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Miscellaneous - 1514 SALEM STREET 4/30/2018 (5)
}_ 1514 SALEM STREET 210/106.A-0027-0000.0 r a North Andover Board of Assessors Public Access �' Page 1 of 1 NORTH North Andover Board of Assessors 'SCH11gt� roperty Record Card Click Seal To Return Parcel ID :210/106.A-0027-0000.0 FY:2009 Community:North Andover SKETCH PHOTO Click on Sketch to Enlarge Click on Photo to Enlarge Search for Parcels Search for Sales i a I � Summary Residence sit Detached Structure 1 Condo 1514 L-A SALEM STREET Commercial Location: 1514 SALEM STREET Owner Name: NEILEY,GEOFFREY C NEILEY,JENNIFER D Owner Address: 1514 SALEM STREET City: NORTH ANDOVER State: MA Zip: 01845 Neighborhood: 6-6 Land Area: 1.56 acres Use Code: 101-SNGL-FAM-RES Total Finished Area: 1924 sqft ASSESSMENTS CURRENT YEAR PREVIOUS YEAR Total Value: 465,000 478,200 Building Value: 252,100 265,300 Land Value: 212,900 212,900 Market Land Value: 212,900 Chapter Land Value: LATEST SALE Sale Price: 100 Sale Date: 11/20/2006 Arme Length Sale A-NO-FAMILY Grantor: NEILEY,GEOFFREY Cod : C Cert Doc: Book: 10501 Page: 60 http://csc-ma.us/PROPAPP/display.do?linkld=1464981&town=NandoverPubAcc 6/2/2009 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/Right front of house, Left/Right rear of house, /righ sid , Left/ Right side of building, Left/Right front of building, Left/Right rear of building, Under deck Address is tL-f City/Town State Zip Code 2. System Owner. so Name Address(if different from location) City/Town ' State �� r 65� Telephone Number B. Pumping Record 1. Date of Pumpinggate 2. Quantity Pumped: Gallons 3. Type of system: ❑ Cesspool(s) Septic Tank ❑ Tight Tank ❑ Other(describe): 4. Effluent Tee Filter present? ❑ Yes 01,410 If yes, was it cleaned? ❑ Yes ❑ No, " 5. Condition of System: 6. System Pumped By: :�._.. Neil.Bateson F5821 RECEIVED Name Vehicle License Nu ber Bateson Enterprises Inc MAY L 7 2014 Company TOWN OF NORTH ANDQVER 7. 7Locati nwhere contents were disposed: HEALTH DEPARTMENT L S. Lowell Waste Water Signitufe HaulwU Date t5form4.doa 06/03 System Pumping Record•Page 1 of 1 NoarH Y6 4oL o �. ti A O cx.�xc�.Krt�wcw 4� CltU PUBLIC HEALTH DEPARTMENT Community Development Division As of: ,dune 11, 2009 q&s is to certif that the individuaCsu6surface disposal system received a SATSTACTORTIMYFE l0N of the: Replacement o,f'thee Sceptic Tankand oisttc6ution Dox By: John Soucy At: 1514 SaCem,Street Map - 106.,9; ('arcef- 27 North Andover, 9 A 01845 The Issuance of this certificate shall not 6e construed as a guarantee that the system will' function satisfgctorzly. usan T Sawyer fu6Cu Ylealth Director 1600 Osgood Street,Forth Andover,Massachusetts 01845 Phone 978.688.9540 Fox 978.688.8476 Web www.townofnorthandover.com ��'l� ��fC�S-Z_ C�`�2 C1 ��I � P 78 NORTH BROADWAY,SALEM,NH 03079 PHONE: 603.898-9339 soUCYIS SEWER FAX $00-641-9379 SERVICE9 INC. f ftxi TO: Cs From: John FAX: PAGES: 2 ((including cover) �� � �(o�V' TEL: DATE: 0 urgent O For Review U Please Comment Q Please Reply ❑Please Recycle Any other questions feel fres to call• I r —42 a 691 � _� � � �� � 0. � J `-F' � 3 � � � �" � � TOWN OF NORTH.ANDOVER °F N°RTk N Office of COMMUNITY DEVELOPMENT AND SERVICES °m HEALTH DEPARTMENT - p 1600 OSGOOD STREET;Building 2-36 '• NORTH ANDOVER,MASSACHUSETTS 01845 ���S,cHUS��th Susan Y. Sawyer,REHS/RS 978.688.9540—Phone Public Health Director 978.688.8476—FAX ONSITE WASTEWATER SYSTEM CONSTRUCTIO LOCATION INFORMATION ADDRESS: '�/ 11 cc� ' °MAP: LOT: �J INSTALLER.- y DESIGNERS—.' PLAN DATE: I BOH APPROVAL DATE ON PLAN: INSPECTIONS TANK INSPECTION: O`C..^t/ I b"'► C9 �ATESJF BED BC1T nn oE-GT4,ON: D®T�©F--F-II�lA9{'JS�B_ DA SITE CONDITIONS ❑Existing septic tank properly abandoned ❑Internal plumbing all to one building sewer ❑Topography not appreciably altered Comments: SEPTIC TANK .s,pqBottom of tank hole has 6" stone base � [� i .5l 'ryWeep hole plugged jv�-"��"' �`~'"� ❑ 1 nk has been installed �p t H-10 to Monolithic construction l►�. Ste-,�� ' Q ✓_ Water tightness of tank has been achieved Visual or Vacuum Test or Water held for 24hrs) Inlet tee inst , ce ed under access port ❑ Outlet teeas baffle effluent filter) installed, ion se centered un er ace ss port ❑ 24" inch cover to within 6" of final9 rade installed over �r AA. i , ��w�' one access port, must be over outlet of tank f effluent filter is present Hydraulic cement around inlet & outlet Wastewater System Documentation—Feb 2006 Page 1 of 6 1 TOWN OF NORTH.ANDOVER F %4 T,{ Office of COMMUNITY DEVELOPMENT AND SERVICES 0 20`l'«0 HEALTH DEPARTMENT 1600 OSGOOD STREET; Building 2-36 *� . s•" NORTH ANDOVER,MASSACHUSETTS 01845 ^GNUS Susan Y. Sawyer,REHS/RS 978.688.9540—Phone Public Health Director 978.688.8476—FAX D-BOX ❑ Installed on stable stone base ❑ , Inlet tee (if pumped or >0.08'/foot) Fv—/ Hydraulic cement around inlet & outlets VFt;l Observed even distribution Speed levelers provided (not required) Comments: 0ru SOIL ABSORPTION SYSTE Bottom of SAS excavated down to soil layer, as provided on plan ❑ Size of SAS excavated as per plan ❑ Title 5 sand installed, if specified on plan ❑ 3/4-1 Y2" double washed stone installed ❑ 1/8-1/2" (peastone) double washed stone installed ❑ Laterals installed and ends connected to header ❑ Laterals vented if impervious material above ❑ Orifices @ 5 & 7 o'clock positions ❑ Gravel-less disposal systems: type, number and location as per plan ❑ Elevations of laterals installed as on approved plan ❑ 40 Mil HDPE barrier installed ❑ Retaining wall (boulder/ concrete /timber/ block) ❑ Final cover as per plan Comments: 4 W ewater System Documentatio;Fb 6 / Page 3 of 6 r" 1, ! fy t l •r _ 1 � Ry • ;I t Y . � A et„ "4 4 2. y • r , r • s t. . y r j p F' 'r J i a r 4 •a.. 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O COL.1K.tMMt.{ It` �.�A SSac�tusE PUBLIC HEALTH DEPARTMENT fommunity Development Division r'FRT1EX9�E 01F COMPLIANCE As of: ,dune 11, 2009 q'his is to cert that the individuaCsudsurface drsposaCsystem received a SAWTACTORTIJVSMC` OX of the: Replacement of the Septic Tankand oistri6ution Bo.0 By., ,john Soucy At: 1 514 SaCem,Street Map - 106.A; Tarcel- 27 North Andover, W 0.1845 The Issuance of this certificate shaCC not 6e construed as a guarantee that the system wilt function satisfcyctoriCy. ,r J usan T Sawyer Pu6Cic�feaCth Director 1600 Osgood Street,North Andover,Massachusetts 01845 Phone 978.688.9540 Fax 978.688.8476 Web www.towoofnorthandover.com I � nein ral, G i5' DelleChiaie, Pamela Subject: Septic- 1514 Salem Street-As-Built Sketch Status: Not Started Percent Complete: 0% Total Work: 0 hours Actual Work: 0 hours Owner: DelleChiaie, Pamela From: Geoff Neiley [GNeiley@btu.com] Sent: Tuesday,June 09, 2009 1:32 PM To: DelleChiaie, Pamela Cc: SoucySewer@comcast.net Subject: RE: Soucy invoice Attachments: 1514 Salem St N.A.jpg Dear Pamela, Attached is the email containing the sketch done by John Soucy for twork at 1514 Salem Stre . John tried to fax this to you this morning, but it does not seem to have reached you. If you d f er informat' ease contact John at 603-898-9339. 1 am looking to get the certificate of compliance as I am in the process of selling my house. If this email and sketch are sufficient, please let me know so that I may pick up my certificate. If it can be emailed to me, please send it to this address, gneiley(a_btu.com or you may call me at 978-930-4695. Thank you for your help and best regards, Geoff Neiley 1514 Salem Street North Andover, MA 10845 From: SoucySewer@comcast.net [mailto:SoucySewer@comcast.net] Sent: Tuesday,June 09, 2009 9:03 AM To: Geoff Neiley Subject: Re: Soucy invoice I Geoff, Attached see a copy of sketch faxed to North Andover Board of Health this morning. i y/ ----- Original Message ----- From: "Geoff Neiley" <GNeiley@btu.com> To: SoucySewer@comcast.net Sent: Tuesday, June 9, 2009 8:55:22 AM GMT -05:00 US/Canada Eastern Subject: RE: Soucy invoice Thank you. I spoke to John last night and he said he would try to fax a sketch of the work to the town of North Andover this morning. If you could email when this has been done, I would greatly appreciate it. I'm selling the house and want to get the"certificate of confirmation"from the town quickly. Best Regards, Geoff From: SoucySewer@comcast.net [mailto:SoucySewer@comcast.net] Sent: Tuesday, June 09, 2009 8:52 AM To: Geoff Neiley Subject: Re: Soucy invoice Good morning Geoff, We ran your credit card yesterday and it went through fine. If you need anyother information/confirmations let us know. Thank you ----- Original Message ----- From: "Geoff Neiley" <GNeiley@btu.com> To: SoucySewer@comcast.net Sent: Monday, June 8, 2009 4:29:47 PM GMT -05:00 US/Canada Eastern Subject: RE: Soucy invoice 2 For my records, can you confirm that you were able to charge my credit card the remaining $4375? Thank you, Geoff Neiley. From: SoucySewer@comcast.net [mailto:SoucySewer@comcast.net] Sent: Monday,June 08, 2009 2:16 PM To: Geoff Neiley Subject: Soucy invoice Attached please find invoice for septic work done at 1514 Salem St., N. Andover. Any questions, please feel free to give me a call. Thankou Y , John Soucy I RE:Soucy invoice I I I 3 .f DelleChiaie, Pamela Subject: Septic- 1514 Salem Street-todo list item Start Date: Thursday, June 04, 2009 Due Date: Thursday, June 11, 2009 Status: Not Started Percent Complete: 0% Total Work: 0 hours Actual Work: 0 hours Owner: DelleChiaie, Pamela From: Sawyer,Susan Sent: Thursday,June 04,2009.3:26 PM To: DelleChiaie, Pamela; Grant, Michele Subject: 1514 salem -todo list item For the file I spoke with Claire Golden and Prescott pump. ➢ Issue— used SDR 35 out of tank to tie into schedule 20 pipe existing, ➢ Should have used Schedule 40 based on N.A. regulation, but the SDR 35 is allowed by tate code. ➢ Conclusions: ok to leave SDR 35 ➢ Issue—water line is less than 12 inches from tank. State code requires 10 feet from the tank. ➢ Conclusion- water line must be relocated to be 10 feet from tank or the pipe may be sleeved to maintain a distance of a minimum of 5 feet from the tank edge. This wasp a best practice recommendation from Claire Golden of DEP., ➢ Issue— John Soucy did not contact the Health Dept when he encountered site conditions that need to be reported to and consulted with the Health Dept. A warning_will be issued in this atter for violation to the State code. � r i 4.1 63 p`V& TN�M Town of North Andover HEALTH DEPARTMENT SACMUSt CHECK#: DATE: .5Z 6 O� LOCATION: H/O NAME: CONTRACTOR NAME: Type of Permit or License: (Check box) ❑ Animal $ ❑ Body'Art Establishment $ ❑ Body Art Practitioner $ ❑ Dumpster $ 'j ❑ 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) $ ❑ Titlee55 spector $ tle 5 Report $�7 G/• w ❑ Other(Indicate) $ v Health Agent Initials White-Applicant Yellow-Health Pink-Treasurer ��ee�s rr= ga r ���' r �6 ,�� �' '� Commonwealth'of Massachusetts Title 5 Official Inspection Form . Subsurface Sewage Disposal System Form-Not for Voluntary Assessments , 1514 Salem Street Property Address Jeff Neiley f7 7jo Owner Owner's Name information is required for North Andover MA 01810 5/19/2009 every page. Citylrown State Zip Code Date of Inspection Inspection results must be submitted on this form. Inspection forms may not be altered in any way. Please see completeness checklist at the end of the form. Important: A. General Information When filling out RECEIVED forms on the computer,use 1. Inspector: only the tab key MAY 2 6 2009 to move your Neil J. Bateson cursor-do not Name of Inspector use the return TOWN OF NORTH ANDOVER key. Bateson Enterprises Inc. HEALTH DEPARTMENT Company Name 111 Argilla Road Company Address Andover Ma 01810 Citylrown State Zip Code 978-475-4786 S115 Telephone Number License Number B. Certification 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. 1 am a DEP approved system inspector pursuant to Section 15.340 of Title 5(310 CMR 15.000).The system: ❑ Passes ® Conditionally Passes ❑ Fails ❑ Needs Further Evaluation by the Local Approving Authority AAA, 5/19/2009 In a or 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 Y P 9 P Y Y has a flow design f g o 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 I and copies sent to the buyer, if applicable, and the approving authority. ****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. t5ins•09108 Title 5 Official Inspection Fonn:Subsurface Sewage Disposal System•Page 1 of 17 I � , Commonwealth'&Massachusetts r . v Title 5 Official Inspection Form Subsurface Sewage Disposal System Foran-Not for Voluntary Assessments 1514 Salem Street Property Address Jeff Neiley Owner Owner's Name information is North Andover MA 01810 5/19/2009 required for every page. Citylrown State Zip Code Date of Inspection B. Certification (cont.) 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. Check the box for"yes", "no"or"not determined" (Y, N, ND)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. ® Y ❑ N ❑ ND(Explain below): Septic tank leaking, liquid level 2' below outlet invert. t5ins•09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 2 of 17 1 Commonwealth'of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 1514 Salem Street Property Address Jeff Neiley Owner Owner's Name information is required for North Andover MA 01810 5/19/2009 every page. City(rown State Zip Code Date of Inspection B. Certification (cont.) B) System Conditionally Passes (cont.): ❑ 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 ❑ Y ® N ❑ ND (Explain below): ❑ obstruction is removed ❑ Y ® N ❑ ND(Explain below): ❑ distribution box is leveled or replaced ❑ Y ® N ❑ ND (Explain below): ❑ 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 ❑ Y ® N ❑ ND (Explain below): ❑ obstruction is removed ❑ Y ® N ❑ ND (Explain below): 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 t5ins•09/08 Title 5 Official Inspection Forth:Subsurface Sewage Disposal System.Page 3 of 17 Commonwealth -of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 1514 Salem Street Property Address Jeff Neiley Owner Owner's(dame information is required for North Andover MA 01810 5/19/2009 every page. Cityrrown State Zip Code Date of Inspection B. Certification (cont.) 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 indicates absent 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: D-Box needs to be replaced, badly corroded. 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 t5ins•09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 4 of 17 � Commonwealth'of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 1514 Salem Street Property Address Jeff Neiley Owner Owner's Name information is required for North Andover MA 01810 5/19/2009 every page. City/Town State Zip Code Date of Inspection B. Certification (cont.) Yes No ® 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 fecal coliform bacteria indicates absent 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 and chain of custody must be attached to this form.] ❑ ® The system is a cesspool serving a facility with a design flow of 2000gpd- 10,000gpd. 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. For large systems, you must indicate either"yes"or"no"to each of the following, in addition to the questions in Section D. 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. t5ins•09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 5 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 1514 Salem Street Property Address Jeff Neiley Owner Owner's Name information is required for North Andover MA 01810 5/19/2009 every page. Citylrown State Zip Code Date of Inspection C. Checklist 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? ® ❑ Was the site inspected for signs of break out? Were all system components, excluding® 1:1Y p 9 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: ® ❑ Existing information. For example, a plan at the Board of Health. ® 1:1Determined in the field (if any of the failure criteria related to Part C is at issue approximation of distance is unacceptable) [310 CMR 15.302(5)] D. System Information Residential Flow Conditions: Number of bedrooms(design): 4 Number of bedrooms(actual): 3 DESIGN flow based on 310 CMR 15.203(for example: 110 gpd x#of bedrooms): 600 t5ins•09108 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 6 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments M , 1514 Salem Street Property Address Jeff Neiley Owner Owner's Name information is required for North Andover MA 01810 5/19/2009 every page. City/Town State Zip Code Date of Inspection D. System Information Description: Number of current residents: 4 Does residence have a garbage grinder? ® Yes ❑ No Is laundry on a separate sewage system?[if yes separate inspection required] ❑ Yes ® No Laundry system inspected? ❑ Yes ❑ No Seasonal use? ❑ Yes ® No Water meter readings, if available(last 2 years usage(gpd)): Yes Detail: Sump pump? ® Yes ❑ No Last date of occupancy: Current Date Commercial/Industrial Flow Conditions: Type of Establishment: Design flow(based on 310 CMR 15.203): Gallons per day(gpd) Basis of design flow(seats/persons/sq.ft., etc.): Grease trap present? ❑ Yes ❑ No Industrial waste holding tank present? ❑ Yes ❑ No Non-sanitary waste discharged to the Title 5 system? ❑ Yes ❑ No Water meter readings, if available: t5ins•09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 7 of 17 Commonwealth'& Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 1514 Salem Street Property Address Jeff Neiley Owner Owner's Name information is wired for required North Andover MA 01810 5/19/2009 every page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Last date of occupancy/use: Date Other(describe below): General Information Pumping Records: Source of information: Pumped 11/3/2008, owner Was system pumped as part of the inspection? ❑ Yes ® No I If yes, volume pumped: gallons How was quantity pumped determined? I Reason for pumping: Type of System: ® Septic tank, distribution box, soil absorption system i ❑ 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) and a copy of latest inspection of the I/A system by system operator under contract ❑ Tight tank. Attach a copy of the DEP approval. ❑ Other(describe): t5ins•09/08 Title 5 Oficial Inspection Forth:Subsurface Sewage Disposal System•Page 8 of 17 Commonwealth'&Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments M 1514 Salem Street Property Address Jeff Neiley Owner Owner's Name information is required for North Andover MA 01810 5/19/2009 every page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Approximate age of all components, date installed(if known)and source of information: 23 years old, 10/8/1986, Final inspection from Health Dept. Were sewage odors detected when arriving at the site? ❑ Yes ® No Building Sewer(locate on site plan): Depth below grade: 2 feet Material of construction: ® cast iron ® 40 PVC ❑ other(explain): Distance from private water supply well or suction line: feet Comments(on condition of joints, venting, evidence of leakage, etc.): 4"Cast iron thru wall, 3" PVC in house, no leaks visible Septic Tank(locate on site plan): 9 Depth below rade: 1 P feet Material of construction: ® concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain) If tank is metal, list age: years Is age confirmed by a Certificate of Compliance? (attach a copy of certificate) ❑ Yes ❑ No 10'x 5'x 4' Dimensions: Sludge depth: t5ins-09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 9 of 17 Commonwealth*of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments M 1514 Salem Street Property Address Jeff Neiley Owner Owner's Name information is required for North Andover MA 01810 5/19/2009 every page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Septic Tank(cont.) Distance from top of sludge to bottom of outlet tee or baffle 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 How were dimensions determined? Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): No inlet tee or baffle. Outlet tee ok. Depth of liquid 2' below outlet invert. Evidence of leakage Grease Trap(locate on site plan): Depth below grade: feet 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: Date t5ins-09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 10 of 17 ' Commonwealth'of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 1514 Salem Street Property Address Jeff Neiley Owner Owner's Name information is required for North Andover MA 01810 5/19/2009 every page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Comments(on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): Tight or Holding Tank(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 per day Alarm present: ❑ Yes ❑ No Alarm level: Alarm in working order: ❑ Yes ❑ No Date of last pumping: Date Comments(condition of alarm and float switches, etc.): "Attach copy of current pumping contract(required). Is copy attached? ❑ Yes ❑ No t5ins-09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 11 of 17 i I , Commonwealth*of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 1514 Salem Street Property Address Jeff Neiley Owner Owner's Name information is North Andover MA 01810 5/19/2009 required for every page. Citylrown State Zip Code Date of Inspection D. System Information (cont.) Distribution Box(if present must be opened) (locate on site plan): Depth of liquid level above outlet invert 2"below outlets 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.): D-Box leaking, liquid level 2"below outlet inverts. Evidence of carryover. D-box badly corroded needs to be replaced. I Pump Chamber(locate on site plan): Pumps in working order: ❑ Yes ❑ No Alarms in working order: ❑ Yes ❑ No Comments(note condition of pump chamber, condition of pumps and appurtenances, etc.): Soil Absorption System (SAS) (locate on site plan, excavation not required): If SAS not located, explain why: t5ins•09108 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 12 of 17 I ` Commonwealth &Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments M , 1514 Salem Street Property Address Jeff Neiley Owner Owner's Name information is required for North Andover MA 01810 5/19/2009 every page. Citylrown State Zip Code Date of Inspection D. System Information (cont.) Type: ❑ leaching pits number: ❑ leaching chambers number: ❑ leaching galleries number: ® leaching trenches number, length: 4 trenches 35' long ❑ 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.): Soil ok. Vegetation ok. No sign of ponding to surface. Cesspools(cesspool must be pumped as part of inspection)(locate on site plan): Number and configuration — Depth to of liquid to inlet invert p P 4 Depth of solids layer Depth of scum layer Dimensions of cesspool Materials of construction Indication of groundwater inflow ❑ Yes ❑ No t5ins•09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 13 of 17 i Commonwealth bf Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 1514 Salem Street Property Address Jeff Neiley Owner Owner's Name information is required for North Andover MA 01810 5/19/2009 every page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) 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.): t5ins-09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 14 of 17 Commonwealth of Massachusetts - - Title 5 official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 1514 Salem Street Property Address Jeff Neiley Owner Owner's Name information is North Andover MA 01810 5/19/2009 required for state Zip Code Date of Inspection every page. City/Town D. System Information (cont.) Sketch Of Sewage Disposal System: Provide a view 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.Check one of the boxes below: ® hand-sketch in the area below ❑ drawing attached separately W & � g a= L4 __'56�`S aCD 3It = a-( `s t1 141as G 5. Form.Subsurface Sewage Disposal System-Page 15 of 17 t5ins-09108 ��✓i GyCfS >'1�� `c'r, � /u ���r /�/j` /I` liJ`� �.SS u..-�-•� �-��.,+✓l._3,-�'- i r,,s,J. !S �-[..s��i ��T ' Commonwealth'of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 1514 Salem Street Property Address Jeff Neiley Owner Owner's Name information is required for North Andover MA 01810 5/19/2009 j every page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Site Exam: ® Check Slope ® Surface water ® Check cellar ® Shallow wells Estimated depth to high round water: 4 p g g feet Please indicate all methods used to determine the high ground water elevation: ® Obtained from system design plans on record If checked, date of design plan reviewed: September 1986 Date ❑ 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: i You must describe how you established the high ground water elevation: As per design plan test pit data Before filing this Inspection Report, please see Report Completeness Checklist on next page. t5ins•09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 16 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments M , 1514 Salem Street Property Address Jeff Neiley Owner Owners Name information is required for North Andover MA 01810 5/19/2009 every page. Cityrrown State Zip Code Date of Inspection E. Report Completeness Checklist E Inspection Summary: A, B, C, D, or E checked ® Inspection Summary D (System Failure Criteria Applicable to All Systems)completed ® System Information—Estimated depth to high groundwater E Sketch of Sewage Disposal System either drawn on page 15 or attached in separate file t5ins-09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 17 of 17 Summary Record Card generated on 5/22/2009 3:18:18 PM by Lisa Evans Page 1 Town of North Andover Tax Map # 210-106.A-0027-0000.0 Parcel Id 17114 1514 SALEM STREET NEILEY, GEOFFREY 1514 SALEM STREET N. ANDOVER, MA 01845 Class 101 Single Family Property Type 1 Residential Size Total 1.56 Acres FY 2009 UB Mailing Index Name/Address Type Loan Number Activelinact. From Until NEILEY,GEOFFREY Payor 1514 SALEM STREET N.ANDOVER,MA 01845 UB Account Maint. Account No Cycle Occupant Name Active/Inactive Bldg Id. 17428.0-1514 SALEM STREET Last Billing Date 4/6/2009 3170098 03 Cycle 03 Active UB Services Maint. Account No.3170098 Service Code Rate Charge Multiplier/Users MISCFEE ADMIN FEE 0.635/8 7.82 1/ WTR WATER 01 ALL METER SIZE 80.61 /1 UB Meter Maintenance Account No.3170098 Serial No Status Location Brand Type Size YTD Cons 13242669 a Active ERT HH METE METE w Water 0.63 0.63 86 Date Reading Code Consumption Posted Date Variance 3/12/2009 429 a Actual 23 4/29/2009 4% 12/5/2008 406 a Actual 20 1/20/2009 -14% 9/8/2008 386 a Actual 25 10/10/2008 24% 6/5/2008 361 a Actual 18 7/16/2008 -8% 3/12/2008 343 a Actual 21 4/11/2008 -9% 12/12/2007 322 a Actual 25 1/22/2008 -14% 9/4/2007 297 a Actual 24 10/12/2007 50% 6/14/2007 273 a Actual 18 7/20/2007 0% 3/14/2007 255 a Actual 18 4/16/2007 -2% 12/12/2006 237 a Actual 17 1/19/2007 -13% 9/18/2006 220 a Actual 21 10/20/2006 19% 6/19/2006 199 a Actual 20 7/10/2006 15% 3/8/2006 179 a Actual 13 4/17/2006 3% 12/21/2005 166 a Actual 16 1/17/2006 -14% 9/14/2005 150 a Actual 16 10/14/2005 14% 6/22/2005 134 a Actual 16 7/15/2005 -17% 3/18/2005 118 a Actual 19 4/5/2005 15% 12/13/2004 99 a Actual 13 1/14/2005 -14% 9/29/2004 86 a Actual 20 10/8/2004 -35% 6/22/2004 66 a Actual 22 7/30/2004 -14% 4/12/2004 44 a Actual 44 5/17/2004 0% 12/12/2003 0 n New Meter 0 12/12/2003 0% I { Commonwealth of Massachusetts Map-Block-Lot 0.4 ��® �a� 106.A-0027- Board of Health Penn----------- B Permit No • ` North Andover BHP-2009--- -- 't c.•�. • P.I. EE ?sS�+swu5ti F.I. $125.00 ----------------------- Disposal Works Construction Permit Permission is hereby granted John Soucy --------------------------------------------------------------------------------------------- to(Repair-TANK&D-BOX)an Individual Sewage Disposal System. at No 1514 SALEM STREET as shown on the application for Disposal Works Construction Permit No. BHP-2009-053 Dated June 02,2009 ued On:Jun-02-2009 F1-L ` Iss �f q IO oT'q , Commonwealth of Massachusetts Map-Block-Lot 106.A-0027- Board of Health North Andover ��s••Try # Certificate of Compliance THIS IS TO CERTIFY,That the Individual Sewage Disposal System (Repair-TANK&D-BOX) by ---John S_ouc__y----------------------------------------------------------------------------------------------------------------------------------------- Installer at No 1514 SALEM STREET ----------------------•----------------------------------------------------------------------------------------------------------------------------------- has been installed in accordance with the provisions of TITLE 5 of the State Environmental Code as described in the application for Disposal Works Construction Permit No. -BHP-2009-053- -- -- ---Dated June 02-,2009 ---- --------- ---- ---------- - - - -------- ----------------------------------------------------------------- Printed On:Jun-02-2009 Board of Health r...r • ,_.YY._,Y+ r..w ON'.M.:.„ 'i""aiv .x+T:�,.I...r.,` x, •M':{.r�T r '•r../wa....l++rvrt•1 � - 4.1 '13 • Town of North Andover HEALTH DEPARTMENT ,SSwCM�st� CHECK#: P��o2� DATE: LOCATION: H/O NAME: G�� ✓a` CONTRACTOR NAME: Type of Permit or License: (Check box) ❑ Animal $ ❑ 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 sign Approval $ ® eptic Disposal Works Construction(DWC) $ � ❑ Septic Disposal Works Installers(DWI) $ ti ❑ Title 5 Inspector $ ❑ Title 5 Report $ ❑ Other. (Indicate) $ C.� Health Agent Initials White Applicant Yellow-Health. Pink-Treasurer 4 Application for Septic Disposal System Y 3pTOD Y' AT Constructionerm - ORTH ANDOVER MA 01845 $250.00—Full Repair CNUSS i $125.00 -C ponent 3^ k Important: Application is hereby made for a permit to: When filling out forms on the ❑ Construct a new on-site sewage disposal system* computer, use only the tab key ❑ Repair or replace an existing on-site sewage disposal system* to move your Repair or replace an existing system component—What? cursor-do not use the return key. A. Facili Information VAI Address or Lof# ` 44 City/Town 2.-*TYPE OF SEPTIC SYSTEM: ❑ Pump ❑ Gravity (choose one) ***If pump system, attach copy of electrical permit to application*** ❑ Conventional System (pipe and stone system) ❑ Infiltrator or Biodiffuser(Gravel-Less) (Attach a copy of your certification to install this type of system. ❑ Pressure Distribution S.A.S. (No D-Box) (Attach Draft Maintenance Agreement) ❑ Pressure Dosed (D-Box Present) S.A.S. 2. Owner Information Name Address(if different from above) City/Town State Zip Code Telephone Number 3. Installer Information '30 u N4 Name ^ Name of Cr pany 77 e Ads W J4A.- Cityrrown �� State Zip Code Telephone Number(Cell Phone#if possible please) 4. Designer Information Name Name of Company Address Cityrrown State Zip Code Telephone Number(Best#to Reach) Application for Disposal System Construction Permit•Page 1 of 2 s� Cof N°oTbgti Application for Septic Disposal System (p aL 6 pConstruction Permit - TOWN OF * t $250.00-Full Repair ORTH ANDOVER, MA 01845 CH q,CU•�� $125.00 - Component � SAS t PAGE 2OF2 A. Facility Information continued.... 5. Type of Building: Residential Dwelling or❑Commercial B. Agreement The undersigned agrees to ensure the construction and maintenance of the afore-described on-site sewage disposal system in accordance with the provisions of Title 5 of the Environmental Code, as well as the Local Subsurface Disposal Regulations for the Town of North Andover, and not to place the system in operation unt' a C ificate of Compliance has been issued by this Board of Health. UC 6 Name Date Applic n Approv y: (Board of Health Representative) a e{ — Date Application Disapp ved for the following reasons: For Office Use Only: 1. Fee Attached. Yest/ No 2. Project Manager Obligation Form Attached. Yes v No 3. Pump System? Ifso,Attach copy ofElectrical Permit Yes No 4. Foundation As-Built. (new construction ronly): Yes No (Same scale as approved plan) 5. Floor Plans?(new construction only): Yes No Application for Disposal System Construction Permit•Page 2 of 2 �T m. SEPTIC SYSTEM INSTALLER PROJECT MANAGEMENT OBLIGATIONS As the North Andover licensed installer for the construction for the septic system for the property at: (Address of septic system) For plans by (Engineer) Relative to the application of 4zOGf (Installer's name) And dated - ngina ate Dated o ay s ate With revisions dated t��JJJ (Last revised date) I understand the following obligationsfot ma gement of this project: 1. As the installer, I am obligated to obtain all permits and Board of Health approved plans prior to performing any work on a site. I must have the approved plans and the permit on site when any work is being done. 2. As the installer, I must call for any and all inspections. If homeowner, contractor,project manager, or any other person not associated with my company schedules an inspection and the system is not ready, then item three shall be applicable. 3. As the installer, I am required to have the necessary work completed prior to the applicable inspections as indicated below. I understand that requesting an inspection,without completion of the items in accordance with Title 5 and the Board of Health Regulations may result in a$50.00 fine being levied against me and/or MY company a. Bottom of Bed—Generally, this is the first (1'� inspection unless there is a retaining wall,which should be done first. The installer must request the inspection but does not have to,be present. b. Final Construction Inspection—Engineer must first do their inspection for elevations, ties, etc. As-built of verbal OK (or e-mail to: healthdeptntownofnorthandover.com) from the engineer must be submitted to the Board of Health, after which installer calls for an inspection time. Installer must be present for this inspection. With a pump system, all electrical work must be ready and able to cause pump to work and alarm to function. c. Final Grade—Installer must request inspection when all grading is complete. Installer does not have to be on-site. 4. As the installer, I understand that only I may perform the work (other than simile excavation)and I am required to complete the installation of the system identified in the attached application for installation. I further understand that work done by others unlicensed to install septic systems in North Andover can constitute reasons for denial of the system and/or revocation or suspension of my license to operate in the Town of North Andover, significant fines to all persons involved are also possible. 5. As the installer, I understand that I must be on-site during the performance of the following construction steps: a. Determination that the proper elevation of the excavation has been reached. b. Inspection of the sand and stone to be used. c. Final inspection by Board of Health staff or consultant. d. Installation of tank, D-Box,pipes, stone, vent,pump chamber,retaining wall and other components. 6. As the installer, I understand that I am solely responsible for the installation of the system as per the approved plans. No instructions by the homeowner,general contractor, or any other persons shall absolve me of this obligation. Undersigned Licensed Septic Installer: J�_Oe_ 4� (Toda X a6 arae—Print) a e— 1 e i ` FORM U - LOT RELEASE FO wl INSTRUCTIONS; RM14 ` form is used to7r- ThisBoards and De t Partments havinthat all neces he a 9 orissa1 dlic IcaPP ant and/or landowner from co jurisdiction have been obtained pprovals/permits from mpliance with an This does not relieve '�► * ***** y applicable or re ** ""APPLICANT FIE OUT ('c" LS quirements. APPLICANTS THIS SECTION****** k,t,k„ LOCATION: Assessors Ma PHONE 7 z f. P Number /(�j � 2Q _ �S SUBDIVISION PARCEL_ STREET / LOT(S) ST. NUMBER_ � _ OFFICIAL USE ONLY****.***,kms, At OM E D SOFT +* ` N GENTS: CO 'ER TION ADM INISTRATOR DATE APPROVED COMMENTS ' 1� DATE REJECTED " 1 TOWN PLANNER DATE APPROVED . i COMMENTS DATE REJECTED FOOD WsPECTOR-HEALT DATE APPROVED DATE REJECTED TIC INSPECTOR LT DATE APPROVED COMMENTS DATE REJECTED Z 1 I � . PUBLIC WORKS_SEWE R/WATER CONNECTIONS 1 DRIVEWAY PERMIT FIRE DEPARTMENT RECEIVED By BUILDING INSPEC P� TOR Revised EoEI 9197jm en PE DATE :a� I 'i I I ~ R/CNAR N/F LLJ E W � FRANCp N71'17'15"E — 178.01' ��A 45.0' 3.61, I SHED Ln 4 N87'015•c� 2. y „ w Lo54 F r - Lz, - c 3 131.2' PROP. 1 STORY �t� X W � N t� 2 STORY L GARAGE WITH W.F.D. ENCLOSED BREEZEWAY } '✓ #1514 (SEE DETAIL) . m f a z Vic,• N v V� o LOT A AREA=77,250 S.F. •77 A C.,,a 1 �..w•y,n.r..^+.�.�."""r".."``i,.*-e..,�,,...rtrvi..+'ti.-n!-T v -... ,..�. r .. t .,.. ...... - .- T--- -- T '-- � - `�...N"",:C+-,,, _ ,.... COM10,\"VVEALTH OF MASSACHUSETTS y, EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS DEPARTMENT OF ENVIRONMENTAL PROTECTION ONE WINTER STREET, BOSTON MA 02108 (617) 292-5500 TRUDY CORE t Secretary ARGEO PAUL CELLUCCI DAVID B. STRUHS Governor Commissioner SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION �,/ Property Address:/jr ! 'Sh C M -1 Name of Owner 14- ffO R f k ft tVD 0 1/C. 0L Address of Owner Date of Inspection: Name of Inspector:(Please Print) am a DEP proved system ins or pursuant to Section 1 of Title 5(310 CMR 15.000) kC�y Name: �C —?` ' /x//10 d f'!r 5 / t Marling Address: 447 K01/L 2,011 h S/' Telephone Number: -Z-7 -2 CW"7 / 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 inspection. The inspection was performed based on my training and experience in the proper function and maintenance of on-site sewage disposal systems. The system: Passes Conditionally Passes _ 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 thirty(30) days of completing this inspection. If the system is a shared system or has a design flow of 10,000 gpd or greater,the inspector and the system owner shall submit the report to the appropriate regional office of the Department of Environmental Protection. The original should be sent to the system owner and copies sent to the buyer,if applicable, and the approving authority. . NOTES AND COMMENTS revised 9/2/98 Page 1ofII APIRA i 01 Primed oe Recycled Paper SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A f, CERTIFICATION(continued) .. 'roperty Address:y� Jwner: Iva Date it ..• 1 �,.}� �r d Date of Inspection: t INSPECTION SUMMARY: Check A, B, C, or D: n. A. SYSTEM PASSES: I have-not found any information which indicates that any of the failure conditions described in 310 CMR 15.303 exist. Any failure criteria not evaluated are indicated below. COMMENTS: B. SYSTEM CONDITIONALLY PASSES: One or more system components as described in the "Conditional Pass"section need to be replaced or repaired. The system, upon f completion of the replacement or repair, as approved by the-Board of Health, will pass. - - - — — Indicate yes, no, or not determined(Y, N, or ND). Describe basis of determination in all instances. If "not determined", explain why not. The septic tank is metal, unless the owner or operator has provided the system inspector with a copy of a Certificate of Compliance(attached)indicating that the tank was installed within twenty (20)years prior to the date of the inspection; or the septic tank, whether or not metal, is cracked,structurally unsound, shows substantial infiltration or exfiltration, or tank failure is imminent. The system will pass inspection if the existing septic tank is replaced with a complying septic tank as approved by the Board of Health. e 'N _ Sewage backup or breakout or high static water level observed in the distribution box is due to broken or obstructed pipe(s) or due to a broken, settled or uneven distribution box. The system will pass inspection if(with approval of the Board of Health). broken pipe(s) are replaced obstruction is removed distribution box is levelled or replaced c _ The system required pumping more than four times a year due to broken of obstructed pipe(s). The system will pass inspection if(with approval of the Board of Health): broken pipe(s) are replaced obstruction is removed revised 9/2/98 Page 2of11 r y r SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A d f CERTIFICATION(continueed) ,/ Property Address: J I /T M �: 1���1 hL // ^I Pa Y if Ile— Owner: �k/ L �� ��, --0 U ¢. Date of Inspection: t, C. FURTHER EVALUATION IS REQUIRED BY THE BOARD OF HEALTH: Ply Conditions exist which require further evaluation by the Board of Health in order to determine if the system is failing to protect the public health, safety and the environment. 11 SYSTEM WILL PASS UNLESS BOARD OF HEALTH DETERMINES IN ACCORDANCE WITH 310 CMR 15.303(1)(b)THAT THE SYSTEM IS NOT FUNCTIONING IN A MANNER WHICH WILL PROTECT THE PUBLIC HEALTH AND 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 AND SAFETY AND THE ENVIRONMENT: The system has a septic tank and soil absorption system(SAS)and the SAS is within 100 feet of a surface water supply or tributary to a surface water supply. The system has a septic tank and soil absorption system and the SAS is within a Zone I of a public water supply well. The system has a septic tank and"soil absorption system and the SAS is within 50 feet of a private water supply well. _ The system has a septic tank and soil absorption system.and the SAS is less than 100 feet but 50 feet or more from a s private water supply well, unless a well water analysis for coliform bacteria and volatile organic compounds indicates that the well is free from pollution from that facility and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm. Method used to determine distance (approximation not valid). 3) OTHER i t l• revised 9/2/98 Page 3of11 • v -� i �....-M>-�7•+"�,...f,.-.T-..'�M'fH�NVr^.'vMT'�Y11�1 �, n i SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A '> CERTIFICATION(contirwedl fr' k Property Address: I f. . 14 c M "' / • '" o ` Y A, I Owner: p ,L c 4W .:< Date of Inspection; D. SYSTEM FAILS: You must indicate either "Yes" or "No" to each of the following: 1 have determined that one or more of the following failure conditions exist as described in 310 CMR 15.303. The basis for this 9 determination is identified below. The Board of Health should be contacted to determine what will be necessary to correct the failure. Yes No _ Backup of sewage into facility or system component due to an 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 flue to an overloaded or clogged SAS or cesspool: Liquid depth in`cesspool s leis than 6" belovt mveri'or availlable volume is less th6h 112 day flow. Required pumping more than 4 times in°the last year NOT due to clogged or obstructed pipe(s). Number of times pumped_. Any portion of the Soil Absorption System, cesspool or privy is below the high groundwater elevation. Any portion of a cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. Any portion of a cesspool or privy is within a Zone I of a public well. 't Any portion of a cesspool or privy is within 50 feet of a private water supply well Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality analysis. If the well has been analyzed to be acceptable, attach p q y y y p copy of well water analysis for coliform bacteria, volatile organic compounds, ammonia nitrogen and nitrate nitrogen. D ° E. LARGE SYSTEM FAILS: You must indicate either "Yes" or "No" to each of the following: r The following criteria apply to large systems in addition to the criteria above: The system serves a facility with a design flow of 10,000 gpd or greater(Large System)and the system is a significant threat to public health and safety and the environment because one or more of the following conditions exist: Yes No _ the system is within 4 0 feet o a surf acerd eking water'-s-upp(y` 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 11 of a public water supply well) The owner or operator of any such system shall upgrade the system in accordance with 310 CMR 15.304(2). Please consult the local regional ,4 office of the Department for further information. U t revised 9/2/98 Page 4ofH. R ' SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST ,/ / rY t Property Address: / I /� � i Q !t T (7 !! fr ,,/p v it Owner: L" !O Date of Inspection: �` ! ��" q,60 J I'> I� Check if the following have been done: You must indicate either "Yes" or "No" as to each of the following: ✓e' No Pumping information was provided by the owner, occupant, or Board of Health. t./ None of the system components have been pumped for at least two weeks and-the system has been receiving rrormal flow rates during that period. Large volumes of water have not been introduced into the system recently or as part of this r inspection. _ As built plans have been obtained and examined. Note if they are not available with N/A. — s The fgcility oridwellingwas i�ispectpd-for#signs of sewage back-up., ` _ The system does not receive non-sanitary or industrial waste flow. _ The site was inspected for signs of breakout. .,I All system components, excluding the Soil Absorption System, have been located on the site. The septic tank manholes were uncovered,opened, and the interior of the septic tank was inspected for condition of baffles or tees, material of construction, dimensions,depth of liquid,depth of sludge, depth of scum. f, The size and location of the Soil Absorption System on the site has been determined based on: Existing information. For example, Plan at B.O.H. Determined in the field (if any of the failure criteria related to Part C is at issue,approximation of distance is unacceptable) [15.302(3)(b)1 r The facility owner (and occupants,if different from owner) were provided with information on the proper.maintena=.6-of SubSurface Disposal Systems. 3 1 1_. p� L revised 9/2/98 Page 5of11 �.. � _... ^.r' . ..'Y" .. r...,..ry.,.•.,.Y T ti..wr V.-., "..,�/'.".,v y.• _�_+- -. .- �-.-�y1.-'. x....-w� .r'\� .. -,-X1.,1-„,1+..-.qn:";`,.. .y�,,.�„n”.}r v "'^" _ , �i SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION rroperty Address:/,✓ '-✓ /Y� .J 7 r y A l 7 r7 /r Al J/P V L`' Owner: Date of Inspection: r FLOW CONDITIONS RESIDENTIAL: Design flow: g.p.d./bedroom. Number of bedrooms (design): Number of bedrooms(actual):_ Total DESIGN flow Number of current residents: Garbage grinder(yes or no):_-S Laundry(separate system) (yes or no)ff'/'�'; If yes, separate inspection required Laundry system inspected lyes or no) Seasonal use lyes or no): ya Water meter readings,if available (last two year's usage(gpd): Sump Pump(yes or no):--- P`J Last date of occupancy:_ A COMMERCIAL/INDUSTRIAL•r .� d .� � E �M- � v.�4 Type of establishment: Design flow: gpd 1 Based on 15.203) Basis of design flow Grease trap present: (yes or no)_ Industrial Waste Holding Tank present: lyes or no)_ Non-sanitary waste discharged to the Title 5 system: (yes or no)_ Water meter readings,if available: Last date of occupancy: OTHER:(Describe) Last date of occupancy: iE GENERAL INFORMATION ;2 PUMPING RECORDS and source of information: System pumped as part of inspection: (yes or no)--V'- If yes, volume pumped: G e+ gallons Reason for pumping: "i'1 r C,+ -�r b i/< L- TYPE OF SYSTEM l./ Septic tank/distribution box/soil absorption system Single cesspool Overflow cesspool Privy Shared system(yes or no) (if yes, attach previous inspection records,if any) I/A Technology etc. Attach copy of up to date operation and maintenance contract Tight Tank. Co - t, gr_ oPy of DWAppro,vat -. .. �yOther APPROXIMATE AGE of all components,date installed(if known)and source of information: Sewage odors detected when arriving at the site: (yes or no) ) 1 i i revised 9/2/98 Page 6of11 { ?F SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM 1, PART C / SYSTEM INFORMATION(continued) fQ. i 'roperty Address: � � 1.•+ +L. �� Owner: �e- Date of Inspection: iy �,.-� <-- � S✓ BUILDING.SEWER: (Locate onsite plan) Depth below grade: Material of construction: 4o cast iron 40 PVC_ other(explain) Distance from private water supply well or suction line Diameter y rr Comments: (condition of joints, venting, evidence of leakage,-etc.) SEPTIC TANK:_N. (locate on site plan) l, } s Depth below grade: Material of construction: t,,eoncrete_metal_Fiberglass _Polyethylene_other(explairi) If tank is metal, list age— Wage confirmed by Certificate of Compliance_(Yes/No) Dimensions: { r( Sludge depth: Distance from top of sludge to bottom of outlet tee or baffle: Scum thickness: / rt Distance from top of scum to top of outlet tee or baffle: 7 r r' Distance from bottom of scum to bottom of outlet tee or baffle: How dimensions were determined: /L I,( 'omments: st (recommendation for pumping, condition of inlet and outlet tees or baffles, depth of liquid level in relation to outlet invert, structural integrity, evidence of leakage, etc.) GREASE TRAP: r (locate on site plan) Depth below grade:_ J-�- Material of construction:_concrete_metal_Fiberglass _Polyethylene_other(explain) Dimensions: Scum thickness: 3 Distance from±top of;scum to top.t f-outlei tee-or baffler ..- 3 Distance from bottom of scum to bottom of outlet tee or baffle: Date of last pumping: Comments: , (recommendation for pumping, condition of inlet and outlet tees or baffles, depth of liquid level in relation to outlet invert, structural integrity, evidence of leakage,etc.) e revised 9/2/98 Page 7of11 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEEMt INFORMATION(continued) Iroperty Address: Owner: Wo L.. /(=- (' ou Date of Inspection: r TIGHT OR HOLDING TANK: (Tank must be pumped prior to, or at time of, inspection) ' (locate on site plan) i Depth below grade:_ Material of construction:_concrete_metal_Fiberglass_Polyethylene_other(explain) Dimensions: Capacity: gallons Design flow: gallons/day Alarm present Alarm level: Alarm in working order: Yes_ No_ p Date of previous pumping: p f 41 i tk� 4 N Comments; r f f " "4 1 9 `a" .� t ' •� p (condition of inlet tee, condition of alarm and float switches, etc.) DISTRIBUTION BOXY-" (locate on site plan) / ~�. Depth of liquid level above outlet invert:�F/"� r t` 3 Comments: (note if level and distribution is equal, evidence of solids carryover, evidence of leakage into or out of box, etc.) t& r/o PUMP CHAMBER:_ , (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.) 1' 1 revised 9/2/98 Page 8ofII ? T a SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) /} �(f 4operty Address: / I .J �T /+ !r ' L !7 �f Wim./' o Jwner: W47 Date of Inspection: SOIL ABSORPTION SYSTEM(SAS):_ ` (locate on site plan,if possible;excavation not required,location may be approximated by non-intrusive methods) F If not located, explain: Type. leaching pits, number:_ leaching chambers, number:_ leaching galleries, number:_ leaching trenches,number, length: leaching fields, number, dimensions: G/'F overflow cesspool,number:_ • Alternative system: Name d,-Technology: V l Comments: (note condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of vegetation, etc.) U 'V411/1 D ,G 012 14 u C.. /G.lJ/Z-C 0 dZ.- / o CESSPOOLS:_ (locate on site plan) Number and configuration: (`( t•, Depth-top.of liquid to inlet invert: Depth of solids layer: t. )epth of scum layer: Dimensions of cesspool: Materials of construction: Indication of groundwater: inflow (cesspool must be pumped as part of inspection) Comments: (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.) F 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.) y r f revised 9/2/98 Page 9of11 ,a p'r SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM F rr PART C w SYSTEM INFORMATION(continued) '.) "roperty Address: � R F» �'/R /` 0 �� l f 41.,, 49 V e )caner: Wo L r� Date of Inspection: SKETCH OF SEWAGE DISPOSAL SYSTEM: include ties to at least two permanent reference landmarks or benchmarks locate all wells within 100' (Locate where public water supply comes into house) bj 14 lq- F 5 / amu r ;AI r �d12 t t,c°co 1 1 revised 9/2/98 Page 10 of 11 f} _ F r SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) operty Address: f :r Jwner: r . {p i t, Date of Inspection. I 4•+ / 1r a (S NRCS Report name Soil Type_ Typical depth to groundwater USGS Date website visited Observation Wells checked Groundwater depth: Shallow Moderate Deep SITE EXAM Slope Surface water Check Cellar 4 Shallow wells Estimated Depth to Groundwater•_Feet 1 Please indicate all the methods used to determine High Groundwater Elevation: Obtained from Design Plans on record Observed Site(Abutting property, observation hole, basement sump etc.) L'-"Determined from local conditions Checked with local Board of health Checked FEMA Maps Checked pumping records Checked local excavators, installers i Used USGS Data Describe how you established the High Groundwater Elevation. (Must be completed) ` /Z 91457 1�2 e4 !i d J I' t revised 9/2/98 Page ttoftt ' r oF' HFo�.►I-) Lar N o(jYN Iry pOVEI�, MA, �. w - 6R Sc�PPL7 ❑ WELL APs�ovCD1�4TC SS Steric sti sTE,-A VGSI6,J APP�{ovt-v p r6, io-3 APRW1,06 AoTliol?,ry COivPITioNs (t)<EFA RR f=ob t1o45 RC"C V4TiCZAJ ( oo K 5 /Q 6ulyng tilt v KOV 5"6:- K�4SoNS '�!) L G�-�, t C SYSTEM 1 STA ILQT�o�1 E7zA, v4T(o,A1 vispEG no&1 P/JS F41L. �tNA(... 11�5PFcrlo n� ,4PP(�OVE,D �i,TC ��-5_g� ,6p�r�vt�vG �O�r+tor�iTy ;?-ANNr r4W IT(OMAL 1),15FbcrjoN5 Ali-,any) NSAPPj�ov6D D,arL✓ R�05o NS•, Ru4L APPROVAL DArE APPRaIVJ6 6 u iHogi t`/ 04/05/2000 18:26 5083736611 STEWART/ANDOVER. PAGE 01 AIRM I i Note) ANtbver- ')36 moon Sf T S SEPTIC TAIL SEWICE Ayd/4- A ne�ev�� 47 WiRQAD SpREor BRADFORD, MA 01835 978-372-7471 MO�TPFi OF MDKIMY REPMT MR T WN OF VIV DATEADDRESS -- - GALLoNS V/ �' cI .,u FORM U - LOT RELEASE FORD INSTRUCTIONS: This form is used to verify that all necessary approvals/permits from Boards and Departments having jurisdiction have been obtained. This does not relieve the applicant and/or landowner from compliance with any applicable local or state law, regulations or requirements. ****************Applicant fills out this section***************** APPLICANT: i l�ti l 1 P _ Phone -<Z)cS'G 8B LOCATION: Assessor's Map Number Parcel Subdivision Lots) Street St. Number ?T ************************Official Use Only************************ RECOM1CMATIONS OF TOWN AGENTS: �^ Date Approved q � Conservation Administrator Date Rejected • Comments Date Approved Town Planner Date Rejected Comments Date Approved -� Health Agent Date Rejected Comments Public Worts - sewer/water connections - driveway pe=it Fire Department Received by Building Inspector Date IU[Ut a - S1'STE\I PU.NJIT\G KECOIW Commonwealth of Massachusetts Massachuse 2 X90 5ygC jj pu»tuinP Record sici�'i U��ncr ystcm oceuon I Date of Pumping Quantity Pumped! Cesspool: No ,t�'T 1'e ❑ Senrir Tnnt•• Nll � Yes S%-stent Pumped by: License Contents transferred to: Date Inspector i nV iff�,+,er• r. . �J S E S Record OEP. 08 has prov1 00 ;hli loan Ior rev y ;o,vl Boar 'OWN OF NORTH ANDOVER Dv O; brr,l{{od to the local 6oarc: o noalcn cIg2AQTH'T)EF'ART.$TDTP,7, orclno av , A. Faclllty Inforrrl�lion _ rs•r �M n gm's;• t�/T.orrn S l i p W L4 QOPQI slam S •' . .l .,, , . ,., Y Ownar•• . 'I r • '1• N�4 r. •.rl•, , /adrlr4 (114V(Or4nl1IQM"Uon) Cq^own Te epnone N,mOel -- mping Record Pvmping CJ 4, #�3. ;TYDe 01 eyslam, .' � ' C699p001(9)__ 10 c Tang T l r Igrl Ten" �f� 4 ; -mYen To:a:'FI�y��P;gs�nt? [' Yv9 n'o lr ya9. rva9 i; c sanav? J Yes -- : ;9yt m,,.�:;, , . SY Pvmped 8y: 'k ,'�•.S::�j,,c•, ., .� y.:)JiA h�,C:�a.Q I' �r�';.►t�?.p,';la;.. . 7;4. loci on.whare corllenla'Wera d!yposea: _ ��1�, •'1 � Ill;,. ;. ' ,,' ,�+rr���' :�,� r'• ,,, �� (/SIL/�Y ��.'�•mes�.gov/dep!w•alar/a➢provaJa/f61orm9.r,.�nain9�ecl C 1 e T —T- ^r t i t\`�)s, i�a�l♦ !I s� i r I ., 3�,1)t�vtiFLA� i t- Ir T t s, 7 777 77777 777 ?'�,;r',;J:�}i •;n.c�,,• � I rP , I } ': r.Y.�kr:�•l�'�..••.L.i. TOWNPFNO$TH ANDOVER SYSTEM PUMPING RECORD 'DATE 5 i q 6 � � SYSTEM OWNER&ADDRESS SYSTEM LOCATION A � r !r U DATE OF PUMPINQ / 7 • QUANTITY'PUMPED CESS POOL N0 Sl � .• $EPTIC TANK NO YES ;. NATURE OF SERVICE;-•RQI�T '' EMERGENCY OBSERVATIONS:' GOOD CONDITION' ::~: � '..'FULL•TO COVER MA GREASE : BAFFLES IN LACE ROOTS LEACHFIELD RUNBACK EXCESSIVE SOLIDS •FLOODED SOLM CARRYOVER OTHER EXPLAIN SYSTEM PUMPED BY �' f COMMENTS: S TRANSFE CONTENT BRED TO'••'•''� -D J, � ��'`�'. . TOWN OF NORTH ANDOVER SYSTEM PUMPING RECORD DATE: J�—,� 0/ SYSTEM OWNER & ADDRESS j SYSTEM LOCATION (example: left front of house) DATE OF PUMPING: , QUANTITY PUMPED GALLONS CESSPOOL: NO . yES � SEPTIC TANK: NO -� YES NATURE OF SERVICE: ROUTINE ✓ __� EMERGENCY OBSERVATIONS: GOOD CONDITION / HEAVY GREASE FULL TO COVER ROOTS ------ BAFFLES IN PLACE EXCESSIVE SOLIDS LEACHFIELD RUNBACK SOL rnS FLOODED -- -- hr.rc Y V EK OTHER (EXPLAIN) _ SYSTEM PUMPED BY: [ �1(��N OF N RYO Heti -OMMENTS: BOARD OF 20 ONTENTS TRANSFERRED TO: Commonwealth of Massachusetts W City/Town of lFE-CEIR-ED System Pumping Record Form 4 11AY '18 Z U 11 M DEP has provided this form for use by local Boards of Health. r-M9tr�rayabe(mUWd but the information must be substantially the same as that provided h 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 houso;je:ft side"'of-iousysight side of house, Left rear of house, right rear ofhouse, left side of building, right rear of building, under deck. Citylrown State Zip Code 2. System Owner: tt Name Address(if different from location) City/Town State �y l _ � Zip Code Telephone Number 9 7q B. Pumping Record 1. Date of Pumping g S f 2. uantity Pumped: 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: �jo\f -J 6. System Pumped By: Neil J. Bateson F5821 Name Vehicle License Number Bateson Enterprises Inc. Company 7. Lo n wh re contents were disposed: G.L.S,..b-''/Lowell Waste Water `t' Signature of Her Date t5form4.doc•06/03 System Pumping Record•Page 1 of 1