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1
i
Commonwealth of Massachusetts `^
City/Town of N
System Pumping-Record
0 2014
Form 4 HI--oL ;
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 Location: Left/Right front of house, Left Right rear of ho e, Left/right side of house, Left/
Right side of building, Left/Right front of building, Left/Right rear of building, Under deck
Address
cityfrown State Zip Code
2. System Owner.
✓•\
Name
Address(if different from location)
CitylTown F Stat /: /�� �p 1 de
Telephone Number G`
= t
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 Q No If yes, was it cleaned? ❑ Yes ❑ No.
" 5. Condition of System:
6. System Pumped By.-
Nell
y:Neil Bateson F5821 RCCrs.IV
Name Vehicle License umber
Bateson Enterprises Inc
Company NOV 19 2013
7. Locatio re contents were disposed: THEA°H IRTH ANDOVER
EPARTMENT
Lowell Waste Water
3
Sig a Haule Date
t5fom4.doc•06/03 System Pumping Record•Page 1 of 1
Commonwealth of Massachusetts RECEIVED
t
City/Town of OCT 16 2012
System Pumping Record TOWN OF NORTH ANDOVER
Form 4 HEALTH DEPARTMENT
U9.
DEP has provided this form'for use by local Boards of Health. QA.er 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 hous , I-Of Rig 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:
V'
Name
Address(if different from location)
Cityrrown State Co
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 a-90 If yes,was it cleaned? ❑ Yes ❑ No
5. Conditiol of ystem:
6. System Pumped By:
Neil Bateson F5821
Name Vehicle License Number
Bateson Enterprises Inc
Company
7. P contents were disposed:
n, Lowell I Waste Water
4.ssignAtYufeHaule Date
t5form4.doc•06103 System Pumping Record•Page 1 of 1
_ Commonwealth of Massachusetts RECEIVED
City/Town of
System Pumping Record OCT 2 4 2006
Form 4
TOWN OF NORTH ANDOVER
HEALTH DEPARTMENT
DEP has provided this form for use by local Boards of Health. ThEs em Pumping Record must
be submitted to the local Board of Health or other approving authority. .
A. Facility Information
Important:
When filling out 1. System_ Lo ation:
forms on the Ia—
computer,use
only the tab key Address
to move your
cursor-do not
use theretum City/Town State--/'— Zip Code
key. 2. System Owner:
-V\
Name
iLl Address(if different from location)
Cityrrown Stat ,ode
< (
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 Leo If yes, was it cleaned? ❑ Yes ❑ No
5. Condition f System�: � n
r•�l t4.t'aU V
AC�
6. System Pumped By
:Name Vehicle Licen§e.Number
Company
.7. Locatio ere conten er posed:
Signa'tu o ler Date
h.ftp://www.mass-govidep/water/approvalt,/t5forms.htm#inspect
t5form4.doc•06103
System Pumping Record•Page 1 of 1
TOWN OF
MSYSTEM PUMPING RECORD.DATE. HEA
SYSTEM OWNER& ADDRESS SYSTEM LOCATION
(example:left front of house)
4f� LA-
DATE OF PUMPING: `'f) )QUAN'IM PUMPED : GALLONS
CESSPOOL: NO L-1---Y—ES SEPTIC TANK: NO YES
NATURE OF SERVICE: ROUTINE ./ EMERGENCY
OBSERVATIONS:
GOOD CONDITION FULL TO COVER
HEAVY GREASE BAFFLES IN PLACE
ROOTS LEACHFIELD RUNBACK
EXCESSIVE SOLIDS T FLOODED
SOLIDS CARRYOVER OTHER(EXPLAIlS)
SYSTEM PUMPED BY: Bateson Enterprises, Inc.
COMMENTS:
i
CONTENTS TRANSFERRED TO: G.L.S.Dowell Waste
1
�D OP H6;a--r-I LOT 3� �LOAA cam
�4pP�� CAry I. ��w0
(,v TES soPPty GJ Tdw� Cl oiELL-
APs�ovED �
SS v 1 SEPTIC 'S £TEA j PES►
DArr' 4PR?OVPJ6 Aur�io,?,ry
CNATiDw5
�I�PPr�vEa D/�TE
R��NS
S,fprf 6 S''5TEM 1 J STA STI OA J
CYeAV4T(0I-J 94rc Q P45S [j F41L-
�wA� t ti5p�rlo�
(11=koy)
D►S�s PP►�Uv�D D,�rC
FwAL APPROVAL D�Or�
I�7_� APPRWWG 4v i Hoy 1 ty 1�
' and of Health
arter,Yws z :
` SUBST ME DISPOSAL DESIGN cHECg LIST
-LOT
Z DISAPPRUM DATE
DATB
. APPROM _(�.:
t provided: Reasons:
j
Title V FAIL :.
Reg 2.5
The submitted plan must shox as a minim:unt
a) the lot to be served-area,dimensions lot f,abntters
b location and log deep observation ho�.es-distance to ties
. location and results percolation tests-distance to ties
v d design calculations be calculations showing required leaching area
- I
location and dimensions of system-including reserve area
existing and prcyposed contours
g) location arty wet areas 4thin 100' of sewage disposal system or
disclaimer-check wetlands mapping
(h) surface and subsurface drains 14thin 100' of sewage disposal
system or disclaimer
(i) location any drainage easerents vithin 100' of swage disposal
system or disclaimer-Planning Board Piles
ir
kno= sources of meter supply within 200' of sevge disposal e _
system or disclaimer
-1-ocation-of-any proposed v oto serve lot-100' from leaching fac'hi g Sa
location of kater lines on property-10' from leaccility
location of. benchmark
drivekays
i ) garbage disposals _
no PVC to be,used in construction -- -- s tic tanl
profile of
q) system-elevations of basement., plumb., pipe, gP
distribution box inlets and outlets, distribution field piping an
Osler elevations - .
r ) ma,-t mam ground -.ester elevation in area seri, er or other
system
(s) plan rm�st be prepared by a Professional.Engineer or ot
professional authorized by lax to prepare such plans
I, -
Reg 6 Septic Tanks
(a) capacities-150%' of flow, rater table, trees, depth of tees,
access, pu.'p3ng
(b) cleanout ool
(c) 10' from cellar wall or inground sing P
(d) 25' from subsurface drains
Distribution Boxes
Reg 10.2
(a) slope greater than 0.08
Reg 10.4 i b)
x
SOIL PROFILE & PERCOLATION TEST DATA.
AlortS Andover,lass. No.&Street Lot No. 3
Loc./Subdiv. Plan Owoer
Investi.gator Observer -_
SOIL PROFILES-DATE
Elev. 2. Elev. y 3. Elev. 4.Elev.
0 0 0 0
1 1 1 1
Ties 'to Test Fits
3 3 3 3
4 4 4 4
S `J S S 5
6 6 6 6
7 7 - 7 7
9. _ 9 1, 9 9 _
LO 10 10 10
Benchmark Location -
Elevation Datum
Percolation Tests-Date
Date-----
Pit Number 1 2 3 4 S
Start Saturation
Start Test-Time
Drop of 311-Time -
Drop
"-Time -Dro of 6"-Time
Mins . l st. 3"Dro
Mins . 2nd 3"Dro -
Percolation Rate
Notes & Sketches on Back
SOIL PROFILE & PERCOLATION TEST DATA
North Andover, Mass. Street No 7-ID Lot No '58
Loc/Subdiv. Pland Owner l.�wio V EST
Investigator Observer 1`1S CL
SOIL PROFILE DATES
1.'Elev 2.Elev 3.Elev 4.Elev
0 0 0 0
�� S Ties Pto estits
*.
I
34 3 3 3
i
4 �L>e 4 4° 4
(a?A-vE L
5 5 5 5 '�1a�s "peAAS
6 6 6 6
7 7 7 7
8 8 8 8
9 9 9 9
10! 10 10 1. 10
Benchmark Location
Elevation Datum
PERCO;,ATION TESTS
DATES
Pit Number 1 2 3 4 5
Start Saturation
Soak-Minutes
Start e
Drop of 3"-Time
Dro of 6"-Time
Moms.lst 3" drop _
Mins.2nd " Drop
Percolation
I
card of Ae„-lth
` North AndovorsMass
SUBSURFACE DISPOSAL DEMON CHECK LIST
LOT Z/
APPROVED DATE DISAPPROVED DATE
Provided: Reasons:
-�Co �n
Title V 4a)
Reg 2.5ubmitted plan must show as a minimum:
a lot to be served-area,dimensicns lot #,abutters
cation and log deep observation hoes-distance to ties
cation and results percolation tests-distance to ties
sign calculations & calculations showing required leaching area
cation and dimensions of system-including reserve area
isting and proposed contours
cation any vat areas t.thin loot of sewage disposal system or
disclairsr-check wetl�nda mapping
(h)---surface and subsurface &- inns -Athin 1001 of sewage disposal
system or disclaimer
(i ovation any drainage easements vithin 1001 of serge disposal
system or disclaimer-P & Board files
�0)) va sources of rater supply within 2001 of sewage disposal
system or disclaimer
) location of any proposed w-,U to serve-lot-1001 from leaching facility
(1) location of water lines on property-101 from leaching facility
rocation of benchmark
driveways
i�
r�no
garbage disposals
PVC to be used in construction
(q) profile of system-elevations of basement, plumb, pipe, septic tarok,
distribution box inlets and outlets, distribution field piping and
Other elevations
maximum ground water elevation in area sewage disposal system
(s) plan roust be prepared by a Professional Engineer or other
professional authorized by law to prepare such plans
Reg 6 S' tic Tanks
capac es-150% of flow, water table, tees, depth of tees,
access, pining
(b) cleanout
(/c) 101 from cellar wall or inground sul m ing pool
/(d) 251 from subsurface drams
Reg 10.2 Distribution Boxes
slope greater MWE 0.08
Reg 10.4 4b) Sp
t '
eibsurface Det;ign Check List Pae 2
FAIL 0$
Lea� Pits
Leaching pits are preferred where the installation is possible
Reg 11.2 calculations of leaching area-minimum 500 sq ft
11.4 ) spacing
11.10 ✓ c) surface drainage 2%
11.11 d) cover material
} e),IIx2 tx4" splash pad
-f) tee at elbow
g) no bends in pipe from d-box to pipe
Leaching Fie ids
Reg 15.1 a no greater an 20 minutes/inch
lb� area- 900 sq ft
15.4 c) constrac on of field
15.8 d) surface drainage 2 %
3.7 e) 201 m cellar wall or i aground swimvdng pool
Leaching TV cher
Reg 14.1 a) c c s of-leaching area-sin 500 sq ft
14.3 b) spacing-lilt min 6 ft with reserve betty-een
14.4 c) dimensio s
14.6 1d) cons tion
1lt.7 e) stone
14.10 f)) surf ce d/rainage 2%
D0U3hill1 Slo e
a) slope x be shown)
b) y/x % 50 = (to be shown)
P
Reg 9.1 a) app
pp vel
9.6 b) sian&by power
1
i
.s
I. - S1�v rC Ncsi' Gc22Ec.T - Tllae4-
FI w crr 0 oQ-rL E-LX,
3, '� �E►ve.1� M h.e.1[,. ►�►'6D-�. Sc�ST�M
4, wsl t o OAC..
'S - l.cc.dcrE c S1�.o� w�[t,�►.*.pc,
'1. -
FIX\ C-WzE K Ej�-r wo-c£
Ceallh of Massachusetts
Massachusetts
System Pumping Record
System Owner System Location
V*"*) Saw 91-to
v!
Date of Pumping: Quantity Pumped: tl`s�gallons
Cesspool: No 1.+ Ves H Septic Tank: No Yes
System Pumped by: vdt`ejea, gitre�GnidN License#
Contents transferrred to : Greater Lawrence Sanitary District
Date: _ Inspector:
c
F
J .� S,OwM Inc.
? r
l—a7
Commonwealth of Massachusetts
/ "• '"`JX Massachusetts
System Pumping Record
System Owner System Location
C
Date of Pumping: 0— t1--- � � Quantity Pumped: ���� gallons
Cesspool: No H— Yes I Septic Tank: No Yes
System Pumped by: Farcom Eieampaej License#
Contents transferrred to : Greater Lawrence Sanitary District
Date: _ Inspector:
TOWN OF NORTH ANDOVER
SYSTEM PUMPING RECORD
i
DATE: T
SYSTEM OWNER &ADDRESS SYSTEM LOCATION
(example: left front of house)
� 2q Sa J _�" l
J 6P t4oLxse-
DATE OF PUMPING: -3_6� QUANTITY PUMPED , C� GALLONS
CESSPOOL: NO YES SEP'T%IC TANK: NO YES
NATURE OF SERVICE: ROUTINE YIEMERGENCY
OBSERVATIONS:
GOOD CONDITION FULL TOV
CO ER
HEAVY GREASE BAFFLES IN PLACE
ROOTS LEACHFIELD RUNBACK
EXCESSIVE SOLIDS FLOODED
SOLIDS CARRYOVER OTHER (EXPLAIN)
SYSTEM PUMPED BY:
COMMENTS:
4V,! UF�'W-iHAMOOI
4
6 ZDOf
CONTENTS TRANSFERRED TO:
TOWN OF
SYSTEM PUMPING RECORD
DATE:
SYSTEM OWNER& ADDRESS SYSTEM LOCATION
n (example:left front of house)
Y
DATE OF PUMPING: QUANTITY PUMPED : IfSob GALLONS
CESSPOOL: NO YES SEPTIC TANK: NO YES
NATURE OF SERVICE: ROUTINE EMERGENCY
OBSERVATIONS:
GOOD CONDITION FULL TO COVER
HEAVY GREASE BAFFLES IN PLACE
ROOTS LEACHFIELD RUNBACK
EXCESSIVE SOLIDS FLOODED
SOLIDS CARRYOVER OTHER(EXPLAIN)
SYSTEM PUMPED BY: Bateson Enterprises, Inc.
COMMENTS:
CONTENTS TRANSFERRED TO: G.L.S.D2 Lowell Waste
Commonwealth f Massachusetts
Massachusetts
System P impina ec
To 2 2004
Eq TH pip' AND pV�R
MENT
System Owner System Location
Art Vk
hCtC.�
Date of Pumping: j [— Quantity Pumped: l 500 gallons
Cesspool: No [ Yes [] Septic Tank: No [] Yes
System Pumped by: TatP.d W License#
Contents transferred to: Greater Lawrence Sanitary District
Date: Inspector:
Commonwealth of Massachusetts
City/Town of
� System Pumping Record f
Form 4 NOV 0 S 2007
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?'Eti k with your
local Board of Health to determine the form they use. The System Pumping Record musfibebmitted to
the local Board of Health or other approving authority.
A. Facility Information
Important:
When filling out 1. System Location:
forms on thew.`
computer,use
only the tab key Address t-4
to move your
cursor-do not City/Town State Zip Code
use the return
key.
��� 2. System Owner:
Name
Address(if different from location)
City/Town State6,, �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 No If yes,was it cleaned? ❑ Yes ❑ No
5. ConditiN
(:)Syste� l`P�u�\
S
6. System Pu ped By.
Name Vehicle License Number
Company
7. Location ere conte is w disposed:
c-
Signatur ul Date
t5form4.doc•06/03 System Pumping Record•Page 1 of 1
Commonwealth of Massachusetts
City/Town of
System Pumping Record FRECEIVED
Form 4 NOV 112008 3 2008
DEP has provided this form for use by local Boards of Health. 6ther forms ma beN � t the
information must be substantially the same as that provided he�e� . �f�R 1h, heck with your
local Board of Health to determine the form they use. The Syste a submitted to
the local Board of Health or other approving authority.
A. Facility Information
Important:
When filling out 1. System Location: Left iron eft rear left sid o Nous Right front, right rear, right side of house.
forms on the
computer, use
only the tab key Address ,fQ� , ,(
to move your (�— l �/� �J �v\ AAV--'-�
cursor-do not City/Town State Zip Code
use the return
key. 2 System Owner:
Name
Address(if different from location)
City/Town State Zip Code
Telephone Number
B. Pumping Record
1. Date of Pumping Date 2. Quantity Pumped: Gallons
3. Type of system: Q Cesspool(s) eptic Tank Q Tight Tank
Q Other(describe):
4. Effluent Tee Filter present? Q Yes [u-1 oo If yes, was it cleaned? Q Yes Q No
5. Condition of System:
LA,
6. System Pumped By:
Neil Bateson F 5821
Name Vehicle License Number
Bateson Enterprises Inc
Company
7. Location where contents were disposed:
tl .L.S.D Lowell Waste Water
igna ure of H u r Date
t5form4.doc•06/03 System Pumping Record•Page 1 of 1
i
Commonwealth of Massachusetts
City/Town of RECEIVED
System Pumping Record ou '13 2010
b S
Form 4
TOWN OF NORTH ANDOVER
DEP has provided this form for use by local Boards of Health. Other forms 1a02&QjLEMMNT
information must be,substantially the same as that provided here. Before using this form, check with your
local Board of Health tQ 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: Le i ight side of house, Left front of house, Right front of house,
L ar of u Left rear of building. Right rear of building.
Address
Cityrrown State Zip Code
2. System Owner:
Name
Address(if different from location)
City/Town State/a� r��(// Z'
2 ode
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 If yes, was it cleaned? ❑ Yes ❑ No
' 5. Condition f S sijemU���
6. System Pumped By:
Neil Bateson F5821
Name Vehicle License Number
Bateson Enterprises Inc
Company
7. Location contents were disposed:
L.S.D Lowell st ter
4 L
0
Signature of a er Date
t5form4.doc•06/03 System Pumping Record•Page 1 of 1
Commonwealth of Massachusetts RECEIVED
City/Town of DEC 15 2009
System Pumping Record
Form 4 TOWN OF NORTH ANDOVER
HEALTH DEPARTMENT
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 tQ determine the form they use. The System Pumping Record must be submitted to
the local Board of Health opotl r approving authority.
A. Facility Information
1. �eyft
s Lesataon: Left side of house, Right side of house, Left front of house, Right front of house,
rear of ho , Right rear of house. Left rear of building. Right rear of building.
Address ��� ��> � '/►/ �jr p� ��
Cityrrown (! 1 State v V o� Zip Code
2. System Owner:
Name
Address(if different from location)
Cityrrown State Zi Code
Telephone Number
B. Pumping Record
1. Date of Pumping
p g 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 ❑ No
5. Condition of System:
����d
6. System Pumped By:
Neil Bateson F5821
Name Vehicle License Number
Bateson Enterprises Inc
Company
7. Locatio here contents were disposed:
G.L.S. Lowell Waste Water
Signature of Hauler Date
t5form4.doc•06/03 System Pumping Record•Page 1 of 1