HomeMy WebLinkAboutMiscellaneous - 927 JOHNSON STREET 4/30/2018I
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5651
Date/ i.......
„ORTp . TOWN OF NORTH ANDOVER
PERMIT FOR GAS INSTALLATION
This certifies that ...` .......
has permission for gas installation ............
P
in the buildings of ... `: .............................
at .. ,F�..- :r ?.. ........ , North -Andover, Mass.
Fee.... '. Lic. No.. .% ....... ......... ....... .
GAS INSPECTOR
WHITE: Applicant CANARY: Building Dept. PINK: Treasurer
L
,1'
U
MASSACHUSETTS UNIFORM APPLICATION FOR PERMIT TO DO ,GASF177ING
(Print or Type)
Mass. Date /' Ci lg 0 Permit ##. s
/ �4
Building Location 9r-�7 J5i)S6"O' , 521 , Owner's Name
C
Tof Occupancy J/�y�J
New p Renovation )j
❑ Plans Submitted: Yes❑ No 1P
Installing Company Name
/
Address �,/ / /,/",
Business Telephone
Name of Licensed Plumber or Gas Fitter
Check one:
Corporation
r . Partnership
e � I 1 :=J Firm/Ca.
Certificate
INSURANCE COVERAGE:
I have a currenL liability insurance pelicy or its substantial equivalent which meets the requirements of MGL Ch. 142.
Yes No CJ
If you have checked yes. please indicate the type coverace by checking the appropriate box.
A liability insurance policy Other type of indemnity ❑ gond ❑
OWNER'S INSURANCE WAIVER: I am aware that the licensee does not have the insurance coverage required by
Chapter 142 of the Mass. General Laws, and that my signature on this permit application waives this requirement.
Check one:
❑
Signature of Owner or Owner's Agent Owner❑ Agent
I hereby certify that all of the details and information I have submitted (or entered) in above application are true and accurate to the best of my
knowledge and that all plumbing work and installations performed under the permit issued for this application will be in compliance with all
Pertinent provisions of the Massachusetts State Gas Code and Chapter 142 of the General Laws.
BY T-- of License:
'Plumber S+gnature of Licensed Plumber or Gas Fitter
Title asfit,er yat
l Master License Number V
City/Town J Journeyman
APPROVED—(07 TH —CUS ONLY)
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2 -ND FLOOR
ARD FLOOR
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4TH FLOOR I
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STH FLOOR
Installing Company Name
/
Address �,/ / /,/",
Business Telephone
Name of Licensed Plumber or Gas Fitter
Check one:
Corporation
r . Partnership
e � I 1 :=J Firm/Ca.
Certificate
INSURANCE COVERAGE:
I have a currenL liability insurance pelicy or its substantial equivalent which meets the requirements of MGL Ch. 142.
Yes No CJ
If you have checked yes. please indicate the type coverace by checking the appropriate box.
A liability insurance policy Other type of indemnity ❑ gond ❑
OWNER'S INSURANCE WAIVER: I am aware that the licensee does not have the insurance coverage required by
Chapter 142 of the Mass. General Laws, and that my signature on this permit application waives this requirement.
Check one:
❑
Signature of Owner or Owner's Agent Owner❑ Agent
I hereby certify that all of the details and information I have submitted (or entered) in above application are true and accurate to the best of my
knowledge and that all plumbing work and installations performed under the permit issued for this application will be in compliance with all
Pertinent provisions of the Massachusetts State Gas Code and Chapter 142 of the General Laws.
BY T-- of License:
'Plumber S+gnature of Licensed Plumber or Gas Fitter
Title asfit,er yat
l Master License Number V
City/Town J Journeyman
APPROVED—(07 TH —CUS ONLY)
y�.ii�•k I (�� 1i•I If.C.{A {� � 1 r 1 1' t ... ,
K tttt�t �•.+It ii �h�N �. ,(7i i 'n�'I ,r , ' jR tt� 1 r '
C4�� UriS r til a�a Q i, ev t t 1 7 i 1Al3
OF NORTH ANDOVER
�.
SYSTEM PUMPING RECORD
r
- ca I�h tlby f '�.�r .,t e 1 �. 1 tl S 'I t �`.� �� f'. 1�{ s �F�, lt�',} •" 7 r � y eel , • ' - . '
1 �M1 V.
SYSTEM O
� c 6�i t" - M,���t KVr�� �, • • +'+M1 � ,tir�/D+MY17\7 ,.' •. •
SYSTEM LOCATION
r?'srl r^ 1 ' (Csiaplei;eft•front of house)
� IL �r Q1 h i}r r•tRs",r ri s � �G.7 ' -. r ..
' .� ! r }Y�) ��L7:1����7'�ji�!7,� ria ���'�•F Ns ��,►�5'�c �L�+• ••llbc,�w �j14 > +J vim••..... ..' ... _ •
�${'
,+s.
¢ f: '(� i i'' , 41 •t Fn '''75'r 'i �wT�M INV. • Y'v "� V�
•'.0 ! t:r s s .Q PUMPED GALLONS
• 'Rs�� ��q',r.'.�` ��•:�'r rNa,f) If �y ��.� � '.. JI . tit iv: ,1+, M�r 't - •
1 : s lat ..YES
,SEPTIC TANK: NO
YES
�i l 1L.��7b, +�+a x ti lC ?Lq 1 TT ^r T Obi' M� •-•C • � .i _ t. r y �I IY �..-� •.. ..: . ! .. ..
EMERGENCY
ry' •:.•Lt'1 ,�S'+�::. rr t {•, �.J- 1. 1�"l,,�tt !pt? t rnji
\ -�
t. -ir +•.'tt_.,'�t; fat lt! ,,` ) !' 1'"v^'A�"�y""�. _ , ,
.r OOODwC/O� �N�D�ITLION ,,,,_�,.; FULL' TO CO
Ir � i GREASE � �� r
ROOTS ----� BAFFLES IN PLACE ,
.e 1
LEA RUNBACK ;, ,`�'I �' x'. 7 't :EXCESSIVE SOLIDS I''LOOCD$ED
s 11
SOms CARRYO
S H ,ytit 5 9 i 1 df 1 • i%i\ OTHER
(EXPLAIN)
-
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Board,oS Health
North An4o4erz,.
JYPf VY ED DATE
t2-3- 1
OK
l !2'3
SEPTIC SISTEK
INSTAM ATICK CHECK LIST �Lar'��,��N 5T
DISUPROVEDrEF�,�AVATICN'
OK AIL
ea+;onst
1. ''Distance tot
a. Wetlands
b. Drains
c Well
2. Water Line Location
3. No PVC Pipe
4. Septic Tank
a. Tees -_Length do To Clean Out Covers
b. Cement Pipe to Tank - or, Both Sides of Tank
5. Distribution Box
a. Covers & Box - No Cracks
b. All Lines Flowing Equal Amounts
c. No Back Flow
6. Leach Field or Trench
a. Dimensions
b. Stone Depth
c. Capped Ends
d. Clean Double Washed Stone
7. Leach Pits.
a. Dinansions
b. Stone Depth
c. Splash Pads
d. Tees
e. Cement, Pipe to Pit - Both Sides
f. Clean Double Washed Stone
8. No Garbage Disposal
9. -F nal Grading Inspection
10. Barricading Covered System
11. As Built Submitted
a. Lot Location
b. Dimensions of System
c. Location with Regard -to Perc Test
d. Elevations
e; Water Table
TOWN OF NORTI-1'ANDOVER. MASSACMUS� TTS
'
orrtct or,
CONSERVATION COMMISSION
°�•"'"'•14°
TELEPHONE 683-7105
�c �w'•t
Pursuant to the authority of the Wetlanus�%rotection Act,
Massachusetts General Laws Chapter 131, Section 40,
as amended,—
and the Town of North Andover's Wetland Protection
and
By Law, the
North Andover Conservation-Commission will holrI a'Public Hearing
•'-- on August 28, 1985 at 8:00 P.M. at the
Town Building
Meeting Room, 120 Main Street, North Andover, YA on the Notice
of Intent of Robert DeLuca ::o alter
land at
.•„_ _ Lots 2 & 3 Salem Str_PPt _ _ for
purposes of
constructing single family dwellings.
Plans are available at the Conservation Cm.mission
Office,
Town Building, 120 Main Street North'Andover, MA, on
Tuesday
from 12:00 noon to 2:00 p.m, and by appointment.
By: G. Vicens
Chairman.
N1%CC '
run once in the N.A. Citizen un
ALS-- 7()R5
r ,
Conies sent to:
Plannin Board
Board Health
Public Works
Highway Dept.
'
_Applicant
,
Engineer
a
DCQE
a
Health � rt
..udover,Kasa%�/��
SUBSURFACE DISPOSAL DESIGN CHECK LIST jean
M 7
LOT
APPROVED DATE �l-Z�-�j
Provided: /`i
V
DISAPPROVED DATE .
Reasons:
S�
Title 0FAIL
teg 2.5
-
Beg 6
The submitted plan must show as a minimums
) the lot to be served-area,dimensions lot #,abutters
b location and log deep observation hoes-Astance to ties
c location and results percolation tests -d .stance to ties
d design calculations k calculations showi,g required leaching area
(e) location and dimensions of system-inelud.ng reserve area
f) existing and proposed contours
(g) location any wet areas within 1001 of se age disposal system or
disclaimer -check wetlands mapping
(h) surface and subsurface drains within X00 of sewage disposal
system or disclaimer
(i) location any drainage easements within LOn' of sewage disposal
system or disclaimer -Planning Board -files
(j) known sources of water supply within 200' of sewage disposal e
system or disclaimer
(k) location of any proposed well to serve lot -1001 from leaching facility
(1) location of water lines on property -101 from leaching facility
(m) location of benchmark _
(n) driveways
(o� garbage disposals
(p no PDC to be used in construction
(q) profile of system-elevationa of basement, plumb, pipe, septic tank,
distribution box inlets and outlets, distribution field piping and
Other elevations
(r) maximum ground water elevation in area arwage disposal system
s) plan mast be prepared by a Professional .z gineer or other
professional authorized by law to prepay, such plans
Septic is Tanks
(a) capacities -150% of flow, water table, to s, depth of tees,
access, pumping
(b) cleanout
(c) 101 from cellar wall or inground suir ln, pool
(d) 250 from subsurface_ drains '
Leg 10.2
Leg 10.4
Distribution Boxes
a) slope greater than 0.08
b} sump
DA FF_
-RECEIVED
'F( -')WN U 'NORTH ANDOVER,
SY'TE PUMPING RECORD AUG TOWN or NO 0 9 2004
0
OW
Or NORTH ANDOVER
SYSTEM OWNER & ADDRESS
/,/- 0 /5
17 -7-oAnsoo 9T.
/v - opino o2e, P)a,
SYSTEM LOCATION
61A)_ r'
DATF, OF VUMPING;. U N PIYM� D-_
'A TITY
CESSPOOL, NO YES Septic NO
YEQ
NAI'URE OF SERVICE: ROUTINE EMERGENCY
OBSERVAFIONS-
GOOD CONDITION FULL TO COVER
HEAVY GREASE BAFFLES IN PLACE
ROOTS LEACHFIELD RUNBACK
EXCESSIVE SOLIDS FLOODED
SOLID CARRYOVER OTHER. EXPLAIN
System Pumped by
C(JMMF--'N-I'S
CON FEN I'S FRANSF ERRED'Fo Q)o S/,L—
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SYSTEM R
pUMFING REC
q 1. ORD
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WNER � •ADD �► • ..
IT
-KEM LOCATION
lO9t or�$
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064
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QqmTrry
PUMPED
GALLONS
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.1EPTIC TANK: Np YES
1 ��.r}:7"�+!"{?�LNy''�4Pi t�::r.W • -�,,y., + � i � 4. J .�.,. '✓ .
n ,•. .. i c� : r Sy .` ..�.{.- iii 1.i,:,•�.r 1t•
r� f CE• ROUTMr,
s.. •
URGENCY
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Fvinn-
C
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.,t a +'h ,i it,•til to �w-� fi�•1`r
i ay[►VY GREgSE.FULL TO COVER
TS: :ROO
BAFFLES IN PLACE
..EXCESSWE'. �_+, ,LEA •
O QLD
RUNBACK
w ODDS rF��,4��, i SSARRYOYEIt -- FLOODED
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subml#ed to the.loca1'6oard of Health or other approylng i
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2. Quantity tY Pum ped:
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..'•r ;'J•'•. •� '+ !. , ,• is - ,
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:; 4•' Effluent Tea Filterpresent?.. ❑ Yes [3 No'
If yes was It cleaned?
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hupJ/www•Mass i6 deal,water/epprpva)slt6fo.rms•htm#InspectAA
Yes No
tJforR1'i.doc+•oQJ01 I' '.; `.
System PumPinq Record Page 1 of i
Commonwealth of Massachusetts
Cit /Town of North Andover
Y SEP 25
System Pumping Record �ui1
TOWN OF NORM ANDOVER '
G^M
Form 4 HEq�TH DE?gRTPv1EryT
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 within 14 days from the pumping date in
accordance with 310 CMR 15.351.
A. Facility Information
Important: When
filling out forms 1
on the computer,
use only the tab
key to move your
cursor - do not
use the return
key.
2
r�
System Location:
Address
North Andover Ma
City/Town State
System Owner:
�i
Name
Address (if different from location)
City/Town
B. Pumping Record
1. Date of Pumping
3. Type of system:
❑ Other (describe)
State
Telephone Number
Date 2. Quantity Pumped:
❑ Cesspool(s) Xseptic Tank ❑ Tight Tank
4. Effluent Tee Filter present? ❑ Yes ❑ No
5. Condition of System:
6. System Pumped By:
Name
Stewart's Septic Service
Company
Zip Code
Zip Code
136
Gallons
❑ Grease Trap
If yes, was it cleaned? ❑ Yes ❑ No
Vehicle License Number
7. Location where contents were disposed:
Stewart's Pre-treatment Plant, 20 So. Mill Bradford, Ma 01835
Signatur 'of
Si ture of Receivind Facility
Date
Date
t5form4.doc• 03/06 System Pumping Record • Page 1 of 1