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HomeMy WebLinkAboutMiscellaneous - 97 BRADFORD STREET 4/30/20181 Commonwealth of Massachusetts = � City/Town of North Andover System Pumping Record Form 4 wy DEP has provided this form for use by local Boards of Health. Other forms may be used, but the Lh information must be substantially the same as that provided here; Before using thisform,. check wit your st be submitted o local Board of Health to determine the form they use. The System d mu Pumping date in the local Board of Health or other approving authority within 14 days from the pumping accordance with 310 CMR 15.351. Important When filling out forms on the computer, use only the tab key to move your cursor - do not use the return key. rarcn A. Facility information RECEIVED 3UL 13 2015 1. System Location: ^Uu UOQ North Andover CityfTown 2. System Owner: Name Ma State Address (if different from location) State City/Town Telephone Number B. Pumping Record 2. Quantity Pumped. 1. Date of Pumping Date d❑ Ti ht Tank 3. Type of system: ❑ Cesspool(s) Septic Tanklg ❑ Other (describe): c. Effluent Tee Filter present? ❑ Yes ❑ No 5. Condition of System: 6. System Pumped By 01886 Zip Code Zip Code j5_0_ Gallons ❑ Grease Trap If.yes, was it clearied? ❑ Yes ❑ No Vehicle License Number Name Stewart's Septic Service Company 7. Location where contents were disposed: Stewart's Pre-treatment Plant, 20 So. Mill Bradford, Ma 01835 . ionature of Hauler Date Date t5form4.doc• 03/06 System Pumping Record - Page 1 ' Location No. 9U % Date , NO*Tq TOWN OF NORTH ANDOVER •. • O9 0 0. .� Certificate of Occupancy $ ACMU`+ Building/Frame Permit Fee $ Foundation Permit Fee $ �- Other Permit Fee $ TOTAL $ _ J Check #^��� 16431- r% Building Inspector TOWN OF NORTH ANDOVER BUILDING DEPARTMENT APPLICATION TO CONSTRUCT REPAIR, RENOVATE, OR DEMOLISH A ONE OR TWO FAMILY DWELLING M _ Y \ & . „ • .,1^" %r'x�%Z W!�'k� y r v"^ Y% S tug .11 .� BUILDING PERMIT NUMBER: �n DATE ISSUED: `7 r SIGNATURE:/f 4&f `' Building Commissionedln for of Buildings Date SECTION 1- SITE INFORMATION 1.1 Property Address: q� -,6 rC"8 iF O 12 6 1.2 Assessors Map and Parcel Number: 0 Map Number Parcel Number ( ZJo Q 1.3 Zoning Information: Zoning District Proposed Use 1.4 Property Dimensions: Lot Areas Frontage ft 1.6 BUILDING SETBACKS ft Front Yard Side Yard Rear Yard Required Provide R 'red Provided Required Provided 1.7 Water Supply M.G.L.C.40. 54) 1.5. Flood Zone Information: Public ❑ Private ❑ 1 Zone Outside Flood Zone ❑ 1.8 Sewerage Disposal System: Municipal ❑ On Site Disposal System ❑ SECTION 2 - PROPERTY OWNERSHIP/AUTHORIZED AGENT 2.1 Owner of Record ' �- 0A '�F-1g-�- Name (Print) Address for Service: Signature Telephone 2.2 Owner of Record: Name Print Address for Service: Signature Telephone SECTION 3 - CONSTRUCTION SERVICES 3.1 Licensed Construction Supervisor: Licensed Construction Supervisor: Address Signature Telephone Not Applicable ❑ License Number Expiration Date 3.2 Registered Home Improvement Contractor Not Applicable ❑ 13 - c( 3 Company Name Registration Number /o T Address Signature Telephone "�— Expiration Date T rn v rn SECTION 4 - WORKERS COMPENSATION (nG.L C 152 & 25c(6) Workers Compensation Insurance affidavit must be completed and submitted with this application. Failure to provide this affidavit will result in the denial of the issuance of the building permit. Signed affidavit Attached Yes .......❑ No ....... 0 SECTION 5 Description of Proposed Work check atl applicable) New Construction ❑ Existing Building ❑ Repair(s) ❑ Alterations(s) ❑ Addition ❑ Accessory Bldg. ❑ Demolition ❑ Other ❑ Specify Brief Description of Proposed Work: SECTION 6 - ESTIMATED CONSTRUCTION COSTS Item Estimated Cost (Dollar) to be Completed by permit applicant Oi+'ICIAL USE Oiii 3t I . Building (a) Building Permit Fee Multiplier 2 Electrical (b) Estimated Total Cost of Construction 3 Plumbing Building Permit fee (a) X (b) 4 Mechanical HVAC 5 Fire Protection 6 Total 1+2+3+4+5 d Check Number SECTION 7a OWNER AUTHORIZATION TO BE COMPLETED WHEN OWNERS AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT I, as Owner/Authorized Agent of subject property Hereby authorize to act on My behalf, in all matters relative to work authorized by this building permit application. Signature of Owner Date SECTION 7b OWNER/AUTHORIZED AGENT DECLARATION I, n z - Cwq:� as Owner/Authorized Agent of subject property Hereby declare that the statements and information on the foregoing application are true and accurate, to the best of my knowledge and belief li,), 6 w,,t1Lt zd gd P t ie .an ature of Owner Agent NO. OF STORIES Date SIZE BASEMENT OR SLAB SIZE OF FLOOR TIMBERS 1 2 ND 3 RD SPAN DIMENSIONS OF SELLS DIMENSIONS OF POSTS DIIv1ENSIONS OF GIRDERS ILEIGHT OF FOUNDATION THICKNESS SIZE OF FOOTING X MATERIAL OF CHIMNEY IS BUILDING ON SOLID OR FILLED LAND IS BUILDING CONNECTED TO NATURAL GAS LINE c C/) m Cl) 0 m ®, CO) 'v C � � d CO) Cl) CD n Z y CL C)• CL y n� C CD CD o CL CD CCD O CD C CD y CL v y CO CD B v CO2 O moZ CD CDO O CD 0 :ice, ar . I r� cJ n \ / O cn � cn O z� 0 cn cn cn tod n C EA C d �• CA C Q N 0 CL Cc0CL0 3 = Of d CA No c C=Lc O m N O IE m Cl) -9 O !2 WC2O N p syr ,. a �. 0= CL ,.., O O m ti : CL m y O1 H W- a �iz CD N CD C c H CDH ,rt o CD CACDo CD a3 N CD o m m m a": : :4 n� CA O �• z 0 I �J O C CD z ►r1 7d a3 f D r" w Chi z 0 I �J O C CD Name The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations Boston, Mass. 02111 Workers' Compensation Insurance Affidavit (boa -5 �AN Location: 1 r otA (PC) (L- c -V- Please Print City r\ fJ ., A v\, � ©V -Q e- Phone # I am a homeowner performing all work myself. I am a sole proprietor and have no one working in any capacity 1 am an employer providing workers' compensation for my employees working on this job. Company name: � ��-AGWx- oo rr � lr ---::) Address - - ?- q C) FA C,K SSA- — City: N Q - V -aa n Phone #- Insurance. Co. - _ Policy # Comoanv name: Address City Phone insurance Co. Policy # Failure to secure coverage as required. under Section 25A or MGL 152 can lead to the imposition of criminal penalties of.a fine up to $1,61;pp.00 and/or one years' imprisonment_as_well-as_c nM pmalsiolheinan-faSTDPYYDW-OftDER,and_afine-OfA$IOD-D)-aliW igai2stn)p_ 1 understand that a copy of this statement may be forwarded to the Office of investigations of the DIA for coverage verification / do hereby eertdyymder the pains and penalties ofP66Ay that the information Provided above is true and correct_ — r- a-3 . Print name Pbome-# Official use only do not write in this arra to be completed by city or town official' City or Town Phi ng El Check if immediate response is required Building Dept .[I Licensing Hoard El Selectman's Office Contact person: Phone A n Health Department E] Other Bay State Roofers, Inc. P.O. Box 189 North Reading, Massachusetts 01864 978-664-0668 MAILING ADDRESS: Eleana Flaras 97 Bradford Street North Andover, MA 01845 April 11, 2003 RE: New Shingle Roof Dear Eleana, Bay State Roofers Inc.; proposes to furnish all material, labor and equipment necessary to perform the following scope of work: 1. Remove approximately 3,300.sq.ft. of the existing asphalt shingle roof down to the wood decking. 2. Install new ice and water shield along the 3' roof edge and in all the roof valleys. 3. Install new 15 lb. felt paper throughout the roof area. 4. 'Install' new white aluminum drip edge along the roof perimeter. 5. A new GAF Architectural 30 -year asphalt roof shingle will be installed over the prepared substrate. 6. , A new ridge vent will be installed to ensure the proper roof ventilation. 7. All roof penetrations and flashing will be installed according to the manufacturers recommended specifications and details. 8. Bay State Roofers, Inc. will properly dispose of all roof debris in our own waste containers. Total Price for this Wo Go — Over: $5,280.00 Note: Any Authorized Signature: $7,590.00 Deposit: $2,500.00 (:0L10"i) 3 �Or� I decking that needs re acement will be an additional $2.00 per sq. ft. Si 0 be 0-JU'e 9 wov Waste containers supplied by Bay State Roofers, Inc. are for the sole purpose. of roof debris. Under no circumstance, is the homeowner to use these containers for "personal refuse CONTRACT ACCEPTANCE The specifications, prices, payment schedule and attached Date: (y D Conditions are satisfactory and hereby accepted. BAY STATE ROOFERS, INc. is authorized to perform work Signature: as specified. Payment will be made as previously outlined. -� NOTE* Unpaid bills over 30 days are subject to 1 1/2% finance charge per month (18% annual) Title: PROVISIONS OF THE AGREEMENT I. PROJECT PROVISIONS e. Damage to Project: Contractor will not be responsible for any a. Guideline: The Project will be constructed in strict conformance damage caused by the Owner, or other causes beyond the control of to the plans and specifications which have been examined and the Contractor. Owner will pay for any restoration work. approved by the Owner. IV. CONTRACTOR'S RIGHTS AND RESPONSIBILITIES b. Compliance: The Project will be completed in strict compliance with all laws, ordinances, rules and regulations of the applicable government authorities. c. Control: The Agreement plans and specifications ate intended to supplement each other. In case of conflict, the plans will control the specifications and the Agreement provisions will control both. d. Charge Orders: As directed by the Owner, construction lender, public body or inspector, any alteration or deviation from the specifications that involves extra cost (subcontract, labor, materials) will be executed only upon the partiesentering into a written change order. Expense incurred because of unusual or unanticipated conditions will be paid for by the Owner. e. aiiowdnces. if the Agieement price inclu6es allowances, and the cost of performing the work is greater or less than this allowance, then the Agreement price will be adjusted accordingly. II. FINANCIAL RIGHTS AND RESPONSIBILITIES a. Labor and Material: Contractor will provide and pay for all labor and materials necessary to complete the Project. Contractor is released from this obligation for expenses incurred when the Owner is in arrears in making progress payments. b. Permits: Contractor will obtain and pay for all required building permits and licenses. c. Taxes, Assessments and Charges: Taxes, special assessments of all descriptions, and charges required by public bodies and utilities will be paid for by the Owner. d. Deposit of Payments: Contractor is required to deposit all payments received prior to completion in an escrow account. In lieu of such a deposit, the Contractor may post a bond or contract of indemnity with the Owner guaranteeing the return or proper application of such payments to the purposes of the contract. All advanced funds will be deposited as indicated under Special Provisions. Monies used in escrow become the property of the Contractor when they are applied according to the Agreement payment schedule, when a breach of contract by the Owner occurs, or when the Agreement has been substantially performed. e. Bankruptcy: If either party becomes bankrupt, the other party has the right to cancel this Agreement. III. OWNER'S RIGHTS AND RESPONSIBILITIES . a. Cancellation: Owner has an unconditional. right to canceLthe Agreement, without penalty or obligation, until midnight of the third business day after the Agreement was signed. Cancellation must be done in writing. Upon cancellation, any property traded in, any payments made under this Agreement, and any negotiated instrument executed will be returned within 10 business days following receipt by the Contractor of cancellation notice. b. Property Lines: Owner shall locate and point out property lines to the Contractor. Contractor may, at his option, require the Owner to provide a licensed land surveyor's map of the property. c. Liens: Failure to pay persons supplying materials or services according to the terms of this Agreement may result in the filing of mechanic's liens on the affected property. Owner has the right to ask the Contractor for lien waivers from all persons supplying these materials or services. In the event any mechanic's lien is filed through no fault of the Owner, then the Contractor agrees to take all steps necessary for the release and discharge of such lien. d. Insurance: Owner will maintain property damage insurance at least equal to the Agreement price. a. Delay: Contractor will be excused for any delay beyond his reasonable control. These delays may include, but are -not limited to Acts of God, labor disputes, inclement weather, acts of public authority, acts of the Owner, or other unforeseen contingencies. b. Right to Stop Work: If any payment under this Agreement is not made when due, the Contractor may suspend work on the job until such time as all payments due have been made. Any failure to make payment is subject to a claim enforced against the property in accordance with the applicable lien laws. c. Substitution of Materials: Contractor may substitute materials without notice to the Owner in order to allow work to proceed, provided that the substituted materials are of no lesser quality than those listed in the specifications. d. Salvage: All salvage resulting from work under this Agreement is to be retained by the Contractor unless other agreements are contained in the written specifications. e. Insurance: Contractor will maintain workers' disability compensation insurance for his employees and comprehensive public liability insurance policies. V. COMPLETION OF PROJECT a. Notice: Owner agrees to sign a Notice of Completion within 5 days after completion of the project. If project passes final inspection and the Owner does not sign the Notice, the Contractor may act as the Owner's agent and sign the Notice. b. Clean-up: Contractor is responsible for removing debris and surplus material from the property, and leaving the property in a neat and orderly condition. VI. CONFLICT PROVISIONS a. Arbitration: Any controversy or claim arising out of this Agreement that cannot be resolved, is subject to arbitration, with an arbitrator of mutual agreement, and all parties (including Owner, Contractor, Architect and Sub -Contractors) are bound to this arbitration. If any party does not appear at arbitration proceedings, the arbitrator is empowered to decide the controversy in accordance with whatever evidence is presented by the party(ies) that do participate. b. Attorney Fees: If either party becomes involved in litigation arising out of Agreement, the Court shall award costs/expenses including attorney fees to the party justly entitled to them. ' c. Limitations: No action related to this Project may be made by either party against the other more than 2 years after the completion of work. VII. GENERAL PROVISIONS a. Notice: Any notice required or permitted under this Agreement may be given by certified or registered mail at the addresses contained in the Agreement. b. Prohibition of Assignment: Neither party may assign this Agreement. or payment due under this Agreement without the written consent of the other party. c. Qualification: This document constitutes the entire agreement of the parties. No other agreements exist. This Agreement can be modified only by written agreement signed by both parties. d. Governance: This Agreement shall be construed in accordance with and governed by, the laws of the state in which the Project is located. I JYMM OWN--- ? eq DATI OF Pvmp)qo: 1414 5 X)L ou p R RECEIVED 'EVED 91 OCT3 A AUG 12 2005 L VA/C Hj�j frLOODED -OWN 0 3T8 TOWN OF NOS ANDOVSR P,� TMS 3QLrD CA"YoYEp,_,. TOWN DEPARTMCN-F EXPLAIN �.'UmmtNJ*Z5 T(- WN OF NORTH AN G, OV 0 8 CI A R.0 OF HEALTH TOWN OF NORTH ANDOVER SYSTEM PUMPING RECORD I NOV —4 2 I EI�l OWNER & ADDRESS SYSTEM LOCATION - - - (example: left frons of house) 97 1 n. L Ac, d b oz - OF PUMPINC: QUANTITY PUMPFD �SI'UUL N'0 YES SEPTIC TANK: NO E` I URC OF SERVICE: ROUTINE V/ EMERCENCY I3>FRV:\TIONS: GOOD CONDITION HEAVY CREASE ROOTS CXCESSIVE SOLIDS SOLIDS CARRYOVER l� NULL TO COV[!I BAFFLES IN PLACI�' LEACHFICLD IZUNI3ACK FLOODED $- Oj�HER (EXPLAIN) --��- >1 > I LM PUMPED BY: �J�IN,IFNTS. u, I I:'. 1'� TRANSFCIZRED TO: — 1.j, mL ,y,: T?.�-as.,r-k..�iv.+. Jc:. :a.�.;k"..,. ar trs.l.».,,d:.o.v.T''?��a+.i::'`t„gH,.a o-e'is 4"'.+liV 'A.rv�. .......1�„f-�..iJ w�.,n],;.�;,;;'ii.b �.Ki' 1'}''°'y�lt1.J;+✓••�i•W,.�,11 y-,,,:: COMMONWEALTH OF MASSACHUSETTS EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS DEPARTMENT OF ENVIRONMENTAL PROTECTION TITLE 5 OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM PART A CERTIFICATION Property Address: 16- - f 'x� Owner's Name: Owner's Address: Date of Inspection: Name of Inspector: (please print) 11, Company Name: Vim Mailing Address, p /1035 Telephone Number: 12 -F- 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 _-- Npeds�urther Evaluation by the Local Approving Authority Inspector's Signature: ,,/� (��� Date: �G D d Z;, The system inspector shall bmit a copy of this inspection report t e Approving Authority (Board of Health or DEP) within 30 days of c 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 ti� _. _ .^ .�.,.� .. ,.�- -... ..-..,_.�r.---•-•�.---�-.-�w---•�---4f•.-Vis•+.--+.—v ;.�•�.•+"..,.�.wti—rsr+G�.+"v.'+e'i�:�wdl-.+�++r� •. ...+•�Tv.�v--....-...y....—�' a M Page 2 of 11 w r . !y OFFICIAL INSPECTION FORM — NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A (� CERTIFICATION (continued) Property Address: Owner• Date of Inspection: Inspection Summary: Check A,B,C,D or E / ALWAYS complete all of Section D A. System Passes:. V I have notr found any information which indicates that any of the failure criteria described in 310 CMR 15.303 or in 310 CMR 15.304 exist. Any failure criteria not evaluated are indicated below. Comments: B. System.Conditionally Passes: One or more system components as described in the "Conditional Pass" section need to be replaced or repaired: The system, upon completion of the replacement or repair, as approved by the Board of Health, will pass. Answer yes, no or not determined (Y,N,ND) in the for the following statements. If "not determined" please explain. . The septic tank is metal and over.20 years old* or the septic tank (whether metal or not) is structurally unsound, exhibits substantial infiltration or exfiltration or tank failure is imminent. System will pass inspection if the existing tank is replaced with a complying septic tank as approved by the Board of Health. *A metal septic tank will pass inspection if it is structurally sound, not leaking and if a Certificate of Compliance indicating that the tank is less than 20 years old is available. ND explain: Observation of sewage backup or break out or high static water level in the distribution box due to broken or obstructed pipe(s) or due to a broken, settled or uneven distribution box. System ;will pass inspection if (with approval of Board of Healtfi). brokens replaced r PteO are P obstruction is removed distribution box is leveled or replaced ND explain: The system required pumping more than 4 times a year due to broken or obstructed pipe(s). The system will pass inspection if (with approval of the Board of Health): broken pipe(s) are replaced obstruction is removed ND explain: v- .. vol�.'4. Page 3 of 1 I OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A �j CERTIFICATION (continued) Property Address: Owner:.1/`/ Date of Inspection: f / 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 functionipg 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 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 fee_ t of a surface water supply or tributary to a surface water supply. The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water supply. — The system has a septic tank and SAS and the SAS is within 50 feet of a private water supply well. _ The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or more from a private water supply well". Method used to determine distance "This system passes if the well water analysis, performed at a DEP certified laboratory, for coliform bacteria and volatile organic compounds indicates that the well is free from pollution from that facility and 'the presence of ainmoma nitrogen and nitrate nitrogen is -equal to or less than 5'pprri, provided thaf�rio other - failure criteria are triggered. A copy of the analysis must be attached to this form. 3. Other: 3 Page 4 g of 11 x fi OFFICIAL INSPECTION FORM — NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address• r S . Owner: -121 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 Noo - ✓' Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool - :ZDischarge or ponding of effluent to the surface of the ground or surface waters due -to an overloaded or -- clogged SAS or"cesspool V' Static liquid level in the distribution box above outlet invert due to `an overloaded or clogged SAS or ,.cesspool _ V Liquid depth in cesspool is less than 6" below invert or available volume is less than'/2 day flow ✓Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number of times pumped .— Any portion of the SAS, cesspool or privy is below high ground water elevation. _,L/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 I of a public well. i/'Any portion of a cesspool or privy is within 50 feet of a private water supply well. ''Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality analysis. [This system passes if the well water analysis, performed at a DEP certified laboratory, for coliform bacteria and volatile organic componeds 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: »...� `fo'be considered a tar eLLs` stem`the s stem -must serve a facili g y y ty with a design flow' of 10,000 gpd to 000 gPd• You must indicate either "yes" or "no' to.4ach of the following: (The following criteria apply to large systems in addition to the criteria above) yes no 4 _ 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 �..�:-..�«+........-...+b.r-.r:.-+�....w..w.wr. a.--�a+,V. i-tw..��.Mr.}k+v-.,�-..�+r.re�*..�a..,Ear.'.�ai^--.Ni ,•+.+.�.t+r�+.a.�M-.+�. .w�... .�„-e,�:,k1,r♦ -`-�ye..v�..s+aa Vii,>.'�.; �.....•.w:..i�i'�.^�""'wr..�.�4w.--ra+' f Page 5 of 11 OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST Property Address:, JI Owner• Date of Inspection: Check if the following have been done. You must indicate "yes" or "no" as to each of the following: Pumping information was provided by the owner, occupant, or Board of Health Were Ay bf the system components pumped of in -the previous iwo 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 ? _,�Z_ Was the facility owner (and occupants if different from owner) provided with information on the proper w. maintenance of subsurface sewage disposal systems The size and location of the Soil Absorption System (SAS) on the site has been determined based on: A 4Via. ..:s•� 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)] 5 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: % z�1%,r2' FLOW CONDITIONS RESIDENTIAL Number of bedrooms (design): Number of bedrooms (actual): DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x # of bedrooms): Number of current residents: � / Does residence have a garbage grinder (yes or no): NO Is laundry on a separate sewage system (yes or no):K [if yes separate inspection required] Laundry system inspected (yes,or no): Seasonal use: (yes o% no):ALO Water meter readings, if available (last 2 years usage (gpd)): Sump pump (yes or 6):/VO ^� Last date of occupancy: �FL C U COMMERCIALANDUSTRIAL Type of establishment: Design flow (based on 310 CMR 15.203): _gnd Basis of design flow (seats%persons/sgft,etc.): Grease trap present (yes or no): Industrial waste holding tank present (yes or no): Non -sanitary waste discharged to the Title 5 system (yes or no): Water meter readings, if available: Last date of occupancy/use: OTHER (describe): GENERAL INFORMATION. Pumping Records Source of information:��Gf ✓# Was system pumped as part of fhe inspection (yes or no)vit;'pumped If yes, volume pumped:Z,) 0 zallons -- How was�uan determined? - Reason for pumping AJ $ :fie C r— /�.. TYP"F SYSTEM Septic tank, distribution box, soil absorption system _ Single cesspool Overflow cesspool — Privy _ Shared system (yes or no) (if yes, attach previous inspection records, if any) _ Innovative/Alternative technology. Attach a copy of the current operation and maintenance contract (to be obtained from system owner) _ Tight tank _ Attach a copy of the DEP approval Other (describe): Approximate ja eo all co ponents, date installed (if known) and source of information: yea r Were sewage odors detected when arriving at the site (yes or no): /tits 6 r Page 7 of 11 OFFICIAL INSPECTION FORM — NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Owner Date of Inspection: BUILDING SEWER (locate on site plan) 11 Depth below grade: _ Materials of construction: cast iron _40 PVC _other (explain): Distance from private water supply well or suction line: Continents (on condition of joints, venting, evidence of leakage, etc.): vF b !. Ira P_ - % V4 A r, f SEPTIC TANK: V (locate on site plan) r/ Depth below grade: / Material of construction: r!'' 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: z X /tJ Sludge depth: Distance from top of sludge to bottom of outlet tee or baffler Scum thickness: I ' � 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: Cc �-e % a C b I`-2 i Comments (on pumping recommendations inlet and outlet tee or baffle condition, structural ..integrity, liquid levels as re o•vutlet invert, evidenc f leak a e, etc.: 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 �v-•w-�---. :....—....r,.�.. •,.—:mss..--; :x Page 8 of I I OFFICIAL INSPECTION FORM — NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: Owner• /_/_�Zi!�V/ 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 -kit Capacity: P` `1 ?'allons ` i t. Design Flow: gallons/day Alarm present (yes oir no): Alarm level: Alarm in working order (yes or no): Date of last pumping: Comments (condition of alarm and float switches, etc.): DISTRIBUTION BOX: Z(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 leak9a e into or out of bQx, etc.): / VC /j PUMP CHAMBER: (locate on site plan) Pumps in working order (yes or no): ( ondition''lof oum )chamber; condition f pumps an j Alarms in working Comments. note c.... p p fIN d appurtenances, etc ). k 11 I 8 t.._ .._... .`....� .r _� a..-�-. ..-...r. . r+..-+--..—w•-^..�.-r�*-.kr.—+'.m...—..,°'r..:----+w�--Q-�. �/'-"�". w'^w'ti,F.""�,rif"'r"a.':"`M'�r4"ry'r^.•� �'d'.g.dYw"'v.+'",'`W,",,fie Page 9 of 11 OFFICIAL INSPECTION FORM — NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: r Owner: Date of Inspection: SOIL ABSORPTION SYSTEM (SAS): (locate on site plan, excavation not required) If SAS not located explain why: YP leaching pits, number: leaching chambers, number: ching galleries, number: leaching trenches, number, length: 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, 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 PRIVY: (locate on site plan) re, level of ponding, codition of vegetation, etc.) - Materials of construction: Dimensions: Depth of solids: Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): 9 'VV4•a--•..r-y't-.�....+�.esds-'tt�t7.�+�a..,Yas^_-�,..> i.►.�-„.�•i lr�lwr-.� Page 10 of 11 OFFICIAL INSPECTION FORM — NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEMINFORMATION (continued) Property Ad res 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. t/� N f” L� � I 10 Page I 1 of 11 OFFICIAL INSPECTION FORM — NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C - ~'° SYSTEM INFORMATION`(continued) Property Address: Owner: Date of Inspection: SITE EXAM Slope Surface water - Check cellar Shallow wells Estimated depth to ground water feet F ti i 3 y` Please indicate (check all methods used to determine the high ground water elevation: Obtained from system design' plans on record If checked, date of design plan reviewed: Observed site (abutting property/observation hole within 150 feet of SAS) Checked with local Board of Health -explain: Checked.with local excavators, installers- (attach documentation) Accessed USGS database explain: You rf, L)ATF_._,377_j2—oy SYSTEM OWNE-a & —ADDRES—S SYSTEM LbEXTiO—N DATE OF PUMPING Slo vc) 4___QUANTlTY PLWPED 1660 CESSPOOL NC)__X_ YES— SEPTIC TANK NO NATURE Or- SERVICE ROUI'iNE--X—. FMERGENCY___ OBSERVATIONS: GO OD CONDITION-- FULL TOCOVF-R HEAVYGRE-ASE — BAFFLES INLACE ROOTS LEACHFIELD RUN13ACK EXCESSIVE SOULS --FLOODED S0LlD CARRYOVEk-- 01TIER EXPLAIN SYSTEM PUMPED BY Af on COMMENTS. CONTENTS -['RANSFERRED To Z -/71) r "PPLICATION FOR SEWAGE DISPOSAL INSTALLATION HEALTH DEPARTMENT - NORTH ANDOVER, MASS. ,hereby made applic tiion fgr a permit for a sewage disposal installation at ,�-�- I will install this system in ac- cordance with all the -1 -Taws of the Commonwealth of Massachusetts and regulations of the Board of Health of the Town of. North Andover. Further, I will construct the house sewer of bell and spigot pipe, the minimum diameter being 4 inches, and will maintain a minimum grade of 1% until 10 feet pre- ceding the septic tank, where the grade shall not exceed 2%. I will install a con- crete septic tank of f') _T01 in size. A manhole (s) permitting easy cleaning will be provided with removable cover (s) of iron or concrete within 12 inches of the ground surface. I will provide subsurface disposal field with 4 inch perforated or open jointed pipe and laid in a series of trenches, the bottom of which will pro- vide a minimum of 2- V 6 lineal (square) feet of effective absorption area. The pipes will be laid on a 6 inch layer of washed gravel or crushed stone ranging in size from 3/4 to 1-1/2 inches (dia.) and the pipes will be surrounded by similar material to a height of 2 inches above the crown of the pipe. The joints of these pipes will be protected from clogging and before filling the trench, 2 inches of gravel or stone 1/8" to 1/41' (dia.) will be placed over the course gravel or stone. The disposal field will be installed at a grade of 4 to 6 inches/100 feet. No single tile line will exceed 100 feet in length and in any case, two lines of tile will be installed. A minimum of 6 feet will be maintained between the center lines of the disposal field trenches and the average depth of trench shall not exceed 36 inches. No part of the installation will be less than 100 feet from any private water supply, 25 feet from any stream, 20 feet from any dwelling or 10 feet from any property line. I further agree not to cover any portion of this installation until approved by inspection officer, as provided below, and to incorporate any additional requirements that may be attached to the permit. Plot Plans must be submitted with application. DATE C 7� Signature of Applicant I hereby issue the above permit for the Board of Health of the Town of North Andover, Massachusetts. DATE %C -7v Signature of Health Agent I have inspected the uncovered system indicated above and find everything done as described. DATE Signature oY Inspecting Officer Percolation Test �-x ."'d Garbage Grinder _ BOARD OF HEALTH TOWN OF NORTH ANDOVER, MASS. C 14AA) Car �-- p- I)d �5-0 Gr r+ L� J6K .60' L w F -S 6N Coa 1. NAME DATE9111Ac .-- 2. ADDRESS IAT N0. TEL.. - 3. NO. OF BEDROOMS — � _ DEN YES,� � NO 4. GARBAGE GRINDER YESNO_L_ 5. SHOW DIMENSIONS OF HOUSE 6. SHOW DISTANCES OF HOUSE TO ALL PROPERTY LINES E:1-3 7. SHOW DIMENSIONS OF LOT 8. SHow LOCATION AND SIZE OF SEPTIC TANK OR CESSPOOL 9. NOTE LOCATION AND DISTANCE OF WELL FROM SEWERAGE SYSTEM 10. SHOW LOCATION OF BROOKS, STREAMS, DITCHES, LEDGE OUTCROP, ETC. 11. SHOW DISTANCE OF SEPTIC TANK OR CESSPOOL F M HOUSE ✓� NOTE: LOCAL REGULATIONS SHOULD'BE READ CAREFULLY. -a, 3 .M P� I- � C 3 1 P� o� Jh 3 �o7- -� i9.Q .�•Q — .9 4cFrE,s t SEE N,ERD,Pt•�N �``���5 1 �o7- -� i9.Q .�•Q — .9 4cFrE,s t SEE N,ERD,Pt•�N �``���5 N U ppa�) H-- 4-1 m 1 Al LL 4- 0 0 N I= ( c ( c c Q >r a� E V w O m H O G. L L S � � U � c O E C CD3 .O R O � O Q CU L~ O I Q f O U O D C r I� Q) E a--+ L rn v 0 Cn C: r ichUs' AA/ `I!co ■Awt%tm �ri'te'GCj ,.g tr1'tf,. :)7%'T•� ,,y,y�rc�♦11:'. ,i,_, .t�..V, ,; ♦�1,$YQIn'Pu p� g Record J, 7(" r `{ ♦c S Yt51rf• I f �. n 1.1 , d♦V a tf71 p arl •; ' SEP 7 200 ` DEP. has provided this form for use by local Boards of Health. Tt kd must � be submitted to the local' Board of Health or other approving aut orl%ALTH DEPARTf�'1ENT A Facility Information . r ��- lmRortant. �,,,yvhen Ung, out 1 : System location:541. forma on the ; , ' 'computer, use Z12a only the tab:key Address to move your-'; d. yO Cursor . do not (/��%� usa the tum' CltY stateZip Code' key System Owner-,' • MI Y 1 Name AM Address (if different from location) City/Town State p Cod Telephone Number B5 Pumping Record .�.,,.,. r Vu1l,li 14 .� ,a 1 Date of Pumping /sZw Dat 2. Quantity Pumped: Gallons 3, :Type of system; ,. ❑ Cesspools) [il-3'Ptic Tank 13 Tight Tank [],.Other (describe); 4 Effluent Tee Filter present? ❑ Yes. If cleaned? . �o yes, was if ❑Yes ❑ No 5♦ on o Cohditlf'S st m'`' Y $ 6 Sy sin Pumped 6y r y .c ,� t J - 4• `if J ,.t+ ,' t?,'i�r +�w 'v' t '��. -9T4 t>•1 rf �Y,i f,1 L?a•' ;/>; -i��f� t II Vehicle llcen$e Number eh1 .Mn* X1,7 r iV�// /'/// �.,,1 lfil� ' �y N'•. Mjf f•l 1{.IN•lyMl ��'i i1.. "r..', ... .. � Y 7 L`dueQn.where contents were di;3posed: : Signature of Hauler: r iL G• r Date hitpJ/wrvw mass-gov/dep/wafer/apprOvals/t5forms,htm#inspect t5fomv4docs 06103 System Pumping Record Page 1 of 1 •Z ;•'�':•i:: ice•. {• •.•+- �.��.y.yiT :;!:.%A ,'�E!'l r G z�i) •... L� 1 �•. r• I� . /'. �•:•ir • ••yr • %•�t � i�' r.ij `(I li�! � • 1 •:�•i�' •�qi ��i ` �"•t• i jiai i r � • J.,•,.�,.�r ,,)r • , � , P 1 ` ' �Y� �, O „ • • •• '�• ' tc� • • • • • - Atli .. •:. • ! : • • • „ JAN r0 SSS 2009 r TOWN bF � f� Y-HrryA' NDOVE-P F ,•:P,umpinn�j �e�ord T r o 2 n 0 n r 3. 7Y➢a PI ay)iam,.. C999�Oo1(y) SaDI!c Tangy 'Q,Olhar (dascriba�`.. 1 Emlan� Tao Fulo('P(�sanr? [' ro9 No lk 7. �.'lo� on.Wher9 oo�lenla'weie dl9posao '•�, ,,:%.;,,�.:'l Sl�nrkur olh+v:+ly�,,X,<.,, ..I , mas,9.gor/daF.�welar/e DGrovaJa/Iblorm�.r �, in9�acl WM -7 YV^ Tai. I Y05 n8) I; C'9ana07 Y — ,_ Vehicle'Jcon+r— n':'^�„ �li — � �. V*,l r1 M'.) Ye m Own ar , — �; Hwni �o �L / µ4 (1IIOVfir'inl r1cvn'buUcn ,•:P,umpinn�j �e�ord T r o 2 n 0 n r 3. 7Y➢a PI ay)iam,.. C999�Oo1(y) SaDI!c Tangy 'Q,Olhar (dascriba�`.. 1 Emlan� Tao Fulo('P(�sanr? [' ro9 No lk 7. �.'lo� on.Wher9 oo�lenla'weie dl9posao '•�, ,,:%.;,,�.:'l Sl�nrkur olh+v:+ly�,,X,<.,, ..I , mas,9.gor/daF.�welar/e DGrovaJa/Iblorm�.r �, in9�acl WM -7 YV^ Tai. I Y05 n8) I; C'9ana07 Y — ,_ Vehicle'Jcon+r— n':'^�„ �li — F11 •. �n. •bq .ilii. .� ,\, - is Commonwealth of Massachusetts City/Town:of NORTH ANDOVER System Pumping. Record Oft 4 DEP has provided this form for use by local Board c be submitted to the local Board of Health or other d III+ ~ 7 2010 mping Record must Zip Code Name IC'y Address (If different from location) City/Town State Zip Code Telephone Number B. Pumping Record /0 1. Date of Pumping Date 2. Quantity Pumped: Gallons 3. I Type of system:. ❑ Cesspool(s) ❑e*`Septic Tank ❑Tight Tank Other (describe): 4. Effluent Tee Filter present? ❑ Yes ❑ No 5. Condition of System: If j es;'was it cleaned? ❑ Yes ❑ No ,11n 6.. S stem Pumped By: me Vehicle License Number Company 7.. Locatio where contents were disposed: ature of Ha - Date http://www.mass.gov/dep/.w eflapprovais/t5forms.htm#lnspect '�- t5form4.doc 06/03 System Pumping Record - Page 1 of 1 Ib, _A.. Facility Information Important: When filling out forms on the 1. System Location: _d1 computer, use 1 only the tab key to move your Address . . V e 1 cursor •. do not use the return CI /Town ty State key' . 2, System Owner i fed mping Record must Zip Code Name IC'y Address (If different from location) City/Town State Zip Code Telephone Number B. Pumping Record /0 1. Date of Pumping Date 2. Quantity Pumped: Gallons 3. I Type of system:. ❑ Cesspool(s) ❑e*`Septic Tank ❑Tight Tank Other (describe): 4. Effluent Tee Filter present? ❑ Yes ❑ No 5. Condition of System: If j es;'was it cleaned? ❑ Yes ❑ No ,11n 6.. S stem Pumped By: me Vehicle License Number Company 7.. Locatio where contents were disposed: ature of Ha - Date http://www.mass.gov/dep/.w eflapprovais/t5forms.htm#lnspect '�- t5form4.doc 06/03 System Pumping Record - Page 1 of 1 Ib, Commonwealth of Massachusetts W City/Town of No.Andover a System Pumping Record Form 4 y soy`' Important: When filling out forms on the computer, use only the tab key to move your cursor - do not use the return key. Ffew DEP has provided this form for use by local Boards of Health. Other forms may be used, but the information must be substantially the same as that provided here. Before using this form, check with your local Board of Health to determine the form they use. The System Pumping Record must be submitted to the local Board of Health or other approving authority within 14 days fr -- accordance with 310 CMR 15.351. A. Facility Information 1. System Locatic Address No.Andover City/Town 2. System Owner: Name Y '-Cn 10, KCA Address (if different from location) City/Town PEG ftR. NO TOWN OR NORTH ANDOVC4 Ma 01845 State Zip Code State Telephone Number Zip Code B. Pumping Record _ 1. Date of Pumping Dat ' 2. Quantity Pumped: 3. Type of system: ❑ Cesspool(s) E Septic Tank ❑ Tight Tank ❑ Other (describe): 4. Effluent Tee Filter present? ❑ Yes I No 5. Condition of System} - By: s Septic Service Gallons ❑ Grease Trap If yes, was it cleaned' ❑ Yes ❑ No Vehicle License Number 7. Location where contents were disposed: Stewart's Pre-treatment Plant, 20 So. Mill Bradford, Ma 01835 C d �a_T Si na of aul Da ` Sika re o Receiving Facility Date / t5form4.doc• 03/06 System Pumping Record • Page 1 of 1