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HomeMy WebLinkAboutMiscellaneous - 115 SPRING HILL ROAD 4/30/2018 (2) ftp. sp�IN6 thu Commonwealth of.Massachusetts �'H'� "g 4 City/Town of leo Andover s 2013 System Pumping Record w„ 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 only the tab key to move your Addr ss cursor-do not No andover Ma use the return key. City/Town State Zip Code 2. System Owner: r� � G A-11-01's Name renin Address(if different from location) City/Town State Zip Code Telephone Number B. Pumping Record _ 1. Date of Pumping Date ' 2• Quantity Pumped: M_� ons 3. Type of system: ❑ Cesspool(s) eptic Tank ❑ Tight Tank ❑ Grease Trap ❑ Other(describe): 4. Effluent Tee Filter present? ❑ Yes ❑ No If yes, was it cleaned? ❑ Yes ❑ No 5. Condition of System: � C9v-v �J 6. System Pumped By: Name Vehicle License Number Stewart's Septic Service Company 7. Location where contents were disposed: Stewart's Pre-treatrperlt Plant, 20 So. Mill Bradford, Ma Q1835 Signature f Hauler Date Sign at r eceiving cility Date t5form4.doc•03/06 System Pumping Record•Page 1 of 1 -A-SSACHUSS:rT OEP.has provldad jhli lofrn ror Geo py ;Deet Boarpy or ,hoe ;r. T� 2008 b© + brrl;{od to the local Boarc cr noalfn o SY3:0m P_: - '• ,, ofotnof p�4"pw'•�i;�hy�.lnority:CVEr� A. Faclllty Inforr��clon ^rl/'z•''F��: c':; �' S)`S:Qm Location:.. �+r�rti /'•^ // o r r :31 V4 num'.c CivTpwn ------ r�'SY', Sy319 6 2 m .� '1 'fit ',•/n.'Nun/� �,.ti� ,•� .'l'. 11'.M., •1 . •,� .'.��' Addro+� (IldVflrin! rOmbuUcn) To opnpno n'�moar -- ,:Pumping Regord 1. D a e o! PIng .. ©0 Pum 2 YDa 0( 0Y3(am;.,' Q Ca99p001(9) apLC TanA _.1 tani O hor(doscribe) , 4.:`yEMUon( Toa FMo r ../ }'09 res i• ;': .;`',,:....��t��;�r,?:,",'''S,:!,, �j(:�,.Il,���r''�'.1, i. I'. Cla naQ? Ye5 �� SY P�'mpad�8y• , r, IG a " r' r k �un��r, �;:;,j�.r , (I�, f f, ; Vohl "(A4 ..,, , C ! n d o Jca r.`1, on wri e e Corllenls'wora dl�posed: .. � �•',`;, ,•il,"'y, ,.. �' RC1 /v/w/�y ��� � 9 p✓v,%aiar/a rove s/fb(orm3.r�mai�9�ec! t ri t7 i?i Z R..: Commonwealth of Massachusetts S `,City/Town of NORTH ANDOVER MAS ANDOVER, ACHUSETTS System Pumping Record OCT 1 2 2006 Form 4 DEP has provided this form for use by local Boards of Health:The System Pumping Record mus be submitted to the local Board of Health or other approving authority. A. Facility Information - Important: When filling out I. System Location: forms on the computer, use only the tab key Addres ----' _—__ _-_ ..^. -_N,/ a to move your /(N �n cursor•do not Cit /Town _1!/ ._—_. use the return y w State -- -' " Zip Code key. -�; 2. System Owner: tet, ; el Name Address(if different from location) - - - -- Cityfrown Stat _.�'7'=0- Telephone Number -"-- - - B. Pumping Record -. 1. Date of Pumping - 2, Quantity Pumped: Gallons 3. Type of system: ❑ Cesspool(s) ,-E!'Septic Tank ❑ Tight Tank ❑ other(describe): 4. Effluent Tee Filter present? ❑ Yes No If yes, was it cleaned? ❑ Yes ❑ No f 5. Condition of System: 6. ASyem Pumped By: vehicle License Number -'-- (S Company //�•' 7. Location where contents were disposed: .A - PW z� o� Si ature of Hau - Date http://www,mask.govt/dep/water/ proyals/t5forms.htm#inspect t5form4.doc,06/03 System Pumping Record•Page t of 1�4RD of HF�aL i�'I L-01 '7 I 5�� ��� ►i5 iVoi�TH AA-)�vEl�, MA, APP�t (,tJ,��Gf� Sv�f'L7• Wnl ❑ WELL ,�P�oycDTYJT'G peso cA APR7\ovjN6 /6urhoj�)ry coNr�,-r�otis= DiS,dPPKpvEp 1AjE R�ASoNS = Dw� SCPT"�c sys-rE�t ►�s�A�T��� 5x/3v4T(olJ I�sPEG►io�J ��r� �- �3 k� c �i�ss I� FAIL- �w�4L 1,U5(�F.�rlon� �PPi�dvE� �i�TC - I I� /�P�'r�r�v�ivG A�T�toi�rry aoy) DtS�PP�vv�D DA i C FVAL APPROVAL D,O�� APP30VVJ6 COMMONWEALTH OF MASSACHUSETTS EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS DEPARTMENT OF ENVIRONMENTAL PROTECTION APR - 7 2003 TITLE 5 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM PART A CERTIFICATION Property Address:��� S�2�N Gf��L � / "00 UF!z, Owner's Name:/-/T_ � ((� Owner's Addresf: Sri^4 t? Date of Inspection: 3- 31— o3 Name of Inspector: (please print) �, M 13 61.514 Company Name: 5 T,eIZ/-J2 r" -T p T C. Mailing Address: O � ^4 L- 5 Telephone Number: ,/ - 17 J - 2 - 7 � CERTIFICATION STATEMENT I certify that I have personally inspected the sewage disposal system at this address and that the information reported below is true,accurate and complete as of the time of the inspection.The inspection was performed based on my training and experience in the proper function and maintenance of on site sewage disposal systems.I am a DEP approved system inspector pursuant to Section 15.340 of Title 5(310 CMR 15.000). The system: Passes Conditionally Passes Needs Further Evaluation by the Local Approving Authority .� Fails Inspector's SiIr ature: Date: �—3/-4 v The system inspector shall submit a copy of this inspection report to the Approving Authority(Board of Health or DEP)within 30 days of completing this inspection.If the system is a shared system or has a design flow of 10,000 gpd or greater,the inspector and the system owner shall submit the report to the appropriate regional office of the DEP.The original should be sent to the system owner and copies sent to the buyer,if applicable,and the approving authority. Notes and Comments ****This report only describes conditions at the time bf inspection and under the conditions of use at that time.This inspection does not address how the system will perform in the future under the same or different conditions of use. Title 5 Inspection Form 6/15/2000 page I a Page 2 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: //� S Pe &4.G- Owner: Date of Inspection: 3 Inspection Summary: Check A,B,C,D or E/ALWAYS complete all of Section D A. System Passes: I have not found any information which indicates that any of the failure criteria described in 310 CMR Y303 or in 310 CMR 15.304 exist.Any failure criteria not evaluated are indicated below. Comments: B. System Conditionally Passes: NkOne or more system components as described in the"Conditional Pass"section need to be replaced or repaired:The system,upon completion of the replacement or repair,as approved by the Board of Health,will pass. Answer yes,no or not determined(Y,N,ND)in the for the following statements.If"not determined"please explain. The septic tank is metal and over 20 years old*or the septic tank(whether metal or not)is structurally unsound,exhibits substantial infiltration or exfiltration or tank failure is imminent. System will pass inspection if the existing tank is replaced with a complying septic tank as approved by the Board of Health. *A metal septic tank will pass inspection if it is structurally sound,not leaking and if a Certificate of Compliance indicating that the tank is less than 20 years old is available. ND explain: Observation of sewage backup or break out or high static water level in the distribution box due to broken or obstructed pipe(s)or due to a broken,settled or uneven distribution_ box. System will pass inspection if(with approval of Board of Health): broken pipes)are replaced obstruction is removed distribution box is leveled or replaced ND explain: The system required pumping more than 4 times a year due to broken or obstructed pipe(s).The system will pass inspection if(with approval of the Board of Health): broken pipe(s)are replaced obstruction is removed ND explain: 2 ' Page 3 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address: 11-161114 L.r� 1� yparJFi2 Owner: (� ,tE./•/ 6 Date of Inspection: - 1- 0 3 C. Further Evaluation is Required by the Board of Health: NA— Conditions exist which require further evaluation by the Board of Health in order to determine if the system is failing to protect public health,safety or the environment. 1. System will pass unless Board of Health determines in accordance with 310 CMR 15.303(1)(b)that the system is not functioning in a manner which will protect public health,safety and the environment: _ Cesspool or privy is within 50 feet of a surface water Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh 2. System will fail unless the Board of Health(and Public Water Supplier,if any)determines that the system is functioning in a manner that protects the public health,safety and environment: _ The system has a septic tank and soil absorption system(SAS)and the SAS is within 100 feet of a surface water supply or tributary to a surface water supply. _ The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water supply. _ The system has a septic tank and SAS and the SAS is within 50 feet of a private water supply well. _ The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or more from a private water supply well".Method used to determine distance "This system passes if the well water analysis,performed at a DEP certified laboratory,for coliform bacteria and volatile organic compounds indicates that the well is free from pollution from that facility and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less thari 5 ppm,provided that no other failure criteria are triggered.A copy of the analysis must be attached to this form. 3. Other: 3 Page 4 of I 1 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address: f/5 S',2 a-1/,/t"; Owner: A4/J,Q-; Date of inspection: 3 —3/ —©3 D. System Failure Criteria applicable to all systems: You must indicate"yes"or"no"to each of the following for all inspections: Yes No/' Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool Z: Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool r �' - L'1101 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'h day flow /Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s).Number of times pumped Any portion of the SAS,cesspool or privy is below high ground water elevation. _✓ Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. Ath Any portion of a cesspool or privy is within a Zone 1 of a public well. Any portion of a cesspool or privy is within 50 feet of a private water supply well. E+-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 coliform bacteria and volatile organic compomids indicates that the well is free from pollution from that facility and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm,provided that no other failure criteria are triggered.A copy of the analysis must be attached to this form.] �y u (Yes/No)The system fails.I have determined that one or more of the above failure criteria exist as described in 310 CMR 15.303,therefore the system fails. The system owner should contact the Board of Health to determine what will be necessary to correct the failure. �! E. Large Systems: F To be considered a large system the system must Serve a facility with a design flow of 10,000 gpd to 15,000 gpd. You must indicate either"yes"or"no"to.each of the following: (The following criteria apply to large systems in addition to the criteria above) yes no _ the system is within 400 feet of 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 11 of a public water supply well , If you have answered"yes"to any question in Section E the system is considered a significant threat,or answered "yes"in Section D above the large system has failed.The owner or operator of any large system considered a significant threat under Section E or failed under Section D shall upgrade the system in accordance with 310 CMR 15.304.The system owner should contact the appropriate regional office of the Department. 4 a Page 5 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST y Property Address:��� _� �7,E'/M� ,�/GL- c� �� ,�51►NUD U/�/�_ Owner: (o Date of Inspection: o3 Check if the following have been done.You must indicate"yes"or"no"as to each of the following: Yes o Pumping information was provided by the owner,occupant,or Board of Health `/Were any of the system components pumped out in the previous two weeks ? Has the system received normal flows in the previous two week period? 111 'Have large volumes of water been introduced to the system recently or as part of this inspection? Were as built plans of the system obtained and examined?(If they were not available note as N/A) Was the facility or dwelling inspected for signs of sewage back up Was the site inspected for signs of break out V _ Were all system components,excluding the SAS,located on site? _�_ Were the septic tank manholes uncovered,opened,and the interior of the tank inspected for the condition of the baffles or tees,material of construction,dimensions,depth of liquid,depth of sludge and depth of scum? _L.-._�_ Was the facility owner(and occupants if different from owner)provided with information on the proper maintenance of subsurface sewage disposal systems? The size and location of the Soil Absorption System(SAS)on the site has been determined based on: Yes no Existing information.For example,a plan at the Board of Health. _ Determined in the field(if any of the failure criteria related to Part C is at issue approximation of distance is unacceptable)[3 10 CMR 15.302(3)(b)] 5 Page 6 of l 1 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION Property Address: /� P��!-/(,��/ ��� /�/ �N dove ✓ Owner: du do Date of Inspection: 3-31-05 FLOW CONDITIONS RESIDENTIAL ,L Number of bedrooms(design): "T Number of bedrooms(actual): DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): Number of current residents:I_ Does residence have a garbage grinder(yes or no): Is laundry on a separate sewage system(yes or no): [if yes separate inspection required] Laundry system;nspected(yes or no): Seasonal use:(yes or no):_/.1 U 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(based on 310 CMR 15.203): gpd Basis of design flow(seats/persons/sqft,etc.): Grease trap present(yes or no):_ Industrial waste holding tank present(yes or no):_ Non-sanitary waste discharged to the Title 5 system(yes or no): Water meter readings,if available: Last date of occupancy/use: OTHER(describe): GENERAL INFORMATION Pumping Records Source of information: Was system pumped as part of the inspection(yes or no):�P 5 If yes,volume pumped: r•v J allons--How was quantity pumped determined? Reason for pumping: ")/t -7,/j.i i1. S- % 2 u c Ti,,I- c, TYPE OF SYSTEM ' ' _ZSeptic tank,distribution box,soil absotptinn system _Single cesspool _Overflow cesspool _Privy _Shared system(yes or no)(if yes,attach previous inspection records,if any) _Innovative/Alternative technology.Attach a copy of the current operation and maintenance contract(to be obtained from system owner) 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 or no): v 6 Page 7ofII OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: //< Owner: ,AU IF4 C _ Date of Inspection: BUILDING SEWER(locate on site plan) Depth below grade: Materials of construction:—cast iron _40 PVC_other(explain): Distance from private water supply well or suction line: Comments(on condition of joints,venting,evidence of leakage,etc.): SEPTIC TANK: (locate on site plan) Depth below grade-/4,4 Material of construction: --*concrete_metal_fiberglass_polyethylene _other(explain) If tank is metal list age:— Is age confirmed by a Certificate of Compliance(yes or no):—(attach a copy of certificate) , Dimensions: & 4� L/ Sludge depth': U" Distance from top of sludge to bottom of outlet tee or baffle: 5 d Scum thickness: Z" Distance from top of scum to top of outlet tee or baffle: Distance from bottom of scum to bottom of outlet tee or baffle: 3 How were dimensions determined: n s/ � /`le— Comments(on pumping recommendations,inlet and outlet tee or baffle condition,structural integrity,liquid levels as related to outlet invert,evidence of leakage,etc.): 7-1 GREASE GREASE TRAP:_(locate on site plan) Depth below grade:_ Material of construction:_concrete metal_fiberglass polyethylene_other (explain): Dimensions: Scum thickness: Distance from top of scum to top of outlet tee or baffle: Distance from bottom of scum to bottom of outlet tee or baffle: Date of last pumping: Comments(on pumping recommendations,inlet and outlet tee or baffle condition,structural integrity,liquid levels as related to outlet invert,evidence of leakage,etc.): 7 Page 8 of l l OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address:'& fPR/h 9k// /ems Owner: ()c Date of Inspection: TIGHT or HOLDING TANK: (tank must be pumped at time of inspection)(locate on site plan) Depth below grade: Material of construction: concrete metal fiberglass polyethylene other(explain): Dimensions: Capacity: gallons 't Design Flow: gallons/day Alarm present(yes or no): Alarm level: Alarm in working order(yes or no): Date of last pumping: Comments(condition of alarm and float switches,etc.): -S DISTRIBUTION BOX: (if present must be opened)(locate on site plan) Depth of liquid level above outlet invert:'., 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.): 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.): 8 r + • Page 9 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: /� ��/ng,G,,/� ,�f/'7 cy0 d P✓ Owner: / 0 7 _ Date of Inspection: SOIL ABSORPTION SYSTEM(SAS): � (locate on site plan,excavation not required) If SAS not located explain why: Typed a ro L/ leaching pits;number:3 /3 j 3 3 leaching chambers,number: leaching galleries,number: leaching trenches,number,length: leaching fields,number,dimensions: overflow cesspool,number: innovative/alternative system Type/name of technology: Comments(note condition of soil,signs of hydraulic failure,level of ponding,damp soil,condition of vegetation, etc.): Me _TAlo 0-F //v-0"e4duC_ "P4 a e CESSPOOLS: (cesspool must be pumped as part of inspection)(locate on site plan) Number and configuration: Depth—top of liquid to inlet invert: Depth of solids layer: Depth of scum layer: Dimensions of cesspool: _ Materials of construction: Indication of groundwater inflow(yes or no): Comments(note condition of soil,signs of hydraulic failure,level of ponding,condition of vegetation,etc.): Jr Ai- A- . PRIVY: (locate on site plan) Materials of construction: Dimensions: Depth of solids: Comments(note condition of soil,signs of hydraulic failure,level of ponding,condition of vegetation,etc.): 9 • Page 10 of 1 I OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) ley Property Address: Owner: d Date of Inspection: —Q 3 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. DoT 1'7 � �4 1 SO R t ('0 kTa 5 a �„ 10 Page l l of l l OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: Owner: Date of I spection: ��—3 1-03 SITE EXAM Slope Surface water Check cellar o L-/ Shallow wells < Estimated depth to ground water % feet Please indicate(check)all methods used to determine the high ground water elevation: Ob ined from system design plans on record-If checked,date of design plan reviewed: Observed site(abutting property/observation hole within 150 feet of SAS) Checked with local Board of Health-explain: Checked.with local excavators,installers-(attach documentation) Accessed USGS database-explain: You must describe how you established the high ground water elevation: 11 O ------------ C). N m0 Ste. F / 7/9 3 124� M 1 RECEIVED _ SEP - 7 2004 i'C)WN OF NO � A1V[3UVEk SYSTEM. PUM 1N RECORD TOWN OF NORTH ANDOVER DA tl- HEALTH DEPARTMENT SYSTEM OWNER& ADDRESS SYSTEM LC?CA77C)N YAG�Lf)rnls l ll � ij AID, CtlWOLM-A-1 m� z, DATE OF PUMPING: l.�P..,D_. .__..__. _pUANTITY Pt ER:_._-. �tSSf'OC)1.: NC? YES SOPUC Tank: NO_ YES._. , NA t'URE OFSERVICE; KOUTI.NeY EMERUENG'Y OBSERVATIONS: GOOD CONDITION FULL't()COVER HEAVY GREASE BAFFLES IN PLACE, ROOTS LEACHPIELD RUNBACK -- EXC=ESSIVE SOLIDS _ FLOODED SOLID CAR.RYOVER,,,,-_^__OTHER EXPLAIN SYbtcrn Pumpcd by c -)MMENTS CoN I LN FS CRANSFhKKED 1-0 BJARD OF HEALTH No .Andover, Mass . SUBSURFACE DISPOSAL DESIGN CHECK LIST LOT7�/d J� I :V6 It( APPROVED DATE Yrj DISAPPRdVID DATE_ / Provided: Reasons: y 1 i Title V FAIL Ob Reg 2.5 The submitted plan must show as a minimum: a) the lot to be served-area,dimensions lot #,abutters b location and loca ion and resultsppercooation tests-distanction e to ties to c d design calculations & calculations showing required leaching area (e) location and dimensions of system-including veserve area f) existing and proposed contours (g) location any fret areas within 100' of sewage disposal system or disclaimer-check wetlands mapping (h) surface and subsurface drains within 100' of sewage disposal system or disclaimer (i) location any drainage easements within 100' of sewage disposal system or disclaimer-Planning Hoard files (J) known sources of water supply within 2001 of sewage dispogal o system or disclaimer (k) location of any, proposed well to serve lot-1001 from leaching facility (1) location of water lines on property-101 from leaching facility (m) location of benchmark (n) driveways (o) garbage disposals (p) no PVC to be used in construction (q) profile of system-elevations of basement, plumb, pipe, septic tank, distribution box inlets and outlets, distribution field piping and otter elevations (r) maximum ground water elevation in area sewage disposal system (s) plan must be prepared by a Professional Engineer or other professional authorized by law to prepare such plans Reg 6 Septic Tanks (a) capacities-150,% of flow, water table, tees, depth of tees, access, pumping (b) cleanout (c) 101 from cellar wall or inground swimming pool (d) 251 from subsurface drains Reg 10.2 7 Distribution Boxes (a) slope greater than 0.08 Reg 10.4 (b) sump Sub Design Desi Chuck List Page 2 FAIL Ox Leaching Pits Leaching pits are preferred where the installation is possible Reg 11.2 a) calculations of leaching area-minimum 500 e4 ft 11.4 b) spacing 11-t10 c surface drainage 2% ?1.11 d� cover material e) YIx2 Ix4" splash pad f) tee at elbow i: g) no bends in pipe from d-box to pipe Le�achi�nFields Reg 15.1 a no greater20 minutes/inch b area.minimum 900 aq ft 15.4 c construction of field 15.8 d) surface drainage 2 % 3.7 e) 20t from cellar wall or inground swimming pool Leaching Twenches Reg 14.1 a) calculations or leaching area-radii 500 sq ft 14.3 b) spacing-4 ft min 6 ft with reserve between 14.4 c) dimensions 14.6 d) construction 14.7 e) stone 14.10 if) surface drainage 2% Downhill Slope a) slope- be shown) b) y/x x 150 - (to be shorn) PWIPS Reg 9.1 a) approval 9.6 b) stand-by power TOWN OF NORTHAN•DOVER SYSTEM PUM,PI.NG RECORD ; - 2 2003 �1 St'EM OWNER & ADDRESSSYSTEM LOCATION (example: left front of house) 7 11711 ; Al,Anjo ve i U:\"I'E OF PUMPING: QUANTITY UANTITY PUMPED /�y�� 0,NLLU�� y y I100L: NO 1//YES ________ SEPTIC TANK: NO YES _ ,� -\TUBE OF SERVICE: ROUTINE EMERGENCY uIISrRYATIONS: FULL TO COYER CG'OOD CONDITION. BAFFLES IN PLACE: HEAVY CREASE ROOTSLEACHFICLD RUNBACK... CXCESSIVE SOLIDS FLOODED SOLIDS CARRYOVER ;pAHER (EXPLAJN) �N,.sTL'M PUMPCD 0Y: ' umm NTS: 1-1ZANSP1C' RREDTO: Commonwealth of Massachusetts _ City/Town of NORTH ANDOVER MASSA H System Pumping Record Form 4 MAY 5 2010 DEP has provided this form for use by local Boards of Health. T eT must be submitted to the local Board of Health or other approving aut A. Facility Information Important: When filling out 1. System Location: forms to the Npr1no // ��/�,computer,use / v(,[ d. only the tab key Address to move your An a , cursor-do not Ci /T W r- use the return own State Zip Code key.. 2. System Owner: C-i nn Name ICS Address(If different from location) Citylrown State Zip Code Telephone Number B. Pumping Record l 1. Date of dumping //c) Date 2. Quantity Pumped: Gallons 3. :Type of system: ❑ Cesspool(s) E/Septic Tank ❑ Tight Tank Other(describe): 4. Effluent Tee Filter present? ❑ Yes ❑ No If yes'was it cleaned? ❑ Yes ❑ No 5. Condition of System: ay-ri 6. System Pumped By: r 10(eme a e Vehicle License Number ( hS c6ftVtC(?. o pang 7. Location vAere contents were disposed: �OC4- C), A0 gnature of 14 r Date http://www.mass.gov/dep/water/approvals/t5forms.htm#inspect t5form4.docf 06/03S tem Pumping . ys Record•Page 1 of 1 Commonwealth of Massachusetts W City/Town of No.Andover 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. = , IVED A. Facility Information (� Important: Nov 1 ` When filling out 1. System Location: forms on theI �' I I I TOWN OF NORTH ANDOVER computer, use I only the tab key Address to move your No.Andover Ma 01810 cursor-do not City/Town State Zip Code use the return key. 2. System Name no Owner: VQ ` c6inIrl1 5 'e7U Address(if different from location) City/Town State Zip Code Telephone Number B. Pumping Record 11� 3r � �yd 1. Date of Pumping Date 2. Quantity Pumped: Gallons 3. Type of system: ❑ Cesspool(s) .Septic Tank ❑ Tight Tank ❑ Grease Trap ❑ Other(describe): 4. Effluent Tee Filter present? ❑ Yes ❑ No If yes, was it cleaned? ❑ Yes ❑ No 5. Condition of System: eian�f 6. S``y§�te�m Pumped By: I Y )ll<-e- S . Name Vehicle License Number Stewart's Septic Service Company 7. Location where contents were disposed: Ste 's P -tr atment Plant, 20 So. Mill Bradford, Ma 01835 S nat a of H ler ( Date CA Signature of Receiving Facility Date t5form4.doc•03/06 System Pumping Record•Page 1 of 1