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Commonwealth of Massachusetts
City/Town of
System Pumping Record
OCT - 9 20061
Form 4 pF NORTH F
_TH DEPARZ
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. SysteLocqtion:
Address
City/Town l V�
2. System Owner:
Name
Address (if different from location)
State Zip Code
Citylrown State S D_O r,,Zi Code
Telephone Number 1
B. Pumping Record
1. Date of Pumping
3. Type of system: ❑
EL.Offie-r (describe):
Q—a3_ 2. Quantity Pumped
Date
Cesspool(s) eptic Ta k
26 -21f --j
Gallons
❑ Tight Tank
4. Effluent Tee Filter present? ❑ Yes O -Na-' If yes, was it cleaned? ❑ Yes ❑ No
5. Conoition ofm:--r� c '"`l t�
6. Syste Pumped By:
Name - Vehicle License Number
Company
7.
Leoontents re disposed:
Date
t5form4.doc• 06/03 — -- - System Pumping Record . Page 1 of 1
TOWN OF /�' "L�
SYSTEM PUMPING RECORD
RECEIVED
DATE: �
NOV - 9 2005
SYSTEM OWNER & ADDRESS
V�
1
DATE OF PUMPING:
TOWN OF HEALTH NORTH
E ARTM NTER
SYSTEM LOCATION
(example: left front of house)
�Yca�C�'
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"QUANTITY
PUMPED: [ GALLONS
CESSPOOL: NO l YES SEPTIC TANK: NO YES
NATURE OF SERVICE: ROUTINE EMERGENCY
OBSERVATIONS:
GOOD CONDITION
FULL TO COVER
HEAVY GREASE
BAFFLES IN PLACE
ROOTS
LEACHFIELD RUNBACK
EXCESSIVE SOLIDS
FLOODED
SOLIDS CARRYOVER
OTHER (EXPLAIN)
SYSTEM PUMPED BY: Bateson Enterprises, Inc.
COMMENTS:
coNTErrrs TRANSFERRED To: G.L.S.D Lowell Waste
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PROFESSIONAL ENGINEERS • LAND SURVEYORS ® PLANNERS
66 PARK STREET 0 ANDOVER, MASSACHUSETTS 01810 O TEL (617) 475.3553, 373-3721
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€� ��of Massachusetts
J Commonwealth
LOT 8 - MILL ROAD
E File No. —
(To be provided by DEOE)
City/Town Nnrr13 Andauer
Applicant Walt -pr T__ .Tnhncnn
Order of Conditions
Massachusetts Wetlands Protection Act
G.L. c.131, §40
and under the Town.of North Andover Bylaw,- Chapter 3.5 A & B
From North Andover Conservation Commission
Walter & Corinne Johnson
To Walter T. ,Johnson Michael & Maura.Shunney
(Name of Applicant) (Na ojgropggo Dr)
Gregory P. Cosci an Douglas Wright
Address 64 Linebrook Road, Ipswich, MA Address Ipswich,N:Chelmsford,Haverhill
Address—
and Salem, MA
This Order is issued and delivered as follows:
❑ �by hand delivery to applicant or representative on (date)
by certified mail, return receipt requested on Or ober 14, 1 986 (date)
This project is located at Lot 8 - Mill Road, North Andover
The property is recorded at the Registry of Northern Essex
Book 2236 Page 27
Certificate (if registered)
The Notice of Intent for this project was filed on August 15 1986 (date)
1986 24,
The public hearing was closed on Sept. (date)
Findings
The North Andover Pon.servation Commission has re dewed the above -referenced Notice of
Intent and plans and has held a public hearing on the project. Based or the information available to the,
NACC at this time, the NACC has determined that
the area on which the proposed work is to be done is significant tv the Following interests In accordance with
•i
the Presumptions of Signif{cance set forth in the regulations for each Area Subject to Protection Under the
Act (check as appropriate):
Public water supply Storm damage prevention
C& Private water supply ® Prevention of pollution*
20 Ground water 6upply ❑ Land containing shellfish
® Flood control 0 Fisheries
P 242- 368
Page -2-
Lot 8 -.Mill Road
NACC`
,.,.,
Therefore, the •hereby find that the following conditions are
..: a:.
necessary, in accordance.with the Performance Standards set forth in the regulations, to protect those inter-
r';Nn.r'C orders that all work shall be performed
ests checked above. The
in accordance with said conditions and with the Notice of Intent referenced above. To the extent that the fol-
lowing conditions modify or differ from the plans, specifications'or other proposals submitted with the Notice
-��
b,,:•§tf , of Intent, the conditions shall control.
I L -
General Conditions
4
9.
M
Failure to comply with all 'condilions stated'herein, and with all related statutes and other regulatory meas-
ures, shall be deemed cause to revoke or modify this Order.
This Order does not grant any property rights or any exclusive privileges; it does not authorize any injury
to private property or invasion of private rights.
This Order does not relieve the permittee or any other person of the necessity of complying with all
other applicable federal, state or local stalules, ordinances, by-laws or regulations.
The work authorized hereunder shall be completed within three years from the date of this Order unless
either of the following apply:
(a) the work is a maintenance dredging. project as provided for in the Act; or •.
(b) the time for completion hap been extended to a specified dale more than three years, but less than -
five years, from the date of issuance and both that dtitc and the special circumstances warranting
the extended tirne period are set forth in this Order.
This Order rnny be extended by the issuing authority for one or more periods of up tri.three years each
upon application to the issuing puthorily at least 30 days prior to the expiration date of the Order.
Any fill used in connection w'ilh this project shall be clean fill, containing no trash, refuse, rubbish or de-
bris, including but not limited to lumber, bricks, plaster, wire, lath, paper, cardboard, pipe, tires, ashes.
refrigerators, motor vehicles or parts of any of the foregoing.
No work shall be undertaken.until all administrative appeal period,s.f[o.m.lhis Order have elapsed or, if
such an appeal has been filed, until all proceedings before the Department have been completed.
Now ork shall be undertaken until.lhe Final Order has been recorded in the Registry of Deeds or the Land
Court for the district in which the land is located, within the chain of title of the affected property. In the
case of recorded land, the Final Order shall also be noted in the Registry's Grantor Index under the name
of the owner of the land upon which the proposed work is to be done. In the case of registered land, the.
Final Order shall also be noted qn the Land Court Certificate of Title of the owner of the land upon which
the proposed work is. to be done. The recording information shall be submitted to the NACC_
on the form at the end of this Order prior to commencement of the work.
A sign shall be displayed at the site not loss than two square feet or more than three square feet in size
bearing the words, "Massachusetts Department of Environmental Quality Engineering,
File Number 242- 368
10. Where the.Department.of Envirgnmental Quality Engineering is requested to make a determination and
to issue a Superseding Order, the Conservation Commission shall be a party to all agency proceedings
and hearings before the Department.
11. Upon completion of the work described herein, the applicant shall forthwith request in writing that a
Certificate of Compliance be issued stating that the work has been satisfactorily completed.
12. The work shall conform to the following pians and special conditions:
0
PAGE -3-
ORDER OF CONDITIONS LOT 8 - MILL ROAD D.E.Q.E.File #242-368
12. The work shall conform to the following documents, plans and additional
conditions•
a. Notice of Intent submitted by Walter T. Johnson
prepared by Westcott Site Services, dated August 12th
1986. Seven (7) sheets.
b. Plan entitled "Septic System and Notice of Intent Plan,
Mill Road Lot 8, North Andover, Massachusetts," prepared
by Westcott Site Services, dated Aug. 8, 1986, revised
Sept. 9, .1986.
C. Letter with calculations from Westcott Site Services,
dated September 25, 1986.
13. Prior to any work on the site, all debris within the wetland resource
areas shall be removed.
14. Prior to any work on the site, a silt fence or a double row of staked hay
bales shall be installed as shown on the plan referencalin Conditions 12(b)
except as follows:
a. The erosion barrier along the westerly property line shall
either be extended uphill to the 125' contour, or (if allowed
by the abettor) shall be extended along the 110' contour
in a westerly direction for an additional 40 to 50 feet.
b. In the area of the wetland crossing for the driveway, the
erosion barriers shall be installed a maximum of 20 feet
apart. No grading or any other work shall be allowed in
the wetland areas outside of this 20 foot corridor.
If the silt fence erosion barrier is employed, it must
conform to the specification on the plan referenced in
Condition #12b. These erosion controls shall be inspected
and approved by the NACC prior to any work on'the site.
15.. All utility installations shall follow the course shown for the water -line
on the plan referenced in Condition 12b.
Page -4-
ORDER OF CONDITIONS LOT 8.- MILL ROAD D.E.Q.E. File 4242-368
16. Upon completion of construction and grading, all disturbed areas shall
be stabilized permanently against erosion. This shall be done either
by sodding, or by loaming, seeding and mulching according to Soil
Conservation Service standards. If the latter course is chosen, stabilization
will be considered once the surface shows complete vegetative cover has
been achieved.
17. All erosion .prevention and sedimentation protection measures found
necessary during construction by the NACC will be implemented at the
direction of the NACC.
18. Any changes in the submitted plans, Notice of Intent, or resulting from
the aforementioned conditions must be submitted to the NACC for approval
prior to implementation. If the NACC finds, by majority vote, said changes
to be significant and/or deviate from the original plans, Notice of Intent
or this Order of Conditions to such an extent that the interests of the
Wetlands Protection Act and Bylaw cannot be protected by this Order of
Conditions and would best be served by the issuance of additional conditions,.
then the NACC will call for another public hearing within 21 days, at the
expense of the applicant, in order to take testimony from all interested
parties. Within 21 days of the close of said public hearing, the NACC will
issue an amended or new Order of Conditions.
19. Any errors found in the plans or information submitted by the applicant
- shall be considered as changes, and procedures outlined above for changes
shall be followed.
20. Members of the NACC shall have the right to enter upon and inspect the
premises to evaluate compliance with this Order of Conditions.
21. Accepted engineering and construction standards and procedures shall be
followed in the completion of the project.
22. Prior to the issuance of a Certificate of Compliance, the applicant shall
submit a letter to the NACC from a registered professional engineer certifying
that the work is in compliance with the plans referenced above and all the
Conditions hereof.
23. The provisions of this Order shall apply to and be binding upon the applicant,
its employees, and pll successors and assigns in interests or control.
24. Issuance of these Cpnditions does not in any way imply or certify that the
site or downstream areas will not be subject to flooding, storm damage, or
any other form of damage due to wetness.
25. A surety performance bond or letter of credit running to the Town of North
Andover shall be prpvided in the amount of $2,000.00, which shall be in all
.respects satisfactory to Town Counsel and the NACC, and shall be posted
with the Treasurer pf the Town of North Andover before commencement of work.
Said bond or letter.of credit shall be conditioned on the completion of
ORDER OF CONDITIONS
Page -4-
LOT 8 MILL ROAD
D.E.Q.E. File #242-368
16. Upon completion of construction and grading, all disturbed areas shall
be stabilized permanently against erosion. This shall be done either
by sodding, or by loaming, seeding and mulching according to Soil
Conservation Service standards. If the latter course is chosen, stabilization
will be considered once the surface shows complete vegetative cover has
.been achieved.
17. All erosion prevention and sedimentation protection measures found
necessary during construction by the NACC will be implemented at the
direction of the NACC.
18. Any changes in the submitted plans, Notice of Intent, or resulting from
the aforementioned conditions must be submitted to the NACC for approval
prior to implementation. If the NACC finds, by majority vote, said changes
to be significant and/or deviate from the original plans, Notice of Intent
or this Order of Conditions to such an extent that the interests of the
Wetlands Protection Act and Bylaw cannot be protected by this Order of:
Conditions and would best be served by the issuance of additional conditions,
then the NACC will call for another public hearing within 21 days, at the
expense of the applicant; in order to take testimony from all interested
parties. Within 21 days of the close of.said public hearing, the NACC will
issue an amended or new Order of Conditions.
19. Any errors found in the plans or information submitted by the applicant
shall be considered as changes, and procedures outlined above for changes.
shall be followed.
20. Members of the NACC shall have the right to enter upon and inspect the
premises to evaluate compliance with this Order of Conditions.
21. Accepted engineering and construction standards and procedures shall be
followed in the completion of the project.
22. Prior to the issuance of a Certificate of Compliance, the applicant shall
submit a letter to the NACC from a registered professional engineer certifying
that the work is in compliance with the plans referenced above and all the
Conditions hereof.
' 23. The provisions of this Order shall apply to and be binding upon the applicant,
' its. employees, and all successors and assigns in interests or control.
j24. Issuance of these Conditions does not in any way imply or certify that the
1, site or downstream areas will not be subject to flooding, storm damage, or
any other form of damage due to wetness.
i
25. A surety performance bond or letter of credit running to the Town of North
Andover shall be provided in the amount of $2,000.00, which shall be in all
respects satisfactory to Town Counsel and the NACC, and shall be posted
i.
with the Treasurer of the Town of North Andover .before commencement of work.
i Said bond or letter of credit shall be conditioned on the completion of
ORDER OF CONDITIONS
E
Page -5-
LOT 8 - MILL ROAD D.E.Q.E. File #242-368
j.
Continued..-...
{f 25. the project, provided that provision, satisfactory to the NACC, has been
made for.performance of any Conditions which are of a continuing nature.
This Condition is issued under the authority of the Town of North Andover
Wetlands Protection Bylaw.
IY
9
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I
Page 6— LOT 8 MILL ROAD
File #242-368
Issued By North Andover Conservation Commission Conservation Commission
d
G,
This Order must be signed by a majority of the Conservation Commission.
• On this R h - _day of October 1 g• 86 , before me
personalty appeared Guillermo J. Vicens , to me known to bo the
person described in and who executed the foregoing Instrument and acknowledged that he/she executed
the some as his/her free act and decd.
-tea•... :
Tanunt "1 5 r 1993
Notary Public My commission expires
Tracy A..Peter
The applicant, the owner, any person aggrieved by this Order, any owner of land abutting the land upon which the proposed work Is to
be done or any ten residents of the city or town In which such land Is located are hereby notified of their right to request the Department
of Environmental Ouslity Englneering to Issue a Superseding Order, providing the request Is made by certified mail or hand delivery le
the Department within ton days from the data of Issuance of this Order. A copy of the requost shall at the s.1mo time be sent by certified
mall or hand delivery to the Conservation Commission and tho nppiicnnt.
• r
Detach on dotted line and submit to the prior to commencement'oll work.
.«.....««..»...».......».......».»..�........................ ...... «...... ....«.
T� Issuing' Authority
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Please be advised that the Order of Conditions for the project at.—
"' I
Number hoo been recorded M the Rapiolry of
��I•
3 :,.: •' '01
,Fps �.
has been noted In the chain of title Of the affected property In accordance with General Condition 8 on
If recorded land. the Instrument number which Identifies this transection Is
j p registered tend, the document number wt11Ch Identifies this trHn3HCIlOn Is
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Applicant.
.Slandture
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7
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
Address of property 18Q Mill Road, North Ando 01845
Owner's name Phillip Wallingford
Date of Inspection March 23, 1.9,95 DjrywE
PART A 6 f IM24SM
CHECKLIST
Check 'if the following have been done:
X Rgmping information was requested of the owner, occupant a r`-Eoard of
Health.
X None of the system components have been pumped ~~'for at least two weeks
and the system has been receiving normal flow rates during that
period. Large volumes of water have not been -introduced into the
system recently or as part of this inspection..'.!..;,`.
NA As built plans have been obtained and examined. Note if they are not
available with N/A.
X The facility or dwelling was inspected for 'signs of sewage back-up.
X The site was inspected for signs of breakout.
All system components, excluding the SAS, have been located on the
site.
-'X 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.
X The size and location of the SAS on the site has been determined based
on existing information or approximated by non -intrusive methods.
X The facility owner (and occupants, if different from owner) were
provided with information on the proper maintenance of SSDS.
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SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART B
SYSTEM INFORMATION
FLOW CONDITIONS
If residential
T number of bedrooms
3 number of current residents
N garbage grinder, yes or- no
Y a�Llaundry connected to system, yes or no
N seasonal use, yes or no
If.nonresidential, calculated flow:
Water meter readings, if available:
N/A (on site well)
Current Last date of occupancy
E
N System pumped as part of inspection,
if yes, volume pumped
Reason for pumping:
yes or no
Type of system
X Septic tank/distribution box/soil absorption system
Single cesspool
Overflow cesspool
Privy
N Shared system (yes or no) (if
n
yes, attach previous inspection
records, if any)
Other (explain) Pump System
Approximate age of all components. Date installed, if known. Source of
information:
Constructed in 1990 as per owner.
N Sewage odors detected when arriving at the site, yes or no
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01
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART B
SYSTEM INFORMATION continued
SEPTIC TANK: X
(locate on site plan)
depth below grade: 21±
material of construction: X concrete metal FRP other(explain)
-Pre -cast conc. tees, manholes being raised to arade on inlet & outlet
dimensions:
L=10' W=6' D=50" (1500 gal) @ time of inspection
0il Sludge depth
distance from top of
�- scum thickness
NA distance from top of
NA distance from bottom
sludge to bottom of outlet tee or baffle
scum to top of outlet tee or baffle
of scum to bottom of outlet tee or baffle
Comments:
(recommendation for pumping, condition of inlet and outlet tees or baffles,
depth of liquid level in relation to outlet invert, structural integrity,
evidence of leakage, recommendations for repairs, etc.)
Tank was pumped recently, outlet tee in good condition, inlet tee
partially broken 2" above flow level (o.k.), minor leaking observed
from saturated topsoil from recent rain
DISTRIBUTION BOX: X 4'+ below grade
(locate on site plan)
Oil depth of liquid level above outlet invert
Comments:
(note if level and distribution is equal, evidence of solids carryover,
evidence of leakage into or out of box, recommendation for repairs, etc.)
Equal distribution to 3 outlets observed, no evidence of solids
carryover. No leakage observed. No backup or ponding observed _
after pump cycle.
PUMP CHAMBER: X
(locate on site plan)
Yes. pumpscin working order, yes or no
Comments:
(note condition of pump chamber, condition of pumps and appurtenances,
recommendations for maintenance or repairs,etc.)
Inlet pipe is routed through top of chamber, access manhole is raised
to finish grade, single pump system, pump operation checked, main enance
performed to electricals and pump switches summer, 1994 as per
conversation with pumper. Minor leaking observed rom saturated
topsoil.. from recent rain).
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SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART B
SYSTEM INFORMATION continued
SOIL ABSORPTION SYSTEM (SAS): X
(locate on site plan, if possible; excavation not required, but may be
approximated by non -intrusive methods)
If not determined to be present, explain:
Type
leaching pits and number
leaching chambers and number
leaching galleries and number
leaching trenches, number,. length 3 trenches @ 87 L.F. _e_a_.__-__4 ft. wide
leaching fields, number, dimensions
overflow cesspool, number
Comments:
(note condition of soil, signs of hydraulic failure, level of ponding,
condition of veg totion, recomme dati ns fo mainte an a or re air ,etc.)
D -Box observed after pump cyc�e.o ponrding or �acckup occuprreds.
CESSPOOLS (locate on site plan):
number and configuration
'`depth -top of liquid to inlet invert
depth of solids layer
depth of scum layer
dimensions of cesspool
materials of construction
indication of groundwater
inflow (cesspool must be pumped as
part of inspection)
N/A
Comments:
(note condition of soil, signs of hydraulic' failure,. level of ponding,
condition of vegetation, recommendations for maintenance or repairs,etc.)
PRIVY:
(locate on site plan)
materials of construction
dimensions
depth of solids
N/A
Comments:
(note condition of soil, signs of hydraulic failure, level of ponding,
condition of vegetation, recommendations for maintenance or repairs,etc.)
v
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11
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART B
SYSTEM INFORMATION continued
SKETCH OF SEWAGE -*DISPOSAL SYSTEM:
include ties to at least two permanent references landmarks or benchmarks
locate all wells within 100'
�' PuHP e-RAM86Z
Tib?: Ft,, . I1yCET 3q.8' Z(�.S' 1 S60 GAC... .
43S� Z 3 .,_7 , SEPr; �. TA
P.d..h,1#. GTTZ- 67,2' 116-S
D-F�ox 113.0' ! 7S,o'
D -sox
e7'
A-1 • -
DEPTH TO GROUNDWATER
41 depth to groundwater (as per soil testing in 1986 from design plan)
system appears to be constructed in cut area @ D -Box end of system (may
have been cause of groundwater problems in the past),
method of determination or approximation:
1. System was found to be below water table -see test holes conducted
b/i/94 on the with Board of Health.
• Drainage (interceptor) designed* (constructed in 1994 as per discussion
w/ Health_ Agent).
• Ground water probe conducted at D -Box during inspection -no water
observed @ 3 feet below the top of the D -Box (drove iron bar below
D -Box into sand fill).
4. Groundwater determined to be at least 1 foot below bottom of S.A.S.
@ time of inspection 3/23/95.
*See plan showing "improvements to subsurface disposal system 7/13/94 by
MPS nn fi 1.P @ bird. of Hlt.
1-�
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
FAILURE CRITERIA
Indicate yes, no, or not determined (Y, N, or ND). Describe basis of
determination in all instances.• If "not determined", explain why not)
N Backup of sewage into facility?
.N - Discharge or ponding of effluent to the surface of the ground or
surface waters?
N :zk
Static liquid level in the distribution box above outlet invert?
NA Liquid depth in cesspool <6" below invert or available volume< 1/2 day
flow?
N Required pumping 4 times or more in the last year?
number of times pumped 1
N Septic tank is metal? cracked? structurally unsound? substantial
infiltration? substantial exfiltration? tank failure imminent?
Is any portion of the SAS, cesspool or -P
rivy:
N below the high groundwater elevation? not at time of insp. 3/23/95
N within 50 feet of a surface water?
N within 100 feet of a surface water supply or tributary to a surface
water supply?
N within a Zone I of a public well?
N within 50 feet of a bordering vegetated wetland or salt marsh
(cesspools and privies only, not the SAS)?
N within 50 feet of a private water supply well?
N 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 analy!
for coliform bacteria, volatile organic compounds, ammonia nitrogen
and nitrate nitrogen.
13
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART D
CERTIFICATION
Name of Inspector Leslie P. Godin
Company Name Merrimack Engineering Services
Compapy Address 66 Park Street, Andover, MA 01810
Certification Statement
I certify that I have personally inspected the sewage disposal system at
this address and that the information reported is true, accurate and
complete as of the time of inspection. The inspection was performed and
any recommendations regarding upgrade, maintenance and repair are
consistent with my training and experience in.the proper function and
manitenance of on-site sewage disposal systems.
Check one:
I have not found any information which indicates that the system fails
to adequately protect public health or the environment as defined in
310 CMR 15.303. Any failure criteria not evaluated are as stated in
the FAILURE CRITERIA section of this form.
I have determined that the system fails to protect public health and.
the environment as defined in 310 CMR 15.303. The basis for this
determination is provided_ in the FAILURE CRITERIA section of this
form.
Inspector's Signature
Date 4/18/95
Original to system owner
Copies to: North Andover Board of Health
Buyer (if applicable)
Approving authority
TOWN OF NORTH ANDOVER
SYSTEM PUMPING RECORD
DATE:
GO) d wiav\,
I 16A 11 [ I W I
(example: left front of house)
J
DATE OF PUMPING: — I QUANTITY PUMPED GALLONS.
CESSPOOL: NO '4 YES SEPTI
_ C TANK: NO YES
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: (:�7 z L
Commonwealth of Massachusetts iRfl�+
City/Town of
W° System Pumping Record ��Oi1
Form 4 TOWN OF NORTH ANDOVER
HEALTH DEPARTMENT—
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 front of house, right front of house, left side of house, right side of house, Left
rear of house, nq rear of h lise ft side of building, right rear of building, under deck.
Citylrown State
2. System Owner:
&W VV4 ct�
Name
Address (if different from location)
Cityrrown
State
Telephone Number
Zip Code
Zip Code
B. Pumping Record
1. Date of Pumping Date L { ' 2. uantity Pumped: Gallons S
3. Type of system: ElCesspool(s) Septic Tank ❑ Tight Tank
❑ Other (describe):
4. Effluent Tee Filter present? ❑ Yes No If yes, was it cleaned? ❑ Yes ❑ No
5. Condition of System:
6. System Pumped By:
Neil J. Bateson
Name
Bateson Enterprises Inc.
Company
7. Location where contents were disposed:
L.S.gI Lovi(ell Waste Water
1-1//
Signature of
F5821
Vehicle License Number
Date
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