HomeMy WebLinkAboutMiscellaneous - 110 FOREST STREET 4/30/2018 (2) swom
110 FOREST STREET J `
4 210/1-06.A-0135-OD00:0
1
a
I
Commonwealth of Massachusetts
W City/Town of North Andover
W° System Pumping Record
Form 4
M
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. RECEIVED
A. Facility Information JUN 75 2015
Important:When TOWN OF NORTH ANDOVER
filling out forms 1. System Location:
on the computer, O HEALTH DEPARTMENT
use only the tab _
key to move your Address
cursor-do not North Andover
use the return
key. City/Town State Zip Code
2. System Owner: I
Name
reMn
Address(if different from location)
City/Town State Zip Code
Telephone Number
B. Pumping Record
1. Date of Pumping �Date — 2. Quantity Pumped: gal ons 0b
3. Type of system: ❑ Cesspool(s) Veptic Tank ❑ Tight Tank ❑ Grease Trap
❑ Other(describe):
4. Effluent Tee Filter present? ❑ Yes ❑ No If yes, was it cleaned? ❑ Yes ❑ No
5. Condition of System:
6. Syste mped By:
N Vehicle License Number
wart's Septic Service
Company
7. Location where contents were disposed:
Stewart's Pre-treatment Plant, 20 So. Mill Bradford, Ma 01835
Signature of Hauler Date
Signature of Receiving Facility Date
t5form4.doc•03/06 System Pumping Record•Page 1 of 1
_ Commonwealth of assa husetts �������®
= City/Town of N• OVe ,'UN � 2om
System Pumping ecord TowN
OF i4.. .'t i.ANDOVER
Form 4 HEALTP Gc�'AR i l,'ENT
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 tc determine the form they use, The System Pumping Record must be submitted to
the local Board of Health car other approving authority within 14 days from ine pumping date in
accordance with 310 CMR 15.351,
A. Facility Infos° nation
Important:When
filling out forms 1. System L tij-do
on the computer,useonly the tabkey to move your Add
cursor-do notuse the return City/Town - StatE – - --- Zip Code
2.
r� 2. System Owner. T� -Cna
Name T
ieun
Address(if different frorn location)
City/TownState Zip Code
Telephone Number
B. Pumping Record
1. Date of Pumpingpate r 5– --72. Quantity Pumped:
tallons -
3. Type of system: Cesspool(s) Septic Tank Tight Tank (I Grease Trap
[] Other(describe): — – --- --- —
4. Effluent Tee F=ilter present? ❑ Yes 9i N If yes; utas it cleaned? '� Yes �No
5. Condition of System: ___
Qc(
6. System Pumped By:
Name �— — Vehicle License Number
Stewart's Septic Service�_ _�
CompanyT
7. Location where contents were disposed:
Stewart' Pre-treatment Plant, 20 So. Mill Bradford, Ma 01835
Sign, pu - Date -- —
ign-uta Reo�g F __---- - � Date
t6form4.doc•03/06 Sy5tsm Pumping Record.Page 1 of 1
RECEIVED
Commonwealth of Massachusetts JUS - 2013
City/Town of No Andover
System Pumping Record TDWALTHN OF DRTHANDDVER
HEALTH DEPARTMENT
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 forms 1. System Location:
on the computer, �-
use onlythe tab 116- fa g S
key to move your Address
ser the rdet mt No andover, Ma
key. City/Town State
Zip Cods
VQ 2. System Owner.
� I
Name
mwr
Address(if different from location)
Citylrown State Zip Code
Telephone Number
B. Pumping Record
1. Date of PumpingDate� i. 2. Quantity Pumped: U
Gallons
3. Type of system: ❑ Cesspool(s) Septic Tank ❑ Tight Tank ❑ Grease Trap
❑ Other(describe):
4. Effluent Tee Filter present? ❑ Yes No If yes, was it cleaned? ❑ Yes ❑ No
5. Condition of ystem:,
6. System Pumped By:
2:z:)O— -�
Name Vehicle License Number
Stewart's Septic Service
Company
7. Location where contents were disposed:
StewhrPs Pre-treatment Plant 20 So. Mill Bradford Ma 01835
Signa Date
Signa of Receiving Facility Date
t5form4.doc•03/06 System Pumping Record•Page t of 1
�1y' (��!ff•r nn y)�alb' ��';';':'•'
f b RST' Al1D ER MASSA H
USETTS
n. Record" "
V 1 • .lo v�������� ��., �I
�'`{ .t,Y, •1`ry'',�f' .I .ray rflfi�f. Ij�,Y 4{�'y ���C)'1.;;1.!,• .,
. . .:I: ;fi'i)'r•�ir�1,�nJJ:,�' �"�li�„•��V:j.l��. .. '
`•
':c DE#ub provided jhtiYform for ueo by local Board* of Hoalth. The System Pum In
be ubml{jod to the.local Board of Hoalth or other approving authorlry,
A; Facility lnforn)atlon
;
L•nRorrinL, y,rri'r'an N�1)9 out'....1; System Location,
:. .
Q*00lab kay Addrey+ /( `3/'
I tu+�M rituml.y; Sfat�
j
kay', ;"lw,`'t';`',,;�"'•' .`�'`'���!'a1. ;;:�•; • ," ... Up Coos
ern Owner, 1
.C', '.� ',r{:p71,'.ru..,1. ;'�.l.�•.I�s,,:'.,;��,' �� : � �M -
" Addro+i(It 04r*nt rpm buUon)
oe
�+y(,v� �� Tolep�one Numper 973
r, B�',Rumping:Regord, IN
of
---
1 t '".;.,Y:.'�'.,Ir••' >)i..�,�a . s,`"ref
Dai of Ptimpinp'' Quand
—Date Z ty P umpee. --
VryP�
❑ Tank
G� ons
Y Cesspool(s) epUc Ten
k ❑ Tight Tank
,( .,.Other(descd1 .'
Effluent Tea Fllfe(Pr�•sent? ,❑ Yeo It yes, was Ic cleana ?
d
ti�tt ;rC,ofi4onLQ(SY.�t m1 t CC11
----
iq
G
„: •• 'il''��r!� �)irf, ' �, ��.Gi'ISL•` �l� .1f� '�,�\';' '�,n VehlcJe 1.1
+ uVlrlilb /
' •: ,'+�'t+`:,�.''A��iti r�1`�:,.,.'��Iy fH�l1'JA�I
n wh
11 r•;r:Ct,;.,,�s,:.
'� , ,.. :I�,;.•.;;: �r .were I posed;
,,;�h"��:'..% ���,:�•,:. . Slpnalw� v(Hiulal;�y,'-;Jr�,.t,.,,,...,,1 ..,: 57# _
h"��Nywvi,mass.gov/dap!ivelor/approva)s/�6(orms,hfminspecc
SWOM Pumping Reco1� • c;,
::moi,' i 'W`I^�" '„ •e. ,:�,; �r/ , ;
;,j0• . *,Q•-; ORTH ANC R. MASSACHUSETTS
iSYte °Puniping Reco'ird
f,''''ti:`!?f � °fit �ir�i✓ti;t �'• r.i ;
DEP..has provided this form
for use by local Boards of Health. The a umping Record ust
be submitted to the Iocal'Board of Health or other approving author , ��
X Facility information 'JUN - 4 .2007
...1. .hen rung Out Sy$tem Locabofl TOWN Ur NORTH ANDOVER
fOriT13 On tt10 LTH DEPARTMENT
computer use
only the tab key Address �//
to move your:; .; C
cursor•do not Cl ��
use the return tY State
t
• Zip Code
Y keySystem Owner, _
r
' , •:, , ; tr Name 1 ' �w—'
Address(If different from ioeation) :
Ctty/Torm Statey) ZJp Code
Telephone Number
6.rPumping Rekord LM
r•� 1 Date of Pumping Date 2. Quantity Pumped:
6�7t5
P Gallons
3,.' '.Typo pf system;, ❑' Cesspool(s) eeptic Tank ❑ Tight Tank
`.Other(describe);
4 Effluent Tea Fliter present?.❑ Yes o If yes, was it cleaned? ❑ Yes
} r > ❑ Q
4.1
f, , r 6 ;Condition of Systgm '' •
„ r
J i Yi.t3.4ic r r•,t.tl.r 111,r. -
6 Sy. Q�ii Pumped By
'� J•,•,^`„ �i.:Y,•'�`'•j'iNM11e•:\t:`..iji`I':� ..�:r:>,:i' �N�.f�."^'rt i,� •
4 i `a: F n J'r 1^�r 4> +�"� f•• h Vehicle Ucenee Number
is •tr ynr Yt3r'h�>l�t,,r�'j�iC�.��.n
Cotrtpe{1y
-, "'Y"";
,�'Y• al ',h''dy'r�31��7Ltfy±J
{ t , 7 Location where contents yvere 1;3posed:
f O
w•�4 Slpnature of Haukr;,> c. ,
4
Date
:http//www.mass.gov/depJwafer/apprGvals/t5forms,htm#Inspect
t5fom�4.doa t)QJ03 System Pumping Record•Page 1 or t
Commonwealth of Massachusetts
W City/Town of NORTH ANDOVER MASSA7ity
:T'S L
. . System Pumping Record
y` Form 4 EB 0 8 2006
u-F NORTH A�00\/ER
DEP has provided this form for use by local Boards of Health. Tl ;urn tF "�To-r-d must
be submitted to the local Board of Health or other approving au
A. Facility Information
Important:
When filling out 1. System Location:
forms the
computer,use
only the tab key Address
to move your
cursor-do not City/Town Stat - Zi Code
use the return P
key. 2. System Owner: '
It
Name cc
Address(if different from location)
City/Town State Zi Code
Telephone Number
B. Pumping Record 2
1. Date of Pumping 3 2. Quantity Pumped:
Date Gallons
3. Type of system: ❑ Cesspool(s) OSeptic Tank ❑ Tight Tank
❑ Other(describe):
4. Effluent Tee Filter present? ❑ Yep � 0 If yes, was it cleaned? ElYe�lo
5. Condition of System: ��
r��o
System Pumped By:
Name Vehicle License Number
Company
7. Location where contents were dis osed: �L
Signature of Hauler Date
http://www.mass.gov/dep/water/approvals/t5forms.htm#inspect
t5form4.doc•06/03 System Pumping Record•Page 1 of 1
OR NORTH"ANDOVER .
SYSTEM PUkPING R.EOOR:D
.. "` L
>>'�'TEM OWNER & ADDRESS SYSTEM LOCATION
oma, / . ••
(example: left front of house)
o//. .
6v, Aw/a�
UATE OF PUMPING:_ � QUANTITY PUMP C-D100P GALLc»,
NO E SEPTIC TANK: NO YES —�
NATURE OF SERVICE; ROUTINE �,EMERGENCY
uIIsrRVATION
GOOD CONDITION. FULL TO COVE It
HEAVY GREASE BAFFLES IN I'LACi:
ROOTS LEACHFIELD RUMBACK.,.
EXCESSIVE SOLIDS FLOODED
SOLIDS CARRYOVERvp,WHKR (EXPi.AiN)
i1'a'ITIM PUMPRY: . •' ,"• , l
�'U�IIviFNTS: '
c U�"1'IsN'1'S' '1'RANSPORRED T0:
TOWN OF NORTH ANDOVER
SYSTEM PUMPING RECORD
DATE:
SYSTEM OWNER & ADDRESS SYSTEM LOCATION
(example: left front of house)
i
-76W�L Duro
DATE OF PUMPING: 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)
SYSTEM PUMPED BY: J,)z
COMMENTS:
CONTENTS TRANSFERRED TO:
a t ,
r TOWN OF NORTH ANDOVER
SYSTEM PUMPING RECORD
R
DATE: -g q„�
1 ;
SYSTEM OWNER& ADDRESS SYSTEM LOCATION
(example: left front of house)
r- JJ
11,0 ��� 51,- J/
x 4,0 :h r:
I
DATE OF PUMPING: S a QUANTITY PUMPED /000 GALLONS
CESSPOOL: NO YES SEPTIC TANK: NO YES
a
: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)
14 l
! -SYSTEM,PUMPED BY: 4A c(b'v
�7 'r77t�lJr+ y0.�jcar 54 }
COMMENTS;
,�tlf , a �• � ,
iq
2DOi
„F! CONTENTS TRANSFERRED TO: To i
! i t
1 L
/address - Title of File pa
9e of
Date File Open: Date file closed:
Doc Document/Action Title Date of Refer to other Purpose of Document/Action and notes
action Document/ document/
Num. Action Department
Board of Appeals — Board of Health — Planning Board — Conservation Commission — Building Department
--- COn-MAiONWEALTH OF MASSACHUSETTS
EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS
DEPARTMENT OF ENVIRONMENTAL PROTECTION
- ONE WINTER STREET, BOSTON MA 02108 (617) 292-5500
TRUDY COME
Secretam
ARGEO PAUL CELLUCCI DAVID B. STRUHS
Governor Commissioner
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
CERTIFICATION
Property Address: Ild I� PST Name of Owner
Address of Owner:
Date of Inspection:
Name of Inspector:(Please Print)
I am a DEP ap oved system inspector pursuant tq,Se tion 15.340 of True 5(310 CMR 15.000)
Company Name: ecirli S P h I
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 inspection. The inspection was performed based on my training and experience in the proper function and
maintenance of on-site sewage disposal systems. The system:
_XPasses
_ Conditionally Passes
Needs Further Evaluation By the Local Approving Authority
_ Fails
inspector's Signature: Date: /
The System Inspector shall submit a copy of this inspection report to the Approving Authority (Board of Health or DEP)within thirty (30)days of
completing this inspection. If the system is a shared system or has a design flow of 10,000 gpd or greater,the inspector and the system owner
shall submit the report to the appropriate regional office of the Department of Environmental Protection. The original should be sent to the
system owner and copies sent to the buyer,if applicable, and the approving authority. .
NOTES AND COMMENTS ,r
`owr Y e Ut U v f �a fLw1 .
Pr �rte.• i�J� U P�`> Gc�P !/
revised 9/2/98 Page 1ofII
i� Printed or Recycled Paper
t �
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM "I 1
PART A t
CERTIFICATION (contin�uJed)
'roperty Address: / J� 0
5r C`,
Jwner:
Date of Inspection:
INSPECTION SUMMARY: Check A, B, C, or D:
A. SYSTEM PASSES:
�I have not found any information which indicates that any of the failure conditions described in 310 CMR 15.303 exist. Any failure
criteria not evaluated are indicated below.
YOMMENTS:
B. SYSTEM CONDITIONALLY PASSES:
�r 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.
Indicate yes, no, or not determined(Y, N, or ND). Describe basis of determination in all instances. If "not determined", explain why not.
The septic tank is metal, unless the owner or operator has provided the system inspector with a copy of a Certificate of
Compliance (attached)indicating that the tank was installed within twenty(20) years prior to the date of the inspection; or
the septic tank, whether or not metal, is cracked,structurally unsound, shows substantial infiltration or exfiltration, or tank
failure is imminent. The system will pass inspection if the existing septic tank is replaced with a complying septic tank as
approved by the Board of Health.
Sewage backup or breakout or high static water level observed in the distribution box is due to broken or obstructed pipe(s)
or due to a broken, settled or uneven distribution box. The system will pass inspection if(with approval of the Board of
Health).
broken pipe(s) are replaced
obstruction is removed
distribution box is levelled or replaced
The system required pumping more than four times a year due to broken or obstructed pipe(s). The system will pass
inspection if(with approval of the Board of Health):
broken pipe(s) are replaced
obstruction is removed
revised 9/2/98 Page 2of11
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION(continued)
Property address: /f) rU�r'SJ "O""loo
oateo;,Inspection: L V
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 the
public health, safety and the environment.
1) SYSTEM)NILL PASS UNLESS BOARD OF HEALTH DETERMINES IN ACCORDANCE WITH 310 CMR 15.303(1)(b)THAT THE SYSTEM
IS NOT FiNCTIONING IN A MANNER WHICH WILL PROTECT THE PUBLIC HEALTH AND SAFETY AND THE ENVIRONMENT:
Cesspool or privy is within 50 feet of 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 AND SAFETY AND THE 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 soil absorption system and the SAS is within a Zone I of a public water supply well.
The system has a septic tank and soil absorption system and the SAS is within 50 feet of a private water supply well.
The system has a septic tank and soil absorption system and the SAS is less than 100 feet but 50 feet or more from a
private water supply well, unless a well water analysis for coliform bacteria and volatile organic compounds indicates that the
well is free from pollution from that facility and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less
than 5 ppm. Method used to determine distance (approximation not valid).
3) OTHER
revised 9/2/98 Page 3of11
•
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION (continued)
Property Address:
Owner: �fj.r Cc
Date of Inspection: v"
D. SYSTEM FAILS:
You must indicate either ' es or No" to each of the following:
have determined that one or more of the following failure conditions exist as described in 310 CMR 15.303. The basis for this
determination is identified below. The Board of Health should be contacted to determine what will be necessary to correct the failure.
Yes No /f ),
Backup of sewage into facility-or system component due to an 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 1/2 day flow.
Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s).
Number of times pumped_.
Any portion of the Soil Absorption System, cesspool or privy is below the high groundwater elevation.
Any portion of a cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply.
Any portion of a cesspool or privy is within a Zone I of a public well.
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. If the well has been analyzed to be acceptable, attach copy of well water analysis for
coliform bacteria, volatile organic compounds, ammonia nitrogen and nitrate nitrogen.
E. LARGE SYSTEM FAILS:
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:
The system serves a facility with a design flow of 10,000 gpd or greater(Large System)and the system is a significant threat to public
health and safety and the environment because one or more of the following conditions exist:
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)
The owner or operator of any such system shall upgrade the system in accordance with 310 CMR 15.304(2). Please consult the local regional
office of the Department for further information.
revised 9/2/98 Page 4ofII
t
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART B
CHECKLIST
Property Address: i
Owner:
Date of Inspection:
Check if the following have been done: You must indicate either "Yes" or "No" as to each of the following:
Yes No
Pumping information was provided by the owner, occupant, or Board of Health.
None of the system components have been pumped for at least two weeks and-the system has been receiving normal flow
rates during that period. Large volumes of water have not been introduced into the system recently or as part of this
inspection.
_ As built plans have been obtained and examined. Note if they are not available with N/A.
_ The facility or dwelling was inspected for signs of sewage back-up.
The system does not receive non-sanitary or industrial waste flow.
_ The site was inspected for signs of breakout.
_ All system components, excluding the Soil Absorption System, have been located on the site.
_ The septic tank manholes were uncovered, opened, and the interior of the septic tank was inspected for condition of baffles
or tees, material of construction, dimensions, depth of liquid,depth of sludge, depth of scum.
The size and location of the Soil Absorption System on the site has been determined based on:
y _ Existing information. For example, Plan at B.O.H.
Determined in the field(if any of the failure criteria related to Part C is at issue, approximation of distance is unacceptable)
115.302(3)(b)I
The facility owner(and occupants,if different from owner) were provided with information on the proper.maintanance.of
Subsurface Disposal Systems.
revised 9/2/98 Page 5ofII
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION
'roperty Address:
Owner:
Date of Inspection:
FLOW CONDITIONS
RESIDENTIAL:
Design flow: g.p.d./bedroom.
Number of bedrooms(design):_ Number of bedrooms(actual):_
Total DESIGN flow
Number of current residents:_
Garbage grinder(yes or no):_
Laundry(separate system) (yes or no):_: If yes, separate-inspection required
Laundry system inspected (yes or no)
Seasonal use(yes or no):_
Water meter readings,if available (last two year's usage(gpd):
Sump Pump(yes or no):_
Last date of occupancy:
COMMERCIAL/INDUSTRIAL: /)
Type of establishment: �d
Design flow: gpd ( Based on 15.203)
Basis of design flow
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:
OTHER:(Describe)
Last date of occupancy:
GENERAL INFORMATION
PUMPING RECORDS and source of information:
System pumped as part of inspection: (yes or no)�/p s
If yes, volume pumped: gallons I
Reason for pumping:
TYPE OF..SYSTEM
tf 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)
1/A Technology etc. Attach copy of up to date operation and maintenance contract
Tight Tank Copy of DEP Approval
Other
APPROXIMATE AGE of all components, date installed(if known)and source of information:
Sewage odors detected when arriving at the site: (yes or no)_
revised 9/2/98 Page 6of11
1 +
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORM TON(continued)
'roperty Address: orrll'ae
Owner:
Date of Inspection: '�'� Co �, f
BUILDING SEWER:
(Locate on site plan)
Depth below grade:
Material of construction:_cast iron=40 PVC_ other (explain)
Distance frorlp�'vate water supply well or suction line
Diameter �l-f�
Comments: (condition of joints, venting, evidence of leakage,-etc.)
SEPTIC TANK:_
(locate on site plan)
Depth below grade:
Material of construction:_concrete_metal_Fiberglass _Polyethylene_other(explain)
If tank is metal, list age_ Is age confirmed by Certificate of Compliance_(Yes/No)
Dimensions:
Sludge depth:
Distance from top of sludge to bottom of outlet tee or baffle:
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:
How dimensions were determined:
'omments:
(recommendation for pumping, condition of inlet and outlet tees or baffles, depth of liquid level in relation to outlet invert, structural integrity,
evidence of leakage, etc.)
GREASE TRAP:
(locate on site plan) 1V4 .
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:
(recommendation for pumping, condition of inlet and outlet tees or baffles, depth of liquid level in relation to outlet invert, structural integrity,
evidence of leakage,etc.)
revised 9/2/98 Page 7of11
� 4
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
f SYSTEM INFORMATION(continued)
'roperty Address:
Owner:
Date of Inspection:
TIGHT OR HOLDING TANK: (Tank must be pumped prior to, or 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
Alarm level: Alarm in working order: Yes_ No_
Date of previous pumping:
Comments:
(condition of inlet tee, condition of alarm and float switches, etc.)
DISTRIBUTION BOX:YJ2
(locate on site plan)
Depth of liquid level above outlet invert: /
Comments:
(note if level and distribution is equal, evidence of solids carryover, evidence of leakage into or out of box, etc.)
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.)
revised 9/2/98 Page 8ofII
4
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
'roperty Address: //19
Jwner: /
Date of Inspection:
SOIL ABSORPTION SYSTEM(SAS):l
(locate on site plan,if possible; excavat. not required,location may be approximated by non-intrusive methods)
If not located, explain:
Type:
leaching pits, number:_
leaching chambers, number:_
leaching galleries, number:_
leaching trenches, number, length:
leaching fields, number, dimensions: 0 f U
overflow cesspool, number:_
Alternative system:
Name of Technology:
Comments:
(note condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of vegetation, etc.)
02 770C 7/9 I-004-e-7 C L yr
CESSPOOLS:_
(locate on site plan)
Number and configuration:
Depth-top of liquid to inlet invert:
Depth of solids layer:
)epth of scum layer:
Oimensions of cesspool:
Materials of construction:
Indication of groundwater:
inflow (cesspool must be pumped as part 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.)
revised 9/2/98 Page 9of11
M
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION ((ccoontinued)
"sroperty Address: d �d�pS� (� 1,4 1-1490 4
Jwner: n !
Date of Inspection: Poe/J�0 G 1j /�� �— �
t-
SKETCH OF SEWAGE DISPOSAL SYSTEM:
include ties to at least two permanent reference landmarks or benchmarks
locate all wells within 100' (Locate where public water supply comes into house)
0- 0
revised 9/2/98 Page 10 of 11
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued?
operty Address:
Jwrm:
Date of Inspection: (�/ v r d
f,~
NRCS Report name
Soil Type_
Typical depth to groundwater
USGS Date website visited
Observation Wells checked
Groundwater depth: Shallow Moderate Deep
SITE EXAM Slope
Surface water
Check Cellar
Shallow wells
Estimated Depth to Groundwater_Feet
Please indicate all the methods used to determine High Groundwater Elevation:
Obtained from Design Plans on record
Oj3served Site(Abutting property, observation hole, basement sump etc.)
L'XDetermined from local conditions
Checked with local Board of health
Checked FEMA Maps
Checked pumping records
Checked local excavators, installers '
Used USGS Data
Describe how you established the High Groundwater Elevation. (Must be completed)
194, 17 17 t ,2 T A . / v
e 2
revised 9/2/98 Page ttof11
7'EALTH OF MASSACHUSETTS
EXECUTnTE OFFICE OF ENVIRONMENTAL AFFAIRS
DEPARTMENT OF ENVIRONMENTAL PROTECTION
ONE WINTER STREET; BOSTON MA 02108 (617) 292-5500
TRUDY CORE
Secretarc
ARGEO PAUL CELLUCCI DAVID B. STRUHS
Governor Commissioner
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION �+ /
Property Address: //L/ V`v
R PS Name o Omer
Address of Owner:
Date of Inspection:
Name of Inspector:(Pleafe Print) 5,1 om &'54
I am a DEP approved system inspector rsuant jo Section 15.340 of Tine 5(310 CMR 15.000)
Company Name: f4 V on J P✓ s N f r G
Matting Address:
Telephone Number, `f y 7/
CERTIFICATION STATEMENT
1 certify that I have personally inspected the sewage disposal system at this address and that the information reported below is true, accurate
and complete as of the time of inspection. The inspection was performed based on my training and experience in the proper function and
maintenance of on-site sewage disposal systems. The system:
_ Passes
Conditionally Passes
Needs Fu her Evaluation BTy the local Approving Authority
Fails
Inspector's Signature: / /I �"` Date: /
V
The System Inspector sha111 submit a copy of this inspection report to the Approving Authority(Board of Health or DEP)within thirty (30)days of
completing this inspection. If the system is a shared system or has a design flow of 10,000 gpd or greater,the inspector and the system owner
shall submit the report to the appropriate regional office of the Department of Environmental Protection. The original should be sent to the
system owner and copies sent to the buyer,if applicable, and the approving authority. .
NOTES AND COMMENTS
r41
revised 9/2/98 Pagel of 11
4i0 Pnraed or Recycled Paper
r,
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION (continued)
'roperty Address: 110 fqXi"y4- '51-
Owner: t<Q C
Date of Inspection: 5
INSPECTION SUMMARY: Check A, 8, C, or D:
A. SYSTEM PASSES: Q
I have not found any information which indicates that any of the failure conditions described in 310 CMR 15.303 exist. Any failure
criteria not evaluated are indicated below.
COMMENTS:
B. SYSTEM CONDITIONALLY PASSES:
One or more system comporlen".as described in the "Conditional Pass" section need to be replaced or repaired. The system, upon
completion of the replacementor,repair, as approved by the Board of Health, will pass.
r
Indicate yes, no,or,not determined'(Y, N, or ND). Describe basis of determination in all instances. If "not determined", explain why not.
The septic tank.is metal, unless the owner or operator has provided the system inspector with a copy of a Certificate of
Compliance (attached)indicating that the tank was installed within twenty (20) years prior to the date of the inspection; or
the septic tank, whether or not metal, is cracked,structurally unsound, shows substantial infiltration or exfiltration, or tank
failure is imminent. The system will pass inspection if the existing septic tank is replaced with a complying septic tank as
approved by the Board of Health.
Sewage backup or breakout or high static water level observed in the distribution box is due to broken or obstructed pipe(s)
or due to a broken, settled or uneven distribution box. The system will pass inspection if(with approval of the Board of
Health).
broken pipe(s) are replaced
obstruction is removed
distribution box is levelled or replaced
The system required pumping more than four times a year due to broken or obstructed pipe(s). The system will pass
inspection if(with approval of the Board of Health):
broken pipe(s) are replaced
obstruction is removed
revised 9/2/98 Page 2of11
r
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION (continued)
Property Address: !/ r' �� /V 6 v
Owner:
Date of Inspection: (� C
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 the
public health,safety and 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 THE PUBLIC HEALTH AND SAFETY AND THE ENVIRONMENT:
_ Cesspool or privy is within 50 feet of surface water
Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh.
, F
2) SYSTEM WILL FAIL UNLESS THE BOARD OF HEALTH IAND PUBLIC WATER SUPPLIER,IF ANY)DETERMINES THAT THE SYSTEM IS
FUNCTIONING IN A MANNER THAT PROTECTS THE PUBLIC HEALTH AND SAFETY AND THE ENVIRONMENT:
The system has a septic tank and soil absorption system(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 soil absorption system and the SAS is within a Zone 1 of a public water supply well.
The system has a septic tank and soil absorption system and the SAS is within 50 feet of a private water supply well.
— The system has a septic tank and soil absorption system and the SAS is less than 100 feet but 50 feet or more from a
private water supply well, unless a well water analysis for coliform bacteria and volatile organic compounds indicates that the
well is free from pollution from that facility and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less
than 5 ppm. Method used to determine distance (approximation not valid).
3) OTHER
revised 9/2/98 Page 3of11
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION (continued)
Property Address: 11,4Owner:
Date of Inspection: P11(s C' ` / 72D. SYSTEM FAILS��S
You must indicate either "Yes" or "No" to each of the following:
I have determined that one or more of the following failure conditions exist as described in 310 CMR 15.303. The basis for this
determination is identified below. The Board of Health should be contacted to determine what will be necessary to correct the failure.
Yes No
Backup of sewage into facility-or system component due to an 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.
W00000, — 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 1/2 day flow.
Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s).
Number of times pumped_.
Any portion of the Soil Absorption System, cesspool or privy is below the high groundwater elevation.
Any portion of a cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply.
Any portion of a cesspool or privy is within a Zone I of a public well.
_ _ 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. If the well has been analyzed to be acceptable, attach copy of well water analysis for
coliform bacteria, volatile organic compounds, ammonia nitrogen and nitrate nitrogen.
E. LARGE SYSTEM FAILS: �-ia0-
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:
The system serves a facility with a design flow of 10,000 gpd or greater(Large System)and the system is a significant threat to public
health and safety and the environment because one or more of the following conditions exist:
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-(WPA)or a mapped Zone II of a public
water supply well)
The owner or operator of any such system shall upgrade the system in accordance with 310 CMR 15.304(2). Please consult the local regional
office of the Department for further information.
revised 9/2/98 Page 4oftl
Y
t+ SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART B
CHECKLIST �f
Property Address: � �(f t��'� l / �' /71t��o
Owner:
Date of Inspection:
Poe S co l�
Check if the following have been done: You must indicate either "Yes" or "No" as to each of the following:
t,'s"" No
_ Pumping information was provided by the owner, occupant, or Board of Health.
None of the system components have been pumped for at least two weeks and the system has been-receiving normal flow
rates during that period. Large volumes of water have not been introduced into the system recently or as part of this
inspection.
As built plans have been obtained and examined. Note if they are not available with N/A.
_ The facility or dwelling was inspected for signs of sewage back-up.
The system does not receive non-sanitary or industrial waste flow.
_ The site was inspected for signs of breakout.
_ All system components, excluding the Soil Absorption System, have been located on the site.
The septic tank manholes were uncovered, opened, and the interior of the septic tank was inspected for condition of baffles
or tees, material of construction, dimensions,depth of liquid,depth of sludge, depth of scum.
The size and location of the Soil Absorption System on the site has been determined based on:
Existing information. For example, Plan at B.O.H.
Determined in the field(if any of the failure criteria related to Part C is at issue, approximation of distance is unacceptable)
115.302(3)(b))
The facility owner (and occupants,if different from owner) were provided with information on the proper maintenance-of
SubSurface Disposal Systems.
revised 9/2/98 Page 5ofII
A
r
c- SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION
'roperty Address: 1/� Qa e�,S' vJ�✓
Owner: J /�
Date of Inspection: y C
�p,,7.,'r' FLOW CONDITIONS
RESIDENTIAL:
Design flow: g.p.ddbedro m.
Number of bedrooms(design): Number of bedrooms (actual):-`
Total DESIGN flow
Number of current residents:
Garbage grinder(yes or no):
-P S
Laundry(separate system) (yes or no):9; If yes, separate.inspection required
Laundry system inspected (yes or no)
Seasonal use(yes or no):_
Water meter readings,if available (last two year's usage(gpd):
Sump Pump(yes or no):__,AV(U
Last date of occupancy:
COMMERCIALIINDUSTRIAL:
Type of establishment:
Design flow: qpd ( Based on 15.203)
Basis of design flow
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:
OTHER:(Describe)
Last date of occupancy:
GENERAL INFORMATION
PUMPING RECORDS and source of information:
System pumped as part of inspection: (yes or no)--�I.P I
If yes, volume pumped:f U gallons
Reason for pumping: t o r fl. Tf.1-Af Z,
TYPE F 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)
I/A Technology etc.Attach copy of up to date operation and maintenance contract
Tight Tank Copy of DEP Approval
Other
APPROXIMATE AGE of all components, date installed(if known)and source of information: ✓
Sewage odors detected when arriving at the site: (yes or no)
revised 9/2/98 Page 6of I1
r
f
1
G SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
'roperty Address: "(/ �� 1'^ 5�' /�i/'C�U
Owner: + (^
Date of Inspection: � 1 Q r 7,
BUILDING SEWER:
(Locate on site plan)
Depth below grade:
Material of construction: cast iron "- PVC_other (explain)
Distance from private water supply well or suction line
Diameter (4 I
Comments: (condition of joints, venting, evidence of leakage,-etc.)
SEPTIC TANK:_
(locate on site plan)
e'
Depth below grade:, � �
Material of construction:_concrete_metal_Fiberglass _Polyethylene_other(explain)
If tank is metal,list age— Is age confirmed by Certificate of Compliance_(Yes/No)
Dimensions: 'f r0-
Sludge depth: ew '
Distance from top of sludge to bottom of outlet tee or baffler
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:
How dimensions were determined:
'omments:
(recommendation for pumping, condition of inlet and outlet tees or baffles, depth of liquid level in relation to outlet invert, structural integrity,
evidence of leakage, etc.)
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:
(recommendation for pumping, condition of inlet and outlet tees or baffles, depth of liquid level in relation to outlet invert, structural integrity,
evidence of leakage,etc.)
revised 9/2/98 Page 7of11
s ,
C, SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(contirwed)
'roperty Address: 116 �
Owner:
Date of Inspection: �j( �S�'G
TIGHT OR HOLDING TANK: must be pumped prior to, or at time of, inspection)
(locate on site plan) I t�Tank
Depth below grade:_
Material of construction:_concrete_metal_Fiberglass_Polyethylene_other(explain)
Dimensions:
Capacity: gallons
Design flow: gallons/day
Alarm present
Alarm level: Alarm in working order:Yes_ No_
Date of previous pumping:
Comments:
(condition of inlet tee, condition of alarm and float switches, etc.)
DISTRIBUTION BOX:
J(
(locate on site plan) I n
Depth of liquid level above outlet invert:��/�
Comments:
(note if level and distribution is equal, evidence of solids carryover, evidence of leakage into or out of box, etc.)
* eeiz h . a Ue, rO �
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.)
revised 9/2/98 Page 8of11
•
e SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
`roperty Address:
Date of Inspection:
SOIL ABSORPTION SYSTEM(SAS):_
(locate on site plan,if possible; excavation not required,location may be approximated by non-intrusive methods)
If not located, explain:
Type:
leaching pits, number:_
leaching chambers, number:_
leaching galleries, number:_
leaching trenches, number, length:
leaching fields, number, dimensions:
overflow cesspool,number:_
Alternative system:
Name of Technology:
Comments:
(note condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of vegetation, etc.)
7I r 9,,e/ 4 _G n r l r J v 4_'_( 'C_' ..
CESSPOOLS:_
(locate on site plan) �[ /
Number and configuration:
Depth-top of liquid to inlet invert:
Depth of solids layer:
)epth of scum layer:
Dimensions of cesspool:
Materials of construction:
Indication of groundwater:
inflow (cesspool must be pumped as part of inspection)
Comments:
(note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.)
PRIVY:_ /� / , r i a
(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.)
revised 9/2/98 Page 9of11
c, SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Noperty Address:
)wner:
Date of Inspection: �( � /nO J t per} I C O
SKETCH OF SEWAGE DISPOSAL SYSTEM:
include ties to at least two permanent reference landmarks or benchmarks
locate all wells within 100' (Locate where public water supply comes into house)
r3
k
tj D
r
revised 9/2/98 Page 10 of 11
r
E �
r
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(corttinued)
operty Address: 110,4 /e�2,� `Ila df-."
Jwner:
Date of Inspection: ,.-2
NRCS Report name
Soil Type_
Typical depth to groundwater
USGS Date website visited
Observation Wells checked
Groundwater depth: Shallow Moderate Deep
SITE EXAM Slope
Surface water
Check Cellar
Shallow wells / f
Estimated Depth to Groundwater Com✓ Feet
I Please indicate all the methods used to determine High Groundwater Elevation:
Obtained from Design Plans on record
Observed Site(Abutting property, observation hole, basement sump etc.)
Determined from local conditions
Checked with local Board of health
Checked FEMA Maps
Checked pumping records
Checked local excavators, installers
Used USGS Data
Describe how you established the High Groundwater Elevation. (Must be completed)
revised 9/2/98 Page ttoftt
t ii,�t i���i k ✓l l.r t 'tN��i¢�'['`!1 ' . . i' /r '' f ,y� �+',r r-
' ; jr to dr •'.'.
10
TQr)F'NO$THgoBYSfiEM PCJIINQRD�
-DATE 5 as 0 �.. l j
1 1
l
SYSTEM OWNER&ADDRESS SYSTEM LOCATION
ND. Cp�,ODv�� yylq
DATE OF PUMPINO__�S"�' �QUANTITY'PUwED VtV
"
CESSPOOL NO YSS \ t SEPTIC TANK NO YES
NATURE OF SERVICE;;"RQV1 E R(QENCY
OBSERVATIONS:-
GOOD
BSERVATIONS:GOOD CONDITION FULL'TO CO,
V1aR
. 4AVY GREASE ;__�;: BAFFLES IN LACE
ROOTS LEACHFMLD RUNBACK
BXCESSIVE S
SOLID 'FLOODED
SOLM CARRYOVER,^„ OTHER EXPLAIN
SYSTEM PUMPED BY
SZ
COMMENTS:
CONTENTS TRANSFERRED To .
•, ., ,, OVER •M
.''1•'.,: �` .� ��o �re�} ;t �p,� :R e cord
,II\ IsT,, Ll,,gi,\1(�I�I�II,L.�.:(, 4'�`1`]�`V,1;'I,•;,
�OfF.he, p/ovldad Woloonfor pro JUL g 20(J9
00 +:bn`Illod to LA locrl8prrc: cr ocor Boarc1 p, oe .-
O�IIn C/ CUloi "J $/ I e�l
"YCFWN O1-a�0lTH AN
A, F a c l l l ty l n l o r rr1 (Ion HEALTH DEPARTMENT
Y^� Y 5)'S;olrn
A -
rn
5i n
,Yrs►am Ownar l+'
IIS�II y •. ����^ .
•�r�' ' I'• r'.4drr�v I
(�4Vlrr'rnl r
• a'n b
Gr••n
V
0
1 �
6,.P..umpin8 Ragord '
0910 pI pv r!1•I:, ll Z
�.
Ty
P1 of
t'r. . POC Tangy
cr!tie�
Etrlu9n.I,1oo Flllo(�Q(4,aonr? [' Yoen'o
:�, 'f..�� ,p�J•;Tr,1• i,(;1r,,'f(l ' ,I''IS; Y91, et I. r.eanao7 , Y
.. . , ; . l/� It'.C�o�d►yon Q(,�y � '.,Y:•
„PVTPIO ay.' '
r04
S', .'i I lr 11.1.. '0 (' I�J I\ .,• �. '
_� .•�,�.:,;�,,�„ ,,�W 9(�`gQ�IOnU,w@/0 d19p0590:
J'
i IV
I
mas4', QYlderv`w9181/9pp/0Y9/allblorm3.nt'naing�ocl Irl,
i r
5 �:rlw„A..,.rta{.•:.: 1 ,.J.. ;lf 1 I:` I 1 J .. " a
i t
f I I
. ,:,,Commonwealth of Massachusetts �!
.City/Town of NORTH ANDOVER MASSAC
System Pumping Record RECEIVIEU
Form 4
JUL _7 2010
DEP has provided this form for use by local Boards of Healt i. The System Pumping F cord must
be submitted to the local Board of Health or other approvin N*NORTH ANDOVER
HEALTH DEPARTMENT
A..Facility information
Important:
When filling out 1. System Location:
forms on the t J
computer,use r
only the tab key Address .
to move your
cursor-.do not jUAndwce . I& I
CI /Town
use the return ty State Zlp Code
key,
2. System Owner.
Name ,
Address(if different from location)
Cltyrrown State Zip Code
Telephone Number
B. Pumping Record
Moo
1. Date of Pumping Date 2. Quantity Pumped: Gallons
3..,Type of system: . ❑ Cesspool(s) OKSeptic Tank ❑ Tight Tank
Other(describe):
4. Effluent Tee Filter present? ❑ Yes ❑ No If yes'was it cleaned? ❑ Yes ❑ No
5. Condition of System:
000,
6. System Pumped By:
(
CG
MO �c VehlGe License Number
/'N
Y .
Company
7. Location where contents were disP osed:
l� ( .
g ure of �oval&llforr.
/
Yut
Date
http:/Amw,.mass.gov/deptwat :htm#Inspect
t5r orrn4.doc 06/03 System Pumping Record-Page 1 of 1
,1+
Commonwealth of Massachusetts
W City/Town of No. Andover X011
W° System Pumping Record JUL
Form 4 TOWN OF NORTM ANDOVER
M HEALTH DEPARTMENT
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 on the
computer,use
only the tab key Address
to move your No.Andover Ma 01845
cursor-do not City/Town State Zip Code
use the return
key. 2 System Owner:
S �
Name
Address(if different from location)
City/Town State Zip Code
Telephone Number
B. Pumping Record
UN
1. Date of Pumping I 2. QuantityPumped:Date p Gallons
3. Type of system: ❑ Cesspool(s) [Septic Tank ❑ Tight Tank ❑ Grease Trap
❑ Other(describe):
4. Effluent Tee Filter present? ❑ Yes ❑ No If yes, was it cleaned? ❑ Yes ❑ No
5. Condition of System:
6. Mm PumpedN-0
�� �
Name Vehicle License Number
Stewart's Septic Service
Company
7. Location where contents were disposed:
t art's Pre-tre tment Plant, 20 So. Mill Bradford, Ma 01835
Si a e of Date
Signature of RedKvRg Facility Date
t5form4.doc•03/06 System Pumping Record•Page 1 of 1
No Andover J&S Development dba
1600 Osgood St Stewart's Septic
Building 20 Suite 2-36 Andover Septic
No.Andover, Ma 01845 58 South Kimball Street
Bradford, MA 01835
Date Name &Address Gallons Comments
2-Jul Bake N Joy Willow St,/ 4800 Grease
3-Jul Coltin 316 Rolwey Tavern Lane 1000 Xsolids HG
9-Jul Bake N joy Willow Ave 5000 Grease&**2 inside grease traps
12-Jul Mukherjee 30 Sherwood Dr--"' 1000 Good
18-Jul Hanny 45 Innis street\/ 1000 good .f
19-Jul Butcher Rte 125 - 200 grease
1KuI Chipolte 93 turnpike 3000 grease
w6-Jul Driscoll 110 Forest street✓ 1500 good
26-Jul Hudson 1850 Salem street/ 1500 good
27-Jul Ferragamo 1112 Tnpk streety 1500 good
27-Jul Perry 303 Berry street V- 1500 good
30-Jul Barry 62 Stone cleave road1000 good
`x-255 �bo &mrmec- �� :� i �c�U ��
�SY 050 Rb-boi-1111 000