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HomeMy WebLinkAboutMiscellaneous - 12 BARCO LANE 4/30/2018 12 BARCO LANE ` 210/104.6-0122-0000.0 1�_ Commonwealth of Massachusetts City/Town of _ System Pumping Record NORTH ANDOVER •ti 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 9 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: v, tl\'� ZU1S When filling out 1. System Location.- forms ocation:forms on the ,/ " TOWI-4 computer.use only the tab key Address .--- �... to move your1 cursor-do not City/Town State Zip Code use the return key. 2 System Owner: CE.r Name Address(if different from location) ---- —— State Zip Code CitylTown .. q� 92y Telephone Number — B. Pumping Record w.. /pa�1. Date of Pumping --I - 2. Quantity Pumped: Gallons Date 3. Type of system: ❑ Cesspool(s) eseptic Tank ❑ Tight Tank ❑ Grease Trap ❑ Other(describe): 4. Effluent Tee Filter present? ❑ Yes O/No If yes, was it cleaned? ZYes ❑ No 5. Condition of System: 6. System Pumped By: Name V4thicle License Humber Company 7. Location where contents were disposed: birilme A` ft_IWA. Ignature of Hauler Date Signature of Receiving Facility Date 15form4.doc•03/06 System Pumping Record-Page i of 1 f,�� A ��� • Form 4 -- System Pumping Record Commonwealth of Massachusetss : Massachusetts System Pumping Record System Owner system Location n;v!- t'�L 1- n•.+ 'L tT�'il'� ;`(:'P,.� :r,„ Ntl Rd X174 0003 y 91y> -974 .0001 Type: Emergency Routine Cesspool: No Yes Septic tank: No Yes ©' Date of Pumping: l Quantity Pumped: ® Gallons System Pumped By: Wind RIVW FfiWvnmenfv1, LLC Permit it: Contents transferred to: Contents Disposed at: SJ Date: Pumper Signature: Condition of System/Other Comments Dep Approved from - 12107195 577 MAIN STREET HUDSON,MA 01749 800-499-1682 WINDRIVER ENVIRONMENTAL SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PROPERTY OWNER'S NAME: BOWEN,DARLENE PROPERTY ADDRESS: 12 BARCO RD., NO. ANDOVER,MA ADDRESS OF OWNER: SAME (IF DIFFERENT) DATE OF INSPECTION: OCTOBER 1, 2002 NAME OF INSPECTOR: THOMAS CHIGAS COMMONWEALTH OF MASSACHUSETTS Z W EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS + d DEPARTMENT OF ENVIRONMENTAL PROTECTION A l.� � W �qM s�av TITLE 5 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM PART A CERTIFICATION Property Address: 12 BARCO RD. NO.ANDOVER,MA Owner's Name:BOWEN,DARLENE Owner's Address: 12 BARCO RD. NO.ANDOVER,MA Date of Inspection: OCTOBER 1,2002 Name of Inspector: (please print)THOMAS CHIGAS Company Name: Windriver Environmental Mailing Address: 577 Main Street Hudson,MA 01749 Telephone Number: 800-499-1682 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: YES Passes Conditionally Passes Needs Further Evaluation by the Local Approving Authority ails r Inspector's Signature: Date: OCTOBER 1, 2002 The system inspector shall submit a copy of is 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 of inspection and under the conditions of use at that time.This inspection does not address how the system will perform in the future under the same or different conditions of use. Title 5 Inspection Form 6/15/2000 page 1 Page 2 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address: 12 BARCO RD. NO.ANDOVER,MA Owner:BOWEN Date of Inspection: OCTOBER 1,2002 Inspection Summary: Check B,C,D or E/ALWAYS complete all of Section D A. System Passes: YES I have not found any information which indicates that any of the failure criteria described in 310 CMR 15.303 or in 310 CMR 15.304 exist.Any failure criteria not evaluated are indicated below. Comments: B. System Conditionally Passes: NO One or more system components as described in the"Conditional Pass"section need to be replaced or repaired. The system,upon completion of the replacement or repair,as approved by the Board of Health,will pass. Answer yes,no or not determined(Y,N,ND)-in the for the following statements.If"not determined"please explain. NO 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: NO 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): NO broken pipe(s)are replaced NO obstruction is removed NO distribution box is leveled or replaced ND explain: NO 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): NO broken pipe(s)are replaced NO obstruction is removed ND explain: 741. c T--.,+;--'P--All,;/Inf)() 2 Page 3 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address: 12 BARCO RD. NO.ANDOVER,MA Owner: BOWEN Date of Inspection: OCTOBER 1,2002 C. Further Evaluation is Required by the Board of Health: NO 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: N/A Cesspool or privy is within 50 feet of a surface water N/A 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: NO 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. NO The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water supply. NO The system has a septic tank and SAS and the SAS is within 50 feet of a private water supply well. NO The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or more from a private water supply well".Method used to determine distance "This system passes if the well water analysis,performed at a DEP certified laboratory,for coliform bacteria and volatile organic compounds indicates that the well is free from pollution from that facility and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm,provided that no other failure criteria are triggered.A copy of the analysis must be attached to this form. 3. Other:N/A 741. c T—., +;—V,., All c/100A 3 Page 4 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address: 12 BARCO RD. NO.ANDOVER,MA Owner: BOWEN Date of Inspection: OCTOBER 1,2002 D. System Failure Criteria applicable to all systems: You must indicate"yes"or"no"to each of the following for all inspections: Yes No NO Backup of sewage into facility or system component due to 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 is less than 6"below invert or available volume is less than'/2 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 NO Any portion of the SAS,cesspool or privy is below high ground water elevation. N/A Any portion of 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 1 of a public 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 certified laboratory,for coliform bacteria and volatile organic compounds indicates that the well is free from pollution from that facility and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm,provided that no other failure criteria are triggered.A copy of the analysis must be attached to this form.] NO(Yes/No)The system fails.I have determined that one or more of the above failure criteria exist as described in 310 CMR 15.303,therefore the system fails.The system owner should contact the Board of Health to determine what will be necessary to correct the failure. E. Large Systems: To be considered a large system the system must serve a facility with a design flow of 10,000 gpd to 15,000 gpd• You must indicate either"yes"or"no"to each of the following: (The following criteria apply to large systems in addition to the criteria above) yes no NO the system is within 400 feet of a surface drinking water supply NO the system is within 200 feet of a tributary to a surface drinking water supply NO 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. Page 5 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST Property Address: 12 BARCO RD. NO.ANDOVER,MA Owner:BOWEN Date of Inspection: OCTOBER 1,2002 Check if the following have been done.You must indicate"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 flows 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 not available note as N/A) YES Was the facility or dwelling inspected for signs of sewage back up? YES Was the site inspected for signs of break out? YES Were all system components,excluding the SAS,located on site YES 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? YES Was the facilityowner and occupants if different from owner provided with information on the ( P ) 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 YES Existing information.For example,a plan at the Board of Health. NO Determined in the field(if any of the failure criteria related to Part C is at issue approximation of distance is unacceptable) [3 10 CMR 15.302(3)(b)] Page 6 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION Property Address: 12 BARCO RD. NO.ANDOVER,MA Owner:BOWEN Date of Inspection: OCTOBER 1,2002 FLOW CONDITIONS RESIDENTIAL Number of bedrooms(design): 4 Number of bedrooms(actual):3 DESIGN flow based on 310 CMR 15.203(for example: 110 gpd x#of bedrooms): 600 Number of current residents:3 Does residence have a garbage grinder(yes or no):NO Is laundry on a separate sewage system(yes or no):NO [if yes separate inspection required] Laundry system inspected(yes or no):N/A Seasonal use: (yes or no):NO Water meter readings,if available(last 2 years usage(gpd)):WELL ON SITE Sump pump(yes or no):YES USE IS FOR THE GARAGE Last date of occupancy: CURRENT 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: OWNER AND RECORDS Was system pumped as part of the inspection(yes or no):NO If yes,volume pumped:_gallons--How was quantity pumped determined? Reason for pumping: SYSTEM PUMPED 9/12/02 TYPE OF SYSTEM YES Septic tank,distribution box,soil absorption system NO Single cesspool NO Overflow cesspool NO Privy NO Shared system(yes or no)(if yes,attach previous inspection records,if any) NO Innovative/Alternative technology.Attach a copy of the current operation and maintenance contract(to be obtained from system owner) NO Tight tank Attach a copy of the DEP approval NO Other(describe): Approximate age of all components,date installed(if known)and source of information: 20 YRS.,OWNER Were sewage odors detected when arriving at the site(yes or no):NO Page 7 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C j SYSTEM INFORMATION(continued) Property Address: 12 BARCO RD. NO.ANDOVER,MA Owner:BOWEN Date of Inspection: OCTOBER 1,2002 BUILDING SEWER(locate on site plan) Depth below grade:39" Materials of construction:411cast iron 40 PVC other(explain): Distance from private water supply well or suction line: 162'FROM S.A.S. Comments(on condition of joints,venting,evidence of leakage,etc.): THERE WERE NO SIGNS OF LEAKAGE IN OR AROUND PIPE,SOILS WERE CLEAN AND DRY. SEPTIC TANK: YES(locate on site plan) Depth below grade:30" Material of construction:YESconcrete 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: 8'L X 5'W X 5'11 OUTLET INVERT 9481'=1,000GAL Sludge depth: <6" Distance from top of sludge to bottom of outlet tee or baffle: 26" 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 were dimensions determined:ROD AND RULER Comments(on pumping recommendations,inlet and outlet tee or baffle condition, structural integrity,liquid levels as related to outlet invert,evidence of leakage,etc.): THE LIQUID LEVEL AT NORMAL HEIGHT.THERE WERE NO SIGNS OF LEAKAGE.SOILS WERE CLEAN AND DRY.THE INLET AND OUTLET BAFFLES ARE CEMENT AND INTACT.THERE WERE LITTLE SIGN OF DECAY AT THE INLET AND OUTLET ENDS OF TANK.THE INLET AND MIDDLE COVERS ARE EXTENDED,THERE 6" UNDER GRADE. GREASE TRAP: NO(locate on site plan) Depth below grade: Material of construction: concrete metal fiberglass polyethylene other(explain): Dimensions: Scum thickness: Distance from top of scum to top of outlet tee or baffle: Distance from bottom of scum to bottom of outlet tee or baffle: Date of last pumping: Comments(on pumping recommendations,inlet and outlet tee or baffle condition,structural integrity,liquid levels as related to outlet invert,evidence of leakage,etc.): Page 8 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 12 BARCO RD. NO.ANDOVER,MA Owner: BOWEN Date of Inspection: OCTOBER 1,2002 TIGHT or HOLDING TANK:NO(tank must be pumped at time of inspection)(locate on site plan) Depth below grade: Material of construction: concrete metal fiberglass polyethylene other(explain): Dimensions: Capacity:_gallons Design Flow:_gallons/day Alarm present(yes or no): Alarm level: Alarm in working order(yes or no): Date of last pumping: Comments(condition_of alarm and float switches,etc.): DISTRIBUTION BOX: YES(if present must be opened)(locate on site plan) Depth of liquid level above outlet invert: 0" DEPTH BELOW GRADE: 27" 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.): THE D-BOX IS LEVEL AND EQUALLY DISTRIBUTING.THERE WERE NO SIGNS OF LEAKAGE OR FAILURE.THERE WERE NO SIGNS OF DECAY OR SOLID CARRYOVER.THERE WERE ONE INLET AND FOUR OUTLETS ALL SCH2O PVC,AN THERE IN GOOD CONDITION. PUMP CHAMBER:NO(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 Page 9 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 12 BARCO RD. NO.ANDOVER,MA Owner:BOWEN Date of Inspection: OCTOBER 1,2002 SOIL ABSORPTION SYSTEM(SAS):YES(locate on site plan,excavation not required) If SAS not located explain why: Type leaching pits,number: leaching chambers,number: leaching galleries,number: leaching trenches,number,length: YES leaching fields,number,dimensions: ONE,45'L X 20'W LEACHBED 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.): THERE WERE NO SIGNS OF FAILURE OR BREAKOUT.THERE WERE NO SIGNS OF STANDING WATER OR POOLING IN OR AROUND AREA,SOILS WERE CLEAN AND DRY.THE LEACH PIPE IS SCH2O PVC AND THERE IN GOOD CONDITION. CESSPOOLS: NO(cesspool must be pumped as part of inspection)(locate on site plan) Number and configuration: Depth—top of liquid to inlet invert: Depth of solids layer: Depth of scum layer: Dimensions of cesspool: Materials of construction: Indication of groundwater inflow(yes or no): Comments(note condition of soil,signs of hydraulic failure,level of ponding,condition of vegetation,etc.): PRIVY:NO(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.): r;+io c T--+;,,,,R..- All ciInnn 9 Page 10 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 12 BARCO RD. NO.ANDOVER,MA Owner:BOWEN Date of Inspection: OCTOBER 1,2002 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. ®� ON 5118 J� ?Pod L acct yard 1Lec.k . Ho L) A 8 P0, �rnn� Sef+tc. ("n)an k 20 A '"Cu \ sedge r 54d -, T I w 59 d 13 4o T r = /3 3 " 10 Page 11 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 12 BARCO RD. NO.ANDOVER,MA Owner: BOWEN Date of Inspection: OCTOBER 1,2002 SITE EXAM Slope:YES Surface water:NONE Check cellar:YES Shallow wells:NONE Estimated depth to ground water 10+feet Please indicate(check)all methods used to determine the high ground water elevation: YES Obtained from system design plans on record-If'checked,date of design plan reviewed:NOV 14,1977 YES Observed site(abutting property/observation hole within 150 feet of SAS) NO Checked with local Board of Health-explain: NO Checked with local excavators,installers-(attach documentation) YES Accessed USGS database-explain:MAPS You must describe how you established the high ground water elevation: THE HOUSE HAS A 4' SLAB FOUNATION WITH SUMP PUMP IN GARAGE.THERE WERE SOIL TESTING DONE 8/2/77 INDICATING NO WATER WAS OBSERVED k 141.5.THE YARD WAS SLOPED AND THERE WERE NO SIGNS OF PONDINS IN OR NEAR SITE.WHILE DIGGING IN YARD THERE WERE NO SIGNS OF HIGH SEASONAL WATER TABLE.THERE WERE NO SIGNS OF ABUTTING PROPERTY'S WELLS OR WETLANDS WITHIN 100' FROM SYSTEM. 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ABso e PT/o^j ,�Eo ISL A h/ 154 iUor To cS'c,4LE Pia-� � � �^ :// - • CP SD EG T w .To/nrr, SCK ,FILL ode -<< • '. �� e �� EcOI/i t! _ s /�B" TO 3�8"' I�ASNE� � 3: �' � ! i • • • 8/T.Fig. PIPE CLQ • • • • •• � • d p TO 114" WASHED � - . +� ? i 1 �� rM- ; ! � �voUBGE- l•V.gS/,/ED 11 d• N1` Q, �+ Ni f �f•j i ` i I,i �;BSo,ePT/Oiy BEIM cYoeeT/OAj v� ; WAGE O„ "ALE woe. /�/' O� 4V' >°ROF/LE AND ,f�65�.ePT/Ow BES /ALAN Awv �S'ECT/o NS �f�EET �r 4 IVV- A4 J♦ SP�NUSETrS L' L E V.4 7/G& W R, 7/ him ok-r. 4_8 .� �olyN�O pR0 SSS\ 4? ea .L'u •G a 67 Z,, T 4 , Go ' 90 c� .s• t 93 D a h - :t Ive q f i l TO: NORTH ANDOVER, MASS J -19 BOARD OF HEALTH t' FROM: DESIGN ENGINEER Re: Soil Absorption Sewage System Inspection This is to certify that I have inspected the construction of the said disposal system at Z -7 131'q P (' 0 l /'1 All—` North Andover, Mass. SITE LOCATION The grades and construction are as specified in my pl sa;r6 ! �tj tions dated 19- i'H n r` cQ O s o' z eg. P'' .� PR j� S nitarian i WELL DATABASE ADDRESS: AGE OF W'ELL: WELL DRILLER: WELL PERlyfIT rr: WELL LOCATION: —W=PERIWr DATE: DEPTH OF WELL/ . TYPE.OF WELL: a.. DRILLED b. DUG c. OWN TYPE OF WATER BEARING ROCK_ WATER ANALYSIS DATE,_ THIGH MANGANESE: :� -- HIGH IRON: Y N C ONTAMINANTS: Y Commonwealth of Massachusetss Form 4 System Pumping Record Massachusetts System Pumping Record r,O- System Owner System Location PrijNry T101,11.("-, barco• Tano It 21 T3 co 1Allg� :Iot"--11 Andcnvc�r, At 0184-.'. North Andiuver, IQ,, 018�: � Y (978)-68;-4 '1)? Type: Emergency Routine Cesspool: No Yes Septic tank. W =Yes Daft of Pumping: qL-6 Quantity Pumped: Gallons System Pumped By: Wind River Environmental, UC Permit#: Contents transferred to: Ca�f�tchburgContents Disposed at. astater pi., MA. I lant, Date: q-(,-05 Pumper Signature: Condition of System/Other Comments Dep Approved Form 12/07/95 CURRIER FORM 4-SYSTEM P l rNG RECORD SEPTIC & DRAIN SERVICE 107 FOREST STREET;MIDDLETON,MA 01949 (978)774-2772 i I OMMONW ALTH OF MASSACHUSETTS i ,MASSACHUSETTS SYSTEM PUMPING RECORD SYSTEM OWNER: SYSTEM LOCATION: J co �ecller 2 � DATE OF PUMPING: 9 QUANTITY Y PUMPED: /, Oo o GALLONS CESSPOOL: NO YES SEPTIC TANK: NO 0 YES SYSTEM PUMPED BY: CURRIER SEPTIC & DRAIN SERVICE CONTENTS TRANSFERRED TO: L S DATE: 9 iS- INSPECTOR: Town,of No'r'th Andover, Massachusetts Form No. 1 NORTHBOARD OF HEALTH ' Fps` bq,yo f / OL �.. 19 / 7 `ryi t: APPLICATION FOR SITE TESTING/INSPECTION ApAATEO PQP`�y SSACHU5�� Applicant NAME ADDRESS TELEPHONE Site Location //�y 7 Engineer '✓ / NAME ADDRESS TELEPHONE Test/Inspection Date and Time CHAIRMAN�BOARD OF HEALTH Fee a , Test No. �S .-D S.S. Permit No. D.W.C. No. 9,17( C.C. Date 1�Plbg. Permit No. EMMMR_ p R /address, lam. 8AQc / Title of File Page of Date t=ile Open: Date file closed: - Doc Document/Action Title Date of Refer to other Purpose of Documernt/Action and notes action Document/ document/ Num• Action Department Board of Appeals - Board of Health - Planniing Board-- Conservation Commission - Building Departrnen,t o� HF i F 1 �.or Z 7 12, 3dRW e4 NaI�Tm povei., MA, A P��i w1Er{ - 0pPLY WELL- ouCD]}li s S SY S iEM VESI �pPi�ovCD D�4r�� /f RDOUWG /&)Ttl6ff)Ty .Y' PC/AA.) DES) &A-)6 FGW,v DATA �I54PPRUvEp COnJp����s IAT6 K�45oNS = 4V4T(oN )A-Aot�-G t ion D/Jr� 10-5. 7 )��SS E] F41L- . �wAL r tiSpE�rlon� �PFRC)VE17 I NS%TI,�G(i MY Co 4D�IT(plJ,4L (nJSF -C.j 10"5 (1=koy) j, cdr�Z op 2 CA R�iJ�NS ' INCo�1�f; r�S�t��",Q j�GO w4S NG - FItipL /JPPRpvAL rE; ,V.),HEN-rAN K W.45 S�E/JaGy iti io 114 C� � FaX P44' ' f� s Town of North Andover, Massachusetts Form No.3IjORTH . BOARD OF HEALTH '` AL —19 87 i f 01 <:�iw... i • .x � ....... I. DISPOSAL WORKS CONSTRUCTION PERMIT `. • ,SSACHUSE Applicant—JON CARR MMII 'Y COAJI��Q(2 � NAME ADDRESS TELEPHONE Site Location LOT 27 4JAR -0 4A. 12- Permission 2Permission is hereby granted to Construct ( ) or Repair tit-an Individual Soil Absorption Sewage Disposal System as shown on the Design Approval S.S. No. CHAIRMAN,BOARD OF HEALTH to 7 Fee D.W.C. No. u LU O Q W UjUj Room -0 0 W >n Q O r a0 �� U f o CY d+ CO rx,P v' 1 O CLa '`r"` n ' o�- O Lu r 1- CO 5 0 ccw Q L V z � A a T $ lei cc PD cz X M (9 I ' I' Town of North Andover, MA Watershed septic System Servicing Report Date:� " 41 ^ / Homeowner: Pumper Street Address: R �� Phone 9 Z f Z 3&Z Phone Nature of Service: Routine Emergency Observations: Good Condition Full to Cover Baffles in Place Leachfield Runback Excessive Solids Heavy Grease Roots Other (Explain) .ii(e�d �-+it h—YYl Description of 'cork: �� -- --- Comments: 1� Ni0 L`I"�i ANTX) ER BOARD OF IE1,1e.LTH :iik5 .`:LL«�i10i3 Ci ALF{ LIST _ — Ari?,GV 1` , ITG`, _EXCAVATION OK Date: i,( �e�l Reason: t0/7'? As Built S�.ibmitt Check: Lot location, dimensions of system, location in regard to percolation tests, depth of system, i•?ater table 2. Distance to Wetland Areas, Drains, Street & House, Drainage Easement and Wells. 3. Water/fsine Location !�. No PV Pipe 5. Septic Tank - 4TOV ent spe to Tank-Joints on both side of' Tank. 6. Distribution Box - No cra6ksin ox or cover, all lines fl r ecually from box. 7. Leach Fields - Dimens' -n s, Stone D pths, Ca_ y ed ends, Clean double shed stone 8. Leach Pits - Dimensions, Depth of Stone, Splash pa(�tces, Cement,-pipe to tank- joints on both sides of tank, Clean double-cashed stone 9. No Garbage! 10. Final Grading ` barricading of sub-surface system NORTH ANDOVER oK SUBSURFACE DISPOSAL SYSTEM CHECK LIST I. General Information Reg. 2. 5 The submitted plan must show as a minimum: (a� the lot to be served (b) .,�ocation and dimensions of the system (including r erve area) (c) ign calculations (d) ca lations showing required leaching area (e) xisting and proposed contours (f) ,,I-o cation and log of deep observation holes - d' tance to ties (g) ation and results of percolation tests - M ance to ties (h) loc tion of any wet areas within 100 ' of the ge disposal system or disclaimer (i) surface and subsurface drains within 100 ' of t>e-__`sewage disposal system or disclaimer (j ) /location of any drainage easements within 10�-' of the sewage disposal system or disclaimer (k) -- nown sources of water supply within 200 ' of tl sewage disposal system or disclaimer (1) ��tion tion of any proposed well to serve the lot (m) of water lines on the property (n) /maximum ground water elevation in the area of sewage disposal system (o) rofile of the system (p) ! PVC is to be used in construction (q) /lo>�ion of benchmark (r) 7n must be prepared by a Professional Engineer or other professional authorized by law to prepare such plans. II. Grba e Disposers III. Septic Tanks Reg. 6 . 1 (a) acities - 150% of flow Reg. 6. 7 (b) �W�f_ er table Reg. 6.8 (c) / s Reg. 6 .9 (d) �th of tees Reg. 6 . 12 (e) /A c ss Reg. 6. 18 (f) �mping W Cleanout _ IV. Pumps Reg. 9. 1 (a) Approval Reg. 9.6 (b) Stand-by power Town of North Andover. MA Watershed Septic System Servicing Report Date: Homeowner: pumper Street Address: lee.` Phone Phone Nature of Service: Routine Emergency Observations: JAI�ndition Full to Cover Baffles in Place Leachf ieldRunback v r4 �'w Excessive Solids Heavy Grease Roots J G Other (Explain) Qr 4 F1 Description of Work: Comments: 107 Forest St. g4 EP\� FORM 4 SYSTEM Pt Ii�1PNG RECORD I•+trldlr,tc n MA 01949 "v r 1 H 6 Y Commonwealth of.Mass achusettsS`' ? tl Massachusetts Sutein Puniy!n Record System weer System oca 77 sz3� t Date of Pumping: j Quantity Pum ed allons p ,..; Cesspool: No ❑ Yes ❑ Septic Tank: No ❑ Yes . Svstem Pumped by License #, Contents transferred to: Date Inspector a- 1 { 1 �1Y .r c a r • .. d r S '�tea •*�'+ •- c 'a t`�' F y t M Form 4 -- System Pumping Record Commonwealth of Massachusetss Massachusetts System Pumping Record System Owner System Location LARL. NE ?,owon DARMIL 1. BAVat 'LAN!: le L.".tS 11011-T AI} Y:U-1 fIA 1.0.. a0.', NQY?TK ..M)VFR, MA 01L4s .20.: (978) 0 14-000.1 ;X76) ;79-0J03 Type: Emergency Routine Ft/ Cesspool: No Yes Septic tank: w Ely- El Date of Pumping: 69- U y -C) ( Quantity Pumped: �,jG(� Gallons System Pumped By: Wind River Environmental, LLC Permit M Contents transferred to: Contents Disposed at: Date: Pumper Signature: Condition of System/Other Comments Dep Approved from - 12/07/95 _C_\ Commonwealth of Massachusetts City/Town of . . System Pumping Record NORTH ANDOVER Form 4 DEP has provided this form for use by local Boards of Health. Other forms may be used,but the information must be substantially the same as that provided here. Before using this form,check with your local Board of Health to determine the form they use.The System Pumping Record must be submitted to the local Board of Health or other approving authority within 14 days from the pumping date in �r ��"•, +rte^ accordance with 310 CMR 15.351. ,L;�c I1q;r6 I y A. Facility information .. + it Important: When filling out 1. System Location: forms on the /�� TOWN OF NORTH ANt�OV�ly L-��"Cv r--_;__ HEALTH Q PAF�TM NT computer,use - _ only the tab key Address y ---- cursor to move our G --- - cursor-do not - ._ _-_-- -----.------------- use the return City/Town St to Zip Code key. 2. System Owner.- Name wner:Name --------- Address(if different from location) - ----- ---�- ---..._.___.. ._._- -------- ---------.—._--____ _.—_ CitylTown - State Zip Code __q yZ �. -_- - --- --- Telephone Number B. Pumping Record 1. Date of Pumping ate 2. Quantity Pumped: Gallons - ff D — 3. Type of system: ❑ Cesspool(s) RR'Ie"ptic 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. System Pumped By: Name Vehicle License Number R Company 7. Location where contents were dispoed: fpswich Water ----------- .__----------1"rea�iment Plant ------ - __ Signature of Hauler Ipswi-ch9 Ott 8 Signature of Receiving Facility----� _�^—�-- -Date - -�-`-----------�---_. _..__.__•—_-._- t5form4.doc•03!06 System Pumping Record•Page 1 of 1