HomeMy WebLinkAboutMiscellaneous - 1432 SALEM STREET 4/30/2018 r
I 1432 SALEM STREET 2 t
_,_-_ 210/106.A-0021-0000.0
Commonwealth of Massachusetts
City/Town of
System Pumping Record
Form 4
DEP has provided this form for use,.by local Boards of Health. Other forms may be used, but the
information must be substantially the same as that provided here. Before using.this form, check with your
local Board of Health to determine the form they use.The System Pumping Record must be submitted to
the local Board of Health or other approving authority.
A. Facility. Information
1. System Location: Left t froInto
Left/Right rear of house, Left/right side of house, Left/
Right side of building, Left/Righilding, Left/Right rear of building, Under deck
Address A Sly-
City/Town C' State Zip Code
2. System Owner.
Name
Address Cd different from location)
citylrownstate ^�
Telephone Number
B. Pumping Record
'
1. Date of Pumping Date 2. Quantity Pumped:
Gallons
3. Type of system: ❑ Cesspool(s) fflepfic Tank
El Tight Tank
❑ Other(describe):
4. Effluent Tee Filter present? ❑ Ye No If yes, was It cleaned? ❑ Yes ❑ No;
5. Condition of..`Sysrjool�
Q\
s: System Pumped By. RECEIVED
Neil Bateson F5821
Name Vehicle Lioense Number MAY
Bateson Enterprises Inc
Company TOWN OF NORTH ANDOVER
HEALTH DEPARTMENT
7. Locati where contents were disposed:
�-S. Lowell Waste Water
- cC-(
Sign a Haul Date
t5fomu4.doa 06103 System Pumping Record•Page 1 of 1
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COMMONWEALTH OF MASSACHUSETTS
i
EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS
a
d DEPARTMENT OF ENVIRONMENTAL PROTECTION
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TITLE S
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM
PART A
CERTIFICATION
Property Address: 1423 Salem Street
North Andover,MA 01845
Owner's Name: Arnab&Kimberly Chakravarti
Owner's Address: Same
Date of Inspection: 10-29-2007
Name of Inspector: (please print)John Soucy
Company Name: Soucy Sewer Service,Inc.
Mailing Address: 78 North Broadway
Salem,NH 03079
Telephone Number: 978-851-8839
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:
X Passes
~ Conditionally Passes
Needs Further Evaluation by the Local Approving Authority
Fails
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. NOTE: This Title 5 is NOT a guarantee/warranty of the future function of the septic
system.
Title 5 Inspection Form 6/15/2000 page 1
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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: 1423 Salem Street
North Andover,MA 01845
Owner's Name: Arnab&Kimberly Chakravarti
Date of Inspection: 10-29-2007
Inspection Summary: Check A,B,C,D or E/ALWAYS complete all of Section D
A. System Passes:
X 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:
Titles S Tncn—tinn Rnr A/7'G/7nn0 2
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Page 3 of 11
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OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION(continued)
Property Address: 1423 Salem Street
North Andover,MA 01845
Owner's Name: Arnab&Kimberly Chakravarti
Date of Inspection: 10-29-2007
C. Further Evaluation-is Required by the Board of Health:
Conditions exist which require further evaluation by the Board of Health in order to determine if the system is
failing to protect public health,safety or the environment.
I
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 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:
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The system has aseptic 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:
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Titles fli G/7flfjn 3
Page 4 of 11
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION(continued)
Property Address: 1423 Salem Street
North Andover,MA 01845
Owner's Name: Arnab&Kimberly Chakravarti
Date of Inspection: 10-29-2007
D. System Failure Criteria applicable to all systems:
You must indicate"yes"or"no"to each of the following for all inspections:
Yes No
X Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool
X Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or
clogged SAS or cesspool
X Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or
cesspool
X Liquid depth in cesspool is less than 6"below invert or available volume is less than %2 day flow
X Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s).Number
of times pumped
X Any portion of the SAS,cesspool or privy is below high ground water elevation.
X Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface
water supply.
X Any portion of a cesspool or privy is within a Zone 1 of a public well.
X Any portion of a cesspool or privy is within 50 feet of a private water supply well.
X 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.]
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 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—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.
Titlo C T7nr ail sionnn 4
Page 5 of 11
OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART B
CHECKLIST
Property Address: 1423 Salem Street
North Andover,MA 01845
Owner's Name: Arnab&Kimberly Chakravarti
Date of Inspection: 10-29-2007
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
_x 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?
_x Have large volumes of water been introduced to the system recently or as part of this inspection?
_x Were as built plans of the system obtained and examined?(If they were not available note as N/A)
x _ Was the facility or dwelling inspected for signs of sewage back up?
Was the site inspected for signs of break out?
x — Were all system components,excluding the SAS, located on site?
_x 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?
x _ 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
_x _ Existing information. For example,a plan at the Board of Health.
_x _ 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)]
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Page 6 of 1 I
OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION
Property Address: 1423 Salem Street
North Andover,MA 01845
Owner's Name: Arnab&Kimberly Chakravarti
Date of Inspection: 10-29-2007
FLOW CONDITIONS
RESIDENTIAL
Number of bedrooms(design): 4 Number of bedrooms(actual): 4
DESIGN flow based on 310 CMR 15.203(for example: 110 gpd x#of bedrooms):_440
Number of current residents:_5
Does residence have a garbage grinder(yes or no): yes *Recommend removal
Is laundry on a separate sewage system(yes or no): no [if yes separate inspection required]
Laundry system inspected(yes or no): no
Seasonal use:(yes or no): no
Water meter readings,if available(last 2 years usage(gpd)): see attached
Sump pump(yes or no): no
Last date of occupancy: recent
COMMERCIAL/INDUSTRIAL N/A
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: Home Owner
Was system pumped as part of the inspection(yes or no): ems
If yes,volume pumped:_1000_gallons--How was quantity pumped determined?Gage on truck
Reason for pumping: Inspection and Maintenance.
TYPE OF SYSTEM
X 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:
Built 2002
Were sewage odors detected when arriving at the site(yes or no):No
Titles S Tnen tinn Rn_ (./1 S/7!1!1!1 6
Page 7 of 11
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: 1423 Salem Street
North Andover,MA 01845
Owner's Name: Arnab&Kimberly Chakravarti
Date of Inspection: 10-29-2007
BUILDING SEWER(locate on site plan)
Depth below grade: 30"
Materials of construction:_X 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.):
SEPTIC TANK: x (locate on site plan)
Depth below grade: 8"
Material'of construction: X 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: 41811x 8'6"
Sludge depth: 3"
Distance from top of sludge to bottom of outlet tee or baffle: 38"
Scum thickness: 2"
Distance from top of scum to top of outlet tee or baffle: 8"
Distance from bottom of scum to bottom of outlet tee or baffle: 14"
How were dimensions determined: Tape&Sludge Tool
Comments(on pumping recommendations,inlet and outlet tee or baffle condition,structural integrity, liquid levels
as related to outlet invert, evidence of leakage,etc.):
GREASE TRAP:_(locate on site plan) N/A
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.):
T41. 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: 1423 Salem Street
North Andover,MA 01845
Owner's Name: Arnab&Kimberly Chakravarti
Date of Inspection: 10-29-2007
TIGHT or HOLDING TANK:_(tank must be pumped at time of inspection)(locate on site plan)N/A
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: X (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.): Flow checked oka
PUMP CHAMBER: X (locate on site plan)
Pumps in working order(yes or no): yes_
Alarms in working order(yes or no): yes_
Comments(note condition of pump chamber,condition of pumps and appurtenances, etc)
Components worked properly. Secondary floats are in workin order.
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Titles C lncnartinn Fnrm 411 C/7Ml1 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: 1423 Salem Street
North Andover,MA 01845
Owner's Name: Arnab&Kimberly Chakravarti
Date of Inspection: 10-29-2007
SOIL ABSORPTION SYSTEM(SAS):_X (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:
_x leaching fields,number, dimensions:l8'x51'
overflow cesspool,number:
innovative/alternative system Type/name of technology:
Comment's(note condition of soil, signs of hydraulic failure,level of ponding,damp soil,condition of vegetation,
etc.): No Sign of Hydraulic Failure.
CESSPOOLS: (cesspool must be pumped as part of inspection)(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:
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)N/A
Materials of construction:
Dimensions:
Depth of solids:
Comments(note condition of soil, signs of hydraulic failure,level of ponding,condition of vegetation,etc.):
Titlo S Tncnartinn Fnrm iii�i�nnn 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: 1423 Salem Street
North Andover,MA 01845
Owner's Name: Arnab&Kimberly Chakravarti
Date of Inspection: 10-29-2007
SKETCH OF SEWAGE DISPOSAL SYSTEM
Provide,a sketch of the sewage disposal system including ties to at least two permanent reference landmarks or
benchmarks. Locate all wells within 100 feet. Locate where public water supply enters the building.
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TO: NORTH ANDOVER, MASS 'ZZ '2 19 '7 2r
BOARD OF HEALTH
FROM: DESIGN ENGINEER Re: Soil Absorption Sewage
System Inspection
This is to certify that I have inspected the construction of the said disposal system at
7— S 5-19/ZFAPI �5 7— - North Andover, Mass.
SITE LOCATION
The grades and construction are as specified in my plans an ations dated
19
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eg. PreEr/Re i rian
SANtTAR\PN
Commonwealth of Massachusetts
City/Town of RECEIVED
System Pumping Record APR 2 5 2006
Form 4
TOWN OF NORTH ANDOVER
i A H DEPART�iENT
DEP has provided this form for use by local Boards of Health..The yate -urx�pi .eco ust
be submitted to the ocal Board of Health or other approving authority. .
A Facility Information
.Important: {(�
When filling out 1. SySt@ft1 LOC tion:
fortes the
computer,use ,
only the tab key Address
to move your
cursor-do not
use the:retum Qityrrown State Zip Code
.key.
2. System Owner
20 -
'Name
Address(if different from location)
Cit rr w
Y
o n
State
Zip Code.. .
J
Telephone Number
B. Pum pIn9
. Record
•
1. Date.of Pumping
Quantity'Pumped.
Date uan Ped: Gallons
3. Type of system: ❑ Cesspool(s) is ank- ❑ Tight_Tank
❑ Other(describe)`
4. Effluent Tee Filter present? ❑ Yes C No If yes, was it cleaned? ❑ Yes ❑ No
5. Condition of System:
6: System Pumped By
Name
Vehicle License Number
Company
7. Locatio where contents were sposed:,
1P
` �
&eo Date
h.ftp://www.mass.govidep/Waterlapptovalt,/t5forrns.htm#inspect
t5fortn4.doc•06103
SYstem Pumping Record•Page 1 of 1
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TOWN OF NORTH ANDOVER
SYSTEM PUMPING RECORD
i
DATE: S-11-6Q2.
SYSTEM OWNER &ADDRESS SYSTEM LOCATION
(example: left front of house)
q 302_
DATE OF PUMPING: 5T . t-QcZ QUANTITY PUMPED_ GALLONS
,
CESSPOOL: NO YES SEPTIC TANK: NO YES
NATURE OF SERVICE: ROUTINE EMERGENCY
OBSERVATIONS:
GOOD CONDITION FULL TO COVER
k HEAVY GREASE BAFFLES IN PLACE
`¢ ROOTS LEACHFIELD RUNBACK
EXCESSIVE SOLIDS FLOODED
SOLIDS CARRYOVER OTHER (EXPLAIN)
SYSTEM PUMPED BY:
COMMENTS:
CONTENTS TRANSFERRED TO:
I
Commonweal tl► of Massachusetts
Massachusetts
System Pumping Record
System Owner System Location
0.-hZaS � y 3 Z J
Date of Pumping: (� ZOO D Quairtity Pumped: 10 OD gallons
Cesspool: No Yes �..) Septic Tank: No Yes
I
System Pumped by: Fetredort Eime�ma License#
Contents transferrrred to : Greater Lawrence Sanitary District
I
Date: _ Inspector
Comionw aNlr of Massachusetts
Massachusetts
Pystem PWn nq Record
System Owner System Location
c-� �`
Date of Pumping: `� Quairiity Pumped: gallons
Cesspool: No P-""� Yes L1 Septic Tank: No U Yes -
_f
� i c4
System Pumped by: 9dL`e4o t v t�iE�ft License.# .
Contents transferrred to : Greater Lawrence.SanitarY District
E�
Date: _ Inspector:
i TOWN OF NOR"
MAY 11 1999
. I
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{ NORTH ANDOVER BOARD OF HEALTH
INSTALLATION CHECK LIST
APP ED DATE DISAPPROVED DATE tXCAVATION OK
NS
11
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FAIL OK 7-2! -Z� /®
Distance To:
Wetlands
Drains
Well
^Dater Line Location
3. No PITC Pipe
4. eptic Tank
Tees - Length & To Clean Out Covers
Ceme Pipe to Tank - On Both Sides of Tank
5. D' ribution Box
Cove Box - No Crack
lowing Equal Amoun-
o� Back o�
6.. Leach Field or Trench
Dimensions
Stone Depth
Capped Ends
Clean Double Washed Stone
A
ts
sions Depth�h Padst Pipe to Pit - Both Sides
Clean Double Washed Stone
No Garbage Disposal
7i nal GradinInspection
i ng P on
�- Barracading Covered System
. As - BuiltSubmitted
Dimensions of System
Location with Regard to Pere Test
Elevations
Water Table
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. . _-.i'_ ._..�:,,r 1�ia..f .� rk /11�.. Y_.-..__-_-__._____.----_.� .-_____--_�� P ,�.� '� u• I f��' � f,."� " '
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SOIL PROFILE & PERCOLATION TEST DATA
. G"%o c>e�' / r'
Town/Cit No.&Street GnrZ Lot No.—O
Loc,./Subdiv. Plan I o wner
Investigatorl „a,- : Gc�/r� Observer
�J r —
SOIL PROFILES-DATE
N) 1. E ev. 2` Elev. 3.
0 �, �,� _ Elev.,. _. _ 4'Elev.
S 0 0 0
2 2 2 2
3 3 3
U�4
4 4 4
5
5
5 S
6 6 6 6
7 7 7 7 -
8 8 --- 8 - 8
9 9 9 9
10 10 10 10
Benchmark Location
Elevation Datum
Percolation Tests-Date
-4171 7
Pit Number, 1 2 3 4 5
Star
t Saturation 3 �3 �
Soak-Mins° 115
Start Test-Time 6
Dr—op—of 3"-Time :Q
Drop of 61'-Time 2 8
Mins. lst 3"Dro
Mins. 2nd .3"Dro
Notes & Sketches on Back Frank C. Gelinas & Associates, North And.
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SUBSURFACE DISPOSAL SYSTEM CHECK LIST
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I. General Information
Reg. 2.5 The submitted plan must show as a minimum:
(a) the lot to be served
(b) location and dimensions of the system (including
! reserve area)
(c) design calculations
(d) existing and proposed contours h71:410 01, �,J
(e) location and log of deep observation holes
(f) location and results of percolation tests -,--
(g)
estsr"(g) location of any streams,-
(h) surface and subsurface drains and wetlands within
100 feet of the sewage disposal system j
(i) known sources of water supply within 200 feet of
the sewage disposal system -' - j
(j ) location of any proposed well to serve the lot
(k) location of water lines on the property
( 1) maximum ground water elevation in the area of the
f sewage disposal system / r t P� d•
(m) a profile of the system no Q„/ 0,0 �
(n) plan must be prepared by a Professional Engineer
! or other professional authorized by law to prepare
such plans &--
(o)
(o) calculations showing required leaching area 14 lE✓'�O Cl l
(p) no PVC is to be used in construction
II. Garbage Disposers /, �e���� A4- d7� a.✓'�
III. Septic Tanks
I Reg. 6. 1 (a) Capacities CLy-
Reg. 6 . 7 (b) Water table `
Reg. 6.8 (c) Tees
Reg. 6.9 (d) Depth of teco .
!
Reg. 6 . 12 (e) Access
Reg. 6 . 18 (f) Pumping G
! IV. Pumps / ¢�ro� ,,,oe �OL� �./r°.� /20G�
Reg. 9. 1 (a) Approval 6
Reg. 9.6 (b) Stand-by power � ''�'
V. Distribution Boxes
tRe . 10. 2 (a) Slopegreater n 0. 08
Reg. 10.4, (b) Sump
VI. Leaching Pits
i e
Leaching pits are preferred where the installation is
possible.
ry �
Reg. 11.2 (a) Calculations of - l/aPhpp�iarea (minimum 500 square feet)
Reg. 11.4 (b) Spacing i
Reg. 11. 10 (c) Surface drainage 2% CO-n o/ele..-.A" nG
Reg. 11. 11 (d) Cover material
VII. Leaching Fields
Reg. 15. 1 (a) Greater than 20 min/inch
It
It
(b) Area (minimum 900 square feet) ,
Reg. 15 .4 (c) Construction of field
Reg. 15 .8 (d) Surface drainage 2%
IX. . Downhill Slope
I
(a) Slope x =
(b) X x 150 =
i
i
I
Iv
TOWN OF t '
APR 2 �
SYSTEM PUMPING RECON � F�
DATE: ,Cq--o
SYSTEM OWNER& ADDRESS SYSTEM LOCATION
(example: left front of house)
�72-cL d
C
c
DATE OF PUMPING: `+ ?--C)Y QUANTITY PUMPED : GALLONS
TANK:• NO YES /
CESSPOOL: NO YES SEPTIC T
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: Bateson Enterprises, Inc.
COMMENTS:
CONTENTS TRANSFERRED TO: G.L.S.D Lowell Waste
I
I
Commonwealth of Massachusetts R E C E I VE'
City/Town of
System Pumping Record MAY 2 12008
Form 4
TCHTH DE A'.TME TER
EA
DEP has provided this form for use by local Boards of Health. Other form -mage use�C;b t e
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.
I ,
I
A. Facility Information
Important:
When filling out 1. System Location:
forms on the
computer,use
only the tab key Address a L4
I to move your C
cursor- not
use the return Citylrowm State Zip Code
key. 2. System Owner:
Name
rte, Address(if different from location)
City/Town State Zip Code
Telephone Number
I
B. Pumping Record
- a ��
1. Date of Pumping Date 2. Quantity Pumped: Gallons
I
3. Type of system: ❑ Cesspool(s) eptic Tank ❑ Tight Tank
❑ Other(describe):
4. Effluent Tee Filter present? El Yes D-90 If yes,was it leaned? El Yes El No
5. Condition of System:
I
6. System Pum �ed�6y: I
Aj�
' . &-��
Name Vehicle License Number
Company
7. Location wh con ents we dis
Signature er Date
t5form4.doc-06/03 System Pumping Record<Page 1 of 1
r
` Clluulullilroallli �f �lailrltelluietl�
• � IVlnssnci�us�lle
BS�teImucrno
� G 02Spvy!
V. Aoj
IJale nr t+wlll►I++� , �� 2� ��( � '
fi-0 Ile 'i o"O ti+� �;] . Yes
ceselluull tiu ,E' 1'el ,
u�es License at
syslefif Pumped by � �•
1.u111e111S:IfQllSlelled 10s
)ole �ilSlle!Cltlt •
i •
I
Commonwealth of Massachusetts
u City/Town of
a
W" System Pumping Record MAY 2010
Form 4 T HEALOWN OTH 0EPA MENF NORTH TER
DEP has provided this form for use by local Boards of Health. Other forms may be use , u e
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 side of house, Right side of house, Left front of hous Right front of house
Left rear of house, Right rear of house. Left rear of building. Right rear of buil
Address
I L4 S
Cityrrown State Zip Code
2. System Owner: l
Name
Address(if different from location)
City/Town State Zip Code
Telephone Number
B. Pumping Record
1. Date of Pumping Date 2• Quantity Pumped: Gallons
3. Type of system: ❑ Cesspool(s) ❑ ic Tank ❑ Tight Tank
❑ Other(describe):
4. Effluent Tee Filter present? ❑ Yes [-lo If yes, was it cleaned? ❑ Yes ❑ No
5. Condition of System:
6. System Pumped By:
Neil Bateson F5821
Name Vehicle License Number
Bateson Enterprises Inc
Company
7. Location where contents were disposed:
L D Lowell Waste Water
jgrPtu a of Haul r Date
t5form4.doc•06/03 System Pumping Record•Page 1 of 1
Commonwealth of Massachusetts
City/Town of
4 System Pumping Record
Form 4
DEP has provided this form'for use by local Boards of Health.Other forms may be used, but the
information must be substantially the same as that provided here. Before using this form, check with your
local Board of Health to determine the form they use. The System Pumping Record must be submitted to
the local Board of Health or other approving authority.
A. Facility Information
1. System Location: Le Right;"ont of ho , Left/Right rear of house, Left/right side of house, Left/
Right side of building, Le ht ron of building, Left/Right rear of building, Under deck
Address Ir v
City/Town State ;Yucca g
2. System Owner.
Name
Address(if different from location)
City/Town State Zip Code
Telephone Number
B. Pumping Record
L(—Y3 A Z�-
I Date of Pumping 2. Quantity
� Date ty Pum�' Gallons
3. Type of system: ❑ Cesspool(s) Septic Tank ❑ Tight Tank
❑ Other(describe):
4'. Effluent Tee Filter present? ❑ Yes No If yes,was it cleaned? ❑ Yes ❑ No
5. Condition of System:
6. System Pumped By:
Neil Bateson F5821
Name Vehicle License Number
Bateson Enterprises Inc
Company
7. Lo her ntents were disposed:
Lowell Waste Water
- - -
Sig, toe Haule Date
t5form4.doc•06/03 . I
System Pumping Record