Loading...
The URL can be used to link to this page
Your browser does not support the video tag.
Home
My WebLink
About
Miscellaneous - 837 DALE STREET 4/30/2018 (2)
-. N CONSTRUCTION APPROVAL HAS PLAN REVIEW FEE BEEN PAID? YES NO PLAN APPROVAL: DATE 7/Z/% APP. BY_ DESIGNER: `56071' V /G PLAN DATE. G CONDITIONS WATER SUPPLY: WN`_ WELL WELL`ERMI_T DRILLER WELL TESTS: ~_---CHEMICAL DAIS BACTERIA 'I`- llATE F1F�PROVED BACTERIA IID.ATE APPROVED COMMENTS: FORM U APPROVAL: APPROVAL TO ISSUE NO DATE ISSUED /�tJG z, 19'?4- BY ----- CONDITIONS: FINAL APPROVAL:. ALL PERMITS PAID YES NO WELL CONSTRUCTION APPROVAL YES NO SEPTIC SYSTEM CONSTRUCTION APPROVAL YES NO OTHER YES NO I sr6�NG�. ANY VARIANCE 7"D FDA/ NEEDED --�=� NO P-,4 /A) -E,.s� V 9�Lq�g¢ FINAL BOARD OF HEALTH APPROVAL: DA TE �69_ IIY : ` I /-. - - _: �*.' '- - • :- ;`:c=` " . • SEPTI G SYS.ZEM_�.NSSg.I.�.AZT_QN - ..:.. - `.i tt ;ty ". i'� t „` _ t, L.ai-; .'1.• i •+' ..5-A —• jar- #� \ t� :4ti:.:*:n d•'r 7- 1. _ '1. _ .. _ . +'x :IS THE' INSTALLER LICENSED? E5 NO 1.TYPE.OF- CONSTRUCTION: REPAIR QIE3eV _ k _ .,NEW CONSTRUCTION: CERTIFIED PLOT PLANREVIEWNO ' tw CONDITIONS OF..APPROVAL YES NO t� (FROM FORM U) a • As ISSUANCE OF DWC PERMIT `' YES NO =rDWC PERMITS N0.�U t a INSTALLER: BEGIN jNSPECTION YES -' _ = EXCAVATION. INSPECTION: :NEEDED: -777777 ir PASSED-.'BY <`.CONSTRUCTION INSPECTION: NEEDED: ' AS BUILT PLAN SATISFACTORY: YES: APPROVAL TO BACKFILL: DATE: / LZ' BY ' "FINAL.GRADING APPROVAL: DATE BY ��/�IGI - - ,j0RTjt 7003 0 aiawdg& Town of1vorth Andover HEALTH DEPARTMENT SACHU CHECK lf:-U4� DATE: 1)4 LOCATION: H/O NAME: CONTRACTOR NAME: Type of Permit or License: (Check box) • Animal $ • Body Art Establishment $ • Body Art Practitioner $ 0 Dumpster $ • Food Service - Type.- $ • Funeral Directors $- • Massage Establishment $ 0 Massage Practice $ • Offal (Septic) Hauler $ • Recreational Camp $- 0 Sun tanning $ 0 Swimming Pool $ 0 Tobacco $ 0 TrashlSolid Waste Hauler $- 0 Well Construction $ SEPTIC Systems: 0 Septic - Soil Testing $ 0 Septic - Design Approval $ 0 Septic Disposal Works Construction (DW0 $ 0 Septic Disposal Works Installers (DW[) 0 Title 5 Inspector $ Title 5 Report $ 0 Other (Indicate) $ Health Agent Initials White - Applicant Yellow - Health Pink - Treasurer 1 M mrrR 1 Owner information is required for every page. Commonwealth of Massachusetts Tide 5 official Inspection Form . Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 837 DALE STREET Property Address PHIL CARGILL Owner's Name N. ANDOVER City/Town MA 01845 08/15/14 State Zip Code Date of Inspection Inspection results must be submitted on this form. Inspection forms may not be altered in any way. Please see completeness checklist at the end of the form. Important: When A. General Information RECEIVED filling out forms on the computer, use only the tab 1. Inspector: SEP 11014 key to move your 1 cursor - do not John J. Soucy use the return key. Name of Inspector 71l OF NORTH ANDOVER HEALTH DEPARTMENT Souc's Sewer Service,'Inc. Q Company Name 78 North Broadway Company Address Salem NH 03079 City/Town State Zip Code 603-898-9339 13397 Telephone Number License Number B. Certification I certify that I have personally inspected the sewage disposal system at this address and that the information reported below is true, accurate and complete as of the time of the inspection. The inspection was performed based on my training and experience in the proper function and maintenance of on site sewage disposal systems. I am a DEP approved system inspector pursuant to Section 15.340 of Title 5 (310 CMR 15.000). The system: ® Passes ❑ Conditionally Passes ❑ Fails ❑ Needs-�urther Evaluation by the Local Approving Authority 08/15/14 Date Thisystem inspector shall submit j(copy of this inspection report to the Approving Authority (Board of Health or DEP) within 30 days of completing this inspection. If the system is a shared system or has a design flow of 10,000 gpd or greater, the inspector and the system owner shall submit the report to the appropriate regional office of the DEP. The original should be sent to the system owner and copies sent to the buyer, if applicable, and the approving authority. ****This report only describes conditions at the time of inspection and under the conditions of use at that time. This inspection does not address how the system will perform in the future under the same or different conditions of use. t5ins • 3/13 Title 5 Official Inspection Form: Subsurface Sewage Disposal System • Page 1 of 17 8 = Commonwealth of Massachusetts W Title 5 Official inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 837 DALE STREET Property Address PHIL CARGILL Owner Owner's Name information is required for every N. ANDOVER MA 01845 08/15/14 — _ page. City/Town state Zip Code Date of Inspection Be Certification (cont.) Inspection Summary: Check A,B,C,D or E /always complete all of Section D A) System Passes: ® I have not found any information which indicates that any of the failure criteria described in 310 CMR 15.303 or in 310 CMR 15.304 exist. Any failure criteria not evaluated are indicated below. Comments: B) System Conditionally Passes: ❑ One or more system components as described in the "Conditional Pass" section need to be replaced or repaired. The system, upon completion of the replacement or repair, as approved by the Board of Health, will pass. Check the box for "yes", "no" or "not determined" (Y, N, ND) 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. ❑ Y ❑ N ❑ ND (Explain below): t5ins • 3/13 Title 5 Official Inspection Form: Subsurface Sewage Disposal System • Page 2 of 17 1 i t ti Commonwealth of Massachusetts W Tib+ie 5 Official inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 837 DALE STREET Property Address PHIL CARGILL Owner information is required for every page. t5ins - 3/13 Owner's Name N. ANDOVER MA 01845 08/15/14 City/Town State Zip Code Date of Inspection B. Certification (cont.) ❑ Pump Chamber pumps/alarms not operational. System will pass with Board of Health approval if pumps/alarms are repaired. B) System Conditionally Passes (cont.): ❑ 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 ❑ Y ❑ N ❑ ND (Explain below): ❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below): ❑ distribution box is leveled or replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ 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 ❑ Y ❑ N ❑ ND (Explain below): ❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below): 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 Title 5 Official Inspection Form: Subsurface Sewage Disposal System • Page 3 of 17 c Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments M 837 DALE STREET Property Address PHIL CARGILL Owner Owner's Name information is required for every N. ANDOVER MA 01845 08/15/14 page. City/Town State Zip Code Date of Inspection B. Certification (cont.) 2. System will fail unless the Board of Health (and Public Water Supplier, if any) determines that the system is functioning in a manner that protects the public health, safety and environment: ❑ The system has a septic tank and soil absorption system (SAS) and the SAS is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water supply. ❑ The system has a septic tank and SAS and the SAS is within 50 feet of a private water supply well. ❑ 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 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 must be attached to this form. 3. Other: D) System Failure Criteria Applicable to All Systems: You must indicate "Yes" or "No" to each of the following for all inspections: Yes No ❑ ® Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool ❑ ® Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool ❑ ® Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool ❑ ® Liquid depth in cesspool is less than 6" below invert or available volume is less than 1/2 day flow t5ins - 3/13 Title 5 Official Inspection Form: Subsurface Sewage Disposal System • Page 4 of 17 Commonwealth of Massachusetts Tile 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 837 DALE STREET Property Address PHIL CARGILL Owner Owner's Name information is required for every N. ANDOVER MA 01845 08/15/14 — page. City/Town State Zip Code Date of Inspection B. Certification (cont.) Yes No ❑ ® Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number of times pumped: ❑ ® Any portion of the SAS, cesspool or privy is below high ground water elevation. ❑ ® Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ ® Any portion of a cesspool or privy is within a Zone 1 of a public well. ❑ Z Any portion of a cesspool or privy is within 50 feet of a private water supply well. ❑ ® Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality analysis. [This system passes if the well water analysis, performed at a DEP certified laboratory, for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis and chain of custody must be attached to this form.] ❑ ® The system is a cesspool serving a facility with a design flow of 2000gpd- 10,000gpd. ❑ ® The system fails. I have determined that one or more of the above failure criteria exist as described in 310 CMR 15.303, therefore the system fails. The system owner should contact the Board of Health to determine what will be necessary to correct the failure. E) Large Systems: To be considered a large system the system must serve a facility with a design flow of 10,000 gpd to 15,000 gpd. For large systems, you must indicate either "yes" or "no" to each of the following, in addition to the questions in Section D. Yes No ❑ ❑ the system is within 400 feet of a surface drinking water supply ❑ ❑ the system is within 200 feet of a tributary to a surface drinking water supply ❑ ❑ the system is located in a nitrogen sensitive area (Interim Wellhead Protection Area — IWPA) or a mapped Zone II of a public water supply well If you have answered "yes" to any question in Section E the system is considered a significant threat, or answered "yes" in Section D above the large system has failed. The owner or operator of any large system considered a significant threat under Section E or failed under Section D shall upgrade the system in accordance with 310 CMR 15.304. The system owner should contact the appropriate regional office of the Department. t5ins • 3/13 Title 5 Official Inspection Form: Subsurface Sewage Disposal System • Page 5 of 17 1 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments °�M a 837 DALE STREET Property Address PHIL C_A_RGILL Owner Owner's Name information is N. ANDOVER MA 01845 08/15/14 required for 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 ❑ ® Were any of the system components pumped out in the previous two weeks? ® ❑ Has the system received normal flows in the previous two week period? ❑ ® Have large volumes of water been introduced to the system recently or as part of this inspection? ® ❑ Were as built plans of the system obtained and examined? (If they were not available note as N/A) ® ❑ Was the facility or dwelling inspected for signs of sewage back up? ® ❑ Was the site inspected for signs of break out? Ei ❑ Were all system components, excluding the SAS, located on site? ® ❑ Were the septic tank manholes uncovered, opened, and the interior of the tank inspected for the condition of the baffles or tees, material of construction, dimensions, depth of liquid, depth of sludge and depth of scum? ® ❑ Was the facility owner (and occupants if different from owner) provided with information on the proper maintenance of subsurface sewage disposal systems? The size and location of the Soil Absorption System (SAS) on the site has been determined based on: • ❑ Existing information. For example, a plan at the Board of Health. • ❑ Determined in the field (if any of the failure criteria related to Part C is at issue approximation of distance is unacceptable) [310 CMR 15.302(5)] D. System Information Residential Flow Conditions: Number of bedrooms (design): 4 Number of bedrooms (actual): 4 DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x # of bedrooms): 440 t5ins - 3/13 Title 5 Official Inspection Form: Subsurface Sewage Disposal System - Page 6 of 17 i Commonwealth of Massachusetts w Ti$•le 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments \M a 837 DALE STREET _ Property Address PHIL CARGILL Owner Owner's Name information is N. ANDOVER MA 01845_ 08/15/14 required for every _ _ page. City/Town State Zip Code Date of Inspection D. System Information Description: Number of current residents: Does residence have a garbage grinder? ❑ Yes ® No Is laundry on a separate sewage system? (Include laundry system inspection ❑ Yes ® No information in this report.) No Laundry system inspected? ❑ Yes ❑ No Seasonal use? ❑ Yes ® No Water meter readings, if available (last 2 years usage (gpd)): Detail: See Attached Sump pump? ❑ Yes ® No Last date of occupancy: Current Date Commercial/Industrial Flow Conditions: Type of Establishment: Design flow (based on 310 CMR 15.203): Gallons per day (gpd) 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: ❑ Yes ❑ No ❑ Yes ❑ No ❑ Yes ❑ No t5ins • 3/13 Title 5 Official Inspection Form: Subsurface Sewage Disposal System • Page 7 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 837 DALE STREET D. System Information (cont.) Last date of occupancy/use: Other (describe below): Pumping Records: Source of information: State Zip Code General Information Was system pumped as part of the inspection? If yes, volume pumped: How was quantity pumped determined? Reason for pumping: Type of System: Date Soucy's Sewer Service 1500 gallons GAUGE ON TRUCK 08/15/14 Date of Inspection Maintenance and Inspection ® Septic tank, distribution box, soil absorption system ❑ Single cesspool ❑ Overflow cesspool ❑ Privy ❑ Shared system (yes or no) (if yes, attach previous inspection records, if any) ❑ Innovative/Alternative technology. Attach a copy of the current operation and maintenance contract (to be obtained from system owner) and a copy of latest inspection of the I/A system by system operator under contract ❑ Tight tank. Attach a copy of the DEP approval. ❑ Other (describe): t5ins • 3/13 Title 5 Official Inspection Form: Subsurface Sewage Disposal System • Page 8 of 17 Property Address PHIL C_ARGILL Owner Owner's Name information is NANDOVER required for every . page. City/Town D. System Information (cont.) Last date of occupancy/use: Other (describe below): Pumping Records: Source of information: State Zip Code General Information Was system pumped as part of the inspection? If yes, volume pumped: How was quantity pumped determined? Reason for pumping: Type of System: Date Soucy's Sewer Service 1500 gallons GAUGE ON TRUCK 08/15/14 Date of Inspection Maintenance and Inspection ® Septic tank, distribution box, soil absorption system ❑ Single cesspool ❑ Overflow cesspool ❑ Privy ❑ Shared system (yes or no) (if yes, attach previous inspection records, if any) ❑ Innovative/Alternative technology. Attach a copy of the current operation and maintenance contract (to be obtained from system owner) and a copy of latest inspection of the I/A system by system operator under contract ❑ Tight tank. Attach a copy of the DEP approval. ❑ Other (describe): t5ins • 3/13 Title 5 Official Inspection Form: Subsurface Sewage Disposal System • Page 8 of 17 Commonwealth of Massachusetts Wi Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 837 DALE STREET Property Address PHIL CARGILL Owner Owner's Name information is required for every N. ANDOVER MA 01845 08/15/14 —_ — page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Approximate age of all components, date installed (if known) and source of information: 1996 Were sewage odors detected when arriving at the site? Building Sewer (locate on site plan): Depth below grade: e611t Material of construction: ® cast iron ❑ 40 PVC ❑ other (explain): Distance from private water supply well or suction line: n/a feet Comments (on condition of joints, venting, evidence of leakage, etc.) Septic Tank (locate on site plan): Depth below grade: Material of construction: ® concrete ❑ metal a 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) Dimensions: Sludge depth: ❑ Yes ❑ No t5ins - 3/13 Title 5 Official Inspection Form: Subsurface Sewage Disposal System • Page 9 of 17 s Commonwealth of Massachusetts _ W iit -le 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 837 DALE STREET Property Address PHIL CARGILL Owner Owner's Name information is required for every N. ANDOVER page. City/Town D. System Information (cont.) Septic Tank (cont.) State Zip Code Distance from top of sludge to bottom of outlet tee or baffle Scum thickness 40" 2" 811 Distance from top of scum to top of outlet tee or baffle Distance from bottom of scum to bottom of outlet tee or baffle 14" 08/15/14 Date of Inspection How were dimensions determined? Tape and sludge tool Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): PUMP TANK ANNUALLY Grease Trap (locate on site plan): Depth below grade: Material of construction: ❑ concrete ❑ metal Dimensions: Scum thickness ❑ fiberglass 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: t5ins - 3/13 feet ❑ polyethylene ❑ other (explain): Date Title 5 Official Inspection Form: Subsurface Sewage Disposal System • Page 10 of 17 Commonwealth of Massachusetts -- W -Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 837 DALE STREET Property Address PHIL C_A_RGILL Owner Owner's Name information is required for every N. ANDOVER MA 01845 08/15/14 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.): TEES ALL IN PLACE 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): Dimensions: Capacity: Design Flow: Alarm present: Alarm level: gallons gallons per day ❑ Yes ❑ No Alarm in working order: ❑ Yes ❑ No Date of last pumping: Date Comments (condition of alarm and float switches, etc.): * Attach copy of current pumping contract (required). Is copy attached? ❑ Yes ❑ No t5ins • 3/13 Title 5 Official Inspection Form: Subsurface Sewage Disposal System • Page 11 of 17 Commonwealth of Massachusetts w Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 837 DALE STREET Property Address PHIL CARGILL Owner Owner's Name information is required for every N. ANDOVER page. City/Town D. System information (cont.) MA 01845 08/15/14 State Zip Code Date of Inspection Distribution Box (if present must be opened) (locate on site plan): Depth of liquid level above outlet invert 0" Comments (note if box is level and distribution to outlets equal, any evidence of solids carryover, any evidence of leakage into or out of box, etc.): "D" BOX REPLACED PRIOR TO INSPECTION. SEE PERMIT Pump Chamber (locate on site plan): Pumps in working order: ❑ Yes ❑ No* Alarms in working order: ❑ Yes ❑ No* Comments (note condition of pump chamber, condition of pumps and appurtenances, etc.): * If pumps or alarms are not in working order, system is a conditional pass. Soil Absorption System (SAS) (locate on site plan, excavation not required): If SAS not located, explain why: t5ins • 3/13 Title 5 Official Inspection Form: Subsurface Sewage Disposal System • Page 12 of 17 w — Commonwealth of Massachusetts Tit -0e 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 837 DALE STREET Property Address _ PHIL CARGILL Owner Owner's Name information is required for every N. ANDOVER MA _ --- _— — 01845 08/15/14 _ page. City/Town State Zip Code Date of Inspection Do System Information (cont.) Type: ❑ leaching pits number: ❑ leaching chambers number: ❑ leaching galleries number: ® leaching trenches number, length: (2) 4'X80' ❑ 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.): NO SIGNS OF HYDRAULIC FAILURE 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 t5ins - 3/13 Title 5 Official Inspection Form: Subsurface Sewage Disposal System - Page 13 of 17 Owner information is required for every page. Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 837 DALE STREET Property Address PHIL CARGILL Owner's Name N. ANDOVER_ MA 01845 08/15/14 City/Town State Zip Code Date of Inspection D. System) Information (cont.) 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.): t5ins - 3/13 Title 5 Official Inspection Form: Subsurface Sewage Disposal System - Page 14 of 17 Comnneomwsalthi of Massachusetts Offic"al Inspection Form Sewage Dsposal System Form Not for Voluntary Assessments 837 S-1-R-r—T ---------- Property Adtlli'eSs I-) Li I L t,./ F; I i I ` A 1 L Owner ner i"lanie information is required 'c- every N. A [,,I D G V E R [ViA 01845 08/15/14 page, S 3"" p CoDate of Inspection .1 m 7), r, Ska,k; Of Smvage Disposal System: Provide a view of the sewage ,disposal system, including ties to atvvo pemniainen t reference landmarks or benchmaiks. 1 '_cc -ate all ,uedZ within 100 feet. Locate �!O�,ere Piufblic water supply enters the building. 'Check one of the boxes below: �n L'he aa -ea below r, �-j - si-k e c�i,asAlfli,-,!g iattached separately I WATER I SERVICE D A I 20 136 1 R�Fs Y VE P/T E,Y, 46 L 82.6T' ___je4 on; ED GE ,5j, 39$61 u, ppunoA Title 5 Official lnspecton Form, Subsurface Sewage Disposal System -Page 15 of 17 Commonwealth of Massachusetts _ w Title 5 Official inspection Form _ Subsurface Sewage Disposal System Form Not for Voluntary Assessments �J 837 DALE STREET Property Address PHIL CARGILL Owner Owner's Name information is N. ANDOVER MA required for every —_ page. City/Town State D. System Information (cont.) Site Exam: ❑ Check Slope ® Surface water ❑ Check cellar ❑ Shallow wells Estimated de th to hi h round water 01845 Zip Code a 08/15/14 Date of Inspection F g g 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: DUG HOLE WITH AUGER IN REAR DROP OFF AREA, APPROXIMATELY 130' FROM SEPTIC, NO WATER AT 60", FRONT ELEVATION APPROXIMATELY Z HIGHER. Before filing this Inspection Report, please see Report Completeness Checklist on next page. t5ins • 3/13 Title 5 Official Inspection Form: Subsurface Sewage Disposal System • Page 16 of 17 Commonwealth of Massachusetts o, Title 5 Official Inspection Form _ Subsurface Sewage Disposal System Form -Not for Voluntary Assessments —_ 837 DALE STREET Property Address PHIL CARGILL Owner Owner's Name information is N_ANDOVER required for every _ page. City/Town MA 01845 State Zip Code E. Report Completeness Checklist 08/15/14 Date of Inspection ❑ Inspection Summary: A, B, C, D, or E checked ❑ Inspection Summary D (System Failure Criteria Applicable to All Systems) completed ❑ System Information – Estimated depth to high groundwater ❑ Sketch of Sewage Disposal System either drawn on page 15 or attached in separate file t5ins • 3/13 Title 5 Official Inspection Form: Subsurface Sewage Disposal System • Page 17 of 17 Permission is hereby granted JOhn-Soucy. -------------- -------------- -------------------------- , ------ to (Repair) an Individual Sewage Disposal System. at No 837 DALE STREET ---------- ------- --------------- I ----------------- ----------- ------------- ------ as shown on the application for Disposal Works Construction Permit No. BHP 0,14-073 Dated August 12; 2014 ---------------- Issued ©n: Aug-12-2014` D C� 11�AL ------------ ---- ------ -------- --------------------- SOMY Rewrd Card gemmed on 7/16/2014 4:07:59 PM by Karen Hanbn t Town of North Andover TaxMap # 210-104.0-0166-0000.0 Parcel id 16687 :. 837 DALE STREET CARGILL PHILLIP & PAULA 837. DALE: STREET . ID.'ANDQVIER; MA ' 01845 Clara 101 Single famfty Property Type Restdentlat Zoning2 1 Residential Zoning3 Residential . Size Total 1.08 Acres FY 2015 U8 Malllna Index . Name/Address Type ; Loan Numtiar• Acttve/inact, From Until CARGILL, PHILLIP 8 PAULA Owner 837 DALE STREET NO. ANDOVER, MA 01845 UB Account'Malnt Account No Cycle Occupant Name Activa/lnactivo Bldg Id. 18170.0 837 DALE STREET Las# bil4ing Date 7!8/2014 3180198 03 Cycle 03 :. ActIve UB Services Maint.. Account No. 3180198 Service Code . ` Rata Charge Multiplier/Users MISCFEE ADMIN FEE 0,61. WS 7.82;: 17 . WTR WATER 01 ALLMETER'SIZE 57.00 /1 UB Meter Maintenance Account No*. 3180198 Serial No Status Location . Brand type Size YTO Cons 39976997. a Active OO.FRONT RIGHT - : METE. METE w Water :. 0.63 0.63 695 Date Reading: ; :Gods -:Consumption ` Posted Data Variance 6/16/2014 3154 m Manual estimate 95 ' 7/1812014 =31% 3113/2014.. 3139: m Marwal.estimate:::. 20 .4/11/2014: 2%. 12/16/2013 3119 rn Manual estimate > 20 `1117/2014 -30% 9/18/2013 3099 m Manual estimate -= 30." 10/16/2013 -4% 6/17/2013 3069:m Manual estimate 30 . ` 112412013: 9% 3/20/2013 :W39: :m Manual estimate , 30 : 4P22/2013 12/13/2012 3009° :.m Manual estirnate : 30 1/912013 - 9/2412012 2979 m Manual estimate 30 10/1k612.: 6/18/2012: 2949:. m Manual estimate " 30 ' 7118121312: it396 MSG... > . 3/19/2012 2919 :s Actual 27 4/14/2012 12/15/2011 2892 a Actual <: 26 : 0.1712012 ' 31 9/18/2011 2866 ;aActuai >: 21,`.10/1312011 28°G 6/13/2011 2846 a Actual:.16 7/20/2011 ; -47% 3/14/2011 2829 : m Manual istimate `, 30<. `411312011 MSG . 12/13/2010 2799 : eActual ;` 24 1/1212011' 9/20/2010 .2775 . aActual 58 ,10J95/2010 98°6 6/11/2010 2717 , aActual 25 7/18/2010. 3/17/2010 2692 a Actual 30 4/14/2010 4°% 12114/2009 2662... of Actual 27 ::1112/2010 24% 9/18/2009 _. 2835 a Actual . . 25 10/15/2009 •13% 6/10/2009 2610 aActuai 24-. 7120!2009 3118/2009 2586. a. Actual 28% 4/29/2009 3% 1211.5/2008 2558 a Actual 26 1/20/2009 9/17/2008 2532 'a Actual 34 10/1042008 -22% 6/10/2008 2498 a Actual : 39 7/16/2008 66% .3/13/2008 2469 aActual 23 4/1172008: '13°% 12/1712007. 2436 .a Actual 29 ' 1/22/2008. -66% PUBLIC HEALTH DEPARTMENT Town, o.']N',arth iv over Community Division FE OF CERTI U COM"11.1-ANCE r Aso©` This is to certify that toe -indiTic. ua-i muj,sj.*a-face disposal system received a SATI.SFACTORY)LINSPECTION of the: Complete Repa]"T ®f -box By: Jof"In S"'�(.)-,acy 83, D d I Map 104C Lot 0155 NorthAndover,MA 01.845 The WIssuan off this certificate shall not be construed as a guarantee that the system will function satisfactorily. 's "01 " "c�"" s Sawyer i Heal t e Heal A naitt 1600 Osgood Street., Worth Andover, Massachusetts 01845 Phone 978.668.9540 Fax 978.688.8476 Web viww.towno',norhondover.com OF r10 R T/� qti ACHU PUBLIC HEALTH DEPARTMENT Town of North Andover Community Development Division CERTIFICATE OF COMPLIANCE As of: 8/15/2014 This is to certify that the individual subsurface disposal system received a SATISFACTORY INSPECTION of the: Complete Repair of D -box By: John Soucy At: 837 Dale Street Map 104C Lot 0155 North Andover, MA 01845 The Issuan of this certificate shall not be construed as a guarantee that the system will function satisfactorily. s Sawyer u is Healt Ant 1600 Osgood Street, North Andover, Massachusetts 01845 Phone 978.688.9540 Fax 978.688.8476 Web www.townofnorthandover.com Important: When filling out forms on the computer, use only the tab key to move your cursor - do not use the return key. _fit Commonwealth of Massachusetts City/Town of NORTH ANDOVER, MASSACHUSETTS System Pumping Record Form 4 DEP has provided this form for use by local Boards of Health. The System Pumping Record must be submitted to the local Board of Health or other approving authority. A. Facility Information 1. System Location: 837 DALE STREET Address N. ANDOVER City/Town 2. System Owner: PHIL CARGILL Name 837 DALE STREET Address (if different from location) N. ANDOVER City/town B. Pumping Record 1. Date of Pumping 3. Type of system: 08/15/14 Date ❑ Cesspool(s) ❑ Other (describe): 4. Effluent Tee Filter present? 5. Condition of System: MA State MA State 978-549-3205 Telephone Number Zip Code Zip Code 1500 2. Quantity Pumped: Gallons ❑ Septic Tank ❑ Tight Tank Yes ❑ No If yes, was it cleaned? 0 Yes ❑ No 6. System Pumped By: Name Company 7. Location where contents were disposed: C, s ,.-D RDWA Signature of HaVer hftp://www.mass.gov/dep/water/approvals/t5forms.htm#inspect Vehicle License Number Date t5form4.doc• 06/03 System Pumping Record • Page 1 of 1 North Andover Health Department Community Development Division ONSITE WASTEWATER SYSTEM CONSTRUCTION NOTES LOCATION INFORMATION ADDRESS: 837 Dale St. MAP: LOT: INSTALLER: John Soucy DESIGNER: PLAN DATE: BOH APPROVAL DATE ON PLAN: INSPECTIONS , D -Box INSPECTION: 8/15/14 �, DATE OF BED BOTTOM INSPECTION: DATE OF FINAL CONSTRUCTION INSPECTION: DATE OF FINAL GRADE INSPECTION: SITE CONDITIONS Comments: SEPTIC TANK ❑ Contractor reports any changes to design plan ❑ Existing septic tank properly abandoned ❑ Internal plumbing all to one building sewer ❑ Topography not appreciably altered ❑ Building sewer in continuous grade, on compacted firm base ❑ Cleanouts per plan ❑ Bottom of tank hole has 6" stone base ❑ Weep hole plugged ❑ 1500 gallon tank has been installed H-10 loading ❑ Monolithic tank construction ❑ Water tightness of tank has been achieved by visual testing ❑ Inlet tee installed, centered under access port ❑ Outlet tee installed, centered under access port (gas baffle/effluent filter) ❑ inch cover to within 6" of finish grade installed over one access port ❑ Hydraulic cement around inlet & outlet Comments: PUMP CHAMBER FS Comments: CONTROL PANEL Bottom of tank hole has 6" stone base Weep hole plugged 1500 gallon Pump Chamber installed H-10 loading Monolithic tan construction Inlet tee instaid, centered under access port Pump(s) installed on stable base Alarm float working Pump On/Off floats Separate on/off f Drain hole in pre si cover at fin access port Water tightness of testing Hydraulic cement a working are line I grade installed over pump nk has been achieved by nd inlet & outlet ❑ Alarm & Pump are o2-at eparate circuits El Alarm sounds when is tripped ❑ Location of control pan�l: basement ❑ Alarm signal located inside: basement Comments: DISTRIBUTION -BOX Installed on stable stone base H-20 D -Box Inlet tee (if pumped or >0.08'/foot) Hydraulic cement around inlet & outlets Observed even distribution Speed levelers provided (not required) Schedule 40 PVC Pipe Comments: Mm Commonwealth of Massachusetts Map -Block -Lot 104.CO155 ----------------------- BOARD OF HEALTH Permit No BHP -2014-0739 North Andover ----------------------- FEE $125.00 ----------------------- DISPOSAL WORKS CONSTRUCTION PERMIT Permission is hereby granted JohnSoucy ..... t --------------------------------------------------------------------------------------- to (Repair) an Individual Sewage Disposal System. atNo 837DALESTREET - - --------------------------------------------------------------------------------------------------------------------------------- as shown on the application for Disposal Works Construction Permit No. BIIP-2014-073 Dated August 12, 2014 ------------------------ - ----------------------- iD 6� Issued On: Aug -12-2014 ---------------------------------------------------------------------------------- IN Commonwealth of Massachusetts Map -Block -Lot 104.CO1 55 ----------------------- BOARD OF HEALTH Penn it No North Andover - BHP -2014-07 - 39 ---- --------------- -- P.I. FEE F.I. $125.00 DISPOSAL WORKS CONSTRUCTION PERMIT Permission is hereby granted John Soucy - - - - - ----------------------------------------------------------------------------------------------- to (Repair) an Individual Sewage Disposal System. atNo 8-37-DALESTREET ------------------------------------------------------------------------------------------------------------------------ as shown on the application for Disposal Works Construction PermitNo. .13HP-20147073. Dated --- August -1-2,-2-0-1-4 ----- Issued On: Aug -12-2014 SVQ mrfl-Ea-r AFY ,40RT" 6969 Town of North Andover HEALTH DEPARTMENT CHUS CHECK DATE: LOCATION:*' 1-1/0 NAME: CONTRACTOR N Type of Permit or License: (Cbeck box) • Animal $ • Body Art Establishment $ • Body Art Practitioner $ 0 Dumpster $ • Food Service - Type: $ • Funeral Directors $- 0 Massage Establishment $ 0 Massage Practice $ • Offal (Septic) Hauler $ • Recreational Camp $ 0 Sun tanning $ • Swimming Pool $ • Tobacco $ • TrashlSolid Waste Hauler $- • Well Construction $ SEPTIC Sustems: • Septic - Soil Testing $ • Septic - Design Approval $ Septic Disposal Works Construction (DWC) $jz It Septic Disposal Works Installers (DW1) $ 0 Title 5 Inspector $ 11 Title 5 Report $ 0 Other. (Indicate) $ Health Agent Initials White - Applicant Yellow - Health Pink - Treasurer WOO I � q-- �-t- I amL °RTH Application for Septic Disposal System 03/20/2014 s Construction Permit —TOWN OF TODAY'S DATE f �W ORTH ANDOVER, MA 01845 $ 250.00 —Full Repair rr"=9 $125.00 - Component Important: Application is hereby made for a permit to: When filling out ❑ Construct a new on-site sewage disposal system* forms on the computer, use ❑ Repair or replace an existing on-site sewage disposal system* only the tab key DISTRIBUTION BOX - H2O to move your Q Repair or replace an existing system component — What .? _ cursor - do not I ��C�I EIVED use the return A. Facility Information H key. 837 DALE STREET Vfl Ab Address or Lot # AUU 12 ZU 14 v N. ANDOVER City/Town 2.- *TYPE OF SEPTIC SYSTEM*: ❑ Pump ®❑ Gravity (choose one) ***If pump system, attach copy of electrical permit to application*** ■❑ Conventional System (pipe and stone system) ❑ Infiltrator or Biodiffuser (Gravel -Less) (Attach a copy of your certification to install this type of system. ❑ Pressure Distribution S.A.S. (No D -Box) (Attach Draft Maintenance Agreement) ❑ Pressure Dosed (D -Box Present) S.A.S. 2. Owner Information PHIL CARGILL TOWN OF NORTH ANDOVER ,114FALTH DEPARTMENT Name 837 DALE STREET Address (if different from above) N. ANDOVER City/Town 3. Installer Information JOHN SOUCY Name 78 N. BROADWAY Address SALEM City/Town 4. Designer Information N/A Name Address City/Town MA 01845 State Zip Code 978-549-3205 Telephone Number SOUCY SEWER SERVICE INC Name of Company NH 03079 State Zip Code 603-898-9339 Telephone Number (Cell Phone # if possible please) Name of Company State Zip Code Telephone Number (Best # to Reach) Application for Disposal System Construction Permit • Page 1 of 2 Application for Septic Disposal System Q Construction Permit - TOWN OF TODAY'S DATE , MA 01845 $ 250.00 - Full Repair ORTH ANDOVER / $125.00 -Component ✓ PAGE 2OF2 A. Facility Information continued.... 5. Type of Building: ff Residential Dwelling or ❑Commercial B. Agreement The undersigned agrees to ensure the construction and maintenance of the afore -described on-site sewa a disposal system in accordance with the provisions of Title 5 of the Environ to Code, as well as the Local Subsurface Disposal Regulations for the Town of Nort ndov r, and not to place the system in operation until a Certificate of Compliance has be issue bV this Boar ealth. 8/12/14 amP Date Applic �in Approved By: Ird'ofalth Representative) Na a Date Application Disapprd for the following reasons: For Office Use Only: 1. FeeAttachedP Yes `' No 2. Project Manager Obligation Form Attached. No 3. Pump Svstem? If so, Attach cogv ofElecttical Permit Yes No 4. Foundation As -Built? (new construction ronly): Yes No (Same scale as approved plan) S. Floor Plans? (new construction only): Yes No Application for Disposal System Construction Permit • Page 2 of 2 TOWN OF NORTH ANDOVER SYSTEM PUMPING RECORD 9 III --W6 ld4;� STEM OWNER & ADDRESS SYSTEM LOCATION (example; left front of house) R,65 � 3id2 Pt �dv3e ►n Co►�� U \"l C OF PUMPINC: "ZG'6Z QUANTITY PUMPED`C ALLf)�� i.,)SPO0L: NO �/YES SEPTIC TANK: NO YES v "ATURE OF SERVICE: ROUTINE EMERGENCY oHl FRV.\TIONS: GOOD CONDITION HFAVY CREASE ROOTS EXCESSIVE SOLIDS SOLIDS CARRYOVER >1 �'l LM PUMPED BY: �U�1lylcNTS: UNI (N 1'� T]I ANSFEIZIZED TO: FULL TO COVCk BAFFLES IN PLAC1'' LEACHFIELD IZUN18ACK . FLOODED Oj�HER (EXPLAIN) CERTIFIED FOUNDA TION PL AN LOCATED /N iv 0. A NDO ICER , MA. SCALE /"= 40' DATE 911 4 Scott L. Gi/es R. L. S. 50 Deer Meadow Rood North Andover, Moss. l i 0 0�0 � N EXIST. FOUND. T.O. W. = /03.5 651 or •9 46,008 S.F. N j \ 67`3`3 �`R= 640'L=82.67` ®A S TREE T / CERTIFY THAT OFFSETS SHOWN ARE FOR THE USE THE OFFSETS OF THE SU/L DING /NSPEC TOR ONLY SHOWN COMPLY AND SUCH USE /S FOR THE . lz� �v WITH THE ZONING DETERM/NATION OF ZONING + ~ 1 SY LAWS OF CONFORMITY OR NON -CONFORMITY `;� ^ A3972 4 NO ANDDVER{MA, WHEN CONSTRUCTED. ,s 6nti�i4J��y 4 WHEN BUIL T. 0 0 3 0 m a un 0 (D tv CD n o (D � Z� a C rnr O o A v 0 A O m 3 a o a co 0 n� a 0 -n = nanvv al P, A rf (D S 3 O � r�r L 1 3 3 A -h r -j o tD (D -� 'a c o CD °, v 0 n c 1 3 r� �D U -1 rn Q -0 Q CSD CD 0 CD CL n. a M rt (D O h C9 CD Cc 73 .O co :L v ,.. D y 0 CD o0 3�=, C y O �( y d • �. cm : C J . C e t •a _ 'O L: I - : L C y+ N (D :. .. o. C L y d d p V y O cc O O F— sym o. C = m N: o O n O F� W O•C ~ C .E COC013 cc RD u d L c0 .E mlr9 m E v�_�c, ' W • C) m p m C CL o -E coo .F maO L •` y ._ H L $ o.Om g Q U J :W Z K Z Q cn � z � - � w NA \, CD U) W m m z co O CD CL L W CD L - L '• . O L c o – v L rL O EL N CL O - C v ` N 'p a� QCIO cm U3 Com.) J z C _CL cLL •o _ p — y Z V Q - c CD z m - _ o a L 0 ` C cm W - O C C Guj nLLJ � �LA- '�Ll L1C c H o OA \ CO) �... z J LLAJ o uCL- > G r� U\ U 1 w p w 51 0 v 7' O O G L u. cn w a U w n; cn w w co cn cn C9 CD Cc 73 .O co :L v ,.. D y 0 CD o0 3�=, C y O �( y d • �. cm : C J . C e t •a _ 'O L: I - : L C y+ N (D :. .. o. C L y d d p V y O cc O O F— sym o. C = m N: o O n O F� W O•C ~ C .E COC013 cc RD u d L c0 .E mlr9 m E v�_�c, ' W • C) m p m C CL o -E coo .F maO L •` y ._ H L $ o.Om g Q U J :W Z K Z Q cn � z � - � w NA \, CD U) W m m z co O CD CL L W CD L - L '• . O L c o – v L rL O EL N CL O - C v ` N 'p a� QCIO cm U3 Com.) J z C _CL cLL •o _ p — y Z V Q - c CD z m - _ o a L 0 ` C cm W - O C C Guj nLLJ � �LA- '�Ll L1C c H o OA \ CO) �... z J LLAJ o uCL- > G Town of North Andover, Massachusetts Form No.1 VkORTH BOARD OF HEALTH, �6 0 0- -%-A 19 0 APPLICATION FOR SITE TESTING/INSPECTION Applicant I r A AA NAME ADDRESS TELEPHONE Site Location Engineer—'( -t 21, NAME ADDRESS TELEPHONE Test/l nspection Date and Time— CHAIRMAN, BOARD OF HEALTH Fee 7) Test No. S.S. Permit No.—D.W.C. No.—C.C. Date—Plbg. Permit No. Z BA R-! 3o�3��sa FORM U - LOT. RELEASE FORM �' i ()3 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 or requirements. *****************************APPLICANT FILLS OUT THIS SECTION APPLICANT �/il(li� /moi. t (J PHONE 9%8 r? LOCATION: Assessors Map Number 10Y. e PARCEL. ���� SUBDIVISION _ LOT (S) STREET P3 77IJ.Q D ST. NUMBERS ************************OFFICIAL USE ONLY************* AGENTS: ATION ADMINISTRA h DATE APPROVED �/ DATE REJECTED COMMENTS TOWN PLANNER COMMENTS FOOD INSPECTOR -HEALTH SEPTIC INSPECTOR -HEALTH COM DATE APPROVED DATE REJECTED DATE APPROVED DATE REJECTED DATE APPROVED DATE REJECTED PUBLIC WORKS - SEWER/WATER CONNECTIONS DRIVEWAY PERMIT FIRE DEPARTMENT RECEIVED BY BUILDING INSPECTOR DATE_ Revised 9W jm A S (cl 0-3 ou ■ . ■ X s Z O O Z M 90 O mn ic r M r r z 0 TOWN OF NORTH ANDOVER BUILDING DEPARTMENT APPLICATION TO CONSTRUCT REPAIR, RENOVATE, OR DEMOLISH A ONE OR TWO FAMILY DWELLING, -7777777-77� ... :7 .. ,. ... .... .... _.,. .. r,... BUILDING PERMIT NUMBER: DATE ISSUED: SIGNATURE: Building Commissioner/inspector of Buildings Date SECTION 1- SITE INFORMATION ` 1.1 Property Address: 1.2 Assessors Map and Parcel Number: Map Number Parcel Number (J( �^ 1.3 Zonying Infformation: Zoning Dia ct Proposed Use 1.4 Property Dimensions: Lot Area (sf) Frontage ft 1.6 BUILDING SETBACKS ft Front Yard Side Yard Rear Yard Required Provide Rapfired Provided Required Provided 1.7 Water Supply M.G.L.C.40. 54) Public ❑ Private ❑ 1.5. Flood Zone Information: .Zone Outside Flood Zone ❑ 1.8 Sewerage Disposal System: Municipal ❑ On Site Disposal System ❑ SECTION 2 - PROPERTY OWNERSHIP/AUTHORIZED AGENT 2.1 Owner of Record game(Print) P?7 © C� �d' / Address for Service: 7V (� Si 0 rt.,e Telephone 2.2 Owner of Record: Name Print Address for Service: Signature Telephone SECTION 3 - CONSTRUCTION SERVICES 3.1 Licensed Construction Supervisor: Licensed Construction Supervisor: Address Signature Telephone Not Applicable ❑ License Number Expiration Date 3.2 Registered Home Improvement Contractor Not Applicable ❑ Company Name Registration Number Address Expiration Date Signature Telephone ou ■ . ■ X s Z O O Z M 90 O mn ic r M r r z 0 SECTION 4 - WORKERS COMPENSATION (T*LG.L C 152 § 25c(6) Workers Compensation Insurance affidavit must be completed and submitted with this application. Failure to provide this affidavit will result in the denial of the issuance of the building permit. Signed affidavit Attached Yes .......❑ No ....... ❑ SECTION 5 Description of Proposed Work(check au applicable) New Construction 11 Existing Building ❑ Repair(s) ❑J Alterations(s) ❑ Addition ❑ Accessory Bldg. ❑ Demolition ❑ Other ❑ Specify Brief Description of Proposed Work: 4 �-x P.� I�` P Ao X a 1z."x 2 SECTION 6 - ESTIMATED CONSTRUCTION COSTS Item Estimated Cost (Dollar) to be CoMpleted by permit applicant CiFFICIAVUSE ONLY. 1. Building � IV � (a) Building Permit Fee Multiplier 2 Electrical (b) Estimated Total Cost of Construction 3 Plumbing Building Permit fee (e) X (b) 4 Mechanical HVAC 5 Fire Protection 6 Total 1+2+3+4+5 Check Number SECTION 7a OWNER AUTHORIZATION TO BE COMPLETED WHEN OWNERS AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT I'C vpA" % e as Owner/Authorized Agent of subject property / Hereby autho ' 4e to act on My b Vf a 1 rs relative to work authorized by this building permit application. S na re.o Date SEC ON 7b OWNER/AUTHORIZED AGENT DECLARATION I, as Owner/Authorized Agent of subject property Hereby declare that the statements and information on the foregoing application are true and accurate, to the best of my knowledge and belief Print Name Signature of Owner/Aent Date NO. OF STORIES SIZE BASEMENT OR SLAB SIZE OF FLOOR TIMBERS 1 ST2 ND 3RD SPAN DIMENSIONS OF SILLS DIMENSIONS OF POSTS DIMENSIONS OF GIRDERS HE-IGIIT OF FOUNDATION THICKNESS SIZE OF FOOTING X MATERIAL OF CHRVINEY IS BUILDING ON SOLID OR FILLED LAND IS BUILDING CONNECTED TO NATURAL GAS LINE Town of North Andover Building Department 27 Charles Street North Andover MA 01845 Tel: 978-6889545 HOMEOWNER LICENSE EXEMPTION Please print. DATE 5'- t19. O�`�' 2 JOB LOCATION (1j� -;> Number Street Address --JJ / Cin Section of Town "HOMEOWNER /? u ?(F, / d"XI �i�� Number Home Phone Work Phone PRESENT MAILING ADDRESS..--- City DDRESS' City Town State The current exemption for "homeowners" was extended to include owner -occupied dwellings of six units or less and to allow such homeowners to engage an individual for hire who does not possess a license, provided that the owner acts as supervisor. (State Building Code Section 109.1.1) Zip Code DEFINITION OF HOMEWOWNER: Person(s) who owns a parcel of land on which he/she resides or intends to reside, on which there is, or is intended to be, a one to six family dwelling, attached or detached structures ac- cessory to such use and and/or farm structures. A person who constructs more than one home in a two-year period shall not be considered a homeowner. Such "homeowner" shall submit to the Building Official, a form acceptable to the Building Official, that he/she shall be responsible for all such work performed under the building permit. (Section 109.1.1) The undersigned "homeowner" assumes responsibility for compliance with the State Building Code and other Applicable codes, by-laws, rules and regulations, The undersigned "homeowner" certifies that Building Department minimum inspection pri comply with said procedures and require HOMEOWNER'S SIGNA APPROVAL OF BUILDING OFFI iderstands the Town of No. Andover and requirements and that he/she will Note: Three family dwelling 35,000 cubic feet, or larger, will be required to comply with State Building Code Section 127.0 Construction Control. N North Andover 801cring Department Tel: 978-688_9545 DEBRIS DISPOSAL FORM In accordance with the provision of MGL c 40 S 54, a condition of Building Permit Number is that .the debris resulting from this work shall be disposed of in a properly licensed solid waste disposal facility as defined by MGL c 11, S.150 A.. The debris will be disposed of in: 5./9,p.? Date NOTE: Demolition permit from the Town of North Andover must be obtained for this project through. the Office of the Building Inspector Zoning Bylaw Review Form r r Town Of North Andover Building Department A 111 " 27 Charles St. North Andover, MA. 01845 "sSaCNUS f'AOTne •°"g Phone 978-688=9545 Fax 978-688-9542 Street:.' 1. .. Ma /Lot: C C l.SIS . Applicant: oyc. I � �_ ._C a.._rt Request- E - Date: - Z _ p Please be advised that after review of your Application. and Plans that your Application is DENIED for the following Zoning Bylaw reasons: Zoning Item Notes A Lot Area 1 Lot area Insufficient 2 Lot Area Preexisting e S 3 Lot Area Complies 4 Insufficient Information B Use 1 Allowed 2 Not Allowed 3 Use Preexisting ; 4 Special Permit Required a S. 5 Insufficient Information C Setback 1 All setbacks comply 2 Front Insufficient 3 Left Side insufficient z g 4 Right Side Insufficient 5 Rear Insufficient 6 Preexisting setbacks) 7 Insufficient Information D Watershed 1 Not in Watershed Lf 2 In Watershed 3 Lot prior to 10/24/94 4 Zone to be Determined 5 Insufficient Information E Historic District 1 In District review required 2 Not in district 3 Insufficient Information RemedY for the above is checked below. Item # Special Permits Planning Board Site Plan Review Special Permit Access other than Fronta e S ecial Permit Frontage Exception Lot Special Permit Common Driveway Special Permit Congregate Housing. Special Permit Continuing Care Retirement Special Permit Inde endent Elderl Housin S ecial Permit Lar a Estate Condo S ecial Permit Planned Develo ment District S ecial Permit Planned Residential Special Permit R-6 Density Special Permit Permit Item # I Variance Setback Variance ParkiIg Variance . Lot Area Variance Height Variance Variance for Si n Special Permits Zoning Board S ecial Permit Non-Conformina Use ZBA Earth Removal S ecial Permit ZBA S ecial Permit Use not Listed but Similar special Permit for Sian Special permit for preexisting The above review and attached explanation of such is based on the plans and information submitted. No definitive review and or advice shall be based on verbal explanations by the applicant nor shall such verbal explanations by the applicant serve to provide definitive answers to the above reasons for Any inaccuracies, misleading information, or other subsequent changes to the information submitted by the applicant shall be grounds for this review to be voided at the discretion of the Building Department. The attached document titled "Plan Review Narrative" shall be attached hereto and incorporated herein by reference. The building department will retain all plans and documentation for the above file. You must file a new permit application form and begin the permitting process. lldrng Department Official Si na —3 Application `� 3 gf. Application Received Application Denied Item Notes F Frontage 1 Frontage Insufficient 2 Frontage Complies 3 Preexisting frontage 4 Insufficient Information 5 -No access over Frontage G Contiguous Building Area 1 Insufficient Area 2 Complies 3 Preexisting CBA Ll P - S '4 Insufficient Information H Building Height 1 Height Exceeds Maximum 2 Complies 3 Preexisting Height S 4 Insufficient Information I Building Coverage 1 Coverage exceeds maximum 2 Coverage Complies 3 Coverage Preexisting 4 Insufficient Information j Sign 1 Sign not allowed 2 Sign Complies 3 Insufficient Information K Parking 1 More Parking Required 2 Parking Complies 37 Insufficient Information 4 1 Pre-existing Parking Item # I Variance Setback Variance ParkiIg Variance . Lot Area Variance Height Variance Variance for Si n Special Permits Zoning Board S ecial Permit Non-Conformina Use ZBA Earth Removal S ecial Permit ZBA S ecial Permit Use not Listed but Similar special Permit for Sian Special permit for preexisting The above review and attached explanation of such is based on the plans and information submitted. No definitive review and or advice shall be based on verbal explanations by the applicant nor shall such verbal explanations by the applicant serve to provide definitive answers to the above reasons for Any inaccuracies, misleading information, or other subsequent changes to the information submitted by the applicant shall be grounds for this review to be voided at the discretion of the Building Department. The attached document titled "Plan Review Narrative" shall be attached hereto and incorporated herein by reference. The building department will retain all plans and documentation for the above file. You must file a new permit application form and begin the permitting process. lldrng Department Official Si na —3 Application `� 3 gf. Application Received Application Denied Plan Review Narrative The following narrative is provided to further explain the rebsons. for..bENIAL for the APPLICATION for the property indicated on the reverse side: r Referred To: e NORTOI , SSACHUSE Town of North Andover, Massachusetts BOARD OF HEALTH Form No. 3 0. c,77 27 19 90 DISPOSAL WORKS CONSTRUCTION PERMIT Applicant —71"c,C J CSI✓CS NAME ADDRESS TELEPHONE Site Location C„"- 7 C4 Permission is hereby granted to Construct (-�<or Repair ( ) an Individual Soil Absorption Sewage Disposal System as shown on the Design Approval S.S. No. � 7.3 Fee CHAIRMAN, BOARD OF HEALTH D.W.C. No. C/li G';� . m r CHAIRMAN, BOARD OF HEALTH D.W.C. No. C/li G';� . BOARD OF HEALTH 120 MAIN STREET NORTH ANDOVER, MASS. 01845 September 30, 1994 Mr. Scott Giles 50 Deermeadow Road North Andover, MA 0.1845 Re: Lot #9 Dale Street Dear Mr. Giles: TEL. 682-6483 Ext23 This letter is to confirm that the North Andover Board of Health, at their meeting of September 29, 1994, granted a variance to North Andover Regulation 4.18, Distances, of the Minimum Requirements for the Subsurface Disposal of Sanitary Sewage to allow 25 feet from the foundation drain to the leaching area on Lot #9 Dale Street. me. If you have any questions, please do not hesitate to call Sincerely, Sandra Starr, R.S. Health Administrator cc: George Perna, Acting Director, PCD Robert Nicetta, Building Inspector File' S oz. IL12' 1,3 0 Z-7- 1126 P'ZZE-5 Z /9 A/ A-).) o/p Z —5 y of� N 01 MORTq ,.•.. 'a t � CMU+E�� Town of North Andover, Massachusetts BOARD OF HEALTH Form N0.2 DESIGN APPROVAL FOR SOIL ABSORPTION SEWAGE DISPOSAL SYSTEM Applicant Site Location d Test No. 4��6 Reference Plans and S tNGINEER DESIG DATE Permission is granted for an individual soil absorption sewage dis os in accordance with regulations of Board of Health, p al system to be installed Fee CnAIRMAN, BOARD OF HEALTH Site System Permit No. 4j r` ', L(,�c !.`c _� L �l�a� T, rt �,1 �! T Pati � ��� hh(lhti �,��ylt��� t���`{���I �+' ��C�+ f ! {.. t!__ c i ;a •. 5 �' r�! y.: E.�: �\t <t :4.•1♦ Z l� i�Y 4 �..�.c:�,�� 1�1i \� �,� l cg' `�. 1- \i ♦ � .. .�-, 'ti� i� �` � �. ! ,: c^ �, 1. : f �. ♦♦ t 74.� t'A4 ! L ''ll�`i` � \ \e tit?V !a 4 ',\!. \� ,a .�., '\ a e t��a.ti �,y- dt(ih�`.h � 1 -� \k4Y•♦t \ T � � i .... �.. �1 t � � ~ e�� E�� � ` R - �:4� � 1 4 ! ♦ 1 �t � �x � +i; 5 ., .a ♦ l !' c s - - - tfyyC`}y"t�` 5 Pbf:iGK'Sh`4i�!�.�''7'3�1 ttRF rlit�l4@ l��'$5 i'�t�Or S 5 67R. ZU?tdly i�4ti1`.t).l Mz .iaXiC"..r,�+,.��'t`•` �°i9..`s�F47c".J:i+•-•-t � n;�Ffi�+`„fi;..r �' _ ..r,....� _ � .s ....., ,.... _.... ..r. _ .. INSTRUCTIONS: This form is used to verity 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: ?\Q Phone Sr 1010 n WCATION: Assessor's Man N i-mber O Parcel Subdivi_1. on Lots; tree= D �? met St. Nu.:,ber Use RECO2-_ENDATIONS OF TOWN AGENTS: 'e:;V - - 41n Date Anoroved g'�2 Ccn �_:at_on Ad -_n is`ratcr Data Re;ect_d Town Planner Cc:-- ert_ Fccd SCC ..._ '. Date Approved Date Rej ec =ad Date Approved Date Re j ec =ed Date Antrcve._���% Data Rejected Wcr�:s - se:-rer/water connections _ - driveway permit F__e D e = a == e.^.t Rec=_ved by Bui'_dina Inspector Date . .+ t '`.#' �„l� f i r � -J♦`� r � C'� Si i((tr�'�,., C � t i ..I r � ` l • r 'r ' ' � t'.1 rr••r 'i r � I' s ,.0 .('t!Y^ sr r f' j .. , • r' �^ � /r � is l f�/p .y.,� Sr,(Tf :'r�V� r_./ / y, _ r . ' `.� y . � �!^�:`: 'ter"iY.:^"`:�• �-�✓; ;,'.. '.: • �'>t.i x�l..nr,t1-�.`;'a %! '':i.r.t� ,li.'s�i�ir►hJrt, '1+... 'ari Via. . •'� � ,,+ ' ,:• �\ AA' t � ,' t�`.t .�`yr � f:�S� frf fR.}f j�It4 r"�.t a r i � � ,r � lr`x ` ���' ��;: � rt• �.ka1`O.F�',4 tir`x � l t• • , ` + f �, r+ � t A • f A A' 1 + i t >t ~ " � !� t � . itit r a , f l t i � - t, ,, fy. ; ,l•N t � rt t� i � l ° t�tta aft ` �- t� rtl. >t ,. i. � x ' ``\ ;: '�l.` �f�,A r ;� � ,� {�ry ;4+(���r, y+�, A'�hi A: r'+ {.`R'i' tyi,t It �'tt'• �(• l 'r t' '�,� � x: ',l tY'r ;•c:r r�. 1lt •,t ti.. Y t.i•l.! . ,.�<) el t, <, j'a Z %, S g31.+4.�" ai h:ir Ai \ S t �t t + 1' r . t� \ \. i a'•.� l l � A 4 �, ,,, 1,. A +:� ��'` ? x.:>f1� i fi t of °� i \'ty�t,''^ ,r ': \ " r to . S p 1 r�:. t A , •' , "A•i'�1 ,1s f.,Y', r�( x. *'��rri ��jL�4•�%..� �.i-�< '%�• R Y � :��tf?r\�t��1'�n+i� i, "Y.Sj.�•is'h',5.r.�"Sf.:?�f,�r>'r'�'`��.r•.'f-�; r;},, 1i�•r d♦ d � (�+,{'S't :' i�y1'j��Yxki'4� \i r4�` ,I ;3Et >tii:, ;`� .1;,,A�' ��� '•' vQ� }s7��:�4Ct ",��e� ��'3 L z\i4 r(�" t�' 11 i , .�\.; �•t ' P c' AT eF �.. .�� ! � 'j -�,a �.��Y z tva at � �r. + i A � •� 1{t � ril �i.¢�w t14: ` a.. .. i. ,:.��..� f '�+ `•'i,,,A, ''� � .h R \ '15 h>'' t ti f k S *;� � Y:'.r1'4r,A. A-; j..'i F . � r'+ � t$ `�` Vit. < k R4�''=`:::>1�„' �t �t i .��; r;�,��; •.'!� �3'+ ;� 1�4t � .(*t'''� � a Kit• ` ,V�l ali,l":j, r� Ott .n'� t Ai �~ f t'T� l�tl.� y 2.. �t`�1 e ,Ai. �Z,, `•• \• Z �'� a�� r t� ,f�:' \� S ,(�� �t► 1°� � t ,\a'AA `L\lw„�r\ �ti�t� 1.dl1��yF � a"1�iyx. \ t "•h.�"SV t"Ck `ti y;t� x;i�.y�ttl�`S?�i1,L.Er-si�'w��a�� r. •'tL� 4 � ., q 3.. .2 aTilA ��i� �tl'•�}�` l.�tyfn z - :�; `•r.� �`r�y+?ll \.r,r +'7-.\f.t:.��d, �Y :�h � .pa"�1 A r •� s\�,'. 1 �1 �: C A t ?r ,t, h A R.t xit a 'i'• � �, (�.� r+. r '-C.. �..^r,il % i; J� i [• f�'" • f f•.r •�eY4f��p.� Y k f . - . , _ • j � !• „ rli?,ice r•�ri� �' � x.?�, w r � '� ` . • • ,. .. . ` ,••1•,•}}' ,''t•`''\ ,t�•,'r \•��•(� �`�{ `t .yet .•,t . `�• ` , 1 , • ,� '\I ,�t•. �t ,Irllc�r.'t•'y\,i yi.i��1`'�� t K-� t\ ;�yta� rF�t „•1,�'fr� t,arr! ;5�•�,�•+::�.: t:1'f�.•! ,� `e � t -�.r L2••-�e! i`�tc 1\1�i•.'�µ.CS`{-��� !���\ `�"�!' tf'Rti Jrr,rx�. i�!:'.�.;F�t��'f',� r'� .r"i'iri• \;i.tcc•` �,.,'t_ '•r. ti .. \ I.` \it\`\t • t ti titic` . t' C.t iV 4 % \ + cy �! �.� \ � .. ,4'^�S• �£�t. ��iE.. f c � '�• ce-k �(��^e i k.•" t\ \ • e j}e1 .., L. c•i t � r � - +c't1wJ=, �,. (,,�-c�l:c��..., .� t.� ► � �(} �,`�.� r, n.,�:. 4 V j,' t � 14r'; :.`.. , t` t •'<. -c ,1, . •� � if �'`+ t �: \��`"t.�yt �. .'(,`•1 <a A -.V..; ��;G7.%.q, c• �F7�••�'', 'j; �•1 -r t' ' , .;t •, ` yo Tjt� .0 .`.et{�� ti,�;vt�` .�;11r�',� \i�;'c?.;!?^�1.1 :h�..t ti�," ,a�.,�G1i ti� "� Z \ i `! ,' t:4 i it ♦.;r\ � `,:. :i'-�Jr i,r � A'�.s \\�. �4.'�.��`6 a'47 �l.e. y, \i:il'"'F \'•*:• ��t tti .! ••,�� \ �t ,\ \ e- ^\ `'r \� t ` ,t .;,`. lone?� sa. r� ► `!.��.�wti�...�Sh.4:.�+1'<`�'. �.t�•`r31,�.,.., C'.*.1, .... r... _ ,. . , .: .._4:.. ,.. - \.. .. .. .. +....i C We, Joan M. Cashman, Ellen Sweeney and John C. Oakley, Trustees of the Odelle F. Cashman Trust u/d/t dated July 21, 1986 filed and registered with Records of Registered Land in the Northern Registry District of Essex County, Massachusetts as Document No. 40693, in consideration of ONE ($1.00) DOLLAR and all other good and valuable consideration paid, grant to Patricia Cashman Connolly, of 81A Church Street, Merrimac, Essex County, Massachusetts With QUITCLAIM covenants a certain parcel of land situate in said North Andover, being shown as Lot nine (9) shown on the hereinafter mentioned plan. All of said boundaries are determined by the Court to be located as shown on Plan No. 40905D, drawn by Thomas E. Neve Associates, Inc., Surveyors, dated May 1, 1987, filed in the Land Registration Office of the Northern Registry District of Essex County, a copy of a portion of which is filed with Certificate of Title No. 10536, Book 76, Page 149. Said premises are conveyed together with the right of the grantees, their heirs, executors, administrators, successors and assigns to pass and re -pass by foot or by farming or gardening equipment, over the area designated on said Plan as "Easement (20.00 Wide)", situated adjacent to the land of Eileen T. Carleton et al as shown on said Plan. Said Easement shall provide said grantees, their heirs, executors, administrators, successors and assigns with a right of access to and from the herein Lot Nine (9) to Lot Sixteen (16). Said premises are also conveyed subject to the rights of the owners of Lot Eight (8), their heirs, executors, administrators, successors and assigns to pass and re -pass, by foot or by farming or gardening equipment, over the area situated adjacent to land of said Carleton and designated on said Plan as "Easement (20.00 Wide)". Said Easement shall provide said owners, their heirs, executors, administrators, successors and assigns with a right of access to and from said Lot Eight (8) to Lot Sixteen (16). This deed is given in accordance with Article SECOND (A) of the above referred to Odelle F. Cashman Trust. Being a portion of the premises, title to which is registered in our names, as Trustees, in the Registered Land Section of the Northern Registry District of Essex County, Massachusetts as Certificate of Title No. 10637 in Book -77, Page 153. Essex, ss. tNG M. CA N, Trustee EY, Truste OAKLEY, rustee COMMONWEALTH OF MASSACHUSETTS March 17 1994 Then personally appeared the above-named Joan M. Cashman, Ellen Sweeney and John C. Oakley, as Trustees aforesaid and acknowledge the foregoing instrument to be their free act and deed, before me. ZL(iY�C �liLc Rosemarie Roche, Notary Public My commission expires: /Q/Z1/Cfl j . 6 SION PLAN OF LAND IN NORTH ANDOVER is E. Neve Associates,Inc., Surveyors May 1, .1987 O� \ •>J,t �SsF ii CT BS 34, q3 SS3.OBy7;E' dh. S' 40,905D c11 Barrell F `y6 Robinson tk .4 g6� Robe, -l. F. .� Carlelon el o% Eileen T. Carlelon "s3� dh.'�0 c7 s0 n dh. CS 40' Qa.33 w �8 510fe ent. f asem E P/an No. 409098 Csrl. Na 9349 $rseivied for e i,aer`�ean Subdivision of Lot 7 b O'CLOCK Shown on Plan 40905—C NOTED ON CERTIRCATE N0. U Filed with Cert. of Title No. 9575 IN REGISTRATION BOOK PAGE North Registry District of Essex County Separate certificates of title may be .issued, -•for land Abutters are shown as shown hePeon as Lots B through 16 _ _ _ _ _ _ _ _ on original decree plan. Copy of part of plan By the court. filed in LAND REGISTRA TION OFFICE JUNE 10, 1988 _JUNE 10_1988 — '' — — — — — Scale of this plan 120 feet to an inch — — — — — — Ae ��r. Louis A. Moore. Engineer for Court ST. KM- lOR I 0 �; (� Q � 3 a3