Loading...
HomeMy WebLinkAboutMiscellaneous - 20 FULLER MEADOW ROAD 4/30/2018 20 FULLER MEADOW ROAD Road f - 21O/1O4.D_O125-OM.O - Il i i i i Commonwealth of Massachusetts City/Town of System Pumping Record Form 4 DEP has provided this form for use-by local Boards of Health. Other forms may be'used, but the information must be substantially the same as that provided here. Before using.this form, check with your local Board of Health to determine the form they use.The System Pumping Record must be submitted to the local Board of Health or other approving authority. A. Facility Information 1. System Locatio Leff ig fronto hou Left/Right rear of house, Left/right side of house, Left/ Right side of buil g, Left/Right front of building, Left/Right rear of building, Under deck Address City/rown State Trp Code 2. System Owner. Name Address(if different from location) Citylrown State --,yam,�• de Telephone Number B. Pumping Record 1. Date of Pumping Date 2. Quantity Pumped: Gallons 3. Type.of sYstem: ❑ Cesspool(s) 3 5e ticc Tank Tight Tank ❑ Other(describe): 4. Effluent Tee Filter present? ❑ Yes 3-No If yes,was it cleaned? ❑ Yes ❑ No. 5. Conditign afste 6. System Pumped By. Neil Bateson F5821 Name Vehicle License Number Bateson Enterprises Inc Company 7. Location contents-were disposed: Cx L S. Lowell Waste Water 41 Sig Haule Date t5fomi4.doc•06/03 System Pumping Record•Page 1 of 1 Commonwealth of Massachusetts City/Town of RECEIVED System Pumping Record y` Form 4 MAY 2 9 2007 DEP has provided this form for use by local Boards of Health. Other ��y Ik�r wbut information must be substantially the same as that provided here. B orel-ijsih jN§ff'6fi3V6h6ck 1 vith 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 Important: When filling out 1. Syste Location: forms on the computer,use only the tab key Address to move your cursor-do not City/Town State Zip Code use the return key. 2. System Owner: Name ISI Address(if different from location) City/Town Stay) _Zip C Telephone Number B. Pumping Record 1. Date of PumpingDate 2. Quantity Pumped: Gallons 3. Type of system: ❑ Cesspool(s) Septic Tank ❑ Tight Tank ❑ Other(describe): 4. Effluent Tee Filter present? ❑ Yes [ lo If yes,was it cleaned? ❑ Yes ❑ No 5. Conditi n of System: A vx,—Ae J 6. Syster IPt��"'UBy:-11 Name Vehicle License Number Company 7. Location vAre cgntentre di sed: 7 , 7 Signatur of aul Date t5form4.doc•06/03 System Pumping Record•Page 1 of 1 D �tressEv ... a _ Title of File Page of Date File Open: Date file closed: Doc Document/Action Title Date of Refer to other Purpose of Document/Action and notes action Document/ document/ Num. Action Department Board of Appeals — Board of Health — Planmmng Board — Conservation Commission — Building, Department r, Commonwealth of Massachusetts Executive Office of Environmental Affairs Department of Environmental Protection APR 15 William F.Weld Governor Trudy Coxe Secretary,ECEA David B. Struhs Commissioner SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A ,- ---_, CERTIFICATION Property Address Ov lfJ✓ ��" Address of Owner: Date of Inspection: i.' — _ / (If different) Name of Inspector: S } Company Name, Address and Telephone Number: tZ u - CERTIFICATION STATEMENT I� S L 4 l7 t 0 tU.), IL <<1 j�✓ Gc/ c.��- I certify that I have personally inspected the sewage disposal system at this address and that the information reported below is true, accurate and complete as of the time of inspection. The inspection was performed based on my training and experience in the proper function and maintenance of on-site sewage disposal systems. The system: Passes Conditionally Passes Needs Further Evaluation By the Local Approving Authority Fails Inspector's Signature: Date: L , 'j 11t4V The System Inspector shall submit a copy of this inspection report to the Approving Authority within thirty (30) days of completing this inspection If the system � a shared system or has a design flow of 10,000 gpd or greater, the inspector and the system owner shall submit the report to the appropriate regional office of the Department of Environmental Protection. The original should be sant t(- ;hr, system owner and copies sant to the buyer, if applicable and the approving duthorit�. INSPECTION SUMMARY: Check A, B, C, or D A] SYSTEM PASSES: lr I have not found any information which indicates that the system violates any of.the failure criteria/as defined in 310 CMR F5.303. Any failure criteria not evaluated are indicated below. t� i B) SYSTEM CONDITIONALLY PASSES: One or more system components need to be replaced or repaired. The system, upon completion of the replacement or repair, passes inspection. Indicate yes, no, or not determined (Y, N, or ND). Describe basis�of determination in•all msfances. If"not determined"; explain why not) The septic tank is metal, 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 conforming septic tank as approved by the Board of Health. (revised 8/15/95) �~ One Winter Street • Boston,Massachusetts 02108 a FAX(617)556-1049 a Telephone(617)292-55W A iJ Pnnled on Recycled Paper A SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATIONcontinu Property Address: Owner: e e Date of Inspection: B) SYSTEM CONDITIONALLY PASSES (continued) t( I 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 1 Cl FURTHER EVALUATION IS REQUIRED BY THE BOARD OF HEALTH: /,f 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 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 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 APPROPRIATE) DETERMINES THAT THE SYSTEM IS FUNCTIONING IN A MANNER THAT PROTECT THE PUBLIC HEALTH AND SAFETY AND THE ENVIRONMENT: the system has a Septic tank and soil absorption system and is witliiu 100 feet to a surfat-e water supply or tributary to a surface water supply. The system hay a septic tank and soil absorption system and is within a Zone I of a public water supply well. The system has a septic tank:and soil absorption,system and is within 50 feet of a private water supply well. _ The system hay a septic tank and soil absorption system and 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. D) SYSTEM FAILS: I have determined that the system violates one or more of the following failure criteria as defined 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. 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. (revised 8/15/95) 2 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: fG f �r°✓ �J ! P-" `rc ,+ �'' � N A i`" Owner: Date of Inspection: D] SYSTEM FAILS (continued): 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 s t t 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: 1,14 The following criteria apply to large systems in addition to the criteria above: The design flo" of system is 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: 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 r := the.system is.located ;,a nitrogen sensitive arva;(Irlterim Wellhead Protection Area (IWPA) or a mapped Zone 11 of a public water supply well The owner or operator of any such system shall bring the system and facility into full compliance with the groundwater treatment program requirements of 314 CMR 5.00 and 6.00. Please consult the local regional office of the Department for further information. (revised 8/15/95) 3 C' SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST Property Address: L /'�°'� Owner: Date of Inspection: 97y Check if the following have been done: ZmpinS information was.requested of the owner„roccupant, and Board of Health_ t _ None of the system components have been pumped for at least two weeks and the system has been receiving normal flow rates 1/1Oring that period. Large volumes of water have not been introduced into the system recently or as part of this inspection. s built plans have been obtained and examined. Note if they are not available with N/A. 7`1 ,/he 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 or / approximated by non-intrusive methods. _The facility o,,,; cr (and occupants, if different from owner), were provided with information on the proper maintenance of Sub- Surface Disposal System. (revised 8/15/95) 4 a SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION Property Address: Owner: 1 �, p �f r ✓ Date of Inspection: f FLOW CONDITIONS RESIDENTIAL: Design flow: gallons Number of bedrooms: Number of current residents: Garbage grinder(yes or no):� Laundry connected to system es or no):�� Seasonal use (yes or no): i Water meter rgadings,,if available: Last date of occupancy: r Gd < COMMERCIAUI NDUSTRIAL: Type of establishment: Design flow: gallons/day 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: OTHER: (Describe) Last date of occupancy: GENERAL INFORMATION PUMPING RECORDS and source of information: 410-ell (1 System pumped as part of inspection: (yes or no) -S If yes, volume pumped d gallons Reason for pun ping, e-"' f TYPE OF,SYSTEM � Septic tank/distribution box/soil absorption system Single cesspool Overflow cesspool Privy Shared system (yes or no) (if yes, attach previous inspection records, if any) Other(explain) APPROXIMATE AGE of all components, date installed (if known) and source of information: Sewage odors detected when arriving at the site: (yes or no) (revised 8/15/95) $ SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: ) ') '4"//,-,, �u P eddy; , /y, Owner: D r e kl-<✓ Date of Inspection: SEPTIC TANK: �� (locate on site pl n) Depth below grade;�� Material of construction: _concrete _metal _FRP —other(explain) Dimensions: P 4, 'r* S Sludge depth: _ Distance from top of sludge to bottom of outlet tee or baffle: r Scum thickness: g, Distance from top of scum to top of outlet tee or baffle- Distance from bottom 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, etc.) I Al `c 1' f p v � G Q?" I l>L'oe 4-C s SAOd Cej,4,7 -/O L e AAC 5 tc' +° 6 U TGC GREASE TRAP:_ 14k (locate on site plan) Depth belo%,,, grade: Material of construction: _concrete _metal _FRP —other(explain) Dimensions: Scum thickness. Distance from top of scum to top of outlet tee or baffle: Distance from bottom nt «r m t,, hottnm of outlet tee or battle Comments: (recommendation for pumping, condition'of inlet and outlet tees br'baffles„depth.ofjigyid level in relation to outlet invert, structural integrity, evidence of leakage, etc.) (revised 8/15/95) 6 f � r , SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C / SYSTEM INFOR/MATION (continued) Property Address: ?� �.-�O r f.� M O.l o/Q,. ��! ( /f✓!/.r U✓ Owner: 1 rte, Date of Inspection: / 4 - FOP" 1 SOIL ABSORPTION SYSTEM (SAS): S (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: leachog pits number:_ leaching chambers; numbef:_` leaching galleries, number: / leaching trenches, number,length: l�/ !` S leaching fields, number, dimensions: overflow cesspool, number: Comments: (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation,etc.) u / S/.r of p !/y /> / ti r 416 JZ_A4.1 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) 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.) (revised 8/15/95) 8 i Cr' SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C ,r SYSTEM INFORMATION (continued) !/ Property Address: o� i��f�'r /t,c j ja4c-^o �J /Y•��/Od r �.. Owner: DQ r-P/r, Date of Inspection: { SKETCH OF SEWAGE DISPOSAL SYSTEM: include ties to at least two permanent references landmarks or benchmarks locate all wells within 100' I (4 G 37 G DEPTH TO GROUNDWATER /r Depth to groundwater: ] feet method of determination or approximation: ill e Wei. 'Irku SC d uk at, L.ow t/ .141 (revised 8/15/95) 9 Commonwealth of Massachusetts p Ems, Massachusetts R�CEIVED' . 2Ld' NOV - 2 2004 TOWN OF NORTH ANDOVER System. Pumping Record HEALTH DEPARTMENT System Owner System Location X20 Date of Pumping: [ (— ( 'Q Quantity Pumped: 1SWO gallons Cesspool: No ] Yes [] Septic Tank: No [] Yes [ System Pumped by: 64a"W License# Contents transferred to: Greater Lawrence Sanitary District Date: Inspector: k X Board %of Bealth N_crt-.,ndocertYABa SUBSURFACE DISPOSAL DESIGN CHECK LIST .- /� F6 LWe- f6e.KS Y -LOT i� DATE / DISAPPROVED DATB APPROD� Reaeonss Provided: i © Ci.owa Goµ T�ETE�t-l�u..eR10+J 1"�$S. Title V FhII. CE Reg 2.5 The submitted plan must show as a mini'mmt the lot to be served-area,dimensions lot #,abntters location and log deep observation holes-distance to ties 4ej) location and results percolation tests-distance to ties design calculations & calculations shoring required leaching area location and dimensions of system-including reserve area existing and proposed contours g) location any wet areas 4tmn 100' of sewage disposal system or disclaimer-check wetlands napping X (h) surface and subsurface drains v*ithin 100t of sewage disposal system or disclaimer ver �(i) location any drainage easements within 1DO' of selvage disposal system or diselai rtir-Planning Board files (3) kno= sources of -sater supply w*itb n 200' of sewp-ge disporzl a _ system or disc]ainer (k) cation of pz�aposed �,-e11 to serve lot_lCq f':Om leaching favi] locationtjF— o£ meter lines on property-10' from lez�hing fa.cili m) location of benchmark In) ) driVekays_ ) garbage disposals ) no PVC to be used in construction . ) profile o£-system-elevations of basement, plumb, pipe, septic tank] distribution box inlets and outlets, distribution field piping and Ob "er elevations -) ma�mam groimd water elevation in area sewage disDOsal system plan must be prepared by a Professional Engineer or-other professional authorized by law to prepare such plans Peg 6 Septic Tanks 10 a) capacities-150 - of flog, water table, tees, depth o£ tees, access, ping b) cleanout Ir (c) 10, from cellar ,-all or inground Z_-�ng pool (d) 25' from subsurface drains Reg 10.2 Distribution Faxes a) s ope greater than 0.08 F.eg 10.4 I b) s� F f • f � l } i � ' s i ! ` E i ( o o 4 l C fLF'vATf Oh HW: -F 1 14LWO S T 114Lf-T Ou,LC I")t•09 L fx.X NL. r 1,',7, { i D BOX -CTLE► I.j?. .t Ftp)FIE L D 13 7.32 t 1 CC'RTI'7Y Tt1AT FNE SEPTIC SYSME M-- !W-TALLEl; AS SFICA,r4-THIS PLAN IS R,L1T p F+S!i r,A1�F,Ah"ti .z CEIAT+f(CATION AU,[- i ,,.�3r LOCATION H3 Peck VAMIl SK! Ahi A352 CO �•, \ Q ♦ ' O QO SEMEPiT F'" 5 / Uvi'`.�1`,�t�_ OV" f-R TOU Lk,DiV,► I ; ti _fit LOCI T i�� . Iw+T 5? ��_L!_FF� �I� cru s to ( T 7 7 , _ may: f� .• Pk£PARE1, Olf JC, P,,' r� 5,z5 L:3g,cri �I I t � 1 , 1 r ' r + r 1 � tl 11 I i t I i ELEVATIONS 62,514 ST INLET 1-'b.24 S T auTLET 136.09. ti G BOX NLET 1�7e P-1 j 0 BOX CUTLET ryIa; ENO FIELD 137.32 I C17 RTI T1fAT THE SEPTIC SYST—f.,* v'W.--. Ih,_'ALLEL AS SHO"WN.THI5 PLAN I NOIT IF.,FNDE D AS A YAW-AN-) OF THE SN STEM: CENT+f ICATION ANO �f-5 LOCATION BY R•P AN— ASS` - - 1 J ` I�i i �yV 1 � •4i ,f, / f 1 r L-{{ tel- 1'-11 'f✓rr OG 11-4 F1�SEME ' J + t NrR TJ{'A GA�,DAJNI �Y LOC: I i { I �"'��` F1�l..�FZ +�f�Uv�': r�4) ' I CS T c 7-27-844 + o N P1 , J i t � � 1 Board' of Health SEPTIC SISTEH North Anc—re-Ex iaaa. S 2 2 INSTAIS.ATIClQ CHECCB LIST LOT'' OVID DATg BISAPPRO�TED . AVATICd� Ob FAIL -------------- ,i FAn OK 1. Distance To: a. Wetlands ' b. Drains C.. Well 2. Water Line Location Z 3. No PPC Pipe . t �. Septic Tank a. _Tees --Length & To Clean Out Covers. b. Cement Pipe to Tank On Both Sides of Tank 5. Distribution Box a. Covers & Box - No Cracks b. All Lines Flouring Equal Amounts c. No Back Flog 6. . Leach Field or Trench a. Dimensions b. Stone Depth a , Capped ids d. Clean Double'Washed 7. Leach Pits a. Dimensions b. Stone Depth c. Splash Pads t d. Tees e. Cmrent Pipe to Pit - Both Sales f. Clean Double Washed Stone 8, No Garbage Disposal ' 9. Final Grading Inspection 10. Barricading Covered System 11. As Built Snbmitted a. Lot Location :. b. Dimensions of System c. Location with Regard-to Pere Test d. Elevations Water Table F i