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HomeMy WebLinkAboutMiscellaneous - 90 GRAY STREET 4/30/2018 (2)N r O FORM U APPROVAL: APPROVAL 1'0 ISSUE NO DATE ISSUED BY CONDITIONS: FINAL APPROVAL: ALL PERMITS PAID WELL CONSTRUCTION APPROVAL SEPTIC SYSTEM CONSTRUCTION APPROVAL OTHER ANY VARIANCE NEEDED FINAL BOARD OF HEALTH APPROVAL: YES NO YES NU YES NO YES NU YES!! NO �GJ/1 DRTE:46j ..BY:... . , . MAP F+# I LOT PARCEL # STREET } _._..__._.._-........ �ONSTRUCTIQN_APPROVAL HAS PLAN REVIEW FEE BEEN PAID? YES NO PLAN APPROVAL: DATE 7/9L APP. BY 9—� DESIGNER: �� C� /GGc S PLAN DATE. " CONDITIONS WATER SUPPLY: �� WELL (ELL—PERMIT WELL TESTS: , CHEMICAL DAIE APPROVED BAC;TERIA I U(afE(1F'Pf2UVEU_^-__-__.._._._____. BACTERIA DATE APPROVED COMMENTS: FORM U APPROVAL: APPROVAL 1'0 ISSUE NO DATE ISSUED BY CONDITIONS: FINAL APPROVAL: ALL PERMITS PAID WELL CONSTRUCTION APPROVAL SEPTIC SYSTEM CONSTRUCTION APPROVAL OTHER ANY VARIANCE NEEDED FINAL BOARD OF HEALTH APPROVAL: YES NO YES NU YES NO YES NU YES!! NO �GJ/1 DRTE:46j ..BY:... -1 TOWN OF NORTH ANDOVE SYSTEM PUMPING RECOR DATE: " v 0 JJariUs ao Gr r Sf RECEIVED AUG 3 0 2005 TOWN OF NORTH ANDOVER HEALTH DEPARTMENT_ (example: left front of house) DATE OF PUMPING: 49 - I to --06 QUANTITY PUMPED % 5'dv GALLONS CESSPOOL: NO YES S PTIC TANK: NO YES NATURE OF SERVICE: ROUTINE EMERGENCY OBSERVATIONS: GOOD CONDITION HEAVY GREASE ROOTS EXCESSIVE SOLIDS SOLIDS CARRYOVER SYSTEM PUMPED BY: t��-C COMMENTS: FULL TO COVER BAFFLES IN PLACE LEACHFIELD RUNBACK FLOODED OTHER (EXPLAIN) CONTENTS TRANSFERRED TO: C; -t--s- . T N OF NORTH 'ANDOVER SYSTEM PIMPING RECORD !) a"f"t:. 3 �TSTEM OWMER & ADDRESS ,, SYSTEKLOCATION— (example: left fwnt of bovse) . 60 vim. ; r i •^ vAII•E OF PUMPIMO:,-?.__ QUANTITY OUMPE>3 r.yllOOL: NO '�- YES SEPTIC TANK: NO YES x NATURE OP SERVICE; ROUTINE ,,,._r, EMERGENCY uIIIERVATIONS: VEit 'GOOD COi1IyITIOhL k�_ FUL�,'I'O CU IN PLACE .�--- .AV'Y CREASE BAFFLESBAFFLESRFLEACHFIELD RUNBACK. ROOTS EXCESSIVE SOLIDS SOLIDS FLOODRD - SOLIDS CARRYOVER LR (EXPl.A1N) - I - r i1.51•EM PUMPCD BY: a• �•u1Ik1E1tTS: I . rs UN•I•I{A''rS' I')iANSEERRED T0: I I Town of North Andover, Massachusetts Form No. 3 f Norrrti BOARD OF HEALTH oetT�a° a,�0 L �o 19 HUS Et DISPOSAL WORKS CONSTRUCTION PERM SS�c IT Applicant C NAME ADDRESS Site Location TELEPHONE Permission is hereby granted to Construct✓�o Sewage Disposal System as shown on rhP r).,;-- Ar Repair_( ) an Individual Soil Absorption TO DAT TIM SAM P FROM14 a-- ��' _M H AREA CODE Q ; OF� NO. N EXT. E M E IE.A kM,G �o IE GNED PHONED ❑ BALL ❑ RETURNED WANTS TO ❑ WILL CALL WAS IN ❑ URGENT ❑ COMMONWEALTH OF MASSACHUSETTS EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS DEPARTMENT OF ENVIRONMENT TITLE 5 , PROTECTION TOWN OF NORTH ANDOVF BOARD OF HEALTH FLMAY 2 3 200 OFFICIAL INSPECTION FORM — NOT FOR VOLUNTARY SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM PART A CERTIFICATION Property Address: �Ia G RA `% S j Owner's Name: L-5 0 V ,t: Owner's Address: dlYc� Date of Inspection: 03 Name of Inspector: (please print) -Ecg o , gu Sc? Company Name: STS L<J A 2 'T _S'Gl P 7-1 C„ Mailing Address: Telephone Number: — `1 J `_ �r%7 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: S Passes Conditionally Passes Needs Further Evaluation by the Local Approving Authority n Fails Inspector's Signature: Date: 6 3 The system inspector shall submit a copy of this inspection report to the Approving Authority (Board of Health or DEP) within 30 days of completing this inspection. If the system is a shared system or has a design flow of 10,000 gpd or greater, the inspector and the system owner shall submit the report to the appropriate regional office of the DEP. The original should be sent to the system owner and copies sent to the buyer, if applicable, and the approving authority. Notes and Comments ****This report only describes conditions at the time of inspection and under the conditions of use at that time. This inspection does not address how the system will perform in the future under the same or different conditions of use. Title 5 Inspection Form 6/15/2000 page I Page 2 of 11 OFFICIAL INSPECTION FORM — NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: 94 5 ! Owner• to Date ofInspection: Inspection Summary: Check A,B,C,D or E / ALWAYS complete all of Section D A. System Passes:t e S 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: P. 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 pipes) are replaced obstruction is removed distribution box is leveled or replaced a 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): ND explain: broken pipe(s) are replaced obstruction is removed - 2 P. Page 3 of 11 OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address:U�? Owner: �94//t" Date of Inspection: Q 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(l)(b) that the system is not functioning in a manner which will protect public health, safety and the environment: — CesspooI or privy is within 50 feet of a surface water Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh 2. System will fail unless the Board of Health (and Public Water Supplier, if any) determines that the system is functioning in a manner that protects the public health, safety and environment: _ The system has a septic tank and soil absorption system (SAS) and the SAS is within 100 feet of a surface water supply or tributary to a surface water supply. _ The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water supply. The system has a septic tank and SAS and the SAS is within 50 feet of a private water supply well. _ The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or more from a private water supply well". Method used to determine distance "This system passes if the well water analysis, performed at a DEP certified laboratory, for coliform bacteria and volatile.organic compounds, indicates that the well is free from pollution from that facility and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis must be attached to this form. 3. Other: Page 4 of 11 OFFICIAL INSPECTION FORM — NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: �(� ra 44-1 5 i Owner: Date of Inspection: I& D. System Failure Criteria applicable to all systems: You must indicate "yes" or "no" to each of the following for all inspections: Yes No Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool L' 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'/2 day flow ✓ Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number of times pumped Any portion of the SAS, cesspool or privy is below high ground water elevation. Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. / Any portion of a cesspool or privy is within a Zone 1 of a public well. L Any portion of a cesspool or privy is within 50 feet of a private water supply well. �! Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality analysis. [This system passes if the well water analysis, performed at a DEP certified laboratory, for coliform bacteria and volatile organic compounds indicates that the well is free from pollution from that facility and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis must be attached to this form.] (Yes/No) The system fails. I have determined that one or more of the above failure criteria exist as described in 310 CMR 15.303. therefore the system fails. The system owner should contact the Board of Health to determine what will be necessary to correct the failure. E. Large Systems:. To be considered a lar�ei�stem the system must serve a facility with a design flow of 10,000 gpd to 15,000 gpd. You must indicate either "yes" or "no" to -each of the following: (The following criteria apply to large systems in addition to the criteria above) yes no the system is within 400 feet of a surface drinking water supply the system is within 200 feet of a tributary to a surface drinking water supply — _ the system is located in a nitrogen sensitive area (Interim Wellhead Protection Area — IWPA) or a mapped Zone II of a public water supply well If you have answered "yes" to any question in Section E the system is considered a significant threat, or answered "yes" in Section D above the large system has failed. The owner or operator of any large system considered a significant threat under Section E or failed under Section D shall upgrade the system in accordance with 310 CMR 15.304. The system owner should contact the appropriate regional office of the Department. 4 f Page 5 of 11 OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST Property Address: �C� (� ✓Q : / S . Owner: /-3/a (/ C Date of Inspection: •C' /-Z. 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 ? _ e b_ Were the septic tank manholes uncovered, opened, and the interior of the tank inspected for the condition of thaffles 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: Ac Y no Existing information. For example, a plan at the Board of Health. _ _ Determined in the field (if any of the failure criteria related to Part C is at issue approximation of distance is unacceptable) [3 10 CMR 15.302(3)(b)] 5 Page 6 of 11 OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION Property Address: 9 v G R/ "/ S r /- /!fin (/-e!-', Owner: Date of Inspection: 5" / V - O 3 FLOW CONDITIONS RESIDENTIAL Number of bedrooms (design): Number of bedrooms (actual): DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x # of bedrooms): Number of current residents: _� Does residence have a garbage grinder (yes or no)H Is laundry on a separate sewage system (yes or no): v [if yes separate inspection required] Laundry system inspected (yes or,no): _ k Seasonal use: (yes or no): /-/ Water meter readings, if available (last 2 years usage (gpd)): ' / 4 flO Sump pump (yes or no): _L1 Last date of occupancy: Q (' c C,1, /,- of 01 COMMERCIAL/INDUSTRIAL Type of establishment: /7 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: / -/I/ Was system pumped as part of the inspection (yes or no): _S�P S If yes, volume pumped: / eTMgallons -- How was quantity pumped determined? Reason for pumping: r1l e- c -,,e 7-141Y i5F9� z E-.1 i= C r'ai1 j �. At TYFE OF SYSTEM _ Septic tank, distribution box, soil absorption system _ Single cesspool _ Overflow cesspool _ Privy _ Shared system (yes or no) (if yes, attach previous inspection records, if any) _ Innovative/Alternative technology. Attach a copy of the current operation and maintenance contract (to be obtained from system owner) _ Tight tank _ Attach a copy of the DEP approval _ Other (describe): Approximate age of all components, date installed (if known) and source of ftiformation: �7c� Were sewage odors detected when arriving at the site (yes or no): -4 Page 7 of 11 OFFICIAL INSPECTION FORM — NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: 1/20 (! Owner: iia v' Date of Inspection: -0 3 BUILDING SEWER (locate on site plan) Depth below grade: 2 f Materials of construction: --cast iron _40 PVC _other (explain): Distance from private water supply well or suction line: Comments (on condition of joints, venting, evidence of leakage, etc.): /`/i C 4- -- 1' j r . t SEPTIC TANK: V (locate on site plan) f, Depth below grade: Material of construction: _concrete _metal _fiberglass _polyethylene other(explain) If tank is metal list age: _ Is age confirmed by a Certificate of Compliance (yes or no): _ (attach a copy of certificate) , Dimensions: / �G r S t 5 - Sludge Sludge depth: " Distance from top of sludge to bottom of outlet tee or baffle: 3 6 Scum thickness: / ° ' Distance from top of scum to top of outlet tee or baffle: 7 Distance from bottom of scum to bottom of outlet tee or baffle: / ti " How were dimensions determined: O N 5 /.r r Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): l� f�/L/_ S (o4Do C'p k4 1-2 tii - /c, L �/a s- L f uc'�S Pta d / /- 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 bathe: 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: 96 G ea -"l 5 r Owner: 1-30 U P Date of Inspection: :c 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: (if present must be opened)(locate on site plan) r Depth of liquid level above outlet invert:��� Comments (note if box is level and distribution to outlets equal, any evidence of solids carryover, any evidence of leakage into or out of box, etc.): /`/CJ L- f 1 t< .7 6 -e /SJ7t &O V /.? ('0 -/1'0/ /-7 v 4 f_ 0 U7- G f—r eg0'a PUMP CHAMBER: /1 (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.): ,» I o 8 Page 9 of 11 a OFFICIAL INSPECTION FORM — NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: 9v Owner: 91 d e Date of Inspection: i Z _ 0 3 SOIL ABSORPTION SYSTEM (SAS): (locate on site plan, excavation not required) If SAS not located explain why: Type leaching pits, number: _ leaching chambers, number: leaching galleries, number: leaching trenches, number, length: i�,eaching fields, numbers dimensions: overflow cesspool, number: innovative/alternative system Type/name of technology: Comments (note condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of vegetation, etc.): u 2-1 c CESSPOOLS: L (cesspool must be pumped as part of inspection)(locate on site plan) Number and configuration: Depth - top of liquid to inlet invert: Depth of solids layer: Depth of scum layer: Dimensions of cesspool: Materials of construction: Indication of groundwater inflow (yes or no): Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): PRIVY: A (locate on site plan) Materials of construction: Dimensions: Depth of solids: Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): Page 10 of 11 OFFICIAL INSPECTION FORINT — NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGEDISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM'INFORMATION (continued) Property Address: 4 _S> Owner: /� ay Date of Inspection: SKETCH OF SEWAGE DISPOSAL SYSTEM Provide a sketch of the sewage disposal system including ties to at least two permanent reference landmarks or benchmarks. Locate all wells within 100 feet. Locate where public water supply enters the building. U 10 /3 4 D e 6 r ' ! I � 1N 10 /3 4 a Page 1 l of 11 y ' OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address:U 4R o Owner: PJLJy e . Date of Inspection: S " / i SITE EXAM Slope Surface water Check cellar Shallow wells Estimated depth to ground water, feet Please indicate (check) all methods used to determine the high ground water elevation: �'Obtained,from system design plans on record - If checked, date of design plan reviewed: Observed site (abutting roperty/observation hole within 150 feet of SAS) - Checked with local Bo d of Health -explain: . Checked.,with local excavators, installers- (attach documentation) Accessed USG§ database -explain: You must describe how you established the high ground water elevation: h 0 6 Q d W JW /� 1 /� _ /�j[/� %fid �j,a7�r✓ CJ/3 i ✓�%° 1 11 0 ,eoM #-5 - r, , PLAN REVIEW CHECKLIST ADDRESS�nr f �,e�Q y � T ENGINEER GENERAL 3 COPIES v STAMP LOCUS NORTH ARROW v CONTOURS � PROFILE L,-' SECTION 0�BENCHMARK SCALE SOIL & PERCS -----ELEVATIONS ✓ WETS. DISCLAIMER WELLS & WETS WATERSHED?O DRIVEWAY/_,-(Elev) WATER LINE FDN DRAIN ,ks/CH40 TESTS CURRENT? c__� SOIL EVAL 1`Q�iG;�Sdti SEPTIC TANK / .6 MIN 150OG .17 INVERT DROP GARB. GRINDER(+200% EDF) 25' TO! CELLAR C/ MANHOLE ELEV "-- GW # COMPS. D -BOX SIZE # LINES FIRST 2' LEVEL STATEMENT A0 U aUq.73 do INLET /2 0 - OUTLETa6?-84 = �`/ (2" OR .17 FT) TEE REQ'D? LEACHING MIN 660 GPD? RESERVE AREA 4' FROM PRIMARY? 2% SLOPE -1 100' TO WETLANDS 100' TO WELLS �' 4' TO S.H.GW_L,--- (5'>2M/IN) 35' TO FND & INTRCPTR DRAINS ✓^ 325' TO SURFACE H2O SUPP e/' 4' PERM. SOIL BELOW FACILITY L_ MIN 12" COVER FILL? ✓(25' if above natural elev; 101if below) BREAKOUT MET. TRENCHES V MIN 660 gpd,\ SLOPE (min .005 or 6"/1001) V SIDEWALL DIST. 3X EFF. W OR D (MIN 6') RESERVE BETWEEN TRENCHES?� IN FILL?MUST ./ BE 10' MIN. Ll___� 4" PEA STONE? VENT? (>3' COVER; LINES >501) BOT c3 + SIDE 6 X LDNG TOT (L x W x #) (DxLx2x#) (G/ft2) Copyright ® 1995 by S.L. Starr PITS MIN 660 LEACHING MIN 1 (131x16') PIT MANHOLE/PIT GW MIN 4' BELOW BOTTOM EXC 2x EFF W OR D 12"-48" STONE BOT + SIDE x LOAD = TOTAL (L x W x #) (2x(L+W) xD x #) (G/ft2) CHAMBERS MIN 660 LEACHING GW MIN 4" BELOW COVER >3 FT - VENT MANHOLES 12"-48" STONE SPLASH PADS SLOPE .005 BED/TRENCH (Bed max. 60' X 601) MIN 13' X 16' PIT BOT + SIDE X LOAD = TOTAL (L x W; x #) (2 x (L+W)xD x #) (G/ft2) I FIELDS MIN 660 GPD X 900 ft2 BED L/ GW MIN 4' BELOW BOTTOM OF FIELD PIPE ENDS JOINED? PEA STONE? L---- DIST LINE SLOPE .005? >31COVER-VENT / SCH 40 ✓ MIN 12" COVER �- i RATE LDG X 660 = '?Dd X = TOTAL ,5-;,dO G/ft2 REQ'D (f t2) LXW DOSING TANKS AND PUMPS DIMENSIONS X X = PUMP CAPACITY 9Pm L W D Vol. DISCHARGE SIZE DISCHARGE RATE DISCHARGE TIME MANHOLES TO GRADE inlet) HWL OP. SWITCH Copyright m 1995 by S.L. Starr, 9Pm ALARM SEP. CIRC. GW (Min. 1' below LWL CHECK VALVE BLEEDER HOLE MANUAL J _. FORM U - LOT RELEASE FORM INSTRUCTIONS: This form is used to verify that all necessary approvals/permits from Boards and Departments having jurisdiction have been obtained. This does not relieve the applicant and/or landowner from compliance with any applicable local or state law, regulations or requirements. ****************Applicant fills out this section***************** APPLICANT: 401",417 F 9,-) 1111S1i✓ Phone (Au 10�1- �G�9 LOCATION: Assessor's Map Number Parcel Subdivision Lot(s) Street 7y ]' L;7_�l St. Number ************************Official Use Only************************ RECOMMENDATIONS OF TOWN AGENTS: I Date Approved Conservation Administrator Date Rejected Comments ltf Q� Date Approved Z Town Planner Date Rejected Comments AQ Ce31(��.nr�_ /�. `1ccn `- Food Inspector -Health Septic Inspector -Health Comments Public Works - sewer/water connections - driveway permit Fire Department Date Approved Date Rejected Date Approved Date Rejected Received by Building Inspector Date (� ��� �� �}.. Offlce Use Ont m _ . 0�I' LIIIIIIl1IITIlUPFI af&LIMPS Permit No. .` Be# rmlern of 1111but �feg Occupancy Fee Checked ISO (leave blank) BOAR OF FIRE PREVENTION REGULATIONS 527 C'dA 12:00 APPLICATION FOR PERMIT TO PERFORM ELECTRICAL WORK.. All work to.be performed in accordance with.the Massachusetts E'ectrical Cade, 527 CMR 12:00 (PLEAS E.PRINT IN INK OR TYPE ALL INFORMATION) Date ANDOVER To the Inspector of Wires: or, Town of ��,�, �� � �� , The udersigned'applies fora permit to perform the electrical wort[ described below. Location. (Street & Number t7wr4er or Tenant jIQ ���-� Owner's Address f5 this pe"rtriit .in conjunction with a building permit: Yes -Ff No (Check Approoriate BOXj Purcose of 8uiiding Utility Authorization No. Ecisting.. Saruice Amps ,---/ �Jci',s Gve�i"ead _ Unagrnd No. of ;ureters New Service Amos ,J Voits Overhear Uncy:nc Na. of {Meters;' Nurnoer,of Feeders and Amoacity. t Lccaticn aria Nature of Prceosed Eiec:rcal Jbcx : N Na, c _:cs ! a. of Tm ransforars ' No. at iSn;Ing i7uttets - .. •�• t KVA No... of Lighting r=,xtures I" "Swimming, ?ror grna e_ grnc. ! Generators iCVA II No. of Emergency Lighting . NC. at Reeec:acie Outlets No. of Oil Eurners i 3arery Units No. of Sw+tcn Outlets No. or Gas Burners { =IRE ALARMS Na. of cones Total. No. of Cetection and No. gr Ranges No..cf ,air C--rc, tons Initiating Cavices ! eat Tata, No. of Cisbosais I . No.of ? at Total Tons K'.v No. at Sounding „evices j ' r No. of Seit Contained No. or ^uisnwasners Soaceiarea Heating K'! Oetec::onrSounding devices { — Mun+cioai ^ Other Heating Cevices Kry I '-ocal i Cannec::cn No. of Criers — i No. or No. of Low vottage tCN i:" Sicns 3ailasts Wiring No. of Water Heaters No. Hyoro Massage -Tubs . No. of Motors Tota: !;P vJ OTHER: INSURANCE COVERAGE; ?ersuant :o-tne reduirements of %tassacnusars 3enefai Laws I have a current Liaoliity Insurance Poircy inctuc:nq Com_:eteq Oceraticns Coverage or .is suds, ecuivaient. Y=S _ NO have suomttieo valid proof et same to the Office. YES _ NO _ it you nave checKea YES. please indicate the type t coverage cy checx+ng the aopr la e cox. �+ INSURANCE. 3CNti, OTHER Z (Please Soec:Y). t rcat,on-Jaffe+ Esurrated Value of Elect tcal 'Mork Wark .:a SRart inscec::on Cate nedueS:aC; ROuIyn .� Signeo'under.the ?enatues'ot ry:,_ LIC. NO. IC NO. Licensee i Signal :re Bus. Tet, No. Address l� � �SY/l +�tN�d �Q { �v �T Alt. ief. No. ��� r_ OWNER'S INSURANCE WAIVEri: t am aware trial ttte Licensee does not nave the insurance coverage or its suostintiai edutvalent as re- Agerg cu,rea by Massacnusetm General Laws-arno :hat my signature on `.nis oerrmt aaoiicauon waives this reau+remenc: Owner tP!easa cnecx.onel; �S elecnone No. PERMIT FEc (Signature of Owner or. Agento 634 ,kORTH 0 F 9 ,SSACMUSEt TOWN OF NORTH ANDOVER PERMIT FOR WIRING This certifies that ...... /47z� ....��u22 �.5...� .1 �1. ......................... has permission to perform l�c s..`.!. e .. .................... wiring in the building of I)?.! ....T Hti.sl v^ ................................. r at .'�vy..... ".. �1��..0 !}'1......5/.�c�"T-......... , North Andover, Mass. ael Fee. . ............ Lic. No.. f4................................................................ ELECTRICAL INSPECTOR WHITE: Applicant 12/3 Afgikilding Dept. PINK: Treasurer 45.00 PAID DATE Sheet of BOARD OF HEALTH TOWN OF NORTH ANDOVER SUBSURFACE DISPOSAL DESIGN REVIEW FEP.(l� PERZIIT # �O� DATE RECEIVED AP PI.IC:ziITC)/t) J61,1-1077�� ASSESSOR'S MAP J r L ARES S ll©rte �T - PARCEL # LOT # STREET Y 5% F.:;G1:1ELR Al, A REVISION DATE OF APPROVAL: Dl�hPPR0V7-D uJITiU�S.S 7 3 /3 CCE5S +,Uf�Uc D itJ 77/9,10 ,t E5 Td 776 ol, IU DTA ' 5 h16 A) ie !.`fir - �.a. ��`^S'a',.�7V..-rt:`:!�'�•Y-•�L"-y.. t. "l:'' '`3. w" �� :`�'.. _..t ri1,, s� �j,Y� r ` � a i w;`+,. �T c. - �,,'.'hl v .,'� 1.. v�:r tip .. -. i w � t--+: 4. T. vp a, ..- La ,. • ..tl �+#1 ♦ 1 `\` �'9 w � a,•�• ,. _ta tiV.i �♦ S�'� � V •� � � � I � � I t• �• , � I I IN Town of North Andover, Massachusetts Form No. 1 t NORTH BOARD OF HEALTH OF,SLED 16'9 - 3��4600 -�> > 19 O kr�• A APPLICATION FOR SITE TESTING/INSPECTION Applicant NAME ADDRESS TELEPHONE Site Location J' r Engineer NAME ADDRESS TELEPHONE Test/Inspection Date and Time /7% 9� /�UG 5r, CHAIRMAN, BOARD OF HEALTH Fee S.S. Permit No. /a9 D.W.C. No. C.C. Date Test No. Plbg. Permit No. .1 140RTh o � Argo a s y ACHUS Town of North Andover, Massachusetts BOARD OF HEALTH DESIGN APPROVAL FOR SOIL ABSORPTION SEWAGE DISPOSAL SYSTEM Form No. 2 199� Applicant Test No. Site Location Eiv-A A A ►� 5Co77' Reference Plans and Specs. -Y —�`� NEER 0 Permission is granted for an individual soil absorption sewage disposal system to be installed in accordance with regulations of Board of Health. Fee -00, HAIRMAN, BOARD OF HEALTH Site System Permit No.—91D-01 / � r Ad Sia K ?Z y C z:Z 3 r Pe- rCr z 72- I2 7 9 12.1 l zZ. ZaeAy- LOT- BOSTON ST. A r^ ^i CERTIFIED PLOT PLAN LOCATED IN NORTH ANDOVER, MA SCALE:1 "= 40" DATE: 4/15/96 I CERTIFY THAT THE OFFSETS SHOWN COMPLY WITH THE ZONING BY LAWS OF NORTH ANDOVER, MA. WHEN BUILT. GRAY ST. OFFSETS SHOWN ARE FOR THE USE OF THE BUILDING INSPECTOR ONLY AND SUCH USE IS FOR THE DETERMINATION OF ZONING CONFORMITY OR NON -CONFORMITY WHEN CONSTRUCTED. iom BOARD OF HEALTH 120 MAIN STREET TEL. 682-6483 NORTH ANDOVER, MASS. 01845 Ext23 July 6, 1995 Mr. Scott Giles 5.0 Deermeadow Road North Andover, MA 01845 Re: Lot #4 Gray Street Dear Scott: This is to inform you that the proposed plans for the site referenced above have been disapproved for the following reasons: 1) Water line missing. 2) Approving authority witness? 3) Access manhole on tank. 4) Lines to be connected and vented if over fifty (50) feet. 5) Three 20 inch access manholes required for tank. (15.228) Also need gas baffle at outlet. 6) Note that note 3 should refer to 15.255(3) of Title V. 7) Please show distance to wetlands. 8) Insufficient leach area. If you have any questions, please do not hesitate to call the Board of Health Office at the number above. Sincerely, Sandra Starr, R.S. Health Administrator SS/cjp