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HomeMy WebLinkAboutMiscellaneous - 175 STONECLEAVE ROAD 4/30/2018 (2),C'\ Commonwealth of Massachusetts Cityffown of North Andover SyPumping Record Fon 4 DEP has provided this form for use by local Boards of Health. Other e ore using thisorms may be uform,b heck with your ut the information must be substantially the same as that provided here 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. System Location: on the computer, use only the tab key to move your Address cursor- do not North Andover use the return City/Town key. &1 2. System Owner: t mrm Name I-15 Address (if different from location) C•ityrowh'' Ma - rC " 886 State G �p Code ��� 15 2015 State Telephone Number Zip Code B. Pumping Record 1-S%55IG I" 2. Quantity Pumped: gallons 1. Date of Pumping Date ❑ 3. Type of system: ❑ Cesspool(s) Septic Tank ❑ Tight Tank Grease Trap ❑ Other (describe): 4. Effluent Tee Filter present? ❑ Yes ❑ No 'If.yes, was it cleaned? ❑ Yes ❑ No 5. Condition of System: 6. S em Pumped.By: Name Stewart's Septic Service Company 7. Location where contents wer �osed: of nature of Receiving Facilely t5form4.doc- 03/06 Vehicle License Number So. Mill Bradford, Ma 01835 Date Date System Pumping Record - Page 1 Commonwealth of Massachusetts City/Town of No Andover ��� � � ?Q11 � TOWN OF N1rOVERSystem Pumping Record HEAL7P � "IPTWHcNT 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 you local Board of Health to determine the form they use. The System Pumping Record must be submitted t( the local Board of Health or other approving authority within 14 days from the pumping date in accordance with 310 CMR 15.351. Address (if different from location) Ma State City/Town State Telephone Number B. Pumping Record 1. Date of Pumping L p g � 2. Quantity ed: Date tY Pum P 3. Type of system: ❑ Cesspool(s) /❑Septic Tank ❑ Tight Tank ❑ Other (describe): 4. Effluent Tee Filter present? ❑ Yes ❑ No 5. Condition of System: 6. S stem Pumped By: S7rt Name Stewart's Septic Service Company 7. Location where contents were disposed: Stewart's re -treatment Plant 20 So Mill Bradfoi Zip Code Zip Code Gallons ❑ Grease Trap !f yes, was it cleaned? ❑ Yes ❑ No Vehicle License Number Ma 01835 Date Date t5form4.doc- 03/06 System Pumping Record • Page 1 of 1 A. Facility Informati®n Important: When filling out forms 1. System Location: on the computer, j - use only the tab key to move your Address cursor - do not use the return No Andover key. City/Town VkA 2. System Owner: ream r Name Address (if different from location) Ma State City/Town State Telephone Number B. Pumping Record 1. Date of Pumping L p g � 2. Quantity ed: Date tY Pum P 3. Type of system: ❑ Cesspool(s) /❑Septic Tank ❑ Tight Tank ❑ Other (describe): 4. Effluent Tee Filter present? ❑ Yes ❑ No 5. Condition of System: 6. S stem Pumped By: S7rt Name Stewart's Septic Service Company 7. Location where contents were disposed: Stewart's re -treatment Plant 20 So Mill Bradfoi Zip Code Zip Code Gallons ❑ Grease Trap !f yes, was it cleaned? ❑ Yes ❑ No Vehicle License Number Ma 01835 Date Date t5form4.doc- 03/06 System Pumping Record • Page 1 of 1 Commonwealth of Massachusetts City/Town of No Andover M.AY '14 2013 a System Pumping Record TOWN Q`NORTH ANDOVER HEALTH DEPARTMENT Form 4 M Svayv' 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. CityTrown _-- Ma State State Telephone Number Zip Code Zip Code B. Pumping Record 1. Date of Pumping2. Quantity.Pumped: Date Gallons 3. Type of system: ❑ Cesspool(s) ET"Septic Tank ❑ Tight Tank ❑ Grease Trap ❑ Other (describe): 4. Effluent Tee Filter present? ❑ Yes ❑ No 5. Condition of System: i 6. System Pumped By: Name Stewart's Septic Service Company 7. Location where contents were disposed: If yes, was it cleaned? ❑ Yes ❑ No Vehicle License Number Stewart's Pre-treatment Plant, 20 So. Mill Bradford, Ma 01835 Signature of Receiving Facility Date Date t5form4.doc• 03/06 System Pumping Record •Page 1 of 1 A. Facility Information Important: When filling out forms 1. System Location: on the computer, use only the tab 175 Stone Cleave Rd key to move your Address cursor - do not No Andover use the return key. City/Town 2. System Owner: Depari Name rerun Address (if different from location) CityTrown _-- Ma State State Telephone Number Zip Code Zip Code B. Pumping Record 1. Date of Pumping2. Quantity.Pumped: Date Gallons 3. Type of system: ❑ Cesspool(s) ET"Septic Tank ❑ Tight Tank ❑ Grease Trap ❑ Other (describe): 4. Effluent Tee Filter present? ❑ Yes ❑ No 5. Condition of System: i 6. System Pumped By: Name Stewart's Septic Service Company 7. Location where contents were disposed: If yes, was it cleaned? ❑ Yes ❑ No Vehicle License Number Stewart's Pre-treatment Plant, 20 So. Mill Bradford, Ma 01835 Signature of Receiving Facility Date Date t5form4.doc• 03/06 System Pumping Record •Page 1 of 1 Commonwealth of Massachusetts u City/Town of No andover System Pumping Record ,M 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. A. Facility Information Important: When filling out forms 1. System Location: on the computer, 177 use only the tab key to move your Address cursor - do not use the`return No Andover - key. r� ' r 2. System Owner — F-�n M Name — Address (if different from location) City/Town Ma State Zip Code State I RECENED JUN 212012 TOWN OF NORTH ANDOVER Telephone Number B. Pumping Record 1. Date of Pumping Date 2. Quantity Pumped: 3. Type of system: ❑ Cesspool(s) Septic Tank ❑ Tight Tank ❑ Other (describe): ty-0-0 Gallons ❑ *Grease Trap 4. Effluent Tee Filter present? ❑ Yes a -No If yes, was it cleaned? ❑ Yes ❑ No 5. Condition of System: e G0 offG a N � 6. System Pumped By: Name Stewart's Septic Service Company 7. Location where contents were disposed: Stewart's Pre-treatment Plant, 20 So. Mill Bradfol Signata of a er It A /'//� Sign ure eceiving Facility t5form4.doc• 03/06 1 - Vehicle License Number Ma 01835 Date Date System Pumping Record • Page 1 of 1 , ?rT' �rC r t sil�cY i ,-- � i•: ,-.:�,st .1-�//[jjJ�/'; /N � a TOWN OF NORTH ANDOVER SYSTEM PUMPING RECORD j,q, DATE - t e SYSTEM nWNFi2 .er A1111DTJ CQ In�s.....�.. _ . --- 4 (example: left front of house f D�,tAyOF-PUMPING: q F �P'tU<s MP- rP.I...N•;Gt :� t . � '1.�TE. QUANTITY �TY P.,.UMPED ' - __ .... ' --aold GALLONS j��d�µ]��Jt.&'*,.{•� s[,J'�%n ^r I^n'TP+, �I �. !+ ESSPOOL: NO _ YES SEPTIC TANK: NO YES J T.+ NATUREOF SERVICE: ROUTINE _ %\ EMERGENCY �+Y OBSERVATIONS: GOOD CONDITION '\ FULL TO COVER y HEAVY GREASE BAFFLES IN PLACE 3 J ROOTS LEACHFIELD RUNBACK r +' EXCESSIVE SOLIDS ' F FLOODED I , SOLIDS CARRYOVER -OTHER (EXPLAIN) } , i Y Zy,`+pr1t��.'7`�3 P , I�SXSTEM PUMPED BY. ,1Jxit 77'�rY.j&j.FsyryY,t r?.'M� Gr HEALTH 'OINTMENTS: �f.1j t.4r}yr*4 `3y1��; �ystlt - �J V =JCCONTENTRANSFERRED D TTS I f ?rT' �rC r t sil�cY i ,-- � i•: ,-.:�,st .1-�//[jjJ�/'; /N � a �Idn1i,�Y.•t ". :. ;�•�� 31 nc•q... R.pAft 170.1 njp 7 V0. my .:�Yi• _ ��- 1. . 1 . • Crlrat�s�-{�-err,; .c� .—• - - — ' �j,(et Y. yr s )r :rR e c o r• Vly�'I �' 1� .�• "J Ir ,l :�d����, Jl. �1��,1��ii1i� �Vi\11'.Ir,l.!,,;.�'� l.d .� ;' , ,r.' DEP._ha� provided form'for u a o by local Board>f of Health. The SWPum ' ba +ubmltjed to the.(OC aI Board of Health or ocher a rovin y �1''° A; Faclllty lnfofitatIon j04A NU19 out'...', t, :: SY$Wm LOCBtlon: a�ly In e ltD kc y AM V) rn o o y oo , AMA) / ° �j�l e� tee, — c,:rz� wl r I L�f use retum:y;c CItY/Tavn ,. State Yr ;V:,S�I 'r.�•li� .St/slem own or.., • ,���'�'',�:'i'iTi;�;/rl;�,;1�,�.,'.%iilTll';�4a�ti•�•.,.rh,�j"1/,• '..,..5.• �''' :i�r'/Wdre+� (II dlNerenl rcvn bcaUon) ���� r.� Ccaa _. SON' O��N blo no Numoor •:,tri, c.' S;' ",,..,, oNIN�`� • ,.r ��,- RumpJng Rer�fo�d Dah of Pumpinp`' 'r 'Type Pl ayalam ❑ . Ce99p001(9� • ❑ Other �..'.� c be •'' Effluayh,! Tea F!Ile(Presenr7.❑ Yas o • - ' y v �•a��,{r�•,�rs'r��r'y),;'/llr/ll r' •'l `�'.,,�.`ts ',, • j.6,11;Cofidl�lon'Q.(;SY. ��9m,,: �•,: . - - , 'i>�•e• ,%r n, �•Qi �.'rL, y;'IJ�/(•` ��•1%rr I �.I ,� �1'�,rt' tr r "• Ci ...,.��.1.q•ul:`•���'`;c„ir;l,'i,arJl.11�.�,.'�.'t.:��' .. ,�. ',;�y'a11,.�,�:�`rl;, � J � �' t���, �1'I'J tfi'•�`�,'r ..L:', . ., ;•+•r"�; n�.i�rr`,r.,.•`�i� fH'I�yaA lt�'�la� �:���dl;f'��1,1��,���1%r',�,��fi���.'�., . . I'.i, Loci , W.on.where co�lentS',Were d!,�posad; ;•;::•h:�;.;,;:�ul>~���',''1 Sbnelwe olHeub �-•--- hr J/www'mess,9ov/dsphveler/approva�aJi6fOrMs,hVn#Inspect -- 2. Quan* Pumped pflc Tank J 311onJ ❑ Tight Tank it yes, was Il cleaned? ❑ Yes El n. I Vahlcla Ucen�e Number SyHam Pwnpinp Rac:;rr ' =: ; , - achusetts . . . . . . . . . . . . . A t 'ity/Town o NORTH ANDOVER MASSA System Pumping Recoird Nov 13 2006 TOWN OF NORTH ANDOVER DEP. has provided this form for use by local Boards of Heal h®� Rt vidf to ecord must be submitted to the local'Board of Health or other approving authority. A: Facility Information ,Important: . , ;_When filling out 1. System Location: foirns. on the'. computer, use only the tab key Address to move your cursor -do not use the return City/Town State Zip Code key.::..... .:.. ; 2.System Owner. Name Address (if different from location) CitylTown state�7U (��OC/a` Telephone Number B.- Pumping Record Date-of Pumping 2. Quantity Pumped. dna Date � Gallons 3. ype of system:. C]Cesspool(s) D Septic Tank ❑ Tight Tank ❑ " Other (describe): 4. Effluent Tee Filter present?. ❑ Yes. G?"No If yes, was it cleaned? ❑ Yes ❑ No 5. Condition of System: t5fomA.doc- 06/03 System Pumping Record • Page 1 of 1 •`'�!� .'�tiy,.r:%::i.•aY'1�6�Y.iC�J,16;r�c'i(�;'�: • .!�Y::i ,: •:�'. •ri,'•: r`� Vit' ;� �`�•:YVj�•h•:v �:�.j'.'�•` ; L,•' .. :,r. �^"r � : y,1, .. pr�i,tyi'�:rY tr.!� N'Y•w• 1:. f'•r •• . ' ,9,r,• • fC)wN u� NUx1'It / J 1 u -A t'� / Qj SY9'T`>a�,•1 PIJMPINU UC REI VED DEC 06200 i TOWN OF NORTH ANDOVER HEALTH DEPARTMENT ADOREU 17 7TI OP Pppt„ NA rVX� op 3�xYlc.�ej x�urlN� RZAYY 08a'118J xC sNo SOI,IpB, PLo�OD U0 SOLfDCAIVSYO1�� �....ONER•EXPLAIN �'VMMrrNT�. y. COMMONWEALTH OF MASSACHUSETTS EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS DEPARTMENT OF ENVIRONMENTAL PROTECTION TITLE 5 OFFICIAL INSPECTION FORM — NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM PART A CERTIFICATION r /Q .S' S�`c.Lc. GL>' mac. Property Address: e /VD . l u #L 1. Owner's Name: r e e— Owner's Address: Date of Inspection: ^"2 'G Name of Inspector: lease print) To /i L h0i cc w i a Company Name: Mailing Address: 7 Telephone Number: 5126 ? 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 Secti n 15.340 of Title 5 (310 CMR 15.000). The system: asses Conditionally Passes Needs Further Evaluation by the Local Approving Authority Fails Inspector's Signature: ate: ai The system inspector shallOdbmit 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. HtJ �E—BOARD1.)�FF 'AtU E�R/ Notes and Comments 'IN 12 2001 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 �"hepfuture_under the same or different conditions of use. Title 5 Inspection Form 6/15/2000 page 1 air —:�age 2 of 11 r �w ` OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION- (continued) Property Address: % s l -t ��. &4 l�I Owner: �!.' % a, - Date of Inspection:V,5­,9 / –G Inspection Summary: Check A,B,C,D or E / ALWAYS complete all of Section D A. System Passes: ave 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. 11Comments: 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: --w--Observation-of sewage�ackup-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): ND explain: broken pipe(s) are replaced obstruction is removed 2 Page 3 of 11 -4 w OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: / 7r S jOr-xe G -e � A0 .4N overi:— Owner: a r Date of Inspection: ,s" ?/– o j 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 unlel's'8pard of health determines in accordance with 310 CM11.15.303(l)(b) that the it system is not functioning in a manner which wilfprotect 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 *'phis -system passAf.iherwell,water analysis,.perforrtred at a:DEP certified laboratory for. coliform bacteria and volatile organic compounds indicates that the well is free from pollution from at 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: O Gc,L Ud /V Gc.t Owner: r Date of Inspection: -G D. System Failure Criteria applicable to all systems: You must indicate "yes" or "no" to each of the following for.all inspections: . Yes backup of sewage into facility o system component due to overloaded or clogged SAS or cesspool; _ V Discharge or ponding of effluent to the surface of the ground or surfac' waters due to an overloaded or clogged SAS or cesspool _ J/- Static liquid level. in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool . _squid depth in cesspool is less than 6" below invert or available volume is less than 1/2 day flow equired pumping more than 4 times in the last year NOT due to clogged or obstructed(s i e . Number / of times pumped p p ) V 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. y portion of a cesspool or privy is within a Zone 1 of a public well. _ `�lgAny 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 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.] (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 gpd. You 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 napped Zone 11 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. r' Page 5 of 11 L OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST Property Address: r 5Q Owner: ` itl A e r Date of Inspection- .$ — 9 / "G % Check if the following have been done. You must indicate `yes" or "no" as to each of the following: Yes o Pumping informatipr ,was provic d by the ow `, occupatit�,or Board,ofHealth' Were any of the system components pumped out in the previous two weeks ? z_ Has the system received normal flows in the previous two week period ? /Have large volumes of water been introduced to the system recently or as part of this inspection ? -Were as built plans of the system obtained and examined? (If they were not available note as N/A) V— Was the facility or dwelling inspected for signs of sewage backup.) 6-/ the site inspected for signs of break out ? V/— Were all system components, excluding the SAS, located on site ? Were the septic tank manholes uncovered. opened, and the interior of the tank inspected for the condition of the baffles or tees, material of construction, dimensions, depth of liquid, depth of sludge acrd depth.of scum ? _ Was the facility owner (and occupants if different from owner) provided withformation o "fthe proper,',. maintenance of subsurface sewage disposal systems ? The size and- location of the SoiI'-Absorption Systetn:(SAS) ori the site has bteen dere aimed based on: Yes no 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)] 5 q �._ ... . .. 'ti.,h .:+`."'.. -. .rn t. v. 'T iv-♦rl--+rY''�e �" r • . _.. ,_. :5+. . "1.-� - ��-y..i • . Page 6 of I 1 OFFICIAL INSPECTION FORM — NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION Property Address: / %S- SrW,-_ gfZe wC Owner: — /1 e tr Date of Inspection: V O FLOW CONDITIONS RESIDENTIAL Number of bedrooms (design):; Number of bedrooms (actual): DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x # of bedrooms): Number of current residents: Does residence have a garbage grinder (yes' r no): Is laundry on a separate sewage system'(ye or no): - [#yes separate mspectioln required] A Laundry system inspected (yes or no): Seasonal use: (yes or no): _ Water meter readings, if available (last 2 years usage (gpd)): Sump pump (yes or no): Last date of occupancy: COMMERCIALANDUSTRIAL Type of establishment: Design flow (based on 310 CMR 15.203): gpd Basis of design flow (seats/persons/sqft,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: (�/�'tQ Iona r f'l/VdaA(-- 56Wc 0 G' ZOGto Was system pumped as part of the inspection (yes or no): If yes; volurr e,pumped:/ gallons -- How,tvas quantity pumped determined?_ Reason for pumping:' %/►S ��° G T '%"ii �✓ IL` y ( t _ ' �� TYPF OF SYSTEM eptic 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: Were sewage odors detected when arriving at the site (yes or no): 'jV ' Page 7 of 11 OFFICIAL INSPECTION FORM — NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address -,2 '�— 7 - �— Ze &t -e .�iV Gf lJ C.tCQ.. Owner: &GL /" Date of Inspection: 15-- 9 /-901 r BUILDING SEWER (locate op, site plan) Depth below grade: v Materials of construction: mast iron 40 PVC other (explain): Distance from private water, sulVly well or.iuctionfit I, + . r. , : P.* ;• 4 -; Comment's (on condition of joints, venting,?evidence of le age, eic.):" au1� SEPTIC TANK: (locate on site plan) Depth below grade: Material of construction: �ncrete _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: „ Distance from top of sludge to bottom of outlet tee or baffle -32- Scum thickness: 2,, 0' Distance from top of scum to top of outlet tee or baffle: G, 6— Distance from bottom of scum to bottom of outlet tee or baffle: / cY `� How were dimensions determined: r Comments (on pumping recommendati� and outlet tee or baffle cond ion, structura`� integrity, liquid levels - as related to outlet invert, evidence of leakage, etc.): /w e e t ©l- O rit-L c r des S voC/ ova GREASE TRAP: r (locate on site plan)' ¢ f 4 Depth below grade: Material of construction: _concrete _metal _fiberglass polyethylene _other (explain): Dimensions: Scum thickness: Distance from top of scum to top of outlet tee or baffle: Distance from bottom of scum to bottom of outlet tee or baffle: Date of last pumping: Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): 7 r Page 8 of 11 OFFICIAL INSPECTION FORM — NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: r r 6-A'.,f Owner: 6-Q ! a r P T Date of Inspection:U6V/ -QT_ 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 . , .,Uolyethyldne other(explain): ► i-Dunensions: 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: Zif present must be opened)(locate on site plan) Depth of liquid level above outlet invert: Comments (note if box is level and distribution to outlets equal, any evidence of solids carryover, .any evidence of leakage into or ut of bo ,-etc.): 6 u o r Ca / Y'!3,0 J.A< ,L ii AL PUMP CHAMBER: (locate on site plan) Pumps in.wo king order (yes_#o):o ) 4 ...A ` Alarms in working order (yes of no): i e1 ti j f Comments (note condition of pump chamber, condition of pumps and appurtenances, etc.): Page 9 of 11 r. OFFICIAL INSPECTION FORM — NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: 126- 570'1.—W— Chet ce /Up �• 4 Owner• a<1 A P Date of Inspection• SOIL ABSORPTION SYSTEM (SAS): -�/(locate on site plan, excavation not required) If SAS not located explain why: ,. , ; Type leaching pits, number: _ leaching chambers, number: leaching galleries, number: leaching trenches, number, length: leaching fields, 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.): CESSPOOLS: (cesspool must be pumped as part of inspection)(locate on site plan) Number and configuration: •`• Depth — top of liquid to inlet invert: Depth of solids layer: Depth of scum layer: q Dimensions of cesspool: Materials of construction:- , Indication ogroundwater inflow (yes or naj: 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.): G7 .,,..��.�....��qr.'f'' w, �...�'...Fu�#;....�..T4uCi _"" ".,-.,�,;� -r ..r ...+•,,,rte.^��.....:.��^t.:.,. eP ♦ 1 Page 10 of 11 �y OFFICIAL INSPECTION FORM — NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: / ;l ,04V',A4 G« Owner: G4 114 e4— Date of Inspection. — %a 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 fee 'Locate where public water supply en lers the building. s J A1 1 1 F � �. • yd- •'--�-awY_`r14'� .- .ten ldlN 4 � 41 F � �. • yd- •'--�-awY_`r14'� .- .ten ldlN 4 Page l l of 11 OFFICIAL INSPECTION FORM — NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: 57'10A4 C Le "-4- Owner: t9' y GtP Date of Inspection,-" SITE EXAM Slope Surface water Check cellar k. -- Shallow wells "Estimated depth to ground water feet ' k 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 excavators, installers- (attach documentation) Accessed USGS database -explain: Yo must describe how you establi' hed the high ground water elevation: n TOWN OF NORTH ANDOVER I SYSTEM PUMPING RECORD )TE!lrl OWNER & ADDRESS T' -,NN OF N!U-R H AN - FO tR/ A RD OF HEA >�' 1 d NOV ` 4 20 SYSTEM LOCATION (exaGmPle: lef( from of house) Cq' 1 DOS e -f u \,IC OF PUMPINC: le5J>?. QUANTITY PUMPCD1OiW (, )SPOOL: NO YES SCPTICTANK: NO YES � ATURE OF SERVICE: ROUTINE EMERGENCY li>FRV_\TIONS: GOOD CONDITION FULL TO COVCIz _ HFAVY CREASE BAFFLES IN PLAC: ROOTS LEACHFICLD RLN,BACK.. EXCESSIVE SOLIDS FLOODED ' SOLIDS CARRYOVER O�HER (EXPLAIN) >� 1 L'M PUMPED GY: /ii'/ ��'i�`��- ` ---- u,1 �1 rNTS: U^�I TIZANSFEIZIZED TO: FOWNO NO 'HANDOVEk SYSTEM INQ RECORD DA cr. SYSTEM OWNER & ADDRESS J 7 `nom �leayse�fia� No.,7fNdoyete, �iq. L)A I h OF PUMPING; SYSTEMLockiffo—N _QIJANTITY PUMPED: CLSSP(X)L: NO YES NO-- YES. -if/ NAWKEOF'SERVICE: ROUTINE PEMER(jEN(')' RECEIVED OCT 0 5 2004 VER TOW,AN OTH F NDOERTp,,HRT A'nNDO4 — LENT 013SERVA rIONS: GOOD CONDI,rION 1,--�FULL 'Tyj [;OVER HEAVY GREASE BAFFLES IN PLACE ROOTS LEACHRELD RUNBACK BXCESSIVE SOLIJDS'--- FLOODED SOLID CA"YOVER--- 0TIfER EXPLAIN System Pumped by �UMMENI'S. CUN ItN I'S I"KANSktRRED 1-0 A/W I (I No Andover J&S Development dba 1600 Osgood St Stewart's Septic Building 20 Suite 2-36 Andover Septic No. Andover, Ma 01845 58 South Kimball Street Bradford, MA 01835 Date & Address Gallons Comments �Name 1-Maj,Patter reality 81 Sawmill Rd 1500 Good 2-May`MulcaFi x350 Shar ners Pond Rd 1500 Good �,G.reen`g 62 Willow Ridge Rd 3 -May) -,E roQS 59 Grandville 1000 Good 2500 Good 4-MayiRincon;1.15 Sherwood Dr 1500 Xsolids HG 9 -May -Callahhn'-940 Foster St 1500 Good 10 -Ma)' Melerim�,1444 Salem St 1500 Xsolids 15-May,Dirak-153 Brenkin ridge Rd / 1500 Good toepari,175 Stone Cleave Rd 1500 Good 16 -May Martin 701 Forest St 1500 Good " XMurphy_16 Carleton Lane 1500 Good 18 -May Vadnergaaf267 Old Cart Way 1500 Good .'S61ano`21,98 Tnok St 1000 Rh 21-May-�Tomicho 1.15 Laconia Cir 1500 Good Reti 42 Cross Bow 1500 Good 24;May:Carbonell 1560 Salem St 1000 Good 29 -May Thurber 210 Farnum St 1500 Good X31=May',Cleary,( Winter green Dr 1000 Good I TOWN br° NIOR-rH ANDQVgR HEALTH DEPARTMENT MASSACHUSETTS UNIFORM APPLICATION FOR PERMIT TO DO PLUMBING (Print or Type) IT�IlP .�Q�t—, Mass. Date Permit #3 7 0 Building Location/SSfn�ca tr2 , d. Owner's Name De (7 / i Type of Occupancy Residential New UJ Renovation ❑ Replacement Plans Submitted:%Yes ❑ No ❑ th FIXTURES Installing Company Name heritage Htg . &Plg . Co. Inc. Check one: Certificate Address_ 35 Pleasant Street IX Corporation 714 Stoneham, Ma 02180. ❑ Partnership Business Telephone 781 —43 8-77 76 f7 Firm/Co. _ Name of Licensed Plumber Gordon Switzer INSURANCE COVERAGE: I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL Ch. 142. Yes ® No ❑ If you have checked yes, please indicate the type coverage by checking the appropriate box. A liability Insurance policy Z Other type of indemnity ❑ Bond ❑ OWNER'S INSURANCE WAIVER: I am aware that the licensee does not have the insurance coverage required by Chapter 142 of the Mass. General Laws,`and that my signature on this permit application waives this requirement. Check one: Owner ❑ Agent ❑ or I hereby certify that all of the details and information I have submitted (or entered) in above application are true and accurate to the best of my knowledge and that all plumbing work and installations performed under the permit issued for this application will be in compliance with all pertinent provisions of the Massachusetts Stale Plumbing Code and Chapter 1422 of the General taws. By Sigfn lure of Licensed Plumber Title Type of License: Master [X Journeyman [] City/Town 8322 APPROVE 0 ICE SE ONLY— License Number_ Z -f I Z N r W N N N Z O Y Hr4 O 0 lL Y J N Y V Q ~W �7 Z O 0 Z LU fY N 'n OJ Z _ N 0) W N Q Cr¢ T Q r 2 a Cr w vl y Z Z a U. �_ ;t _ a a c 3 rd b rd i J V Z 0 7 6 N w ¢ Q W - Q Z a a , W r z u> a i r 3 o a 3 x N O a a z N ►- Y Z m a o �. o ¢— F- ax J Q Y z o w w ►- a o LL Y o v 14 ri Q 3 Y Q J Q m x to N o V) o Q J Q 3 O z Q r- J yr J LL Q c7 ¢ D.1 C a .t Q 3 O Q it m r0 33 rd rd 33�' rd SUB-BSMT. BASEMENT IST FLOOR 2ND FLOOR 3RD FLOOR 4TH FLOOR STH FLOOR 6TH FLOOR 7TH FLOOR STH FLOOR Installing Company Name heritage Htg . &Plg . Co. Inc. Check one: Certificate Address_ 35 Pleasant Street IX Corporation 714 Stoneham, Ma 02180. ❑ Partnership Business Telephone 781 —43 8-77 76 f7 Firm/Co. _ Name of Licensed Plumber Gordon Switzer INSURANCE COVERAGE: I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL Ch. 142. Yes ® No ❑ If you have checked yes, please indicate the type coverage by checking the appropriate box. A liability Insurance policy Z Other type of indemnity ❑ Bond ❑ OWNER'S INSURANCE WAIVER: I am aware that the licensee does not have the insurance coverage required by Chapter 142 of the Mass. General Laws,`and that my signature on this permit application waives this requirement. Check one: Owner ❑ Agent ❑ or I hereby certify that all of the details and information I have submitted (or entered) in above application are true and accurate to the best of my knowledge and that all plumbing work and installations performed under the permit issued for this application will be in compliance with all pertinent provisions of the Massachusetts Stale Plumbing Code and Chapter 1422 of the General taws. By Sigfn lure of Licensed Plumber Title Type of License: Master [X Journeyman [] City/Town 8322 APPROVE 0 ICE SE ONLY— License Number_ O z m J a 0 O O i-' r 0 S' a Q' O z a Q m LL U. O z W O a a U 'd J W � a a a z TOWN OF NORTH ANDOVER PERMIT FOR PLUMBING This certifies that.. �"..`. ...j.:- -.. - . ��...... • . has permission to perform .....P .............................. plumbing in the buildings of ... �.�. l�<A,� �.................... at ..1-2 ! .... ... `............ . North Andover, Mass. Fee. 3.? . Lic. No..}� . ? .� .. / ......... . PLUMBING INSPECTOR Check # � 0 579