HomeMy WebLinkAboutMiscellaneous - 128 MILL ROAD 4/30/2018 (2) 128 miLL ROAD -I
210/107 4"0000'0
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North Andover Board of Assessors Public Access Page 1 of 1
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Property
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Parcel ID:210/107.C-0014-0000.0 Community:North Andover
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Summary
Residence
Detached Structure
Condo
Commercial
Comparable Sales
128 MILL ROAD �� J
Location: 128 MILL ROAD
Owner Name: LIEBLICH,JASON
Owner Address: 128 MILL ROAD
City: NORTH ANDOVER State:MA ZIP: 01845
Neighborhood: 5-5 Land Area:3.03 acres
Use Code: 101 -SNGL-FAM-RES Total Finished Area: 4324 sqft
ASSESSMENTS CURRENT YEAR PREVIOUS YEAR
Total Value: 1,028,000 939,400
Building Value: 804,000 747,800
Land Value: 224,000 191,600
Market Land Value: 224,000
Chapter Land Value:
LATESTSALE
Sale Price: 973,000 Sale Date: 12/02/2004
Arms Length Sale Code: Y-YES-VALID Grantor:WATT,LORENA
Cert Doc: Book:9225 Page: 67
http://csc-ma.us/NandoverPubAcc/jsp/Home.jsp?Page=3&Linkld=993048 7/11/2007
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NOTES:
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"Registered Owner:Stella&Roman Chistyakov �, y
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.Parcel ID: 210/107.C-00140000.0 �t
'Deed Ref.:Book 14331,Page 332
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`Plan Ref.:Plan No.14689 of 2004
Plan No.931 of 1983
Plan No.9317 of 1983 0 6 O�°qo°�
•Zone:R2 ' a
"Septic system location show on this plan is S4e•1-4.15•E
aproximate and based on Commonwealth of \ N579500" - –
Massachusetts Title 5 Official Inspection Form DH FAD
&HELD
dated April 24,2014. MILL(PUBLIC-WIDTH VARIES)ROAD Plot PIan
128 Mill Road
North Andover, MA 01845
GRAPHIC SCA ' LRno
LE
K
w o 20 w 50 160 10 Andrew Square,Suite 201B
South Boston,MA 02127
Neil Murphy Lic.0Surveyor
� FEET
Professional Land Surr00111� Tel.857-544-3061
veyor ( ) www.land-mapping.com
1 inch = 40 ft
Date: July 14, 2017
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NOTES: / s �
•Registered Owner.Stella 8 Roman Chistyakov ' a,
Parcel ID: 2101107.C-0014-0000.0 'o( •�
"Deed Ref.:Book 14331,Page 332 m
'Plan Ref.:Plan No.14689 of 2004
Plan No.931 of 1983
Plan No.9317 of 1983
I �
•Zone:R2
Septic system location show on this plan is s.a•u'1s'E
aproximate and based on Commonwealth of NST'orao^H ss.m
95.00
Massachusetts Title 5 Official Inspection Form DH—D
d HEIR
dated April 24,2014. MILL(PUBLIC.WIDTH VARIEs)ROAD Plot PIan
128 Mill Road
North Andover, MA 01845
GRAPHIC SCALE 'Lim nff6
o 10 Andrew Square,Suite 2018
South Boston,MA 02127
Neil J. Murphy Lic.P7460 Tel.857.544-3061
Pro(essionol Land Surveyor (IN FEW www.land-mapping.mm
1 mca-40 n Date: July 14, 2017
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Poolhouse Plan
SCALE: 1/42"=l'—O"
MAIN FLOOR AREA = 384 SF
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24'-0"
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- - - - - - - - - - - - - -
8" CONCRETE FROST WALL
STEP TOP OF WALL
10"X16" CONCRETE FOOTING
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4" CONCRETE SLAB
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ON VAPOR BARRIER
o ON 6" COMPACTED GRAVEL
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Commonwealth of Massachusetts RECEIVED
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
fztg
< 3
�•" 128 Mill Road NP-.,F NQRTH AN 1! Rt
Property Address
Peter Catalano
Owner Owner's Name
information is
required for every North Andover MA 01845 4/24/2014
page. City/rown State Zip Code Date of Inspection
Inspection results must be submitted on this form. Inspection forms may not be altered in any
way. Please see completeness checklist at the end of the form.
Important:When A. General Information
filling out forms
on the computer,
use only the tab 1. Inspector:
key to move your
cursor-do not Neil J. Bateson
use the return Name of Inspector
key.
Bateson Enterprises Inc.
� Company Name
111 Argilla Road
Company Address
Andover MA 01810
Cityrrown State Zip Code
978-475-4786 S115
Telephone Number License Number
B. Certification
I certify that I have personally inspected the sewage disposal system at this address and that the
information reported below is true, accurate and complete as of the time of the inspection. The inspection
was performed based on my training and experience in the proper function and maintenance of on site
sewage disposal systems. I am a DEP approved system inspector pursuant to Section 15.340 of
Title 5(310 CMR 15.000).The system:
® Passes ❑ Conditionally Passes ❑ Fails
❑ ee s Further Evaluation by the Local Approving Authority
t �
%j 4/24/2014
Inspe or's Signat, Date
The system inspector shall submit a copy of this inspection report to the Approving Authority(Board
of Health or DEP)within 30 days of completing this inspection. If the system is a shared system or
has a design flow of 10,000 gpd or greater, the inspector and the system owner shall submit the
report to the appropriate regional office of the DEP. The original should be sent to the system owner
and copies sent to the buyer, if applicable, and the approving authority..
****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.
t5ins•3113 Title 5 official Inspection Form:Subsurface Sewage Disposal System•Page 1 of 17
Commonwealth of Massachusetts
t Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
r 128 Mill Road
Property Address
Peter Catalano
Owner owner's Name
information is
required for every North Andover MA 01845 4/24/2014
page. Cityfrown State Zip Code Date of Inspection
B. Certification (cont.)
Inspection Summary: Check A,B,C,D or E/always complete all of Section D
A) System Passes:
® 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.
Check the box for"yes", "no"or"not determined" (Y, N, ND)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.
❑ Y ❑ N ❑ ND (Explain below):
t5ins•3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 2 of 17
I
Commonwealth of Massachusetts
= rhTitle 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
t
128 Mill Road
Property Address
Peter Catalano
Owner Owner's Name
information is
required for every North Andover MA 01845 4/24/2014
page. City/Town State Zip Code Date of Inspection
B. Certification (cont.)
❑ Pump Chamber pumps/alarms not operational. System will pass with Board of Health approval if
pumps/alarms are repaired.
B) System Conditionally Passes(cont.):
❑ 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 ❑ Y ❑ N ❑ ND(Explain below):
❑ obstruction is removed ❑ Y ❑ N ❑ ND(Explain below):
❑ distribution box is leveled or replaced ❑ Y ❑ N ❑ ND(Explain below):
❑ 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 ElY ElN ❑ ND(Explain below):
❑ obstruction is removed ❑ Y ❑ N ❑ ND(Explain below):
C) 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. p
System will ass unless Board of Health determines in.accordance with 310 CMR
Y
15.303(1)(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
t5ins•3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 3 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
i p
Subsurface Sewa a Disposal System Form-Not for Volunta Assessments
9 ry
t
128 Mill Road
Property Address
Peter Catalano
Owner Owner's Name
information is North Andover MA 01845 4/24/2014
required for every
page. City/Town State Zip Code Date of Inspection
B. Certification (cont.)
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 fecal
coliform bacteria indicates absent 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:
D) System Failure Criteria Applicable to All Systems:
You must indicate"Yes" or"No"to each of the following for all 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
El ®
Liquid depth in cesspool is less than 6 below invert or available volume is less
,
than /Z day flow
t5ins•3113 Title 5 Oficial inspection Form:Subsurface Sewage Disposal System•Page 4 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
s 128 Mill Road
Property Address
Peter Catalano
Owner Owner's Name
information is North Andover MA 01845 4/24/2014
required for every
page. Cityfrown State Zip Code Date of Inspection
B. Certification (cont.)
Yes No
❑ ® Required pumping more than 4 times in the last year NOT due to clogged or
obstructed pipe(s). Number of times pumped:
❑ Z Any portion of the SAS, cesspool or privy is below high ground water elevation.
❑ ® Any portion of cesspool or 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 N the well water analysis, performed at a DEP certified
laboratory,for fecal coliform bacteria indicates absent 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
and chain of custody must be attached to this form.]
❑ ® The system is a cesspool serving a facility with a design flow of 2000gpd-
10,000gpd.
❑ ® The system fails. I have determined that one or more of the above failure
criteria exist as described in 310 CMR 15.303, therefore the system fails. The
system owner should contact the Board of Health to determine what will be
necessary to correct the failure.
E) Large Systems: To be considered a large system the system must serve a facility with a
design flow of 10,000 gpd to 15,000 gpd.
For large systems, you must indicate either"yes"or"no"to each of the following, in addition to the
questions in Section D.
Yes No
❑ ❑ the system is within 400 feet of a surface drinking water supply
❑ ❑ the system is within 200 feet of a tributary to a surface drinking water supply
❑ ❑ the system is located in a nitrogen sensitive area (Interim Wellhead Protection
Area—IWPA)or a mapped Zone II of a public water supply well
If you have answered"yes"to any question in Section E the system is considered a significant threat,
or answered"yes" in Section D above the large system has failed. The owner or operator of any large
system considered a significant threat under Section E or failed under Section D shall upgrade the
system in accordance with 310 CMR 15.304. The system owner should contact the appropriate
regional office of the Department.
t5ins•3113 Title 5 Official Inspection Forth:Subsurface Sewage Disposal System•Page 5 of 17
I
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
128 Mill Road
Property Address
Peter Catalano
Owner Owner's Name
information is
required for every North Andover MA 01845 4/24/2014
page. Citylrown State Zip Code Date of Inspection
C. Checklist
Check if the following have been done. You must indicate"yes" or"no"as to each of the following:
Yes No
® ❑ Pumping information was provided by the owner, occupant, or Board of Health
❑ ® 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 part 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?
Z ❑ 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 scum?
® ❑ 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:
® ❑ 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) [310 CMR 15.302(5)]
D. System Information
Residential Flow Conditions:
Number of bedrooms(design): 4 Number of bedrooms(actual): 4
DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): 600
t5ins•3113 7Me 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 6 of 17
n�
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not fbi Voluntary Assessments
�( 128 Mill Road
Property Address
Peter Catalano
Owner Owners Name
information is
required for every North Andover MA 01845 4/24/2014
page. Citylrown State Zip Code Date of Inspection
D. System Information
Description:.
Number of current residents: 2
Does residence have a garbage grinder? ® Yes ❑ No
Is laundry on a separate sewage system?(Include laundry system inspection El Yes ® No
information in this report.)
Laundry system inspected? ❑ Yes ❑ No
Seasonal use? ❑ Yes Z, No
Water meter readings, if available(last 2 years usage(gpd)): On well water
Detail:
Sump pump? ® Yes ❑ No
Last date of occupancy: Current
Date
Commercial/industrial Flow Conditions:
Type of Establishment:
Design flow(based on 310 CMR 15.203): Gallons per day(gpd)
Basis of design flow(seats/persons/sq.ft., etc.):
Grease trap present? ❑ Yes ❑ No
Industrial waste holding tank present? ❑ Yes ❑ No
Non-sanitary waste discharged to the Title 5 system? ❑ Yes ❑ No
Water meter readings, if available:
t5ins-3113 Title 5 Official Inspection Forth:Subsurface Sewage Disposal System•Page 7 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
128 Mill Road
Property Address
Peter Catalano
Owner Owner's Name
information is
required for every North Andover MA 01845 4/24/2014
page. Cityrrown State Zip Code Date of Inspection
D. System Information (cont.)
Last date of occupancy/use: Date
Other(describe below):
General Information-
Pumping Records:
Source of information:
Pumped three years ago, owner
Was system pumped as part of the inspection? ® Yes ❑ No
If yes, volume pumped: 1500
gallons
How was quantity pumped determined? Measure tank
Reason for pumping: Inspect tank&tees
Type of System:
® Septic tank, distribution box, soil absorption system
❑ Single cesspool
❑ Overflow cesspool
❑ Privy
❑ Shared system (yes or no) (if yes, attach previous inspection records, if any)
❑ Innovative/Alternative technology.Attach a copy of the current operation and
maintenance contract(to be obtained from system owner)and a copy of latest
inspection of the I/A system by system operator under contract
Tight tank. Attach a copy of the DEP approval.
❑ Other(describe):
t5in_•3113. Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page.8.of.17
' Commonwealth of Massachusetts
Title 5 Official Inspection` ` I In ecton Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
P Y
" 128 Mill Road
Property Address
Peter Catalano
Owner Owner's Name
information is
required for every North Andover MA 01845 4/24/2014
page. Cityrrown State Zip Code Date of Inspection
D. System Information (cont.)
Approximate age of all components, date installed (if known)and source of information:
28
,ears old, 9/2/1986, as built plan
Y
Were sewage odors detected when arriving at the site? ❑ Yes ® No
Building Sewer(locate on site plan):
Depth below grade: eet
Material of construction:
® cast iron Z 40 PVC ❑ other(explain):
Distance from private water supply well or suction line: feet
Comments(on condition of joints, venting, evidence of leakage, etc.):
4"Cast Iron through wall, 3"&4" PVC in house, no leaks visible
Septic Tank(locate on site plan):,
Depth below grade: 4
feet
Material of construction:
® concrete ❑ metal ❑fiberglass ❑ polyethylene ❑ other(explain)
If tank is metal; list age:
years
Is age confirmed by a Certificate of Compliance?(attach a copy of certificate) ❑ Yes ❑ No
Dimensions: 10'x 5'x 4'
Sludge depth:
3"
t5ins-3113. Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 9 of.17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form Not for VoluntaryAssessments
128 Mill Road
Property Address
Peter Catalano
Owner Owners Name
information is
required for every North Andover MA 01845 4/24/2014
page. Cityrrown State Zip Code Date of Inspection
D. System Information (cont.)
Septic Tank-(cont.)
Distance from top of sludge to bottom of outlet tee or baffle
30"
Scum thickness.
3"
8"
Distance from top of scum to top of outlet tee or baffle
Distance from bottom of scum to bottom of outlet tee or baffle
12" �
How were dimensions determined? Tape Measure
Comments(on pumping recommendations, inlet and outlet tee or baffle condition,.structural integrity,.
liquid levels as related to outlet invert, evidence of leakage, etc.):
Pumped septic tank. Inlet tee ok. Outlet tee ok. Depth of liquid at outlet invert. No
evidence of leakage.
Grease Trap(locate on site plan):
Depth below grade: feet
Material of construction:
❑ concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain):
Dimensions:
Scum thickness
Distance from top of scum to top of outlet tee or baffle
Distance from bottom of scum to bottom of outlet tee or baffle
Date of last pumping: Date-
t5ins.•3113. Title.5 Official lnspedion Form:Subsurface Sewage Disposal System•Page 10 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
r 128 Mill Road
Property Address
Peter Catalano
Owner owner's Name
information is
required for every North Andover MA 01845 4/24/2014
page. Cityfrown State Zip Code Date of Inspection
D. System Information (cont.)
Comments(on pumping recommendations, inlet and outlet tee or baffle condition,structural integrity,
liquid levels as related to outlet invert, evidence of leakage, etc.):
Tight or Holding Tank(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 per day
Alarm present: 0_ Yes ❑ No
Alarm level: Alarm in working order: ❑ Yes ❑ No
Date of last pumping: Date
Comments(condition of alarm and float switches, etc..):
" Attach copy of current pumping contract(required). Is copy attached? ❑ Yes ❑ No
t5ins•3113_ Title 5 Official Inspection form:Subsurface.Sewage Disposal System-Page.11 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
128 Mill Road
Property Address
Peter Catalano
Owner Owner's dame
information is North Andover MA 01845 4/24/2014
required for every
page. City/rown State Zip Code Date of Inspection
D. System Information (cont.)
Distribution Box(if present must be opened) (locate on site plan);
Depth of liquid level above outlet invert
0"
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.):
D-box level &distribution equal,has flow levelers. Evidence of carryover.Pumped d-box to
clean. No evidence of leakage
Pump Chamber(locate on site plan):
Pumps in working order: ❑ Yes ❑ No*
Alarms in working order: ❑ Yes ❑ No*
Comments(note condition of pump chamber, condition of pumps and appurtenances, etc.):
*If pumps or alarms are not.in working order,.system is a conditional pass.
Soil Absorption System(SAS) (locate on site plan, excavation not required):
If SAS not located, explain why:
t5ins•3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page.12 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
128 Mill Road
Property Address
Peter Catalano
Owner Owner's Name
information is
required for every North Andover MA 01845 4/24/2014
page. Cityrrown State Zip Code Date of Inspection
D. System Information (cont.)
Type:
❑ leaching_pits number:
❑ leaching chambers number:
❑ leaching galleries number:
❑ leaching trenches number, length:
® leaching fields number, dimensions:
1 field 20'x 45'
overflow cesspool number:
❑ innovative/alternative system
Type/name of technology:
Comments(note condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of
vegetation, etc.):
Soil ok. Vegetation ok. No sign of ponding to surface.
Cesspools (cesspool must be pumped as part of inspection) (locate on.site plan):
Number and configuration
Depth—top of liquid to inlet invert.
Depth of solids layer
Depth of scum layer
Dimensions of cesspool
Materials of construction.
Indication of groundwater inflow ❑ Yes ❑ No
t5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 13.or 17
' Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
r 128 Mill Road
Property Address
Peter Catalano
Owner Owner's Name
information is
required for every North Andover MA 01845 4/24/2014
page. Cityrrown State Zip Code Date of Inspection
D. System Information (cont.)
Comments(note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation,
etc.):
Privy(locate on site plan):
Materials of construction:
Dimensions
Depth of solids
Comments(note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation,
etc..):.
t5ins•3/1.3 T.it e.5 Official Inspection Form:Subsurface Sewage Disposal System•Page 14 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
lug
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
128 Mill Road
Property Address
Peter Catalano
Owner Owner's Name
information is North Andover MA 01845 4/24/2014
required for every
page. Cityfrown State Zip Code Date of Inspection
D. System Information (cont.)
Sketch Of Sewage Disposal System: Provide a view 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. Check one of the boxes below:
® hand-sketch in the area below
❑ drawing attached separately
PH
0�o
i
Loa t lost
t5ins•3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page.15 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
128 Mill Road
Property Address
Peter Catalano
Owner Owners Name
information is
required for every North Andover MA 01845 4/24/2014
page. Cityrrown State Zip Code Date of Inspection
D. System Information (cont.)
Site Exam:
Z Check Slope
Surface water
® Check cellar
® Shallow wells
Estimated depth to high ground water: 4
feet
Please indicate all methods used to determine the high ground water elevation:
® Obtained from system design plans on record
If checked, date of design plan reviewed: 5/15/1984
Date
❑ Observed site (abutting property/observation hole within 150 feet of SAS)
® Checked with local Board of Health-explain:
Design plan
❑ Checked with local excavators, installers-(attach documentation)
❑ Accessed USGS database-explain:
You must describe how you established the high ground water elevation:
Test pit data on design plan
Before filing this Inspection Report, please see Report Completeness Checklist on next page.
t5ins-3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 16 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
r 128 Mill Road
Property Address
Peter Catalano
Owner Owner's Name
information is
required for every North Andover MA 01845 4/24/2014
page. Cityrrown State Zip Code Date of Inspection
E. Report Completeness Checklist
® Inspection Summary: A, B, C, D, or E checked
® Inspection Summary D (System Failure Criteria Applicable to All Systems)completed
® System Information—Estimated depth to high groundwater
® Sketch of Sewage Disposal System either drawn on page 15 or attached in separate file
t5ins-3113 Title 5 official Inspection Form:Subsurface Sewage Disposal System-Page 17 of 17
. . Commonwealth of Massachusetts
City/Town of .
System PtImping Record
Form 4
DEP has providec this form for us&by local Boards of Health. Other forms may be'used, but the
information must a substantially the same as that provided here. Before using.this form,check with your
local Board of He ilth to determine the form they use.The System Pumping Record must be submitted to
the local Board of Health or other approving authority.
A. Facility. Ir iformation
1. System Locati n: Left/Right front of house, Left/Right rear of house, LeftIg ide o—f h s�, Left/
Right side of t uilding, Left/Right front of building, Left/Right rear of building, Under deck
Address a
Dda
Cdy/Town L state Zip Code
2. System Owne . f
Name' C4
Address(if different from location)
cityfrown ' state Zip Code
Telephone Number
B. Pumping Record
1. Date of Pumping D (� �� Quantity Pumped:
Gallons ,.
3. Type of system: ❑ Cesspool(s) Septic Tank ❑ Tight Tank
Other(describe):
4. Effluent Tee Filter present? ❑ Yes No If yes, was it cleaned? ❑ Yes ❑ No
' 5. Condition of System:
yvt
6: System Pumped By:
Neil.Bateson F5821
Name Vehicle License Number
Bateson Enterprises Inc'
company
7. Loca 'where contents.were disposed:
� S: Lowell Waste Water
Sig HaUl Date
t5form4.doc 06/03 System Pumping Record•Page 1 of 1
8/31/2016 Town of North Andover Mail-Fwd:Building codes-128 Mill road
N0ni ;OVER
Massachuse s Michele Grant<mgrant@northandoverma.gov>
Fwd: Building codes - 128 Mill road
1 message
P. Stella <s.schisty@gmail.com> Wed, Aug 31, 2016 at 12:55 PM
To: mgrant@northandoverma.gov
Michele,
We are trying to figure out how to position detached garage on our property on 128 mill road. The area under
consideration is far away from the leach field and septic tank, however it is close the well. I can't find any distance
requirements between proposed detached garage and existing well. Can you advise me on town requirements (if any)
that I should be taking into consideration when position proposed garage on the plot plan ?
Thank you for your help
Stella Chistyakov
978-257-0476
40
-------- Forwarded message ----------
From: Maura Deems <mdeems@northandoverma.gov>
Date: Wed, Aug 31, 2016 at 8:44 AM
Subject: Re: Building codes - 128 Mill road
To: "P. Stella" <s.schisty@gmail.com>
Stella,
The contact in the health department for septic review is Michele Grant, mgrant@northandoverma.gov
Thank you,
Maura
On Wed, Aug 31, 2016 at 7:39 AM, P. Stella <s.schisty@gmail.com> wrote:
Maura,
Thank you for the voice mail, I found the document and page you are referring to. Can you provide an e-mail to a
health department? THe document is silent about the well and I need to locate garage properly on the plt plan before
submitting to town and therefore need to understand the set backs from the well to the garage. (My septic is far away
and nota concern, just s well)
Again, thank you for your help
Stella
978-257-0476
On Tue, Aug 30, 2016 at 11:13 AM, Maura Deems <mdeems@northandoverma.gov> wrote:
Stella,
Just left you a voicemail at 11:15 am regarding the above questions.
Thank you,
Maura Deems
Building Department Assistant
Town of North Andover
On Mon, Aug 29, 2016 at 3:11 PM, P. Stella <s.schisty@gmail.com> wrote:
Dear Maura,
We are trying to figure out if a detached garage will fit on our property at 128 mill road. Can you help us
understanding the following town requirements:
https://mai l.google.com/mai I/ca/u/O/?ui=2&ik=d4458df3dg&view=pt&search=i nbox&th=156el870fcdf87ab&sim l=156el870fcdf87ab 1/3
OF�t%JLu ,6'qq�
ION
o
6
� o,Pqco—i—K. 'V T
PUBLIC HEALTH DEPARTMENT
S
Community Development Division 3o I
To: All North Andover Residents with Septic Systems and Garbage Grinders
1
Please note that due to recent reviews of Title 5 Reports, your property has been identified as
maintaining a working garbage grinder that is being used in conjunction with a septic system.
The Health Department is concerned for the longevity of your septic system.
Garbage grinders are never recommended where septic systems are used, but if they are installed,
the system must be specifically designed to handle the waste from them; your system can not
handle the waste as designed. Please note that continued use of this grinder could quickly cause
a pre-mature failure of your septic system, resulting in a large expenditure to replace it. The
North Andover Health Department recommends that you remove it from your home as soon as
possible.
Some information regarding regular maintenance of your septic system is attached. Please call
the Health Department-at 978.688.9540 if you have any questions, or e-mail your questions to:
healthdeptgtowhofnorthandover.com.
Thank you for taking the time to consider the impact that your current setup has on your septic
system and"the environment.
Sincerely,
Susan Y. Sawyer, REHS/7t�
Public Health Director
/pfd
Enc: Septic System Information: http://www.mass. og v/dep/water/wastewater/dodont htm
1600 Osgood Street, North Andover, Massachusetts 01845
Phone 978.688.9540 Fax 978.688.8476 Web http://www.townofnortharidover.com
OR
{ p ION P�_ _
4SSACHUSE�
PUBLIC HEALTH DEPARTMENT
Community Development Division , I
To: All North Andover Residents with Septic Systems and Garbage Grinders
Please note that due to recent reviews of Title 5 Reports, your property has been identified as
maintaining a working garbage grinder that is being used in conjunction with a septic system.
The Health Department is concerned for the longevity of your septic system.
Garbage grinders are never recommended where septic systems are used, but if they are installed,
the system must be specifically designed to handle the waste from them; your system can not
handle the waste as designed. Please note that continued use of this grinder could quickly cause
a pre-mature failure of your septic system, resulting in a large expenditure to replace it. The
North Andover Health Department recommends that you remove it from your home as soon as
possible.
Some information regarding regular maintenance of your septic system is attached. Please call
the Health Department-at 978.688.9540 if you have any questions, or e-mail your questions to:
healthdeptLtownofnorthandover.com.
Thank you for taking the time to consider the impact that your current setup has on your septic
system and'the environment.
Sincerely,
Susan Y. Sawyer, REHS/
Public Health Director
/pfd
Enc: Septic System Information: http://www.mass.g.ov/dei)/water/wastewater/dodont.htm
`I
1600 Osgood Street, North Andover, Massachusetts 01845
Phone 978.688.9540 Fax 978.688.8476 Web http://www.townofnorthandover.com
Of,NORTH 6 / 82
• Town of North Andover
A HEALTH DEPARTMENT
,SSACMU`�t
CHECK#: DATE•
LOCATION: ix - 111
H/O NAME: 1 14
CONTRACTOR NAME:
Type of Permit or License:(Check box)
❑ Animal $
❑ Body Art Establishment $
❑ Body Art Practitioner $
❑ Dumpster $
❑ Food Service-Type. $
❑ Funeral Directors $
❑ Massage Establishment $
❑ Massage Practice $
❑ Offal(Septic)Hauler $
❑ Recreational Camp $
❑ Sun tanning $
❑ Swimming Pool $
❑ Tobacco $
❑ TrashlSolid Waste Hauler $
❑ Well Construction $
SEPTIC Systems:
❑ Septic-Soil Testing $
❑ Septic-Design Approval $
❑ Septic Disposal Works Construction(DWC) $
❑ Septic Disposal Works Installers(DWI) $
❑ Title 5 Inspector $
Title 5 Report $
❑ Other:(Indicate) $
U�)
Health Agent Initials
White-Applicant Yellow-Health Pink-Treasurer
ti
NORTry
671, 8
Of . o y'�NO
Town of North Andover
^' HEALTH DEPARTMENT
,SSACMUSE4
CHECK#: _ DATE:
LOCATION: 1
00 -
1-1/0 NAME: 6
CONTRACTOR NAME:
Type of Permit or License: (Check box)
❑ Animal $
❑ Body Art Establishment $
❑ Body Art Practitioner $
❑ Dumpster $
❑ Food Service-Type. $
❑ Funeral Directors $
❑ Massage Establishment $
❑ Massage Practice $
❑ Offal(Septic)Hauler $
❑ Recreational Camp $
❑ Sun tanning $
.❑ Swimming Pool $
❑ Tobacco $
❑ Trash/Solid Waste Hauler $
❑ Well Construction $
SEPTIC Systems:
❑ Septic-Soil Testing $
❑ Septic-Design Approval $
❑ Septic Disposal Works Construction(DWC) $
❑ Septic Disposal Works Installers(DWI) $
❑ Title 5 Inspector $�
Title 5 Report $ �
❑ Other. (Indicate) $
Health Agent Initials
White-Applicant Yellow-Health Pink-Treasurer
i
z
Gf,NORTH
°.♦
9
• Town of North Andover
HEALTH DEPARTMENT
,S'SACNUSt�
CHECK#: DATE: D
LOCATION:
H/O NAME: CGC�
CONTRACTOR NAME:
Type of Permit or License(Check box)
❑ Animal $
❑ Body Art Establishment $
❑ Body Art Practitioner $
❑ Dumpster $
❑ Food Service-Type: $
❑ Funeral Directors $
❑ Massage Establishment $
❑ Massage Practice $
❑ Offal(Septic)Hauler $
❑ Recreational Camp $
❑ Sun tanning $
❑ Swimming Pool $
❑ Tobacco $
❑ Trash/Solid Waste Hauler $
❑ Well Construction $
SEPTIC Systems:
❑ Septic-Soil Testing $
❑ Septic-Design Approval $
❑ Septic Disposal Works Construction(DWC) $
❑ Septic Disposal Works Installers(DWI) $
❑ Title 5-Inspector $
i le 5 R
D,i'T Report $
❑ Other:(Indicate) $
2526
Health Agent Initials
White-Applicant Yellow-Health Pink-Treasurer
R.J. INSPECTIONS, INC. 117 91
TOWN OF NORTH ANDOVER 7/9/2007
Title V fee for 128 Mill Road 50.00
Citizens Bank-Operating 128 Mill Road 50.00
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Septic System Information
128 MILL ROAD
Printed On: Wednesday,July 11, 2007
System ID: BHS-2002-1168
General System Information Latest Permit Information
Calcaluted Design Flow: Test Pits Septic Tank Disposal Trench
Design Flow: One Two Capacity: Number:
Design Flow Provided: Minutes per inch: Width: Width:
Total Flow: Depth: Length: Length:
Seasonal: No No Depth to Water: Diameter: Leaching:
Grinder: Yes No Soil Type: Depth:
Laundry: No No
Haulincr/Pumping Listing uantit
Type System Type Pumped Pumped By Transferred To Disposed At Date Pumped allons
Routine Septic Tank Andover Septic 20 So. Mill Street, Bradford 09/27/2006 1500
Comments: good
Ins .ections: --
Inspected: Expires: Inspector. Status:
07/02/2007 James Wright Conditionally Passes
Comments: Title 5-Needs new D-Box;caving in.
GeoTMS®2007 Des Lauriers Municipal Solutions, Inc. Page 1 of 1
F NORTF1
O , 'qq,
M6'6 OL
O
t
A ago)
r * _
COCNICMt WKN
��SSACHUS����
PUBLIC HEALTH DEPARTMENT
Community Development Division
CERTI FICArIE O F CO_Vl�1'.GI.AgCE
As of.-
August
f:August 7, 2007
This is to cert that the individual su6surface disposal system received a
SATISTFACZ0RMSTECTI0Yof the:
Distribution Bo,-� Only
Repaired By:
Todd Bateson
At:
128 WiffWpad
Wap 107-C; Got 14
.7lrorth Andover, JKA 01845
'The Issuance of this certificate shall not 6e construed as a guarantee that the system will
function satisfactorily.
,.,,S a Sawyer
Pu6iic Ifealth Director
1600 Osgood Street,North Andover,Massachusetts 01845
Phone 978.688.9540 Fax 978.688.8476 Web www.townofnorthandover.com
Commonwealth of Massachusetts
u Title 5 Official Inspection Form
m
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
128 Mill Rd North Andover, MA 01845
Property Address
Owner
F1 i ZahP� & Jascr
c)n Li PbI i h
_
information is Owner's Name
required for North Andnvpr MA 01845 08/07/07
every page. City/Town State Zip Code Date of Inspection
Inspection results must be submitted on this form. Inspection forms may not be altered in any
way.
Important:
When filling out A. General Information
forms on the
computer, use 1. Inspector: R RECEiVE
only the tab key
to move your James Wright
cursor-do not
use the return Name of Inspector AUG 2 7 2007
key. RJ Inspections, Inc, ntA !Q n T cm
Company Name L_VHEALTH DEPA iVI:EN' ..
VQ 270 Lawren .Pt
Company Address '
Methuen
City/Town -- State 01 8e 4
Zip Cod
( 978 ) 68'1 -8759
Telephone Number License Number
S. Certification
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 f
p o the inspection. The e 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 C 5.000). The system:
(� asses ❑ Conditionally Passes ❑ Fails
Needs Further Evaluation by the Local Approving Authority
/tel. ..... _ _;
% Inspector's Signatpi---- D
The system inspector shall submit a copy of this inspection report to the Approving Authority (Board
of Health or DEP) within 30 days of completing this inspection. If the system is a shared system or
has adesi n flow of 10 000 gpdor9r
eater, 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.
****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 condition f
s o use.
Title v Inspection Form•O8106
Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Pae 1 of 15
Y 9
Commonwealth of Massachusetts
i Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
128 Mill Rd. North Andover, MA 01845
Property Address
Elizabeth & Jason Lieblich
Owner Owner's Name
information is
required for North Andover MA 01845 08/07/07
every page. City/Town State Zip Code Date of Inspection
B. Certification (cont.)
Inspection Summary: Check A,B,C,D or E/always complete all of Section D
A) System P es:
r 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: \
--�/�` / % r_zl, ' X
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 bbx. System will
pass inspection if(with approval of Board of Health):
❑ broken pipe(s) are replaced
❑ obstruction is removed
Title v Inspection Form•08/06 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 2 of 15
Aug 17 07 06:51a Turkishlamps.com 7074319852 p.2
1 F �1QR7Ff �
O
► IOLntM,..l� �
�SS�I�HUS��
PUBLIC HEALTH DEPARTMENT
Community Development Division
C -.; A. -C.�� ()E (-10C
J-.; 49VCE
A.-,;-, of:
August: 7, 2007
his is to cert that the indtividuaCs-Osu,face drsposaCsystem-receiveda
SA117ST4CT012`YI ST E07M-I ''of the:
1D. istfibution BoX only
WepairedBY.
ToddBateson
128 91' 9� qad
Map 107. , Lot 14
Xorth,gndo-(Jer, MA 01845
7Tw Issuance of this certiftcate shalt not be construed as a guarantee that the system wiCC
function satisfactorily.
ell
Susav'IY. Sawyer
PuTCc7featth Director
1600 Osgood Sireel,liodh Andover,laossachusetts 01845
Phone 918.688.9540 Fax 918.688.8416 Web www.lownofnorthandover.com
Cl)
Q
of .�tio Commonwealth of Massachusetts Map-Block-Lot
107.C-0014-
LO ° 31 Board of Health
Perrnii No 1
'.'.. North Andover BHP-2007-0245
........................
O �SSACwUSE FEE
$125.00
....._.... . ...._.._.
Disposal Works Construction Permit
Permission is hereby granted Todd Bateson I I
to(Repair-D-BOX REPLACEMENT)an Individual Sewage Disposal System,
sit No l 7 Si l�rlTT T n^A.T'.
=..-.. = ..........................
as shown on the application for Disposal Works Construction Permit No. BHP-2007-024 Dated July 27,2007
... . . ..:............
1
Issued On:Jul-27-2007 -- ........
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4. '
COMMONWEALTH OF MASSACHUSETTS >/
EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS
DEPARTMENT OF ENVPROTECTION ENVIRONMENTAL PROTE C '
y
t
TITLE 5
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM
PART A
CERTIFICATION
Property Address: 12g A4}11 PAz
Na Anr3ypr MA f118d5
Owner's Name:R1 i 7aheth r inh] -h
Owner's Address: 128 Mill Rd.
No. Andover MA 01845Mni--PARTMENT
Date ofinspection: ,July 2, 2007. ,.._,___
Name of Inspector: (please print).Tamps �jri ��_ JUL
Company Name:R,T TpGpecti ons- Tnr•
Mailing Address:_270 LawrQ,nnp q
e thu ens MA 01 844 E'R
Telephone Number: ( 9'78 ) 681 -8759
CERTIFICATION STATEMENT
I certify that I have personally inspected the sewage disposal system at this address and that the information reported
below is true,accurate and complete as of the time of the inspection. The inspection was performed based on my
training and experience in the proper function and maintenance of on site sewage disposal systems. I am a DEP
approved system inspector pursuant to Section 15.340 of Title 5(310 CMR 15.000). The system:
basses
,/Conditionally Passes
Needs Further Evaluation by the Local Approving Authority
Fails
Inspector's Signature:
.__Date; �
The system inspectors bmit a copy of this inspection report to the Approving Authority(Board of Health or
DEP)within 30 days o 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 perfor rl in the future under the same or different
conditions of use.
A
Title 5 Inspection Form 6/15/2000 page 1
Page 2 of 11
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION (continued)
Property Address: 12 8' Mi 11 Rd.
No. Andover, MA 01845
Owner: F� ; �aLAth T i hl i c-h
Date of Ins p }ection: July 2, 2007
Inspection Summary: Check A,B,C,D or E/ALWAYS complete all of Section D
A. System Passes:
1 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 onditionally 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.
NDexpl�ai
./ Ubservati
on 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
cdon is removed
distribution box is leveledre lace
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:
2
Page 3 of 11
OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION(continued)
Property Address: 1 2 R Mill Rd
RT
o Anr�n er, MA Q_1845
Owner:_F1 ; gab h Lieblich
Date of Inspection: July 2, 2007
C. Further Evaluation is Required by the Board of Health:
Conditions exist which require further evaluati y the Board of Health in order to determine if the system
is failing to protect public health,safety or the en ' nment.
1. System will pass unless Board ealth determines in accordance with 310 CMR 15.303(1)(b) that the
system is not functioning ' 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
Z. 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 SA Zone 1 of a public water supply.
_ The system has a septic tank and and the SAS is within 50 feet of a private water supply well.
_ The system has a septic 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:
3
Page 4 of 11
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION(continued)
Property Address: 128 Mill Rd.
No. Andover1 MA 01845
Owner: Elizabeth Lieblich
Date of Inspection: July 2, 2007
D. System Failure Criteria applicable to all systems:
You must indicate"yes"or"no"to each of the following for all inspections:
Yes No
T ✓�/ ackup of sewage into facility or system component due to overloaded
k! Discharge or ponding of effluent to the surface of the ground or surface waters
due
SAS or cesspool
dogged SAS or cesspool e s de to an overloaded or
— Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or
cesspool
xlquid depth in cesspool is less than 6"below invert or available volume is less than '/2 day flow
Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s).Number
tunes pumped
�,,Any portion of the SAS,cesspool or privy is below high ground water elevation.
y portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a sur
water supply. face
-�, y portion of a cesspool or privy is within a Zone 1 of a public well.
✓✓ y 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 buteater than
gI' 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 ofammonia
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.]
/f'�J(Yes/No)The system fails. I have determined that one or more of the above failure criteria exist as
described in 310 CMR 15.303,therefore the system fails.The system owner should contact the Board of
Health to determine what will be necessary to correct the failure.
E. Large Systems:
To be considered a large system the system must serve a facility with a design flow of 10,000 gpd to 15,000
gpd.
You must indicate either"yes"or"no"to each of the following:
(The following criteria apply to large systems in addition to the criteria above)
yes no
_ the system is within 400 feet a surface drinking water supply
the system is withi 00 feet of a tributary to a surface drinking water supply
the system i ocated in a nitrogen sensitive areaInterim
( Wellhead Protection Area—IWPA)or a mapped
Zone II of a public water supply well
If you have answered"yes"to any question in Section E the system is considered a significant threat,or-answered
"yes" in Section.1)above the large system has failed.The owner oro operator of an I
significant threat under Section E or failedp Y large system considered a
under Section n
shall upgrade the stem in
15.304.The system owner should contact the appropriate regional office of the D partmentordance with 310 CMR
4
Page 5 of 11
OFFICIAL INSPECTION FORM--NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART B
CHECKLIST
Property Address: 1.28 Mill Rd.
No. Andover, ,MA 01845
Owner Elizabeth j,i, blich
Date of inspection: July 2, 2007
Check if the following have been done.You must indicate"yes"or"no" as to each of the following:
Yes o
'Pumping information was provided by the owner, occupant,or Board of Health
✓. 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 art of this inspection?
P P
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 scum ?
ZWas the facility owner(and occupants if different from owner provided with information formation 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:
Yes
J Existing information.For example,a plan at the Board of Health.
Determined in the field(if any of the failurc criteria related to Part C Is at issue approximation of distance
is unacceptable) [310 CMR 15.302(3)(b))
5
Page 6 of 11
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION
Property Address: 128 Mill Rd.
No. Andover, MA 01845
Owner:_Elizabeth Lieblieh
Date of Inspection: July 2 y 20-0-7
RESIDENTIAL FLOW 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(yes or no):
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):—
Water meter readings, if available(last 2 years usage(gpd)):
Sump pump(yes or no):
Last date of occupancy: k-
COMMERCIALANDUSTRIAL
Type of establishment:
Design flow(based on 310 CMR 15.203 2-nd
Basis of de>hold'
eats/perso etc.): -
Grease traps or _
Industrial wtank present(yes or no):—
Non-sanitacharged to the Title 5 system(yes or no):
Water mete , if available:
Last date of occupancy/use:
OTHER(describe):
GENERAL INFORMATION
Pumping Records
Source of information: el,,�'<�t
Was system pumped as part of the inspection(yes or no): ,trO
If yes,volume pumped: gallons----How was quantity pumped determined?
Reason for pumping:
TYP F SYSTEM
Septic tank,distribution box, soil absorption system
Single cesspool
Overflow cesspool
_Privy
—Shared system(yes or no)(if yes,attach previous inspection records, if any)
_Innovative/Alternative 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, die installed(if known)and source of information:
Were sewage odors detected.when arriving at the site(yes or no):N ^
6
Page 9 of 11
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: .128 Mill Rd.
]din_ Andover, MA 01845
Owner: Elizahefh T j Phlich
Date of Inspection: July 2, 2007
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:
cling trenches,number, length: _
?� leaching fields,number,dimensions: .
overflow cesspool,number:
innovative/alternative system Type/name of technology:
Comments(note condition of soil, signs of hydraulic failure, level of ponding,damp soil, condition of vegetation,
etc.):
CESSPOOLS:T(cesspool must be pumped as part of inspection)(locate on site plan)
Number and configuration:
Depth—top of liquid to inlet invert:
Depth of solids layer:
Depth of scum layer:
Dimensions of cesspool:
Materials of constructio .
Indiction of groundwa er inflow(yes or no):
Comments(note condition of soil, signs of hydraulic failure,level of ponding,condition of vegetation,etc,):
PRIVY: . (locate on site plan)
Materials of construction:
Dimensions:
Depth of solids:
Comments(note condition soil,signs of hydraulic failure,level of ponding, condition of vegetation,etc.):
9
Page 10 of 11
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: 128 Mill Rd.
_NO_ Andover, MA_ 01845
Owner: F1 ;3.abph Lieblich
Date of Inspection: Ju lY 2 2007
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.
10
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Page I 1 of 11
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: 12 S M i 1 1 Ed-
No
d-
No Anrinvpr- MA 01845
Owner:P] i zahP h r i eblich
Date of Inspection: July 2, 2007
SITE EXAM
Slope
Surface water
Check cellar
a ow we s
Estimated depth to ground water�eet
Please indicate(check)all methods used to determine the high ground water elevation:
g
Obtained from system design plans on record-If checked,date of design Plan reviewed:
wed:Obse rved site(abutting pro rh/observation hole within
150 feet of SAS
Checked with local Board of Health
explain:
Checked with local excavators, installers-(attach documentation
Accesseddatabase-
explain:
USGS database ex lain;
P
You must describe how you established the high ground water elevation:
11
Page 1 of 3
SUMMARY OF GROUND-WATER LEVELS MAY 2007 PROVISIONAL
(NOTE: Wells with * also available in real-time at top of Ground-Water
Data page; OWc, monthly measured value used in high ground-water level
estimation report, USGS Open-File Report 80-1205. )
WELL L START NET CHANGE DEPARTURE WATER LEVEL
T I YEAR IN MONTH IN ONE FROM BELOW LAND-
0 T OF YEAR MONTHLY SURFACE
P H RECORD MEDIAN DATUM
0 0 (OWC)
(FEET) (FEET) (FEET) (FEET) DAY
MASSACHUSETTS
ACTON 158 * TS 1965 - 0.26 - 0.07 + 2.16 15.62 22
ANDOVER 462 VS 1968 - 0.32 - 0.98 + 0.68 13.71 23
ATTLEBORO 83 VS 1964 - 0.35 - 0.28 + 0.16 3.49 23
BARNSTABLE 230 FS 1957 + 0.73 + 0.83 + 1.21 21.69 30
BARNSTABLE 247 FS 1962 + 1.81 + 0.65 + 1.98 21.72 30
BECKET 12 TS 1986 - 0.42 - 0.90 - 0.03 3.42 22
BLANDFORD 9 VS 1986 ----- - 0.22 + 0.33 1.94 22
BOURNE 198 FS 1962 + 0.48 + 1.36 + 1.28 31.15 29
BREWSTER 21 FS 1962 + 0.23 + 0.16 + 1.65 7.97 22
BREWSTER 22 * FS 1962 + 0.56 + 0.69 + 1.46 28.59 22
CHATHAM 138 FS 1962 + 0.63 + 0.30 + 0.30 22.79 24
CHESHIRE 2 HT 1951 - 2.29 - 1.90 - 1.43 5.00 23
CHICOPEE 95 TS 1984 + 0.44 + 0.32 + 0.45 20.40 21
COLRAIN 8 VS 1965 - 1.40 + 0.44 + 1.08 16.33 23
CONCORD 165 TS 1965 + 1.14 + 1.09 + 2.42 38.39 22
CONCORD 167 TS 1965 + 0.17 + 0.27 + 1.41 5.21 > 22
CUMMINGTON 13 VS 1986 - 2.08 - 0.78 - 0.16 4.60 23
DEDHAM 231 ST 1965 - 0.83 - 0.91 + 0.65 5.21 22
DEERFIELD 44 VS 1965 + 0.04 + 0.05 + 0.36 2.32 23
DOVER 10 TS 1965 + 0.16 + 0.85 + 0.70 31.30 22
DUXBURY 79 * VS 1965 -
0.47 + 0.26 + 0.85 7.27 21
DUXBURY 80 VR 1965 - 0.56 - 0.33 + 1.16 20.56 21
EAST BRIDGEWATER 30 HT 1958 - 1.70 - 0.94 + 0.67 5.85 25
EDGARTOWN 52 VS 1976 + 1.06 + 1.00 + 1.40 15.57 29
FOXBOROUGH 3 TS 1965 - 0.09 + 0.63 + 0.72 17.72 21
FREETOWN 23 TS 1964 - 0.48 + 0.14 + 0.95 12.06 23
GEORGETOWN 168 VS 1965 - 0.42 - 0.99 - 0.18 4.46 23
GRANBY 68 VS 1954 - 0.39 + 0.70 + 0.57 6.19 21
GRANVILLE 5 TS 1965 + 1.30 + 0.33 + 0.77 31.00 22
GRANVILLE 6 SS 1965 - 1.89 - 1.61 - 0.60 4.93 22
GREAT BARRINGTON 2 VT 1951 - 1.55 - 1.06 + 0.82 9.21 21
HANSON 76 VS 1964 - 0.24 - 0.11 + 0.28 4.27 21
HARDWICK 1 TS 1965 - 0.99 + 1.79 - 0.44 13.89 22
HAVERHILL 23 TS 1960 - 1.09 - 1.43 + 1.65 8.78 23
HAWLEY 8 ST 1986 - 0.65 - 0.34 + 0.33 2.84 23
LAKEVILLE 14 * TS 1964 - 1.44 - 0.05 + 2.33 10.79 21
LEXINGTON 104 VS 1965 + 0.29 + 0.21 + 1.18 1.25 22
MASHPEE 29 FS 1976 + 0.00 + 0.54 + 0.63 6.99 29
MIDDLEBOROUGH 82 VT 1965 - 2.89 - 1.03 + 1.35 5.33 21
MONTGOMERY 19 SS 1986 - 1.00 - 0.32 + 0.21 0.70 22
NANTUCKET 228 FS 1976 + 0.86 + 0.82 + 0.55 23.83 30
NEW BEDFORD 116 VS 1964 - 0.09 + 0.03 + 0.35 3.70 23
NEWBURY 27 VT 1965 - 0.78 - 1.00 + 1.80 3.55 23
NORFOLK 27 * VS 1965 - 0.01 + 0.30 + 0.46 5.40 21
NORTHBRIDGE 54 VS 1984 - 0.25 + 0.45 + 0.80 3.13 > 24
NORTON 37 FS 1964 - 1.45 - 1.01 + 1.44 5.80 21
ORANGE 63 TS 1985 - 0.61 - 0.30 - 0.30 6.52 22
OTIS 7 VS 1965 - 2.22 - 0.97 - 0.05 7.98 22
PELHAM 23 * SR 1981 - 0.71 + 0.79 - 2.30 15.03 22
http://ma.water.usgs.gov/cUrTent-cond/data/2007-05.txt 6/6/2007
Page 2 of 3
PELHAM 24 SS 1984 - 0.30 + 0.11 + 0.54 3.12 22
PETERSHAM 16 ST 1984 - 3.97 + 0.69 + 0.65 12.50 22
PITTSFIELD 51 * VS 1963 - 0.72 - 0.11 + 0.32 14.24 22
PLYMOUTH 22 TS 1956 + 0.27 + 0.13 + 1.15 21.83 25
PLYMOUTH 494 SS 1985 + 0.16 - 0.08 + 3.21 26.20 24
SANDWICH 252 FS 1962 + 0.16 + 0.14 + 0.40 46.52 29
SANDWICH 253 FS 1962 + 0.25 + 1.03 + 2.36 47.08 29
SEEKONK 275 VS 1964 - 0.15 - 0.13 + 0.67 5.45 23
SHEFFIELD 58 FS 1987 + 0.43 + 0.00 + 1.04 11.18 21
SOUTHBOROUGH 12 HT 1990 + 0.32 + 1.52 + 3.99 1.83 > 22
STERLING 1 ST 1947 - 1.06 - 0.87 - 0.21 3.41 22
STERLING 177 SS 1995 - 1.61 - 1.36 - 0.47 14.65 < 22
SUNDERLAND 7 SS 1957 - 0.08 + 0.71 + 1.86 8.72 23
SUNDERLAND 68 VS 1983 - 0.68 - 0.32 + 0.35 2.40 23
TAUNTON 337 TS 1964 - 0.70 - 0.35 + 0.72 7.80 21
TEMPLETON 3 VS 1957 - 0.45 - 0.25 + 0.13 3.45 22
TOPSFIELD 1 HT 1936 - 1.53 - 1.18 + 1.89 8.96 23
TOWNSEND 13 TS 1965 + 0.04 + 0.20 + 1.75 10.14 22
TRURO 1 TS 1950 - 0.01 - 0.21 + 0.57 10.04 22
TRURO 89 TS 1962 + 0.07 - 0.11 + 0.34 11.42 22
WAKEFIELD 38 * FS 1965 - 0.27 + 0.19 + 1.03 5.36 23
WARE 43 VS 1965 - 0.54 + 0.38 + 2.29 6.44 22
WAREHAM 51 TS 1959 - 0.52 + 0.45 + 0.54 5.95 24
WAYLAND 2 TS 1965 - 0.16 + 0.30 + 0.63 14.73 22
WEBSTER 1 HS 1958 - 0.65 + 3.62 + 1.05 12.10 21
WELLFLEET 17 VS 1962 + 0.43 + 0.51 + 0.24 9.61 22
WENHAM 76 VS 1965 - 0.37 - 0.68 + 0.49 1.83 23
WEST BOYLSTON 26 SS 1995 - 0.78 + 0.25 + 1.99 3.04 > 22
WEST BROOKFIELD 2 TS 1959 + 0.29 + 0.28 + 1.04 17.22 22
WESTHAMPTON 20 SS 1986 + 0.54 + 3.23 + 2.00 5.89 22
WESTFIELD 62 SS 1957 - 1.21 + 0.06 + 0.14 6.25 22
WESTFIELD 152 TS 1986 - 0.35 + 0.01 + 0.89 2.47 22
WESTFORD 160 VS 2001 - 0.44 + 0.10 ----- 10.30 > 21
WEYMOUTH 2 FT 1965 - 1.32 - 0.64 + 1.98 7.04 21
WEYMOUTH 3 VS 1965 - 0.33 - 0.04 + 0.55 4.27 21
WEYMOUTH 4 TS 1965 - 0.44 + 0.01 + 1.00 5.61 21
WILBRAHAM 55 TS 1965 - 0.13 + 4.77 + 1.16 35.19 21
WILMINGTON 78 * FS 1951 0.34 - 0.30 + 1.27 6.05 23
WINCHENDON 13 ST 1939 - 0.10 + 0.14 + 0.91 3 .43 22
WINCHESTER 14 ST 1940 - 0.06 - 0.09 + 3.01 7.09 > 23
RHODE ISLAND
BURRILLVILLE 187 TS 1968 - 0.69 + 0.08 + 0.13 14.29 22
BURRILLVILLE 395 UT 1992 ----- ----- ----- -----
BURRILLVILLE 396 VT 1992 ----- ----- ----- -----
BURRILLVILLE 397 HT 1992 ----- ----- ----- -----
BURRILLVILLE 398 HT 1992 ----- ----- ----- -----
CHARLESTOWN 18 FS 1946 - 2.19 - 1.25 + 1.26 15.17 21
CHARLESTOWN 586 VT 1992 ----- ----- ----- -----
CHARLESTOWN 587 ST 1992 ----- ----- ----- -----
COVENTRY 342 VS 1991 - 2.05 - 1.46 + 0.59 8.13 22
COVENTRY 411 SS 1961 - 1.10 + 0.05 + 0.74 19.96 22
COVENTRY 466 VT 1992 ----- ----- ----- -----
CRANSTON CITY 439 ST 1992 ----- ----- ----- -----
CUMBERLAND 265 SS 1946 - 1.42 - 1.33 + 0.92 11.51 22
EXETER 6 VS 1948 - 0.64 + 0.15 + 0.93 4 .46 22
EXETER 158 ST 1991 - 2.08 - 2.13 + 0.83 6.73 22
EXETER 238 FT 1991 - 0.57 - 0.23 + 0.44 11.45 21
EXETER 278 HT 1991 - 2.90 - 2.56 + 0.51 9.61 21
EXETER 475 VS 1981 - 0.66 + 0.90 + 0.86 12.39 22
EXETER 554 SS 1988 - 0.89 0.41 + 0.20 9.37 21
FOSTER 40 HT 1991 + 0.04 - 0.34 + 1.88 3.41 22
FOSTER 290 HT 1992 ----- ----- ----- -----
http://ma.water.usgs.gov/current-cond/data/2007-05.txt 6/6/2007
• ' ' Page 3 of 3
d
HOPKINTON 67 ST 1991 - 3.85 2.67 + 1.30 12.82 22
LINCOLN 84 VS 1946 - 0.69 - 0.63 + 1.46 3.34 22
LITTLE COMPTON 142 ST 1992 ----- ----- -----
NEW SHOREHAM 258 UT 1991 ----- -----
NORTH KINGSTOWN 255 VS 1954 - 1.35 - 1.11 + 0.84 6.64 21
NORTH SMITHFIELD 21 TS 1947 - 1.25 - 0.87 + 0.96 6.53 22
PORTSMOUTH 551 HT 1992 ----- ----- ----- -----
PROVIDENCE 48 TS 1944 - 0.29 + 0.12 + 2.57 3.47 22
RICHMOND 417 VS 1976 - 0.84 - 0.34 + 0.29 6.06 21
RICHMOND 600* TS 1977 - 0.43 - 0.73 + 0.53 32.73 22
RICHMOND 785 FS 1989 + 0.02 + 1.56 + 1.95 20.83 22
SOUTH KINGSTOWN 6 VS 1955 - 1.22 + 0.59 + 0.81 10.66 21
SOUTH KINGSTOWN 1198FS 1988 - 1.38 - 0.23 + 0.41 6.96 21
TIVERTON 274 TT 1990 ----- -----
WARWICK 59 ST 1991 - 0.14 - 0.31 + 0.66 4.67 22
WESTERLY 522 FS 1969 - 1.00 - 0.33 + 0.39 11.62 21
WEST GREENWICH 181 US 1969 _ 2.20 - 1.68 + 0.43 15.31 22
WEST GREENWICH 206 ST 1991 - 0.04 - 0.02 + 0.28 3 .74 21
- -------------------------------
>> SET NEW HIGH OR EQUALED HIGHEST RECORDED WATER LEVEL FOR PERIOD OF RECORD
> SET NEW HIGH OR EQUALED HIGHEST RECORDED WATER LEVEL FOR END OF MAY
<< SET NEW LOW OR EQUALED LOWEST RECORDED WATER LEVEL FOR PERIOD OF RECORD
< SET NEW LOW OR EQUALED LOWEST RECORDED WATER LEVEL FOR END OF MAY
------ - DATA NOT AVAILABLE
TOPOGRAPHIC (TOPO) SETTING: F=FLAT, G=FLOOD PLAIN, H=HILLTOP, S=HILLSIDE,
T=TERRACE, U=UNDULATING, V=VALLEY, W=UPLAND DRAW
LITHOLOGY (LITHO) : G=GRAVEL, R=ROCK, S=SAND, T=TILL
CONTENTS OF MAJOR RESERVOIRS (ESTIMATED END OF MONTH READINGS)
(MILLIONS OF CUBIC FEET)
MONTH-END PERCENT OF PERCENT
RESERVOIR CONTENTS AVERAGE FULL
BORDEN BR + COBBLE MTN RES, MA 3110 101 92
QUABBIN RESERVOIR, MA 55255 --- 100
SCITUATE RESERVOIR, RI 5063 106 103
STREAMFLOW FOR SELECTED INDEX STATIONS (CUBIC FEET PER SECOND)
MONTH-END PERCENT MAXIMUM DATE MINIMUM DATE
STREAM MEAN MEDIAN FOR MONTH FOR MONTH
CHARLES RIVER, MA 546 143 877 01 263 16
E. BR. HOUSATONIC RIVER, MA 92.2 68 219 01 40 26
PAWCATUCK RIVER, RI 301 128 462 01 163 31
WARE RIVER, MA 321 147 ----
-------------------------------------------------------------------------
A MONTHLY REPORT PREPARED BY THE
U.S. GEOLOGICAL SURVEY
MASSACHUSETTS-RHODE ISLAND WATER SCIENCE CENTER
10 BEARFOOT ROAD, NORTHBOROUGH, MA 01532
IN COOPERATION WITH THE MASSACHUSETTS DEPT. OF CONSERVATION AND RECREATION,
MASSACHUSETTS DEPT. OF ENVIRONMENTAL PROTECTION, CAPE COD COMMISSION, RHODE ISLAND
DEPT. OF ENVIRONMENTAL MANAGEMENT, AND THE PROVIDENCE WATER SUPPLY BOARD
http://ma.water.usgs.gov/current_cond/data/2007_05.txt 6/6/2007
• Page 8 of l I
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: 128 Mill Rd,
Nn AndavPr, MA 01845
Owner: 7;4hn+- r ; Ahl ; �h
Date of Inspection:July 2, 2007
TIGHT or HOLDING TANK: (tank must be pumped at time.of inspection)(locate on site plan)
Depth below grade:
Material of construction: concrete metal "fiberglass___polyethylene ather(expl'ain):
Dimensions:
Capacity: ga ns
Design Flow: allons/day
Alarm present(yes or no):
Alarm level. in working order(yes or no):
Date of last pumping•
Comments(condition of alarm and float switches,etc.):
DISTRIBUTION BOX: _ (if present must be opened)(locate on site plan).
Depth of liquid level above outlet invert:
Comments(note if box is level and distri u6 tion to outlets equal,any evidence of solids carryover,aily evidence of
leakag�utto or out of box,etc.).
PUMP CHAMBER: (locate on site plan)
Pumps in working order(yes or no):
Alarms in working order(yes or no):
Comments(note condition of purr amber,condition of pumps and appurtenances,etc.):
8
Page 7 of I 1
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: _ 128 Mill Rd.
No- Andover, MA 01845
Owner: PI izabeth Lieblich
Date of Inspection: July 2, 2007
BUILDING SEWER(locate on site plan)
Depth below grade:
Materials of construction: cast iron T40 PVC_other(explain);
Distance from private water supply well or suction line:
Comments(on condition of joints, venting,evidence of leakage,etc.):
SEPTIC TANK:____(locate on site plan)
Depth below grade:
Material of construction:_✓concrete Imetal_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: Ia
Sludge depth: f"
Distance from top of sludge to bottom of outlet tee or baffle: _3
Scum thickness:--0
Distance from top of scum to top of outlet tee or baffle:
Distance from bottom of scum to bottom of outlet tee or baffle: jG
How were dimensions determined: ('GG/'/f r
Comments(on pumping recommendations, inlet and outlet tee or baffle condition,structural integrity, liquid levels
as related to outlet invert,evidence of leakage,etc.):
/27
GREASE TRAP:_(locate on site plan)
Depth below grade:_
Material of construction: concrete metal fib
(explain); s T polyethylene,other
—
Dimemiom:
Scum thickness:
Distance from top of scum op of outlet tee or baffle:
Distance from bottom scum to bottom of outlet tee or baffle:
Date of last pump"
Comments(on pumping recommendations,inlet and outlet tee or baffle condition,structural integrity,liquid levels
as related to outlet invert,evidence of leakage,etc.):
7
128 MILL ROAD JS-2008-000123
Proiect Detail Report '
Printed On:Fri Aug 10,2007
Project Name: _
GIS#: 7780 Project No: JS-2008-000123 Owner of Record LIEBLICH,JASON
.1 ncn* A Map:i 107.0 Date Submitted: Jul-26-2007 128 MILL ROAD
Block: 0014 Status: Open NORTH ANDOVER,MA 01845
o ! Lot: — Work Category: Work Location: 128 MILL ROAD
r Zoning: Proposed Use: District:
land Use: 101 Proposed Use Detail Subdivision
SSACNt18t
Description Septic D-Box Replacement Comments•
of Work:
Department Status
GeoTMS Module: Status File No. Comments: LCDatc:
Board of Health GREEN FLAG BHJ-2007-000028
Permit History
Type: Permit No: Issue Date Status Work Category Contractor Project No: Description of Work:
DWC Component Repair - BHP-2007-0245 Jul-27-2007 Open JS-2008-000123
Inspection History
Inspection Type: Permit Type: Permit No: Insp Date: Status: Inspector: Project No: Comment:
io ox O DWC Component Repai - - o BHP-200 - ug-07- LLC Y Susan wyer JS-2008- 23
Distribution Box Only DWC Component Repair -D-Bo BHP-2007-0245 Aug-07-2007 FULL COMPLY Susan Sawyer JS-2008-000123 2 risers to 6"to grade
Hent Repa P-2007- -2007 New Susan Sawyer JS-2008-000123
-Bo� DW mponent Repair - 07-0245 7-2007 Susan S
GeoTMS®2007 Des Lauriers Municipal Solutions,Inc. Pagel of 1
'41" r •
TOWN OF NORTH ANDOVER Of NORTH 7
Office of COMMUNITY DEVELOPMENT AND SERVICES a?
HEALTH DEPARTMENT
1.600 OSGOOD STREET; Building 2-36
NORTH ANDOVER,MASSACHUSETTS 01845 ��ssACHUgrS`
Susan Y. Sawyer,REHS/RS 978.688.9540—Phone
Public Health Director 978.688.8476—FAX
c'
D-Box o �j bS , f
❑ Installed on stable stone base ry
❑ Inlet tee (if pumped or >0.08'/foot)
Hydraulic cement around inlet & outlets
Observed even distribution � ��
Speed levelers provided (not required)
Comments:
Z. R14- s
S00*
� c�
SOIL ABSORPTION SYSTEM
❑ Bottom of SAS excavated down to soil layer, as
1C provided on plan
❑ Size of SAS excavated as per plan
❑ Title 5 sand installed, if specified on plan
❑ 3/4-11/2" double washed stone installed
❑ 1/8-1/2" (peastone) double washed stone installed
❑ Laterals installed and ends connected to header
❑ Laterals vented if impervious material above
❑ Orifices @ 5 & 7 o'clock positions
❑ Gravel-less disposal systems: type, number and
location as per plan
❑ Elevations of laterals installed as on approved plan
❑ 40 Mil HDPE barrier installed
❑ Retaining wall (boulder/ concrete /timber/ block)
❑ Final cover as per plan
Comments:
i
Wastewater System Documentation—Feb 2006
Page 3 of 6
asp$
'" ����"
���,,._
..,.
� �
�'S�.
t
C� .. - �
1
Map-Block-Lot
I 'A **k , Commonwealth of Massachusetts P
C� 107.C-0014-
f _____
__________________
nr ° Board of Health Permit No
North Andover BHP-2007-0245
.«: :.. P.I. FEE
is3
"cwu5t� F.I. $125.00
Disposal Works Construction Permit
Permission is hereby granted Todd Bateson
to(Repair-D-BOX REPLACEMENT)an Individual Sewage Disposal System.
at No 128 MILL ROAD ------------------------_.------------
as shown on the application for Disposal Works Construction Permit No. 13HP-20077024 y July July 27,2007
— ---------
U ► ' ^*1e---------------------
Issued On:Jul-27-2007 Board of Health
n,."'"'",�o Commonwealth of Massachusetts oic�oola�t
°r r t Board of Health
North Andover
f ♦ � 4
• gyp•\ � i
-••�.°����� Certificate of Compliance
iSs�cMust<
THIS IS TO CERTIFY,That the Individual Sewage Disposal System (Repair-D-BOX REPLACEME
by Todd Bateson
---------------------------- -
Installer
at No 128 MILL ROAD
has been installed in accordance with the provisions of TITLE 5 of the State Environmental Code as described in the
application for Disposal Works Construction Permit No. -BHP-2007-024-- -- ---Dated July 27,2907---------
----------------- ---- ----
----- --------
Printed On:Jul-27-2007 Board of Health
AORT 6 sal System l-/►-�3_Q
F j oop v�j O� TODAY'S DATE
AL
i lY l�l
• 20PPMW Town of North Andover [A 01845 $ 250.00-Full Repair
` '• °.: HEALTH DEPARTMENT $125.00 -Component
,SSA C HUSKS �d..,,CHECK#: (.3aM� DATE: /
LOCATION: ���G%�i�� u lisposal system* � �I,
• G lite sewage disposals stem*
H/O NAME: r C.C . em component JUL 2 6 2007
` CONTRACTOR NAME: � `--'�-' -'
TOWN OF NORI!'i h,.<�r SER
HEALTH DEPkRT\�cIJT
Type of Permit or License: (Check box) -----
0 Animal $ -- ---- ——--
❑ Body Art Establishment $
❑ Body Art Practitioner $
❑ Dumpster $
❑ Food Service-Type: $ ;al permit application***
❑ Funeral Directors $ tem)
❑ Massage Establishment $
3ch a copy of your certification to install this type of system.
�
❑ Massage Practice $ kttach Draft Maintenance Agreement)
❑ Offal(Septic)Hauler $
❑ Recreational Camp $
❑ Sun tanning
❑ Swimming Pool
❑ Tobacco $ �' 74 --
❑ Trash/Solid Waste Hauler $ State zip Code
❑ Well Construction $ — --- —
Telephone Number
SEPTIC Systems:
i
❑ Septic-Soil Testing $
❑ Septic-Design Approval $ dQ Name EMIT 6N ENTERPRISES. I
Septic Disposal Works ConstrugNOW WCC $ �� rgif Road N�._
❑ Septic Disposal Works Installlelrrss(D/� $ _ Andover, MA p
❑ Title 5 Inspector $ State lei Q Zip Code
`.� U157--01 )0 .
❑ Title 5 Report $ Telephone Number(Cell Phone#if possible please)
❑ Other:(Indicate) $
Name of Company
i
2547
Health Agent Initials --- ---------.__ _-__-.-- _-. --
State Zip Code
White-Applicant Yellow-Health Pink-Treasurer f Telephone Number(Best#to Reach)
"} Application for Disposal System Construction Permit•Page 1 of 2
c ,
Application for Septic Disposal System _
of .�., , �tio ----.
' ' p Construction Permit — TO VYN OF TODAY'S DATE
• ORTH ANDOVERMA 01845 $ 250.00—Full Repair
$125.00-Component
PAGE 2OF2
A. Facility Information continued...,
5. Type of Building: sidential Dwelling or❑Commercial
B. Agreement
The undersigned agrees to ensure the construction and maintenance of the afore-described
on-site sewage disposal system in accordance with the provisions of`Title 5 of the
Environmental Code, as well as the Local Subsurface Disposal Regulations for the Town of
North Andover,and not to place the system in operation until a Certificate of Compliance has
been issue y his Board of Health.
Name Date
Application pproved By: oard of Health Representative)
W-3 ,47
Name Date
X 11
Application Disapproved for t e followin reasons:
.For Office Use Only:
L Fee Attached? Yes No
2. Project Manager Obligation Form Attached? Yes_ No
3. Pump S, sy tem? If so,Attacb copy of Electrical Permit Yes No
4. Foundation As-Built?(new construction ronly): Yes No
(Same scale as approved plan)
5. Floor Plans?(new construction only): Ye _ No
SEPTIC SYSTEM INSTALLER PROJECT MANAGEMENT OBLIGATIONS
As the North Andover licensed installer for the construction for the septic system for the property at:
(-Address of septic system) For plans by
..�( (Engineer)
Relative to the application of ,,._----._._.
(Installer's naine) And dated
ngina ate
Dated / — J3 6
oclays ate With revisions dated
(Last revised date)
I understand the following obligations for management of this project:
1. As the installer,I am obligated to obtain all permits and Board of Health approved plans prior to
performing any work on a site. I must have the approved dans and the permit on site when any work is
being done.
2. As the installer,I must call for any and all inspections. If homeowner, contractor,project manager,or any
other person not associated with my company schedules an inspection and the system is not ready,then
item three shall be applicable.
3. As the installer,1,am required to have the necessary work completed prior to the applicable inspections as
indicated below. I understand that requesting an inspection without completion of the items in accordance
with Title 5 and the Board of Health Regulations may result in a X50.00 fine being levied against me and/or
my company
a. Bottom of Bed—Generally,this is the first(15)inspection unless there is a retaining wall,which
should be done first. The installer must request the inspection but does not have to be present.
b. Final Construction Inspection—Engineer must first do their inspection for elevations,ties, etc.
As-built of verbal OK(or e-mail to: healthdept a,townofnorthandover.com) from the engineer must
be submitted to the Board of Health,after which installer calls for an inspection time. Installer must
be present for this inspection. With a pump system,all electrical work must be ready and able to
cause pump to work and alarm to function.
c. Final Grade—Installer must request inspection when all grading is complete. Installer does not
have to be on-site.
4. As the installer,I understand that only I may perform the work(other than Pimple excavation)and I am required
to complete the installation of the system identified in the attached application for installation. I further
understand that work done by others unlicensed to install septic systems in North Andover can constitute
reasons for denial of the system and/or revocation or suspension of my license to operate in the Town of
North Andover,significant fines to all persons involved are also possible.
5. As the installer,I understand that I must be on-site during the performance of the following construction
steps:
a. Determination that the proper elevation of the excavation bas been reached
b. Inspection of the sand and stone to be used
c. Final inspection by Board ofHealth staffor consultant
d. Installation of tank,D-Box,pipes, stone, veno pump chamber,retaining wall and other
components.
6. As the installer, I understand that I am solely responsible for the installation of the system as per the
approved plans No instructions by the homeowner,general contractor, or any other persons shall absolve
me of this obligation.
Undersigned Licensed Septic Installer: (Today's Date)
(Name—Print) r —Signe
G �fLAD 6•tiO
w� h L a
SSACHUSH L'E
PUBLIC HEALTH DEPARTMENT
Community Development Division
Cv/
1(elO
To: All North Andover Residents with Septic Systems and Garbage Grinders
Please note that due to recent reviews of Title 5 Reports, your property has been identified as
maintaining a working garbage grinder that is being used in conjunction with a septic system.
The Health Department is concerned for the longevity of your septic system.
Garbage grinders are never recommended where septic systems are used, but if they are installed,
the system must be specifically designed to handle the waste from them; your system can not
handle the waste as designed. Please note that continued use of this grinder could quickly cause
a pre-mature failure of your septic system, resulting in a large expenditure to replace it. The
North Andover Health Department recommends that you remove it from your home as soon as
possible.
Some information regarding regular maintenance of your septic system is attached. Please call
the Health Department at 978.688.9540 if you have any questions, or e-mail your questions to:
healthdept(c�townofnorthandover.com.
Thank you for taking the time to consider the impact that your current setup has on your septic
system and the environment.
Sincerely,
Susan Y. Sawyer, REHS/
Public Health Director
/pfd
a
Enc: Septic System Information: http:// � rtm
1600 Osgood Street, North Andover, Massachusetts 01845
Phone 978.688.9540 Fax 978.688.8476 Web http://www.townofnorthandover.com
NORTH
6gti0
0
F �
'�.
�4p�AATfO
�SSACHUS�� R LIc
PUBLIC HEALTH DEPARTMENT
Community Development Division
K's 8' 1 1'xk
To: All North Andover Residents with Septic Systems and Garbage Grinders
Please note that due to recent reviews of Title 5 Reports, your property has been identified as
maintaining a working garbage grinder that is being used in conjunction with a septic system.
The Health Department is concerned for the longevity of your septic system.
Garbage grinders are never recommended where septic systems are used, but if they are installed,
the system must be specifically designed to handle the waste from them; your system can not
handle the waste as designed. Please note that continued use of this grinder could quickly cause
a pre-mature failure of your septic system, resulting in a large expenditure to replace it. The
North Andover Health Department recommends that you remove it from your home as soon as
possible.
Some information regarding regular maintenance of your septic system is attached. Please call
the Health Department at 978.688.9540 if you have any questions, or e-mail your questions to:
healthdeptktownofnorthandover.com.
Thank you for taking the time to consider the impact that your current setup has on your septic
system and the environment.
Sincerely,
Susan Y. Sawyer, REHS/
Public Health Director
/pfd
Enc: Septic System Information: http://www.mass.gov/del)/water/wastewater/dodont.htm
htm
1600 Osgood Street, North Andover,Massachusetts 01845
1 Phone 978.688.9540 Fax 978.688.8476 Web http://www.townofnorthandover.com
tvld�.b Lr,r .. ivrryurr nesource rruLecuen- 3epuc 3ystemS/riue :): miormauonfornom... rage i of i
How Do I as a System Owner Properly Care for my Septic System?
Conventional on-site septic systems can function very well with minimal care.In fact,most septic tanks will only
require an inspection and pumping out by a professional every three to five years if they are used properly.This does not
pertain to 1/A systems,which need more frequent oversight.
DO... I DON'T...
Do have the system inspected and pumped every 3 to 5 Do not use your toilet or sink as a trash can by dumping
years.If the tank fills up with an excess of solids,the non-biodegradables(cigarette butts,diapers,feminine
wastewater will not have enough time to settle in the products,etc.)or grease down your sink or toilet.Non-
tank.These excess solids will then pass on to the leach biodegradables can clog the pipes,while grease can
field,where they will clog the drain lines and soil. thicken and clog the pipes.Store cooking oils,fats,and
grease in a can for disposal in the garbage.
More information on pumng
Do know the location of the septic system and drain Do not put paint thinner,polyurethane,anti-freeze,
field,and keep a record of all inspections,pumpings, pesticides,some dyes,disinfectants,water softeners,and
repairs,contract or engineering work for future other strong chemicals into the system.These can cause
references.Keep a sketch of it handy for service visits. major upsets in the septic tank by killing the biological
part of your septic system and polluting the groundwater.
Small amounts of standard household cleaners,drain
cleansers,detergents,etc.will be diluted in the tank and
should cause no damage to the system.
Do grow grass or small plants(not trees or shrubs)above Do not use a garbage grinder or disposal,which feeds
the septic system to hold the drain field in place.Water into the septic tank.If you do have one in the house,
conservation through creative landscaping is a great way severely limit its use.Adding food wastes or other solids
to control excess runoff. reduces your system's capacity and increases the need to
pump the on-site tank.If you use a grinder,the system
must be pumped more often.
Do install water-conserving devices in faucets, Do not plant trees within 30 feet of your system or
showerheads and toilets to reduce the volume of water park/drive over any part of the system.Tree roots will
running into the on-site system.Repair dripping faucets clog your pipes,and heavy vehicles may cause your
and leaking toilets,run washing machines and drainfield to collapse.
dishwashers only when full,and avoid long showers.
Do divert roof drains and surface water from driveways Do not allow anyone to repair or pump your system
and hillsides away from the septic system.Keep sump without first checking that they are licensed-system
pumps and house footing drains away from the system as professionals.
well.
Do take leftover hazardous chemicals to your approved Do not perform excessive laundry loads with your
hazardous waste collection center for disposal.Use washing machine.Doing load after load does not allow
bleach,disinfectants,and drain and toilet bowl cleaners your septic tank time to adequately treat wastes and
sparingly and in accordance with product labels. overwhelms the entire system with excess wastewater.
You could therefore be flooding your drain field without
allowing sufficient recovery time.You should consult
your tank_professional to determine the gallon capacity
and number of loads per day that can safely go into the
system.
Do use only septic system additives that have been Do not use chemical solvents to clean the plumbing or
allowed for usage in Massachusetts by DEP.Additives septic system. "Miracle"chemicals will kill
that are allowe__d for use in Massachusetts have been microorganisms that consume harmful wastes.These
determined not to produce a harmful effect to the products can also cause groundwater contamination.
individual system or its components or to the
environment at large.
http://209.85.165.104/search?q=cache:OSxS WhzZovAJ:www.mass.gov/dep/water/wastew... 1/22/2007
Town of North Andover Licensed Septic System Installers (Disposal Works Installer's)
(Please note that the septic installer is licensed only-- not the company)
Five or more
installations
within the last
Renewed Name year #of CompanyPhone#
1 x Amor,Robert 0 R.T.Amor 978-948-3341
2 x Bateson,ToddF'D 16 113ateson Enterprises, Inc. 978-475-1474
3 x Beaulieu,Serge R. 0 Roadway Excavators 603.893.9189
4 x Breen,Peter 2 Peter Breen Excavating, Inc. 978-687-7774
5 x Busby,Philip A.Jr. 0 Busby Construction Co., Inc. 603-362-4650
6 x Carr,John 0 Ramey Construction 978-683-6791
7 x Colosi,Philip A. 0 Colosi Construction LLC 978-777-5679
8 x Coyle,Kevin 1 Kevin Coyle 1 978-479.2818
9 x Currier,James H. 0 James H.Currier Construction Co, Inc978-774-6685
10 x DeLucia,Rocci Jr. 0 Frank DeLucia&Son, Inc. 1 978-686-8200
11 x Divincenzo,John L. 2 Andover Septic/J&S Dev.Corp. 978-521-5251
12 x Giard,Daniel 0 Daniel A.Giard Septic Service 978-686-7653
13 x Hall,Bill,Inc. 0 Bill Hall, Inc. 1 978-689-3711
14 x Hartigan,James 0 James Hartigan 978-766-0087
15 x Hayes,John 0 J.B.H.Compact Equip.Co. 978-686-5229
16 ( x Hoehn,Bruce 1 Bruce Hoehn 1 978-372-8274
17 x Hutton,Arthur 0 Hutton's General Construction, Inc. 978-685-2627
18 x Innis,Robert L. 0 R.L.I.Corp. 1 978-663-6006
19 x Kellett,James 5 1 Kellett Excavating 781.953.7146
20 j x Marsh,Steve 0 The Westchester Co. 978-742-9778
21 x Maynard,Dave 0 Maynard Construction 603-228-4436
22 New Murray,David 1 Ranger Development Corp. 978-375-4997
23 x Osgood,Ben 2 New England Engineering 978-686-1768
24 x Pearce,Warren 0 Pearce Construction 978-664-5264
25 x Petrosino,Angelo 0 lAngelo Petrosino 978-664-2030
26 x Quinlan,Timothy 0 Quinlan&Rand Builders 978-682-1570
27 x Reilly,Mike 4 F.P.Reilly&Sons 978-475-1237
28 x Sawyer,William T. 0 Arco Excavators, Inc. 603-642-8910
29 x Shaw,John III 0 Wildwood Excavation, Inc. 978-474-8088
30 x Slombo,Robert 0 Robert Slombo 603-659-6962
31 x Soucy,John J. 6 Soucy's Sewer Service 978-470-1400
32 New Sullivan,Jack 0 Jack Sullivan 1 978-352-7871
33 I x Surianello,Joseph 0 Ralph Surianello, Inc. 617-799-3900
34 1 x ITodd,Charles R. - Charles R.Todd Contractor, Inc. 978-667-7853
35 x Craig Waelty 978-664-2126
36 x JW Watson,Jr. Inc. 978-475-3262
37 x J.Whyman Construction 781-334-2323
38 Nem Dave Zaloga 603-765-9296
Note: The SeF nd September of each year.
G� ie exam at 978.688.9540.
J_ _ Last Updated: 2/9/2007
Town of North Andover Licensed Septic System Installers (Disposal Works Installer's)
(Please note that the septic installer is licensed only-- not the company)
Five or more
installations
within the last
Renewed Name year #of Company _ Phone#
1 ( x Amor,Robert 0 R.T.Amor 978-948-3341
2 x Bateson,Todd t�'D 16 113ateson Enterprises, Inc. 978-475-1474
3 x Beaulieu,Serge R. 0 Roadway Excavators 603.893.9189
4 x Breen,Peter 2 Peter Breen Excavating, Inc. 978-687-7774
5 x Busby,Philip A.Jr. 0 Busby Construction Co., Inc. 603-362-4650
6 x Carr,John 0 Ramey Construction 978-683-6791
7 x Colosi,Philip A. 0 Colosi Construction LLC 978-777-5679
8 x Coyle,Kevin 1 Kevin Coyle 978-479.2818
9 x Currier,James H. 0 James H.Currier Construction Co, Inc978-774-6685
10 x DeLucia,Rocci Jr. 0 Frank DeLucia&Son, Inc. 978-686-8200
11 x Divincenzo,John L. 2 Andover Septic/J&S Dev.Corp. 978-521-5251
12 x Giard,Daniel 0 Daniel A.Giard Septic Service 978-686-7653
13 x Hall,Bill,Inc. 0 Bill Hall, Inc. 1 978-689-3711
14 x Hartigan,James 0 James Hartigan 978-766-0087
15 x Hayes,John 0 J.B.H.Compact Equip.Co. 978-686-5229
16 x Hoehn,Bruce 1 Bruce Hoehn I 1 978-372-8274
17 x Hutton,Arthur 0 Hutton's General Construction, Inc. 978-685-2627
18 x Innis,Robert L. 0 R.L.I.Corp. 978-663-6006
19 x Kellett,James 5 Kellett Excavating 781.953.7146
20 x Marsh,Steve 0 The Westchester Co. 978-742-9778
21 x Maynard,Dave 0 Maynard Construction 603-228-4436
22 New Murray,David 1 Ranger Development Corp. 978-375-4997
23 x Osgood,Ben 2 New England Engineering 978-686-1768
24 x Pearce,Warren 0 1pearce Construction 978-664-5264
25 x Petrosino,Angelo 0 Angelo Petrosino 978-664-2030
26 x Quinlan,Timothy 0 Quinlan&Rand Builders 978-682-1570
27 i x Reilly,Mike 4 F.P.Reilly&Sons 978-475-1237
28 x Sawyer,William T. 0 Arco Excavators, Inc. 603-642-8910
29 x Shaw,John III 0 lWildwood Excavation, Inc. 978-474-8088
30 x Slombo,Robert 0 Robert Slombo 603-659-6962
31 x Soucy,John J. 6 Soucy's Sewer Service 978-470-1400
32 New Sullivan,Jack 0 Jack Sullivan 978-352-7871
33 x Surianello,Joseph 0 Ralph Surianello, Inc. 617-799-3900
34 x Todd,Charles R. 2 Charles R.Todd Contractor, Inc. 978-667-7853
35 x Waelty,Craig(Skip) 1 Craig Waelty 1 I 978-664-2126
36 x Watson,Joseph 3 JW Watson,Jr. Inc. 978-475-3262
37 x jWhyman,Jon 1 J.Whyman Construction 781-334-2323
38 New Izaloga,Dave 0 Dave Zaloga 1 603-765-9296
Note: The Septic Installer Exam is held in January.March.May.July and September of each year.
You must call the Health Department to sign up for the exam at 978.688.9540.
j The testing fee is$25.
Last Updated: 2/9/2007
� H
Commonwealth of Massachusetts
7 City/Town of'NORTH ANDOVER MA
SSACHU
„; SETTS
System Pumping Record
;, Form 4
DEP has provided this form for use by local Boards of Health. The System Pumping Record mu:
be submitted to the local Board of Health or other approving authorFity.___--�
A. Facility Information
important: OCT1 2 2006
When filling out 1. System Location:
forms on the .
computer, use ,� /1G �C �OV N OF NORTh A,, .
only the tab key Address ... -._..-.._—._—_�.—.,,---.- - -•---_---.____:-_.-._ . . .
to move your ___
cursor• et not Cit /Town e • State =----
use the return y Zi ode -
key.
all
P C
2. System Owner:
Name
Address(if different from
m location) ------._.._...__------_..__._...--•----------..----
CityrTown _ ---------- Stat _—�__—.---- Zip Code - --
_____-__.---___
.--------
Telephone Number_
B. Pumping Record
_. 1. Date of Pumping Date -- 2, Quantity Pumped:
Gallons
3. Type of system: ❑ Cesspool(s) is Tank ❑ Tight Tank
❑ Other(describe): - _. _-- —____.—_._..-----._ -.—. ------ — ---..........
4. Effluent Tee Filter present? ❑ Yes o If yes, was it cleaned? ❑ Yes ❑ No
r
5. Condition of System:
Sy em Pumped By:
ame Vehicle License Number
Company -
7. Location where contents were disposed:
Si elute of Hsu �� ----- _.__
Date
http://www.mas§�gov/dep/water/ provals/t5forms,htm#inspect
t5form4.doc-06/03
System Pumping Record•Page i of
COMMONWEALTH OF MASSACHUSETTS
EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS
DEPARTMENT OF ENVIRONMENTAL PROTECTION
�r
I �
TITLE 5
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM
PART A
CERTIFICATION
Property Address:�02! /yi 4/-I-o O U E 2
Owner's Name:
Owner's Address: �3— 74A41-- ,.40 �
Date of Inspection: :3-- v
Name of Inspector: (please print) S,4m 4 -�
Company Name: Q N ootlel�7 S Pd iic �.
Mailing Address:' 9, y S A-1/// 5 T
1,4111
Telephone Number'2F--, 3:7-2, i g�
CERTIFICATION STATEMENT
I certify that I have personally inspected the sewage disposal system at this address and that the information reported
below is true,accurate and complete as of the time of the inspection.The inspection was performed based on my
training and experience in the proper function and maintenance of on site sewage disposal systems.I am a DEP
approved system inspector pursuant to Section 15.340 of Title 5(310 CMR 15.000). The system:
Passes
Conditionally Passes
Needs Further Evaluation by the Local Approving Authority
Fails
A4,4 Inspector's Signature: 1 Date: �—%--G q
1
The system inspector shall submit a copy of this inspection report to the Approving Authority(Board of Health or
DEP)within 30 days of completing this inspection.If the system is a shared system or has a design flow of 10,000
gpd or greater,the inspector and the system owner shall submit the report to the appropriate regional office of the
DEP.The original should be sent to the system owner and copies sent to the buyer,if applicable,and the approving
authority.
Notes and Comments
****This report only describes conditions at the time of inspection and under the conditions of use at that
time.This inspection does not address how the system will perform in the future under the same or different
conditions of use.
Title 5 Inspection Form 6/15/2000 page 1
Page 2 of 11
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION (continued)
Property Address:
�l• I��-lt�Uyr.2
Owner: /W 4,7":
Date of Insp c doe t n:
Inspection Summary: Check A,B,C,D or E/ALWAYS complete all of Section D
A. System Passes: t/r S
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 pipes)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:
2
w
Page 3 of 11
OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION(continued)
Property Address: 1,V *4 7`f
Owner•
Date of Inspection:
C. 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. System will pass unless Board of Health determines in accordance with 310 CMR 15.303(1)(b)that the
system is not functioning in a manner which will protect public health,safety and the environment:
_ 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:
3
Tage 4 of 11
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION(continued)
Property Address: LG. /
Owner: buy ?"?"
Date of Inspection:
D. System Failure Criteria applicable to all systems:
You must indicate"yes"or"no"to each of the following for all inspections:
Yes No , R
t- ga-ckup 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
L,-liquid depth in cesspool is less than 6"below invert or available volume is less than'/2 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 or 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.]
Ali)(Yes/No)The system fails.I have determined that one or more of the above failure criteria exist as
described in 310 CMR 15.303,therefore the system fails.The system owner should contact the Board of
Health to determine what will be necessary to correct the failure.
E. Large Systems: ,.
Y
To be considered a large system the system must serve a facility with a des4gn flow of 10,000 gpd to 15,000
gpd•
You must indicate either"yes"or"no"to eacli of the following:
(The following criteria apply to large systems in addition to the criteria above)
yes no
the system is within 400 feet of a surface drinking water supply
the system is within 200 feet of a tributary to a surface drinking water supply
the system is located in a nitrogen sensitive area(Interim Wellhead Protection Area—IWPA)or a mapped
Zone II of a public water supply well ,a
If you have answered"yes"to any question in Section E the system is considered a significant threat,or answered
"yes'in Section D above the large system has failed.The owner or operator of any large system considered a
significant threat under Section E or failed under Section D shall upgrade the system in accordance with 310 CMR
15.304.The system owner should contact the appropriate regional office of the Department.
4
Page 5 of 11
R OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART B
CHECKLIST
Property Address: Z:'�-f Mt// W.
til. 4-f 1 V0 U 1E2.
Owner: /,{J ,--r
Date of Inspection: Ely S�
Check if the following have been done.You must indicate"yes"or"no"as to each of the following:
Yes No z
�./ Pumping information was provided by the owner,occupant,or Board of Health
`—Were any of the system components pumped out in the previous two weeks?
c Has the system received normal flows in the previous two week period?
4A4-ave large volumes of water been introduced to the system recently or as part 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?
r
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
ebbaffles 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
maintenance of subsurface sewage disposal systems?
The size and location of the Soil Absorption System(SAS)on the site has been determined based on:
Ye ono F
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)]
5
Page 6 of 1 I
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION
Property Address: I t l It T
1:)--,F- A,41 t.t, JZ-
Owner:
Date of Inspection:
FLOW CONDITIONS
RESIDENTIAL
Number of bedrooms(design):4 Number of bedrooms(actual):
DESIGN flow based on 310 CMR 15.203(for example: l 10 gpd x#of bedrooms):
Number of current residents: .3
Does residence have a garbage grinder(yes or no):
Is laundry on a separate sewage system(yes or no):70 [if yes separate inspection required)
Laundry system inspected(yes or no):
Seasonal use:(yes or no):196
Water meter readings,if available(last 2 years usage(gpd)):
Sump pump(yes or no): HO
Last date of occupancy: , j Q
COMMERCIALANDUSTRIAL
Type of establishment: /14 4—
Design flow(based on 310 CMR 15.203): gpd
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):
GENERAL INFORMATION
Pumping Records
Source of information:
Was system pumped as part of the inspection(yes or no):-6�S
If yes,volume pumped: ,00 allons--How was quantity pumped determined? 7-
Reason for pumping: ('4 e,ek- i 4-'W tie 5 T2 u c T—Ult
Y
TYPE-OF SYSTEM
f eptic tank,distribution box,soil absotptian system
_Single cesspool
Overflow cesspool
—ivy
_Shared system(yes or no)(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)
_Tight tank _Attach a copy of the DEP approval
_Other(describe):
Approximate age of all components,date installed(if known)and source of information:
Were sewage odors detected when arriving at the site(yes or no):�U
6
c Page 7 of 11
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: AN-14- Jelll
Owner•
Date of Inspection:
BUILDING SEWER(locate on site plan)
Depth below grade: 3 6
Materials of construction: 'fast iron 40 PV.0_other(explain):
Distance from private water supply well_or suction line:
Comments(on condition of joints/,v1enting,evidence of leakage,etc.):
SEPTIC TANK:!(locate on site plan)
Depth below grade:
Material of construction:_✓concrete_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:
Sludge depth: /„ `i
Distance from top of sludge to bottom of outlet tee or baffle: 3 Y
Scum thickness: `1 y
Distance from top of scum to top of outlet tee or baffle:
Distance from bottom of scum to bottom of outlet tee or baffle:
How were dimensions determined: 0A1 $ / TE
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� COdWJ4riatel_ y�Fa►-/- �u��.Y� - !3�it/=`. -t- �-r���c �Uov
14
GREASE TRAP: (locate on site plan) .
Depth below grade:
Material of construction:_concrete_metal_fiberglass_polyethylene_other
(explain):
Dimensions:
Scum thickness:
Distance from top of scum to top of outlet tee or baffle:
Distance from bottom of scum to bottom of outlet tee or baffle:
Date of last pumping:
Comments(on pumping recommendations,inlet and outlet tee or baffle condition,structural integrity,liquid levels
as related to outlet invert,evidence of leakage,etc.):
7
y Page 8 of l l
a OFFICIAL INSPECTION FORM.—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEMINFORMATION(continued)
Property Address: y� /Yi// K77i
Owner:
Date of Inspection:
TIGHT or HOLDING TANK:
(tank must be pumped at time of inspection)(locate on site plan)
/`�,
Depth below grade: 4-
Material
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:j IL_(if present must be opened)(locate on site plan)
Depth of liquid level above outlet invert: vd /
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.):
/)U X &Oy d JYO LF,4i�S
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.):
8
Page 9 of 11
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM I,N/FORMATION(continued)
Property Address: /y�LL Kd
Owner: 14"
Date of Inspection: p 4
SOIL ABSORPTION SYSTEM(SAS): �r'(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:
1,/leaching fields,number,dimensions: ...1 U X 4-1� 1i
overflow cesspool,number:
innovative/alternative system Type/name of technology:
Comments(note condition of soil,signs of hydraulic failure,level of ponding,damp soil,condition of vegetation,
etc.):
CESSPOOLS: (cesspool must be pumped as part of inspection)(locate on site plan)
Number and configuration:
Depth—top of liquid to inlet invert:
Depth of solids layer:
Depth of scum layer:
Dimensions of cesspool:
Materials of construction:
Indication of groundwater inflow(yes or no.):
Comments(note condition of soil,signs of hydraulic failure,level of ponding,condition of vegetation,etc.):
PRIVY: (locate on site plan)
Materials of construction:
n
Dimensions:
Depth of solids:
Comments(note condition of soil,signs of hydraulic failure,level of ponding,condition of vegetation,etc.):
9
Wage.10 of 11
i OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM'INFORMATION(continued)
Property Address: /eco-
�/ 4n!nUill:rL
Owner: W 7¢7"'7"
Date of Inspection: —�-0.V
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.
i
f
13� � = 17/ �
p
10
a
Page 11 of 11
r
OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: ��� "I/ /?d
Owner:
Date of Inspection:
SITE EXAM
Slope 'YI' S Zoic
Surface water N u N
Check cellar /-/0'W C_ .
Shallow wells 14.ik
i
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:
11
FORM 4 - SYSTEM PUMPING RECORD
Commonwealth of Massachusetts
North Andover, Massachusetts
System Pumping Record
System Owner: System Location:
Lorena Watt rear yard
128 Mill Road
North Andover
Date of Pumping: April 30, 2002 Quantity Pumped: 1500 gallons
Cesspool: No LYes /X/ Septic Tank: No Yes L/
System Pumped by: Service Pumping & Drain Co. , Inc. License # 109-OOH
Contents transferred to: Lawrence Treatment Plant
Date: April 30, 2002 Pumper: A.M.
This is PROPRIETARY and CONFIDENTIAL information that may be used
only by the Board of Health for regulatory purposes.
BOARD OF HEALTH
Town of North Andover,Mass .
Permit #
Date August 2719 86
APPLICATION FOR WELL & PUMP PERMIT
Application is hereby made for permit to drill a well (xi . Application is
made to install (_) a pump system.
Location: Address Mill Road, North Andover., Mass.
Lot
Owner Robert Smith Address 118 Auburn Street, Medford, Tel .
Well Contractor CharlesM.RollinsCo.,Inc. Address 129 Depot Road, Boxford,Mass. Tel .887-2320
. Pump Contractor Address Tel . . -
WELL CONTRACTOR (To be completed at time of pump test )
- Type of Well Drilled Well used for Domestic
Diameter of Well 6" Size of. Casing 6"
i
Depth of Bed Rock 12-2 ' Depth casing into Bed Rock 147 '
Was Seal Tested? Yes ( ) No ( ) Date of Testing
Depth of X11 505 ' _. Well Ended in W.ha-t- Material Rock
Depth to Water_ 64 ' Delivers 172 Gals .Per Min. for 4 hours
Drawdown feet after pumping fhours, at GPM
Date of
8=23-86
Completion / o� iy' r
r
Signature Well C.6ntractor/`�
n J��.0�iC Ji.'::n••r••r•is'n is� n'ir:�J.ab d.J.L y J.iis i�"n is'n"n'is is is'n'is is is:':. n n n:. n:.ri n..i.i. n n n n:. n i.n n n n..n n n�n n
n..n/\/r�ri n r .rte JJr _r, r.J .rte.r. rr .rte J..r.Jr.J.J.J.✓ .V J..V.1..L.r.J .L
PUMP INSTALLER (To be-• f-i,lled in- before installation)
Size & Name Pump ! ' _;_PumR Type Used
,Water Pump. Delivers GPM Sire of Tank
Pipe Material Used in Well : Cast Iron (_) Galvanized (_) Plastic (_I
Well Pit ( ) or Pitless .Adapter (_)
Was sleeve used to protect pipe? Yes (_) NO(_) 'Type or Name Well Seal
Date
�t1M1��+t11r�41`'14�4��s414s4Sa1M141h1��141414Sk1�fhk1a14141�t�M5�ttY�It�tstittiHSi1�1S�iS'tStlrf5r5'cz ;'S''cQ��C1�� :Ps:�� r D��� ���������
Date Water analysis repor-t submitted to Board of Health
Date release given tD owner of record & Bldg. Insp
Health Inspector
(1a4R� of H60 --H t.ar �- M i u,
MA, �
APPU c4k �_ MA-- OeiL�
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FV AL APPROVAL
If r,+ i.if -w:_ ..- Ki ..,..: E w, t rr Y .q;t+r rr. , Y'r^, :ywin "�•,r ,: + Li tl - - - -
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' ' �.,.std.,,.s..sv+�-"�xj.t..:■t.,c�.A«"b:�.p.+w.r.�•J�. .,i:.'� - •�, - ." � �...wMJ�:•.a..`._.�.•r. :- "+nl.
;D01L
Lot No
North li.�ndover, Nass. Street No - s
Pl and Owner7�
LOC/Subdiv. �- —
�' C�
Investigator Observer-
SOIL PROFILE DATES
1_wlev
2.El ev 3•EleV I+.E]_ev
p 0 0 0
T-i�es to Te,-
- Pits
-2 2 2 - 2 -- -
3 3 = 3
4 4 4 - --
► " 5 - -- 5 — --
5 — 5
V
10!- --� 10 - --- _ 10 -- 10 - --
BenMrK — --Location -.
Elevation -- Datum --- - --
PEPCOJ A^1ION `T'ESTS
DATE'S -_ -_
?�� - - — ---
Fit umber _ ( 1 2--- - - 3
Start Saturation-- -- - —_ _-- _ --- ---- —
So�ti:Drop of 3"-Time - ------ ------ - -
Drop of 6" Time - - - - -
_i,.t_.ns.1st 3" drop -- — ---- - -
11 Y1
pe, cola cion
a SOIL PROFILE & PERCOLATION TESL` ilAl'A
North Andover, Mass. Street No FAt'L, q'® Lot No
Loc/Subdiv. Pland Owner 1'tl C-
Investigatory Observer
SOIL PROFILE DATES
l Alev 2.Elev 3.Elev 4.Elev
3
o � o o o � "
1 1 1 1
Tires Pits est
2 2 2 2 r
3 3 3 3
4 4 4 4 Ott
5 5 5 5 6
6 �Ali-
6 6 I 6
7 7 7 7
8 8 8 8
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Subsurface Sewage Disposal System
Umspection Report
Tittle V
Town ®f North Andover
ftard of Health Copy
Service Pumping & Drain Co., Inc. (617) 245-7576
P.O. Boz 4" (MM) 754-9265
Wakefield, Ma 01=0 Fax (617) 245-75"
William F. Weld Commonwealth of Massachusetts
Governor Executive Office of Environmental affairs
Trudy Coxe
Secretary Department of Environmental Protection
David B. Struhs
Coitmiiss inner
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION
Property Address: 128 Mill Road North Andover, MA Address of Owner
Date of Inspection: June 26, 1996 (if different)
Name of Inspector: Richard A. Mottolo
Company: Service Pumping & Drain Co. , Inc. P.O. Box 498 Wakefield Ma 01880 (617)245-7576
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
inspection. The inspection was performed based on my training and experience in the roper
function and maintenance of on-site sewage disposal systems. The system:
X Passes
Conditionallv Passes
Needs Further Evaluation By the Local Approving Authority
Fails
Inspector's Signature: 9J Date: 6
The system Inspector shall submit a copy of this inspection report to the Approving
Authority within thirty (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 Department of
environmental Protection.
The original should be sent to the system owner and copies sent to the buyer, If_
applicable and the approving authority.
INSPECTION SUMMARY
Check A, B C, or D:
A] SYSTEM PASSES:
X I have not found any information which indicates that the system violates any of the
failure criteria as defined in 310 CMR 15.303.
Any failure criteria not evaluated are indicated below.
B] SYSTEM CONDITIONALLY PASSES:
One or more system components need to be replaced or repaired. The system, upon
completion of the replacement or repair, passes inspection.
Indicate yes, no, or not determined (Y, N or ND) Describe basis of determination in all
instances. (If "not determined", e�,.plain why not.)
The septic tank: is metal cracked, structurally unsound, shows substantial
infiltration or exfiltration, or tank failure is imminent. The system will
pass inspection if the existing septic tank is replaced with a conforming
septic approved- , , Health.
tali}: as app i ov�d 1 y the Board �f Health.
(revised 11/03/95)
One Winter Street o Boston, Mass. 02108 o Fax (617)556-1049 o Phone (617)292-5500
1
3
I
SUBSURFACE SEWAGE DISPOSAL SYSTEMS INSPECTION FORM
PART A
CERTIFICATION (continued)
Property Address: 128 Mill Road North Andover, MA 01845
Owner: Robert Smith
Date of Inspection: June 26, 1996
B] SYSTEM CONDITIONALLY PASSES (continued)
Sewage backup or breakout or high static water level observed in the
distribution box is due to broken or obstructed pipe(s) or due to a broken,
settled or uneven distribution box. The system will pass inspection if (with
approval of the Board of Health) :
broken pipe(s) are replaced
obstruction is removed
distribution box is leveled or replaced
The system required pumping more than four times a year due to broken or
obstructed pipe(s) . The system will pass inspection if (with approval of the
Board of Health) :
C] 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 top protect the public health, safety and the
environment.
1) SYSTEM WILL PASS UNLESS BOARD OF HEALTH DETERMINES THAT THE SYSTEM IS NOT
FUNCTIONING IN A MANNER WHICH WILL PROTECT THE PUBLIC HEALTH AND SAFETY AND THE
ENVIRONMENT:
Cesspool or privy is within 50 feet of 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
APPROPRIATE) DETERMINES THAT THE SYSTEM IS FUNCTIONING IN A MANNER THAT PROTECTS THE
PUBLIC HEALTH AND SAFETY AND THE ENVIRONMENT:
The system has a septic tank and soil absorption system and is within 100 feet
to a surface water supply or tributary to a surface water supply.
The system has a septic tank and soil absorption system and is within a Zone I
of a public water supply well.
The system has a septic tank and soil absorption system and is within 50 feet
of a private water supply well.
The system has a septic tank and soil absorption system and is less than 100
feet but 50 feet or more from a private water supply well, unless a well water
analvsis for coliform bacteria and volatile compounds organic indicates that.
g
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.
3) OTHER
(revised 11/03/95)
2
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION (continued)
Property Address: 128 Mill Road North Andover, MA 01845
Owner: Robert Smith
Date of Inspection: June 26, 1996
D] SYSTEM FAILS:
I have determined that the system violates one or more of the following failure
c tir eria as defined in 310 CMR 15.303. The basis for this determination is identified
below. The Board of Health should be contacted to determine what will be necessary to
correct the failure.
Backup of sewage into facility or system component due to an 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.
St.at.ic. 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 invertor available volume is
less than 1,,� 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 Soil Absorption System, cesspool or privy is below the high
groundwater elevation.
Any portion of a cesspool or 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 I 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.
If thewell has been analyzed to be acceptable, attach copy of well water
analysis for coliform bacteria, volatile organic compounds, ammonia nitrogen and
nitrate nitrogen.
E] LARGE SYSTEM FAILS:
The following Criteria apply to large systems in addition to the criteria above:
The system serves a facility with a design flow of 10,000 gpd or greater (Large
System) and the system is a significant threat to public health and safety and the
environment because one or more of the following conditions exist:
the system is within 400 feet of a surface drinking water supply.
the system is within 200 feet of tributary to a surface drinking water supply
the system is located in a nitrogen sensitive. area (Interim Wellhead Protection
Area (IWPA) or a mapped Zone II of a public. water supply well)
The owner or operator of any such system shall bring the system and facility into full
compliance with the groundwater treatment program requirements of 314 CPIR 5.00 and 6.00
Please consult the local regional office of the Department for further information.
(revised 11/03195)
3
1�
SUBSURFACE SEWAGE DISPOSAL SYSTEM! INSPECTION FORM
FART B
CHECKLIST
Property Address: 128 Mill Road North Andover, MA 01845
Owner: Robert Smith
Date of Inspection: June 26, 1996
i
Check if the following have been done:
j X Pumping information was requested of the owner, occupant, and Board of Health.
X None of the system components have been pumped for at least two weeks and the
system has been receiving normal flow rates during that period. Large volumes of
water have not been introduced into the system recently or as part of this
inspection.
X As built plans have been obtained and examined. Note if they are not available
with N/A.
X The facility or dwelling was inspected for signs of sewage back-up.
X The system does not. receive non-sanitary or industrial waste flow.
X The site was inspected for signs of breakout.
X All system components, excluding the Soil Absorption System, have been located on
the site.
<`_ The septic tank manholes were uncovered, opened, and the interior of the septic
tank was inspected for condition of baffles or tees, material of construction,
dimensions, depth of liquid, depth of sludge, depth of scum.
X The si7.e and location of the Soil Absorption System on the site has been
determined based on existing information or approzimated by non-intrusive methods.
X The facility owner (and occupants, if different from owner) were provided with
information on the proper maintenance of Subsurface Disposal System.
E
(revised 11/03/95)
4
3
9
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION
Property Address: 128 Mill Road North Andover, 14A 01845
Owner: Robert Smith
Date of Inspection: June 26, 1996
FLOW CONDITIONS
RESIDENTIAL:
Design flow: --- gallons
Number of Bedrooms: 4
Number of current residents: 4
Garbage grinder (yes or no) : yes
Laundry connected to system (yes or no) : yes
Seasonal use (yes or no) : no
Water meter readings, if available: private well on site estimated at 150'+ from SAS
Last date of occupancy: occupied
CODMRERCIAL/INDUSTRIAL: ,
Type of establishment:
Design flow: gallons/da_y
Grease trap present: (yes or no)
i
Industrial Waste Holding Tank present.: (yes or no)
Non-sanitary waste discharged to the Title 5 system: (yes or no) j
Water meter readings, if available:
Last date of occupancy:
OTHER(Describe)
Last date of occupancy:
GENERAL INFORMATION
PUMPING RECORDS and source of information:
System pumped as part of inspection: (yes or no) ves
If yes, volume pumped: 1500 gallons
Reason for pumping: never pumped
TYPE OF SYSTEM
X Septic tank/distribution box/soil absorption system
Single Cesspool
Overflow Cesspool
Privy
no Shared system (yes or no) (if yes, attached previous inspection records, if any)
Other (explain)
3
APPROXIMATE AGE of all components, date. installed (if known) and source of information:
9 years per owner
Sewage odors detected when arriving at the site: (yes or no) no
(revised 11/03/95)
5
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Property Address: 128 14ill Road North Andover, MA 01845
Owner: Robert Smith
Date of Inspection: June 26, 1996
SEPTIC TANK: Y
�
(locate on si—
te elan}
Depth below grade: 44" built up to within 6" with riser
Material of construction: X concrete _metal FRP other (explain)
Dimensions:
Sludge. depth: 8"
Distance from too s udge to bottom of outlet tee or baffle: 30"
Scum thickness: 3"
Distance from top of scum to ton of outlet tee Or baffle: 5"
Distance from bottom of scum to bottom of outlet tee or baffle: 15"
Comments:
(recommendation for pumping, condition of inlet and outlet tees or baffles, depth of
liquid level in relation to outlet invert, structural integrity, evidence of leakage,
etc. ) outlet T had to be replaced with p.v.c.
GREASE TRAP: N
(locate on site plan)
Depth below grade:
Material of construction: _concrete _metal _FRP other (explain)
Dimensions:
Scum Thickness
Distance from top of scum to top of outlet tee or baffle:
Distance from bottom of scum to bottom of outlet tee or baffle:
Comments:
{recommendation for pumping, condition of inlet and outlet tees or baffles, depth of
liquid level in relation to outlet invert, structural integrity, evidence of leakage,
etc. )
l
f
(revised 11/03/95)
6
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Property Address: 128 Mill Road North Andover, MA 01845
Owner: Robert Smith
Date of Inspection: June 26, 1996
TIGHT OR HOLDING TANK: N
(locate on site Man)
Depth below grade:
Material of construction: _concrete metal _FRP other (explain)
Dimensions:
Capacity: gallons
Design flow: gallons/day
Alarm level:
Comments:
(condition of inlet tee, condition of alarm and float switches, etc. )
DISTRIBUTION BOX: Y
(locate on site plan)
Depth of liquid level above outlet invert: none
Comments:
(note if level and distribution is equal, evidence of solids carryover, evidence of
leakage into or out of box, etc. No visible signs of failure.
PU11P CHAMBER: N
(locate on site plan)
Pumps in working order: (yes or no)
Comments:
(note condition of pump chamber, condition of pumps and appurtenances, etc. )
(revised 11/03/95)
7
i
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Property Address: 128 Mill Road North Andover, MA 01845
Owner: Robert Smith
Date of Inspection: June 26, 1996
SOIL ABSORPTION SYSTEM (SAS) : Y
(locate on site plan, if possible; excavation not required, but may be approximated by
non-intrusive methods)
If not determined to be present, explain:
Type:
leaching pits, number:
leaching chambers, number:
leaching galleries, number:
leaching trenches, number, length:
leaching fields, number, dimensions: 1 - 15'x20'
overflow cesspool, number:
Continents: (note condition of soil, signs of hydraulic failure, level of ponding, condition
of vegetation, etc. ) No visible signs of failure.
CESSPOOLS: N
(locate on site plan)
Number and configuration:
Depth-top of liquid to inlet invert:
Depth of solids layer:
Depth of scum layer:
Dimensions of cesspool:
Materials of construction:
Indication of groundwater:
Inflow (cesspool must be pumped as part of inspection)
Comments: (note condition of soil, signs of hydraulic failure, level of ponding, condition
of vegetation, etc. )
PRIVY: N I
(locate on site plan)
i
Materials of construction: Dimensions: 1
Depth of solids:
I
Comments: (note condition of soil, signs of hydraulic failure, level of ponding, condition
of vegetation, etc. )
i
(revised 11%03%95)
8
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Property Address: 128 Mill Road North Andover, MA 01845
Owner: Robert Smith
Date of Inspection: June 26, 1996
SKETCH OF SEWAGE DISPOSAL SYSTEM:
include ties to at least two permanent references landmarks or benchmarks
locate all wells within 100'
DEPTH TO GROUNDWATER
Depth to groundwater: feet
method of determination or approximation:
(revised 11/03/95)
9
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SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
ADDENDUM 1
Property Address: 128 Mill Road North Andover, MA 01845
Owner: Robert Smith
Date of Inspection: June 26, 1996
Initial
I
Gas service line to the house goes directly over the middle
of the septic tank. Outlet cover is now built. tip within 6"
of grade with a riser.
Service Pumping & Drain Co. , Inc. has been retained by the owner to provide an inspection
of the on site sewage disposal system as defined by 310 CMR 15.303. D.E.P. guidance
instructs the inspector to make an evaluation of tfie systems performance on the day of the
inspection. The Title 5 Inspection is not designed to provide information to demonstrate
that the system will adequately serve the use to be placed upon it by the new owner as
stated in 15.302. This inspection is not a warranty or guarantee of the systems future
performance, and does not either empress or imply that.
(revised 11/03/95)
H OF NOoF�A
N
fOW gORRD
�U FORM 4 - SYSTEM PUMPING RECORD
Commonwealth of Massachusetts
North Andover, Massachusetts
System Pumping Record
System Owner System Location
Robert Smith
128 Mill Road
North Andover
Date of Pumping: June 26, 1996 Quantity Pumped: 1500 gallons
Cesspool: No /X/ Yes F-1 Septic Tank: No /—/ Yes T
System Pumped by: Service Pumping & Drain Co. , Inc. License # 636
Contents transferred to: Lawrence Treatment Plant
Date: June 26, 1996 Pumper: A.M.
This is PROPRIETARY and CONFIDENTIAL information which may be used
only by the Board of Health for regulatory purposes.
I
i
I
FORM 4 - SYSTEM PUMPING RECORD
Commonwealth of Massachusetts
North Andover, Massachusetts
MAY 9
System Pumping Record
System Owner: System Location:
Lorena Williams side yard
128 Mill Road
North Andover
Date of Pumping: April 25, 2000 Quantity Pumped: 1500 gallons
Cesspool: No /X/Yes /—/ Septic Tank: No i-1 Yes /X/
System Pumped by: Service Pumping & Drain Co. , Inc. License # 636
Contents transferred to: Lawrence Treatment Plant
Date: April 25, 2000 Pumper: P.K.
This is PROPRIETARY and CONFIDENTIAL information that may be used
only by the Board of Health for regulatory purposes.
• -' �P�. 'fit-+
TOWN OF NORTH ANDOVER
SYSTEM PUMPING RECORD
DATE__
o —
SYSTEM OWNER&ADDRESS SYSTEM LOCATION
oa
DATE OF PUMPING;' —OZ QUANTITY PUMPED Z0 062
CESSPOOL, NO ZYES�__ SEPTIC
TANK NO YES
NA'T'URE OF SERVICE: R®UTINE � EMERGENCY
OBSERVATIONS:
GOOD CONDITION FULL TO COVER
HEAVY GREASE BAFFLES IN LACE
ROOTS LEACHFIELD RUNBACK
EXCESSIVE SOLIDS FLOODED
SOLID CARRYOVER OTHER EXPLAIN
SYSTEM PUMPED BY -17L
COMMENTS:
l
CONTENTS TRANSFERRED TO S, _ eLL
Commonwealth of Massachusetts
City/Town of
System Pumping Record OCT 2 3 2008
Form 4
DEP has provided this form for use by local Boards of Health. Other forms may be used, but the
information must be substantially the same as that provided here. Before using this form, check with your
local Board of Health to determine the form they use. The System Pumping Record must be submitted to
the local Board of Health or other approving authority.
A. Facility Information
Important:
When filling out 1. System Location: Left front, left rear, left side of house. Right front, right rear, right side of house.
forms on the
computer,use
only the tab key Address
to move your ;N4 _
cursor-do not
use the return City/Town State Zip Code
key. 2 System Owner:
Name
Address(if different from location)
Cityrrown State oche -
Telephone Number
B. Pumping Record
1. Date of Pumping Date 2. Quantity Pumped: Gallons
3. Type of system: Q Cesspool(s) _ eptic Tank Q Tight Tank
Q Other(describe):
4. Effluent Tee Filter present? Q Yes If yes, was it cleaned? Q Yes Q No
5. Condition of System:
6. System Pumped By:
Neil Bateson F 5821
Name Vehicle License Number
Bateson Enterprises Inc
Company
7. Locationhere contents were disposed:
L.S.D Lowell Waste Water
Pign Pureofu r Date(✓v
t5form4.doc•06/03 System Pumping Record•Page 1 of 1
Commonwealth of Massachusetts
City/Town of RECCIVED
System Pumping Record
Form 4 Nov 3 0 'M i
DEP has provided this form for use by local Boards of Health. Other fo mowN of NORTH ANDov
�-I�J��1�i� ,�� Tb���the�e
information must be substantially the same as that provided here. Bef o , c ec with your
local Board of Health to determine the form they use.The System Pumping Record must be submitted to
the local Board of Health or other approving authority.
A. Facility Information
1. System Location: Left/Right front of house, Left/Right rear of house, Left ri h side of hous eft/
Right side of building, Left/Right front of building, Left/Right rear of building, Under c
Address �, I ^ '
City/Town 0 State Zip Code
2. System Owner:
Name
Address(if different from location)
Cityrrown Statt, Zip Code
Telephone N
p e umber
B. Pumping Record ^�
1. Date of Pumping Date 2. Quantity Pumped: Gallons
n
s
3. Type of system: ❑ Cesspool(s) Septic Tank ❑ Tight Tank
❑ Other(describe):
4. Effluent Tee Filter present? ❑ Yes [jlqo"� If yes, was it cleaned? ❑ Yes ❑ No
5. Condi 'o of System:
6. System Pumped By:
Neil Bateson F5821
Name Vehicle License Number
Bateson Enterprises Inc
Company
ASign
4Haulej
tents were disposed:
Lowell Waste Water
Date
t5form4.doce 06/03 System Pumping Record a Page 1 of 1