Loading...
HomeMy WebLinkAboutTitle V Inspection Report - 410 FOREST STREET 4/3/2018 Commonwealth of Massachusetts _a Title 5 Official Inspection Farm Subsurface Sewage Disposal System Form - Not for Voluntary Assessments a w o <",, Y .4 410 Forest Street .• "" Property Address David Breen `` OwnerOwner's -__---- .__ ... � �� Name - informat on requedtfor levery North Andover MA Sate 01845 pode Date o2 nspection w 18 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. Important:When A. General Information filling out forms on the computer, use only the tab 1. Inspector. key to move your cursor-do not Neil J. Bateson N use the return --- o -Name of-.-._- f I ..._._._._.-._.._-_.--......---------------------- key. Inspector . _ Bateson Enterprises Inc. r Company Name 111 Argilla Road Company Address �+ Andover MA 01810 - _.._.._._._.__.............._._------------_--.__— City[Town State Zip Code 978-475-4786SI-15 - ------- ------..-_..-a_ 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 ❑ Falls ❑ - ds Further Evaluation by the Local Approving Authority 3-23-2018 Inspector's Signatu 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 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.doc-rev.6116 Title 5 official Inspection Form:Subsurface Sewage Disposal System•Page 1 of 17 »~� Commonwealth of Massachusetts Title 5 Official Inspection Form ' Subsurface Sewage Disposal SysteNmForrn -NothorVo|untaryAooeaernnnbs 410 Forest Street 0-r—oper-ty Address David Breen ---- Owner Owner's Name information i's North Andover MA 01845 3-23-2018 n°qu|e0fornwe� �G��—' Z��m� paga. ~'n''~~^ � on B, Certification /coDt.\ Inspection Summary: Check A.8,C.DorE/always complete all ofSection O A> System Passes: | have not found any information which indicates that any mfthe 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: F-1 one or more system components as described in the "Conditional Pass" section need to be replaced or repaired. The myutem, upon completion of the replacement or rapair, as approved by the Board of Health, will pass. Check the box for"yes", "no" or"not determined" 0/. N. ND) for the following statements. If"not determined," please explain. i | The septic tank is metal and over 20 years old*or the septic tank r metal Or mN is structurally unmound, exhibits substantial infiltration or exf|traUon or bank failure is imminent. System will pass inspection if the existing tank is replaced with a complying septic tank as approved bythe Board of Health. «A metal septic tank will pass inspection if it is structurally sound, not leaking and if Certificate of Compliance indicating that the tank is |gse than 20 years old is available. �� Y �l N �� ND (Explain be|Vw): Commonwealth of Massachusetts r Title 5 Official Inspection Farm Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 410 Forest Street Property Address David Breen Owner Owner's Name information is North Andover MA 01845 3-23-2018 required for every ___--------.�_.... _-...__..—_. _. ___—__ _ — _. page, Cltyf i own 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 (cant.): ❑ 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.doc-rev.6116 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 3 of 17 i � | | � Commonwealth of Massachusetts -N�~��N�� �� ��^���"��~��N 0��������°��~���� ����0°U�� Title �� ��yNNN��0��N Nmw�~�������N��mm Form mmm ^ Subsurface Sewage Dioposa| SystemmFunn-NotforVb\untmryAsaeoamentx 410 Forest Street Property Address David Breen Owner Owner's Name information imNodbAndover &8A D1�4� 3-23-2O18 required �o�_- �� page. ~'r'~-'' Zip Code Date of Inspection B. Certification (cont.) 2. ^ O m�l�f� unless the Board of Health hmmd Public Water Suppi#er, if any) determines that the system |mfunctioning <namanner that protects the public health, safety and environment: Fl The system has a septic tank and soil absorption system (SA8) and the SAS iswithin 10Ufeet ofasurface water supply ortributary huosurface water supply. F1 The system has eseptic tank and SAS and the SAS iuwithin aZone 1ofmpublic water supply. Fl The system has a septic tank and SAS and the SAS is within 50 feet of private water supply well. � F� The system has eseptic tank and SAS and the SAS isless than 10Ofeet but 5Ofeet or � more from a private water supply vvaU°°. Method used todetermine 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 tothis form. 3. Other: D\ System Failure Criteria Applicable toAll Systems: You must indicate '^Yes" mr''No" toeach ofthe following for all inspections: Yeo No �l �� Backup ofsavvmQainto fadUtyorsystem nonnponmntdue tooverloaded nr | �� �� clogged SAS orcesspool Discharge orponding ofeffluent tuthe surface ofthe ground orsurface waters due tVanoverloaded o[clogged SAS Orcesspool � Static liquid level in the distribution box above outlet invert due to an overloaded Fl [� orclogged SAS Orcesspool F� �� Liquid depth in cesspool is less than 0'' � below invenravai|ob|avo|ume is |eoS �� �� than 1/2 day flow em".do*'rev.*ws Title aOfficial Inspection Form:avum.mceSewage Disposal System'Page*m1r | � Commonwealth of Massachusetts Title"�°*^�N�� 0� ��'���������N N����������������� ����U�8�� �� ��V� � N��N��0 Nmm���������N��mw Form ` Subsurface Sewage Disposal System Form 'Not for Voluntary Assessments 41OForest Street 0-r-o-perty Address David Breen ----- Owner nwno,'uNamo information is North Andover MA 01845 3-23-2018 required for every page. ~7 Zip Code Date of Inspection '"''~^'' State B. Certification (cont.) Yes No Required pumping more than 4times inthe last year NOT due toclogged or obatruntedpipe(s). Number oftimes pumped: _____ Anyportion nfthe SAS, cesspool urprivy iobelow high ground water elevation. Fl �� Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary tom surface water supply. � Any portion of cesspool or privy is within a Zone 1 of public well. El 0 Any portion of cesspool or privy in within 50 feet of private water supply vve||. Any portion of a ueaep0o| 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 ifthe well water analysis, performed mtmDEP certified laboratory,for fecal coliform bacteria indicates absent and the presence � mfammonia nitrogen and nitrate nitrogen isequal toorless than 5 ppm, / provided that noother failure criteria are triggered. Acopy ofthe analysis and chain ofcustody must beattached tmthis Yqrmm] Fl �� Theayatamninocesnpoo|uarvingafooi|ityvviihadmaignf|Vvvof2O00Qpd- �� �� 10.000gpd. Fl �� The system fails. | have determined that one or more of the above failure criteria exist aa described in 310 CMR 15.303, therefore the system fails. The system owner should contact the Board ofHealth todetermine what will be necessary tocorrect the failure. E} Large Systems: To be considered a large system the system must serve o facility with m design flow of10,0UQBpdtm15'000Qpd. For large systems, you must indicate either"yes" or"no" to each of the following, in addition to the questions inSection D. Yes No the system iowithin 400feet nf@surface drinking water supply [l �l the uvatam is within 200 feet ufa tributary to m surface drinking water supply � El �l the system is located in a nitrogen sensitive area (|nter|rnVVe||head Protection | �� �� Area—|VVPA)or8mapped Zone |) ofapublic water supply well � If you have answered "yes" to any question in Section Ethe system is considered a significant threat, ormn�vmanmd"y�o" in8�ob � Section The ovvneroroperator ufany large � � sVst8On considered G significant threat under Section E or failed under Section D shall upgrade the system inaccordance with 31DCMR 15.3O4. The system owner should contact the appropriate regional office ofthe Department, mnnxoc.rev.ono Title sOfficial Inspection Form:Subsurface Sewage Disposal System^Page nwn � Commonwealth of Massachusetts Title 5 Official Inspection Form ^ Subsurface Sewage Disposal System Form Not for Voluntary Assessments 410Forest Street j5roperty Address David Breen Owner Owners Name information is required for ov" North Andover MA 01845 3-23-2018 — State Zip Code Date of Inspection page. ~`r'`^'' C. Checklist Check if the following have been done. You must indicate"yes" or"no" as to each of the following: Yen No Z El Pumping information was provided by the owner, occupant, or Board of Health F1 0 Were any ofthe system components pumped out in the previous two weeks? | N F-1 Has the system received normal flows inthe previous two week period? Have large volumes of water been introduced to the system recently or as part of this inspection? Were esbuilt p|mneofthe aymtannobtained and examined? /|ftheyvveFenot �� [l ` =~ �� avoi|ab|e note as N/A) Was the facility ordwelling inspected for signs Vfsewage back up? �� �� VVasthe site inspected for signs ofbreak out? � "" `� � 0 Were all system components, excluding the SAS, located onsite? Z Fl Were the septic tank manholes uncovered, opened, and the interior 0fthe tank inspected for the condition of the baffles or tees, material of construction, dimensions, depth ofliquid, depth nfsludge and depth ofscum? 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 ofthe Soil Absorption System (SAS) onthe site has been determined based on: El Existing information. For example, a plan at the Board of Health. Determined inthe field (ifany ofthe haUurecriteria related ioPa�Cimatissue ` appnoximationofdistance isunacceptable) [3i0CW1R15.3O2(5)l D. System Information Residential Flow Conditions: Number ofbedrooms (design): 4-------' Number of bedrooms (actual): 4---------- � OOO DESIGN flow based on310CMR 15.2U3 (for example: 1100pdu#ofbed[oonls): ---------- Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form Not for Voluntary Assessments 410 Forest Street Property Address David Breen ------ --------- Owner Owner's Name information is North Andover MA 01845 3-23-2018 required for every page. Cityfrown State Zip Code Date of Inspection D. System Information Description: 2 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.) Laundry system inspected? D Yes El No Seasonal use? F1 Yes N No On well water Water meter readings, if available (last 2 years usage (gpd)): Detail: Sump pump? Yes ❑ No Last date of occupancy: Dtrent 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? n Yes F] No Industrial waste holding tank present? F] Yes F] No Non-sanitary waste discharged to the Title 5 system? El Yes [] No Water meter readings, if available: t5lns.doc,-rev.6116 Title 5 Official Inspection Form:Subsurface Sewage Disposal System Page 7 of 17 <C, Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form Not for Voluntary Assessments 410 Forest Street PropertyAddress David Breen Owner Owner's Name information is North AndoverMA 01845 3-23-2018 -—---- required for every — page. Ci-t—y/Town State Zip Code Date of Inspection D. System Information (cont.) Last date of occupancy/use: Date Other(describe below): General Information Pumping Records: owner Source of information: Pumped 2010, ---------Was system pumped as part of the inspection? Yes ❑ No If yes, volume pumped: 1500gallons How was quantity pumped determined? Measured tank Reason for pumping: -Inspect tank&tees Type of System: z 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 El Tight tank. Attach a copy of the DEP approval. ❑ Other(describe): 15ins.doc-rev.6116 Title 5 Official inspection Form:Subsurface Sewage Disposal System-Page 8 of 17 Commonwealth of Massachusetts M Tale 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments .�' 410 Forest Street Property Address i David Breen Owner Owner's Name information is North Andover MA 01845 3-23-2018 required for every ___----_ page. City/Town State Zip Code Date of Inspection D. System Information (cont.) , Approximate age of all components, date installed (if known) and source of information: 22years old, 9-4-1996, as built plan. Were sewage odors detected when arriving at the site? ❑ Yes 0 No Building Sewer(locate on site plan): 1.5 Depth below grade: feet Material 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.): 4" PVC through wall, 3" PVC in house, no leaks visible. Septic Tank(locate on site plan): Depth below rade: 0.5 feet Material of construction: 0 concrete ❑ metal ❑ fiberglass C1 polyethylene ❑ other(explain) --------------I I If tank is metal, list age: years Is age confirmed by a Certificate of Compliance? (attach a copy of certificate) ❑ Yes ❑ No Dimensions: 10'x 5'x 4' 8" Sludge depth: t6ins.doc-rev.6116 Title 5 official Inspection Form:Subsurface Sewage Disposal System-Page 9 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Farm Subsurface Sewage Disposal System Form -Not for Voluntary Assessments t ' 410 Forest Street Property Address David Breen Owner Owner's Name information is North Andover MA 01845 3-23-2018 required for every _____-- .._......-- -__- page City/Town _ State Zip Code [late of Inspection D. System information (cont.) Septic Tank(cont.) 25"' Distance from top of sludge to bottom of outlet tee or baffle 2 __._ ------- 311 - _3'" Scum thickness p___...__ 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 12"- --- Mow 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.): Inlet tee ok. Outlet tee ok. Depth of liquid at outlet invert. No evidence of leakage. Pumped septic tank. I Grease Trap (locate on site plan): Depth below grade: Material of construction: © concrete 0 metal [ fiberglass ® polyethylene ❑ other(explain): _--.._.- f Dimensions: Scum thickness Distance from top of scum to top of outlet tee or baffle -----._..___...._........._._._.._... .m_.___......_..._.--_--------_— Distance from bottom of scum to bottom of outlet tee or baffle _..__.._..------_-.._.a.._----------- Date of last pumping: l5ins.doc•rev.6116 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 �r 410 Forest Street Property Address David Breen Owner Owner"s Name information is MA 01845 3-23-2018 North Andover required for every —it fy.._f_._ .— —. _. page Cown State Zip Code Date of Inspection D. System Information (cont.) Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, t 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: El concrete ❑ metal ❑fiberglass polyethylene ❑ other(explain): Dimensions: Capacity: gallons i Design Flow; g gallons per day V Alarm present: n 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 Mns.doc•rev.6116 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 410 Forest Street Property Address David Breen Owner Owner's Name information is North Andover MA 01846 3-23-2018 required for every _ -- page Clty/fown _ State Zip Code Date of Inspection D. System Information (cant.) 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 carryover, pumped d-box to clean. D-box cover broken, replaced same. 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.): i * 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.doc-rev.6116 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 12 of W Commonwealth of Massachusetts - N Title 5 Official Inspection Form _ – Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 410 Forest Street Property Address--- _ David Breen Owner Owner's Name—� information is North AndoverMA 01845 3-23-2018 . required for every _ ....._._.-_..�..__._— page CttyfT"own State Zip Code Date of Inspection i D. System Information (cont.) Type: ❑ leaching pits number: ❑ leaching chambers number: ® leaching galleries number: ® leaching trenches number, length: 3 trenches 50'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.): Lawn snow covered. No sign of ponding to surface. i Cesspools (cesspool must be pumped as part of inspection) (locate on site plan): Number and configuration Depth–top of liquid to inlet invert -----.------ --------- Depth -__ Depth of solids layer Depth of scum layer Dimensions of cesspool Materials of construction — -- -- -------- Indication of groundwater inflow ❑ Yes ❑ No t5ins.doc-rev.6116 Title 5 Oficial Inspection Form:Subsurface Sewage Disposal System•Page 13 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 410 Forest Street ------- Property Address David Breen Owner Owner's Name information is North AndMA 01845 3-23-2018 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,doc-rev.6116 Title 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 410 Forest Street Property Address David Breen OwnerOwner's Name information is North Andover MA 01845 3-23-2018 required for every -------- 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: N hand-sketch in the area below El drawing attached separately 0 W VI) 4 A D-5oy- 0, 15ins,doc•rev.6116 Title 5 Official trispection 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 410 Forest Street Property Address David Breen Owner Owners Name information is required for every North Andover MA 01845 3-23-2018 page. CityrTown State Zip Code Date of Inspection D. System Information (cont.) Site Exam: Z Check Slope Surface water Check cellar Z Shallow wells Estimated depth to high ground water: >4 feet Please indicate all methods used to determine the high ground water elevation: z Obtained from system design plans on record If checked, date of design plan reviewed: 5-8-1995 Date El Observed site (abutting property/observation hole within 150 feet of SAS) z Checked with local Board of Health - explain: Design plan ------- ❑ Checked with local excavators, installers -(attach documentation) El Accessed USGS database-explain: You must describe how you established the high ground water elevation: Test pit data on design plan shows water table @ 5' —------------------------ .......... ------------------------ ----------------- ---------------- ------ Before filing this Inspection Report, please see Report Completeness Checklist on next page. t5ins.doc-rev.6/16 Title 5 Official inspection Form;Subsurface Sewage Disposal System-Page 16 of 17 Commonwealth of Massachusetts r Title 5 Official inspection Form n Subsurface Sewage Disposal System Farm - Not for Voluntary Assessments 410 Forest Street Property Address David Breen Owner Owner's Name information is North And MA 011845 3-23-2018 required for every _._m__- __..---.�.r_____. _... _ — ....___ —..---------.� page. City/Town 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 i I i I i t5ins.doc-rev.6116 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 17 of 17 Commonwealth of Massachusetts .9 QWTown of . µa 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 iocal Board of Health to determine the forr"n they use.The System Pumping Record must be submitte�d,to 3 the local Board of Health or other approving authority.' ' A. Facility. Informia#ion, 1. System Location: eft Righ rota of house Left/Right rear of house, Left/right side of house, Left Right side of builLeft/Rig rano buildirig, Left/Right rear of building, Under deck Address " C JJC Citynown State Zip Code 2. System Owner. Name' Address(if different from location) Cityfrown ' State- Zip Code Telephone Number ----------------- } _ 1 .Be Pumping Record 1. Date of Pumping -62. Quantity Pumped: ate Gallons ,. 3. Type-of system: ❑ Cesspool(s) 9-le-ptic Tank ❑ Tight Tank ❑ Other(describe): 4. Effluent Tee Filter present? ❑ Yes No if yes, was it cleaned? ❑ Yes ❑ No, 5. Condition of System: 6: System Pumped By: i Neil.Bateson.' F5821 Name Vehicle License Number Bateson Ehterprises Inc- Company 7. La W*2Q w contents-were disposed: C LAHtiule JD Lowed Waste Water Sign Date 5farm4.dac•06/43 System Pumping Record•Page 1 of 1 Com. monwea(th of Massachusetts CiWTown of . Sy�torn Pumping.Record Form 4 DEP has provided this form for use-by local Boards o"Mealth. Other form's 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 forrn they use. The System Pumping Record must be submitted to the local.Board of Health or other approving authority. A. Facility Ilnforrrllation 1. System Locationglgapjeftl Rig h rant�ono Left/Right rear of house, Left/right side of house, Left C Right side of buil Rig ildlhg, Left/Right rear df building, Under deck Address Grtyrrown State Zip Code Z. System Owner. 8c�t(\ Name' Address(if different from location) City/Town State- Zip Cade t 69 QAC �•.;' Telephone Number ; ' .B. Pum°pingi Record 1. Date of Pumping . p 9 pate 2. Quantity Pumped: Gallons 3. Type-of system. ® Cesspool(s) (Q e tic Tank ❑ Tight Tank Other(describe): 4. Effluent Tee Filter present? E3 Ye No If yes, was it cleaned? ❑ Yes ❑ No, ' 5. Condition of System: t 6: System Pumped By: Neil.Bateson 1=5621 Name Vehicle License Number Bateson Enterprises lnc• Company 7. Lo n wlberq contents-were disposed: t L Lowell Waste Wafer Sign a Houle Date Torm4.doo•06/03 System Pumping Record•Page 1 of 1 Y p yORT1y "own of North Andover HEALTH DEPARTMENT sarocuuso �„ 11 CHECK. #: ���, DATE; w LOCATION: H/O NAME. AD / , . '.,.. CONTRACTOR NAME. '. ` °� Tvve of Permit or License:(Check box) ❑ Animal ❑ Body Art Establishrnent $ Cl Body Art Practitioner ❑ Dumpster $ • Food Service-Type:___ $ �� ❑ Funeral Directors $� El Massage Establishment ❑ Massage Practice $ ❑ Offal(Septic.) Hauler $ • Recreational Camp $�_ ❑ Sun tanning $. ❑ Swimming Pawl ❑ Tobacco $� ❑ Trash/Solid Waste Hauler $ _.. ❑ Well Construction $ SEPTIC S'jgLt tits, ❑ Septic-Sail Testing $ ❑ Septic-Design Approval $ CJ Septic Disposal Works Construction(DWC) $ ❑ Septic Disposal Works Installers(DWI) ❑ Title 5 Inspector $ Title 5 Report $ •m ❑ Other. (Indicate)_. $ Heak Agent Initials White-Applicant Yellow-health Pink- Treasurer