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HomeMy WebLinkAboutTitle V Inspection Report - 145 BRADFORD STREET 2/29/2016 Commonwealth of Massachusetts Title * Y 0 Subsurface Sewage Disposal System Form ®Not for Voluntary Assessments 145 Bradford Street Property Address Robert Gruber — Owner Owner's Name information is North Andover MA 01845 — 2/29/2016 required for every State Zip Code Date of Inspection page City/Town 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. w' Important:When General Information filling out farms on the computer, �f�'fG use only the tab 1. Inspector: key to move your TOWN O Y I€;aFRTH A NLDOV I f cursor-do not Neil J. Bateson — An 1�4 LEu:`AB1ML ' use the return Name of Inspector key. Bateson Enterprises Inc. r� Company Name 111 Argilla Road _ Company Address Andover MA _ 01810 City/Town State Zip Code 978-475-4786 S 1 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 ❑ Needs Further Evaluation by the Local Approving Authority 2/29/2016 Inspectors S gnature Date The system inspector shall submit a copy of this inspection report to the Approving Authority(Board of Health or DEP)within 30 days of completing this inspection. If the system is a shared system or has a design flow of 10,000 gpd or greater, the inspector and the system owner shall submit the report to the appropriate regional office of the DEP. The original should be sent to the system owner and copies sent to the buyer, if applicable, and the approving authority. ****This report only describes conditions at the time of inspection and under the conditions of use at that time. This inspection does not address how the system will perform in the future under the same or different conditions of use. t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 1 of 17 Commonwealth of Massachusetts Title 5 Official Inspection r Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 145 Bradford Street Property Address Robert Gruber Owner Owner's Name information is North Andover MA 01845 2/29/2016 required for every State Zip Code Date of Inspection page. City/Town B. Certification (cont.) 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 ❑ 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 145 Bradford Street Property Address Robert Gruber Owner Owner's Name information is required for every North Andover MA 01845 2/29/2016 page. Cityrrown 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 ❑ 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•3113 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 145 Bradford Street Property Address Robert Gruber Owner Owner's Name information is North Andover MA 01845 2/29/2016 required for every State Zip Code Date of Inspection page. City/Town B. Certification (cons.) 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 1/2 day flow [sins•3173 Title 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 145 Bradford Street Property Address Robert Gruber Owner Owner's Name information is North Andover MA 01845 2/29/2016 required for every te of In City/Town State Zip Code Daspection page. B. Certification (cons) Yes No ® Required pumping more than 4 times in the last year NOT due to clogged or F1 obstructed pi!e(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. E] ® 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 fps. I have determined that one or more of the above failure criteria exist s described in 310 CMR 15.303, therefore the system fails. The system owne i 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 El F-1 the system is located in a nitrogen sensitive area (Interim Wellhead Protection Area— IWPA)i 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. Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 5 of 17 t5ins•3113 Commonwealth of Massachusetts Title 5 official Inspection Form U, Subsurface Sewage Disposal System Form Not for Voluntary Assessments i 145 Bradford Street Property Address Robert Gruber Owner owner's Name MA 018_ 45 2/29/2016 information is North Andover State Zip Code Date of Inspection required for every City/Town page. G. Checklist Check if the following have been done. You must indicate"yes" or"no" as to each of the following: Yes No ® [] Pumping information was provided by the owner, occupant, or Board of Health ❑ ® Were any of the system components pumped out in the previous two weeks? ® [] Has the system received normal flows in the previous two week period? ® Have large volumes of water been introduced to the system recently or as part of El 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? ® F� 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: 4 Number of bedrooms (actual): 4--- Number of bedrooms(design): DESIGN flow based on 310 CMR 15.203(for example: 110 gpd x#of bedrooms): 600 Title 6 Official Inspeotion Form:Subsurfaos Sewage Disposal System-Page 6 of 17 thins•3113 Commonwealth of MsssaChusetts Title 5 Official Inspection rm Subsurface Sewage Disposal System Form Not for Voluntary Assessments 145 Bradford Street Property Address Robert Gruber j Owner owners Name MA 01845 2129/2016 information is North Andover Zip required for every State Code Date of Inspection page. CitylTown D. System Information Description: 4 Number of current residents: 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.) ❑ Yes ❑ No Laundry system inspected? ❑ Yes ® No Seasonal use? Yes Water meter readings, if available(last 2 years usage (gpd)): Detail: ❑ Yes ® No Sump pump? Current Last date of occupancy: Date Commercial/Industrial Flow Conditions: Type of Establishment: Design flow(based on 310 CMR 15.203): Gallons per day(gpd) Basis of design flow(seats/persons/sq.ft., etc.): Grease trap present? ❑ Yes ❑ No Industrial waste holding tank present? ❑ Yes ❑ No Non-sanitary waste discharged to the Title 5 system? ❑ Yes ❑ No Water meter readings, if available: Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 7 or 17 t5ins 3113 Commonwealth of Massachusetts Title 5 Official Inspection Form a Subsurface Sewage Disposal System Form Not for Voluntary Assessments 145 Bradford Street Property Address Robert Gruber owner Owner's Name MA 01845 2/29/2016 information is North Andover required for every city/Town State Zip Code Date of Inspection page. D, System Information (conQ Last date of occupancy/use: Date Other(describe below): General Information Pumping Records: Pumped 2008,owner Source of information: Was system pumped as part of the inspection? ® Yes ❑ No 1500 If yes, volume pumped: gallons How was quantity pumped determined? Measured tank Inspect tank&tees Reason for pumping: Type of System: ® Septic tank, distribution box, soil absorption system ❑ Single cesspool ❑ Overflow cesspool ❑ Privy ❑ Shared system (yes or no) (if yes, attach previous inspection records, if any) ❑ Innovative/Alternative technology. Attach a copy of the current operation and maintenance contract(to be obtained from system owner) and a copy of latest inspection of the I/A system by system operator under contract ❑ Tight tank. Attach a copy of the DEP approval. ❑ Other(describe): Title 5 official Inspection Form:Subsurface Sewage Disposal System-Page S of 17 t5ins•3113 COMMo tiwcalth 6f Massachulsatts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 1 145 Bradford Street Propert-Address Robert Gruber Owner owners Name MA 018 45 __ 2/29/2016 information is North Andover State Zip Code Date of Inspection required for every City/Town page. D. System Information (cont) Approximate age of all components, date installed (if known) and source of information: 31 years old, 7122/1985 as built plan. Were sewage odors detected when arriving at the site? ❑ Yes ® No Building Sewer(locate on site plan): 5 Depth below grade: 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.): finished celar uanable to see pipin Septic Tank(locate on site plan): 4 Depth below grade: feet Material of construction ® concrete ❑ metal ❑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 10' x 5' x4' Dimensions: 4" Sludge depth: Title 5 Official Inspection Form:Subsurface Sewage Disposal System•page 9 of 17 t5ins•3/13 Cott mciinwdaith cif 11 aagachusetta Title 5 Official In ti n Assessments Subsurface Sewage Disposal System Form - Not for Voluntary Y 145 Bradford Street Property Address Robert Gruber Owner Owner's Name information is North Andover MA Cod 2/29/2016 ji required for every City(rown State Zp Code Date of Inspection page. D. System Information (cunt,) Septic Tank(cont.) 29" Distance from top of sludge to bottom of outlet tee or baffle 4" Scum thickness 8" Distance from top of scum to top of outlet tee or baffle Distance from bottom of scum to bottom of outlet tee or baffle 11" Tape measure How were dimensions determined? 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. Outlet tee ok. Depth of liquid at outlet invert. No evidence of leakage. Center cover has riser 1' deep. 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 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 10 of 17 t5ins-3/13 commnwealth of Masaaehuaatta Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments " 145 Bradford Street I roperty Address Robert Gruber Owner Owner's Name information is MA 01845 2/29/2016 North Andover required for every City/Town State Zip Code Date of Inspection page. D, System Information (cone,) 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•3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 11 of 17 y Commonwealth of Massachusetts rA Title 5 Official Inspection Form Subsurface Sewage Disposal System Form Not for Voluntary Assessments i 145 Bradford Street o t Property Address Robert Gruber Owner Owner's Name information is North Andover MA 01845 2/29/2016 required for every CityRown State Zip Code Date of Inspection page. D. System Information (cont.) Distribution Box(if present must be opened) (locate on site plan): 0 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 level &distribution equal No evidence of leakage. Evidence of light carryover. 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 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 " 145 Bradford Street Fropert—Address Robert Gruber Owner owner's Name information is North Andover MA 01845 2/29/2016 A required for every North A State Zip Code Date of Inspection page. CityfTown D, System Information (cunt.) Type: ❑ leaching pits number: ❑ leaching chambers number: ❑ leaching galleries number: 5 trenches 61' ® leaching trenches number, length: long ❑ leaching fields number, dimensions: ❑ overflow cesspool number: ❑ innovative/alternative system Type/name of technology: Comments (note condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of vegetation, 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•3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 13 of 17 Commonwealth of Massachusetts Title 5 Official Inspection r a Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 145 Bradford Street Property Address Robert Gruber Owner Owner's Name information is North Andover MA 01845 2/2912016 required for every State Zip Code Date of Inspection page City/town D. System Information (cone:) 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.): 51ns•3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System,Page 14 of 17 commonwealth of MassaehUigetts Title official Inspection Form a Subsurface Sewage Disposal System Form-Not for Voluntary Assessments " 145 Bradford Street Property Address Robert Gruber Owner Owner's Name information is North Andover MA 01845 016 required for every City Town State Zip Code Date ate o of Inspection f page. D. SystOM Information (cunt.) Sketch Of Sewage Disposal System: Provide a view of the sewage disposal system, including ties to at least two permanent reference f e building. Check one of the boxeslbelolwwithin 100 feet. Locate where public water nters the bu ® hand-sketch in the area below ❑ drewiMg attached separately Fj _P w 3 �• 1 'Q = Lf o 3 361511 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 15 of 17 151ns•3113 Commio wealth of Ma8SaChUS6tt!9 Mmum Title 5 Official Inspection r Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 145 Bradford Street Property/address Robert Gruber Owner Owner's Name information is North Andover MA 01845 2/29/2016 required for every page. CityfTown 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: 513/1984_ 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: As per test pit data on design plan 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 C6tbtMh ealth of Msssachtlsaft - Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 145 Bradford Street ` Property Address Robert Gruber Owner Owner's Name information is North Andover MA 01845 2/29/2016 required for every page. City(rown 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#3113 Me 5 Official trrapebdon Form:Subsurface sewage Disposal System-Page 17 of 17 Page 1 Summary Record Card generated on 2/23/2016 10:26:41 AM by Karen Hanlon Town of North Andover Tax Map # 210-061.0-0003-0000.0 Parcel Id 10541 145 BRADFORD STREET THERESE & ROBERT GRUBER 145 BRADFORD STREET NORTH ANDOVER, MA 01845 Property Type 1 Residential Class 101 Single Family Zoning3 1 Residential Zoning2 1 Residential Size Total 0.93 Acres FY 2016 UB Mailing Index Loan Number Active/Inact. From Until Name/Address Type THERESE&ROBERT GRUBER Owner 145 BRADFORD STREET NORTH ANDOVER, MA 01845 GAUDETTE,TIMOTHY Previous Customer Inactive 7/9/2008 145 BRADFORD STREET N,ANDOVER,MA 01845 UB Account Maint. Active/Inactive Account No Cycle Occupant Name Bldg Id. 15234.0-145 BRADFORD STREET Last Billing Date 12/15/2015 Active 2120193 02 Cycle 02 UB Services Maint. Account No.2120193 Charge Multiplier/Users Service Code Rate MISCFEE ADMIN FEE 0.635/8 7 82 1/ WTR WATER 01 ALL METER SIZE 214.75 /1 UB Meter Maintenance Account No.2120193 Brand Type Size YTD Cons Serial No Status Location b Badger w Water 0.63 0.63 608 35078158 a Active ERT HH g Variance Date Reading Code Consumption Posted Date 57% 2/12/2016 635 a Actual 21 83% 11/9/2015 614 aActual 45 9/14/2015 16% 8/14/2015 569 a Actual 26 9/14/2015 -3% 5/14/2015 543 a Actual 22 6/22/2015 -16% 2/13/2015 521 a Actual 25 3/20/2015 8% 11/6/2014 496 aActual 2 12/1 49% 8/12/2014 470 a Actual 25 5 9/11/22014 014 -21% 5/15/2014 445 a Actual 17 6/12/2014 428 a Actual 24 3/17/2014 "3% 2/14/2014 21 12/20/2013 18% 11/6/2013 404 aActual 3% 8/13/2013 383 a Actual 19 9/18/2013 18 6118/2013 -7% 5/14/2013 364 a Actual 22 3/13/2013 -1% 2/14/2013 346 a Actual -4% 11/5/2012 324 a Actual 18 12/13/ 4% 8/15/2012 306 a Actual 21 9/26/20012 12 9% 5/15/2012 285 a Actual 20 6/20/2012 265 a Actual 20 3/14/2012 -15% 2/14/2012 20 12/15/2011 -14% 11/7/2011 245 aActual 22% 8/15/2011 225 a Actual 26 9/14/2011 199 aActual 20 6/13/2011 1% 5/13/2011 22 3/15/2011 10% 2/14/2011 179 a Actual -2% 11/8/2010 157 aActual 18 12/13/ 8/12/2010 139 a Actual 19 9/13/20010 10 "3% 120 a Actual 20 6/9/2010 32% 5/13/2010 15 3/11/2010 -16% 2/9/2010 100 a Actual 6% 11/9/2009 85 aActual 17 12/11/2009 : 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 I. System Locatio ; Left Ig ront of fio s L ft/Right rear of house, Left/right side of house, Left/ Right side of buil In�ft/Rig ront of bng, Left/Right rear of building, Under deck . Address City/Town State Zip Code 2. System Owner. Name' Address(if different from location) City/Town State Telephone Number i .B. Pumping record 1. Date of Pumping Date 2• Quantity Pumped: Gallons Y 3. Type-of system: ❑ Cesspool(s) Septic Tank ❑ Tight Tank ❑ Other(describe): 4. Effluent Tee Filter present? ❑ Yes No If yes, was it cleaned? ❑ Yes ❑ Na 5. Condition of System: 6. System Pumped By: Neil.Bateso n F5821 Name Vehicle License Number Bateson Enterprises Inc Company 7. Location where contents-were disposed: L S Lowell Waste Water Sign a Haule Date t5form4.doc-06103 System Pumping Record•Page 1 of 1