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HomeMy WebLinkAboutMiscellaneous - 1265 SALEM STREET 4/30/2018 (2) �' 1� Commonwealth of Massachusetts RIC"EIVED City/Town of AUG 0 7_iJ15 System Pumping Record NORTH ANDOVER TOWN OF NORHEALTH Form 4 n,p.•�r','LR � HEALTH 0EPAr\i;., f 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 1. System Location.- forms ocation:forms on the '1 computer,use only the tab key Addre tomove your _ �./ Io, /V U� — cursor-do not ___..._ .... Slale Zip Code use the return Cily(Tawn key. 2 System Owr)er: --- - _.._ lk�kt C6 Name %A - �° Address(if different from location) " Cityrrown State Zip Code Telephone Number B. Pumping Record Quantity Pumped: --I� 1. Date of Pumping Date 2. Gallons 3. Type of system: ❑ Cesspool(s) Srptic 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: Wind River Environmental I '� Name 1763 Westt rD Ave. vehicleyt_icense Number Company i.W.WT•n 7. Location w re tents were disposed: I lPWch' A4A. Signature of Ha er Date Signature of Receiving Facility Date 15form4.doc•03106 System Pumping Record•Page t of 1 Commonwealthjof assac usetts ����' `"� City/Town of I�'i1L 3 1 2008 o � System Pumping Recor TOWN OF NORTH ANDOVER Form 4 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 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 1. System Location: forms the computer,use I (X.�� � 1 only the tab key Address to move your V O(-A n A,n d oy<,i M� cursor-do not r use the return City/Town State Zip Code key. 2. System Owner: Q Allison �lalle�l� Name Address(if different from location) City/Town State Zip Code Telephone Number B. Pumping Record 1. Date of Pumping 7Date oq S-o-7 2. Quantity Pumped: 100c Gallons 3. Type of system: ❑ Cesspool(s) [Septic Tank ❑ Tight Tank ❑ Grease Trap ❑ Other(describe): 4. Effluent Tee Filter present? ❑ Yes Eq'*`No If yes, was it cleaned? ❑ Yes ❑ No 5. Condition of S stem: Goo 6. System Pumped By: J, Yy, Gal 1w) 09 131 NameVehicle License Number ��Yirohmen�c�,1 Company 7. Location where contents were disposed: ii samtmnnia M -7— Signature of Hauer l ' Date Signature of Receiving Facility Date t5form4.doc•03/06 System Pumping Record•Page 1 of 1 i Commonwealth of Massachusetts =1 ! City/Town of NORTH ANDOVER MASSACHUSETT - System Pumping Record /= Form 4 'N E: i � DEP has provided this form for use by local Boards of Health. T e System Pumping Reco d mu,, be submitted to the local Board of Health or other approving aut ority. JUL 19 2006 A. Facility Information TOWN UF NORTH ANDOVER Important: HEALTH DEPARTMENT When filling out 1. System Location: forms on the computer, use only the tab key Address - --- to move your cursor-do not Cit /Town — -- -._ --- use the return City/Town -----r key. ---- State ' Zip Code /---h 2. System Owner: Name - --- —-- -- ------ -- ---...-- - ---- -- -- - SII" 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: ❑ Cesspool(s) Septic Tank ,\ ❑ Tight Tank ❑ Other(describe): -------- _-_-__ 4. Effluent Tee Filter present? ❑ Yes�No If es, was it cleaned? ❑ Yes y ❑ No 5. Condition of System: 6. Sy em Pumped By: Name -- --- — -- -- Vehicle License Number - Company - 7. Location where contents were disposed: __�__ ----- - - - p Si ature of Haul Daie- http://www.mass.gov/dep/water/ --- http://www.mass.gov/dep/water/ provals/t5forms.htm#inspect L t5form4.doc•06/03 System Pumping Record•Page 1 of 1 900.2, - NEW ENGLAND ENGINEERING SERVICES INC T(�V�N OO -117 AIR 0 NE'DT January 21, 2004 North Andover Board of Health Town Hall Annex 27 Charles Street North Andover, MA 01845 RE: TITLE V REPORT: 1265 Salem Street,North Andover, MA Dear Sir or Madam: Enclosed is a copy of the Title V report for the above referenced property. The system PASSED our inspection. If there are any questions please call me at my office, 686-1768. Sincerely - � 0 Benjamin C. Osgoo , r. 60 BEECHWOOD DRIVE-NORTH ANDOVER, MA 01845-(978)686-1768-(888)359-7645-FAX(978)685-1099 830 Livingston Street Tewksbury, MA 01876 Telephone: (978)851-8839 Fax: (978)851-3326 North Andover Town Board of Health 27 Charles Street North Andover,MA 01845 September 12, 2002 To Whom it May Concern, I am writing this letter to nullify a Title V Inspection Report completed on June 7, 2002. The current homeowner is Anthony DiNapoli,the address is 1265 Salem Street in North Andover,MA 01845. I cannot guarantee this system to function properly.On Tuesday, September 11,2002 I was passing by the said address and sighted construction being done to the property,finding a large construction crane located on top of the current leaching field. Due to my findings I cannot be responsible if the system fails at any time. I have taken pictures of the sight to support my decision. If there are any questions or concerns concerning my decision please do not hesitate to contact my office. Sincerely, 0 U t" John J. Soucy i 2 4 r BATE S ON ENTERPRISES, INC. 111 Argilla Road Andover, MA 01810 Phone: (978) 475-1474 Fax: (978) 475-5451 October 31, 2002 TtR ,d QF NOANDOv�3/ EOARD OF HEALTH Chucks Tree Service 686 Clark Road Noy Tewksbury, MA 01876 RE: Voluntary Septic Inspection @ 1265 Salem Street,North Andover A voluntary septic inspection was performed at the above address to determine if the 30- ton crane did any damage. A camera was used to inspect the leach lines. There was no apparent damage. Mr. Brian Lagrasse from the North Andover Board of Health was present to witness the inspection. Neil Bateson Bateson Enterprises, Inc. (DomesticU.St.Postal Service CERTIFIED MAIL RECEIPT Only; M Article Sent To: co0 r-9 Postage $ S N fr' f1l Certified Fee a O Retum Receipt Fee Postmark 1 �� Here r-91 (Endorsement Required) C3 Restricted Delivery Fee r-3 (Endorsement Required) °°°��, 0 Total Postage&Fees `W N N Name(Please Print Clearly)(To be completed by mailer) M 11• �� `-' -------------------------------------------- 0' Street Apt.J11o.;or P Box No. O � �_ .....................................................�t� �� � City,St t,ZIP 4 Q� � 0��"l` Certified Mail Provides: ■A mailing receipt ■A unique identifier for your mailpiece ■A signature upon delivery ■A record of delivery kept by the Postal Service for two years Important Reminders: ■Certified Mail may ONLY be combined with First-Class Mail or Priority Mail. ■Certified Mail is not available for any class of international mail. ■ NO INSURANCE COVERAGE IS PROVIDED with Certified Mail. For valuables,please consider Insured or Registered Mail. ■For an additional fee,a Return Receipt may be requested to provide proof of delivery.To obtain Return Receipt service,please complete and attach a Return Receipt(PS Form 3811)to the article and add applicable postage to cover the fee.Endorse mailpiece"Return Receipt Requested".To receive a fee waiver for a duplicate return receipt,a USPS postmark on your Certified Mail receipt is required. ■For an additional fee, delivery may be restricted to the addressee or addressee's authorized agent.Advise the clerk or mark the mailpiece with the endorsement"Restricted Delivery". ■If a postmark on the Certified Mail receipt is desired,please present the arti- cle at the post office for postmarking. If a postmark on the Certified Mail receipt is not needed,detach and affix label with postage and mail. IMPORTANT.Save this receipt and present it when making an inquiry. PS Form 3800,July 1999 (Reverse) 102595-99-M-1938 a Town of North Andover oT ,tio Office of the Health Department Community Development and Services Division �o 27 Charles Street North Andover,Massachusetts 01845 4ss�eHu Sandra Starr Telephone(978)688-9540 Public Health Director Fax(978)688-9542 NORTH ANDOVER BOARD OF HEALTH ORDER LETTER September 30, 2002 To Owner of Record: Anthony DiNapoli 1265 Salem Street North Andover, MA 01845 Staff from the North Andover Health Department witnessed a 38-ton crane performing tree removal activity on your property at the above referenced address on September 11,2002. The crane performing the tree removal activity was located directly on top of the septic system and leaching area. The location of the crane was unacceptable and was in violation of 310 CMR 15.226(3) and 310 CMR 15.246(1). The location of the crane may have caused serious damage to the subsurface sewage disposal system. 310 CMR 15.226(3)states "Tanks, covers, connections and piping shall be designed and constructed so as to withstand an anticipated minimum H-10 loading. Any tank installed in a location where there is potential for vehicles or heavy equipment to pass over it shall be designed to withstand an H-20 loading". The septic system located on your property was designed for H-10 loading (residential application) and not designed to support heavy machinery or vehicular traffic. 310 CMR 15.246(1) states "Excavation for construction of a soil absorption system may be by mechanical means, provided care is taken to assure that the soil at the bottom of the excavation is not compacted or smeared. The bottom and sides of the excavation shall be level and scarified. Vehicular traffic and parking of vehicles or equipment in or on the area of the soil absorption system should be avoided at all times prior, during and after construction of the system". The crane was directly on top of the soil absorption system for an extended period of time. Staff from the Health Department spoke with the contractor on site from Chucks Tree Removal Service and ordered the immediate removal and/or relocation of the crane. In accordance with 310 CMR 15.026(1)you are hereby ORDERED to have a licensed Title 5 Inspector perform a Title 5 Inspection by no later than October 15,2002. BOARD OF APPEALS 688-9541 BUILDING 688-9545 CONSERVATION 688-9530 HEALTH 688-9540 PLANNING 688-9535 1 Please have the septic inspector contact the Board of Health to schedule the inspection with Health Department staff. An Agent of the Board of Health must be present to witness this inspection. Failure to comply within the specified time period may result in further action by the North Andover Board of Health. You have the right to request a hearing before the Board of Health if you feel this order should be modified or withdrawn. A request for said hearing must be made in writing and received by the Health Department within seven (7) days from the receipt of this order. At said hearing you will be given an opportunity to be heard and to present witnesses and documentary evidence as to why this order should be modified or withdrawn. You may be represented by an attorney. You have the right to inspect and obtain copies of all relevant records concerning the matter to be heard. Certified Mail# 7099 3220 0010 32416803 RegularMail Pe, �vi,J e, td2ref 1oJ1107, If you have any questions or concerns, please contact the Health Department either personally or by a representative of your choice at 978-688-9540 between the hours of 8:30 A.M. and 4:30 P.M.,Monday through Friday. Sincerely, Brian J. LaGrasse Health Inspector CC: Board of Health File U.S. Postal Service CERTIFIE3 MAIL RECEIPT (Dod7estic Mail Only; r lArticle Sent To: - Er // e A rq Postage $ t S N30M Certified Fee C3 Return Receipt Fee Postmark r-1 (Endorsement Required) s Here C3 Restricted Delivery Fee 0 (Endorsement Required) O Total Postage&Fees $ fl.lru Name Pl as riot Clearly)(To be completed by mailer) M �ee� t e rs --Street,Apf.-o--WPO No----------------------------------------------------------- 0"' Street,Apt.No- PO Box No.S� o r%- CCity, ---- 1 ity,Statee,ZI +4 t .. Town of North Andover QF NORTFf Office of the Health Department .0,10 "`. if N. Community Development and Services Division 27 Charles Street E�°<• w 4� 7 °RATE° �• North Andover,Massachusetts 01845 Rssac►+usE` Sandra Starr Telephone (978) 688-9540 Public Health Director Fax (978) 688-9542 NORTH ANDOVER BOARD OF HEALTH ORDER LETTER September 24, 2002 I� >Nndove Record: �"` 1 �� alae Qee S Rogers ee r,M 1845 Staff from the North Andover Health Department witnessed a 38-ton crane performing tree removal activity on your property at the above referenced address on September 11, 2002. The crane performing the tree removal activity was located directly on top of the septic system and leaching area. The location of the crane was unacceptable and was in violation of 310 CMR 15.226(3) and 310 CMR 15.246(1). The location of the crane may have caused serious damage to the subsurface sewage disposal system. 310 CMR 15.226(3) states "Tanks, covers, connections and piping shall be designed and constructed so as to withstand an anticipated minimum H-10 loading. Any tank installed in a location where there is potential for vehicles or heavy equipment to pass over it shall be designed to withstand an H-20 loading". The septic system located on your property was designed for H-10 loading (residential application) and not designed to support heavy machinery or vehicular traffic. 310 CMR 15.246(1) states "Excavation for construction of a soil absorption system may be by mechanical means,provided care is taken to assure that the soil at the bottom of the excavation is not compacted or smeared. The bottom and sides of the excavation shall be level and scarified. Vehicular traffic and parking of vehicles or equipment in or on the area of the soil absorption system should be avoided at all times prior, during and after construction of the system". The crane was directly on top of the soil absorption system for an extended period of time. Staff from the Health Department spoke with the contractor on site from Chucks Tree Removal Service and ordered the immediate removal and/or relocation of the crane. In accordance with 310 CMR 15.026(1) you are hereby ORDERED to have a licensed Title 5 Inspector perform a Title 5 Inspection by no later than October 7, 2002. BOARD OF APPEALS 688-9541 BUILDING 688-9545 CONSERVATION 688-9530 HEALTH 688-9540 PLANNING 688-9535 sj • Please have the septic inspector contact the Board of Health to schedule the inspection with Health Department staff. An Agent of the Board of Health must be present to witness this inspection. Failure to comply within the specified time period may result in further action by the North Andover Board of Health. You have the right to request a hearing before the Board of Health if you feel this order should be modified or withdrawn. A request for said hearing must be made in writing and received by the Health Department within seven (7) days from the receipt of this order. At said hearing you will be given an opportunity to be heard and to present witnesses and documentary evidence as to why this order should be modified or withdrawn. You may be represented by an attorney. You have the right to inspect and obtain copies of all relevant records concerning the matter to be heard. Certified Mail# 7099 3220 0010 3241 6797 Regular Mail If you have any questions or concerns,please contact the Health Department either personally or by a representative of your choice at 978-688-9540 between the hours of 8:30 A.M. and 4:30 P.M., Monday through Friday. Sincerely, an . LaGrasse Health Inspector CC: Board of Health File �r In 5 BOARD OF HEALTH TOWN OF NORTH ANDOVER, MASS. 010 4.fi 0$ �6-7t7- 50 , FL 1. NAME ��� r �' DATE s 2. ADDRESS �� leP7 ls� LOT NO.I TEL. ( 3. NO. OF BEDROOMS ,7 01 DEN YES NO 4. GARBAGE GRINDER YES _ NO 5. SHOW DIMENSIONS OF HOUSE 6. SHOW DISTANCES OF HOUSE TO ALL PROPERTY LINES 7. SHOW DIMENSIONS OF LOT 8. SHOW LOCATION AND SIZE OF SEPTIC TANK OR CESSPOOL /O 9. NOTE LOCATION AND DISTANCE OF WELL FROM SEWERAGE SYSTEM y 10. SHOW LOCATION OF BROOKS, STREAMS, DITCHES, LEDGE OUTCROP, ETC. 11. SHOW DISTANCE OF SEPTIC TANK OR CESSPOOL FROM HOUSE NOTE: LOCAL REGULATIONS SHOULD BE READ CAREFULLY. i • • •---- 1-v vrvrr•UHM ANF'ucATION FOR PERMIT TO DO GASFITTINQ (Print or Type) NORTH ANDOVER, , Mass. DatBufldlng e Location laCO S S1}l e� Permit # 8� Owner's Name _ -riFO Ropy r� New ❑ Renovation ❑ Replacement C�( Plans Submitted: Yes ❑ No ❑ X C - a u a o n d J M W M V a! H V XIC M so 10 z f x A : � ` et H R s" 1Is13140) ° ILi O O �C 06 11, p lot y a !- o 1 sue—ssMT. •AIRMEHT 1sT FLOORIL :fID,FLOOR I !RD FLOOR 4TH FLOOR aTHFLOOR STH FLOOR TTHFLOOR + aTN FLOOR /� Check one: Certificate Installing Company Name A toC� l.V�i�e S S '� MCorp. Address E CI d Partnership ❑ Firm/Co. Business Telephone Sy& pc�d - Yf,2 Name of Ucensed Plumber or Gas Fitter AAA,9K _ S INSURANCE COVERAGE: Check one 1 have a current IlabW1ty Insurance policy or Its substantia) equivalent. ' Yes X No ❑ If you have checked yes, please Indicate the type coverage by checking the appropriate box. A liability Insurance policy ❑ Other type of Indemnity ❑ Bond ❑ OWNER'S INSURANCE WAIVER: I am aware that the licensee does not have the Insurance coverage required by Chapter 142 of the Mass. General Laws, and that my signature on this parmlt application waives this requirement. Check one: %naturs of Owner or Owner's ken Owner ❑ Agent ❑ I hereby certify that all of the details and Information I have submitted(or entered)M above application are true and accurate to the best of my knowledge and that all plumbing work and Installations performed under the permit issued for this i tion II In compliance with all pertinent provisions of the Massachusetts State oas Code and Chapter 142 of the General T of re nse:TNb Plur na eo um er or as er Gasry� astr Lice se Number ZO VO`7 Cftumeyman MPFKYVED(OFFICE USE ONLY) BELOW FOR OFFICE USE ONLY FINAL INSPECTION SKETCHES PROGRESS INSPECTIOW FEE NO. APPLICATION FOR PERMIT TO DO GASFITTING NAME do TYPE OF BUILDING LOCATION OF BUILDING PLUMBER OR GASFtTTER —• - LIC. NO. PERMIT GRANTED DATE GAS INSPECTOR Date.. ... f. . . . . . . . . . . . . 7 Y Q* NORTH TOWN OF NORTH ANDOVER S��Eo �6q�0 f� �f •a OA PERMIT FOR GAS INSTALLATION SA US r 1991 This certifies that. . . . `: . -�'. . . . . . .. . . . . . . . has permission for gas installation !t�... . .. .. .: . . . ... . . . . .. . . in the buildings of . . . . . `�. . .. . . . . . . . .. . . . . . . . . . . . . . . . . . . . . at . :'.''.G. . . . .! . .t. . .`. . . . . . . . . . . . . . . ., North Andover, Mass. Fee,,/�`. .�.� . Lic. No�.. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . GAS INSPECTOR WHITE:Applicant CANARY: Building Dept. PINK:Treasurer GOLD: File i MASSACHUSETTS UNIFORM APPLICATION FOR PERMIT TO DO GASFITTING t (Print or Type) ,t NORTH ANDOVER Mass. Date 1huilding Location �/� �S l,1,1 S7 Permit # /5 .� Owners Name • New '7 Renovation D Replacement Plans Submitted D FIXTURES a� ul 27 to = F ut a Cr tII 6 W W 0 N d tL W 4 ti N It N O V W = 07 W oc Q O In > W us W to W z ¢ = tr W a w W F z O G c� a- x � r z �. WH a > tr. t- w o t i W z 4 W e a .. m _ O z Q .to y C W a a Q o o w tj� o W t= x o z U. nt- sua—$SMT. BASEMENT IST FLOOR 2MD FLOOR 3RD FLOOR ' 4TH FLOOR 5TH FLOOR 6TH FLOOR 7TK FLOOR STH FLOOR (Print or Type) Check one: Certificate Installing Company Name2 _ Q Corp. Address /� �,/� . Partner. Firm/Co. Business Telephone:-, arc Name of Licensed Plumber or Gas Fitter Insurance Coverage: Indicate the type of insurance• coverage by checking the appropriate box: Liability insurance policy _CT<] Other type of indemnity Bond Insurance Waiver: I , the undersigned, have been made aware that the licensee of this application does not have any one of the above three insurance coverages. Signature of owner/agent of property Owner 17 Agent 11 i hereby certify that all of the details and information I have submitted (or entered)in above application are true and accurate to the best of my knowledge and that all plumbing work and (nsaUations performed under Petmit issued for this application will-be in compliance;with all pattaent provisions of tho Massachusetts State Gas Code and CIupter 14:of USO General Laws. ' •' By TYPE LICENSE: Plumber Title Gas-fitter- Signature of Licensed City/Town: Master Plumber or Gasfitter 9 7 Journeyman ��`EZ G/ APPROVED (OFFICE USE ONLY) License Number ti i - Date.. .. ....:. ....i.�.. i ,�pRTI, TOWN OF NORTH ANDOVER pf s«to ,e,'t'O 3r �� O PERMIT FOR GAS INSTALLATION ' 9 , i t i SSACNUSEt This certifies that . . . . . %. .r. !.`./f. . . . . . . . . . . . . . .. . . . . .,1. . has permission for gas installation' !f . . . . .. . . .... . ... . in the buildings-of !` r.,,`.` f'.!r'.'. .`. . .�. . . . . . . . . . . . . . . . . . . at North Andover, Mass. Fee.%. . . . . . Lic. No-,,.`.f�l.t.. . . . . . . . . . . . . . . . . . . . . . . . . . . . ;, , ,t- -; GAS INSPECTOR WHITE:Applicant CANARY: BUilding Dept. PINK:Treasurer GOLD:File PATRICK J. DONOVAN ASSOCIATES, INC. Claim. and otoss Adjustments P. O. BOX 110 WAKEFIELD, MA 01880 TEL. (781) 245-5540 — FAX (781) 245-7016 August 31, 2000 Building Commissioner City or Town Hall North Andover, MA 01845 Insured : Ted M & Ellen D Rogers Property Address : 1265 Salem St, North Andover Insurer : Preferred Mutual Ins Co Policy Number : PHOO100566062 Type of Loss : Water Damage Date of Loss : 8/29/00 Our File # : WAP31258 Claim has been made involving loss, damage or destruction of the above-captioned property, which may either exceed $1,000 or cause Mass. Gen. Laws, Chapter 143, Section 6, to be applicable. If any notice under Mass. Gen. Laws, Chapter 139, Section 3B is appropriate, please direct it to the attention of the writer and include a reference to the captioned Insured, location, policy number, date of loss and file number. On this date, I caused copies of this notice to be sent to the persons named above at the addresses indicated above by first class mail. vy,"'. 4A_4_4� Vern Laws, Adjuster VL/so ASSOCIATION ATION OF INDEPENDENT INSURINCB ADJUSTERS GNAT Al ASSOCIATION NPJRANa of Massachusetts 05/11/2000 15:57 5083736611 STEWART/ANDOVER PAGE 02 i,)d Ma n S STEWART IS SEPTIC TAW SMWICE Na rIh A 47 RAIIROAD STRM BRADFORD, MA 01835 W.oui Lie- jC/ -Cp6 4 jnS4C4-II Lie- # / t'> 978-372-7471 MMM OF MONMLY REPORT FOR TOWN OF DATE ADDRESS GMIOM LI log- c 7 C; 7 /oaf L� Q (� •J 4,iLl {., r: Olt 7 BOARD OF HEALTH TOWN OF NORTH ANDOVER, MASS. X00 1. NAME DATE 2. ADDRESS LOT N0. / TEL. l7� 3. NO. OF BEDROOMS j DEN YES NO 4. GARBAGE GRINDER YES _ NO 5. SHOW DIMENSIONS OF HOUSE 6. SHOW DISTANCES OF HOUSE TO ALL PROPERTY LINES 7. SHOW DIMENSIONS OF LOT / 8. SHOW LOCATION AND SIZE OF SEPTIC TANK OR CESSPOOL " ?9 9. NOTE LOCATION AND DISTANCE OF WELL FROM SEWERAGE SYSTEM 10. SHOW LOCATION OF BROOKS, STREAMS, DITCHES, LEDGE OUTCROP, ETC. 11. SHOW DISTANCE OF SEPTIC TANK OR CESSPOOL FROM HOUSE NOTE: LOCAL REGULATIONS SHOULD BE READ CAREFULLY. BOARD OF HEALTH OF NORTH ANDOVER) MASSACHUSETTS SEWAGE DISPOSAL DATE 3T NAME OF APPLICANT George Farr LOCATION Lot #17 - 1265 Salem Street Address of lot no, BUILDING: Dwelling X Other SYSTEM: New X Repair GENERAL DESCRIPTION OF LAND high SUBSOIL: Clay___ Gravel Sand PERCOLATION TEST 6 minutes per inch, MINIMUM INSTALLATION RECOMMENDATIONS CONCRETE SEPTIC TANK J,Q00 gallon capacity. LEACH FIELD 200 lineal feet of drain pipe. Q),k, jy William J. r' scoll , Eng i eer Board of Hea h l J f /s?L� 4/v� Yv� APPLICATION FOR SEWAGE DISPOSAL INSTALLATION HEALTH DEPARTMENT - NORTH ANDOVER, MASS. I here y make application for apermit for a sewage disposal installation at. - 17- /9.C- ��e . I will install this system in ac- cordance with all the laws of the Commonwealth of Massachusetts and regulations of the Board of Health of the Town of North Andover. Further, I will construct the house sewer of bell and spigot pipe, the minimum diameter being 4 inches, and will maintain a minimum grade of 1% until 10 feet pre- ceding the septic tank, where t ,e grade shall not exceed 2%. I will install a con- crete septic tank of /� in size. A manhole (s) permitting easy cleaning will be provided with removable cover (s) of iron or concrete within 12 inches of the ground surface. I will provide subsurface disposal field with 4 inch perforated or open jointed pipe and laid in a series of trenches, the bottom of which will pro- vide a minimum of 2 e-e lineal (square) feet of effective absorption area. The pipes will be laid on a 6 inch layer of washed gravel or crushed stone ranging in size from 3/4 to 1-1/2 inches (dia.) and the pipes will be surrounded by similar material to a height of 2 inches above the crown of the pipe. The joints of these pipes will be protected from clogging and before filling the trench, 2 inches of gravel or stone 1/8" to 1/4" (dia.) will be placed over the course gravel or stone. The disposal field will be installed at a grade of 4 to 6 inches/100 feet. No single the line will exceed 100 feet in length and in any case, two lines of tile will be installed. A minimum of 6 feet will be maintained between the center lines of the disposal field trenches and the average depth of trench shall not exceed 36 inches. No part. of the installation will be less than 100 feet from any private water supply, 25 feet from any stream, 20 feet from any dwelling or 10 feet from any property line. I further agree not to cover any portion of this installation until approved by the inspection officer, as provided below, and to incorporate any additional requirements that m4y be,attached to the permit. Plot Plan mustG be ups bmitted with application. DATE Si ture of 'Applicant I hereby issue the above permit for the Board of Health of the Town of North Andover, Massachusetts. DATE 7-/ 6. -7a 1 Signature of Health Agent I have inspected the uncovered system indicated above and find everything done as described. DATE h)UU __-V Signatuig of Inspecting OTficer Percolation Test Garbage Grinder �� � `4NORrk gtia �o m NORTH ANDOVER FIRE DEPARTMENT 0, CENTRAL FIRE HEADQUARTERS 124 Main Street 9SSgCHU North Andover, Mass. 01845 WILLIAM V. DOLAN .+►'� N RTM ANDO�R/ Chief of Department ARD OF HEALTH Tel. (508) 686-3812 T10 :SANDY STARR, HEALTH DEPT. (508) 689-4350 FROM:LT. SHAY SEp 51995 RE:CO INCIDENT 9/11/95 Dear Sandy; Here is the information we spoke about for the incident C 1265 Salem St. I have included our Fire Dept. SOP'S and all forms sent to the fire marshalls office. There is also a copy of my log for the incident, should you need to document anything. Chief Dolan.. is aware of the situation and will be working with all of us and will make any necessary changes, and also try to get you more standards from the gas company. Also find the only tech manual I could get from Bay State on oven CO emission testing. Note that 35-800 PPM is permissible measured C the vent the way we did. Though this reading seems high, as the Chief pointed out our main concern is the level in the room or space the appliance is in. Hopefully we can get standards for other potential emitters of CO and apply them to our checking process. Hope this helps. Yours Truly, LT. Charles M. Shay ''SMOKE DETECTORS SAVE LIVES" (PAX 0/� WILLIAM F.WELD i of O W4mm&N&*dd STEPHEN D.COAN GOVERNOR G�QQ� STATE FIRE MARSHAL KATHLEEN M.OTOOLE � � g4 adje& 02V5 THOMAS P.LEONARD SECRETARY DEPUTY STATE FIRE MARSHAL TELEPHONE(617)351-6000 FACSIMILE(617)566-2600 To: Heads of Fire Departments/Fire Districts From: Stephen D. Coan State Fire Marshal Date: February 2, 1995 Subject: Coding and Voluntary Reporting of CO Alarms Carbon monoxide detectors were heavily marketed over the holiday season. This new technology is placing additional demands on frequently understaffed fire departments. We need to be able to track the frequency of these calls, how many incidents indicated a dangerous level of CO and how many people (casualties) required medical transport. We would like to use the existing Massachusetts Fire Incident Reporting System (MFIRS) to track these calls and to keep it as simple as possible. By law,fire departments are only required to submit fires or explosions resulting in a dollar loss or human casualty. Reporting these incidents is voluntary. • Use Situation Fo,ind Code 75 — CO Detector Activation, a new code, for CO detectors that activated in response to pollution or some unknown trigger. While we would prefer to find very little carbon monoxide, we cannot generally make indoor air purer than that found outside. • Use Situation Found 48— CO Hazard, another new code,for an identifiable CO emergency whether or not a CO detector activated. The presence of CO was confirmed and some corrective action was indicated. Please send hard copy and any narratives for all real CO emergencies. • Complete the incident report down to Line I as you would for any non-fire incident. • Complete casualty reports for anyone suffering from CO exposure. A Century of Service Preserving life and property from fire,explosion,electrical and related hazards through public education,investigation, regulation,law enforcement and technical assistance to fire departments and the public since 1894 w r NORTH ANDOVER FIRE DEPARTMENT STANDARD OPERATING PROCEDURE (SOP) SECTION IV CARBON MONOXIDE LEAK PAGE 1 of 4 EFFECTIVE DATE: 1 February 1995 PURPOSE: To establish a procedure for the North Andover Fire Department's response to reports of carbon monoxide(CO) incidents. The department's purpose in responding is to take an initial size up of the situation, assist the residents and to advise them of the safety issues relative to CO. The department is not responding to correct the source of the problem. COMMON TERMINOLOGY: Carbon Monoxide: A colorless, odorless,toxic gas. CO is produced by the incomplete combustion of fuels such as natural gas, propane, heating oil, kerosene, coal, charcoal, gasoline or wood. Carbon Monoxide Detector: a device which responds to Carbon Monoxide in levels of parts per million. Approved devices have a UL label. The two most common types are those which utilize a synthetic hemoglobin which darkens with increased concentrations of CO and a plug-in model which contains a small microprocessor and emits a warning noise when concentration levels of CO reach certain limits. The first type is reset by leaving it in a CO-free environment for 6-24 hours. The second type `J will reset if unplugged. These detectors sound upon receiving preset levels of concentrations either a high level for a short duration or low levels for a long duration. DISPATCH Upon receipt of a call reporting a possible carbon monoxide leak or a carbon monoxide detector sounding,with no symptoms of illness: 1. Dispatch the nearest engine company and advise the caller to immediately evacuate the building with any other persons present in the dwelling and await outside for the arrival of the fire department and not to reenter the building. 2. If the caller is reporting symptoms of illness, which may include headache, dizziness, nausea, flu like symptoms, dizziness or fatique in addition to the alarm sounding also respond an ambulance and P-2. It is important that the occupants evacuate the area as quick as possible and not remain in a potentially dangerous atmosphere. SAFETY No one shall enter the building until the arrival of the fire department personnel who will be wearing positive pressure self-contained breathing apparatus. Carbon monoxide is an insidious gas which more readily combines with the blood than does oxygen in the blood. RESPONSE Without illness Nearest Engine company AIM multigas detector With illness- Nearest Engine company AIM multigas detector Ambulance P-2 Page 2- SOP- Carbon Monoxide Leak The first arriving fire officer shall: insure that the building has been evacuated. commence an investigation which shall include 1. accounting for all persons who may have been in the building at the time of the call. 2. inspection of the interior of the building using the AIM multi gas detector set for CO concentrations by personnel wearing full SCBA. 3. Take a reading with the AIM detector for CO prior to entering the dwelling to provide you with the ambient CO level. When taking the reading insure that you are in an area away from CO sources (exhaust, vents etc.) 4. CO concentrations: a. 3 - 4 PPM are normal in a house without persons who smoke b. in dwellings where persons smoke the ambient CO could be in the 9-10 PPM range depending on the frequency of smoking. 5. readings in the dwelling 9 PPM ABOVE THE AMBIENT is an indication of a serious problem. 6. if dwelling has gas operated appliances notify the gas company to respond. 7. if you attain readings 9 PPM above the ambient have central dispatch notify the following agencies: a. the Board of Health b. the gas inspector if there are gas appliances and the source of CO can be attributed to the gas appliance or when no source can be definitively pinpointed as the source. c. the Fire Chief 8. if the source of CO is detected eliminate the source, shut off the appliance, ventilate, advise residents to seek medical evaluation and provide transport if necessary, await the arrival of the board of health. 9. Assist the Board of Health agent in any way possible in completing their evaluation of the situation. 10. Always use the CO.checklist when inspecting a home and provide the home owner with a copy of the CO notice of dangerous situation. 11. Under Mass. General Law only the Board of Health can allow rehabitation of a dwelling if it has previously been determined to be a danger to health. 12. Utilize your network of resources,Red Cross, TIP, Gas Company, local agencies and departments. 13. Complete a fire incident report using the guidelines established by the State Fire Marshal's office, r Page 3- SOP CHECKLIST FOR CARBON MONOXIDE Location of Incident: Date of incident QUICK CHECKLIST OF OCCUPANTS Headache yes no Fatigue yes no Nausea yes no Dizziness yes no Confusion yes no Are any members of the household feeling ill? yes no Do the residents feel better away from the house?yes no Since the detector's alarm went off, what have you done? Shut- off carbon monoxide sources yes no If yes which sources Let in fresh air? yes no If yes how did you let the air in How long did you let the air in PPM reading ambient outside the dwelling Highest PPM reading in the dwelling Carbon monoxide detector present? yes no If yes list the number of detetors locations and make, and serial number of each below. 1. 2. 3. 4 Which detector(s)by number above activated? SOURCE CHECKLIST LOCATION PPM READING Chimney clogged flue,blocked opening Fireplace(s) Natural gas, LPG, Wood(indicate type for each fireplace) 1. 3. 2. 4. Gas Appliance (if Gas Company on Scene they can perform this check) (IF MORE THAN 1 OF THE FOLLOWING APPLIANCES LIST EACH ADDITIONAL ON THE COMMENTS PAGE WITH ITS LOCATION, AND PPM READING) refrigerator stove vent over stove clothes dryer water heater (chimney pipe) furnace (gas,oil;leaking flue/chimney pipe barbacue grill (in eclosed or semi enclosed area Oil burner car garage ` Entranceway from garage to house Name of individual operating the CO monitor Person completing the Checklist _ Page 4 - SOP- Carbon Monoxide Leak COMMENTS PAGE INCIDENT LOACATION INCIDENT DATE INCIDENT TIME Massachusetts Fire MASSACHUSETTS FIRE INCIDENT REPORT ,- DEPARTMENT OF PUBLIC SAFETY OFFICE OF THE STATE FIRE MARSHAL �Rept 1010 Commonwealth Avenue Boston,Massachusetts 02215 "", nn q 10 FDID# Department Orfl� Re ised FORM r 09 FR32 If Exposure Day Of 1 Sun 2 Mon 3 Tu offs ' #f f1i Incident# Fire only. ' l Week 4 Wed 5 Thu 6 Fd Z 11 ❑Structure fire 17❑Outside spill with fire SEE MANUAL 00 13❑Vehicle fire 18❑Other fires not classified FOR OTHER Z Z 1 ❑Extinguishment 5❑Stand by MUTUALAOD 1=Z© CALLS C W 2❑Rescue or Assistance 6❑Salvage 1 ❑geed Q 14❑Brush,grass,leaves 47❑Chemical spill Y 3❑Investigation only 7 0 Ambulance dW rA 2 El Given �� 15❑Trash,rubbish 44❑Power line down rid' V Q H.LL Q H 4❑Remove Hazard 8❑Fill in.Move up s n NIA j y 16 EJ Explosion.No after fire 45 O Arcing electric equipment 1 FIXWROPEFINUSE(Oc q ancy) IGNITION FACTOR ERA O ���� � r�• 's s �', 7 �.> f£ + � 4 i'r� ry Sfy � .. :' f"�„ � s� ^I NAMIw #SS Esta} TIrLEP¥fisi � "ERWA ILAST FIRS t Ntl) MEE METHOD OF ALARM CO INSPECTION NO.FIRE SERVICE PERSONNEL NO.ENGINESf NO.AERIAL APPARATU$� O 13 1 Telephone direct DISTRICT RESPONDED RESPONDED RESPONDED 2 Municipal alarm system 3 Private alarm system N0.TANKERS NO.OTHER VEHICLES 4 Radio SHIFT HAZARDOUS MATERIAL PRESENT? 5 Verbal YES❑ NO[IRESPONDED RESPONDED 6 No alarm recd. �' 7 Tie-line(911) SUBSTANCE 8 Voice signal municipal alarm NO ALARMS USE FP 33 signal FOR ALL 9 Not classified above 0 Undetermined or not reported Special Equipment Used? file ftCASUALTIES O 20 FIRE NUP64BEROFM NUMBER OF NUMBER OF NUMBER OF RESCUES FATALITIESEA N 01 INJURIES FATALITIES t SERVICE INJURIES OTHERu O MOBILE PROPERTY TYPE VEHICLE STOLEN? Yes O No❑ 11 AUTO,VAN 22 TRUCK UNDER 1 TON ESTIMATED TOTAL Insurance Co. i 12 BUS 41 BOAT,UNDER 65' DOLLAR LOSS 13 MOTORCYCLE Total Insurance $ Claim Paid 1 $ 21 TRUCK OVER 1 TON 08 NONE YEAR MAKE MODEL COLOR LICENSE NO. VIN# 30 j IF EQUIPMENT INVOLVED YEAR MAKE MODEL SERIAL NO. # 40 IN IGNITION OCOMPLEX AREA OF EQUIPMENT INVOLVED IN IGNITIONS ORIGIN } FORM OF HEAT IGNITION MATERIAL IGNITED FORM r,TYPE n s r,. METHOD OF LEVEL OF FIRE ORIGIN Number of Stories CONSTRUCTION TYPE f OEXTINGUISHMENT 1 ❑Grade level to 9 ft. 1 F7 1 story 1 ❑Fire resistive 1 Lj Self extinguished 2[1.10 to 19 feet 2 r 2.story 2❑ Heavy timber 2 n Make shift aids 3 i_,20 to29 feet 3❑3 to 4 stories 3 C1 Protected noncombustible 3❑ Portable extinguisher 4 17 30 to 49 feet 4 17 5 to 6 stories 4 n Unprotected noncombustible 4❑Automatic ext.system 5❑50 to 70 feet 5 C-11 7 to 12 stories 5 M Protected ordinary 5❑ Pre-connect hose tank only 6 177 Over 70 feet 6^ 13 to 24 stories s: 6 n Unprotected ordinary r 6 l7 Pre-connect hose!hydrant draft standpipe 7❑ Objects in flight 7 u 25 to 49 stories 7 M Protected wood frame tar 3 7 Fl Hand-laid hoseihydrant draft standpipe 8 F1 Below ground level 8 0 50 stories or more 8'-1 Unprotected wood frame F° 8❑ Master stream device 9❑ Not classified above 9❑Not classified above w,Z' 0 Fl Undetermined 1 0 C1 Undetermined or not reported O EXTENT OF DAMAGE Flame Smoke DETECTOR PERFORMANCE SPRINKLER PERFORMANCE I 1 Confined to the object of origin 1 ❑ Det.in room or space of fire origin—oper. 1 FJ Equipment operated 2 Confined to part of room or area of origin 2❑ Det.not in rm.or space of fire origin—oper. 2 F7 Equipment should have operated— 1 3 Confined to room of origin 3 C1 Det.in rm.or space of origin—no opec did not 4 Confined to the fire-rated comp.of origin © 4 t 1 Det.not in rm.or space of origin—no opec 3 1 1 Equipment pre.but fire too small { O 5 Confined to floor of origin 5 M Det. in rm.or space of fire origin but to opec } 6 Confined to structure of origin fire too small to opec 9 i I Not classified above 7 Extended beyond structure of origin 9(-Not classified above 0 n Undetermined or not reported $: 0 F Undetermined or not reported 8 P. No equipment present(NiAI �r 9 No damage of this type(NiAI 8❑ No detectors present WA) '<<• -., h ' OIF SMOKE SPREAD MATERIAL GENERATING MOST SMOKE FORM TYPE BEYOND ROOM OF ORIGIN AVENUE OF SMOKE TRAVEL 7❑ Utility opening in floor ! ® 1 ❑Air handling duct 4❑Stairwell 9 7)Not classified above . 2 0 Corridor 5 Cl Opening in construction 0 17 Undetermined or not reported WEATHER 3❑Elevator shaft 6❑ Utility opening in wall 8❑No avenue of smoke travel IN/A) CONDITIONS Entries contained in this report are intended for thesole use of the State Fire Marshal.Estimations and evaluations made herein represent"most likely'and"rrost probable" cause and effect.Any representation as to the validity or MEMBER MAKING REPOR DATE accuracy of reported conditions outside the State Fire f Marshal's office,is neither intended nor implied. G/,// FIRE MARSHAL •+ F.M._1 i Yes 2 7 No ORIGINAL:FIRE DEPARTMENT CARBON COPY:STATE FIRE MARSHAL ,.. Page 3- SOP CHECKLIST FOR CARBON MONOXIDE Location of Incident: /t2(0 Date of incident HE I T z4 r- p� QUICK t Headache yes nFatigue :: ' Yes noo Nausea yes nDizziness yes no ✓M I Confusiones no� 11.e 1001 !0'c t CIM& /w /,c �2e cbmy t Y 100 fts+ FOR o� pw'ts. cQecl�Ve Are any members of the household feeling ill? yes no TR'^/!sP°�;� ` A0 s1'"►P tor►' ' Do the residents feel better away from the house?yes no Since a detector's alarm went ofy what have you one? Shut- off carbon monoxide sources yes nok£ # If yes which sources eA) S--to y6'. v/Let in fresh air? yes no If yes how did you let the air in ;;,7 How long did you let the air in ,#04;oe to 4RAi eA I i9,R"41K 09 PPM reading ambient outside the dwelling no/ i Highest PPM reading in the dwelling 350 A±S Tb0E, VeNt.a 001 A<< APOMS fi,74�s V4 Carbon monoxide detector present? yes ✓ no If yes list the Humber of detetors locations and make,.and serial number of each tow. :, 1. 'eco FIC o�e /�a/( �iR T /9/PST 6- 375,3'7d? �F r � FT 3. 4. Which detector(s)by number above activated? d SOURCE CHECKLIST LOCATION PPM READING Chimney clogged flue,blocked opening OCA 1 ry Fireplace(s) Natural gas,LPG,Wood(indicate type for each fireplace) ' 1. ,Dt tl oo I ,©D M�ro,PcCctt,lJ9 3. 2. 4, Gas Appliance (if Gas Company on Scene they can perform-this check) (IF MORE THAN 1 OF THE FOLLOWING APPLIANCES LIST EACH ADDITIONAL ON THE COMMENTS PAGE WITH ITS LOCATION,AND PPM READING) refrigerator N A stove �-k'I� .fid kf�,v�;�6 avg vent over stove " clothes dryer water heater (chimney pipe) furnace (L,oiljeaking flue/chimney pipe Ce IM4 00 ' barbacue grill (in eclosed or semi enclosed area /U� Oil burner ,t1 A s car garage LJi�iDe� g� 8 Abuse 001 {' r Entranceway from garage to house Sa �" 001 ; Name of individual operating the CO monitor 1,f ' Person completing the Checklist •�( ' , ". VIA— • _ _NO _ t • I :A1 r T �: ��l�rr L, .� 1� • , u �■_ MAIN' IM x +� r_ i. � L „� F 2y�rF,iF a t :i �f t a, 3 ' 5 I1' p / d 1111!10.1�zn orm .i ♦ Ian/) / . �.� i/ •r • i �� i -Mol KLMi • c I / M• i vii no --mill a I! • � �� � �• "/ • i rte• • � •�,• w r i ♦ , 4 �� . I rip fg .a I •r , t P:S Z -� �'' t • F ht':: °` r�r '�'�.x�S. + i s t 1Fy t k 7 •t''s>a �+ a k b{Ms R tttj w 'f M1 • �r.�ti i. r r � v.t �k r. r a att+ Thr tJr"` stl Y t •..a f Sf}S rr Y3Y9t fry++yrs{!f„` A{1Y' TP i,\ a •• r r• sr k 9 t rF r �pp to ala�z�' Yy} ^ + '1 t t! 'U+SIJ r•fi"vj�{fix it a S ��}.5 jY't `� `'r c tti�2 \'f. '7fi`F +C'` o 4 s{`; Ad C L k {t vt S9t s tr tiLLJ . } Fy4,tYXx�rZ vT+S+! �)ya-ti erjAfa++j''�].a t? r� r^ �r�)<'�,t,,h4;�` 93tC�" ,tf•�'a+\�}�. �.�„f - t Cyt�Ai, +7�r�7,�{ 'rEr?a1^ a '(n` ) �Y1a°±n�}r y+J nkr F L� .'v ° Kt^�� i�. �sf a b � �' •Fty\ YtS , � 'w:`i b�w���VFt$tt�SYi'A•�a}t' n�+ +w r�t� 'L,'�k �+� \iryn��)� y�� L�.,"S`r�:+}t`�^� G����a�.����'l��� r ..yr ya a'9 '�j iL.;j„aij9 r ist;s�( rif 5r� L Nt+' +",�'S `M�,���k i•�S ( �';�F�'.w^xti l�`.)Y�,�`y5`�`,�,���ap v�sa>,t.: O v, T�'�t,L,{i♦� * Y+.e',.i't,,,,��5`ti '}' kA'��,�(f l 9` �q fxM1 v } �.v ti s r,i'^�`-{y,d�t h t v1 �7 ,l•.Y 11 pitaF'k"' tAA ZWV/) w. a,4y� U E('1 +t +'M) z � t 4 +'41 �•i'+vAa,ice, (x[ �t .v +xy Q 7+ \�{-�Kt}m //1 LLI tLLIt cc cc cay '� a r,Y Cls ti•7..,?. � t� m U) L ccQcn Q Lu (.0 L ti T _�• •yam Z FOREWORD The purpose of this manual is to educate the Service Technician and other field personnel on the 'procedures used to calculate the carbon monoxide(CO)output of a gas range a per the eiirrent standards and methods. . ,�. The standards,. ' .. and�methods-covered in this manual were,«developed by the American National Standards Institute(ANSI).All GE gas appliance .designs are tested to these standards by the American Gas Association (AGA) and have the AGA seal of approval on the appliance rating label.. At the present date (August 1994) a nation wide standard covering the maximum allowable CO permissible in a residence or a procedure for measuring CO in a residence has not been established. Many of the gas utility companies and some communities have established local ' standards and methods of measurement that are not compatible with the methods used by the gas cooking appliance industry_ The information in this manual should help you understand how gas appliance designs are tested and put you in a better position to resolve issues on a local level. Carbon monoxide: A colorless, odorless, extremely poisonous gas, CO, formed by incomplete combustion of carbon or a carbonaceous material, including gasoline. Concentration of CO in air Inhalation time and toxic symptoms developed 9 ppm (0.0009%) The maximum allowable concentration for short term exposure in a living area according to ASHRAE 35 ppm (0.0035%) The maximum allowable concentration for continuous exposure in any 8 hour period, according to federal law. 200 PPM* Slight headache, tiredness, dizziness, nausea after 2-3 hours. 400 ppm (0.04%) Frontal headaches within 1-2 hours, life-threatening after 3 hours, also maximum parts per million in We gas according to EPA and AGA. 800 ppm (0.08%) Dizziness, nausea and convulsions within 45 minutes. Unconsciousness within 2 hours. Death within 2-3 hours 1,600 ppm (0.16%) Headache, dizziness and nausea within 20 minutes. Death within 1 hour. 3,200 ppm (0.32%) Headache, dizziness and nausea within 5-10 minutes. Death within 30 minutes. i 6,400 ppm (0.64%) Headache, dizziness and nausea within 1-2 minutes. Death within 10-15 minutes. 12,800 ppm (1.28%) Death within 1-3 minutes. 10,000 ppm (parts per million) equals 1% by volume. 'Maximum CO concentration for exposure at any time as prescribed by OSHA. Effects can vary significantly based on age, sex, weight and overall state of health. TESTING OVEN BURNERS NATURAL GAS FORMULA: To check the burner, set the oven for bake (AIR-FREE CO CARBON AIR-FREE or broil. Select the highest temperature 12.2 REFERENCE X MONOXIDE _ CARBON ACTUALLY possible to prevent the burner from cycling (CO2ACTU MEASUREDD))ALMEASURED MONOXIDE off during the test. Of the burner cycles off during the test, let the oven cool and repeat the test.)Allow the oven to preheat for a NATURAL GAS EXAMPLE: minimum of 5 minutes after the burner 12.2 =2.35 2.35 X.012=.028%(280 PARTS ignites before testing. 5•2 PER MILLION CO AIR-FREE) Hold the meter nozzle approximately 1 inch inside the oven vent or as close to the vent as possible on models with a slotted vent opening. Point the meter nozzle straight into the vent so the air blows PROPANE(LP)GAS FORMULA: directly into the nozzle. Move the nozzle (AIR-FREE CO, CARSON AIR-FREE 14 REFERENCE] MONOXIDE _ CARBON slowly across the width of the vent at a ? (CO2 ACTUALLY X ACTUALLY _ MONOXIDE uniform speed. MEASURED) MEASURED Record the carbon dioxide and carbon PROPANE(LP)GAS EXAMPLE: monoxide readings. Be sure to allow the meter reading to stabilize before recording 14 the numbers. Use the formulas shown to =2.69 2.69 x.012=.032% (PER MILLION s. 2 LION �-- 1 calculate the air-free values. Co AIR-FREE) TESTING SURFACE BURNERS A method to duplicate the AGA test method for surface burner emissions in the field has not been developed for GE ranges at present. Testing of the surface burners in the appliance design stages is accomplished by using a large collector hood to capture the emissions from all 4 (or 5) surface burners at the same time.This type of collector hood is heavy and bulky and would not be practical for use in a consumer's home. A portable collector suitable for field use that meets AGA standards is currently in the development stages. I For example,oven"A"requires a large The large volume of air flow through the oven dilutes the carbon volume of air flow for proper baking monoxide before it reaches the results. An air sample taken at the vent of vent. this oven will usually contain a relatively low percentage of carbon monoxide because of the large amount of air diluting the sample. OQ D (D 0) Oven"B"requires a small volume of air flow.There will be less air in a sample taken at the vent of this oven,resulting in a higher percentage of carbon monoxide in the vent sample. Ovens"A" and"B"may be emitting about the same amount of carbon monoxide by volume. 0 A carbon monoxide reading taken at each o 0 oven vent in the example may vary from as low as .0035%(35 parts per million) from pVEN A oven"A" and up o . 0 0 parts per million) in oven"B". The small amount of air flow Both oven designs emit levels of carbon through the oven results in less air monoxide that fall below the maximum mixed with the carbon monoxide. allowable "air free" limit of.08% (800 parts per million) as design-certified by The Amencan as Association(AGA). O O � � 0 The"air-free" method of measurement factors out oven design differences that affect or dilute the carbon monoxide sample taken at the vent. To make an air free measurement, an instrument capable of measuring both ' carbon monoxide(CO) and carbon dioxide (CO2) is required. L. The air-free method is the method used by o the oven manufacturer and the American OVEN B Gas Association. C� \y 2 A _ ORIFICE AND BURNER ALIGNMENT: --'� The orifice must inject the gas straight ORIFICE AND BURNER ALIGNMENT into the burner. If the gas is injected into the burner at an angle,the amount of •,•, primary air mixed with the gas will be L reduced, resulting in incomplete combustion. It is possible for the orifice and gas supply tube or the orifice and ItiwOnGl valve assembly to be bent,resulting in „l an improper injection angle.This is especially true on ranges that have been converted for use on LP gas. INJECTION ANGLE PAMt AM owRCE GAS/ PRESSURE OVER GASSED BURNER: The flame must not extend beyond the edges of the flame spreader(burner baffle). If flame appears too large, reduce gas flow to the burner by tightening the orifice in the LP direction. FLME MUST NOT Note: If the burner is found to be over EXTEND BEYOND gassed, check the flame spreader for FNLAME EDSPOREADER signs of warpage. A warped flame spreader can increase the carbon monoxide output and must be replaced a 6 CALCULATION SHEET 2 for models fueled by Propane (LP) Gas PROPANE (LP) GAS FORMULA: (AIR-FREE CO2 CARBON AIR-FREE 14 REFERENCE) MONOXIDE _ CARBON X ACTUALLY MONOXIDE ? (CO2 ACTUALLY MEASURED MEASURED) PROPANE (LP) GAS EXAMPLE: _ 14 = 2.69 2.69 X .012= .032% (320 PARTS 5.2 PER MILLION CO AIR-FREE) C; r MAXIMUM ALLOWABLE AIR FREE EMISSION IS 800 PARTS PER MILLION (.08%) TOWN OF NORTH ANDOVER SYSTEM PUMPING RECORD , ! 6 2003 DATE: i SYSTEM OWNER& ADDRESS SYSTEM LOCATION (example: left front of house) DATE OF PUMPING: ( QUANTITY PUMPED 1506 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: < 1 O U c\) S S e w e'r �rUl COMMENTS: CONTENTS TRANSFERRED TO: L S• 0. COMMONWEALTH OF MASSACHUSETTS EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS DEPARTMENT OF ENVIRONMENTAL PR..OT-ECTION V 5� 1 TITLE 5 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM PART A CERTIFICATION Property Address: 1 2 ,S �✓' A I.t:M 5f R E E"r jj O 2TK A ii C v tlL Owner's Name:_ ( GK l p<—.1V%P fr12 F Owner's Address: S T tZ 0 2T1 © .�►�✓d Date of Inspection: Name of Inspector:(please print) Beni amin C. Osgood, Jr. CompanyName:New England Engineering Services Inc. Mailing Address:60 Beechwood Drive North Andover, MA 01845 Telephone Number: 978-686-1768 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 15.004 The system: Passes Conditionally Passes Needs Further Evaluation by the Local Approving Authority Fails Inspector's Signature: C Date: r The system inspector shall submit a copy of this inspectioneport 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. x Page 2 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address:_ 1265 SSALEM STREET _ NORTH ANDOVER,MA Owner: VICKI DEMPAIRE Date of Inspection:_ 1/1904 Inspection Summary: Check A B C,D or E/ALWAYS complete all of Section D A. .System Passes: V 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: (� 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. 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 pipe(s)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: Page 3 of 11 OFFICIAL INSPECTION FORM -NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address:. 1265 SSALEM STREET NORTH ANDOVER,MA Owner: VICKI DEMPAIRE Date.of Inspection: 1/1904 C. Further Evaluation is Required by the Board of Health: MConditions exist which require further evaluation by the Board of Health m 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(l)(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 than 5 ppm,provided that no other failure criteria are triggered.A copy of the analysis must be attached to this form. 3. Other. Page 4 of 1 I OFFICIAL INSPECTION FORM r-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address; 1265 SSALEM STREET NORTH ANDOVER,MA Owner: VICKI DEWAIRE Date of Inspection 1/1904 D. System Failure unteria appucame to an systems: You mast indicate"yes"or"no"to each of the following for alt inspections: Yes No ✓' Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool _ ✓' Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool ✓' 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'/z 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 of privy is within 100 feet of a surface water supply or tributary to a surface water supply. 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. . ✓ 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.] JN 0 (Yes/No)The system faik I have determined that one or more of the above failure criteria exist as described in 310 CMR 15303,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' dicate either"yes"or`Sno"to each of the following: (The follo teria apply to large systems in addition to the trite' yes no the system is within 400 f a surfs inking water supply the system is within 200 f a trib o a surface drinking water supply _ — the system is ted in a nitrogen sensitive area(Int Wellhead Protection Area—IWPA)or a mapped Zone a public water supply well If you have answered"yes"to any question in Section E the system is consid a significant threat,or answered `yes"in Section D above the large system has failed.The owner or operator of an ge system considered a significant threat under Section E or failed under Section D shall upgrade the system in rdance 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:_ 1265 SSALEM STREET NORTH ANDOVER,MA Owner: VICKI DEMPAIRE Date of Inspection: 1/1904 Check if the following have been done.You must indicate"yes"or`Sid'as to each of the following Yes No Pumping information was provided by the owner,occupant,or Board of Health R✓ 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? Have large volumes of water been introduced to the system recently or as pact 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? 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 scam? 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: YYTe 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)] Page 6 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION Property Address: 1265 SSALEM STREET NORTH ANDOVER,MA Owner: VICKI DEMPAIRE Date of Inspection 1/1904 RESIDENTIAL FLAW CONDITIONS Number of bedrooms(design): Number of bedrooms(actual): DESIGN flow based on 310 CMR 15.203(for example: 110 gpd x#of bedrooms): Number of current residents: Does residence have a garbage grinder(ares or no):flD Is laundry on a separate sewage system(yes or no):& [if yes separate inspection required] Laundry system inspected(yes or no):— Seasonal use:(yes or no):/v0 Water meter readings,if available(last 2 years usage(gpd)): Sump pump(yes or no):-Vfa Last date of occwmcr. G.y rrc.��--------------- -- - COMMERCIAL/INDUSTRIAL Type of establishment: Design flow(based on 310 CMR 15.203): 1;pd Basis of design flow(seats/persons/sgft 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): Pumping Records GENERAL INFORMATION Source of information:`�� „Z 5 OgjZ k t-( {2Pca 2 t>5 Was system pumped as part of the inspe ton(yes or ones If yes,volume pumped: gallons--How was quantity pumped determined? Reason for pumping: TYPE OF SYSTEM -&L/geptic tank,distribution box,soil absorption system —Single cesspool Overflow cesspool Privy Shared system(yes or no)(if yes,attach previous inspection records,if any) _Innovative/Altemative 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: n L� �PfaRSi- D2r'Z jD}{ Reco27 S Were sewage odors detected when arriving at the site(yes or no): Page 7 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address:_ 1265 SSALEM STREET Owner: NORTH ANDOVER,MA VICKI DEWAIRE Date of Inspection:, 1/1904 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.): 1-7L 1,00 1(.S L•+nDF� o Fi YrJV M N 1 SEPTIC TANK:_(locate on site plan) Depth below grade: I Z,- Material Material of construction::;�concxete 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: IV Sludge depth: 41 Distance from top of slud�e to bottom of outlet tee or baffle: 2 7 c Scum thickness: tC lI Distance from top of scum to top of outlet tee or baffle: (� Distance from bottom of scam to bottom of outlet tee or baffle: 20" How were dimensions determined: m cc,y v 2syn GIL Comments(on pumping recommendations,inlet and outlet tee or baffle condition,structural integrity,liquid levels as related to outlet invert,evidence of leakage,etc.): !1 n I !� �N G�►1�- zr S3AT� �5 �� -RaJ� Gin .p 1J� nF IQ ?L)C GREASE TRAP:A0ocate on site plan) Depth below grade:_ Material of construction: concrete metal fiberglass (explain): _polyethylene other Dimensions: Scum thiclmess: 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 umpingComments(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:_ 1265 SSALEM STREET NORTH ANDOVER,MA Owner: VICKI DEMPAIRE Date of Inspection:. 1/1904 TIGHT or HOLDING TANK:AtA(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: (if present must be%ened)(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.): _0 Y j rn n K �3cTt10/1 r107- 6QLI A►- z) I.-s�Jc{,,4"1d. 01-4 otkQW L,�%✓�L �S / S /ZECl7iKt l/17�L� /t/J ZIIAGNCC c�i� �,F,14KAlrG DR eA2Ry 0VC4 — 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.): Page 9 of l 1 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address•_ 1265 SSALEM STREET NORTH ANDOVER,MA Owner: VICKI DEMPAIRE Date of Inspection;. 1/1904 SOIL ABSORPTION SYSTEM(SAS): (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: (leaching fields,number,dimensions: i2v. )(190, overflow cesspool,number: innovativelalternative system Type/name of technology: Comments(note condition of soil,signs of hydraulic failure,level of ponding,damp soil,condition of vegetation, etc.): CESSPOO1SWL4-(cesspool must be pumped as part of inspectionxlocate 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: 411j, (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.): Page 10 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 1265 SSALEM STREET NORTH ANDOVER,MA Owner. VICKI DEMPAIRE Date of Inspection: 1/1904 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. JZc�SG 9 i VA tib i .,� Z,0 40 SAL- r. Al" Page 11 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address:_ 1265 SSALEM STREET Owner: NORTH ANDOVER,MA VICKI DEMPAIRE Date of Inspection: 1/1904 SITE EXAM Slope /ole �v /0 Surface water (Lc,,,�- c erx Check cellar Shallow wells N�� Estimated depth to ground water feet Please indicate(check)all methods used to determine the high ground water elevation: Obtained 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: s5&4; FVsr.s o•cA; ,.�,4- �2 ��•��� F�e,.�.. Cum ��c.t r c v+. Inc✓c c, [ f1/� 7 0 C, H t L-L- r COMMONWEALTH OF MASSACHUSETTS { f ,EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS d DEPARTMENT OF ENVIRONMENTAL PROTECTION , 41r..: ' .. {j,.f•f f •J't?e'� :f`..a, f`'RJ ';' 4 + j F L 4 ° TITLE 5 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS i f: SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM k + PART A CERTIFICATION Property Address .'f<-, Owner's Name: Owner's Address. ,,,�_ ..,.. . _...: Date of Inspection: ! Nauru ofInspector; lease print) Company Name, o u cWA ,1Vlatling pddres t z J 1© ' Telephoue Number:, 6/ 0, 1 � .c,>0 .: ,•_ . , n , CERTIFICA►TION S14 a I cerrifyxhat I.have Personally inspected thesewage disposal system at this address and that the information reported I below is true,accurate and.complete,as of the.time,of the;inspection.The inspection was performed based on my training andxggrience in the proper'fuuction 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: J' i° Passes Conditionally.Passes` a` ' Needs Further Evaluation by the Local Approving Authority x `l Fails A a !max :,itSfiF `!•�::rz4 �.MS' fel.dd`fr`, + , t t InsPectoa's�i +hra.. Date: j The Systen►utspector shall subm' a copy of inspection port to the Approving Authority(Board of Health or DEP)within"30 days of completing this inspe on.If the s stem is a shared system or has a design flow of 10,000 h 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, }�. /1 ♦� : «{ his!report'ouly describes conditions at the time of inspection and under the conditions of use at that time.This inspection does not address hpw the system will perform in the future under the same or different 'z conditions of use. }"a 5 Title S Ins on Form 6115 000 P n Page I . " Page 2 of 11 OFFICIAL INSPECTION FORM—'NOT FOR VOLUNTARY ASSESSMENTS 4 SUBSURFACE.SEWAGE DISPOSAL SYSTEM INSPECTION FORM ,. ` PART A CERTIFICATION(continued) Owner: pate of InS n Inspection Summary.;Check A,B,C D or E/ALWAYS complete all of Section D . Vit *aoA?( 4 �I have not found any information which indicates that any of the failure criteria described in 310 15.303 or in 310 CMR 15.304 exist.Any failure criteria not evaluated are indicated below. CMR �cM •,•: :CO , Y flan} • � � A.` M1_!!(i4! F�}�•`.t Ci T i! c r .. �f ...� .. .. Y S, ' ' t r �. •4 •,4. Sy*m,ConditionaUy Passes:. y. 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. Answor yes,no or not determined(Y,N,ND)in the for the following statements.If"not determined"please exp Nt .1J i",•t � r.r'lv j. Theiseptic tank is'metal and over 20 years old*or the'septic tank(whether metal or not)is structurally unsound;exhibits substantial infiltration or exfiltiation or tank failure is imminent.System will pass inspection if the Y' 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. "y 7 f rati.ND Qxplaim� N-1:i1:d(� i)ivo l tti't, !(� a t , =J ; ` ; a''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 r approval of Board of health): l:s) ,ieg+ f°:_,:'broken pipe(s)are replaced ' ve obstruction is removed distribution box is leveled or replaced NDC lain, t Xp Cwt.,1 •.' , r -. .. c The system required pumping more than 4 times a year due to broken or obstructed pipe(s).The system will Pus inspection if(with approval of the Board of Health): broken pipe(s)are replaced '1 obstruction is removed ia� r;J�tct?ea}M, 1< Viii '4'.Jz. 'r.lr :kr.af .ar:1s•Ma' )z _ •�. "s ) �i F' 1 ii � AwL :i,a l.�' ' t F f. J•i s' ii:r. . 1 �al.lic..4 �.iciS.t;� �! ? .i r'fki•i 4, ;� •4 lain. i r y;� A ' F ND i fs rwsi+{�p,�°` k: , t$r s '.�f r�} k`tf # j+ r f r• { 4- •4Jt'.' h.r :a k.sa: °^4 ... '�,! rf t 2 1 Page 3 of 11 J. . OF.FICL&L::INSrKMON FORM>=NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART'A CERTIFICATION(continued) Y Property 1#� i5`sK�r�T.'4.V�Yer:`h Date of Irusspection: i 11,11oc, Further Evaluation is Required by the Board of Health: ` 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. —S Ys Will pass unless Board of Health determines in accordance with 310 CMR 15.303(lxb)that the ayatem Isnot functioning in a manner which will protect public health,safety and the environment: �! spogl,pr privy is.within 50 feot,of a surfacie:water } Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh e-t!;SIJ!) f " vvT'': s.i r, .i„ i ty� g o1r tr+! System will fail unless the Board of Health(and Public Water Supplier,if any)determines that the `r system is functioning in a manner that protects the public health,safety and environment: +' _n_T system has aseptic tattle and soil absorptipn'system(SAS)and the SAS is within 100 feet of a ,§W4c0-Water supply or tributary to a surface water supply. x. t,. , _ ,'ire system,has a septic tank and,SAS and.the:SAS is within a Zone 1 of a public water supply. a 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 } `fir:PnYate w—4er 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 k the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm,provided that no other failure materia are triggered,A copy,of the analysis must be attached to this form. i< 4 f { Fr �s��'lzi vyrijrlt .�52 Qther: � + I ��:, + a.' • _ � , i a war,fil;ctstT ,z1 t; 31 t 4 .i>j �tf>. x i • - �� d .4 ' :Page 4 of I 1 OFFICIAL;:INSPECTION FORM ' NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM .a. PART A ' CERTIFICATION(continued) Property Address. 5 SSCP ierr► �, ""' R. ,Dak of iu� Y duJt System FatluwCriteria applicable to all systems. "You must igdicate"yes"•or,'Nto'f.to each of the following for all inspections: r 4 V j' `gyp Af sewage into facility-or system component due to overloaded or clogged SAS or cesspool Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or ' clogged SAS or cesspool . Static liquid level in the distribution box above outlet invert due to an overloaded or clogged _ gg SAS or sspool Liquid depth in cesspool is less than 6"belowinvert or available volume is less than %day flow Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s).Number f of times pumped Y portion of the SAS,cesspool or privy is below high ground water elevation. An portion of cesspool or privy is within 100 feet of a surface water supply tributary water Supply. PP Y or Lary to a surface ,T. �✓jAnyportion ofa cess I.or. ✓ P� 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. bAny portion of a cesspool or n poo 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, kms' 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 5l' ppm,provided that no other failure criteria are triggered.A copy of the analysis must be attached to this form.] " (YeslR The system fails.I have:determiaeci 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. ' rt`(4L To be considered a large system the system must serve a facility with a design flow of 10,000 gpd 4015,000 :. gl t .-You must indicate either"yes"or"no"to each of the following: , (11te following criteria apply to large systems in addition to the criteria above) system is withut 400 feet of a surface drinking water supply __.. •. ,,,,_ , the systems within 200 feet of a tnbutary to s drinkin Vie. g water supply the system is located in a nitrogen sensitive area(Interim Wellhead Protection Area—I WPA)or a mapped Zone H of a public water supply well ; K If yo»have answered"yes"to any question in Section E the system is considered a significant threat,or answered "Yes"to 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. ff KINK^ K Page S of 11 si t, OFk'ICIAL INSPECTION FORM.—:NOTYOR VOLUNTARY ASSESSMENTS SUBSURFACE,SEWAGE DISPOSAL SYSTEM INSPECTION FORM .i PART B CHECKLIST n ri�ti ,drt ProPorty Aiddress: .. a a OWAeI: ' -2A Jew UTi? Date of 1I4pCCt10q: 1 Check if the followiii have been done.You must indicate es"or"no"as to each of the following: t4 . ' YeV Not r Pumping information Was.provided by.the owner,occupant,or Board of Health r '' any of the system components pumped out in the previous two weeks? .,,,,; Has the system received normal flows in the previous two week period? 4 u �`� t t n✓ eve.large volumes of water been introduced to the system ` y recently or as part of this inspection? ?; 'r "Were as built plans of the system Obtained t Y twined and exatnined?(If the were not g - t Y o available note as N/A) / .►L, Was the facility or dwelling inspected for signs of sewage back up? ,�.., Was,the site inspected for signs of break out? Were all system components,excluding the SAS,located on site? { ti ..►L_ Were the septic tank manholes uncovered,opened,and the interior of the tank inspected for the condition-.. f of the baffles or tees,material of construction,dimensions;depth of liquid,depth of sludge and depth of scum? Was the facility owner(and occupants if different from owner)provided with information on the proper k` maintenance of subsurface sewage disposal systems? r The size and location of the Soil Absorption System(SAS)on the site has been determined based on: y C ,VO .. .7Existinft �p g information.For example,a plan at the Board of Health. v Determined in the field(if any ofthe failure,criteria related to Part C is at issue approximation of distance is unacceptable)[310 CMR 15.302(3)(b)l fstif njStC<'xa:i SJ;, . t3f I1tifi iit;;C:; t Page 6 of 11. a. OFFICIAL INSPECTION FORMNOTYOR VOLUNTARY ASSESSMENTS } SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION Plrwpet'ty Address: alc5riJ � pections U W1114Q: !F h FLOW CONDITIONS 4 RESIDENTIAL Number of bedrooms(design): f n.€i:Number of bedrooms(actual): DESIGN Aow based on"310`CMR 15.203 for exam L Number of cuirent ( example: 110 gpd x#of bedrooms): �00 residents: ��— Y . Does residence have a arb e (y ) y�C*P*,ft*eeQg ag gander es or no : # Is laundry on a separate sewage system(yes.or no).ID [if yes separate inspection required] Laundry system inspected(yes or no): Y : Seasonal use:(yes or no): 11Q ,a t. •; E4 f , ` Water meter readings,if available(last 2 f' pd;: Sump pump(yes r Y usage(gPd))' �D Afkic�i®Q 0 no): Last date of occupancy: r x,} TRLAk '+ ''�!1�f! ,:.•,r 'ria t_� :ari"!t t{}i!`,. .',wl(:`ts .:F; "• COMMERCIpI,RNpUS Type of estebli$hment;.; } Design flow(based on 310 C 15.203): aad tr, Basis of design flow(seats/persons/sq%etc.):. ' Orem trap present(yes or no); ' r Industrial waste holding tank present(yes or no): a " Non-sauatary waste discharged to the Title 5 system(yes or no):_ Water meter readings,if available: ' Last date of occupancy/use Ph-,l )(to's:a�(11 1(7.P iJ*;1 i�(a'.)I ° P t •s� 4 4 j j�. ' a 4 OTHER GENERAL IKdil e'7 j"4 t�.k 'I!){�li�.lf£t4!.i.tltS,(It+ 47 INFORMATION RMATION" Pumping•Records Source of in_formatioa: Was system pumped as of a inspection�(yesno): If yes,volume pumped: ` Reason for pumping: '—gallons—How was quantity pumped determined? �'' _ TY OF SYSTEM ' a4,Septic tank,'distributionl box,soil absorption system.Single ¢ s cesspool 1 Privy...... es or n ,-.,.Shared system(Y o)(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) F "77'44t k ,.. Attach a copy of the DEP approval 1, (¢escnbe) Approximate age of all ponents,date installed.(if known)and source of information: Were.sewage odors detected when arriving at the site(yes or no):AD ,l a� axe' t � }"`.;{ s"'4� .•d . , y- .f -t •�,, -t1E '..}syr 4 . 9 s OFFICIAL INSPECTION:FORM-=NOT FOR VOLUNTARY ASSESSMENTS } SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART.C. SYSTEM.INFORMATION(continued) P� "_1, AOdros;; '2-46L�.1 Q)�. ' •:r�. 2 M rz. , !i Mater Qf +KQQ: Y �ihrs�r>r `xrk�'F3aY ,§«•.' {t�: § i c i .. ,d Ig �, .KUMING SEWER(locate on site plan) ,Depth below grade. Materials of construction: ;cast iron's.4 X40 PVC other xplain): ` Distance from private water supply well or suction line: Comments(on condition of joints,venting,evidence of leaks e,etc.): ` 4 ,?TIC'TANK: (locate onsite plan) f tb below grad D4p w e: Material of construction:, concrete_„_metal_fiberglass__polyethylene other(ex lain r If tank is metal list e: Is ag ,_„_ age confirmed by a Certificate of Compliance(yes or no):_(attach a copy of h i Sludge r � f r F Je tL. } x y k` Distance from top of sly�dge to bottom of outlet tee or bade. Scum thicknessr '- — ;' Distance from top of scum to top of outlet tee or bade: $'� Y Distance from bottom of scum to bottom of outlet tee or baffle:�� w , How were dimensions determined: Comments(on pumping recommendations,inlet and outle tee or baffle condition,structural integrity,liquid levels ,K ' as related VORtet invert,evidence o�eakage,etc.): ` r GREASE TRAP' ovate onsite plan) Depth..below 8rade �• _ . _ ... .. r` ' Material of construction: concrete_metal fiber lass__polyethylene „ (explain): ..— g ylene_other Dimetasions: + ' Scum thiclatess: L y `Distance from top of scum to top of outlet tee or baffle: t Distance from bottom of scum to bottom of outlet tee or baffle: Date of last.pumping: , f r co Monts(on P PMg recommendations,inlet and outlet tee or baffle condition,structural integrity, as.related to outlet inv leakage, grity,liquid levels ert,evidence of leaks a etc.): s r Page 8 of 11 �A r OFFICIAL-.INSPECTION FORM•=NOT FOR VOLUNTAR Y ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM ... >; PART C SYSTEM INFORMATION(continued) ' Property Address: - � }, A A y-er MA 61 us , Owner: Ted s of Inspections 01-1116 TIGHT or HOLDING"TANK• (tank must be pumped at time of inspection)(locate on site plan) .t Depth below grade a Material of constra n coacrete metal—fiberglass rgl _polyethylene other(explain): Dimensions: 41 ' ° Ca ' _,gallons v;yT"' Design Flow: allons/day Alarm present(yes or no): Alarm level .,Alarm in working order(yes or no): 4 Date of last pumping; { Comxnents (condition of alarm and float switches,etc.): kk T §']DISTRIBUTION : (if present must be opened)(locate onsite plan) ; All 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.): } pf le- .. l:+4d'Y s.k.lil1..A f; " .• :1; t• ..1..1;1. a ,.. .. 4 truin CHAMBER: #Qqcate on Se"plan) tq ii ji,�d Pumps lA working order(yes or no) n d .working order(yes or no): 'j, w Comments.(note condition of pump chamber,condition of pumps and appurtenances,et"'.): 1 t{r 41 64. t t y ?, �t �t a 4 R i _ _ •d' 4xYt��a a iati ;1 ! t(,�'1 is � d 8 (` r Page 9 of 11 ss k ^ i E OMCIALI INSPECTION FORM=NOT FOR VOLUNTARY ASSESSMENTS i. SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM iJ rib. PART..0 f 4' SYSTEM INFORMATION(continued) { C i rte►AddOlqon ress. '�� • � - 'r, _ A9 E�v�l e uer�,.r'I�DI FsNS - . k:. DAto of Inspection. i c '7k�ii.4a ORMON SYSTEM(SAS): (locate on site plan,excavation not required) d f If SAS aoi�las .eP1in.why: tr ,r;;t•ia,� ,i . . `� S� r '1}gyp leaching pits,number. f c" .;�,,;;>leachto$chambe Vis,number eaching galleries;.number. s leachio trench n ' $ es, umber,length: ' `leaching fields,number,dimensions: , overflow cesspool,number. innovativOalternative system Type/name of technology: . Comments(note condition of soil,signs of hydraulic failure,level of ponding,damp soil,condition of vegetation, etc.): I 1 (cesspool must be pumped as part of inspection)( locate on site plan) k r #Number and configurati 1 on: '! M" Depth to +of liquid to inl ` p q et in Dept of solids layer. Depth.of scum layer. z 3 i Din�nsioas of cesspool: I Materials of construction: Indication of ` groundwater inflow(yes or no): E ' Comments(note condition of soil,'si gqs of hydraulic failure,level of ponding,condition:of vegetation,etc.): , • :r PRm, 7 (locate on site plan) 'Materials of co nsttucttgn. !. Dimensions �` ------------ Depth of solids: Comments(note condition of soil,sips r 11, gns of hydraulic failure,level of ponding,condition of vegetation,etc.): r .. ^ J. f Spr I 1 � eii X4l.Lw ru Ft-•� it i• .. tY ! L,,z f ��i!+'j�'' ikll•� `. fit: 1 ti" Page 10 of 11 �,►� Y OFFICIAL'INSPECTION FORM-�NOT FOR VOLUNTARY ASSESSMENTS Yi } SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM .'Frz PART C ,'' SYSTEM INFORMATION(continued) q rE{ ,t d Pro 5 8 pe�rty Address. I ID OwIIer:•' c r , ,�a Qf IIIIs its �1CCt1oIIt• ZT p rt t��4t t;•t�F�Z,t s{ Ti •' �.an+e!..�.u.e*,..�++'.�e,vri«,�. . .,_..., .•�( x. f f.; SICI tiiiiAF$'WAGE DISPOSAL SYSTEM Provide a sketch of the sewage disposal system including ties to at least two permanent reference landmarks or s benchmarks.Locate all wells within.100 feet.Locate where public water supply enters the building. .4A is } ,C;c?t 16 i ,',.!'J �•, i 1 t I. ._ sY,,a el r'Xr1f!. �i ;, r ,i `� /per ,,.•./ t� �' iS alt ;F 4 1 � ijj F 4 tfi ty a;l tY ° .t;t x k 1 } " •, y p.„ y y . oh ?-: i, i w4 �Fal� ,..' ,, a t �f: .tiJ i .iT ? _ c• C�Yf ytt. t , u t I 10 , Y 1 �.��`�'� a .:1t,;. � . ; �� �Jr �; �-• ,: .� -' �° E f. f p ofy o"w� lF k;Cr, F_ , �����v—'`�\ ��• S erg s{ r .Page 11.of 11 . :h OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM rfx PART Cot SYSTEM INFORMATION(continued) 3��` j 'ii /t r0r'r-lr,s*'dd ��'\{.'{��S�i/I Yr w4or. ��rti l M�r 54�.Y•4s, 4 - _ F .. . � Fs p aha a Date 01t10�i E `14t IS Yp 41y�1 7.y. } TrcF C�rcf { i. Slope f. rF 4t y �� W Y. s''Check'cellar f. t4 , Shallow wells , " stunted depth to ground water feet - t Please indicate(check)all methods used to determine the high ground water elevation: btawed from system design plans on record-If check date of design Observed site(abutting �' Plan reviewed: hole within 150 feet of SAS) Checked with local Board of Health-explain: ,a Checked with local excavators,installers-(attach documentation) Accessed USGS database ex plaui: 4. �t l You mist,idescn*be how you establ' bed the high ground water elevation: r f' l VVti Ir :n 1 w ��,• �� � � � � r x �u, r! k t tr ' a t l ! d + r h Z. 4 J r t 11 y a - vMi-r a r wj4hf' $ f'1F"t'"Srt tti(•.� l r.. // F .cM s: i 11 �.: vo; u�t rrnL lu:u► r�� vta 506 a573 ;WORTH ANDOVER DPW Z002 � i J 1' - , i i+l, r='. 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I Ibllhxll,�.nl,l ? ��. 3 � j U,f`I`lr�t, ��` � •n{aw.m.!.,: Y 's 1 2� {'�11l4,�'i}1i,tiu d a� y� r• r n 1 iA, � �n�'jio � � ��• i�s�xl.�, '� .It �,,. -ti: 13.1,r 1t1' a, .' ,�, '�, 1'•}���' ly,,,` ',.'Q:�� op �}Y � '!�',ra�•Nw I' I'�� 1) }i{}frr'1 �.a. rlbl:•' ,I� V,�i SNI p r ".I �e;I'!�F� ic': , i �:r, 1x C..I 19 iii r•�In.:e1.,1.�a�:.t./ v 1; 17,?j ir�hti {fir , ir. S . ��,�•,:,�yhry„ tt'I 1 , {�}a'1!J' f��.A,:n,�„i,I.Y��. n I�"Ir 1 i.:} 'V yy IV;-I.. it 1, •t��lfilk`yr�i?iv ....-11�•�Ii l�t: ' ,.•, �,1 4��, t,r, ++(C+1 i f 1(141 S{!lt I.af I Y< 4 8 , t�i5 i �� 'vv tt.7.11�5�tal�uiy }1Y!, `� y t 11 "�A k1�N�"1!�!r'• `,��F.Ihl11 ,� lj �'R" iYYMMMj F'llLI j9 .1' I�,��,� 11' Illitifil. lai1A; iti�, J�c�l r x'13r� s;al° 1.' a 1� p h C e � c c. _• .;. s _ �_ s _�-- _tet: ��i ..- _��.-`�—,-:'c'; :.h�.=tea:'-- _ -_�J_�r-`m's's.=� Q• ti •--���__-:_. .:3.-,_^ =rte�:�_-_=�_�Y_.:, :. - TER BILLING BISTORT S. TED METER *1: 3-1604043-16040411R3160404-ROCEIi �- 1265 SALEM ST CYCLE a ------------SERVICE PRIflR CURRENT USE MATER S1:WER FEES TOTAL 1t 4 00-19 119/09f1999 24S8 2503 &)45 122.85 0.00 0.00 122.85 1 20 2 2060-23 41/10/2©©® 2503 2523 til20 Sb_60 0-08 0.90 54-4 t, x 3 2000-33 03!29!2000 2523 2543 { } 28 54-60 8.90- 0-88 S4.6 4 20011-43 116/15/2000 2543 2563 (x)20 S4.60 0.08 8.00 54.6 ' S 2001-13 09/11/2000 2S68 2600 `1) 37 101.01 8_00 11-00 112-111 y W a � f loo 5 Ole m 3L REWlEU CHOICE a or <ENTER> BORE HISTURY: z LL - orae CL tom' G Form 4 -- System Pumping Record Commonwealth of AAassaehusetss Massachusetts ,System Pumping Record r System Owner System Location Tom: Emergency Routine Cesspool: No Yes Septic tank: WoYes Date of Pumping: _�f ,G'q Quantity Pumped: �6nllons System Pumped By: Wind River Em7ronnrenta/, LLC Permit#: Contents transferred to: Contents Disposed at: 1 Date: Pumper Signature: Condition of System/0"w Comments RECEIVED AUG 0 4 2004 TOWN OF NORTH ANDOVER HEALTH DEPARTMENT Dep Approved Form - 12/07/95 'C'\ Commonwealth of Massachusetts City/Town of System Pumping Record NORTH AND VE.T n ,4 Form 4 OW DEP has provided this form for use by local Boards of Health. Other fo m NN�NR R t!M information must be substantially the same as that provided here. Befo h 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 1. System Location: forms on the oZ b5 �1 em computer,use l I only the tab key Address ` to move your 1�qc��, a�Yl�©VGA -- - — — I��v,�/ �A cursor-do not use the return City/Town State Zip Code key. 2. System Owner: Alk 5oy) _i-lal l ' dv, Name ------ ---- —.---- - Address(if different from locations --- - --- - - --- ---- -- - City/Town StateZip Code bu1 233- 9 0 3 -------- Telephone Number B. Pumping Record 1. Date of Pumping 7- 93- 10 - 2. Quantity Pumped: - -- DateGallo 3. Type of system: ❑ Cesspool(s) VSeptic Tank ❑ Tight Tank ❑ Grease Trap ❑ Other(describe): --- — -— --- --- -- ---- ----- 4. Effluent Tee Filter present? ❑ Yes R(No If yes, was it cleaned? ❑ Yes /No 5. Conditions of System: 6. System Pumped By: Name Vehicle License Number _ W►nc� +�►Ve�r_ Env Pro rnen�i,( Company 7. Location where contents were disposed: Signature of Hauler fit Q - --- Signature of Receiving Facility Date -- — t5form4.doc•03/06 System Pumping Record•Page 1 of 1