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Home My WebLink AboutMiscellaneous - 89 GRAY STREET 4/30/2018EIF oco V G7 p O QW Cn O � M o m o � 0 0 q.p o 0) m A �. id CDm0 'd w o 40 0 00 CL a 1-4 oro. U • . • � 0 •cri� rA ° � •. r2a0.�►P4 COCf rn 0 t-{ O d C3 O Z 3 O W CO)CO S ttU x W 111 a b O Q WCO D p. a �0> 4, zwz< 0 w (0)0) • QWQOD } a z J Q Z0C-4 > O • � J l0 a O N ; o a o z tw( o c The Commonwealtli of Massacliuseits Department of Industrial.Accidents Office of Investigations 600 Washington Street Boston, MA 02111 ►vww.mass gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electriciains/Plutnbers Applicant Information Please Print Legibly Mame (Business/Organization/Individual):Tr� A,/.4� i! %y!A 11✓t' - � Address:__ City/State/Zip.-__k(��,/ f�,�/ 019 d Phone Are you an employer? Check the appropriate box: 1.$ I am a employer with 4. ❑ I am a general contractor and I employees (full and/or part time).* have hired the sub -contractors 2. ❑ I am a sole proprietor or partner- listed on the attached sheet. t ship and have no employees • These sub -contractors have working for me in any capacity. workers' comp. insurance. [No workers' comp. insurance 5. ❑ We are a corporation and its required.] officers have exercised their 3. ❑ I am a homeowner doing all work right of exemption per MGL . myself. [No workers' comp. c. 152, § 1(4), and we have. no insurance required.] t employees. [No workers' comp. insurance required.] Type of project (required): 6. ❑ New construction 7. ❑ Remodeling 8. ❑ Demolition 9. ❑ Building addition 10.❑ Electrical repairs or additions 11.❑ Plumbing repairs oradditions 12. Roof. repairs 13. 'Other *Any applicant that checks box 61 must also fill. out the section below showing their workers' compensation policy information. t Homeowners who submit this affidavit. indicating they are doing all work and then hire outside contractors must submit a new affidavit indicalingsuch. #Contractors that check this box must attached an additional sheet showing the name of the sub -contractors and their workers' comp. policy information. l ani an employer ilrat is provitlir:g workers' compensation insrrrance for my employees Belo}n is the policy and job site information. Insurance Company Name: y6Ain 1":&& a/A/P �crp Policy # or Self -ins. Lie. #:_ �2 �.�% j 7 Expiration Date:,--=�2=�1� Job Site Address: c% /t�'t� City/State/Zip: &,0&& 14v&VdA #/I- }j jy,5- Attach a copy of the workers' compensation policy declaration page (showing the policy number and expiration date). Failure to secure coverage as required under. Section 25A of MGL c. 152 can lead to the imposition of criminal penalties of a fine up to $1,500.00 andlor one-year imprisonment, as well as civil penalties in the form of a STOP WORK ORDER and a fine of up to $250.00 a day against the violator. Be advised that a copy of this statement may be forwarded to the Offrcedf Investigations of the DTA for insurance coverage verification. I tlo hereby certify and pei:alties of perjury that the information: provided above is trice and correct. Official rise only. ,Do not write in this area, to be completed by city or town official. City or Town: Permit/License # Issuing Authority (circle one): 1. Board of Health 2. Building Department 3. City/Town Clerk 4. EIectrical Inspector 5. Plumbing Inspector 6. Other Contact Person: Phone #: i W CL C O N 4. C C O Ctl Lo + O 4 ) Q M O. m p 0-0 N*U >ZE ME 0 41 O cC R 2 U p .J C O O f- 3 OQ U W n. (a ,� n. ® MAPFRE The Commerce Insurance Company"' Citation Insurance Company'^ Commerce" Gore Road, Webster, Massachusetts 01570 INSURANCE- 508.949.15001 www.commerceinsurance.com February 20, 2015 BUILDING COMMISSIONER or INSPECTOR OF BUILDINGS TOWN/CITY HALL NORTH ANDOVER MA 01845 RE: Our Insured: DIANA DECARO Property Address: 89 GRAY ST. Policy#: BCVSZT Date of Loss: 02/14/2015 File#: JXAR01-HNVRA2 Board of Health or Board of Selectmen Town/City Hall Claim has been made involving loss, damage, or destruction of the above captioned property which may exceed $1,000, or cause Massachusetts General Laws, Chapter 143, Section 6 to be applicable. If any notice under Massachusetts General Laws, Chapter 139, Section 3B is appropriate, please direct it to my attention. Please reference the above captioned insured, location, policy number, date of loss, and file number on any correspondence. REBECCA MCGOVERN THERRIEN Telephone: (508)949-1500 Ext: 15189 Sr Claim Representative, Property Toll Free: 1-800-221-1605, Ext: 15189 On this date, I cause copies of this notice to be sent to the persons indicated above, at the address above, by first class mail. February 20, 2015 CIC 254 (Rev. 4/95) MAIL M33 RS LO)4IPEN5 MON (b't-G•1' C 152 § 25Ctn) rovida this atii, 4-W ORKE Compensation insurance affidavit must be completed and submitted with this apl lication, Fal ore to p denial of the issuance of the build N0.......0 tad affidavit Attached Ycs "" cable Addition I 1 pcdcti tion of pro ed Work �k� Rosi Alteratians(s) l I 'EMON . Existing Building New Cottstrtwtion 0 Aues';Ory I)Idg. Danoiition fl Other griecify 3riel'Dcsn tion of proposcd Work: � c LL►yi r� :Lb��2A-�T ... SECTION 6 - ESTIMATED CO Estimated OA (Alar) to be pFFK'IA USE ONLY item Com Ieted b -rtnit a licttnt pertttit F`: (A) Building I, tfuilding 17 �.� Multi lien (h') EstimatcLl Totttl Cost of 2 f Construction ;lectric al c (h) i:,,a Permit fee ( > 3 5 t'1tE t'tacuu• �•1'`l WHEN (; Total 1�2+3+ +� O Pt, FTCD AUTHO SECTION 7e OWNEK R[7.ATi0r TOB) C M OWNERS AGENT OR C:ONTRAC'I C AppL1FS gOlt BUILDING pEK s /Authnri7.ed Agent of subject props nv L. _ ......�- l ('Ci.S✓�c =- to act un .jLC? .. � _, .... ... •. � �rtttit uppliu,Fiun. � Hurcby twilion'tc. (� – — My. l,elialf, i„ :ill int -stets relative to wvut t�th ted b)' this tuttldutb 1w Date Si na«11cr SEC'r10N 7b OWNER/AU'CHORI2ED AGENT bEC.I.ARAT10 a, ()x ter/Aut}tbl'i7.ed Agent of subject I; propert}' tt[s Luul inCunnatiuu uu tI►c [ur4:guing HpPlicaFitm arc tntc ttnLl accurxtc, to fisc Ile", of mp Ijiuw'let g�: f lenity declare that. slit' tE,Fetlte and beftcf iriIlF NameyG Dute tio�,ntilr<' Qt (}wrtterJA Vitt -- _ - NO. OF 5 L (etc Si,i+i� 1 2 SIY.t: (H; FL(101t'i'IMt1Fat, SPAN DIAAENSIONSOI; S1I,1.S I)1MI:.NSIf)NS Ul 1'(} Cti TH L)iMENSIOWN UH (ifl�t)F.RS Ec?tJ9DAn0N FORM U - LOT RELEASE FORM DNS: This form is used to verify that all necessary approvals/permits from Departments having jurisdiction have been obtained. This does not relieve t and/or landowner from compliance with any, applicable or requirements. APPLICANT FILLS OUT THIS SECTION APPLICANT %a, r) �' 'r`Y� PHONE LOCATION: Assessor's Map Number ,0 OD30 PARCEL SUBDIVISIIOiNG; LOT (S) STREET / `�� ST. NUMBER OFFICIAL USE ONLY RECOMMENDATIONS OF TOWN AGENTS: I CONSERVATION ADMINISTRATOR DATE APPROVED DATE REJECTED COMMENTS TOWN PLANNER DATE APPROVED DATE REJECTED COMMENTS FOOD INSPECTOR-HEAKH DATE APPROVED ,.DATE REJECTED PUBLIC WORKS - SEWERIWATER CONNECTIONS DRIVEWAY PERMIT n, F P c 1% 1c n FIRE DEPARTMENT 200 RECEIVED BY BUILDING INSPECTOR DATE ROVWW9197JM BUIL 'wu DEPT. FORM U - LOT RELEASE FORM bNS: This form is used to verify that all necessary approvals/permits from Departments having jurisdiction have been obtained. This does not relieve t and/or landowner from compliance with any, applicable or requirements. APPLICANT FILLS OUT THIS SECTION APPLICANT �" '�`�� PHONE LOCATION: Assessor's Map Number_Z02)D 00 30 PARCEL SUBDIVISIONC; �✓ ( LOT (S) STREET � / v `rte LI ✓ ST. NUMBER OFFICIAL USE ONL RECOMMENDATIONS OF TOWN AGENTS: TION ADMINISTRATOR DATE APPROVED DATE REJECTED COMMENTS TOWN PLANNER DATE APPROVED DATE REJECTED COMMENTS FOOD INSPECTOR -HEA TH DATE APPROVED DATE REJECTED A/ A DATE APPROVED PUBLIC WORKS - SEWERIWATER CONNECTIONS DRIVEWAY PERMITc1VE-D FIRE DEPARTMENT 200 RECEIVED BY BUILDING INSPECTOR DATE Revhwd9%97jm BUIL�!w%-J` DEPT. N B9 Nick 6A,",mhAoes, Y WEALTH OF MASSACHUSETTS VE OFFICE OF ENVIRONMENTAL AFFAIRS MENT OF ENVIRONMENTAL PROTECTION TITLE 5 OFFICIAL INSPECTION FORM — NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM PART A CERTIFICATION Property Address: Owner's Name: _ Owner's Address: Date of Inspection Name of Inspector: (please print) ?-) Et--)TA-,A. A.) C QsC-oj n J ti Company Name: 14cw Pe� &L -AA, P r,vcr �ivcc (LlN G - Mailing Address:_ l� (3 t c i w t�,, p D 2L a C NO 2X1-( A-4.0 b a& Telephone Number: R Z 5'- 65 (e- / 7 6E> A OF NON'TH ANDOV'W BOARD OF HEALTH JUN -T 22M i 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 elcperience 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: V/ Passes Conditionally Passes Needs Further Evaluation by the Local Approving Authority Fails Inspector's Signature: �Date: 6 6 0 The system inspector shall submit a copy of this inspectgn 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: _ 89 GRAY STREET NORTH ANDOVER, MA Owner: DANA GORDON Date sof Inspection: _ 6/6/02 Inspection Summary: Check n,es,t;,u or r,, �,..na., ,,,,..r___e all of Section D A. System Passes: 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: or more system components. as described in the "Conditional Pass" section need to be rep or repaired The em, upon completion -of the'replacement or repair, as approved by the Board of m, will pa§s. Answer yes, no or not ermined (Y,N,ND) in the for the following statements. I of determined" please explain. The septic tank is metal d ova 20 years old* or the septic tank ( er metal or not) is structurally unsound, exhibits:substantial infil tion or exfiltration or tank failure is ' inent. System will pass inspection if the existing task is.replaced with a carp ' g septic tank as approved b e Board of Health. *A metal septic tank will pass =20 i if it is structurally soon of leaking and if a Certificate of Compliance indicating that the tank is less told is available. ND explain: Observation of sewage backup or br or static water level in the distribution box due to broken or obstructed pipe(s) or due to`a broken, settl or uneven 'bution box. System will pass inspection if (with approval of Board of -Health): oken pipe(s) are reply obstruction is removed distribution box is leveled or rep cod ND explain: The sys m 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: 89 GRAY STREET NORTH ANDOVER, MA Owner: DIANNA GORDON Date of Ins 6/6/02 Inspection: _ G Farther Evaluation is Required by the Board of Health: is Conditions exist which require further evaluation by the Board of Health in order to determine if the system Lg to protect public health, safety or the environment. 1. em will pass:unless Board of Health determines in accordance with 310 CMR 15.300VA) that the syste not functioning in a manner which will protect public health, safety and the ronment: — Cesspoo privy is within 50 feet of a surface water Cesspool or "vy is within 50 feet of a bordering vegetated wetland or a sal arsh 2. System will fail unless the Board of th (and Public Water Supplier, -if any) determines that the system is :functioning in7a manner that Prot the pub ' ealth, safety and environment: The system has a septic tank and soil system (SAS) and the SAS is within 100 feet of a surface water supply or tributary to a surfa ter ly. The system has a septic tank SAS and the SAS is wi a Zone 1 of a public water supply. The em has a system septi and SAS and the SAS is within 50 of a private water supply well. The system has tic tank and SAS and the SAS is less than 100 feet t 50 feet or more from a private watersup well**. Method used to determine distance **This passes if the well water analysis, performed at a DEP certified laborat , or coliform bacteria d volatileorganic compounds indicates that the well is free from pollution from that facility and the ce of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other we 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; _ 89 GRAY STREET _ NORTH ANDOVER, MA Owner: DIANNA GORDON Date -of Inspection: _ 6/6/02 D. System Failure Criteria applicable to an systems: You most indicate "yes" or `ono" 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 v 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 %: day flow If 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. 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.] NO (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. EN rge Systems: To be co red a1arge system the system must serve a facility with a design flow of 10,000 gpd to 15,000 hPd You must indicate either " or "no" to each of the following: (The following criteria apply to a systems in addition to the criteria above) Yes no the system is within 400 feet of a surface g supply the system is within 200 feet of a tribu to a surface ' g water supply — the system is located in a ' ogen sensitive area (Interim W=anysidered IWPA) or a mapped Zone lI of a public er supply well If you have answ 'yes" to any question in Section E the system ishreat, or answered "yes" in S D above the large system has failed. The owner or osidered a signifi t threat under Section E or failed under Section Dshall 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: _ Owner: Date of Inspection: _ 89 GRAY STREET NORTH ANDOVER, MA DIANNA GORDON 6/6/02 Check if the following have been done. You must indicate `des" or "no" as to each of the following: Yes No Pumping information was provided by the owner, occupant, or Board of Health f 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_ ? V 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) V/_ Was the ficility or dwelling inspected for signs of sewage back up ? 1/ 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 br tees, material of construction, dimensions, depthof 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. Z'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)] `4S i Page 6 of 11 OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION Property Address: _ Owner. Date of Inspection: _ 89 GRAY STREET NORTH ANDOVER, MA DIANNA GORDON 6/6/02 RESIDENTIAL Number of bedrooms (design): Number of bedrooms (actual): DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x # of bedrooms): Number of current residents: 3 Does residence have a garbage grinder (yes or no): �dcs Is laundry on a separate sewage system (yes or no): iii [if yes separate inspection required] Laundry system inspected (yes or no): = Seasonal use: (yes or no): ,U o Water meter readings, if available (last 2 years usage (gpd)): Sump pump (yes or no): 4f-5 Last date of occupancy: c.,,, r e ,— COMMERCIAL/INDUSTRIAL Type of establishment: Design flow (based on 310 CMR 15.203): end Basis of design flow (seats/persons/sgft,etd.): Grease trap present Cm or no): _ Industrial waste holding tank present (yes or no): — Non -sanitary waste discharged to the Title 5 system (yes or no): — Water meta readings, if available: Last date of occupancy/use- OTHER (describe): GENERAL INFORMATION Pumping Records Source of information: /V c %'v /K PE -D L► -7 ucf}i2 S Was system pumped as part of the inspection (yes or no): &0 If yes, volume pumped; gallons — How was quantity pumped determined? Reason for pumping: M TYPE OF SYSTEM . Septic tank, distribution box, soil absorption system — Single cesspool Overflow cesspool Privy Shared system (yes or no) (if yes, attach previous inspection records, if any) _ Innovative(Alternative technology. Attach a copy of the current operation and maintenance contract (to be obtained from system owner) — Tight tank _ Attach a copy of the DEP approval — Other (describe): Approximate age of all components, date installed (if known) and source of information: Were sewage odors detected when arriving at the site (yes or no): ,/V`o Page 7 of I I OFFICIAL INSPECTION FORM — NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: _ 89 GRAY STREET _ NORTH ANDOVER, MA Owner DIANNA GORDON Date of Inspection:. 6/6/02 KUDING SEWER (locate on site plan) Depth below grade: Materials of construction: cast iron 40 PVC other (explain): Distance from private water supply well or suction line: Comments (on condition of joints, venting, evidence of leakage, etc.): CSDy CY o el b 1 e\ t .v A& H A& SEPTIC TANK: _ (locate on site plan) Depth below grade: J 2 Material of construction: Zconcrete 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: _ f opo C 4a En ac_ r?W JA� Sludge depth: z " Distance from top of sludge to bottom of outlet tee or baffle: 3 7 - Scum Same thickness: 2 Distance from top of scum to top of outlet tee or baffle: 6 Distance from bottom of scum to bottom of outlet tee or baffle: How were dimensions determined: v,zc Dc K Comments (on pumping recommendations, inlet and outlet tee or bate condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): 12 o/l cyNfl.i7ON Pvc -7-ClIF rAj &:eoD CoND,1c0/l GREASE TRAP: A%t(locate on site plan) Depth below grade: _ Material of construction: concrete metal _fiberglass _polyethylene other (explain): Dimensions: Scum thickness: Distance from top of spun 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 8 of 11 z' OFFICIAL INSPECTION FORM — NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: _ 89 GRAY STREET - NORTH ANDOVER, MA Owner: DIANNA GORDON Date of Inspection: 6/6/02 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): Alum level: Alarm in working order (yes or no): Date of last pumping: Comments (condition of alarm and float switches, etc.): S TRIBUTION BOX: (if present must be opaned)(locate on site plan) Depth of liquid level above outlet invert: V4 ;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.): Fox �n o�c rr� D nr5T2LBv-Z.)ni E -Q,) i7 S o L. D S C A-2rtiy o.r�lL o a L.eclri4q c t� c 2 y ✓'i PUMP CHAMBER: M (locate on site plan) Pumps in working order (yes or no): Alarms in working order (yes or no): Comments (note condition of pump chamber, condition of pumps and appurtenances, etc.): Page 9 of 11 5:'rP OFFICIAL INSPECTION FORM — NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: _ 89 GRAY STREET NORTH ANDOVER, MA Owner: DIANNA GORDON Date of Inspection:. 6/6/02 SOIL ABSORPTION 0 10 A r i a kozW). �.,,� ...� _.._ r—,4 ezcavation 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 Typetname of technology: Comments (note condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of vegetation, etc.): AREA- U'F �-isi �..n ►.o it,s YL0 pAA04-L-N`J Nce or- P&toC�� T.>%irtiP 4c_ VCC465—A-ilaN. t.vl,— SdiL CLd'Uvvip 1 N C>, c 47(r-5T1-C�t T &Z -)i L ) s D CESSPOOLS: /V k (cesspool must be pumped as part of inspectionxlocate 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: A (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: _ Owner. Date of Inspection: 89 GRAY STREET NORTH ANDOVER, MA DIANNA GORDON 6/6/02 SKETM 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. M Page 11 of 11 OFFICIAL INSPECTION FORM — NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: _ Owner: Date of Inspection: _ SITE EXAM Slope Surface water Check cellar Shallow wells 89 GRAY STREET NORTH ANDOVER, MA DIANNA GORDON 6/6/02 Estimated depth to ground water Oo feet 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: Arco. o F sus Tc w. , S . csC D llil33✓� 6,1 P GAJ 9 P�. A -c r rrl4-13_ No , A) 6-'M - 02 U0 =I(- 4AJ'Ds „v a10-,-� A&EA-s._ FORM U - LOT RELEASE FORM r- INSTRUCTIONS: This form is used to verify that all necessary approvals/permits=_f.�om- Boards and Departments having jurisdiction have been obtained. This does not`r ii e.. the applicant and/or landowner from compliance with any applicable or requiref e"h7jts. " **'`APPLICANT FILLS OUT THIS SECTION CO APPLICANT ?Aer- l ?O rh ✓1 PHONE LOCATION: Assessors Map Number /07 D PARCEL_ f SUBDIVISION LOT (S) STREET C /GLc1 �)�� r ST. NUMBER ""'"'*"OFFICIAL USE ONLY*** h RECOMMENDATIONS OF TOWN AGENTS: CONSERVATION ADMINIaTRATOR DATE APPROVED DATE -REJECTED COMMENTS TOWN PLANNER DATE APPROVED M�1 DATE REJECTED COMMENTS FOOD INSPECTOR -HEALTH DATE APPROVED o, DATE REJECTED SEPTIC I OR -HEALTH DATE APPROVED DATE REJECTED COMMENTS PUBLIC WORKS - SEWER/WATER CONNECTIONS DRIVEWAY PERMIT FIRE DEPARTMENT RECEIVED BY BUILDING INSPECTOR DATE W, *NOV-30-95 THU 10:06 H .Zo 'T' (! MORTGAGE INSPECTION PIAN "A" �„ , �0 • °'� y„ Zg_9S" Dead MW*d in SSA 1', Registry of Deeds. Book Z9 <3 Page 2y0 And beln9 shown as lot P7 on a plan by rj.'tm k & Oated and recorded 91 Q$ '?l a.,A# l� 9124 Book Page This Inspection plan was not compiled from an instrument Survey and is not Intended to be recorded. Under no circumstances are offsets to be used for establishing property lines or for construction purposes of any type. Location of the structures as shown hereon either were in compffance with the local zoning by-laws in effect when _ �`��G 4.4' constructed (with respect to structural setback requirements only), or were exempt from violation enforcement action under Mass. G.L. Title VII. Chapter 40A. Section 7. pz No.Zso�' a vwn nereon does not lie within the Flood Hazard Zone on F.F.M.A. Community Map by one Accurate determination cannot be made unessza vertical control — Flood Hazard has beenetermined survey is poorforrtmednd is not necessarily accurate. DESIMONE SURVEY SERVICE, INC. 38 Coffee Street Medway, MA 02038 N .Zo 'T' (! MORTGAGE INSPECTION PIAN "A" �„ , �0 • °'� y„ Zg_9S" Dead MW*d in SSA 1', Registry of Deeds. Book Z9 <3 Page 2y0 And beln9 shown as lot P7 on a plan by rj.'tm k & Oated and recorded 91 Q$ '?l a.,A# l� 9124 Book Page This Inspection plan was not compiled from an instrument Survey and is not Intended to be recorded. Under no circumstances are offsets to be used for establishing property lines or for construction purposes of any type. Location of the structures as shown hereon either were in compffance with the local zoning by-laws in effect when _ �`��G 4.4' constructed (with respect to structural setback requirements only), or were exempt from violation enforcement action under Mass. G.L. Title VII. Chapter 40A. Section 7. pz No.Zso�' a vwn nereon does not lie within the Flood Hazard Zone on F.F.M.A. Community Map by one Accurate determination cannot be made unessza vertical control — Flood Hazard has beenetermined survey is poorforrtmednd is not necessarily accurate. DESIMONE SURVEY SERVICE, INC. 38 Coffee Street Medway, MA 02038 GC4RD op H�, l--1 NdI�TN AupnUc-I-�I MA, s 0 ,4SFU C4ti I tJ - Sc Lkfy 1a Wu6R �SO Pf V D Towel D wEC,(.. �� oyCD 1�4TC S3 5EPTi c SY S TE," ,I A PPR�o\.1 ED D15APPR6vED RQSONS ,DLJL 7 4V4T(aO pwrE' APr7WPJ6 Aurhoi? ry PGAAJ DE54 &IJ6K 1FUV P14T� Co�Q1T�o�5 D/� I E -3 in ew SLlct I (OL---)L�ff '5 Pr(C SYSTEM I J SjA 1. ATIOA J )"J'Pt-6-PoAJ D/JrE - --" S (� Fra I� I ti5PFcrlon) P(PE FROAA How ry V O r �l PA S5 � R)L ppPR6VE �I,TC (9 ��j 6PPi�vrN� Avr�o��try (�2 DISH PPi'o\j6 p D,a rC 166450 NS RAL /JPPR)vAL D,ME � 54Am3wvJ6 16u i HoR1 �� • OF 0ORT" OFFICES,OF: ;' ?" ��° Town of d. n APPEALS NfJRTH ANDOVER BUILDING CONSERVATION 3BAOHue DIVISION OF HEALTH V/ PLANNING PLANNING & COMMUNITY DEVELOPMENT KAREN H.P. NELSON, DIRECTOR Gail and Alexander Glass 89 Gray Street North Andover, Mass. May 13 1988 � 0-T T--- 120 Main Street North Andover, WSs-II(ISCUS01845 ((i 17) G85-4775 re= Septic System Failure 89 Gray Street It has come to the attention of the Health Department that your Septic System is overflowing • This is a health hazard which must be corrected. Since the house is currently _ for sale this problem must be addressed now. If the house is sold to some one who is not aware of the problem you could be held liable for damages of up to three times the price of repair. Sincerely Sanitarian Heal Dept. mg/gc Pude by /974 i Address C� Nature of complaint BOA"jL ZD -OF HEALTH 120 MAIN STREET NORTH ANDOVER, MASS. 01845 COMPLAINT FORM a, S",J 4 y TEL. 682-6400 DATE _Tel. Location Occupant Owner or A gent �a_a,p, Address DO NOT WRITE BELOW THIS LINE Referred to Date of Investigation ' Result of investigation SM1R (S dv6A_FcdA_,AAJ6 1Stcptfou ckj T(-11:f� o,u &J " ,kvAJ`. pqiv' I Sw rH �5 CGv G� SU f?o�Gr/ - Recommendations Action taken (�Mq �- 'V SqA TO: NORTH ANDOVER, MASS 19 7 - BOARD OF HEALTH FROM: DESIGN ENGINEER Re: Soil Absorption Sewage System Inspection 1 This is to certify that I have inspected the construction of the said disposal system at ��2a.�� North Andover, Mass. E LOCATION The grades and construction are as specified in my plans and specifications dated . S 19 7' g. Pr . E (neer/Reg. S itarian J� '4 p Lor F 6.eat- STREEr f 1 9BR, &4RY S, I9%5 catE / = SO [l03EPH t r 15,.,,,,,.44,,,> H/L c 11/4`v IfOAD " NO. 94,4,0 ,v4 , MASS. T2z. toy ¢= X983 Erb TCN,'- AREA C:l f 3 AV Jr�.REET I �n m i I i 1 I� II o w � � 1 °�°� S.F• � - I Lv Y. -cur I:J WA( -Lel Erb TCN,'- AREA C:l f 3 AV Jr�.REET . t I ro' VJA*44W ty) t po� 40 NEW ENGLAND ENGINEERING SERVICES INC �O� RD OF HEAAND H � / of L - June 7, 2002 North Andover Board of Health Town Hall Annex 27 Charles Street North Andover, MA 01845 RE: TITLE V REPORT: 89 Gray Street, North Andover, MA Dear Sirs: Enclosed is a copy of the Title V report for the above referenced property. The system PASSED our inspection. If there are any questions please call me at my office, 686-1768. Sincerely L3 c c� Benjadlin C. Osgoo, Jr. 60 BEECHWOOD DRIVE -NORTH ANDOVER, MA 01845-(978) 686-1768 - (888) 359-7645 -FAX (978) 685-1099