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HomeMy WebLinkAboutMiscellaneous - 93 SHERWOOD DRIVE 4/30/2018Ai x LOT & STREET Ar -t MAP/PARCEL CONSTRUCTION APPROVAL HAS PLAN REVIEW FEE BEEN PAID? NO PLAN APPROVAL DATE APP. BY DESIGNER: IV �V � PLAN DATE CONDITIONS WATER SUPPLY: WELL WELL PERMIT \ DRILLER WELL TESTS: PLUMBING SIGNOFF COMMENTS: CHEMI BACTERIA I BACTERIA II DATE APPROVED DATE APPROVED WIRING SIGNO 411OW'o"t:47 FORM U APPROVAL: APPROVAL TO ISSUE YES NO DATE ISSUED BY CONDITIONS: FINAL APPROVAL: ALL PERMITS PAID YES NO WELL CONSTRUCTION APPROVAL YES NO SEPTIC SYSTEM CONSTRUCTION APPROVAL YES NO OTHER YES NO ANY VARIANCE NEEDED YES NO FINAL BOARD OF HEALTH APPROVAL: DATE: BY: � r i SEPTIC SYSTEM INSTALLATION v it IS THE INSTALLER LICENSED? YES NO TYPE OF CONSTRUCTION: _ NEW REPAIR NEW CONSTRUCTION: CERTIFIED PLOT PLAN REVIEW NO CONDITIONS OF APPROVAL YES NO (FROM FORM U) ISSUANCE OF DWC PERMIT YES NO DWC PERMIT PAID?/ _ ES NO DWC PERMIT NO. c/ INSTALLER:' -13, BEGIN INSPECTION YES 0: EXCAVATION INSPECTION: NEEDED: PASSEDy AL9q7 BY CONSTRUCTION INSPECTION: NEEDED: AS BUILT PLAN SATISFACTORY: L( -E4,.) APPROVAL TO BACKFILL: DATE: BY FINAL GRADING APPROVAL: DATE BY FINAL CONSTRUCTION APPROVAL: DATE: 07 ! Y .-'1" X33 i f� `,J~✓ a/ 93 ���1 Commonwealth of Massachusetts Map -Block -Lot 105.00070 BOARD OF HEALTH -----------Permit No ------------ North Andover - BHP -2017-0326 ---------------------- P.I. FEE F.I. $175.00 ----------------------- DISPOSAL WORKS CONSTRUCTION PERMIT Permission is hereby granted _ to (Construct) an Individual Sewage Disposal System. at No 93 SHERWOOD DRIVE ---------------------------------------------------------------------------------------------------------------------------------------------------------- as shown on the application for Disposal Works Construction Permit No. BHP -2017-032 Dated February 21, 2017 ---------------------------------------------------- ------------------------- Issued On: Feb -21-2017 BOARD OF HEALTH Commonwealth of Massachusetts BOARD OF HEALTH North Andover CERTIFICATE OF COMPLIANCE THIS IS TO CERTIFY, That the Individual Sewage Disposal System (Construct) by -------------------------------------------------------------------------------------------------------------- Installer Map -Block -Lot 105.00070 ----------------------- at No 93 SHERWOOD DRIVE -----------------------------------------------------------------------------------------------------------=---------------------------------------------- has been installed in accordance with the provisions of TITLE 5 of the State Environmental Code as described in the application for Disposal Works Construction Permit No.BHP-2017-032 Dated February -21,-2017 ------------------ ------------------ -- ----------------------------------------------------------------- Printed On: Feb -21-2017 BOARD OF HEALTH ---------------------------------------------------------------------------------- • • ySgTLED`76g6 PUBLIC HEALTH DEPARTMENT Town of North Andover Community and Economic Development Division CERTIFICATE OF. COMPLIANCE As of: February 27, 2017 This is to certify that the individual subsurface disposal system received a SATISFACTORY INSPECTION of the: Distribution -Box Replacement By: John J. Soucy At: 93 Sherwood Street Map 105.0 Lot 70 North Andover, MA 01845 this ce tai to sly ll nol be construed as a guarantee that the system will function satisfactorily. NVchele Grant Public Health Agent 120 Main St., North Andover, Massachusetts 01845 Phone 918.688.9540 Fax 918.688.9542 Web www.northandoverma.gov North Andover Health Department (ommunity and Economic Development Division ONSITE WASTEWATER SYSTEM CONSTRUCTION NOTES LOCATION INFORMATION ADDRESS: 93 Sherwood INSTALLER: Soucy Sewer — John J DESIGNER: PLAN DATE: BOH APPROVAL DATE ON PLAN: INSPECTIONS MAP: 105.0 LOT: 70 Soucy TANK INSPECTION: DATE OF BED BOTTOM INSPECTION: DATE OF FINAL CONSTRUCTION INSPECTION: DATE OF FINAL GRADE INSPECTION: SITE CONDITIONS Comments: DISTRIBUTION -BOX ❑ Contractor reports any changes to design plan ❑ Existing septic tank properly abandoned' ❑ Internal plumbing all to one building sewer ❑ Topography not appreciably altered ® Installed on stable stone base ® H-20 D -Box ® Inlet tee (if pumped or >0.08'/foot) ® Hydraulic cement around inlet & outlets ® Observed even distribution ® Speed levelers provided (not required) ® Schedule 40 PVC Pipe Comments: Make sure pipes are properly bedded FINAL GRADE ❑ Loamed ❑ Seeded ❑ Cover per plan Comments: DOCUMENTS NEEDED ❑ Certification of Installation Form submitted By engineer and signed and dated by Engineer and installer f no A, V @ 4'4'ct� North Andover Health Department Community and Economic Development Division ONSITE WASTEWATER SYSTEM CONSTRUCTION NOTES LOCATION INFORMATION ADDRESS: 93 Sherwood MAP: INSTALLER: Sdv�y sQw�' DESIGNER:. PLAN DATE: BOH APPROVAL DATE ON PLAN: INSPECTIONS TANK INSPECTION:t DATE OF BED BOTTOM INSPECTION: DATE OF FINAL CONSTRUCTION INSPECTION: DATE OF FINAL GRADE INSPECTION: SITE CONDITIONS Comments: LOT: 7o ❑ Contractor reports any changes to design plan ❑ Existing septic tank properly abandoned ❑ Internal plumbing all to one building sewer ❑ Topography not appreciably altered DISTRIBUTION -BOX Installed on stable stone base ^/ H-20 D -Box LJ Inlet tee (if pumped or >0.08'/foot) 11 Hydraulic cement around inlet & outlets Observed even distribution VI peed levelers provided (not required) Schedule 40 PVC Pipe Comments: FINAL GRADE ❑ Loamed ❑ Seeded ❑ Cover per plan Comments: DOCUMENTS NEEDED ❑ Certification of Installation Form 4 submitted By engineer and signed and dated by Engineer and installer Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 93 SHERWOOD DR Property Address MONISHA NABAR Owner Owner's Name information is r,-',,.,2,2-7,/17 t' required for every N. ANDOVER MA 01845 , .2/27,/17 page. City/Town State Zip Code ,./bate 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: When A. General Information filling out forms on the computer, use only the tab�� key to move your 1. Inspector: cursor- do notuse John J. Soucy ,L`.b� ��P'�°��� key.the return Name of Inspector SouC 's Sewer Service Inc. o �� Company Name 78 North Broadway Company Address Salem NH 03079 City/Town State Zip Code 603-898-9339 13397 Telephone Number License Number B. Certification 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 6 (310 CMR 15.000). The system: ® Passes ❑ Needs ❑ Conditionally Passes ❑ Fails Evaluation by the Local Approving Authority 2/24/17 Date The system inspector shall submi?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 - 3/13 Title 5 Official Inspection Form: Subsurface Sewage Disposal System - Page 1 of 17 MHz Owner information is required for every page. Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 93 SHERWOOD DR Property Address MONISHA NABAR Owner's Name N.ANDOVER Cityrrown B. Certification (cont.) MA 01845 2/27/17 State Zip Code Date of Inspection Inspection Summary: Check A, B,C,D or E / always complete all of Section D A) System Passes: ® 1 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. 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 - 3/13 Title 5 Official Inspection Form: Subsurface Sewage Disposal System • Page 2 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 93 SHERWOOD DR Property Address MONISHA NABAR Owner Owner's Name information is required for every N. ANDOVER MA 01845 2/27/17 page. Citylrown State Zip Code Date of Inspection B. Certification (cont.) ❑ Pump Chamber pumps/alarms not operational. System will pass with Board of Health approval if pumps/alarms are repaired. B) System Conditionally Passes (cont.): ❑ 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 ❑ Y ❑ Y ❑ Y ❑ N ❑ N ❑ N ❑ ❑ ❑ ND (Explain below): ND (Explain below): ND (Explain below): El 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 - 3113 Title 5 Official Inspection Forth: Subsurface Sewage Disposal System • Page 3 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments ,.•�'" 93 SHERWOOD DR Property Address MONISHA NABAR Owner Owner's Name information is required for every N. ANDOVER MA 01845 2/27/17 , page. Cityrrown 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 ❑ ® 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 Y day flow t5ins - 3113 Tide 5 Official Inspection Form: Subsurface Sewage Disposal System - Page 4 of 17 Commonwealth of Massachusetts . Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 93 SHERWOOD DR Property Address MONISHA NABAR Owner Owners Name information is required for every N. ANDOVER MA 01845 2/27/17 page. Cityrrown State Zip Code Date of Inspection B. Certification (cont.) Yes No ❑ ® 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 e El ® Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. El ® Any portion of a cesspool or privy is within a Zone 1 of a public well. El® Any portion of a cesspool or privy is within 50 feet of a private water supply w El® Any portion of a cesspool or privy is less than 100 feet but greater than 50 fee from a private water supply well with no acceptable water quality analysis. [fh 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 analys and chain of custody must be attached to this form.] E] ® The system is a cesspool serving a facility with a design flow of 2000gpd- 10,000gpd. F,® 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 systems, you must indicate either "yes" or "no" to each of the following, in addition to the questions in Section D. 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. t5ins - 3113 Title 5 Official Inspection Form: Subsurface Sewage Disposal System • Page 5 of 17 II. t is is 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 systems, you must indicate either "yes" or "no" to each of the following, in addition to the questions in Section D. 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. t5ins - 3113 Title 5 Official Inspection Form: Subsurface Sewage Disposal System • Page 5 of 17 ® ❑ 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, Commonwealth of Massachusetts . Title 5 Official Inspection Form _ Subsurface Sewage Disposal System Form - Not for Voluntary Assessments information on the proper maintenance of subsurface sewage disposal systems? 93 SHERWOOD DR The size and location of the Soil Absorption System (SAS) on the site has Property Address ® ❑ Existing information. For example, a plan at the Board of Health. MONISHA NABAR Determined in the field (if any of the failure criteria related to Part C is at issue Owner Owner's Name information is required for every N. ANDOVER MA 01845 2/27/17 page. City(fown State Zip Code Date of Inspection C. Checklist f Check if the following have been done. You must indicate "yes" or "no" as to each of the following: Yes No i ® ❑ 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): 5, Number of bedrooms (actual): 4 DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x # of bedrooms): 550 t5ins • 3/13 i Title 5 Official Inspection Form: Subsurface Sewage Disposal System • Page 6 of 17 S Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 93 SHERWOOD DR Property Address MONISHA NABAR Owner Owner's Name information is N. ANDOVER required for every page. Cityrrown D. System Information Description: MA 01845 State Zip Code 2/27/17 Date of Inspection Number of current residents: 3 Does residence have a garbage grinder? ® Yes ❑ No Is laundry on a separate sewage system? (Include laundry system inspection ❑ Yes ® No information in this report.) Laundry system inspected? ❑ Yes ® No Seasonal use? ❑ Yes ® No Water meter readings, if available (last 2 years usage (gpd)): Detail: RECOMMEND REMOVAL OF GARBAGE GRINDER SEE ATTACHED WATER METER READINGS Sump pump? Last date of occupancy: Commercial/industrial Flow Conditions: Type of Establishment: Design flow (based on 310 CMR 15.203): Basis of design flow (seats/persons/sq.ft., etc.): Grease trap present? Industrial waste holding tank present? Non -sanitary waste discharged to the Title 5 system? Water meter readings, if available: Gallons per day (gpd) ❑ Yes ® No CURRENT Date ❑ Yes ❑ No ❑ Yes ❑ No ❑ Yes ❑ No t5ins - 3/13 Title 5 Official Inspection Form: Subsurface Sewage Disposal System • Page 7 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 93 SHERWOOD DR Property Address MONISHA NABAR Owner Owners Name information is required for every N. ANDOVER MA 01845 2/27/17 page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Last date of occupancy/use: 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: Type of System: CURRENT Date Soucv's Sewer Service Inc 1500 gallons Gauge on truck Maintenance and Inspection ® Yes ❑ No ® 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 • 3/13 Title 5 Official Inspection Form: Subsurface Sewage Disposal System • Page 8 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments M 93 SHERWOOD DR Property Address MONISHA NABAR Owner Owner's Name information is N. ANDOVER required for every page. City/Town D. System Information (cont.) MA 01845 State Zip Code 2/27/17 Date of Inspection Approximate age of all components, date installed (if known) and source of information: Were sewage odors detected when arriving at the site? Building Sewer (locate on site plan): Depth below grade: 1_5 feet Material of construction: ❑ 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.): NO EVIDENCE OF LEAKAGE Septic Tank (locate on site plan): Depth below grade: Material of construction: ® concrete ❑ metal .4 feet ❑ Yes ® No ❑ fiberglass ❑ polyethylene ❑ other (explain) If tank is metal, list age: years Is age confirmed by a Certificate of Compliance? (attach a copy of certificate) Dimensions: 10.5' X 6' Sludge depth: 3" ❑ Yes ❑ No t5ins • 3/13 Title 5 Official Inspection Form: Subsurface Sewage Disposal System • Page 9 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form o Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 93 SHERWOOD DR Property Address MONISHA NABAR Owner Owner's Name information is required for every N. ANDOVER MA 01845 2/27/17 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Septic Tank (cont.) Distance from top of sludge to bottom of outlet tee or baffle 35" 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 25" 15" How were dimensions determined? TAPE & SLUDGE TOOL Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): BOTH TEES IN PLACE, TANK IS STRUCTURALLY SOUND, NO APPARENT LEAKS Grease Trap (locate on site plan): Depth below grade: Material of construction: ❑ concrete ❑ metal ❑ fiberglass 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: t5ins • 3113 feet ❑ polyethylene ❑ other (explain): Date Title 5 Official Inspection Form: Subsurface Sewage Disposal System • Page 10 of 17 a Commonwealth of Massachusetts Title 5 Official Inspection Form ' Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 93 SHERWOOD DR Property Address MONISHA NABAR Owner Owner's Name information is required for every N. ANDOVER MA 01845 2/27(17 page. City/Town State Zip Code Date of Inspection D. System Information (cont) Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related 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 of construction: ❑concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other (explain): Dimensions: Capacity: gallons Design Flow: gallons per day Alarm present: ❑ Yes ❑ No Alarm level: Alarm in working order: ❑ Yes ❑ No Date of last pumping: Date Comments (condition of alarm and float switches, etc.): *Attach copy of current pumping contract (required). Is copy attached? ❑ Yes ❑ No t5ins - 3/13 Title 5 Official Inspection Form: Subsurface Sewage Disposal System - Page 11 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments , 93 SHERWOOD DR Property Address MONISHA NABAR Owner Owner's Name information is required for every N. ANDOVER MA 01845 2/27/17 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Distribution Box (if present must be opened) (locate on site plan): 0,1 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.): "D" BOX REPLACED BEFORE INSPECTION ( SEE ATTACHED PERMIT) Pump Chamber (locate on site plan): Pumps in working order: ❑ Yes ❑ No* Alarms in working order: ❑ Yes ❑ No* Comments (note condition of pump chamber, condition of pumps and appurtenances, etc.): *.If pumps or alarms are not in working order, system is a conditional pass. Soil Absorption System (SAS) (locate on site plan, excavation not required): If SAS not located, explain why: f t5ins • 3113 Title 5 official Inspection Form: Subsurface Sewage Disposal System • Page 12 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 93 SHERWOOD DR Property Address MONISHA NABAR Owner Owner's Name information is N. ANDOVER required for every page. City/Town D. System Information (cont.) ' Type: MA 01845 2/27/17 State Zip Code Date of Inspection ❑ leaching pits number: ❑ leaching chambers number: ❑ leaching galleries number: ® leaching trenches number, length: (2) 3' X 60' ❑ leaching fields number, dimensions: ❑ overflow cesspool number: ❑ innovative/alternative system Type/name of technology: Comments (note condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of vegetation, etc.): NO SIGNS OF HYDRAULIC FAILURE Cesspools (cesspool must be pumped as part of inspection) (locate on site plan): Number and configuration Depth — top of liquid to inlet invert Depth of solids layer Depth of scum layer Dimensions of cesspool Materials of construction Indication of groundwater inflow ❑ Yes ❑ No t5ins - 3/13 Title 5 Official Inspection Form: Subsurface Sewage Disposal System • Page 13 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form o Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 93 SHERWOOD DR Property Address MONISHA NABAR Owner Owner's Name information is N. ANDOVER MA 01845 2/27/17 required for every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 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.): t5ins • 3113 Tie 5 Official Inspection Form: Subsurface Sewage Disposal System • Page 14 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 93 SHERWOOD DR Property Address MONISHA NABAR Owner Owner's Name information is required for every N. ANDOVER MA 01845 2127/17 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Sketch Of Sewage Disposal System: Provide a view 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. Check one of the boxes below: ❑ hand -sketch in the area below ❑ drawing attached separately n kE)USe D ("t VeV t. O t �S-a- d[00j lsee� C_ t s -� D-4 D-R4L:;'-3©' 7 icf 15ins • 3113 Title 5 Oficial Inspection Form: Subsurface Sewage Disposal System • Page 15 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments M 93 SHERWOOD DR Property Address MONISHA NABAR Owner Owner's Name information is required for every N. ANDOVER MA 01845 2/27/17 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Site Exam: ® Check Slope ® Surface water ® Check cellar ❑ Shallow wells 5' Estimated depth to high ground water. feet Please indicate all methods used to determine the high ground water elevation: ® Obtained from system design plans on record 04/21/1995 If checked, date of design plan reviewed. Date ® 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: DUG HOLE WITH AUGER 2.5' BELOW "D" BOX BOTTOM, NO WATER AT 5' Before filing this Inspection Report, please see Report Completeness Checklist on next page. t5ins • 3/13 Title 5 Official 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 93 SHERWOOD DR Property Address MONISHA NABAR Owner Owner's Name information is N. ANDOVER required for every page. City/Town MA 01845 2/27/17 State Zip Code Date of Inspection E. Report Completeness Checklist ❑ Inspection Summary: A, B, C, D, or E checked ❑ Inspection Summary D (System Failure Criteria Applicable to All Systems) completed ❑ System Information — Estimated depth to high groundwater ❑ Sketch of Sewage Disposal System either drawn on page 15 or attached in separate file t5ins • 3/13 Title 5 Official Inspection Form: Subsurface Sewage Disposal System - Page 17 of 17 . Commonwealth of Massachusetts Map -Block -Loi .Po5:co BOARD OF HEALTH . Permit No ma--' ...... North Andover BHP -2010326 HP ... -'- •- FEE i $175.00 DISPOSAL WORKS CONSTRUCTION PERMIT -4a (f-(a4.t- 7- � d Y- 6a SE✓c Permission >s hereby granted ...........__...P .................... ..' ----..._.......I -- ——�..........._.................. to (Construct) an Individual Sewage Disposal System. at No93 SHERWOOD DRIVE ... - _. as shown on the application for.Disposal Works Construction Permit No. BHP- 032 Feb ry 21, 2017 Issued On: Feb -21-2017 OF ------- " .............. .........— -- ........_......__.........._.. Tri Summary Record Card generated an 2127/2017 8:45:23AM by Tare Hurley Town of North Andover Tax Map # 210-105.0-0070-0000.0 Parcel Id 16986 93 SHERWOOD DRIVE NABAR, RAVI Since Jan 2013 NABAR, MONISHA, R. 93 SHERWOOD DRIVE NORTH ANDOVER, MA 01845 Page 1 Class 101 Single Family Property Type 1 Residential Zoning2 1 Residential Zoning3 1 Residential Size Total 0.92 Acres FY 2017 UB Mailina Index Name/Address Type Loan Number Active/Inact. From Until ROBERT & DONNA LINDENSTRUTH Owner 93 SHERWOOD DRIVE NORTH ANDOVER MA 01845 MOORE, JULIE Previous Customer Inactive 2/21/2012 93 SHERWOOD DR NORTH ANDOVER, MA 01845 RAVI NABAR Previous Customer Inactive 3132017 93 SHERWOOD DRIVE NORTH ANDOVER MA 01845 UB Account Maint. Account No Cycle Occupant Name ActivelInactive Bldg Id. 17697.0 - 93 SHERWOOD DRIVE last Billing Date W1/2017 3170368 03 Cycle 03 Active UB Services Maint. Account No. 3170368 Service Code Rate Charge MultiplierlUsers MISCFEEADMIN FEE 0.63 518 7.82 1/ WTR WATER 01 ALL METER SIZE 153.70 /1 UB Meter Maintenance Account No. 3170368 Serial No Status Location Brand Type Size YTD Cons 40535330 a Active ERT HH b Badger W Water 0.63 0.63 1972 Date Reading Code Consumption Posted Date Variance 2/21/2017 1705 f Final Bill 34 2/21/2017 -50% 12/8/2016 1671 a Actual 81 1/23/2017 -540A 9/92016 1590 a Actual 173 10/24/2016 472% 6/132016 1417 a Actual 33 8/2/2016 24% 3192016 1384 aActual 25 4/22/2016 -71% 12/102015 1359 a Actual 88 1202016 48% 9/912015 1271 a Actual 167 10/16/2015 150% 6110/2015 1104 a Actual 66 7242015 164% 3/12/2015 1036 a Actual 25 4/282015 -61% 12/12/2014 1013 a Actual 66 1/152015 -52% 9/112014 947 a Actual 139 101152014 374% 6/10/2014 808 aActual 29 7/162014 100% 3/10/2014 779 a Actual 14 4/112014 -69% 12/11/2013 765 a Actual 46 1/17/2014 -63% 9/122013 719 a Actual 127 10115/2013 154% 6/122013 592 a Actual 49 7/24/2013 86% 3/142013 543 aActual 27 422/2013 40% 12/12/2012 516 aActual 44 1!9/2013 -640A 9/13/2012 472 a Actual 128 10/15/2012 3590A 6/122012 344 a Actual 27 7116/2012 30% • 7777 Of ,NORTH ♦ i, a Town of North Andover `�'•°,,,,° .. ,' HEALTH DEPARTMENT ,SSACNUSE� p CHECK #: �O 8 DATE: 7-01 � LOCATION: S [/"Gc �r / H/O NAME: CONTRACTOR NAME: Sit) CU Type of Permit or License: (Check box) ❑ Animal $ ❑ Body Art Establishment $ ❑ Body Art Practitioner ti $ ❑ Dumpster $ ❑ Food Service - Type: $ ❑ Funeral Directors $ ❑ Massage Establishment $ ❑ Massage Practice $ ❑ Offal (Septic) Hauler $ ❑ Recreational Camp $ ❑ Sun tanning $ ❑ Swimming Pool $ ❑ Tobacco $ ❑ TrasIVSolid Waste Hauler $ ❑ Well Construction $ SEPTIC Sustems: ❑ Septic - Soil Testing $ ❑ Septic - Design Approval $ ❑ Septic Disposal Works Construction (DWC) $ ❑ Septic Disposal Works Installers (DWI) $ X ❑Title 5 Inspector $ Title 5 Report $� ❑ Other. (Indicate) $ He gent Initials White - Applicant Yellow - Health Pink - Treasurer n Map -Block -Lot Commonwealth of Massachusetts 105 coo7o -- ----------------------- BOARD OF HEALTH Permit No . North Andover BHP -2017-0326 ------------ - -- PA. FEE 4 F.I. $175.00 ----------------------- DISPOSAL WORKS CONSTRUCTION PERMIT Permission is hereby granted --------------------- --�ate_ to (Construct) an Individual Sewage Disposal System.i at No93 ��� SHERWOOD DRIVE l ---------------------------------- as shown on the application for Disposal Works Construction Permit No. BHP -2017-032 Dated February 21, 2017 ---------------------------------------------------- --------------- Issued On: Feb -21-2017 BOARD OF HEALTH Commonwealth of Massachusetts Map -Block -Lot 105.00070 BOARD OF HEALTH ----------------------- North Andover CERTIFICATE OF COMPLIANCE THIS IS TO CERTIFY, That the Individual Sewage Disposal System (Construct) by Installer at No 93 SHERWOOD DRIVE has been installed in accordance with the provisions of TITLE 5 of the State Environmental Code as described in the application for Disposal Works Construction Permit No. BHP -2017-032 Dated February 21, 20.17 ----------------------------------------------------------------- Printed On: Feb -21-2017 BOARD OF HEALTH • w Commonwealth of Massachusetts Map ---M-^ • 105.C13007007 -Lot 0 BOARD OF HEALTH PermitNo -� North Andover BHP -2017-0326 - ---------------------- FEE $175.00 DISPOSAL WORKS CONSTRUCTION PERMIT Permission is hereby granted to (Construct) an Individual Sewage Disposal System. at No 93 SHERWOOD DRIVE ---------------------------------------------------------------------------------------------------------------------------------------------------------- as shown on the application for Disposal Works Construction Permit No. BHP -2017-032 Dated February 21, 2017 ---------------------------------------------------- Issued On: Feb -21-2017 BOARD OF HEALTH SEPTIC Systems: ❑ Septic - Soil Testing $ ❑ Septic- Design Approval $ —y Septic Disposal Works Construction (DWC) $ 1 / 5 ❑ Septic Disposal Works Installers (DWI) $ ❑ Title 5 Inspector $ ❑ Title 5 Report $ ❑ Other: (Indicate) Health Agent Initials White - Applicant Yellow - Health Pink - Treasurer 7767 • 3p ' oc F _r 9 Town of North Andover HEALTH DEPARTMENT IO CHECK #: OOo �4 �% DATE: � LOCATION: H/O NAME: CONTRACTOR NAME: So 0Cc;/ 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 $ ❑ Trash/Solid Waste Hauler $ ❑ Well Construction $ SEPTIC Systems: ❑ Septic - Soil Testing $ ❑ Septic- Design Approval $ —y Septic Disposal Works Construction (DWC) $ 1 / 5 ❑ Septic Disposal Works Installers (DWI) $ ❑ Title 5 Inspector $ ❑ Title 5 Report $ ❑ Other: (Indicate) Health Agent Initials White - Applicant Yellow - Health Pink - Treasurer Important: When filling out forms on the computer, use only the tab key to move your cursor - do not use the return key. i� reium',- Application for Septic Disposal Svstem Construction Permit -TOWN OF NORTH ANDOVER, MA 01845 Application is hereby made for a permit to: ❑ Construct a new on-site sewage disposal system* 2/6/17 TODAY'S DATE $350.00 - Full Repair X $175.00 - Component ❑ Repair or replace an existing on-site sewage disposal system* EZ Repair or replace an existing system component —What? D BOX A. Facility Information 93 SHERWOOD DRIVE Address or Lot # N.ANDOVER City/Town 2.- *TYPE OF SEPTIC SYSTEM*: ➢ ❑ Pump E Gravity (choose one) ***If pump system, attach copy of electrical permit to application*** ➢ ❑ Conventional System (pipe and stone system) ➢ ❑ Infiltrator or Biodiffuser (Gravel -Less) (Attach a copy of your certification to install this type of system.) ➢ ❑ Pressure Distribution S.A.S. (No D -Box) ➢ ❑ Pressure Dosed (D -Box Present) S.A.S. ➢ ❑ Does the system require an effluent filter? Yes No _-/ if yes, does plan specify make and model of filter? YES = (no further info. needed) NO = (installer must specify brand of filter before DWC issuance) What is the Make? 2. Owner Information MONISHA NABAR Name 93 SHERWOOD DR Address (if different from above) N.ANDOVER City/Town Email address 3. Installer Information JOHN SOUCY Name 78 N. BROADWAY Address SALEM City/Town 4. Designer Information orz Name Address City/Town What is the Model. MA State 585-314-2360 Telephone Number 01845 Zip Code SOUCY SEWER SERVICE INC Name of Company NH State 603-216-7175 03079 Zip Code Telephone Number (Cell Phone # if possible please) Name of Company State Zip Code Telephone Number (Best # to Reach) Application for Disposal System Construction Permit • Page 1 of 2 Application for Septic Disposal System Construction Permit - TOWN OF NORTH ANDOVER, MA 01845 PAGE 2OF2 A. Facility Information continued.... 5. Type of Building: EoResidential Dwelling or ❑Commercial B. Agreement 2/6/17 TODAY'S DATE $350.00 - Full Repair $175.00 - Component The undersigned agrees to ensure the construction and maintenance of the afore -described on-site sewage disposal system in accordance with the provisions of Title 5 of the Environ ental Code, as well as the Local Subsurface Disposal Regulations for the Town of North over. I understand that until a final Certificate of Compliance has been issued by this oar of Hea the installed system is not approved. N e Date Application Approved By: (Board of Health Representative) Name Date Application Disapproved for the following reasons: For Office Use Only: I Fee Attached. Yes No 2. Project Manager Obligation Form Attached. Yes No 3. Pump System? If so, Attach copy of Electrical Permit Yes No Applicant received copy of "Electrical Inspection Notes for Septic Systems" Yes No Handout. 4. Reviewedapproval letter, allpaperworkreceivedP Yes I No 5. Foundation As -Built? (new construction only): Yes No (Same scale as approved plan) G. Floor Plans? (new construction only): Yes No Application for Disposal System Construction Permit • Page 2 of 2 Owner information is required for every page. Important: When filling out forms on the computer, use only the tab key to move your cursor - do not use the rett_frn key. ietran t5ins • 11/10 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 93 Sherwood Drive Property Address •• Jullie Moore Owner's Name North Andover Cityrrown MA 01845 State Zip Code 9/30/2011 Date of Inspection 0 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_ A. General Information Inspector: Neil James Bateson ITVVNX NORTH ANUuvr-r` Name of Inspector HEALTH D Bateson Enterprises Inc. Company Name 111 Argilla Road Company Address Andover MA 01810 Cityrrown State Zip Code 978-475-4786 SI -15 Telephone Number License Number B. Certification 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 ❑ Needryf urther Evaluation by the Local Approving Authority 9/9/2011 Insp is rignature 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. 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 93 Sherwood Drive Property Address Jullie Moore Owner Owner's Name information is required for every North Andover MA 01845 page. City/Town State Zip Code B. Certification (cont.) 9/30/2011 Date of Inspection Inspection Summary: Check A,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 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. 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 El N ❑ ND (Explain below): t5ins • 11/10 Title 5 Official Inspection Form: Subsurface Sewage Disposal System • Page 2 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments M 93 Sherwood Drive Property Address Jullie Moore Owner Owner's Name information is North Andover required for every page. Cityrrown B. Certification (cont.) MA 01845 9/30/2011 State Zip Code Date of Inspection B) System Conditionally Passes (cont.): ❑ 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 ❑ 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 • 11/10 Title 5 Official Inspection Forth: 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 93 Sherwood Drive Property Address Jullie Moore Owner's Name North Andover MA 01845 9/30/2011 Cityrrown 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 ❑ ® Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool ❑ -0 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 % day flow t5ins • 11/10 Title 5 Official Inspection Form: Subsurface Sewage Disposal System • Page 4 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form a Subsurface Sewage Disposal System Form - Not for Voluntary Assessments M 93 Sherwood Drive Property Address Jullie Moore Owner Owner's Name information is required for every North -Andover MA 01845 9/30/2011 page. CityfTown State Zip Code Date of Inspection B. Certification (cont.) Yes No ❑ ® 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. % El ® 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 systems, you must indicate either "yes" or "no" to each of the following, in addition to the questions in Section D. 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. t5ins • 11/10 Tide 5 Official Inspection Forth: 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 93 Sherwood Drive Property Address Jullie Moore Owner owners Name information is required for every North Andover MA 01845 9/30/2011 page. Citylrown 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 i - ® ❑ 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: G Number of bedrooms (design): Number of bedrooms (actual): DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x # of bedrooms): 550 t5ins • 11110 Title 5 Official Inspection Forth: Subsurface Sewage Disposal System • Page 6 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments y 93 Sherwood Drive D. System Information Description: Number of current residents: MA 01845 State Zip Code 9/30/2011 Date of Inspection Does residence have a garbage grinder? Property Address Yes Jullie Moore Owner Owner's Name information is North Andover required for every No page. Citylrown D. System Information Description: Number of current residents: MA 01845 State Zip Code 9/30/2011 Date of Inspection 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 years usage (gPd))� Yes Detail: Sump pump? ❑ Yes ® No Last date of occupancy: Current Date Commercial/Industrial Flow Conditions: Type of Establishment: Design flow (based on 310 CMR 15.203): Basis of design flow (seats/persons/sq.ft., etc.): Grease trap present? Industrial waste holding tank present? Non -sanitary waste discharged to the Title 5 system? Water meter readings, if available: Gallons per day (gpd) ❑ Yes ❑ No ❑ Yes ❑ No ❑ Yes ❑ No t5ins - 11/10 We 5 Official Inspection Forth: Subsurface Sewage Disposal System - Page 7 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 93 Sherwood Drive D. System Information (cont.) Last date of occupancy/use: Other (describe below): Pumping Records: Source of information: MA 01845 9/30/2011 State Zip Code Date of Inspection Date General Information Was system pumped as part of the inspection? If yes, volume pumped: How was quantity pumped determined? Reason for pumping: Pumped 2003, owner 1500 gallons Measured tank tank & tees Type of System: ® Septic tank, distribution box, soil absorption system ❑ Single cesspool ❑ Overflow cesspool ❑ Privy ® Yes ❑ No ❑ 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 Forth: Subsurface Sewage Disposal System • Page 8 of 17 Property Address Jullie Moore Owner Owner's Name information is required for every North Andover page. Cityrrown D. System Information (cont.) Last date of occupancy/use: Other (describe below): Pumping Records: Source of information: MA 01845 9/30/2011 State Zip Code Date of Inspection Date General Information Was system pumped as part of the inspection? If yes, volume pumped: How was quantity pumped determined? Reason for pumping: Pumped 2003, owner 1500 gallons Measured tank tank & tees Type of System: ® Septic tank, distribution box, soil absorption system ❑ Single cesspool ❑ Overflow cesspool ❑ Privy ® Yes ❑ No ❑ 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 Forth: Subsurface Sewage Disposal System • Page 8 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 93 Sherwood Drive Property Address Jullie Moore Owner Owner's Name information is North Andover required for every page. City/Town MA 01845 9/30/2011 State Zip Code Date of Inspection D. System Information (cont.) Approximate age of all components, date installed (if known) and source of information: 14 years old, 5/31/1997, as built plan Were sewage odors detected when arriving at the site? Building Sewer (locate on site plan): Depth below rade: 1.3 p g feet Material of construction: ❑ 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.): 4" PVC thru wall, 3"PVC in house, no leaks visible Septic Tank (locate on site plan): Depth below grade: Material of construction: ® concrete ❑ metal .3 feet ❑ Yes ® No ❑ fiberglass ❑ polyethylene ❑ other (explain) If tank is metal, list age: years Is age confirmed by a Certificate of Compliance? (attach a copy of certificate) Dimensions: 10'x 5'x 4' Sludge depth: 4" ❑ Yes ❑ No t51ns -11/10 Title 5 Official Inspection Form: Subsurface Sewage Disposal System - Page 9 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 93 Sherwood Drive Property Address Jullie Moore Owner Owners Name information is required for every North Andover MA 01845 9/30/2011 page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Septic Tank (cont.) Distance from top of sludge to bottom of outlet tee or baffle 23" 2" Scum thickness 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 19" How were dimensions determined? 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.): 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: feet 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: Date t5ins • 11/10 Title 5 Official Inspection Form: Subsurface Sewage Disposal System • Page 10 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 93 Sherwood Drive Property Address Jullie Moore Owner Owner's Name information is required for every North Andover MA 01845 9/30/2011 page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related 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 of construction: ❑ concrete ❑ metal Dimensions: Capacity: Design Flow: Alarm present: Alarm level: ❑ fiberglass ❑ polyethylene ❑ other (explain): gallons gallons per day ❑ Yes ❑ No Alarm in working order: ❑ Yes ❑ No Date of last pumping: Date Comments (condition of alarm and float switches, etc.): * Attach copy of current pumping contract (required). Is copy attached? ❑ Yes ❑ No t5ins • 11/10 Title 5 Official Inspection Form: Subsurface Sewage Disposal System • Page 11 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 93 Sherwood Drive Property Address Jullie Moore Owner Owner's Name information is North Andover required for every page. Cityrrown D. System Information (cont.) MA 01845 State Zip Code 9/30/2011 Date of Inspection Distribution Box (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, has flow levelers. No evidence of leakage. Evidence of carryover, pumped d -box to clean. Pump Chamber (locate on site plan): Pumps in working order: ❑ Yes ❑ No Alarms in working order: ❑ Yes ❑ No Comments (note condition of pump chamber, condition of pumps and appurtenances, etc.): Soil Absorption System (SAS) (locate on site plan, excavation not required): If SAS not located, explain why: t5ins • 11/10 Title 5 Official Inspection Form: Subsurface Sewage Disposal System • Page 12 of 17 � Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments M y�93 Sherwood Drive D. System Information (cont.) MA 01845 9/30/2011 State Zip Code Date of Inspection Type: Property Address Jullie Moore Owner Owner's Name information is required for every North Andover page. Cityrrown D. System Information (cont.) MA 01845 9/30/2011 State Zip Code Date of Inspection Type: ❑ leaching pits number: ❑ leaching chambers number: ❑ leaching galleries number: ® leaching trenches number, length: ❑ leaching fields number, dimensions: 2 trenches 60' long ❑ 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.): Soil ok. Vegetation ok. No sign of ponding to surface. Cesspools (cesspool must be pumped as part of inspection) (locate on site plan): Number and configuration Depth — top of liquid to inlet invert Depth of solids layer Depth of scum layer Dimensions of cesspool Materials of construction Indication of groundwater inflow ❑ Yes ❑ No t5ins • 11/10 Title 5 Official Inspection form: Subsurface Sewage Disposal System • Page 13 of 17 Owner information is required for every page. E Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 93 Sherwood Drive Property Address Jullie Moore Owner's Name North Andover MA 01845 9/30/2011 Cityrrown State Zip Code Date of Inspection D. System Information (cont.) 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.): t5ins • 11/10 Title 5 Official Inspection Forth: Subsurface Sewage Disposal System • Page 14 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments M 'r 93 Sherwood Drive Property Address Jullie Moore Owner Owner's Name information is required for every North Andover MA 01845 9/30/2011 page. Citylrown State Zip Code Date of Inspection D. System Information (cont.) Sketch Of Sewage Disposal System: Provide a view 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. Check one of the boxes below: ® hand -sketch in the area below ❑ drawing attached separately YV 0 a a� ID, L4 k 03R> O�L :' 301' t5ins - 11/10 Tittle 5 Official Inspection Form: Subsurface Sewage Disposal System • Page 15 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments r 93 Sherwood Drive Property Address Jullie Moore Owner Owner's Name information is required for every North Andover MA 01845 9/30/2011 page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Site Exam: ® Check Slope ® Surface water ® Check cellar ® Shallow wells Estimated depth to high ground water: >4 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: 4/21/1995 Date ❑ Observed site (abutting property/observation hole within 150 feet of SAS) ® Checked with local Board of Health - explain: Design plan ❑ Checked with local excavators, installers - (attach documentation) ❑ Accessed USGS database - explain: You must describe how you established the high ground water elevation: Test pit data shows water @ 5' on design plan Before filing this Inspection Report, please see Report Completeness Checklist on next page. t5ins • 11110 Title 5 Official Inspection Forth: 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 y 93 Sherwood Drive Property Address Jullie Moore Owner Owner's Name information is required for every North Andover MA 01845 9/30/2011 page. Cityrrown State Zip Code Date of Inspection E. Report Completeness Checklist ® Inspection Summary: A, B, C, D, or E checked ® Inspection Summary D (System Failure Criteria Applicable to All Systems) completed ® System Information — Estimated depth to high groundwater ® Sketch of Sewage Disposal System either drawn on page 15 or attached in separate file t5ins -11/10 Title 5 Official Inspection Form: Subsurface Sewage Disposal System • Page 17 of 17 Summary Record Card generated on 9/26/2011 1:12:27 PM by Lisa Evans Town of North Andover Tax Map # 210-105.C-0070-0000.0 Parcel Id 16986 93 SHERWOOD DRIVE MOORE, JULIE 93 SHERWOOD DR NORTH ANDOVER, MA 01845 Class 101 Single Family Size Total 0.92 Acres FY 2011 UB Mailina Index Name/Address MOORE, JULIE 93 SHERWOOD DR NORTH ANDOVER, MA 01845 UB Account Maint. Account No Cycle Bldg Id. 1769.0 - 93 SHERWOOD DRIVE 3170368 03 Cycle 03 UB Services Maint. Account No. 3170368 Service Code MISCFEE ADMIN FEE WTR WATER UB Meter Maintenance Account No. 3170368 Brand Serial No Status YTD Cons 40535330 a Active b Badger Date Reading 9/13/2011 281 6/7/2011 26 3/7/2011 18 12/8/2010 10 9/22/2010 0 9/22/2010 2945 6/8/2010 2678 3/9/2010 2661 12/8/2009 2653 9/8/2009 2625 6/8/2009 2605 3/13/2009 2567 12/9/2008 2560 9/10/2008 2552 6/6/2008 2410 3/7/2008 2387 12/11/200,7 2377 9/5/2007 2325 6/19/2007 2192 3/15/2007 2160 12/12/2006 2150 9/18/2006 2141 Trouble Code:03 a Actual 6/19/2006 2027 3/8/2006 1973 Trouble Code:03 4/29/2009 Property Type Type Loan Number Active/Inact. From Payor Occupant Name Active/Inactive Last Billing Date 7/13/2011 Active Rate Charge Multiplier/Users 0.635/8 7.82 1/ 01 ALL METER SIZE 30.40 /1 Page 1 1 Residential Until Location Brand Type Size YTD Cons ERT HH b Badger w Water 0.63 0.63 293 Code Consumption Posted Date Variance a Actual 255 2892% a Actual 8 7/20/2011 -3% a Actual 8 4/13/2011 -31% a Actual 10 1/12/2011 -100% n New Meter 0 10/15/2010 -100% r Replacement 267 10/15/2010 1248% a Actual 17 7/15/2010 112% a Actual 8 4/14/2010 -71% a Actual 28 1/12/2010 42% a Actual 20 10/15/2009 -50% a Actual 38 7/20/2009 487% a Actual 7 4/29/2009 -16% a Actual 8 1/20/2009 -94% a Actual 142 10/10/2008 485% a Actual 23 7/16/2008 120% a Actual 10 4/11/2008 -79% a Actual 52 1/22/2008 -69% a Actual 133 10/12/2007 412% a Actual 32 7/20/2007 210% m Manual estimate 10 4/16/2007 2% a Actual 9 1/19/2007 -92% a Actual 114 10/20/2006 139% a Actual 54 7/10/2006 469% a Actual 7 4/17/2006 -93% Commonwealth of Massachusetts City/Town of System Pumping Record Form 4 DEP has provided this form for use by local Boards of Health. Other forms may be used, but the information must be substantially the same as that provided here. Before using this form, check with your local Board of Health to determine the form they use. The System Pumping Record must be submitted to the local Board of Health or other approving authority. A. Facility Information 1. System LocatioK"6.. Right not of house.? Left / Right rear of house, Left / right side of house, Left. / Right side of buI Ing, Left / Right front of building, Left / Right rear of building, Under deck Address Gla Cityrrown State 2. System Owner. Name Address (if different from location) City/Town B. Pumping Record 1. Date of Pumping 3. Type of system: ❑ ❑ Other (describe): HOC) s 4E�_ &�-3o—I( Date Cesspool(s) 4. Effluent Tee Filter present? ❑ Yes No 5. Condition of System: 6. System Pumped By: /vac-t/t,', Zip Code State Zip Code Telephone Number — 2. Quantity Pumped Septic Tank l S- Gallons ❑ Tight Tank If yes, was it cleaned? ❑ Yes ❑ No Neil Bateson F5821 Name Vehicle License Number Bateson Enterprises Inc Company 7. Location where contents were disposed: Waste Water Date t5form4.doc• 06103 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 Health. Other information must be substantially the same as that provided here. BE local Board of Health to determine the form they use. The System P the local Board of Health or other approving authority. A. Facility Information 1. System Location:a ont of hot rear of house, righ rear of house f ;cls with your submitted to sight front of house, left side of house, right side of house, Left side of building, right rear of building, under deck. City/Town State Zip Code 2. System Owner: Name Address (if different from location) City/Town State Zip Code &6� - '-C 20 �? � Telephone Number B. Pumping Record 1. Date of Pumping I� l Quantity Pumped: 5y Date Gallons 3. Type of system: ❑ Cesspool(s) Septic Tank ❑ Tight Tank ❑ Other (describe): 4. Effluent Tee Filter present? ❑ Yes No 5. Condition of System: 6. System Pumped By: Neil J. Bateson Name Bateson Enterprises Inc. Company 7. Lo' where contents were disposed: rG. L. Lowell Waste Water Signature of Hauler If yes, was it cleaned? ❑ Yes ❑ No F5821 Vehicle License Number Date t5form4.doc• 06/03 System Pumping Record • Page 1 of 1 IL Commonwealth of Massachusetts City/Town of NORTH AH®®VER, M System Pumping Record Form 4 Important: When filling out forms on the computer, use only the tab key to move your cursor - do not use the return key. �Q maen DEFT has provided this form for use by local Boards of Health. be submitted to the local Board of Health or other approving a A. Facility Information 1. System Location: CH S Ws ecoi d mu; t ority. T� JUL 1 9 2006 -- TOWN OF Ni)RTH ANDOVER ''\HEArTH DEPARTMENT Aaaress City/Town State 2. System Owner: , Zip Code Name ,a kir unTerem nom iocation) City/Town 1. Date of Pumping Type of system: ❑ Other (describe) State p Zip Code - Telephone Number Date 2• Quantity Pumped: allons ❑ Cesspool(s);peptic Tank ❑ Tight Tank 4. Effluent Tee Filter present? ❑ Yes 0 _ 5. Condition of System: &M VON 711-fi, 11-6174- 1 0. %"70' -0. 1� %�_ Company 7. Location where contents were disposed: �4G -s0iiature of Haul http://wviw.mass.gov/dep/water/ provals/t5forms.htm#inspect If yes, was it cleaned? ❑ Yes ❑ No Vehicle License Number Q t5form4.doc• 06/03 System Pumping Record • Page 1 of 1 Commonwealth of Massachusetts q City/Town of 5 NA3 System Pumping Record '� Form 4 joWN of NoRTN ,N ANT ,t EALTH DEPAR�, DEP has provided this form for use-, by local Boards of Health. Other forms --may be used, but the information must be substantially the same as that provided here. Before using.this form, check with your local Board of Health to determine the form they use. The System Pumping Record must be submitted to the local Board of Health or other approving authority. A. Facility Information 1. System Locatio . Lift Rig ron of house, eft / Right rear of house, Left / right side of house, Left / Right side of bui g, Left / Right front o building, Left / Right rear of building, Under deck Address City/rown State Zip Code 2. System Owner. Name Address (if different from location) Citylrown state Telephone Number B. Pumping Record -77 1. Date of Pumping Date ��eptic uan ' Pumped: Gallons 3. Type of system: ❑ Cesspool(s) Tank El Tight Tank ❑ Other (describe): 4. Effluent Tee Filter present? ❑ Yes o If, yes, was it cleaned? ❑ Yes ❑ No. 5. Conditio of System: V"N., 6. System Pumped By. Neil Bateson F5821 Name Vehicle License Number Bateson Enterprises Inc- Company ncCompany 7. Loq%io re contents were disposed: Lowell Waste Water SA l'o �7-13 . Bz6z-a� uleq I Date t5form4.doc• 06/03 System Pumping Record • Page 1 of 1 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 CERTIIFICATION Property Address: 0 Owner's Name:,, Owner's Address: Date of Inspection: Name of Inspector: (please pri t) 7 Li 1J/U//lC��i Company Name:";�10,0 lh;,�tl '—)PO,17C, Mailing Address. / (- Telephone Number: V710'–s.3-32– % V CERTIFICATION STATEMENT I certify that I have personally inspected the sewage disposal system at this address and that the information reported below is true, accurate and complete as of the time of the inspection. The inspection was performed based on my training and experience in the proper function and maintenance of on site sewage disposal systems. I am a DEP approved system inspector pursuant to Section 15.340 of Title 5 (310 CMR 15.000). The system: Passes Conditionally Passes Needs F er Evaluation by the Local Approving Authority F s N Inspector's Signature: / - Date: %o Ahr Z- The system inspector shall bmit a copy of this inspection report t the Approving Authority (Board of Health or DEP) within 30 days of co pleting 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 r Page 2 of 1.1 OFFICIAL INSPECTION FORM — NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: .0wner• Date of Inspection: Inspection Summary: Check A,B,C,D or E / ALWAYS complete all of Section D A. System Passes:. . --IL- 1 have not found any, information which indicates that any of the failure criteria described in 310 C 15.303 or in 310 CMR 15.304 exist. Any failure criteria not evaluated are indicated below. 4 Comments: r i 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 ,f it is structurally sound, not leaking and if a Certificate of Compliance indicating that the tank is less than 20 ys 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,Heaith):. z - - broken pipes) 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): ND explain: broken pipe(s) are replaced obstruction is removed 2 M' Page 3 of 11 OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address Owner:: J/ Date of Inspection: zo // ., 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) thatthe system is not functioning.in a manner which will protect public health, safety and the environment: A - _ Cesspool or privy is within 50 feet of a surface water Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh 2. System will fail unless the Board of Health (and Public Water Supplier, if any) determines that the system is functioning in a manner that protects the public health, safety -and environment: _ The system has a septic tank and soil absorption system (SAS) and the SAS'is within 100 feet of a surface water supply or tributary to a surface water supply. _ The system has a septic tank and SAS and the SAS is within a Zone I 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 isequal to or less than 5 ppm, provided that noother failure criteria are triggered. A copy of the analysis must be attaclied'to`tltis form. 3. Other: Page 4 of l I OFFICIAL. INSPECTION FORINT — NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: Owner — Date of Inspection: D. System Failure Criteria applicable to all systems: You must indicate "yes" or "no" to each of the following for all inspections: Yes No/ , _ Vackup 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 dogged SAS.o cesspool i Static liquid level in the distribution box above outlet invert due to A overloaded or clogged SAS or ter. cesspool 5��LRequired iquid depth in cesspool is less than 6" below invert or available volume is less than''/zday flow pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number /Uf 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. e Any portion of a cesspool or privy is within a Zone 1 of a public well. _ 20-o,* y 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 compomds indicates that the well is free from pollution from that facility and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis must be attached to this form.] / (Yes/No) The system fails. I have determined that one or more of the above failure criteria exist as described in 310 CMR 15.303. therefore the system fails. The system owner should contact the Board of Health to determine what will be necessary to correct the failure. E., Large Systems: To be considered a large-system"the systelii uiust'serve a"facility with, d sign 11owJbf 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 N 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 Page 5 of 11 OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST Property Address: Owner• �'"' Date of Inspection: Check if the following have been done. You must indicate "yes" or "no" as to each of the following: Yes o ' Pumping information was provided by the owner, occupant, or Board of Health Were any of tM�system`components pumped out in the previous two weeps _,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: �. .. { t _ .. , t .., . ..•. ... , ,..�, .. _.. 0....,y.. o ... ..,� _ Yes no -_ !/^ Existing information. For example, a plan at the Board of Health. Determined in the field (if any of the failure criteria related to Part C is at issue approximation of distance is unacceptable) [3 10 CMR 15.302(3)(b)] G� 0 Page 6 of 11 OFFICIAL INSPECTION FORM — NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION Property Address Owner: Date of Inspection: / FLOW CONDITIONS RESIDENTIAL Number of bedrooms (design): Number of bedrooms (actual): DESIGN flow based on 310 CW 15.203 (for example: 110 gpd x # of bedrooms): Number of current residents: Does residence have a garbage grinder (yes or r o).NO Is laundry on a separate sewage system (yes or no):hV A [if yes separate inspection required] Laundry system. inspected (,yes or no): Seasonal use: (yes or no):U ` Water meter readings, if available (last 2 years usage (gpd)): Sump pump (yes or no):N Last date of occupancy: CC Lu 0 14 COMMERCIALANDUSTRIAL Type of establishment: Design flow (based on 310 CMR 15.203): gpd. Basis of design flow (seats/persons/sgft,etc.): Grease trap present (yes or no): Industrial waste holding tank present (yes or no): _ Non -sanitary waste discharged to the Title 5 system (yes or no): Water meter readings, if available: Last date of occupancy/use: OTHER (describe): GENERAL INFORMATION Pumping Records 6 Source of information: F/� Was system pumped as part of tlie inspection (yes or no)tVD If yes, volume pumped: gallons -- How was quantity pumped determined? Reason for pumping: TY P F SYSTEM-- _ Septic tank, distribution box, soil absosptiaa 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 instal ed ':5— yea r j 1-5—/ }31� known) end source of information: Were sewage odors detected when arriving at the site (yes or no): 6 0 ' ,4,.. „ 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: ! Owner: Date of Inspection: Lam... BUILDING SEWER (locate on site plan) / rr Depth below grade: Materials of construction: _cast iron ✓ 40 PVC _other (explain): Distance from private water supply well or suction line: Comments (on condition of joints, venting, evidence of leakage, etc.): SEPTIC TANK:V (locate on site plan) Depth below grade: Material of construction: _✓concrete _metal _fiberglass _polyethylene _other(explain) If tank is metal list age: _ Is age confirmed by a Certificate of Compliance (yes or no): _ (attach a copy of certificate) Dimensions: -5 5, Y, Sludge depth: Distance from top of sludge to bottom of outlet tee or baffle: 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: How were dimensions determined: 41 A{ Comments (on pumping recommendations, unlet and outlet tee or baffle condition, structural integri , liquid ievels as related4e-outlet invert, evidence of leakagA etc.): v 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.): 7 Page 8 of I 1 OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: 1T Owner: Date of Inspection: TIGHT or HOLDING TANK: (tank must be pumped at time of inspection)(locate on site plan) Depth below grade: Material of construction: concrete metal fiberglass _polyethylene other(explain): Dimensions - Capacity: alloris "3 �+¢ 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) 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 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): 8 Page 9 of 11 OFFICIAL INSPECTION FORM — NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) . Property Address:i"(,� Owner: (1 Date of Inspection: SOIL ABSORPTION SYSTEM (SAS): (locate on site plan, excavation not required) If SAS not located explain why: Type leaching pits, number:'_d t n leaching chambers, number: leaching gaffe—ries, number: 3Z-1eaching trenches, number, length: I PNC tP S &e e p leaching fields, number, dimensions: overflow cesspool, number: innovative/alternative system Type/name of technology: Comments (note condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of vegetation, etc.): �` U , J.t G CESSPOOLS: (cesspool must be pumped as part of inspection)(locate on site plan) Number and configuration: Depth — top of liquid to inlet invert: Depth of solids layer: Depth of scum layer: Dimensions of cesspool: Materials of construction: Indication of groundwater inflow (yes or no): Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): PRIVY: (locate on site plan) Materials of construction: Dimensions: Depth of solids: Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): 9 • Page 10 of I I OFFICIAL INSPECTION FORM — NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE D1SPOSAL SYSTEM INSPECTION FORM PART C SYSTEM'INFORMATION (continued) Property Address:7,J Owner• 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. A, A 10 p _I A Page 1.1 of 11 ,i OFFICIAL INSPECTION FORM NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM s PART C SYSTEM INFORMATION (continued) ' Property Address: /��.1�� Owner: Date of Inspection: SITE EXAM Slope Surface water Check cellar Shallow wells im Estimated depth to ground w ter feet - Please indicate (check) all' methods used to determine the;4iigh ground water elevation: �tained from system design plans on record - If checked, date of design plan reviewed: Cf % Observed siteabuttinproperty/observation hole within 150 feet of SAS site(abutting ) Checked with local Board of Health -explain: Checked.with local excavators, installers- (attach documentation) Accessed USGS database -explain: You r be how you established .the gh groun water elev f'ou 'loin elu e 4 h � � y 5 North Andover Health Department 1600 Osgood Street Building 20, Suite 2-36 North Andover, MA 01845 978.688.9540 - Phone 978.688.8476 — Fax healthdept(Aitownofnorthandover.com - E-mail www.townofnorthandover.com - Website Letter ®f Transmittal Page _ of T0: � DATE: COMPANY: FROM: Pamela DelleChiaie, Health Department Assistant Phone: RE: � Fax: ��J, C J We are sending you. O Copy of Letter O Plans 0-04er (fill in below) These are transmitted as checked below: );, O=wMvd as ➢ OForgpvld ➢ ➢ OForRa*-wx dax tv# ➢ L7AsRquixd ➢ OFnr'Yawax REMARKS: COPY TO: COPY TO: SIGNED:/'(/` COPY TO: TRANSMISSION VERIFICATION REPORT TIME 05124/2006 14:01 NAME HEALTH FAX 9786888476 TEL 9786888476 SER.# 0004J120960 DATEJIME 05124 13:52 FAX NO./NAME 89786838027 DURATION 00:00:55 PAGE(S) 03 RESULT OK MODE STANDARD ECM Plan Of L and /n North Andover, Mass. sho wing "As—Built" Sanitary Disposal System Lot 13 — 93 Sherwood Drive Prepared For Timberland Builders, Inc. Scale: 1 " = 20' Dote: May 31, 1997 Zoning District: R- 1 - Residence 1 District (Planned Residential Development) � v ` \ ° w e t i o n o \o \ N � rn ` _ w cs N � ` d S 33896 Schedule of Inv Invert ® Foundation = 141 Septic Tank In = 142.62' Septic Tank Out = 142.32 D -Box In = 141.84' D -Box Out = 141.65' Trench In = 141.65', 141. Trench End = 141.28', 14, Note: Prop Subdi vision f D g3 �\ ri� 0 rte\ Ex�elling o� o\\ Our,dation co top Of F1 44.61 ffev M 15.06' P 95.3 ' water Vent W H ' I 1 _ ` 1 1 , `1 .O 1 1 1 3 1 \ \ C 1 , 1 , 1 \ n -Z B ` G ,o .E F `D—Box A Septi Goa n Septic Tank 1,2 M 0 Leach Trench System: 2 Trenches: 62' Long, 4' Wide, 12" Deep l hereby certify that l have inspected the construction of this disposal system and that the construction and final grading has been in accordance with the designer's intent and that the materials used conform to the plan specifications and 310 CMR 15.0. This plan has been prepared for the purpose of showing is Schedule of Tie Distances the 'As—Built" conditions of the sanitary disposal system installed on the premises. All work was done in substantial AE = 15.4' AG = 42.3' Cl = 41.5' conformance with the design plans as prepared. All work was BE = 21.5' BG = 45. 1' Dl = 34.6' done within the construction limitations expected for a job of this type. AF = 26.4' CH = 29.9' BF = 30.8' DH = 18.7' ne data taken from a Definitive 5131197 Desi �i P.E. Dote i IOMN M. MORINN 8 Thnma.a F. Aba nia foo %nn � �( ƒ / �/ » J bri ƒ ƒ ® PLAN REVIEW CHECKLIST ADDRESS -/-07-/,3 ENGINEER1G--V GENERAL 3 COPIES STAMP LOCUS NORTH ARROW SCALE CONTOURS 1/ PROFILE L1 SECTION L BENCHMARK e� SOIL & PERCS ELEVATIONS WETS. DISCLAIMER L --'-WELLS & WETS WATERSHED? DRIVEWAY �Elev) WATER LINE 6--' FDN DRAIN L-- SCH40 L--� TESTS CURRENT? 1---- SOIL EVAL 5. U P S U SEPTIC TANK MIN 150OG(/ .17 INVERT DROP &----- GARB. GRINDER(+200% EDF) ' TO CELLAR f/ MANHOLE 2�� ELEV c-' GW `�� ## COMPS. D -BOX SIZEJJ ## LINES FIRST 2' LEVEL STATEMENT INLET /. 74 - OUTLET /,P,,531 ( 2" OR .17 FT) TEE REQ' D? ,4/0 LEACHINGS �- MIN GPD?y RESERVE AREAL,"" 4' FROM PRIMARY?Z� 2% SLOPE 100' TO WETLANDS L"'.- 100' TO WELLS L--- 4' TO S.H.GW5'>2M/IN) 35' TO FND & INTRCPTR DRAINS 325' TO SURFACE H2O SUPP 4' PERM. SOIL BELOW FACILITY ✓ MIN 12" COVER ''-FILL? (25' if above natural elev; 10'if below) BREAKOUT MET? TRENCHES MIN--64-9-gpd SLOPE (min .005 or 611/1001) z� SIDEWALL DIST. 3X EFF. W OR D (MIN 6') RESERVE BETWEEN TRENCHES? FILL? FILL? MUST BE 10' MIN. v 4" PEA STONE?6"� VENT? (>3' COVER; LINES >501) BOT 406 + SIDE o2D2� X LDNG_ i 74�-= TOT 4,4 J446 (L x W x #) (DxLx2x#) (G/ft2) -41 �-g �A � Copyright 0 1995 by S.L. Starr 7 No. THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH Town OF North Andover FEE AVVIiration for BigVasal t5ptrm Tongtrnrtion rrrmit Application is hereby made for a Permit to Install 0 ) or Repair/Replace ( ) an Individual Sewage Disposal System at: Sherwood Drive Lot 13 Location - Address or Lot No. Timberland Builders, Inc. 15 Clement Court, Haverhill, MA 01832 Owner Address Designer or Installer Address Type of Building Size Lot 40,220 Sq. feet Dwelling — No. of Bedrooms 4 Expansion Attic ( n6 Garbage Grinder fio) Other — Type of Building No. of persons Showers ( ) —Cafeteria ( ) Other fixtures Design Flow 5 5 gallons per person per day. Calculated daily flow 440 gallons. Septic Tank — Liquid capacity 1500 gallons Lengthl 0' 6 " Width 614" Diameter – – – – Depth 5 ' 4 " Disposal Trench — No. 2 Width 4Total Length 10 0' Total leaching area 6 00 sq. ft. Seepage Pit No. Diameter Depth below inlet Total leaching area sq. ft. Other Distribution box Dosing tank (no Percolation Test Results Performed by Thomas E. Neve Assoc., IncElate 8/8/95 Test Pit No. 112 minutes per inch Depth of Test Pit 12 0 " Depth to groundwater No Gro i ndwater Test Pit No. z18- Z2 minutes per inch Depth of Test Pit 17 2 " Depth to groundwater No Groundwater Description of Soil See soil logs on Sani tar)z Disposal S)jstem Design #,q-1449-13 by Thomas F_ NPVP Assnr-iatPG� Tl](--- Dated• 41/11/96 Revised- 10/92196. Nature of Repairs or Alterations — Answer when applicable Date Last Inspected Agreement: — The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of TITLE 5 of the State Environmental Code. The undersigned further agrees not to place the system in operation until a Certificate of Compliance has been issued by the Board of Health. Signed Application Approved By Application Disapproved for the following reasons: on Permit No. Issued Date THE COMMONWEALTH OF MASSACHUSETTS Date Date Date BOARD OF HEALTH Trrtifiratr of Tomplianrr THIS IS TO CERTIFY, That the On -Site Sewage Disposal System installed ( ) or Repaired/Replaced for at has been constructed in accordance with the provisions of TITLE 5 of The State Environmental Code as described in the application for Disposal System Construction Permit No. dated Use of this system is conditioned on compliance with the provisions set forth below: THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE SYSTEM WILL FUNCTION AS DESIGNED. This Certificate expires on DATE Inspector No. THE COMMONWEALTH OF MASSACHUSETTS FEE BOARD OF HEALTH 'Disposal t5-i�stem Tonstrnrtion Prrmit Permission is hereby granted to to Construct ( ) or Repair/Replace ( ) an On -Site Sewage Disposal System located at Street as described on the application for Disposal System Construction Permit. The Applicant recognizes his/her duty to comply with Title 5 and the following local provisions or special conditions. All construction must be completed within three years of the date below. DATE FORM 1255 (REV. 4/95) H&W HOBBSB WARREN TM PUBLISHERS - BOSTON Board of Health THIS FORM APPROVED BY THE MASSACHUSETTS DEPARTMENT OF ENVIRONMENTAL PROTECTION c FORM 11 - SOIL EVALUATOR FORM PAGE 1 of 3 No. 1449-13 Date: 10/24/96 Commonwealth of Massachusetts North Andover, Massachusetts Soil Suitability Assessment for On-site Sewage DiWosal Performed By: Steven J. D'Urso Witnesses By: Mike Rosati 13 - Sherwood Drive Construction, X Repair, Office Review Published Soil Survey Available: No Year Published: 1981 Drainage Class: Excessively Drained Surficial Geologic Report Available: No Year Published: Geologic Material (Map Unit): Landform: Kame Flood insurance Rate Map: Date: 5/12/92 Owners Name, Address, and Telephone # Timberland Builders, Inc 40 Sunset Rock Road Andover, MA 01810 (508) 475-8715 Yes X Publication Scale: 1" =1320' Soil Map Unit:HfD(Hinkley) Soil Limitations: Severe (slope) X Yes Publication Scale: Above 500 year flood boundary: No Yes X Within 500 year flood boundary: No X Yes Within 100 year flood boundary: No X Yes Wetland Area: National Wetland Inventory Map (Map Unit): Wetlands Conservancy Program Map (Map Unit): Current Water Resource Conditions (USES): Month Range: Above Normal: Normal: X Below Normal: Other References Reviewed: DEP APPROVED FORM -12/07/95 0 FORM 11 - SOIL EVALUATOR FORM Page 2 of 3 Location Address or Lot No. Lot 13 - Sherwood Drive OIC -site Review Deep Hole Number: 3 Date: 5/12/92 Time: AM Location (identify on site plan) See sanitary disposal system design Land Use: Residential Slope (%0)15-25 Surface Stones Vegetation: Wooded Weather: Fair Landform: Kame Position on landscape (sketch on the back) See sanitary disposal system design (locus map) Distances from: Open Water Body 110+/- ft Drainage way N/A ft Possible Wet Area 110+/- ft Property Line 65 +/- ft (from left lot line) Drinking Water Well N/A ft Other DEEP OBSERVATION HOLE LOG* Depth from Soil Horizon Soil Texture Soil Color Soil Other Surface (inches) (USDA) (Munsell) Mottling (Structure, stones, Boulders, Consistency, %Gravel) 011-611 A None 6" - 24" Bw None 24" - 180" Cl S/Gr None Stratified * M WviUM OF 2 HOLES REQUIRED AT EVERY PROPOSED DISPOSAL AREA Parent Material (geologic): Outwash Depth to Bedrock: None Depth to Groundwater: Standing Water in the Hole: None Weeping from Pit Face: None Estimated Seasonal High Water: None DEP APPROVED FORM -12/07/95 Location Address or Lot No. Lot 13 - Sherwood Drive Method Used: FORM 11 - SOIL EVALUATOR FORM Determination for Seasonal L h Fater Table No Groundwater Evidence Found Depth observed standing in observation hole inches Depth weeping from side of observation hole inches Depth to soil mottles inches Ground water adjustment feet Index Well Number Reading Date Index well level Adjustment factor Adjusted ground water level D01h of Naturally Occurring pervious Material Certification Does at least four feet of naturally occurring pervious material exist in all areas observed throughout the area proposed for the soil absorption system? Yes If not, what is the depth of naturally occurring pervious material ? I certify that on 11 (date) I have passed the soil evaluator examination approved by the Department of Environmental Protection and that the above analysis was performed by me consistent with the required training, expertise and experience described in 310 CMR 15.017. Signature / C Date �0 / AX,2 DEP APPROVED FORM -12/07/95 Page 3 of 3 No. 1449-13 FORM 11 - SOIL EVALUATOR FORM PAGE 1 of 3 Date: 10/24/96 Commonwealth of Massachusetts North Andover, Massachusetts Soil Suitability Assessmentfor On-site Sewage Disposal Performed By: Steven J. D'Urso Witnesses By: Sandra Starr 13 - Sherwood Drive ew Construction, X Repair, Office Review Published Soil Survey Available: No Year Published: 1981 Drainage Class: Excessively Drained Surficial Geologic Report Available: No Year Published: Geologic Material (Map Unit): Landform: Kame Flood Insurance Rate Map: Date: 4/19/95 Owners Name, Address, and Telephone # Timberland Builders, Inc 40 Sunset Rock Road Andover, MA 01810 (508) 475-8715 Yes X Publication Scale: 1" =1320' Soil Map Unit:HfD(Hinkley) Soil Limitations: Severe (slope) X Yes Publication Scale: Above 500 year flood boundary: No Yes X Within 500 year flood boundary: No X Yes Within 100 year flood boundary: No X Yes Wetland Area: National Wetland Inventory Map (Map Unit): Wetlands Conservancy Program Map (Map Unit): Current Water Resource Conditions (USES): Month Range: Above Normal: Normal: X Below Normal: Other References Reviewed: DEP APPROVED FORM -12/07/95 FORM i 1 - SOIL EVALUATOR FORM Page 2 of 3 Location Address or Lot No. Lot 13 - Sherwood Drive On-site Review Deep Hole Number: 17-2 Date: 4/19/95 Time: AM Weather: Fair Location (identify on site plan) See sanitary disposal system design Land Use: Residential Slope (%)15-25 Surface Stones Vegetation: Wooded Landform: Kame Position on landscape (sketch on the back) See sanitary disposal system design (locus map) Distances from: Open Water Body 130+/- ft Drainage way N/A ft Possible Wet Area 130+/- ft Property Line 25 +/- ft (from left lot line) Drinking Water Well N/A ft Other DEEP OBSERVATION HOLE LOG* Depth from Soil Horizon Soil Texture Soil Color Soil Other Surface (inches) (USDA) (Munsell) Mottling (Structure, stones, Boulders, Consistency, %Gravel) 011-611 A None 6" - 42" Bwl& Gr/L/S & None Bw2 L/F/S 4211-12011 C1 Gr/C/S None Single Grain Loose * MINIMUM OF 2 HOLES REQUIRED AT EVERY PROPOSED DISPOSAL AREA Parent Material (geologic): Outwash Depth to Bedrock: None Depth to Groundwater: Standing Water in the Hole: None Weeping from Pit Face: None Estimated Seasonal High Water: None DEP APPROVED FORM -12/07/95 Location Address or Lot No. Lot 13 - Sherwood Drive Method used: FORM i 1 - SOIL EVALUATOR FORM Determination for Seasonal Hi Water Table No Groundwater Evidence Found Depth observed standing in observation hole inches Depth weeping from side of observation hole inches Depth to soil mottles inches Ground water adjustment feet Index Well Number Reading Date Index well level Adjustment factor Adjusted ground water level Depth of Naturally Occurring Pervious Material Certification Does at least four feet of naturally occurring pervious material exist in all areas observed throughout the area proposed for the soil absorption system? Yes If not, what is the depth of naturally occurring pervious material ? I certify that on l l 6 (date) I have passed the soil evaluator examination approved by the Department of Environmental Protection and that the above analysis was performed by me consistent with the required training, expertise and experience described in 310 CMR 15.017. Signature (�t'e , / Date /a /9G DEP APPROVED FORM -12/07/95 Page 3 of 3 FORINT 12 - PERCOLATION TEST Location Address or Lot No. Lot 13 - Sherwood Drive Commonwealth of Massachusetts North Andover, Massachusetts Percolation Test * Date: 8/8/95 Time: PM Observation Hole # P95-30 Depth of Perc 60" Start Pre-soak 3:55pm End Pre-soak Would not hold soak Time at 12" Time at 9" Time at 6" Time (9"-6") Rate Min./Inch 2 * Minimum of 1 percolation test must be performed in both the primary area AND reserve area. Site Passed: X Site Failed: Performed By: Steven J. D'Urso Witnessed By: Sandra Starr Comments: DEP APPROVED FORM -12/07/95 FORM 1 i - SOIL EVALUATOR FORM PAGE 1 of 3 No. 1449-13 Date: 10/24/96 Commonwealth of Massachusetts North Andover, Massachusetts Soil Suitability Assessment for On-site Sewage Disposal Performed By: Steven S. D`Urso Witnesses By: Sandra Starr 13 - Sherwood Drive Construction, X Repair, Date: 4/21/95 Owners Name, Address, and Telephone # Timberland Builders, Inc 40 Sunset Rock Road Andover, MA 01810 (508)475-8715 Office Review Published Soil Survey Available: No Yes X Year Published: 1981 Publication Scale: 1" =1320° Soil Map Unit:HfD(Hinkley) Drainage Class: Excessively Drained Soil Limitations: Severe (slope) Surficial Geologic Report Available: No X Yes Year Published: Publication Scale: Geologic Material (Map Unit): Landform: Kame Flood Insurance Rate Map: Above 500 year flood boundary: No Yes X Within 500 year flood boundary: No X Yes Within 100 year flood boundary: No X Yes Wetland Area: National Wetland Inventory Map (Map Unit): Wetlands Conservancy Program Map (Map Unit): Current Water Resource Conditions (USGS): Month Range: Above Normal: Normal: X Below Normal: Other References Reviewed: DEP APPROVED FORM -12/07/95 FORM 11 - SOIL EVALUATOR FORM Page 2 of 3 Location Address or Lot No. Lot 13 -Sherwood Drive On-site Review Deep Hole Number: 18-1 Date: 4/21/95 Time: AM Location (identify on site plan) See sanitary disposal system design Land Use: Residential Slope (%)15-25 Surface Stones Vegetation: Wooded Landform: Kame weather: Fair Position on landscape (sketch on the back) See sanitary disposal system design (locus map) Distances from: Open Water Body 140+/- ft Drainage way N/A ft Possible Wet Area 140+/- ft Property Line 25 +/- ft (from right lot line) Drinking Water Well N/A ft Other DEEP OBSERVATION HOLE LOG* Depth from Soil Horizon Soil Texture Soil Color Soil Other Surface (inches) (USDA) (Munsell) Mottling (Structure, stones, Boulders, Consistency, % Gravel) 011-611 A F/S/L None 611-3611 Bw Gr/L/S None 36" - 156" Cl S, Gr/C/S l OYR None Stratified 4/4 156" - 172" C2 Gr/S/L 2.5Y 5/4 None * MINIMUM OF 2 HOLES REQUIRED AT EVERY PROPOSED DISPOSAL AREA Parent Material (geologic): Outwash Depth to Bedrock None Depth to Groundwater: Standing Water in the Hole: None Weeping from Pit Face: None Estimated Seasonal High Water: None DEP APPROVED FORM -12/07/95 Location Address or Lot No. Lot 13 - Sherwood Drive Method Used: FORM I 1 - SOIL EVALUATOR FORM Determination for Seasonal high mater Table No Groundwater Evidence Found Depth observed standing in observation hole inches Depth weeping from side of observation hole inches Depth to soil mottles inches Ground water adjustment feet Index Well Number Reading Date Index well level Adjustment factor Adjusted ground water level Depth of Naturally Occurring Pervious Material Certification Does at least four feet of naturally occurring pervious material exist in all areas observed throughout the area proposed for the soil absorption system? Yes If not, what is the depth of naturally occurring pervious material ? I certify that on / [ (date) I have passed the soil evaluator examination approved by the Department of Environmental Protection and that the above analysis was performed by me consistent with the required training, expertise and experience described in 310 CMR 15.017. Signature 1 Date U / 6 DEP APPROVED FORM -12/07/95 Page 3 of 3 FORM 12 - PERCOLATION TEST Location Address or Lot No. Lot 13 - Sherwood Drive Commonwealth of Massachusetts North Andover, Massachusetts Percolation Test * Date: 8/8/95 Time: PM Observation Hole # P95-31 Depth of Perc 60" Start Pre-soak 4:05pm End Pre-soak Would not hold soak Time at 12" Time at 9" Time at 6" Time (9"-6") Rate Min./Inch 2 * Minimum of I percolation test must be performed in both the primary area AND reserve area. Site Passed: X Site Failed: 'Performed By. Steven J. D'Urso Witnessed By: Sandra Starr Comments: DEP APPROVED FORM -12/07/95 C row (D � ry. � ,,�► o�w, N ' i n � �• Ci � N' 'x= � -1 N• .� t�D e'er p N � D d" m CD 3 d0 o :3 fi o °J O O Z S ,'v D O ; S n D Z Or a o o D o o N = 73 i e a LN _ a N ^ ( O �' 3 N Z S c z Z a _ m cY W o 3 g 3 3 a n o <' � Z o a m D (/1 r o S Q m �D Ln r T m M o Z o m w APPLICATION FOR DISPOSAL WORKS CONSTRUCTION PERMIT DATE: C/%g CURRENT INSTALLER'S LICENSE# LOCATION: G- o / 3 �� e �•- e o �.� . LICENSED INSTALLER: s SIGNATURE: `&�TELEPHONE# J—®8 CHECK ONE: REPAIR: NEW CONSTRUCTION: IF NEW CONSTUCTION, PLEASE ATTACH FOUNDATION AS -BUILT. $75.00 Fee Attached? Foundation As -Built? Administrative Use Only Yes No Yes �� No Approvals Date: �/ �� v. y C � d 'D O CD C'7 Z CO) CD O CL d = CO) ]oma v � o � c v cD CD O cr d CD SSD O CD W W a. C O CO) CD CZ g CO) �C I CO)CD O � Z O CD 0 CD " '.s n, /'^^ 0 O VI \ / u -.y O Q cn cn �. e`f 0 \ O y c a 09 = CD c c m cn cn " '.s n, 7� n ' P6C/)In w 0 O O -.y O Q In N A. = O 0 y a 09 = CD c c m C7 d 0m N IJ Z ?-0 H ::j CL 0 =r CD .moi W O y CD O N 0 o ='m' o a _ _ CD c -� O N. C! o CD a N = S m f :..: J2 0=r�; N m OCD CD c» C C sm CD O y N Q N d 01 ca C:l CL N c C co ...> O y N O 1N 3 g CD to 0 �Of CD o NCD :1 .� 0 co CRte. = G O 0 je " �? z n, 7� n ' P6C/)In w a n O pd n IJ TO J D TIME / / AM l p S P H FROM AREA ODE,,,..��`` —vim O NO. ; G C3, '1 �'�f OF '�� �-! EXT. gc}` E m E IM g E A M G O E Y S SIGNED PHONEjj ALL ❑ RETURNED ❑ SAENTSTO ❑ WILALCALL WAS IN ❑ URGENT ❑ North Andover Health Department 146 Main Street North Andover, MA 01845 �'1 • • .4 • 1 To: Fax: From: Date: Re: Pages: Qkkh k4 R'R ❑ Urgent ❑ For Review ❑ Please Comment ❑ Please Reply ❑ Please Recycle / o \ o e / = \ e < ° / r 7 y 3 / ® = 0 4 $ 0 <. & / e _/ % CDL u / y C 7 « D / ® CD y \ / e \ e / u e J \ @ 2 » \ \ / \ J Z / / 0 ® _ Z = Q / _ 2 co & m F. / %// } \ c » \ \ \ \ \ / 71 \ f \ 2c0 2 m » / \ ®LA \ © \ Q m ? a ` » g 3 -» C) = \ y ^ 0- X \ / / % & % = m 2 \ a » e / g c ƒ ] 0 * 7 /' 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: 1 III) �3E2LAiJ� 3(-IIL�O�.0 Phone 508 _39 X53 I LOCATION: Assessor's Map Number j0(PP Parcel 14 + /''D Subdivision 5Ati Y Lot(s) 3 Street 51'--,E2W0oc� St. Number 9_ ************************Official Use Only************************ RE NDATIONS OF TOWN AGENTS: V/X,X5�761 (PM, Date Approved lq L Conservation Administrator Date Rejected Comments Date Approved Town Planner Date Rejected _ Comments od Inspector -Health Septic Inspector -Health AO Comments Date Approved Date Rejected Date Approved /Z 9 Date Rejected Public Works - sewer/water connections 2 49-� 7 - driveway permit Fire Department Received by Building Inspector Date f NORTIy O � 4 w A t „ ,SSACHUSEt� Town of North Andover, Massachusetts BOARD OF HEALTH DESIGN APPROVAL FOR SOIL ABSORPTION SEWAGE DISPOSAL SYSTEM ApplicantTest No. Site Location��-- Reference Plans and Specs IN TE Permission is granted for an individual soil absorption sewage disposal system to be installed in accordance with regulations of Board of Health. _- 76t7 t, -u CHAIRMAN, BOARD OF HEALTH � ev pp Fee Site System Permit NorS kJ5/11/�FJt1 t7 1D., Ji DUdj/,ibOII 5ILWAKI/ANDUVtK PAGE ui �11 Sr'r's s�rrc 1 �c SERVrcL Alain St 47 mUipOAD g� Ne Hsi H L1 ndo✓Rr. , MA 01835 W-mul 978-372-7471 Lie- MONM or Y ROUC PCR TUM CF I .1(3cb to 0a taco l 1; f ' one -- . cal^- V"-010,4�w SerSrq/c.�S 64-e-9 P �% he 114y R&A14 4t 197 l �,1� $1 l Cgnd 4j- I Q I .1(3cb to 0a taco l 1; �1' �/� � -��-� �� � , TOWN OF NORTH ANDOVER SYSTEM PUMPING RECORD WO A �l STEM OWNER & ADDRESS 9� SYSTEM LOCATION (example: left }}front of house) n fry+ i U:\"I'E OF PUMPING; -2 -(17 QUANTITY PUMPED/ CALLO �.� C I:-�.SI'OOL: NO L,," YES SEPTIC TANK: NO YES 4� NATURE OF SERVICE: ROUTINEI::��EMERGENCY UBSERVATIONS: GOOD CONDITION HFAVY GREASE ROOTS EXCESSIVE SOLIDS SOLIDS CARRYOVER .Y�TlLM PUMPED BY LUMMENTS: FULL TO COVER BAFFLE'S IN PLACE LEACHFIELD RUNBACK FLOODED Oj�HER (EXPLAIN) UN ENTI ; TRANSFERRED TO: Insurance Adjustment Service, Inc. 435 King St. Littleton, MA 01460 (978) 952-6966 Fax (978) 952-2459 UNDER MASSACHUSETTS GENERAL LAWS CHAPTER 139 SECTION 3B TO: Town of N. Andover Board of Health/Building Inspector N. Andover, MA 01845 RE: Insured: George & Property Addr 0 Sherwood Dr. North Andover, MA 01845 Date of Loss Policy Number: 2/1/2004 UP22456424B Type of Loss: vehicle/freeze up File or Claim Number: 13512 Date: February 5, 2004 c� Atloc. k it_.�..�'• 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, Ch. 139, Sec. 38 is appropriate, please direct it to the attention of the writer and include a reference to the captioned insured, locations, policy number, date of loss and claim or file number. Thank you for your cooperation. Very T ours, G Scott O'Neil Adjuster Ext. 129 Insurance Adjustment Service, Inc. 139 Billerica Road, Unit A-1 Chelmsford, MA 01824 (978) 256-3334 Fax (978) 256-3354 UNDER MASSACHUSETTS GENERAL LAWS CHAPTER 139 SECTION 3B Date: April 14, 2008 TO: Board of Health/Building Inspector RE: Insured: Julie Moore Property Address: 93 Sherwood Dr No. Andover, MA 01845 Date of Loss: 4/4/2008 Policy Number: lIP2245642 Type of Loss: Hot water heater let go, causing interior water damage. File or Claim Number: 47887 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, Ch. 139, Sec. 38 is appropriate, please direct it to the attention of the writer and include a reference to the captioned insured, locations, policy number, date of loss and claim or file number. Thank you for your cooperation. Very Truly yours, Tim Martino Adjuster Ext. 135 ?y�nvw` Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments SHERWOOD DR Property Address NABAR 1711 Owner Owner's Name information is N. ANDOVER MA 01845 2/27/17 required for every page. Cityrrown State Zip Code Date of Inspection 9,I)e.5 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: When filling out forms on the computer, use only the tab key to move your cursor- do not use the return key. A. General Information Inspector: SID 21T John J. Soucy - - - FEB _..11100 err Name of InspectorOF NO�QPR�MEN� Soucy's Sewer Service Inc. 10 .�t4 Company Name 78 North Broadway Company Address Salem NH 03079 City/Town State Zip Code 603-898-9339 13397 Telephone Number License Number B. Certification 0 I certify that I have personally inspected the sewage disposal system at this address and thatlh�' 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 Evaluation by the Local Approving Authority 2/24/17 Date The system inspector shall submiea 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 - 3/13 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 93 SHERWOOD DR Property Address MONISHA NABAR Owner Owner's Name information is N. ANDOVER required for every page. Cityrrown B. Certification (cont.) MA 01845 2/27/17 State Zip Code Date of Inspection Inspection Summary: Check A, 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 in 310 CMR 15.303 or in 310 CMR 15.304 exist. Any failure criteria not evaluated are indicated below. Comments: 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. 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 - 3113 Title 5 Official Inspection Forth: Subsurface Sewage Disposal System • Page 2 of V Commonwealth of Massachusetts Title 5 official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments r 93 SHERWOOD DR Property Address MONISHA NABAR Owner Owner's Name information is required for every N. ANDOVER MA 01845 2/27/17 page. Cityfrown State Zip Code Date of Inspection B. Certification (cont.) ❑ Pump Chamber pumps/alarms not operational. System will pass with Board of Health approval if pumps/alarms are repaired. B) System Conditionally Passes (cont.): ❑ 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 ❑ Y ❑ N ❑ ND (Explain below): ❑ Y ❑ N ❑ ND (Explain below): ❑ 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 . W3 Title 5 Official Inspection Form: Subsurface Sewage Disposal System • Page 3 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 93 SHERWOOD DR Property Address MONISHA NABAR Owner Owner's Name information is required for every N. ANDOVER MA 01845 2/27/17 page. Cityfrown 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 wafter 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 ❑ ® 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 '/ day flow t5ins - 3/13 Tide 5 Official Inspection Form: Subsurface Sewage Disposal System - Page 4 of 17 ❑ ® The system is a cesspool serving a facility with a design flow of 2000gpd- 10,000gpd. ❑ ® The system falls. 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 systems, you must indicate either "yes" or "no" to each of the following, in addition to the questions in Section D. 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. t5ins • 3/13 Idle 5 Official 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 't 93 SHERWOOD DR Property Address MONISHA NABAR Owner Owner's Name information is required for every N. ANDOVER MA 01845 2/27/17 page. Cityrrown State Zip Code Date of Inspection B. Certification (cont.) Yes No ❑ ® Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number of times pumped: ❑ ® Any portion of the SAS, cesspool or privy is below high ground water elevation. ❑ ® Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ ® Any portion of a cesspool or privy is within a Zone 1 of a public well. ❑ ® Any portion of a cesspool or privy is within 50 feet of a private water supply well. ❑ ® Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality analysis. [This system passes if the well water analysis, performed at a DEP certified laboratory, for 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 falls. 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 systems, you must indicate either "yes" or "no" to each of the following, in addition to the questions in Section D. 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. t5ins • 3/13 Idle 5 Official 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 2/27/17 Date of Inspection Check if the following have been done. You must indicate "yes" or "no" as to each of the following: Yes 93 SHERWOOD DR Property Address ❑ MONISHA NABAR Owner Owner's Name information is required for every N. ANDOVER MA 01845 page. Cityrrown State Zip Code ❑ C. Checklist 2/27/17 Date of Inspection 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): 5 Number of bedrooms (actual): 4 DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x # of bedrooms): 550 t5ins • 3113 Title 5 Official Inspection Form: Subsurface Sewage Disposal System • Page 6 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments �•'� 93 SHERWOOD DR Property Address MONISHA NABAR Owner Owner's Name information is N. ANDOVER required for every page. Cityrrown D. System Information Description: MA 01845 2/27/17 State Zip Code Date of Inspection Number of current residents: 3 Does residence have a garbage grinder? ® Yes ❑ No Is laundry on a separate sewage system? (Include laundry system inspection ❑ Yes ® No information in this report) Laundry system inspected? ❑ Yes ® No Seasonal use? ❑ Yes ® No Water meter readings, if available (last 2 years usage (gpd)): Detail: RECOMMEND REMOVAL OF GARBAGE GRINDER SEE ATTACHED WATER METER READINGS Sump pump? Last date of occupancy: CommerciaUlndustrial Flow Conditions: Type of Establishment: Design flow (based on 310 CMR 15.203): Basis of design flow (seats/persons/sq.ft., etc.): Grease trap present? Industrial waste holding tank present? Non -sanitary waste discharged to the Title 5 system? Water meter readings, if available: Gallons per day (gpd) ❑ Yes ® No CURRENT Date ❑ Yes ❑ No ❑ Yes ❑ No ❑ Yes ❑ No t5ins - 3113 Title 5 official Inspection Form: Subsurface Sewage Disposal System - Page 7 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 93 SHERWOOD DR Property Address MONISHA NABAR Owner Owner's Name information is N. ANDOVER MA 01845 2/27/17 required for every page. Cityfrown State Zip Code Date of Inspection D. System Information (cont.) Last date of occupancy/use: CURRENT 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: Type of System: Soucy's Sewer Service Inc 1500 gallons Gauge on truck Maintenance and Inspection ® Septic tank, distribution box, soil absorption system ❑ Single cesspool ❑ Overflow cesspool ❑ Privy ® Yes ❑ No ❑ 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 - 3113 Title 6 Official inspection Form: Subsurface Sewage Disposal System • Page 8 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 93 SHERWOOD DR Property Address MONISHA NABAR Owner Owner's Name information is N. ANDOVER MA 01845 2/27/17 required for every page. Citylrown State Zip Code Date of Inspection D. System Information (cont.) Approximate age of all components, date installed (if known) and source of information: Were sewage odors detected when arriving at the site? Building Sewer (locate on site plan): Depth below grade: 1_5 feet Material of construction: ❑ 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.): NO EVIDENCE OF LEAKAGE Septic Tank (locate on site plan): Depth below grade: Material of construction: ® concrete ❑ metal .4 feet ❑ Yes ® No ❑ fiberglass , ❑ polyethylene ❑ other (explain) If tank is metal, list age: . years Is age confirmed by a Certificate of Compliance? (attach a copy of certificate) ❑ Yes ❑ No Dimensions: 10.5'X 6' Sludge depth: 3" t5ins • 3113 Title 5 Official Inspection Form: Subsurface Sewage Disposal System • Page 9 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 93 SHERWOOD DR Property Address MONISHA NABAR Owner Owner's Name information is required for every N. ANDOVER MA 01845 2/27/17 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Septic Tank (cont.) Distance from top of sludge to bottom of outlet tee or baffle 35" Scum thickness 25" Distance from top of scum to top of outlet tee or baffle Tv Distance from bottom of scum to bottom of outlet tee or baffle 15" How were dimensions determined? TAPE 8r SLUDGE TOOL Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): BOTH TEES IN PLACE, TANK IS STRUCTURALLY SOUND, NO APPARENT LEAKS Grease Trap (locate on site plan): Depth below grade: Material of construction: ❑ concrete ❑ metal ❑ fiberglass 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: t5ins • 3113 feet ❑ polyethylene ❑ other (explain): Date Tide 5 Official Inspection Form: Subsurface Sewage Disposal System • Page 10 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 93 SHERWOOD DR Property Address MONISHA NABAR Owner Owner's Name information is required for every N. ANDOVER MA 01845 2/27/17 page. Cityfrown State Zip Code Date of Inspection D. System Information (cont.) Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related 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 of construction: ❑ concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other (explain): . Dimensions: Capacity: Design Flow: Alarm present: Alarm level: Date of last pumping: gallons gallons per day ❑ Yes ❑ No Alarm in working order: ❑ Yes ❑ No Date Comments (condition of alarm and float switches, etc.): * Attach copy of current pumping contract (required). Is copy attached? ❑ Yes ❑ No t5ins - 3113 Titin 6 Official Inspection Form: Subsurface Sewage Disposal System - Page 11 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 93 SHERWOOD DR Property Address MONISHA NABAR Owner Owners Name information is required for every N. ANDOVER MA 01845 2/27/17 page. City/Town State Zip Code 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 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 REPLACED BEFORE INSPECTION ( SEE ATTACHED PERMIT) Pump Chamber (locate on site plan): Pumps in working order: ❑ Yes ❑ No" Alarms in working order: ❑ Yes ❑ No` Comments (note condition of pump chamber, condition of pumps and appurtenances, etc.): " If pumps or alarms are not in working order, system is a conditional pass. Soil Absorption System (SAS) (locate on site plan, excavation not required): If SAS not located, explain why: t5ins • 3/13 Title 5 Official Inspection Forth: Subsurface Sewage Disposal System • Page 12 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 93 SHERWOOD DR ,p Property Address MONISHA NABAR Owner Owner's Name information is required for every N. ANDOVER MA 01845 2/27/17 page. Citylrown State Zip Code Date of Inspection D. System Information (cont.) 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) 3' X 60' Type/name of technology: Comments (note condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of vegetation, etc:): NO SIGNS OF HYDRAULIC FAILURE Cesspools (cesspool must be pumped as part of inspection) (locate on site plan): Number and configuration Depth — top of liquid to inlet invert Depth of solids layer Depth of scum layer Dimensions of cesspool Materials of construction Indication of groundwater inflow t5ins • 3113 ❑ Yes ❑ No Title 5 official Inspection Form: Subsurface Sewage Disposal System - Page 13 of 17 Commonwealth of Massachusetts upTitle 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 93 SHERWOOD DR Property Address MONISHA NABAR Owner Owner's Name information is required for every N. ANDOVER MA 01845 2/27/17 page. Cityfrown state Zip Code Date of Inspection D. System Information (cont.) Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): i 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.): t5ins - 3113 Title 5 Official Inspection Forth: Subsurface Sewage Disposal System • Page 14 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 93 SHERWOOD DR Property Address MONISHA NABAR Owner Owner's Name information is required for every N. ANDOVER MA 01845 2/27/17 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Sketch Of Sewage Disposal System: Provide a view 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. Check one of the boxes below: ❑ hand -sketch in the area below ❑ drawing attached separately W 1001 TN�c. nn DrIt veli-XI t5ins - 3/13 Title 5 Official Inspection Form: Subsurface Sewage Disposal System • Page 15 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments .. 93 SHERWOOD DR Check Slope Property Address Surface water MONISHA NABAR Owner Owner's Name information is required for every N. ANDOVER page. City/Town D. System Information (cont.) Site Exam: ® Check Slope ® Surface water ® Check cellar ❑ Shallow wells MA 01845 State Zip Code 2/27/17 Date of Inspection Estimated high depth to round water: 5' p g g 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: 04/21/1995 Date ® 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: DUG HOLE WITH AUGER 2.5' BELOW "D" BOX BOTTOM, NO WATER AT 5' Before filing this Inspection Report, please see Report Completeness Checklist on next page. t5ins - 3113 Title 5 Official Inspection Form: Subsurface Sewage Disposal System - Page 16 of 17 , Commonwealth of Massachusetts Title 5 Official Inspection Form 9 Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 93 SHERWOOD DR Property Address MONISHA NABAR Owner Owner's Name information is N. ANDOVER required for every page. City/Town MA 01845 2127/17 State Zip Code Date of Inspection E. Report Completeness Checklist ❑ Inspection Summary: A, B, C, D, or E checked ❑ Inspection Summary D (System Failure Criteria Applicable to All Systems) completed ❑ System Information — Estimated depth to high groundwater ❑ Sketch of Sewage Disposal System either drawn on page 15 or attached in separate file t5ins • 3/13 Title 5 Official Inspection Forth: Subsurface' Sewage Disposal System • Page 17 of 17 Commonwealth of Massachusetts Map-BMdo-L11 105.00070 BOARD OF HEALTH •--------..._....... PennitNo North Andover BHP-2017-0326 ........ .......... PE $175.00 DISPOSAL WORKS CONSTRUCTION PERMIT (k�c �—did Sam Permission is hereby granted ...-1...fl ......�t ....p._......._......-- ---. �._.._.. ��...--••-•----�......._.-.....--•-•------........... 1 to (Consttuct) an Individual Sewage Disposal System. at No 93 SHERWOOD DRIVE as shown on the a ppficatim for, i spos ai W o rks Czastruction Permit No. BHP- -032 Feb ty 21, 2017 Issued On. Feb-21-2017 OF ; J • Summary Ricard Card generated an 2/2712017 8:45:23AM by Tare Hurley Page 1 Town of North Andover Tax Map # 210-105.C-0070-0000.0 Parcel Id 16986 93 SHERWOOD DRIVE NABAR, RAVI Since Jan 2013 NABAR, MONISHA, R. 93 SHERWOOD DRIVE NORTH ANDOVER, MA 01845 Class 101 Single Family Property Type 1 Residential Zoning2 1 Residential Zoning3 1 Residential Size Total 0.92 Acres FY 2017 UB Mailinsal Index Name/Address iype Loan Number Activellnact. From Until ROBERT & DONNA LINDENSTRUTH Owner 93 SHERWOOD DRIVE NORTH ANDOVER MA 01845 MOORE, JULIE Previous Customer Inactive 2/21/2012 93 SHERWOOD DR NORTH ANDOVER, MA 01845 RAVI NABAR Previous Customer Inactive 3/3/2017 93 SHERWOOD DRIVE NORTH ANDOVER MA 01845 UB Account Maint. Account No Cycle Occupant Name ActivelInactive Bldg Id. 17697.0 - 93 SHERWOOD DRIVE Last Billing Date 2!21/2017 3170368 03 Cycle 03 Active UB Services Maint. Account No. 3170368 Service Code Rate Charge Multiplier/Users MISCFEEADMIN FEE 0.63 5/B 7.82 1/ WTR WATER 01 ALL METER SIZE 153.70 /1 UB Meter Maintenance Account No. 3170368 Serial No Status Location Brand Type Size YTD Cons 40535330 a Active ERT HH b Badger w Water 0.63 0.63 1972 Date Reading Code Consumption Posted Date Variance 2/21/2017 1705 f Final Bill 34 2/21/2017 -50% 12/8/2016 1671 aActual 81 1/23/2017 -54% 9/9/2016 1590 a Actual 173 10/24/2016 472% 6/1312016 1417 a Actual 33 8/212016 24% 3/9/2016 1384 aActual 26 4/22/2016 -71% 1211012015 1359 aActual 88 1/20/2016 48% 9/9/2015 1271 a Actual 167 10/16/2015 150% 6/1012015 1104 a Actual 66 7/24/2015 164% 3/12/2015 1038 a Actual 25 4/28/2015 -61% 12/1212014 1013 a Actual 66 1/1512015 -52% 9/1112014 947 a Actual 139 1011512014 374% 6/10/2014 808 a Actual 29 7/16/2014 100% 3/10/2014 779 a Actual 14 4/11/2014 -69% 12/11/2013 765 a Actual 46 1117/2014 -63% 9/12/2013 719 a Actual 127 10/15/2013 154% 6112/2013 592 aActual 49 7124/2013 860/4 3/1412013 543 aActual 27 4/2212013 40% 12/12/2012 516 aActual 44 1/9/2013 -64% 9/13/2012 472 a Actual 128 10/15/2012 359% 6/12/2012 344 a Actual 27 7/16/2012 30% 0 310 C, 10.ag Farm ff _ Commonwealth i --+E==. of tvlassachusetts OE? Fite No. 242-810 (To oe oroviaed by CE?) 01v 'Town ' North Andover A00t7C3n( Douglas Seaver Lot 13 #93 Sherwood Drive Certificate of Compliance Massachusetts Wetlands Protection Act, C.L. c. 131,.§40 � North Andover Conservation Commission Issuing Authority ic Douglas Seaver 93 Sherwood Drive (Name) (Adcressl oate of Issuance October 7, 1998 n:s Car-tiicate is issued to work regulated by an Oraer of Conditions issued to Timberland Builders, Inc. dated 6/7/96 and issued by the NACC It is hereby certified that the work regulated by the above -referencia Oraer of ConCittcns tis bean satisfactorily competed. 7, Q It is hereby certified that only the fallowing portions of the work regulated by the a -cove -refer- enced Oroer of Canditions have been satistac:arily completed: (if the Certificate of Compliance aces not include the entire project. specify what portions are included.) 1_ ' Q It is nere�-,y certified that the work regulated by the above -referenced Oreer of Concitians vias never commenced. The Oraer of Conditions has lapsed and is there!ore no lonoer vaiid. No-luture H•crx sublec: to reculation unaer the Act may be commenced wttncut liitnc a new Ncuce c! Intent anc receivnc a new Order of Conditions. .........................................................................................------•-•..... ,._._.................. (Leave Soace elanK) M I ti:. -4 "�1 Date ... V.Z.✓, v . .....I...... TOWN OF NORTH ANDOVER p PERMIT FOR WIRING This certifies that ......... .f G �'t E/2 C ....................................... ................................... k has permission to perform ......,.n�,r�'V�t. rt . SS' ......... wiring in the building of ....... J .:......! . * .�.�..................................... l3 Jh�2Guca� 1�f North Andover, Mass. � . Fee ..................... Lic. No. 3 R� ! ............ ) el . .. .......... J( ELECTRICAL INSPECTOR Check# -2 -v 7 Commonwealth of Massachusetts Department of Fire Services BOARD OF FIRE PREVENTION REGULATIONS Official Use Only Permit No. Occupancy and Fee Checked [Rev. 9/05] 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 IN INK ORT 21�__ L F RMATION) Date:' �— City or Town of: To the Inspector of Wires: By this application the undersigned gives notice of, Pis or her intention to perfo the electrical work described below. Location (Street & Number) Owner or Tenant 514",e_ otP>Dt—_ Telephone No. Owner's Address < < Is this permit in conjunction with a building permit? Yes ❑ No (Check Appropriate Box) Purpose of Building Utility Authorization No. Existing Service Amps / Volts Overhead ❑ Undgrd ❑ No. of Meters 'New Service Amps J Volts Overhead ❑ Undgrd ❑ No. of Meters Number of Feeders and Ampacity o Location and Nature of Proposed Electrical Work: rmmnletinn nfthe follawint, table may he waived by thP'1ncnectnr nfWirov No. of Recessed Luminaires No. of Ceil: Susp. (Paddle) Fans rans . Total Transformers KVA ' T No. of Luminaire Outlets No. of Hot Tubs' Generators KVA . No. of Luminaires Swimming Pool Above ❑•. In-LJ rnd. rnd.., o. o Emergency Lighting Batter Units No. of Receptacle Outlets No. of Oil Burners FIRE ALARMS No. of Zones No. of Switches No. of Gas Burners No. of Detection and initiating Devices No. of Ranges No. of Air Cond. Total Tons No. of Alerting Devices No. of Waste Disposers Heat Pump Totals: Number . ...... Tons ........................ KW No. of Self -Contained - Detection/Alertin Devices No. of Dishwashers Space/Area Heating KW Municipal Local El Connection ❑Other No. of Dryers Heating Appliances Ki Security Systems:* No. of Devices or Equivalent No. of WaterKW Heaters No. of No. of Signs Ballasts Data Wiring: No. of Devices or Equivalent No. Hydromassage Bathtubs No. of Motors Total HP Telecommunications Wiring: No. of Devices or E uivalent (OTHER: Attach additional detail if desired, or as required by the Inspector of Wires. Estimated Value f I tr. 1 Work• 7� (When required by municipal policy.) Work to Start: Inspections to be requested in accordance with NEC Rule 10, 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:) 1 certify, under the pains and penalties of perjury, that the information on this application is true and -complete FIRM NAME: Q T SWit? cf r 1 SER. V / PS LIC. NO.: / 53 3 C Licensee: /C%�� ,_;.. A _."Nw,& Signature ! LIC. NO.: ? 6P�. (If applicable, enter' xempt" in the. license.numl!k�er line.) Bus: Tel. No.- F Address:, � C L/hT� J) e, %� //1 0/f Alt. Tel. No.: -394 *Security System Contractor License required for this work; if applicable, enter the license number here: S30-0, U .4 2_I OWNER'S INSURANCE WAIVER: I am aware that the Licensee does.not have the liability insurance coverage normally required by law. By my signature. below, I hereby waive this requirement. I am the (check one) F1 owner El owner's agent._. Owner/Agent PERMIT FEE: $ a Signature Telephone No. Location � "' �.`. ,. [Sate 3-oLI o7.a TOWN OF NORTH ANDOVER x FAMML AL ; Certificate of Occupancy $ Building/Frame Permit Fee $ Foundation.,Permit Fee $. .'Ss�cHu5E� Other• Permit Fee r. Q Sewer Connection Fee $ --"""` A ?.20 Water Connection Fee $ /D TOTAL $ H - CL dd+ifrl ns o Gl7 Di AuKllic Works i . Location No. Ci Date -!J o<",°oT;�tia TOWN OF NORTH ANDOVER A Certificate of Occupancy $ * _ Building/Frame Permit Fee $0 �sswcr+uSEt Foundation Permit Fee $ Other Permit Fee `� $ 5 Sewer Connection Fee $ i Water Connection Fee $ TOTAL $ See Building In ector N2 10725' - - Div. Public Works �f 1p- No.LL. ' 9 ,SswcHusEt d t 10724 k y TOWN OF Certificate of Occ '^"'.a+.�.✓ms's""^'.:'+.-a..,._ 'r3'... .-:�-.+--..�f� r."? $ �J C) C) Date NORTH ANDOVER upancy $ C $ <Z i Building Ins p for { ,XI Div. Public Works. Building/Frame Permit.Fee Foundation Permit Fee` Other Permit Fee -Sewer Connection Fee Water Connection Fee TOTAL PERMIT -NG* - -APPLICATION FOR. PERMIT TO BUILD — NORTH ANDOVER, MASS. /V PAGE 1 MAP iqO. 10L. 6C ZONE R i LOT NO. f� I SUB DIV. LOT NO.j,-� 2 RECORD OF OWNERSHIP iDATE RLAjo L'1. lwepiSrGr G� BOOK PAGE X d 14,qq(p 'T LOCATION 27 c 4 Rw� .�P-WS— \R� V� PURPOSE OF BUILDING nrC iL/�/V OWNER'S NAME - `m esr2 L-AOrs C ^rs N \i NO. OF STORIES ^� SIZE OWNER'S ADDRESS — o • BASEMENT OR SLAB ARCHITECT'S NAME -�b'MFS .,� SIZE OF FLOOR TIMBERS IST ,U 2ND Q � 3RD BUILDER'S NAME ^Z- `m ,aC SPAN ' ^ �T OF SILLS � .(?l DISTANCE TO NEAREST BUILDING p _ f T DIMENSIONS [l 'i 1 coV DISTANCE FROM STREET cps POSTS 7- � 12 DISTANCE FROM LOT LINES - SIDES (jS "/ .3D f REAR •^G")_ T O'` GIRDERS ^ n A tQ--5�Z AREA OF LOT c(,z "1 0,2 r+P FRONTAGE lis HEIGHT HEIGHT OF FOUNDATION �l-rT' THICKNESS O0ll IS BUILDING NEW VE -5 SIZE OF FOOTING 0 X Q r IS BUILDING ADDITION? 00 MATERIAL OF CHIMNEY V'nAS�UA IS BUILDING ALTERATION , `� IS BUILDING ON SOLID OR FILLED LAND Scx_\p WILL BUILDING CONFORM TOP+ REQUIREMENTS OF CODE YES C IS BUILDING CONNECTED TO TOWN WATER �C g BOARD OF APPEALS ACTION. IF ANY , 1 IS BUILDING CONNECTED TO TOWN SEWER NU IS BUILDING CONNECTED TO NATURAL GAS LINE '�� INSTRUCTIONS I SEE BOTH SIDES PAGE 1 FILL OUT SECTIONS 1 - 3 1 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 AND APPROVED BY BUILDING INSPECTOR DATE FILED SIGNATURE OF OWNER OR s FEE C �- v. 'o PERMIT GRANTED 19 M* d 3 PROPERTY INFORMATION LAND COST Q c/ EST. BLDG. COST EST. BLDG. COST PER SQ. FT. EST. BLDG. COST PER ROOM SEPTIC PERMIT NO. 4 APPROVED BY BUILDING INSPECTOR OWNER TEL. # OF - 393- 1539 CONTR.TEL.# CONTR. LIC. # �� \ \� H.I.C. # —_- �o __ /o r? as f F z BUILDING RECORD 1 OCCUPANCY 12 _ SINGLE FAMILY THIS SECTION MUST SHOW EXACT DIMENSIONS OF LOT AND DISTANCE FROM MULTI. FAMILY LOT LINES AND EXACT DIMENSIONS OF BUILDINGS. WITH PORCHES. GA- RAGES. ETC. SUPERIMPOSED. THIS REPLACES PLOT PLAN. B'M'T 2nd _ ELECTRIC �•. 1st 13rd I NO HEATING � \ SiOkIES t OFFICES APARTMENTS CONSTRUCTION 2 FOUNDATION 8 INTERIOR FINISH 3 1 2 13 PINE CONCRETE CONCRETE BL'K. BRICK OR STONE HARDWRD PIERS PLASTER DRY WALL — UNPIN. 3 BASEMENT AREA FULL Ix FIN. B'M'T' AREA _ 1/4 1/2 FIN. ATTIC AREA NO B M'T FIRE PLACES _ HEAD ROOM _ MODERN KITCHEN 4 WALLS I 9 FLOORS CLAPBOARDS B 1 2 3 _ _ _ DROP SIDING WOOD SHINGLES CONCRETE EARTH ASPHALT SIDING ASBESTOS SIDING VERT. SIDING HARMt."D COMMCN ASPH. TILE STUCCO ON MASONRY STUCCO ON FRAME _ BRICK ON MASONRY. BRICK ON FRAME CONC. OR CINDER BLK. ATTIC STRS. 8 FLOOR _ WIRING STONE ON MASONRY STONE ON FRAME SUPERIOR I� POOR ADEQUATE NONE 5 ROOF 10 PLUMBING GABLE GAMBRELMANSARD I A HIP BATH 13 FIX.) TOILET RM. 12 FIX.) _ FLAT SHED WATER CLOSET _ ASPHALT SHINGLES LAVATORY_ = WOOD SHINGES KITCHEN SINK __ SLATE NO PLUMBING TAR 8 GRAVEL STALL SHOWER _ _ ROLL ROOFING MODERN FIXTURES TILE FLOOR _ TILE DADO 6 FRAMING I 11 HEATING WOOD JOIST PIPELESS FURNACE _ FORCED HOT-AIR FURN. TIMBER BMS. & COLS. STEAM STEEL BMS. & COLS. HOT W'T'R OR VAPOR WOOD RAFTERS AIR CONDITIONING RADIANT H'T'G UNIT HEATERS 7 NO. OF ROOMS GAS s OIL B'M'T 2nd _ ELECTRIC �•. 1st 13rd I NO HEATING � \ t B'M'T 2nd _ ELECTRIC �•. 1st 13rd I NO HEATING � \ 46 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: �m �E�LAIVQ `r3UlLlJ,E� Phone 503 - 313- X539 1 �5� LOCATION: Assessor's Map Number iy(.nH Parcel Subdivision'Lot (s) 3 Street Sy1E.2Wooc� St. Number _ ************************Official Use Only************************ RE NDATIONS OF TOWN AGENTS: , Date Approved Conservation Administrator Date Rejected Comments h LAXE 04 itlL Date Approved zii Town Planner Date Rejected Comments Date Approved _ od Inspector -Health Date Rejected Date Approved �z Septic Inspector -Health Date Rejected �Id Comments Public Works - sewer/water connections Q0 2-14% driveway permit tr) ' (OP `9 % .Fire Department Received by Building Inspector Date Z LIY 4 N A N C, i L PARTNER F6X NO. 6177426987 e7Z., Sxpire6, CS Restricted fe: is 4 i! EBRfcYt Pia ea03a P, 02 V. V�"' �K. I � Al cn cn n 0 zcn cn O F—� c cn n cn cn y 0 ti (n cn Pod po 0 x n cp ai 0 co Cl n 0 CL Z CD zi ff Im CD O to ao El zr C) CD Q C= 0 ca CD Im 01 cm Al cn cn n 0 zcn cn O F—� c cn n cn cn y 0 ti (n cn Pod po 0 x n cp ai 0 0 CL zi rL cp to El zr A', 'TIC wm t P.O. BOX 907 TIMBERLAND BUILDERS NORTH ANDOVER MA. 01845 STEPHEN R. KARETA TO THE BUILDING INSPECTOR, DUE TO RECENT CHANGES IN OUR ORGANIZATION WE WOULD LIKE TO CHANGE ALL OF THE BUILDING PERMITS CURRENTLY OUT WITH TIMBERLAND BUILDERS TO REFLECT THAT ROBERT INNIS IS THE CONSTRUCTION SUPERVISOR ON ALL OF OUR PERMITS AND WORK SITES. ROBERT INNIS HAS A MASSACHUSETTS CONSTRUCTION SUPERVISORS LICENSE # ©b Sl 3?2 THE PROPERTIES AFFECTED ARE: 158 FOREST ST. PERMIT NO# 604 10 JERAD PLACE LOT15A PERMIT NO# 444 44 SHERWOOD AVE LOT 2 PERMIT NO# 560 96 SHERWOOD AVE LOT 7 PERMIT NO# PEnD.j 93::SHERWOODr.AVE LOT -1-3--- .. - ---_.,._._PE.RMIT- -NO#-._.. -90- - 67 SHERWOOD AVE LOT 16 PERMIT NO# 603 IF YOU HAVE ANY QUESTIONS OR COMMENTS PLEASE DO NOT HESITATE TO CONTACT ME AT 508-557-5531 ASAP 2 5 ,r r i 4 ►TE ,OF USE & OCCUPANCY wn of North Andover ®ate THIS CERTIFIES THAT ,DON 3 .S�!'��' �%sJ6,Lr i -I l, ACCORDANCE f OF THE MASSACHUSETTS STATE BUILDING CODE AND IONS AS MAY APPLY. ERTIFICATE ISSUED TOD�.ct ADDRESS i ding Inspe ar y C CA C) . CD aZ CA R CL C' CD y O d C 06 ^� Q =r9+ m CD 6 cc 1CD � C CD cor Cm. C2 y \ Cl CA 0 CD Q CD I- t^ :"1 ho;) (24,) ►��yy tri 2 AIL .l ✓ :- r'y Q �4Xn s Q y '41- s�mmm ao d� y •��•: a .Y1 U,;� Qi 4f(. Z C �"0 tT, Ol y + r;; ?did T ..r = moyy s N! S O 0 -4> �►� > o -♦ og� owl CA EL aC.COD . m CL o g m mm� ' C m .�� fA l C w 01 y CL C N i _. IE m CIO o � m ACD"y p H 0 `V . ` mom y CD o'I a s y CD � �1 43 -ft► .0 =m:�_:G aCD� G a C I- t^ :"1 ho;) (24,) ►��yy tri 2 AIL .l ✓ :- r'y Q �4Xn 3 '41- ON a �f a •��•: .Y1 U,;� Qi 4f(. + r;; s S PERMIT NO. APPLICATION FOR PERMIT TO BUILD — NORTH ANDOVER, MASS. PAGE 1 MAP KBO. LOT NO. /5 f 14 12 RECORD OF OWNERSHIP DATE BOOK PAGE rl 7,,n,.NE SUB DIV. LOT NO.=OF.STORIES LOCATION OWNERS NAMET\m(J Et; L,A.,'p V SIZE OWNER'S ADDRESS P. 0 aC�c q n l A � SOU �J BASEMENT OR SLAB —_�/ _ �� Jf� ARCHITECT'S NAME ',J "f(` SIZE OF FLOOR TIMBERS IST _/I IND BUILDER'S NAME 3RD SPAN DISTANCE TO NEAREST BUILDING DIMENSIONS OF SILLS DISTANCE FROM STREET POSTS DISTANCE FROM LOT LINES - SIDES REAR GIRDERS AREA OF LOT FRONTAGE HEIGHT OF FOUNDATION THICKNESS IS BUILDING NEW SIZE OF FOOTING x IS BUILDING ADDITION MATERIAL OF CHIMNEY IS BUILDING ALTERATION IS BUILDING ON SOLID OR FILLED LAND WILL BUILDING CONFORM TO REQUIREMENTS OF CODE IS BUILDING CONNECTED TO TOWN WATER BOARD OF APPEALS ACTION, IF ANY - IS BUILDING CONNECTED TO TOWN SEWER IS BUILDING CONNECTED TO NATURAL GAS LINE INSTRUCTIONS 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 MUSTBE FILED AND APPR WED BY BUILDING INSPECTOR ^ DATE FILED V /� FEE PERMIT GRANTED 1 I MAY 1 2 1997 R 3 PROPERTY INFORMATION LAND COST EST. BLDG. EST. BLDG. COST PER SQ. i /, (� EST. BLDG. COST PFR ROOM SEPTIC PERMIT NO. 4 APPROVED BY NUILDING INtP[CTOR OWNER TELA/ 373- '153'3 CONTR. TEL. N CONTR. LIC. # H.I.C. A' TION INTERIOR FINISH r 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. a z 13 �.I��pJT v��i�® T tn11bNE���^' D W D — �+ c ITER WAIL E B' M' T' ATTIC FLOORS B 1 CRETE _ 'H _ 9W'D _ MON 1. TILE _ WIRING .1 PLUMBING 1 (3 FIX.) ET RM. (2 FIX.► ER CLOSET VORY JEN SINK PLUMBING L SHOWER ERN FIXTURES FLOOR DADO HEATING IRNACE CONDITIONING WoGZK �e� - ca rJ -� � � is N � � APP �.o a� � C©x ► 2-- — TIL_( A F-- — (AN 0(54 PPROX^ X — Vz t ri�s H �.r� p. pelznx 49 X VA—, HEAS��m��►�$- ��r 6 t) u t Nvs i-+ .. f � f O cr o Eo So .0 y G � 3 m p m CA • H H a C2 T Z ?� H w o m a '-fes o ��d H CDM CD $ O > > m 0 10 �. p O O C N n M. C =r yp p CL +m fCp C?; - m m ti m � Cis C to d O NGO H a dcr CL H m �mH NJ H -k C* CD C2 CD =r C�lb 0 CD i M. CD ^r 1 v� Hco �r M` * 3r dd a.o �+ _ C-)Cl)� o � C 0 W v cn Cl pOH y C `C n CA CO) 'O CD O CA CD O 0. C7 C C. F y �0 OO Co C7 :,• CDCL O Q w' CD o CA CD C CD co) _. CL C2 �■ Q H �CD i CO) w O CD a Z C31 CD CD O cr o Eo So .0 y G � 3 m p m CA • H H a C2 T Z ?� H w o m a '-fes o ��d H CDM CD $ O > > m 0 10 �. p O O C N n M. C =r yp p CL +m fCp C?; - m m ti m � Cis C to d O NGO H a dcr CL H m �mH NJ H -k C* CD C2 CD =r C�lb 0 CD i M. CD ^r 1 v� Hco �r M` * 3r dd a.o �+ _ C-)Cl)� o � C 0 W v cn a pOH �Oe 0 p O tiO' l O O n O CA y 0 9 It 10 O t t g4 n I . I _•� •••••••.•� .•� v1�IrL17M 111"f'L/l.�iilUlY still i'CriMli 0� uv ('L�JIVIL7a1w IPdnt or Typal yav NORTH ANDOVER, . Maas. Dale m� --19 _10 Buing c", Louts n / 3 c5��� w 00 D Permit f1 3 .7 G 9 Ownees Name New EA Renovation p Replacement p Plans Submitted: Yes ❑ No. ❑ FIXTUAE9 / Check one: Installing Company Name W! `�il �`I D0%i+e�1�j/ ®�1� 6 ❑ Corp. AddresD ❑ Partnership lle4 (C / ❑ Firm/Co. Business Telephone r - e-9 Name of Ucensed Plumber INSURANCE COVERAGE: check one I have a current Ilabilty Insurance policy or Its substantial equivalent Yes ❑ No ❑ It you have checked y". please indicate the type coverage by checking the appropriate box A Ilablilly Insurance policy tJ Other typed Indemnity O Bond ❑ Certificate OWNER'S INSURANCE WAIVER: I am aware that the Ilceniee does not have the Insurance coverage required by Chapter 142 of the Mass. General Laws, and that my signature an this permit application waives this requirement. Check one: Owner p Agent p SIgnatufs at er or owner's AGent I hereby cwflty that all of the details and information 1 have submitted for entered) In above application are true and accurate to the best of my knowledge and that a0 plumbing work and Installations performed under the pemit rlasued for We application will be ti pertinent provisions of the Massachusetts State Plumbing Mode anGum Chapter 142 of tM GplAA compliance with all AITWIED (OFFICE USE ONLY) Signature Plumber License Number �6a C—% Type of Plumbing Ucanse: Master ❑ Journeyman )EI Nown / Check one: Installing Company Name W! `�il �`I D0%i+e�1�j/ ®�1� 6 ❑ Corp. AddresD ❑ Partnership lle4 (C / ❑ Firm/Co. Business Telephone r - e-9 Name of Ucensed Plumber INSURANCE COVERAGE: check one I have a current Ilabilty Insurance policy or Its substantial equivalent Yes ❑ No ❑ It you have checked y". please indicate the type coverage by checking the appropriate box A Ilablilly Insurance policy tJ Other typed Indemnity O Bond ❑ Certificate OWNER'S INSURANCE WAIVER: I am aware that the Ilceniee does not have the Insurance coverage required by Chapter 142 of the Mass. General Laws, and that my signature an this permit application waives this requirement. Check one: Owner p Agent p SIgnatufs at er or owner's AGent I hereby cwflty that all of the details and information 1 have submitted for entered) In above application are true and accurate to the best of my knowledge and that a0 plumbing work and Installations performed under the pemit rlasued for We application will be ti pertinent provisions of the Massachusetts State Plumbing Mode anGum Chapter 142 of tM GplAA compliance with all AITWIED (OFFICE USE ONLY) Signature Plumber License Number �6a C—% Type of Plumbing Ucanse: Master ❑ Journeyman )EI 'Date.. TOWN OF NORTH ANDOVER PERMIT FOR PLUMBING This certifies that ......� .......... has permission .to perform .... AV.e..0 . M;,� ' .. ........... . plumbing.in the buildings of ............. at... - -57/ / -ti, -�-0 � . ............. North Andover, Mass. Fee.4!Pv.,- . Lira No..c?./ v. .`r ........... 6 ... ........... . PLUMBING INSPECTOR 04/29/97 15:16 400.00 PAID WHITE: Applicant CANARY: Building Dept. PINK: Treasurer UNIFORM PP C T � � MASSACHUSETTS UNIF A Li A ION FOR PERMIT TO 00 GASFiTTtNG •. (Print or Type) NORTH ANDOVER Mass. Date L( S tuilding Location C W06)-_::> Permit's J Owners Name New Renovation II Replacement Plans Submitted II ~ s F)X—iro^'- G11 (Print or Type) Installing Company Address ame �O%�'t Check one: Certificate Q Corp. Partner. Firm/Co. m %-0 - - - ta s m e . Q = to Fc- w U c� = t c c jjtJ 6 C C Q = Q U` d LII y j w t Y t u ut a UJ Ful' i 4 - r. UA _ - F. ..w w `� a u_ w l-- v 1 cs l-- - us La Ct3 - >- t CL SJ$-3S7.iT. BASEk1EaT .. t -; I ::.! . --! _ -! •I I I ! i i I I ( I I t � -!__ �:� �-: .L-..-� - _�� ..E.z.� :. I-1STFLOC R .I i ! ( I 1. I - t ► ► i { f I I i I I ..:t _.L.,_I ;Iw� �.v�_,;. --no FLOOR j 1Ra FLOOR 4TH FLOOR 15TH FLOOR I ( I ( i ( I( I E f I { I } i f I I I..- i i- I I. . STH FLOOR 7TH FLOOR aTRr-LooR_f (Print or Type) Installing Company Address ame �O%�'t Check one: Certificate Q Corp. Partner. Firm/Co. Name of Licensed ;Plumber or .Cas Fitter Insurance Coverace:. lndica,e -::e ,ype of insurance coverage by checking the appropriate. -box:. Liabilit insurance...policy. Ct^er type o-1 indemnit Sond. Insurance Waiver: 1, the undersicned, 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 or property Owner Agent - - - - I hc:ehy ccrtify that all of the details and information i have anhnsitted (er entered) in above apriiction are tme and accurate to the best of my k -10 -ledge and tlLat W plumbing work and tnatall.atioea 7sz•'0=c'. undcr Pesrait, 1=ccd ro: this sppilcat:on rill be In compiisnca with all pctln=t provisions of L11a 3{assacivactts State Car Cade snd (1aptes :e: cf =6a t,c-nes Lara. 3v T'_'n = T Date:-}.,!� - 6.9 NORTH TOWN OF,NORTH ANDOVER PERMIT FOR GAS`INSTALLATION . CHU This certifies that has permission for gas installationin the buildings'of,? at North' der, Mas Fee.`7. �� .: Lic. No. ! G `.l.. FJ,t,.. 99 GASINSPECTOR WHITE: Applicant CANARY: Building Dept. PINK: Treasurer . GOLb File