HomeMy WebLinkAboutMiscellaneous - 1535 SALEM STREET 4/30/2018 1535 SALEM STREET f
210/106.6-0001-0000.0 �f
a
Commonwealth Of Massachusetts
Cifyff own ®f North Andover
System Pumping Record
Form 4 forms may be used, but the
DEP has provided this form for use by local Boards of
Health. Other fo Y _
your
information must be substantially the same as that provided here. Before using this fans check
h c mined
- local Board of Health to determine-the form they use.The System Pumping date in
the local Board of Health or other approving authority within 14 days from the pumping,,
accordance with 310 CMR 15.351.
A_ Facility information
important When
1. System Location:
th
Sill out forms Y
on he computer,
use only the tab
key to move your Address Me 01886
cursor-do not North Andover State Zip Code
use the return Cityn-own
key.
2. System Owner:
�s O
Name
2rvn
Address("r"different from location)
State Zip Code
. Cityrown
� Telephone Number
B. Pumpian9 Re, (ee--� / IV-No
—
V 2. Quantity Pumped: Gallons
Date of Pumping Date
Tight Tank E] Grease Trap
�e tic Tank ❑
3. Type of system: ❑ Cesspool(s) P
���5 ❑ Other(describe):
t C.VNo If.yes,was it cleaned?A. '
E] No
A. -Effluent Tee Filter present. ❑ .Yes ❑
5. Condition of System:
6. System°Pumped By:
Vehicle License Number
Name
Stewart's Septic Service
company
7. Location where contents were disposed:
Stewart's Pre-treatment Plant, 20 So. Mill Bradford, Ma 01835
Date
Si r
ignature of Receiving Facility Date
System Pumping Record-Page
t5form4.doc-03/06
COMMONWEALTH OF MASSACHUSETTS
EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS
DEPARTMENT OF ENVIRONMENTALTROTECTION
T0Ai%1iV CF 001
f
JUN 212003
TYLE s -- __..
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM
PART A
CERTIFICATION
Property Address: ;.:✓I p
Owner's Name: rl:1 -p— V.4
Owner's Address:
Date of Inspection: ii
Name of Inspector: (please print) I_C!
Company Name: 'r —
Mailing Address: o p
Telephone Number: (o C)
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.Th t
ns echo
n
. , was performed based on my
training and experience in the proper function and maintenance of on"site sewage disposal systems. I am a DEP
approved system inspector pursuant to Section 15.340 of Title 5(310 CMR 15.000). The system:
Passes
Conditionally Passes
Needs Further Evaluation by the Local Approving Authority
Fails
P g
Inspector's Signatur Date:
The system inspector shall submit a copy of this inspe ' 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 Commen �
****This report aly describesditions at the time of inspection and under the conditions of use at that
time.This inspection does not address how the system will perform in the future under the same or different
conditions of use.
Title 5 Insnection Fnrn, Fit Cnnnn ____ ,
r
Page 2 of I 1
OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION (continued)
Property Address:/.
t
Owner:
Date of Inspection: (n /—cS,-5
Inspection Summary: Cbeck A,B,C,D or E/ALWAYS complete all of Section D
A. System Passes:
I have not found any information which indicates that anv of the failure criteria described in 310 CMR
15.E 3 or.in 3 10 CMR 15.304 exist.Any failure criteria not evaluated are indicated below.
Comments*
B. System Con tionally Passes:
One or mor system components as described in the"Conditional Pass"section need io be replaced or
repaired. The system,upon completion of the replacement or repair,as approved by oard.of Health,will pass.
Answer yes,no or not det ined(Y,N,ND)in the for the following meths.If"not determined"please
explain.
The septic.tank is metal an over 20 years old* or the tank.(whether metal or not)is structurally
unsound, exhibits substantial infiltm ' nor exfiltration or ailuro is imminent.System will pass inspection if the
existins tank is replaced with a complye septic tank as proved by the Board of Health. =
'A metal septic tank will pass inspection i ' is struc lly sound,not leaking and if a Certificate of Compliance
indicating that the tank is less than 20 years o s ailabic.
ND explain:
Observation of sewage ba p or break out or high s 'c water level in the distribution box"due to broken or
obstructed pipe(s)or due to a. en,settled or uneven distribute box.System will pass inspection if(with
approval of Board of Hea
broken pipe(s)are replaced
obstruction is removed
distribution box is leveled or replaced
NDa ain: ...:. _.........-,N_ . ..._.
"The system required pumping more than 4 times a year due to broken or obstructed pipe(s).The system will
pass inspection if(with approval of the Board of Health):
broken pipe(s)are replaced
obstruction is removed
ND explain:
Page 3 of I 1
OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
-PART A
CERTIFICATION(continued)
Property Address• -3 � -
Owner: PyLt �
Date of Inspection:
C. Further Evaluation is Required by the Board of Health:
Con 'tions exist which require further evaluation by the Board of Hee tfi in order to determine if the system
is failing to pr ect public health,safety or the environment. /
1. System wil ass unless Board of.Health determines in ac drdance with 310 CMR 15303(1)(b) that the
system is not ctioning in a manner which will prote public health,safety and the environment:
Cesspool or pri is within 50 feet of a surface ter
_ Cesspool or privy' ithin 50 feet of a borde ' g vegetated wetland or a salt marsh
2. System will fail unless the Board o ea l (and Public Water Supplier,if any determines that the
system is functioning in a manner thprotects a public.health,safety and environment:
_ The system has a septic and soil absorption stem(SAS)and the SAS is within 100 feet of a
surface water supply or tribu . to a surface water sup
_ The system has a se c tank and SAS and the SAS is wt a Zone 1 of a public water supply.
The system has septic tank and SAS and the SAS.is within. feet of private water supply well.
_ The system a septic tank and SAS and the SAS is less than 100 t but 50 feet or more from a
private water su ply well*•-Method used to determine distance
"This syst passes if the well water analysis,performed at a DEP certified lab ratory, for coliform
bacteria volatile organic compounds indicates that the well is free from pollution from that facility and
the pros- ce of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm,provided that no other
failur, criteria are triggered.A copy of the analysis must be attached to this form.
r
Other:
r
' V•
Page 4 of 11 4
OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION(continued)
Property Address-,
Owner:
Date of Inspection: (;2_j �-A
D. System Failure Criteria applicable to all systems:
You must indicate"yes"or:"no-to each of the following for 211 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
-a� 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 I00 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 S.ppm,provided that no other failure criteria
are triggered.A copy of the analysis must be attached to this form.]
(Yes/No)The system fails. 1 have determined that one or more of the above failure criteria exist as
described in 310 CMR 15.303.therefore the system fails. The system owner should contact the Board of
Health to determine what will be necessary to correct the failure.
E. Large Systems:
To be considered a large system the system must serve a facility with a design flow of 10,000 gpd to 15,000
gPd-
You must indi to either"yes"or"no"to each of the following: 'rJ
(The following c ria apply to large systems in addition to the cr• to above)
yes no
— _ the system is within 0 feet of a surface ing water supply
— _ the system is within 200 feet tributary to a surface drinking water supply
_ — the system is locate . a nitrogen se ' 've area(Interim Wellhead Protection Area–IWPA)or a mapped
Zone I1 of a pu ' water supply well _
If you have ered"yes"to any question in Section E the s tem is considered a significant threat,or answered
"yes" • gn
ye ection D above the large system has failed.The owner 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.
Page 5 of 11
1
y OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART B
CHECKLIST
Property Address• Z `,j SySf
Owner:
Date of Inspection: (, [
Check if the following have been done_ You must indicate`yes"or"no"as to each of the followins:
Yes No
Q _ 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 simns of break-out?
_ Were all system components,excluding the SAS, located on site?
X _ Were the septic tank manholes uncovered, opened,and the interior of the tank-inspected for the condition
of the baffles or tees,material of construction, dimensions,depth of liquid,depth of sludge and depth of scum?
_ 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(DSAS)on the site has been determined based on:
Yes ino
-!611A-- 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)]
S
Page 6 of 1 I
OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOS_4L SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION
Property Address: / S 3 -e—vu-, S.j
C�
Owner:
Date of Inspection:
FLOW CONDITIONS
RESIDENTIAL
Number of bedrooms(design): Nutnber of bedrooms(actual):
DESIGN flow based on 310 CMR 15.203 (for example: 110 pd x#of bedrooms):
Number of current residents: 3
Does residence have a.garbage grinder(yes or no):
Is laundry on a separate sewage system(yes or no): f yes separate inspection required]
Laundry system inspected(yes/or no):
Seasonal use:(yes or no):L
Water meter readings,if avai ble(last 2 years usage(gpd)):/i�
Sump pump(yes or no):
Last date of occupancy: ��
COMMERCL ANDUSTRIAL
Type of establishment:
Design flow(based on 310 CMR 15.203): and
Basis of design flow(seats/persons/sgft,etc.):
Grease trap present(yes or no):_
Industrial waste holding tank present(yes or no):_
Non-sanitary waste discharged to the Title 5 system(yes or no):
Water meter readings,if available:
Last date of occupancy/use:
OTHER(describe):
GENERAL INFORMATION
Pumping Records /
Source of information:!°ftL� Q,p f 0lf Eft �(` f
Was system-pumped as part of the inspection(yes or no): A/-
Ifyes, volume pumped: gallons—How was quantity pumped determined?
Reason for pumping:
TYPE OF SYSTEM
Septic tank, distribution box,soil absorption system
_Single cesspool
Overflow cesspool
Privy
shared system(yes or no)(if yes,attach previous inspection records, if any)
_Innovative/Alternative technology. Attach a copy of the current operation and maintenance contract(to be
obtained from system owner)
_Tight tank _Attach a copy of the DEP approval
_Other(describe):
Approximate age of all components,date installed(if I wn)and source of information:
ale
Were sewage odors detected when arriving at the site(yes or no)A- J
Page 7 of 11
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
. PART C
SYSTEM INFORMATION(continued)
Property Address: 5 A-4 e,
Owner:
Date of Inspection:
BUILDING SEWER(locate on site plan)
Depth below grade:
Materials of construction:_cast iron_40 PVC_other(explain):
Distance.from private water supply well or suction line:
Comments(on condition of joints,venting,evidence of leakage, etc.):
SEPTIC TANK:C-(locate on site plan) (�,►.,/3
Depth below grade: j4
l
Material of construction:x1concrete_metal_fiberglass_polyethylene
—other(explain)
If tar*is metal list age:_ Is age confirmed by a Certificate of Compliance(yes or no):
certificate) _(attach a copy of
Dimensions: CIS
Sludge depth: L@�
Distance from top of sludge to bottom of outlet tee or baffle: cam.
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: --7
Comments(on pumping recommendations, et and outlet tee or baffle condition,structural integrity, liquid levels
as elated o utlet invert, evidence of lege,etc.):
GREASE TRAP:_(locate on sitep )an O
( i �
Depth below grade:—
Material of construction:_concrete . metal fiberglass_polyethylene other
(explain): — — —
Dimensions:
Scum thickness:
Distance from top of scum to top of outlet tee or baffle:
Distance from bottom of scum to bottom of outlet tee or baffle.
Date of last pumping:
Comments(on pumping recommendations,inlet and outlet tee or-baffle condition,structural integrity, liquid levels
as related to outlet invert, evidence of leakage, etc.):
Page 8 of 11
OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address:
Owner: �t,
�nr1' C
Date of Inspection: , ---( _-- ,
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/day
Alarm present(yes or no):
Alarm level: Alarm in working order(yes or no):
Date of last pumping:
Comments(condition of alarm and float switches, etc.):
i
DISTRIBUTION BOX: (if present must be opened)(locate on site plan)
Depth of liquid level above outlet invert:_
Comments(note if box is level and distribution to outlets equal,any evidence of solids carryover any evidence of
eakage ' or out of box,;et r7 > _�
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.):
i
Page 9 of I 1
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address:
Owner: zc' {i
Date of Inspection:
SOIL ABSORPTION SYSTEM (SAS):X,-(locate on site plan,excavation not required)
If SAS not Ipcated explain why:
Type
leaching pits,number:_
leaching chambers,number.
- leaching galleries,number-
! leaching trenches,number, length:
leaching fields.number,dimensions:
overflow cesspool.number.
innovativeialtemative system Type!name of technology:
Comments(note condition of soil, signs of hydraulic failure, level of ponding,damp soil,condition of vegetation,
etc.):
Icy 5ON,- ,
CESSPOOLS: (cesspool must be pumped as part of inspection)(locate on site plan)
Number and configuration:
Depth—top of liquid to inlet inven:
Depth of solids laver:
Depth of scum laver.
Dimensions of cesspool:
Materials of construction:
Indication of groundwater inflow(yes or no):
Comments(note condition of soil,signs of hydraulic failure, level ofondin� condition ondition 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.):
Page 10 of I l `
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address:CS
J
Owner: �,2 i
Date of Inspection: -L�
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.
/ l PP
/
I SJR . J3
}--b
)1A t-,4�
Page 11 of 11
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOS_4L SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address:
, C
owner: c t�
Date of Inspection: ( .
SITE EXAM
Slope
Surface water
Check cellar
Shallow wells
Estimated depth to groundwater,/ feet
Please indicate(check)all methods used to determine the high ground water elevation:
Obtained from system design plans on record-If checked,date of desien plan reviewed:
Observed site(abutting propertyiobservation hole within 150 feet of SAS)
Checked with local Board of Health-explain:
Checked with local excavators, installers-(attach documentation)
Accessed USGS database-explain:
Y must describe how you establis}led the higb.grou d water el eva 'on•
A-5 0 xc + 1V\ � _ A
6re CL
L
TRANSMISSION VERIFICATION REPORT
TIME 06/28/2006 16:11
NAME HEALTH
FAX 9786888476
TEL 9786888476
SER.# 000B4J120960
DATE,TIME 06128 16:08
FAX NO./NAME 819784752951
DURATION 00:02:23
PAGE(S) 06
RESULT OK
MODE STANDARD
ECM
Hart Andoaer Health be artme t o� °
1 600 Osgood Street
� $� ob;tit M �e �4
Building 20, Suite 2-36 Letter of Transmittal
North Andover, MA 01845LAM
978.688.9540 Phone Cat
Page of _ ��s
s
6 �
978.b88.$47 �a� p u
cw
bAplthdep townmFnorthandoveneom-E-mail
wwwAownofnorthmndouer.com-Website
TU: DATE: l
COMPANY: FROM: Pamela DelleChinie,Health Department Assistant
Phone
r"."
x:
W0 are sending you: Q Copy of Letter O Plans D Other ffilllin below)
These are transmitted as checked below:
➢ ZL74Pvm L7FwAAmxd ➢ 171 ri/ miwfar
➢ ➢ L7&r&%i4yavdax M"Hi
➢ ➢ > l7J6m ttf5r
REMARKS!
COPY T0:
North Andover Health Department t40RT#t
1600 Osgood Street Letter of Transmittal °
Building 20, Suite 2-36
North Andover, MA 01845 -
978.688.9540 - Phone '0 C_LAK.
Page �
978.688.8476 �_ � �RA
of reo Fax ss
s
Acr+u
healthdept(CD-townofnorthandover com- E-mail
www.townofnorthandover.com-Website
TO: DATE:
COMPANY: / FROM: Pamela DelleChiaie,Health Department Assistant
Phone: c�
Fax: �• '��J �j/
We are sending you: O Copy of Letter OP/ons O Other(fill in below)
These are transmitted as checked below:
➢ D*pmved ➢ L7rffA "vd ➢ OlPesv k* cgaiesfor
➢ R ➢ ororlPe►�waadarnn�nt end
➢ a.4slPeigviiad ➢ DArrowise ➢ 01670 Wpiesfor&t,
REMARKS:
COPY TO:
COPY TO:
COPY TO: SIGNED: ✓�
f
APPLICATION FOR SEWAGE DISPOSAL INSTALLATION
HEALTH DEPARTMENT - NORTH ANDOVER, MASS.
•I her6by_make application for a permit for a sewage disposal installation at
/, '3 . I will install this system in ac-
cordance with all the laws of the Commonwealth of Massachusetts and regulations of
the Board of Health of the Town of North Andover.
Further, I will construct the house sewer of bell and spigot pipe, the minimum
diameter being 4 inches, and will maintain a minimum grade of 1% until 10 feet pre-
ceding the septic tank, where the grade shall not exceed 2%. I will install a con-
crete septic tank of f in size. A manhole (s) permitting easy cleaning
will be provided with removable cover (s) of iron or concrete within 12 inches of
the ground surface. I will provide subsurface disposal field with 4 inch perforated
or open jointed pipe and laid in a series of trenches, the bottom of which will pro-
vide a minimum of 'Z- v---0 lineal (square) feet of effective absorption area.
The pipes will be laid on a 6 inch layer of washed gravel or crushed stone ranging
in size from 3/4 to 1-1/2 inches (dia.) and the pipes will be surrounded by similar
material to a height of 2 inches above the crown of the pipe, The joints of these
pipes will be protected from clogging and before filling the trench, 2 inches of
gravel or stone 1/8" to 1/4" (dia.) will be placed over the course gravel or stone.
The disposal field will be installed at a grade of 4 to 6 inches/100 feet. No single
tile line will exceed 100 feet in length and in any case, two lines of tile will be
installed. A minimum of 6 feet will be maintained between the center lines of the
/ disposal field trenches and the average depth of trench shall not exceed 36 inches.
No part of the installation will be less than 100 feet from any private water supply,
25 feet from any stream, 20 feet from any dwelling or 10 feet from any property line.
f I further agree not to cover any portion of this installation until approved by the
inspection officer, as provided below, and to incorporate- any additional requirements
that may be attached to the permit. Plot Plans must be submitted with application.
DATE
e
Si at of Applicant
I hereby issue the above permit for the Board of Health of the Town of North
Andover, Massachusetts.
DATE ! ' a /7
Signature of Health Agent
I have inspected the uncovered system indicated above and find everything done
as described.
DATE
Signature of Inspecting Officer
Percolation Test JJ C)", �.
Garbage Grinder
BOARD OF HEALTH '
TOWN OF NORTH ANDOVER, MASS.
Ll
::zO0
Nv
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1. NAME t < G�J�'"�� n �%~ DATE
2. ADDRESS �-� � SGJ�0'J7 �� LOT NO. /� TEL.
3. NO. OF BEDROOMS 3 7 DEN YESy NO
4. GARBAGE GRINDER YES NO
5. SHOW DIMENSIONS OF HOUSE
6. SHOW DISTANCES OF HOUSE TO ALL PROPERTY LINES
7. SHOW DIMENSIONS OF LOT
8. SHOW LOCATION AND SIZE OF SEPTIC TANK OR CESSPOOL
9. NOTE LOCATION AND DISTANCE OF WELL FROM SEWERAGE SYSTEM
10. SHOW LOCATION OF BROOKS STREAMS DITCHES LEDGE OUTCROP ETC.
11. SHOW DISTANCE OF SEPTIC TANK OR CESSPOOL FROM HOUSE
NOTE: LOCAL REGULATIONS SHOULD BE READ CAREFULLY.
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bg�k 4 E f'6C,f QL P C't 4i . T&5r DATE
dna � � � i ii'Cfi fl2uA' /1,A14C4{,10,4'3'3
(',area.
'BOARD OF HEALTH OF NORTH ANDOVER , MASSACHUSETTS
SEWAGE DISPOSAL
DATE
NAME OF APPLICANT (' nrrre F,8t't'
LOCATION 153 mgt em .st—
Address of lot no.
BUILDING: Dwelling Other
SYSTEM: New Repair
GENERAL DESCRIPTION OF LAND high
SUBSOIL: Clays Gravel Sand
PERCOLATION TEST minutes per inch.
MINIMUM INSTALLATION RECOMMENDATIONS
CONCRETEEPT TANK
I 5 IC AN nnn gallon capacity.
_
LEACH FIELD 200 lineal feet of drain pipe,
Wiliam J riscoll, Engin er
Board of OaJlth
TC�V'r�l nc �{lRT'�9� ?�?
_?;� �'ER/
Commonwealth of Massachusetts
R 1997
a o SIA
, Massachusetts
System Pumping Record
i
System Owner System Location
Date of Pumping: . `> — — Quantity Pumped: l / gallons
Cesspool: No Yes U Septic Wank: No U Yes
System Pumped by: License#
P
Contents transferrred to : Greater Lawrence Sanitary District
Date: Inspector:
i
r
Conn nw alth of Massachusetts
MassachuscUs
System Pumping Record
System Owner System Location
Date of Pumping: �j--�`"f�� '�� Quai►lity Pumped: gallons
Cesspool: No Yes L:J Septic Tank: No Ll Yes [_•�-
System Pumped by: elredea ErerrE tied License#
Contents transferrred to : Greater Lawrence Sanitary District
llate: _ Inspectors
f,
Commonwealth of Massachusetts
M AnJ"J6 , Massachusetts
System Pumping Record
System Owner System Location
"A-0 K-35
Date of Pumping: C��Z,3/jq Quantity Pumped: � a�b gallons
Cesspool: No �.�1 Yes L:J Septic Tank: No �._� Yes
} e p}
System Pumped by: vare4oet License#
Contents transferrred to : Greater Lawrence Sanitary District
llate: Inspector:
TOWN OF NORTH ANDOVER/
_
SO
ARD„ARD OF HEALTH
.5 ?
1999
TOWN OF NORTH ANDOVER
SYSTEM PUMPING RECORD
DATE:
SYSTEM OWNER & ADDRESS SYSTEM LOCATION
--- (example: left front of house)
ISS
DATE OF PUMPING: ANTITY PUMPED G GALLONS
CESSPOOL: NO ` YES SEPTIC TANK: NO YES
NATURE OF SERVICE: ROUTINE ` EMERGENCY
OBSERVATIONS:
GOOD CONDITION FULL TO COVER
HEAVY GREASE BAFFLES IN PLACE
ROOTS LEACHFIELD RUNBACK
EXCESSIVE SOLIDS FLOODED
SOLIDS CARRYOVER OTHER (EXPLAIN)
SYSTEM PUMPED BY:
I
COMMENTS:
CONTENTS TRANSFERRED TO: � S A%
TOWN OF NORTH ANDOVER
SYSTEM PUMPING RECORD 2
DATE•
SYSTEM OWNER &ADDRESS SYSTEM LOCATION
_ (example: left front of house)
- -� CA-
(-L
DATE OF PUMPING: �a—�� QUANTITY PUMPED �;. �`"� GALLONS
CESSPOOL: NO ---�YES SEPTIC TANK: NO YES
NATURE OF SERVICE: ROUTINE V EMERGENCY
OBSERVATIONS:
GOOD CONDITION FULL TO COVER
HEAVY GREASE BAFFLES IN PLACE
ROOTS LEACHFIELD RUNBACK
EXCESSIVE SOLIDS FLOODED
SOLIDS CARRYOVER OTHER (EXPLAIN)
SYSTEM PUMPED BY:
COMMENTS:
CONTENTS TRANSFERRED TO:
Insurance Adjustment Service, Inc.
435 King St.
Littleton, MA 01460
(978) 952-6966
Fax (978) 952-2459
UNDER MASSACHUSETTS GENERAL LAWS CHAPTER 139 SECTION 3B
Date: November 21,2003
TO: Town of North Andover
Board of Health/Building Inspector
North Andover,MA 01845
RE: Insured: Deborah&Michael Fried f Nov2 6 2003
5
Property Address: 1535 Salem St.
North Andover,MA 01845
Date of Loss: 11/18/2003
Policy Number: BP0668442
Type of Loss: oil leak from oil tank
File or Claim Number: 11656
Claim has been made involving loss, damage or destruction of the above captioned property, which may either
II� exceed$1,000.00 or cause Mass. Gen. Laws, Chapter 143, Section 6,to be applicable.
If any notice under Mass. Gen. Laws, Ch. 139, Sec. 38 is appropriate, please direct it to the attention of the
writer and include a reference to the captioned insured, locations, policy number, date of loss and claim or file
number.
Thank you for your cooperation.
Ve 1 ours,
Scott O'Neil
Adjuster
Ext. 129
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�LN Commonwealth of Massachusetts
City/Town of
RR EC
W° System Pumping Record
Form 4 , 4 2010
DEP has provided this form for use by local Boards of Health. Ot ed, bu the
information must be substantially the same as that provided here. BI ck with your
local Board of Health to determine the form they use. The System u Al 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 hous richt side o ea , Left
rear of house, right rear of house, left side of building, right rear of building, under deck.
City/Town State Zip Code
2. System Owner:
Name
I
Address(if different from location)
City/Town State Zip Code
Telephone Number
B. Pumping Record
1. Date of Pumping Date 2. Quantity Pumped: Gallons
3. Type of system: ❑ Cesspool(s) Septic Tank ❑ Tight Tank
❑ Other(describe):
4. Effluent Tee Filter present? ❑ Yes No If yes, was it cleaned? ❑ Yes ❑ No
5. Conditiv0a��
t � VV
6. System Pumped By:
Neil J. Bateson F5821
Name Vehicle License Number
Bateson Enterprises Inc.
Company
j 7. Location where contents were disposed:
.L.S. Lowe W to Water
�'— —/C)
Signature of HAI Date
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