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HomeMy WebLinkAboutBuilding Permit #Exception - 705 MIDDLETON STREET 7/17/2013 k"COV "COV L � Commonwealth of Massachusetts _ . City/Town of No'andover AUG '� 6 10i3 System Pumping Record TOINNOFNORTHANDOVER HEALTH DEPARTMENT Form 4 1M yve`' 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 from the pumping date in accordance with 310 CMR 15.351. A. Facility Information Important:When I filling out forms 1. System Location: on the computer, use only the tab 705 Middleton Rd key to move your Address cursor-do not No Andover' --- Ma - use the return City/Town State Zip Code key. 2. System Owner: Lopiano, Leo Name renen Address(if different from location) City/Town State Zip Code Telephone Number B. Pumping Record l 1. Date of Pumping Date 2. Quantity Pumped: Gallons 3. Type of system: ❑ Cesspool(s) eptic Tank ❑ Tight Tank ❑ Grease Trap ❑ Other(describe): - 4. Effluent Tee Filter present? ❑ Yes Ka?'No If yes, was it cleaned? ❑ Yes ❑ No 5. Condition of System: 6. System Pumped y: N.P- 7 Name Vehicle License Number Stewart's Septic Service Company 7. Location where contents were disposed: Stewart's Pre-treatment Plant, 20 So. Mill Bradford, Ma 01835 Signature of Hauler Date Signature of Receiving Facility Date t5form4.doc•03/06 System Pumping Record•Page 1 of 1 I Commonwealth of Massachusetts RECEIVED a W City/Town of NORTH ANDOVER JUN I C 201 System Pumping Record TOWN OF NORTH kIif)UVER Form 4 HEALTH,laEPAPITMENT 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 from the pumping date in accordance with 310 CMR 15.351. A. Facility Information Important:When filling out forms 1. System Location: on the computer, (01 �I Uuse only the tab LJ! ` �)1 � �'\l�'• key to move your Address cursor-do not NORTH ANDOVER Ma use the return City/Town State Zip Code key. 2. System Owner: 4 k LIINQno Name r Address(if different from location) City/Town State Zip Code Telephone Number B. Pumping Record _ 16 0 1. Date of Pumping Date 2. Quantity Pumped. Gallons 3. Type of system: ❑ Cesspool(s) [Septic Tank ❑ Tight Tank ❑ Grease Trap ❑ Other(describe): 4. Effluent Tee Filter present? ❑ Yes ❑ No If yes, was it cleaned? ❑ Yes ❑ No 5. Condition of System: ti 6. SyqW Pumped By: Name Vehicle License Number Stewart's Septic Service Company 7. Location where contents were disposed: wa s Pre-treatment Plant, 20 So. Mill Bradford, Ma 01835 k I ignature of Hauler Date Signature of Receiving Facility Date t5form4.doc•03/06 System Pumping Record•Page 1 of 1 1yJI1U(J {� IN f. sY chusetts y 'nor': ORT�:ANDOVEMAS SACHUSETTS +'iJj,; ;; DEP•.ha: `rovide 1 I�ECEIV�D Pr d this form for use by to al Boar sof Health. The System Pumping Record mus; be submltted to the.locai'13oard of Healthor other aPProvin9 au tho Ity. A; Facility information , Ling,oft'nt:,; '• .; ,:. ..:,r.• ,.',:' .. ,:,•.;.`•;',;';`.:;`,�': '�� TOWN OF NORTH ANDOVER System Location'`' HEALTH DEPARTMENT ony the tab key ' ` Address to move you[:: .., .dl2�� -- .cursor..•do of � usitherotum':%= .;:..City/Town . . .'/. Stat 7� V{ ]I ':•,':,' 4�'7 t;,�;:,';�, ;.•':: ,,.:�I•.'�•,,; L.I,Code '}>✓'r1. ?• ...'2,':;.SyS 8 OWnef. r;,'. . . �i•;rA�i�;(tl.4�r!`'' "f :i''t, :.'•,y N'. ;f�:NYril� y i.,,,:•j ly l:r rt•i•r, ,.., _. Address(If different from location) State 9�7 ZI C Telephone Number L > ,J , g,p.uln 1 e r, 0 n, :.R r ' n�� ,'�N,�•, .L+''':6•".,iii.':'=','�';L;.�11:1.,�;t„ ��r,�,� ,/ , • 1, / �� Dawof pumping' Date 2, QuantJty Pumped; /1 Gallons 3 s @, ste m;'� YP. 0 , . r.' Y :'❑• Cess ool s P ( Septic Tank ❑ Tight Tank "Other(describe), 4'; Effluent Tee Fllter p rosent? Yes No P ❑ If yes, was It cleaned? ❑ Yes ❑ No :i: t�_'. ,. .;..,•,n�..eLfh(:+i A.li'��...,:r,.r,:i:ay./ �1,ter,`, �'� Ilvi l.lii• v,. 1'' ' .. _.. ,{ `n•..y.,:J,.�• .7;�"(V:(i�,; +l:tLv�,...,� ,.1.to l{1.;YJ:,,.� ... .V .. .t' :n�r: :l;r;.17,„iur,.��;4” ,,'_'•:I;''r1+tid4.>.::`" . . . ;�,.� as r'1 r•IJ, r; ::i !�'1'.('•(t••1,1'�;..�, 6 Sy PPM a �a. ;�,. " �'>�'{., 'f��,; '1� - Vehicle Ucan+e Number �J y ----- �Y7/Y .r:h .i• •.:�)• .. ,, V1.1�M'),1�.� bll,'` �1�`{�411rT;1. J/ I _ -�y., � >.••:i••- a�•UJ•7�d5;.,',• q4i,JY.uwf �,i1[(���),� ir.a♦, t'r� I�';�'.:: . +.", .!'�•` '>,•`Y./'J•r;•: l•y::r• �'.' J4 r v�b l; Jry! C�#''v.�...,1�„1.:.Ir,j , .y'!y,f T.i:+�l.•..1 /,�.', ✓j'rpa ]y.Fjrl;.•.,.:,..:�bIW`t(` ' yvere:dloposed: �lc,i i..%tom.• ;;1.':•'.r. ':1('i,�:.(::.��• , "J{ •.;.. ,5 �r�iS{t �,avr L1.?t't� ,!,r• .,.,% "1�ry'�,v ... — � / •/ ' '.,• :' <.:;;.�':,a:�••;�,,,�:��^�.•r.;..Slpnatwe.o(Haule(;iw ' •Y.' 1.. /� Date http://www,mass.gov/dep/water/approvajs/t5forms,htm#Inspect • t5form4,doa!OddQ3 � •. , • ' fSystem Pumping Record Page i ot i Commonwealth of Massachusetts City/Town of NORTH ANDOVER, MASSACHUSETTS System Pumping Record RECEIVED Form 4 f{1�1n DEP has provided this form for use by local Boards of Health. The Syste Pu4i' KAA liiust be submitted to the local Board of Health or other approving authority. —"--�_, TOWN OF NORTH ANDOVER A. Facility Information s� Important: When filling out 1. JOE Location: forms on the j�- computer,use - 1 ' ' I 1 yari only the tab key d ess to move your o cursor-do not use the return City/Town State Zip Code` key. ey 2. System Owner: �I Name ~' Address(if different from location) City/Town State Zip Code Telephone Number B. Pumping Record /a(, ho &00 1. Date of Pumping Dat 2. Quantity Pumped: Gallons 3. Type of system: ❑ Cesspool(s) 19 Septic Tank ❑ Tight Tank Other(describe): 4. Effluent Tee Filter present? ❑ Yes ❑ No If yes,was it cleaned? ❑ Yes ❑ No 5. Condition of System: 6. S stem Pum d By: r S S6 1A.2, ,blame '» � Vehicle License Number Company 7. Location where contents were disposed: Signature of Hauler Date http://www.rhass.gov/deptwater/approvals/t5forms.htm#inspect t5form4.doc-06/03 System Pumping Record•Page 1 of 1 TOWN OF NORTH ANDOVER SYSTEM PUMPING RECORD DATE: - SYSTEM OWNER & ADDRESS SYSTEM LOCATION (example: left front of house) 1- . Ila 61 DATE OF PUMPING/ZELE QUANTITY PUMPED �I, GAL LONS CESSPOOL: NO 4 YES -__ SEPTIC TANK: NO _ YES 'MATURE OF SERVICE: ROUTINE EMERGENCY OBSERVATIONS: GOOD CONDITION HEAVY GREASE FULL TO COVER ROOTS ------- BAFFLES IN PLACE EXCESSIVE SOLIDS LEACHFIELD RUNBACK SOLIDS CARRYOVER -- FLOODED OTHER (EXPLAIN) SYSTEM PUMPED BY: BOA��OF HEALTF1 O:MMENTS: ? ��2 ONTENTS TRANSFERRED TO: M Ala4h Awn6ver 12.6- 4.,>» AG?in Sf. STjjfT S SEPTIC TANK SERVICE 47 RAILROAD STREET Na/4h L)rlt7.o�/�/' BRADFORD, MA 01835 uA Lie. r Sl-cam 978-372-7471 M Ll OF REPORT � 70M OF . M�TrHLY DATE AD�s GALWNS CO 4MM IJ91V bex6a,5-t- o 7s rIuh9aII � , 1400 1� Nc r 1 ( cher-,gip. ree//) boo 6 � 06 i02c�2 95,3FdrP5r 5,k xj r\44 /lam 15 60 -�'c'S.�rT,q:,,,���"r..f„!*'i7"'�•u.��{1..s..n'Its'+��n. .,7�,:A.�b'�"r''.h9`,K�i�'�;asja'+SzDi"wv1."'1���8'n�"4+�t�rw.+•'T:.`,t;i:...Yt-1{�i-',"',r�i"a,.v.�rt}i'�-��,kvfM;•��.NJ'��1':�iil-1''S.'-n-�,�r'tvY'--i.M-- tip,,. ,. a TIGER ENVIRONMENT N°FN °F�' -'-� ENGINEERING IoW 969 WASHINGTON STREET n� ` BRAINTREE, MA 02184 617-849-0088r N SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECT FORM w f PART A - CERTIFICATION t Address of Property: -105 ►4 Tyma rbo 2oA� Address of Owner: (if different) Town: too . Awi�,o\a;Q HA Owner's Name: ,. Date of Inspection: 9 " gyp' �� 1 �'� ���' ��� i l VoluntaryAssessment Name of Inspector:i poi i T�_ iNO (Not Reported) Name 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 inspection.The inspection was performed based on my training and experience in the proper function and maintenance of on-site sewage disposal systems. The system: X ,Passes Conditionally Passes Needs Furth Evaluation By The Local Approving Authority Fails Inspector's Signature: Date: 4 The system inspector shall submit a copy of this inspection report to the Approving Authority within thirty(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 Iwner shall submit the report to the appropriate regional office of the Department of Environmental Protection. The original should be sent to the system owner and copies sent to the buyer, if applicable, and the approving authority. i INSPECTION SUMMARY: ( Check A, B, C, or D A] SYSTEM PASSES: r X I have not found any information which indicates that the system violates any of the failure criteria as defined in 310 CMR 15.303. Any failure criteria not evaluated are indicated below. B] SYSTEM CONDITIONALLY PASSES: One or more system components need to be replaced or repaired.The system,upon completion of the replacement t; or repair, passes inspection. ?4. Indicate yes, no, or not determined (Y, N, or ND). Describe basis of determination in all instances. If "not determined", explain why not). The septic tank is metal,cracked, structurally unsound, shows substantial infiltration or exfiltration, or tank failure is imminent. The system will pass inspection if the existing septic tank is replaced with a conforming septic tank as approved by the Board of Health. *vµ"*•d:u'! '.irPr'^`i....tA�` : t'i..^*:to'"n.,�t@�;+"',..:,.;mV,fiti?d'dri' 4,r rn5?PF'tAaji� ' •Rut y"�`'. ' TIGER ENVIRONMENTAL ENGINEERING 969 WASHINGTON STREET BRAINTREE, MA 02184 617-849-0088 ` " SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A , P CERTIFICATION(continued)` Property Address: :•,/05 M�7.�Z66-ra T N- Z"wo �_. Owner: �--r k Date of Inspection: '. s},,'SY :•EM CO.NDITION.AI.LY;�QAS,�S{continued) h,. Sewage backup or breakout or high static water level observed in the distribution box is due to broken or obstructed pipe(s)or due to a broken,settled,or uneven distribution box.The system will pass inspection rf(with approval of the . Board of Health): "- broken pipes) are replaced obstructionlis removed ' distribution box is levelled or replaced The system required pumping more than four times a year due to broken or obstructed pipe(s).The system will pass inspection if(with approval of the Board of Health): r. 77>' broken pipe(s.) are placed,, obstruction is removed m C] OUR ER EVALUATION IS REQUIRED BY THE BOARD OF HEALTH: ` Conditions exist which require'further evaluation by the Board of Health in order to deterrnin_ a if the system is failing to protect the public health,safety and the environment. 1) SYSTEM WILL PASS UNLESS BOARD OF HEALTH DETERMINES THAT THE SYSTEM IS NOT FUNCTIONING IN A MANNER WHICH WILL PROTECT THE PUBLIC HEALTH AND SAFETY AND THE ENVIRONMENT: Cesspool or privy is within 50 feet of a surface water n` Cesspool or pFivy-is-uvithin.50 feet.of'a bordenng,:vegetated0etfand or salt marsh 2) SYSTEM WILL FAIL UNLESS THE BOARD OF HEALTH(AND PUBLIC WATER SUPPLIER,IF APPROPRIATE) DETERMINES THAT THE SYSTEM IS FUNCTIONING IN A MANNER THAT PROTECTS THE PUBLIC HEALTH AND SAFETY AND THE ENVIRONMENT: The system has a septic tank and soil absorption system and is within 100 feet of a surface water supply or tributary to a surface water supply. The.system has a septic tank and soil absorption system and is within a Zone 1 of a public water supply well. . The system has a septic tank arid`soil absorption system and is within 50 feet of a private water supply well; The system has a septic tank and soil absorption system and is less than 100 feet but 50 feet or more from a private water supply,well,unless a well water analysis for coliform bacteria and volatile'organic compounds indicates that the well is free from pollution from that facility and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm. R :, 2 •ek,^ r'.r...�...,..., Nlh t ,. r, x +,,d. r,w.-.w •• � � T#G R ENVIRONMENTAL ENGINEERING 5 969 WASHINGTON STREET BRAINTREE, MA 02184 617-849-0088 . . r 711 SUBSURFACE:SEWAGE DISPOSAL SYSTEM,INSPECTION FORM, PARTA. CERTIFICATION(continued) Property Address: _/05 m rme7ad P, A).*UVef,, 1�,q Owner: F,D 2 CG Date of Inspection: tt /SYSM FAILS: I have determined that the system violates one or more of the following failure criteria assdefined in 310 CMR 15.303. Tn k3' sis for this d tenni toms`ii entified°below.The 138arid of Heaffht"i h&-Id be ' htacted,to-determine what will be necessary to correct the failure. I , Backup of sewage into facility or system component due to an overloaded or clogged SAS or cesspool Dischargeor 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. x Liquid depth in cesspool is less than 6" below invert or available volume is less than 1/2 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 soil absorption system, cesspool or privy is below the liigh groundwater elevation. Any portion of a 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: f t-. 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 t` well with no acceptable water quality analysis. If the well has been analyzed to be acceptable,attach copy. of well water analysis for coliform bacteria,volatile organic compounds,ammonia nitrogen and nitrate nitrogen. E] LARG SYSTEM FAILS: The follo ng criteria apply to large systems in addition to the criteria above: The design flow of system is 10,000 gpd or greater(large system) and the system is a significant threat to public health and safety and the environment because one or more of the following conditions exist: „. Thesystem is ithin 400 Jeet of a surface drinking water supply The,,system is within°20o fee'Vof a tributa7y td a Suface 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). The owner or operator of any such system shall bring the system and facility into full compliance with the groundwater treatment °I program requirements of 314 CMR 5.00 and 6.00. Please consult the local regional office of the Department for further information. The intent of 310 CMR 15.302 is to provide reasonable guidelines for the inspection of existing systems in as non-intrusive a manner as is possible to avoid damage to the.system and any unnecessary disturbance of the surrounding soil area which is f. related to the treatment process. The inspection is not designed to provide information to demonstrate that the .system willI adequately serve the use to be laced u on it b the new owner.The inspection criteria are-intended to allow for time) inspection a q , Y p P Y p Y' P to avoid undue delay in the transfer of property. t f I understand that this report does not constitute a warranty or guarantee of future operation. Client or Representative Date �' 3 , TIGER ENVIRONMENTAL ENGINEERING ,r 969 WASHINGTON STREET BRAINTREE, MA 02184 617-849-0088 - SYSTEM IN s SUBSURFACE SEWAGE DISPOSAL INSPECTION FORM - {; PART6' .CHECKLIST Property Address: 7d S m A&M4 � Oo• &�tadZMA :s Owner: t -. J,. Date of Inspection: 4'3o-% Check if the following have been done: r i:.".+r 'Si: '��"�, z•.''- +�».tr.. fi,,' S:. � V/ Pumping information was requested of the owner,occupant,,and Board of Health. 0' y/ None of the"system components have been pumped for at least two weeks and the system has been receiving normal flow rates during that period. Large volumes of water have not been introduced into the system recently or as part of this inspection. As built plans have been obtained and examined. Note if they are not available with N/A. +rM / The facility or dwelling was inspected for signs of sewage back-up. V The system does not receive non-sanitary or industrial waste flow. The site was inspected for-'signs of breakout. All system components, excluding the soil absorption system, have been located on the site. The septic tank manholes were uncovered, opened, and the interior of the septic tank was inspected for condition of baffles or tees, material of construction, dimensions, depth of liquid,depth of sludge, depth of scum. 1/ The size and location of the soil absorption system on the site has been determined based on existing information or approximated by non-intrusive methods. This(ability,owher,(and.odcupanfs,,,if differentfrom.own er);w�ere rov.ided withdinformation on the proper maintenance of subsurface disposal system. Y' r4 5:i 4 4 ......,:.`�rw*s•r,:.vw:Vu'�.',t¢:�rr$'4(lir,•r+^a,..t^r—...,,•.1.;-rr^-�,...r..wf;;Wfi�f,....tt.' <a.v..+>j;,,..r�� }j1',W�7 Ji°A:r,'`,'t,*wMy,.ra:,:y,��nir'�'.i'C+r�t'.n.:rrd4s.w.,';,rr-i. G,�'`+�,;6y�.. . -r, TIGER ENVIRONMENTAL ENGINEERING 969 WASHINGTON STREET .M. BRAINTREE, MA 02184 . 617-849-0088- SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM: PART C j. SYSTEM INFORMATION Property Address: JOS M Ib troy Rte; 4. Owner: �J 2 G ; q Date of Inspection: 4-146 T- FLOW CONDITIONS I RESIDENTIAL: ¢> . Desi+gn;flpw�,�30�rgallons�.,.-E-� _ Number of bedrooms: ,Number of current residents:' .2,- Garbage grinder: (yes or no) ,7A Laundry connected to system`(.yes or no) ES Seasonal use: (yes or no) _ :a Wate(meter.readings;if availatle Plm Last date of occupancy: eu A"4y � D COMMERCIAL/INDUSTRIAL: f Type of establishment: Design flow- gallons/day Grease"trap present:.(yes or no) w. Industrial waste holding tank present. (y.es or no) Non-sanitarywaste discharged to the Title 5 system: (yes or no) , Water meter readings, if available: 1. Last date of occupancy: OTHER: (Describe) Last date of occupancy: y GENERAL INFORMATION PUMPING RECORDS�'and source of information. b 1»arr,4S System pumped as part of inspection:(yes or no) A//0 If yes, volume pumped: gallons Reason for pumping: TYPE OF SYSTEM: g: Septic tank/distribution box/soil absorption system 4 Single cesspool :Overflow cesspool Privy y f 40 Shared system(yes or no)(if yes, attach:previous records, if an ) other(explain): Sec.- sMr�3<r� i; Al APPROXIMATE AGE of all components, date installed(if known) and source of information: t 5 • r ..;.ti.-,w'�rr••r'+�ut.r+...,ra.iF"'r.TM•. M},._f„ w .y._� ,. .-..y ., � :y,,.- •_;f"k:,�.,r:h: .,xs�>:..�,.ti;�''°"J"` r?r TIGER ENVIRONMENTAL ENGINEERING 969 WASHINGTON STREET BRAINTREE, MA 02184 r 617-849-0088 w S� SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM:r ` f PART C SYSTEM INFORMATION(continued) Property Address: zzceraj 17.E A� Umad Owner: r Date of Inspection: - - � _ v M' l Sewage odors"detected when arriving at the site: (yes or no) KI© { {880+16T{'.1 n. . . t @ ..y .. .? e5 41 Vln b f (locate on site plan) Depth below grade: , `# Material of construction: Xi-concrete metal FRP other(explain) Dimensions: # "� �� �'- © x- O' 'JEEP ` Sludge depth: McWe Distance from top of sludge to bottom of outlet tee or baffle: Scum thickness: . MoME Distance from top of scum to top of outlet tee or baffle: Distance from bottom of scum to bottom'of outlet tee or baffle: Y b Comments (recommendation for pumping, condition of inlet and outlet tees or baffles, depth of liquid levet in relation to outlet invert, structural integrity; evidence of leakage, etc.) Meijk . 6&J C t+iMdilf A-r Es2AtE Mo ' 1 COMM 1j�U.M- �y .�-�-�� ����Np(/.�E.T�� ,,.�,pp�. . l_I(.2,j1� &Ue- f✓U0J /`I aUT�� wyetr- I lT7l/i 7QI�CIOL� nrUcml`ftA4 �1UN� I\l� 4EJ t N CJF t OWAtzE . GREASE TRAP: No (locate on site plan) �. Depth 6elo4 grade =r >•"' . a �� ' ;: , : r u t'r �.. : Material of construction,., concrete metal FRP oAr(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: Comments< (recommendation for pumping,condition of inlet and outlet tees or baffles,depth of liquid level in relation to outlet invert, ,. structural integrity,evidence of leakage, etc.) 4a ' 6 1. wzh`y.s�. n.; .t,s w, «^ .^+ �, �{�- +� 7 i +, e ♦ ay..;..r+.r ! ;:v -Y.Y Ky lk.... ..,. .. „ _ .- ,� ,.. �-, .. •�+�'3 � '4.:;;.mow�ti •`y.u.'+..� TS�¢:.y.Yy.Y+. °K,.' �=' ' TIGER ENVIRONMENTAL ENGINEERING 969 WASHINGTON STREET BRAINTREE, MA 02184 ' 617-849-0.088 . n °SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM: F 4� y .� PART C <e SYSTEM INFORMATION(continued) iso &bg� A Property Address: �Ii'cti1 Owner: Date of Inspection TIGHT OR HOLDING TANK Depth below .grade;.. Material of construction: ° x oncrete metal FRP other(explain) Dimensions: Capacity: gallons Design flow: gallons/day .. Alarm level: t Comments. (condition of inlet tee, condition of alarm and float switches etc) �. DISTRIBUTION BOX: W r-H 2. bol- erS (locate on site plan) Depth of liquid level above outlet invert: EVEN! Comments: (note if level and distribution is equal evidence of solids carry over, evidence of leakage into or out of box, etc.) A. V fbENC.#_: 'OF SmaiS C dz'z y og em. No >I:--y i-cg N CE. OF l£-AtCkT_-jE i nrro o K acrr C�—" Boy'. PUMP CHAMBER: 'tom (locate on site plan) Pumps in working order: (yes or no)*� Corm nts: (note condition of pump chamber, o nditionof pumps and appurtenances etc,)' CIA - Fj (. P 7 • .•�`J s ¢Y.;�•^ µ ..r�'� � .,�. .Yr {' f�',1 q M1E,r_.t, .xv •ry. ,. e'� ^a, . v,. a - •y f TIGER ENVIRONMENTAL ENGINEERING 969 WASHINGTON STREET BRAINTREE, MA 02184 }: f '617-849-00 8 "`SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION:FORM F F PART C r SYSTEM INFO MATION(continued) !k Property Address: �OS PA iMZ r,,j ., �Q• � � rF, Owner: : .W Date of Inspection: 4-230–% I �0 q SOIL ABSORPTION SYSTEM(SAS): fe-5- (locate on sitl,plan, if possible excavation not required, but may be approximated by Aon-intrusivd methods) 14 If not determined to be present, explain: N Type' Leaching pits, number: Leaching chambers, num er_ , Leaching galleries, numbeY4 .: -'—,Leaching trenches, number, length: t 6S 6A Leaching fields, number,dimensions: Overflow cesspool, number: comments:;(,note,condition of soil,signs of hydraulic failure; level of ponding, condition of vegetation, etc.) � ► '+tom PJ0 51.66 'OF' N tit :r -� V. T1W. . .. jj CESSPOOLS X30 r (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: y Indication of groundwater: Inlbw cess of roust be umpe `a a of irr ec on ' -4 t 4 "comments: (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.). PRIVY: i (locate onsite plan) , Materials of construction. Dimensions: F p - - De th of solids: - Comments: (note condition of soil; signs-of hydraulic failure, level of ponding;condition of vegetation, etc.) . 8 — I W;Y. n TIGER ENVIRONMENTAL ENGINEERING 969 WASHINGTON STREET BRAINTREE, MA 02184' .� �r 617-849-0088, , SUBS�IRFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM., } ` PART C SYSTEM INS MATION(continued) 1 Property Address: �a HIAW6r`z�a l � M0. ,MA Owner: f Date of Inspection: 'rr 'SKETCH OF SEWAGE DISPOSAL SYSTEM: Include ties to at least two permanent references landmarks gr benchmarks ,� t _ Locate,1all�rellsyw�th�n,!:Op' rt. r ,p h . . . . . . . . . . . . . . . . .. ,. ., .� . . . . . . . . . . . . w y � :. :. .fit e .. - _�} . 4 y • t 1 j i{��''Y •: }yam 77""�� ♦ /�{��' 1� �rfl.{r ..✓� �` �V/r f •�� i �L'. i t ::'1 Rt r4` �w.w► 1 '.i.l �� t t y4 • r -:.:. N Auw� s . . • . . . . . . . . . TA ►� 51r Iz t'. ! a 'iy, . . �,+ ,� .. V1 ,�. a � . . J .r,, . �� •i, --• �tsTRti3u w J 8Mx ZG!' l DEPTH TO GROUNDWATE Depth to groundwater �'�`��feet • pP w Method of�deterrninat�on ora roximation � ' rk - 14 If 9 " , I)�''i'{LE:�C,��r 11�,IS•,11��' •�,'�J��'i 1�1 h�r1S,+Jl r(�r�'f M�y'1,ijlj'�b iC 11 r f/•!i. r '�+ 7- , ti r, ; �'.------.—._-.._ ..._. la,j•!'�.� ��{'1.r5/',,/!11' 11,141,r41r�.:J)illa�i'IrYi�lhli�;%11'4`!1 lr1`'IA1It1 , 'r• I� S � �./ ;•,�ii 11`I + I;' (IN1(�1C+)J'!yl�17! Zk �.,r .l.r,�.�;�ti.1`i't•i`Ia,I J.f,1 :./ly fi.!'`11p Il,f+r 4.r,:,11. •r::lr :7. tY ('.n-1r fel 11 y111�y1)�s+M •+I i v, �t i rl la)` 1 ', `y' ` ;,(t.,',1!r;•I':11' 17'.7.' �•1,.,� ':'��:•��',.1','•I:i,• �, �t (��lY��'� 1. f) � �, ',II� t ) IS 1 ' gip-� �•i4l f,..�• ` +S{'' NORT ,a SYSTEM pUiYlpr:j��,'RI.D Cotte .. 1 ,,.,1.. 1 I• .. .. M M",UwN�R k-ADDR:CSS ,.. SYSTCM LOCM -- 0 � e-ia (ez� ale; Icf�:froni of nou,� QUANTITY 'I'UM('GD {) '" '.'I:it,•: �I ,1 llS4 i!/�'1)'r 1rY'ft Uu' i I ,: ",•1, .r fa;'•1'i YQ j:7ll(,,�. .1,17,f'.',.Y,J.�!��4`, ro. 1��'1.r`..,.. � . C'I':»I'UU.I ;�NO YES PTI CYTA IN K: N 0 Y F �TUfirE OF SERYICEt" ROUTINE, EMERC EI�CY I • 1.111>(',(ZY;IT�IO�S,� ,k, `.G U• . U L:'TU CUYCI�. C;KEAS.0° ':1 „�a'FFILS IN I�I,AC LEACHFICLD ItUNUA G XCC tY .S. S •li. ;, F I�0 O.D E D . o' u '�'���:�, �'� . ., �: .Y, :C��j•HSR` PLA-IN) •.I:rri^'•tc1�:Yl:r''y'f ,, , ,,t';� 1, �} ''t' ;,��;;,;, 1,,: ff, ;l:)r.,a..:.5.s i .•:�1:i,,..r..v(' I ,t�,)ry-.�,.�,1;,1r!. !�°�')•I J':li:li,1;�1,�,'� �'� [/,!'f,,,',Y Y.1 —.—_... .. � :'.Y .r,5. ;(.. )� •LJy,C:A. rC.:n •.r:'.� ... ..�;` Ir(^t`: I I r'Jt.rf'• .u. rur.k oV da, a• -'i. `r .1 ,• r� J' 7 I it ta 'if,� {.{ G,��•ti�hl.t ' 'nti. .f'Ile :51'I •• S'(r;t. .ylpl_,.�t"f,/,1;.:["1 i�'yrJr.nal:r:i,,,>r; tia; i 1 � p•f 7.•tt�' d 'llr 2 ,a1,Ay1'J t:�1 ti r !,, � - ' `�'V. •y+.�i'1•:: ',r�'.G:',S�.L:(lis,',r�':,'4':i:�,�frdl;v 1�:+�1 ..L,.. .. of TOWN OF NORTH ANDOVER I't ,� �C/�J.— SYSTEM PUMPINQ R.ECO}tl.,r S S SM OWNER& ADDRESS SYSTEM LOCATInN DATE OF PUMP1Nq; ...___._QUANTITY PUMPED. _ . 63SP00L\NO __ YES . SOPc c TLnk: NU, YES NA ruKu of SBRVICE: P.Ov'rlNE. _ RECD _ �M�RUENC'1' IVE® OUSBAVA'nom: JUN 0 3 2005 0000 CONDITION FULL. 'IU t,`pYErR FiZ3AYY O tP.A,98 _� BAMES IN PLACE, TUHEALTH DE ARTME�VER Kom ._ LE,tiCF{FIeLD RUNBACK SXCQS$7YE SOUIDS. _.. FLOODED . SOLIDCARRYOYER, OTHER EXPLAIN $yd by �uN rEN•l� rtt��N�r•�k�u rc, Commonwealth of Massachusetts _ City/Town of North Andover System Pumping Record Form 4 ^M Sy`e 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 from the pumping[1 a7te in__. accordance with 310 CMR 15.351. ED A. Facility Information OT 10 Qi1 Important: When filling out 1. System Location: TOWN OF NORTH ANDOVeri forms on the HEALTH 17EPARTMENT computer, use 71 only the tab key Address to move your No.Andover Ma 01845 cursor-do not City/Town State Zip Code use the return key. 2 System Owner: Name Address(if different from location) City/Town State Zip Code Telephone Number B. Pumping Record _ I /� 1. Date of Pumping Cl ! I 2. Quantity Pumped: Date Callon 3. Type of system: ❑ Cesspool(s) C113"eptic Tank ❑ Tight Tank ❑ Grease Trap ❑ Other(describe): 4. Effluent Tee Filter present? ❑ Yes ❑ No If yes, was it cleaned? ❑ Yes ❑ No 5. Condition of System: 6. ystem Pu ped By: Name Vehicle License Number Stewart's Septic Service Company 7. Location where contents were disposed: Onwa art's Pre-trea ment Plant, 0 So. Mill Bradford, Ma 01835 ure of Hauler Date Signature of k6ceMng Facility Date t5form4.doc•03/06 System Pumping Record•Page 1 of 1