORM 11. - SOIL EVALUATOR FORM
Page 1 of 3
Date: 3 Z S/Y(
No.
Commonwealth of Massachusetts
Nor?1 riE�vbvvr�►2 , Massachusetts
Soil Suitability Assessment for On-site Sewage Dtsnosal
Performed By :...........S.I..I�..V.. �........(�..c �(!Z..S a ........................................
... Date:
�� �qs......
S�
St4NQY ........
Witnessed By:............ .......................................... .
..............................................................................................................
LO f 4 0""" e. 1n1FSS1N19 OEVELONME�t1r-COrLp
«
Lamm Address Address. and
L«# Te�eptme, -44 6RE19T P0AJ0 0P-tV6
J5VEK 612EEAJ 9STnTF-5 �3OXFomoj M!9 0197,1
ew construction ( Repair ❑ 88 '? ` 310 Z
Office Review
Published Soil Survey Available: No Yes ❑
/ ` 13� ( IS4 Soil Map Unit Cr C .............
Year Published Publication Scale
...........
Drainage Class
t„�EU- D�l:!!�Soil Limitations C,.�►'L.G..�.....S.tiff/c..,S.�.....0�.r?.(�'L...I.D....IZ.P.C.��.............
Surficial Geologic Report Available: No 2--l'Yes ❑
Year Published
Publication Scale
-Unit...............................................................
GeologicMaterial (Map )..........................................................................................
..............................
Landform
Flood Insurance Rate Map:
Above 500 Year flood boundary No ❑Yes lJ
Within 500 year flood boundary No ❑Yes ❑
Within 100 year flood boundary No ❑Yes ❑
Wetland Area:
National Wetland Inventory Map (map
unit) ..................
..................................................................................................
Wetlands Conservancy Program Map (map unit)
Current Water Resource Conditions (USGS): Month
Range :Above Normal ❑Normal ❑Beltw Normal ❑
Other References Reviewed:
DEP APPROVED FORM - 12/07195
<Ii
FORM 11 - SOIL. EVALUATOR FORM
Page 2of3
Location Address or Lot No. W7- 4 rsWi"tZG AE k Jjoww
On-site Review
Deep Hole Number 4-1 Date::::'t/.0/4? - Time:......:.:.... Weather
Location (identify on site plan)
Land Use ::!^.��.Nq - Slope (%) .O -S Surface Stones
Vegetation .:...::..::::. ..
Landform..... .::.::.:.:::.::.:. :...._ ......._..:.. .
Position on landscape (sketch on the back) .
Distances from:
Open Water Body feet Drainage way ._ feet
Possible Wet Area %S feet Property Line .. ZS feet
Drinking Water Well . feet Other
DEEP OBSERVATION HOLE =0G'
Depth from
Surface (Inches)
Soil Horizon
Soil Texture
(USDA)
Soil Color
(Munsell)
Soil
Mottling
Other
(Structure, Stones, Boulders. Consistency, %
Grave0-5-
-5-
3v
3
13w
FsL
NYXI-.
-5p - 8 6
G
tJ6 5 L
2,SY5A
--'
M rat - M Frf2
- MIIV11vWw1 yr 4nv�ca na. �ay...w r.. .._. _-_- -_-_ - --- - ---
Parent Material (geologic) DepthtoSedrock: 36
Depth to Groundwater: Standing Water in the Hole: NONj Weeping from Pit Face: 'V ov*- _
Estimated Seasonal High Ground Water: S 86 --
DEP APPROVED FORM - 12/07/95
M
FORM 11 - SOIL. EVALUATOR FORM
Page 2 of 3
Location Address or Lot No. (.pT 4 fV�1Z6P_1=.>zA/ �ST/97 5
On-site Review
been Hole Number ..47Z Date:.:::4.�6Time: :..._...... Weather
Location (identify on site plan)
Land Use :::�,10C c. glp Slope (%) 0-11,S Surface Stones
Vegetation
Landform ....:.. ,:...:...:: _:
Position on landscape (sketch on the back) .......:..::: -
Distances from:
Open Water Body. . - feet Drainage way feet
Possible Wet Area ../S?. feet Property Line ....... feet
Drinking Water Well feet Other ..:.:.
DEEP OBSERVATION HOLE LOG*
Depth from
Surface (Inches)
Soil Horizon
Soil Texture
(USDA)
Soil Color
(Munsell)
Soil
Mottling
Other
(Structure, Stones, Boulleders, Consistency, %
Grav
S' 3Z
1 Lj.l- z
C-
FS C-
IUY/Z S%6
3Z -84
G
65( -
G 5 L
Z,JYS%2
—
/hFYLl - ,✓1F�j2
W/ pS c
pvu��rS
" MINIMUM Ut L HULtb htUU1ntu r. i cv cn I I --I- ........, - - /
�f C
Parent Material (geologic) T -(c --C. DepthtoBedrock:
Depth to Groundwater: Standing Water in the Hole: Al Un/.f Weeping from Pit Face: ot/m✓' — _
Estimated Seasonal High Ground Water: i S4 --
DEP APPROVED FORM - 12/07/95
w
FORM 11 - SOIL EVALUATOR FORM
Page 3 of 3
Location Address or. Lot No. UT 4 Q veA6rZ9oW f 6Ti1 /1 J
Determination ,dor Seasonal Water Table
Method Used:
❑ Depth observed standing in observation hole ................... inches
❑ Depth weeping from side of observation hole ................. inches
❑Depth to soil mottles inches /VC/14i c 66"
❑ Ground water adjustment ................... feet
Index Well Number .................. Reading Date ................... Index well level ...................
Adjustment factor :.................. Adjusted ground water level ........................................................
Depth of Naturally Occurring Pervious Material
Does at least four feet of naturally occurring pervious material exist in all areas -
observed throughout the. area proposed. for the. soil absorption system? y9S
If not, what is. the depth of naturally occurring pervious material?
Certification
I certify that on ff (date) I have passed the soil evaluator examination
approved by the Department of Environmental Protection and thatthe above analysis
was performed by me consistent with the required training, expertise and experience
described in 310 CMR 15.017.
r -
Signature Jk,4 Date
DEP APPROVED FORM - 12107/95
FORM 12 - PERCOLATION TEST
Location Address or Lot No. (;,T 4 gvC"ee_rV 1 174 ,5
COMMONWEALTH OF MASSACHUSETTS
Al0n 1il1 k}Nb OyVt , Massachusetts
Percolation Test*
Date: ... ..ZI��'9S— Time:_...
Observation Hole #
Depth of Perc
I
Start Pre-soak
/O; S4
�p ; 3q-
4End
EndPre. -soak
W'0
I V,, 49
Time at 12"
o l
Time at 9"
Time at 6"
Time (9"-6")
5 Al rn/
/ 7 ,'►9�,t/
Rate Min./Inch
C Z
* Minimum of 1 percolation test must be performedin both the primary area AND
reserve
area.
Site Passed L9' Site. Failed ❑
Performed By: C IS(SnAMSEA/ 4 SE<ZG1. l/yice
Witnessed By: 5^Noy sly / ,i�c.t�9�/ F0P20
Comments:
DEP APPROVED FORM - 12/07/95
S"
DATE cQ 81
Sheet of
BOARD OF HEALTH
TOWN OF NORTH ANDOVER
SUBSURFACE DISPOSAL DESIGN REVIEW
FEE PERMIT # DATE RECEIVED
APPLICANT ``J 03043 5//l/A ASSESSOR'S MAP
ADDRESS
ENGINEER
PARCEL #
LOT # ¢ CE✓�i2G�e�c�n� c srz
STREET
ADDRESS /loo 50M M6,,e
PLAN DATE / //O /9G REVISION DATE
CONDITIONS OF APPROVAL:
APPROVED
DISAPPROVED
(310
���, S6iL GUA�vATal2 ��'n1$ /v1155 /NGC
lk�,QIVI-106C- 7-0
TESTS 515 I/VG
TY
Commonwealth of Massachusettsi
City/Town of .� 2Q�2
System Pumping Record [HEALTH
��NpFNORTHANDOVER
~ Form 4 DEPARTMENT
M
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.
A. Facility Information
1. System Location: Left / Right front of house, Left / ht rear of nous Left /right side of house, Left /
Right side of building, Left / Right front of building, Left / Right rear of building, Under deck
Address
City/Town
2. System Owner.
Name
Address (if different from location)
Citylrown
B. Pumping Record
1. Date of Pumping
3. Type of system: ❑
state
Zip Code
State � p.Code
Telephone Number
Date • Quan . Pumped: Gallons
Cesspool(s);,:e--ptic Tank ❑ Tight Tank
❑ Other (describe):
4. Effluent Tee Filter present? ❑ Yes [ No � If yes, was it cleaned? ❑ Yes ❑ No
5. Condition of
6. System Pumped By:
Neil Bateson
Name
Bateson Entemrises Inc
Company
7. Loca ' contents were disposed:
G. L, SQ Lowell Waste Water
F5821
Vehicle License Number
9 --?--fa
Date
t5form4.doc• 06103 System Pumping Record • Page 1 of 1
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No..............
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH JAN .uJ................... OF.....%1l .t��.� ?.......11.1 .Q .E. ............
Apliftration for 11itiitooal Maim Tnttnfrurf nit fi
Application is hereby made for a Permit to Construct ( x) or Repair ( ) an Individual Sewage Disposal
System at:
Ev&R&R&-ExJ ESTA7Z7'S LU 77 k
...........•-----------------------------------------------------------------------------------•-. -----------------------------------------------------------....--•-------•---•---........---
Loeation • Address or Lot No.
�✓A..._a7 ..�nP 1.Z ..-- � f� .. ��C7��- p�zv
owner Address
------------------------------------------------------------------------------------ •--••-•---
Installer Address
Type of Building Size Lot ------
1. - /A -------------- -
A e/ §� et
-----
Dwelling —No. of Bedrooms ......... ..� / ................................Expansion Attic ( ) Garbage Grinder ( )
Other—Type of Building ............................ No. of persons----- ....................... Showers ( ) —Cafeteria ( )
Otherfixtures -------------------------------- J ...................................
Design Flow............................................gallons per person er day. Total daily flow .......... .16-.6..0 ..................... .gallolls.
Scptic Tat ��igttid capacity -1 .-gallons Length/o-. l ....._.. W i d t I ....... Diameter ................
Disposal It --- No ..................... Width.. . 5;P ............ Total Length. -..SD.---.--- Total leaching area.--- 4 .....sq. ft.
Seepage Pit No ..................... Diameter .................... Depth below inlet.................... Total leaching area .................. sq. ft.
Other Distribution box ( 1,-� Dosing tank ( )
0
Percolation Test Results Performed by.. d 1ClS Jls�2fP�Yz f ...........
Date.7���,9�.. ......................
�7�
4p Test P '
it No. L.�� ---- minutes per inch Depth of Test Pit._.... 6'...j__ _ Depth to ground water.. b..Ak!F...._._.
4 –Z Test Pit No. 2---- 9 ---------- per incl.t. Depth of Test. Pit ----- 8.5.4"....... Depth to ground water..,A*0 -..........
....---•--.--------------------------------------------------------------------------------------------------------------------•----•
Descriptionof Soil....---` C7/l'1Gt✓i�..... �00.11- ----------------------------------------------------------------------------------------------- --------------------------
..........................................................•-----........................................................................ ................................................ •...........
•----------•--------•-----------•-•----------------------------------------------•----....-•-------..._...........---•----------....-•------• ................................. ......................
Nature of Repairs or Alterations — Answer when applicable .......................................... ................. ...................................
..---•-----•--•----------------•-•--•---.........•--•---------------•--------....------•--••-•----•----......----...----------------....----------••-----••---...........------------...._•---..........
Agreement:
The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with
the provisions of TITLE 5 of the State Sanitary Code — The undersigned further agrees not to place the system in
operation until a Certificate of Compliance has been issued by the board of health.
Signed--......................................... ...........................................
nate
ApplicationApproved By ................... ........................................... :
Date
Application Disapproved for the followbig reasons: .................. ..................... •---•------•------•.............................. ..-•----
•----------------------------•--•------------•---•---------•----•-•---------•-----------••--••------•-......------•-----.......------------•----.....--------.....----_.....------..-----•--•---------.
Date
PermitNo ....................... ................................. Issued_................. .....................................
Date
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
.......................................... OF
Cnrrtifiratr of Tomftfiuttre'.
THIS IS TO CERTIFY, That the Individual Sewage Disposal System constructed ( ) or Repaired ( )
by...............•-------------------.........._..------------------------------------•----------------.......--------...._.........------•-----------------.....----------•----•...
Installer
at..............................................
has been installed in accordance with the provisions of TITLE 5 of The State Sanitary Code as described in the
application for Disposal Works Construction Permit No ......................................... dated ... :.-..........................................
THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE
SYSTEM WILL FUNCTION SATISFACTORY.
DATE......................................... ---------•---•....................... Inspector.----••------•---•••--------------•--------........----•-•-------•---•--•--••---...
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
......................................... OF .......................................................
No................•-------- .......-..................... FEE ........................
UinfrnnFtf IV, orlm Tomi#rur#iott jlrruti#
Permissionis hereby granted ....................... :......... --•---------- --- --•r r.....................................................................................
to Construct ( ) or Repair ( ) an Individual Sewage Disposal System
atNo...............................................................................
- ...............
Street
as shown on the application for Disposal Woi ks Construction Permit No_____________________ Dated ................... .......................
DATE...................................... -.........................................
FORM 1255 HOBBS & WARREN, INC.. PUBLISHERS
-------------------------------------------•-----•-------....----------•-------------------............
Board of Ilealt6