HomeMy WebLinkAboutMiscellaneous - 173 RALEIGH TAVERN LANE 4/30/2018W
Commonwealth of M ss chusetts
City/Town of
System Pumping Recer
bV
Form 4
DEP has provided this form for use by local Boards of Health. Other forms may be used, but the
information must be substantially the same as that provided here. Before using this form, check with your
local Board of Health to determine the form they use. The System Pumping Record must be submitted to
the local Board of Health or other approving authority within 14 days from the pumping date in
accordance with 310 CMR 15.351.
Important: When
filling out forms
on the computer,
use only the tab
key to move your
cursor - do not
use the return
key.
t5form4.doc• 03/06
A. Facility Information
1. System Location:
r7 t2
Rxo
Address ( _ _ o C
City/Town State Zip Code
2. System Owner:
Name
Address (if different from location)
City/Town
B. Pumping Record
State Zip Code
Telephonef4umber
1. Date of Pumping pateI � d ),-? ) �24-70
`, 2. Quantity Pumped: Gallons
3. Type of system: ❑ Cesspool(s) P
Septic Tank ElTight Tank ElGrease Trap
ElOther (describe):
4. Effluent Tee Filter present? ❑ Yes jj No
jVA
5. Condition of System:
System Pumped By:
N e
Stewart's Septic Service
Company
7. Location where contents were disposed:
If yes, was it cleaned? ❑ Yes ❑ No
Vehicle License'Number '-t1}1j
u
R-0 ANpOVER
► NN O 1-1 iEPARTMENT
System Pumping Record • Page 1 of 1
InI t hof Massachusetts. -1 ,
MASS 00 ACHS
!Ly!,
System Pumping Redded
Nov 132006
TOWN OF NORTH ANDOVER
of Health.1rh
DER has provided this form for use by local Boards"Ou"W"
&W 61-Jord
&� —
must
be submitted to the local Board of Health or other approving authority.
Ai. Facility Information .
Wrien filling out.
fohns on the ;
System Location:
// /i2�
computer, use ,-,...
only the tab key
Address
to move your
cursor - do notZip
Ureturn se the retu
City[Town State Code
2.': System Owner
Name
_7SAVneZ7777
Address (if different from location)
City/Town State Zip Code
Telephone Number
B. Pumping Record
)671olo&
I.. Date Date 2. 1 Quantity Pumped:
of Pumping -dallons
3. Type of system: El Cesspool(s) Septic Tank ❑ Tight Tank
C Other (describe):
4. Effluent Tee Filter present?. D Yes a<o If yes, was it cleaned? D Yes E] No
q:.
5 Condition ond of System:'
6. Sy%e i Pumped'By:
�iFC.,
Name ; Vehicle License Number
Company
7.: Location where contents were disposed:
X4 a4ld Ma
Signature of Haul.er..% Date
ht4i:/twww.mass.gov/dep/water/approva.Is/t5forms.htm#inspect
t . 5foffn4.do4,- 06/03 System Pumping Record - Page 1 of 1
TOWN OF
SYSTEM PUMPING RECO RECEIvED
DATE: -On Q
SYSTEM OWNER & ADDRESS
SEP _ 7 2005
T04"NEAOLTH 0 PARTME ANDOTER
SYSTEM LOCATION
(example: left front of house)
0- 6L� �- 6w ,-
DATE OF PUMPING: L QUANTITY PUMPED: ` D 0 G LONS
CESSPOOL: NO YES SEPTIC TANK: NO YES
NATURE OF SERVICE: ROUTINE EMERGENCY
OBSERVATIONS:
GOOD CONDITION
HEAVY GREASE
ROOTS
EXCESSIVE SOLIDS
SOLIDS CARRYOVER
FULL TO COVER
BAFFLES IN PLACE
LEACHFIELD RUNBACK
FLOODED
OTBER (EXPLAIN)
SYSTEM PUMPED BY: Bateson Enterprises, Inc.
COMMENTS:
CONTENTS TRANSFERRED TO:
G.L.S.D
Lowell Waste
F0101 Q • SYSTEM t'UNHIL\G KEC01W
commonwealth of Alassachuse
, Massachu
Sv_stem Purltpit19 hecc
Tsietn M ner —System Loiiifioll
l -713 -�
Dntc of Punypinu �' I �� Quantity 1'urr�ped: t C
Cesspool: No ,1'� ties E]renlir Tanl•1 tl'. 0 Yes 0�
IA
System Pumped by: License !1:
Colltents transferred
Date
Inspector
1.
'nt11t 111n�y1=nNli of hlaQap�lltcaells
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�ynlait� �►�v1�e _�
n C -C._.
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t.luatllity I'ut1U►t:J: ���gnlltllu
Septic Took: Nu
Sy1�l�ttt Ihllisir�sl by: �'it�'eA�r� �K'��t1�4 I.Ic�ti91: � _
"IIt1i�ltiR 1181181011th Its : i�iaGGwi i►iiit�111:� �Ni1� rtr H IlI�,
1of11"`...
COMMONWEALTH OF MASSACHUSETTS
EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS
DEPARTMENT OF ENVIRONMENTAL PROTECTION
TITLE 5
OFFICIAL INSPECTION FORM- NOT FOR VOLUNTARY ASSESSMENT
SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM
PART A
CERTIFICATION
Property Address: 173 Raleigh Tavern Lane North Andover, MA 01845
Owner's Name: Terry L. Price
Owner's Address: 173 Raleigh Tavem Lane North Andover, MA 01845
Date of Inspection: June 22, 2005
Name of Inspector: (please print) Benjamin C. Osgood, Jr. Certified Title 5 Inspector
Company Name: New England Engineering Services Inc.
Mailing Address: 60 Beechwood Drive North Andover, MA 01845
Telephone Number. 97"86-1768
RECEIVED
JUN 2 7 2005
TOWN OF NORTH ANDOVER
HEALTH DEPARTMENT
CERTIFICATION STATEMENT
I certify that I have personally inspected the sewage disposal system at this address and that the information reported below is true,
accurate and complete as of the time of the inspection. The inspection was performed based on my training and experience in the
proper function and maintenance of the on site sewage disposal systems. I am a DEP approved system inspector pursuant to Section
15340 of Title 5 (3 10 CMR 15.000). The system:
_Passes
Conditionally Passes
Needs Further Evaluation by the Local Approving Authority
Fails
Inspector's Signature:C Date: Z 2
The system inspection shall submit a copy of this inspection report to the Approving Authority ( Board of Health or DEP) within 30
days of completing this inspection If the system is a shared system or has a design flow of 10,000 gpd or greater, the inspector and
the system owner shall submit the report to the appropriate regional office of the DEP. The original should be sent to the system
owner and copies sent to the buyer, if applicable, and the approving authority.
Notes and Comments
****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.
2of11
OFFICIAL INSPECTION FORM — NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION (continued)
Property Address: 173 Raleigh Tavern Lane North Andover, MA 01845
Owner's Name: Terry L. Price
Date of Inspection: June 22, 2005
Inspection Summary: Check A, B, C, D or E/ALWAYS complete all of Section D
A. System Passes:
I have not found any information which indicates that any of the failure criteria described in 310 CMR 15.303 or in 310 CMR
15.304 exist. Any failure criteria not evaluated are indicated below.
Comments:
B. System Conditionally Passes:
One or more system components as described in the "Conditional Pass" section need to be replaced or repaired. The system,
upon completion of the replacement or repair, as approved by the Board of Health, will pass.
Answer yes, no or not determined (Y,N,ND) in the for the following statements. If "not determined" please explain.
The septic tank is metal and over 20 years old* or the septic tank (whether metal or not) is structurally unsound, exhibits
substantial infiltration or exfiltration or tank failure is imminent. System will pass inspection if the existing tank is replaced with a
complying septic tank as approved by the Board of Health
*A metal septic tank will pass inspection if it is structurally sound, not leaking and if a Certificate of Compliance indicating that the
tank is less than 20 years old is available.
ND explain:
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
Obstruction is removed
Distribution box is leveled or replaced
ND explain:
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 pipes) are replaced
Obstruction is removed
ND explain_
3 of 11
OFFICIAL INSPECTION FORM — NOT FOR VOLUNTARY ASSESSMENT
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION (continued)
Property Address: 173 Raleigh Tavern Lane North Andover, MA 01845
Owner's Name: Terry L. Price
Date of Inspection: June 22, 2005
C. Further Evaluation is Required by the Board of Health:
ALO 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 amanner which will protect public health, safety and the environment:
Cesspool or privy is within 50 feet of a surface water
Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh
2. System will fail unless the Board of Health ( and Public Water Supplier, if any) determines that the system is
functioning in a manner that protects the public health, safety and environment:
The system has a septic tank and (SAS) Soil Absorption System and the (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 the SAS is within 50 feet of a private water supply well.
The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or more from a private
water supply well**. Method used to determine distance
** This system passes if the well water analysis, performed at a DEP certified laboratory, for coliform bacteria and
volatile organize 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 5ppm, provided that no other failure criteria are
triggered. A copy of the analysis must be attached to this form.
3. Other.
4of11
OFFICIAL INSPECTION FORM — NOT FOR VOLUNTARY ASSESSMENT
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION (continued)
Property Address: 173 Raleigh Tavern Lane North Andover, MA 01845
Owner's Name: Terry L. Price
Date of Inspection: June 22, 2005
D. System 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
V Discharge or ponding of effluent to the surface of the ground or surface waters due to an overload or clogged SAS or
cesspool.
V Static liquid level in the distribution box above outlet invert due to an overload or clogged SAS or cesspool
Liquid depth in cesspool is less than 6" below invert or available volume is less than V2 day flow
Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number of times
pumper
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.
v 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
coliform bacteria and volatile organic compounds indicates that the well is free from pollution from that facility and the
presence of ammonia nitrogen and nitrogen is equal to or less than 5ppm, provided that no other failure criteria are
triggered. A copy of the analysis must be attached to this form.)
Al 0 (Yes/No) The system fails. I have determined that one or more of the above failure criteria exist as described in
.3 10 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 in tate either "yes" or "no" to each of the following:
(The following ;rAQ0a apply to large systems in addition to the criteria above)
Yes No
The system is witfiin,4,00 feet of a surface drinking water
The system is within 200 feetbf a tributaryyjo-a-surface drinking water supply
The system is located in a
of a public water supper
(Interim Wellhead Protection Area — IWPA) or a mapped Zone 11
If you answered "yes" to uestion in Section E the system is conside ignificant threat, or answered "yes" in Section D above
the large system 15 ed The owner or operator of any large system consider significant threat under Section E or failed under
Section D shall pgrade the system in accordance with 310 CMR 15.304. The system r should contact the appropriate regional
office of the Department.
5of11
OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENT
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART B
CHECKLIST
Property Address: 173 Raleigh Tavern Lane North Andover, MA 01845
Owner's Name: Terry L. Price
Date of Inspection: June 22, 2005
Check if the following have been done. You must indicate "ves" or "no" as to each of the followinn:
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 ?
Yes No/
Have large volumes of water been introduced to the system recently or as part of an 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 sign of break out?
Were all system components, excluding the SAS, located on site?
Were all the septic tank manholes uncovered, opened, and the arterior 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 difference from owner) provided with information on the proper
maintenance of the 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) [3 10 CMR 15.302(3)(b))
7of11
OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENT
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Property Address: 173 Raleigh Tavern Lane North Andover, MA 01845
Owner's Name: Terry L. Price
Date of Inspection: June 22, 2005
BUILDING SEWER (locate on site plan)
Depth below grade: a `I
Materials of construction: cast iron 40 PVC ^other (explain)
Distance from private water supply well or suction line: "V %/q
Comments (on condition of joints, venting, evidence of leakage, etc.):
0(+srMe,- ;- f::-LNtsrlc 7 . F1 PF N6—, 0L's t3 c t5
SEPTIC TANK: (locate on site plan)
Depth below grade: I Z '
Material of construction: x concrete metal fiberglass polyethylene
Other (explain)
If tank is metal list age: Is age confirmed by a Certificate of Compliance (yes or no): (attach a copy of certificate)
Dimensions:
Sludge depth: C�
Distance from top of sludge to bottom of outlet tee or baffle: / 7
Scum thickness: / 7 -
Distance
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: ,V7 6 A sy � c S it � ie_
Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet
invert, evidence of leakage, etc.):
T -&j V, l -j 6-o 0 D c 0 N. —1 I N 6-00,-) t o .- o• T)O /-J .
Re•CvnnE0D I-ArjIL. z PUn/t?EL, _ t%C0MG,-)(D 1ztSi=2S ELti5��L
'T L,-,/ n IN (o " c?t" -Iv (S Fi 6--(Z � C CSN f4 LL
GREASE TRAP: N (locate on site plan)
Depth below grade:
Materials 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 sludge 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.
8of11
OFFICIAL INSPECTION FORM — NOT FOR VOLUNTARY ASSESSMENT
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Property Address: 173 Raleigh Tavern Lane North Andover, MA 01845
Owner's Name: Terry L. Price
Date of Inspection: June 22, 2005
TIGHT OR HOLDING TANK. -__/(tank N� must be pumped at time of inspection)(locate on site plan)
Depth below grade:
Materials 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.):
DISTRIBUTION BOX: (if present must be opened)(locate on site plan)
Depth of liquid level above outlet invert: O
Comments ( note if box is level and distribution to outlets equal, any evidnence of solids carryover, any evidence of leakage into or
out of box, etc.):
L N of-,- Co .0 T? 0 SO nA t C Hp✓1.1 6kJe/L per- `. j ,y 0 D G .y c_ (-
l -EA -11 0 &-F I kj b i2 00—, o /< "o ' F- l 6Au i4L. JZ�- e o nit e Alb
N i i A'Lt- R
-/?,I ti 01- 0 &-C. 6/Z,5: ,
PUMP CHAMBER /0,4- (locate on sire 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.):
9of11
OFFICIAL INSPECTION FORM — NOT FOR VOLUNTARY ASSESSMENT
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Property Address: 173 Raleigh Tavern Lane North Andover, MA 01845
Owner's Name: Terry L. Price
Date of Inspection: June 22, 2005
SOIL ABSORPTION SYSTEM (SAS): (locate on site plan, excavation not required
H SAS not located explain why
TYPE
leaching pits number
leaching chambers, number
leaching galleries number
leaching trenches, number in length
--Z. leaching fields, number, dimensions: i—e e.- c rt z, e v N K N o,..� ,v
overflow cesspool, number:
innovative/alternative system Type/name of technology:
Comments ( note condition of soil, signs of hydraulic failure. Level of ponding, damp soil, condition of vegetation, etc)
f}"2-Liq- or See -7-e- M 1-0011-5 ,vo AIIA, L- /I/J D el C e OF
�j c-, DA,%4P Sof L_�R Jtil oS�I(� C� �L'Gz CiJN
i"
CESSPOOLS: /y 4 (cesspool must be pumped as part of inspection) pocate 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 or no)
Comments(note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.):
PRIVY: (locate on site plan)
Material of construction:
Dimensions:
Depth of solids
Comments (note condition of soil signs of hydraulic failure, level of ponding, condition of vegetation, etc.
10 of 11
OFFICIAL INSPECTION FORM — NOT FOR VOLUNTARY ASSESSMENT
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Property Address: 173 Raleigh Tavern Lane North Andover, MA 01845
Owner's Name: Terry L. Price
Date of Inspection: June 22, 2005
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.
i l 5� R� ccs
Z 1 G .S
1- D� .30,3
rc`, -- L—
11 of 11
OFFICIAL INSPECTION FORM — NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Property Address: 173 Raleigh Tavern Lane North Andover, MA 01845
Owner's Name: Terry L. Price
Date of Inspection: June 22, 2005
SITE EXAM
Slope
Surface water
Check cellar
Shallow wells
Estimated depth to ground water 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 design plan reviewed:
Observed site (abutting property/observation hole within 150 feet of SAS)
Checked with local Board of Health — explain:
Checked with local excavator, installers — (attach documentation)
Accessed USGS database -explain:
You must describe how you established the high ground water elevation:
.F
11 of 11
OFFICIAL INSPECTION FORM — NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Property Address: 173 Raleigh Tavern Lane North Andover, MA 01845
Owner's Name: Terry L. Price
Date of Inspection: June 22, 2005
SM EXAM
Slope
Surface water
Check cellar
Shallow wells
Estimated depth to ground water __�/_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 design plan reviewed:
_ Observed site (abutting property/observation hole within 150 feet of SAS)
Checked with local Board of Health — explain:
_ Checked with local excavator, installers — (attach documentation)
Accessed USGS database-explain.-
You
atabase-explain:
You must describe how you established the high ground water elevation:
f
NEW ENGLAND ENGINEERING SERVICES
INC
REd ED
June 23, 2005 JUN 2 7
2005
TOWN OFN
O-RFH
NO,n`TH ANDOVER
North Andover Board of Health HEALTH DEPARTMENT
400 Osgood Street
North Andover, MA 01845
RE: TITLE V REPORT: RE: 173 Raleigh Tavern Lane North Andover, MA
Dear Sir or Madam:
Enclosed is a copy of the Title V report for the above referenced property. The system
PASSED our inspection.
If there are any questions please call me at my office, 686-1768.
Sincerely,
cJ(
Benjamin C. Osg d, Jr.
Certified Title 5 Inspector
60 BEECHWOOD DRIVE - NORTH ANDOVER, MA 01845 - (978) 686-1768 - (888) 359-7645 - FAX (978) 685-1099
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W City/Town of No.Andover
a System Pumping Record
iG^M Svy•
Form 4
DEP has provided this form for use by local Boards of Health. Other forms may be used, but the
information must be substantially the same as that provided here. Before using this form, check with your
local Board of Health to determine the form they use. The System"I&M�P/Date
ubmitted to
the local Board of Health or other approving authority within 14 da
accordance with 310 CMR 15.351.
A. Facility Information
Important:
When filling out
forms on the
computer, use
only the tab key
to move your
cursor - do not
use the return
key.
VQ
renrm
1
TOWN OF NORTH ANOOVER
_ -.. -. www. -A. -LIT
No.HnoOVer Iyla u-1040
City/Town State Zip Code
2. System
Name
Address (if different from location)
City/Town
State
Zip Code
Telephone Number
B. Pumping Record
I
1. Date of Pumping `Date 2. Quantity Pumped: Gallons
3. Type of system: ❑ Cesspool(s) x Septic Tank ❑ Tight Tank ❑ Grease Trap
❑ Other (describe):
4. Effluent Tee Filter present? ❑ Yes ❑ No
5. Condition of System:
6. Syafgm Pumped By:
-�-rn nKe.
N me
Stewart's Septic Service
Company
If yes, was it cleaned? ❑ Yes ❑ No
Vehicle License Number
7. Location where contents were disposed:
Stewart's Pre-treatment Plant, 20 So. Mill Bradford, Ma 01835
Signatureaule Date
–10 — 'lli \
Signature of ece' m acility Date
t5form4.doc• 03/06 System Pumping Record •Page 1 of 1
`C -N Commonwealth of Massachusetts
w City/Town of North Andover
W° System Pumping Record
Form 4
GSM
I LE3 �.. 51013
TOWN OF NMIK A,9%( .
HEALTH DEPART,
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 out forms 1
on the computer,
use only the tab
key to move your
cursor - do not
use the return
System Location: f
L
Address
North Andover
key. City/Town
2. System Owner:
tI
�I
Name
h
Address (if different from location)
City/Town
B. Pumping Record
1. Date of Pumping
3. Type of system:
❑ Other (describe)
n
�j Qv( -3(
Ma 01845
State Zip Code
State
Telephone Number
Zip Code
ll- 00
Date 2. Quantity Pumped: Gallons
❑ Cesspool(s) Septic Tank ❑ Tight Tank ❑ Grease Trap
4. Effluent Tee Filter present? ❑ Yes 0 No
5. Condition of System:
If yes, was it cleaned? ❑ Yes ❑ No
6. System Pumped By:
Name Vehicle License Number
Stewart's Septic Service
Company
7. Location where contents were disposed:
Stewart's Pre-treatment Plant. 20 So. Mill Bradford. Ma 01835
signature otVauier
Signature
t5form4.doc• 03/06 System Pumping Record • Page 1 of 1