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Home My WebLink AboutMiscellaneous - 1818 SALEM STREET 4/30/2018 (2)N O 6-4 Commonwealth of Massachusetts W City/Town of NORTH ANDOVER, MASSACHUSETTS System Pumping Record Form 4 'M Important: When filling out forms on the computer, use only the tab key to move your cursor - do not use the return key. nnun .. 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 1. System Location:JJ /1r11F rA ,� Address DEC 16 2013 L TOWN OF Nl„i i i i ANDOVER City/Town State zip cooe 2. System Owner: Name Address (if different from location) Cityrrown State Telephone Number Zip Code B. Pumping Record /> 1. Date of Pumping ' 2. Quantity Pumped: Date Gallons 3. Type of system: ❑ Cesspool(s) r 4Septic Tank ❑ Tight Tank ❑ Other (describe): 4. Effluent Tee Filter present? lin Yes ❑ No 5. Condition of System: 6. System Pumped By: Jd If yes, was it cleaned? (D5 Yes ❑ No Name Vehicle License Number R &� � WC Company 7. Location where contents were disposed: UJAJOK, SCX..i)71WS GLUP,.�'1Z�/l�Yl Signature of Hauler Date http://www.mass.gov/dep/water/approvals/t5forms.htm#inspect t5form4.doc• 06/03 System Pumping Record • Page 1 of 1 ,nn h Yl 4 a �L lii 1�1 r} At"4's lr cr r t �.. Co;monwealth of Massachusetts C:rfy/Town of`NORTH ANDOVER MASSACHUSET System Pumping Record TS Form 4 OCT 1 2 6 DEP has provided this form for use by local Boards of Health. The System Pumping•Record mu: be submitted to the local Board of Health or other approving authority, - - A. Facility Information I - Important: When filling out 1. System Location: forms on the . computer, use 4. only the tab key Address o move your cursor - do not use the return city/Town '—'— ----- ___ State — key. ... Zip Code ----._._..... 2. System Owner: Name s',, Address (if different from I _ __ ...... State •Zip Code Telephone Number_^ "— - - B. Pumping Record A 1. Date of Pumping 5a4�� -- 2. Quantit Pum ed: — y p Gallons — - ❑ Cesspool(s) eptic Tank ❑ Tight Tank ❑ Other (describe): 3. Type of system: /-...... ... ..... ... 4. Effluent Tee Filter present? [3Yes If yes, was it cleaned? ❑Yes ❑ No 5. Condition of System: 6. Sy em Pumped By: ame -- ---__— J __ _ Vehicle license Number — -- - Compeny:. 7. Location where contents were disposed: S �0)q au http://www.mas .gov/dep/water/ palate --`- --- --- ---------- •-. _.. MY t5form4.doc- 06/03 System Pumping Record - Page 1 of 1 ' • ' 1 • •I:A :r1• •I'1„ 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. 3I7t flll,,s 'out this se yonA"I****x** t**xx*x exX �APPLICV;Pr: ��'� G l (�' (5��, ��l �J �; hone LOCkTION. Assessor's Map- Nu.;ber Lot;_; St. *�c�cic�cx*x�cz�e�e�ixx**xxx�i�e�ixry=;Cla1 Use Onl`>>t�e�ciex�iiexie*iexxx�i�ix�cx�c�c�i e� /'RECODY-MENDATIONS OF TOWN AGENTS: Daze Ap_r:. •_ed CZ -_e_ : Daze Re, ec ___ Torn ?_a..r.er --- - - - _ ,al7i�U G z"3 /Y/& y 200 Dame Amzrcved Dame Re'ecma_ Daze Amz e Dame Re- e _e_ Dame Apm : e4 Daze Re-ecz__ _ ;__ rycr.._ - se-.:er, ::az_Y ccn-, ecm_cns _ - drivewayoer-� _re Derarz-en: Re___ved by Building InsPe_zcr Daz_ Board of Health North An ver Haas. )FYPR9nM DATE v % 50 t FAIL OK ,✓ BEMC SISTEM INSUILATICH CHECK LIST LOT ' �) AVAT1s Og FAIL 1. Distance Tot a. Wetlands b. Drains c. Well 2. Water Line Location 3- No PVC Pipe }s. Septic Tank - a�. _Tess -_Length & To Clean Out Covers b. Cement Pipe to Tank Cd Both Sides of Tank 5. Distribution Box a. Covers & Box - No Cracks b. All Lines Flowing Equal Amounts c. No Back Flow 6.. Leach Field or Trench a. Dimensions b. Stone Depth c: Capped 'Eads d. Clean Double Washed Stone 7. Leach Pits a. Dimens no b. Stone epth c. Spla Pads d. Tea e. C t Pipe to Pit - Both Sides. f. C can Double Washed Stone 8. No Garbage Disposal 9. yinal Graffi Inspection 10. Barricading Covered System 11. As Built Submitted - a. Lot Location b. Dimensions of System c. Location with Regard_to Pere Test d. Elevations e. Water Table Board of Health North Andover,Mass SUBSURFACE DISPOSAL DESIGN CHECK LIST LOT APPROVED DATE DISAPPROVED DATE i Provided: Reasons: I iv -Apo) { Tei a FAIL / Reg 2.5 j�The submitted plan t tf ow as a minimums the lot to be served-area,dimensions lot # abutters location and log deep observation hoes-distanceto ties location and results percolation tests-distance to ties design calculations & calculations showing requiredleaching area location and dimensions of system -including reserve area existing and proposed contours g) location any wet areas within loot of sewage disposal system or disclaimer-check wetlands mapping h) surface and subsurface drains within 100+ of sewage disposal system or disclaimer i) location any drainage easements v4thin 1001 of sewage disposal • _ system or disclaimer-Planning Board files (j) knom sources of inter supply within 2001 of sewage disposal system or disclaimer (k-j location of ang proposed well to serve lot-1001 from leaching facility location of vater lines on property-101 from leaching facility location of benchmark driveways garbage disposals ,/ no PVC to be used in construction q) profile of system-elevations of basement, plumb, pipe, septic tank, distribution box inlets and outlets, distribution field piping and Other elevations ) maxLmam ground water elevation in area sewage disposal system (s) plan must be prepared by a Professional Engineer or other professional authorized by lax to prepare such plans Reg 6 Sqptic Tanks (a) capacities--T50% of flow, water table, tees, depth of tees, i access, pumping cleanout ) 101 from cellar wall or inground suLmming pool (d) 251 from subsurface drains Reg 10.2 ✓ Distribution Boxes a) 0 pe greater than 0.08 Reg 10.4b) sump .pPROV ED Dt0TE PROVIDED Title 5 Reg. 2.5 F to Reg. 6 NORTH A10OVER BOARD Or HEALTH � / DISAPPROVED DATE TIME REASON The submitted plan must show as a minumum: (a) the lot to be served (area, dimensions, lot //,abutters) (Planning Board -files) �b) location and log of deep observation holes -distance to ties ( ) location and results of percolation tests -distance to ties (d) design calculations & calculations showing required / leaching area (e) location and dimensions of system -(including reserve area)' �existing and proposed contours l g _ location of any wet areas within 100 of the sewage disposal system ot- disclaimer (check wetlands mappine (h) surface and subsurface drains within 100' of sewage disposal system or disclaimer �) location of any drainage easements within 100' of sewagedisposal system or disclaimer (planning board files) known- sources_ of water supply- within- 200' of sewage disi)osai=-system-ter= _disclaimer-. - proposed -well to serve- the _lot (100' ��- -location-:.of any p p from leaching facility) , from.leachi: location -of water lines on property ( 0 �/ facilities) ilm location of benchmark A(q, �driveways garbage disposers no PVC is to be used in construction a profile of the system (elevations of basement, plu pipe septic tank, distribution box inlets and outlet= distribution•field piping and any other elevations) (r.,- maximum ground water elevation in area of sewage dit .system (s) plan must be prepared by a Professional Engineer or other professional authorized by law to prepare sucl plans Septic Tanks (a,_ Capacities - 150% of flow, water table, tees, depth of tees, access, pumping, Cleanout 10' from cellar wall or inground swimming pool d 25' from subsurface drains TOWN OF NORTH ANDOVER SYSTEM PUMPING RECORD DATE: R)cb jAN " 6 2003 SYSTEM OWNER & ADDRESS SYSTEM LOCATION 31 m Dn.-(example: left front of house) DATE OF PUMPING: — QUANTITY PUMPED �ALLONS CESSPOOL: NO — . 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: COMMENTS: CONTENTS TRANSFERRED TO:-.,l�- a Commonwealth of NORTH ANDOVER 0 1% ANN MARIE ERRICO Date of Pumping: _ 9/05/08 i Viv*& -6 ..i 0 -"— s • w'r *-t1/ ari OCT 14 208 TOV IN C' -9 HEALI :. 1818 SALEM STREET Quandtj• Pumped: 1000 gallons Cesspool: NO 0 yes. ❑ Septic Tank: No ❑ Yes RAGGS SEPTIC SERVICE. INC. System Pumped by: d.b.a. S. A. ComEAQ SEPTIC License is Contents transferred 'to:_ a�L RAYNON'. Dace 9/05/08 Inspector RAGGS SEPTIC SERVICE. It Sao RECEIVED Cotoetonitvukh of 1►lmse6usetts \J I �,� .1 ZU�o N. �,.,�� , Massachusetts TOWN OF NORTH ANDOVER HEALTH DEPARTMENT Lrc Date of Pumping:. t 1 0 1 1 c Cesspool: No Er Quantity Pumped: I L 0 0 gallons Yes. ❑ Septic Tank: No ❑ Yes RAGGS SEPTIC SERVICE, INC. System pumped by: d.b.a. E. 11. COMEAtT SEPTIC License R: Contents transkrred 'to:�, Date I6\k fit Inspector RAGGS SEPTIC SERVICE. INC