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Commonwealth of Massachusetts®
City/Town of
System Pumping Record AUG -1 2007
Form 4 TOWN OF NORTH ANDOVER
HEALTH DEPARTMENT
DEP has provided this form for use by local Boards of Health. Other fomes may be used, but the
infomnation 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. Systerrl Locatio
Address
City/Town
2. System Owner:
Name
Address (if different from location)
City/Town
t
State Zip Code
;- f Wr"
Telephone Number
B. Pumping Record � -C-)
1. Date of Pumping Date 2. Quantity Pumped:
3. Type of system: ❑
❑ Other (describe):
Gallons
Cesspools)eptic Tank ❑ Tight Tank
4. Effluent Tee Filter present? ❑ Yes 8'NNo` If yes, was it cleaned? ❑ Yes ❑ No
5. Condition Syst emv��-
• - ped
Name
Company
7. Location
c� onte%�7a . I o:
„ \ nr
'f �-' 5-- � (
Vehicle License Number
Date
t5form4.doc• 06/03 System Pumping Record • Page 1 of 1
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Board. of Health
North A}ndovergMass.
nn OK
SEPTIC STSTEM
INSTALLATICK COCK LISP
1. Distance Tot
a. Wetlands
b. Drains
c. Well
2. Water Line Location
3. No PVC Pipe
4. Septic Tank
a. Tees - Length & To Clean Out Corers
b. Cement Pipe to Tank On 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 Ends
d. Clean Double Washed Stone
7. Leach Pits
a. Dimens s
b.S Depth
c. lash Pads
Tees
e. Cement Pipe to Pit - Both Sides
f. Clean Double Washed Stone
8. No Garbage Di spo sal
9. Final Grading 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
a
TO: NORTH ANDOVER, MASS 19 '7q
BOARD OF HEALTH
FROM: DESIGN ENGINEER Re: Soil Absorption Sewage
System Inspection
This is to certify that I have inspected the construction of the said disposal system at
oT 3 zi c RAN y///rt- /-/f /y 6 North Andover, Mass.
SITE LOCATION
The grades and construction are as specified in my plans and specifications dated
19 .
:�I'RGYALS-7- M AJ.
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f i o 1 ; c orks �r
'. SUBSURFACE DISPOSAL SYSTEM CHECK LIST Lo
NORTH ANDOVER BOARD OF HEALTH��
APPROVED DATE PROVIDED DI APPROVED DATE TIME REASON
Title 5
Reg. 2.5
Reg. 6
The submitted plan must show as a minumum:
the lot to be served (area,dimensions,l,ot /j,abutters)
(Planning Board files)
location and log of deep observation holes -distance
to ties
location and results of percolation tests -distance
to ties
design calculations & calculations showing required
leaching area
location and dimensions of system (including reserve
area)
existing and proposed contours
location of any wet areas within 100' of the sewage
disposal system or disclaimer (check wetlands mapping)
surface and subsurface drains within 100' of sewage
disposal system ordisclaimer
location of any drainage easements within 100' of
sewage disposal system or disclaimer (planning board
files)
known sources of water supply within 200' of sewage
disposal system or disclaimer
location of any proposed well to serve the lot (100'
from leaching facility)
location of waterlines on property (10' from leaching
facilities)
location of benchmark
driveways
garbage disposers
no PVC is to be used in construction
a profile of the system (elevations of basement, plumber:
pipe septic tank, distribution box inlets and outle-s,
distribution field piping and any other elevations)
maximum ground water elevation in area of sewage disposa=l
system
plan must be prepared by a Professional Engineer or
other professional authorized by law to prepare such
plans
Septic Tanks
I-
(a)� Opacities - 150% of flow, water table, tees, depth
of tees, access, pumping,
(b Cleanout
(c) 10' from cellar wall or inground swimming pool
(d) 25' from subsurface drains
0
A.
Nor"11-h Andover Subsurface disposal system check list - Page 2
Reg.10.2
Reg.10.4
Reg. 11.2
Reg. 11.4
Reg.11 .1 C
Reg.11.11
Reg. 15.1
Reg.15.1
Reg. 15.4
Reg. 15.8
Reg. 3.7
Reg.14.1
Reg.14.3
Reg.14.4
14.5
Reg.14.6
Reg.14.7
Reg.14.1C
Reg. 9.1
Reg. 9.6
it IOKI Distribution Boxes
a Slope greater than 0.08
b� Sump
Leaching Pits
Leaching pits are preferred where the installation is
possible
(a) Calculations of leaching area (minimum 500 S.F.)
(b) Spacing
(c) Surface drainage 2%
(d) Cover material
Leaching Fields (3) I �"
(a)�NoGreater than 20 minutes/inch
ecl
Area (minimum 900 S.F.)
Construction of field
(d) Surface drainage 2%
(e) .20' from -cellar wall or inground swimming pool
Leaching Trenches
(a) Calculations of leaching area (min. 500 S.F.)
MSpacing (4 ft. min. 6 ft. with reserve between)
Dimensions
(d) Construction
(e) Stone
(f) Surface drainage 2%
Downhill Slope
a) Slope y/x = (to be shown)
b) y/x X 150 = (to be shown)
Pum -Pa
(a) Approval
(b) Stand --by power
SOIL PROFILE & PERCOLATION TEST DATA
Board of Health -North Andover, Mass.
Street__ ZA�.,, Lot No.
Subdivision' Owner
Investigator Observer Ll
1. Date
Elev.
Feet Inches
0 0
Q
0]
SOIL PROFILES
2. Date 3. Date
Elev. Elev.
4. Date
Elev.
Ties to Test Pits
1.
ote: Top & subsoil depth; depths of other soil types; depth of water table;
depth of refusal.
PERCOLATION TESTS
Pit Number
1 2 3 4 5
Start Saturation
Soak'.Mins.
Q t�
Start Test -Time
e f 5
Drop of 3"—Time
ill .
Drop of 6" -Time
T',5'5
Mins. 1 st 3" Drop
ZZ
Mins. 2n.d 3" Drop
Rate Min. In.
SOIL PROFILE & PERCOLATION TEST DATA..
U '
Town/City No.&Street r{�.,� �). ��� Lot No. .3-
�J Loc. /Subdiv. , -� ��-t'/ Plan owner.�f--r.
Investigator��,--b� 9-Q// Observer
SOIL PROFILES -DATE -
A
�? 1. E1 v. 2' Elev. 3' Elev. 4'Elev.
0 `s %% 0 0 0
2
3
4
5
0
9
2
3
4
5
6
7
s
M
2
3
4
5
6
7
s
9
10 10 I 10 1 10
Benchmark Location
Elevation Datum
Percolation Tests -Date
Pit Number 1 2 3 4 5
Start Saturation
Soak -Mins.
Start Test -Time
Drop of 3" -Time
Drop of 6" -Time
Mi.ns.lst 3"Dro
Mins.2nd 3"Drop
Notes & Sketches on Back Frank C. Gelinas & Associates, North And.
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