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HomeMy WebLinkAboutMiscellaneous - 135 ACADEMY ROAD 4/30/2018 135 ACADEMY ROAD 210/096.0-0039-0000.0 1 i 1 i I i I I l t I i Commonwealth of Massachusetts ; City/Town of Nov Z4 ZU14 System Pumping-Record TOWN 0.1, ,i r svjlJUv R Form 4 HEA r, 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 forum 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, Le i ht:;7ig=rhtorfeaor , Left/right side of house, Left/ Right side of building, Left/Right front of building, Le of building, Under deck Address 1 CWTown State Zip Code 2. System Owner. Name \ Address(if different from location) City/Town State �® -gip Code ; Telephone Number _ r B. Pumping Record 1. Date of Pumping Date 2. Quantity Pumped: Gallons 3. Type of system: ❑ Cesspool(s) GI-Septic-1 a'nk. El 'right Tank ❑ Other(describe): 4. Effluent Tee Filter present? ❑ Yes D_Mo__� If yes,was it cleaned? ❑ Yes ❑ No: ' 5. Condition of te . 6. System Pumped By. Neil.Batesbn F5821 Name Vehicle License Number . Bateson Enterprises Inc' Company 7. Location here contents were disposed: O. S. Lowell Waste Water f Sig Haule Date t5form4.doe-06/03 System Pumping Record•Page 1 of 1 IN Commonwealth of Massachusetts = City/Town of System Pumping Record Form 4 DEP has provided this form for us&by local Boards of Health. Other forms may be used, but the information must be substantially the same as that provided here. Before using.this form, check with your local Board of Health to determine the form they use.The System Pumping Record must be submitted to the local Board of Health or other approving authority. A. Facility Information 1. System Location: Left/Right front of house, Left , Left/right side of house, Left/ Right side of building, Left/Right front of building, Left/Right rear of building, Under deck Address t 2 J e-r City/Town State Zip Code 2. System Owner. Name Address(if different from location) City/Town StateL q p de ` 'l�° Telephone Number B. Pumping Record 1. Date of Pumping Date 2. Quantity Pumped: Gallons . ❑ Cesspool(s)3. Type of system: D'pSeptic Tank Tight Tank ❑ Other(describe): 4. Effluent Tee Filter present? ❑ Yes a--No If yes, was it cleaned? ❑ Yes ❑ No I 5. Condificp of System t Y ea �Zl J `1 V 6. System Pumped By: Neil.Bateson F 5 8 2 1 rNO Name Vehicle Lioense�Number Bateson Enterprises Inc HFa QHN�RTygNp�V company - D�PTMFNT R 7. Locationa contents were disposed: Ca.. S. Lowell Waste Water Signitufe qj HaulerU Date t5form4.doc•06103 System Pumping Record•Page 1 of 1 Commonwealth of Massachusetts, C'V-:::a City/Town of C N System Pumping Record DEC 11 ZU12 y Form 4 TOWN OF N4 TH AI\23t'cR ; DEP has provided this form for use-by local Boards of Health. Other forms may be used, but the information must be substantially the same as that provided here. Before using.this form, check with your local Board of Health to determine the form they use.The System Pumping Record must be submitted to the local Board of Health or other approving authority. A. Facility Information 1. System Location: Left/Right front of house, Le I fit rear of ho , Left/right side of house, Left 1 Right side of building, Left/Right front of building, Left/Right rear of building, Under deck Address City/Town State Zip Code 2. System Owner. C' r Name `` \ Address(if different from location) Cityrrown Stat lin ode E2��— �' Telephone Number B. Pumping Record 1. Date of Pumping Date 2. Quantity Pumped: Gallons I t 3. Type of system: ❑ Cesspool(s) eptic Tank El Tight Tank ❑ Other(describe): 4. Effluent Tee Filter present? ❑ Yes 2--Nio If yes, was it cleaned? ❑ Yes ❑ No 5. Conditio of yst�em�: � 6. System Pumped By: Neil Bateson F5821 Name Vehicle License Number Bateson Enterprises Inc Company 7. Loca ' ere contents were disposed: G . S. Lowell Waste Water it Sign t e Haule Date t5form4.doc•06/03 System Pumping Y ' g Recerr•Page 1 of 1 i Commonwealth of Massachusetts c usetts City/Town of lVD System Pumping Record Form 4 NOV 15 N i l T WNOFN DEP has provided this form for use by local Boards of Health. Ot r ►r� slA $ u the information must be substantially the same as that provided here. rtlr ;c k 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, Le fight�ofe, Left/right side of house, Left/ Right side of building, Left/Right front of building, a f building, Under deck Address City/Town State Zip Code 2. System Owner: Name Address(if different from location) City/Town State �r /�Q�Zip Code Telephone Number L� B. Pumping Record 1. Date of Pumping Date 2. Quantity Pumped: Gallons 3. Type of system: ❑ Cesspool(s) Septic Tank ❑ Tight Tank ❑ Other(describe): 4. Effluent Tee Filter present? ❑ Yes No If yes, was it cleaned? ❑ Yes ❑ No 5. Condition ofstem: rr AA d�sJ� I" (� - � V-\- 6. System Pumped By: Neil Bateson F5821 Name Vehicle License Number Bateson Enterprises Inc Company 7. Locati where contents were disposed: G.L Lowell Waste Water l ( --3_ it Sign to a Haule Date t5form4.doc•06/03 System Pumping Record•Page 1 of 1 Commonwealth of Massachusetts City/Town of FereAWW)Q-9i6 CEIVED System Pumping Record Form 4 T 2 © 2009 M DEP has provided this form for use by local Boards of Healt4r,+ S�n , butthe information must be,substantially the same as that provided _fhtsN orax,check with your local Board of Health tQ determine the form they use.The Syitemm—Pumping Record must be submitted to the local Board of Health or otter approving authority. A. Facility Information 1. Syste o.* Left side of house, Right side of house, Left front of house, Right front of house, eft rear of h se, I ht rear of house. Left rear of building. Right rear of building. Address � Cityrrown State N Zip Code 2. System Owner: Name Address(if different from location) Cityrrown State Telephone Number (J / B. Pumping Record 1. Date of Pumping Date 2. Quantity Pumped: Gallons 3. Type of system: ❑ Cesspool(s) Septic Tank ❑ Tight Tank ❑ Other(describe): 4. Effluent Tee Filter present? ❑ Yes No If yes,was it cleaned?. ❑ Yes ❑ No 5. Condit of System: kkio �C6 � S 6. System Pumped By: Neil Bateson F6821 Name Vehicle License Number Bateson Enterprises Inc Company 7. Locatio e e contents were disposed: G.L.S.D Lowell Waste Water / Signature of Hauler Date t5form4.doc•06/03 System Pumping Record•Page 1 of 1 Commonwealth of Massachusetts City/Town of OCT 2 3 2008 System Pumping Record Form 4 o" 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 r ; left si of house Right front, right rear, right side of house. forms on the computer,use only the tab key Address 1 to move your ` cursor-do not use the return City/Town tate Zip Code key. 2. System Owner: rck� Name Address(if different from location) CitylTown State q Zip Code Telephone Number B. Pumping Record 1. Date of Pumping Date 2. Quantity Pumped: Gallons 3. Type of system: Ej Cesspool(s) Septic Tank El Tight Tank Other(describe): 4. Effluent Tee Filter present? YesIf yes, was it cleaned? Yes No 5. Condition of System: 6. System Pumped By: Neil Bateson F 5821 Name Vehicle License Number Bateson Enterprises Inc Company 7. Location where contents were disposed: L.S.D Lowell Waste Water igna ure of H u r Date t5form4.doc°06103 System Pumping Record°Page 1 of 1 -CN- Commonwealth of Massachusetts City/Town of -C ' � System Pumping Record NOV o 5 2007 Form 4 TOWN OF NORTH DEP has provided this form for use by local Boards of Health. Otherytomis'rmm ' 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. Sy em Location: forms on the ��,�— C) computer,use only the tab key Address to move your cursor-do not City/Town StaI6 Zip Code use the return key. 2. System Owner: &� Name ISI Address(if different from location) Cityrrown State Zip Code Telephone Number B. Pumping Record 1. Date of Pumping Date 2. Quantity Pumped: Gallons 3. Type of system: ❑ Cesspool(s) eptic Tank ❑ Tight Tank ❑ Other(describe): 4. Effluent Tee Filter present? ❑ Yes No If yes,was it cleaned? ❑ Yes ❑ No 5. Condition of System: 6. System Pumped By- Name CSL'a Vehicle License Number Company 7. Location ere contents ere disposed: SignatA cl H uler VDate t5form4.doc•06/03 System Pumping Record•Page 1 of 1 Septic System Information 'c—_' 135 ACADEMY ROAD Printed On:Friday, November 03,2006 System/D: BHS-2002-1856 General System Information Latest Permit Information Calcaluted Design Flow. Test Pits Septic Tank Disposal Trench Design Flow: One Two Capacity: Number. p ty: Design Flow Provided: Minutes per inch: Width: Width: Total Flow: Depth: Length: Length: Seasonal: No No Depth to Water: Diameter: Leaching: Grinder: No No Soil Type: Depth: Laundry: No No Hau/ing/Pumpin4 Listin Quantity Type System Type Pumped Pumped By Transferred To Disposed At Date Pumped (gallons) Routine Septic Tank Bateson Enterprises 10/19/2004 500 Routine Septic Tank Bateson Ent GLSD 04/04/2005 750 Routine Septic Tank Bateson Ent GLSD 11/03/2006 750 Comments: Normal level in tank GeoTMS®2006 Des Lauriers Municipal Solutions, Inc. Page 1 of 1 _ Commonwealth of Massachusetts City/Town of I ED System Pumping Record �E��d� J Form 4 NOV - 3 DEP has provided this form for use by local Boards of Health The System P ltFfB cord must be submitted to the.local Board of Health or other approving u�g�-tg NO P R �Nj HENJ A. Facility Information Important: When filling out 1. Syst m Location: forms the computer.use only the tab key Address to move your ' C�t�L` _ IUD4 �4k�424q� /`, cursor-do not use th&retum Qrtyrrow�m Sta Zip Code key. 2. System Owner: Name Address(if different from location) Cityfrown ..: State I ��^ Zip bde Telephone Number B. Pumping Record 1 Date.of Pumping nate 2. Quantity Pumped: Gallons 3. Type of system: ❑ Cesspool(s) Septic Tank- ❑ Tight:Tank ❑ Other(describe): 4: Effluent Tee Filter present? ❑ Yes If yes,was it cleaned? ❑ Yes ❑ No 5. Condition of System, � �&a� 6: SystemufnApBTi Name VehicI icense Number Company -- 7. Location 11 re c ntents`: ere dis sed:. Xj— Signat o au r Date j http://www.mass.gov/dep/water!approvals/t5forms.htm#inspect t5fomr4.doc-06103 System Pumping Record•Page 1 of t i TOWN OF N SYSTEM PUMPING RECORDRECEIVED DATE: G� NOV - 9 2005 TOWN OF NORTH ANDOVER HEALTH DEPARTMENT SYSTEM OWNER&ADDRESS SYSTEM LOCATION (example:left front of house) p) cAL') S DATE OF PUMPING: QUANTITY PUMPED: GALLONS CESSPOOL: NO YES SEPTIC TANK: NO YES NATURE OF SERVICE: ROUTINE l EMERGENCY OBSERVATIONS: GOOD CONDITION FULL TO COVER HEAVY GREASE BAFFLES IN PLACE ROOTS LEACHFIELD RUNBACK EXCESSIVE SOLIDS FLOODED SOLIDS CARRYOVER OTHER(EXPLAIN) SYSTEM PUMPED BY: Bateson Enterprises, Inc. COMMENTS: CONTErrrs TRANSFERRED To: G.L.S.D �owefl Waste C� - ► a COMMONWEALTH OF MASSACHUSETTS EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS DEPARTMENT OF ENVIRONMENTAL PROTECTION ONE WINTER STREET,BOSTON MA 02108 (617) 292-5500 TRUDY COKE Secretary ARGEO PAUL CELLUCCI DAVID B. STRUHS Governor Comrniss;oner SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION Property Address• Name of Owner � of Owner: (3 Date of Inspection: ;Z).2.-5 I '1 q Name of Inspector:(Please Print) Benj amin C. Osgood, Jr 1 am a DEP approved system inspector pursuant to Section 15.340 of Tide 5 1310 CMR 15.000) Company Name: New England Engineering S_ervi_ces Inc. Maifng Address: 33 Walker Rd , Sid fe 230 North Andover, MA 01845 Telephone Number: 978-686-1768 CERTIFICATION STATEMENT I certify that I have personally inspected the sewage disposal system at this address and that the information reported below is true, accurate and complete as of the time of inspection. The inspection was performed based on my training and experience in the proper function and maintenance of on-site sewage disposal systems. The system: Passes Conditionally Passes y Needs Further Evaluation By the Local Approving Authority Fails 1 Inspector's Signature: Date: __7 L3 The System Inspector shall submit a copy of this inspection report to the Approving Authority(Board of Health or DEP)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-Env'ironmental Protection. The original should be sent to-" system owner and copies sent to the buyer,if applicable, and the approving authority. NOTES AND COMMENTS revised 9/2/98 Page I of I] 0. Primed on Recycled Papa i SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address: 13 s A<<,�4�r••� 2S� i. A.. Owner: ( c S t t_ k&r b6 o 5 Date of Inspection: 21Z 3 f t Ct INSPECTION SUMMARY: Check A, B, C, of D: A. SYSTEM PASSES: ✓ I have not found any information which indicates that any of the failure conditions described in 310 CMR 15.303 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. Indicate yes, no, or not determined(Y,N,or ND). Describe basis of determination in all instances. If "not determined",explain why not. The septic tank is metal,unless the owner or operator has provided the system inspector with a copy of a Certificate of Compliance(attached)indicating that the tank was installed within twenty (20) years prior to the date of the inspection:or the septic tank, whether or not metal, is 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 complying septic tank as approved by the Board of Health. 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 levelled or replaced The system required pumping-more than four-times a yeardue to broken or obstructed pipe(s). The system vral petrs'� inspection if(with approval of the Board of Health): - '-- broken pipe(s) are replaced obstruction is removed revised 9/2/98 Page 2of11 t / SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address: 13 s Owner: cs 1 c c 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 the public health,safety and the environment. 11 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.IPRQTECT THE PUBLIC HEALTHAND SAFETY AND THE ENIOBONMEKr: 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 ANY)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(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 soil absorption system and the SAS is within a Zone I of a public water supply well. _ The system has a septic tank and soil absorption system and the SAS is within 50 feet of a private water supply well. _ The system has a septic tank and soil absorption system and the SAS is less than 100 feet but 50 feet or more from a private water supply well,unless a well water analysis 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. Method used to determine distance (approximation not valid). 3) OTHER revised 9/2/98 Page 3ofII SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address: 13 A c cJc r, '20 Owner: �` y l;c H of Date of Inspection: Z) Z D. SYSTEM FAILS: You must indicate either "Yes"or"No" to each of the following: I have determined that one or more of the following failure conditions exist as described 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. Yes No _ Backup of sewage into facility-or-e"tem component•due,to an overloaded orvbgged SASor•cesspool. y--�" "• 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 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 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. E. LARGE SYSTEM FAILS: 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: 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: Yes No the system is within 400 feet of a surface drinking water supply the system-is-witNo 200 feet -a eurtaoadrinkiwg water•supply - -- -- - — _ the system is located in a nitrogen sensitive area(Interim Wellhead Protection Area-IWPA)or a mapped Zone 11 of a public water supply well) The owner or operator of any such system shall upgrade the system in accordance with 310 CMR 15.304(2). Please consult the local regional office of the Department for further inforgiation. revised 9/2/98 Page 4orII i SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST I I Property address: 1 IggGcCQc'"^y IW, N• A nNC:c2 Owner: Date of kupec ion: � -e s Ile Z t 2319�t Check if the following have been done:You must indicate either "Yes"or"No" as to each of the following: Yes No ✓ _ Pumping information was provided by the owner,occupant,or Board of Health. None of the system compoaents.lwwboen pua►pod+lorstJeast two aweekc ari-al-the'rystem hasbwoar caiassgwrsSKai flow rates during that period. large volumes of water have not been introduced into the system recently or as part of this inspection. L As built plans have been obtained and examined. Note if they are not available with N/A. _ The facility or dwelling was inspected for signs of sewage back-up. 1� The system does not receive non-sanitary or industrial waste flow. The site was inspected for signs of breakout. All system components, excluding the Soil Absorption System, have been located on the site. _V _ 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. The size and location of the Soil Absorption System ortthesite has been determined based on: JExisting information. For example, Plan at B.O.H. Determined in the field(if any of the failure criteria related to Part C is at issue,approximation of distance is unacceptable) 115.302(3)(b)) J - _ The facility owner(and.occupanis.if differew from.ommer),ware,prmrided.with i-formation.Dn tha pro^p��sinfa^�w-�^t SubSurface Disposal Systems. revised 9/2/98 PageofII SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION Property Address: Owner: ' 3' RC�cl.c �,y 1n Date of Ins Le.y l e )4 s Z1 Z,3(C1C FLOW CONDITIONS RESIDENTIAL: Design flow: •— g.p.d./bedroom. 2 Number of bedrooms(design): Number of bedrooms(actual): 3 Total DESIGN flow Number of current residents: / Garbage grinder(yes or no):� Laundry(separate system) (yes or no):^4�; If yes, separate inspection required _ Laundry system inspected (Yes or no)-- Seasonal use(yes or no): N Water meter readings,if available(last two year's usage(gpd): I Sump Pump(yes or no): A� Last date of occupancy: ('._L2L—fi COMMERCIALANDUSTRtAL: Type of establishment: Design flow: qpd 1 Based on 15.203) Basis of design flow 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: OTHER:(Describe) Last date of occupancy: GENERAL INFORMATION PUMPING RECORDS and source of information: E•ic� System pumped as part of inspection: (yes or no)_6.2e If yes,volume pumped: gallons 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) I/A Technology etc.Attach copy of up to date operation and maintenance contract Tight Tank Copy of DEP Approval Other U APPROXIMATE AGE of all components,date instaNedfif known)-end source o 4Movmation: /-n ks ne„ve Sewage odors detected when-arriving at the site:(yes or no)4/-- revised 9/2/98 Page 6of11 I SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: )j i9 CciGut Owner: / Date of Inspection: 2` ZClC1 BUILDING SEWER: (Locate on site plan) Depth below grade:_ Material of construction:_cast iron_40 PVC_other lexplain) Distance from private water supply well or suction line Diameter Comments:(condition�J of joints,venting,evidence of toark1age,-etc.) n SEPTIC TANK:_ (locate on site plan) Depth below grade:—JoL.p -rc"tet, 'V' Material of construction:-,,�ncrete_metal_Fiberglass _Polyethylene_other(explain) If tank is fnetal,list age_ ls.age.confumed by Certificate of Compliance_(Yes/No) Dimensions: lov✓ [7r,/t!�rt s Sludge depth: y 'r / Distance from top of sludge to bottom of outlet tee or baffle: �« Att -Cc crr-�s I In IC - Scum thickness: 2" 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 dimensions were determined: Me-&j.,.^( -`-12e ie, Comments: (recommendation for pumping, condition of inlet and outlet tees or-baffles, depth of liquid level in relation t�outlet invert,structurelmintegrity, evidence of leakage,etc.) TfANsA !.,L) CD!A C k?e. . /Q1-1C/2- A, " rJ GREASE TRAPYJ�/ (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: (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.) revised 9/2/98 Page 7ofII SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C nnSYSTEM INFORMATION(continued) Property Addlrww: 1 a 5 C c.<(1v�H y `nn� N- fl �u•.�1'- Date of lempeetion: 21231gc� TIGHT OR HOLDING TANK:(Tank must be pumped prior to, or at time of,inspection) (locate on site plan) Depth below grade:_ Materiel of construction:_concrete_metal_Fiberglass_Polyethylene_other(explain) Dimensions: Capacity: gallons Design flow: gallons/day Alarm present Alarm level: Alarm in working order: Yes_ No_ Date of previous pumping: Comments: (condition of inlet tee, condition of alarm and float switches,etc.) DISTRIBUTION BOX:_ (locate on site plan) Depth of liquid level above outlet invert: ^ Comments: (note if level and distribution is aqua l,�evirnee of solids c/arrryover,eviden�cee of leakage into or out of box etc.) - - 6"J k 1&t (_TC c',:X Ce' E',i' F 6.f c!- z'v �Lc,ocr.� PUMP CHAMBER:AZ(f- (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.) revised 9/2/98 Page 8ofII I i SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: i35 1,.s! b1`�ct- Datee of Inspection: e L) L3 � SOIL ABSORPTION SYSTEM(SAS):_ (locate on site plan,if possible;excavation not required,location may be approximated by non-intrusive methods) If not located,explain: Type: leaching pits,number:_ leaching chambers,number:_ leaching galleries,number:_ leaching trenches,number,length: leaching fields,number,dimensions: overflow cesspool,number:_ Alternative system: Name of Technology: Comments: (note condition of soil,signs of hydraulic failure,level of ponding,damp soil,condition of vegetation,etc.) CESSPOOLS:Li (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 o1 inspection) 0 Comments: (note condition of soil,signs of hydreulic failure,level of pending,condition of-vegetation,etc.) _ PRIVY: --4':4 (locate on site plan) Materjals of construction: Dimensions: Depth of solids: Comments: (note condition of soil,signs of hydraulic failure,level of ponding,condition of vegetation,etc.) revised 9/2/98 page 9orif revised 9/2/98 Page 10eru r' IV - -- 'o TOWN OF NORTH ANDOVER SYSTEM PUMPING RECORD �� 9 2001 DATE: SYSTEM OWNER&ADDRESS SYSTEM LOCATION (example: left front of house) f 5 AcJ-cvvL� �J DATE OF PUMPING:_ QUANTITY PUMPED GALLONS CESSPOOL: NO ZYES SEPTIC TANK: NO YES NATURE OF SERVICE: ROUTINE EMERGENCY OBSERVATIONS: GOOD CONDITION FULL TO COVER HEAVY GREASE BAFFLES IN PLACE ROOTS LEACHFIELD RUNBACK EXCESSIVE SOLIDS FLOODED SOLIDS CARRYOVER OTHER(EXPLAIN) SYSTEM PUMPED BY: COMMENTS: CONTENTS TRANSFERRED TO: L� I T TOWN OF V "L.14� SYSTEM PUMPING RECORD DATE: Nov 2 620" SYSTEM OWNER& ADDRESS SYSTEM LOCATION F ' (example:left front of house) 42�� '�-24j� (� ea'-� C)� PA �U DATE OF PUMPING. C -Z 3 QUANTITY PUMPED : / 5� GALLONS CESSPOOL: NO �ES� SEPTIC TANK: NO YES NATURE OF SERVICE: ROUTINE EMERGENCY OBSERVATIONS: GOOD CONDITION FULL TO COVER HEAVY GREASE BAFFLES IN PLACE ROOTS LEACIHULD RUNBACK EXCESSIVE SOLIDS FLOODED SOLIDS CARRYOVER OTHER(EXPLAIN) SYSTEM PUMPED BY: Bateson Enterprises, Inc. COMMENTS: CONTENTS TRANSFERRED TO: G.L.S.D Lowell Waste C,pmmonwealth of Massachusetts Massachusetts System Pumping Record System Owner System Location QA,. Date of Pumping: �' � �--� �'t Quantity Pumped: 1021 gallons Cesspool: No{-]�/ Yes [] Septic Tank: No [I Yes — System Pumped by: Va&4" Fa&qWae4 License# Contents transferred to: Greater Lawrence Sanitary District Date: Inspector: JAN Commonwealth of Massachusetts Massachusetts System Pumping Record System Owner System Location P� C'V�) 1 ( -3 s- 464--g-4r.-ou, Date of Pumping: l V — CJ Quantity Pumped: -;�,= llons Cesspool: No Yes [] Septic Tank: No [] Yes H' System Pumped by: lva&4d oG smavMae4 License# Contents transferred to: Greater Lawrence Sanitary District Date: Inspector: 27 NEW ENGLAND ENGINEERING SERVICES INC TOWN OF NORTH ANDOVER/ BOARD OF HEALTH FEB 2 6 1999 February 24, 1999 North Andover Board of Health Town Hall Annex 27 Charles Street North Andover,MA 01845 RE: TITLE V REPORT: 135 Academy Rd,North Andover Enclosed is a copy of the revised Title V report for the above referenced property. The system passes our.inspection. If there are any questions please call me at my office, 686-1768. Yours truly, BVnjamin C. Osg6a Jr., E.I.T. President 33 WALKER ROAD-SUITE 23-NORTH ANDOVER,MA 01845-(978)686-1768-(888)359-7645-FAX(978)685-1099 i30 ��� � APPLICATION FOR SEWAGE DISPOSAL INSTALLATION HEALTH DEPARTMENT - NORTH ANDOVER, MASS. I hereby application for a permit for a sewage disposal installation at S-/3 � �= 4d= . I will install this system in ac- cordance with all the laws of the Commonwealth of Massachusetts and regulations of the Board of Health of the Town of North Andover. Further, I will construct the house sewer of bell and spigot pipe, the minimum diameter being 4 inches, and will maintain a minimum grade of 1% until 10 feet pre- ceding the septic tank, where the grade shall not exceed 290. I will install a con- crete septic tank of / in size. A manhole (s) permitting easy cleaning will be provided with removable cover (s) of ironor concrete within 12 inches of the ground surface. I will provide subsurface disposal field with 4 inch perforated or open jointed pipe and laid in a series of trenches, the bottom of which will pro- vide a minimum of lineal (square) feet of effective absorption area. The pipes will be laid on a 6 inch layer of washed gravel or crushed stone ranging in size from 3/4 to 1-1/2 inches (dia.) and the pipes will be surrounded by similar material to a height of 2 inches above the crown of the pipe. The joints of these pipes will be protected from clogging and before filling the trench, 2 inches of gravel or stone 1/8" to 1/4" (dia.) will be placed over the course gravel or stone. The disposal field will be installed at a grade of 4 to 6 inches/100 feet. No single tile line will exceed 100 feet in length and in any case, two lines of tile will be installed. A minimum of 6 feet will be maintained between. the center lines of the disposal field trenches and the average depth of trench shall not exceed 36 inches. No part of the installation will be less than 100 feet from any private water supply, 25 feet from any stream, 20 feet from any dwelling or 10 feet from any property line. I further agree not to cover any portion of this installation until approved by the inspection officer, as provided below, and to incorporate any additional requirements that may be attached to the permit. Plot Plans must be submitted with application. DATE Signature of Applicant I hereby issue the above permit for the Board of Health of the Town of North Andover, Massachusetts. DATE Signat e o He -Ith Argent I have inspected the uncovered system indicated above and find everything done as described. DATE C l 7 c Signature of I pecting Officer 1 Percolation Test Qt Garbage Grinder • r: re, BOARD OF HEALTH TOWN OF NORTH ANDOVER, MASS. 1 7 kc so O 1. NA DATE 2. ADDRESS 34' _ 1 , LOT N0. TEL. b-c/--'00c, 3. NO. OF'BEDROOMS DEN YES / NO 4. GARBAGE GRINDER YES NO 5. SHOW DIMENSIONS OF HOUSE 6. SHOW DISTANCES OF HOUSE TO ALL PROPERTY LINES 7. SHOW DIMENSIONS OF LOT 8. SHOW LOCATION AND SIZE OF SEPTIC TANK OR CESSPOOL 9. NOTE LOCATION AND DISTANCE OF WELL FROM SEWERAGE SYSTEM 10. SHOW LOCATION OF BROOKS, STREAMS, DITCHES, LEDGE OUTCROP, ETC. 11. SHOW DISTANCE OF SEPTIC TANK OR CESSPOOL FROM HOUSE NOTE: LOCAL REGULATIONS SHOULD BE READ CAREFULLY. A- . . .� BOARD OF HEALTH OF NORTH ANDOVER, MASSACHUSETTS SEWAGE DISPOSAL DATE !R/1), NAME OF APPLICANT XM_ Snhwar�r LOCATION Address of lot no, BUILDING: Dwelling X Other SYSTEM: New Repair X GENERAL DESCRIPTION OF LAND high SUBSOIL: Clay Gravel Sand 4:�� X PERCOLATION TEST A. minutes per inch, MINIMUM INSTALLATION RECOMMENDATIONS CONCRETE SEPTIC TANK- 1 ,000 gallon capacity. LEACH FIELD 200 lineal feet of drain pipe, William J. Dr' coil , Engineer Board of Heal Commonwealth of Massachusetts RECEIVE® -AA do tib , Massachusetts NOV - 2 2004 TOWN OF NORTH ANDOVER HEALTH DEPARTMENT System Pumping Record System Owner System Location V(xv✓k �"'&<—b f_ "-v 'S Date of Pumping: Quantity Pumped: gallons Cesspool: No 1"// Yes [] Septic Tank: No [] Yes [y/ System Pumped by: Far"" 4FLicense# Contents transferred to: Greater Lawrence Sanitary District Date: Inspector: