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TOWN OF NORTH ANDOVER
SYSTEM PUMPING RECORD
DATE: I k) v0d D1
SYSTEM OWNER & ADDRESS SYSTEM LOCATION
��--- (example: left front of house)
is C �W QAr+ Ute, R r X-%+ rC �-
5n� �
� - dvnd � � 1A. `�'�t sfJ'Y1�J
DATE OF PUMPING: QUANTITY PUMPED.. GALLONS
CESS ZYES POOL: NO SEPTIC TANK: NO YES V
NATURE OF SERVICE: ROUTINE EMERGENCY
OBSERVATIONS:
GOOD CONDITION
HEAVY GREASE
ROOTS
EXCESSIVE SOLIDS
SOLIDS CARRYOVER
SYSTEM PUMPED BY:
COMMENTS:
FULL TO COVER
BAFFLES IN PLACE
LEACHFIELD RUNBACK
FLOODED
OTHER (EXPLAIN)
CONTENTS TRANSFERRED TO:
Commonwealth of Massachusetts
City/Town of - �J
w° System Pumping Record
Form 4
20ia
DEP has, provided this form for use by local Boards of Health. Ot f,�f �rix,s� may be used, bu the
information must be substantially the same as that provided here Bfjr I i�i`r- i�} ck with your
local Board of Health to determine the form they use. The System 't b submitted to
the local Board of Health or other approving authority.
A. Facility Information
1. System Location: Left side of house, fiieZ��
iuildir
Left front of house, Right front of house,
Left rear of house, Right rear of house.g. Rightrear of building.
Address 1 01��
City/Town at Vl Zip Code
2. System Owner: ---
0V\
Name
Address (if different from location)
City/Town State ^ s d —1 ®o dip Code
Telephone Number a
B. Pumping Record
1. Date of Pumping
4—'S--10
Date
3. Type of system: ❑ Cesspool(s)
❑ Other (describe):
4. Effluent Tee Filter present? ❑ Yes lio
— 2. Quantity Pumped
eptic Tank
Gallons
❑ Tight Tank
If yes, was it cleaned? ❑ Yes ❑ No
5. Condition of System: 1 �� � �
I�-)(-�+V�rz�, ` j GJ' caro
6. System Pumped By:
Neil Bateson
Name
Bateson Enterprises Inc
Company
7. Location where contents were disposed:
L�iS.D n /, Lowell Waste Water
of
F5821
Vehicle License Number
Date
t5form4.doc• 06/03 System Pumping Record • Page 1 of 1
Commonwealth of Massachusetts
City/Town of .
System Pumping- Record RECEVE®
Form 4 JUL l b 201h
DEP has provided this form for use by local Boards of Health. Oth pr�r_ S4mayibelused; but the
information must be substantially the same as that provided here. Beftif Hibiffig.fthis;form, check with your
local Board of Health to determine the form they use. The System Pumping Record must be submitted to
the local Board of Health or other approving authority.
A. Facility Information
1. System Location: Left / Right front of house, Left/ Right rear of house, Left i h side of ho , Left/
Right side of building, Left / Right front of building, Left / Right rear of building, Under deck
Address
Cityrrown l ` 7—State
2. System Owner.
__r___ti zP
Address (d different from location)
Cityfrown Stat /1 ! Zip Zde ;
Telephone Number <
B. Pumping Record
1. Date of Pumping Date 2. Quantity Pumped: Canons t
3. Type of system. ❑ Cesspool(s) ff Septic Tank ❑ Tight Tank
❑ Other (describe):
4. Effluent Tee Filter present? ❑ Yes [;I- If yes, was it cleaned? ❑ Yes ❑ No,
5. Condition of System•
6.. System Pumped By:
Neil. Bateson
Name
Bateson Enterprises Inc
Company
7. Loo a contents were disposed:
i� GLLS. _ Lowell Waste WE
F5821
Vehicle License Number
Date
t5form4.doc- 06/03 System Pumping Record • Page 1 of 1
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AS BUILT PLAN
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OF
SUBSURFACE DISPOSAL SYSTEM
LOCATED IN
NORTH AND6!/El2 MA
AS PREPARED FOR.
R'• T /�>IcHA/L'O
DATE: JuNE-, lays
SCALE: / " = g p
---------------
MERRIMACK ENGINEERING SERVICES, INC.
PROFESSIONAL ENGINEERS • LAND SURVEYORS • PLANNERS.
66 PARK STREET • ANDOVER, MASSACHUSETTS WSW 9 TEL. (5a6) 475-3555, 373.5721
FLZ:-VATIOAJS
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OF
SUBSURFACE DISPOSAL SYSTEM
LOCATED IN
NORTH AND6!/El2 MA
AS PREPARED FOR.
R'• T /�>IcHA/L'O
DATE: JuNE-, lays
SCALE: / " = g p
---------------
MERRIMACK ENGINEERING SERVICES, INC.
PROFESSIONAL ENGINEERS • LAND SURVEYORS • PLANNERS.
66 PARK STREET • ANDOVER, MASSACHUSETTS WSW 9 TEL. (5a6) 475-3555, 373.5721
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LOCATED IN
NORTH .4 /vo6vcll�f I" MA
AS PREPARED FOR.
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DATE: ,Tun/ / 1,715
S CALE: 0 C 2),,
MERRIMACK ENGINEERING SERVICES, INC.
PROFESSIONAL ENGINEERS • LAND SURVEYORS • PLANNERS,
66 PARK STREET • ANDOVER, MASSACHUSETTS 018T0 0 TEL (sae) 475-3555, 373.5721
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LOCATED IN
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AS PREPARED FOR.
T k 1 CffA !eU . Co,2P
DATE: ,Tun/ / 1,715
S CALE: 0 C 2),,
MERRIMACK ENGINEERING SERVICES, INC.
PROFESSIONAL ENGINEERS • LAND SURVEYORS • PLANNERS,
66 PARK STREET • ANDOVER, MASSACHUSETTS 018T0 0 TEL (sae) 475-3555, 373.5721
WATER SUPPLY: WELL
WELL PERMIT DRILLER
WELL TESTS: CHEMICAL DATE APPROVED _
BAC�Y I DATE APPROVED
BACTERIA II DATE APPROVED
COMMENTS:
FORM U APPROVALS APPROVAL TO ISSUE YE NO
DATE ISSUED- /��%- BY
CONDITIONS: _
FINAL APPROVAL:
.ALL PERMITS PAID
WELL CONSTRUCTION APPROVAL
SEPTIC SYSTEM CONSTRUCTION APPROVAL
..OTHER
ANY VARIANCE NEEDED
FINAL BOARD OF HEALTH APPROVAL:
�YE9' NO
Y NO
NO
NO
YE NO
DATE: �A7 _BY: -e 2-- __
IS THE INSTALLER LICENSED? -,_YES ] NO
_._ TYPE OF CONSTRUCTION: NEW RERAIR
NEW CONSTRUCTION: CERTIFIED PLOT PLAN REVIEW YES NO
CONDITIONS OF.APPROVAL ES NO
(FROM FORM U)
ISSUANCE OF DWC PERMIT �.0 NO
DWC PERMIT N0. /'�� INSTALLER:
BEGIN .INSPECTION YES NO:
EXCAVATION.INSRECTION: NEEDED:
tr 7"
PASSED-�i / C% w BY
CONSTRUCTION INSPECTION: NEEDED:-
AS
EEDEDzAS I_T PlN SATISFACTORY:Af
S-s-
APPROVAL TO BACKFILL: DATE: �n�G J BY-
z4
Y
FINAL.GRADING APPROVAL: DATE ` BY _
FINAL CONSTRUCTION APPROVAL:
DATE:'
LI�9� _BY _ _
FORM U - IAT 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.
****************App i.cant fills out this section*****************
R, APPLICANT: , �� ,� Phone
LOCATION: Assessor's Map Number Parcel
Subdivisions �,e� L�l� Lot (s } %
Street �W St. Number j7�
************************Official Use
RECOMMENDAT ONS OF TOWN r-ENTS:
Conservation Adninistrar-or
Com. -rents
Town Planner
Comments
Food inspector -Health
Seo -z --:c Insnecmcr-Health
Comlnen cs
Date Anuroved
Date Rejected
Date Approved L'
Date Rej ec :ed
Date Approved
Date Rejected
Date Approved��
Dare Rej ec zee
Put? '-c Wcr::s - sewer,/warner connections _���J 3.4—�5
- driveway permit
Fire Denar4zment
Received by Building Inspector Dare
NORT►,
1 w
A
t i
,SSACHUStt
Town of North Andover, Massachusetts
BOARD OF HEALTH
Form No. 2
�r� l 01
DESIGN APPROVAL FOR
SOIL ABSORPTION SEWAGE DISPOSAL SYSTEM
Applicant J�-�� L v�`'�'��- Test No.
Site Location LQT U-'�--�-- (�-1�-��C W(L6
Reference Plans and Spe
a
Permission is granted for an individual soil absorption sewage disposal system to be installed
in accordance with regulations of Board of Health.
Fee Lo
�f a '
CHAIRMAN, BOARD OF HEALTH
Site System Permit No.
DATE_ 10��6 �9Z Sheet of
BOARD OF HEALTH
TOWN OF NORTH ANDOVER
/ SUBSURFACE DISPOSAL DESIGN REVIEW j
FEE( PERMIT # 15-86 DATE RECEIVED
APPLICANT
ADDRESS
ENGINEER �E/IP,//YiACK
ADDRESS
ASSESSOR'S MAP /®
PARCEL # 2 7
LOT #
STREET/ -6 C-41?;- Ll AY
PLAN DATE 9 /a 419�REVISION DATE
CONDITIONS OF APPROVAL: )I hop T L' TE951-1 G iti ARBA Z)
/%O i 3)LGc9r� y'Q/lJ fj il�}i/V DUTl/�LG �G�V
APPROVED
DISAPPROVED
PLAN REVIEW CHECKLIST
ADDRESS,/?( /G� C.9/1T L't�jl/ ENGINEER
GENERAL
3 COPIES U STAMP `/ LOCUS �'� NORTH ARROW tom' SCALE
ge
CONTOURS PROFILE SECTION 1/ BENCHMARK_/"65�-r SOIL &
PERC INFO ELEVATIONS WETS. DISCLAIMER 6--- WELLS &
WETLANDS C,-' WATERSHED?A�) DRIVEWAY (Elev) WATER LINE
DCG P
FDN DRAIN SCH40 C/ TESTS CURRENT? PiT o v lilCsr -s pc o,c
�EfgtN A21-_%3
SEPTIC TANK
MIN 1500G. (/ .17 INVERT DROP GARB. GRINDER /�(+200% EDF)
25' TO CELLAR C/� MANHOLE TO GRADE L/ ELEV GW
D -BOX
SIZE # LINES FIRST 2' LEVEL STATEMENT
INLET/ 74,0 - OUTLET /7927 = • 17 ( 2 " OR .17 FT) TEE REQ' D? Ay
LEACHING
RESERVE AREA 4' FROM PRIMARY? !,-' 100' TO WETLANDS e/ 2% SLOPE
100' TO WELLSy' 35' TO FND & INTRCPTR DRAINS L--"'- 4' TO S.H.GW
325' TO SURFACE H2O SUPPi/' 4' PERM. SOIL BELOW FACILITY
MIN 12" COVER/ FILL?.--,- (25' if above natural elev; 0'' ' f below)
BREAKOUT MET?��
TRENCHES
MIN 660 gpd�
SLOPE (min
.005 or 6'1/1001)z_--"_'
'/100') >3'
COVER? - VENT
SIDEWALL DIST.
2X EFF. W OR
D (MIN 61) IS RESERVE BETWEEN
TRENCHES? L,---"
IN FILL? L--'
MUST BE 10' MIN.y 4"
PEA STONE? 6�
BOT X
LDNG-95- + SIDE 3�0 X LDNG 575
= TOT �o S C�loCj
(L x W x #)
(G/ft2)
(DxLx2x#)
!107 Forest St.
Middleton, MA 01949
(508) 7.742772
FILE# 33199A
C'&rAVAV,�PS RV�.
BQARD OF HFATH
POVE�R/
1 W
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PROPERTY OWNER'S NAME:—Cl n r
PROPERTY ADDRESS:
ADDRESS OF OWNER:_ Sa m e.
(if different)
DATE OF INSPECTION: _31 MA_ PCA 199P
NAME OF INSPECTOR:
0 THE PROFESSIONAL EXPERTS IN THE SEPTIC AND DRAIN INDUSTRY -
I
rD
COMMONWEALTH OF MASSACHUSETTS
EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS
DEPARTMENT OF ENVIRONMENTAL PROTECTION
ONE WINTER STREET, BOSTON MA 02108 (617) 292-5500
TRUDY COXE
Secretary
ARGEO PAUL CELLUCCI DAVID B. STRUHS
Governor Commissioner
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A I
^�,
�/%� CERTIFICATION
Property Address: / 75 o Id Cc r f way � /mover
Name of Owner5tr
Address of Owner•_ _ _�(] n7e
Date of Inspection:
3/ lvxRch 1991'
Name of Inspector: (Please Print) 7h� S
I am a DEP approved system i Pact or Pursuanto Section 15.340 of Title 5 (310 CMR 15.000)
Company Name: er t C
Mailing Address: 7 �Z�
Telephone Number: -
_7 7Zi
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 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:
Y Passes ,
_ Conditionally Passes
_ Needs Further Evaluation By the Local Approving Authority
_ Fails
Inspector's Signature: Date:
v�J �
The System Inspector shall submit a copy of this inspection report to the Approving Authority (Board. of Health or DEP )within thirty (30) days of
completing this inspection. If the system is a shared system or has a design flow of 10,000 gpd or greater, the inspector and the system owner
` shall submit the report to the appropriate regional office of the Department of Environmental Protection. The original should be sent to the
system owner and copies sent to the buyer, if applicable, and the approving authority. ..
NOTES AND COMMENTS
revised 9/2/98 Pagel of 11
4iPrinted on Recycled Paper
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
,, CERTIFICATION (continued)
Property Address: /.7S 0/af c y?d a4y �
Owner: Clark
Date of Inspection:3/�A�G,
INSPECTION SUMMARY: Check
O B, C, or D:
A. SYSTEM PASSES:
Ves I have not found any information which indicates that any of the failure conditions described in 310 CMR 15.303 exist. Any failure
criteria not evaluated are Indicated below.
COMMENTS:
B. SYSTEM CONDITIONALLY PASSES:
NOne or more system components as described in the "Conditional Pass" section need to replaced or,repaired. The system, upon
completion of the replacement or repair, as approved by the Board of Health, will pass.
i
Indicate yes„no, or not determined (Y, N, or NO). Describe basis of determination in all instances. If "not determined", explain why not..
The septic tank is metal, unless the owner or operator has provided the system inspector with a copy of a Certificate of
Compliance (attached) indicating that the tank was installed within twenty (20) years prior to the date of the inspection; or
the septic tank, whether or not metal, )k cracked, structurally unsound, shows substantial infiltration or exfiltration, or tank
failure is imminent. The system will pass inspection if the existing septic tank Is 'replaced with a complying septic tank as
approved by the Board of Health.
i
Sewage backup or breakout or high static water level observed In the distribution! box is due to broken or obstructedi e(s)
or due to a broken, settled or uneven distribution box. The system will pass inspectionapproval of the Board if (with a p of f
Health).
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 ( i approval of the Board of Health): . .
broken pipe(s) are replaced
obstruction is removed
I
re,lsed 9/2/98 Page 2of11
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
/�` ,,/ /t-c.(�.� CERTIFICATION (continued)
Property Address: // O/U r)
Owner: Char -K
Date of Inspection/)VR9M t7
C. FURTHER EVALUATION IS REQUIRED BY THE BOARD OF HEALTH:
NConditions exist which require further evaluation by the Board of Health in order to determinelif the system is failing to protect the
public health, safety and 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 THE PUBLIC HEALTH AND SAFETY AND THE ENVIRONMENT:
Cesspool or privy is within 50 feet of surface water
Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh.
21 SYSTEM WILL FAIL UNLESS THE BOARD OF HEALTH (AND PUBLIC WATER SUPPLIER, IF ANY) DETERMINES THAT THE SYSTEM IS
FUNCTIONING IN A MANNER THAT PROTECTS THE PUBLIC HEALTH AND SAFETY AND THE ENVIRONMENT:
The system has a septic tank and soil absorption system (SAS) and the SAS is within 100 feet of a surface water supply or
tributary to a surface water supply.
The system has a septic tank and soil absorption system and the SAS is within a Zone I of a public water supply well.
The system has a septic tank and soil absorption system and the SAS is within 50 feet of a private water supply well.
The system has a septic tank and soil absorption system and the SAS is less than 100 feet but 50 feet or more from a
private water supply well, unless a well water analysis for coliform bacteria and volatile organic compounds indicates that the
well is free from pollution from that facility and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less
than 5 ppm. Method used to determine distance (approximation not valid).
3) OTHER
A
revised 9/2/98 Page 3ortl
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION (continued)
Property Address: `5 olvwrlGaal
Owner: Clark,
Date of Inspection: '31 Awd 99
D. SYSTEM FAILS:
Yoh ynust indicate either "Yes" or "No" to each of the following:
I have determined that one or more of the following failure conditions exist as described 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 correct the failure.
Yes f�o�
Backup of sewage into facility -or system component- due�to an overloaded or-cloggedd-SAS or -cesspool.
i
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 S4S 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 times pumped
L Any portion of the Soil Absorption System, cesspool or privy is below the high groundwater elevation.
_ Any portion of a cesspool or privy is within 100 feet of a surface water supply or ;tributary to a surface water supply.
Any portion of a cesspool or privy is within a Zone I of a public well.
Any portion of a cesspool or privy is within 50 feet of a private water supply well:
A4 Any portion of a cesspool or privy is less -than 100 feet but greater than 50 feet from a private water supply well with no
acceptable water quality analysis. If the well has been analyzed to be acceptable; attach copy of well water analysis for
-coliform bacteria, volatile organic -compounds, ammonia nitrogen and nitrate nitrogen.
E. LARGE SYSTEM FAILS:
You must indicate either "Yes" or "No" to each of the following:
\ The following criteria apply to large systems in addition to the criteria 0161ve:
system serves a facility with a design flow of 10,000 gp r greater (Large System) and the system is a significant threat to public
th.and safety and the environment because one or a of the following conditions exist: •
Yes No
the system is - hin�400
the system is wit 'rf200
the sys is located in a
we supply well)
of f a surface drinking water supply
t of a tributary to a surface drinking water supply, -
rogem ensitive area (Interim Wellhead Protection Area : IWPA) or a mapped Zone II of a public
The owner or erator of any such system shall upgrade the system -1 accordance with 310 CMR 15.304(2). Please consult the local regional
office of a Department for further information.
revised 9/2%98 Page 4of11
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART B I
CHECKLIST
Property Address: lorOlaf C qr' � wQY
Owner:
Date of Inspection: A -44,0 d) 99
Check if the following have been done: You must indicate either "Yes" or "No" as to each of the following:
Yes JC No
Pumping information was provided by the owner, occupant, or Board of Health.
_ None of the system com one t h
p n s ave been pumped4oratJeast two weeks and -the system has -been -receiving rwrmal 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 receive 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 manholes were uncovered, opened, and the interior of the septic tank was inspected for condition of baffles
or tees, material of construction, dimensions, depth of liquid, depth of sludge, depth of scum.
The size and location of the Soil Absorption System on•the site has been determined based on:
— Existing information. For example, Plan at B.O.H.
Determined in the field (if any of the failure criteria related to Part
115.302(3)(b)] C is at issue, approximation of distance is unacceptable)
The facility owner (and occupants,if different from. owner) :were.provided.with information.on.U�e.proper rnaintena�f
SubSurface Disposal Systems.
i
revi-sed 9/2/98
Page 5 of I1
SUBSURFACE SEWAGE DISPOSAL SYSTEM I
PART C NSPECTION FORM
H SYSTEM INFORMATION
' operty Address
Owner: .60rk
Date of Inspection: S114 -114X j,t 14X n�
RESIDENTIAL- FLOW CONDITIONS
Design flow: 499•p•d•/bedroom.
Number of bedrooms ( e ign):� Number of bedrooms (actual): Al
Total DESIGN flow
Number of current residents0(e
Garbage grinder (yes or no):
Laundry (separate system) or
of
Laundry system inspected or If'yes, separate inspectionrequired
Seasonal use (yes or no):.a:YL! Q
Water meter readings, if available (last two year's usage (gpd): 01/-9> C�z n
Sump Pump (yes or no):m 7�r y/S U. O -71P
z�—
Last date of occupancy:t
Design flo-Wa , ---
Basis of design ti
Grease t;ap present:
Industiial Vaste Holding
Non -sanitary waste discl
Water meter readings, if
Last date of occunancue
OTHER:
Last dat
occupancy:
or no)
( Based on 15.
'r(yes or no)_
Title 5 system: (yes or no),_
GENERAL INFORMATION
PUMPING RECORDS and source of information:
System pumped as partof inspection: (yes or
If yes, volume pumped:' ----- gallons
Reason for pumping: -
TYPE OF SYSTEM
S Septic tank/distribution box/soil absorption system
IV_ Single cesspool
Overflow cesspool
Privy
Shared system (yes or no) (if yes, attach previous inspection records, if any)
I/A Technology etc. Attach copy of up to date operation and maintenan
Tight Tank Copy of DEP Approval ce contract
Other
APPROXIMATE AGE of all components, date installed iif known) and source of information: ,
Sewage odors detected when arriving at the site: (yes or no)
revised 9/2/98
Page 6 of ti
i
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTIOWFORM
PART C
SYSTEM INFORMATION (continued) .
Property Address: 17,5o161 cart
Owner: C/ark J
Date of Inspection 31 MgRC�i
BUILDING SEWER:
(Locate on site plan)
u
Depth below grade:,
Material of construction: _ cast iron 240 PVC _ other (explain)
Distance from priyate water supply well or suction line
Diameter
Comments: (yondition of joint vgnting evidence of leakage, -etc.)
X/^ f'i/00n el � /o.� fir. ,s --
SEPTIC TANK:�eS
(locate on site p an)
Depth below grade: 141
Material of construction: _✓concrete _metal _Fiberglass _Polyethylene _other(explain)
i
Ifaank is metal, list age Js.age.confirmed-
by Certificate of Compliance — (Yes/No)
Dimensions:In L X Scr� X S /,/ n eI /�II/P%'T y /SDD .91 / T4.7k .
Sludge depth:
Distance from top of sludge to bottom of outlet tee or baffle:
Scum thickness:
Distance from top o scum to top of outlet tee or baffle:--5-
Distance
affle:—Distance from bottom of scum to bo 0 of outlet tee or ba le3_F—
How dimensions were determined;
Comments:
(recommendation for pumping, ondition o m t and outlet tees of ba les, epth liq el in relation to outlet invert,
evOence of legkage„dtcJ �s0 /.#I IP� �iJ�✓ .viT/v.L •. ��
GREASE TRAP , &_
(locate on site plan)
Depth w grade:_
Material of struction: _concrete _metal _Fiberglass
Dimensions:
Scum thickness:
Distance from top of scum to of outlet tee or be I�
Distance from bottom of scum to ttom of out te
to or baffle:
Date of last pumping:
Comments:
(recomm d t' f
_other(explain)
en a ion or. pumping, ndition of inlet an utlet tees or baffles, depth of liquid level in r
evidence of leakage, etc.) to outlet invert, structural integrity,
revised 9/2/98
Page 7 of 11
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Property Address:
Owner:
Date of Inspection:
31 Amlzch
TIGHT OR HOLDING TANK
(Tank must be pumped prior to, or at time of, inspec 'oh)
(locate site plan)
Depth below gra
Material of constructs concrete metal Fiber lass _Pol et
y �y ene _other(explain)
/ I
Capacity: gallons
Design flow: gallons/day
Alarm present
Alarm level: Alarm in wor ing order. Yes
Date of previous pumping:
Comments:
(condition of inlet tee, ndition of alarm and float switches, etc.)
DISTRIBUTION BOX S � � OW
(locate on site plan) f
Depth of liquid levet above outlet invert: r
,omments:
'note if level aDd di tributi n is equ I, ev%'den} pf solids.carryover, evid@�ce of leakage into or out of ox, etc.)_
PUMP CHAMBEi:-
(locate o "sitteplan)
Pumps in working or (Yes or No)
Alarms in working order ( r No)
Comments:
(note condition of pump chambpr o dit• n of pumps and appurtenances, etc.)
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
?roperty Address: /73 0/d Carl &aX
Owner;
Date of Inspecti
SOIL ABSORPTION SYSTEM (SAS) Y
(locate on site plan, if possible; excavation not required, location may be approximated by non -intrusive methods)
If not located, explain: ^ 11
Type:
leaching pits, number:_
leaching chambers, number:
leaching galleries, number:
leaching trenches, number, length: �5Q L
leaching fields, number, dimensions: �C
overflow cesspool, number:_ ✓��
Alternative system:
Name of Technology:
Comments:
(note condition of soil, signs of hvdraulic fAilura ia.,oi of ,.—
",CESSPOOLS:
(I to onsite plan)
Number .r
Depth-top of uid to inlet invert:
Depth of solids la r:
Depth of scum layer:
Dimensions of cesspool: _
Materials of construction:
Indication of groundwater:
inflow (cesspool ust be p ped as part of inspection)
Comments:/ N
(note coo ion of soil, signs of hydraulic failure, level
P IVY:
(I! on site plan)
Materials of co truct
Depth of solids
Comments:
(note condition ofsoil
I
condition of vegetation, etc.)
i
failure, level of ponding, condition of vegetation; etc.)
revised 9/2/98 Page 9of11
Dimi ensions•
i
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
`roperty Address: �7S Old ar�r/ to"a(/
Owner: elark. �/
Date of Inspection:
SKETCH OF SEWAGE DISPOSAL SYSTEM:
include ties to at least two permanent reference landmarks or benchmarks
locate all wells within 100' (Locate where public water supply comes into house)
revised 9/2/98
i j alp .
4�a
Douse
r° �cj
D�o( Car�Wa
_y
Page 10 of 11
led ger
32IS"
a �o T1
A
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
,3roperty Address: /15D/c� Carl
Owner: mar k. -
Date of Inspection3`
NRCS Report name
Soil Type_ /
Typical depth to groundwater
USGS Date website visited
Observation Wells checked
Groundwater depth: Shallow Moderate
SITE EXAM Slope ld ?? ,J
Surface water Aon.e,',
Check Cellar rtes ) Ury
Shallow wells J
Estimated Depth to Groundwater _ Feet
Please indicate all the methods used to determine High Groundwater Elevation:
!/Obtained from Design Plans on record
/Observed.Site (Abutting property, observation hole, basement sump etc.)
VDetermined from local conditions
Checked with local Board of health
Checked FEMA Maps
Checked pumping records
_Checked local excavators, installers
/
✓ Used USGS Data +
i
p
i
0
Describe how you established the High Groundwater Elevation. (Must be completed)
l f� /t;) SU/�1 P1VMP iiJ �JQ Seh�erl Sehi 1 '
p� 40 Sl9h s
'5 rsTem, `4erc was ho l��cc� lorJ o�wk-'
lard is 1v>ell Jwrr��Jh�
r
ProI� s 14)41E wig1y rsrr
Alb W1.013 or l�tA,QS�je 5 w � in Om S ,STew(
y
"A
revised 9/2/98 Page 11 of 11
I
BOARD OF HEALTH
January 22, 1993
120 MAIN STREET TEL. 682-6483
NORTH ANDOVER, MASS. 01845 Ext. 32
JAN 2 5
'rEP-JCE SAV?„C s 8
Les Godin .fiij
Merrimack Engineering Services, Inc.
66 Park Street
Andover, MA 01810
Dear Les:
This is to confirm that at the Board of Health meeting held
on January 21, 1993, the Board granted variances to North Andover
regulations: 2.14-4, minimum design flow for single family
dwellings, for Lots 1 and 18 Old Cart Way; 17.03, spacing between
leach trenches for Lots 8, 10, 11, and 14 Old Cart Way; 4.18
distance to a catch basin for Lot 5 Old Cart Way; 4.14 to allow a
twenty minute design rate.
With these variances, all current lots on Old Cart Way have
been approved, specifically, Lots 1, 2, 4, 5, 6, 7, 8, 9, 10, 11,
12, 13, 14, 15, 16, 17, 18, 19, 20 and 21.
If you have any questions, please do not hesitate to call. -
Sincerely,
Sandy Starr
Town of North Andover, Massachusetts Form No. 3
NORTH
BOARD OF HEALTH
f , r
o� 9
O 9
K i
DISPOSAL WORKS CONSTRUCTION PERMIT
,SgACHUSEt
Applicant�:�C-)Gr �L �
NAME ADDRESS TELEPHONE
Site Location `-C�k 0 t L C ri 1. ➢ o-.A—
Permission is hereby granted to Construct (� or Repair ( ) an Individual Soil Absorption
Sewage Disposal System as shown on the Design Approval S.S. No.
Fee 150
EL
CH MAN, BOARD OF HEALTH
D.W.C. No. -)30
t; .t�+ � .! tt 1 11 .., t .t •y.t �v '�'4 +sky (1�'1 .F t tit. �r.� ) f t r t n � - �-` .� ' �.
I t\ r' -
+j1y��klt..�`
�-`• ez i � Al ! 1 i' ` �''f ll "h � � �_ � �� � w L.'cCll \ 'f i a y { � \t 'x t . . +, l ! . ♦ � , !.� �+ i
�_ �yr „� }yi \ 1, i ' ..�A E �r. \t � !1 '1 �\ ii -1' �_- � 1 ♦ s+i '. r " l� '
..+'.aa'`�.. .h...� .'� .. �+l,cr:1"S- ;o."i,'.���T��Y.��:\�� 'e�• kb.,��'�.� �;SiS.�!��t �'�:K._A. ... X11.. �.. �_ t.t . _.. ?. ,!-.�.� ,. ,..�. �.i..S: ? �..S i:S:. ..
C d7' ~'` 49.7 E'tir-
ova
N 2 eve, oB b
A
co LO
00 �
EPT G TA
AS BUILT PLAN
OF
SUBSURFACE DISPOSAL SYSTEM
LOCATED IN
NIOR 7Ty A /vo 6 ve-1<f MA
AS PREPARED FOR.
DATE:
SCALE: 10 '(7 2)dc
IZZ
.T "A45
MERRIMACK ENGINEERING SERVICES, INC.
PROFESSIONAL ENGINEERS • LAND SURVEYORS 0 PLANNERS:
66 PARK STREET 0 ANDOVER, MASSACHUSETTS 0181'0 • TEL. (51-19) 475.3355, 373.5721
F Z C V A // O A45
ScPi/C TAN r-
fi N
—�
r�
7 -OF
of FaUNPA-Tid&(
MANHOLC covEK
3 L2, S '
3 '
fz Al/
D/ST"- &Ox
38,b
g� O
.
r 7I /A/ 56 TlCTANK
/7-� 78
�c6 !� rR � /
o
�. �. a �
'I
ouT `` �
= 17—i- 57
l��. /5,
/N a -moo x
174, 57 1
C AJO Tfe " /
9 7. O
,,
I, /3
74. 2 3
rt3
10.6
17. S. o
It
,. %3 EG/A% 7,PE�cI�'f(193
/74. 2 2
7 3. '17
?3.99
3
= /73 -/ -;
C d7' ~'` 49.7 E'tir-
ova
N 2 eve, oB b
A
co LO
00 �
EPT G TA
AS BUILT PLAN
OF
SUBSURFACE DISPOSAL SYSTEM
LOCATED IN
NIOR 7Ty A /vo 6 ve-1<f MA
AS PREPARED FOR.
DATE:
SCALE: 10 '(7 2)dc
IZZ
.T "A45
MERRIMACK ENGINEERING SERVICES, INC.
PROFESSIONAL ENGINEERS • LAND SURVEYORS 0 PLANNERS:
66 PARK STREET 0 ANDOVER, MASSACHUSETTS 0181'0 • TEL. (51-19) 475.3355, 373.5721
PHONE CALL
FOR ��?�.�1 ,,.� GATE 1_�M PAVO P.M.
m
P.HONEO I
OF � - -
PHONE T47 , �✓ / OURCA�
ARE :OO EFER EXTENSION
PLEASE CALL
M ESSAG
1-0 WILL CALL
:AGAIN
CAME TO
SEE YOU
WANTS TO
SEE YOU
SIGNED TOPS FORS 4003
NOTES
s .$
1
4
Commonwealth. of Massachusetts RECEIVED
City/Town of I 2 5 200
System Pumping Record A
Form 4 TOWN OF NORTH DO R
HEALTH DEPART -N
DEP has provided this form for use by local Boards of Health.. The System Pumping Record must
be submitted to the local Board of Health or other approving authority. -
A. Facility Information
.Important:
When fining out 1. System Location:
forms on the �`
computer, use
only the tab key Address ,^ /
to move your / -7 �� v
cursor - do not City/Town l State
use theretum Zip Code
key.
2. System Owner:
' JU
Name
Address (if different from location)
Cityrrown Stat Zip Code"
Telephone Number
B. Pumping Record
1. Date. of Pumping 2Quantity Pumped -
Date Gallons
3. Type of system: E] Cesspool(s) ❑,eptk
�
❑ Tight.TaW
❑ Other (describe):
4. Effluent Tee Filter present? ❑ Yes ff No if yes, was it cleaned? ❑ Yes ❑ No
5. Condition of System:
6. System Pumped By
'
ANam Vehicle License Number
Company
.7. Loca " where contents ere disposed::
http://www.mass
t5form4.doc• 06103
�_
atu e f Hauler
p/ a r/approvals/t5forms.htm#inspect
107 Forest St.
Middleton, MA 01949
(508)774-2772
CO
I1'lIIlOAWP,aItj
FORA? 4 - SYSTEM PU1VNNIG RECORD--
�achusPttc
System Pumnin Ryrnrd
•stem
yztem "cation
�C
X75 d I cciv-f ��, N- N p6�c ..
25�gZ y
Date of pumping:
Quantity Pumped:Jj
—------_gallons
Cesspool: No ❑ Yes
❑ Septic Tank: No ❑ Yes
System Pumped bv.- CU's .Cw
Contents transferred to: License
Date
Inspector _
O
Town of North Andover
Health Department Date: olt� 0 ,6
White - Applicant Yellow - Health Pink - Treasurer
Location:
-
(Indicate Address, if Residential, or Name of Bmi
Check #: 7Jf (m
_�1
G7�
Type
of Permit or License: (Circle)
r ➢
Animal
$
➢
Dumpster
$
➢
Food Service - Type.-
ype:Funeral
FuneralDirectors
$
➢
Massage Establishment
$
➢
Massage Practice
$
➢
Offal (Septic) Hauler
$
'. ➢
Recreational Camp
$
i ➢
SEPTIC PERMITS:
❑
Septic - Soil Testing
$
❑
Septic - Design Approval
$
❑
Septic Disposal Works Construction (DWC) $
❑
Septic Disposal Works Installers (DWI)
$
➢
Sun tanning
$
➢
Swimming Pool
$
➢
Tobacco
$
➢
TrashlSolid Waste Hauler
$
➢
Well Construction
$
0-0
�0,
➢
OTHER: (Indicate)
Health Agent Initials
1544
White - Applicant Yellow - Health Pink - Treasurer
COMMONWEALTH OF MASSACHUSETTS
EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS
DEPARTMENT OF ENVIRONMENTAL PROTECTION
WCEvVIE®
APR 2 5 2006
I TOWN OLTH QEPARTANDOVER
O VER
TITLE 5
OFFICIAL INSPECTION FORM — NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM
PART A
CERTIFICATION
Property Address: _175 Old Cart Way _
—North Andover
Owner's Name: Graham Jones
Owner's Address: _175 Old Cart Way
_ North Andover, MA 01845_
Date of Inspection: 4/18/2006_
Name of Inspector: Ned J Bateson_
Company Name: Bateson Enterprises Inc.
Mailing Address: _111 Argilla Road_
_Andover, Ma. 01810_
Telephone Number: _( 978 ) 475-4786_
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 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:
X Passes
Conditionally Passes
Needs Fuqher Evaluation by the Local Approving Authority
F'
Inspector's Signature: Date: _4/18/2006_
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
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.
Page 2 of 11
OFFICIAL INSPECTION FORM — NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION (continued)
Property Address: _175 Old Cart Way_
_ North Andover_
Owner- —Jones—
Date
Jones_Date of Inspection: 4/18/2006
Inspection Summary: Check A,B,C,D or E / ALWAYS complete all of Section D
A. System Passes:
X 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 pipe(s) are replaced
obstruction is removed
ND explain:
Page 3 of 11
OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION (continued)
Property Address: _175 Old Cart Way-
– North Andover_
Owner: _Jones
Date of Inspection: _4/18/2006
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
2. System will fail unless the Board of Health (and Public Water Supplier, if any) determines that the
system is functioning in a manner that protects the public health, safety and environment:
The system has a septic tank and soil absorption system (SAS) and the SAS is within 100 feet of a
-surface water supply or tributary to a surface water supply.
The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water supply.
The system has a septic tank and SAS and the SAS is within 50 feet of a private water supply well.
The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or more from a
private water supply well". Method used to determine distance —
"This system passes if the well water analysis, performed at a DEP certified laboratory, for coliform
bacteria and volatile organic compounds indicates that the well is free from pollution from that facility and
the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other
failure criteria are triggered. A copy of the analysis must be attached to this form.
3. Other:
Page 4 of 11
OFFICIAL INSPECTION FORM — NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION (continued)
Property Address: _175 Old Cart Way _
_ North Andover_
Owner: _Jones
Date of Inspection: 4/18/2006
D. System Failure Criteria applicable to all systems:
You must indicate `yes" or `no" to each of the following for all inspections:
_ No Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool
No Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or
clogged SAS or cesspool
No Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or
cesspool
No_ Liquid depth in cesspool is less than 6" below invert or available volume is'h day flow.
_No_ Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s).
Number of times pumped
_ _No Any portion of the SAS, cesspool or privy is below high ground water elevation.
_ _No_ Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface
water supply.
_ _No_ Any portion of a cesspool or privy is within a Zone 1 of a public well.
_No_ Any portion of a cesspool or privy is within 50 feet of a private water supply well.
_No_ 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 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.]
_No_ (Yes/No) 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
YYou must indicate either "yes" or `no" to each of the following:
(The following criteria apply to large systems in addition to the criteria above)
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 Il 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.
Page 5 of 11
OFFICIAL INSPECTION FORM — NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART B
CHECKLIST
Property Address: _175 Old Cart Way _
_ North Andover _
Owner: _Jones _
Date of Inspection: 4/18/2006
Check if the following have been done. You must indicate "yes" or "no" as to each of the following:
Yes No
Yes_ _ Pumping information was provided by the owner, occupant, or Board of Health
_No Were any of the system components pumped out in the previous two weeks ?
Yes_ — Has the system received normal flows in the previous two week period ?
No Have large volumes of water been introduced to the system recently or as part of this inspection ?
Yes Were as built plans of the system obtained and examined?
Yes Was the facility or dwelling inspected for signs of sewage back up ?
_Yes _ Was the site inspected for signs of break out ?
_Yes _ Were all system components, excluding the SAS, located on site ?
_Yes_ _ 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 ?
_Yes_ _ 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:
Yes no
_Yes_ _ Existing information.
_Yes_ _ 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)]
Page 6 of 11
OFFICIAL INSPECTION FORM — NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION
Property Address: _175 Old Cart Way-
– North Andover–
Owner: _Jones _
Date of Inspection: _4/18/2006
FLOW CONDITIONS
RESIDENTIAL
Number of bedrooms (design): _4_ Number of bedrooms (actual): _4_
DESIGN flow based on 310 CMR 15.203 _600_
Number of current residents: _3
Does residence have a garbage grinder (yes or no): Yes_
Is laundry on a separate sewage system (yes or no): No_
Laundry system inspected (yes or no):
Seasonal use: (yes or no): _No_
Water meter reading: Yes _
Sump pump (yes or no): _No
Last date of occupancy: _Current
COMMERCIALtINDUSTRIAL
Type of establishment:
Design flow (based on 310 CMR 15.203): `gpd
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: Pumped two years ago, owner _
Was system pumped as part of the inspection (yes or no): _Yes_
If yes, volume pumped: _1500_ gallons -- How was quantity pumped determined? _Measured tank_
Reason for pumping: _Inspect tank & tees _
TYPE OF SYSTEM
X 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 known) and source of information: _11 years old, 6/12/1995,
as built plan _
Were sewage odors detected when arriving at the site (yes or no): No
Page 7 of 11
OFFICIAL INSPECTION FORM — NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Property Address: _175 Old Cart Way_
_ North Andover _
Owner: _Jones
Date of Inspection: 4/18/2006
BUILDING SEWER _ X _ (locate on site plan)
Depth below grade: _3'
Materials of construction: _ cast iron X_40 PVC _other
Distance from private water supply well or suction line:
Comments (on condition of joints, venting, evidence of leakage, etc.) 4" PVC thru wall. 3" PVC in house, no
leaks visible
SEPTIC TANKS: X
Depth below grade: _2' _
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: 10' x 5' x 4' _
Sludge depth: —3" _
Distance from top of sludge to bottom of outlet tee or baffle: 24" _
Scum thickness: _3"
Distance from top of scum to top of outlet tee or baffle: -
8" -Distance from bottom of scum to bottom of outlet tee or baffle: _1811
_
How were dimensions determined: _Tape Measure _
Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels
as related to outlet invert, evidence of leakage, etc Pumped septic tank. Inlet tee ok. Outlet tee ok. Depth of
liquid at outlet invert. No evidence of leakage. Center cover has riser 4" deep
GREASE TRAP: _(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 battle:
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: _175 Old Cart Way-
-
North Andover—
Owner: _Jones
Date of Inspection: 4/18/2006_
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.):
DISTRIBUTION BOX: _X_
Depth below grade 30"_
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.):_D-box level & distribution equal. No evidence of leakage. Evidence of
carryover. Pumped d -box to clean _
PUMP CHAMBER: _ (locate on site plan)
Pump in working order (yes or no):
Alarm in working order (yes or no):
Comments (note condition of pump chamber, condition of pumps and appurtenances, etc.):
Page 9 of 11
OFFICIAL INSPECTION FORM — NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Property Address: _175 Old Cart Way_
_ North Andover _
Owner: _Jones
Date of Inspection: _4/18/2006
SOIL ABSORPTION SYSTEM (SAS): X (locate on site plan, excavation not required)
If SAS not located explain why:
Type
leaching pits, number: _
leaching chambers, number: —
leaching galleries, number:
X_ leaching trenches, number, length: 3 trenches 50' long_
leaching field, number, dimensions:
overflow cesspool, number:
innovative/alternative system Type/name of technology:
Comments (note condition of soil, signs of hydraulic failure, level of ponding damp soil, condition of vegetation,
etc.): _ Soil oL Vegetation ok. No sign of ponding to surface. _
CESSPOOLS:
Number and configuration: _ _
Depth —top of liquid to inlet invert: _
Depth of sludge 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)
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 11
OFFICIAL INSPECTION FORM — NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Property Address: _175 Old Cart Way_
North Andover—
Owner: _Jones
Date of Inspection: 4/18aW
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.
Page 11 of 11
OFFICIAL INSPECTION FORM — NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Property Address: _175 Old Cart Way _
_ North Andover—
Owner: _Jones _
Date of Inspection: _4/18/2006_
SITE EXAM
Slope
Surface water
Check cellar
Shallow wells
Estimated depth to groundwater _ 4' _
Please indicate (check) all methods used to determine the high ground water elevation:
X Obtained from system design plans on record - If checked, date of design plan reviewed: _5/13/1986
Observed site (abutting property/observation hole within 150 feet of SAS)
Checked with local Board of Health -explain: _
Checked with local excavators, installers- (attach documentation)
Accessed USGS database -explain:
You must describe how you established the high ground water elevation: No water 4' deep as per design plan
test pit data. _
0
Summary Record Card generated on 4/13/2006 1:56:40 PM by Elaine Barclay
Town of North Andover
Tax Map # 210-107.B-0106-0000.0
175 OLD CART WAY
JONES, GRAHAM
175 OLD CART WAY
NORTH ANDOVER, MA
01845
Page 1
Class 101 Single Family
Property Type
1 Residential
Size Total 1.01 Acres
FY 2006
UB Mailing Index
Name/Address
Type
Loan Number
Active/inact. From
Until
JONES, GRAHAM
Payor
175 OLD CART WAY
NORTH ANDOVER, MA
01845
UB Account Maint.
Account No Cycle
Occupant Name
Active/Inactive
Bldg Id. 13792.0 - 175 OLD CART WAY
Last Billing Date 2/3/2006
1090469 01 Cycle 01
Active
UB Services Maint.
Service Code
Rate
Charge
Multiplier/Users
MISCFEE ADMIN FEE
0.635/8
7.82
1/
WTR WATER
01 ALL METER SIZE 67.80
/1
UB Meter Maintenance
Serial No Status
Location
Brand
Type Size
YTD Cons
32772691 a Active
ERT HH
b Badger
w Water 0.63 0.63
Date Reading
Code
Consumption
Posted Date
Variance
1/24/2006 0
n New Meter
0
2/13/2006
-100%
1/24/2006 - 2516
r Replacement
20
2/13/2006
-81%
10/27/2005 2496
a Actual
112
11/9/2005
243%
Trouble Code:03
7/25/2005 2384
a Actual
33
8/10/2005
83%
4/21/2005 2351
a Actual
15
5/13/2005
-20%
2/1/2005 2336
a Actual
23
2/15/2005
-22%
Trouble Code:03
10/27/2004 2313
a Actual
26
11/15/2004
-63%
Trouble Code:03
8/3/2004 2287
a Actual
70
8/25/2004
204%
Trouble Code:03
5/10/2004 2217
a Actual
26
6/8/2004
10%
2/4/2004 2191
, a Actual
23
2/24/2004
0%
11/3/2003 2168
n New Meter
0
11/3/2003
0%
Tel: (978) 475-4786
Fax: (978) 475-5451
BATESON ENTERPRISES, INC.
Excavating -Water.& Sewer Lines -Septic Systems & Pumping Service
111 Argilla Road Andover, Mass. 01810
Title 5 Inspection Report
Property Address: 175 Old Cart Way
Owner: Jones
Date of Inspection: 4/18/2006
My report contained herein does not constitute a guarantee of future usage and the functionality of the existing
septic system. Such report issued herewith is merely based upon my observations, and I hereby disclaim any further
operation of your current septic system.
UBson Neil
Bateson Enterprises, Inc.
Commonwealth of Massachusetts
City/Town of
System Pumping Record
Form 4
DEP has provided this form for use, -by local Boards of Health. Other forms may be used, but the
information must be substantially the same as that provided here. Before using.this form, check with your
local Board of Health to determine the form they use. The System Pumping Record must be submitted to
the local Board of Health or other approving authority.
A. Facility Information
1. System Location: Left / Right front of house, Left / Right near of house, Left AjI side of hous , Left /
Right side of building, Left / Right front of building, Left / Right rear of building, Under deck
Address Las
Cityrrown state `— P
Zi Code
2. System Owner.
P
Name
' atel
Address (if different from location)
Cilylrown State Zip Code
Telephone Number
B. Pumping Record
1. Date of Pumping
3. Type of system.-
0
ystem:
❑ Other (describe):
l–` 2 Quantity Pumped:
Date Gallons
Cesspool(s) Septic Tank ❑ Tight Tank
4. Effluent Tee Filter present? ❑ Yes
5. Condition of System:
6. System Pumped By.
7.
t5form4.doe- 06/03
Neil Bateson
Name
Bateson Enterprises Inc
Company
where contents were disposed:
No If, yes, was it cleaned? , —
VE
v ` MAY 2 7 2014
AF NORTH ANDOVER
F5821
Vehicle License Number
System Pumping Record • Page 1 of 1