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Miscellaneous - 20 NORTH CROSS ROAD 4/30/2018
_N O o IIS O 9) z ;x r� an F-1 fti d9 CO 14t C. M I� yU r� 111 > t?A M 0alC` att ttl ;max a X nl IA vi tTl C► .. A PUBLIC HEALTH DEPARTMENT Town of North Andover Community Development Division CERTIFICATE OF COMPLIANCE As of: 11/24/2014 This is to certify that the individual subsurface disposal system received a SATISFACTORY INSPECTION of the: Complete Repair of D -Box and outlet tee By: Todd Bateson At: 20 North Cross Road Map 038.0 Lot 0182 North - I over, MA 01845 of this cti� not be construed as a guarantee that the system will function satisfactorily. Michele Grant ' Public Health Agent 1600 Osgood Street, North Andover, Massachusetts 01845 Phone 978.688.9540 Fax 978.688.8476 Web www.townofnorthandover.com 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 Location: Left/ Right front of house, Left/ Right rear of hous. Le ig , sideouse, Left / Right side of building, Left / Right front of building, Left / Right rear of building, Un e Address Cityrrown state 2. System Owner. Name Zip Code r`- Address (if different from location) City/Town , t v State ( Zi Code ; Telephone Number B. Pumping Record 1. Date of Pumping 2. QuantityPum Date ped Gallons 3. Type of system: ❑ Cesspool(s) eptic 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. 7. Neil. Bateson F5821 Name Vehicle License Number Bateson Enterprises Inc - Company contents were disposed: Date ` t5fomA.doc- 06/03 System Pumping Record • Page 1 of 1 Owner information is required for every page. Important: When filling out forms on the computer, use only the tab key to move your cursor - do not use the return key. ISI Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 20 North Cross Property Address Marc Ouellette Owner's Name North Andover City/Town MA 01845 State Zip Code 11/21/2014 Date of Inspection Inspection results must be submitted on this form. Inspection forms may not be altered in any way. Please see completeness checklist at the end of the form. A. General Information 1. Inspector: Neil J. Bateson Name of Inspector Bateson Enterprises Inc. Company Name 111 Argilla Road Company Address Andover City/Town 978-475-4786 Telephone Number B. Certification MA State S115 License Number 01810_ RE zip co"T UCt.# 0 ! 2014 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. 1 am a DEP approved system inspector pursuant to Section 15.340 of Title 5 (310 CMR 15.000). The system: ® Passes ❑ Conditionally Passes ❑ Fails ❑ "seeds Alurther luation by the Local Approving Authority 11/21/2014 Inspet-toM Sidnature Lj Date The system inspector shall submit 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. ****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 in the future under the same or different conditions of use. t5ins • 3/13 Title 5 Official Inspection Form: Subsurface Sewage Disposal System • Page 1 of 17 Owner information is required for every page. Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 20 North Cross Property Address Marc Ouellette Owner's Name North Andover MA 01845 11/21/2014 Cityrrown State Zip Code Date of Inspection B. Certification (cont.) Inspection Summary: Check A,B,C,D or E / always complete all of Section D A) System Passes: ® I have 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. Comments: After permit from B.O.H., install new outlet tee with gas baffle & new d -box, septic system now passes Title 5 inspection 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. Check the box for "yes", "no" or "not determined" (Y, N, ND) 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. ❑ Y ® N ❑ ND (Explain below): t5ins • 3/13 Title 5 Official Inspection Form: Subsurface Sewage Disposal System • Page 2 of 17 PUBLIC HEALTH DEPARTMENT Town of North Andover Community Development Division CERTIFICATE OF COMPLIANCE As of: 11/24/2014 This is to certify that the individual subsurface disposal system received a SATISFACTORY INSPECTION of the: Complete Repair of D -Box and outlet tee By: Todd Bateson At: 20 North Cross Road Map 038.0 Lot 0182 North An-- MA 01845 Issuance of this c i c A not be construed as a guarantee that the system will function satisfactorily. Michele Grant ' Public Health Agent 1600 Osgood Street, North Andover, Massachusetts 01845 Phone 978.688.9540 Fax 978.688.8476 Web www.townofnorthandover.com A North Andover Health Department (ommunity Development Division ONSITE WASTEWATER SYSTEM CONSTRUCTION NOTES LOCATION INFORMAJION ADDRESS:,'(O O S MAP: LOT: INSTALLER: Todd Bateson DESIGNER: PLAN DATE: BOH APPROVAL DATE ON PLAN: INSPECTIONS D x(, RA&+ d , 1I1 TANK INSPECTION: l,I DATE OF BED BOTTOM INSPECTION: DATE OF FINAL CONSTRUCTION INSPECTION: DATE OF FINAL GRADE INSPECTION: SITE CONDITIONS Comments: SEPTIC TANK ❑ Contractor reports any changes to design plan ❑ Existing septic tank properly abandoned ❑ Internal plumbing all to one building sewer ❑ Topography not appreciably altered ❑ Building sewer in continuous grade, on compacted firm base ❑ Cleanouts per plan ❑ Bottom of tank hole has 6” stone base ❑ Weep hole plugged ❑ 1500 gallon tank has been installed H-10 loading ❑ Monolithic tank construction ❑ Water tightness of tank has been achieved by visual testing ❑ Inlet tee installed, centered under access port .01 %, ❑ Outlet tee installed, centered under access port Comments: (gas baffle/effluent filter) ❑ inch cover to within 6" of finish grade installed over one access port ❑ Hydraulic cement around inlet & outlet Comments: PUMP CHAMBER ❑ Bottom of tank hole has 6" stone base ❑ Weep hole plugged ❑ 1500 gallon Pump Chamber installed ❑ H-10 loading ❑ Monolithic tank construction ❑ Inlet tee installed, centered under access port ❑ Pump(s) installed on stable base ❑ Alarm float working ❑ Pump On/Off floats working ❑ Separate on/off floats ❑ Drain hole in pressure line ❑ cover at final grade installed over pump access port ❑ Water tightness of tank has been achieved by testing ❑ Hydraulic cement around inlet & outlet Comments: CONTROL PANEL ❑ Alarm & Pump are on separate circuits ❑ Alarm sounds when float is tripped ❑ Location of control panel: basement ❑ Alarm signal located inside: basement Comments: DISTRIBUTION -BOX Installed on stable stone base �] H-20 D -Box ❑, Inlet tee (if pumped or >0.08'/foot) Hydraulic cement around inlet & outlets V[� Observed even distribution ✓, Speed levelers provided (not required) 0 Schedule 40 PVC Pipe Comments: co 00 Lci O W O i �• M IL = LW Aj,r� of a mj w E� O O � U x. a o J r z =o 0o< p �Of o o Q z O o E E Q �; 3 LL IL y U d (,1)Cd Y a O; Z ° z Cd ° 0 ° ° o Cd• --•-•-•-•----------------•-•-•-------••••••••••••••••••••••••••••••. o: p: 00: Cl; : kr)eq N N C. N ran: 0 o Z Z O Z Z Z .-, 4.1 _ cc r H � � 0 x � a � LU x o a o U m > CU s. a) z ------------------------------------------------------------------ 0 N Important When filling out forms on the computer, use only the tab key to move your cursor - do not use the return key. rem Application for Septic Disposal Svstem Construction Permit - TOWN OF NORTH ANDOVER, MA 01845 Construct a new on-site sewage disposal system' TODAY'S DATE $ 250:00 — Full Repair $425.00 - Component ❑Re it or replace an existing on-site sewage disposalsystem' Repair or replace an existing system component — What? .g A. Facility Information ")© '4w4, Z-"" f�L Address or Lot # CitylTown 2: *TYPE OF SEPTIC SYSTEM*: ➢ ❑ Pump ['C;ravity (choose one) —If pump system, attach copy of electrical permit to application— ➢ ❑ Conventional System (pipe and stone system) ➢ ❑ Infiltrator or Biodiffuser (Gravel -Less) (Attach a copy ➢ ❑ Pressure Distribution S.A.S. (No D -Box) ➢ ❑ Pressure Dosed (D -Box Present) S.A.S. �QV VER TOVvpv Or �`jptErr F1 U � FOUR is type of system.) ➢ ❑ Does the system require an effluent filter? Yes No ff yes, does plan specify make and model of filter? YES = (no further info, needed) NO = (installer must specify brand of filter before DWC issuance) What is the Makers What is the ModW 2. Owner Information ?dame Address (if different from above) 0✓c9 Cityrrown stateZipZip Code 1� /v !iri ,� �' T -8 - Telephone Number 3. Installer Information Name c Name of CompBATECON ENTERPRISES, INC. Address —1LA.JA PIUAU ANDOVER, IVA 0 i si 0 Cityrrown State Zip Code f7f-e1-6-7— °7� Telephone Number (Cell Phone # if possible please) 4. Designer Informa 'on Name Name of Company Address City/Town State Zip Code Telephone Number (Best # to Reach) Application for Disposal System Construction Permit - Page 1 of 2 ,r . Application ..for Septic Disposal System y p Construction-Permit—TOWN.-OF, TODAY'S DATE ORTH ANDOVER, MA 01845 $.250.00 - Full Repair �.�s 4"•'"' $125.00 -Component S^��5 PAGE 2 OF 2 A. Facility. Information continued.... 5. Type -of Building:esidential Dwelling or ❑Commercial B. Agreement The undersigned agrees to ensure the construction and maintenance of the afore -described on-site sewage disposal system In accordance with the provisions of Title 5 of the Environmental Code, as well as the Local Subsurface Disposal Regulations for the Town of North Andover, and not to place the system fn operation untfl a Certificate of Compliance has been Issue y this Board of Health. Narnez Date Application Ap roved By: (Bo of Health Representative) Name �/ 7 / i Date I for the%flowing reasons: For Office Use Only: 1 Fee Attached. yesxNo 2. ProjectManager Obligation Form Attached.? yes 3.: Puma .stem? Ifso� Attach covy ofElectrical Permit : T 4. Foundation As Built.? (new construction ronly); y (Same scale as approved plan) 5. FloorPlans? (new construction only). Appifcatibn Ior•pj6po3al Systern:Constraction Permit Page 2 02 SEM C'SM " ROJECT i1 h: As fl�e.N¢rth AndOvar.li =cd&iaudjOr fqrt4e• tm-fotheseptic gatem.fot.the�ugpc�ty$t . �J Gtoss � • • {Ade treaty at tep@c 1yat0m) -For plata b3 R*ti" to tw.appucatim cf d Aa eSds;% (Bu at -I tumej Heed dated Dshd �— h7 —� ---- W I undmtand the following 4b2igatiom for nmagement of -01b project: i. As the iasm&4 I r+.m.ob2igated ext abWm aff pegpIts and Board of -Health apploved plans to affitwag an wo& da it site: L= bm saroravedat •vL ase �nrsf e+'4Y Z. his tlic ,I,piiist•4MRfar =y and sRIgpt d=& I£hoixemmem contract ect p 04ocistaed � mp e�paay �ea � colon and mafla , a= an 4�er eraott not � � y stem' &Mb a pl eb2e. is not ready, that I As t4 WWU4. I it a: e ' usa W to. have stie tset�sary C ifl&�.p�� b ' ied b_t�,u€tr�tsmc� the aPPI%a k casts ss reeri�eatfnd,s,s ift�fw�l'i}1fR terl�w»i i.i�w�41i1_s. ahou'Id b�I }' `Via. there is a zci�zromg , v "Ch. w #fin i wi,,, but daea• dot have to be pan='. • . A; biillt af,v f6p — dErtheibn feu Irjm*m tom, etc, esbAt OK-(ar e -=:d tb: be tt bmit6cd•tos &je Board fram the etfgitteer;nust be presaut far t2 ecflost, with s c*m tome. J�tsta]Ic= itiust t�vrgtkpm?st bg resdp sud able to cavae �t�ialg.t6.*10 2c acidshy to , . ; . • c. �� �stsitier:assst teq�tt,�t mspe tvh "til i$ ccua Itte: ... )Ave to be an"fite. • - P Insts Ier does not 4. &-the *tIJIM-I 130 that oalq I my peri'mm the voth'(offiwt6ax M6�0� m cas�piete tfiajnamliati+tta of eke syatrs idem #tierstept j I srui reggited 5.. lie tfie�aat�•it�aderat�titiitbstImew �e:ari=ni��th ".. . V .'.�.- � .. ' - -. :' � piar#ce-ref tfit foIIc�a►i�g co�t�c�ion . ately s: 1+: Ietrrrnfn$�o� dlarfe p�Ferelevrtdaa aEftht exri�tan l�a� bcr rcwabcdt A IRS Pett%tn aftheA=d xndatridvV U wed Co Fi�Jfaspee7oir8oauta��:Fetisltlratffortuit d In�slrllatfa ofmnlr, l 1$a�ri pY r4st Mont, vet, P: m fiber, ret l tixrg xs3rtisflLl tstbcr . eomPaneatu. b. AS the inst et'I ileixLc t eta do I al st; 4 �+etn s' tier �+ Uaden.lanfAr IIcaa:Ed Sentic:?nst (Tod a i -i. r NORTH of � . • wo s � Town of North Andover ,,,,.:� HEALTH DEPARTMENT wSS�cHus�t CHECK #: LOCATIO H/O NAIL CONTRA( 7159 Type of Permit or License: (Check box) ❑ Animal $ ❑ Body Art Establishment $ ❑ Body Art Practitioner $ ❑ Dumpster $ ❑ Food Service - Type: $ ❑ Funeral Directors $ ❑ Massage Establishment $ ❑ Massage Practice $ ❑ Offal (Septic) Hauler $ ❑ Recreational Camp $ ❑ Sun tanning $ ❑ Swimming Pool $ ❑ Tobacco $ ❑ Trash/Solid Waste Hauler $ ❑ Well Construction $ SEPTIC Systems: ❑ Septic - Soil Testing $ ❑ Septic - Design Approval $ ❑ Septic Disposal Works Construction (DWC) $ ❑ Septic Disposal Works Installers (DWI) $ ❑ Title 5 Inspector $i., -i� Title 5 Report x ❑ Other: (Indicate) $ k Health Agent Initials White - Applicant Yellow - Health Pink - Treasurer Owner information is required for every page. Important: When filling out forms on the computer, use only the tab key to move your cursor - do not use the return key. ISI Commonwealth of Massachusetts i� Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 20 North Cross Road Property Address Marc Ouellette Owner's Name North Andover City/Town MA 01845 State Zip Code Inspection results must be submitted on this form. Inspection forms way. Please see completeness checklist at the end of the form. A. General Information 1. Inspector: Neil J. Bateson Name of Inspector Bateson Enterpri Company Name 111 Arailla Road Inc. Company Address Andover MA Cityfrown State 9784754786 S115 Telephone Number License Number 11/11/2014 Date of Inspection iay not be altered in any RECEWL-V NOV 1 2014 i OVr4 of. NORTH ANDD , ,HEAi.s?' 17EPARTMEN� 01810 Zip Code B. Certification 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 he inspection. The inspection was performed based on my training and experience in the proper function and maintenance of on site sewage disposal systems. 1 am a DEP approved system inspector pursuant to Section 15.340 of Title 5 (310 CMR 15.000). The system: ❑ Passes ® Conditionally Passes Fails I ❑ Nee F rther E ti07% by the Local Approving Authority 11/11/2014 Inspect rs ig ature IDate The system inspector shall submit a copy of this inspection report to they 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 syster>l 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. ****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 in the future under the same or different conditions of use. t5ins • 3/13 Titlef5 Official Inspection Form: Subsurface Sewage Disposal System • Page 1 of 17 Owner information is required for every page. Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 20 North Cross Road Property Address Marc Ouellette Owner's Name North Andover MA 01845 11/11/2014 Cityrrown State Zip Code Date of Inspection B. Certification (cont.) Inspection Summary: Check A,B,C,D or E / always complete all of Section D A) System Passes: ❑ 1 have 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. 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. Check the box for "yes", "no" or "not determined" (Y, N, ND) 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. ❑ Y ® N ❑ ND (Explain below): t5ins • 3/13 Title 5 Official Inspection Form: Subsurface Sewage Disposal System • Page 2 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 20 North Cross Road Property Address Marc Ouellette Owner Owner's Name information is required for North Andover MA 01845 11/11/2014 every page. Cityrrown State Zip Code Date of Inspection B. Certification (cont.) ❑ Pump Chamber pumps/alarms not operational. System will pass with Board of Health approval if pumps/alarms are repaired. B) System Conditionally Passes (cont.): ❑ Observation of sewage backup 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 ❑ Y ® N ❑ ND (Explain below): ❑ obstruction is removed ❑ Y ® N ❑ ND (Explain below): ❑ distribution box is leveled or replaced ❑ Y ® N ❑ ND (Explain below): ❑ 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): ❑ broken pipe(s) are replaced ❑ Y ® N ❑ ND (Explain below): ❑ obstruction is removed ❑ Y ® N ❑ ND (Explain below): 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 unless Board of Health determines in accordance with 310 CMR 15.303(1)(b) that the system is not functioning in a manner which will protect 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 t5ins • 3113 Title 5 Official Inspection Form: Subsurface Sewage Disposal System • Page 3 of 17 Owner information is required for every page. Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 20 North Cross Road Property Address Marc Ouellette Owner's Name North Andover Cityrrown B. Certification (cont.) NIA 01845 State Zip Code 11/11/2014 Date of Inspection 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: ** This system passes if the well water analysis, performed at a DEP certified laboratory, for fecal coliform bacteria indicates absent 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: Outlet tee in septic tank & d -box needs to be replaced. D) System Failure Criteria Applicable to All Systems: You must indicate "Yes" or "No" to each of the following for all inspections: Yes No ❑ ® Backup of sewage into facility or system component due to 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 '/2 day flow t5ins • 3/13 Title 5 Official Inspection Form: Subsurface Sewage Disposal System • Page 4 of 17 ❑ ® The system is a cesspool serving a facility with a design flow of 2000gpd- 10,000gpd. ❑ ® 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. For large systems, you must indicate either "yes" or "no" to each of the following, in addition to the questions in Section D. 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 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. t5ins • 3/13 Title 5 Official Inspection Form: Subsurface Sewage Disposal System • Page 5 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 20 North Cross Road Property Address Marc Ouellette Owner Owner's Name information is required for North Andover MA 01845 11/11/2014 every page. City/Town State Zip Code Date of Inspection B. Certification (cont.) Yes No ❑ ® 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 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. ❑ ® Any portion of a cesspool or privy is within a Zone 1 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. [This system passes if the well water analysis, performed at a DEP certified laboratory, for fecal coliform bacteria indicates absent 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 and chain of custody must be attached to this form.] ❑ ® The system is a cesspool serving a facility with a design flow of 2000gpd- 10,000gpd. ❑ ® 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. For large systems, you must indicate either "yes" or "no" to each of the following, in addition to the questions in Section D. 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 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. t5ins • 3/13 Title 5 Official Inspection Form: Subsurface Sewage Disposal System • Page 5 of 17 Owner information is required for every page. Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 20 North Cross Road Property Address Marc Ouellette Owners Name North Andover MA 01845 11/11/2014 Cityrrown State Zip Code Date of Inspection C. Checklist Check if the following have been done. You must indicate "yes" or "no" as to each of the following: Yes No ® ❑ Pumping information was provided by the owner, occupant, or Board of Health ❑ ® Were any of the system components pumped out in the previous two weeks? ❑ ® 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) ® ❑ Was the facility or dwelling inspected for signs of sewage back up? ® ❑ Was the site inspected for signs of break out? ® ❑ 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 and depth of scum? ® ❑ Was the facility owner (and occupants if different from owner) provided with information on the proper�maintenance of subsurface sewage disposal systems? The size and location ofithe Soil Absorption System (SAS) on the site has been determined based on: ® ❑ 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) [310 CMR 15.302(5)] D. System Information Residential Flow Conditions: Number of bedrooms (design): 3 Number of bedrooms (actual): DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x # of bedrooms): 450 t5ins • 3/13 Title 5 Official Inspection Form: Subsurface Sewage Disposal System • Page 6 of 17 Commonwealth of Massachusetts +Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments ug 20 North Cross Road Property Address Marc Ouellette Owner Owner's Name information is required for North Andover NIA 01845 every page. Citylrown State Zip Code D. System Information Description: Number of current residents: 11/11/2014 Date of Inspection Does residence have a garbage grinder? ® Yes ❑ No Is laundry on a separate sewage system? (Include laundry system inspection ❑ Yes ® No information in this report.) Industrial waste holding tank present? ❑ Yes Laundry system inspected? ❑ Yes ❑ No Seasonaluse? ❑ Yes ® No Water meter readings, if available last 2 ears usage d 9 ( Y 9 (gp ))� Yes Detail: Sump pump? ❑ Yes ® No Last date of occupancy: Current Date Commercial/Industrial Flow Conditions: Type of Establishment: Design flow (based on 310 CMR 15.203): Gallons per day (gpd) Basis of design flow (seats/persons/sq.ft., etc.): Grease trap present? ❑ Yes ❑ No Industrial waste holding tank present? ❑ Yes ❑ No Non -sanitary waste discharged to the Title 5 system? ❑ Yes ❑ No Water meter readings, if available: t5ins • 3/13 Title 5 Official Inspection Form: Subsurface Sewage Disposal System - Page 7 of 17 Owner information is required for every page. Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 20 North Cross Road Property Address Marc Ouellette Owner's Name North Andover MA 01845 11/11/2014 City/Town State Zip Code Date of Inspection D. System Information (cont.) Last date of occupancy/use: Other (describe below): General Information Pumping Records: Source of information: Was system pumped as part of the inspection? If yes, volume pumped: How was quantity pumped determined? Reason for pumping: Date Pumped 2012, owner gallons Type of System: ® Septic tank, distribution box, soil absorption system ❑ Single cesspool ❑ Overflow cesspool ❑ Privy ❑ Yes ® No ❑ 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) and a copy of latest inspection of the I/A system by system operator under contract ❑ Tight tank. Attach a copy of the DEP approval. ❑ Other (describe): t5ins • 3113 Title 5 Official Inspection Form: Subsurface Sewage Disposal System • Page 8 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments J 20 North Cross Road Property Address Marc Ouellette Owner Owner's Name information is required for North Andover MA 01845 11/11/2014 every page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Approximate age of all components, date installed (if known) and source of information: 26 years old, 9/1/1988, as built plan Were sewage odors detected when arriving at the site? Building Sewer (locate on site plan): Depth below grade: feet Material of construction: ® cast iron ® 40 PVC ❑ other (explain): Distance from private water supply well or suction line: feet Comments (on condition of joints, venting, evidence of leakage, etc.): 4" Cast iron through wall, 3" PVC in house, no leaks visible Septic Tank (locate on site plan): Depth below grade: Material of construction: ® concrete ❑ metal C feet ❑ Yes ® No ❑ fiberglass ❑ polyethylene ❑ other (explain) If tank is metal, list age: years Is age confirmed by a Certificate of Compliance? (attach a copy of certificate) Dimensions: 10'x5'x4' Sludge depth: 2" ❑ Yes ❑ No t5ins • 3113 Title 5 Official Inspection Form: Subsurface Sewage Disposal System • Page 9 of 17 Commonwealth of Massachusetts t Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 20 North Cross Road Property Address Marc Ouellette Owner Owner's Name information is required for North Andover MA 01845 11/11/2014 every page. Citylrown State Zip Code Date of Inspection D. System Information (cont.) Septic Tank (cont.) Distance from top of sludge to bottom of outlet tee or baffle 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 N/A Y N/A = Outlet tee corroded off N/A How were dimensions determined? Tape Measure Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): Inlet tee ok. Outlet tee corroded off, needs to be replaced. Depth of liquid at outlet invert. No evidecne of leakaae. Grease Trap (locate on site plan): Depth below grade: Material of construction: ❑ concrete ❑ metal ❑ fiberglass 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: t5ins • 3/13 feet ❑ polyethylene ❑ other (explain): Date Title 5 Official Inspection Form: Subsurface Sewage Disposal System • Page 10 of 17 Owner information is required for every page. Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 20 North Cross Road Property Address Marc Ouellette Owner's Name North Andover MA 01845 11/11/2014 Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): 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 ❑ polyethylene ❑ other (explain): Dimensions: Capacity: gallons Design Flow: gallons per day Alarm present: ❑ Yes ❑ No Alarm level: Alarm in working order: ❑ Yes ❑ No Date of last pumping: Date Comments (condition of alarm and float switches, etc.): * Attach copy of current pumping contract (required). Is copy attached? ❑ Yes ❑ No t5ins - 3/13 Title 5 Official Inspection Form: Subsurface Sewage Disposal System - Page 11 of 17 S r".y Owner information is required for every page. Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 20 North Cross Road Property Address Marc Ouellette Owner's Name North Andover Cityrrown D. System Information (cont.) MA 01845 State Zip Code Distribution Box (if present must be opened) (locate on site plan): Depth of liquid level above outlet invert 0 11/11/2014 Date of Inspection Comments (note if box is level and distribution to outlets equal, any evidence of solids carryover, any evidence of leakage into or out of box, etc.): D -box level & distribution equal. Evidence of carryover. D -box cover broken, replaced it. D - box badly corroded, needs to be replaced. Pump Chamber (locate on site plan): Pumps in working order: ❑ Yes ❑ No* Alarms in working order: ❑ Yes ❑ No* Comments (note condition of pump chamber, condition of pumps and appurtenances, etc.): * If pumps or alarms are not in working order, 'system is a conditional pass. Soil Absorption System (SAS) (locate on site plan, excavation not required): If SAS not located, explain why: t5ins - 3113 Title 5 Official Inspection Form: Subsurface Sewage Disposal System - Page 12 of 17 Owner information is required for every page. t5ins - 3/13 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 20 North Cross Road Property Address Marc Ouellette Owner's Name North Andover MA 01845 11/11/2014 Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Type: ❑ leaching pits number: ❑ leaching chambers number: ❑ leaching galleries number: ® leaching trenches number, length: 2 trenches 50' long ❑ 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.): Soil ok. Vegetation ok. No sign of ponding to surface. Three trees growing on end of trenches, should be cut down. 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 Dimensions of cesspool Materials of construction Indication of groundwater inflow ❑ Yes ❑ No Title 5 Official Inspection Forth: Subsurface Sewage Disposal System . Page 13 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 20 North Cross Road ,p Property Address Marc Ouellette Owner Owner's Name information is required for North Andover MA 01845 11/11/2014 every page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) 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.): t5ins • 3113 Title 5 Official Inspection Form: Subsurface Sewage Disposal System • Page 14 of 17 Owner information is required for every page. Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 20 North Cross Road Property Address Marc Ouellette Owner's Name North Andover MA 01845 11/11/2014 Citylrown State Zip Code Date of Inspection D. System Information (cont.) Sketch Of Sewage Disposal System: Provide:a view of the sewage disposal system, including ties to at least two permanent reference landmarks or benchmarks. Locate all wells within 1.00 feet. Locate where public water supply enters the building. Check one of the boxes below: ® hand -sketch in the area below ❑ drawing attached separately -DG33 = 30 16 11 0 t5ins • 3/13 Title 5 official Inspection Form: Subsurface Sewage Disposal System • Page 15 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 20 North Cross Road Site Exam: ® Property Address ® Marc Ouellette Owner Owner's Name information is required for North Andover MA every page. City/Town State D. System Information (cont.) Site Exam: ® Check Slope ® Surface water ® Check cellar ® Shallow wells 01845 11/11/2014 Zip Code Date of Inspection Estimated depth to high ground water: '4 feet Please indicate all methods used to determine the high ground water elevation: ® Obtained from system design plans on record If checked, date of design plan reviewed: 4/19/1985 Date ❑ Observed site (abutting property/observation hole within 150 feet of SAS) ® Checked with local Board of Health - explain: Design plan ❑ Checked with local excavators, installers - (attach documentation) ❑ Accessed USGS database - explain: You must describe how you established the high ground water elevation: As per design plan test pit data Before filing this.lnspection Report, please; see Report Completeness Checklist on next page. t5ins • 3/13 Title 5 Official Inspection Form: Subsurface Sewage Disposal System • Page 16 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 20 North Cross Road Property Address Marc Ouellette Owner Owner's Name information is required for North Andover MA 01845 11/11/2014 every page. Citylrown State Zip Code Date of Inspection E. Report Completeness Checklist ® Inspection Summary: A, B, C, D, or E checked ® Inspection Summary D (System Failure Criteria Applicable to All Systems) completed ® System Information — Estimated depth to high groundwater ® Sketch of Sewage Disposal System either drawn on page 15 or attached in separate file t5ins • 3113 Title 5 Official Inspection Form: Subsurface Sewage Disposal System • Page 17 of 17 Summary Record Card generated on 10/29/2014 10:03:46 AM by Karen Hanlon Town of North Andover Tax Map # 210-038.0-0182-0000.0 Parcel Id 13252 20 NORTH CROSS ROAD OUELLETTE, MARC PO BOX 1994 ANDOVER, MA 01810 Nage 1 Class 101 Single Family Property Type 1 Residential Zoning2 1 Residential Zoning3 1 Residential Size Total 1 Acres FY 2015 UB Mailina Index Name/Address Type Loan Number Active/Inact. From OUELLETTE, MARC Payor PO BOX 1994 ANDOVER, MA 01810 UB Account Maint. Account No Cycle Occupant Name Active/Inactive Bldg Id. 14003.0 - 20 NORTH CROSS ROAD Last Billing Date 9/4/2014 2100533 02 Cycle 02 Active UB Services Maint. Account No. 2100533 Service Code Rate Charge Multiplier/Users MISCFEE ADMIN FEE 1 1 9.18 1/ WTR WATER 01 ALL METER SIZE 303.55 /1 UB Meter Maintenance Account No. 2100533 Brand Serial No Status YTD Cons 35352417 a Active b Badger Date Reading 8/5/2014 681 5/9/2014 620 2/7/2014 _ .----620 _ 11/1/2013 619 8/5/2013 565 5/2/2013 527 2/6/2013, 527 10/331J20'1 2 526 .-..-.---&1C12012 434 5/4/2012 398 2/7/2012 398 11/2/2011 396 8/4/2011 278 5/4/2011 235 2/3/2011 233 11/1/2010 232 8/5/2010 100 5/5/2010 71 2/3/2010 68 11/3/2009 67 8/5/2009 14 7/9/2009 0 5/6/2009 3770 MSG -98% 2/4/2009 3760 MSG 181% 11/4/2008 3740 8/5/2008 3710 5/6/2008 3620 Until Location Brand Type Size YTD Cons ERT HH b Badger w Water 1 1 667 Code Consumption Posted Date Variance a Actual 61 9/11/2014 -100% a Actual 0 6/12/2014 -100% a Actual 1 3/17/2014 -98% a Actual 54 12/20/2013 53% a Actual 38 9/18/2013 -100% a Actual 0 6/18/2013 -100% a Actual 1 3/13/2013 -99% a Actual 92 12/13/2012 179% a Actual 36 9/26/2012 -100% a Actual 0 6/20/2012 -100% a Actual 2 3/14/2012 -98% a Actual 118 12/15/2011 181% a Actual 43 9/14/2011 2003% a Actual 2 6/13/2011 109% a Actual 1 3/15/2011 -99% a Actual 132 12/13/2010 376% a Actual 29 9/13/2010 856% a Actual 3 6/9/2010 203% a Actual 1 3/11/2010 -98% a Actual 53 12/11/2009 14% aActual 14 9/11/2009 0% n New Meter 0 9/11/2009 0% m Manual estimate 10 6/16/2009 -49% m Manual estimate 20 3/16/2009 -34% a Actual 30 12/10/2008 -67% a Actual 90 9/12/2008 810% a Actual 10 6/18/2008 -51% mil AS—BUILT ELEVATIONS I N V. PIPE AT HOUSE INV. PIPE .INTO SEPTIC TANK INV. PIPE OUT OF SEPTIC TANK INV. PIPE INTO D.BOX . INV. PIPE OUT OF D.BOX TO TRENCH I IN V. PI PE OUT OF D. BOX TO TRENCH 2 INV. END OF PIPE TRENCH I IN:'. END OF PIPE TRENCH 2 176.17 175.98 �. 175.69 175.51 175.32 175.32 175.08 175.14 AS •BUILT" SUB • SURFACE DISPOSAL SYSTEM IN NORTH ANDOVER, MA. FOR: MARY FRANZ Scale: 1 = 40' _ Date: SEPTEMBER 1 ,1988 RICHARD F KAMINSKI AND ASSOCIATES , INC. ENGINEERS ARCHITECT SURVEYORS LAND PLANNERS NORTH ANDOVER , MASS. 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 Location: Left / Right front of house, Le i t rear of hous Left /right side of house, Left/ Right side of building, Left / Right front of building, Left / Right rear of building, Under deck Address Cityfrown State Zip Code 2. System Owner. Name' Address (if different from location) City/Town ' State P f - s � Telephone Number B. Pumping Record Ccs ��' 1. Date of Pumping 2. Quantity Pumped: Date ry Gallons 3. Type of system. ❑ Cesspool(s) Septic Tank ❑ Tight Tank ❑ Other (describe): 4. Effluent Tee Filter present? ❑ Yep No If yes, was it cleaned? ❑ Yes ❑ No; 5. Condition stem: 6. System Pumped By. - Nell y:Neil. Bateson F5821 DEC' D 9 2013 Name Vehicle License Number Bateson Enterprises Inc Company 7. contents were disposed: t5form4.doo• 06/03 System Pumping Record •Page 1 of 1 Commonwealth of Massachusetts Massachusetts System Pumping Record System Owner Ocjofl41e_ System Location Date of Pumping: q ---% —qa2 Quantity Pumped: I 1�> N�gallons Cesspool: No" Yes ❑ Septic Tank: No ❑ System Pumped by: hitt`¢ " 46d&o ded License # Contents transferrred to : Greater Lawrence Sanitary District Date: ___ Inspector: Yes f 4�� Of:, HE4L AtipnvE),7-,j M4, Y 'S 1) bc.�1rJ ❑ WEt.c._ APoyCD]1�T'C G SY 5 T EM VE51 �- "ovC-D %PAr6- 7- 7- b viN6Aurtjoi,?rry r SAY l T LAS Qt-&, A-1110RE- - aov'SE.-- DI PPRl�VED �/J'1E SySr&v� r5 0-r. FOR 5 `r2 R SONS : 56ak UMC -Ii4-� StPj (C Sy STEM ijS►Au- ATIo" EYU-4V4Tc0,,-1 V4rG FINAL I uSP6—�-Tloo DtSAPF)�ovt;P DArC RCASo N.S ❑ RASS ❑ F41L. FV AL APPROVAL D,oT APPRoar�G �u i t-�oR� ri 6D02 r 1���os I'm AS—BUILT ELEVATIONS AS • B U I LT INV. PIPE AT HOUSE 176.17 SUB • SURFACE DISPOSAL INV. PIPE .INTO SEPTIC TANK 175.98 INV. PIPE OUT OF SEPTIC TANK 175.69 SYSTEM INV. PIPE INTO D.BOX 175.51 INV. PIPE OUT OF D.BOX TO TRENCH 1 175.32 IN INV PIPE OUT OF D.BOX TO TRENCH 2 175.32 NORTH ANDOVER, MA. INV. END OF PIPE TRENCH 1 175.08 INV. END OF PIPE TRENCH 2 175.14 FOR : MARY FRANZ SCale: I" = 40' Date: SEPTEMBER 1 ,1988 RICHARD F KAMINSKI AND ASSOCIATES , INC. ENGINEERS ARCHITECT SURVEYORS LAND PLANNERS NORTH ANDOVER , MASS. TOWN OF SYSTEM PU DATE: SYSTEM OWNER & ADDRESS V GM�fo 2 7 -�j - C(o �� G RECO RECEIVED SEP 14 2004 TOWN OF NORTH ANDOVER HEALTH DEPARTMENT SYSTEM LOCATION (example: left front of house) (pack a -t ko ust DATE OF PUMPING: J'� - (5 q QUANTITY PUMPED: SOD GALLONS 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 (EXPLAIN) SYSTEM PUMPED BY: Bateson Enterprises, Inc. • l u_lu l 3 O CONTENTS TRANSFERRED TO: G.L.S.D V Lowell Waste Commonwealth of Massachusetts City/Town of W° System Pumping Record Form 4 `lull DEP has provided this form for use by local Boards of Health. OtheMmm vMJCMiu§8@C it e rn�'e•u I'11�pA6�TM�, information must be substantially the same as that provided here. �eT„ ��k 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 / Right front of house, Left / I rear of house eft / right side of house, Left / Right side of building,�.gft / Right front of Wilding, Left / Right rear of building, Under deck Address ' I City/Town 2. System Owner. Name Address (if different from location) Cityrrown State State Telephone Number Zip Code Zip Code B. Pumping Record 1. Date of Pumping ;2. antity Pumped: DateGallons 3. Type of system: ElCesspool(s) Septic Tank ❑ Tight Tank ❑ Other (describe): 4. Effluent Tee Filter present? ❑ Yes 5. Condition of System: 6. System Pumped By: Neil Bateson Name Bateson Enterprises Inc Company No If yes, was it cleaned? ❑ Yes ❑ No 7. Location where contents were disposed: Lowell Waste Water F5821 Vehicle License Number C[ — Date t5fomt4.doc• 06/03 System Pumping Recons •Page 1 of 1