HomeMy WebLinkAboutMiscellaneous - 1234 SALEM STREET 4/30/2018 (2) 1234 SALEM STREET -_
210/106.A-0184-0000.0 _
S
Commonwealth of Massachusetts
City/Town of North 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.
A. Facility Information RECEIVED
Important:"When JUN 1
filling out forms 1. System Location: � LrSck
�� 2015
on the computer,use only the tab V _ _ —
key to move your Address TQVGi<tQF N0l`ffH ANDOVER
cursor-do not North Andover HEALTH DEPARTMENT
use the return
key. City/Town State Zip Code
2. System Owner:
_ Yl�CI'Yl
Name — ------------- -
rewn
Address(if different from location)
City/Town State Zip Code
Telephone Number
B. Pumping Record
,It) 17� /500
1. Date of Pumping D --^2. Quantity Pumped: gallon
3. Type of system: ❑ Cesspool(s) Septic Tank ❑ Tight Tank ❑ Grease Trap
❑ Other(describe): — -- —--- —
4. Effluent Tee Filter present? ❑ Yes ❑ No If yes, was it cleaned? ❑ Yes ❑ No
5. Condition of System:
6. System Pumped By:
Vehicle License Number
�te �er�vicee
o any -— .. ---- -
7. Location where contents were disposed:
Stewart's Pre-treatment Plant, 20 So. Mill Bradford, Ma 01835
Signature of Hauler Date
Signature of Receiving Facility Date
t5form4.doc•03/06 System Pumping Record•Page 1 of 1
i
RECEIVED
Commonwealth of Massachusetts
City/Town of North Andover NiAr2 0 7 2013
a System Pumping Record TOWN OF NORTH ANDOVER
Form 4 HEALTH DEPARTMENT
�y I
SVO
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,
acivTnuse only the tab �
key to move your Address
cursor-do not North Andover Ma
use the return
key. Cityrrown State Zip Code
2. System Owner:
1:)C)
Name
reran
Address(if different from location)
City/Town State Zip Code
Telephone Number
B. Pumping Record
p Gallons
1. Date of Pumping Quantit Pum ed: D
3. Type of system: ❑ Cesspool(s) /1 Septic Tank E] Tight Tank El Grease Trap
El Other(describe): /
4. Effluent Tee Filter present? ❑ Yes No If yes, was it cleaned? ❑ Yes ❑ No
5. Condition of System:
6. Sy tem Pumpe By:
ne
ame Vehicle License Number
Stewart's Septic Service
Company
7. Location where contents were disposed:
rt's Pre-treatment Plant, 20 So. Mill Bradford, Ma 01835
gnature of Hauler Date
Signature of Receiving Facility Date
t5form4.doc•03/06 System Pumping Record•Page 1 of 1
12
"` HEALTH
' Fr••r6E �21
Cornrnonwealth of Massachusetts
RECEIVED
0 City/Town of �RT� ANDOVER MA AC�it�� T
SYSte Pumping Record NOV
Farm 4 17 2006
DEP has providedthis formfor use by local Boards of Health ThSystem TOWN OF NORTH ANDOVER
P T E
be submitted to the local Board of Health or other approving authority,
A. Facility Information'
important:
When filling out I. Systern Location:
fo the
computer;the
use _
onlynly the tat;key
to move your — --
use the return City/Town
key. — yrn rodA--------
�;, System Gwner:
Narne
Address rpt differ -
ent rrcm la�atiani —_
--
5tate
'releprsane Number —
E3- PumPing Record
� v
1. Crate of Pumping Quantity Pumped:
G Ilgng
3. -type of system: Q cesspool(s) septic Tangy
El Tight Tank
❑
Other(describe): ---------------_.....,_.,._ .
4_ Effluent Tee Filter present? ❑ YeS ❑ No If yes, was it Cleaned? y�
(� Yes ❑ Na
5. Condition of System:
ty. System Pumped 6y.
�
�
Vehicle icensr>Numb r ----
iramo.ny � �.,��IC�i~-�,� ------�--
7. Location Wfare Contents we.ee disposed:
Siam urr or r-teu er --------- —�D -- �� --�,_--
http:tlavvvw.rrtass.yc►v/deplwateripprb IS/t5forms.htin#inspect Date— --
t6fdrrO.dcc•06103
System Pum06-19 Record•Page 1 Of T
a
i
i
i
'C
LOT 13 \ti
0�
^� LOT 114 l
LOT IZA C
63 e/
40
i N
/500 hh a N
SEPTIC1 ��-
D-BOX-
O
th
LOT 12.
o°
-�t- 12-31
-a
0
0
SLOPE IZf04111FE ENT j ^
T` NP
C/50) X - /50 - _
. .. .. .. : ... . . .... .
.. .. . . .. .
i r p
s o 2IM95 r
DESIGN EG EV/d T/ON 4T. . ..... . .(TOP OF STONE) = .. . . . ... . ... .. . .. .. .. .... ....
EXIST/NC ELEVZT/ON .47 . . . .. . . . . REQU/SPED F/LL
�L�y.�1T/ONS
DES/�:N ,45 3U/LT 445 UUIL T
/Nl/PIPE OUT OF 9011,5 LF /44 &/
INV PIPE INTO T.4NK /44.3/ SUB —%5&&8CP1,51POS44
INV PIPE OUT OF TANK 144.46 /44. 24 SYSTEM
INl/. PIPE INTO D. BOX 143.86 /43.83
INV P/PE OUT OF D. BOX 143.69 143. 78 //V
INV END OF PIPE , 143.50 /43.3/ NORT11 ,0100VL4R, MA.
TRENCII L 143.,?O 143.31 FO/2
TRCV"3 /43.SO 14-3-31
GtiaTEie EL EI/,4 TION N4 bVj4TER �OR�3 S REq L T Y 7R1JS T
QT /37,00
,4VE2.10E 5TONE 5C.4L E : / _ 40 D4 TE: NOV 1,3.1985
DEPTH ,47 P,eOBE Cl1R/ST/,4NSEN 6N- 61 E"MINCS, ,1NC.
NOTE'.- T///5 PLSIN 15 NOT ,4 W,,4, le,4NTY II4 �t'ENOZ�1 .4!/E., ,�,�,41�E�Pr�,�/LL, 1W.4.
OF T//E SYSTEM BUT .4 tlEeIFIC.4RON
OF T/1E LOC.4T/ON OF T,yE EY45TIN6
ST,eUMlIff5.
RECEIVED
Commonwealth of Massachusetts APR 15 2009
City/TOwn of \�J ���� 11�1� � TOWN OF NORTH AiVOUVER
1 Ilr HEALTH DEPARTMENT
System Pumping Record
Facility Information:
System Location:
SQI eh'I S +
Address
City/Town Y"1y) lJ 15
State Zip Code
System Ow
Name: a
Actress (if different from location of pump)
City/T'own
State Zip Code
Telephone Number q3'79
Pumping Record
Date of Pumping 311 Quantity Pumped �00 gallons
Type of System Septic Tank Grease Trap Other----(what)
System Pumped by. I L
Company ROOTER-MAN 12 East Dracut Rd., Methuen, MA 01844
Location where contents were dis osed:
Signature of Hauler n Date 7j
I
RECEIVE
_ i iAY '13 2011
.9
� as5ssac" e.tl VSB"S
TOWN OF NORTH ANDOVER
HEALTH DEPARTMENT
Record
7U17i 1�)C:Zt1t31'! lf �i11i1
Stott
Q
F.silti C Te-n p
e�J✓
iJ:r:[t.:L'.s QC2eu4 T eb YY S^ar^p,, /; _
- % CQ
7
3 2` `
BUBBURFACE SWAGE D;ISPOS.AL SYSTEM INSPECTION FORM r
Address` of property ".� 2`3' Sce�G^ti 5TT N, Npd �� /1��
Owner' s name19-7"H'( SMi4w.
Dane ofInspection ,� 31a5"
PART A
,CHECKLIST
CYie`ck , ;f the fo lowing have;been.,dorie.
Pumpa.ng znforma,tion' was requested of the owner, occupant, and Board of
Done of th,e syaem campo}zents have been 'pumped for at. 7,east two weeks
a.nd the sy tem=has been ' receivIng normal: fiow rates during that
period. , Large; volumes 'of :water,`have "not been introduced into the
system' recently +or :a$rpart "of h�s .. nspection.
As buiflt plans have been obtained and examined. Note 1f the are :not
available with -, A
The facility or dwelling w'as inspected for signs of sewage .back up
..The ste` w.as inspected .for. signs of `breakout..
A1`1 system components, °excluding thea SAS', have been located on the
site _.
The se tic tank manholes were un ve-r-ed enednc -:the interior• of
p �'
the septic;;tankras inspected fgr condition of :baffles or„ tees,
<; , s , .
,.
-material of coftstruction; fid'imensions, depth of Iiquid, 'depth 'of
sludge, depth :of":scum ,.f 4 {
The size and 1`ocatian "of th'e SAS 'bns the�,site. has- been determined based
do ex sting ;information or :appr.oximated";by non �.ntrusive ;method's..
a The facility ownerF (ani occupants, IT d `fferent ,`fromowner) were .
p
zovded 'with in`formationp,on tYie prQper.`maintenance of -SSD S,
,.
C, 4 _
s � - .. 8:
�3 2
BU$SURFACE SEWAGE DhSPOSAL 8Y8TEM INSPECTION FORM
." , 1 . FART.:B .
V SYSTEM �.INFORMATION -
+�:J J
RrY� �* S 4 U A J *} `� t
FLOW CONDITI NS
;r, -
If res`Identi1 . al'
r r , ', ,
�ffl'number of bed-rooms ,
�;.._ number of current residents I
x�_ °.garbage grinder, ..yes `o`r
no
_. ,� 3-aundry donnected:'to system, yes or: no 1..
_� seasona _:use, .yes or no 11 ;
3 2 .l Y.. �.:.. ..... :, ,
,� ;
§Tf=nonreszdental, .aalculated flaw:
, '� R -
t x-T Z 2 _ t- r - .. 2
t .
WateI .r ,meter readings, if available: "
. .
.�tc�,ct _ °Last date of r
"occupancy ` 't ..
F: r1.
' ';GENERAL INFORMATION
Pumping records and source of information:
�kI
1. .
, :'.
System PumAed as pert of1 r `inspectio:n, yes ox no
l;f yes, volume pumped 'oo C��}i; .
Reason tifor puLmpz.ng , , s, I
_.z, .
P v y
t - f . 2 li. G..
�+�rpe o system k r
' s ;,
r-yG �SeptXc" tank/di.stritbutign box/soil absorption=fsystem '"
Si'ng1,e' cesspool r �; r. Y
Overfl°ow% cesspool 2
�,, �; . Rrxvy r , y. i
°Shared, sys1.tem (yes for :no) (if yes',` rattachpreious inspection +
records, if any) = il
-- in),..(explain)
Approximate: age. of: all : componI II en s. ..Date �installed., zf :known. Source of
i�nf6rination: .
,, _ .
�1 `t'e�
J �,:.r• f
o SewageYodors detected when arriwin1. g.'at the cite, yes 'or no
r r ; t � /
a F i a 2 - 'r ' *♦
y
�.. .r
As
.1. ,r.
. - � $_, ..
':n
I S: f'r *, �.'
S0 I - j, dF
�'ta, c + x4 1 �:.r r a, _2 1. k pi' .t +I. J>t +r
_4 Y 'Yl^ J !J '1 t - .. 7 _E S h -i{/ d?tk e <. �'Y +k� -V.� f ", I"C'�"f� D y
y/ S-- r ;y -� 't.tK ! ? A s ..,, 3 �'a. � 4 cox k :?' " =a } -aki. x,.a,-Jy.T• �wK,f.> ak+ r r,,
y, t`z +4 .r y ,.. t r� 1.,. c .r r-rr.a f,.rt v' a♦X1 a A�` t' . h ;
,,:;a''' tS'f." v�v'?t�>�`fc +. .�-Su,,: �.. t3Z-.&t... ,r-:.,•:;S p+.i.i .� .;".-fi):: +.`,a`n aVUx; _ ♦ e .�aT.17, �„r' 3 5f;� t-M �3rr'c ti�,t,+i<:.:N. ]v.sP. yi.
11 I. - .r r 'k
SUBSURFACE SEWAGE .DISP0.SAL SYSTEM jNSPECTION•.FORM
{
ART,-
FORMATION
:SY$TEM INFORMATION' continued` �.
l ,
EPTIC TANK
loc
a( ate an ,site plan) .
' ;: .. . •
P,. .
depth below grade
material bf construcio ✓ concrete . metal. FRP other(explain)
dlmenslos• 50�
:kludge depth' '
'distance' from -topr of.:'s1 dge to bottom `of outlet tee or baffle
6" ,"scum thickness = :Y
�,stance«. from top ofy "scum` to op of outlet: tee>.or baffle
11dis;tance fxom bottom _of scum to' bottom of .outlet tee or baffle
Comments•
(r e,comit encatzon f-or pumping, , condition of .inlet and outlet tees ..or baffles,
`depth °of °liquid 1'evel>=in relation :to .outlenvert;: structural r�tegrzy,'
e�. dence; of aeakage, recommendations for ,repairs: }
'DISTRIBUTION %BOX
,.(Iocate' on te`�plan)�"�
"( depth of liquid ;level above outlet invert
Comments
(note 1f ; lev.elr and d�.:stributa.on is' ega .r,r{eY�dence cf solids carryover,
evid.en°ce` of leakage; �}ito or ,out 'of, bU* r �commendat'�.on °far repairs, tc. )
.
4i %al
PUMP. CHAMBER
(locate ;on site plan)_
pumps in works ng order, eyes or 'no
Comments• FY a y :w
(notecondlt' onf of .pumps ohamber, condition of ::pumps and appurtenances,
recommendations for maintenance oz repairs,etc )
y1 q•. .\ f ) \
}
.. Vo ,
10
trh ` __3 2
'* SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART B _
:A SYSTEM INFORMATION :cont.inued
SOIL ABSORPTION SYSTEM (SAS)
(locate ton site plan ``A I. -p.os`sible excavation not >required, but maybe
approximated .by tenon-intrusive :methods);
"c.
L 4 r L
°If not determined to `be .;pzesent, explain:
4
Type
leaching; pits and number
: leachinghchambers and: number
leaching-rgalleres and n:umber:` , ,..
leach *.ng trenches, number, length
leach ng Melds number, dimensions
overflowcesspooh, number`
4
Comments::
("note condition .:of soil , signs of; hydr.aul c failure, level of ponding, ,
o ma - or..rapa1rs,,Tetc. )
condition of ve etation, recommendations far main
9 ..
S:
t3 2�` OBJ S
cd O Ft'"PlS v r9 t''
CESSPOQLS (loca�ke an site plan)
1 «i•
number and confa.guratiQn
depth stop of= laquJd 'to in ;invert
depth6:1.1 ds layer } is
;'depth off scum 'layer
d' be
"ns o:f cesspool *"
ma.erials of, construction
t
indcataon o:f groundwater ,-
flgw c,esspo;ol must be pumped as
part of inspection}
Comments,: ,
(note cor�dltion. of . sail, 's>gns of hydrauii.c fai]ure; 1eve1 ;pf -pond]ng,
corid'itagA of` vegetation, reco'mme'ndations 'for maintenance or repa�rs,etc.)
Z y.. f
'T
'PRIVY
(locate on sate plan)
: a
materials of do'rnstruction
dimensi`Qns {-
depth o f solids }s
Commof ents;; n (G
(note condi t=ion .of soil , (sign's ofhydraulic- ' falur-e, level ' ,ponding, t
condition of vegetaton, : reetommendations for maintenance or repairs;:etc.)
-]i L W J -
4,
S�U$$URFACE SEWAGE< DISPOSAL SYSTEM INSPECTIW:FORM
SYSTEM INFORMATION continued
` SKETGH�OF SEWAGE DISPpSALSYSTEM• , ;;
include ties tp at least two permanent references landmarks or benchmarks:
1`ocate 'all welVls within 100'.' a
^
) -
. _ D.o ' -
0
Hbi
:r
/.QENc.-HCS .';
DEPTH 'TO , Ts o4rt�
dth to e
eNt6,2; pF TR�vK
P . gr
oundwater�
method: of} cleterminatlon -or.,approximon��
ati
m; ..:
w r •.S (ZAP, .
+Y'+ k• t -:, + ' .s d "^ t; 'ark r" r ''z - e c 7
f. 9
122
rgUBSURFACE SEWAGE_ 3�ISB3�lL :8f8TEi
--INSPECTION"FORM
1
r _ ; PART
Y
E FAILURE CRITERIA
Indicate y.es, ;no, ,or not determined (Y, . N, or ND) . Describe basas of
determd nataon"',1 n all in"stances. ' If :"not` determined" explain why,;note
.^,,..
Backup ,of ,sewage into ;facility-?
:F r
;, Discharge or ponding of effluent to. the` surface of the ground or
surface .waters'
;' rad S_ `F �.rai ( �' ✓. is. �., , i 3 4 4
-x - 6 'C.,vy,3 `• r..y
Static liquid aevel in,;the `dastrabutaon°boxy above outlet invert.
Lqua'd depth in ce spool <6" be�owdnvert Qryavailabe valume< 1/'2 day
t '
s flow'�' -
Requared pumping 4times or more n the last. year?
number of •.tames ,pumped,
Septic tank is :metai� ,cracked�" ueturally unsound?::substantial
fn- it substantial exfiltrat '.on' -tank° failure :imminent?
f
Is any portionof "the SAS, 'cesspool '.or privy:
.below, th,e.;h�gh ygroundw;ater;ele'va.ton�
wthi.n. 50 , feet 'of a sur:face`;water�
100 feet of= .a surface' water supply. ori
tributary to:> a surface
water ' up,ply' = 1 _
,
Within a :Zone I, `of a :public well
,, within 50 ;feet ,of, -a bordering vegetated wetland or salt marsh
(cnesspool5 and privies only", not the: SAS
e.
11"✓ vithl n: 50 feet ;of ..a private ,water, supply `we11?
1e`ss than 100 f,eet,.but area er -than S0 feet from';a private water
supply well 'w th no ' acceptabib oaten-quality analysis? If the. well
has been analyzed to be.,.acceptable, attach copy' o`f we'll water :analysiq
for coliform bacteria, yolatile,..organac compounds, ..ammonia nitrogen
Arid n'ltrate nitrogen.'. -
u . SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTIO.1N -FORM
' PART D;
CERTIFICATION
Name of Inspector g „jGt,w"�` :� Qs Or60o
. .
Company;+Name ? �-
Company Address
S-34 3-3 k rL
Certification `Statement
I certify ;
that.:I haue :personalIy _inspected the- sewage .:disposah: system:At
this A.ddress and that the information reported is .true; accurate and
4 '
complete as:,.
Qf `'the time`of i'nspcctioh' The: inspection was ;performed .and
any recommendations regardiing'upgrade, maintenance. and ?repar .are
con's stent`: with; my trainzng, and 'experie de in; the propez-fu*� tion and
man`ltenance oi:'on site sewage disposal systems.7` '
Check one f
, �2 'hfiave, not ,found any information. Which indicates `.tha thesystem fails`
i
toadequately protect -puble health or the environment as 'dekin edin
310" .CMR .15 :303 :Any f.a'' lur.e cr' .:ter a not evaluated` are :xas stated'.,in .
the FAILURE CRITERIA section of :this form
haves determi.n'ed �that rthe system fails :to protect publicY,health and
tte.`env�ronment as' defined =i n ,31'0 CMR `15. 3 Q3= • The :basis for. tha s
de}termination `is provided in``the FAILURE:` CRITERIA section of this:
f ohm
Inspector sSignature
3Date }> n
Oxgzna to sysaem.=.owher eI
:
Copies' "to A
i lV'.a
Buyer ;(1f :appl%cable)
Approv'i'ng authority
-