HomeMy WebLinkAboutMiscellaneous - 130 LACONIA CIRCLE 4/30/2018 (2) !- 210/].05_""60-0000.0
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RECEIVED
Commonwealth of Massachusetts
DD
City/Town of NAY 4 2013
System Pumping Record NORTH ANDDAooEP RTM LATER
Form 4
DEP has provided this form fq.r use by local Boards of Health. Other forms may be used, but the
information must be substantially the same as that provided here. Before using this form, check with your
local Board of Health to determine the form they use.The System Pumping Record must be submitted to
the local Board of Health or other approving authority within 14 days from the pumping date in
accordance with 310 CMR 15.351.
A. Facility information
Important:
When filling out 1. System Location:
forms on the �' p
computer,use
only the tab key Address �( \^
to move your -- -— O c h_.. �c ove _ .-. .. -. �" r, 0`Is Lf -
cursor-do not state Zip Code
use the return
City(Town
key. 2. System Owner:
Name
Address(if diNetent from location}
----------------
City/Town tate Zip Code
phone Number ——.
B. Pumping Record
2. Quantity Pumped: J-500-
1-
_50_.-
1. Date of Pumping Date Gallons
3. Type of system: ❑ Cesspool(s) Septic.Tank ❑ Tight Tank ❑ Grease Trap
❑ Other(describe)
4. Effluent Tee Filter present? ❑ Yes v❑/No If yes, was it cleaned? ❑ Yes [SiNo `
5. Condition of System:
6. System Pumped By:
--
Name Vehicle License Num er
Company
7. Location where contents were disposed:
I
G_ .L.S.D. - - - --
Signature of Hauler �h Andover. IVDA. Date
-
Signature of Receiving Facility Date
t5form4.doc•03/06 System Pumping Record•Page t of 1
Commonwealth of Massachusetts
City/Town of NORTH ANDOVER MASSACHUS TS
System-Pumping Record
Form 4
DEP has provided this form for use by local Boards of Health. The System Pumg'ng Record must
be submitted to the local Board of Health or other appro tng agtho�rityNED
A. Facility Information APR 0 4 2006
Important:
When filling out 1. System Location:
forms on the TOWN OF NORTH ANDOVER
computer,use /,�(� ( �C.y n+/1 C J'
HEALTH DEPARTMENT
only the tab key Address
to move your n 1I p
cursor-do not �y
use the return City/Town State Zip Code
key.
r
2. System Owner:
1. ,e SC h w,• c ` T
--
.. � Name --- ---...--
Address(if different from location)
City/Town State Zip Code
Telephone Number
B. Pumping Record
1. Date of Pumping Date Z a f) 2. Quantity Pumped:
Gallons
3. Type of system: ❑ Cesspool(s) P---Septic Tank ❑ Tight Tank
❑ Other(describe): —
4. Effluent Tee Filter present? ❑ Yes No If yes, was it cleaned? ❑ Yes No
5. Condition of System:
6. 8yste Pumped By:
UA _ _
Name _ p Vehicle License Number
L 'vt L ti 1 n tM e '1
Company
7. Location where contents were disposed:
Signature
of Hauler Date
http://www.mass.gov/dep/water/approvals/t5forms.htm#inspect
t5form4.doc•06/03 System Pumping Record•Page 1 of 1
Form 4 -- System Pumping Record
Commonwealth of Mossachusetss
Massachusetts
'"�v OFttC2RTI ,
System Pumping Record BOARD
J Cx
System Owner System Location
Sc imidt Gre.;or, Primary Home
I hi Ucct.i . Cir 130 L.:aro,ia Ci:
North Au6mjr. K% OlA4, North ArAiver WtA, OIA45
:978} t25--6026 v (978)-725-6026 x
�rhMIr{t
Type: Emergency Routine
Cesspool: No Yes Septic tads: W r7Ycs
Date of Pumping: L!�� 1 —�� Quantity Pumped: 'Gallons
System Pumped By: Wind Nmr Envirnna►entoi, LLC Permit#:
Contents transferred to:
Contents Disposed at:
Date: Pumper Signature:
Condition of System/Other Comments
Dep Approved Fran, - 12107195
' U LOT RELEAsE FORM
rNSTRUCTrOrvs. T $I' a. - F'
Boards and De h►sto used to verify that all necessary
the applicant and/�ments� Irl . d rY approvals/
pe
vi Jurisdiction have been obtained. This dOeS emrltts Prof
or►ando not r
from compliance with any applicable or requirements.
quirements.
A 'PLfCAr�l 'F1LLS OUTTH►S SECTION******
APPLICANTVI
LOCATIONPHONE
: „
Assessor's Map Number
SUBDIVISION PARCEL /ter-
STREET Ze:j G LOT(S)
OFFICI:4L USE QNLY
REP MENDA IDMS
TQWN AG
E
NTS•
` CONSERVATION ADININI
ATOR DATE'4PPRpVE.D
DATE REJECTED i 03
COMMENTS i
TOWN pLANNER
DATE APPROv
DATE REJECTED
COMMENTS
FOOD INSPE O HEALTH
DATE APPROVED
DATE REJECTED
SEPTIC INSPECTOR-HEALTH
DATE APPROVED.
DATE=;REJECTED,: ��
COMMEN _
e�,�-e ���.I• (a,�, � ��5�'c�.. fie;
PUBLIC WORkS-SEWEA/WATER CONNECTIONS NOW v1�
DRIVEWAY PERMIT
FIRE DEPARTMENT
RECEIVED By BUILDING INSPECTOR
Revised 9197 jm 'D,4TE
TOWN OF NORTH ANDOVER fi
PUBLIC HEALTH DEPARTMENT00p
27 CHARLES STREET
NORTH ANDOVER,MASSACHUSETTS'01845 �9S R„•o <5
$ACHU
Sandra Starr Telephone(978)688-9540
Public Health Director FAX(978)688-9542
July 30, 2003
Gregg Schmidt
130 Laconia Circle
North Andover, MA 01845
Re: Application for 2nd floor addition
Dear Mr. Schmidt:
Your additional information for the application for an addition at 130 Laconia Circle has
been reviewed by the Health Department. Although originally designed to serve a four-bedroom
dwelling without a garbage grinder, under current Title 5 regulations the septic system has been
found to be undersized,both for the existing home and for any addition. Furthermore, since the
original septic design was not sized for a garbage grinder, the existing grinder must be removed
immediately. The removal must be inspected by Board of Health staff. In order for the Health
Department to approve your application for an addition, the septic system will have to be
upgraded to comply with current Title 5 regulations.
If you wish to proceed with your plans for an addition, I suggest that you hire a civil
engineer and/or a Massachusetts DEP certified site evaluator to apply to the Health Department
for soil tests. Hopefully the enclosed documents will be of help to you if you choose to proceed
with this upgrade.
Please call the office at 978-688-9540 to set up an inspection date.
Sincerely
Sandra Starr, R.S., C.H.O.
Public Health Director
W/enc.
Cc: Building
File
Town of North Andover NORTH
O6gg4sD °.4
Office of the Health Department Q�
p
Community Development and Services Divisi®n 00
William J. Scott,Division Director � 4•�--�-• "
°
Rw � tJ
27 Charles Street ,ssgcHus¢s<
Sandra Starr North Andover,Massachusetts 01845 Telephone(978)688-9540
Health Director Fax(978)688-9542
Mr. Gregg Schmidt
130 Laconia Circle j
North Andover,MA 01845
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Re: Application for: 2nd Floor Addition
Dear Mr. Schmidt:
Your application for an addition at 130 Laconia Circle has been reviewed by the Health Department. The
application was denied on July 3,2003 for the following reasons:
1. Missing infonnation
2. Passing Title 5,inspection of septic system required—chances are that the current system is too small.
3. ❑ Location of structure not acceptable
To address the problem(s):
If#1 is checked,please supply:
a. -4 Floor plan of existing and proposed addition—all rooms
b. Certified plot plan showing house,septic system and proposed project in scale
N#2 is checked:
a. 4 Have the septic system insp d by a certified Title 5 inspector to determine the size of the system
and whether it is operating pro ly: OR r
b. Tie-in to municipal sewer
If#3 is checked:
a. Relocate the project
Please feel free to call the Health Office at 978-688-9540 with any questions you may have.
Sincerely,
Reviewer
Cc: Building Department
File
BOARD OF �' -
�PEALS 688-941 BUIL,Di'svG X88-954 CONSF,RZ.ATION 688-9530 NURSE 688-9543 PLAh,�I4G 688-9535 '
NEW ENGLAND ENGINEERING SERVICES
INC
July 21, 2003
North Andover Roard of Health TOWN OF NORTH ANDOVER/
Town Hall Annex BOARD OF HEALTH
27 Charles Street
North Andover, MA 01845 .n 2 n CD
RE: TITLE V REPORT: 130 Laconia Circle,North Andover, MA
Dear Sirs:
Enclosed is a copy of the Title V report for the above referenced property. The system PASSED
our inspection.
If there are any questions please call me at my office, 686-1768.
Sincerely
Benjamin C. Osgood, Jr.
60 BEECHWOOD DRIVE-NORTH ANDOVER, MA 01845-(978)686-1768-(888)359-7645-FAX(978)685-1099
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COMMONWEALTH OF MASSACHUSETTS
EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS
W
DEPARTMENT OF ENVIRONMENTAL PROTECTION
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TITLE 5 j
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM
PART A
CERTIFICATION
Property Address: P 3 o L 4(-o iy A c ,2cL--
Owner's Name: Dt�-g B/C� A14AA i p-1
Owner's Address:__►3 )-,qC u N 1#+
Date of Inspection:
L0(JN-,.,00-P1
Svt9h E H,^.I�QQ"���Name fRD QF HEALTH
o Inspector: lease Tint Ben'amin C. Os ood(P P Jr.
CompanyName:New England Engineering Services Inc. nn B�MailingAddress:60 Beechwood Drive, 2 c3 23North Andov , MA_ 01845Telephone Number: 978-686-1768 -- j
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:
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/Passes
Conditionally Passes
Needs Further Evaluation by the Local Approving Authority
Fails
Inspector's Signature: C Date: Z
The system inspector shall submit a copy of this inspecton report to the Approving Authority(Board of Health or
DEP)within 30 days of completing this inspection.If the em is a shared
cyst tem or has a design flow o
f100
� 00
gn
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.
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Page 2 of 11
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION (continued)
Property Address:_ 130 LACONIA CIRCLE
NORTH ANDOVER,MA
Owner: DEBBIE SCHMIDT
Date of Inspection: 7/21/03
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Inspection Summary: Check A,B,C,D or E/ALWAYS complete all of Section D
A. .System Passes:
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:
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B. System Conditionally Passes:
One or more system components as described in the"Conditional PaWl section need to be replaced or
repaired.The system,upon completion of the replacement or repair,as approved by the Board of e�lth,will pass.
Answer yes,n or not determined(Y,N,ND)in the for the following.statem .If"not determined"please
explain.
The tic tank i etal and over 20 ears old*or
�P y the septi ether metal or not)is structurally i
unsound,exhibits substantl infiltration or exfiltration or tank fail is imminent.System will pass inspection if the
existing tank is replaced with mplying septic tank as appro by the Board of Health.
*A metal septic tank will pass' ion if it is structurall und,not leaking and if a Certificate of Compliance
indicating that the tank is less than 2 ears old is avai e.
ND explain:
Observation of sewage ba break or high static water level in the distribution box due to broken or
obstructed pipe(s)or due to a br ,settled or une distribution box.System will pass inspection if(with
approval of Board of Healt*
broken pipe(s)are rced
obstruction is removed
distribution box is leveled replaced
ND explain:
The system required pumping more than 4 times a year due to brok 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:
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Page 3 of 11
OFFICIAL INSPECTION FORM -NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION(continued)
Property Address:_ 130 LACONIA CIRCLE
NORTH ANDOVER,MA
Owner: DEBBIE SCHMIDT
Date of Inspection:_ 7/21/03
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 iling to protect public health,safety or the environment.
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1. stem will pass unless Board of Health determines in accordance with 310 CMR 15.303(1)that the
em is not functioning in a manner which will protect public health,safety and the en 'fonment:
1 or privy is within 50 feet of a surface water
01 or privy is within 50 feet of a bordering vegetated wetland or a salt
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2. System will fail unless the)Board of Health(and Public Wa Supplier,if any)determines that the
system is functioning in:septic
manneT that protects the public herih,safety and environment:
— The system has tank and soil absorption em(SAS)and the SAS is within 100 feet of a
surface water supply or tributary to a surface water pply.
— The system has a septic tank and SAS , the SAS is within a Zone 1 of a public water supply.
— The system has a septic tank and Sand the SAS is within 50 feet of a private water supply well.
_ The system has a septic and SAS and the AS is less than 100 feet but 50 feet or more from a
private water supply well" ethod used to determin4stance
"This system p the well water analysis,performed aat a DEP certified laboratory,for coliform
bacteria and volatd organic compounds indicates that the weld DEP
from pollution from that facility and
the presence ppf/s onia nitrogen and nitrate nitrogen is equal to orless than 5 ppm,provided that no other
failure cri efia are triggered.A copy of the analysis must be attached Wb 'is form.
3. Other:.
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Page 4 of 11
OFFICIAL INSPECTION FORINT—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION(continued)
Property Address:_ 130 LACONIA CIKCLt
NORTH ANDOVER,MA
Owner: DEBBIE SCHMIDT
Date of Inspection: 7/21/03
D. System Failure Criteria applicable to all systems:
You must indicate"yes"or`5no"to each of the following for all inspections:
Yes No
✓
Backup of se Bac
— _ wage into facility or system component due to overloaded or clogged SAS or cesspool
Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or
clogged SAS or cesspool
Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or
cesspool
Liquid depth in cesspool is less than 6"below invert or available volume is less than 1/2 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.]
(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 ousidered a large system the system must serve a facility with a design flow of 10,000 gpd to 15,000
gpd.
You must indi either`yes"or"no?'to each of the following:
(The following triter ly to large systems in addition to the criteria above)
yes no
_ _ the system is within 400 fee a surface drinking water suppl
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_ the system is within 200 feet of a tribu to ace drinking water supply
_ — the system is located in a nitron - sensitive area( Wellhead Protection Area–IWPA)or a mapped
Zone 11 of a public water supply well
If you have answered"yes"to any question in Section E the system is consid a significant threat,or answered
"yes"in l motion D above the large system has failed.The owner or operator of anya system considered a
significant threat under Section E or failed under Section D shall upgrade the system in rdance with 310 CMR
15.304.The system owner should contact the appropriate regional office of the Department.
Page 5 of 11
OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART B
CHECKLIST
Property Address:_ 130 LACONIA CIRCLE
NORTH ANDOVER,MA
Owner: DEBBIE SCHMIDT
Date of Inspection: 7/21/03
— I
Check if the following have been done.You must indicate`yes"or"no"as to each of the following:
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Yes No
✓_ Pumping information was provided by the owner,occupant,or Board of Health
_ -1Z 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?
V" 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?
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:
Yes no
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)1310 CMR 15.302(3)(b)]
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Page 6 of 11
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OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION
Property Address:_ 130 LACONIA CIRCLE
NORTH ANDOVER,MA
Owner: DEBBIE SCHMIDT
Date of Inspection: 7/21/03
FLOW CONDITIONS
RESIDENTIAL
Number of bedrooms(design): Number of bedrooms(actual):
DESIGN flow based on 310 CMR 15.203(for example: 110d x#of bedrooms):
)
Number of current residents: 4 _
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):_ZV
Water meter readings,if available(last 2 years usage(gpd)): yo d
Sump Pump(yes or no):yV
Last date of occupancy Grrrt,<j-
COMMERCIALIINDUSTRIAL
Type of establishment:
Design flow(based on 310 CMR 15.203): 2nd
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:
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OTHER(describe):
GENERAL INFORMATION
Pumping Records
Source of information: La..s 1::4 11 Pte- p -n ,
Was system pumped as part of the inspection(yes or no): A/O
If yes,volume pumped: glions—How was quantity pumped um determined?
Reason for pumping:
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)
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—Tight tank _Attach a copy of the DEP approval
Other(describe): i
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Approximate age of all components,date installed(if known)and source of information:
at on.
Were sewage odors detected when arriving at the site(yes or no): &L)
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Page 7 of 11
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OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address:_ 130 LACONIA CIRCLE
_ NORTH ANDOVER,MA
Owner: DEBBIE SCHMIDT
Date of Inspection:` 7/21/03
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BUILDING SEWER(locate on site plan)
Depth below grade: _
Materials of construction: cast iron 40 PVC other(explain):
Distance from private water supply well or suction line:
Comments(on condition of joints,venting,evidence of leakage,etc.):
P r►ilC L,00y.S 01ti �,v 6A&C^ icN i
SEPTIC TANK:_(locate on site plan)
Depth below grade: y I
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: t,5-oa (fit t-w v 5
Sludge depth: Z°'
Distance from top of sludge to bottom of outlet tee or baffle: 2 ��
Scum thickness. z"
Distance from top of scum to top of outlet tee or baffle: 9
Distance from bottom of scum to bottom of outlet tee or baffle: /,3"
How were dimensions determined:
Comments(an pumping recommendations,inlet and outlet tee or bale condition,structural integrity,liquid levels
as related to outlet invert,evidence of leakage,etc.):
2✓I t%/4 0!►d 01/- C6 J--, Yno Al I C aN c 2z5 1 f✓ CMAC G��)�
�LOv �'N� NSJWLLtiJIstl(L
2 S w�Tit�N H` yF Fr.vcsH
&-a49 PL- OPC- A./+N(�s
GREASE TRAP:y-bocate on site plan)
Depth below grade:_
Material of construction: concretemetal 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 etc.leakage, :
)
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Page 8 of 11
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OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
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Property Address:. 130 LACONIA CIKCLE
NORTH ANDOVER,MA
Owner: DEBBIE SCHMIDT
Date of Inspection: 7/21/03
TIGHT or HOLDING TANK:&L(tank must be pumped at time of inspection)(locate on site plan)
Depth below grade:
Material of construction: concrete metal fiberglass_polyethylene other(explain):
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Dimensions:
Capacity: gallons
Design Flow: gallons/day
Alarm present(yes or no):
Alarm level: Alarm in working order(yes or no):
Date of last pumping:
Comments(condition of alarm and float switches,etc.):
DISTRIBUTION BOX: (if present must be 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.): A
oil, c.0.,,, pc1t7A.1
/Lt K ' N£ e�-`i fix)/t C-As 1 1-:-/-7
PUMP CHAMBER: 4/&(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.):
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Page 9 of 11
OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM j
PART C
SYSTEM INFORMATION(continued)
Property Address:_ 130 LACONIA C1KCLh
NORTH ANDOVER,MA
Owner: DEBBIE SCHMIDT
Date of Inspection:_ 7/21/03
SOIL ABSORPTION SYSTEM(SAS): (locate on site plan,excavation not required)
If SAS not located explain why:
Type
leaching pits,number:_
leaching chambers,number:
leaching galleries,number:
leaching trenches,number,length: 2_ i&F N c 14 E 5G—
leaching fields,number,dimensions:
overflow cesspool,number:
innovativetalternative system Typetname of technology:
Comments(note condition of soil,signs of hydraulic failure,level of ponding,damp soil,condition of vegetation,
etc.):
12CA.JC14 6c�c14-% 'Q0—Ae.94
CESSPOOLS:tV4-(cesspool must be pumped as part of inspectionXlocate on site plan)
Number and configuration:
Depth—top of liquid to inlet invert:
Depth of solids layer:
Depth of scum layer:
Dimensions of cesspool:
Materials of construction.
Indication of groundwater inflow(yes or no):
Comments(note condition of soil,signs of hydraulic failure,level of ponding,condition of vegetation,etc.):
PRIVY:/VI (locate on site plan)
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Materials of construction:
Dimensions:
Depth of solids:
Comments(note condition of soil,signs of hydraulic failure,level of ponding,condition of vegetation,etc.):
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Page 10 of 11
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: 130 LACONIA CIRCLE;
NORTH ANDOVER,MA
Owner: DEBBIE SCHMIDT
Date of Inspection 7/21/03
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.
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Page 11 of 11
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OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address:_ 130 LACONIA CIRCLh
NORTH ANDOVER,MA
Owner: DEBBIE SCHMIDT
Date of Inspection: 7/21/03
SITE EXAM
Slope
Surface water
Check cellar
Shallow wells
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 most describe how you established the high ground water elevation:
PA!j CA 10 A-
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° RAGGSINC .
�
� Subsurface Soil Disposal
0 Inspection Report
In Accordance With
0 Title 5 (310CMR 15.000)
0
0
a
a
Se ng you Since 1g98
P. O. Box 1027, Concord, MA 01742
(508) 369-1100 / (800) 287-5541
FAX (508) 897-3848
U
FORM 4-SYSTEM PUMPING RECORD
CUR ER
SEPTIC & DRAIN SERVICE
107 FOREST STREET; MIDDLETON,MA 01949
(978) 774-2772.
COMMONWEALTH OF MASSACHUSETTS.
MASSACHUSETTS
i
SYSTEM PUMPING RECORD
SYSTEM OWNER: SYSTEM LOCATION: C
I,4j �ti ���11 Z`S�t uv�Nch a T Sf CPS
-7
DATE OF PUMPING: A) 2 s
QUANTITY PUMPED: GALLONS
CESSPOOL: NO F-� YES F7 SEPTIC TANK: NO 0 YES FVJ
I `
SYSTEM PUMPED BY: CURRIER SEPTIC & DRAIN SERVICE
CONTENTS TRANSFERRED TO:
DATE:
INSPECTOR:
Form 4 -- System Pumping Record
Commonwealth of Massachusetss
Massachusetts
System Pumping Record
System Owner System Location
1
Type: Emergency Routine
Cesspool: No Yes Septic tank: No Yes ��—
Date of Pumping: 01 Quantity Pumped: /fa p Gallons
System Pumped By: Wind Riva Envyro mentos, LLC Permit#:
Contents transferred to:
Contents Disposed at: ( SIT)
Date: U `� / Pumper Signature:
Condition of System/Other Comments
- ORITC U 0V h14V P'I1
Dep Approved from - 12/07/95
LJ
RAGGS, INC., P. 0. Box 1027, CONCORD, MA 01742
- (508) 369-1100
a OFFICIAL CERTIFICATION
i
a SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION
IN ACCORDANCE WITH TITLE 5 (310 CMR 15.000)
a .
0
CERTIFICATION PREPARED FOR: Robert and Roberta Goldschneider
a
a
ADDRESS OF PROPERTY: 130 Laconia Circle
North Andover, MA 01845
DATE OF INSPECTION: July 18, 1995
a
RESULTS:
a X This property has PASSED the criteria set
forth in 310 CMR 15.000.
This o has FAILED the criteria set
property ert y
aforth in 310 CMR 15.000.
a
RAGGS, INC., P.O. BOX 1027, CONCORD, MA 01742
a
. (508)369-1100
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
ADDRESS OF PROPERTY: 130 Laconia Circle
North Andover, MA 01845
OWNER'S NAME: Robert and Roberta Goldschneider
DATE OF INSPECTION: July 18, 1995
aPART A
CHECKLIST
The following have been done -
1 Pumping information was requested of the owner, occupant, and Board of Health: Yes
2. 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: .Yes
a
3. As-built plans have been obtained and examined: Yes
4. The facility or dwelling was inspected for signs of sewage back-up: Yes
5. The site was inspected for signs of breakout: Yes
6. All system components, excluding the SAS, have been located on the site: Yes
7. The septic tank manholes were uncovered opened, and the interior of the septic tank was
p P p
inspected for condition of baffles or tees, material of construction, dimensions, depth of
aliquid, depth of sludge, depth of scum: Yes
8. The size and location of the SAS on the site has been determined based on existing
information or approximated by non-intrusive methods: Yes
a 9. The facility owner (and occupants, if different from owner) were provided with information
the proper maintenance of SSDS: Enclosed with report.
a
aRAGGS, INC., P.O. BOX 1027, CONCORD, MA 01742 (508)369-1100
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
a PART B
SYSTEM INFORMATION
FLOW CONDITIONS
a
Residential: number of bedrooms: 4
number of current residents: 4
garbage grinder: no
laundry connected to system: yes
seasonal use: no
a
Non-Residential, calculated flow:
Water meter readings: see Appendix D private well: no
aLast date of occupancy: occupied
GENERAL INFORMATION
a
Pumping records and source of information: see Appendix A; Homeowner
System pumped as part of inspection: yes Volume pumped: 1,500 gallons
Reason for pumping: Examiantion of the structural integrity of the tank.
Type of system-
Septic tank/distribution box/soil absorption system: yes
Single cesspool:
Overflow cesspool:
Privy:
Shared system:
Other:
Approximate age of all components: 8 years
Date installed. 9/5/86
Source of information: Board of Health Records
Sewage odors detected when arriving at the site: no
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aRAGGS, INC., P.O. BOX 1027, CONCORD, MA 01742 (508)369-1100
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
aPART B
SYSTEM INFORMATION continued
SEPTIC TANK (locate on site plan) -- see Appendix B
Depth below grade: 4'2"
aMaterial of construction - Concrete: X Metal: FRP: Other:
Dimensions: 10'6" X 5'8" X 5'8"
Sludge depth: 18"
Distance from top of sludge to bottom of outlet tee or baffle: 2'1"
Scum thickness: 4"
a Distance from top of scum to top of outlet tee or baffle:
Distance from bottom of scum to bottom of outlet tee or baffle:
Recommendation for pumping: annually
Condition of inlet and outlet tees or baffles: good
Depth of liquid level in relation to outlet invert: level
aStructural integrity: good Evidence of leakage: some
Recommendation for maintenance: pump annually; wash and seal tank, replace section of
crushed pipe leading to d-box - see Appendix E
DISTRIBUTION BOX (locate on site plan) -- see Appendix B
aDepth of liquid level above outlet invert: zero
Level and distribution are equal: yes Evidence of solids carryover: none
Evidence of leakage into or out or box: none
Recommendation for repairs: none
a
PUMP CHAMBER (locate on site plan) -- n/a
Pumps in working order:
Condition of pump chamber:
Condition of pumps and appurtenances:
Recommendation for maintenance or repairs:
j
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3
i
RAGGS, INC., P.O. BOX 1027, CONCORD, MA 01742 (508)369-1100
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART B
SYSTEM INFORMATION continued
SOIL ABSORPTION SYSTEM (SAS) -- see Appendix B
(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 and number:
Leaching chambers and number:
Leaching galleries and number:
Leaching trenches, number, length: two trenches; each approximately 50' long
a Leaching fields, number, dimensions:
Overflow cesspool, number.-
Condition
umber:Condition of soil: good Signs of hydraulic failures: none
Level of ponding: none Condition of vegetation: good
Recommendations for maintenance or repairs: none
CESSPOOLS (locate on site plan) -- n/a
Number and configuration:
Depth-top of liquid to inlet invert:
Depth of solids layer: Depth of scum layer:
Dimensions of cesspool:
Materials of construction:
j Indication of groundwater inflow:
(cesspool must be pumped as part of inspection)
Condition of soil: Signs of hydraulic failure:
Level of ponding: Condition of vegetation:
Recommendations for maintenance or repairs:
PRIVY(locate on site plan) -- n/a
Materials of construction:
Dimensions:
Depth of solids:
Condition of soil: Signs of hydraulic failure:
Level of ponding: Condition of vegetation:
Recommendations for maintenance or repairs:
a
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aRAGGS, INC., P.O. BOX 1027, CONCORD, MA 01742 (508)369-1100
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART B
SYSTEM INFORMATION continued
aSKETCH OF SEWAGE DISPOSAL SYSTEM
* Include ties to at least two permanent references, landmarks or benchmarks
* Locate all wells within 100 ft.
a
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SEE APPENDIX B
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DEPTH TO GROUNDWATER: More than 6'.
METHOD OF DETERMINATION OR APPROXIMATION: Augered a four inch hole to a depth
of approximately 6'. No groundwater was determined to be present.
a
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RAGGS, INC., P.O. BOX 1027, CONCORD, MA 01742 (508)369-1100
DSUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
FAILURE CRITERIA
Indicate yes, no, not applicable or not determined (Y, N, N/A or ND). Describe basis of
determined in all instances. If"not determined", explain why not.
1. There is backup of sewage into facility: N
a 2. There is evidence of or discharge ponding of effluent to the surface of the ground or
p 9
surface waters: N
3. The static liquid level in the distribution box is above outlet invert: N
a4. Liquid depth in cesspool is <6 in. below invert or available is < 1/2 day flow: N/A
5. Required pumping 4 times or more in the last year: N
number of times pumped: N/A
6.a Septic tank is: Metal: N Cracked: N Structural) unsound: N
p Y
Substantial infiltration: N Substantial exfiltration: N
n Tank failure imminent: N
7. Any portion of the SAS, cesspool or privy is below the high groundwater elevation.. N
8. Within 50 feet of a surface water: N
a9. Within 100 feet of a surface water supply or tributary to a surface water supply: N
a10. Within a Zone I of a public well: N
11. Within 50 feet of a bordering vegetated wetland or salt marsh (cesspools and privies
only, not the SAS): N
12. Within 50 feet of a private water supply well: N
13. Less than 100 feet but greater than 50 feet from a private water supply well with no
acceptable water quality analysis: N
If the well has been analyzed to be acceptable, attach copy of well water analysis for
coliform bacteria, volatile organic compounds, ammonia nitrogen and nitrate nitrogen.
6
a
RAGGS, INC., P.O. BOX 1027, CONCORD, MA 01742 (508)369-1100
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART D
CERTIFICATION
Name of Inspector: Martin Weiss, P. E.
Company Name: Raggs, Inc.
p Y
Company Address: P. 0. Box 1027, Concord, MA 01742
Certification Statement
certify that I have personally inspected the sewage disposal system at this address and that
the information reported is true, accurate and complete as of the time of inspection. The
inspection was performed and any recommendation regarding upgrade, maintenance and
D repair are consistent with my training and experience in the proper function and maintenance of
on-site sewage disposal systems.
Check one:
I have not found any information which indicates that the system fails to adequately
protect public health or the environment as defined in 310 CMR 15.303. Any failure criteria not
evaluated are as stated in the FAILURE CRITERIA section of this form.
I have determined that the system fails to protect public health and the environment as
Y p
defined in 310 CMR 15.303. The basis for this determination is provided in the FAILURE
CRITERIA section of this form.
t
112,d'95
aInspector's Signature bate
Martin Weiss, Professional Engineer#19501
Raggs, ,Inc.,certifies that all work performed on the aforementioned property was done in
accordance with`the guidelines set forth in Title 5 (310 CMR 15.303).
`' i�5 '04 -711/4 s/
Fred T. Fish, President Date
Raggs Septic Service, Inc. d/b/a E. A. Comeau
File No.: 95-5788/GOLDSCHNEI
Copies to:
Payer of inspection
Local Board of Health or its agent
7
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RAGGS, INC., P.O. BOX 1027, CONCORD, MA 01742 (508)369-1100
a -
0
a APPENDIX A:
HISTORICAL
PUMPING RECORDS, REPAIR RECORDS
a
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RAGGS, INC., P.O. BOX 1027, CONCORD, MA 01742 (508)369-1100
a
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a
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130 Laconia Circle, North Andover, MA 01845
aPrior to inspection, system was never pumped per homeowner.
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RAGGS, INC., P.O. BOX 1027, CONCORD, MA 01742 (508)369-1100
a
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D
D
APPENDIX B:.
D
SITE PLAN / AS BUILT PLAN
D
D
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D
D
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CER FOUNDAT/ON PL N
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LOCATED IN kJopTN A.•�a
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-S.L.GILES R.L.S.
LAWRENCE Q NORTH ANDOVER
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I CERT/FY THAT TH OFFSETS SHOWN ARE FOR THE USE OF
OFFSETS SHOWN THE BUIL D/NG INSPECTOR ONLY B SUCH
CONFORM TO THE USE IS FOR DETERM/NATION OFZOJV/NGj
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ZONING B Y L A W OF CONFORMITY OR NON CONFORMITY
Aj Da o..-z WHEN TAKEN.
RAGGS, INC., P.O. BOX 1027, CONCORD, MA 01742 (508)369-1100
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aRAGGS, INC., P.O. SOX 1027, CONCORD, MA 01742 (508)369-1100
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APPENDIX C:
LISTING SHEET
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aRAGGS, INC., P.O. BOX 1027, CONCORD, MA 01742 (508)369-1100
130 Laconia Cirice, North Andover, MA 01845
0 No listing sheet was available for this property.
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DRAGGS, INC., P.O. BOX 1027, CONCORD, MA 01742 (508)369-1100
I
E
! D
D
D
D
D
Appendix D:
D
DWater Usage
Documentation
D
ID
' D I
' D
D
D
D
' D
D
D
14
� D
| |
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Manf Cd : ] Units: ripe S^ Z=' ' '�
� LJ Req : Inst : Cnct : Disc: cu
Wrk Cd : ] Mt Code: ] Met Loc: ,`' ""^
] Serial #: 0030495652
| | Notes: 5/8" TRI-1W
Cur: 529 A Prev : 513 A 2nd Prev : 500 A [2
From: 01/19/95 To: 05/01/95 Cur2: Prev2:
Next : Cns Cr : Mth Bill : 03 User:
� �� -------- [3] | Last 12 Billing
--- First 12 Billing Months ------ ------
� 06/95 16 A 12/93 14 A | 06/92 9 A �
03/95 13 A 09/93 14 A 103/92 16 A '
12/94 11 A 06/93 7 A |
� 12 A 03/93 13 A |
09/94 �
06/94 10 A 12/92 14 A | �
� i ] 03/94 13 E 09/92 16 � �
| First 12 Total : 153 � Last 12 Total : 25
<ESC} to Enter New Meter Number
| | (M> odify, <D}elete or <N> ext
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RAGGS, INC., P.O. BOX 1027, CONCORD, MA 01742 (508)369-1100
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15
RAGGS, INC., P.O. BOX 1027, CONCORD, MA 01742 (508)369-1100
a
a
Appendix E:
Recommendations:
Repair, Pumping, & Maintenance
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aRAGGS, INC., P.O. BOX 1027, CONCORD, MA 01742 (508)369-1100
Recommendations
for
e
130 Laconia Circle, North Andover, MA 01845
a
1. Wash and seal tank.
2. Replace crushed pipe leading from tank to d-box.
3. Pump annually.
Note: Items # 1& 2 were completed on 7/18/95.
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General Maintenance Recommendations
Proper maintenance of your septic system can help prevent premature failure of
your soil absorption system. Raggs, Inc. recommends the following:
DO PUMP your system ANNUALLY.
O DO OPEN your D-Box every THREE TO FOUR YEARS.
DO ensure that your VENT PIPES are installed properly.
DO make sure you know where your TANK is LOCATED.
a DO make sure you know where your LEACHING FIELD is LOCATED.
DO look for GREEN STRIPES over leaching field.
DO check to determine if you can smell any ODORS from field location.
aDO bring your COVERS WITHIN 6" OF GRADE.
DO USE LIQUID DETERGENT.
DO USE NON-ABRASIVE HOUSEHOLD CLEANING PRODUCTS.
DO USE ENVIRONMENTALLY SAFE PRODUCTS.
DO INSTALL WATER SAVING DEVICES, where appropriate.
DO USE SMALL AMOUNTS OF BLEACH when cleaning toilets, etc.
RAGGS SEPTIC SERVICE, INC.
d.b.a. E.A. COMEAU SEPTIC
DP.O. Dox 1027 Oincor(l, Massarhuscu.s 01712 (8M) '287-5541 (508).169-1100 FAX(508)897-3848
a
o
�P °B7ou Since 1895
aGeneral Maintenance Recommendations con'd
DONT DISPOSE anything NON-BIODEGRADABLE IN TOILETS.
(i.e.: cigarettes, sanitary napkins)
DON'T use caustic CHEMICALS.
DON'T wash paint brushes used in latex or oil PAINT.
I
DON'T allow any PAINT, THINNERS to go down sink or toilets.
i
DON'T allow ANY GREASE or FAT to enter system.
DONT DISPOSE BONES, EGG SHELLS, COFFEE GROUNDS„ etc. when
using a garbage disposal
DON'T use powdered detergents with phosphates.
DON'T use any DRAIN CLEANERS.
DON'T use any ENZYMES.
DON'T use any GREASE DISSOLVERS.
DO NOT ADD ANY ADDITIVES TO YOUR SYSTEM FOR ANY REASON.
In the event of a clog or other plumbing problem, contact your local
plumber, rooter or pumper.
DON'T PLANT any trees or shrubs OVER THE LEACHING FIELD.
'
DONT ALLOW SPRINKLER SYSTEMS or other WATERING i E NG DEVICES
OVER THE LEACHING FIELD.
DON'T DRIVE any VEHICLES or place any HEAVY OBJECTS ON TOP OF THE
LEACHING FIELD.
a RAGES SEPTIC SERVICE, INC.
d.b.a. E.A. COMEAU SEPTIC
I'" 11w, 1W7 Cmwonl, Massachiisew 017.17 (SM) 287-55.11 (508) 309-11(.X) TAX (508)8')7-:1848
CERT/F/ED FOUNDATION PLAN
LOCATED /N f-J*FVTw X az)aoM
SCALE./"= 4' DATE: 4- 1 a
S.L.G/LES R.L.S.
L AWRENCE a NORTH ANDOVER
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/ CERT/FY THAT THE OFFSETS SHOWN ARE FOR THE USE OF
OFFSE TS SHOWN -THE BU/LD/NG/INSPECTOR ONL Y, B SUCH 41
CONFORM TO THE USE /S FOR DETERMINATION OFZON/NG
ZON/NG B Y L AW OF CONFORM/ 1
T Y-OR NON CONFORM/T Y yw }
�Josi-1-� WHEN TAKE/V.
-- d=- i'
COMMONWEALTH OF MASSACHUSETTS
EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS
DEPARTMENT OF ENVIRONMENTAL PROTECTION
7 Sy
TITLE 5
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM
PART A
CERTIFICATIONTONR C-
fr? i D' OF HEr1TH
Property Address: 130 L4(-C,ni 1 A 2 �
Owner's Name: �c I4 itA I f>—i JUL z 3
Owner's Address: ►3 s> h 4c a Al,A- G,lut r
Jg
Date of inspection: Z
P � v .. �
Name of Inspector:(pleaseprint) Beni amin C. Osgood, Jr.
f'4 CompanyName:New England Engineering Services Inc.
Mailing Address:6_0Beechwood Drive,
Horth Andover. ILA_ 01845
Telephone Number: 978-686-1768
CERTIFICATION STATEMENT
I certify that I have personally inspected the sewage disposal system at this address and that the information reported
below is true accurate and complete as of the time of the inspection.The inspection was performed based on my
training and experience in the proper function and maintenance of on site sewage disposal systems.I am a DEP
approved system inspector pursuant to Section 15.340 of Title 5(310 CMR 15.000). The system:
/Passes
Conditionally Passes
Needs Further Evaluation by the Local Approving Authority
Fails
Inspector's Signature: C Date: �z
The system inspector shall submit a copy of this inspecton 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.
Page 2 of 11
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION (continued)
Property Address:_ 130 LACONIA CIRCLE
NORTH ANDOVER;MA
Owner: DEBBIE SCHMIDT
Date of Inspection: 7/21/03
Inspection Summary: Check A B C,D or E/ALWAYS complete all of Section D
A. System Passes:
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 Ith,will pass.
Answer yes,n or not determined(Y,N,ND)in the for the following. .If"not determined"please
i explain.
The septic tank i etal and over 20 years old*or the septic ether metal or not)is structurally
unsound,exhibits substan infiltration or exfiltration or tank fail is imminent.System will pass inspection if the
existing tank is replaced with plying septic tank as appro by the Board of Health.
*A metal septic tank will pass' ion if it is structurall und,not leaking and if a Certificate of Compliance
indicating that the tank is less than 2 s old is avai e.
ND explain:
Observation ofsewage ba break or high static water level in the distribution box due to broken or
obstructed pipe(s)or due to a br settled or une distribution box.System will pass inspection if(with
approval of Board of Heal
broken pipe(s)are r cod
obstruction is removed
distribution box is leveled replaced
ND explain:
i
The system required pumping more than 4 times a year due to brok 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
i
ND explain:
Page 3 of 11
OFFICIAL INSPECTION FORM -NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE.DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION(continued)
Property Address:_ 130 LACONIA CIRCLE
_ NORTH ANDOVER,MA
Owner: DEBBIE SCHMIDT
Date of Inspection:. 7/21/03
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 iling to protect public health,safety or the environment.
1. tem will pass unless Board of Health determines in accordance with 310 CMR 15.303(1
that the
em is not functioning in a manner which will protect public health,safety and the en onment:
i
1 or i
is within— privy surface water
of or privy is within 50 feet of a bordering vegetated wetland or a salt m
2. System will fail unless the�Board of Health(and Public Wa Supplier,if any)determines that the
system is functioning in a mannetf that protects the public h th,safety and environment:
_ The system has a septic tank soil absorption em(SAS)and the SAS is within 100 feet of a
surface water supply or tributary to a'surface water pply.
.t
The system has a septic tank and SA the SAS is within a Zone 1 of a public water supply.
— The system has a septic tank and S andhe SAS is within 50 feet of a private water supply well.
The system has a septic and SAS and the,�ASis less than 100 feet but 50 feet or more from a
private water supply well" ethod used to determine distance
"This system if the well water analysis,performed at DEP certified laboratory,for coliforgn
bacteria and vol a organic compounds indicates that the well -, ee from pollution from that facility and
the presence ammonia nitrogen and nitrate nitrogen is equal to oNess than 5 ppm,provided that no other
failure cri are triggered.A copy of the analysis must be attached to. us form.
3. Other:.
Page 4 of 11
it
OFFICIAL INSPECTION FORM--NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION (continued)
i
Property Address:_ 130 LACONIA CIRCLE
NORTH ANDOVER,MA
Owner: DEBBIE SCHMIDT
Date of Inspection: 7/21/03
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
Liquid depth in cesspool is less than 6"below invert or available volume is less than'/z day flow
'! Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s).Number
of times pumped
Any portion of the SAS,cesspool or privy is below high ground water elevation.
r 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.
y 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 fromollution from that t facilitand 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.
-_&L))(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 em fails.The s em owner should
� contact the
yst 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
l;l�•
You must inch either"yes"or"no"to each of the following:
! (The following triter ly to large systems in addition to the criteria above)
� yes no
— _ the system is within 400 fee a surface drinking water SUP
i
_ — the system is within 200 feet of a tribe to ace drinking water supply
— — the system is located in a nitr��o,.gg sensitive area( Wellhead Protection Area–IWPA)or a mapped
Zone II of a public wataupply well
If you have answered"yes"to any question in Section E the system is consid a significant threat,
"yes"in action D above the large system has failed.The owner or.operator of aneconsideredtem answered
li
significant threat under Section E or failed under Section D shall upgrade the system in rdance with 0 CMR
15.304.The system owner should contact the appropriate regional office of the Department.
Page 5 of 11
OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART B
CHECKLIST
Property Address:_ 130 LACONIA CIRCLE
NORTH ANDOVER,MA
Owner: DEBBIE SCHMIDT
Date of Inspection: 7/21/03
ii
Check if the following have been done.You must indicate`fires"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 therevio
p us two we*period .
V' Have large volumes of water been introduced to the system recently or as part of this inspection 2
_ } Were as built plans of the system obtained and examined?(If they were not available note as N/A)
vl — 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?
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:
Yes no
SII
—/Determined
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(3)(b)]
Page 6 of 11
OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGEDISPOSALSYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION
Property Address:_ 130 LACONIA CIRCLE
NORTH ANDOVER,MA
Owner: DEBBIE SCHNMT
Date of Inspection: 7/21/03
FLOW CONDITIONS
RESIDENTIAL
Number of bedrooms(design): Number of bedrooms(actual): y
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):_p/0
Water meter readings,if available(last 2 years usage(gpd)): yo 'v
Sump pump(yes or no):-AI.Q
Last date of occupancy:
COMMERCIALIINDUSTRIAL
Type of establishment:
Design flow(based on 310 CMR 15.203):
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:__ �asl 1 (gee. 4c 4•n c,P,
Was system pumped as part of the inspection(yes or no): A/0
If yes,volume pumped: gallons--How was quantity pumped determined?
Reason for pumping:
TYV 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 an
Innovative(Alternative technology.Attach a copy of the current operation maintenance contract to be
obtained from system owner)
l�
_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):
Page 7 of 11
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address:_ 130 LACONIA CIRCLE
_ NORTH ANDOVER,MA
Owner: DEBBIE SCHMIDT
Date of Inspection:_ 7/21/03
BUILDING SEWER(locate on site plan)
Depth below grade: !J'
Materials of construction: cast iron 40 PVC other(explain):
Distance from private water supply well or suction line.
'Comments(on condition of joints,venting,evidence of leakage,etc.):
>+ KS oI ti �u s N—
�r�' P ao biyl^ I
SEPTIC TANK:_(locate on site plan)
Depth below grade: Lj I
Material of construction:,vcencxete metal fiberglass_polyethylene
other(explain)
If tank is metal list age:_ Is age confirmed d by a Certificate of Compliance(yes or no):_(attach a copy of
certificate)
Dimensions: tSoo Crit I.w as
Sludge depth: 2"
Distance from top of sludge to bottom of outlet tee or baffle:
Scum thickness: z"
Distance from top of scum to top of outlet tee or baffle: 'f�
Distance from bottom of scum to bottom of outlet tee or baffle: 1�q,,
How were dimensions determined:_ �vtc n ,7.),/j_
Comments(on pumping recommendations,inlet and outlet tee or baffle condition,structural integrity,liquid levels
as related to outlet invert,evidence of leakage,etc.):
T/I•n:A 04 eo.f7 mo Al . c o,.J c ,2E i i TC�S 1 r✓ pK
R6Co.� C NP INsT)At-c-iA- C, 21St�fts � v��Tt�tN h" OF fAli SH
PL,- OpCAi
GREASE TRAP:9-A(locate on site plan)
Depth below grade:
Material of construction: concretemetal 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.):
{
I
Page 8 of 11
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address:• 130 LAC:ONIA CIKC:LE
NORTH ANDOVER,MA
Owner: DEBBIE SCHMIDT
Date of Inspection: 7/21/03 I
TIGHT or HOLDING TANK:LL(tank must be pumped at time of inspection)(locate on site plan)
Depth below grade:
Material of construction: concrete metal fiberglass_polyethylene other(explain):
Dimensions:
Capacity- gallons
Design Flow: gallons/day
Alarm present(yes or no):
Alarm level: Alarm in working order(yes or no):
Date of last pumping:
I
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: D"
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.):
F!0:6 1� n
Y!OX 1A/ . oil, CO3n j7 t1JA/" Re CJ iV►Gn/7 P-t's 2 PL INS ( !)
_'�J /LtrFK� /n/S Q�f i7..�i' Er�S fL✓�
PUMP CHAMBER: 4W(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.):
I
i
I
i�
I
;I
i
I
i
t
Page 9 of 11
h
OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address:_ 130 LACONIA CIKCLh
NORTH ANDOVER,MA
Owner: DEBBIE SC'HNMT
Date of Inspection:_ 7/21/03
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:
y"leaching trenche,number,length: 2 i O_C Ar c is r S, ��` i-a,.j G--
leaching fields,number,dimensions:
overflow cesspool,number:
innovative/alternative system Typetname of technology:
Comments(note condition of soil,signs of hydraulic failure,level of ponding,damp soil,condition of vegetation,
etc.):
i2CNCkrs E.a its 1o/-.4rl
CESSPOOLS:M4— must be pumped as part of inspectionXlocate on site plan)
Number and configuration:
Depth—top of liquid to inlet invert:
Depth of solids layer:
Depth of scum layer:
Dimensions of cesspool:
Materials of construction:
Indication of groundwater inflow(yes or no):
Comments(note condition of soil,signs of hydraulic failure,level of ponding,condition of vegetation,etc.):
I
PRIVY:4L/ (locate on site plan)
Materials of construction:
Dimensions:
Depth of solids:
Comments(note condition of soil,signs of hydraulic failure,level of ponding,condition of vegetation,etc.):
Page 10 of 11
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Pro Address;
Property 130 LAC.UNIA CiK(:Lti
NORTH ANDOVER,MA
Owner: DEBBIE SCHMIDT
Date of Inspection 7/21/03
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.
J
� a
xp
L
4
Page 11 of 11
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
i
Property Address:_
130
LACONIA C:1KCL1;
NORTH ANDOVER,MA
Owner: DEBBIE SC
HMID
T
Date of Inspection: 7/21/03
SITE EXAM
Slope
Surface water
Check cellar
Shallow wells
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:
O ays C
+15[ mA-05
I
I
i
i
FORM 4- SYSTEM PUMPING RECORD
JRRIER
SEPTIC & DRAIN SERVICE
FOREST STREET;MIDDLETON, MA 01949
(978)774-2772
COMMONWEALTH OF MASSACHUSETTS
MASSACHUSETTS
i
SYSTEM PUMPING RECORD
SYSTEM OWNER: sc1 m � � SYSTEM LOCATION: { t
Ll
)3c) lc�03 r c �� ��
-f e R,,c 'K
was-- 6oa6
4 I
I
I
DATE OF PUMPING: l0'�s g QUANTITY PUMPED: /SSC) GALLONS
i
CESSPOOL: NO 0 YES F7 SEPTIC TANK: NO a YES E:g—
SYSTEM PUMPED BY: CURRIER SEPTIC & DRAIN SERVICE
CONTENTS TRANSFERRED TO:
DATE: /d-�S-/ S� INSPECTOR:
I
)413D °P HEAL-111 L-or _7 Z-,toN f,4 Cf
7TH AupOVEI,�, MA,
❑ WEU_ APP oueD DI f'
SS 5cff1c sY s TE, ll
�Ppl�ovepD DArt' 1jPMou NG AU„--,ot-�,Ty
COAJ iTiOiJ5=
Al E C 7-0
DI5APPK6V5p D/�IE
R�ASUNS =
j5-X4V4Ttolj J/ JSP�6710A J ��rG - -PASS PQIt-
nNAL l Q5p6—�-TloA
QPPI�dVED �/JTCl!'Z�b �P('tzIJV�NG �uT�tDl��iy��
AVD(TI0,0A, 1>J5Fz.i Ioo ���,o►�Y)
DASAPP dv'D D,arC
R�/j50 NS•,
FKAL OPFOVAL
,. % 15- 6 AP��a��G �u►Haj;I ry�
�doveealthr,Masa
SUBSURFACE DISPOSAL DESIGN CHECK LIST
.LOT # j 64LOAAA CIl?-
�-
APPROM DATE DISAPPROVED DATE
Provided: Reasons:
title V FAIL CK
leg 2.5 The submitted plan must show as a ndnimums
r a) the lot to be served-area,dimensions lot #,.abutters
b location and log deep observation hoes-distance to ties
C location and results percolation tests-distance to ties
d design calculations & calculations showing required leaching area
(e) location and dimensions of system-including reserve area
f) existing and proposed contours
(g) location any wet areas Athin 1001 of sewage disposal system or
----_- . disclaimer-check wetlands mapping
(h) surface and subsurface drains within 1001 of sewage disposal
system or disclaimer
(i) location any drainage easements within ].001 of sewage disposal
system or disclaimer-Planning Board file ; C
(J) known sources of water supply within 200 ' of sewage disposal a
system or disclaimer
(k) location of any proposed well to serve l t-1001 from leaching facility
(1) location of water lines on property-101 .rom leaching facility
(m) location of benchmark
(n) driveways
(o) garbage disposals
(p) no PVC to be used in construction
(q) profile of system-elevations of basement, jtumb, pipe, septic tank,
distribution box inlets and outlets, distribution field piping and
Other elevations
(r) maximum ground water elevation in area sewage disposal system
(s) plan mast be prepared by a Professional Engineer or other
professional authorized by law to prepare such plans
Reg 6 Septic Tanks
(a) capacities-150%- of flog, water table, tees, depth of tees,
access, pumping
(b) cleanout
(c) 101 from cellar wall or inground s .ng pool
(d) 251 from subsurface drains
leg 10.2 Distribution Boxes
(a) slope greater than 0.08
leg 10.4 b) sump
M
rt�rnr+ �
iedti&form for-use by fbs Other kghs trt,Checwith your
OE?has provdsubstantially tssaoathat provided hereBefo aus
information must be
use.The System Pumping Record must be subrhitted.,to
local Board of Health to determine the form they. within 14 days from the pumping date-in
the local Board of Health or other approving authority
accordance with 310 CMR'15.351.
A. Facility information
Important, 4; System Location
When Utting,out /
forms on the �0 L Q c U n 1 eA -
computer,use r-- - —
ony me lab'key Address ` M A
to move your f`" h n State Z►p.'Cod
,curs'or:do not Gtyfrown
use.,lhe'reluin
key. -1 System Owner;
Na" _
Addrrfts(if different from locations). {
- -
Sta Zip Code
Cily/Fown - - C1 7 -_+►_ �q Q Iv _. ...
'Totephone Number
B, pumping Record
5
Quantity Pumped' �Gal*s
1.. Date of Pumping pate
3. Type-of system: Ej
Cesspool(s). V5epticTanlr [] Tight Tattle E' Grease Trap
Q Other(describe): -
4_ Effluent Tee Filter present? [] Yes O'-No If yeas, was it cleaned? Yes Z] No.
5. Condition of System:
6. System Pumped B
_- Vehicle lleense,N.u+nber
Name
_._-•.---fix• l Yl lJ• .-,1�1�,1� � ., .. - --
Company
7. Location where contents were disposed`
• _. .._..�.. - Date . - -_ -•-•- -- - .
Signarureof,Iia r V,0 An4,W �. _ - - —�_ _ •-- - -
6goalure'o1f eceM,ng Faciidy
— -- _ Date
Sys.lem'pumping ReWd_•Page 1 of f
1510im4,do&03!06
I