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Home My WebLink AboutTitle V Inspection Report - 81 PADDOCK LANE 4/30/2018 Commonwealth of MassachusettsE ��,�'I E Title 5 Official Inspection Form APR 3 NI Subsurface Sewage Disposal System Form- Not for Voluntary Assessments Tom fl L F iIOOI'��I E ..` 81 Paddock Lane __... ___.. _ . I' IH Lei°AiUV7ENT Property Address Rod rigowBallon Owner Owner's Name required for every tion is North Andover MA 01845 04/02/2018 require _.�.._..._...._._..__.._. page. Cityl-rown State Zip Code Date of Inspection Inspection results must be submitted on this form. Inspection forms may not be altered in any way. Please see completeness checklist at the end of the form. Important:When filling out forms A. General Information on the computer, use only the tab 1. Inspector: key to move your cursor-do not Robert Herrick use the return _......._...._..__.m._.._._,.... ------- -----_-__-----.._._._..-- key. Name of Inspector Wind River Environmental rah Company Name 46 Lizotte Drive Company Address ,F n Marlborough MA 01752 City/Town State Zip Code (978)833-7924 5113759 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 I k�p 'sSignature 04/02/2018 re 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 � , x�^ Commonwealth of Massachusetts "�==��0�� '��°��°��0 0��°�� 0�� Title �� Official� �mm�� N��m � 0—��mmmw �� ~� ��,�.� Subsurface Sewage Disposal System Form Not for Voluntary Assessments 81 Paddock Lane Property Address Rodrigo_B ||un _ Owner Owner's Name information is North Andover MA 01845 04/O�/2018 rnqvir*d�rov�ry -------- --------' uo�e� Q�y[ro�n ��Ve �ipCode oovaof|nspammn B. Certification (cont.) Inspection Summary: Check A.B.C,DorE/always complete all ofSection D AJ System Passes: I have not found any information which indicates that any of the failure criteria described in 310 CMR 15.303orin 310 CMR 15.304exist. Any failure criteria not evaluated are indicated below. � Comments: E) 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 ofHealth, 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 pemm inspection if it is structurally sound, not leaking and if Certificate of Compliance indicating that the tank iu less than 2Uyears old is available. [l Y F-1 N El ND (Explain be|ovv): . � Commonwealth of Massachusetts =0�=��0�� `��"��"��0 ��°=�=�� nMk Title �� °�� w� Inspection N—��mmm � Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 81 Paddock Lane Property Address Rdrigo Ballon Owner Owner's Name information is North Andover MA01845 O4K}�/�U18 mquimdfnro°o� ---�� -------- '----- page. CityfT»«n State Zip Code Date ufInspection B. Certification (cont.) El Pump Chamber pumps/alarms not operational. System will pass with Board of Health approval if pumps/alarms are repaired. B> System Conditionally Passes (uonL): Observation | � to broken or obstructed pipe(s) Vrdue hoa broken, settled or uneven distribution box. System will � pass inspection if(with approval of Board of Health): � • broken pipe/n\ are replaced 0 Y Fl N F1 NO (Explain below): • obstruction isremoved F] Y E] N F] ND (Explain below): Fl distribution box is leveled or replaced F-1 Y N n ND (Explain below): Fl The system required pumping more than 4Umes ayear due to broken or obstructed pipe(s). The uyaham will pass inspection if(with approval of the Board of Health): 0 broken pipe(a)ere replaced F1 Y n N n ND (Explain below): �l obstruction is removed El Y 0 N 0 N[} (Explain below): C\ Further Evaluation is Required by the 0mond of Health: F1 Conditions exist which require further evaluation by the Board of Health in order to determine if the system is failing to protect public hea|th, safety orthe environment. 1. System will pass unless Board ofHealth determines |naccordance with 310 CMR 15.303(1)(b) that the system is not functioning |n mmanner which will protect public health, safety and the environment: n Cesspool or privy is within 50 feed of surface water Fl Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh Commonwealth of Massachusetts ry W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form Not for Voluntary Assessments :W , 81 Paddock Lane Property Address Rodrigo Ballon Owner Owner's Name information is North Andover MA 01845 04/02/2018 required for every &y/Town— .,.... _._. ..... ..__— ......_ _..,. .. .......... page. Clty/Town State Zip Code Date of Inspection B. Certification (cont.) 2. System will fail unless the Board of Health (and Public Water Supplier, if any) determines that the system is functioning in a manner that protects the public health, safety and environment: ❑ The system has a septic tank and soil absorption system (SAS)and the SAS is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water supply. ❑ The system has a septic tank and SAS and the SAS is within 50 feet of a private water supply well. ❑ The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or more from a private water supply well". Method used to determine distance: **This system passes if the well water analysis, performed at a DEP certified laboratory, for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis must be attached to this form. 3. Other: D) System Failure Criteria Applicable to All Systems: You must indicate "Yes" or"No"to each of the following for all inspections: Yes No ❑ ® Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool Discharge or ponding of effluent to the surface of the ground or surface waters El ® due to an overloaded or clogged SAS or cesspool ❑ M Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool ❑ 0 Liquid depth in cesspool is less than 6" below invert or available volume is less than '/2 day flow 15ins.doc•rev.6116 'Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 4 of 17 i , Commonwealth of Massachusetts =�^=��N�� *��°��0 N��=��=�� * �� =�� Inspection 0—�°wmmm Subsurface Sewage Disposal System Form Not for Voluntary Assessments 81 Paddock Lane Rodrigo Ballon Ba||on Owner Owner's Name information is North MA U1845 mqu|�d�revery ----- �------- 04/02/2018 Q�� n State Zip Date | ------ page. ",, � B. Certification (cont.) Yes No �� H Raquinadpumping more than 4U8N meainthe |��ymorOTduetndogQedor �� obstructed pipe(s). Number oftimes pumped: _____. n z Any portion of the SAS, cesspool or privy is below high ground water elevation. �l �� Any po�ionofcesspool orprivy isvv|tMn10Ofeet ofasu�ooevwatwrsupply or �� tributary too surface water supply. El Z Any portion of cesspool or privy is within a Zone 1 of public m/m||. El Z Any portion of a cesspool or privy is within 50 feet of a private water supply well. El z 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 ifthe well water analysis, performed ataDEP certified laboratory,for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal tomrless than 5 ppm, provided that no other failure criteria are triggered. Acopy mfthe analysis and chain pfcustody must beattached to this form.] � � �� Theoystem |maoenspon| son/ingafaci|ityvv|thadeaignf|nvvuf20OOgpd- �� 10.000gpd. �l �� The symtwnmfaUs. | have determined that one nrmore ofthe above failure �� " criteria exist aadescribed in 310CK4Fl15.303, therefore the system fails. The system owner should contact the Board nfHealth todetermine what will be necessary tocorrect the failure. E1 Large Systems: To be considered a large system the system must serve mfacility with a design flow mf1B'Q00 gpdto15,000 gAd. For large systems, you must indicate either"yes" or"no" to each of the following, in addition to the questions inSection D. Yes No 0 D the system is within 400 feet of surface drinking water supply Fl E-1 the system is within 200 feet of tributary to a surface drinking water supply �� F� the system is located in e nitrogen sensitive area(interim VVe||hnad Protection � �� Area— |VVPA)oramapped Zone || nfapublic water supply well � |fyou have answered "yea" hoany question inSection Ethe system isconsidered asignificant threat, or answered "yes" in Section D above the |mrQn system has failed. The owner oroperator 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 ofthe Department. wm,.00"'rev.o/`6 Title oOfficial Inspection Form:Subsurface Sewage Disposal System'Page o^/1, ^ Commonwealth of Massachusetts "�� "��0 N�� Q��M� Title �� m��NNN��N��N Inspection �-��mm � � Subsurface Sem/age Dispmaa| SyotennForrn - NntforVo|untoryAaoenomonts �1 Paddock _ �rope rtyAddross Rodriqo Ballon Owner Owner's Name information is North AndoverMA 01845 04/02/2018 mqu|m4�/every page. Ci�yfrown State Zip Code Date ofInspection C. Checklist | ChaokifUhefoUow|nghavebenndonn. Youmnwmtindicab*^ves' or"no" esto8@ohofthefo|Nvvng: Yeo No M El Pumping information was provided by the nwner, occupant, or Board of Health El M Were any ofthe system components pumped out inthe previous two weeks? E Fl Has the system received normal flows |nthe previous two week period? �� Hovolarge volumes nfwater been inboducedtothe system recently ormspart of �� this inspection? �� l VVeremebuilt plans ofthe system obtained and examined? (if they were not �� available note oaN/4) E El Was the facility nrdwelling inspected for signs ofsewage back up? fl Was the site inspected for signs ofbreak out? El Were all system components, excluding the SAS, located on site? El Were the septic tank manholes uncovered, opened, and the interior of the tank inspected for the condition of the baffles or toes' material of construction, dimensions, depth of liquid, depth of sludge and depth of scum? �� F� Was the facility owner(end occupants ifdifferent from owner) provided with �� information on the proper maintenance of subsurface sewage disposal systems? The size and location mfthe Soil Absorption System /S&S\ onthe site has been determined based on: Existing information. For example, a plan at the Board of Health. Determined in the field (if any ofthe failure criteria related to Part C is at issue approximation o/distance isunacceptable) [310CMR 15.302(S)] D. System Information Residential Flow Conditions: 4 Number cJbedrooms(jem�n): -------- Number ofbedrooms (ecb4ua\� 600 DESIGN OES|GNflow based nn310CMR 15.2O3 (for example: 110gpdx#ofbednnnms): ---------- Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form Not for Voluntary Assessments 81 Paddock Lane Property Address Rodrigo_Ballon Owner Owner's Name information is required for every North Andover MA 01845 04/02/2018 page. City/Town State Zip Code Date of Inspection............. D. System Information Description: The system is made up of a Septic Tank, Distribution Box and SAS. ............. 2 Number of current residents: Does residence have a garbage grinder? Yes 0 No Is laundry on a separate sewage system? (include laundry system inspection El Yes 0 No information in this report.) Laundry system inspected? El Yes 0 No Seasonaluse? El Yes 0 No Water meter readings, if available(last 2 years usage (gpd)): Well Water Detail: Well Water Sump pump? El Yes ® No Last date of occuancy: Current pDate....._...__..___._ ate 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? El Yes [:1 No Non-sanitary waste discharged to the Title 5 system? F1 Yes F-1 No Water meter readings, if available: t5ins.doc-rev.6116 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 7 o€17 Commonwealth of Massachusetts °�=�N� � ��"�N ��=�� Title �� ~�� N�w� Inspection ��mm � m Subsurface Sewage Disposal System Form - Not for Voluntary Assessments Paddock Lane Property Address Rodri.qo BU Owner 0wner'»N-am a information is North Andover MA01845 04/02/2018nquimdforovery page. City/Town State Zip Code Date ofInspection D. System Information (cont.) Last date ofoncupanoy/usa' ' Other(describe below): General Information Pumping Records: Source of information: VVindF{k/erEnvironmental - Last pumped nn � 03/02/2018. See attached nacord. Was system pumped aopart nfthe inspection? Fl Yes 0 No If yes, volume' QaUvnp How was quantity pumped determined? Reason for pumping: Type mfSystem: N Septic tank, distribution box, soil absorption system E-1 Single cesspool 0 Overflow cesspool [] Privy R Shared system (yes or no) (if yes, attach previous inspection records, if any) El 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 ofthe |64system bvsystem operator under contract El Tight tank. Attach acopy ofthe DEP approval. El Other(describe): mmsuop'rev.m16 Title sOfficial Inspection Form:Subsurface Sewage Disposal System'Page oof 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form Not for Voluntary Assessments fa 81 Paddock Lane .......... Property Address Rodriqo Ballon Owner Owner's Name information is North Andover MA 01845 04/02/2018 required for every page. State Zip Code Date of Inspection D. System Information (cont.) Approximate age of all components, date installed (if known)and source of information: 1984 Were sewage odors detected when arriving at the site? El Yes 0 No Building Sewer(locate on site plan): 1 Depth below grade: feet Material of construction: El cast iron H 40 PVC El other(explain): Distance from private water supply well or suction line: Over 100 feet feet Comments (on condition of joints, venting, evidence of leakage, etc.): All joints are solid. No signs of leakage. Vented through building sewer. ----------- Septic Tank(locate on site plan): Depth below grade: 0.6' feet Material of construction: H concrete F] metal F-1 fiberglass El polyethylene El other(explain) . ............. —------------ If tank is metal, list age: years Is age confirmed by a Certificate of Compliance? (attach a copy of certificate) El Yes El No 1 Dimensions: 0' x 5'x 4' Sludge depth: 2" t5ins.doc-rev.6116 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 9 of 17 \ ` Commonwealth of Massachusetts Title 5 Official Inspection orm Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 81 Paddock Lone PmpertyAddmoo Rodrigo Ballon ___-�� Owner Owne/eNome information is required for every North Andover MA 81845 Q 4/0212018 page. City/Town State Zip Code Date n/Inspection � D. System Information (cont.) Septic Tank (cont.) Distance from top ofsludge h) bottom nfoutlet tee orbaffle 30" 1" Scum thickness 7.5" Di��cofmm �pofmum �t� ufm��t� or ��m Distance from bottom nfscum tobottom ofoutlet tee orbaffle 14" T- _MeasureSludge d Judge How were dimensions determined? Comments (on pumping recommendations, inlet and outlet tee orbaffle condition, structural integrity, liquid levels onrelated h> outlet invert, evidence ofleakage, ebz]: Recommend yearly pumping. The inlet and outlet are solid with nnsigns nfleakage. The liquid level is DK in relation to the inverts. Grease Trap (locate onsite p|on): Depth below grade:� fen Material ofconstruction: F-1 concrete El metal Fj fiberglass El polyethylene Elother(exp|ain): Dimensions: Scum thickness � Distance from top ofscum totop ofoutlet tee orbaffle Distsnoe from bottom nfscum tobottom nfoutlet tee orbaffle Date of last pumping: Date Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form Not for Voluntary Assessments 81 Paddock Lane -------------- Property Address Rodrigo.,Bal ........ Owner Owner's Name information is required for every North Andover MA 01845 04/02/2018 page. Cit /Town State Zip Code Date of Inspection D. System Information (cont.) Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc,): Tight or Holding Tank(tank must be pumped at time of inspection) (locate on site plan): Depth below grade: Material of construction: D concrete El metal El fiberglass ❑ polyethylene F-1 other(explain): Dimensions: ............ Capacity: gallons Design Flow: ..........gallons per day Alarm present: El Yes [:1 No Alarm level: Alarm in working order: El Yes F] No Date of last pumping: Date Comments (condition of alarm and float switches, etc.): ------------ ------------ ----------- Attach copy of current pumping contract(required). Is copy attached? El Yes R No t5ins.doc-rev.6/16 Title 5 Official Inspection Form;Subsurface Sewage Disposal System-Page 11 of 17 ^ ' «�~ Commonwealth of Massachusetts =��N�� ~��N 0��i�� M��| Title �� °�N��N Inspection Form Subsurface SevvageOisposm| SVsternFarmm - NntforVo|untaryAmomaemente 81 Paddock Lane Property Address Rodrigo Ballon Owner Owner's Name information is equ|��|bruvn� North MA 01845 04/02C2018 page. okr'ovn State Zip Code Date nfInspection D. System Information (cont.) Distribution Box (if present must bmopened) (locate onsite p|an): Depth ofliquid level above outlet invert O" Comments (note ifbox |slevel and distribution tooutlets equal, any evidence ofsolids carryover, any � evidence ofleakage into orout ufbox, et ]: � The distribution box is solid with no signs of leakage in or out. The liquid level is OK in relation to the inverts. Pump Chamber(locate onsite p|on>: Pumps |nworking order: [l Yea El No* Alarms inworking order: El Yee El No* Comments (note condition of pump chamber, condition of pumps and appurtenances, etc.): _ ° |fpumps oralarms are not inworking order, system ivaconditional pass. Soil Absorption System (SAS)(locate on site plan, excavation not required): If SAS not |ooatod, explain why: Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form Not for Voluntary Assessments 81 Paddock Lane Property Address Rodrigo Ballon' " Owner Owner's Name information is North Andover MA 01845 04/02/2018 required for every page. Cityfrown State Zip Code Date of Inspection ---------- D. System Information (cont.) Type: El leaching pits number: 0 leaching chambers number: ❑ leaching galleries number: leaching trenches number, length: 2 x 64' ❑ leaching fields number, dimensions: —— E-1 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 is dry with no signs of hydraulic failure and no ponding. The vegetation is normal for the area. ................ .......... 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.doc-rev.6116 Title 5 Official 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 81 Paddock Lane Property Address Rodrigo Ballon jg� Owner Owner's Name information is North Andover MA 01845 04/02/2018 required for every - page. 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.): .......... --------- .......... ........... 15ins.doc-rev.6116 Title 5 Officiai Inspection Form:Subsurface Sewage Disposal System-Page 14 of 17 Commonwealth of Massachusetts - _ , Title Official InspectionForm ... a Subsurface Sewage Disposal System Form - Not for Voluntary Assessments �4! 81 Paddock Lane Property Address Rodrigo Ballon Owner Owner's Name information is North Andover MA 01845 04/02/2018 required for every _......_._._ -._ __...._..___..._ ---._.._ ....._ — page, Gity[Town State Zip Code Date of Inspection D. System Information (cant.) Sketch Of Sewage Disposal System: Provide a view of the sewage disposal system, including ties to at least two permanent reference landmarks or benchmarks, Locate all wells within 100 feet. Locate where public water supply enters the building. Check one of the boxes below: ❑ hand-sketch in the area below ® drawing attached separately l5ins.doc-rev,6116 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 15 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form Not for Voluntary Assessments 81 Paddock Lane Property Address Rodriclo Ballon Owner 6wne'e�-N-ame information is ed for every North Andover MA 01845 04/02/2018 requir page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Site Exam: Check Slope Surface water Check cellar Shallow wells 41 Estimated depth to high ground water: .fe I et 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: 05/93/1980 Date El Observed site (abutting property/observation hole within 150 feet of SAS) El Checked with local Board of Health - explain: El Checked with local excavators, installers - (attach documentation) El Accessed USGS database -explain: You must describe how you established the high ground water elevation: Obtained from plan on file with BOH. ........... Before filing this Inspection Report, please see Report Completeness Checklist on next page. t5ins.doc,-rev.6116 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 16 of 17 Commonwealth of Massachusetts Title 5 Official Inspection For w o Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 81 Paddock Lane _.. ......._.... Property Address Rodrigo Ballon._..._ Owner Owner's dame information is North Andover MA 01845 04/02/2018 required for every _._._._ _.._.._ ....__...., ._ _._. page, Cltyrrown 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.doc•rev.6116 Title 5 official Inspection Form:Subsurface Sewage Disposal System-Page 17 of 17 C(][OM0WDVVeB|fh of Massachusetts City/Town of NORTH ANDQ�LELRMASSACHUSETTS System PumTing Record Form 4 DEP has provided this form for use by local Boards of Health. The System Pump be submitted to the local Board of Health or other approving authority. flotRecord nV00' A. Facility Info-rmation When filling Out 1. � forms on the computer,use only the tab key *odmmto move your Wcursor-do notm�hAnduva �A 01845 � � ��.m� ��----- "=v� mmm oum | �;. _' —_ � ^' ~/ i Name �ty,To�-. __-__ State Zip 7ooe--'--- -� u3. ruomopwxvg Record ' | / /��\(l ' 1. D�uofPumping ��-��--� �. �uardMyPumped� ' J �� Gallons 3. Type o[system: [] Cesspool(s) A°apdcTank Tight Tank � El Other(describe): ------ � � 4. Effluent Tee Filter present? c� v~s [l No |fyes,was itcleaned? [a-Yes Fl No � 5. Condition ofSystem: \ -' 06 6. System Pumped By: me Vehicle (� | VmndR�o Environmental ---''--- | 7. Location where contents were disposed: ! 1, PDat | 1,0swich, MA. hKpx�vmxwmaam mmo -- ! mmov*uoc-vmnu System Pumping Record`Page 1o/1 I 44" An Lot . a j1; zr ,vm N6flWY/ e lotsr VIE a Y;"'o, ' l w f r f A�1 MiU'Mryv ,l � + }, iT Arh � V)1u Mr � ✓� MMI �' 0 too , r " AW" r.m-,a'4M�" "Y" ✓ d F ,fiN$&. , M,� hit �� I) - 1. w40, 404 � MTV v an 4 oi, C J"C-v',r 4a K V u Body Art Practitioner $_______