HomeMy WebLinkAboutMiscellaneous - 845 WINTER STREET 4/30/2018 (2)w -
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• ,; € MAP
LOT #
PARCEL # STREET _I+L
CONSTRUCTION AP __, ...... AL
HAS PLAN REVIEW FEE BEEN PAID? J YES NO
PLAN APPROVAL: DATE v� / APP. BY.__��C��l�l�
DESIGNER: t37-&Ve _d) 'Vk2 0 PLAN DA'I-E:_ ?i
CONDITIONS
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WATER SUPPLY: OWN WELL
WELL PERMIT _ DRILLER._._._.__.__..._----.-_-__.__..._..............._._:_.._...----........
WELL TESTS: CHEMICAL DAIS APPRUVEU,.._..___..___..__._.___.
BAC ARIA II DATE OPPRUVED
*BACTERIA II DATE APPROVED ------
COMMENTS:.
FORM U APPROVAL: APPROVAL TO ISSUE YE5 NO
DATE ISSUED By�-
CONDITIONS:
FINAL APPROVAL:.
ALL PERMITS PAID ES--- NO
WELL CONSTRUCTION APPROVAL -=Y NU
SEPTIC SYSTEM CONSTRUCTION APPRUV-KCL YES NO
OTHER NO
ANY VARIANCE NEEDED
FINAL BOARD OF HEALTH APPROVAL:
YES NO
DATE:. _..__......._..._ ....BY: _..
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LICENSED? YES
NO
IS'T64E' INSTALLER
^
_NEW
REPAIR**:
P AI R'
CONSTRUCTION'TYPE. OF
._ .. -
PLAN 'REVIEW- `C-
NO
CONSTRUCTION:-,. CERTIFIED PLOT.
.NEW
:�..... :- YES
• 1 �,.: �: '_., CONDITIONS OF.. APPROVAL.
NO
:: _;=:
FORM U)
�".. --.
• ;'` .iii _ . _ '.`.,: .-:: •'. - • .J��' �
YES
N 0
.IISSUANCE OF DWC PERMIT
N0. : ' INSTALLER:
-'.DWC PERMIT
,
.'.: BEGIN INSPECTION='''`'�
.....:. . ...:.. :....
''
�r• . :: ,'.: ..: ; .: ::- ..
EXCAVATION., INSPECTION: ..NEEDED
n
PASSED
.
INSPECTION= NEEDED:
..,-.CONSTRUCTION
AS BUILT PLAN SATISFACTORY: YES:
APPROVAL TO BACKFILL: DATE: BY
' •FINAL.GRADING APPROVAL: DATE BY
'' FINAL CONSTRUCTION APPROVAL: DATE: BY
Commonwealth of Massachusetts f
City/Town of ► h,;a'3 204
System Pumping Record TZ0%` Jy.
Form 4 • _�A r� 7 ° _
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 / Right rear of housee . rig ife-16f hhous eft /
Right side of building, Left / Right front of building, Left / Right rear of Wilding, Un er ec c
Address Ll
'�- / , I (A / 5* (/ v
4
City/Town (,� w ✓'4\�—�%'"� State Zp
2. System Owner.
Name'
Address (if different from location)
CitylTown State Zi Code
Telephone Number
B Pumping Record
1. Date of Pumping
3. Type of system: ❑
ther (describe):
a as -I L/
Date
2. Quantity Pumped:
Cesspools)eptic Tank
4. Effluent Tee Filter present? ❑ Y" ❑ No
5. Condition of System: I ��
6. System Pu ped By. P
Neil. Bateson
Name
Bateson Enterprises Inc
Company
7. Location ybere�contents were disposed:
,3
Gallons
❑ Tight Tank
If yes, was it cleaned? ❑ Yes ❑ No,
F5821
Vehicle License Number
Date
0
t5fomu4.doe- 06/03 System Pumping Record • Page 1 of 1
Important:
When filling out
forms on the
computer, use
only the tab key
to move your
cursor - do not
use the return
key.
Commonwealth of Massachusetts
City/Town of
System Pumping Record
Form 4
DEP has provided this form for use by local Boards of He;
information must be substantially the same as that provid(
local Board of Health to determine the form they use. The
the local Board of Health or other approving authority.
VF. IVED
t hr„(n
C'
0 but the
check with your
Pumping Record must be submitted to
A. Facility Information
1. System Location: Left front, left re , l�ofhouse-ight front, right rear, right side of house.
Address ` , V\A-e� 1 &te�/ ,1yG v�nw`.
Cityrrown !n State Zip Code
2. System Owner: rA
Name
Address (if different from location)
Cityrrown Staten
Telephone Number
B. Pumping Record f
1. Date of Pumping � ~ + � 2. QuantityPumped:
p g Datep Gallons
3. Type of system: Cesspool(s) Septic Tank Tight Tank
Ej Other (describe):
4. Effluent Tee Filter present? C] Yes No If yes, was it cleaned? r] Yes [ No
5. Condition of System: 1
ia d f ,M n l � v,,-
6. System Pumped By:
Neil Bateson
Name
Bateson Enterprises Inc
Company
7. Location-wkere contents were disposed:
of
Lowell Waste Water
F 5821
Vehicle License Number
3-�--((D
Date
t5form4.doc• 06/03 System Pumping Record • Page 1 of 1
FORM U - LOT RELEASE FORM
16 'Fib 1-c CC -
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g `o _0 �- —
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.
R----APPLIGANT FILLS OUT THIS SECTION*********-*************
APPLICANT % ` PHONE J -42(o
LOCATION: Assessor's Map Number G PARCEL_b2--
SUBDIVISION � LOT (S)
STREET VVI ST. NUMBERO T,�
*******************************-OFFICIAL USE
AGENTS:
��, r 6v&Vy
ICON ERVATION ADMINIS ATOR DATE APPR VED
DATE REJECTED
COMMENTS s
TOWN PLANNER
COMMENTS
DATE APPROVED
DATE REJECTED
FOOD INSPECTOR -HEALTH DATE APPROVED
]r DATE REJECTED
SEPTIC_ INSPECTOR -HEALTH. DATE APPROVED
DATE REJECTED
PUBLIC WORKS - SEWER/WATER CONNECTIONS
DRIVEWAY PERMIT
FIRE DEPARTMENT
RECEIVED BY BUILDING INSPECTO
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COMMONWEALTH OF MASSACHUSETTS
EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS
DEPARTMENT OF ENVIRONMENTAL PROTECTION
TITLE 5
OFFICIAL INSPECTION FORM — NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM
PART A
CERTIFICATION7C?;14+�! OF �� ANDO E
Property Address:
111o, - �.��� o ��ys 1 S� 3
Owner's Name: N r(j�oe ✓%�. il� / 9�
Owner's Address: s a e y ➢ [____ _.]
Date of Inspection: 4 47,T3 L_ -
Name of Inspector: (please print) �jo rj e&
Company Name: —rZa'e'e 6 6Ai3% ire rvi4e-,!
Mailing Address: 9 a a b a /e .ey:
ovfX � overs �.9 b/�y�
Telephone Number: - J g y 7,>0
CERTIFICATION STATEMENT
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
_ Needs Further Evaluation by the Local Approving Authority
Fails
Inspector's Signature: ��3- / � �� Date: a 3
The system inspector shall submit a copy of this inspection report to the Approving Authority (Board of Health or
DEP) within 30 days of completing this inspection. If the system is a shared system or has a design flow of 10,000
gpd or greater, the inspector and the system owner shall submit the report to the appropriate regional office of the
DEP. The original should be sent to the system owner and copies sent to the buyer, if applicable, and the approving
authority.
Notes and Comments
****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.
Page 2 of 11
OFFICIAL INSPECTION FORM — NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION (continued)
Property Address: e yS �fh✓ �l'f
Owner:
Date of Inspection: c?-
Inspection Summary: Check A,B,C,D or E / ALWAYS complete all of Section D
A. System Passes:
I/' I have not found any information which indicates that any of the failure criteria described in 310 CMR
15.303 or in 310 CMR 15.304 exist. Any failure criteria not evaluated are indicated below.
Comments:
B. System Conditionally Passes:
One or more system components as described in the "Conditional Pass" section need to be replaced or
repaired. The system, upon completion of the replacement or repair, as approved by the Board of Health, will pass.
Answer yes, no or not determined (Y,N,ND) in the for the following statements. If "not determined" please
explain.
The septic tank is metal and over 20 years old* or the septic tank (whether metal or not) is structurally
unsound, exhibits substantial infiltration or exfiltration or tank failure is imminent. System will pass inspection if the
existing tank is replaced with a complying septic tank as approved by the Board of Health.
*A metal septic tank will pass inspection if it is structurally sound, not leaking and if a Certificate of Compliance
indicating that the tank is less than 20 years old is available.
ND explain:
Observation of sewage backup or break out or high static water level in the distribution box due to broken or
obstructed pipe(s) or due to a broken, settled or uneven distribution box. System will pass inspection if (with
approval of Board of Health):
broken pipe(s) are replaced
obstruction is removed
distribution box is leveled or replaced
ND explain:
The system required pumping more than 4 times a year due to broken or obstructed pipe(s). The system will
pass inspection if (with approval of the Board of Health):
broken pipe(s) are replaced
obstruction is removed
ND explain:
Page 3 of 11
OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION (continued)
Property Address:
nP 1#1 of Va ys—
Owner• 1971, r A/v e-
Date of Inspection: i ado/u j
C. Further Evaluation is Required by the Board of Health:
Conditions exist which require further evaluation by the Board of Health in order to determine if the system
is failing to protect public health, safety or the environment.
1. System will pass unless Board of Health determines in accordance with 310 CMR 15.303(1)(b) that the
system is not functioning in a manner which will protect public health, safety and the environment:
Cesspool or privy is within 50 feet of a surface water
Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh
2. System will fail unless the Board of Health (and Public Water Supplier, if any) determines that the
system is functioning in a manner that protects the public health, safety and environment:
_ The system has a septic tank and soil absorption system (SAS) and the SAS is within 100 feet of a
surface water supply or tributary to a surface water supply.
The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water supply.
_ The system has a septic tank and SAS and the SAS is within 50 feet of a private water supply well.
_ The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or more from a
private water supply well". Method used to determine distance
"This system passes if the well water analysis, performed at a DEP certified laboratory, for coliform
bacteria and volatile organic compounds indicates that the well is free from pollution from that facility 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:
Page 4 of 11
OFFICIAL INSPECTION FORM — NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION (continued)
Property Address:y�%� fe✓ ✓�
0/ .42 ka—
Owner: /9tzo ✓ 4
Date of Inspection: yo/111 .4-1/-,3
D. System Failure Criteria applicable to all systems:
You must indicate "yes" or "no" to each of the following for all inspections:
Yes No
_ 1-' Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool
vDischarge 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
1'11,V Liquid depth in cesspool is less than 6" below invert or available volume is less than ''/z day flow
Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number
of times pumped
_V" 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.
IZ4 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 coliform bacteria and volatile organic compounds
indicates that the well is free from pollution from that facility 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.]
_ (Yes/No) 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.
You must indicate either "yes" or "no" to each of the following:
(The following criteria apply to large systems in addition to the criteria above)
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.
Page 5 of 11
OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART B
CHECKLIST
Property Address: Ca,�,, �/%4�e✓
Owner: /1j �✓o ��
Date of Inspection: b _3
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 ?
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
Yes no
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) [3 10 CMR 15.302(3)(b)]
Page 6 of 11
OFFICIAL INSPECTION FORM — NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION
Property Address: �p XJ—
Owner:
SOwner• `01o6 %
Date of Inspection: 44 d -d" -/v-3
FLOW CONDITIONS
RESIDENTIAL
Number of bedrooms (design): y Number of bedrooms (actual):
DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x # of bedrooms): d 0 9 o�
Number of current residents: 9—
Does
Does residence have a garbage grinder (yes or no):
Is laundry on a separate sewage system (yes or no): [if yes separate inspection required]
Laundry system inspected (yes or no): 1",
Seasonal use: (yes or no): Ha
Water meter readings, if available (last 2 years usage (gpd)):
Sump pump (yes or no): _/o
Last date of occupancy:
COMMERCIALANDUSTRIAL
Type of establishment:
Design flow (based on 310 CMR 15.203): gpd
Basis of design flow (seats/persons/sgft,etc.):
Grease trap present (yes or no): _
Industrial waste holding tank present (yes or no):
Non -sanitary waste discharged to the Title 5 system (yes or no):
Water meter readings, if available:
Last date of occupancy/use:
OTHER (describe):
GENERAL INFORMATION
Pumping Records
Source of information: lPe �G ;h f r(, y d weer
Was system pumped aspartpart� pection (yes or no): _zv&
If yes, volume pumped: _gallons -- How was quantity pumped determined?
Reason for pumping:
TYPE OF SYSTEM
_Septic tank, distribution box, soil absorption system
_ Single cesspool
_ Overflow cesspool
_ Privy
_ Shared system (yes or no) (if yes, attach previous inspection records, if any)
Innovative/Alternative technology. Attach a copy of the current operation and maintenance contract (to be
obtained from system owner)
Tight tank Attach a copy of the DEP approval
_ Other (describe):
of all components, date installed (if known) and source of information:
Were sewage odors detected when arriving at the site (yes or no): I'
Page 7 of 11
OFFICIAL INSPECTION FORM — NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Property Address: (-7-
Owner:
Date of Inspection: x/03
BUILDING SEWER (locate on site plan)
Depth below grade: / 710 ¢ lee
Materials of construction: _cast iron X40 PVC _other (explain):
Distance from private water supply well or suction line: -1,4
Comments (on condition of joints, venting, evidence of leakage, etc.):
SEPTIC TANK:,ZZ (locate on site plan)
Depth below grade: -
Material of construction: ✓concrete _metal _fiberglass _polyethylene
_other(explain)
If tank is metal list age: _ Is age confirmed by a Certificate of Compliance (yes or no): _ (attach a copy of
certificate)
Dimensions: cs x e,
Sludge depth:—�
Distance from top of sludge to bottom of outlet tee or baffle:
Scum thickness: -Y /
Distance from top of scum to top of outlet tee or baffle: d,
Distance from bottom of scum to bottom of outleT-tee or baffle:
How were dimensions determined:
Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels
as related to outlet invert, evidence of leakage,/etc.):
GREASE TRAP: _(locate on site plan)
Depth below grade
Material of construction: _concrete _metal _fiberglass polyethylene other
(explain):
Dimensions:
Scum thickness:
Distance from top of scum to top of outlet tee or baffle:
Distance from bottom of scum to bottom of outlet tee or baffle:
Date of last pumping:
Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels
as related to outlet invert, evidence of leakage, etc.):
Page 8of11
OFFICIAL INSPECTION FORM — NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Property Address: c}` 9r �n7�cr "/
'17/9 O
Owner: /;;7N r ol,A
Date of Inspection:
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: gallons
Design Flow: gallons/day
Alarm present (yes or no):
Alarm level: Alarm in working order (yes or no):
Date of last pumping:
Comments (condition of alarm and float switches, etc:):
DISTRIBUTION BOX: Zof present must be opened)(locate on site plan)
Depth of liquid level above outlet invert:
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.):
PUMP CHAMBER'' rs (locate on site plan)
Pumps in working order (yes or no):,r
Alarms in working order (yes or no):,r
Comments (note condition of pump chamber, condition of pumps and appurtenances, etc/.):
Page 9 of 11
OFFICIAL INSPECTION FORM — NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Property Address: c% y� `� ht� c1,`•
Owner•
Date of Inspection: ja
SOIL ABSORPTION SYSTEM (SAS): (locate on site plan, excavation not required)
If SAS not located explain why:
Type
leaching pits, number: _
leaching chambers, number:
leaching galleries, number:
leaching trenches, number, length:
leaching fields, number, dimensions:
overflow cesspool, number:
innovative/alternative system Type/name of technology:
Comments (note condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of vegetation,
etc.): /
Y. V' a q its . - 7-,;/'- If
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 or no):
Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.):
PRIVY: (locate on site plan)
Materials of construction:
Dimensions:
Depth of solids:
Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.):
Page 10 of 11
OFFICIAL INSPECTION FORM — NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Property Address: do ks
%iv✓� /7nG✓vier �!/� D/��5�
Owner: /flu rG✓ cti
Date of Inspection:
SKETCH OF SEWAGE DISPOSAL SYSTEM
Provide a sketch of the sewage disposal system including ties to at least two permanent reference landmarks or
benchmarks. Locate all wells within 100 feet. Locate where public water supply enters the building.
4,., 4" /f- pl-)ti Oh reaov0l
Page 11 of 11
OFFICIAL INSPECTION FORM — NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Property Address: o0
Owner: �%vrG►!oG
Date of Inspection:
SITE EXAM
Slope
Surface water
Check cellar
Shallow wells
Estimated depth to ground water feet /0/161/ D h Y e L' � -�
Please indicate (check) all methods used to determine the high ground water elevation:
Obtained from system design plans on record - If checked, date of design plan reviewed:
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:
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Name
The Commonwealth of Massachusetts
Department of Industrial Accidents
Office of investigations
Boston, Mass. 02111
Workers' Compensation Insurance Affidavit
Name: /
Location: W I %,- -- S
I am a homeowner
all work myself.
I am a sole proprietor and have no one working in any capacity
Please Print
�am an employer providing workers' compensation for my employees working on this job.
Ll
Address Q I/JcS�-+ir
city. 06[- YS— Phone # _ 6 6p -i
Insurance. Co. L4 '' C- .� Policv # b 1, 'Z—• til 6% 7 - �p2,3,V
I Company name:
Address
Cifv Phonic'# -
Fail ue to segue coverage as requlned: under Section 25A or MGL 152 can lead to the imposition of criminal
Peres of.a fine up to $1.500:00
andlor one years' imprisonments vtelLas_civg4 naltiesjnsheimn-&-a STOP1l40W-ORDERand afie---oto RQDjatlaY--gainst1
understand that a copy of this statement may be forwarded to the Office of Investigations of the DIA for coverage verification.
10
/ do hereby car* under the pains and penalties of perjury that Me /rrfannahw is true and correct.
Signature 1 71 patP
Print
11 -
Official use only do not write in this area to be completed by city or town dficiar
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City or Town PermMicensing.
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Check Y immediate response is required Building Dept
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El Selectman's Office
Contact person: Phone # E] Health Department
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U ONS:Thisform is used to verify that all necessary approvals/permits froknd Departments having jurisdiction have been obtained. This does not relieve
>p i.carit and/or landowner from compliance with any applicable or requirements.
---------- `°°°°°"°'°*******APPLICANT FILLS OUT THIS
APPLICANT
LOCATION: Assessor's Map Number �1
SUBDIVISION O'%�
STREET
ATION
AGENTS:
PHONE O '1-02�P
PARCEL 00
LOT (S)
ST. NUMBER4/
ONLY
DATE APPROVED
DATE REJECTED
COMMENTS V s
TOWN PLANNER
COMMENTS
FOOD INSPECTOR -HEALTH
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SEPTIC INSPECTOR -HEALTH
COMMENTS_ t ��''`j 4,V
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DATE APPROVED
DATE REJECTED
DATE APPROVED
DATE REJECTED
VATS APPROVED.
DA
TE- 2. G
PUBLIC WORKS - SEWER/WATER CONNECTIONS
DRIVEWAY PERMIT
FIRE DEPARTMENT
RECEIVED BY BUILDING INSPECTOR DATE____
Revised 9197 jm
STEVEN J. D'URSO
Environmental Designs
22 Lilly Pond Road
W. Boxford, MA 01921
(508) 352-9872
TO / G3F
> WE ARE SENDING YOU QrAttached ❑ Under separate cover via_
❑ Shop drawings XPrints ❑ Plans
❑ Copy of letter ❑ Change order ❑
L EUV Q OF
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ATTENTION
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❑ Samples
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❑ Specifications
COPIES
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DESCRIPTION
❑ For approval
❑ Approved as submitted
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For your use
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❑ Submit
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> ❑ As requested
❑ Returned for corrections
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❑
TCtWN 01 FRnAPN RS H E NL VER% I
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❑ FOR BIDS DUE
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PRINTS RETURNED
AFTER LOAN TO US
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❑ For approval
❑ Approved as submitted
❑ Resubmit
copies for approval
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❑ Approved as noted
❑ Submit
copies for distribution
> ❑ As requested
❑ Returned for corrections
❑ Return
corrected prints
❑ For review and comment
❑
❑ FOR BIDS DUE
19 ❑
PRINTS RETURNED
AFTER LOAN TO US
REMARKS
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SIGNED:
if enclosures are not as noted, kindly notify us at nnre
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FORM U - IAT RELEASE FORM
INSTRUCTIONS: This form is used to verify that all necessary
approvals/permits from Boards and Departments having jurisdiction
have been obtained. This does not relieve the applicant and/or
landowner from compliance with any applicable local or state law,
regulations or requirements.
****************Applicant fills out this section*****************
APPLICANT: nPU' a! .
LOCATION: Assessor's Map Number 1419Y Z2
Subdivision X��_iti.
Street �2, lAJ�er e e f
Phone (`7k S -S 7Ss
Parcel
Lots) 4
St. Number
************************Official Use Only************************
RECOMMENDATI N OF OWN ENTS:
/ Date Approved
Conservation/ Date Rejected
kdComments M f �S ,,,v Sl y
Town Planner
Comments
Food Inspector -Health
'0 A A _IL4
Septic Inspector -Health
Comments
Public Works - sewer/water connections
- driveway permit
Fire Department
Date Approved
Date Rejected
Date Approved
Date Rejected
Date Approved
Date Rejected
Received by Building Inspector Date
Town of North Andover, Massachusetts Form No. 2
t MORTq BOARD OF HEALTH
o
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DESIGN APPROVAL FOR
SS4CHUSEt SOIL ABSORPTION SEWAGE DISPOSAL SYSTEM
Applicant (1 -4 - ja
Test No.
Site Location �-tl� # �JU �J � tip U-
Reference Plans and Specs. ' ' a;—�s��.
ENGINEER DESIGN DATE
Permission is granted for an individual soil absorption sewage disposal system to be installed
in accordance with regulations of Board of Health.
Fee
CHAIRMAN, BOARD OF HEALTH
Site System Permit No. 90
1.`t_t♦,
�t'r'._.nli :wL[_.,. �a._'�t.;_?:rt ;�t�.t °`>4ti... ...\.._. _.. ♦,L 1. ^1;°'i.�`, �. _ .. .. ., ..._.
... `
1r A A iw�� ip'1�1 1 yl rr l41� 4, -
OF
O.F NORTH'A,�'D0VFR
SYSTEM PUMPI.1`!G RCOR1
i.
OWNFR & ADDRESS
SYSTCM LOCATION
(MmPle: Ick front of house)
/
A/11�''
,
U:VI C`0F PUMPING; 3
(QUANTITY f UMPQD L Lc�,,
»I'0UI.°'fv0 ;YES
SEPTIC TANK: N0. YES
•
VATURE OF SERYICE:'. ROUTINE.
EMERCEN'CY
IISrRYAT10NS; E
1000-b CONUITLON.,. r.,.
NULL TU COY C,
.'FIFd;YY G;RI"rr�SG
.13AFFLLS IN PLACE
R�:o:rsl
LEACHFICI,Q RUNBACK..,
C.XCESSI'YE.'':SWDS
FLOODED'
SOLLUS CA;RRYOYER'
�(J�HF.ft (EXPLA-IN)
.f
r"NTS.
•
moo.., ..A�o.,� �orlvral-cdws; •anu mar -my -signature on"mis-permit
appiscatioh-wait/-a$-tni-s-t-eiquirettl`9-51 t -Owner Agent
(Please check one)
Telephone No. PERMIT FEE 5
(Signature of Owner or Agent)
x•6565
Date ........ .. .. . ... .... /A
Ix L
TOWN OF NORTH ANDOVER
PERMIT FOR WIRING
Thiscertifies that ........ '�./ ...........j ............................................................... W1
.
has permission to perform ....... ............. .............. .......... ................I ..(........
•
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wiring in the building of ................•r............ . \.. .....................................
at .................... .......... ....... ............... ,North Andover, Mass.
FeeA J.,t)G ... Lic. No.j.-Z. ...........................................................
ELECTRICAL INSPECTOR
WHITE: Applicant CANARY: Building Dept. PINK: Treasurer GOLD: File