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Home My WebLink AboutMiscellaneous - 135 JOHNNY CAKE STREET 4/30/2018 (3)� _- - - / » J�ti� rE 4(�f� Of NORiM 1 4 w• E 2 Town of North Andover ��'•�:,:�:: HEALTH DEPARTMENT ,SSACNUSt� CHECK#: L s DATE: 02 LOCATION: . H/O NAME: CONTRACTOR NAME: Type of Permit or License:(Check box) ❑ Animal 1 $ ❑ Body Art Establishment $ ❑ Body Art Practitioner $ ❑ Dumpster $ ❑ Food Service-Type:_ $ ❑ Funeral Directors $ ❑ Massage Establishment $ ❑ Massage Practice $ ❑ Offal(Septic)Hauler $ ❑ Recreational Camp $ ❑ Sun tanning $ ❑ Swimming Pool $ ❑ Tobacco $ ❑ Trash/Solid Waste Hauler $ ❑ Well Construction $ SEPTIC Systems: ❑ Septic-Soil Testing $ ❑ Septic-Design Approval $ ❑ Septic Disposal Works Construction(DWC) $ ❑ Septic Disposal Works Installers(DWI) $ ❑ /Title 5 Inspector $ C3 Title 5 Report $� ❑ Other. (Indicate) $ YHeaii' A ent Initials White-Applicant Yellow-Health Pink- PP Treasur. Commonwealth of Massachusetts City/Town of North Andover ZAPR System Pumping Record1i Form 4 TOH ANDOVER DEP has provided this form for use by local Boards of Health. Other for H 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 computer, use 135 Johnny Cake only the tab key Address to move your N. Anodver Ma 01886 cursor-do not City/Town use the return State Zip Code key. 2. System Owner: QComerford Name 'eh01 Address(if different from location) City/Town State Zip Code Telephone Number B. Pumping Record 1. Date of Pumping 1 2. Quantity Pumped:Date E;Co Ga ons 3. Type of system: ❑ Cesspool(s) 9—Septic Tank ❑ Tight Tank ❑ Grease Trap ❑ Other(describe): 4. Effluent Tee Filter present? ❑ Yes ❑ No If yes, was it cleaned? ❑ Yes ❑ No 5. Condition of System: 6. m Pumped By: Name Vehicle License Number Stewart's Septic Service Company 7. Location where contents were disposed: Stewart's Pre-treatment Plant, 20 So. Mill Bradford, Ma 01835 Signature of Hauler Date Signature of Receiving Facility Date t5form4.doc•03/06 System Pumping Record•Page 1 of 1 li TOWN OF NORTH ANDOVER SYSTEM PUMPING RECORD DATE: SYSTEM OWNER &ADDRESS SYSTEM LOCATION (example: left front of house) �Ct� 55 DATE OF PUMPING:QUANTITY PUMPED : 1;CxZ GALLONS CESSPOOL: NO ,//YES ES SEPTIC TANK: NO YES NATURE OF SERVICE: ROUTINE EMERGENCY OBSERVATIONS: GOOD CONDITION FULL TO COVER HEAVY GREASE BAFFLES IN PLACE ROOTS LEACHFIELD RUNBACK EXCESSIVE SOLIDS FLOODED SOLIDS CARRYOVER OTHER (EXPLAIN) SYSTEM PUMPED BY: COMMENTS: �- - CONTENTS TRANSFERRED TO: �.V V COMMONWEALTH OF MASSACHUSETTS EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS DEPARTMENT OF ENVIRONMENTAL PROTECTION TITLE 5 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM PART A CERTIFICATION Property Address: 315— O N CSL �I rte_ Owner's Name: RECEIVED Owner's Address: Sal P Date of Inspection: —� �" JUN 2 3 2005 Name of Inspector: (please print) �aGY1 /Jy5 c� TOWN OF NORTH ANDOVER Company Name: Cs-59 HEALTH DEPARTMENT Mailing Address: J. r Telephone Number: CERTIFICATION STATEMENT 1 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: XPasses Conditionally Passes Needs Further Evaluation by the Local Approving Authority ails Inspector's Signature: Date: The system inspector shall submit a copy of this inspection report to the Approving Authority(Board of Health or DEP)within 30 days of completing this inspection. If the system is a shared system or has a design flow of 10,000 gpd or greater,the inspector and the system owner shall submit the report to the appropriate regional office of the DEP.The original should be sent to the system owner and copies sent to the buyer, if applicable, and the approving authority. Notes and Comments ****This report only describes conditions at the time of inspection and under the conditions of use at that time. This inspection does not address how the system will perform in the future under the same or different conditions of use. Title 5 Inspection Form 6/15/2000 page 1 t , Page 2 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: 3. t? /-/0 - 'c Owner: l�g�yj Date of Inspection: 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 i 15.303 or in 310 CMR 15.304 exist. Any failure criteria not evaluated are indicated below. I . Comments: B. System Conditionally Passes: /ll One or more system components as described in the"Conditional Pass"section need to be replaced or repaired:The system,upon completion of the replacement or repair,as approved by the Board of Health,will pass. Answer yes,no or not determined(Y,N,ND)in the for the following statements. If"not determined"please explain. The septic tank is metal and over 20 years old* or the septic tank(whether metal or not)is structurally unsound,exhibits substantial infiltration or exfiltration or tank failure is imminent. System will pass inspection if the existing tank is replaced with a complying septic tank as approved by the Board of Health. *A metal septic tank will pass inspection if it is structurally sound,not leaking and if a Certificate of Compliance indicating that the tank is less than 20 years old is available. ND explain: Observation of sewage backup or break out or high static water level in the distribution box due to broken or obstructed pipe(s)or due to a broken,settled or uneven distribution box. System will pass inspection if(with approval of Board of Health): broken pipes)are replaced obstruction is removed distribution box is leveled or replaced ND explain: The system required pumping more than 4 times a year due to broken or obstructed pipe(s).The system will pass inspection if(with.approval of the Board of Health): broken pipe(s)are replaced obstruction is removed ND explain: i Ili 2 i Page 3 of 11 OFFICIAL INSPECTION FORM -NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address: S e e -t✓ Owner: 1-A- , Date of Inspection: o_-5- C. C. Further Evaluation is Required by the Board of Health: /V/� Conditions exist which require further evaluation by the Board of Health in order to determine if the system is failing to protect public health, safety or the environment. 1. System will pass unless Board of Health determines in accordance with 310 CMR 15.303(1)(b)that the system is not functioning in a manner which will protect public health,safety and the environment: _ Cesspool or privy is within 50 feet of a surface water Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh 2. System will fail unless the Board of Health(and Public Water Supplier, if any)determines that the system is functioning in a manner that protects the public health,safety and environment: _ The system has a septic tank and soil absorption system (SAS)and the SAS is within 100 feet of a surface water supply or tributary to a surface water supply. _ The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water supply. _ The system has a septic tank and SAS and the SAS is within 50 feet of a private water supply well. _ The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or more from a private water supply well". Method used to determine distance "This system passes if the well water analysis,performed at a DEP certified laboratory, for coliform bacteria and volatile organic compounds indicates that the well is free from pollution from that facility and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered. A copy Y of the analysis must be attached to this form. I 3. Other: i 3 I Page 4 of 1 1 OFFICIAL INSPECTION FORM — NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: S— d61lf0,4110 )VC vtr Owner: 444 A0<.S/ Date of Inspection: —pS- ' 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 '/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 vibutary to a surface water supply. _7Any portion of a cesspool or privy is within a Zone 1 of a public well. y portion of a cesspool or privy is within 50 feet of a private water supply well. Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality analysis. (This system passes if the well water analvsis, performed at a DEP certified laboratory, for coliform bacteria and volatile organic compoueds 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 ;vstem fails. The system owner should contact the Board of Health to determine what will be necessary to correct the failure. I ' E. Large Systems: /U/ To be considered a large system the system must serve a facility, with a design flow of 10,000 gpd to 15,000 gpd. You must indicate either"yes" or"no" to each of the following: (The following criteria apply to large systems in addition to the criteria above) yes no _ the system is within 400 feet of a surface drinking water supply — _ the system is within 200 feet of a tributary to a surface drinking water supply the system is located in a nitrogen sensitive area (Interim Wellhead Protection Area — I WPA) or a mapped Zone 11 of a public water supply well _ If you have answered "yes" to any question in Section E t_he system is considered a significant threat, or answered "yes" in Section D above the large system has failed. The owner or operator of any large system considered a significant threat under Section E or failed under Section D shall upgrade the system in accordance with 3 10 CMR 15.304. The system owner should contact the appropriate regional office of the Department. 4 Page 5 of 11 OFFICIAL INSPECTION FORM -NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST Property Address: vt L►'��ta Owner: Date of Inspection: Check if the following have been done. You must indicate"yes"or"no"as to each of the following: Yes No ✓_ Pumping information was provided by the owner, occupant, or Board of Health Were any of the system components pumped out in the previous two weeks Has the system received normal flows in the previous two week period ? Have large volumes of water been introduced to the system recently or as part of this inspection ? ✓ _ Were as built plans of the system obtained and examined? (If they were not available note as N/A) _✓_ Was the facility or dwelling inspected for signs of sewage back up f_ Was the site inspected for signs of break out J 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 i The size and location of the Soil Absorption System (SAS)on the site has been determined based on: Ye 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) [3 10 CMR 15.302(3)(b)J i 5 Page 6 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION Property Address: _A d Owner: Date of Inspection: FLOW CONDITIONS RESIDENTIAL Number of bedrooms(design): 4 Number of bedrooms(actual): DESIGN flow based on 310 CMR 15.203 (for example: 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): Alo [if yes separate inspection required] Laundry system inspected(yes or no): Seasonal use: (yes or no):_j Water meter readings, if avai d le(last 2 years usage(gpd)): Sump pump(yes or no): Last date of occupancy: —0 0 ONO/-e d COMMERCIAL/INDUSTRIAL Type of establishment: Design flow(based on 310 CMR 15.203): gpd Basis of design flow(seats/persons/sgft,etc.): Grease trap present(yes or no):_ Industrial waste holding tank present(yes or no):_ Non-sanitary waste discharged to the Title 5 system(yes or no): Water meter readings, if available: Last date of occupancy/use: OTHER(describe): GENERAL INFORMATION Pumping Records Source of information: STCwar1T-s C-O Was system pumped as part of the inspection(yes or no): 146 If yes, volume pumped:_gallons--How was quantity pumped determined? Reason for pumping: vY'E 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) _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):14 0 6 Page 7 of I 1 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: J%3.5- JC` yn� ra/1� /V6 /ji�w o D a/-e✓ Owner: Gl4yh��SS Date of Inspection: BUILDING SEWER(locate on site plan) Depth below grade: /�' Materials of construction:—cast iron C, 40 PVC_other(explain): Distance from private water supply well or suction line: Comments(on condition of'oints, venting,evidence of leakage,etc.): �o SEPTIC TANK: _(locate on site plan) Depth below grade:/. Material of construction:✓concrete—metal_fiberglass polyethylene other(explain) If tank is metal list age:_ Is age confirmed by a Certificate of Compliance(yes or no):_(attach a copy of certificate) y Dimensions:T6 Sludge depth: �r Distance from top of sludge to bottom of outlet tee or baffle: 37 Scum thickness: 0 Distance from top of scum to top of outlet tee or baffle: Distance from bottom of scum to bottom of outlet tee or baffle: How were dimensions determined: Comments(on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invey evide ce of leakage,etc f C d Olt U mpl.4G A/ (gat) 10 C'OW01 7'140./ GREASE I TRAP: - ate on site plan) — p ) Depth below grade:— Material of construction: —concrete_metal_fiberglass polyethylene—other (explain): Dimensions: Scum thickness: Distance from top of scum to top of outlet tee or baffle: Distance from bottom of scum to bottom of outlet tee or baffle: Date of last pumping: Comments(on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): i I i ' i 7 Page 8 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: Owner: Date of Inspection: (— (,n .f TIGHT or HOLDING TANK:�/—A(tank must be pumped at time of inspection)(locate on site plan) Depth below grade: Material of construction: concrete metal fiberglass polyethylene other(explain): Dimensions: Capacity: gallons Design Flow: gallons/day Alarm present(yes or no): Alarm level: Alarm in working order(yes or no): Date of last pumping: Comments(condition of alarm and float switches,etc.): DISTRIBUTION BOX:�5 (if present must be opened)(locate on site plan) Depth of liquid level above outlet invert: ,) Comments(note if box is level and distribution to outlets equal,any evidence of solids carryover, any evidence of leakage into or out of box, etc.): flax. G"06P C6 IJ d'A-1 �� 7- PUMP CHAMBER: // i cafe 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 8 1 Pag e9of11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: � U�1 /7 nl C/5t11 Owner: Date of Inspection: /— C.--0 S— I SOIL ABSORPTION SYSTEM(SAS): eS(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: 0 44iq6 u �C lOz leaching fields,number,dimensions: overflow cesspool,number: innovative/alternative system Type/name of technology: Comments(note condition of soil,signs of hydraulic failure,level of ponding,damp soil, condition of vegetation, etc.): a Lac. f-M CESSPOOLS: (�e�Spool must be pumped as part of inspection)(locate on site plan) Number and configuration: Depth—top of liquid to inlet invert: Depth of solids layer: Depth of scum layer: Dimensions of cesspool: Materials of construction: Indication of groundwater inflow(yes or no): Comments(note condition of soil,signs of hydraulic failure, level of ponding,condition of vegetation,etc.): I PRIVY: (locate on site panj� Materials of construction: Dimensions: Depth of solids: Comments(note condition of soil,signs of hydraulic failure, level of ponding,condition of vegetation,etc.): 9 Page 10 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: ar 11 ZFZr Y Owner: 4,tO#04 SS/ Date of Inspection: 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. �r 13 C �v�[T rRcNcl�eS 1 i a . 73 j a{� 10 Page I I of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: , ® V,64'v Owner: Date of Inspection: G— A-0 5" SITE EXAM Slope Surface water Check cellar R Shallow wells H Estimated depth to ground water/69-4—feet Pleaseindicate(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: 7�� 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: /7c519H OA4 RP coa-n ,6S? I i I 11 _ G os--, J C) w T /I�j C'�' C't iZ t4, T'/ i G ry i COMMONWEALTH OF MASSACHUSETTS EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS 0 DEPARTMENT OF ENVIRONMENTAL PROTECTION r V TITLE 5 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM PART A CERTIFICATION Property Address: i3� .io ti l/YC�is'� RECEIVED eyo�rr��aoyr2 Owner's Name: MAR - 2 2005 Owner's Address: TOWN OF NORTH ANDOVER Date of Inspection: �- f e 0.5 HEALTH DEPARTMENT Name of Inspector: (please print) ,Q/Lull FAA44.192 Company Name: VO2Mr-d:ST 1-5—YVV 67A6 Mailing Address: Fr luaa exl �!z7 ,JA&MV Allf 0192-3 Telephone Number: 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: :z;z-- zDate: .24//6/0 The system inspector shall submit a copy of this inspection report to the Approving Authority(Board of Health or DEP)within 30 days of completing this inspection. If the system is a shared system or has a design flow of 10,000 gpd or greater,the inspector and the system owner shall submit the report to the appropriate regional office of the DEP.The original should be sent to the system owner and copies sent to the buyer, if applicable,and the approving authority. Notes and Comments ****This report only describes conditions at the time of inspection and under the conditions of use at that time. This inspection does not address how the system will perform in the future under the same or different conditions of use. Title 5 Inspection Form 6/15/2000 page 1 Page 2 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: 61hV/1/y C��' WOA-0 rhe 14-A11Q01/iz Owner: ZA171 WS S Date of Inspection: --2 Inspection Summary: Check A,B,C,D or E/ALWAYS complete all of Section D A.System Passes: I have not found any information which indicates that any of the failure criteria described in 310 CMR 15.303 or in 310 CMR 15.304 exist. Any failure criteria not evaluated are indicated below. Comments: B. System Conditionally Passes: One or more system components as described in the"Conditional Pass"section need to be replaced or repaired.The system, upon completion of the replacement or repair,as approved by the Board of Health, will pass. Answer yes,no or not determined (Y,N,ND)in the for the following statements. If"not determined"please explain. The septic tank is metal and over 20 years old* or the septic tank(whether metal or not) is structurally unsound,exhibits substantial infiltration or exfiltration or tank failure is imminent. System will pass inspection if the existing tank is replaced with a complying septic tank as approved by the Board of Health. *A metal septic tank will pass inspection if it is structurally sound,not leaking and if a Certificate of Compliance indicating that the tank is less than 20 years old is available. ND explain: Observation of sewage backup or break out or high static water level in the distribution box due to broken or obstructed pipe(s)or due to a broken,settled or uneven distribution box. System will pass inspection if(with approval of Board of Health): broken pipe(s)are replaced obstruction is removed distribution box is leveled or replaced ND explain: The system required pumping more than 4 times a year due to broken or obstructed pipe(s).The system will pass inspection if(with approval of the Board of Health): broken pipe(s)are replaced obstruction is removed ND explain: Page 3 of 1 I OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address: 4;457J-0E /`lI C/+"'.0 ®27771 ifl©ate Owner: G - $S Date of Inspection: C. Further Evaluation is Required by the Board of Health: y Conditions exist which require further evaluation by the Board of Health in order to determine if the system is failing to protect public health, safety or the environment. 1. System will pass unless Board of Health determines in accordance with 310 CMR 15.303(1)(b)that the system is not functioning in a manner which will protect public health,safety and the environment: Cesspool or privy is within 50 feet of a surface water _ Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh 2. System will fail unless the Board of Health(and Public Water Supplier,if any)determines that the system is functioning in a manner that protects the public health,safety and environment: _ The system has a septic tank and soil absorption system (SAS)and the SAS is within 100 feet of a surface water supply or tributary to a surface water supply. The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water supply. _ The system has a septic tank and SAS and the SAS is within 50 feet of a private water supply well. _ The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or more from a private water supply well". Method used to determine distance "This system passes if the well water analysis,performed at a DEP certified laboratory, for coliform bacteria and volatile organic compounds indicates that the well is free from pollution from that facility and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered.A copy of the analysis must be attached to this form. 3. Other: 3 Page 4 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address: 136- 100,0-1-77 35/UO,0-1-77 U, Owner:_�A9 jo SS/ Date of Inspection: jz D. System Failure Criteria applicable to all systems: You must indicate"yes"or"no"to each of the following for all inspections: Yes No V* 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 Matic liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or _/1/ cesspool � Liquid depth in cesspool is less than 6"below invert or available volume is less than 1/2day 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 compomads 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.] NO(Yes/No)The system fails. I have determined that one or more of the above failure criteria exist as described in 310 CMR 15.303.therefore the system fails. The system owner should contact the Board of Health to determine what will be necessary to correct the failure. E. Large Systems: To be considered a large stem the system must serve a facility with a design flow of 10,000 gpd to 15,000 gpd. You must indicate either"yes"or"no"to each of the following: (The following criteria apply to large systems in addition to the criteria above) yes no the system is within 400 feet of a surface drinking water supply the system is within 200 feet of a tributary to a surface drinking water supply the system is located in a nitrogen sensitive area(Interim Wellhead Protection Area—IWPA)or a mapped Zone II of a public water supply well If you have answered"yes"to any question in Section E the system is considered a significant threat,or answered "yes" in Section D above the large system has failed. The owner or operator of any large system considered a significant threat under Section E or failed under Section D shall upgrade the system in accordance with 310 CMR 15.304. The system owner should contact the appropriate regional office of the Department. 4 Page 5 of I 1 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST Property Address: 13,5--v7-6NWN1 e*%41� 7MIOT/4"p- Owner: 1 c _ Date of Inspection: z ZZ p,$ Check if the following have been done. You must indicate"yes"or"no"as to each of the following: Yes o Pumping information was provided by the owner,occupant, or Board of Health (I-,S 17Ww/,¢4e-1--s) _/ Were any of the system components pumped out in the previous two weeks? L1PA1,v7—OF�iVsP/�GGy7oAl� Has the system received normal flows in the previous two week period? Have large volumes of water been introduced to the system recently or as part of this inspection? P/Were as built plans of the system obtained and examined?(If they were not available note as N/A) Was the facility or dwelling inspected for signs of sewage back up? Was the site inspected for signs of break out? Were all system components, excluding the SAS, located on site? Were the septic tank manholes uncovered, opened,and the interior of the tank inspected for the condition of the baffles or tees,material of construction,dimensions,depth of liquid,depth of sludge and depth of scum? 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 Cis at issue approximation of distance is unacceptable) [3 10 CMR 15.302(3)(b)] 5 Page 6 of I 1 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION Property Address: oF,O DD7�F2 Owner: Date of Inspection: / 4 FLOW CONDITIONS RESIDENTIAL Number of bedrooms(design): .3 Number of bedrooms(actual): � DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms).. Number of current residents: ot�NF Does residence have a garbage grinder(yes or no): Al � 'e .SZ'*1'W E 1_11-ACR-151 /5 '/O/ Is laundry on a separate sewage system(yes or no): /J/ [if yes separate inspection required] Laundry system inspected(yes or no): Seasonal use: (yes or no): Water meter readings,if available(last 2 years usage(gpd)): Sump pump(yes or no): Al Last date of occupancy: C_0,94 1 COMMERCIALANDUSTRIAL Type of establishment: Design flow(based on 310 CMR 15.203):_ gpd Basis of design flow(seats/persons/sqft,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: S Was system pumped as part of the inspection(yes or no): If yes, volume pumped: /000 gallons--How was quantity pumped determined? U�G� Reason for pumping: /16*V y (I lErzj4S)!!_ C 0,1U J itJ7— TYPE OF SYSTEM tff'g—eptic tank,distribution box,soil absorption system _Single cesspool _Overflow cesspool _Privy _Shared system(yes or no)(if yes,attach previous inspection records, if any) _Innovative/Alternative technology. Attach a copy of the current operation and maintenance contract(to be obtained from system owner) Tight tank —Attach a copy of the DEP approval —Other(describe): Approximate age of all components,date installed(if known)and source of information: a.o f;ri's r-�-- Were sewage odors detected when arriving at the site(yes or no): /v 6 Page 7 of 1 l OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: � ✓Ohm cs� Owner: 21.1" s Date of Inspection: z- D BUILDING SEWER(locate on site plan) Depth below grade: /8 Materials of construction:_cast iron L`/40 PVC other(explain): Distance from private water supply well or suction line: Comments(on condition of joints,venting,evidence of leakage,etc.): 600D CGrv/J 177,0,/ SEPTIC TANK:_(locate on site plan) it Depth below grade: 124 Material of construction: t,,<oncrete_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) I I Dimensions: k 6 Sludge depth: / It I� Distance from top of sludtge to bottom of outlet tee or baffle: �D Scum thickness: 12 Distance from top of scum to top of outlet tee or baffle: Distance from bottom of scum to bottom of outlet tee or baffle: f t How were dimensions determined: /=/FL/J 06.S41?j11As4 Comments(on pumping recommendations, inlet and outlet tee or baffle condition,structural integrity, liquid levels as related to outlet invert,evidence of leakage,etc.): �fJ/!�/� /9-jt/A,C✓y¢'L s 'I/r G d2��95� G'Q�i//J��11j• /�-�!/if/C/.*�'(___ TL!--Carrgst!�E- tial rA GREASE TRAP:_(locate on site plan) A,111+ Depth below grade: Material of construction:_concrete_metal_fiberglass polyethylene_other (explain): Dimensions: Scum thickness: Distance from top of scum to top of outlet tee or baffle: Distance from bottom of scum to bottom of outlet tee or baffle: Date of last pumping: Comments(on pumping recommendations,inlet and outlet tee or baffle condition,structural integrity, liquid levels as related to outlet invert,evidence of leakage,etc.): 7 Page 8 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) I Property Address: /�S 'O/�tJ/1l �! ,S% U .e Owner: Date of Inspection: 2— TIGHT or HOLDING TANK:Otank must be pumped at time of inspection)(locate on site plan) Depth below grade: Material of construction: concrete metal fiberglass_polyethylene other(explain): Dimensions: Capacity: gallons Design Flow: gallons/day Alarm present(yes or no): Alarm level: Alarm in working order(yes or no): Date of last pumping: Comments(condition of alarm and float switches,etc.): DISTRIBUTION BOX: V (if present must be opened)(locate on site plan) Depth of liquid level above outlet invert. Comments(note if box is level and distribution to outlets equal,any evidence of solids carryover,any evidence of leakage into or out of box,etc.): PUMP CHAMBER:A (locate on site plan) Pumps in working order(yes or no): Alarms in working order(yes or no): Comments(note condition of pump chamber,condition of pumps and appurtenances,etc.): 8 Page 9 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 131101ZAIAI.,q:�AK6 A1A�l/Dcsfl�l2 Owner• SSS Date of Inspection: z- O 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: z 1 /leaching trenches,number, length:-A 2 ;2oX 30�� t/ - vN�a t'tc�-tJ 4Z,U6 6 leaching fields,number,dimensions: overflow cesspool,number: innovative/alternative system Type/name of technology: Comments(note condition of soil,signs of hydraulic failure, level of ponding,damp soil,condition of vegetation, etc.): 1 vv NA1tT1 A/G sAVU-) ` t CA ' .11"Olup tyl—Inut ,ave- TO P/24-/N )/!//s J 0A," CESSPOOLS: esspool must be pumped as part of inspect ion)(locate on site plan) Number and con figuration: Depth-top of liquid to inlet invert: Depth of solids layer: Depth of scum layer: Dimensions of cesspool: Materials of construction: Indication of groundwater inflow(yes or no): Comments(note condition of soil,signs of hydraulic failure, level of ponding,condition of vegetation,etc.): PRIVY: (locate on site plan) Materials of construction: Dimensions: Depth of solids: Comments(note condition of soil,signs of hydraulic failure, level of ponding,condition of vegetation,etc.): 9 Page 10 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM .� PART C SYSTEM'INFORMATION(continued) Property Address: �3�TONrU / 'f S ,009-771- 0Ura R— Owner: Gsi6hs5 f Date of Inspection: Z Q 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. G 1 V A--c 0 6—c- 8,0-G8-© A_D °73 °=ter I 10 Page 11 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: /3,5_ v o11yA/)G4i3C- s% _ Off/ Owner: L� �Rv n Date of Inspection: 21� 6S SITE EXAM Slope O 3 Surface water 7 YOO Check cellar 1),oe—Wo Pum/0 Shallow wells S�� j C/�-�L 1:9,4S//) Estimated depth to ground water feet C/,5/7;9: 6411 Z-7- U I° ' NO 7-/A"6i2[5 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) 6A43vT'rF_a-i',+-i s a b S V.SMM 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: /504.4mo SU'd Tff.(_-TAD TO /=LGc�Dioyc 7019 0/7 11 J / M ,AM '-/D,4,S s � 8"�q 1- 0- � 7e5l , 76 / �, z t AORTN , O "90 3? BOARD OF HEALTH 41 m 120 MAIN STREET TEL. 682-6483 'SSACNUSE� NORTH ANDOVER, MASS. 01845 Ext23 Date: January 19, 1994 RE: 135 Johnnycake Street, North Andover, MA To Whom it May Concern: The individual subsurface disposal system at 135 Johnny Cake Street, North Andover, MA was installed and inspected in 1985 according to current regulations and to the approved design plan on file at the North Andover Board of Health Office. Sincerely, Sandra Starr, Health Agent cc: Jim Lampassi ;l i f HORTh 1 O ,,ao +O 3? BOARD OF HEALTH 120 MAIN STREET TEL. 682-6483 'SSACHUSEt NORTH ANDOVER, MASS. 01845 Ext23 Date: January 19, 1994 RE: 135 Johnnycake Street, North Andover, MA To Whom it May Concern: The individual subsurface disposal system at 135 Johnny Cake Street, North Andover, MA was installed and inspected in 1985 according to current regulations and to the approved design plan on file at the North Andover Board of Health Office. Sincerely, -Ixd— ILIL-) Sandra Starr, Health Agent cc: Jim Lampassi i I Town of North ,Andover MA Watershed se tic system ° servicing Reuort Date: 1` L(_9 L, Homeowner• �J� S �5 Pumper : BATESON ENTERPRISES. INC. 111 . Street �3 S �� C 2 V��, Address: ARGlLLA RD. ANI]nVFFinP.A 01810 Phone Phone : 75 --LF7-3 C, Nature of Service: Routine U V-\' ' \%emsi enc Emer v 4 Y , i observations: Good Condition Full to Cover Baffles in Place Leachfield Runback Excessive Solids Heavy Grease _. Other (Explain) i Description of Work: Comments: _ TOWN OF kc - SYSTEM PUMPING RECORD 8 2003 � I i APR � DATE:, SYSTEM OWNER& ADDRESS SYSTEM LOCATION (example:left front of house) I (n 5 Ca- DATE OF PUMPING: Q _ L S UANTITY PUMPED : GALLONS CESSPOOL: NO YES SEPTIC TANK: NO YES�i NATURE OF SERVICE: ROUTINE EMERGENCY OBSERVATIONS: GOOD CONDITION FULL TO COVER HEAVY GREASE BAFFLES IN PLACE ROOTS LEACHFULD RUNBACK EXCESSIVE SOLIDS FLOODED SOLIDS CARRYOVER OTHER(EXPLAIN) SYSTEM PUMPED BY: Bateson Enterprises, Inc. COMMENTS: l CONTENTS TRANSFERRED TO: k i TC,".T, F NORTH ANDOVER -1(7 'r r F SYST.P M PUMPING RECORD t , DATE CD�I b/D SYSTEM OWNER&ADDRESS SYSTEM LOCATION Lort) sst' 5 ��lolbnn7CMe- !STNo 13 DATE OF PUMPING:_-6�--/a-b ___,_QUANTITY PUMPED:__,&oja CESSPOOL: NO__-_____VEST Septic Tank: NO YES NATURE OF SERVICE: ROUTINE_'--�EMERGENCY OBSERVATIONS: GOOD CONDITION FUEL TO COVER _ HEAVY GREASE BAFFLES IN PLACE - ROOTS LEACHFIELD RUNBACK EXCESSIVE SOLIDS !/FLOODED SOLID CARRYOVER---CARRYO`TER_--OTHER EXPLAIN System Pumped by _�—/'1�(/t/e- � COMMENTS_ CONTENTS TRANSFERRED TO�^ O?b i Town of North Andover No�Tti Of^^oto 6'gq.O Community Development and Services Division O= �p Office of the Health Department 400 OSGOOD STREET North Andover,Massachusetts 01845 sNCHU50 Susan Y.Sawyer,REHS/RS Public Health Director (978)688-9540-Phone (978)688-9542-Fax Date: l 0,6 l 14 D�0 0' Address: 1D r 1 1'1►r11.1 ,North Andover,MA 01845 Re: Application for: Dear: ( ✓�(�YYl. �5 t y Your application forO-B3 t 164 (Imi at OT 10k h�!'&"as been reviewed by the Health Department. The application was denied on, .y, jc ,3kC7 2004 for the following reasons: 1. �/ Missing information 2. fiX Passing Title 5 inspection of septic system required 3. ❑ Location of structure not acceptable 4. ❑ Undersized septic system To address the problem(s): If#1 is checked, please supply: Floor plan of existing and proposed addition—all rooms b. Certified plot plan showing house,septic system and proposed project in scale If#2 is c ked: Have the septic system inspected by a certified Title 5 inspector to determine the size of the system whether it is operating properly: OR � b. Tie-in to municipal sewer I If#3 Is checked: a. Relocate the project If#4 is checked: a. Provide additional information proving that the existing septic system meets current capacity requirements. Please consult an engineer to determine the flow capacity of the septic system. Please feel free to call the Health Office at 978-688-9540 with anquestions Y q you may have. Sincerely, c � ewer y' Cc: Building Department File BOARD OF AP(�I;nl_.S G88-9541 BUILDING 688-9Alh BOARD CONSERVATION 688-9530 NURSE 688-9543 PLANNING 688-9535 I Town of North Andover f NAW7H q A +K4++m ien No Community Development and Services Division Office of the Health Department 400 OSGOOD STREET North Andover,Massachusetts 01845 �►qs$"`"° e�'� aceau� Susan Y.Sawyer,RENS/RS (978)688-9540-Phone Public Health Director (978)688-9542-Fax r Date: Address: ' J � 1 n�� ,North Andover,MA 01845 REIVE D Re: Application for: �(;�,�PC(. I MAR 2 2005 Dear. �� +' m��-�v� i TOWN Or NORTH ANDOVER Your.application forGtr + g2�Em1.� .HEALTH DEPARTMENT app at �",' 701 r`n��-has been re ► vu By tau MUM Department. The application was denied on, c� 1C7D5 2004 for the following reasons: 1- Missing information 2. Passing Title 5 inspection of septic system required d 3. ❑ Location of structure not acceptable 4. ❑ Undersized septic system To address the Moblem(s): If#1 Is checked, please supply: Floor plan of existing and proposed addition-all rooms b. Certified plot plan showing house,septic system and proposed project inscale If#21s e ked: a. Have the septic system inspected by a certified Title 5 d to inspector determine termme the size of the system and whether it is operating properly: OR b. Tie-in to municipal sewer If#3 Is checked: a. Relocate the project If#4 is checked: a. Provide additional information proving that the existing septic system meets current capacity requirements. Please consult an engineer to determine the flow capacity of the septic system. Please feel free to call the Health Office at 978-688-9540 with any questions you may have. Sincerely, c 4R ewer Cc: Building.Department File BOARD(_)F APP6:AE S 688-9541 BUILDING,688-9545 CONSEiRVA•L'10N 688-9530 NIJRSIi 683-9543 PL,ANNJNG 699-9535 Board of Realth ` North AndoverLHriaa. SEPTIC S15TEH INSTA?.LATICK Cfflr.K LISP LOT J® 'yYCA \ ' �OVID DI DATE SAPPriU�TED AV 'rATICB� OK FAIL \' Rea Rons t G 55- FAIL SFAIL ' OK 1. Distance Tot a. Wetlands — b. Drains c.. Well �`V'J ��-•�L-�� `•'� �l� 2. Water Line Location I . No PPC Pipe �c. Septic Tank a. ..Tees --Length & To Clean Out Covers. b. Cement Pipe to Tank on Both Sides of Tank ---- 5. Distribution Box a. Covers k Box - No Cracks b. All Lines.Flowing Equal Amounts C.. No Back Flow Leach Field or Trench a. Dimensions b. Stone Depth c. Capped Ends d. Clean Double Washed Stone 7. Leach Fits a. Dimansi.ons b. Stone Depth C. flash Pads d. Tees e. Cement Pipe to Pit - Both Sides f. Clean Double Washed Stone 8. No Garbage Di spo sal 9. Anal Grading Inspection 10. Barricading Covered System 11. As Built Submitted a. Lot Location b. Dimensions of System c. Location with Regard-to Perc Test d. 'Elevations e: Water Table _-BOARD OF HEALTH No.Andover, MaS . SUBSURFACE DISPOSAL DESIGN CHECK LIST w LOT JgLIA yW� APPROM -- DATE -ZDISAPPROVED DATE Providdd: Reasons: -� Title V FAIL CK Reg 2.5 The submitted plan mast show as a minimult a) the lot to be served-area,dimensions lot #,abutters b location and log deep observation hoe s-distance to ties c location and results percolation tests -distance to ties d design calculations & calculations sharing required leaching area (e) location and dimensions of system-in0 lding reserve area f) existing and proposed contours (g) location any wet areas within loot ,f .iewage 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 1001 of sewage disposal system or disclaimer-Planning Board files (3) known sources of water supply within 2001 of sewage disposals . system or disclaimer, (k) location of any proposed well to serve lot-100, from leaching facility (1) location of water lines on property-101 from 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, plumb, pipe, septic tank, distribution box inlets and outlets, c*4.stribution field piping and Other elevations (r) maximum ground water elevation in area sewage disposal system (s) plan mast be prepared by a Profession . Engineer or, other professional authorized by law to prep. re such plans Reg 6 Septic Tanks (a) capacities-150% of flow, water table, ees, depth of tees, access, pumping (b) cleanout (c) 101 from cellar wall or inground swimming pool (d) 251 from subsurface drains Reg 10.2 Distribution Boxes (a) Slope greater ME 0.08 Reg 10.11 b) k r. i Con none ealth of Massachusetts Massacliusetts System Pumying Record System Owner System Location Q Date of Pumping: Quantity Pumped: gallons Cesspool: No Yes Septic Tank: No H Yes System Pumped by: Fare-dart gr{&7laed License # Contents transferrred to : Greater Lawrence Sanitary District Date: Inspector- P Tq ,_ 42 Iggg 4 FORM U - LOT RELEASE FORM q INS C ONS: This form is used to verify that all necessary provals/permits from Board an `Departments having jurisdiction have been obtained. This does not relieve t the a "lici r t and/or landowner from compliance with any applicable or requirements. FILLS OUT THIS SECTION APPLICANT PHONE_�2' LOCATION: Assessor's Map Number PARCEL SUBDIVISION LOT (S) STREET ST. NUMBER *************OFFICIAL USE ONLY'"******* 2)ee Te Be ded l RECO NIDATIONS OF TOWN AGENTS: _ fVb- 77olc GONSERVATION ADMINI TRATOR DATE APPROVED DATE REJECTED COMMENTS SUS b-�.5 ( n. cc-6'y`-e OVA • -� ��-2d QU-�!� , �-�. l -6 Cie- TOWN hTOWN PLANNER DATE APPROVED V( ,t ! i� DATE REJECTED' t Z� COMMENTS FOOD INS P CTOR-HEALTH DATE APPROVED DATE REJECTED TIC PECTOR-HEALTH DATE APPROVED �f DATE REJECTED ! COMMENTS PUBLIC WORKS -SEWER/WATER CONNECTIONS r DRIVEWAY PERMIT / FIRE DEPARTMENT RECEIVED BY BUILDING INSPECTOR -DATE „yam TOWN OF NORTH ANDOVER SYSTEM PUMPING RECORD DATE: 'L3-0 SYSTEM OWNER &ADDRESS SYSTEM LOCATION ` (example: left front of house) DATE OF PUMPING: QUANTITY PUMPED . GALLONS CESSPOOL: NO J YES SEPTIC TANK:T NO YES V 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: �. _ a RECE N Commonwealth of Massachusetts W City/Town of North Andover NOV 212012 System Pumping Record TOWN OENORTHANDOVER Form 4 HEALTH DEPARTMENT M DEP has provided this form for use by local Boards of Health. Other forms may be used, but the information must be substantially the same as that provided here. Before using this form, check with your local Board of Health to determine the form they use. The System Pumping Record must be submitted to the local Board of Health or other approving authority within 14 days from the pumping date in j accordance with 310 CMR 15.351. A. Facility Information 3 l Important:When filling out forms 1. System Loc 'tion: on the computer, IC�h n Gaji6eS use only the tab key to move your Address cursor-do not use the return North Andover Ma 01845 key Cityrrown �. .--�"` State Zip Code r� 2. System Owner:/ cowff ro Pave Name remnn Address(if different from location) City/Town State Zip Code Telephone Number B. Pumping Record 1. Date of Pumping 2. Quantity Pumped: 1500 Date p Gallons 3. Type of system: ❑ Cesspool(s) Septic Tank ❑ Tight Tank ❑ Grease Trap ❑ Other(describe): 4. Effluent Tee Filter present? ❑ Yes ❑ No If yes, was it cleaned? ❑ Yes ❑ No 5. Condition of System: 6. stem Pumped By: am Vehicle License Number Stewart's Septic Service Company 7. Location where contents were disposed: wart's Pre-treatment Plant, 20 I Bradford, Ma 01835 gnature of Hauler Date Signature of Receiving Facility Date t5form4.doc•03/06 System Pumping Record•Page 1 of 1