HomeMy WebLinkAboutMiscellaneous - 144 GRANVILLE LANE 4/30/2018 (2) \ I b ��,
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TOWN OF
SYSTEM PUMPING RECORD
DATE:
1!
SYSTEM OWNER& ADDRESS SYSTEM
LOCATION--`-(example:left front of house)
6�avtvl
DATE OF PUMPING: `"(, —04 QUANTITY PUMPED: 10Q�C G NS
CESSPOOL: NO YES DTIC 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: Bateson Enterprises, Inc.
COMMENTS:
CONTENTS TRANSFERRED TO: G.L.S.D Lowell Waste
Commonwealth of Massachusetts
—P4- ��4Massachusetts
Svstem Pumping Record
System Owner System Location
LI mjwl Ye-
Lv\-.
Date of Pumping: l ' Quantity Pumped: gallons
Cesspool: No 1J Yes Ll Septic Tank: No U Yes
System Pumped by: vareQort Srf&006 iQed License#
Contents transferrred to : Greater Lawrence Sanitary District
Date: Inspector:
Commonwealth of Massachusetts F,HEALTH
I!!ED
City/Town of
W° System Pumping Record 2013
Form 4 H ANDOVER
ARTMENT
DEP has provided this form for use:by local Boards of Health. Other forms may be use , u
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 Righ aet�`' r of Nous Left/right side of house,Left/
Right side of building, Left/Right front of bul Ing, Left/Right rear of building,i@§Neck - '
Address
City/Town v State Zip Code
2. System Owner:
Name
Address(if different from location)
City/Town Stat Zi Code
Telephone Number
B. Pumping Record r�
t b�3 � a
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 If yes, was it cleaned? ❑ Yes ❑ No
" 5. Conditiq®f.Systern:
6. System Pumped By:
Neil Bateson F5821
Name Vehicle License Number
Bateson Enterprises Inc
Company
7. Location where contents were disposed:
Lowell Waste Water /
(5--
SignAtufe I Haule Date
t5form4.doc•06/03 System Pumping Record•Page 1 of 1
-N Commonwealth of Massachusetts
City/Town of
System Pumping Record AUG 2 6 2008
FOI'IYl 4 ,ti�`H AND�VER `
-r:N OF �HTy;tNT
HEATH
DEP has provided this form for use by local Boards of Health.Other mfs 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:
forms on the +�
computer, use
only the tab key Address
to move your
cursor-do not Cityfrown State Tip Code
use the return
key. 2. System Owner:
VQ
V Name
ISI Address(if different from location)
Citylrown State S_,, �p Code
�- � g
Telephone Number
B. Pumping Record
1. Date of Pumping Date 2. Quantity Pumped: Gallons
3. Type of system: ❑ Cesspool(s) [ ptic Tank ❑ Tight Tank
❑ Other(describe): ,,-�-, ../�
4. Effluent Tee Filter present? El Yes�lvo If yes,was it cleaned? ❑ Yes ❑ No
5. Condition oS7s A (-P�.P-A �
6. System Pumped By:
Name Vehicle License Number
Company
7. Locatio whe a cont is disposed:
r
SignatuF6 csy�le Date
t5fam4.doc-06/03 System Pumping Record•Page 1 of 1
RECEIV.L�
Commonwealth of Massachusetts
City/Town of MAY 2 9 2007
System Pumping Record TOWN OF NORTH ANDOVER
Form 4 HEALTH DEPARTMENT
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 Locaiipn:
forms on the
computer,use
only the tab key Address ` �`-'� co ( _ J\M V IC-
tomove your � � t Ark��
cursor-do not City/Town State Zip Code
use the return
key.
2. System Owner:
Name
11 Address(if different from location)
�Y /
City/Town State
CC 7 6—a
Telephone Number
B. Pumping Record
1. Date of PumpingDate 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�:
6. System Py B-���
Name Vehicle License Number
Company
bAv�
7. Location a co tents disd:
Signature of au Date
t5form4.doc•06/03 System Pumping Record•Page 1 of 1
dr a
Z�4& 1.k—
t7 —
FILE
— FILE
. 4
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TITLE.V INSPECTIONS
r
Dean G. Luseomb II & Sons
" = �5:0.,Box 135 REDEIVED
Middleton, MA 01949
1-978-774-4065 JUN 2 0 2005
TOWN OF NORTH ANDOVER
HEALTH DEPARTMENT
`- "LICENSED PLUMBER #20285
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
I _
PROPERTY OWNERS NAME:
PROPERTY ADDRESS: _L77r _v_�,�I� �Q�� I-fA(dovP.I- Mc,
o.
ADDRESS OF OWNER: --- Sone____
(if different)
DATE OF INSPECTION: __-__J LAn� - r zoo
- -----7------------------- -----
NAME OF INSPECTOR: ---Deal
QUALITY I. S NUMBER ONE TO- U.S
i
COMMONWEALTH OF MASSACHUSETTS
m f EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS
d DEPARTMENT OF ENVIRONMENTAL PROTECTION
F
w
DEAN G. LUSCOMB II & SONS
5 P.O. BOX 135
MIDDLETON, MA 01949
1 -978-774-4065
TITLE 5
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM
PART A
CERTIFICATION
RECEIVED
Property Address:J q H S ro tw o(e. Lane.
rf\A JUN 2 0 2005
Owner's Name:5Qr>d r Torr m00 rQ
Owner's Address: so ryie TOWN OF NORTH ANDOVER
Date of Inspection: U n e- 16 Obs HEALTH DEPARTMENT
Name of Inspector: (please print) Dean G Luscomb II
Company Name:Dean G. Luscomb II & Sons
Mailing Address:p_0_ Box 135
Middleton, MA 01949
Telephone Number: 978-774-4065
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 Y
sewage disposal systems. I am a DEP
approved system inspector pursuant to Section 15.340 of Title 5(310 CMR 15.000). The system:
Y Passes
Conditionally Passes
Needs Further Evaluation by the Local Approving Authority
Fails
Inspector's Signature: �-Jjr, Date: Thin r? IZCV
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
I
****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.
1
UCdll lz. Uu5l:Vltlu 11 OE JVlla
P.O. Box 135
�• Page 2 of 11 Middleton, MA 01 949
1 -978-774-4065
OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION (continued)
Property Address: H Gran Vt-i Ie- Lane
W, Andc>\)e.r. MA
Owner. errornag rA
Date of Inspection:_6_1&_ 05
Inspection Summary: Checlh,C,D or E/ALWAYS complete all of Section D
A. System Passes:
1/ 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:
hLObservation 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:
tv The system required pumping more than 4 times a year due to broken or obstructed pipe(s).The system will
pass inspection if(with approval of the Board of Health):
broken pipe(s)are replaced
obstruction is removed
ND explain-
2
Dean G. Luscomb II & Sons
Page 3 of 1 l P.O. Box 135
Middleton, MA 01949
1-978-774-4065
OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION(continued)
Property Address: 14 G ra vwL l l e 1. ar)e
LI. A r,dOyer* Mfg
Owner:TerrolrnCLO ra
Date of Inspection: (p- I!p-05
C. Further Evaluation is Required by the Board of Health:
Conditions exist which require further evaluation by the Board of Health in order to determine if the system
is failing to protect public health,safety or the environment.
1. System will pass unless Board of Health determines in accordance with 310 CMR 15.303(1)(b)that the
system is not functioning in a manner which will protect public health,safety and the environment:
Cesspool or privy is within 50 feet of a surface water
Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh
2. System will fail unless the Board of Health(and Public Water Supplier,if any)determines that the
system is functioning in a manner that protects the public health,safety and environment:
/" The system has a septic tank and soil absorption system(SAS)and the SAS is within 100 feet of a
surface water supply or tributary to a surface water supply.
!" The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water supply.
/v The system has a septic tank and SAS and the SAS is within 50 feet of a private water supply well.
1" 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
Ue ul U. Ljub Null. 11 a JVtla
P.O. Box 135
Page 4 of 1 I Middleton, MA 01949
1-978-774-4065
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION(continued)
Property Address: 114 q Q t'any 0 1 e Lath'
N. Andc-)uer, Nl
Owner:Te rrarnaq ra
Date of Inspection:
D. System Failure Criteria applicable to all systems:
You must indicate"yes"or"no"to each of the following for all inspections:
Yes No
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_day flow
Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s).Number
of times pumped .
N Any portion of the SAS,cesspool or privy is below high ground water elevation.
N Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface
water supply.
0�1 Any portion of a cesspool or privy is within a Zone 1 of a public well.
N Any portion of a cesspool or privy is within 50 feet of a private water supply well.
A) 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 forma
00 0(Yes(9 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.
Large Systems:
To be c dered a large system the system must serve a facility with a design flow of 10,000 gpd to 15,000
gpd•
You must indicate eit es"or"no"to each of the following:
(The following criteria apply rge systems in addition to the criteria above)
yes no
the system is within 400 feet of a surfac 'nkin er supply
the system is within 200 feet of a tr' ary to a surfac nking water supply
_
the system is located i nitrogen sensitive area(Interim Wellhea tection Area—IWPA)or a mapped
Zone II of a pu ' water supply well
If you have ag eyed"yes"to any question in Section E the system is considered a significant t t or answered
"Yes" ip�4<ion D above the large system has failed.The owner or operator of any large system const ed a
psi lficant threat under Section E or failed under Section D shall upgrade the system in accordance with 31 R
. " 15.304.The system owner should contact the appropriate regional office of the Department.
4
UeWl 10. UWJULA W 11 Ot JV11b
Page 5 of 11 P.O. Box 135
Pa
g Middleton, MA 01949
1-978-774-4065
OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART B
CHECKLIST
Property Address: y ED Y Q n V f'I f @. Ln .
NlAndouer. M-A
Owner, err TY)oar
Date of Inspection: b- 1 (o- 05
Check if the following have been done.You must indicate"yes"or"no"as to each of the following:
Yes No
Z"_ Pumping information was provided by the owner,occupant,or Board of Health
Were any of the system components pumped out in the previous two weeks?
I
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?
I
Was the site inspected for signs of break out?
_ Were all system components,excluding the SAS,located on site?
f _ 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?
!
AZ — 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: j
Yes no
_ Existing information.For example,a plan at the Board of Health.
Determined in the field(if any of the failure criteria related to Part C is at issue approximation of distance
is unacceptable)[3 10 CMR 15.302(3)(b)]
5
VGQIl V.LIIJI.ViIW 11 ll VViiJ
P.O. Box 135
Page 6 of 11 Middleton, MA 01949
1-978-774-4065
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION
Property Address: 1 H 0 G r a riv 1'I I e Ln
Irl .A nd bu e t•. MA
Owner•Te r Y o rno O 1'"a
Date of Inspection: (.D - 1n- Q 5
FLOW CONDITIONS
RESIDENTIAL
Number of bedrooms(design): Number of bedrooms(actual): ��,���� �J
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®or no):E6S
Is laundry on a separate sewM�e system(yes ordo_[�Xa [if yes separate inspection required]
Laundry system inspecte<e, or no):Ygt,�,
Seasonal use:(yes or(ffD14v
Water meter readings, if available(last 2 years usage(gpd)): o Wc&-c C'
Sump pump(yes orm-o), NO f
Last date of occupancy: zfy rM C
Q�IERCI'ALANDUSTRIAL
Type of esr labtisbment:
Design flow(base 0 CMR 15.203): gpd
Basis of design flow(seats/pe sgft,etc.):
Grease trap present(yes or no):_
Industrial waste holding tank present(yes or _
Non-sanitary waste discharged i e 5 system(yes or
Water meter readings ' ailable:
Last date of o ancy/use:
O ER(describe):
GENERAL INFORMATION
Pumping Records
Source of information: 0". w
, M
Was system pumped as part of the inspection yes or4gr_&X-1
If yes,volume pumped: 1d C• g`alloNs--How was quantity pumped determined?
Reason for pumping:k4o
T�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 e of l cpm onents,1jate installed(if known)and source of information:
AX
Were sewage odors detected when arriving at the site(yes oi<& :&b
6
Ut=ZUI V. UUJI.I-AtIQ 11 tX
P.O. Box 135
Page 7 of 11 Middleton, MA 01949
1-978-774-4065
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: 14 H (3r a n V t:l I C I-r)
N, Andover.
Owner:Terra tY3QQ 1-0
Date of Inspection: a `1
BUILDING SEWER(locate on site plan) t/.mss
Depth below grade: //
Materials of construction:�jEast iron _40 PVC_other(explain):
Distance from private water supply well or suction line:
Comments(on condition of joints,venting,evi ec�ce of leakage,etc.):
2ror? w/N, br., lZ-
SEPTIC TANK:YeS (locate on site plan)
/i
Depth below grade: -// �
Material of construction: t/concrete metal fiberglass_polyethylene
_other(explain) Pne pec-&'�Jz— CG)C'r-" ' IIC2�C�o�1
If tank is metal list age:,U Is age confirm d by a Certificate of Compliance(yes or no): (attach a copy of
certificate)
Dimensions: 5 �/����k 5 �i elPk gt40� �CJd�`�°t' f
Sludge depth: </" u
Distance from top of sludge to bottom of outlet tee or baffle:
Scum thickness: <11e ,y
Distance from top of scum to top of outlet tee or baffle:
Distance from bottom of scum to bottom of outlet tee or baffle:_240"
How were dimensions determined: zg
Comments(on pumping recommendati s,inlet and outlet tee or baffle condition,structural integrity,liquid levels
as related to outlet invert,evidence of leakage,a ): e
G Tan f a�ecQ CC _.f ate. t on e
e-T Y—Unnl*7 24 its eor�e{ c�r�rkin� Giy �
f
Sv f'c S dfo .'a r-eg i rr- pu,.1f 'nci at-
G" t—GREASE TRAP:/V41ocate on site plan)
Depth below g
Material of construction. concrete_metal_fiberglass_polyethylene_other
(explain):
Dimensions:
Scum thickness:
Distance from top of scum to top of outle r affle:
Distance from bottom of scum om of outlet tee or baffle:
Date of last pumpm
Commentso, mpig r
necommendations, inlet and outlet tee or baffle condition,str ural integrity, liquid levels
as relatett"to outlet invert,evidence of leakage,etc.):
7
Dean G. Luscomb II & Sons
P.O. Box 135
Page 8 of I I Middleton, MA 01949
1-978-774-4065
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: IL-4H Co r Q IAV o « Ln ,
Irl, U T1A
Owner- r-v-0 rri Cll 0 rCt
Date of Inspection:
`
TIGHT or HOLDING TANK:/v���
(tank must be pumped at time of inspection)(locate on si an)
Depth below grade:`"`
Material of construction: `"�ow ete metal fiberglass ylene other(explain):
Dimensions:
Capacity: gallons
Design Flow: ons/day ''"
Alarm present(yes or no): '
Alarm level: larm in working order(yes or no):
Date of last rng:
Com s(condition of alarm and float switches,etc.):
DISTRIBUTION BOX:YeS(if present must be opened)(locate on site plan) :D. j3c�k tS k I_
Depth of liquid level above outlet invert: Zro
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.):
74i 7J /3ox I� /, v / wJa✓7 even �r's��-�iC'n , l9,ur`� ►, u+,"
:D—/3o>/t T3 s unni a ; ' co � eke i; e
PUMP CHA.MBE, R�(locate on site plan) .
Pumps in working order(yes or no):
Alarms in working order(yes
Comm_ e- ntslo� ron of pump chamber,condition of pumps anftppWenances,etc.):
8
Ued11 l7. UU.SI:IAt1U 11 U Uva1.7
P.O. Box 135
Page 9 of I I Middleton, MA 01949
1-978-774-4065
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address:�H q 6 ra n V 1. a l e Ln
N A ndbv2r. NAA
Owner:TE r ra m
Date of Inspection: v
SOIL ABSORPTION SYSTEM(SAS): OS (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:
leaching fields,number,dimensions:—Ltj24,Cki, ,e ,dl 70 6�0 Z"// ,
overflow cesspool,number:
innovative/alternative system Type/name of technology. T
Comments(note condition of soil,signs of hydraulic failure,level of ponding,damp soil,condition of vegetation,
etc.):
SAS is ti-) goocd
500 ih Ali Cry-0, TS df-&A cz + w/ Ne, 5�rt✓��
,CESSPOOLS:Yg (cesspool must be pumped as part of inspection)(locate on site plan) pil-a r
Number and configuration: ( - `�1 of SAO 11-e- /a1A170('7
QSe
Depth-top of liquid to inlet invert: AJ 7q U
Depth of solids layer: N"X�
Depth of slum layer: N/R
Dimerisiods'ofcesspool:
Materials of construction: fioL Z),4!Fl fed WZ S n-.e_
Indication of groundwater inflow(yes o Na
Comments(note condition of soil,signs of hydraulic failure, vel of ponding,condition of vegetation,etc.). �f
#AW'S
PRIVY:/D(locate on site plan)
Materials oc fist ction:
Dimensions: ---- ---
Depth of solids:
Comments(note condition of soil,signs of h u of ponding,condition of vegetation,etc.):
i
a
•
P.O. Box u135
Page 10 of 11 Middleton, MA 01949
R 1-978-774-4065
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: H S r'(.1!hV 0 E e Ln
W, A ndcOp P r. Ni A
Owner: jp_r rQ-m QCT r Q
Date of Inspection: (2':"[(C>- (�
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.
131?)T5
13-t4 D
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Floor � V°3�
/�7 Gro�nvi�l� f..a.•'�
1t
l
�rcc t> � bar- 10
r LIeWl l7. LiUJIA_A11U 11 (x JVtio
P.O. Box 135
Page 1 I of I I Middleton, MA 01949
1-978-774-4065
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: (pro nvl:!de �..h
W .An o v e Ir L8A
Owner: Frr-aJV-)Q r
Date of Inspection: � -�'l(0-nJ
SITE EXAM
✓Slope &-oo'd �ac% were t Sc�S !S �ccat!e
t/Surface water tJ-or*c.,
✓Check cellar IJc) 54,v.,,�p pip
U Shallow wells Wr%c.
1
Estimated depth to ground water feet
Please indicate(check)all methods used to determine the high ground water elevation:
V btained from system design plans on record-If checked,date of design plan reviewed:
bserved site(abutting property/observation hole within 150feet of SAS)
✓ Checked with local Board of Health-explain: f ro5rt ��G S en
Checked with local excavators, installers-( ttach ocumentation)
/ T.
& Accessed USGS database-explain: —Ps eel
You must describe how you established the high ground water elevation:
a
rtt G���4t'Ccl ids /.��'i'.•� 71�
d
11
Commonwealth of Massachusetts
+• r TOWN OF NORTH ANDOVER/
Massachusetts t BOARD OF HEALTH
o
2
OCT 51996 ,
{
system Pumping Record
System Owner System Location
Date of Pumping: . l� I Quafitity Pumped: /Q C, gallons
Cess pool: No Yes Septic Tank: No Yes
System Pumped by: Sladdst sfi&virida License
Contents transferrred to : greater §wrertce§antarV District
Date: Inspector:
,a
Commonwealth of Massachusetts
CitylTown of 'EGEI'v �
System Pumping Record U C r 3 o Zoos
Form 4
' N
TOWN OF ov)OVER
DEP has provided this form for use by local Boards of H alth F0ftj5 T'_iAe sed, but the
information must be,substantially the same as that provided here. Before using this form, check with your
local Board of Health tQ determine the form they use. The System Pumping Record must be submitted to
the local Board of Health or-othe'r approving authority.
A. Facility Information
1. System Location: Left side o se, Right side of house, Left front of house, Right front of house,
Left rear of house t rear of house Left rear of building. Right rear of building.
Address
Cityrrown C Cil vv vl, State Zip Code
2. System Owner:
Name
Address(if different from location)
Cityrrown State Zip Code
Tele-p onNumber
B. Pumping Record
1. Date of Pumping 10 j — 2_ Quantity Pumped: i
Date 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:
I
6. System Pumped By:
Neil Bateson F5821
Name Vehicle License Number
Bateson Enterprises Inc
Company
7. Location where contents were disposed:
L.S. Lowell Waste Water
Signature of Hauler Date
t5form4.doc-06/03 System Pumping Record•Page 1 of 1
Commonwealth of Massachusetts - - _-
City/Town of w
W° System Pumping Record SEP 27 2011
Form.4 TOWN OF NORTH ANDOVER
HEALTH DEPARTMENT
DEP has provided this form for use by local Boards of 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 front of house, right front of house, left side of house, right side of house, Left
rear of house, right rear of house, left side of building, right rear of building, under deck.
L—V-\ /VC)44-(A' "U-1114
Cityrrown State Zip Code
2. System Owner:
Name
Address(if different from location)
City/Town State Ipcode
Telephone Number
B. Pumping Record
l(
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 Sto
-,\(- L,\- 4z-�z�
6. System Pumped By:
Neil J. Bateson F5821
Name Vehicle License Number
Bateson Enterprises Inc.
Company
7. L where contents were disposed:
G.L46of
Lowell ste ter
1 q �l(
Signuler Date
t5form4.doc•06/03 System Pumping Record•Page 1 of 1