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HomeMy WebLinkAboutMiscellaneous - 181 JOHNNY CAKE STREET 4/30/2018a rr H (D (D [t f Important: When filling out forms on the computer, use only the tab key to move your cursor - do not use the return key. VS 2 - Commonwealth of Massachusetts Cit /Town of Y OCT 2 2008 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 Locatio .Left fron left rear, left side hous . Right front, right rear, right side of house. Address City/Town State Zip Code 2. System Owner: Name Address (if different from location) City/Town B. Pumping Record 1. Date of Pumping 3. Type of system: El [) Other (describe): State Zip Code < Telephone Number Date Cesspool(s) — 2. Quantity Pumped eptic Tank Gallons Tight Tank 4. Effluent Tee Filter present? 0 Yes Eg"No If yes, was it cleaned? El Yes [I No 5. Condition of System: V—�'o 6. System Pumped By: Neil Bateson Name Bateson Enterprises Inc Company 7. Location where contents were disposed: of t5form4.doc• 06/03 Lowell Waste Water F 5821 Vehicle License Number c,--, — Os - Dat System Pumping Record • Page 1 of 7 Commonwealth. of Massachusetts City/Town of System Pumping Record OCT 1 2 20 i4,y Sv Form 4 -DEP has provided this form for use by local Boards of ealth- =TMe-System-PirmF be submitted to the local Board of Health or other approving authority. . Important: When filling out forms on the computer, use only the tab key ` to move your cursor - do not use the return key. A. Facility Information 1. System�ocatio��— Address Cityrrown State 2. System Owner: �nco Zip Code Name - Address (i(different from location) CityfTown State i Codes Telephone Number - Record must B. Pumping Record 1. Date of Pumping 2. Quantity Pumped. Date Gallons 3. Type of system: ❑ Cesspool(s) Septic Tank- ❑Tight Tank ❑ Other (describe): 4: Effluent Tee Filter present? El Yes ❑140 If yes, was it cleaned? ❑ Yes ❑ No 5. Condi'on of System: 6. Systm Pur"ped By'' Name Company --- 7. Locati where conte we posed: http://www.mass.g t5form4.doc• 06103 Vehicle Ucense Number _C uler Date 'approvals/t5forms. htm#inspect System Pumping Record • Page 1 of 1 TOWN OF NORTH ANDOVER SYSTEM PUMPING RECORD DATE: f SYSTEM OWNER & ADDRESS DATE OF PUMPING: ?' / 5 - 0-2— SYSTEM LOCATION (example: left front of house) QUANTITY PUMPED /5-y I/ GALLONS CESSPOOL: NO `" YES SEPTIC K: NO NATURE OF SERVICE: ROUTINE EMERGENCY OBSERVATIONS: GOOD CONDITION HEAVY GREASE ROOTS EXCESSIVE SOLIDS SOLIDS CARRYOVER JY Y TL PUMPED BY: YES FULL TO COVER BAFFLES IN PLACE LEACHFIELD RUNBACK FLOODED OTHER (EXPLAIN) COMMENTS: CONTENTS TRANSFERRED TO: ARGEO PAUL CELLUCCI Governor COMMONWEALTH OF MASSACHUSETTS EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS DEPARTMENT OF ENVIRONMENTAL PROTECTION ONE WINTER STREET, BOSTON MA 02108 (617) 292-5500 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION Property Address: 19-1 0 h V Cakee , Si', Namof Ownsr W I I iLCYyi YYl LAI CCN Date of Inspection: �b i M A 0 12 u `address of Owner: Name a Inspector: ( Pnnt) Z"T-011 n la—, nz I Caw I sm a DEP approved system inspector pursuant "to Section 15.340 of Title 5(310 CMR 15.000) Company Name: � t:t.3Gf S Mairm Address:n Y►) }t 0) $ !� Telephone Number: C17 9 CERTIFICATION STATEMENT TRUDY COXE Secretary DAVID B. STRUHS Commissioner 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 age disposal systems. The system: 2_ Passes _ Conditionally Passes _ Needs rther Evalus 'on By the Local Approving Authority _ Fails Inspector's SiBnsture: Date: /6 The System Inspector shall4mit a op f this i pection report to the Approving Authori y (Board of Health or DEP)within thirty (30) days of completing this inspection. f the systa 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 appropriate regional office of the Department of Environmental Protection. The original should be sent to the system owner and copies tent to the buyer, if applicable, and the approving authority. NOTES AND COMMENTS revised 9/2/98 Pagel of 11 0 Printed nn Re"rl,d paper SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) --- ftoperty address: ($ i JS h n n j c a -k- e- 7An d o J c-', MA p ls� y 5 Owner: 19 ri� 0 M ki Dab of Inspection: to I 2;q 417 INSPECTION SUMMARY: 0=1 A. JB, C, or A :11 TEM PASSES: 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: One or more system components as described in the "Conditional Pass" section need to be replaced or repaired. The system, upon completion of the replacement or repair, as approved by the Board of Health, will pass. Indicate yes; no, or not determined (Y. N, or 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, is 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. Sewage backup or breakout or high static water level observed in the distribution box is due to broken or obstructed pipe(s) or due to a broken, settled or uneven distribution box. The system will pass inspection if (with approval of the Board of Health). broken pipe(s) are replaced obstruction is removed distribution box Is levelled or replaced The system required pumping more than four times a year due to broken or obstructed pipe(s). The system will pass inspection if (with approval of the Board of Health): broken pipe(s) are replaced obstruction is removed Es revised 9/2/98 L Page 2 of 11 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: 1$1 h n v►� Cake �3t. K A V14D J C r, m f{ b 1 g N'3 Owner: 6ri an rn 1' l CA.h4 Dam of Inspection: I o ( as aq 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 the public health, safety and the environment. 1) SYSTEM WILL PASS UNLESS BOARD OF HEALTH DETERMINES W 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. 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 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 go revised 9/2/98 Page 3 of 11 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: ► 8"t IOh n n( cck-e- S t. N. A n d o U e.,rI hn A o i r a b Owner: sri & n Ky LI CAJI� Dab of Inspection: ( D ( 'a a I a `1 D. SYSTEM FAILS: You must 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 No Backup of sewage into facility or system component due to an overloaded or clogged SAS or cesspool. Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool. Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool. Liquid depth in cesspool is less than 6" below invert or available volume is less than 1/2 day flow. Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number of times pumped _ 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. 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 above: The system serves a facility with a design flow of 10,000 gpd or greater (Large System) and the system is a significant threat to public health and safety and the environment because one or more of the following conditions exist: Yes No the system is within 400 feet of a surface drinking water supply the system is within 200 feet of a tributary to a surface drinking water supply the system is located in a nitrogen sensitive area (interim Wellhead Protection Area - IWPA) or a mapped Zone II of a public water supply well) The owner or operator of any such system shall upgrade the system in accordance with 310 CMR 15.304(2). Please consult the local regional office of the Department for further information. FM revised 9/2/98 N Page 4 or 11 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST Property Address: I r i -Tonnn4 CA -LC. 5t. N. A nd o o e r, MA o f v -Li 5 Owner: err*." Mio ca -hi Dae of Inspection: t a I aa.1 419 Check if the following have been done: You must indicate either "Yes" or "No" as to each of the following: Yep No Pumping information was provided by the owner, occupant, or Board of Health. Z_ None of the system components have been pumped for at least two weeks and the system has been,receiving nornmal flow rates during that period. Large volumes of water have not been introduced into the system recently or as part of this inspection. 4�- 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, Pian at B.O.H. Determined in the field (if any of the failure criteria related to Part C is at issue, approximation of distance is unacceptable) [15.302(3)(b)) The facility owner (and occupants, if different from owner) were provided with information on the proper maintenance of SubSurface Disposal Systems. revised 9/2/98 Page 5of 11 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION Property Address: I T I Sh n n q ca -k- e_ A r d o J e r, Yn A 0 l e W( S Owner: 15 r i 4 -ti M wij Cath Dae of Insp "on: 1 01 2,Z /q 9 . FLOW CONDITIONS RESIDENTIAL - Design flow-(Q0—(Q0m. / Number of bedrooms des' n):� Number of bedrooms (actual):_/ Total DESIGN flow —► Number of current residents: n pp Garbage grinder (yes or no): lu►�oV�Q Laundry (separate system) (yes or no):i2p, If yes, separate inspection required Laundry system inspected jyos or no) Seasonal use lyes or no): Water meter readings, if available (last two year's usage (gpd): Sump Pump (yes or no):11—Z> Last date of occupancy. T ' COMMERCIAL/INDUSTRIAL— Type of establishment: Design flow: aad 1 B ed on 15.203) Basis of design flow Grease trap present: lyes or no)_ Industrial Waste Holding Tank present: lyes or no)_ Non -sanitary waste discharged to the Title 5 system: (yes or no)_ Water meter readings, if available: Last date of occupancy: OTHER: (Describe) '.eat date of occupancy: GENERAL INFORMATION PUMPING RECORDS and source of information: System pumped as part of ins ction: lyes or no) If yes, volume pumped: y �gaIlona Reason for pumping: TYPE o YSTEM Septic tank/distribution box/soil absorption system Single cesspool Overflow cesspool. Privy Shared system lyes or no) (if yes, attach previous inspection records, if any) I/A Technology etc. Attach copy of up to date operation and maintenance contract Tight Tank Copy of DEP Approval Other APPROXIMATE AGE of all components, date installed (if known) and source of information: L Sewage odors detected when arriving at the site: (yes or no) !no M revised 9/2/98 N Page 6 of 11 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) -� Property Address: I S ( Oh n n ►� C Jc-e- Owner: $r 1 &n YY1 N l CaY1 Date of Inspection: 16 1 a a g q BUILDING SEWER: (Locate on site plan) Si-, IN, A nd,0 J e.-, M(4 O t -e u 5 L � Depth below grade:,C' Material of construction: ast iron _ 40 PVC _ other (explain) Distance from, private water supply well or suction line . Arjlq Diameter __a[__ Comments: (condition of joints, venting, evidence of leakage, etc.) SEPTIC TANK - (locate on site plan) �r Depth below grader Material of construction: _concrete _metal _Fiberglass _Polyethylene _other(explain) If tank is -t ova _ .a age connrmea Dy Uertiticate of Compliance _ (Yes/No) Dimensions: Sludge depth: Distance from op of Sludge to bottom of outlet tee or baffler Scum thickness:_ Distance from top of scum to top of outlet tee or baffle: _Z 41, Distance from bottom of scum to bottom of outulat tee or baffle: Ls How dimensions were determined: PQa- —'ay— Comments: (recommendation for pumping, ctfnditi n of ir�(et and outl t s or baffles, dept �j of liquid I vel in relation toi% utl t invert, structural integrity, evidence of leakage, etc.) _ , --V--V _ %_. GREASE TRAP: (locate on site plani 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: Data of last pumping: Comments: (recommendation for pumping, condition of inlet and outlet tees or baffles, depth of liquid level in relation to outlet invert, structural integrity, evidence of leakage, etc.) revised 9/2/98 N Page 7 of 11 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: t'? t h n n ►.1 CA -I( -,— Owner - A -I( -,.Owner: Br i" yn i t,l e4- hq Date of Inspection: 1 0`.2 a f g 4 Z+. N, _A rldw e r, m iq o i s g 5 TIGHT OR HOLDING TANK• (Tank must be pumped prior to, or at time of, inspection) (locate on site pian) Depth below grade: Material of construction: _concrete _metal _Fiberglass _Polyethylene _otherlexplain) Dimensions: Capacity:_ gallons Design flow: gallons/day Alarm present Alarm level: Alarm in working order: Yes Date Date of previous pumping: _ _ Comments: (condition of inlet toe, condition of alarm and float switches, etc.) DISTRIBUTION BO) (locate on site plan) lepth of liquid level above outlet invert:,_ Comments: (nod if level and distribution is equal, evidence of PUMP CHAMBER:�'' (locate on site plan carryover, evidence of leakage into or out of box, Pumps in working order: (Yes or No) Alarms in working order (Yes or No) Comments: (note condition of pump chamber, condition of pumps and appurtenances, etc.) IN revised 9/2/98 N Page 8 or n SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) — Property Address: t 1 SOh n n C&Y—e-cS u, A Vick 0 0 c, M ft 6 IM b Owner: $rIG-r\ )YiKiC'LZhq Date of Inspection: 10 1 a;?-/ 0i a SOIL ABSORPTION SYSTEM (SAS) (locate on site plan, if possible; excavation not required, location may be approximated by non -intrusive methods) If not located, explain:. type: leaching pits, number: leaching chambers, number:_ leaching galleries, number:_ leaching trenches, number, length: leaching fields, number, dimensions: overflow cesspool, number:_ Alternative system: Name of Technology Comments: (note condii CESSPOOLS:. (locate on site of soil, signs of ponding, damp,soil, condition of vegetation etc.) 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) Comments: (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.) PRIVY: &;lan) (locate Materials of construction: Dimensions: Depth of solids: Comments: (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.) revised 9/2/98 01 Page 9 of 11 SUBSURFACE SEWAGE DISPOSAL SYSTEM WSPECTION FORM PART C SYSTEM WFORMATION (contuwd) efop.ny Address: I I Sa h 110 4 Cake 5t. N. A hAc D e r- M j o l g y 6 Ownen 13ria,n m�cahu Date of Inspection: SKETCH OF SEWAGE DISPOSAL SYSTEM: Include flet to at lent two permanent reference landmarks or benchmarks locate all wells within 100' (Locate where public water supply comes into house) ••" ••�-�� ...: ao.. worLn -over Isom. Dov. 608 688 9642 15 I I OCT 4 199 e9ex revised 9/2/98 P.O1 Pate 10 or 11 508 6ES 9542 PAGE. 001 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: 11-1 -'50 h h n t j C&t t° 3+. N. A-YAo J c.r, MA 0 (S6 4 5 Owner: 1564-1 YYLW co -hi Das of Inspeedm: I NRCS Report name Soil Type_ Typical depth to groundwater USGS Date website visited Observation Wells checked Groundwater depth: Shallow Moderate Deep SITE EXAM Slope Surface water Check Cellar Shallow wells I Estimated Depth to Groundwater Feet Please indicate all the methods used to determine High Groundwater Elevation: _ZObtained from Design Plans on record Observed Site (Abutting property, observation hole, basement sump etc.) Determined from local conditions Checked with local Board of health Checked FEMA Maps Checked pumping records ' Checked local excavators, installers Used USGS Data Describe how o�ujestablished the High Groundwater Elevation. (Must be completed) h ,/ T f�, C�}A LAIII revised 9/2/98 Page 11 of 11 tuiu4/9U MON 10:05 FAX, 978 688 9573 Or r-9 r-9 1 Or N r ED \ an H u L/1 . ■ .. FIrr Q ® d 4J 7 1 Tr W W I� �+©~c loon LL. 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CA O••rl ■■ •• 1 L�.aaC7.o.cAc.Ltn •• Q I T r T T 7" T- Q C O X I I`\•�`r.\•tiN 01L O I I ��pp NC% a W Co LL I 1 ©� V -©©L-1 v 978 688 9573 R' Q001 q;. 0.; PAGE. 001 3 Fl y 4 1 1 TOWN OF SYSTEM I DATE: ±0 SYSTEM OWNER & ADDRESS �cP v 1 G RECO SYSTEM LOCATION (example: left front of house) RECEIVED APR 2 5 2005 TOIAIN OF NORTH ANDOVER HEALTH DEPARTMENT DATE OF PUMPING: - 0 c, QUANTITY PUMPED: 5afiZ2 GALLO CESSPOOL: NO YES EPTIC TANK: NO YES NATURE OF SERVICE: ROUTINE EMERGENCY OBSERVATIONS: GOOD CONDITION HEAVY GREASE ROOTS EXCESSIVE SOLIDS SOLIDS CARRYOVER FULL TO COVER BAFFLES IN PLACE LEACHFIELD RUNBACK FLOODED OTHER (EXPLAIl4) SYSTEM PUMPED BY: Bateson Enterprises, Inc. COMMENTS: CONTENTS TRANSFERRED TO: G.L.S.D Lowell Waste rl it 1L N1 V) s' tiM Zf!c, uj 4 V1 sy Ll -4 �o rl vi 4z Na 03 m M t a V) 13 kn 4- 'ci, a STM' cl wj 01 .Q 14 N, Zj so UJ . ,�lJ �! o a W 1. 1, o Q �. o 0 0 Q �, c ol -45 ed; If s" Q r e 00 401 4CZk i� u Qi 11 O 41 i� u Z's 13 Ala t 0jigML C 11 t Board of Health North AnyerLN.aaa. APPROVED DATE Is SEPTIC STSTEM INSTA.d.ATICK CMrK LIST DI SAPPROVED DATE Rea -Roast Lar X AVATI CH Old FAIL 1. Distance Tot a. Wetlands b. Drains c.. Well 2. Water Line Location 3• No PPC Pipe 4. Septic Tank, a. Tees -_Length & To Clean Out Cover $ b. Cement Pipe to Tank - On Both Sidi s of Tank 5. Distribution Box a. Covers & Box - No Cracks b. All Lines Flo-,Ang Equal Amount - c. No Back Flow b. Leach Field or Trench a. Di.mensionse b. Stone Depth c. Capped Inds d. Clean Double Washed Stone 7. Leach Pits a. Dimensions b. Stone Depth c. Splash Pads d. Tees e. Cement Pipe to Pit - Both Sides f. Clean Double Washed Stone 8. No Garbage Disposal Final Grading Inspection 10. Barricading Covered System 11. As Built Submitted a. Lot Location. b. Dimensions of System c. Location with Regard—to Pexc Test d. Elevations e: Water Table TO: NORTH ANDOVER, MASS ��t �— Zl 19 0,5— BOARD ,5'BOARD OF HEALTH FROM: DESIGN ENGINEER Re: $,oil Absorption Sewage System Inspection This is to certify that I have inspected the construction of the said disposal system at iNorth Andover, Mass. SITE LOCATION The grades and construction are as specified in my plans and specifications dated 0 Health .Mover,Mas s APPROVE .Provide is DATE SUBSURFACE DISPOSAL DESIGN CHDCK LIST �5 LOT - JrJH"wc& J- 6- w4S i DISAPPROVED DATE Reasons: Title V Reg 2.5 — - --- _---- FAIL OK n The submitted plan must show as a mini:AMI a) the lot to be served -area, dimensions lot t" abutters b location and log deep observation hoes -distance to ties c location and results percolation tests-d_stance to tiea d design calculations & calculations showing requirdd leaching area (e) location and dimensions of system -including reserve area f) existing and proposed contours (g) location any wet areas within 1001 of sewage disposal system or disclaimer -check wetlands mapping (h) surface and subsurface drains within 1001 of sewage disposal system or disclaimer (i) location any drainage easements within 1001 of sewage disposal system or disclaimer -Planning Board Piles (j) known sources of water supply within 2001 of sewage disposal o system or disclaimer (k) location of any proposed well to serve Iot-1001 from leaching f�cility (1) location of water lines on property -101 from leaching facility . (m) location of benchmark (n) driveways (o) garbage disposals (p) no PVC to be used in construction (q) profile of system -elevations of basemen!, plumb, pipe, septic tank, distribution box inlets and outlets, diLLribution field piping and Other elevations (r) maximum ground water elevation in area a.vage disposal systems (s) plan must be prepared by a Professional En61neer or other professional authorized by law to preparF such plans Reg 6 Septic Tanks (a) capacities -156% of flow, water table, tees,depth of tees, access, pumping (b) cleanout (c) 101 from cellar wall or inground suLmming pool (d) 251 from subsurface drains Reg 10.2 Distribution Boxes Reg 10.4(b) "pe greater ME 0.08 Y I I I I i t 1 —1_ NJ !l i - J �I I I I I � I I I I i t 1 —1_ I � I i t 1 —1_ 1 7 !l i - J �I I I I I � I � I i t 1 —1_ 1 7 !l - J �I Nd 19LvllvL L E �twaret Cir• 7A1,06 - co ��_�l/nlG, Mass � • o t � a 9 � all, a T S` 17S�91 P�f A i7s•�z Pith 1793� �'S-R� SEP,-iC fANK Commonwealth of Massachusetts RECEIVED City/Town of a System Pumping Record DEC 15 2009 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 tQ determine the form they use. The System Pumping Record must be submitted to the local Board of Health mother approving authority. A. Facility Information 1. System Location: Left side of house, Right side of hou L�jqul , Right front of house, Left rear of house, Right rear of house. Left rear of buildinglding. Address S t City/Town 1 2. System Owner: Name Aaaress (n aitterent trom location) City/Town B. Pumping Record 1. Date of Pumping 3. Type of system: ❑ State Zip Code State de Telephone Number Date 2. Quantity Pumped: Cesspool(s) Septic Tank ❑ Other (describe): 4. Effluent Tee Filter present? ❑ Yes No 5. Condition of System: 6. System Pumped By Neil Bateson Name Bateson Enterprises Inc Company 7. Location where contents were disposed: �G_LS_D Lowell Waste Water r Signature of Hauler Gallons ❑ Tight Tank If yes, was it cleaned? ❑ Yes ❑ No F5821 Vehicle License Number t 6 —c_)? Date t5form4.doc• 06/03 System Pumping Record • Page 1 of 1 -C-\ Commonwealth of Massachusetts City/Town of 4° System Pumping Record Form .4 �M 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 usiRgAbi8=forts; che- Gk$wfth# ur local Board of Health to determine the form they use. The System Pumping RecAVt-i WE nitte to the local Board of Health or other approving authority. A. Facility Information N 1. System Loca '�rigre�arof TOWN OF NORTH ANDOVER y fight front of house, left side of h sd��a h�t�,itasn, L _ ft rear of house,eft side of building, right rear of building, under deck. Cityrrown State Zip Code 2. System Owner: Cj -- Name Address (if different from location) City/Town State(Q 7 3—,, Code Telephone Number B. Pumping Record '— 1. Date of Pumping Date 2. Quantity Pumped: 3. Type of system: ❑ Cesspool(s) Septic Tank (S �� Gallons ❑ Tight Tank If yes, was it cleaned? ❑ Yes ❑ No F5821 Vehicle License Number Date MRAI WA System Pumping Record • Page 1 of 1 1. ❑ Other (describe): 4. Effluent Tee Filter present? ❑ Yes No 5. Conditio of ystem: &JD ��LL'a)j� 6. System Pumped By: Neil J. Bateson Name Bateson Enterprises Inc. Company 7. Locatio. here contents were disposed: G.L.S. Lowell steYifater Signa u oft f auler t5form4.doc• 06/03 (S �� Gallons ❑ Tight Tank If yes, was it cleaned? ❑ Yes ❑ No F5821 Vehicle License Number Date MRAI WA System Pumping Record • Page 1 of 1 1.