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HomeMy WebLinkAboutMiscellaneous - 89 LOST POND LANE 4/30/2018N ' • .. y �. _ � . '.'i'�?: L? H {;/ �.! a�lgs ...tom! it ` ' ' i��„ uc. a - ,� •..� H a�.,. v�,r,,,p; � `_ - � � •�tMt� i a _ ,. nl— MAP #w? LOT # `'�' ; ... - } PARCEL # STREET�QQ_._..; ' �O.NSTRUCTIp.N APPROVAL, HAS PLAN REVIEW FEE BEEN PAID? jI OYES NUPLAN APPROVAL:DATE 1Z- Zy/ `APP. BY _ DESIGNER: PLAN DA -TE. CONDITIONS WATER SUPPLY: WELL PERMIT WELL TESTS: COMMENTS: TOWN CHEMICAL BAC"TER WELL DAZE APPROVED DA f E flF'PRUVED BACTERIA II DATE APPROVED FORM U APPROVAL: APPROVAL TO ISSUE YE5 NO DATE ISSUED z/ 46 CONDITIONS: FINAL APPROVAL: ALL PERMITS PAID YES NO WELL CONSTRUCTION APPROVAL YES NO SEPTIC SYSTEM CONSTRUCTION APPROVAL YES NO OTHER YES NU ANY VARIANCE NEEDED FINAL BOARD OF HEALTH APPROVAL: YES NO DATE: A/ ...DY: 4 6236 . O • Town of North Andover HEALTH DEPARTMENT ,SSACMU`+t� CHECK #: — DATE: LOCATION: ` S) _ • • .� WAA IM -0, Type of Permit or License: (Check box) ❑ Animal $ ❑ Body Art Establishment $ ❑ Body Art Practitioner $ ❑ Dumpster $ ❑ Food Service - Type. $ ❑ Funeral Directors $ ❑ Massage Establishment $ ❑ Massage Practice $ ❑ Offal (Septic) Hauler $ ❑ Recreational Camp $ ❑ Sun tanning $ ❑ Swimming Pool $ ❑ Tobacco $ ❑ TrashIsolid Waste Hauler $ ❑ Well Construction $ SEPTIC Systems: ❑ Septic - Soil Testing $ ❑ Septic - Design Approval $ ❑ Septic Disposal Works Construction (DWC) $ ❑ Septic Disposal Works Installers (DWI) $ ❑ Title 5 Inspector $ ❑ Title 5 Report $ ❑ Other: (Indicate) $ Health Ajent Initials White - Applicant Yellow - Health Pink - Treasurer Fas # TTTLE V INSPECTIONS Dean G. Luscomb II & Sons P.O. Box 135 Middleton, MA 01949 978-774-4065 Licensed Plumber #20285 SUBSURFACE SEWAGE DISPOSAL SYSTEM INPSECTION FORM PROPERTY OWNERS NAME JDQ O 1 E PROPERTY ADDRESSFq L O S+ O n C N. A nd o Ve r. M i1 ADDRESS OF OWNER (i€diff..t) Sn e DATE OF INSPECTION A J tU J NAME OF INSPECTOR _Q L u- se d M QUALITY IS NUMBER 01M TO US. RECEIVED Auu MW TOWN OF NORTH ANDOVER HEALTH DEPARTMENT .1 Fas # TTTLE V INSPECTIONS Dean G. Luscomb II & Sons P.O. Box 135 Middleton, MA 01949 978-774-4065 Licensed Plumber #20285 SUBSURFACE SEWAGE DISPOSAL SYSTEM INPSECTION FORM PROPERTY OWNERS NAME JDQ O 1 E PROPERTY ADDRESSFq L O S+ O n C N. A nd o Ve r. M i1 ADDRESS OF OWNER (i€diff..t) Sn e DATE OF INSPECTION A J tU J NAME OF INSPECTOR _Q L u- se d M QUALITY IS NUMBER 01M TO US. RECEIVED Auu MW TOWN OF NORTH ANDOVER HEALTH DEPARTMENT Owner information is required for every page. Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 89 Lost Pond Lane Property Address Dooley Owner's Name North Andover Cityfrown MA August 9, 2012 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: A. General Information When filling out forms on the computer, use 1. Inspector: only the tab key to move your Dean G. Luscomb II cursor - do not Name of Inspector use the return key. Dean G. Luscomb II & Sons Company Name P.O. Box 135 Company Address Middleton City/Town 978-774-4065 Telephone Number B. Certification MA State S1848 License Number 01949 Zip Code 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 Further Evaluation by the Local Approving Authority Insp ctor's Signature August 9, 2012 Date 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. ****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 • 11110 Title 5 Official Inspection Form: Subsurface Sewage Disposal System • Page 1 of 17 "� Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments °wM 89 Lost Pond Lane Property Address Owner Owner's Name information is required for North Andover MA August 9, 2012 every page. City/Town State Zip Code Date of Inspection B. Certification (cont.) Inspection Summary: Chec(9,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 S 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. O 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 • 11/10 Title 5 Official Inspection Forth: Subsurface Sewage Disposal System • Page 2 of 17 0 Owner information is required for every page. 0 D, Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 89 Lost Pond Lane Property Address Dooley Owner's Name North Andover Cityrrown B. Certification (cont.) B) System Conditionally Passes (cont.): MA State Zip Code August 9, 2012 Date of Inspection ❑ 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).- El ealth): ❑ 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 t5ins • 11110 Title 5 Official Inspection Form: Subsurface Sewage Disposal System • Page 3 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 89 Lost Pond Lane Property Address Owner's Name North Andover MA August 9, 2012 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 Il ❑ �J ® 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 • 11/10 Title 5 Official Inspection Form: Subsurface Sewage Disposal System • Page 4 of 17 ❑ ® 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 syistepms, you must indicate either "yes" or "no" to each of the following, in addition to the questions in Sec D. Yes No ❑ ❑ the system I ithin 400 feet of urface drinking water supply ❑ ❑ the system is within 2 eet of a tributary to a surface drinking water supply ❑ ❑ the system is I ted in a nitr n sensitive area (Interim Wellhead Protection Area — IW or a mapped Zone a public water supply well If you have answered "ye ' o any question in Section E the Sys is considered a significant threat, or answered "yes" in ction D above the large system has failed. owner or operator of any large system consider a significant threat under Section E or failed under S ion D shall upgrade the system in a rdance with 310 CMR 15.304. The system owner should con the appropriate regional -office of the Department. t5ins • 11/10 Title 5 Oficial Inspection Form: Subsurface Sewage Disposal System • Page 5 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form _ Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 89 Lost Pond Lane Property Address Dooley Owner Owner's Name information is required for North Andover MA August 9, 2012 9 every page. City/Town State Zip Code Date of Inspection B. Certification (cont.) Yes No n ❑ ® Required pumping more than 4 times in the last year NOT due to clogged or 0 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 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 syistepms, you must indicate either "yes" or "no" to each of the following, in addition to the questions in Sec D. Yes No ❑ ❑ the system I ithin 400 feet of urface drinking water supply ❑ ❑ the system is within 2 eet of a tributary to a surface drinking water supply ❑ ❑ the system is I ted in a nitr n sensitive area (Interim Wellhead Protection Area — IW or a mapped Zone a public water supply well If you have answered "ye ' o any question in Section E the Sys is considered a significant threat, or answered "yes" in ction D above the large system has failed. owner or operator of any large system consider a significant threat under Section E or failed under S ion D shall upgrade the system in a rdance with 310 CMR 15.304. The system owner should con the appropriate regional -office of the Department. t5ins • 11/10 Title 5 Oficial Inspection Form: Subsurface Sewage Disposal System • Page 5 of 17 ' Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 89 Lost Pond Lane Property Address Dooley Owner Owner's Name information is North Andover MA August 9, 2012 required for 9 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? ® ❑ 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 gpd t5ins - 11/10 Title 5 Official Inspection Form: Subsurface Sewage Disposal System - Page 6 of 17 ' Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments M 89 Lost Pond Lane Property Address Yes ❑ No ❑ Dooley ❑ No ❑ Yes Owner Owner's Name No information is North Andover MA required for August 9, 2012 9 every page. City/Town State Zip Code Date of Inspection D. System Information Description: Owner and town Number of current residents: 7 Does residence have a garbage grinder? ❑ Yes ® No Is laundry on a separate sewage system? [if yes separate inspection required] ❑ Yes ® No Laundry system inspected? ❑ Yes ® No Seasonal use? ❑ Yes ® No Water meter readings, if available last 2 ears usage d 9 ( Y 9 (gP ))� town water Detail: --II Sump pump? ❑ Yes ® No Last date of occupancy: Current Date Commercial/Industrial Flow Conditions: Type of Esta ' hment: Design flow (based on 31 R 15.203): Basis of design flow (seats/persons/sq. ., Grease trap present? Industrial waste holding tank preewt'f_"' Non -sanitary waste arged to the Title 5 system? Water meter readings, if available: Gallons per day (gpd) ❑ Yes ❑ No ❑ Yes ❑ No ❑ Yes ❑ No t5ins - 11/10 Title 5 Official Inspection Form: Subsurface Sewage Disposal System • Page 7 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 89 Lost Pond Lane Property Address Dooley Owner's Name North Andover MA August 9, 2012 City/Town State Zip Code Date of Inspection D. System Information (cont.) Last daeT'of ec ancy/use: Date Other (describe below): General Information Pumping Records: Source of information: Was system pumped as part of the inspection? If yes, volume pumped: How was quantity pumped determined? Reason for pumping: Pumped on average every year - owner and town gallons No need at this time 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) 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 • 11/10 Title 5 Official Inspection Form: Subsurface Sewage Disposal System • Page 8 of 17 <C\1 Commonwealth of Massachusetts Title 5 Official Inspection Form a Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 89 Lost Pond Lane Property Address Dooley Owner Owner's Name information is required for North Andover MA August 9, 2012 every page. Cityfrown State Zip Code Date of Inspection D. System Information (cont.) Approximate age of all components, date installed (if known) and source of information: System was installed in 1996 - 16 yrs old - owner and town Were sewage odors detected when arriving at the site? ❑ Yes ® No Building Sewer (locate on site plan): / Depth below grade: 24"feet Material of construction.- El onstruction:❑ cast iron ® 40 PVC ❑ other (explain): Distance from private water supply well or suction line: feet Comments (on condition of joints, venting, evidence of leakage, etc.): Main line and joints are in very good shape with no signs of any problems. Septic Tank (locate on site plan): / Depth below grade: 12"feet Material of construction: ® concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other (explain) Precast rectangular concrete 1500 gallons Llfank is metal, list age: ea ca e o ompliance? (attach a copy of certificate) ❑Yes o Dimensions: 5'Dx5'Wx10'L I�WVJd Sludge depth: 1" t5ins • 11/10 Title 5 Official Inspection Form: Subsurface Sewage Disposal System - Page 9 of 17 . <C Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments �M 89 Lost Pond Lane Property Address Owner Owner's Name information is required for North Andover every page. City/Town D. System Information (cont.) Septic Tank (cont.) State Zip Code August 9, 2012 Date of Inspection Distance from top of sludge to bottom of outlet tee or baffle 34" Scum thickness 1" 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 15" How were dimensions determined? sticks and tape measure Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): The septic tank and baffles are in very good condition. The solids in the tank are very light. The liquid in the tank is running at it's correct working heigth. The tank does not require pumping at this time. Trap (locate on site plan): �0 Depth belo rade: Material of constructi ❑ concrete ❑ metal Dimensions: Scum thickness Distance from top of Distancefrom orr Date of last pumping: t5ins - 11/10 ❑ fiberglass ❑ c�o top of outlet tee or baffle of scum to bottom of outlet tee or baffle feet ❑ other (explain): Date Title 5 Official Inspection Forth: Subsurface Sewage Disposal System - Page 10 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 89 Lost Pond Lane Property Address Owner's Name North Andover MA August 9, 2012 Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Co is (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels a d to outlet invert, evidence of leakage, etc.): Tight or Holding Tank (tank must be pumped at time of inspection) (locate on site plan): Depth below grade: Material o onstruction: ❑ concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other (explain): Dimensions: Capacity: Design Flow: Alarm present: Alarm level: Date of last pumping: Comments (condition of alarm gallons ;Zr'day ❑ No alarm in working order: / Date float switches, etc.): `° Attach copy of current pumping contract (required). Is copy attached? ❑ Yes ❑ No ❑ Yes ❑ No t5ins • 11/10 Title 5 Official Inspection Form: Subsurface Sewage Disposal System • Page 11 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 89 Lost Pond Lane Property Address Dooley Owner's Name North Andover Cityrrown RAA vamc �iN vv..c August 9, 2012 Date of Inspection D. System Information (cont.) Distribution Box (if present must be opened) (locate on site plan): Depth of liquid level above outlet invert Zero " 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.): The d -box is 27" below grade andis 16" x 16" square. The liquid in the d -box is running at it's correct working heigth. The soil in this area is clean and dry with no signs of any problems. This area is covered with well maintained green grass. Pump Chamber (locate on site plan): U Pumps in wo order: ❑ Yes ❑ No Alarms in working order: es ❑ No Comments (note condition of pum�cham�b ition of pumps and appurtenances, etc.): Soil Absorption System (SAS) (locate on site plan, excavation not required): / If SAS not located, explain why: S.A.S. was located by d -box and level area of yard. t5ins • 11/10 Title 5 Official Inspection Form: Subsurface Sewage Disposal System - Page 12 of 17 I �'\ Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments ;M 89 Lost Pond Lane Property Address Dooley Owner Owner's Name information is ired for North Andover requ every page. Cityrrown �j t5ins • 11/10 D. System Information (cont.) State Zip Code August 9, 2012 Date of Inspection Type: ❑ leaching pits number: ❑ leaching chambers number: ❑ leaching galleries number: ® leaching trenches number, length: ❑ leaching fields number, dimensions: ❑ overflow cesspool number: ❑ innovative/alternative system 2 - 56' long Type/name of technology: Comments (note condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of vegetation, etc.): The S.A.S. is in very good condition with no signs of any problems. The soil in this area is clean with no signs of ponding or breakout. This area is covered with well maintained green grass. ools (cesspool must be pumped as part of inspection) (locate on site plan): Number and con tion Depth — top of liquid to inlet inve Depth of solids layer Depth of scum layer Dimensions of cess a+D Materials of eon' struction Indication of groundwater inflow ❑ Yes ❑ N\,. 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 89 Lost Pond Lane Property Address Dooley Owner's Name North Andover City/Town D. System Information (cont.) etc.): MA August 9, 2012 State Zip Code Date of Inspection ote condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, Privyyy'(lac`ate on site plan): V Materials of Dimensions Depth of solids Comments (note condition of soil ns of hydraulic a level of ponding, condition of vegetation, etc.): t5ins • 11/10 Title 5 Official Inspection Form: Subsurface Sewage Disposal System • Page 14 of 17 ' —Mff Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 89 Lost Pond Lane Property Address Owner Owner's Name U information is North Andover MA required for every page. City/Town State Zip August 9, 2012 Date of Inspection D. System Information (cont.) Sketch Of Seaocagg-D the sewage disposal system, including ties to at o per en reference landmarks or benchmarks. Locate all wells within 100 feet. Locate ere public water supply enters the building. Check one of the boxes below: ® hand -sketch in the area below ❑ drawing attached separately Bozic a (1 v,,& 901,ki�-e. A t - F9 L. A Pare La^� 13b t = li ' / �1 AbX =34 6 R Ear ASD 0ClSepvG Ta -AIL -0-iso-i �1 \lyevlt t5ins • 11/10 Title 5 Official Inspection Form: Subsurface Sewage Disposal System • Page 15 of 17 `��� Za s� ('oh k L rz Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 89 Lost Pond Lane Property Address Owner Owner's Name information is required for North Andover MA every page. City/Town State Zip Code D. System Information (cont.) Site Exam: ® Check Slope G re�� ® Surfacewater lost p6P4 ® Check cellar 'D f -I 06 SN r� r P u M ® Shallow wells Nonce August 9, 2012 Date of Inspection Estimated depth to high ground water: 4'+ below grade 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. 4-25-95 Date ® Observed site (abutting property/observation hole within 150 feet of SAS) ® Checked with local Board of Health - explain: Proposed, asbuilt and previous title v on file. ❑ Checked with local excavators, installers - (attach documentation) ❑ Accessed USGS database - explain: You must describe how you established the high ground water elevation: Deep hole test #1 showed 52" to ground water. Deep hole test #2 showed 48" to ground water. The basement of the house is 7' below grade with no sump pump. This is a raised system to maintain adaguate ground water separation. Before filing this Inspection Report, please see Report Completeness Checklist on next page. t5ins • 11/10 Title 5 Oficial Inspection Form: Subsurface Sewage Disposal System • Page 16 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 89 Lost Pond Lane Property Address Owner Owner's Name information is North Andover MA required for every page. City/Town State E. Report Completeness Checklist August 9, 2012 Zip Code Date of Inspection E Inspection Summary: A, B, C, D, or E checked E Inspection Summary D (System Failure Criteria Applicable to All Systems) completed E System Information — Estimated depth to high groundwater E Sketch of Sewage Disposal System either drawn on page 15 or attached in separate file t5ins • 11110 Title 5 official Inspection Form: Subsurface Sewage Disposal System • Page 17 of 17 kJ8/ bb/ 1b12 11'J:11 y t8b88'Jb tJ WW I EH SEWEK DEF' I PAGE 01/02 Summary ROWd Caro gonerateo on SM12M, x,5414 AM DY Mauroon MMU10Y Page 1 Town of North Andover Tax Map ## 210-104,B-0217-0000,0 Parcel Id 16473 89 LOST POND LANE DOOLEY, KEVIN & JUDY 89 LOST POND LANE NORTH ANDOVER, NAA 01845 Class 101 Single Family -- - Property Type 1 Residential Zoning2 1 Residential Zoning3 1 Residential Size Total 0.69 Acres FY 2013 US Mailina Index Name/Address Type Loan Number Activelinact From Until DOOLEY, KEVIN & JUDY Payor 89 LOST POND LANE NORTH ANDOVER, MA 01845 UB Account Malnt. 2 �� Account No Cycle Occupant Name Active/Inactive Bldg Id. 18000.0 - 89 LOST POND LANE Last Billing Date 7/9/2012 3160029 03 Cycle 03 Active US Services Maint. Account No. 3180029 Service Code Rate Charge Multiplier/Users M=FEE ADMIN FETE 0.63518 7.82 11 WTR WATER of ALL METER SIZE 148.15 /1 US Meter Maintenance Account No. 3180029 Serial No Status Location Brand Type Size YTD Cons 13242770 a Active 00 METE METE w Wafer 0.63 0.63 635 Date Reading Code Consumption Posted Date Variance 6/18/2012 1513 a Actual 33 7/16/2012 5% 3/20/2012 1480 a Actual 32 4114/2012 -12% 12/19/2011 1448 a Actual 37 1/17/2012 -4% 9/16/2011 1411 a Actual 39 10/13/2011 0% 6/13/2011 1372 a Actual 37 7/20/2011 9% 3/15/2011 1335 a Actual 34 03/2011 10% 12/15/2010 1301 aActual 31 1/12/2011 -12% 9/16/2010 1270 a Actual 37 10/15/2010 8% -22% 3/18/2010 1201 a Actual 44 4/14/2010 19% 12/1412009 1157 2Actual 35 1/12/2010 -10% 9/16/2009 1122 a Actual 43 10/15/2009 4% 6/10/2009 1079 a Actual 36 7/20/2009 5% 3/17/2009 104$ a Actual 37 412.9/2009 -2% 12/15/2008 1006 a Actual 37 1/20/2009 -24% 9/16/2008 969 a Actual 53 10/10/2008 25% 6/10/2008 918 a Actual 38 7/16/2008 23% 3/14/2008 878 a Actual 31 4/11/2008 -29% 12/17/2007 847 a Actual 47 1/22/2008 -42% 9/1312007 800 a Actual 72 10/12/2007 63% 6/20/2007 728 a Actual 50 7/20/2007 42% 3/16/2007 678 a Actual 34 4/16/2007 .3% 12113/2006 644 a Actual 32 1/19/2007 -65% 9/19/2006 612 a Actual 98 10/20/2008 183% 6/20/2006 514 a Actual 35 7/10/2006 -7% 3/20/2006 479 a Actual 31 4/17/2006 -7% 113/2006 448 a Actual 48 1/17/2006 -67% 9/15/2005 400 a Actual 123 10/14/2005 89% Trouble Code:03 6/14/2005 277 a Actual 58 7/15/2005 40% T(1WN (1F SYSTEM PUMPING RECORD DATE: 6? SYSTEM OWNER & ADDRESS U),l SYSTEM LOCATION (example: left front of house) v 0 DATE OF PUMPING: QUANTITY PUMPED : CESSPOOL: NO YES SEPTIC TANK: NO YES NATURE OF SERVICE: ROUTINE EMERGENCY OBSERVATIONS: GOOD CONDITION HEAVY GREASE ROOTS EXCESSIVE SOLIDS SOLIDS CARRYOVER FULL TO COVER BAFFLES IN PLACE LEACIFIELD RUNBACK FLOODED OTHER (EXPLAIN) SYSTEM PUMPED BY: Bateson Enterprises, Inc. COMMENTS: CONTENTS TRANSFERRED TO: G.L.S.D Lowell Waste GALLONS TOWN OF NORTH ANDOVER SYSTEM PUMPING RECORD DATE: 1 C�� J (example: left front of house) a� � DATE OF PUMPING: -4 QUANTITY PUMPED (51 GALLONS CESSPOOL: NO YES SEPTIC TANK: NO YES NATURE OF SERVICE: ROUTINE EMERGENCY OBSERVATIONS: GOOD CONDITION HEAVY GREASE ROOTS EXCESSIVE SOLIDS SOLIDS CARRYOVER FULL TO COVER BAFFLES IN PLACE LEACHFIELD RUNBACK FLOODED OTHER (EXPLAIN) SYSTEM PUMPED BY: e��k e—gr,� COMMENTS: CONTENTS TRANSFERRED TO: C c, S, v TOWN OF NORTH ANDOVER SYSTEM PUMPING RECORD DATE: (, 2-1 ^C1 56vD li� �-Mi pow �n( (example: left front of house) tf�Ll�s'e— DATE OF PUMPING: E-22-01 QUANTITY PUMPED GALLONS CESSPOOL: NO I YES SEPTIC TANK: NO YES NATURE OF SERVICE: ROUTINE OBSERVATIONS: GOOD CONDITION HEAVY GREASE ROOTS EXCESSIVE SOLIDS SOLIDS CARRYOVER SYSTEM PUMPED BY: COMMENTS: EMERGENCY FULL TO COVER BAFFLES IN PLACE LEACHFIELD RUNBACK FLOODED OTHER (EXPLAIN) 3 12001 CONTENTS TRANSFERRED TO:`- .Important: When filling out forms on the computer, use only the tab key ` to move your cursor - do not use the return key. U0�I LAI Commonwealth of Massachusetts City/Town of I FAUG2 System Pumping Record Form 4 DEP has provided this form for use by local Boards of Health. be submitted to the local Board of Health or other approving authority.. A. Facility Information 1. System Location: Address City/Town 2. System Owner: State Zip Code Name - Address (i(different from location) Cityfrown Stat_' ^od Telephone Number B. Pumping Record 1. .Date. of Pumping Date 2. Quantity Pumped: Gallons 3. Type of system: ❑ Cesspool(s)ptic Tank- ❑ Tight Tank ❑ Other (describe): 4. Effluent Tee Filter present? ❑ Yes ❑.146�— If yes, was it cleaned? ❑ Yes ❑ No 5. Condition of System:. w x(1 � 6. System ru.TmpekBy ( Name Vehicle Company -- 7. License Number must vate http://www.mass.gov/dep/water/approvals/t5forms.htm#inspect t5form4.doc• 06/03 System Pumping Record • Page 1 of 1 IC-`\ Commonwealth of Massachusetts City/Town of --- - - — System Pumping Record �� ` Form 4 NQ .A 4U , 0' DEP has provided this form for use by local Boards of HP I&4er fp.r s,�p .b used, but the information must be substantially the same as that provi ere��oe 1uLrlg;Shi form, check with your local Board of Health to determine the form they use. T PGffp— gff R must be submitted to the local Board of Health or other approving authority. A. Facility Information 1. System Location: Left i ht front of hous Left / Right rear of house, Left / right side of house, Left / Right side of building, Left / Right front of building, Left / Right rear of building, Under deck Address Sq P,,7:A R-� / , Cityrrown State Zip Code 2. System Owner: Name Address (if different from location) City/Town State — Z) r 11�Stp.Eode Telephone Number B. Pumping Record 1. Date of Pumping 3. Type of system: ❑ ❑ Other (describe)' Date 2. Quantity Pumped Cesspool(s)Septic Tank Gallons ❑ Tight Tank 4. Effluent Tee Filter present? ❑ Yes If yes, was it cleaned? ❑ Yes ❑ No 5. Condition of $yc Jia (_0,4j a 6. System Pumped By: Neil Bateson Name Bateson Enterprises Inc Company 7. Location where contents were disposed: G.L,�S. _ Lowell Waste Water F5821 Vehicle License Number Date t5form4.doc• 06/03 System Pumping Record • Page 1 of 1 Commonwealth of Massachusetts City/Town of System Pumping Record Form 4 iG^M DEP has provided this form for use by local Boards of H NOV - 2 Z'ui0 TOWN OF NORTH ANDOVER I HEALTH DEPARTMENT sed, 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: � ��- ; (�r—�� � `� �/► ®U c� /, Address City/Town State Zip Code 2. System Owner: 1 Name Address (if different from location) City/Town B. Pumping Record 1. Date of Pumping 3. Type of system: ❑ State Code- -LO Cod '� Telephone Number Date 2. Quantity Pumped: Gallons Cesspool(s)9-�S A6ptic Tank ❑ Tight Tank ❑ Other (describe): 4. Effluent Tee Filter present? ❑ Yes .I�o If yes, was it cleaned? ❑ Yes ❑ No 5. Condition of System: V,\'� \ U\,- 6. System Pumped By: Name ;� J Company 7. Lqc here contents were disposed: G.L.S. Vehicle License Number Date t5form4.doc• 06/03 System Pumping Record • Page 1 of 1 Commonwealth of Massachusetts City/Town of System Pumping Record Form 4 �M DEP has provided this form for use by local Boards of Hey information must be, substantially the same as that provid( local Board of Health tQ determine the form they use. The the local Board of Health or-ottller approving authority. RECEIVED SEP 2 8 2009 arvformsl r_beb% d, but the check with your Pumping Record must be submitted to A. Facility Information 1. System Location: Left side of house, Right side of house, Left front of hous iQht front of hous Left rear of house, Right rear of house. Left rear of building. Right rear of building. Address City/rown 2. System Owner. Name Address (if different from location) City/Town State Zip Code State Zip Code baa-23� S - Telephone Number B. Pumping Record 1. Date of Pumping Date 2- Quantity Pumped 3. Type of system: ❑ Cesspool(s)eptic Tank ❑ Other (describe): 4. Effluent Tee Filter present? ❑ Yes No 5. Condition of System: / �� J� "/,)J7� ( 6. System Pumped By: Neil Bateson Name Bateson Enterprises Inc Company 7. Location where contents were disposed: L Lowell Waste Water Signature of Hauler Gallons ❑ Tight Tank If yes, was it cleaned? ❑ Yes ❑ No F5821 Vehicle License Number q' - 1"C�5 -v Date t5form4.doc- 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. VQ law F221 -SM Commonwealth of Massachusetts City/Town of System Pumping Record Form 4 o c T- 9 2008 DEP has provided this form for use by local Boards of Health.;Ofher forms may be used, but the information must be substantially the same as that provided hereBefore using this form check with your local Board of Health to deterrrune 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 Address Cityrrown 2. System Owner. Name Address (if different from location) Cityrrown (�!)� �0(-)ZQ . -- c v l State Zip Code State p Code S—A— � 2. Telephone Number B. Pumping Record 1. Date of Pumping Date 2. Quantity Pumped 3. Type of system: ❑ ❑ Other (describe): Cesspool(s) eptic Tank Gallons ❑ Tight Tank 4. Effluent Tee Filter present? ❑ Yes L -No If yes, was it cleaned? ❑ Yes ❑ No 5. Condition V\of System: T��e �'-oA 6. Syste Pumped-�Sy: Name ehiGe License Number Company 7. Location y7e Ttent re dred: Date t5form4.doc• 06/03 System Pumping Record • Page 1 of 1 DATE: CURPE-,,N'T -INSTALLER'S LICE -NSE TOCATION: ZO /0 -7 LICENSED ENSTALLER: k,:71,P c SIGNATURE: 9Vj TELEPHONES CHECK ONE: REPAIR: NEN VCONS TRUCTION: IF NEW CONSTUCTION, PLEASE ATTACH FOUNDATION AS -BUILT. $75.00 Fee Attached? Foundation As -Built? Approval Administrative Use Only Yes / No Yes No Date: �IllaA� E !J- Ir_ 3 O 10 ovER kk► NMOL LL) Q NOW Q (n =or 9 LcsT /moo vD �, �auND/3ri0� Tad CLo s T© s y 576 iZ-'�C36 rCJOT /yE'�T `'9 o u /9 PP,eo v6w "t a,, ,(JZ5 ECE//�T�DiJ E vvuv u START P-638 TM & ® 1992 Warner Bros., Inc.W, C-1 q 01. aN W cz LU z c o W4 A O GO Z 4 W =C2 W b 'y c Ea =1 c V W c c o v g o w U x o o C/) C/) LU z O S 2' O 0 E C L Q � w Z CD CL C* y � C C CO) 0 Gi .g m m G3 CD CD CD CD C LO !O o Q CL. �a ca C 0 C �� .v J 'D FL Q3ca CD �..� h C CL tC C CO) cm c o m c =C2 � C H O C ca V o. c ev m s C2 WE CFm Z o c y oO oma-:0 O Vcm mi o. :R E ail ev I a O ym 3 .• O - y m `: = y y C c O y m CD O _ CLC...)m y m ' r L o vs c c H Q a = o C _ m H O COi Z C c Z o c f- a O •O = m o E- o 'ao m .y O F� ac �E d= CO CJD yLU Z o C.3 CD C3 V2a m cm _ m O H 0- o CL O S 2' O 0 E C L Q � w Z CD CL C* y � C C CO) 0 Gi .g m m G3 CD CD CD CD C LO !O o Q CL. �a ca C 0 C �� .v J 'D FL Q3ca CD �..� h C CL tC C CO) cm FORD U - `v" RI.' iCAT 10 iN FG:RI 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: ( i "` j c r_ ` Phone: LOCATION: Assessor's Map Number IOU Parcel Subdivision S Lot (s) Street 6,57- =5 R, 1' o �? ^v C St. Number ************************Official Use Only************************ RECOMMENDATIONS OF TOWN AGENTS: Conservation Administrator Comments Town Planner Comments Food Inspector -Health ✓ Septic Inspector -Health Comments Public Works - sewer/water connections - driveway permit Fire Department Received by Building Inspector Date Approved Date Rejected Date Approved Date Rejected Date Approved Date Rejected Date Approved /� , -�jQ,Z Date Rejected Date Town of North Andover, Massachusetts Form No. 2 ?o.tMot'rh BOARD OF HEALTH 19 A DESIGN APPROVAL FOR JS^C""St` SOIL ABSORPTION SEWAGE DISPOSAL SYSTEM Applicant bm— Test No. Site Location Cur # Ct ��—'(" �O ►�� Reference Plans and Specs DESIGN Permission is granted for an individual soil absorption sewage disposal system to be installed in accordance with regulations of Board of Health. Fee 40 CHAIRMAN, BOARD OF HEALTH Site System Permit No. , r THOMAS E. NEVE ASSOCIATES, INC. Engineers • Land Surveyors • Land Use Planners 447 Boston Street US #1 TOPSFIELD, MASSACHUSETTS 01983 (508) 887.8586 FAX (508) 887-3480 TO DATE !Z ��� JOB NO. 17-1 Ini ATTENTIONG•� DESCRIPTION t21 195 tz' sera hh FoL t�c-t s t�s+E.o s+a.-�.-� p►sPc� P��ie� TOWN OF NORTH ANDOVER/ WE ARE SENDING YOU 'Attached ❑ Under separate cover via I_thE following items: > El;;fin Shop drawings V_ Prints El Plans Samples SpecifiJat9rk995 ❑ Copy of letter ❑ Change order ❑ COPIES DATE NO. DESCRIPTION t21 195 tz' sera hh FoL t�c-t s t�s+E.o s+a.-�.-� p►sPc� P��ie� THESE ARE TRANSMITTED as checked below: ❑ For approval ❑ For your use ❑ As requested ❑ Approved as submitted ❑ Approved as noted ❑ Returned for corrections ❑ For review and comment ❑ Resubmit 4— El ❑ Submit ❑ Return copies for approval copies for distribution corrected prints ❑ FORBIDS DUE 19 ❑ PRINTS RETURNED AFTER LOAN TO US REMARKS 1>15f*a- . FLS P':+� F t''s� � C�'0� -gyp —ryw- 1zb012_ T�;} + �3��i� IGE F�fl�J t ��[". i7fee- a.t2 M f_�-r '.�Cq 5.1 -TC- A►-zO -C�t�P ti� Go>~1 vE�tZ -ctc�1. -rvt1E- GNA��f�5 -� DL S t C_ ►til S' -Q S�tf�'vt W t'7"L� N E.uJ C-a.YZ�c. tt��G vsA-'t�CL_ EL�.V i�TLOr�� oIF 1 Z 3+cJ -- k V:ku .. t-3or-CtL Sott_. Ev44t_0F}-cbs��S c-ct+Ftcper�ta-� iso-c� Qrr}b-!g. «,�.1.JEPf?ATto�-A o.J �Z118�95 --� � Gs.�.�a�uc. w ► '� t•J 15' � s -PS -tart Aac� . - viae -tr>L4 rot- •-a::I,_vr_ -rtr tr tam `f c_A H+gvc— C; LAIC tc*:Ss , COPY TO 0�' RECYCLED PAPER: 9 Contents: 40% Pre -Consumer• 10% Post -Consumer S►rr-�tc.��-,tr SIGNED: - • �.�. �t t . i if enclosures are not as noted, kindly notify us at once. PLAN REVIEW CHECKLIST ADDRESS 47— 5W S7' 26AA X.42 ENGINEER GENERAL 3 COPIES [/ STAMP C--' LOCUS L--' NORTH ARROWS SCALEy 6"Ic- CONTOURSc/ PROFILE (i-- SECTION BENCHMARKS SOIL & PERCS — ELEVATIONS --/ WETS. DISCLAIMER WELLS & WETS WATERSHED?/1/0 DRIVEWAY r/ (Eley) WATER LINE &--' FDN DRAINi/ SCH40TESTS CURRENT?19q4 SOIL EVAL .. SEPTIC TANK MIN 150OG t/ .17 INVERT DROP !/ GARB. GRINDER(+200% EDF) 25' TO CELLAR E-"� MANHOLE ELEV �� GW ---- # COMPS. D -BOX SIZE # LINES FIRST 2' LEVEL STATEMENT INLET 06, 3y _ OUTLET L30•16 _ ( 2" OR .17 FT) TEE REQ `D? Avo /51,z,::) LEACHING MIN 660 GPD? RESERVE AREA i�-4' FROM PRIMARY? tl� 2% SLOPE 100' TO WETLANDS Ll"_ 100' TO WELLS L`_ 4' TO S.H.GW C-- 0M/IN) 35' TO FND & INTRCPTR DRAINS 325' TO SURFACE H2O SUPP G� 4' PERM. SOIL BELOW FACILITY MIN 12" COVER " FILL?_'�(25' C if above natural elev; 10'if below) BREAKOUT MET?Lj,� TRENCHES MIN 660 gpd SLOPE (min .005 or 6"/100') SIDEWALL DIST. 3X EFF. W OR D (MIN 6') L`� RESERVE BETWEEN TRENCHES? 4,� IN FILL? 4--' MUST BE 10' MIN. /,-' 4" PEA STONE? !/ VENT? (>3' COVER; LINES >50') BOT 440 + SIDE 448 X LDNG '74L = TOT X63 ?666 (L x W x #) (DxLx2x#) (G/ft2) Copyright 0 1995 by S.L. Starr TOWN OF M- �ft�'bq. SYSTEM PUMPING RECORD z. DATE: f6 -X - (3 SYSTEM OWNER & ADDRESS SYSTEM LOCATION (example: left front of house) bo�-e� �A S LO4,P10JACKI 1� I DATE OF PUMPING: -02� ^ d QUANTITY PUMPED: I S©� GALLONS / I CESSPOOL: NO �/ YES SEPTIC TANK: NO YES 7 NATURE OF SERVICE: ROUTINE EMERGENCY OBSERVATIONS: GOOD CONDITION HEAVY GREASE ROOTS EXCESSIVE SOLIDS SOLIDS CARRYOVER FULL TO COVER BAFFLES IN PLACE LEACHFIELD RUNBACK FLOODED OTHER (EXPLAIN) SYSTEM PUMPED BY: Bateson Enterprises, Inc. COMMENTS: CONTENTS TRANSFERRED TO: TOWN OF- SYSTEM PUMPING RECO RECEIVED DATE: (5-0q SYSTEM OWNER & ADDRESS NO *c 10 s� POS OCT 19 2004 TOWN OF NORTH ANDOVER HEALTH DEPARTMENT SYSTEM LOCATION (example: left front of house) r1j�{ �o� a`vlous�_- DATE OF PUMPING: q-tS-j0qQUANTITY PUMPED: l SOO GALLONS CESSPOOL: NO YES SEPTIC TANK: NO YES NATURE OF SERVICE: ROUTINE EMERGENCY OBSERVATIONS: GOOD CONDITION HEAVY GREASE ROOTS EXCESSIVE SOLIDS SOLIDS CARRYOVER FULL TO COVER BAFFLES IN PLACE LEACHFIELD RUNBACK FLOODED OTHER (EXPLAIN) SYSTEM PUMPED BY: Bateson Enterprises, Inc. COMMENTS: CONTENTS TRANSFERRED TO: G.L.S.D 'J Lowell Waste 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 CERTIFICATION r Property Address: 89 Lost Pond Road_ _North Andover_ Owner's Name: _Edwin Shaw_ Owner's Address: 89 Lost Pond Road_ _North Andover, MA 01845_ Date of Inspection: _7/12/2002_ Name of Inspector: Neil J. Bateson Company Name: Bateson Enterprises Inc._ Mailing Address: _111 Argilla Road_ _Andover, Ma. 01810_ Telephone Number: _( 978 ) 475-4786_ 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: _X Passes Conditionally Passes Needs Further Evaluation by the Local Approving Authority "Fails (�� Inspector's Signature: ate: _7/12/2002_ 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: _89 Lost Pond Road_ _North Andover — Owner: Shaw Date of Inspection: _7/12/2002_ Inspection Summary: Check A,B,C,D or E / ALWAYS complete all of Section D A. System Passes: _X 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: _89 Lost Pond Road_ _North Andover— Owner: Shaw Date of Inspection: 7/12/2002_ 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 T 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: _89 Lost Pond Road_ _North Andover— Owner: Shaw Date of Inspection: _7/12/2002 D. System Failure Criteria applicable to all systems: You must indicate "yes" or "no" to each of the following for all inspections: Yes No _ _No_ Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool —No_ Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool T _No_ Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool _ _No_ Liquid depth in cesspool is less than 6" below invert or available volume is less than 1/2 day flow _No_ Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number of times pumped _ _No_ Any portion of the SAS, cesspool or privy is below high ground water elevation. _No_ Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. _No_ Any portion of a cesspool or privy is within a Zone 1 of a public well. _ NoAny portion of a cesspool or privy is within 50 feet of a private water supply well. _ — No 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. 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 11 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: _89 Lost Pond Road_ North Andover Owner: Shaw Date of Inspection: _7/12/2002_ Check if the following have been done. You must indicate "yes" or "no" as to each of the following: Yes No _Yes _ Pumping information was provided by the owner, occupant, or Board of Health No Were any of the system components pumped out in the previous two weeks ? Yes _ Has the system received normal flows in the previous two week period ? No_ Have large volumes of water been introduced to the system recently or as part of this inspection ? Yes _ Were as built plans of the system obtained and examined? (If they were not available note as N/A) Yes_ _ Was the facility or dwelling inspected for signs of sewage back up ? Yes_ _ Was the site inspected for signs of break out ? Yes _ Were all system components, excluding the SAS, located on site ? _Yes_ _ 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 ? _Yes_ _ 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 _Yes _ Existing information. For example, a plan at the Board of Health. No 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: _89 Lost Pond Road_ North Andover– Owner: Shaw Date of Inspection: _7/12/2002_ FLOW CONDITIONS RESIDENTIAL 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): _660 Number of current residents: _2 Does residence have a garbage grinder (yes or no): _No Is laundry on a separate sewage system (yes or no): No_ [if yes separate inspection required] Laundry system inspected (yes or no): Seasonal use: (yes or no): _No_ Water meter readings: _Jan. 00 to Jan. 02 =13,700 Ft3 x 7.5 =102,750 Gals./730 Days =141 Gals./Day _ Sump pump (yes or no): _No_ * Has sprinkler system Last date of occupancy: _Current COMIVIERCIAL/INDUSTRIAL 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: Pumped 6/21/01, owner Was system pumped as part of the inspection (yes or no): Yes_ If yes, volume pumped: _1500_gallons -- How was quantity pumped determined? _Measured tank _ Reason for pumping: Inspect tank & tees TYPE OF SYSTEM X_ 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: _6 years old. 11/21/1996 As built plan _ Were sewage odors detected when arriving at the site (yes or no): No Page 7 of I 1 OFFICIAL INSPECTION FORM — NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: _89 Lost Pond Road_ North Andover - Owner: Shaw Date of Inspection: 7/12/2002_ BUILDING SEWER (locate on site plan) X Depth below grade: 24" Materials of construction: _cast iron —X-40 PVC _other (explain): Distance from private water supply well or suction line: Comments (on condition of joints, venting, evidence of leakage, etc.): _4" PVC thru wall to septic tank. 3" PVC in house. No leaks SEPTIC TANK: X locate on site plan) Depth below grade: _12" Material of construction: —X—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: 10' x 5' x 4' Sludge depth 1" Distance from top of sludge to bottom of outlet tee or baffle: 26" Scum thickness: 1" Distance from top of scum to top of outlet tee or baffle: 8" Distance from bottom of scum to bottom of outlet tee or baffle: _20"_ How were dimensions determined: _Subtract scum & sludge depth to tee length. _ Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): Pumped septic tank. Inlet tee ok. Outlet tee ok. Depth of liquid at outlet invert. No evidence of leakage. _ 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 8 of 11 OFFICIAL INSPECTION FORM — NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: _89 Last Pond Road_ North Andover— Owner: Shaw Date of Inspection: _7/12/2002_ 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. _X (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 level. Distribution equal. No evidence of leakage. Evidence of solid carryover, pumped d -box to clean. _ PUMP CHAMBER: (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 OFFICIAL INSPECTION FORM — NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: _89 Lost Pond Road_ North Andover — Owner: Shaw Date of Inspection: 7/12/2002_ SOIL ABSORPTION SYSTEM (SAS): X (locate on site plan, excavation not required) If SAS not located explain why: Type leaching pits, number: _ leaching chambers, number: leaching galleries, number: X_ leaching trenches, number, length: —2 trenches 56' long_ 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, _Soil oL Vegetation oL No sign of ponding to surface. CESSPOOLS: (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: (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: _89 Lost Pond Road_ North Andover — Owner: Shaw Date of Inspection: 7/12/2002_ 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. A to Tank = 37'T' A to D -Boz = 38'1" B to Tank =14'4" B to D -Boz = 23'4" Page 11 of 11 OFFICIAL INSPECTION FORM — NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: _89 Lost Pond Road_ _North Andover— Owner: Shaw Date of Inspection: _7/12/2002_ SITE EXAM Slope Surface water Check cellar Shallow wells Estimated depth to ground water 5 feet Please indicate (check) all methods used to determine the high ground water elevation: _X Obtained from system design plans on record - If checked, date of design plan reviewed: _11/30/1995 _ 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: As per design plan_ Tel: (978) 475-4786 Fax: (978) 475-5451 BATESON ENTERPRISES, INC. Excavating -Water.& Sewer Lines -Septic Systems & Pumping Service 111 Argilla Road .Andover, Mass. 01810 Title 5 Inspection Report Property Address: 89 Lost Pond Road, North Andover Owner: Shaw Date of Inspection: 7/12/2002 My report contained herein does not constitute a guarantee of future usage and the functionality of the existing septic system. Such report issued herewith is merely based upon my observations, and I hereby disclaim any further operation of your current septic system. Neil J. Bateson Bateson Enterprises, Inc. F. z Commonwealth of Massachusetts City/Town of System Pumping Record Form 4 OCT 3 0 2007 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. B. Pumping Record 1. Date of Pumping 3. Type of system: ❑ ❑ Other (describe): to -c% Date 2. Quantity Pumped Cesspool(s) D-!5eptic Tank Gallons ❑ Tight Tank 4. Effluent Tee Filter present? ❑ Yes 9190If yes, was it cleaned? ❑ Yes ❑ No 5. Condition of System: � D�"�OA 6. SysteEn Pumped By: Name 1 777> Vehicle License Number Company 7. Location co tents ere t5form4.doc• 06/03 System Pumping Record • Page 1 of 1 A. Facility Information Important: When filling out forms on the 1. System Location: r� use computer, only the tab key Address to move your ` cursor - do not use the return city/Town State Zip Code key. � 2. System Owner: l Name Address (if different from location) CitylTown State /I� � --zil3 Telephone Number B. Pumping Record 1. Date of Pumping 3. Type of system: ❑ ❑ Other (describe): to -c% Date 2. Quantity Pumped Cesspool(s) D-!5eptic Tank Gallons ❑ Tight Tank 4. Effluent Tee Filter present? ❑ Yes 9190If yes, was it cleaned? ❑ Yes ❑ No 5. Condition of System: � D�"�OA 6. SysteEn Pumped By: Name 1 777> Vehicle License Number Company 7. Location co tents ere t5form4.doc• 06/03 System Pumping Record • Page 1 of 1 N Date ... 2.: "'C . %. Z... TOWN OF NORTH ANDOVER PERMIT FOR WIRING This certifies that !1M ©vlf� U ................ ............................. has permission to perform ................44 w !-7 I.. ............................... wiring in the building of ....... �Y v ....................................................... g . LOS 7" fl Lam% ; No Andover, Mass. at.................. �7 66 � Fee .....' 5..... Lic. No........... 77..............................��2 .. , ELECTRiCALINSPECTOR Check N 3_L/ 105', 3 9 U% 3i,'d � rn O ES' .y . p• EY w n �i O Q` o CD ❑ o w�r'. aKPI��� �i•oo�`oo`°o w '�ap-n� lbw o � O G tVCM�, '.'Y CD 84- :+ 0 r�i� p• ��• p' p O w• o Hyo MaMo�'t3 Ep .o a.o �aQ' G kl CD n FI: w p; rn O4 �C b N•'ci a �. O 'a N UO O CD cD C PI O P I 1_1 40 R .�. w � pco p, [D �p O t'hN O 0 b 0 o w ti p p yrn cD o w e, pni M P OQ rn C,x C yh rn p' ti rn OR cc��;; WW cv n co C � y cD a� g O ti P. p p.o rn � • .'� p . O n n rt , p, w 'w'�' .�f � W M a ~• O W N GJ C00 �ii p ..111.--..---.. el...& o/ M36-4-wett, 2.Partment 4 -7ire SeP[/WGe9 BOARD OF FIRE PREVENTION REGULATIONS Official Use Only Permit No. -,n5- Occupancy and Fee Checked ev. 1/07] (leave blank) APPLICATION FOR PERMIT TO PERFORM ELECTRICAL WORK All work to be performed in accordance with the Massachusetts Electrical Code (MEC), 527 CMR 12.00 (PLEASE PRINT WINK OR TYPE ALL INFORMATION) Date: City or Town of • To the Inspector of Wires: By this application the undersigned gives notice ofhisor her intention to perform the electrical work described below. Location (Street & Number) C::k °N \.o Sv-\- Q. Parcel ID: Owner or Tenant Telephone Noy)'Z,7 Jr. S Owner's Address Is this permit in conjunction with a building permit? Yes ❑ No Q (Check Appropriate Box) Purpose of Building `c Q,S Utility Authorization No. Existing Service Amps / Volts Overhead ❑ Undgrd ❑ No. of Meters New Service Amps / Volts Overhead ❑ Undgrd ❑ No. of Meters Number of Feeders and Ampacity Location and Nature of Proposed Electrical Work: Completion of the followingtable may be ivaived by the Inspector of Tle'ires. Attach additional detail f desired, or as required by the inspector of wires. Estimated Value of Electrical Work: (When required by municipal policy.) Work to Start: Inspections to be requested in accordance with MEC Rule 14, and upon completion. INSURANCE COVERAGE: Unless waived by the owner, no permit for the performance of electrical work may issue unless the licensee provides proof of liability insurance including "completed operation" coverage or its substantial equivalent. The undersigned certifies that such coverage is in force, and has exhibited proof of same to the permit issuing office. CHECK ONE: INSURANCE ❑ BOND ❑ OTHER ❑ (Specify:) I certify, under the pains and penalties of perjury, that the information on this application is true and complete. FIRM NAME: l;�:. \-fk NK1NC:;t r SQr v c¢5 `Y+ C LIC. NO.: Licensee: Loy -"b W 4V}o Signature LIC. NO.: (%% (If applicable, enter "exempt " in the license number line) Bus, Tel. No.:''\ol -33\ Address: \ VJ Q\\ \n!s- & n 1� i the,\ n Alt. Tel. No. `t \ 6 3°!% �0 *Per M.G.L. c. 147, s. 57-61, security work requires Department of Public Safety "S" License: Lic. No. OWNER'S INSURANCE WAIVER: I atri aware that the Licensee sloes not have the liability insurance coverage normally yu ?'.:1 by law. By ray signature b210;i', l hereby �Ja'_Ve t121S ,irt :. r_ _ -- t!'P • t'- ., �n0 0 owner [� Qwn r'S ^Pn'`. Owner/Agent Lms Signature - -- e`< No. I'E. IIT .FEE, 5 � No. of Total No. of Recessed Luminaires No. of Ceil.-Susp. (Paddle) Fans Transformers KVA No. of Luminaire Outlets No. of Hot Tubs Generators KVA No. of Luminaires AboveIm- Swimming Pool rnd. E1.0 rnd. o. o Emergency Lighting Batte Units No. of Receptacle Outlets No. of Oil Burners FIRE ALARMS No. of Zones No. of Detection and No. of Switches No. of Gas Burners Initiating Devices No. of Ranges o No. of Air Cond. Toonsl No. of Alerting Devices Heat Pum Nua�aber Tons KW No. of Self -Contained Disposers No. of Waste Dis P Totals _-_ ..._.........._._ ..................---------.- Detection/Alerting Devices No. of Dishwashers Space/Area Keating KW Local ❑ Municipal ❑ Other Connection No. of Dryers Y Heating Appliances KW Security Systems:* No. of Devices or Equivalent No. of WaterKms, No. of No. of Data Wiring: Heaters Signs Ballasts No. of Devices or Equivalent No. Hydromassage Bathtubs 3 g No. of Motors Total RP ��iring: Telecommunications of No. of Devices or Equivalent OTHER: Attach additional detail f desired, or as required by the inspector of wires. Estimated Value of Electrical Work: (When required by municipal policy.) Work to Start: Inspections to be requested in accordance with MEC Rule 14, and upon completion. INSURANCE COVERAGE: Unless waived by the owner, no permit for the performance of electrical work may issue unless the licensee provides proof of liability insurance including "completed operation" coverage or its substantial equivalent. The undersigned certifies that such coverage is in force, and has exhibited proof of same to the permit issuing office. CHECK ONE: INSURANCE ❑ BOND ❑ OTHER ❑ (Specify:) I certify, under the pains and penalties of perjury, that the information on this application is true and complete. FIRM NAME: l;�:. \-fk NK1NC:;t r SQr v c¢5 `Y+ C LIC. NO.: Licensee: Loy -"b W 4V}o Signature LIC. NO.: (%% (If applicable, enter "exempt " in the license number line) Bus, Tel. No.:''\ol -33\ Address: \ VJ Q\\ \n!s- & n 1� i the,\ n Alt. Tel. No. `t \ 6 3°!% �0 *Per M.G.L. c. 147, s. 57-61, security work requires Department of Public Safety "S" License: Lic. No. OWNER'S INSURANCE WAIVER: I atri aware that the Licensee sloes not have the liability insurance coverage normally yu ?'.:1 by law. By ray signature b210;i', l hereby �Ja'_Ve t121S ,irt :. r_ _ -- t!'P • t'- ., �n0 0 owner [� Qwn r'S ^Pn'`. Owner/Agent Lms Signature - -- e`< No. I'E. IIT .FEE, 5 � Phone. 978-632-2660 JAMES A. TRUDEAU Fax. 978-632-2662 Adjustment Service Inc. P. O. Box 7 Gardner, MA 01440 claims(iOrudeauadi.com Notice of Casualty Loss of Building Under Massachusetts General Laws, Chapter 139, Section 313 August 16, 2013 Building Inspector 120 Main Street North Andover, MA 01845 Board of Health 120 Main Street North Andover, MA 01845 Fire Department Dept. of Records 124 Main Street North Andover, MA 01845 Insured: Kevin & Judith Dooley Loss Location: 89 Lost Pond Lane, North Andover, MA 01845 Insurance Company: The Concord Group Ins. Companies Policy No.: 1046822 Date of Loss: August 16, 2013 File Number: 13-11683 Claim Number: 0001111353 Type of Loss: Water & Mold Damage Claim has been made involving loss, damage, or destruction of the above captioned property, which may either exceed $1,000.00 or cause "Mass. Gen. Laws, Chapter 143, Section 6" to be applicable. If any notice under "Mass. Gen. Laws, Chapter 139, Section 3B" is appropriate, please direct it to the writer and include a reference to the captioned insured, location, policy number, date of loss, and file or claim number. On this date, I cause copies of this notice to be sent to the person(s) named above at the address indicated by first class mail. Sincerely, James A. Trudeau General Adjuster P TYPE OR PRINT CLEARLY MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK CITY ps. � �_ __ __ �� MA DATE r�� -�� �� I PERMIT # JOBSITE ADDRESS�I . OWNER'S NAME' ,�d OWNER ADDRESS ;—j TEL �l 64 2 ? 3 6 S ! FAX «4 — OCCUPANCY TYPE COMMERCIAL L�a EDUCATIONAL D NEW:,-- RENOVATION:,,_,_]( -.- I FIXTURES 7 FLOOR— I BSM I I CROSS CONNECTION DEVICE DEDICATED SPECIAL WASTE SYSTEM _ DEDICATED GASIOIUSAND SYSTEM DEDICATED GREASE SYSTEM DEDICATED GRAY WATER SYSTEM DEDICATED WATER RECYCLE SYSTEM W DRINKING FOUNTAIN FOOD DISPOSER FLOOR / AREA DRAIN INTERCEPTOR (INTERIOR) - LAVATORY ROOF DRAIN SHOWER STALL SERVICE I MOP SINK TOILET URINAL WASHING MACHINE CONNECTION WATER HEATER ALL TYPES WATER PIPING OTHER ' • 1 Honrh c O A 4.• Ss�Cwusu� This certifies that RESIDENTIAL! PLANS SUBMITTED: YES L_1 NO`�' Date. TOWN OF NORTH ANDOVER PERMIT FOR PLUMBING - A � / d � ��" " /"' e , "./_ / has permission to perform ...�'l�'t� plumbin` iinth)Zldings of ..,:5 Fee.32�4� . Lic. No...9�ZF' -; N�rtAndover, Mass. `�1 Check # (OPLUMBING INSPECTOR ....... INSURANCE COVERAGE: I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL Ch. 142 YES LXJ NO Li IF YOU CHECKED YES, PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW LIABILITY INSURANCE POLICY CXj OTHER TYPE OF INDEMNITY E] BOND OWNER'S INSURANCE WAIVER: I am aware that the licensee does not have the insurance coverage required by Chapter 142 of the Massachusetts General taws, and that my signature on this permit application waives this requirement. SIGNATURE OF OWNER OR AGENT CHECK ONE ONLY: OWNER {J AGENT I rMIUDy cerury mai ai or ate MIME ano KHormaum I nave swmmea or en Brea regarnung aft application are true and accurate to the best of my knowledge and that all plumbing work and installations performed under tate permit issued for this application will be in compliance VI'Pertlinent provision of the Massachusetts State Plumbing Code and Chapter 142 of the General Laws. PLUMBER'S NAME :'RrQ.`(Yl o x o�w LICENSE # SIGNATURE MP JP;; CORPORATIONk)W,7 , g jPARTNERSHIP[J#j= -'-yjLLC L,"# COMPANY NAME,�6. �,�\ vQ��M�t n� ; ADDRESS j\ W e,`\tr-, CITY ��r C s` v1---_.__—_-_ I STATE 1�— ZIP - , @1T � L'j Zee 6 S s� TEL FAX CELL' ?EMAIL W F Q oo z a ❑ rAw F LU a a z LU 0 CO) W CA n W 9 w � w N a z a 0 w a CL S2 W x w H LL a rAF a x a q6 (,�_ ___� Office Use Onty 01 (f amn IInll ran II� fif'la- fizz, s2tt Permit No./ ( / .Y �e artmt iri of ulrlirafe2t� Occupancy & Fee Checked f yg4 (leave blank) D OF FlRE PREtJENT10N REGULATIONS 527 VJR 12:90 APPLICATION FOR PERMIT TO PERFORM ELECTRICAL WORK All work to be performed in accordance with the Massachusetts Electrical Code, 527 CMA 12:00 (PLEASE PRINT IN INK OR TYPE ALL INFORMATION) Oate 41 (XW or Town of NORTH "raTnOVER To the Inspector of wires: The udersigned applies for a permit to perform the ele tricat work described be i7 Location (Street & Number) Owner or Tenant N n Owner's Address _ Is this permit in conjun .'an with a buiidi permit' Yes V fVo — (Check AppropriateSox) Purccs2 of Buiidina nj Utility Authorization No. �Qo 60� Existing Service Amos _J Veit Overread _ Unagrnd � No. of Meters New Service �0V Amos=—Voits Overread Uncg:na r -No. of Meters Numcer of Feeders and Ampacity Lccaiicn anc Nature of Prcposec Electrical :'lcn< Total. Na. of �tct -:as No. of Transformers KVA No. at L :gnvng Outlets ' ; At)CVS — :n- — 1 KVA - Na. at Lighting F+xtures i Swimming ?Sot grna. — cmc. '— ( Generators I No. of Emergency Lighting . No. at=ecectacie Outlets 0 i No. at Oil Burners j ; 3aCery Units OTHER: INSURANCE COVERAGE: Rursuant :o the reautrements at '.tassacmusers ;enerat Laws I have a current Liaatiity Insurance nave suomtnea valid proof Ct,Policy inctuctng Ccna:e(ee cerattens Caveraae or as suostanttai eeutvatent. YES t a t0 trio Office- YES N - It -jOu nave cnecxec vES. ptease +natcate :ne type at coverage ay, checxwng the aoProortat ox: _ (E�cotraaon Dater INSURANCE NO = OTHER _ .tPtease,Scec: yl Esumatec Value of E: ctrtca .Nor 5 Fnai�- Werx :a Start Inscec::on Cate Aacuestec: Rough Signea unaargeenanes at penury` GLIC. NO. �3 =;RM NAME C Si atcre LIC. NO Licensee Sri � � Bus. Tel. Na. Address POe / C Jy �---� Att. Tet. ."1a. OWNER -S INSURANCE WAIVES: I am aware that the Licensee noes not nave the insurance coverage or its suostanttal eautvale ent - autrea ov Massachusetts General Laws. aria :hat my signature an :n:s Derm- a aoPttcatton waives this reaurrement. Owjtpf� � 9 (P!ease' cnecx one). II��' :ete.cr,one No. PERMIT FES S (Signature at Owner or Agent No. or Gas=urrers I F:RE ALARMS No. of Zones Na at Swrtc^t Outlets Olaf No. of Celection and, No. at flanges No. of Air C.:rc. tans initiating Oavtees No. of Oiseosals meat Total I No.af ?u:r.as :ons Tata1 K',v No. at Sounding Zevtces No. of Sett Contained / Oetect:anrSounaing Oevtces NO. of uisnwasners - ScacetArea nearing Muntcioai —Other No. at Orfers / Heausia Oev:ces CyV cat _ Cannec•:cn _ No. at No. of Low Vaitage No. water Heaters KwV �I Signs 3atlasts Wiring of No "-tvoro Massage Tubs ` /' { No: of MctCrS Total tiP OTHER: INSURANCE COVERAGE: Rursuant :o the reautrements at '.tassacmusers ;enerat Laws I have a current Liaatiity Insurance nave suomtnea valid proof Ct,Policy inctuctng Ccna:e(ee cerattens Caveraae or as suostanttai eeutvatent. YES t a t0 trio Office- YES N - It -jOu nave cnecxec vES. ptease +natcate :ne type at coverage ay, checxwng the aoProortat ox: _ (E�cotraaon Dater INSURANCE NO = OTHER _ .tPtease,Scec: yl Esumatec Value of E: ctrtca .Nor 5 Fnai�- Werx :a Start Inscec::on Cate Aacuestec: Rough Signea unaargeenanes at penury` GLIC. NO. �3 =;RM NAME C Si atcre LIC. NO Licensee Sri � � Bus. Tel. Na. Address POe / C Jy �---� Att. Tet. ."1a. OWNER -S INSURANCE WAIVES: I am aware that the Licensee noes not nave the insurance coverage or its suostanttal eautvale ent - autrea ov Massachusetts General Laws. aria :hat my signature an :n:s Derm- a aoPttcatton waives this reaurrement. Owjtpf� � 9 (P!ease' cnecx one). II��' :ete.cr,one No. PERMIT FES S (Signature at Owner or Agent MASSACHUSETTS UNIFORM APPLICATION FOR PERMIT TO DO GASFITTIU' G (Print or Type) t NORTH ANDOVER Mass. Date _ tuilding Location Permit # ✓ Owners Name S ? New Renovation II Replacement Plans Submitted D ameAd(Print or Type) ' Installing Company Name— Address dress OA/-i,�, Business Telephone:�'�1c� Name of Licensed Plumber or Gas Fitter Check one: Certificate Q Corp. Partner. E./Firm/Co. Insurance Coverage: Indicate the type of insurance coverage by checking the appropriate box: Liability insurance policy = Othler type of indemnity 0 Bond E] Insurance Waiver: I, the undersiened, have been made aware that the licensee of this application does not rn of the above three insurance coverages. • N � V C F C us C O V F� 'n t- a y. tt2 _� t O E- 0 tc e . ¢ O tII uJ W ` < Tal C C O = S O W 01 N O V � = = 07 sl iO-• to G O t] W 4) . W m; z a= c a¢ ut r W F' = H C t-- d us Q y O 0 W U. � < � c G a < -4 O Q O G� iL �• Q O o. W F- t— O BASEMENT I Z ST FLOOR I I I I I I I I I1 I I I I I I{ i 2ND FLOOR tt ! 3RQ FLOOR 4TH FLOOR ( I ! I I I I I I 5TH FLOOR 6THFLOOR TTI{ FLOOR STH FLOOR ( I I ameAd(Print or Type) ' Installing Company Name— Address dress OA/-i,�, Business Telephone:�'�1c� Name of Licensed Plumber or Gas Fitter Check one: Certificate Q Corp. Partner. E./Firm/Co. Insurance Coverage: Indicate the type of insurance coverage by checking the appropriate box: Liability insurance policy = Othler type of indemnity 0 Bond E] Insurance Waiver: I, the undersiened, have been made aware that the licensee of this application does not have any one of the above three insurance coverages. Signature of owner/agent of property Owner 17 Agent F7 I hcteby Certify that all of the details and information I have submitted (or entered) in &Love application are true and accurate to the best of my knowtedge and that aU plumbing work and Installations xtformeC under' ft unit issued for this apptiation will be In compliance With &11 rcrttatat provisions of the Massachusetts State Cas t;adc and Cuptet 241 cf Tho Ccner:i Laws. _ B Y TYPE' LICENSE: Plumber Title r 2 3 Gasfitter Signature of L' ensed Y Master P1uGasfitter C•t /Town: journeyman � APPROVED (OFFICE USE ONLY) License IJumber e. jo ;. 1- 2412 Date—! � :.?.a :-nq-6 .. 0* 'Of?'rh Aao TOWN OF NORTH ANDOVER 16 04. PERMIT FOR GAS INSTALLATION 2 SSACH S This certifies that . . . &' . I .;in AY - has permission for gas installation ... ... Ol�bzt-',' in the buildings ofab-�.' . . .......... at 99 North Andover, Mae Fee, 3() '-0 Lic. No.. ............. ............. GAS INSPECTOR WHITE: Applicant CANARY: Dept. PINK: Treasurer GOLD: File 659 NORTh pf t.a° ,•,ti0 V. Oglow. 9 Date.../..Y TOWN OF NORTH ANDOVER PERMIT FOR WIRING ,SSACNus� 6 This certifies that .......l ...C.u<.`f .....��..`�/....r.. �..j3.1.►�. .....�..` EE has permission to perform ... .:,.A.(.cu(.o........ ...................... IE3 wiring building of ...... ..1, .�jj..x. t .�fdj�.. >...t...... J ............................ Cin/the at ..................... . North Andover, Mass. i Fee. . .... 41-4W... Lic. No. ..................... ELECTRICAL INSPECTOR C � tA (P CU WHITE: Applicant CANARY: Building Dept. PINK: Treasurer The Commonwealth of Massachusetts °"``°t1te only Department of Public Safety pe`"t` 35 BOARD OF FIRE PREVENTION REGULATIONS S27 CMR 1200 Oceapso`> s "° 3/90 (�aa�e blank) APPLICATION FOR PERMIT TO PERFORM ELECTRICAL WOR All work to be performed In accordance with the Masaachusetu Electrical Code. S27 CMR 12:00 (PLEASE PRINT IN INK OR TYPE .ALL INFORHATION) Date 12/16/_96 City or Town of North Andover To the Inspector o£ hires: The undersigned applies for a permit to perform the electrical Work described below. Ti0cmtion (Street & Number) 89 Lost Pond Road M'ner or Tenant :F1.,int16ck ,1n . (mems Address 89 Lost Pond Road, North Andover, MA Is this permit in conjunction with a building permit: Yes ❑ No ❑ (C�eck Appropriate Box) Purpose of Building Utility Authorization N0. Existing Service Amps / V It os Overhead ❑ Undgrd ❑ No. of Meters Few Service Amps / Volts Overhead ❑ Undgrd❑ No. o_c Meters Nitmder of Fteders and Ampacit n • Security System y Locatioand Nature of Proposed Electrical Work —$9 Tt Pon Road, NO Andover, MA 01845 Nb:, of Lith't.ing Outlets Nb, of Lighting Fixtures No. of Receptacle Outlets No. of Switch Outlets No. of Ranges No. of Disposals Nb► of.Dithwashers No. of Dryers No. of Water Heaters No. Hydro Massage Tubs OTHER: I1.4-iq Alarm No. of Hot Tubs Swimming Pool Above In ❑ ❑ INo. of Transforn,!rs Total KVA 'Generators grnd. grnd KVA No. of Oil Burners INo. of Emergency Lighting Battery Units No. of Gas Burners _ FIRE ALARMS rio. of Zones No. of Air Cond. Total tons No. of Detection and No. of Neat Total Total Initiating Devices Pum s Tons KW No. of Sounding Devices Space/Area Heating KW No. of Self Contained Detection/Sounding Devices Heating Devices KW Local ❑ Hun ict?zl Connection ❑ Other No, of o, o Signs Ballasts Low Voltage Wirine No. of Motors Total HP INSURANCE COVERAGE: Pursuant to the requirements of Massachusetts General Laws I have a current Liability Insurance Policy including Completed Operations Coverage or its substantial equivalent. YES 0 NO ❑ I have submitted valid proof of same to this office. YES[] NO ❑ If you have checked YES, please indicate the type of coverage by checking the appropriate box. INSURANCE ❑ BOND ❑ OTHER ❑ (Please Specify) Estimated Value of Electrical Work 11,600 Work to Start -12J16494— Inspection Date Requested: Signed under the penalties of perjury: FIRM t;Aw Barry Security Systems,Inc. Licensee Peter M. Barry 7__ Sire Address 13 Alexa d R d;_ . _ Expiration Date Rough Final n er oa ,Unit 5B, Billeri 21—Bus. i ,. OWNER'S INSURANCE WAIVER: I am aware that the Licensee does not have the i stantial equivalent as required by Massachusetts General Laws, and that my application waives this requirement. Owner Agent (Please check one) Telephone No. --_-I,IC. No. 798C LIC. N0. 798 No 508-667-9 No. ranee coverage or its sub - nature on this permit rFPiITT FFP C 35.00 A.)��p� Location Rrr J No. SW Date r i TOWN OF NORTH ANDOVER Certificate of Occupancy $ Building/Frame Permit Fee $ Foundation Permit Fee $ Other Permit Fee $ Sewer Connection Fee $ Water Connection Fee $ r)'j TOTAL $ (ja 110/l M 12:04 150.00 PAID Building Inspector '' 1,.1 Div. Public Works Location No. Date r TOWN OF NORTH ANDOVER Certificate of Occupancy $ Building/Frame Permit Fee $ Foundation Permit Fee $ Other Permit Fee Sewer Connection Fee Water Connection Fee TOTAL tv .. 63 -auildin-glIn for Div. P c Works E��zIT+'r��• APPLICATION FOR PERMIT TO BUILD — NORTH ANDOVER, MASS. PAGE 1 MAP KJO. V;q�Re%C LOT NO. F /Z! / ! Z3 /z 2 RECORD OF OWNERSHIP iDATE 'PAGE ZONE SUB DIV. LOT NO. I F%!N/ L rf ` �'v 6 - 8 - 5S (BOOK — 9z 7/z 3G LO ATIONF / 1) 5 / fO A/p L , N PURPOSE OF BUILDING OWNER'S NAME Fi(^l T1- r,f Ll (el C, NO. OF STORIES SIZE Y i OWNER'S ADDRESS P.0 D Q x 4 ElL7 f 57 BASEMENT OR SLAB fJ �p cP M e ARCHITECT'S NAME ,5-,qf� �C✓y' ry ^' SIZE OF FLOOR TIMBERS) IST ,t fC) 2ND 2A' f (, 3RD BUILDER'S NAME /7'//N/ 6 O C 1r /N SPAN /91 DISTANCE TO NEAREST BUILDING �h� VV DIMENSIONS OF SILLS "' POSTS L• DISTANCE FROM STREET 1 5' f DISTANCE FROM LOT LINES - SIDES 6 � L% b ' REAR V r � � ` " GIRDERS � ��Z �+ / 11 AREA OF LOT �� I� S F FRONTAGE /O o f HEIGHT OF FOUNDATION '7 )�!/!CJ THICKNESS /D IS BUILDING NEW ye <, SIZE OF FOOTING /U '7® X IS BUILDING ADDITION jU O MATERIAL OF CHIMNEY IS BUILDING ALTERATION .A! © IS BUILDING ON SOLID OR FILLED LAND WILL BUILDING CONFORM TO REQUIREMENTS OF CODE I/(i Y IS BUILDING CONNECTED TO TOWN WATER X BOARD OF APPEALS ACTION. IF ANY // 0 IS BUILDING CONNECTED TO TOWN SEWER N v IS BUILDING CONNECTED TO NATURAL GAS LINE /v INSTRUCTIONS t SEE BOTH SIDES PAGE 1 FILL OUT SECTIONS 1 - 3 PAGE 2 FILL OUT SECTIONS 1 - 12 ELECTRIC METEPS MUST BE ON OUTSIDE OF BUILDING ATTACHED GARAGES MUST CONFORM TO STATE FIRE REGULATIONS PLANS MUST BE FILED/AN AP ROVED BY BUILDING INSPECTOR DATE FILED f/ v ' 'SIGNATURE OF OWNER OR AUTHORIZED AGENT If FEE Dw.M1T GRANTED 19 M� 3 PROPERTY INFORMATION LAND COST 0d, O o o EST. BLDG. COST ���^ VC C EST. BLDG. COST PER SQ. FT. EST. BLDG. COST PER ROOM SEPTIC PERMIT NO. 4 APPROVED BY �NILDINO INSPWA=OI! OWNER TEL. N ' g CONTR. TEL. N (2 CONTR. LIC. # H.I.C. # I OCCUPANCY MULTI. FAMILY _I OFFICES APARTMENTS CONSTRUCTION 2 FOUNDATION 8 INTERIOR FINISH CONCRETE a 1 2 UNF, 3 BASEMENT II AREA FULL V. 1/1 1/. FIN. B'M'T AREA FIN. ATTIC AREA _ _ N_O 8 M T HEAD ROOM FIRE PLACES MODERN KITCHEN _ TIMBER BMS. 6 COLS. STEAM 4 WALLS I 9 FLOORS CLAPBOARDS AIR CONDITIONING B _ 1 22 f 3 I_ _ _ DROP SIDING WOOD SHINGLES ASPHALT SIDING ASBESTOS SIDING VERT. SIDING _ CONCRETE EARTH HARD"d'D COMMCN ASPH. TILE STUCCO ON MASONRY STUCCO ON FRAME ELECTRIC NO HEATING BRICK ON MASONRY BRICK ON FRAME ATTIC STIRS. & FLOOR I_ CONC. OR CINDER BILK. WIRING STONE ON MASONRY 5 ROOF 11 10 PLUMBING GABLE I I HIP f II BATH 13 FIX.) - _I WOOD SLATE SHINGES KITCHEN SINK �ICAN PPLUMBING I I TAR R RAVFI BUILDING RECORD 12 THIS SECTION MUST SHOW EXACT DIMENSIONS OF LOT AND DISTANCE FROM LOT LINES AND EXACT DIMENSIONS OF BUILDINGS. WITH PORCHES. GA- RAGES. ETC. SUPERIMPOSED. THIS REPLACES PLOT PLAN. r 1 a 0 6 FRAMING WOOD JOIST I 11 HEATING W+► rc.=►U [",� J {y y��M +� 3'"M.Vfidip {r TOM �y (il PIPELESS FURNACE FORCED HOT AIR FURN. TIMBER BMS. 6 COLS. STEAM STEEL BMS. 3 COLS. _ WOOD RAFTERS 7 NO. OF ROOMS B'M'T2nd _ 1st 13rd HOT W'T'R OR VAPOR AIR CONDITIONING RADIANT H'T'G UNIT HEATERS GAS ILL ELECTRIC NO HEATING Growth Management Bylaw Exemption Statement ` Town of North Andover Building Department This form shall be used to assist the Building Department in their determination of exemptions under section 8.7.6 of the Town of North Andover Growth Management Bylaw. The building applicant shall provide all of the necessary information as requested below. Name of Applicant on Building Permit (below) Address of Property for Permit (below) 5 - Wap and Parcel : Purpose of Application (check below) Phone Number of Applicant: Single Family _ Two Family .' 6'r- k SSe I the undersigned applicant for the above property attest that the attached building permit for which this form is completed does comply with the EXEMPTION section 8.7.6 of the North Andover Growth Management Bylaw. I also understand providing this form does not absolve me or any party to this permit from the requirements of obtaining other permits required prior to the issuance of the Building Permit. Further I understand that my interpretation of the EXEMPTION status is subject to review by the Building Department and is only officially accepted when the Building Permit is issued. Based on section 8.7.6 of the North Andover Growth Bylaw the above lot and the work as applied for on the above lot, in the building permit application and associated attachments, complies with one or more of the following sections as indicated by a check mark. This is an application for a building permit for the enlargement, restoration, or reconstruction of a dwelling in existence as of the effective date of this by-law, provided that no additional residential unit is created. L �fhe lot(s) were/was created prior to May 6, 1996 are exempt from the provisions of this Section 8.7 of the Zoning Bylaw. This application is for dwelling units for low and/or moderate income families or individuals, where all of the conditions of 8.7.6.c are met and/or represents Dwelling units for senior residents, where occupancy of the units is restricted to senior persons through a properly executed and recorded deed restriction running with the land. For purposes of this Section "senior" shall mean persons over the age of 55. This application is a part of a development project which voluntarily agreed to a minimum 40% permanent reduction in density, (buildable lots), below the density, (buildable lots), permitted under zoning and feasible given the environmental conditions of the tract, with the surplus land equal to at least ten buildable acres and permanently designated as open space and/or farmland. The land to be preserved shall be protected from development by an Agricultural Preservation Restriction, Conservation Restriction, dedication to the Town, or other similar mechanism approved by the Planning Board that will ensure its protection. This application represents a tract of land existing and not held by a Developer in common ownership with an adjacent parcel on the effective date of this Section 8.7 shall receive a one-time exemption from the Planned Growth Rate and Development Scheduling provisions for the purpose of constructing one single family dwelling unit on the parcel. This application represents a lot which is ready for building permits,(i.e. all other permits from all other boards and commissions have been received and the project is in compliance with those permits), and the Development Schedule does not accommodate issuing a building permit in that Year, one building permit will be issued per Year per Development until such time as the Development Schedule accommodates issuing building permits. Applicant must supply approved form U with this EXEMPTION. Please provide any and all information that would assist the Building Department in making a determination that your application is allowed one or more of the above EXEMPTIONS. By signing below I attest to the accuracy of the information provided and that the attached building permit is allowed a EXEMPTION as cited abov . Further I understand that the submittal of misleading and or inaccur ee,�nfo oration, or the checkin off of an above item which does not comply, whether done to my knowle o ot,'is rounds for ref ' 1 y the Building Department to issue a Building Per it. bz�Z,a.G �.o fo 1 6 Sig i re of Owner or uthorized A ent who signed the Attached Building Permit D to This form must be attached to the Building Permit upon application for such permit. OCT — 9 )� ; FORM U - VERIFICATION FORM INSTRUCTIONS: This form is used to verify that all necessary approvals/permits from Boards and Departments having jurisdiction have been obtained. This does not relieve the applicant and/or landowner from compliance with any applicable local or state law, regulations or requirements. ****************Applicant fills out this section*****************APPLICANT : N / G ac -� Phone/ LOCATION: Assessor's Map Number % q e ParcelF I?/ IT, 1?3t /?Y Subdivision /_DST Reoc Lots) Street ( o s% /:.::7 ea 0 G-fiN C St. Number T *********************9ff ial Use Only************************ Conservation Admini for Comments Caw 0 Town Planner Comments Food Inspector -Health ✓ Septic Inspector -Health Comments • Date Approved Date Rejected Date Approved Date Rejected Date Approved Date Rejected Date Approved Date Rejected Public Works - sewer/water connections zT111 ��-�-<� - driv way pe Fire Department Received by Building Inspector C! -CT - 9 ) w— 9-: -'?r- Date DEPARTMENT OF PUBLIC SAFETY CONSTRUCTION SUPERVISOR LICENSE Nutber: Expires: Birthdate: CS 005693. 01/13/1998 01/13/1956 . Restricted' Toy 00 DAVID A XINORED 40 MARBLERIDGE RD POBOX531 N ANDOVER, MA 01845 Restricted To: co 17650 00 - None lA - Masonry only ` 16 - 1 3 2 Fatily Motes i Failure to Possess a current edition of the Massachusetts State 8uiildiny Code is cause for revocation of this license. W A r► ui L6 CD F. 6 amz c o m c EY, O C2 7a �� til; � �► �\�� � u C" �Z � � '� O '3-S r V V ACL U y QV C C W O ih tii 4 cn Cc • p � w° lkz- k- �1 ` O 8 V ) rpr c W C a n4 ii. o N c4 cn cn W A r► ui L6 CD F. 6 amz E (A N O A CD cm m O cm CQ N CD Z A Z O Lmm c o m c C2 � N O C V V ACL QV C C W O CO = w Cc • p � zcf) OZ �O �1 E¢ V ) rpr c W C a o N \ � C w O O �a CJ g cm C Com. N _A N W N ECD � CD 0 cv N mm o C �a N ' dCL O O MA n ?c O r~ V ca CL m O H C CD _ D m 3 aCOO o W C W ,,=D 'O C •N r W � W .E CZt C w CD V ca 'a c co m V2 ..i CL m -5 O .a C2 h O a4m E (A N O A CD cm m O cm CQ N CD Z A Z O Lmm w a O G3 O Z o C. O CO C C as cm I p� co r. A O O 'E m m CD CD- L O O a a Ca O � � C O a O o - c z GD CD Ca. Ul rA C C cc E F cU :Z zcf) OZ �O V ) W � U w w a O G3 O Z o C. O CO C C as cm I p� co r. A O O 'E m m CD CD- L O O a a Ca O � � C O a O o - c z GD CD Ca. Ul rA C C cc E r- U L' O o 5 d ob Q UJ 1 cn p a W a rit LL i O o � s � ' 00 w = z z 00 OO Q0 vn a z � as Q c WO +� M x u CD HrA H M � xLr) �° ro�o¢� �o� F, P4 ZJ° Q A N W U 4 /D Fro Commonwealth of Massachusetts RECE;, ED L JOYCE BRADSHAWPEP I'll. No. 242-777 TOWN CLERK NORTH ANDOVER (to ww, 011111 PH IY,Town Aooticant Nnrr•h Anrinvar Flintlock, Inc. c/o David Kindred Lot 9 Lost Pond Lane Order of Conditions Massachusetts Wetlands Protection Act G.L. c. 131, §40 and under the Town of North Andover's, Bylaw Chapter 3.5 NORTH ANDOVER CONSERVATION COf*1ISSION Flintlock, Inc. To c/o David Kindred (Name of Applicant) P 0 Box 531 No. Andover MA 01845 Address This Order is issued and delivered as follows: Same as Applicant (14arne of property ownerl Address Same as Applicant O by hand delivery to applicant or representative on XZP� by certified mail, return receipt requested on January 18, 1996 P406 914 816 fhis project is located at Lot 9 Lost Pond Lane (dale) (date) i The property is recorded at the Registry of NnrrhPrn rss�� - Book 4272 Page 028 Certificate (if registered) The Notice of Intent for this project was filed on Oct. 6 1995 (dale) The public hearing was closed on December 6, 1995 (dale) Findings The North Andover Conservation Commission has revie%ved the above-relerenced Holrce of Intent and plans and has held a public hearing on the project. Based on tile information arallaole IC the NACC at this time, the has determined Illat the area on which the proposed work is to be done is significant to the lolla%virig interests in accoroance mll, the Presumptions of Significance "gorth in the regulations for each Area Subject to Prolec:rorl Irinder the x Recreation Act (check as appropriate): Ch. 178: — Prevention of Erosion & Sedimentation Ch. 1788 Wildlife Pubilo water supply [ Flood control ❑ Lnnd containing shelflish [ Private water supply Storm damage Prevention ® Fisheries Ground water supply L� Prevention of pollution ® Protection of wildlile habitat Total Filing Fee Submitted $250.00 State Share $112.50 _ CitylTown Share $137.50 (? ; lee irl oxcess of S25) Pnrtinn 1 State Portion S