Loading...
HomeMy WebLinkAboutMiscellaneous - 114 VEST WAY 4/30/2018yj, Commonwealth of Massachusetts City/Town of MAY 9 2014 System Pumping Record TOWN OF NORTH ANDOVER F�!*A1TIi DSPP4rfENT Form 4 -ti --- DEP has provided this form for useby 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. A. Facility Information 1. System Location: Left / Right front of house, Left / Right rear of house,(6 ig of hous , Left/ Right side of building, Left / Right front of building, Left / Right rear of building, Under dec Address V cidyfrown tate 1 Zip Code 2. System Owner. U Name Address rd different from location) c4frown State Ap Code Telephone Number 1 B. Pumping Record 1. Date of Pumping Date 2. Quantity Pumped: Canons 3. Type of system: ❑ Cesspool(s) eptic Tank ❑ Tight Tank ❑ Other (describe): 4. Effluent Tee Filter present? ❑ Yes If yes, was it cleaned? ❑ Yes ❑ No; 5. Condition ofs 6. System Pumped By: Neil. Bateson Name Bateson Enterprises Inc - Company 7. Locaere contents were disposed: aLS-D' ')_ Lowell Waste Water F5821 Vehicle License Number 5 -- Date t5form4.doc- 06/03 System Pumping Record • Page 1 of 1 Commonwealth of Massachusetts RECEI U City/Town of System Pumping Record i 5 2011 sF Form 4 TOWN OF NORTH ANDOVER M v HEALTH DEPARTMENT DEP has provided this form for use by local Boards of Health. er or, ut 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. A. Facility Information 1. System Location: Left/ Right front of house, Left/ Right rear of hous , ft right id of , Left / Right side of building, Left / Right front of building, Left / Right rear of b -0 -Ming, Under deck Address City/Town State 2. System Owner: Name Address (if different from location) City/Town B. Pumping Record 1. Date of Pumping 3. Type of system: ❑ ❑ Other (describe): Date Cesspool(s) Zip Code State � {� �7 dip Cade Telephone Number — 2. Quantity Pumped EY'Septic Tank ("5-66 Gallons ❑ Tight Tank 4. Effluent Tee Filter present? ❑ Yes [3 -"No If yes, was it cleaned? ❑ Yes ❑ No 5. Condition of�S� m*� r�lv 6. System Pumped By: Neil Bateson Name Bateson Enterprises Inc Company 7. Locatiomwberg contents were disposed: Waste Water F5821 Vehicle,License Number CV -�-f-(t Date t5form4.doc• 06/03 System Pumping Record • Page 1 of 1 1c NL, 41 4o, .1 til I N IL LOT i -jj 14 b, 4."d Laff LET 140.14 r 139.83 OD I S r C'i'T r r 139.75 L -64,.VLFT 119 13 .1 til I N IL LOT i -jj 14 b, 4."d Laff LET 140.14 r 139.83 S r C'i'T r r 139.75 L -64,.VLFT 119 13 t,�TJTL 139.16 1 P.0 FiEL.D # c�Rr; r Tr rFiTs,4F Sc1-,TI c sYjrch: �,,• a �risi',allK. 5 S: i ;, IN. THS PLAN 6 NJ r i, : T, -Nct--L , S A'k'. j1: --'v+; T i ;.LPERTY CESCRif 71 DI': rr:"3f:-P Lr D PLAIT S 1 I9 ! •1,5N41 00 PE -ANO M.R-,SATI,f,.-',.HA, �N CO iDITIOt,S IN THE F1� ,, cc) ww&VF6, (e;Foo) C ON 12 l 'v V 0 N m m a 0 O O R 3 t �a � C a a� 04 cu m o y E a e ca w N O a C a o m = w w a _ ci O N 3 d O a e w 3 w n O c m o y a ayi ti co a a 42 U I- m N a m a� a �0 a y a d Y J Z Z Z y o lu d O a v f4 L d � U � c H O H a d (D Z Z Z d w h U o W w O p J m H N 4:a e ih cn c%) C O ami y p N w m y ayi a a� S o O m o 0 0 3 e� U m o U a: rL O is a d •' m a� c a = V V 4 o Ip m (D C C7 O G 12 C7 0 N m m a Of NORTH b - a Town of North Andover HEALTH DEPARTMENT ,SSwCHUSt< CHECK #: ��� DATE: LOCATION: H/O NAME: CONTRACTOR NAME: Type of Permit or License: (Check box) ❑ Animal ❑ Body Art Establishment ❑ Body Art Practitioner ❑ Dumpster ❑ Food Service - Type: ❑ Funeral Directors ❑ Massage Establishment ❑ Massage Practice ❑ Offal (Septic) Hauler ❑ Recreational Camp ❑ Sun tanning ❑ Swimming Pool ❑ Tobacco ❑ Trash/Solid Waste Hauler ❑ Well Construction SEPTIC Systems: ❑ Septic - Soil Testing ❑ Septic -Design Approval ❑ Septic Disposal Works Construction (DWC) ❑ Septic Disposal Works Installers (DWI) ❑ Title 5 Inspector 2 Title 5 Report ❑ Other. (Indicate) $ *2341Health Agent Initials White - Applicant Yellow - Health Pink - Treasurer K • Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Asses: Property Address �" �1JfEt�hJ GNe�Sv-i� a I�v20w5 �f Owner Owner's Name information is required for N N� 011re Z A yC every page. City/Town State Zip Code Date of Inspection Inspection results must be submitted on this form. Inspection forms may not be altered in any way. Important: When filling out A. General Information W forms on the computer, use 1. Inspector: only the tab key to move your cursor - do not Name of Inspector use the return key. J�Q�-o+aSlLl SG►.�5 6 hJG- Company Name 2a b KE�� Company Address d� City/Town State Zip Code 6?70-360-9 3s8 Telephone Number License Number B. Certification I certify that I have personally inspected the sewage disposal system at this address and that the information reported below is true, accurate and complete as of the time of the inspection. The inspection was performed based on my training and experience in the proper function and maintenance of on site sewage disposal systems. I am a DEP approved system inspector pursuant to Section 15.340 of Title 5 (310 CMR 15.000). The system: PT"Passes ❑ Conditionally Passes ❑ Fails ❑ Needs Further Evaluation by the Local Approving Authority — -r'? - / Date The syste Insp r shall submit a copy of this inspection report to the Approving Authority (Board of Healt or P) within 30 days of completing this inspection. If the system is a shared system or has a d ign flow of 10,000 gpd or greater, the inspector and the system owner shall submit the report to the appropriate regional office of the DEP. The original should be sent to the system owner and copies sent to the buyer, if applicable, and the approving authority. ****This report only describes conditions at the time of inspection and under the conditions of use at that time. This inspection does not address how the system will perform in the future under the same or different conditions of use. t5insp.doc • 08/06 Title 5 Official Inspection Form: Subsurface Sewage Disposal System • Page 1 of 15 AR 7 2010/ M 0 / HWIN OF NORTH EALLI H DE ARTM � TER ��U-1 1 Property Address �" �1JfEt�hJ GNe�Sv-i� a I�v20w5 �f Owner Owner's Name information is required for N N� 011re Z A yC every page. City/Town State Zip Code Date of Inspection Inspection results must be submitted on this form. Inspection forms may not be altered in any way. Important: When filling out A. General Information W forms on the computer, use 1. Inspector: only the tab key to move your cursor - do not Name of Inspector use the return key. J�Q�-o+aSlLl SG►.�5 6 hJG- Company Name 2a b KE�� Company Address d� City/Town State Zip Code 6?70-360-9 3s8 Telephone Number License Number B. Certification I certify that I have personally inspected the sewage disposal system at this address and that the information reported below is true, accurate and complete as of the time of the inspection. The inspection was performed based on my training and experience in the proper function and maintenance of on site sewage disposal systems. I am a DEP approved system inspector pursuant to Section 15.340 of Title 5 (310 CMR 15.000). The system: PT"Passes ❑ Conditionally Passes ❑ Fails ❑ Needs Further Evaluation by the Local Approving Authority — -r'? - / Date The syste Insp r shall submit a copy of this inspection report to the Approving Authority (Board of Healt or P) within 30 days of completing this inspection. If the system is a shared system or has a d ign flow of 10,000 gpd or greater, the inspector and the system owner shall submit the report to the appropriate regional office of the DEP. The original should be sent to the system owner and copies sent to the buyer, if applicable, and the approving authority. ****This report only describes conditions at the time of inspection and under the conditions of use at that time. This inspection does not address how the system will perform in the future under the same or different conditions of use. t5insp.doc • 08/06 Title 5 Official Inspection Form: Subsurface Sewage Disposal System • Page 1 of 15 s r ' Owner information is required for every page. Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments I t%l Property Address Aev ?-a L.,-) 5 re c Owner's Name /V - A MA vilgq-5- zJz?, /0-7 City/Town State Zip Code Date of InsiJ6ction B. Certification (cont.) Inspection Summary: Check A,B,C,D or E / always complete all of Section D A) System Passes: ❑ I have not found any information w ' indicates that any of the failure criteria described in 310 CMR 15.303 or in 310 R 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 e ❑ for the following statements. If "not determined," please explain. ❑ The septic tank is metal over 20 years old* or the septic tank (whether metal or not) is structurally unsown xhibits substantial infiltration or exfiltration or tank failure is imminent. System will pas 'nspection if the existing tank is replaced with a complying septic tank as approved by7e Board of Health. * A metalleptic 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 Heatfh): ❑ broken pipe(s) are re ❑ obstructi7��ved t5insp.doc • 08106 Title 5 Official Inspection Form: Subsurface Sewage Disposal System •Page 2 of 15 • y , Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments UCS Wt�►�l Property Address Owner Owner's Name information is � �� cyLn- al �: 'i 2� G required for I"� 7 every page. Cityfrown State Zip Code Date of Inspection B. Certification (cont.) B) System Conditionally Passes (cont.): ❑ distribution box is leveled or replaced ND Explain: ❑ The system required pumpiri` more than 4 times a year due to broken or obstructed pipe(s). The system will pass inspecti,c' if (with approval of the Board of Health): ❑ broken pipe/are replaced ❑ obstruct' n is removed ND Explain: 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 deter s in accordance with 310 CMR 15.303(1)(b) that the system is not functioni in a manner which will protect public health, safety and the environment: El Cesspool or privy is within 5 eet 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 Oe Board of Health (and Public Water Supplier, if any) determines that the syste .n 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. t5insp.doc • 08/06 Title 5 Official Inspection Form: Subsurface Sewage Disposal System • Page 3 of 15 Owner information is required for every page. Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments Property Address 1 H Vg S✓sj Liell-N Owner's Name fV 14rjAOVF- >G /a 6 (P��� 2 •-L9 City/Town State Zip Code Date of I spection B. Certification (cont.) C) Further Evaluation is Required by the Board of Health (cont.): ❑ 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 er analysis, performed at a DEP certified laboratory, for coliform bacteria indicates absent anqtKe presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided at no other failure criteria are triggered. A copy of the analysis must be attached to this form. 3. Other: D) System Failure Criteria Applicable to All Systems: You must indicate "Yes" or "No" to each of the following for all inspections: Yes No ❑ ©el Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool ❑ 0. 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 ❑ E?r Liquid depth in cesspool is less than 6" below invert or available volume is less than'/2 day flow ❑ Z Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number of times pumped: ❑ [/f Any portion of the SAS, cesspool or privy is below high ground water elevation. ❑ M Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. l5insp.doc - 08/06 Title 5 Official Inspection Form: Subsurface Sewage Disposal System - Page 4 of 15 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments i ] y Property Address 1 --11) W5V-: Owner Owner's Name information is required for hi, C)i &I Z Z8 every page. City/Town State Zip Code Date of Inspection B. Certification (cont.) D) System Failure Criteria Applicable to All Systems (cont.): Yes No ❑ []" Any portion of a cesspool or privy is within a Zone 1 of a public well. ❑ Q. Any portion of a cesspool or privy is within 50 feet of a private water supply well. ❑ 0' Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality analysis. [This system passes if the well water analysis, performed at a DEP certified laboratory, for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis and chain of custody must be attached to this form.] ❑ The system is a cesspool serving a facility with a design flow of 2000gpd- 10,000gpd. ❑ The system fails. I have determined that one or more of the above failure criteria exist as described in 310 CMR 15.303, therefore the system fails. The system owner should contact the Board of Health to determine what will be necessary to correct the failure. E) Large Systems: To be considered a large system the system must serve a facility with a design flow of 10,000 gpd to 15,000 gpd. For large systems, you must indicate either "yes" or "no" to each of the following, in addition to the questions in Section D. Yes No ❑ ❑ the system ithin 400 feet of a surface drinking water supply ❑ ❑ system is within 200 feet of a tributary to a surface drinking water supply ❑ the system is located in a nitrogen sensitive area (Interim Wellhead Protection Area — IWPA) or a mapped Zone II of a public water supply well If you have answered "yes" to any question in Section E the system is considered a significant threat, or answered "yes" in Section D above the large system has failed. The owner or operator of any large system considered a significant threat under Section E or failed under Section D shall upgrade the system in accordance with 310 CMR 15.304. The system owner should contact the appropriate regional office of the Department. t5insp.doc • 08/06 Title 5 Official Inspection Form: Subsurface Sewage Disposal System • Page 5 of 15 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments I i L-1 V &-<, T- W,+-1 Property Address Owner Owner's Name information is PU VJI' oV8K- required for every page. City/Town C. Checklist R. oc,5 -,—,% /V?/,l Ur61lS 2 %ze /0'7 State Zip Code Date of Inspection Check if the following have been done. You must indicate "yes" or "no" as to each of the following: Yes No 211 ❑ Pumping information was provided by the owner, occupant, or Board of Health ❑ [/ Were any of the system components pumped out in the previous two weeks? [fr ❑ Has the system received normal flows in the previous two week period? ❑ E]ol Have large volumes of water been introduced to the system recently or as part of this inspection? Q. ❑ 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? The size and location of the Soil Absorption System (SAS) on the site has been determined based on: '(� ❑ Existing information. For example, a plan at the Board of Health. ❑ 2r Determined in the field (if any of the failure criteria related to Part C is at issue approximation of distance is unacceptable) [310 CMR 15.302(5)] t5insp.doc • 08/06 Title 5 Oficial Inspection Form: Subsurface Sewage Disposal System - Page 6 of 15 0 Was the site inspected for signs of break out? [� ❑ Were all system components, excluding the SAS, located on site? [2 ❑ 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? d❑ Was the facility owner (and occupants if different from owner) provided with information on the proper maintenance of subsurface sewage disposal systems? The size and location of the Soil Absorption System (SAS) on the site has been determined based on: '(� ❑ Existing information. For example, a plan at the Board of Health. ❑ 2r Determined in the field (if any of the failure criteria related to Part C is at issue approximation of distance is unacceptable) [310 CMR 15.302(5)] t5insp.doc • 08/06 Title 5 Oficial Inspection Form: Subsurface Sewage Disposal System - Page 6 of 15 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments MaV jtj V-6; W "� Property Address e_0 Owner Owner's Name information is required for kq-t�;�c�✓ �A ( 9 q� 7/ �� �� every page. City/Town State Zip Code Date of Inspection D. System Information Residential Flow Conditions: ✓, Number of bedrooms (design): Number of bedrooms (actual): DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x # of bedrooms): Number of current residents: Does residence have a garbage grinder? Is laundry on a separate sewage system? [if yes separate inspection required] Laundry system inspected? Seasonaluse? Water meter readings, if available (last 2 years usage (gpd)): Sump pump? Last date of occupancy: Commercial/Industrial Flow Conditions: Type of Establishment: Design flow (based on 310 CMR 15.203): Basis of design flow (seats/persons/s etc.): Grease trap present? Industrial waste hol ' g tank present? Non -sanitary Ste discharged to the Title 5 system? Water meter readings, if available: Last date of occupancy/use: Other (describe): Gallons per day (gpd) Date M_ — ❑ Yes ET--N-o ❑ Yes a No ❑ #/o ❑ Yes 0 No X50 ❑ Yes 2-INo 0&G v P/ &-,& Date ❑ Yes ❑ No ❑ Yes ❑ No ❑ Yes ❑ No l5insp.doc - 08106 Title 5 Official Inspection Form: Subsurface Sewage Disposal System • Page 7 of 15 Commonwealth of Massachusetts W Title 5 Official Inspection Form o Subsurface Sewage Disposal System Form - Not for Voluntary Assessments H 9 ' Property Address j'/'/V R/a L,5 'AA Owner information is required for every page. Owner's Name City/Town State Zip Code Date of Inspection D. System Information (cont.) General Information Pumping Records: Source of information: Was system pumped as part of the inspection? If yes, volume pumped: How was quantity pumped determined? Reason for pumping: 3© H 1 -M6 -r 17 mol gallons Type of System: 21-� Septic tank, distribution box, soil absorption system ❑ Single cesspool ❑ Overflow cesspool ❑ Privy ❑ Yes R No ❑ 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): Approximate age of all components, date installed (if known) and source of information: Were sewage odors detected when arriving at the site? ❑ Yes [3 --Ho l5insp.doc • 08/06 Title 5 Official Inspection Form: Subsurface Sewage Disposal System - Page 8 of 15 Commonwealth of Massachusetts v Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments Property Address Ky (t, 4 las 5 ✓• Owner Owner's Name information is % required for w / - A ru��� Q Yr-)tl+ 8 Lim 2 12' 0-7 every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Building Sewer (locate on site plan): Depth below grade: feet Material of construction: Z' -cast iron ❑ 40 PVC ❑ other (explain): Distance from private water supply well or suction line: feet Comments (on condition of joints, venting, evidence of leakage, etc.): W>A—%. *–r ELT \ CL KT Septic Tank (locate on site plan): 2 ►t Depth below grade: feet Material of construction: concrete El metal ❑ fiberglass ❑ polyethylene ❑ other (explain) If tank is metal, list age: years Is age confirmed by a Certificate of Compliance? (attach a copy of certificate) ❑ Yes*q/Wb-- Dimensions: 2 " 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 N/ `*- How were dimensions determined? t5insp.doc - 08/06 Title 5 Official Inspection Form: Subsurface Sewage Disposal System • Page 9 of 15 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments I t H Ve J Property Address �Cv rLcawS� . Owner Owner's Name information is 1, required for every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage,) etc.): Grease Trap (locate on site plan): Depth below grade: feet Material of construction: ❑ concrete ❑ metal ❑ fiberglass ❑ polye ene ❑ other (explain): Dimensions: Scum thickness Distance from top of scum toZbottomof Distance from bottom of scuor baffle Date of last pumping: Date Comments (on pu ,ing recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): Tiqht or Holdinq Tank (tank must be pumped at time of inspection) (locate on site plan): Depth below grade: Material of construction: ❑ concrete ❑ ❑ polyethylene ❑ other (explain): t5insp.doc • 08/06 Title 5 Official Inspection Form: Subsurface Sewage Disposal System • Page 10 of 15 Commonwealth of Massachusetts -- - - u Title 5 Official Inspection Form =� Subsurface Sewage Disposal System Form - Not for Voluntary Assessments tLA �lESr w Property Address 1-6, 2 IZ.L W 5 iG Owner Owner's Name information is required for tV- A eV1 d V E'R_ /—W o f gq s 1z /2101 Ld every page. City/Town State Zip Code Date of Ins ection D. System Information (cont.) Tight or Holding Tank (cont.) Dimensions: Capacity: Design Flow: Alarm present: Alarm level: gallons gallons per day ❑ Yes ❑ No Alarm in working order: Date of last pumpiny Date Comments (condition of alarm and float switches, etc.): ❑ Yes ❑ No * Attach copy of current pumping contract (required). Is copy attached? ❑ Yes ❑ No Distribution Box (if present must be opened) (locate on site plan): Depth of liquid level above outlet invert © K Comments (note if box is level and distribution to outlets equal, any evidence of solids carryover, any evidence of leakage into or out of box, etc.): M ---.5a L�/b C4 0e.1121 y 0 ✓-11-2- L wv 51 G hJ a G C '9- t L L, 4p- c' Pump Chamber (locate on site plan): Pumps in working order: ❑ Yes E]No Alarms in working order: ❑ Yes ❑ No t5insp.doc - 08/06 Title 5 Official Inspection Form: Subsurface Sewage Disposal System • Page 11 of 15 Commonwealth of Massachusetts -- Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments Lj Property Address KV eo is V -t Owner information is required for every page. Owner's Name fL/. ANj^-,�ny:e 4z- PA4- City/Town State D. System Information (cont.) dieyS Z/z*ID Zip Code Date of Inspection Comments (note condition of pumpGh1ffiber, condition of pumps and appurtenances, etc.): Soil Absorption System (SAS) (locate on site plan, excavation not required): If SAS not located, explain why: Type: ❑ leaching pits ❑ leaching chambers ❑ leaching galleries ❑ leaching trenches [ff" leaching fields ❑ overflow cesspool ❑ innovative/alternative system Type/name of technology: number: number: number: number, length: , FI CL -IN number, dimensions: 1-1.,Q e-,- number: S number: Comments (note condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of vegetation, etc.): 10vo SNL /fl0 Cg0 C �.�1 I vee- 54- gTeEri `Dzs Foe X00 5pC( I-rL.c v fzEGav Ie CC N yd � pC9 -torr, L( SDer" 44n i -,E . t5insp.doc - 08/06 Title 5 Official Inspection Form: Subsurface Sewage Disposal System • Page 12 of 15 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments f 1 l L/d `/ Property Address '�li Q-O'Lvs �G'l Owner Owner's Name information is �N p �� 2 �2 log required forrV every page. City/Town State Zip Code Date of Inspectio D. System Information (cont.) 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 constructio Indication of grou water inflow ❑ Yes ❑ No Comments (no 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 ( to condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): t5insp.doc • 08/06 Title 5 Official Inspection Form: Subsurface Sewage Disposal System • Page 13 of 15 C, • Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments Property Address Owner Owner's Name information is required for _ fi %vim aVF h every page. City/Town State Zip Code Date of Insp ction D. System Information (cont.) 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. Z$� B- C S }3-'b &9'a C tj`i30 � m e vesr W<LL()w--QZEC - D I,c,iwG WA t5insp.doc - 08/06 Title 5 Official Inspection Form: Subsurface Sewage Disposal System - Page 14 of 15 • A Owner information is required for every page. Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments LA VeST w 1 Property Address I -eV Owner's Name City/Town State D. System Information (cont.) Site Exam: Check Slope [R'Surface water -,t> Q H ['Check cellar z, [hallow wells No^v 16 of 8`i-- 2 /2& / Zip Code Date of Inspection Estimated depth to ground water: r' feet y Please indicate all methods used to determine the high ground water elevation: u Obtained from system design plans on record If checked, date of design plan reviewed: IZJ /83 Date Observed site (abutting property/observation hole within 150 feet of SAS) Checked with local Board of Health - explain: ❑ Checked with local excavators, installers - (attach documentation) ❑ Accessed USGS database - explain: You must describe how you established the high ground water elevation: GALL -Act_ 3>e,-( 0Z—`6-,N14V tPERC, TE -.S7" f %4Q 44QLL Lo a c-tl�s &JI) Q-e<,c ej�S P o <w Lis _rr I vs PC; ► o ...� 1�-r �-A t o 1 k, 1 of t5insp.doc • 08/06 Title 5 Official Inspection Form: Subsurface Sewage Disposal System • Page 15 of 15 f PETER F. REILLY 136 ANDOVER STREET ANDOVER, MA 01810 (978) 375-3750 Ti. i OCT 3 0 2001 TITLE V OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL INSPECTION FORM PART A - CERTIFICATION Property Address: 114 Vest Way, North Andover, MA 01845 Name of Owner: Keating Address of Owner: same Name of Inspector: Peter F. Reilly Company Name: same Mailing Address: 136 Andover Street, Andover, MA 01810 Telephone Number: (978) 375-3750 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. I am a DEP approved system inspector pursuant to Section 15.340 of Title 5 (310 CMR 15.000) The system: ✓ Passes N/A Conditionally Passes N/A Needs Further Evalw N/A Fails / Inspector's Signature: Peter F. Reilly the Local Approving Authority Date: October 6, 2001 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 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 a the time of inspection and under 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 (See attached Disclaimer). OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL INSPECTION FORM PART A - CERTIFICATION (continued) Property Address: 114 Vest Way, North Andover Owner's Name: Keating Date of Inspection: 10/6/01 INSPECTION SUMMARY: A. SYSTEM PASSES: Check A, B, C, D, or E / ALWAYS complete all of Section D ✓ I have not found any information which indicates that the system violates any of the failure criteria as defined in 310 CMR 15.303. Any failure criteria not evaluated are indicated below. COMMENTS: The system met the Pass Criteria of Title V. B. SYSTEM CONDITIONALLY PASSES: N/A 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). Describe basis of determination in all instances. If "not determined", explain why not) N The septic tank is metal, and over 20 years old* or the septic tank (whether metal or not) is 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. *'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: N Observation of a sewage backup or breakout or high static water level 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): N/A broken pipe(s) are replaced N/A obstruction is removed N/A 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): N/A broken pipe(s) are replaced N/A obstruction is removed OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL INSPECTION FORM PART A - CERTIFICATION (continued) Property Address: 114 Vest Way, North Andover Owner's Name: Keating Date of Inspection: 10/6/01 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 environment. 1. System will pass unless Board of Health determines in accordance with 310 CMR 15.3030)(b) that the system is not functioning in a manner which will protect public health, safety and the environment: N/A Cesspool of privy is within 50 feet of a surface water N/A Cesspool or privy is within 50 feet of a bordering vegetated wetland or 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: N/A The system has a septic tank and soil absorption system (SAS) and the SAS is within 100 feet to a surface water supply or tributary to a surface water supply. N/A The system has a septic tank and SAS and the SAS is within a Zone I of a public water supply well. N/A The system has a septic tank and SAS and the SAS is within 50 feet of a private water supply well. N/A The system has a septic tank and SAS the SAS is less than 100 feet but 50 feet or more from a private water supply well. * * Method used to determine distance N/A This system passes if the water well water analysis, performed at a certified DEP 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. A copy of the analysis must be attached to this form. 3. Other N/A OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL INSPECTION FORM PART A - CERTIFICATION (continued) Property Address: 114 Vest Way, North Andover Owner's Name: Keating Date of Inspection: 10/6/01 D. System Failure Criteria applicable to all systems: You must indicate "Yes" or "No" to each of the following for a// inspections: Yes No No Backup of sewage into facility or system component due to an overloaded or clogged SAS or cesspool. No Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool. No Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool. N/A Liquid depth in cesspool less than 6" below invert or available volume < % day flow. No required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number of times pumped: once No Any portion of the Soil Absorption System, cesspool or privy is below the high groundwater elevation. N/A Any portion of a cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. N/A Any portion of a cesspool or privy is within a Zone I of a private water supply well. N/A Any portion of a cesspool or privy is within 50 feet of a private water supply well. N/A 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 laboratory, for coliform bacteria, volatile organic compounds, ammonia nitrogen and nitrate nitrogen is less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis must be attached to this form). N/A The system fails. I have determined that one or more of the above failure criteria exist as defined in 310 CMR 15.303, therefore the system fails. The property owner should contact the Board of Health should be contacted 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 a large system in addition to the criteria above) N/A The design flow of system is 10,000 gpd or greater (Large System) and the system is a significant threat to public health and safety and the environment because one or more of the following conditions exist: Yes No N/A The system is within 400 feet of a surface drinking water supply N/A The system is within 200 feet of a tributary to a surface drinking water supply N/A The system is located in a nitrogen sensitive area (Interim Wellhead Area - IWPA) or a mapped Zone II of a public water supply well) If you have answered "yes" to any question in Section E the system is considered a significant threat, or answered "yes" in Section D above the large system has failed. The owner or operator of any such 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. OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL INSPECTION FORM PART B - CHECKLIST Property Address: 114 Vest Way, North Andover Owner's Name: Keating Date of Inspection: 10/6/01 Check if the following have been done. You must indicate either "Yes" or "No" as to each of the following: Yes No Yes Pumping information was provided by the owner, occupant, or Board of Health. No Were any of the system components pumped out in the previous two weeks ? Yes Has the system received normal flow in the previous two week period ? No Have large volumes of water been introduced to the system recently or as part of this inspection ? Yes Were as built plans of the system obtained and examined ? (If they were available note as N/A) Yes Was the facility or dwelling was inspected for signs of sewage backup ? Yes Was the site was inspected for signs of breakout ? Yes Were all system components, excluding the SAS, have been located on the site ? Yes Were the septic tank manholes uncovered, opened and the interior of the septic tank inspected for condition of baffles or tees, material of construction, dimensions, depth of liquid, depth of sludge, depth of scum ? Yes Was the facility owner (and occupants of if different from the owner) provided information on the proper maintenance of subsurface sewerage disposal systems ? The size and location of the Soil Absorption System (SAS) on the site has been determined based on: Yes No Yes Existing information. For example, a plan at the Board of Health. N/A Determined in the field if any of the failure criteria related to Part C is at issue (approximation of distance is unacceptable) [11 5.302(3)(b)]. OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL INSPECTION FORM PART C - SYSTEM INFORMATION Property Address: 114 Vest Way, North Andover Owner's Name: Keating Date of Inspection: 10/6/01 FLOW CONDITIONS RESIDENTIAL: Number of bedrooms (design): Number of bedrooms (actual): DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x # of bedrooms: Number of Current residents: Does the residence have a garbage grinder (yes or no): Is the laundry on a separate sewerage system (yes or no): Laundry system inspected (yes or no): Seasonal use (yes or no): Water meter readings, if available (last 2 years usage [gpd]) Sump Pump (yes or no): Last date of occupancy: COMMERCIAL/INDUSTRIAL: Type of Establishment: Design Flow gpd (based on 15.203): Basis of Design Flow (seats/persons/sq.ft., 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) PUMPING RECORDS 4 4 600 god 1 no no (if yes, separate inspection required) N/A no about 150 gpd no current N/A N/A N/A N/A N/A N/A N/A N/A N/A GENERAL INFORMATION Source of Information: owner Was system pumped as part of inspection (yes or no): no if yes, volume pumped (gallons): N/A How was quantity pumped determined ? N/A Reason for pumping: N/A TYPE OF SYSTEM ✓ Septic tank/distribution box, soil absorption system Single cesspool Overflow cesspool Privy NO 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 the system owner) Tight Tank Attach a copy of the DEP Approval Other (describe): Approximate age of all components, date installed (if known) and source of information: Original system - installed in 1987 according to public records. Were sewerage odors detected when arriving at the site (yes of no): no OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL INSPECTION FORM PART C - SYSTEM INFORMATION (continued) Property Address: 114 Vest Way, North Andover Owner's Name: Keating Date of Inspection: 10/6/01 BUILDING SEWER: (locate on site plan) Depth below grade: about 6"-8" Materials of construction: ✓ cast iron 40 PVC other (explain) Distance from private water supply well or suction line N/A Diameter: 4" Comments: Condition of joints, venting, evidence of leakage, etc.) Building sewer was watertight and appeared sound at foundation. SEPTIC TANK: ✓ (locate on site plan) Depth below grade: about 2" - 4" Material of construction: ✓ concrete metal Fiberglass Polyethylene other (explain) If tank is metal, list age N/A Is age confirmed by Certificate of Compliance N/A (Yes/No) Dimensions: rectangular - 1,500 gallons Sludge depth: < 1 " Distance from top of sludge to bottom of outlet tee or baffle: 28" Scum thickness: < 1 " Distance from top of scum to top of outlet tee or baffle: 7" Distance from bottom of scum to bottom of outlet tee or baffle: 16" How dimensions were determined: observation / estimation Comments: (on pumping recommendations, of inlet and outlet tees or baffle condition, structural integrity, liquid level as related to outlet invert, evidence of leakage, etc.) Tank was watertight and appeared to be functioning properly. GREASE TRAP: N/A (locate on site plan) Depth below grade: material of construction: concrete metal FRP other (explain) Dimensions: N/A Scum thickness: N/A Distance from top of scum to top of outlet tee or baffle: N/A Distance from bottom of scum to bottom of outlet tee or baffle: N/A Date of Last Pumping: N/A Comments: (on pumping recommendations, of inlet and outlet tees or baffle condition, structural integrity, liquid level as related to outlet invert, evidence of leakage, etc.) N/A OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL INSPECTION FORM PART C - SYSTEM INFORMATION (continued) Property Address: 114 Vest Way, North Andover Owner's Name: Keating Date of Inspection: 10/6/01 TIGHT or HOLDING TANK: N/A (tank must be pumped at time of inspection) (locate on site plan) Depth below grade: N/A material of construction: concrete metal Dimensions: N/A Capacity: N/A Design Flow: N/A Alarm Present (yes or no): N/A Alarm level: N/A Alarm in working order (yes or no): N/A Date of last pumping: N/A Fiberglass Polyethylene other (explain) gallons gallons per day Comments: (condition of alarm and float switches, etc.) N/A DISTRIBUTION BOX: ✓ (locate on site plan) 0" depth of liquid above outlet invert Comments: (note if level and distribution is equal, evidence of solids carryover, evidence of leakage into or out of box, recommendation for repairs, etc.) D -box was level. Five lines leading to SAS were accepting effluent evenly, some lines stronger than others. D -box was about 12" below surface. PUMP CHAMBER: N/A (locate on site plan) Pumps in working order (yes or no) N/A Alarms in working order (yes or no) N/A Comments: (note condition of pump chamber, condition of pumps and appurtenances, etc.) N/A OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL INSPECTION FORM PART C - SYSTEM INFORMATION (continued) Property Address: 114 Vest Way, North Andover, MA Owner's Name: Keating Date of Inspection: 10/6/01 SOIL ABSORPTION SYSTEM (SAS): ✓ (locate on site plan, if possible; excavation not required) If SAS not located, explain why: Type leaching pits, number leaching chambers and number leaching galleries and number leaching trenches, number, length ✓ leaching fields, number, dimensions overflow cesspool, number alternative system (name of technology) N/A N/A N/A N/A 1 field 20' x 40' per "as -built" plan N/A N/A Comments: (note condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of vegetation, etc.) Soils in area of SAS looked good, no evidence of ponding, damp soil, or breakout. CESSPOOLS: N/A (locate on site plan) Number and configuration N/A Depth -top of liquid to inlet invert N/A Depth of solids layer N/A Depth of scum layer N/A Dimensions of cesspool N/A Materials of construction N/A Indication of groundwater inflow (cesspool must be pumped as part of inspection) N/A Comments: (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, recommendations for maintenance or repairs, etc.) not applicable PRIVY: N/A (locate on site plan) Materials of construction Dimensions Depth of solids N/A N/A N/A Comments: (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, recommendations for maintenance or repairs, etc.) not applicable P OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL INSPECTION FORM PART C - SYSTEM INFORMATION (continued) Property Address: 114 Vest Way, North Andover, MA Owner's Name: Keating Date of Inspection: 10/6/01 SKETCH OF SEWAGE DISPOSAL SYSTEM: Provide a sketch of the sewerage disposal system including ties to at least two permanent reference landmarks or benchmarks. Locate all wells within 100'. Locate where public water supply enters the building. SEPTIC TANK TIES D -BOX TIES: NOTE: A to Inlet (1) 26'6" A to Center (C) 27'0" A to Outlet (0) 28'0" A to Box 43'0' Willow Tree to Box 37'3" The system is in the rear yard. ISoo 9,//ten See fig f -a" le, B to Inlet 43'0" B to Center 45'6" B to Outlet 48'6" B to Box 68'0' V OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL INSPECTION FORM PART C - SYSTEM INFORMATION (continued) Property Address: 114 Vest Way, North Andover, MA Owner's Name: Keating Date of Inspection: 10/6/01 SITE EXAM Slope flat in area of system Surface water none observed Check cellar dry Shallow wells none observed Estimated Depth to Groundwater > 1 " (below bottom of SAS) Please indicate (check) all methods used to determine the high ground water elevation: Y Obtained from Design Plans on record - if checked, date of design plan reviewed: 1987 Y Observed site (abutting property, observation hole within 150 feet of SAS) Y Check with Local Board of Health - explain: information on file Y Check local excavators, installers - (attach documentation) N Accessed USGS Database - explain: website too complicated You must describe how you established the high ground water elevation.* 1987 Design Plan indicated groundwater was nearly 6 feet below SAS as designed. However, groundwater conditions can change over time and I cannot confirm the current precise depth of groundwater. This can only be done with a soil evaluation test. *Inspector's Note: Soil Evaluation is the currently recognized method for determining or establishing the high groundwater elevation. Since I am not a licensed or certified soil evaluator, I am not qualified to determine or establish the high groundwater elevation beyond the public information available, such as recent design plans of the site or the nearby area. My estimation of the high groundwater elevation is based on a due diligence effort to obtain all available information both on and off the site and my experience as a certified subsurface disposal system inspector. (see attached Disclaimer) DISCLAIMER This passing septic inspection under Massachusetts Title V is in no way a guaranty or warranty of the inspected septic system. The inspection is a "snapshot in time" and does not constitute a complete assessment of the quality or potential longevity of the septic system. The pass/fail criteria are specific and outlined in detail in this report. Under the limited criteria of a Title V inspection, it is impossible to determine how long any septic system will last. The inspector made a diligent effort to certify the septic system based on the criteria required under Title V. Under Massachusetts Title V, soil evaluation is the accepted method of determining the high groundwater elevation. This inspector is not a certified soil evaluator and is therefore not qualified under Title V to determine or establish the high groundwater elevation. The method used to estimate the high groundwater for this inspection was based on the public records and methods of observation described on the previous page. Groundwater levels can vary greatly from season to season, year to year and soil evaluation is considered the most reliable method of groundwater determination under Title V. Inspector October 6, 2001 Com.monwealth.,,of Massachusetts _ b.4t Town of -NORTH ANDOVER MASSACHU TSS System Pumping Record Form 4' OCT 12 2006 DEP. has provided this form for use by local Boards of Health. The System Pumping R_ ecoid must be submitted to the local Board of Health or other approving authority. A. Facility Information Important: When filling out forms on the computer, use only the tab key to move your cursor - do not Use the return key. nen 1 System Location: Address Cityrrown 2. System Owner: State Zip Code ,�f r� rows i�► Name Address (if differentfromlocatio City/Town State Zip Code ' Telephone Number B. Pumping RecordIL 1. 1. Date of Pumping Date 2. Quantity Pumped: Gallons 3. Type of system: ❑ Cesspool(s) g;;fttic Tank ❑ Tight Tank ❑ ` Other (describe): 711 4. Effluent Tee Filter present? ❑ Yes o If yes, was it cleaned? ❑ Yes [No 5. Condition of System: . w 6. Sy em Pumped By: Name. Vehicle License Number a"rd� Ina. Company 7. Location where contents were disposed: C59-0 , � .�I ��-- 4/f0�d/ ma Signature of Hauler . http:/twww.mass.gov/dep/Water/approvals/t5forms.htm#inspect Date t5fomA.doc• 06/03 System Pumping Record • Page 1 of 1 dam (q 90.0 EM zaq�aaz2 adoTs (a) saxoH uoTIMT-149M suTsap aos3znsgns moz3 l5a (p) Tood Su7mrpts puno.2u F jo, Ttsx zetTeo moij s OT (o ,�noueaTo (q) 2uTdzmd 'ss000E 'saeT jo tadep 'saal `aTcdn jolt' " 'MoTd 3o %OSS s. _ a r� oadao (s) sTMs aT S sos-rd gzrw arudaad o -I ArC Xq pazWotnna Tauol.4aajo.sd aatno zo zontTj-2rq TmcoTss joad a dq rq gszri re-ld (s wrjsSs jusod-Tp e3.. -.2s vom al uollvAcire zap punoL2 na=perat (,z suoT4seaTe zs-ct9 Pur ?uTdld p,CaW uoT-IngTj4s';P 'spa-Dno pu a s,�aM xoq uoTgngT v sTp 'xuer}, alldas 'adTd 'qunld '- awwasvq jo 3o oUjozd (b uoTgonjjsuoo uT pesa eq oo. Odd ou (d slasodsTp 92egzm8 (o sAemaaTzp (u 3[amgouaq 3o uoTjsooT (m S-ITTIo$3 $uW=oT moo OT-Sg..xadazd uo saaTT za4mm So uoT}BooT (T lT.IFzv.T BuTgosal mwj loot--4oT adzes o3 ITeA pasodozd Atme jo uo-;Ieo t asUMasTp ao wr-"W .g s TeiodsTp 42-i..= , dc' sC3? uTqj7a STddns z3111 -LA 3o saaauc4 V=.a A sa iTI3 P.v?c i 2rq.. .io M-3-jsds, Taeod-a T}, a res jo ,C4crt C'0't� _ z�-^ esewpxp Im uo:lla; (l zGMMosTp zo m;48As . Tseo&Tp 92%,-tas 3o a OOT u s p so-edznsgns pue aovj.ms (q; 2uTddlm sptraTgert *)ago-zewaTastp zo w3ga s TesodsTp 92emes 3o s ()(iC Wmp svers 49A date uoypnot (8, szao,4uoo pasodozd pus 2uTgspce (j; sass adzasau 2nTpnT0uT-nrensa8 3o suoTsuawIP pue M-PV-JO(e, sats AtrFgaeeT Tnbsj 2trTxags staoTgBTaoTso V suoFTsTnaTsa u2 'Pep P' saTj o,4 eauzgsTp-9499,4 uoT,4sTo=ed nTwea pus uoT,4saoT a' s®Tg of aatm-ISTp-sopq uoTpseaesgo drip Bo -E pus uoTg$aot Q, 9JVj4PgV'# 401 stx0T.Sa2 sTpraaza-pas.zas aq 014 -40I eta (8' stcrcursjur u s ss hogs Tg= usid Pa?lTugus eqL r(-01 2"H Z-oT 23H 9 2eH S -Z tag y�0 M -T A OT,TI s s mquaH : ga P S -,oad &tea (12' R, . d CF .0,4;dv ml s- -. - . -,r �{ .: .zeAod Aq-pue;s (q 9.6 Tuoadde (8 T•6 deg s (tgnoqs eq o,4) = OST Y x/S (tzogs eq o,) = x S edoojs a TS TTTqwo0 s �Z e�8a�eap��' eoa�.rns {a - -- — - OT • �� euo�s (a L•t�T uo onr49uo0 (P 9 • ttT jotfE usanpq aeaesaa tuTM U 9 Ulm 1-2upuds (q £ • tjT b$ 005-se.z8 2u7pvaT jo uo o {8 leg seggwra zuTqowl Zood 8upm*s punoOuT .zo TTin xMeo eoij gOZ (e L'£ % Z e2eupap oosaans (p , g•Sz PT®T,i Jo uonona4suoo (o t�•ST u be 006 mw;a -8e m (q RouT/sed OZ uma je sea ou (E -d j•Sj fag sPTaU 2uTqouerl edTr1 o,� x-oq-p aosa adTd u; spueq on (2 AogTa vu Sol (a - P8d ge8Tdatixi 7,,t,Z (e TeT.salm .Aaoa (p TT' TT %Z eavapup a*fans • (o OT' TT � be oar �-s p-gt.*E o� o suo �osds {g � �• � #4; IT Be BIgT'sod sT uoT4v-[MsuT eq� eja, pew zq3aad Exa slid 2aTgoua7 I sITd _ _1 20 1 UY'd Board of Health North Ancjaver:Haaa. IFAIL SEPTIC SYSTEM INSTALLATICK CMK LISP Inst -+6 AVATION OK JAIL OK /40U'Vr-D '561) 1. Distance To: coV a. Wetlands a� b. Drains c.. well ��2. Water Line Location 3. No PPC Pipe Septic Tank 1 / a. _Tess _Length & To Clean Ont Covers. b. Cement Pipe to Tank on Both Sides of Tank Distribution Box a. Covers & Box - No Cracks b. All Lines Flowing Equal Amounts c. No Back Flow 6.- Leach Field or Trench a. Dimensions 101 b. D�ph c. Capp ds ��/d. C]�K= Double Washed Stone ,f 77. beach Pits a. Dimansi s b. Stone epth c9P sh Pads d.:T s e. emaent Pipe to Pit - Both Sides f. Clean Double Washed Stone 8. No Garbage Disposal 9. Final Grading Inspection 10. Barricading Covered System 11. As Built Submitted a. Lot Location b. Dimensions of System fe0o" c. Location with Regard -to Pere Test d. Elevations e; Water Table Commonwealth of Massachusetts City/Town of System Pumping Record .';. Form 4 DEP has provided this form for use by local Boards of HealthE0M0W:itW"M may be used but the information must be, substantially the same as that provided check with your local Board of Health tQ determine the form they use. The Sy be submitted to the local Board of Health mother approving authority. A. Facility Information 1. System Locati �Fear ight side of house, Left front of house, Right front of house, Left rear of hous Left rear of building. Right rear of building. Address rl �Kt City/Town v State Zip Code 2. System Owner: Name Address (if different from location) City/Town St�ateN � / Zip Code Telephone Number B. Pumping Record 1. Date of Pumping Date 2. Quantity Pumped: Gallons 3. Type of system: ❑ Cesspool(s) Septic Tank ❑ Tight Tank ❑ Other (describe): 4. Effluent Tee Filter present? ❑ Yes If yes, was it cleaned? ❑ Yes ❑ No 5. Condition of.Sy�s�teacd n18�GU2� 6. System Pumped By: Neil Bateson Name Bateson Enterprises Inc Company 7. Locafie[pcontents were disposed: G. F5821 Vehicle License Number Date U —/' C 1 � t5fonn4.doc- 06/03 System Pumping Record • Page 1 of 1