HomeMy WebLinkAboutMiscellaneous - 102 SUGARCANE LANE 4/30/2018 (2)y . v
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STREET-
CONSIR UCTIO.N_APP
HAS PLAN REVIEW FEE .BEEN PAID? YES NO
PLAN APPROVAL: DATE )p. BY �
DESIGNER: PLAN DATE. �� Z Zy-
CONDITIONS
WATER UPPLY:(::TOWN WELL
WELL PERMIT DRILLER
WELL TESTS: CH L DAZE APPRUVED
BACTERIA I DA I E f)PPRUVED
BACTERIA II DA i' PR(
COMMENTS:
FORM U APPROVAL: APPROVAL TO ISSUE YES NO
DATE ISSUED 11 BY
CONDITIONS:
FINAL APPROVAL:
ALL PERMITS PAID YES NO
WELL CONSTRUCTION APPROVAL YES NU
SEPTIC SYSTEM CONSTRUCTION APPROVAL YES NO
OTHER YES NU
ANY VARIANCE NEEDED YES NO
FINAL BOARD OF HEALTH APPROVAL: DATE:.CG BY:,�
'E._G�SY�CM_+�NSIfl4L,gtI Q�l
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•
sx: 1.
'THE'INSTALLER LICENSED? + `�+ YES
NO
`TYPE. OF- CONSTRUCTION: —" NE
REPAIR
• '- ..:.NEW CONSTRUCTION:,.,. CERTIFIED PLOT PLAN REVIEW YES
NO
ONDITIONS OF:. APPROVAL YES
NO
(FROM FORM U),.
' ISSUANCE OF DWC PERMIT YES
NO
DWC PERMIT N0. - `- INSTALLER:��L
BEG IN,INSPECTIONYES 0:
EXCAVATION , INSPECTION: ; NEEDED:
PASSED —BY
., :.:CONSTRUCTION INSPECTION: =; NEEDED:
AS BUILT PLAN SATISFACTORY: �? y
APPROVAL. TO BACKFILL: DATE: BY
DATE
GRADING APPROVAL:
t
/�/BY
...FINAL CONSTRUCTION APPROVAL: DATE:
_/"�"
-C-\ Commonwealth of Massachusetts VAR r,`, 2014
City/Town of -
- - NORTH ANDOVER ,'- .-,y'�
System Pumping Record ' '1 i41
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 within 14 days from the pumping date in
accordance with 310 CMR 15.351.
A. Facility Information
Important:
When filling out 1. System Location.-
forms
ocation:forms on the
computer, use —_/O'Z S G G.� Cu•• L_ — ---.- —.----_.—.-_--
only the tab key Address
to move your
cursor - do not CityfTown — State Zip Code
use the return
key. 2. System Owner:
Name
Address (if different from location) ----- — - - ----
City/Town State Zip Code
0711 5,s -i -----
Telephone Number
B. Pumping Record
2. QuantityPumped: Gallon
1. Date of Pumping Date p
3. Type of system: ❑ Cesspool(s) Ly --Septic Tank ❑ Tight Tank ❑ Grease Trap
❑ Other (describe):--- — - - -
4. Effluent Tee Filter present? ❑ Yes [9'No If yes, was it cleaned? ❑ Yes ❑ No
5. Condition of System:
Ale
6. System Pumped By:
Name
Company
z ;7/1-7 /
Vehicle License Number
7. Location where contents were disposed: I W.W.1;p
Signature of Hauler
Signature of Receiving Facility
Date
Date
t5form4.doc• 03/06 System Pumping Record • Page 1 of 1
f.
of MORiM ,h
•a• o
0
0 eZ . 9
Town of North Andover
'�'•�;, ;o :: HEALTH DEPARTMENT
,sS�tCNUstt
l
CHECK #: I DATE: I C )
LOCATION:
H/O NAME:
CONTRACTOR N
6619
13
Type
of Permit or License: (Check box)
$
❑
Animal
$
❑
Body Art Establishment
$
❑
Body Art Practitioner
$
❑
Dumpster
$
❑
Food Service - Type:
$
❑
Funeral Directors
$
❑
Massage Establishment
$
❑
Massage Practice
$
❑
Offal (Septic) Hauler
$
❑
Recreational Camp
$
❑
Sun tanning
$
❑
Swimming Pool
$
❑
Tobacco
$
❑
Trash/Solid Waste Hauler
$
❑
Well Construction
$
SEPTIC Sustems:
❑
Septic - Soil Testing
$
❑
Septic - Design Approval
$
❑
Septic Disposal Works Construction (DWC)
$
❑
Septic Disposal Works Installers (DWI)
$
❑
Title 5 Inspector
$
❑
Title 5 Report
$
❑
Other: (Indicate)
$
Health Agent Initials
White - Applicant Yellow - Health Pink - Treasurer
Owner
information is
required for every
page.
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
102 Sugarcane Ln
Property Address
William Cunningham
Owner's Name
North Andover
City/Town
RECEIVED
OCT 2 2, 2013
TOWN OF NORTH ANDOVER
Ma 01845 10/1/13 / (f /
State Zip Code Date of Inspecti (y9
it
VI
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
Mike Graham
use the return
Name of Inspector
key.
C
Windriver
Company Name
163 Western ave
Company Address
Gloucester
City/Town
978-282-7315
Telephone Number
B. Certification
Ma
01930
State Zip Code
1356b
License Number
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
Inspector's Signature
./6P-�F- 13
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
Owner
information is
required for every
page.
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
102 Sugarcane Ln
Property Address
William Cunningham
Owner's Name
North Andover
Cityfrown
B. Certification (cont.)
Ma 01845
State Zip Code
10/1/13
Date of Inspection
Inspection Summary: Check A,B,C,D or E / always complete all of Section D
A) System Passes:
® 1 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
Owner
information is
required for every
page.
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
102 Sugarcane Ln
Property Address
William Cunningham
Owner's Name
North Andover
City/Town
B. Certification (cont.)
nna n1Ra-rt
State Zip Code Date of Inspection
❑ 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
Owner
information is
required for every
page.
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
102 Sugarcane Ln
Property Address
William Cunningham
Owner's Name
North Andover
Cityrrown
B. Certification (cont.)
Ma 01845 10/1/13
State Zip Code Date of Inspection
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'/2 day flow
t5ins • 3113
Title 5 Official Inspection Form: Subsurface Sewage Disposal System • Page 4 of 17
Commonwealth of Massachusetts
W Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
102 Sugarcane Ln
Property Address
William Cunningham
Owner Owner's Name
nformation is
equined for every North Andover Ma 01845 10/1/13
equire
age. City/Town State Zip Code Date of Inspection
B. Certification (cont.)
Yes No
El® Required pumping more than 4 times in the last year NOT due to clogged or
obstructed pipe(s). Number of times pumped:
❑ ® Any portion of the SAS, cesspool or privy is below high ground water elevation.
E]® Any portion of cesspool or privy is within 100 feet of a surface water supply or
tributary to a surface water supply.
El® Any portion of a cesspool or privy is within a Zone 1 of a public well.
El® Any portion of a cesspool or privy is within 50 feet of a private water supply well.
El® 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.]
i
r
p
❑ ® The system is a cesspool serving a facility with a design flow of 2000gpd-
10,000gpd.
❑ ® The system fails. I have determined that one or more of the above failure
criteria exist as described in 310 CMR 15.303, therefore the system fails. The
system owner should contact the Board of Health to determine what will be
necessary to correct the failure.
E) Large Systems: 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
❑
❑
Area — IWPA) or a mapped Zone II of a public water supply well
❑ ® The system is a cesspool serving a facility with a design flow of 2000gpd-
10,000gpd.
❑ ® The system fails. I have determined that one or more of the above failure
criteria exist as described in 310 CMR 15.303, therefore the system fails. The
system owner should contact the Board of Health to determine what will be
necessary to correct the failure.
E) Large Systems: 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
❑
❑
the system is located in a nitrogen sensitive area (Interim Wellhead Protection
Area — IWPA) or a mapped Zone II of a public water supply well
If you have answered "yes" to any question in Section E the system is considered a significant threat,
or answered "yes" in Section D above the large system has failed. The owner or operator of any large
system considered a significant threat under Section E or failed under Section D shall upgrade the
system in accordance with 310 CMR 15.304. The system owner should contact the appropriate
regional office of the Department.
t5ins • 3113 Title 5 Official Inspection Form: Subsurface Sewage Disposal System • Page 5 of 17
Commonwealth of Massachusetts
W Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
102 Sugarcane Ln
�M
Property Address
William Cunningham
Owner Owner's Name
information is
required for every North Andover Ma 01845 10/1/13
page. City/Town State Zip Code Date of Inspection
C. 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
this inspection?
® ❑
Were as built plans of the system obtained and examined? (If they were not
available note as N/A)
® ❑
Was the facility or dwelling inspected for signs of sewage back up?
® ❑
Was the site inspected for signs of break out?
® ❑
Were all system components, excluding the SAS, located on site?
® ❑
Were the septic tank manholes uncovered, opened, and the interior of the tank
inspected for the condition of the baffles or tees, material of construction,
dimensions, depth of liquid, depth of sludge and depth of scum?
® ❑
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:
Number of bedrooms (design): 4 Number of bedrooms (actual): 4
DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x # of bedrooms): 440
t5ins • 3113 Title 5 Official Inspection Form: Subsurface Sewage Disposal System • Page 6 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
wM 102 Sugarcane Ln
Property Address
William Cunningham
Owner Owner's Name
information is
required for every North Andover Ma 01845 10/1/13
page. City/Town State Zip Code Date of Inspection
D. System Information
Description:
t5ins - 3/13 Title 5 Official Inspection Form: Subsurface Sewage Disposal System - Page 7 of 17
Number of current residents:
3
Does residence have a garbage grinder?
❑
Yes
®
No
Is laundry on a separate sewage system? (Include laundry system inspection
information in this report.)
❑
Yes
®
No
Laundry system inspected?
®
Yes
❑
No
Seasonaluse?
❑
Yes
®
No
Water meter readings, if available (last 2 years usage (gpd)):
57.75gpd
Detail:
Sump pump?
❑
Yes
®
No
Last date of occupancy:
Current
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:
t5ins - 3/13 Title 5 Official Inspection Form: Subsurface Sewage Disposal System - Page 7 of 17
q 1
Commonwealth of Massachusetts
W Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
�M 102 Sugarcane Ln
Property Address
William Cunningham
Owner Owner's Name
information is
required for every North Andover Ma 01845 10/1/13
page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
Last date of occupancy/use:
Other (describe below):
General Information
Pumping Records:
Date
Source of information: Owner/Windriver
Was system pumped as part of the inspection?
Ifyes, volume pumped1500
:
gallons
How was quantity pumped determined? Pump truck/tape measure
Reason for pumping: Check structural intergrity
® Yes ❑ No
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):
t5ins - 3/13 Title 5 Official Inspection Form: Subsurface Sewage Disposal System - Page 8 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
�M 102 Sugarcane Ln
Property Address
William Cunningham
Owner Owner's Name
information is
required for every North Andover
page. Citylrown
D. System Information (cont.)
Ma 01845 10/1/13
State Zip Code Date of Inspection
Approximate age of all components, date installed (if known) and source of information:
Unknown
Were sewage odors detected when arriving at the site? ❑ Yes ® No
Building Sewer (locate on site plan)
Depth below grade: 10"feet
Material of construction:
❑ cast iron ® 40 PVC ❑ other (explain):
Distance from private water supply well or suction line: 50
feet
Comments (on condition of joints, venting, evidence of leakage, etc.):
All joints and venting in good condition. No evidence of leakage.
Septic Tank (locate on site plan):
Depth below grade:
Material of construction:
® concrete ❑ metal
T'
feet
❑ 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
Dimensions: H-5' L -10x6 W -5'x3"
Sludge depth:
4"
t5ins • 3/13 Title 5 Official Inspection Form: Subsurface Sewage Disposal System - Page 9 of 17
Commonwealth of Massachusetts
W Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
102 Sugarcane Ln
Property Address
William Cunningham
Owner Owner's Name
information is
required for every North Andover Ma 01845 10/1/13
page. CitylTown State Zip Code Date of Inspection
D. System Information (cont.)
Septic Tank (cont.)
Distance from top of sludge to bottom of outlet tee or baffle
31"
Scum thickness
1"
Distance from top of scum to top of outlet tee or baffle 6
Distance from bottom of scum to bottom of outlet tee or baffle
12"
How were dimensions determined? Tape measure/ sludge judge
Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity,
liquid levels as related to outlet invert, evidence of leakage, etc.):
Recommend yearly pump. The inlet and outlet are in place. The structural integrity of the tank is
good. The liquid levels are good and there is no evidence of leakage.
Grease Trap (locate on site plan):
Depth below grade:
Material of construction:
❑ concrete ❑ metal
❑ fiberglass
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:
t5ins - 3113
feet
❑ polyethylene ❑ other (explain):
Date
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
102 Sugarcane Ln
Property Address
William Cunningham _
Owner Owner's Name
information is
required for every North Andover Ma 01845 10/1/13
page. Cityrrown 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:
❑ concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other (explain):
Dimensions:
Capacity:
Design Flow:
gallons
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 • 3/13 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
^ 102 Sugarcane
Property Address
William Cunnir
Owner Owner's Name
information is
required for every North Andover
page. City/Town
D. System Information (cont.)
Ln
ham
Ma 01845 10/1/13
State Zip Code Date of Inspection
Distribution Box (if present must be opened) (locate on site plan):
Depth of liquid level above outlet invert
Ni
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 is level and distribution to all outlets is equal. There is no evidence of carry over or leakage into
or out of the D -box. D -box is 13" deep.
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
_ o Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
102 Sugarcane Ln
Property Address
William Cunningham
Owner Owner's Name
information is
required for every North Andover
page. Cityfrown
D. System Information (cont.)
Type:
❑
leaching pits
®
leaching chambers
❑
leaching galleries
❑
leaching trenches
❑
leaching fields
❑
overflow cesspool
❑
innovative/alternative system
Ma 01845
State Zip Code
10/1/13
Date of Inspection
number:
4
number: 25x16
number:
number, length:
number, dimensions:
number:
Type/name of technology:
Comments (note condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of
vegetation, etc.):
The condition of the soil is sandy and granular. There are no signs of hydraulic failure, no ponding or
damp soil. The condition of the vegetation is good.
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 - 3/13 Title 5 Official Inspection Form: Subsurface Sewage Disposal System - Page 13 of 17
F
O
a
I 102 Sugarcan(
�M
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
Property Address
William Cunnir
Owner Owner's Name
information is
required for every North Andover
page. City/Town
D. System Information (cont.)
Ln
ham
Ma 01845 10/1/13
State Zip Code Date of Inspection
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 • 3/13 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
° 102 Sugarcane Ln
Property Address
William Cunningham
Owner Owner's Name
information is
required for every North Andover Ma 01845 10/1/13
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:
® hand -sketch in the area below
❑ drawing attached separately
t5inc • 3113 Tido 5 Official Inspection Form. Subsurfaco So ago Disposal Syctom • Fago 15 of 17
1(
Commonwealth of Massachusetts
W Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
M
102 Sugarcane Ln
Property Address
William Cunningham
Owner Owner's Name
information is
required for every North Andover Ma
page. City/Town State
D. System Information (cont.)
Site Exam:
®
Check Slope
®
Surface water
®
Check cellar
®
Shallow wells
E tit A +h +^ hh d t o
01845 10/1/13
Zip Code Date of Inspection
78
s ma a ep o ig groun wa er. feet
Please indicate all methods used to determine the high ground water elevation:
/1
►1
Obtained from system design plans on record
If checked, date of design plan reviewed. 9/8/95
Date
Observed site (abutting property/observation hole within 150 feet of SAS)
Checked with local Board of Health - explain:
❑ Checked with local excavators, installers - (attach documentation)
❑ Accessed USGS database - explain:
You must describe how you established the high ground water elevation:
Christian Serqi Inc. duq on 9/8/95. The plan is on file at the local board of health.
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
Commonwealth of Massachusetts
W Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
°wM 102 Sugarcane Ln
Property Address
William Cunningham
Owner Owner's Name
information is
required for every North Andover Ma 01845 10/1/13
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
t5ins • 3/13 Title 5 Official Inspection Form: Subsurface Sewage Disposal System • Page 17 of 17
Commonwealth of Massachusetts
City/Town of
System Pumping Record NORTH ANDOVER
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 within 14 days fro p.4h, e�pu-mpipg.date in _
accordance with 310 CMR 15.351. CPV
6. System Pumped By:
Vehicle License Number — -- —`�- -
N e i
Company
7. Location where contents were disposed:
Signature of Hauler
Signature of Receiving Facility —� — Date
15form4.doc• 03/06 System Pumping Record • Page 1 of 1
A.
Facility Information
JUN - 4 2011
Important:
When filling out
1.
System Location:
TOWN OF NORT14 ANDOVER
HEALTH DEPARTMENT
forms on the
computer. use
((�� ���✓
only the tab key
to move your
Address
T -
cursor - do not
—` -
City(rown
State Zip Code
use the return
key.
2
System Owner:
Name
different from location)
Address (if
City/Town
State Zip Code
_7_11_LIA ------ - -_ ---- -
Telephone Number
B.
Pumping Record
j
1.
Date of Pumping—2.
Date
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? [PI Yes ❑ No
5.
Condition of System:
----------
6. System Pumped By:
Vehicle License Number — -- —`�- -
N e i
Company
7. Location where contents were disposed:
Signature of Hauler
Signature of Receiving Facility —� — Date
15form4.doc• 03/06 System Pumping Record • Page 1 of 1
TOWN OF NOR H Aga^�,,_
BOARD 0� H
. 1 i
SUGARCANE LANE A STEM
LOCATED IN NORTH ANDOVER, MA.
SCALE:1 "=40' DATE: 7/20/96
R=60'
L=100' Scott L. Giles R.P.L.S.
50 Deer Meadow Road
North Andover, Mass.
LO
0-
J M
N
H
0
J
LOT 7 r
AV
I CERTIFY THAT
THE OFFSETS
SHOWN COMPLY
WITH THE ZONING
BY LAWS OF
NORTH ANDOVER, MA.
WHEN BUILT.
TABLE OF ELEVATIONS
LOT 6
37,196 S.F.
210'5�ARE THE
OF THE BUILDINSHOWG INSPECTOR ONLYE
AND SUCH USE IS FORE HE
DETERMINATION OF ZONING
CONFORMITY OR NON—CONFORMITf
WHEN CONSTRUCTED.
0
Form No. 4
Town of North Andover, Massachusetts
BOARD OF HEALTH
CERTIFICATE OF COMPLIANCE
This is to certify that
the Individual Soil Absorption Sewage Disposal System constructed (X ) or repaired
by Bill Sawyer
INSTALLER
at 102 Sugarcane Lane, North Andover, MA 01845
SITE LOCATION
has been installed in accordance with Board of Health Regulations as described in the Design
Approval Site System Permit No. 764 dated Seat. 11, 19 95
The issuance of this certificate shall not be construed as a guarantee that the system will
function satisfactorily.
BOARD OF FIEWLTH ENGINEER
TO
DAT
TINJ,
'QO PM
FROM
AREA CODE
NO. (O�-� �6 �"I
OF
In
EXT.
M
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SIGNED
PHONE
I'RETURNED
ALL
WAS IN
UH(zEM
BACK
CALL
SEE YOU
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EXT.
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A
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hAQ-'
SIGNED
PHONED
BACK CAr[❑ CALL E SEE YOUTO L]
WILL AGAIN ALL ❑ WAS IN ❑ URGE
1
A
iV�4 SEF) -R YT:
.-
ENVJJtONMENTAL
n n r i+_ r\
CUIE �OE'a,: 4. ;ygTE vi PJ1v1Pi?�X ;RECORD
107 FOREST S?:U T; �bLr- jl r h!.A 019491978] ?i4-2177:
IvLSSACEi'_EPIS...
S;xTxS
SYSTEM D --
t t-` aXSTEM LOCA? 10U., -- " —
l�0A ccv,Cgv► fI
ie
DATE OF PUMPY.IG-� �G Q � p
QljANT!Ty- PuN ilED: QAII ONS
CESSPOOL: No —oe YDS C—
S—PPMC TASIA_: Y.;t
SYSTEM pUiPcD BY: CITE tEfi'C & b�2 Vii' V SRVI�
O4'`P ` NTS "i` tSFFRR--D TG:� ._.
Id iib u:5l JUiC I.C. ,i_�:
.�]�-'.1��1—,---�1T 'i�, � ,..., ;..;�r.„�1 ea:.. :i.cfl�• �l`,IdF+dS �:Ob-1
Td WHST :2-6 WOE TI "; ,D 90;-701JSL6L6T : 'C I ;x.H.� HSUMdH0 lOdrS 3->i'His : Wod
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Town of North Andover, Massachusetts Form No. 3
pCRTH - BOARD OF HEALTH
19 9
1. 9
�,S',r:e•��� DISPOSAL WORKS CONSTRUCTION PERMIT
SACHUSE
Applicant,�,�
NAME - ADDRESS TELEPHONE
Site Location _U1T G J UCS&CAA-le-
Permission is hereby granted to Construct (If/Or Repair ( ) an Individual Soil Absorption
Sewage Disposal System as shown on the Design Approval S.S. No._ ' to u
' OACRD OF HEALTH
Fee D.W.C. No. ?4,
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FORM U - VERIFICATION FORM
INSTRUCTIONS: This form is used to verify that all necessary
approvals/permits from Boards and Departments having jurisdiction
have been obtained. This does not relieve the applicant and/or
landowner from compliance with any applicable local or state law,
regulations or requirements.
****************Applicant fills out this section*****************
APPLICANT: �jcj F �,flc'XS ( oyr/� IAlt,.W,41i4 Phone J`✓S'%-//�%J
LOCATION: Assessor's Map Number fb 1 Parcel 6 a(e`�
Subdivision Lot(s)
Street Eck _ W'0n*,tlE LAA1,E St. Number %0.
o S - ,3 0
*** ***** *************Official Use Only************************
, C>J- � R�CO NDAT OF TOWN AGENTS:
C
Date Approved �, l
C servati n Administrator Date Rejected
Comments
Town Planner
Comments
Date Approved
Date Rejected
Date Approved
Food Inspector -Health Date.Rejected
r Date Approved
Septic Inspector -Health Date Rejected
Comments / //-� 1/`f�%�G�f-
Public Works - sewer/water connections
- driveway permit
Fire Department
Received by Building Inspector
Date
SUGARCANE LANE AS -BUILT SEPTIC SYSTEM
LOCATED IN NORTH ANDOVER, MA.
SCALE:1 "=40' DATE: 7/20/96
R=60'
L-100 Scott L. Giles R.P.L.S.
50 Deer Meadow Road
North Andover, Mass.
0
O m
L 77
sm
U
N �Ipir, `4B OF E TI S
'o 3 i ION
q 24.7(Yi _ : LOT 6
18 _ 7,196 S.F.
--2�
210'4
/O d. S"C'ne Ci*uf C�}NE , lJ. AlJb ovice, MR
T00 19 STIO � LODS SbK289 805 9
2T:8T 96-�2-LO
7-24-1996 2:36PH
DAT
TG:
FRO.
FPD,.1 COLOI,,JIAL v'ILLACE SCIS 682 2397
OF PAGr
S W/COIIvIE.R:-_Z---
'call if .-;I
.1 t
ME S SAGE, S :
Cc�' on v-, 1 a Corp.
-ary, B,,Z-er, Homes
CO i
Or'-� -1 Village Real Estate
,es
(1508) 682-2320 C),PF!Cw-
( -dt,CjY— �, F
'08) 82 39 7 AX
�Etf
/S
P. I
7-24-1996 : _;6P 1 FRU 1 COLOkl I AL V I LLAGE SOS 682 2397
07-%N4 13:12 2 5509 GS32645 SCOTT L G I LES
SUGARCANE LANE
R=$0`
L -t =
u7
o�
i
�
n
cv
M
1W
ileo
AS -BUILT SEPTIC SYSTEM
LOCATED IN NORTH! ANDOVER, MA.
SCALE.1"=40° DATE' 7/20/96
Soott L. Giles R.P.L.S.
50 Deer Meadow .Road
North Andover, Mass.
�- LOT 7
I hereby comity the I he inspected
the construction of this disposel system
and that the construction and final
pradlrr.j has been in accordance with the
dasipners intent and that the materials
used conform to the plan speclOcaWns
end 310 CMR 15.00
t
TABLE OF ELEVATIONS
Z'1(•54
LOT ,
37,198 S.F.
P.
�
` [
`
*
TRCTlOH
REPUHT
*
*
JUL-24-96 WE1; 09 16 AM
*
*
*
*
FOR
TOWN OF NORTH ANDOyER
542
*
*
*
*
SEND
*
*
DATE START
RECEIVER
PAGES TIME NOTE
*
*
*
*
JUL-24 09 14
AM 86822397
3 1'45n OK
*
*
*
*****************
*****************************************
t I
TOWN OF NORTH ANDOVER
HEALTH DEPARTMENT
120 MAIN STREET
NORTH ANDOVER, MA 01845
Telefax Transmittal Form
02Lj C3 q�o
Date
Addressee:
From:
Name:
Firm:
Street:
City, State, Zip:
Telefax phone number: 5 -OF - 6k ,�- - a3 9 %
Town Hall Annex
Health Department
146 Main Street
North Andover, MA 01845
Telephone # (508) 688-9540
Telefax # (508) 688-9542
Total number of pages, including transmittal form
I'f you do not receive all pages, notify sender immediately.
Additional Comments:
6.
Final Grading: Conducted after system has been
approved and has been backfilled. The installer should
have the system graded as per the plan of the disposal
system.
1.12 Prior to Final Inspection and backfilling of the
disposal system, a designer shall make an inspection of
the disposal system and prepare an As -built Plan to be
submitted to the Board of Health. (See As -built
Requirements, Section 6.05)
1.13 As -built Plan to be submitted to the Board of Health.
Appointment is made for Final Inspection.
1.14 After backfilling, a designer shall make an inspection
of the grading around the septic system. The designer
shall certify that the system has been constructed in
--� substantial conformance with the approved plan, that
the materials used were in conformance with the plan
specifications and that the final grading substantially
conforms to the proposed plans.
1.15 Upon receipt and acceptance of a designers
certification and the As -built Plan, and upon
satisfactory inspections by the Board of Health, the
Board of Health shall sign the Certificate of
occupancy.
1.16 Repairs: Repairs to systems other than single family
residents shall be proRo`sed on a plan prepared by a
professional engineer.- The Board of Health requires
the use of a designer for repairs to a disposal system
associated with a single family residence. However, a
full set of design plans may not be necessary to
conduct the necessary repairs on such a system. The
Board of Health or its agent may waive this requirement
under certain circumstances.
Ok7-11 /� 0o
/1lQ �
r: -s
1991
g. Distances from the corners of the house to the
center of the tank and distribution box.
h. The following certification shall be submitted to
the Board of Health, "I hereby certify that I have
inspected the construction of this disposal system
and that the construction and final grading has
been in accordance with the designer's intent and
that the materials used conform to the plan
specifications and 310 CMR 15.00".
i. As -built Plan and certification shall be prepared
by a registered Professional Engineer, Sanitarian
or Registered Land Surveyor.
y\
TO
DATE
TIM AM
V PM
"F
AREA ODE
NO.
OF
�CC
EXT.
G
m
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gyp
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SIGNED
PHONEDBACK
RNED ❑
❑
ALL ❑
WAS IN ❑
URGENT ❑
CALL
SEE YOUO
AGAIN
y\
7-24' 19 b 8: 1 OAP 1 FPGt,,l COLOt',,IIAL vILL4kGE 568 682 2397 P. 2
/C
?
4 OF WAGES "vii ,COVER:
,-olonial Village r)ev. Corr.
Wili 14
�alyl Barrett Homes
--Colonial villacfe Real Estate
H -*L li'sicte Homes
i�tJ' -82-2390 OFFT-F,
Construction
Ii508)
v
I. -d
SUGARCANE LANE
.)
0 : up
N
R=6U
L=100'
116
AS -BUILT SEPTIC SYSTEM
LOCATED IN NORTH ANDOVER, MA.
SCALE:1 "-40' DATE: 7/20/96
Scutt L. Giles R.P.L.S.
54 Deer Meadow Road
North Andover, Mass.
LOf\7
t
1
TABLE OF ELEVATIONS
7A()o
LOT 6
37,196 S. F,
too 19
S3119 -I 11005
St920 80S a
ZT:St 96-2-Ld
/ 65I -f -99
SOS 301V -1 -IIA _1b' I P"JO-17:7 V^JOd_�
HVS I. :9 966 I.-T'z.-L
SUGARCANE LANE
L
o_
N
H
0
J
R=60'
L=100'
I CERTIFY THAT
THE OFFSETS
SHOWN COMPLY
WITH THE ZONING
BY LAWS OF
NORTH ANDOVER, MA.
WHEN BUILT.
CERTIFIED PLOT PLAN .
LOCATED IN NORTH ANDOVER, MA.
SCALE:1 "=40' DATE: 5/30/96
Scott L. Giles R.P.L.S.
50 Deer Meadow Road
North Andover, Mass.
0
z P'f S
. 4
LOT 7
LOT 6
37,196 S.F.
OFFSETS SHOWN ARE FOR THE US
2A '541 OF THE BUILDING INSPECTOR ONLYE
AND SUCH USE IS FOR THE
DETERMINATION -OF ZONING
CONFORMITY OR NON -CONFORMITY
WHEN CONSTRUCTED.
ID
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S 64'54'24" W 210.54'
TOWN OF NORTH ANDOWER/
BOARD OF HEALTH
KIM
SUGARCANE LLN� JIFIED PLOT PLAN
LOCATED IN NORTH ANDOVER, MA.
SCALE: 1 "=40'DATE: 5/30/96
R=60'
L=100' Scott F Giles p P I R
50 Deer Meadow Road
North Andover, Mass.
Sc
LOT 7 TI
fCl$TEaEO
Off. 4
17,
EXE
0
NOS A�
LOT 6
37,196 S.F.
I CERTIFY THAT
THE OFFSETS
X OFFSETS SHOWN ARE FOR THE USE
SHOWN COMPLY
OF THE BUILDING INSPECTOR ONLY
WITH THE ZONING•
AND SUCH USE IS FOR THE
DETERMINATION OF ZONING
NORWS ANDOVER, MA. F
H AN
CONFORMITY OR NON=CONFORMITY
WHEN BUILT.
WHEN CONSTRUCTED,
TOWN OF NORTH ANDOVt7H/
BOARD OF HEA.L.TH
ILI
SUGARCANE LANE
TfFIED PLOT PLAN
LOCATED IN NORTH ANDOVER, MA.
SCALE: 1 "=40' DATE: 5/30/96
R=60'
L=100' Scott L. Giles R.P.L.S.
�o
50 Deer Meadow Road
North Andover, Mass.
-.,
o �►
co
O •"^'« .
N
O Sc G
� N
LOT.7
,� Ec►sTtRE°o
•b.�nx�� t.�a�s
o -
LOT 6
! 37,196 S.F.
0
CERTIFY THAT
SHOWN COMPLY 21().5A OFFSETS
F THE BUILDING NSPECOTOR ON Y
WITH THE ZONING AND SUCH USE IS FOR THE
BY LAWS OF DETERMINATION OF ZONING
NORTH ANDOVER, MA. CONFORMITY OR NON=CONFORMITY
WHEN BUILT. WHEN CONSTRUCTED.
SUGARCANE LANE
0 B
co
0
ti
N
N
0
J
R=60'
L=100'
CERTIFIED PLOT PLAN
LOCATED IN NORTH ANDOVER, MA.
SCALE:1 "=40' DATE: 5/30/96
Scott L. Giles R. P. L. S.
50 Deer Meadow Road
North Andover, Mass.
4.
LOT 7.
0/\
2
G
FX�s�`NG o� X12$
LOT 6
37,196 S.F.
0
�s/3o�QG
I CERTIFY THAT 54OFFSETS SHOWN ARE FOR THE USE
THE OFFSETS OF THE BUILDING INSPECTOR ONLY
SHOWN COMPLY AND SUCH USE IS FOR THE
WITH THE ZONING DETERMINATION OF ZONING
BY LAWSVCONFORMITY OR NON -CONFORMITY
NORTH ANDOVER, MA.
WHEN BUILT. WHEN CONSTRUCTED.
ce�
No................ ........
THE COMMONWEALTH OF MASSACI-IU
BOA—RFD--OV HEALTH
............Tow.V............Or.....No.Rrl�...
A} IthrM#iott for Ro#aWal Wor1w Tutt,tt#r
ication is hereby made for a Permit to Construct ( ✓J"'or Repair
--...-•-•-- DoT._._.....,.... Sf vEN._.oKs..........--•---------
or Lot No.
MA
Address
Sewage Disposal
........... SALA&". Nf...1 N6..........
Location . Address
�K ..S!.. ....
t-t!.k4 Liu .
Owner
...................................................•-••-••••.................................................--••-•..............._.................................. _..............
Installer Address
3uilding - Size Lot.... 3 7112.(P.......Sq. feet
fling — No. of Bedrooms ........... 4............................ERpansion Attic ( ) Garbage Grinder ( )
r — Type of Building ............................ No. of persons............................ Showers ( ) — Cafeteria ( )
Otherfixtures............................................................................---........................_._.......__....:..._.........
low .............. !. ................ gallons per person ped day. Total daily flow.:...............�A.1W................. gallons.
Lnk — Liquid ca.pacity.1MOPgallons Length........"6... Width .ik.'.4... Diameter .... ----....... Depth..S---T "
..
Trench — No. ...I ................ Width.......... j ....... .- Total Length ......- ............ Total leaching area _.............:.....sq. ft.
P g 564 ••-
Pit No ...... I .............. 13re .l�2. .._ Depth below inlet.............. Total leaching area... s ft.
>tribution box (X) Dosing tank ( )
In Test Results' Performed by ..... GHK(.S.VANSEh..-f... Sl l if./.Ali........�l �Iyj�5�i�9s�
Pit No. I ... `.Z...... minutes per inch DepthAof Test Pit .... 77.V!........ Depth to ground water ...... 4L~......... 93-$
Pit No. 2..........:.....minutes per inch Depth of Test Pit ..... ..7A ......... Depth to ground water ......4..; � ......_... 9S -4
..d .................................................................................................. -•----..::...............................................
Description of Soil..... $TR 1VrLO....G PS.. Pf ..M.C.Q(.Rft.-T.D_ ..�I.9M.JE... S M..12...If...GtZ!411 (............................
..........................................................................•------.................------•---------....--•----•--.........----................-----....-------...........----------......
.................... :...................................... .................................................................... ----------•-....-----•••--•-----------•-.............-•---.......--------
Nature of Repairs or Alterations — Answer when applicable...............................................................................................
...................... ..,e-_........................................................-----.............................................................................................................
Agreement:
The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with
the provisions of TITLE 5 of the State Sanitary Code — The undersigned further agrees not to place the system in
operation until a Certificate of Compliance has been issued by the board of health.
Signed..................................................................................... ................................
Date
ApplicationApproved By...............................................................................:.:................ ..._..-•-....---•--•-------.._........
Date
Application Disapproved for the following reasons: ............................ 4 .......................
............................................................
.....................................•--•---........................•-•---................_...---•-•........---••---•..........---•--.....-------•-••---...............---................---•-
Date
PermitNo ......................................................... Issued _..................... ....
Date
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
.......................................... .....................................................................................
Ter#ifirate of Toutplittttre
THIS IS TO CERTIFY, That the Individual Sewage Disposal System constructed ( ) or Repaired ( )
by..................................................................----..----• --i„..ii..------ .......---.....---......----•---------•------•--................----•-•...............--
S
at............................................... :_._.._.....
has been installed in accordance with the provisions of TITLE 5 of The State Sanitary Code as described in the
application for Disposal Works Construction Permit No ......................................... dated ................................................
THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE
SYSTEM WILL FUNCTION SATISFACTORY.
DATE............................................................••--•-----•-•---=--. Inspector .................................... :-----•---.......I
THE 'COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
.......................................... OF
..............................................................................:......
No ......................•-- FEE---............
�iu�rla,ttttl �urltu (�utt�#rnr#run �rruti#
Permissionis hereby granted...::........................................................................................................................................
to Construct ( ) or Repair ( ) an Individual Sewage Disposal System
atNo ...................................
Street
as shown on the application for Disposal Works Construction Permit No ..................... Dated ..........................................
...............•-•------.._.__.......--•--....----........................._........---.................
DATE......Board of Ifcnith
:............................:............---•-----....-----......---•----
FORM 1255 HOBSS & WARREN. INC.. PUBLISHERS
PITS
MIN 66.0 LEACHING MIN 1 (13' 16') PIT C",-/ MANHOLE/PITy
i
GW MIN 4" BELOW BOTTOM L/,, ---'0, 2x FF W OR D,---1111-4811 S NE L --'BOT + SDE{ /low 'OAD = TOTAL
(L x W x #) f (2x(L+W)xD x #) (G/ft2)
CHAMBERS
MIN 660 LEACHING (/ GW MIN 4" BELOW C / COVER >3 FT - VENT `--
MANHOLES � 12"-48" STONE SPLASH PADS , SLOPE .005
BED/TRENCH ✓ (Bed max. 60' X 601) MIN 13' X 16' PIT L-/
BOT 400 + SIDE 16 4 X LOAD = TOTAL Z G6 = 6466
(L x W x #) (2 x (L+W)xD x #) (G/ft2)
3� Lca
FIELDS
MIN 660 GPD 900 ft2 BED PERC RATE FASTER THAN 20M/IN
GW MIN 4' BELOW BOTTOM OF FIELD PIPE ENDS JOINED?
4" PEA STONE? DIST LINE SLOPE .005? >3'COVER-VENT
SCH 40 MIN 12" COVER
RATE LDG
ft2/G
X 660 = = TOTAL
REQ' D ( ft2 ) LXW
DOSING TANKS AND PUMPS
DIMENSIONS X X =
L W D Vol.
DISCHARGE SIZE
MANHOLES TO GRADE
inlet) HWL
OP. SWITCH
Copyright C 1993 by S.L. Starr
DISCHARGE RATE
ALARM SEP. CIRC.
LWL CHECK VALVE
PUMP CAPACITY gpm
gpm
DISCHARGE TIME
GW (Min. 1' below
BLEEDER HOLE MANUAL
6U 7— !7d/CJ(J
i
zP/-mesh' P," 5
7
% PLAN REVIEW CHECKLIST
ADDRESS ENGINEER QI6T1,gV:5 A)4-SCi2G/
GENERAL
3 COPIES STAMPz-� LOCUS - NORTH ARROW �� SCALE
CONTOURS C/ PROFILE (/ SECTION z/ BENCHMARK SOIL &
PERC INFO v ELEVATIONS �� WETS. DISCLAIMER (-� WELLS &
WETLANDS(/ WATERSHED? A DRIVEWAY V(Elev) WATER LINE
FDN DRAIN ✓� SCH40 Z/ TESTS CURRENT? L ---
SEPTIC TANK
MIN 150OG .17 INVERT DROP ✓ GARB. GRINDERJL(+200% EDF)
25' TO CELLAR A-- MANHOLE TO GRADE ELEV GW
D -BOX
SIZE # LINES FIRST 2' LEVEL STATEMENT
INLET /a 4,175 OUTLET /A . 17 ( 2" OR .17 FT) TEE REQ' D?&<:�D
LEACHING
MIN 660 GPD? RESERVE AREA 4' FROM PRIMARY? 2% SLOPE
100' TO WETLANDS 1-,� 100TO WELLS L,-' 4' TO S. H. GW ---'--
35' TO FND & INTRCPTR DRAINS 325' TO SURFACE H2O SUPP �--�
4' PERM. SOIL BELOW FACILITY tom" MIN 12" COVER L ----FILL? 11X (25'
if above natural elev; 101if below) BREAKOUT MET?
TRENCHES
MIN 660 gpd SLOPE (min .005 or 6"/1001) >31COVER?-VENT
SIDEWALL DIST. 2X EFF. W OR D (MIN 61) IS RESERVE BETWEEN
TRENCHES? IN FILL? MUST BE 10' MIN. 4" PEA STONE?
BOT X LDNG + SIDE X LDNG = TOT
(L x W x #) (G/ft2) (DxLx2x#) (G/ft2)
Copyright Q 1993 by S.L. Starr
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FORK U - LOT FtELASE FORK
INSTRUCTIONS: This form is used to verify that all necessary
approvals/permits from Boards and Departments having jurisdiction
have been obtained. This does not relieve the applicant and/or
landowner from compliance with any applicable local or state law,
regulations or requirements.
****************Applicant fills out this section*****************
APPLICANT: �d. C Uig Ly� _ �O.CQ Phone -a 7 -2X20
LOCATION: Assessor's Map Number /n 4� 9 Parcel / y
Subdivision X71DAlGS Lot(s) 0/
Street .S'vsAa G9 IVe_ C.Apt St. Number
************************Official Use Only************************
RECOMMENDATIONS OF TOWN AGENTS:
Conservation Administrator
Comments
Town Planner
Comments
Food erInispectto/r-Health
,//m!/i/y3
Septic Inspector -Health
Comments
Public Works - sewer/water connections
- driveway permit
Fire Department
Date Approved
Date Rejected
Date Approved
Date Rejected
Date Approved
Date Rejected l
Date Approved
Date Rejected
Received by Building Inspector Date
:s
SUGARCANE LANE AS -BUILT SEPTIC SYSTEM
LOCATED IN NORTH ANDOVER, MA.
SCALE:1 '=40' DATE: 7/20/96
R-69
L=100 Scott L. Giles, R.PI.S.
50 Deer Meadow Road
North Andover, Mass.
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Commonwealth of Massachusetts
W City/Town of NORTH ANDOVER, MASSACHUSETTS
System Pumping Record
oY Form 4
DEP has provided this form for use by local Boards of Health. The Sys umping Record must
be submitted to the local Board of Health or other approving authb rity.
A. Facility Information '�iNn I V ZUU
Important: S�dVN O - NC��
When filling out 1 • System Location: f- , /�LAtHEALTH D
forms on the
computer, use �G
only the tab key Addres
tcursor - do not s`+
o move your Oom ANDo� � I J
City /Town
use the return' State Zip Code
key.
r 2. System Owner:
WJ 4 LAA A &A
Name AA
Address (if different from location)
City/Town State Zip Code
Q -55 It L40
Telephone Number
B. Pumping Record
1. Date of Pumping Date ®� 2. Quantity Pumped:
Gallons
3. Type of system: ❑ Cesspool(s) It Septic Tank ❑ Tight Tank
❑ Other (describe):
4. Effluent Tee Filter present? ❑ Yes ❑
5. Condition of System:
Gpop
6. System Pumped By:
No If yes, was it cleaned? ❑ Yes ❑ No
Name Vehicle License Number
Company
7. Location where contents were disposed:
I yj W -F
\0k UL-ANJ�-'
Signature ofiHauler Date
http://www.mass.gov/dep/water/approvals/t5forms.htm#inspect
t5form4.doc• 06/03 System Pumping Record • Page 1 of 1
��
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Sawyer, Susan
From: Sawyer, Susan
Sent: Monday, February 06, 2012 1:58 PM
To: Grant, Michele; Hughes, Jennifer
Cc: DelleChiaie, Pamela
Subject: FW: beavers
This is what I sent to the person who sent the letter at 84 Sugarcane, she said she would pass it on to the one at 102
Sugarcane.
FYI
Susan
From: Sawyer, Susan
Sent: Monday, February 06, 2012 1:57 PM
To: 'lishans77@gmail.com'
Subject: beavers
Hi Lisa,
Here are a couple of links and things that relate to your interest in beaver issues in the state. As I noted, the water levels
this year have not receded as in pervious years, however it is still possible that beavers could be part of the issue. Also,
water level alone does not meet criteria to issue an emergency permit. There must be imminent danger involved. It was a
pleasure speaking with you.
Susan
http://www.bing.com/maps/#JnE9LjgOJTJic3VnYXJOYW51JTJibGFuZSUyYm5vcnRoJTJiYW5kb3ZIciUyYml hJTJiJTdIc3N
OLjAIN2VwZy4xJmJiPTQyLiY2MOE5MDkzMTQzMTEIN2UtNzEuMDU 1 MD02MDk2NDQOJTdINDIuNjU3NDc4MDQ1 MD11
OCU3ZS03MS4wN'IwNDEyOTc1 NTQ5
here is a birds eye view of the vast swamps in your area. The town office has received similar complaints in the past.
Both of these people are familiar with N. Andover.
mike(a.beaversolutions.com
Mike Callahan
Beaver Solutions
Cell: (413) 695-0484
John Benedetto — not sure of the contact info.
Below is an excerpt of the response given by town departments on a similar concern several years ago. An extensive site
walk was conducted and no issues meeting criteria for an emergency beaver permit were found. The remedies given
below would still be current today. If you choose, beaver trapping can be done at this time of year. Licensed trappers are
found on the MA DEP website. If you find a dam causing issues, the professional will let you know of your options per the
law.
1) The dam located on Cedar Lane appears to be on private property, therefore any action relating to this.particular dam
would be addressed to the homeowner. This was determined by Mr. Hmurciak's review of the local maps.
2) In short the expansion of the swamp that has occurred by the beavers reclamation of their territory is not considered a
Health Issue at this time. In fact the conservation would be adverse to tampering with this protected resource area and
associated ecosystem/wildlife habitat if the impact was not deemed a public health issue.
4) As this office is not inclined to allow an emergency permit for the relief of the current situations, a state permit could be
applied for. This office would assist you or any homeowner if this measure was requested as per the N. Andover town
meeting vote regarding beavers. You may want to consider speaking with other potentially impacted homeowners to see if
there are those who are interested in either joining in on the cost and/or possibly finding a homeowner with a health
situation that could trigger the need for an emergency permit to be ordered.
5) http://www.mass.gov/dfwele/dfw/dfwpdf/dfw trapping regs.r)df
This link takes you to the MA trapping laws. There are times of the year that a trapper can be hired to trap the beavers
without coming to the Health and Conservation. For more information you might want to contact a local trapper. They can
assess the swamp and let you know the options such as installing a flow device. Bear in mind that permission from the
homeowner would be needed to access their property. A professional in beavers may even have a better idea of how to
tackle your concerns.
In closing, all the members of the town staff that attended the site walk do understand your concern as a homeowner in
regards to the possible expansion of the existing surrounding wetlands, however we are bound to make decisions in
accordance with the laws given to us. In this case, there does not appear to be enough compelling evidence of an
emergency to trigger this portion of the regulation, therefore without that evidence, it is currently the neighborhood who
could address the problem rather than an Order to Correct. We understand that the situation could change and you could
end up in an emergency situation that could cause us to take action, but for now it does not meet the criteria.
Swsatt Salll#4
J ub& Neaety4 1Dlwdoa
1600 Uagood Stwd
MUg: 20, unit 2-36
.Nedlf andov", .MQ 119845
mice 978 688-9540
fax 978 688-8476
All email messages and attached content sent from and to this email account are public
records unless qualified as an exemption under the
[ http://www.sec.state.ma.us/pre/Dreidx.htm ]Massachusetts Public Records Law.
4
1r5�,�� 5 -7-]
APPLICATION FOR 10 -DAY EMERGENCY BEAVER OR MUSKRAT�ERMIT
TO BE FILLED OUT BY APPLICANT
Name:
Address:
Fee (if applicable): $
Date: 2- R - /Z
�
Town: Alnrl% U �L�JVef"� Zip Code: 01g �
Daytime Tel. # qZ8' �`7 Z t & Evening Tel. #
Agent Name: Tel. #
(if applicable)
[`3-3'Z012
OF NORTH ANDOVER
Is the problem entirely on your property? Yes: No: V Don't Know:
Note: If the problem does not occur entirely on the applicant's property, consent
forms from all other property owners must be obtained.
Type of Complaint: Provide a detailed description of the perceived threat to public health and
safety
&Va4y-15
1
- k2 arc_' � G-7
Under M.G.L. c. 131, s. 80A, an emergency permit authorizes the applicant or his duly authorized agent
to immediately remedy the threat to human health and safety by one or more of the following options: (a)
the use of conibear or box or cage -type traps for the taking of beaver or muskrat, subject to regulations;
(b) the breaching of dams, dikes, bogs or berms; and/or (c) employing any non -lethal management of
water -flow devices. The emergency permit will be good for 10 days from the date of issue.
- 3 - >.Z
Signature of Applicant: Date:
NOTE: Options (b) and/or (c) above require applicant to get conservation commission approval prior to
such work in accordance with the wetlands protection act.
APPLICATION FOR 10 -DAY EMERGENCY BEAVER OR MUSKRAT PERMIT
TO BEWILLED 06 BY
Name; ,)KfV -S
Go"—
Address:
Town:N
Fee (if applicable): $
Date: 9 1 ( ( Z
Zip Code: 0
Daytime Tel. # l� '1',�lJ' Evening Tel. #
Agent Name:
(if applicable)
Tel. # I REC
TOWN OF NORTH ANDOVER
FiEA1�TH DEPARTMENT
"Is the problem entirely on your property? Yes: No: Alr Don't Know:
Note: If the problem does not occur entirely on the applicant's property, consent
forms from all other property owners must be obtained.
Type of Complaint: Provide a detailed description of the perceived threat to public health and
r
Under M.G.L. c. 131, s. 80A, an emergency permit authorizes the applicant or his duly authorized agent
to immediately remedy the threat to human health and safety by one or more of the following options: (a)
the use of conibear or box or cage -type traps for the taking of beaver or muskrat, subject to regulations;
(b) the breaching of dams, dikes, bogs or berms; and/or 6(1111 -T
e ploying any non -lethal management of
water -flow devices. Th mergency permit will be oo for 10 days from the date of issue.
Signature of Appy a4�,, Date:: 1
NOTE: Options ("d/or (c) above require applicar4)to get conservation commission approval prior to
such work in accordance with the wetlands protection act.
� � ^° '•Wig' '�. �^+� .. -yy t, ��::, v,:
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Cc: Hmurciak, Bill; Cyr, John; McKay, Alison; Grant, Michele
Subject: Sugarcane Lane
Dear Mr. Marshall,
I am sorry for the delay in getting back to you. in regard to the beaver concerns that we have been
discussing over the past few months. As was mentioned in regards to the site walk, the purpose was to
gain knowledge into identifying the location of the dams as well as to evaluate the potential problems. As
you are aware, all those persons listed above except for Jon Cyr attended this extensive site walk.
Since that time, I have spoken to Bill and Alison about this matter and we have collectively determined
the following.
1) The dam located on Cedar Lane appears to be on private property, therefore any action relating to this
particular dam would be addressed to the homeowner at #66 Cedar Lane and not the Town. This was
determined by Mr. Hmurciak's review of the local maps.
2) Discussion and review of the law was completed in regards to the complaint that the dam is causing an
emergency and an emergency permit should be required of the homeowner to mitigate the problem. This
would be done under the guise of the MA nuisance laws. In reviewing the current condition of the swamp,
if such a permit application was submitted by the homeowner, the permit application would be denied
based upon the Conservation and Health's opinion that it does not meet the definition set forth in the state
regulation. In short the expansion of the swamp that has occurred by the beavers reclamation of their
territory is not considered a Health Issue at this time. In fact the conservation would be adverse to
tampering with this protected resource area and associated ecosystem/wildlife habitat if the impact was
not deemed a public health issue.
3) The Health Department will notify the homeowner at #66 Cedar Lane that a beaver dam has been
located on their property and that it could potentially cause problems for neighbors that could result in an
order to correct. It will be requested that the homeowner respond to the Health Office for additional details
on the state and local jurisdictions regarding beaver dams. If the homeowner chooses to request our
assistance in gaining a state permit, we will assist them. However, please be aware that should the
homeowner apply for a local permit, the same determination would need to be made as to whether the
area would be considered a public health or safety issue.
4) As this office is not inclined to allow an emergency permit for the relief of the current situations, a state
permit could be applied for. This office would assist you or any homeowner if this measure was requested
as per the N. Andover town meeting vote regarding beavers. You may want to consider speaking with
other potentially impacted homeowners to see if there are those who are interested in either joining in on
the cost and/or possibly finding a homeowner with a health situation that could trigger the need for an
emergency permit to be ordered.
5) http://www.mass.gov/dfwele/dfw/dfwpdf/dfw_trapping_regs.pdf
This link takes you to the MA trapping laws. There are times of the year that a trapper can be hired to trap
the beavers without coming to the Health and Conservation. For more information you might want to
contact a local trapper. They can assess the swamp and let you know the options such as installing a flow
device. Bear in mind that permission from the homeowner would be needed to access their property. A
professional in beavers may even have a better idea of how to tackle your concerns.
In closing, all the members of the town staff that attended the site walk do understand your concern as a
homeowner in regards to the possible expansion of the existing surrounding wetlands, however we are
bound to make decisions in accordance with the laws given to us. In this case, there does not appear to
be enough compelling evidence of an emergency to trigger this portion of the regulation, therefore without
that evidence, it is currently the neighborhood who could address the problem rather than an Order to
Correct. We understand that the situation could change and you could end up in an emergency situation
that could cause us to take action, but for now it does not meet the criteria.
I expect that you all may have comment to this letter and if I spoke for someone incorrectly please let me
know and I will retract the statement if necessary.
Thank you,
Susan Sawyer, Health Director
Alison McKay, Conservation Administrator
System Owner '
"unn.tyhtm Wi ,, I t.itot
lot :;uq,trc:trt"Ln
40r*h Andover MA. otA45
(978) 557 11411 %
Type: Em
Cesspool: W
Date of Pumping:
System Pumped By:
Contents transferred to:
Contents Disposed at:
Form 4 -- System Pumping Record
Commonwealth of Mossachusetss
: Massachusetts
System Pumping Record
Routine
Yes
Wind River Environmental, LLC
System Location
'rimary H✓Iii
oz Eii9occans t n
.lrt:h Andover HA n1.A4
978)-55"7-1140 x
tontaham
Septic tank: W =Yes M
Quantity Pumped: 14�M 6alkms
Permit #:
c9t5D. y%rte
Dep Appmved From - 12/07/95
Town of North Andover, Massachusetts Form No. 1
NORTH BOARD OF HEALTH
O�T'(1•E.I�6 �'Y�
ye.. s pL 19 9S
APPLICATION FOR SITE TESTING/INSPECTION
Applican
Site Location 11
Engineer
Test/Inspection Date and Time
Fee)
L=
CHAIRMAN, BOARD OF HEALTH
Test No. 10 Uo
S.S. Permit No. D.W.C. No. C.C. Date Plbg. Permit No.
Town of North Andover, Massachusetts Form No. 1
r1ORTH BOARD OF HEALTH
616�o0 19 c?�
_ V {
APPLICATION FOR SITE TESTING/INSPECTION
Applicant
NAME ADDRESS TELEPHONE
Site Location 1 /t�T
Engineer
Test/Inspection Date and Time
Fee J
CHAIRMAN, BOARD OF HEALTH
Test No. (a G -
S.S. Permit No. D.W.C. No. C.C. Date Plbg. Permit No.
107 Furest St. j
Middleton, MA 01949 10
(508) 774-2772 S�QJ\GAs
ddag
-9194jaolp
�v�CE
FORM 4 - SYSTEM PLIMPLNG RECORD
Conus t
onweal.h of Massachusetts
— N -%gNTrjve.v� , Massachusetts
System Pumping Record
� stem Owner
C,AVU CL.'m 1,4
/OZ-SCG-ClG%-CClGl-Q-
AI-4vTjvt�c
557-11,10
Dat: of Pumpinn- ��—
Cesspool: 1\o ❑ Yes ❑
r
SY stem Pumped by: C CAU ems.
Contenls transferred to:
Date /—/i9 ( ~
system Location
CG2-IC-. 0 F pjc;S)e``- Lco4kcou"l
00 1
4 -lc -e, , i.4 Puri 1 CiKc-L ,
Quantity Pumped:___,gallons
Septic Tank: No ❑ Yes
Inspector
License 4:
0 THE PROFESSIONAL EXPERTS IN THE SEPTIC AND DRAIN INDUSTRY 0
Commonwealth of assac usetts
City/Town of 3
a System Pumping Recor .LV9 D
Form 4
DEC 0 4 2009
DEP has provided this form for use by local Boards of Health. Other form may be used, but the
information must be substantially the same as that provided here. Beforeour
local Board of Health to determine the form they use. The System Pumpi _ itt 'd 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 on the
computer, use
only the tab key
to move your
cursor - do not
use the return
key.
1. System Location:
1
f
City/Town
2. System Owner: f
C to r
Name
Address (if different from location)
City/Town
0 1(gq�5
State Zip Code
State Zip Code
Telephone Number
B. Pumping Record
1. Date of Pumping 4 _U f 2 Quantity Pumped:
Date
3. Type of system: ❑ Cesspool(s) Septic Tank ❑ Tight Tank
❑ Other (describe):
4. Effluent Tee Filter present? Yes ❑ No
5. Condition of System:
6. System Pumped B
del
Name
Company
7. Location where contents were disposed:
Signature of Hauler
Signature of Receiving Facility
ls'�U
Gallons
❑ Grease Trap
If yes, was it cleaned? Yes ❑ No
Vehicle License Number
Date
Date
G.L.S.D.
Lawrence, M.A.
t5form4.doc• 03/06' System Pumping Record • Page 1 of 1
Commonwealth of Massachusetts QCT 10 20,2
City/Town Of
TOWN MEALUTN pEPANORTHR AND
R
System Pumping Record NORTH ANDOV
Form 4
y 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:
1 system Location:
When filling out y
forms on the
computer, use ---------
only the tab key Address/f %G
�+//
to move your City/Town , /�� T/'1 �'�Zip G ( _
cursor - do not -- .._"_ State Code
U
use the return
key. 2. System Owner:
Name
—...- -- -
�^ Address (if different from location) -
-___ State Zip o e
City/Town
Telephone Number _
B. Pumping Record
—/�/. , -/ Z-=- 2, Quantity Pumped: Ga1s2v .. .
1. Date of Pumping___J_-
- (Date
3. Type of system: ❑ Cesspool(s) eptic Tank ❑ Tight Tank ❑ Grease Trap
❑ Other (describe): — — - -- -
4. Effluent Tee Filter present? es ❑ No If yes, was it cleaned?es ❑ No
5. .Condition of Sys m:
6. System Pumped By.
Name
Company
7. Location where contents were disposed:
Signature of Hauler
Signature of Receiving Facility
15form4.doc• 03106
Vehicle License Number
Ciate
Date
System Pumping Record • Page t of 1