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HomeMy WebLinkAboutMiscellaneous - 1542 SALEM STREET 4/30/2018 (2) 1542 SALEM STREET 210/106.B-0053-0000.0 j -6808 Of,NO cT 1ti . O • Town of North Andover HEALTH DEPARTMENT �Sa^cHustt CHECK#: DATE: " LOCATIONAS 14 H/O NAME: CONTRACTOR NA �. 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-Design Approval $ ❑ Septic Disposal Works Construction(DWC) $ ❑ Septic Disposal Works Installers(DWI) $ ❑ Title 5 Inspector $-`��� Title 5 Report $ \])� ��J(� ❑ Other. (Indicate) $ O�2 Health Agent Initials White-Applicant Yellow-Health Pink-Treasurer Commonwealth of Massachusetts R Title Official Inspection Form _ Subsurface Sewage Disposal System Form - Not for Voluntary Assessments \�. 1542 Salem Street Property Address Cheyrl Pryor Owner Owner's Name information is required for North Andover MA 01845 May 6 2014 every page. City/Town 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 RECEI When filling out forms on the computer, use 1. Inspector: MAY `L7 2014 only the tab key to move your Mike Graham R cursor-do not Name of Inspector use the return HEALTH DEPARTMENT key. Wind River Environmental Company Name f� 163 Western Ave Company Address Gloucester MA 01930 8h° City/Town State Zip Code 978-282-7315 13560 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 andcomplete 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 dibpusal syslerrrs. I 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 Inspector's Signature Date The system inspector shall submit a copy of this inspection report to the Approving Authority (Board of Health or DEP)within 30 days of completing this inspection. If the system is a shared system or has a design flow of 10,000 god 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. "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. t5inc•3/13 7itlo 5 Official Inopootion Form:Subcurfaco Sowago Dicpocal Sy-ton)•Pago 1 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 1542 Salem Street Property Address Cheyrl Pryor Owner Owner's Name information is required for North Andover MA 01845 May 6, 2014 every page. City/Town 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: ® 1 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): t5ins-3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 2 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 1542 Salem Street Property Address Cheyrl Pryor Owner Owner's Name information is North Andover MA 01845 May 6, 2014 required for y every page. Cityrrown State Zip Code Date of Inspection B. Certification (cont.) ❑ Pump Chamber pumps/alarms not operational. System will pass with Board of Health approval if pumps/alarms are repaired. 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•3/13 Title 5 Official Inspection Form: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 1542 Salem Street Property Address Cheyrl Pryor Owner Owner's Name information is required for North Andover MA 01845 May 6, 2014 every page. CityFrown 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 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 must be attached to this form. 3. Other: 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•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 4 of 17 Commonwealth of Massachusetts W� Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 1542 Salem Street Property Address Cheyrl Pryor Owner Owner's Name information is North Andover MA 01845 May 6, 2014 required for y 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•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 5 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form o Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 1542 Salem Street Property Address Cheyrl Pryor Owner Owner's Name information is required for North Andover MA 01845 May 6, 2014 every page. City/Town 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 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. ❑ ® Determined 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): 4 DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): 440 t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 6 of 17 Commonwealth of Massachusetts w Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 1542 Salem Street Property Address Cheyrl Pryor Owner Owner's Name information is North Andover MA 01845 May 6, 2014 required for Y every page. City/Town State Zip Code Date of Inspection D. System Information Description: Septic tank distribution box and PC. 2 Number of current residents: Does residence have a garbage grinder? ❑ Yes ® No Is laundry on a separate sewage system? (Include laundry system inspection ❑ Yes ® No information in this report.) Laundry system inspected? ® Yes ❑ No Seasonaluse? ❑ Yes ® No Water meter readings, if available last 2 ears usage d 26.56 gpd 9 ( Y 9 (gpd)): Detail: Water records were emailed to WIRE on 5/14, 2014. 1938 gal/730. 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•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 7 of 17 Commonwealth of Massachusetts w Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 1542 Salem Street Property Address Cheyrl Pryor Owner Owner's Name information is required for North Andover MA 01845 May 6, 2014 every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Last date of occupancy/use: CurrentDate Other(describe below): General Information Pumping Records: Source of information: Owner/WRE Was system pumped as part of the inspection? ® Yes ❑ No If yes, volume pumped: 1500 gallons gallons How was quantity pumped determined? Pump truck/tape measure Reason for pumping: Check structural intergrity 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)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-3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 8 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 1542 Salem Street Property Address Cheyrl Pryor Owner Owner's Name information is required for North Andover MA 01845 May 6, 2014 every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Approximate age of all components, date installed (if known) and source of information: Installed on November 12, 1989. Were sewage odors detected when arriving at the site? ❑ Yes ® No Building Sewer(locate on site plan): Depth below grade: feet Material of construction: ❑ cast iron ®40 PVC ❑ other(explain): Distance from private water supply well or suction line: 44' feet Comments (on condition of joints, venting, evidence of leakage, etc.): All joints and venting are in good shape. No evidence of any leakage. Septic Tank (locate on site plan): Depth below grade: 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 Dimensions: 10'x 5'x 5' Sludge depth: 4" t5ins•3113 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 1542 Salem Street Property Address Cheyrl Pryor Owner Owner's Name information is required for North Andover MA 01845 May 6, 2014 every page. City/Town 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 26 2" Scum thickness Distance from top of scum to top of outlet tee or baffle 6" Distance from bottom of scum to bottom of outlet tee or baffle 13" How were dimensions determined? Sludge judge tape Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): Recommend yearly pump. The inlet and outlet tee are in place. The structural integrity of tank is good. The liquid level is good. There is no 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-3/13 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 1542 Salem Street Property Address Cheyrl Pryor Owner Owner's Name information is required for North Andover MA 01845 May 6, 2014 every page. City/Town 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-3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 11 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 1542 Salem Street Property Address Cheyrl Pryor Owner Owner's Name information is required for North Andover MA 01845 May 6, 2014 every page. City/Town 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 0" Comments (note if box is level and distribution to outlets equal, any evidence of solids carryover, any evidence of leakage into or out of box, etc.): The D-box is level and distribution to outlets is equal. There is no evidence of carryover or leakage into or out of the box. D-box is 10" deep. 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.): The pump chamber is in good condition and appurenances are working well. * If pumps or alarms are not in working order, system is a conditional pass. Soil Absorption System (SAS) (locate on site plan, excavation not required): If SAS not located, explain why: t5ins•3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 12 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 1542 Salem Street Property Address Cheyrl Pryor Owner Owner's Name information is required for North Andover MA 01845 May 6, 2014 every page. CitylTown State Zip Code Date of Inspection D. System Information (cont.) Type: ❑ leaching pits number: ❑ leaching chambers number: ❑ leaching galleries number: ® leaching trenches number, length: 4x80' ❑ leaching fields number, dimensions: ❑ overflow cesspool number: ❑ innovative/alternatives stem Y T e/name of technology: 9Y: Comments (note condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of vegetation, etc.): The condition of the soil is good, grass over field. There are no signs of hydraulic failure. There is no ponding or damp soil. Cesspools (cesspool must be pumped as part of inspection) (locate on site plan): Number and configuration Depth—top of liquid to inlet invert Depth of solids layer Depth of scum layer Dimensions of cesspool Materials of construction Indication of groundwater inflow ❑ Yes ❑ No t5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 13 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 1542 Salem Street M Property Address Cheyrl Pryor Owner Owner's Name information is required for North Andover MA 01845 May 6, 2014 every page. Cityfrown 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•3113 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 1542 Salem Street Property Address Cheyrl Pryor Owner Owner's Name information is required for North Andover MA 01845 May 6 2014 every page. City/Town State Zip Code Date of Inspection 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 a� - G I1' ZJ Iii ' Tido 5 Official In,p—tion Foran Subs rfaco Soy ago D:opocalraoo 1S;t I? Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 1542 Salem Street Property Address Cheyrl Pryor Owner Owner's Name information is North Andover MA 01845 May 6, 2014 required for y every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Site Exam: ® Check Slope ® Surface water ® Check cellar ® Shallow wells Estimated depth to high ground water: 48"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: April 25, 1997 Date ® Observed site (abutting property/observation hole within 150 feet of SAS) ❑ Checked with local Board of Health -explain: Plans are on file at the Board of Health for 4/25/97 ❑ Checked with local excavators, installers - (attach documentation) ❑ Accessed USGS database -explain: You must describe how you established the high ground water elevation: BOH dug on property right next door on April 25, 1997. The ESHG was 4'. Before filing this Inspection Report, please see Report Completeness Checklist on next page. t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 16 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 1542 Salem Street Property Address Cheyrl Pryor Owner Owner's Name information is required for North Andover MA 01845 May 6, 2014 every page. City/Town State Zip Code Date of Inspection E. Report Completeness Checklist ® 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 ® Sketch of Sewage Disposal System either drawn on page 15 or attached in separate file t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 17 of 17 ill Wind River Environmental Title 5 Inspection Cover Report Name Address 1 �Z Town Al C. Branch Date Gam/ Inspector � Commonwealth of Massachusetts RECEIVED City/Town of , UL C 3 2014 System Pumping Record NORTH ANDOVE TOWN OF NORTH ANDOVER Form 4 1 HFAI TH naPARTIIAPRIT y DEP has provided this form for use by local Boards of Health. Other forms may be used,but the information must be substantially the same as that provided here. Before using this form, check with your local Board of Health to determine the form they use.The System Pumping Record must be submitted to the local Board of Health or other approving authority within 14 days from the pumping date in accordance with 310 CMR 15.351, A. Facility information Important: When filling outY oca io forms on the 1. stem - - computer.use ---- � r� .--- only the tab key Address /� a 7 S to move your �(� _7_a.. ✓ - .—__....__ cursor-do not Zip City(Town State - use the return key. 2. System Owner: Name Address(if different from location) State Zip Code Telephone Number —. B. Pumping Record _ 2. Quantity Pumped: Gauons 1. Date of Pumping --Oate 3. Type of system: ❑ Cesspool(s) Septic Tank ❑ Tight Tank ❑ Grease Trap ❑ Other(describe): 4. Effluent Tee Filter present? Yes ❑ No If yes, was it cleaned? es ❑ No 5. Condition of S 6. System Pumped By: —�— Vehicle License Number Name , 1'/)i A)`.(mac Company 241lly 400fq 7. Location where contents were disposed: -- — - ------..--... - ... .- --- ----- -- .�� bate G Signature of Hauler Date Signature of Receiving Facility Date 15form4.doc•03106 System Pumping Record-Page 1 of 1 i _C_\ Commonwealth of Massachusetts RECEIVED I %J City/Town of .1 06 2812 _ System Pumping Record NORTH ANDO TE FNORTH ANDOVER Form 4 HEALTH DEPARTMENT forms may be used,but the Other o this form for use by local Boards of Health. Y P has provided k with your DE R this form, check Y Before using here. Be 9 information must be substantially the same as that provided e local Board of Health to determine the form they use.The System Pumping Record must be submitted to the local Board of Health or other approving authority within 14 days from the pumping date in accordance with 310 CMR 15.351. A. Facility information Important: When filling out 1. System Location: forms on the _. .. computer,useonly the tab key Address to move your /Y-tiiY -- cursor-do not --�- "�- - --- State Zip Code use the return City/Town key. 2. System Owner: / "" Name I— / � -------- ------_. �+* Address(if different from location) State Zip Code City/Town Telephone Number B. Pumping Record / a -- .� 2. Quantity Pumped: Gallons � 1. Date of Pumping Date 3. Type of system: ❑ Cesspool(s) Septic Tank ❑ Tight Tank ❑ Grease Trap ❑ Other(describe): 4. Effluent Tee Filter present? s No If yes, was it cleaned? Yes ❑ No 5. Condition of S tem: -CJO_ - - --- - - - - 6. System Pumped By. Name Vehicle License Number 1 Company 7. Location where contents were disposed: Signature of Hauler Oate Signature of Receiving Facility Date 15form4.doc•03/06 system Pumping Record•Page 1 of 1 r Commonwealthof assac usetts City/Town ofVD 4$1? System Pumping Recor NOV 0 7 2008 Form 4 TOWN OF NOfgP!AN(DOVER DEP has provided this form for use by local Boards of Health. Other information must be substantially the same as that provided here. Before using this form, check with your local Board of Health to determine the form they use. The System Pumping Record must be submitted to the local Board of Health or other approving authority within 14 days from the pumping date in accordance with 310 CMR 15.351. A. Facility Information Important: When filling out 1. System Location: forms the ��, i^ 'Sc, �� �� computer,use "1 d� J ` t only the tab key Address to move your ^ �J NA cursor-do not -' `� ► use the return City/Town State Zil?Code key. 2 System Owner: Name Its Address(if different from location) City/Town State Zip Code Telephone Number B. Pumping Record 1. Date of Pumping — 2. Quantity Pumped: ��®® Date Gallons 3. Type of system: ❑ Cesspool(s) f5d Septic Tank ❑ Tight Tank ❑ Grease Trap ❑ Other(describe): 4. Effluent Tee Filter present? ❑ Yes No If yes, was it cleaned? ❑ Yes No 5. Condition of System: 6. System Pumped By: IM,\(,2 QJftSo n Name -� Vehicle License Number wi,4 1LJe't, &yir0"MBn+0L1 Company Ipswich Water 7. Location where contents were dispoTfeatment Plant 1r��+�eiich M® 01938 ( Signattrre of Hauler Date 1 Signature of Receiving Facility Date t5form4.doc•03/06 System Pumping Record•Page 1 of 1 Commonwealth of Massachusetts City/Town of RECEIVED System Pumping Record NORTH ANDOVER Form 4 JUN - 9 2010 DEP has provided this form for use by local Boards of Health. Other forms may a used, but the information must be substantially the same as that provided here. Before using ti WWR_06iN iXNMXER local Board of Health to determine the form they use.The System Pumping Rec rd MlnMTWXIbWTj01 T the local Board of Health or other approving authority within 14 days from the pumping date in accordance with 310 CMR 15.351. A. Facility Information Important: When filling out 1. System Location: forms on the -T computer,use -----.— ..--- --...------------_ ._ only the tab key Addre s �t `_ /� to move your tJ� f Y1 /'" nY ©yc,( --I"I'!-- — -- �---- cursor-do not -- -- --- -- State Zip Code use the return City/Town key. 2 System Owner: Name �-- - �—--- --------- ---- — ------ �° Address(if different from location) city/Town State Zip Code 9-78- 68a - Telephone Number B. Pumping Record 1. Date of Pumping D _ d, 4 0 — 2. Quantity Pumped: Gallons ------- 3. Type of system: ❑ Cesspool(s) [0 Septic Tank ❑ Tight Tank ❑ Grease Trap Other(describe): ---- --- -- -- 4. Effluent Tee Filter present? YYes ❑ No If yes, was it cleaned? [; Yes ❑ No 5. Condition of System: 6. System Pumped By: lctn � 7L1�7� Nam Vehicle License Number EnviyeynmcnW Company Ipswich water 7. Location where contents were disposed: Treatment Plant Signature of Hauler Date Signature of Receiving Facility — Date t5form4.doc•03106 System Pumping Record•Page 1 of 1 FORM 4-SYSTRM PUMPING CURRIER SEPTIC & DRAIN SERVICE 107 FORESTSTREFT, kl.],DDLFT0N. ,.\,L%01949 (978" 7,74-2-72 M&MONIVVEALTH OF MASSACHUSETTS IAS SACHUSETTS S 17S TE,411 P UMPTIVG RECORD SYSTEIIAOWNER: S YST ETV�LOCATT f O,N: L out eit-ye- A-( (c cpsof - 80/4 A ec-d DATE OF PU,-,%41'ING. Ah-L40- I --QUANTITi' PURIPED: c� GALLONS CESSPOOL: NO �ES FE'TIC TANK: NO YES SYSTEM PUMPED BY: CURRMR SEPTIC &_L)R,4JN SERVICE, CONTENTS TRANISFERRM TO: Z- s DATF- L/ o a rN.SPECTOR- ow I . (11�1 of N ► lT Z �� +WOO - r IN .,, NoO OVEI? MiQ 5 5 2 1 ,r* 5 .1 SCPTi c Sy s $f P�� DES► �,vei� ,� �c.5 `' 774 CotJ91r(o,05 - F ➢i SAPPtzn VC- g, D REASONS - 60 y rUJv�RT ► A) G%Jr l SS FrL Y; Aw- tiSP�rlcnJ Pi P� FSMQue RID : -p. 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