HomeMy WebLinkAboutMiscellaneous - 120 LIBERTY STREET 4/30/2018 120LIbEKIYz5ixetr
210/090.6-0056-0000.0
1
Commonwealth of Massachusetts
= City/Town of
System Pumping-Record
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.
A. Facility. Information
1. System Locatio . Le Rig oni of house, eft/Right rear of house, Left/right side of house, Left/
Right side of building, Left/Right front o wilding, Left/Right rear of building, Under deck
Address
C" !Town
ity State Zip Code
2. System Owner.
Name
To
Address(if different from location)
Citylrown ' State Zip Code
Telephone Number
r
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 No If yes,was it cleaned? ❑ Yes ❑ Na
5. Condition of System:
6: System Pumped By.-
Nell
y:Neil.Bateson F5821
Name Vehicle License Number
Bateson Enterprises Inc
Company
7. Lo a contents were disposed:
G.L S. Lowell Waste Water
'0 A. Bx6��-�
Sign Hhul Date
t5form4.doa 06/03 System Pumping Record•Page 1 of 1
I�
7
F,le- 9,5 _ �8
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM l
� H
Address of property 1 zv g Cal-Y s►, ivo RT-
rll NE ,
Owner's name -rHo,r,,�}�
. . Date of Inspection
PART A
CHECKLIST
Check if the following have been done:
Pumping information was requested of the owner, occupant, and Board of
Health.
),Z-None of the system components have been pumped for at least two weeks
and the system has been. receiving normal flow rates during that
9 t
9
period. Large volumes of water have not been introduced into the
system recently or as part 'of this inspection.
As built plans have been obtained and examined. Note if they are not
available with N/A.
The facility or dwelling was inspected for signs of sewage back-up.
—V The site was inspected for signs of breakout.
✓� All system components, excluding the SAS, have been located on the
site.
r,/ The septic tank manholes were uncovered, opened, and the interior of
the septic tank was inspected for condition of baffles or tees,'
'material of construction, dimensions, depth of liquid, ' depth of
sludge, depth of scum.
The size and location of the SAS on the site has been determined based
on existing information or approximated by non-intrusive methods.
The facility owner (and occupants, if different .from owner) were
provided with information on, the proper maintenance of SSDS.
j
8
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART B
SYSTEM INFORMATION
FLOW CONDITIONS
If residential
number of bedrooms
number of current residents,
garbage grinder, yes or no
Y: laundry connected to system, yes or no
N seasonal use, yes or no
If nonresidential, calculated flow:
Water meter readings, if available:
f
i
^tee + Last date of occupancy ,
GENERAL INFORMATION
i
Pumping records and source of information:
gf=5 System pumped as part of inspection, yes or no
if yes, volume pumped6,-r?-L_
Reason for pumping:
C 770 �c✓ r r 'Si9 �.( �9iL D Y-9 y 4•c P.
Type of system
Septic tank/distribution box/soil absorption system
Single cesspool
Overflow cesspool
Privy
Shared system (yes or no) (if yes, attach previous inspection
records, if any)
Other (explain)
Approximate age of all components. Date installed, if known. Source of
information:
K 5
,-`,L_ Sewage odors detected when arriving at the site, yes or no
. I
9
2
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION ORM
PART B
.SYSTEM INFORMATION continued
SEPTIC TANK:
(locate on site plan)
depth below grade:
-- -
material of construction: ,concrete metal FRP other(explain)
dimensions: 15-0 C' 6-4 L
sludge depth
�- distance from top of sludge to bottom of outlet tee or baffle
D scum thickness
:et distance from top of scum to top of outlet tee or baffle
�- distance from bottom of scum to bottom of outlet tee or baffle
Comments:
(recommendation for pumping, condition of inlet and outlet tees or baffles,
depth of liquid level in relation to outlet invert, structural integrity,
evidence of leakage, recommendation's for repairs, etc. )
i aA,;ati TZ:c A Ce P r �s s P���, T�=5 Ti4�✓�S !-�/�� ��i G 2 v4 c�
~A)I-16 j_C-' ?:'j ?-t' c E/VTO 17-
DISTRIBUTION
DISTRIBUTION BOX:
(locate on site plan)
depth of liquid level above outlet invert
Comments:
(note if level and distribution is equal, evidence of solids carryover,
evidence of leakage into or out of b x, recommendation r repa.�rs, etc. )
C 4�: �t1 v� G t l) r-1 Q < . �•�., vc 7 Cg,
X
PUMP CHAMBER:
(locate on site plan)
pumps in working order, yes or no
Comments:
(note condition of pump chamber, condition of pumps and appurtenances,
recommendations for maintenance or r/epairs,etc. )
X. ;.� C' lea vin C-1-9 /.;0n.S �/c;fi.1,� 1 i (dpi G-Lf li9ti/�
t- -S �� ..+� ►>c�� rte..! i'.r ti�+�s .: --2 r' �,L aS H F-i
P t;.t.t P c►-I►9tit t3 <'�2 1-1 T4s 2 is eF�z 6-2i4C�c�
10
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM _ 1
PART B t
SYSTEM INFORMATION continued
SOIL ABSORPTION SYSTEM (SAS) :
(locate on site plan, if possible; excavation not required, but may be
approximated by non-intrusive methods)
If not determined to be present, explain:
Type
i
leaching pits and number
leaching chambers and number i
leaching galleries and number
leaching trenches, number, length
leaching fields, number, dimensions ;
overflow cesspool, number
Comments:
(note condition of soil, signs of hydraulic failure, level of ponding,
condition of vegetation, recommendations for maintenance or repairs,etc. )
CESSPOOLS (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 (cesspool must be pumped as
part of inspection)
Comments:
(note condition of soil, signs of hydraulic failure, level 'of ponding,
condition of vegetation, recommendations for maintenance or repairs,etc. )
PRIVY:
(locate on site plan)
materials of construction
dimensions
depth of solids
Comments:
(note condition of soil, signs of hydraulic failure, - level of ponding,
condition of vegetation, recommendations for maintenance or repairs,etc. )
Y
. 11
! SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM ;
PART B
SYSTEM INFORMATION continued
SKETCH OF SEWAGE DISPOSAL SYSTEM:
include ties to at least two permanent references landmarks or benchmarks
I
locate all wells within 100 '
i
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-7, 1 Z5 t
y r �sr
3j. 3 6; i
4Sr
Ti4NX
P, C r1 i4 M a I
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T-
T T
UiS��a Ql7 J 1C!v aC,
DEPTH TO GROUNDWATER
r
depth to groundwater
method of determination or approximation:
M., f n a'� 3
12
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
FAILURE CRITERIA
Indicate yes, no, or not determined. (Y, N, or ND) . Describe basis of
determination in all instances. If ! "not determined", explain why not)
A' Backup of sewage into facility?
ADischarge or ponding of effluent to the surface of the ground or
surface waters?
i
Static liquid level in the distribution box above outlet invert?
i
A'
Liquid depth in cesspool <6" bielow invert or available volume< 1/2 day
flow?
i
i
IAJ Required pumping 4 times or more in the last year?
number of times pumped 6 f
i
Septic tank is metal? cracked? structurally unsound? substantial
infiltration? substantial exfiltration? tank failure imminent?
Is any portion of the SAS, cesspool or privy:
/ below the high groundwater elevation?
i
within 50 feet of a surface water?
/ within . 100 feet of a surface water .supply or tributary to a surface
water supply?
within a Zone I of a public well?
{
within 50 feet of a bordering vegetated wetland or salt marsh
(cesspools and privies only, not the SAS) ?
r�y within 50 feet of a private water supply well?
less than 100 feet but greater than 50 feet from a private water
supply well with no acceptable water quality analysis? If the well
has been analyzed to be acceptable, attach copy of well water analysis
for coliform bacteria, volatile organic compounds, ammonia nitrogen
and nitrate nitrogen.
13
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART D r
CERTIFICATION
Name of Inspector Ben) 4AM. V . C 9G co
Company Name A) Ev-' E�vC,i,4tia GAG-I,vC�2iti�Cr s�2��tc c s Z/I�c
a
Company Address 3_3 w a�- K e 2 0 .v_ ¢nJ o G ✓L •4 d b Ys
i
Certification Statement
I certify that I have personally inspected the sewage disposal system at
this .address and that the information reported is true, accurate and
complete as of the time of inspection. The inspection was performed and
any recommendations regarding upgrade, maintenance and- repair are
consistent with my training and experience in the proper function and
manitenance of on-site sewage disposIal systems.
Check e:
I have not found any information which indicates that the system fails
to adequately protect public health or the environment as defined in
310 CMR 15. 303 . Any failure criteria not evaluated areas stated in
the FAILURE CRITERIA section of this form.
I
I have determined that the system fails to protect public health and
the environment as defined in 310 CMR 15. 303 . The basis for this
determination is provided in the FAILURE CRITERIA section of this
form.
i
Inspector' s
Signature
Date
I
Original to system owner
Copies to:.
i
Buyer (if applicable)
Approving authority
i
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04/06/1997 15:02 5083736611 STEWART/ANDOVER �~ PAGE 02
lae Moen StSTE TSS MPTIC Tua sic
47 RA ulM STRELpr
MA 01835
W6ocrl L � IS/-Lld�
978-372.7471
MOMB OF
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7MN cpDATE �
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TOWN OF NORTH ANDOVER ��- , ,,9T
SYSTEM PUMPING RECORD
I7 APR - 7 2003
i EM OWNER & ADDRESS SYSTEM LOCATION
(example; left front of house)
der LS
i
U:�'I'E OF PUMPINC;v� 7 QUANTITY 'PUMPEDLLU� �
C. .-SP00L: NI0 YES SEPTIC TANK; NO YES
I
ATURE OF SERVICE; ROUTINE EMERGENCY
COOD CONDITION. FULL TO COYER
HFAYYICREASE BAFFLES IN PLACE
ROOTS; LEACHFIELD RUNBACK
EXCESSIVE SOLIDS FLOODED
SOLID.S�CARRYOVER ,Oj�HFR (EXPLAIN)
>1 .�.)TLM PUMPED BY:
UNI M PNTS':
u� I I:'NTr tl ANSFEIZRLD TO:
RECEIVED
Commonwealth of Massachusetts APR 2 3 2009
City/Town Own Of T
OW OF NORTH ANDOVER
System Pumping Record EALTH DEPARTMENT
Form 4
DEP has provided this form for use by local Boards of Health. Other forms may be used;but the
information must be substantially the same as that provided here. Before using this form, check with your
local Board of Health to determine the form they use. The System Pumping Record must be submitted to
the local Board of Health or other approving authority.
A. Facility Information
Important: _
When filling out 1. System LocaW eft ron , left rear, left side of house. Right front, right rear, right s' a of odse.
forms on the
computer,use
only the tab key Address r
to move your
cursor-do not
use the return City/Town State Zip Code
key. 2. System Owner:
I p A e:�A �
Name
Address(if different from location)
City/Town I State—
Telephone Number �f-S
B. Pumping Record
1. Date of Pumping 2. Quantity Pumped: '
,Date Gallons
3. Type of system: Cesspool(s) ptic Tank Tight Tank
Other(describe):
4. Effluent Tee Filter present?, Yes L--moo If yes,was it cleaned? Yes No
5. Conditio f System: L
6. System Pumped By:
Neil Bateson F 5821
Name Vehicle License Number
Bateson Enterprises Inc
Company
7. Locat re contents were disposed:
0o s.D Lowell Waste Water
igna ure of H Or Date
t5form4.doc•06/03 System Pumping Record•Page 1 of 1
___7777
Commonwealth ofMassa usetts
City/Town of n OCT 1 2006
System Pumping Record TOWN OF NORTH ANDOVER
HEALTH DEPARTMENT
Form 4
A. Facility Informati n
System Owner: Uj M,
Address: Telephone Number
B. Pumping Record O I.,
JW
1. Date of Pumping C� --
2. Quantity Pumped: Gallons
3. Type of system: Cesspool(s) �Septicank 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:
7.
Name Vehicle License Number
Company:Rooterman 12 East Dracut Rd. Methuen,MA 01844
7. Location where contents were disposed:
Signature of HaulerAlu P i
Date
Signature of Receiving Facility
I
Commonwealth of Massachusetts RECEIVE®
City/Town of ocT 0 t 1013
a
System Pumping Record TOWN OF NORTH ANDOVER
Form 4 HEALTH DEPARTI§4T
DEP has provided this form for us&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.
A. Facility. Information
1. System Location/Rig ro eft/Right rear of house, Left/right side of house, Left/
Right side of building, Left/Right front of building, Left/Right rear of building, Under deck
Address
Cityrrown State Zip Code
.2. System Owner.
P
Name
Address(if different from location)
City/Town State Zip Code
Telephone Number r
B. Pumping Record
1. Date of Pumping r 3 ��2uantity Pumped: baaDateGallons
3. Type of system: ❑ Cesspool(s) Septic Tank ❑ Tight Tank
❑ Other(describe):
4. Effluent Tee Filter present? ❑ Yes No If,yes, was it cleaned? ❑ Yes ❑ No.
5. Condition of system:
6. System Pumped By:
Neil.Bateson F5821
Name Vehicle License Number
Bateson Enterprises Inc-
Company
nc Company
7. Lo tion where contents were disposed:
Lowell Waste Water
Signitufe Haule Date
t5fomm4.doc•06/03 System Pumping Record•Page 1 of 1
Commonwealth of Massachusetts
City/Town of Rote'er
a
System Pumping Record
Form 4 MAY 2 5 2010
DEP has provided this form for use by local Boards of Health. Othe MINN t e
information must be substantially the same as that provided here. , k 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 side of house, Right side of house, Left ront of house, Right front of house,
Left rear ofuse,�Rig t rear of house. Left rear of building. Right rear o building.
Address
ve�-
City/Town State Zip Code
2. System Owner- 1
Name
Address(if different from location)
City/Town State Zip Code
Telephone Number
B. Pumping Record ,l
1. Date of Pumping ( 2. Quantity Pumped: Soc)
Date Gallons
3. Type of system: ❑ Cesspool(s) a/Septic Tank ❑ Tight Tank
❑ Other(describe):
4. Effluent Tee Filter present? ❑ Yes 2/No If yes,was it cleaned? ❑ Yes ❑ No
5. Condition of System:
6. System Pumped By:
Neil Bateson F5821
Name Vehicle License Number
Bateson Enterprises Inc
Company'
7. Location w contents were disposed:
.L D Lowell Waste Water
A I�,94
g toe of Haul r Date
t5form4.doc•06/03 System Pumping Record•Page 1 of 1
t
Commonwealth of Massachusetts
W City/Town of
a System Pumping Record
Form.4JON 14 Z
9
DEP has provided this form for use by local Boards of Healtl Other forms may u , but the
1' check with our
information must be substantially the same as that provided � uNiir hksr or y
local Board of Health to determine the form they use.The S 1p'tffge st be submitted to
the local Board of Health or other approving authority.
A. Facility Information
1. System Location Left front of hous ..fight front of house, left side of house, right side of house, Left
rear of house, right rear of house, left side of building, right rear of building, under deck.
City/Town State Zip Code
2. System Owner:
Name
Address(if different from location)
City/Town StaZip Code
Telephone Number
B. Pumping Record
1. Date of Pumping Date 2. Quantity Pumped: Gallons
3. Type of system: ❑ Cesspool(s) eptic Tank ❑ Tight Tank
❑ Other(describe):
4. Effluent Tee Filter present? ❑ Yes No. If yes, was it cleaned? ❑ Yes ❑ No
5. Condition of System:
6. System Pumped By:
Neil J. Bateson F5821
Name Vehicle License Number
Bateson Enterprises Inc.
Company
7. Loc w;Ire contents were disposed:
L.S. Lowell ste ter
Sigril oft
f auler Date
t5form4.doc•06/03 . System Pumping Record•Page 1 of 1