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HomeMy WebLinkAboutMiscellaneous - 171 LACONIA CIRCLE 4/30/2018 171 LACONIA CIRCLE I I , 210/9D5_D-0078-0000.D le —_ - I T 1 I i Commonwealth of Massachusetts City/Town of RECEIVED System Pumping Record Form 4 FkUG 0 4 2014 DEP has provided this form for use,by local Boards of Health091`� t ylse , but the information must be substantially the same as that provided h � �€ I`e`•asin�i , 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 i `t��ofhou--6-0, Left/right side of house, LeftRight side of building, Left/Right front of building, Left building, Under deck Address City/Town State Zip Code 2. System Owner. � - Na Name �- Address(if different from location) Citylrown State Telephone Number �r B. Pumping Record 1. Date of Pumping Date 2. Quantity Pumped: Gallons 3. Type of system: ❑ Cesspool(s) eptic Tank ❑ Tight Tank ❑ Other(describe): 4. Effluent Tee Filter present? El Ye Q-Ko If yes, was it cleaned? ❑ Yes ❑ No: ' 5. Condition of Sys�a 6. System Pumped By.- Nell. y:Neil.Bateson F5821 Name Vehicle License Number Bateson Enterprises Inc- Company 7. Locati0owhere contents were disposed: Lowell Waste Water Sig a Haul paw tmorm4.doc-06/03 System Pumping Record•Page 1 of 1 Commonwealth of MassachusettsLRECE ��® City/Town of RECEIVED System Pumping Record 2013 . Form 4H ANDOVER DEP has rovided this form for use,b local Boards of HARTMENT P Y e used, but the information must be substantially the same as that provided here. Before usin .this form, Y check with our 9 local Board of Health to determine the form the T y use. he 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/ i ht rear of house Left/right side of house, Left/ Right side of building, Left Rightht front of building,.Left/RIg rea r of building, Under deck Address City/Town State V Zip Code 2. System Owner. Name Address(if different from location) City/Town Stated Code Telephone Number B. Pumping Record 1. Date of P 6 ` 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 es � L�" yes, it cleaned? Yes R No, 5. Condit on f System: 6. System Pumped By: Neil Bateson F5821 Name Vehicle License Number Bateson Enterprises Inc Company 7. Location where contents were disposed: G.L S. Lowell Waste Water Sign t e Haule Date t5form4.doc•06/03 System y tem Pumping Record Page 1 of 1 _ _ � —Srf�✓ �R au_f —�� taAIR 644 • 1 ,Co 12 A /Soo GN �• 5�� 1._C__.f RALIl........_._ tI o = L� OD :.3.1 _ 1 a Commonwealth of Massachusetts city/Town of I FTOV�VN ECEIVE® System Pumping Record Form 4 R 0 3 2006 NNORTH AN VDEP has provided this form for use by local Boards of Health. ThfPiumpmg�We�o`� must be submitted to the.local Board of Health or other approving authy. . X Facility Information Important: When filling out 1. System Location: forms the computer.use only the tab key Address // i 4 to move your l ( �l C cursor-do not . St use thereturn ate City/Town Zip Code key. 2. System Own r3 Name Address(i(different from location) Cityrrown State Code' Telephone Number B. Pumping Record r 1. Date.of Pumping ✓ _` rD 2. Quantity: Date t ty Pumped: Gallons 3. Type of system: ❑ Cesspool(s) W�septic Tank- ❑ Tight.Tank ❑ Other(describe): 4. Effluent Tee Filter present? ❑ Yes If yes, was it cleaned? ❑ Yes ❑ No 5. Condition of Syst 6. Syste PAP ed By; Name Vehicle License Number Company -- T Location ere contents were disposed: Signat o a ler Date http://www.mass.gqv/dep/*waterippprovalt/t5forms.htm#inspect t5form4.doc•06103 System Pumping Record•Page 1 of 1 i I _ s TOWN OF NORTH ANDOVER FEB 19 20 1 SYSTEM PUMPING RECORD j DATE: (0,03 _ s SYSTEM OWNER &ADDRESS SYSTEM LOCATION B (example: left front of house) 047 0,0 � DATE OF PUMPING: QUANTITY PUMPED c��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: COMMENTS: CONTENTS TRANSFERRED TO: Town of North Andover, MA SO; HEALTH A - -2.---- , Watershed Septic System MAR 1 9 2001 Servicing Report Date: 2/`16/01 Homeowner: DIVYA BHATNAGAR Pumper : RAGGS SEPTIC SERVICE INC. Street 171 LACONIA CIRCLE Address: P.O. BOX 1027 , CONCORD MA Phone 978-683-8689 Phone 978-369-1100 Nature of Service: Routine XX Emergency Observations : Good Condition Full to Cover Baffles in Place Leachfield Runback Excessive Solids Heavy Grease Roots _._...._._...._ Other (Explain) Description of Work: Pu'.K4PEng TTC TANK Comments : M.E.S. FEBRUARY 2001 TOWN REPORT NAME ADDRESS TOWN PUMPER TYPE GAL DATE P.H. ; Stop& Shop Rome 114 N. Andover Dana Nash& Son Grease 4241 02/27/01 5O Sop &Shop Rome 114 N. Andover Dana Nash & Son Grease 3108 02/27101 5.50 Bmn ga x 714ainnni Circle N. Andover Raggs Septic Septic 157 02/16/01 5.50 . � . . . w*�¢� t o: FORM 4 - SYSTEM PUNEPM RECORD Commonwealth of Massachusetts NORTH ANDOVER , Massachusetts System Pumping Record }'stem %%mer System Location BHATNAGAR 171 LACONIA CIRCLE Date of Pumping: 12/2/9 9 Quantity Pumped: 1500 gallons Cesspool: No ❑ Yes ❑ Septic Tank: No ❑ Yes El RAGGS SEPTIC SERVICE, INC. System Pumped by. d .b. a - E. A. COMEAU SEPTIC License l: Contents transferred to: FITCHBURG Date 1/24/00 Inspector w.�ei�+m.�wrer�u.-w.ert 7 +m .sur .^,r.,,. ..,nfi.N.,�..:,•....�,.,...,•s.........••.�,.�,...,,. .n.un•.,.,..,.,,.a.,w�..�,a,.,.«.. a w.w,s�-r:.�,;.mvm...s:w-:. �«m.,.aa.r,nsow nosarw�rho�.r«a..«.:.rs:..a...o.�ax...✓.w,,.vx 1410 sjam i Y T e t• I is 't Laf 1.2R t, r t M ` 1 G rca•�•.w,r�.•erynwti+.y..r�,neq,ven v,n-lnarppWwy��+!waw+kir:.yminen'n•nYl"�M°�"+�.1�:Asn.rwa,..�yy-.Y'�wtM+ae+<x�•oyrq`.,pq^y'oa�M!'�' "��•r•.s,wavra+.rz*xwe.ti�•^�•++•wrbKHm*„w+�::..v«rown�•r.s,..na.vul„v�.:�w,+srunewa� ' ti hr ,W'Wrerrlywrgiy,Fw,sy„yrw,,,e, FORM U - LOT RELEASE FORM 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: N 1 C 414 6"4. P - 45;�4}A) Phone 79 Y- V O LOCATION: Assessor's Map Number /O S,J7 Parcel 7 Subdivision Lots) _/Z Street St. Number 12-L— ************************Official Use Only************************ /RECOMMENDATIONS OF TOWN AGENTS: ^'Conservation Administrat Date Approved °r' Date Rejected Comments Date Approved Town Planner Date Rejected Comments "\ Date A Health ent Approved SYS Z Date Rejected Comments �6� ly /�clS EST � 4�0 � 0A,( �cl' Public works - sewer/water connections - driveway permit Fire Department Received by Building Inspector Date P-URD ofHFA,T i-1 �cT (2;Q CACONVr GIS ` d ITN &pnve)�I MA, FbWtt ❑ (.UEU- A� oycD STC sS v i���� St�Tlc Sy STEM �s►G-� ._ 1JPR v►AJ6 /uThoj�)rk/ CoAJjTiavS= /pv �NSTo ?J w)?OOG- CvrSG�v��v ID G" �1�PPRoVED �Tov zr cv '✓�J,� t�Jcs-f ,�� _ l,✓��C�v��� 3C- R�4SoNS TAokc Arvv �- �h� " CG►u��rYw 1`I�� NC�S� Dw� 5fPTf SYSTEM t�j S T�'u4T��� CYI.4V4Tto,►J l"SPEGTIOA J P4rc 41H:?ISS ❑ FQIL �wA� I;US(�F�i lona 4PPROOEP �i�TC —�� 'rzaIOW6 AUT�for?rry AW(TIOMAC. IAJY6z j jotj 11=A►-�Y) P� AsS"V Z r ,--G 00, DtSAp��vv�� D,arC Fw4L APP(�')VAL APPRavr1,16 16v IrOk L, _ TOWN OF NORTH ANDOVER OCT 3 1 s SYSTEM PUMPING RECORD 200 DATE: 10/26/01 SYSTEM OWNER & ADDRESS SYSTEM LOCATION BHATANGAR (example: left front of house) 1.71 LACONIA CIRCLE DATE OF PUMPING: 7/3/01 6VANTITY PUMPED 2 5 0 0 GALLONS CESSPOOL: NO x YES SEPTIC TANK: NO YES 1� NATURE OF SERVICE: ROUTINE X 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: RAGGS SEPTIC SERVICE INC ' I COMMENTS: CONTENTS TRANSFERRED TO: FITCHBURG i I TOWN OF SYSTEM P PING RECORD r c�M 1.116A N-6�� O DATE: _dd� SYSTEM OWNER& ADDRESS SYSTEM LOCATION -- �n (example: left front of house) Y IGI` G�v4 G DATE OF PUMPING: QUANTITY PUMPED : - GALLONS CESSPOOL: NO ES SEPTIC TANK: NO YES NATURE OF SERVICE: ROUTINE EMERGENCY OBSERVATIONS: GOOD CONDITION FULL TO COVER HEAVY GREASE BAFFLES IN PLACE ROOTS LEACIFIELD RUNBACK EXCESSIVE SOLIDS FLOODED SOLIDS CARRYOVER OTHER(EXPLAIN) SYSTEM PUMPED BY: Bateson Enterprises, Inc. COMMENTS: I CONTENTS TRANSFERRED TO: G.L.S.D Lowell Waste - I 2222_.__.....__._. TO - - _ l OSE CO'vtJ•'f0N\t'EALTH OF MASSACHUSETTS y EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS IJUN ( � I DEPARTMENT OF ENVIRONMENTAL PROTECTION ONE TINTER STREET. BOSTON. NtA 02210E 61 x-293-SSOo i TRUDY COXE W'ILLIA*,!F WELD Scactar% � Govcrno: ARGEO PAUL CELLUCCI DAVID B.STRUHS Lt.Governor SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM Commissioner PART A G CERTIFICATION Property Address: /'7! _L-ct 'i a� C l rr ler �U �K�- Address of Owner: Date of Inspection: 1 S'�$_._. (I! di(iercnt) Name of Inspector: BENJAMIN C. OSGOOD JR. 1 am a DEP approved system inspector pursuant to Section 15.340 of Title S (310 CMR 15.000) Company Name: NEW ENGLAND ENGINEERING SERVICES, INC. Mailing Address: 33 WALKER ROAD, NORTH ANDOVER, MA_01845 Telephone Number: 508-686-1768 CERTIFICATION STATEMENT r 1 cenify that 1 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 — LL t Condrttonalh Passes Needs Further Evaluation By the Local Approving Authority Fails Inspector's Signature: Date: The System !nspector shalt submit a copy of this nspection report to the Approving Authority 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 bgyer, if applicable. and the approving authority I INSPECTION SUMMARY: Check A, B, C, or D: AI SYSTEM ASSES: 1 have not iound any information which indicates that the system violates any of the failure cr:te:ia as d-fined in 310 CMR 15.303. Any failure criteria not evaluated are indicated below. COMMENTS: BI 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. Indicate yes, no. or not determined (Y. N.or ND). Describe basis of determination in at( 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 tattachedl indicating that the tank was insulted within twenty(201 years prior to the date of the inspection: or the septic tank, whether or not metal, is cracked, structurally unsound, shows substantial infiltration or exfiltation, or tank failure is imminent. The system will pus inspection i(the existing septic tank is replaced with a conforming septic tank as approved by the Board of Health. .22...22,. ...... ..�. r.,,. . .,. ,n f ....... ..... .. ....... SUBSURFACE SEWAGE DISPOSAL. SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: / / 'L a C O VII a 4f,rc 1 C Owner: Tan e I qq yl Date of Inspection: 9 �jsl�a , B) SYSTEM CONDITIONALLY PASSES lcontinuedl 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;. Describe observations: broken pipe(s) are replaced obstruction is removed distribution box is levelled or replaced The system required pumping more than four times a year due to broken or obstructed pipe(s). The system will pass inspection if(with approval of the Board of Health)7 i broken pipe(s) are replaces cbstruction is removed C) FURTHER EVALUATION IS REQUIRED BY THE BOARD OF HEALTH: Conditions exist which reouire 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: t) SYSTEM WILL PASS UNLESS BOARD OF HEALTH DETERMINES THAT THE SYSTEM IS NOT FUNCTIONING IN A MANNER WHICH WILL PROTECT THE PUBLIC HEALTH AND SAFETY AND THE ENVIRONSAENT: Cesspool or p(i.v,s within 50 feet of a surface water Cesspool or prix-,•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 APPROPRIATE) 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 t00 feet to a surface water supply or tributary to a suriace water supply. I The system has a septic tank and soil absorption system and the SAS is within a Zone 1 of a public water supp'v well. _ The system has a septic tank and soil absorption system and the SAS is within SO 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 SO feet or more from a private water supply well, unless a well water analysis for coliform bacteria and volatile organic compounds indicates that the well is free irom pollution from that facility and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than S ppm. Method used to determine distance (approximation not valid). 3) OTHER i i i (rwir.d 04/]s/97) x•17• 2 of 10 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: Owner: 3aH e L-_C 3C7_V1 Dale of Inspection: �Isl�s D) SYSTEM FAILS: You must indicate either -Yes" or "No" as to each of the following: I have determined that the system violates one or more of the following failure criteria as defined in 310 CMR 15.303. The basis for this determination is identified below. The Board of Health should be contacted to determine what will be necessary to conva 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 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 1/2 day flow, Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number of uroses pumped ped _. Any portion of the Soil Absorption System, cesspool or privy is below the high groundwater elevation. Acv 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. Am portion of a cesspool or privy is within 50 feet of a private water supply well Anv portion of a cesspool or privy is less than 100 feet but greater than S0.feet from a private water supply well with no acceptable Nater quality analysis. If the well has been analyzed to be acceptable, attach copv of well water analysis for colnorm bactpria, volatile organic compounds, ammonia nitrogen and nitrate nitrogen. E] LARGE SYSTEM FAILS: You must indicate either "Yes- or'No"as to each of the following: The following criteria apply to large systems in addition to the criteria above: The system serves a faeility with a design flow of 10,000 go 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 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) The owner or operator of any such system shall bring the system and facility into full compliance with the groundwater treatment program requirements of 314 CMR 5.00 and 6.00. Please consult the local regional office of the Department for further information. i (rrvillad 04/25/21) Page I of 10 I SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST I Property Address: 1"11 1.ctcphAJ do,.)e.e Owner: Dale of Inspection:v e FQ y crh 4q& Check if the following have been done: You must indicate either 'Yes- or 'No- as to each-of the following: Yeses No Pumping information was provided by the owner, occupant, or Board of Health. I None of the system components have been pumped for at least two weeks and the system has been receiving normal flow rates during that period. Large volumes of water have not been introduced into the system recently or / as part of this inspection) ✓ _ As built plans have been obtained and examined. Note if they are not available with N/A. ✓ _ The facility or dwelling was inspected for signs of sewage back-up. ✓ _ The system does not recF(ve non-sanitary or industrial waste flow. / The site was inspected for signs of breakout. ' _ All system components. excluding the Soil Absorption System, have been located on the site. The septic tank manholets were uncovered, opened, and the interior of the septic tank was in1pected for condition of baffles or tees, material of construction, dimensions, depth of liquid, depth of sludge, depth of scum. / The size and location of the Soil Absorption System on the site has been determined based on: _✓ _ The facility owner(and occupants, if different from owners were provided with information on the proper maintenance of Sub-Surface Disposal System. ✓ _ Existing information. Ex.tPlan at B.O.H. t Determined in the field tai any of the failure criteria related to Pan C is at issue, approximation of distance is unacceptable) (15.302(3)(b)J l I (r•vim•d 04/25/971 rag. 4 of 10 i SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION-FORM PART C SYSTEM INFORMATION Property Address: 1 11 l.a o�.i Q e t`c k /�f , IL},,, ooa Owner. Date of Inspection: �1s�48 FLOW CONDITIONS RESIDENTIAL: Design flow: 1.p.dJbedroom for S.A.S Number of bedrooms: Number of current rest ents: Garbage gsr.der (yes or no): Al Laundry connected to system (yes or no) Seasonal use (yes or no):/V ✓ 1 Water meter readings, if available (last two (1) year usage (gpd): )&j e ��►7 2 y ect�s = �3c�. (T.c� D. .Sump Pump (yes or no): Al l v►Lo.tet.� � '/ Last date of occupancy: L U,^,-e T N ©M, �'`'�� ^ts „✓n S ;.� vC COMMERCIAUI NDUSTRIAL: Type of establishment: Design flow: pIIons/day Grease trap present: (yes or no!_ , Industrial Waste Holding Tank present: ryes or no)_ Non-sanitary waste discharged to the Title 5 system: (yes or no)_ Water meter readings, rt available last dace of o•-cupanc•: t t OTHER: (Describe) Last date of occupancy. GENERAL INFORMATION PUMPING RECORDS and source of information t nc c '. sn btR- System pumped as pan of inspection: (yes or no)_ I(yes, volume pumped: Qallo�s 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) Ocher VA Technology etc. Copy of up to date contract? APPROXIMATE AGE of all components, date installed (i(known) and source of information: 9 UCcf/Z.S V Sewage odors detected when arriving at the site: (yes or no)�O (ravla•d 04/25/971 - i Page 5 of 20 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: V7 ( Ci r-c.to A-), 09 cY O j e1L. Owner: a Dale of Inspection: ��sl48 BUILDING SEWER: (Locate on site plan) Depth below grade:" Material of construction: cast iron _40 PVC_other(explain) Distance from private water supply well or suction lire Diameter Comments: (condition of joints, venting, evidence RRf leakage• etc.) o f o ! I,es 9 C)0 c nt e sf SEPTIC TANK:_ (locate on site plana Y Depth below grade: Material of construction: Zconcrete _metal _Fiberglas) _Polyethylene _other(explain) l(tank is metal, list age _ Is age confirmed by Cenrircate of Compliance _(Yes/No] , Dimensions: /S-6 0 &."AS. Sludge depth: L Z ' „ Distance from top of sludge to bottom of outlet tee or baiflp Z�y t M Scum thickness: 4 2 „ Distance from top of scum to top of outlet tee or baffle: Distance from bottom of scum to bonom of outlet tee or baifle:_IJ9 How dimensions were determined: /Yl Gus JK .sT!ey� Comments: (recommendation for pumping, condition of inlet and outltt tees or baes, depth o( iqy id level in relation to outlet invert, strglural integrity, evidence of leakage 1 etc.) 9'1 14 0 d7 00­ C ✓1 1`1v/l- �vq C-e e Tec ^ d ca., . �0e c '.rer-,c e2 d 12e,-.r was �u w 7x�� h " b >`1.�,5 GREASE TRAP:A1j64- (locate on site,plan) 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 bonom of scum to bottom of outlet tee or baKle: 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.) (=wiaud 04/25/77) aa9. i; of 10 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: 171 � cov.. c. C r- e A). 4 ,c0Ove2Owner: Ji Date of Inspectionct $1 c a f e4 TIGHT OR HOLDING TANK;dZ/9 iTank must be pumped prior to, or at time, of inspection) (locate on site plan) Depth below grade: Material of construction: _concrete _metal_Fiberglass _Polyethylene —other(explain) Dimensions: Capacm: gallons Design floes• gallon/da% ► Alarm level Alarm in working order_ Yes: _ No Date of previous pumping: Comments: (condition of inlet tee. condition of alarm and float switches, etc.) DISTRIBUTION BOX:_ (locate on site plan) Depth of liquid level above outlet inven: Comments: (note ii level and distribution is equal. evidence of soA/D carryoler, evidence oT- nce of leakage into or out of box, etc.) QcIX ✓� !aO'DC t!O•rd'1,;6 y eoe'denre I I I PUMP CHAMBER:_ . (locate on site plan) Pumps in working order: (Yes or Not 4�s Alarms in working order(Yes or No) Zj 5 Comments: (note condition of pump chamber, condition of pumps and appurtenances, etc.) cpm o 4flAQ i.+6 l/L l6c�rGS 0 K (revived 04/25/171 rag. 7 of 10 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM t PART C SYSTEM INFORMATION (continued) Property Address: 1-11 1,u co viq e�r�lC N, #}„S Owner: a4,4 e i O Date of Inspection: ka�4✓t f-Is�q$ SOIL ABSORPTION SYSTEM (SAS):_ (locate on site plan. if possible; excavation not required. but may be approximated by non-intrusive methods) If not determined to be present, explain: Type: leaching pits. number:_ leaching chambers. number:_ leaching galleries. number: I leaching trenches. number length: 2 — C7 %/Yn cht 5 ' leaching fields. number. dimensions:_ overflow cesspool. number: Alternative system: Name of.Technology: Comments: ' (note condition of soil. signs pf hydraulic failur4, level of ponding, condition of vegetation, etc.) CESSPOOLS: (locate on site plant Number and configuration: Depth-top of liquid to inlet raven: Dr-pth of solids layer: r Depth of scum laver: Dimensions of cesspool: Materials of construction: I I Indication of groundwater: inflow (cesspool must be pumped as pan of inspection) 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: (mote condition of soil. signs of hydiaulic failure• level of ponding, condition of vegetation. etc.) (revised 04/2S/27) Paq• • of 20 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C- SYSTEM INFORMATION (continued) Property Address: I-� C'. lac tei AJ. f}..6J.SeQ Owner. Date of Inspection: SKETCH OF SEWAGE DISPOSAL SYSTEM: include ties to at least two permanent references landmarks or benchrnarks locate all wells within 100' (Locate where public water supply comes into house) H C V X p IS ir,,, eS Cts J fl'� 50' v r� TAA;,K • t So, � 35 r 1 Trzc1, J c es 1 , 1 I (r.vi..d 04/75/971 P.qo 2 of 10 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: 17( 1 ek cc'vt 4'.'L C;f,1, Q /� Owner: / /V• (ova tY cit, Date of Inspection: J an e- � Q,.) Is- Depth to Groundwater Feet Please indicate all the methods used to determine High Groundwater Elevation: Obtained from Design Plans on record Observation of Site (Abutting property observation' hole, basement sump etc.) Determine it irom local conditions Check .wth !oca!'Buard of health Checi. FEMA MapS Check pumping recotds Check local excavators, installers Use USGS Data Describe in .our own swords how you established the High Groundwater Elevation.!(Must be completed) L \ � I1` U-5-(--S, 5110..,.E WG�1 ! be.(0— Imo'`L ccc 4 Z'1 S�S+1Cir• s> (ot C(�d�C C� lf!� t'1DOf 4�.Y I JJ i �(..c VIO.iSC �a�j yrlal' �u-< .57- �/� �v^^I:>. I I tr.vl•.d 04/75/97, P•q. 10 of 10 Commonwealth of Massachusetts City/Town ofiVE® vSystem Pumping Record Form 4 ' APR 2 2008 DEP has provided this form for use by local Boards of Health. 'F` is;, the information must be substantially the same as that provided herrBeorelu ' eck with your local Board of Health to determine the form they use. The System Pumping Record must be submitted to the local Board of Health or other approving authority. A. Facility Information Important: When filling out 1. System Location: forms on the computer,use only the tab key Address to move your f `7 cursor-do not Cityfrown State Zip Code use the return key. 2 System Owner: dL rL 6 G�3!7--"�. Name Address(if different from location) Citylrown State Telephone Number B. Pumping Record 1. Date of Pumping Date 2. Quantity Pumped: Gallons 3. Type of system: ❑ Cesspool(s) 9—Septic Tank ❑ Tight Tank ❑ Other(describe): 4. Effluent Tee Filter present? ❑ Yes [1-146 If yes,was it cleaned? ❑ Yes ❑ No 5. Condition of System: 6. Syste PumMBy: -� 1 -�-- a-� Name Vehicle License Number Company 7. Locatioamhere cont s71Tposed: Signatur of au Date t5form4.doc-06/03 System Pumping Record>Page 1 of 1 Commonwealth of Massachusetts RECEIVED City/Town of System Pumping Record MAR 2 7 2009 Form 4 TOWN OF NORTH ANDOVER \1V HEALTH DEPARTMENT DEP has provided this form for use by local Boards of Health. Other forms may be used, but Me information must be substantially the same as that provided here. Before using this form, check with your local Board of Health to determine the form they use.The System Pumping Record must be submitted to the local Board of Health or other approving authority. A. Facility Information Important: When filling out 1. System Location: Left front, left rear, left side of house. Right front right re , right sid of hous forms on the computer,use only the tab key Address f � 1_ to move your. t 77 -aGc�v-�q C G, ' cursor-do not use the return Cityfrown State Zip Code key. �_--� 2. System Owner: t Name Address(if different from location) CitylTown State„ Zip Code Telephone Number CC77 B. Pumping Record el 1. Date of Pumping Date 2. Quantity Pumped: Gallons 3. Type of system: 8 Cesspool(s) ptic Tank Tight Tank Other(describe): 4. Effluent Tee Filter present? 0 Yes �o If yes,was it cleaned? p Yes Ll No i 5. Condition of System: 6. System Pumped By: Neil Bateson F 5821 Name Vehicle License Number Bateson Enterprises Inc Company 7. Location where contents were disposed: L.S.D Lowell Waste Water r3 -—c 9 igna ure of H u r Date t5form4.doc•06/03 System Pumping Record•Page 1 of 1 f Commonwealth of Massachusetts w City/Town of RECEIVED a System Pumping Record k1M Svy`e� Form 4 APR 'I 2010 DEP has provided this form for use by local Boards of Health. Other forms m I*DOVER information must be substantially the same as that provided here. Before usi tMUMMIAtMogr local Board of Health to determine the form they use. The System Pumping ecord must be submitted to the local Board of Health or other approving authority. A. Facility Information 1. System Location: Left side of house, Right side of house, Left front of house, Right front of house, Left rear of houpe-, Ig t r r fhous Left rear of building. Right rear of building. Address p} ? City/Town `�V State Q VV Zip Code 2. System Owner: Name Address(d different from location) Ci /Town tY Stat Zip Code )SS3 &0 Te phone Number B. Pumping Record 1. Date of Pumping Dat 2. Quantity Pumped: Gallons 3. Type of system: ❑ Cesspool(s) eptic Tank ❑ Tight Tank ❑ Other(describe): 4. Effluent Tee Filter present? ❑ Yes D-40 If yes, was it cleaned? ❑ Yes ❑ No 5. Condition of System: I 6. System Pumped By: Neil Bateson F5821 Name Vehicle License Number Bateson Enterprises Inc Company 7. Location where contents were disposed: D Lowell Waste Water �Igrptute of Haul r Date i t5form4.doc•06/03 System Pumping Record•Page 1 of 1 I Commonwealth of Massachusetts City/Town of W° System Pumping Record Form.4 SVO� 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 Pumpin aCIAESUS f�t�C mitt d to the local Board of Health or other approving authority. % A. Facility Information ail jyt,a ISP&TTH DOVER 1. System Location: L fi of e, right front of house, left side of hLA410-(t side ,up, ft i�.— -., e.,rear of hous right rear of hous side of building, right rear of builmder-zi . � c City/Town State Zip Code 2. System Owner: Name Address.(if different from location) City/Town State Telephone Number B. Pumping Record �D i r ��-- 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 EJ-lqo If yes, was it cleaned? ❑ Yes ❑ No 5. Condition of ystf m: �L I 6. System Pumped By: Neil J. Bateson F5821 Name Vehicle License Number Bateson Enterprises Inc. Company 7. Location where contents were disposed: .L.S. well ste ter Signa u of auler Date t5form4.doc•06/03 System Pumping Record•Page 1 of 1