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HomeMy WebLinkAboutMiscellaneous - 1041 FOREST STREET 4/30/2018e^ .1 PARCEL # ol I \\,I LOT # STREET ...-,t--...._..._..._...___ QQNaiRvClT.ORJ9RRRQvp4t HAS PLAN REVIEW FEE .BEEN PAID? YES NO PLAN APPROVAL: DATE . BY APP. LatTaL.. DESIGNER: P-,eA)q6,4 & 6-6 PLAN DA TE. CONDITIONS WATER SUPPLY: TOWN _Y WELL PERMIT DRILLER.-... WELL TESTS: CHEMICAL DnIE fll_-'PRUVED._�A�/_ff BACTERIA I DA I E (IPPIRUVEL) 61iU-Iq� BACTERIA II DATE APPROVED COMMENTS: FORM U APPROVAL: APPROVAL TO ISSUE YES DATE ISSUED BY ....... ........ CONDITIONS: FINAL APPROVAL: ALL PERMITS PAID YES NO WELL CONSTRUCTION APPROVAL "y5_57-1 NU SEPTIC SYSTEM CONSTRUCTION APPROVAL YES NO OTHER YES NO ANY VARIANCE NEEDED FINAL BOARD OF HEALTH APPROVAL: YES NU DR BY: I 9 SSACH Permit # 404 JUIN 1 51994 BOARD OF HEALTH NORTH ANDOVER, MASS. APPLICATION FOR WELL AND PUMP PERMIT A permit is requested to: drill a well x ; Date ,TUNE 2 1994 install a pump xxx LOCATION: In' # � PnPFcT ST Lot # 3 Owner MP ^40PRT_S C'APUSn Address Tel .t N Well Contrctr F.M-YOUNC4 APTESIAN T�=. Add. 36 PFLFPM PD Tel 603-898-2504 Pump Contrctr Y(IT NG BPM PUMP M INC Add. 36 PELHAM rd Tel 60.3-RQR-2504 WELLS (To be completed at time of pump test.) Type of well DISUse D6 H r'J/ �G Diameter of well 21 Size of casing 17Ilbs Depth of bed rock ,3 Depth casing into bedrock /? Seal been tested? Yes (/� No (_ ) Date of test Depth of well Z6,5 I- bSI- Water -bearing rock___j Depth to water r20 ' Delivers Q GPM for `/ /t"S (how long?) Drawdown 60 feet after pump ing—m!? hours at GPM Date of completion G Signa ure of well trac or ******************************************************* ************* PUMPS (To be filled in before installation.) r / Name & size of pump J-41 /j Type c t, a ��yL � Size of tank Pump delivers /S GPM Pipe used in well: Cast iron (_) Galvanized (_) Plastic Sleeve used to protect pipe? Yes (_) No ( Type w�ll seal . /lam/ �svl� Date L/ J� Signature o pump in ll Dat water analy report submitted to Board th PlAsing inspector f VWiring (ipsjbr6ctor Boar .of Health HORTM OL O A ,SSACHUSEt ■ Applicant as� 1 �ri .+7 .�{ � 'W1.aR.�6.: 4 •i.: h.. Pl � i . 1... � .t.,. �.. ...,. � l`��� ,. � . ..1 �. Form No. 3 Town of North Andover, Massachusetts BOARD OF HEALTH 19 9 U DISPOSAL WORKS CONSTRUCTION PERMIT NAME - __R_-- Site Location Permission is hereby granted to Construct or Repair ( ) an Individual Soil Absorption Sewage Disposal System as shown on the Design Approval S.S. No. A CHAI MAN, BOARD OF HEALTH %a D.W.C. No.i:. iu Fee 'Y'OtJNCi BF:[ i.3' 06-13-94 09: 226RM 1601 #2 ` 603-893-4260 a—..wHrww.rr�» e•... - - -W ENGLAND A/ Ab LitsDONLTD. 45 Stites Road, Suite 206 Salem, New Hampshire 03079 WATER P11ALYS 1 S RESUL"'S NAME: ANDREW & MLAURICE SLDR . DATE: 12- un -94 SAMPLE LOCATION: LOT 3 LAB.# 11585 FOREST STREET N. AND01,ER , IiA -------------------------------- TEST RESULTS MCL UNITS STANDARD HARDNESS ............. ''ti.0 75 mg/1 * EPA So, ALKALINITY........... 83.0 --- mg/1 Secondary IRON ................. 0.07 0.3 trig/l Secondary CALCIUM .............. 40.8 100 mg/l Secondary MANGANESE............ 0.164: 0.05 mg/1 * Secondary CONDUCTIVITY......... 0.365 --- MS/cm Secondary PH ................... 7.3 6.5 8.5 Secondary TURBIDITY ..... (Note) 0 _3 1 NTU PRIMARY CHLORIDES............ 0 250 mg/1 Secondary SULFATE .............. ND 250 mg/1 Secondary NITRATES ............. 2 10 mg/1 PRIMARY NITRITES ............. 0. 72 z mg/1 PRIMARY COPPER ............... 0.05 1.3 mg/1 PRIMARY SODIUM ............... 24 250 mg/1 Secondary TOTAL DISOLVF.D SOLIDS 177.6 500 mg/i Secondary COLIFORM BACTERIA.... 0 <1 colony/100 :ttl PRIMARY NON -COLIFORM BACTERIA G <200 rot./100 mi PRIMARY COLOR ................ 0 15 C. U. Secondary ODOR ................. I+D 3 T.O.N. Secoiidaiy MAGNESIUM............ 6.3 50 mg/1 Secondary. * - Indicates parameters which exceed the Maximum Concaminant Level (MCL) or pH range as established by the EPA. Primary Stds. are Stds. that are related to health issues. Secondary Stds. are aestethic in quality and should not affect healthy individuals. WATER MEETS EPA STANDARDS FOR DRINKING WATER (NOTE) 5 NTU is acceptable rf Tested by: for non- surface waters. , (` 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: 't f'(/iL 0 %'� -Ur Phone l91/ - 7/ LOCATION: Assessor's Map Number Parcel Subdivision ` Of'- k P� L 0'� Lot (s � `• Street 7('I; St. Nu:aber In'! ! ************************Official Use Only*******************x**** RECOMMENDATIONS OF TOWN AGENTS: Conseriation Administrator Cc en is Town Planner Co=ents Food _nspector- ealth Septic inspec ..._- Dealt^ CJ-� erts ic Wcr::s - sewer/water connections drivewav permit F_re Decar- tee.^.t Received by Building Ins:.ector Date Approved Date Re; ec ted Date Approved l Date Refected Date Approved Date Rej ec ted Date Approved �s Date Re; ecte,-, Date z¢ ,'i jl_ , EIKS, clk-: —1 E—_:W, 07 7 -,15 1;111 i F3'21 1 x#'2 NAME. NEW ENGLAND RAD C)pqi LTD. � Stiles poed. Sulte 2()8 Saler, flew harvsh.re WATER ANALYSIS RES11L'1,S ANDREW & MAURICE 9LORs, 803.883.4260 "m - 0 i n. e . � fA , IM, 0"'INEW DATEI-12-.fun-94 SAMPLE LOCATION: LO'T 3 FOREST STREET L"`qE. L15i3S TEST 12ESGDTS mc 1 ''' U N :' `� � r } STANDARD RAR i,V i ••• IRON .... 83.0 mg/1 NPA Soft . ..... .. CALL ` " 0. a7 --- mg/1 Secondy s i .... .`. .. « . 40. d . 3 mg/ � Secondary CON,.;, c'°a I V1 T Y ' : • ... � -=- ^r r3 = � `9/I Secondary . • .... PH... 0.365 �g/Z ecn- * S ndary ... .. TURBIDITY... 7.3 --05 ms/c,"! Seconddry (Note} CHLORZDEB. 0.13 6.5 8.5 :��•=c�i;d� aZ ' ....... SULFA'T'E 40 r 1 Na"T t'�i MARY'. ...... NITRATES ........ ND 2�U g/1, seco,,dard ...... ... NITRITES 0.2 �C mgr". Secondary ............. COPPER.... 0.002 1C ''fig/1 PR)MARy SODIUM 0.05 a mg✓�' PRIMARY ............... TOTAL DISOLVED 24 1.3 mg F -.t T.MARY SOLIDS COLIFORM BACTERIA.... 177,6 25n 5'. rim ` -T Secondary VON--COLIFO^.•� BACTERIA � ntgli <i Cola,.;; 1.00 rel Secondary COLOR.. .... � " " r i2J0 col jm 10 itiI PRIMARY )DOR.... 0 PRIMIARY 4AGNESI... L� ND 15 C, u. Secondary ••••..,,, 6.3 �. �.U.td• Secondary �� mg/i Se rndicatep ?-ameters which exceed the Maxi:aum Contaminant Level (MCL) zenge as estab"Shed by the EPA.ry Stds. are Stds. t -'Lt are tel re aestethic in a e�. =o jealth issues. Secondary Stds. quality and should net affect health ^dJ �►:;dund , o kTER MEETS ?A STANDARDS )R DRINKING WATER 40TE; 5 NTU is acceptable for ror,- w�ate suxf c _r_--`-_-__ a e L s . Town of North Andover, Massachusetts Form No. 1 NORTH BOARD OF HEALTH 19 APPLICATION FOR SITE TESTING/INSPECTION Applican Site Location ('0T -&�- Engineer NAME ADDRESS TELEPHONE Test/Inspection Date and Time c� CHAIRMAN, BOARD OF HEALTH Fee � I '57D Test No. 5 39"***' S.S. Permit No. D.W.C. No. C.C. Date Plbg. Permit No. Town of North Andover, Massachusetts BOARD OF HEALTH 'E° , yC' APPLICATION FOR SITE TESTING/INSPECTION Form No. 1 19 Applicant NAME ADDRESS TELEPHONE Site Location Engineer NAME ADDRESS TELEPHONE Test/Inspection Date and Time Fee CHAIRMAN, BOARD OF HEALTH Test No. S.S. Permit No. D.W.C. No. C.C. Date Plbg. Permit No. f �10RT1/ O.�•�to o � � w A sACNus t� Town of North Andover, Massachusetts BOARD OF HEALTH -9&c6,-Me6;f / 7 19 DESIGN APPROVAL FOR SOIL ABSORPTION SEWAGE DISPOSAL SYSTEM Applicant �OC --B/g1',RF%o/�00 Test No. Site Location ADT 0/ee 5/7— Reference T Form No. 2 Reference Plans and Specs. -JOG �/�� BAGALLn ENGINEER DESIGN DATE Permission is granted for an individual soil absorption sewage disposal system to be installed in accordance with regulations of Board of Health. Fee 4D- O a CHAIRMAN, BOARD OF HEALTH Site System Permit No. 4�z3zf Department of Environmental Management/Division of Water Resources WELL COMPLETION REPORT WELL 101.Oif �'O T , GEOGRAPHIC DESCRIPTION Address- — X -L- YH ANDOVER IATA N S E W of (feet/ (circle) City/Townn Well ownA-PRffNt & MAIIRl('r, BMS (road) Address P.O. BOX 1327 SEARROOK, N.H..03874 (nil. in tenthsl N S W Oi (clyde Board of Health permit obtained: yes ❑ no ❑ intersect. w/ (road) WELL USE WELL DATA �* Domesticg] Public ❑ Industrial E] Total well depth ft. Monitoring ❑ Other Depth to bedrock ,t ft. Water -bearing rock/unconsolidated material: Method drilled ,/ r. Date drilled DescriptionF'L'f� CASING Water -bearing zones: el Type � f -c 1) From11 1 To Length G ft. Dia LL D.) 1 j'1 in. 2) From To 3) From To Length into bedrock ft. Gravel pack well: dia. Protective well seal: Screen: dia. Grout. Other Dnite3 d�Q�C: Slog' length —from— to STATIC WATER LEVEL (all wells) Static water level below land surface_ ft. Date <� WELL TEST (production weiis) Drawdown Gf' eft. after PumpingA/—hr. min. at gpm How measured'' ff) fty ` e Recover ��ft. after—lir. -�� min. LOG of FORMATIONS I COMMENTS i Driller E' YC -W7 S'R' Firm Address 36 'nrLAF'�' Ritlii City/Town qPI F,`f INT Tx 0307P Supervising Driller RegA 51i BOARD OF HEALTH COTY Permit # 404 i BOARD OF HEALTH NORTH ANDOVER, MASS. APPLICATION FOR WELL AND PUMP PERMIT Date JUNE 2 1994 A permit is requested to: drill a well xx install a pump xxx LOCATION: IrT►' # FnPFSm ST Lot # ani 10.0-40V ISQ7 Owner MP MOPRI! CAPUSO Address Tel /V Well Contrctr FJ4.YOUNC- APTESIAN WELLAdd. 36 PFLNPM PD Tel 603-893-2504 Pump Contrctr YnLTIIG BPOS PUMP CO INC Add. 3E PFLNAM rd Tel 603-808-2504 WELLS (To be completed at time of pump test.) _ Type of well Qe� `�� Use D 6 H r J/ G Diameter of well 6" Size of casing 17llbs Depth of bed rock 3 Depth casing into bedrock /E , Seal been tested? Yes ('�No () Date of test / Depth of well 5/6s' Water -bearing rock—yro�7"' �/'q Depth to water 096 Delivers p GPM for���5 I (how long?) Drawdown 00 feet after pumpinghours at 16 GPM Date of completion A/ f1l "'F- �"e 40!tj� Signa ure of well trac or PUMPS (To be filled in before installation.) r Name & size of pump 6 Type c14 4 'ece Size of tank Pump delivers IS GPM Pipe used in well: Cast iron (_) Galvanized (_) Plastic (L� Sleeve used to protect pipe? Yes (_) No ( Type w 11 seal ��� �� e Date L Signature o pump in 11 Date water analysis report submitted to Board of Health Plumbing inspector Wiring inspector Board of Health BOARD OF HEALTH 120 MAIN STREET NORTH ANDOVER, MASS. 01845 Joseph Barbagallo 1 Westward Circle No. Reading, MA 01864 Dear Joe: TEL. 682.6483 Ext23 April 7, 1994 Today I met with Michael Rosati and went over Lots 1 and 2 (now called Lots 3 and 4, respectively) Sharpner's Pond Road, locating the test pits which were done in 1992. On the basis of the findings made out there, I must inform you that the septic plans for these two lots are disapproved. The locations of the soil tests on the plans do not match with the actual locations. In addition, I found no bench marks in the field and found that the topography does not agree. If you have any questions, please do not hesitate to call the office. Sincerely, Sandra Starr, R.S. Health Administrator cc: Karen Nelson, Dir. PCD Maurice Caruso File TOWN OF NORTH ANDOVER SYSTEM PUMPING RECORD DATE: SYSTEM OWNER & ADDRESS AN// �Nzdt Aallve (41 SYSTEM LOCATION (example: left front of house) /-RO/N + DATE OF PUMPING: OP3-0/ QUANTITY PUMPED GALLONS CESSPOOL: NO ✓/YES SEPTIC TANK: NO YES NATURE OF SERVICE: ROUTINE ✓ EMERGENCY OBSERVATIONS: GOOD CONDITION FULL TO COVER HEAVY GREASE BAFFLES IN PLACE ROOTS LEACHFIELD RUNBACK EXCESSIVE SOLIDS FLOODED SOLIDS CARRYOVER OTHER (EXPLAIN) �./ i � 143J1f1 t iJ 1114 1�L ii i ter' COMMENTS: //7 4 -le CONTENTS TRANSFERRED TO: COMMONWEALTH OF MASSACHUSETTS EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS DEPARTMENT OF ENVIRONMENTAL PROTECTION TITLE 5 OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM PART A CERTIFICATION Property Address: i (A i yaQre-,xc,-� Owner's Name: f��� Tcvlm OFNORTH ANp01;t pyo Owner's Address: BOARD OF HEALTH Date of Inspection: C- Name of Inspector: ( lease print Company Name: S "r Mailing Address: Telephone Number: - 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 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: Inspector's Signature: asses Conditionally Passes Needs Fur)oer Evaluoon by the Local Approving Authority Date: The system inspector shall kybmit a copy of this inspection report to ofe Approving Authority (Board of Health or DEP) within 30 days of cohfpleting 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. Notes and Comments ****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. Title 5 Inspection Form 6/15/2000 page I Page 2 of 11 OFFICIAL INSPECTION FORM — NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: Owner Date of Inspection: . 2ZDI Inspection Summary: Check A,B,C,D or E / ALWAYS complete all of Section D A., System Passes: V I have not found any information which indicates that any of the failure criteria described in 310 CMR 15.303 or in 310 CMR 15.304 exist. Any failure criteria not evaluated are indicated below. Comments: B. System Conditionally Passes: One or more system components as described in the "Conditional Pass" section need to be replaced or repaired: The system, upon completion of the replacement or repair, as approved by the Board of Health, will pass. Answer yes, no or not determined (Y,N,ND) in the 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. ND explain: 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 pipes) are replaced obstruction is removed distribution box is leveled or replaced ND explain: 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 obstruction is removed ND explain: Page 3 of 11 OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address:� iQ aC� . �1 �n Owner: Date of Inspection: 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 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 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, provided that no other failure criteria are triggered. A copy of the analysis must be attached to this form. 3. Other: Page 4 of 11 V OFFICIAL INSPECTION FORM — NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: r f.r , Owner. elXS�_ Date of Inspection: l Q -- D. - D. System Failure Criteria applicable to all systems: You must indicate "yes" or "no" to each of the following for all inspections: Yes No/� V Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool TZDischarge 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 V2 day flow i�Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number of times pumped . P_ Any portion of the SAS, cesspool or privy is below high ground water elevation. Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface 14 water supply. N Any portion of a cesspool or privy is within a Zone 1 of a public well. y portion of a cesspool or privy is within 50 feet of a private water supply well. Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality analysis. [This system passes if the well water analysis, performed at a DEP certified laboratory, for coliform bacteria and volatile organic compon8ds 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, provided that no other failure criteria are triggered. A copy of the analysis must be attached to this form.] (Yes/No) 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. You must indicate either "yes" or "no" to.4ach of the following: (The following criteria apply to large systems in addition to the criteria above) yes no the system is within 400 feet ofa 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 11 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. 4 Page 5 of I 1 4 OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST Property Address: S , Owner: Date of Inspection: Check if the following have been done. You must indicate "yes" or "no" as to each of the following: Yes o Pumping information was provided by the owner, occupant, or Board of Health _zWere any of the system components pumped out in the previous two weeks ? Has the system received normal flows in the previous two week period ? V 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 ? V — 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: Yes no _ _ Existing information. For example, a plan at the Board of Health. IDetermined in the field (if any of the failure criteria related to Part C is at issue approximation of distance is unacceptable) [3 10 CMR 15.302(3)(b)] Page 6 of 11 OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION Property Address: )0 41 Owner• ct),- Date of Inspection: FLOW CONDITIONS RESIDENTIAL Number of bedrooms (design): —_ / Number of bedrooms (actual): DESIGN flow based on 310 CN%15.203 (for example: 110 gpd x # of bedrooms): Number of current residents: _c Does residence have a garbage grinder (yes or no): Is laundry on a separate sewage system (yes or noS[if yes separate inspection required] Laundry system inspected (yes or no): Seasonal use: (yes or no): /V -v Water meter readings, if avaUable (last 2 years usage (gpd)): Sump pump (yes or no):/V 0 �• t Last date of occupancy: (r'U I i e-`'1 COMMERCIAL/INDUSTRIAL Type of establishment: Design flow (based on 310 CMR 15.203): zDd Basis of design flow (seats/persons/sqft,etc.): Grease trap present (yes or no): _ Industrial waste holding tank present (yes or no): — Non -sanitary waste discharged to the Title 5 system (yes or no): _ Water meter readings, if available: Last date of occupancy/use: OTHER (describe): INFORMATION Pumping Records Source of information: f 0^0DC7 Was system pumped as part of thJ inspection (yes or no): es - If yes, volume pumped: AW allons __How was uantl�ty pumped determined? Reason for pumping: /�U,$ Ate•]' TYP F SYSTEM eptic tank, distribution box, soil absorption system _ Single cesspool Overflow cesspool — ivy _ 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) — Tight tank _ Attach a copy of the DEP approval _ Other (describe): knowLIand squr9e of Were sewage odors detected when arriving at the site (yes or no)A Page 7 of I 1 OFFICIAL INSPECTION FORM — NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: ]OW *I Owner: ii ?' Date of Inspection: BUILDING SEWER (locate on site plan) Depth below grade: Materials of construction: _cast iron iZ11000PVC _other explain): _ Distance from private water supply well or suction line: A0 'r Comments (on condition of joints, venting, evidence of leakage, etc.): SEPTIC TANK: V(locate on site plan) Depth below grade: Material of construction: oncrete _metal _fiberglass _polyethylene other(explain) If_tank is metal list age: _ Is age confirmed by a Certificate of Compliance (yes or no): _ (attach a copy of certificate) 5— �_� n Z� 6 Dimensions: Sludge depth: 4k -r Distance from top of slWge to bottom of outlet tee or baffler Scum thickness: _C9 — y Distance from top of scum to top of outlet tee or baffle: Distance from bottom of scum to bottomja outlet tee or:�affle How were dimensions determined: U V Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structurintegrity, liquid levels as relatecLto outlet invert, evid'enct of V&aee_etc ): I ,, a) _ GREASE TRAP: _(locate on site plan) Depth below grade: Material of construction: _concrete _metal _fiberglass _polyethylene _other (explain): Dimensions: Scum thickness: Distance from top of scum to top of outlet tee or baffle: Distance from bottom of scum to bottom of outlet tee or baffle: Date of last pumping: Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): Page 8 of 11 OFFICIAL INSPECTION FORM — NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: ? ' Owner: Date of Inspection: j TIGHT or HOLDING TANK: (tank must be pumped at time of inspection)(locate on site plan) Depth below grade: Material of construction: concrete metal fiberglass _polyethylene other(explain): Dimensions: Capacity: gallons Design Flow: gallons/day Alarm present (yes or no): Alarm level: Alarm in working order (yes or no): Date of last pumping: Comments (condition of alarm and float switches, etc.): DISTRIBUTION BOX: 3z <ifresent must be opened)(locate on site plan) Depth of liquid level above outlet invert: 0 Comments (note if box is level and distribution to outlets equal. anv evidence of solids carrvnver PUMP CHAMBER: (locate on site plan) Pumps in working order (yes or no): Alarms in working order (yes or no): Comments (note condition of pump chamber, condition of pumps and appurtenances, etc.): Page 9 of I 1 OFFICIAL INSPECTION FORM — NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL. SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: 04ft— Owner• 4 Date of Inspection: SOIL ABSORPTION SYSTEM (SAS): (locate on site plan, excavation not -required) If SAS not located explain why: Type leaching pits, number: leaching chambers, number: leaching leaching galleries, number: + , leaching trenches, number, length: �,'! X .3 }C / leaching fields, number, dimensions:` overflow cesspool, number: innovative/alternative system Type/name of technology: Comments (note condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of veeetation_ 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 or no): 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.): 9 Page 10 of l l OFFICIAL INSPECTION FORM — NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM 'INFORMATION (continued) Property Address: W4 s s r,. Owner: Date of Inspection: -? SKETCH OF SEWAGE DISPOSAL SYSTEM Provide a sketch 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. i N 10 Page 11 of 11 OFFICIAL INSPECTION FORM — NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: Owner: Date of Inspection: SITE EXAM Slope Surface water Check cellar Shallow wells i Estimated depth to ground water-7—feet Please indicate (check) all methods used to determine the high ground water elevation: __JNntained from system design plans on record - If checked, date of design plan reviewed: 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 high ground water elevation: __— I _GLC 64" a /e. % a Ui 11 COMMONWEALTH OF MASSACHUSETTS EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS DEPARTMENT OF ENVIRONMENTAL PROTECTION TOWN OF NORTH ANDOVER/ I BOARD OF HEALTH y� 1� ) f TITLE 5 OFFICIAL INSPECTION FORM — NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM PART A CERTIFICATION Property Address: I 1A I �--nfC-:,T S1. Owner's Name !a Cc'? _ Owner's Address: Date of Inspection: Name of Inspector: ( lease print Company Name: L Mailing Address: 4r7 151177 Telephone Number: G — - 114-9 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 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: Inspector's Signature: asses Conditionally Passes Needs Furjlier Evalu,)tion by the Local Approving Authority Date: ��1�l The system inspector shall�ybmit a copy of this inspection report toge Approving Authority (Board of Health or DEP) within 30 days of co pleting 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. Notes and Comments ****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. Title 5 Inspection Form 6/15/2000 page I e — - -► Page 2 of 11 OFFICIAL INSPECTION FORM — NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: ► t>y I S Owner: -P-,-;, Gtst _ Date of Inspection: Inspection Summary: Check A,B,C,D or E / ALWAYS complete all of Section D A. System Passes: �/I have not found any information which indicates that any of the failure criteria described in 310 CMR 15.303 or in 310 CMR 15.304 exist. Any failure: criteria not evaluated are indicated below. Comments: B. System Conditionally Passes: One or more system components as described in the "Conditional Pass" section need to be replaced or repaired: The system, upon completion of the replacement or repair, as approved by the Board of Health, will pass. Answer yes, no or not determined (Y,N,ND) in the 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. ND explain: 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 obstruction is removed distribution box is leveled or replaced ND explain: 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 obstruction is removed ND explain: Page 3 of I 1 OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: 1 ( rC Sl S-1- ori+ h DLW-.r — Owner: cks Date of Inspection: 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 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 coliform bacteria and volatile organic-compourids 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, provided that no other failure criteria are triggered. A copy of the analysis must be attached to this form. 3. Other: 3 V . y Page 4 of 11 OFFICIAL INSPECTION FORM — NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: Tr C- Owner.- Date of Inspection: D. System Failure Criteria applicable to all systems: You must indicate "yes" or "no" to each of the following for all inspections: Yes No/' f Backup of sewage into facility or system component dug 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 I/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 SAS, cesspool or privy is below high ground water elevation. -jZAny portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. J Any portion of a cesspool or privy is within a Zone 1 of a public well. An,,Any portion of a cesspool or privy is within 50 feet of a private water supply well. Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality analysis. [This system passes if the well water analysis, performed at a DEP certified laboratory, for 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, provided that no other failure criteria are triggered. A copy of the analysis must be attached to this form.] (Yes/No) 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. You must indicate either "yes" or "no" to each of the following: (The following criteria apply to large systems in addition to the criteria above) yes no _ _ the system is within 400 feet of 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 crapped 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. Page 5 of 11 OFFICIAL INSPECTION FORM — NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST Property Address: Owner -3R (A c'p—+ Date of Inspection: Check if the following have been done. You must indicate "yes" or "no" as to each of the following: Yes -%To � _ Pumping information *as provided by the own€r, occupant, or board of Health -Were any of the system components pumped out in the previous two weeks ? I Has the system received normal flows in the previous two week period ? Xave large volumes of water been introduced to the system recently or as part of this inspection ? 1� 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 ? -Z-1— 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 S©il Absorption -System (SAS) on the site has been determined based on: Yes�no "I _ Existing information. For example, a plan at the Board of Health. _Ieo� Determined in the field (if any of the failure criteria related to Part C is at issue approximation of distance is unacceptable) [3 10 CMR 15.302(3)(b)] Page 6 of I I OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION Property Address: 1041 o r Owner: r Date of Inspection: j2 FLOW CONDITIONS RESIDENTIAL Number of bedrooms (design): -/ Number of bedrooms (actual): DESIGN flow based on 310 05.203 (for example: 110 gpd x # of bedrooms): Number of current residents: Does residence have a garbage gnl &r (yes drno)' S - } yes '2t r–O(ri:,1� Gk;. U, Is laundry on a separate sewage system (yes or no). �, if separate inspection required) Laundry system inspected (yesgr no): _ Seasonal use: (yes or no): i tI Water meter readings, if available (last 2 years usage (gpd)): Sump pump (yes or no): N U Last date of occupancy: _(Z� { COMMERCIAL/INDUSTRIAL Type of establishment: Design flow (based on 310 CMR 15.203): gpd Basis of design flow (seats/persons/sqft,etc.): Grease trap present (yes or no): _ Industrial waste holding tank present (yes or no): _ Non -sanitary waste discharged to the Title 5 system (yes or no): _ Water meter readings, if available: Last date of occupancy/use: OTHER (describe): GENERAL INFORMATION Pumping Records Source of information: G MQ ?1O �AS % DD O Was system pumped as part of thef inspection (yes or no):e°g' If yes, volume pumped: A06gallons -- How was_quanti pumped determined? Reason for pumping: -P-3 P'L ;� , , >/ >� A"'t TYPJ#10F SYSTEM eptic tank, distribution box, soil absorptvm system _ Single cesspool _ Overflow cesspool _ Privy _ Shared system (yes or no) (if yes, attach previous inspection records, if any) _ Innovative/Altemative technology. Attach a copy of the current operation and maintenance contract (to be obtained from system owner) — Tight tank _ Attach a copy of the DEP approval _ Other (describe): knownland sqt v of ri�fli!, Were sewage odors detected when arriving at the site (yes or no):/') Q 0 Page 7 of 11 OFFICIAL INSPECTION FORM — NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: )04/ Sl r 1 Owner• Date of Inspection: zz-6/_ BUILDING SEWER (locate on site plan) Depth below grade: l Materials of construction: cast iron A400PVC _other (explain): —- Distance from privptewale supply well or §Vction line: ii Comments (on condition of joints, venting, evidence of leakage, etc.): SEPTIC TANK: "f(locate on site plan) Depth below grade: Material of construction: _Lo4ncrete _metal _fiberglass _polyethylene _other(explain) If tank is metal list age: _ Is age confirmed by a Certificate of Compliance (yes or no): _ (attach a copy of certificate) ` Dimensions:" $ ' Sludge depth: S Distance from top of stage to bottom of outlet tee or baffle Scum thickness: 19 y Distance from top of scum to top of outlet tee or baffle: Distance from bottom of scum to bottom outlet tee or baffle - 4 ` How were dimensions determined: / Q /OQ /'�'t L� t/ Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structur integrity, liquid levels as rSlat4to outlet invert,,evidenck ofje;kage,et.&.): ,► „ GREASE TRAP: (locate on site plan) Depth below grade: Material of construction: _concrete _metal _fiberglass _polyethylene _other (explain): Dimensions: Scum thickness: Distance from top of scum to top of outlet tee or baffle: Distance from bottom of scum to bottom of outlet tee or baffle: Date of last pumping: Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): 7 Page 8 of 11 OFFICIAL INSPECTION FORM — NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: 0 Owner: t Date of Inspection: TIGHT or HOLDING TANK: (tank must be pumped at time of inspection)(locate on site plan) Depth below grade: Material of construction: t~oncrete tnetalfiberglass polyethylene other(explain): Dimensions: Capacity: gallons Design Flow: gallons/day Alarm present (yes or no): Alarm level: Alarm in working order (yes or no): Date of last pumping: Comments (condition of alarm and float switches, etc.): DISTRIBUTION BOX:(if present must be opened)(locate on site plan) Depth of liquid level above outlet invert: 0 Comments (note if box is level and distribution to outlets equal, any evidence of solids carryover_ anv evidence of PUMP CHAMBER: (locate on site plan) Pumps in working order (yes or no): Alarms iit working order (yes or rio): Comments (note condition of pump cher, condition of pumps and appurtenances, etc.): . • • 01 Page 9 of 11 OFFICIAL INSPECTION FORM — NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C. SYSTEM INFORMATION (continued) Property Address: 041 Owner: Date of Inspection: – SOIL ABSORPTION SYSTEM (SAS): (locate on site plan, excavation not -required) If SAS not located explain why: v Type leaching pits, number: _ leaching chambers, number: leaching galleries, number: I I , leaching trenches, number, length: 6S X 3 )c / leaching fields, number, dimensions: overflow cesspool, number: innovative/alternative system Type/name of technology: Comments (note condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of vegetation, 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 or no): -. — Comments (note condition of soil, sigffs of hydraulic faijure, level ofponding, 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.): (b Page 10 of 11 OFFICIAL INSPECTION FORM — NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM'INFORMATION (continued) Property Address: 1 dY rc . n_ Z Owner: W CjS-e Date of Inspection: SKETCH OF SEWAGE DISPOSAL SYSTEM Provide a sketch of the sewage disposal system including ties to at least tw(Epermanent reference landmarks or z benchmarks. Locate all wells within 100 feenL,ocate where publigwater supply enters the building... t?� N] 10 f Page 11 of 11 OFFICIAL INSPECTION FORM — NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: - S S7 �. Owner: Date of Inspection: SITE EXAM Slope Surface water Check cellar f t 1 \ s Shaljow wells t i Estimated depth to ground water feet Pleaseii�nddicate (check) all methods used to determine the high ground water elevation: 1,16btained from system design plans on record - If checked, date of design plan reviewed: 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: Y�,p must describe how you estaplish t high ground water elevation:- , ; P1� �/ e244_ ova ;� �, 7a /j/ /A& v��r II "i;M. �� QQruT[ �1•�.il','' •. ' i - '.. :, I�r'', •'•�l"•�'��,%i; •' �t<r �`��''• ORT• y 'r�wE MA 'vrn . m1w. �'Joy��y, . :I, ..}.(t;;.,v+IVB,I;�1'1:.'•jt`�,���'J��l�fr�t�rlp:4: to •)ib•,.,:�+1',�(i1V!.Yiyl;':, V i/' �QR !.�(.,Y{,+t�/',,. 1,., 1','r,',1'7!;'j',F' i•w'wl/(7r ^� .r ((A .� I DEP,has A►Y f•'' provided �hla,form for ues by local Boards of alth, ba subml(tad`'to the.local'Board of Health or other a ro The Sy,3 EQM,RAJM' ing Recorc m_ �,.. r•<': ;::j,:•:::,:y' : ,;r,1;: :,'c; a. PP tL0%CryiAR ; yr A: FacIII HE ty,.inforli tlon . .�JsrWnen•(Ilunp�ovi ':1',;;•Systsm locatJon;`�'�� • ,"; forms, on ;U�e, ;,a•,.'.. • ��� .. 1/0 only the trio key Address ; to move yow 'A % Y. tVN �wWmiyy� /::r,'t'i',bt. t:ill,,l )IK'gS'1 ; 'lt'�''r w�•r.I:i�' ;:'. : ' $loto zip VQe };Y i.�•r �'J', Vk.�'S�•111'�i ji:, "'I'' ,,i,'�': •�I:. ' .a�'•sr',l: 3,, 5�;t;��,t,21 �,sYSternlOWn9r'�1 ,,'F ,,, -. r , ' . �'` r } e ,IkY�", °''''•' � 1i'•`'•jr Y'I•rj ;,, t, li ,alr•r r' , ' r' Nuns '4:i•,n r,,,v"(1"l;{,.:"'..,. 1.:., ,I'' � •r. i.1 r, •;y.1.;'', .,I , ,,l/lt;' ��! Fj,l,'.,, �,',�.'r:Sit J:�� •(:. Addro4 (If 0crent from bcaUon) • • •.',�: �,; ':�CltyRown,•��.:,;�at,':1;.`, ,.:• Stele' of Telephone Number I/C: `•'�l:^.f %IwfY:lJa��n'�iir ;J.;.1111,>I,.l';I'':�:!7;'1'•:5',' , Date!of Pumpin .,, ;',' • Dale 2, QuanUty Pumped. - �t ,,.,'... ,,. •: :.''' ,.. Gallon yp,9 Pf,ayatem,`; ';` ❑ Cesspooi(s) �eptic Tank ❑ TI9ht '•��/.,'.; :,'1 ,::�,: ' Tank " �. �,.� ,'i �•,' lid.. •�1l o`i: .,Other (desQdbl.01 , EffliiOilt Taa Flits '.: r . 'r' 411, ttk,r, �'r: r��:r Cjrl'•�S9nil .❑ No I( yes, was It cleaned? ❑ Ye ry ;•,1�.�'i',�Nrl;� tqJ LLIG m''..' ., ... .:;�.1:{�:y.,,.,•,t^,7jy�t• •�,(„Y•jJ'riafl•�J,7� ' i ...;i.t(1�1( Jn I:�r,�•;'•,,, ' ,; ;�',•,:,•. ,;4 ��1.'•,`/`;,�;It3iJ,',.,Jd7j;(r:r•;i��r;J.'t�/fy!M }''ry�%q�,'�'�'�„r:: . .. +.i �l�'i:, •.1 :.,1 r 4(%"il, ,.,t (� , 1:4�}(�.'I'fis��; J, •-• •,i'�•:. ')� �fi:'�'�.lf,',l'�.I"i+tf:4at';':t1(i'{t'r'1i�tAl,�.y;,5,;��,,' • ,'i,,'. ;: f`,'`; s: ;l ;'_��J:�l i.'4,r ���1�r%7wl�a(ia,�!'i�i�..J�'�1��,1f�1}f!r,��r;;(��1:'���;:��;:.... �. :.c::,s,;. :,•: ;,+•wo'ti , ••rV v'N r it^."JF'�l v {1l+ 1:►,l ii.:.::;:' • � •;,'t•.i�'y�•;/'r r4,'r.,:.�,�.fN'�I�{.��41y!� 7 �• (j, •.''jt.i' i,',,r .�.,': 't `.�,.,, t:,�!ti.l 1 1"l:'•,r•i;,;, 1<� Jy.ra' •;, '.Z;1''` •�`•.r. ,�,;• .r�;�.•;r�•,:>;'7;;%tl'oca on•whe•re•cor�tents' a :d •o ,, ...;,,, .:'.,.i;'I:r}<ifa:i: rl�',f...,l),.•ai�'d1' ;�;I,,�i t ,';� li. ,'\,� \f l'1 tj;'y'r. Jt!�,t��li ,l'S1 ''i,,. 11 .• ':i: (` � j'I'..'. I•Jrla �•.:'f l,�:. r.tl :'i:"'� ., ^ „ .. .�'::/: x.:54; f/ ��j,;••;,t%, :'�; ti�'I..��r:1':4;1J';,•�'!;�,'�:,'�.,lr, r'r1''f:5'''lt'` ., "�. •lY �s{ 5,,1;11 •, it' •: .`;;iJ� tW'.�•JJiidl'C t rl [ 1, i., � ',�r�f• {'�l"%'nl If , :`., ,.:rt':•'•r .,.�lS,;•::r:; ';.�';r,t•,ti.;r•r,�, ,yb,•:;1• •t,., Y,1 q's,:;'',:. �.,• :`'.:;',•�:,;�'�•''� •1";�',°ra,:.:!`Sbne<lJreolHiub : hUpJ/�ww,mass,9ov/dep!wier/apprCvaJs%t6(om IVehlcJe ucenrfe Number Syflem Pumpinp Record ' Page 4 v Important: When filling out forms on the computer, use only the tab key to move your cursor - do not use the return key. tab Commonwealth of Massachusetts City/Town of North Andover S P R d 1. �1 5 2013 ystem u111P U ecor TO'.- •aLis- rForm 4�n ��QrE R `R_ •F,_ 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 1. System Location: Address North Andover City/Town 2. System Owner Name Address (if different from location) City/Town t Ma State State Telephone Number 01845 Zip Code Zip Code B. Pumping Record �j 1. Date of Pumpinga77 2. Quantity Pumped: /` OG Date Gallons 3. Type of system: ❑ Cesspool(s) Septic Tank ❑ Tight Tank ❑ Grease Trap ❑ Other (describe): 4. Effluent Tee Filter present? ❑ Yes /] No 5. Condition of System: If yes, was it cleaned? ❑ Yes ❑ No 6.tem Pumped By: 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 re of Hauler / Date 1 /63hl Signature of Receivin acility Date t5form4.doc• 03/06 System Pumping Record • Page 1 of 1 V— O N f� i c m o - V � O � � O c tOA E O e, L r � a a f L � O C al i V C CT �6 VO c �+ R a C a) o € c I GCQ 0 ca O m I H n C O a Q v� O Q m 3 U O O C f� f0 Z