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Miscellaneous - 201 CARLTON LANE 4/30/2018
N O O v D 0 N O V b S 0 0 Commonwealth of Massachusetts _ W City/Town of NO. ANDOVER a 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. reran 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 usi 's form, check k with your local Board of Health to determine the form they use. The System Pumping ecoRE0 itte o the local Board of Health or other approving authority within 14 days from th pumping dale In accordance with 310 CMR 15.351. A. Facility Information TOWN OF NORTH ANDOVER HEALTH DEPARTUPUr 1. System Location: 201 CARLTON LN. Address NO. ANDOVER MA 01845 City/Town State Zip Code 2. System Owner: ROBERT DOHERTY Name Address (if different from location) City/Town B. Pumping Record 1. Date of Pumping 5/6/13 Date 3. Type of system: ❑ Cesspool(s) ❑ Other (describe): State Telephone Number Zip Code 2. Quantity Pumped: 1500 Gallons ® Septic Tank ❑ Tight Tank ❑ Grease Trap 4. Effluent Tee Filter present? ❑ Yes ® No 5. Condition of System: 6. System Pumped By: JAMES H. CURRIER Name J's SEPTIC & DRAIN Company 7. Location where contents were disposed: GLSD Signature of Hauler 11-1 Signature of Receiving Facility If yes, was it cleaned? ❑ Yes ❑ No H79 406 Vehicle License Number 5/6/13 Date Date t5form4.doc• 03/06 System Pumping Record • Page 1 of 1 .1J . R, MASSACf�U�SE S - Roco� - - • Yfl.:. 4y J+ it%l}l lJrhlij(•';1u, ^(,, �.A, :,,. ,.'',(} 'DE 4.. ri•(r a7 t.l• 411",•.:. .. CT �. 5 0 DEP has prov(ded this form for use by local Boards of Health. T e System Pumping Record must be submitted to the.local'Board of Health or other approving auth ion N OF NC.," r HEALTH D_ k Facility information ;�,,,Wrien f>runa out 1: System Location, w on the'; a�/ � �•v (.t '�OY� .. L�� �;z..:•'corr�puter, used`;; : ,:';::: ::: • only the tab key Address to move your wr:or, • do not CI /Town .'US* the rotum f tY' J State Zip Code key.'; r � � s, tt�� �.:: ;2Y' •.System Owner; 'r ,:. r Nam, o Address (if different from location) CIVITown t State 6P�Zp Cod ` Telephone Number ,F.• J it I. j ., ���� ;r ,'P(umping:Record, ..•r''+.,. <•� J• • 'Date of Pumping Date 2. Quantity Pumped: 31. `.Type gf.system:`. ❑ Cessp©ol(s) ptic Tank ❑ Tight Tank LT.(..0ther (describe):"77. 4, Effluent Tee Filter present? 13Y o If yes, was If cleaned? El Yes ❑ No .tit Nth ,i/5•:�+!•r •:�J,tJi(,i �'.' e �. S con Tee fSys� t mY"' .. _.. .. t ...In r.•n..,, r! J Y'( VJ t ,�,: f ♦ ..� L,y r 1. 1 � 6 Sy Q Pumped By' } 7 Vehicle Ucenee Number 04 'Jilk y�/ •�' ,�! .,' J ,''�5�3. �. � WS Y:•r't' ):!'. j.1'! �1 y�. �'J'!(l�Ui� t.4•:; \ , i J :'i•.. :j��UJ' •1.d�';'."J'��,.Zt;•Ir.J41�•',.�a'rt+,':•',... ,,,. `,:.!':'�.'��,;ri'. �..%rt,•i .'ay::'Nv'K¢•iiA,,'J+;�w, `,;;}'•t,;,1' i�;!�'�i' "' Jt r{ ¢' 7..:> LocafJon.where Contents yvere.dl;3posed: tlp ;;'` :..`;r;: a ;i:��'"•� :;4,(:; 'Slpna ofHauler;i>'. ;;a:.e.:,., Date httpYAvwo�.inass.gov/depiwater/���PprOV41s/t5forms,htm#lnspect t5fornA.doC-o8/os System Pumping Record Page 1 of I I nust A Facility Information Arwrtant. ". x �rWhan'filung out 1 . System location. fortes: on the `' computer, use Of only the tab key Address to move your,.; cunwr • do not CI (Town i use the return ly State Zip Code key v 2 System Owner. 4 Name Address (if different from location) City/Town.,..State . Zip Code 97Y - �' Telephone Number B: Pumping Record bilo 1� • 1 . `.Date- of Pumping oats 2. Quantity Pumped: v al ons Type of system ❑ Cesspool(s) (Deptic Tank ❑ Tight Tank []' Other describe 4 Effluent Tee Filter present?. ❑ Yes. 0 If yes, was it cleaned? ElYes [DNo S ' ;Condition of RVstgm Sra�I Ir 6 Sy em Pumped By:.... Name s : r x Vehicle Ucen$e Number y, i Il f it I>' n r I � • v� Vl -.1 .,(- JhS., >ti r W.}y 1Wi>.�°'•�...� ;I�"' I<IC h� //� �. � � . I � Location where contents were df;3posed: Y `l ji xf l gnat of Hauier; c. http://www.mass.g stet/apprpv.Wad forms.htm#Uspect t5forrn4_doc. M83 Date System Pumping Record • Page 1 of 1 Commonwealth of Massach _ r City/Town of No. Andover System Pumping Record Form 4 k,M VOV,'v TO��ea NORTH ANDOVER DEP has provided this form for use by I cal Boards of Health. thatm M96 t the information must be subst 4 tially the me as that provided here.using this form, check with your local Board of Health to det rmine th form they use. The System Pumping Record must be submitted to the local Board of Health or ther ap roving authority. Important: When filling out forms on the computer, use only the tab key to move your cursor - do not use the return key. VIQ ienm RECEIVED APR - 8 2005 A. Facility Informati 1. System Location: 201 Carlton Lane Address No. Andover MA 01845 City/Town State Zip Code 2. System Owner: Robert Dohertv Name Address (if different from location) City/Town B. Pumping Record 1. Date of Pumping 03/21/05 Date 3. Type of system: ❑ Cesspool(s) ❑ Other (describe): 4. Effluent Tee Filter present? ❑ Yes W No 5. Condition of System: Good Condition 6. System Pumped By: Beniamin Shute Name J's Septic & Drain Company 7. Location where contents were disposed: GLSD Of State Telephone Number 2. Quantity Pumped [0 Septic Tank Zip Code 1500 Gallons ❑ Tight Tank If yes, was it cleaned? ❑ Yes ❑ No H79 406 Vehicle License Number 03/21/05 Date t5form4.doc• 06/03 System Pumping Record • Page 1 of 1 TO: NORTH ANDOVER, MASS _ S.RP 't '4 19 � 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 q /4 04X r-/— 74 -ON N -Q. North Andover, Mass. SITE LOCATION The grades and construction are as specified in my plans and specifications dated V'j C2 SSOCi clt' ` IU6 r -k As i/V Grouod �PZ4,A) ora Co 4f © .o eg. n er/ye nit ian � -f F0 �a AJ 1 n 05/11/2000 15:57 5083736611 STEWART/ANDOVER PAGE 02 )v 16(4) Alvl16ver Q-6.4. Nalad M«n St rlh A W,mul Liz- iC/-12664 ) rl S' C4 N Lee- 4- /.1-9-0 MD MMY REPORT MR TtWN OF DATE ADMIESS 36 M!EWMT IS SEPTIC ThM SERVICE 47 RAIIROAL) STREET BRADFORD, MA 01835 978-372-7471 MCN7% OF COMMONWEALTH OF MASSACHUSETTS EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS DEPARTMENT OF ENVIRONME�TULZRUM�7 ON� BOARD OF HFALTii t: r TITLE 5 OFFICIAL INSPECTION FORM — NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM PART A CERTIFICATION Property Address: C�,2,9/ Owner's Name: Owner's Address: Date of Inspection: Name of Inspector: ( lease print)4. > Company Name: Mailing Address: Z m Telephone Number: CERTIFICATION STATEMENT 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. I am a DEP approved system inspector pursuant to Se n 15.340 of Title 5 (310 CMR 15.000). The system: Passes Conditionally Passes Needs Further Evaluation by the Local Approving Authority Inspector's Signature: dA1,- y2j��C.Date: O Z.. The system inspector shall s6bmit 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. Notes and Comments ****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. Title 5 Inspection Form 6/15/2000 page 1 n ' ' 1,Page 2 of l l OFFICIAL INSPECTION FORM — NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: C�It4, L Q Owner: f.,ItIA #11Y Date of Insp tion: Inspection Summary: Check A,B,C,D or E / ALWAYS complete all of Section D N A. System Passes: _ZI have not found any information which indicates that any of the failure criteria described in 310 CMR 15.303 or in 310 CMR 15.3 04 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. Answer yes, no or not determined (Y,N,ND) in the 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. - ND explain: 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 pipes) are replaced obstruction is removed distribution box is leveled or replaced ND explain: 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 obstruction is removed - ND explain: ,'A dr Page 3 of 1 I OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: dl elJl Owner: Date of Ins pec 'on: — 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 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 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 nitrogen4s 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: Page 4 of 11 OFFICIAL INSPECTION FORM — NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: /,f . Z7 9 Owner: px7jv 10l' Date of Inspecti : 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 ors=pool Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool squid 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 . &04Any portion of the SAS, cesspool or privy is below high ground water elevation. F000 Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface +water supply. _ Vo Any portion of a cesspool or privy is within a Zone 1 of a public well. T� Any portion of a cesspool or privy is within 50 feet of a private water supply well. L� 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 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, provided that no other failure criteria are triggered. A copy of the analysis must be attached to this form.] NjQ (Yes/No) 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 of10,000 gpd to 15,000 gpd• 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) 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 11 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. 4 Page 5 of 11 OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST Property Address: Avlr Owner: &nw/7' , Date of Inspe tion: Check if the following have been done. You must indicate "yes" or "no" as to each of the following: Yes o Pumping information was provided by the owner, occupant, or Board of Health -4zWereiny of.the`!' stein'omponents pumped out imhe previous two weeks ? . Has the system received normal flows in the previous two week period ? �iHave large volumes of water been introduced to the system recently or as part of this inspection ? _ AWere 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 ? -i,Z— 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 of the Soil Absorption System (SAS) on the site has been determined based on: Yes no - _ -V 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) [3 10 CMR 15.302(3)(b)] 5 e 4 Page 6 of I 1 OFFICIAL INSPECTION FORM — NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION Property Address: i' / Owner: Date of Inspec i n: FLOW CONDITIONS RESIDENTIAL Number of bedrooms (design): Number of bedrooms (actual): DESIGN flow based on 310 C ,15.203 (for example: 110 gpd x # of bedrooms): Number of current residents: ! Does residence have a garbage grinder (yes or no). -/UO Is laundry on a separate sewage system (yes or no): ALnif yes separate inspection required] Laundry system in (yes or no): — (y s Seasonal use: es or no ), • Water meter readings, if available (last 2 years usage (gpd)): Sump pump (yes or no): Last date of occupancy:O CC op COMMERCIAL/INDUSTRIAL Type of establishment: Design flow (based on 310 CMR 15.203): and Basis of design flow (seats/persons/sqft,etc.): 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/use: OTHER (describe): GENERAL INFORMATION Pumping Records Source of information: Gr P'n to Z�ya _Q Was system pumped as part of the inspection (y& or no): If yes, volume pumped/�O allons -- How,,,_,_w sAuan ity pumped determined? Reason for pumping: / /J S 41P GT / ,h TYP F SYSTEM eptic tank, distribution box, soil absotptiam system _ Single cesspool _ Overflow cesspool _ Privy _ 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) — Tight tank _ Attach a copy of the DEP approval _ Other (describe): date installed (if known) and source of information: Were sewage odors detected when arriving at the site (yes or no): ko ox Page 7 of 11 OFFICIAL INSPECTION FORM — NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address:/ / /A Owner: j4"1"j)j7LQ1 Date of Inspe tion: BUILDING SEWER (locate on site plan) 6 r� Depth below grade: Materials of construction: mast iron _40 PVC _other (explain): Distance from private water supply well or suction line: Comments (on condition of joints, venting, evidence of leakage, etc.): SEPTIC TANK: _ (locate on site plan) r' Depth below grade: Material of construction: je<oncrete _metal _fiberglass _polyethylene _other(explain) If tank is metal list age: _ Is age confirmed by a Certificate of Compliance (yes or no): _ (attach a copy of certificate) Dimensions, 4-- <' - <--g Sludge depth: e-re�r Distance from top o s edge to bottom of outlet tee or baffle: & Scum thickness: • .L, -I Distance from top of scum to top of outlet tee or baffle: Ir Distance from bottom of scum to bottom of outlet tee or baffle: How were dimensions determined: % � r/J L,'i Comments (on pumping recommendations and outlet tee or baffle condition, structural integrity, liquid levels as relay t ut et invert, a ofM �e' S %hl Jo6d/! �•P_ GREASE TRAP: _(locate on site plan) 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: Date of last pumping: Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): M ' Page 8 of 11 OFFICIAL INSPECTION FORM — NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: Oldl Owner: Date of Ins ction: TIGHT or HOLDING TANK: Depth below grade: Material of construction: concrete (tank must be pumped at time of inspection)(locate on site plan) metal fiberglass _polyethylene other(explain): Dimensions: 1 Capacity: _ gallons y Design Flow: gallons/day Alarm present (yes or no): Alarm level: Alarm in working order (yes or no): Date of last pumping: Comments (condition of alarm and float switches, etc.): t DISTRIBUTION BOX:(if present must be opened)(locate on site plan) Depth of liquid level above outlet invert: Comments (note if box is level and distribution to outlets equal, any evidence of solids carryover, anv evidence of PUMP CHAMBER: (locate on site plan) Pumps in working order (yes or no): Alarms in working order (yes or no): Comments (note condition of pump chamber{ condition -o€ -pumps and appurtenances, etc:): . 8 e " . Page 9 of 11 OFFICIAL INSPECTION FORM — NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address:001 &11 e Owner: WZ7941yj Date of Insp tion: SOIL ABSORPTION SYSTEM (SAS): (locate on site plan, excavation not -required) If SAS not located explain why: Type'» t leaching pits, number: _ B leaching chambers, number: '19aching galleries, number:•M chingtrenches, number, length: . �'e/yC 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 ve etation, etc.): NO .Sa / L S /V o 0 AJ A)6 /)I e4 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 or no): s 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.): 9 .• Page 10 of 11 OFFICIAL INSPECTION FORINT — NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM'INFORMATION (continued) Property Ad rens: Owner: Date of Insp ction: SKETCH OF SEWAGE DISPOSAL SYSTEM Provide a sketch of the sewage disposal system including ties to at least two permanent reference landmarks or benchmarks. Locate all wells within 100 feet. Locate where public water supply enters the building. A 10 4 s 1 !r «F + Page l l of l l OFFICIAL INSPECTION FORM — NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) PropertyAddress• / ?1i-_1hAt4 "ZL Owner: Date of 14nip 7— SITE EXAM Slope Surface water Check cellar Shallow wells Estimated depth togougd water-. , feet t I Please indicate (check) all methods used to determine the high ground water elevation: Obtained from system design plans on record - If checked, date of design plan reviewed: Observed site (abutting property/observation hole within 150 feet of SAS) Checked with local Board of Health -explain: Checked.with local excavators, installers- (attach documentation) Accessed USGS database -explain: You must describe how you established the high elevation: A I -A-41- Gv ct t /`✓ V1Pt V 'C f \ /v o S f�. N f o(- tx) 4 t f f 6 ticr'•"- j i 11 TOWN OF NORTH ANDOVER SYSTEM PUMPING RECORD DATI *0-2— SYST 1ER & ADDRESS SYSTEM LOCATION (example: left front of house) W��2z �D Z�� -Frjn f o DATI IPING: ki-3 �A QUANTITY PUMPED GALLONS CESS NO X YES SEPTIC TANK: NO YES �^ NAT[ SERVICE: ROUTINE �_ EMERGENCY OBSI `NS: CONDITION FULL TO COVER Y GREASE BAFFLES IN PLACE LEACHFIELD RUNBACK SIVE SOLIDS FLOODED S CARRYOVER OTHER (EXPLAIN) SYST PED BY: CON CON' 'ZANSFERRED TO: ��S? P� Qa Y � a Com•NO a i iso-73.---- ,E'/yof LiN.t lS9-So _ 9, 4 8r u «�------------ r%; *curl("s rhfr``yY 1171rAj<+i t v` - �111 9 1,� , � { � 1 a1�t �U, ��1�` r 4'1 �, �7„ •r. 1• f Ir r , (�1 ' , P {r' • ,'r� f )�7. t "It•. + r � . P . t}+ `4. .i �.a y ' � �'1 e+ "I � 1 , � .� ! h l ,t l } r q!',,F1 1..�t ',+J � ti ,�, a r ,;+Y, •irpl, • Zt r '7' OWN :.• SYS � ANDO'�ER .' • �.,;: T� PUMPING REC y1.1;�tlff� - vy .j{�y�.M1,,t{L,• y� �j ORD �:7" '1�f'1 �IF,'EA�i{� '•�ti C`t riAM, rl ilr'r f� �} �.`� i t [ • ,'r'F�F,S 1 y'1 1 r �'�(.`x1A�#V�I)��yf '' w r,j R � ! 1 .1 al ', ,.. , r Sr, la i •+'"y.'. � •'tA. A 88Ni ;e4r .r .�'�. t fi•r + ~r ; ii � r r . � ��' + �; '�.. �IIY;�iR.l r i7'ral;w.��uj •1 y � .,t r �) � h,r •7 ! !j. ! 4r � �'r(yl •Y y ,'J �ji� nyV , e". '. y�pr�1 rT9• 1" I. �r 1 ;i: 1.- i�,l H�. �' , .' v . TEM p�Sm J{yC�ATION of ao 1�.ry..rt ry�,�� j�! I Fro 'S3�" r •.A,r �thl\.!+G,�'tjP'�:`ii,lA' 7�'il }.C�j Ztl i•Yr {�Ysw ,•� ,,Y i. .� ::k r ! ''7'V�6i'•i t I, !+dry,. .� 77. -QJ` " "'QUAxT r A t t rttlt ♦.. / . �•t {. •rva i/4/* SNS EEpEEA ;c rrALyI�N Ilt��l ,J ih�Y✓t� r v—Al��,r.� JV■ •}•}{�'i^'A}���+T{! •\O a�j�r-T �t a r, !'.V ri �ai i�''�A`��'",fli J.. ' .. • " ES sEMIC TANK: Np YES 46111 UTIM ��' �t • �•MERGENCY t �!r+1L'.(fj1 L�hl i �1 ,.Jt.; .� �.,. "�?'''!'►,y?•`fir.' -_'��� •. �% T�OH ,�•ii,1, ;.,t, I S',� , � •rt I � r t"nn�•t�r;, ,. , G .,,.;'FIJLL �T • SSE .: � ICNOVF,IZ • .: :. ... EXCESSIVE SOLIDS- LEA PLACE ,:.now SODS CARRY6 ---..:'—FLOODEDLD RUI�g d - , YOV ACK �. x t �.*..•.. OTHER (F"LAM ��,yA,t �Y �•a% �E�,,r'f ,nnJ7YY#.i , r �7� yh{'�•;�,:..r1i , r i ' .t1; ; _1 MINIMUM 01 ANA M} r �, ^���:C PFS !'kkr' t � r ,� , , r I . .. ' •�' . xi ji'�1' tfd' { %',� hf I ! M 4 •.. , . . �' r F .. l;i: ,.41 !!''''IlllllllllllllllillillilljlllllI U ,.:J•n:,R 1:^a 1�1'r� � ::A \ 4 . i 7r t' 14 ,r , i 1>w,. •.r , I t A a'It 4, AIA • 4, h y -06 ca � � x4Y1 ►, !',, 7gi�tht}�t � � f Syllf"�'�'� /►E'.' .�� .�/ ,,C/A � L � • .w .ArA/ I 1 , NEW ENGLAND ENGINEERING SERVICES INC November 14, 1996 North Andover Board of Health Tom -n Hall Annex Main Street North Andover, MA 01845 RE: TITLE V REPORT Enclosed is the Title V report for 201 Carlton Lane, North Andover, MA. The system did pass the inspection. If there are any questions please call me at my office, 686-1768. Yours truly, Jamin C. ood J . resident '- TC1W 1 C)F tNfr)RrH A 'l OVER/ 804,RD C1F R,;STH 191996 d 33 WALKER RD. - SUITE 22 - NORTH ANDOVER, MA 01845 - (508) 686-1768 William F. Weld Governor Argeo Paul Cellucci LL C*wemor Q jW.. O t4 BOARD Commonwealth of Massachusetts Executive Office of Environmental Affairs Department of Environmental Protection SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION Property Address; 2 O ( f } (Z LTA` N LAA) e "o, ,,J 0I ,N A- Address of Owner. Date of Inspection: ((1 $, �{ 6 (If different) N f l Trudy Coxe s—st" David B. Struhs Commia(orw ame o Inspector. Benjamin C. Osgood Jr. Company Name, Address and Telephone Number. New England Engineering Services, Inc. 33 Walker Road, North Andover, Ma 01845 CERTIFICATION STATEMENT Tel. 508-686-1768 Fax. 508-685-1099 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: asses _ Conditionally Passes Needs Further Evaluation By the Local Approving Authority Fails Inspector's Signature: &-s of 6y � Date: ////G` The System Ins J' / X16 The S tyste If the tor s� emit a copy of this inspection report to the Approving Authority within thirty (30) days of completing this 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 Department of Environmental Protection. The original should be sent to the system owner and copies sent to the buyer, if applicable and the approving authority. INSPECTION SUMMARY: Check A, B, C, or D: A] SYSTEM PASSES: have not found any information which indicates that them violates later any of the failure criteria as defined is 310 CMR 15.303. Any failure criteria not evaluated are indicated below. B] SYSTEM CONDITIONALLY PASSES: One or more system components need to be replaced or repaired, The inspection. sym upon completion of the replacement or repair, passes Indicate yes, no, or not determined (Y, N, or ND). Describe basis of determination in all instances. If "not determined", lain 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 11/03/95) One Winter Street a Boston, Massachusetts 02108 • FAX (617) 556-1049 • Telephone (617) 292-5500 w ice} Printed on Recyded Paper 94 - k/ SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: `Z (>I C H R LTo.v LAN , iv, '9A-) Do u C 2, .&4 A Owner. M il.V Date of Inspection: B] SYSTEM CONDITIONALLY PASSES (continued) 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 Boatel of Health): broken pipe(s) are replaced obstruction is removed Cl 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 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 within 100 feet to a surface water supply or tributary to a surface water supply. _, The system has 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 has 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. 3) OTHER (revised 11/03/95) SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: 0 / C /9R t To u Owner. fc7tE � qN Date of Inspection: Dl SYSTEM FAILS: ")n!t , "V- AN DGur ✓{ titA 76 -yr 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. 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 112 day flow. Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number of times pumped AZ Any portion of the Soil Absorption System, cesspool or privy is below the high groundwater elevation. FL Any portion of a cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. Al Any portion of a cesspool or privy is within a Zone I of a public well. L Any portion of a cesspool or privy is within 50 feet of a private water supply well. A 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. El LARGE SYSTEM FAILS: 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: 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 lI 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 11/03/95) 3 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST Property Addrem tot c A e i -Tc, •j L AN t= / N- r4^j 0 a vE 2t M A Owner. Co1.EMA�/ Date of Inspection: Check if the following have been done: 6,ePumping information was requested of the owner, occupant, and Boatel of Health. None of the system components have been pumped for at least two weeks and the system has been receiving normal flow rates during that period. Large volumes of water have not been introduced into the system recently or as part of this inspection. ief.As built plans have been obtained and examined. Note if they are not available with N/A LThe facility or dwelling was inspected for signs of sewage back-up. ZThe system does not receive non -sanitary or industrial waste flow ,The site was inspected for signs of breakout. ZAll system components, excluding the Soil Absorption System, have been located on the site. ZThe 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 owner (and occupants, if different from owner) were provided with information on the proper maintenance of Sub- surface Disposal System. (revised 11/03/95) 4 16-411 Property Addresw jo o Own SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION CARLiotj er: SOLI=MM�t! Date of Inspection: '-4N!r , "V. ANO -00 E i, /Lt.} RESIDENTIAL.FLOW CONDITIONS Design flow: gallons Number of bedrooms: Number of current residents: Z Garbage grinder (yea or no).� Laundry connected to system or no): Seasonal use (yes or no) _61 Water meter readings, if available: Last date of occupancy: GV COMMERCIAL /INDUSTRIAL: Type of establishment: Design flow:----gallons/day Grease trap present: (yea 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: System pumped as part of inspection: (yes oz=— If If yes, volume pumped: gallons Reason for pumping: TYPE OF SYSTEM �C 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: 1 / N ea R s FAD/" A-S-Qr> /L7— Sewage odors detected when arriving at the site: (yes or no)/A/— (revised 11/03/95) '76 —4'el SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: Q o( C A V j_TZ ,,, L p uF, ,.., Z' Owner. C!°pLCkAN Date of Inspection: k 19 l.16 SEPTIC TANK_ (locate on site plan) AL Depth below grade: Material of constriction: VSoncrete _metal _FRP _other(ezplam) Dimensions: 1,5-6 © Gy'F L W .A►.S Sludge depth: 41 " Distance from top of sludge to bottom of outlet tee or baffle:" Scum thickness: 4 1 ` 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.) _TAn! 16 /5 i N &-000 STP -a1 c.TC) &A t- cc- o , 7-7 A rll =N s PE f'TIO,'/ t 00 G 9-A e,.,AJ E'n! Ds 0,'C= -7241V K N e,T /3 CL cS 5 AAL r= GREASE TRAP:_ (locate on site plan) Depth below 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 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.) (revised 11/03/95) 6 96 -y. SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property A(ldress: 201 C A 2LTo A.1 i.14N t,* .v . An) OO J c Q /vtA; Owner. eOIFM Ate/ Date of Inspection: TIGHT OR HOLDING TANK_ (locate on site plan) Depth below grade: Material of construction: _concrete _metal _FRP other(explain) Dimensions: Capacity: gallons Design flow: gallons/day Alarm level: Comments: (condition of inlet tee, condition of alarm and float switches, etc.) DISTRIBUTION BOX_ (locate on site plan) Depth of liquid level above outlet invert: Comments: (note if level and distribution is equal, evidence of solids carryover, evidence of leakage into or out of box, etc.) — 0- fsox 13 ST199714)U- Tb TF Aox SFIyyLA —Papp A 13 i y RE a.r,k 2r P4AGE l.v -rlaC .v4 XT FES -/tFW 2S X0.,1= tS SuG-M Ti -V PUMP CHAMBER_ (locate on site plan) Pumps in working order:(_yes or no) Comments: (note condition of pump chamber, condition of pumps and appurtenances, etc.) (revised 11/03/95) 16-Y/ SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) � Address: 2 0 1 c OR � b Prop L 14� C �J. H N coLkMAti Date of Inspection: 1061,76 l 61,7b SOIL ABSORPTION SYSTEM (SAS):_ (locate on site plan, if possible; excavation not required, but may pp be approximated by non -intrusive methods) If not determined to be present, explain: Type: ming per, number- leaching umberleaching chambers, number:_ leaching galleries, number: leaching trenches, number,length:_ t' y�,g -712 F N< H C S leaching fields, number, dimensions: overflow cesspool, number: Comments: (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation etc.) Ar?9—z+ of .svk r`,&t j ,- -. e � ,.. ,. _. _ ... _ 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: Depth of solids: Dimensions: Comments: (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.) (revised 11/03/95) SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (oontinued) Property Addrew Z Owner. 1 c A 2 i T (3 .0 L. Vg� AJ F , N r4 �v p U Date of Inspection: M R SI(ETCH OF SEWAGE DISPOSAL SYSTEM; inchide tier to at least two permanent references landmarks or benchmarks locate all wells within 100' DEPTH TO GROUNDWATER Depth to Voundwater.__jc'-p--feet method of determination or approximation: (revised 11/03/95) 9 2-`ia� -FaEtjCMEs W 1/y C-„qoLx1v 1 4 -- a R,S” i_ a ��� o� a o �N S113S�a� L _ 1-91, S914 P 7W fa Nig' \\ S -- - Board of Health North Andove.riHaaa. -ICP- DATE BEPTIC SZSTEH, INSTA.d.ATIM CHECK"LIST DI SAPMUiED SS Reasunst LOT EXCAVATICK Ob FAIL C 1. Distance To: a. Wetlands b. Drains c.. Well 2. Water Line Location 3. No PVC Pipe. 4. Septic Tank a. Tees -_Length & To Clean Out Covera b. Cement Pipe to Tank - On Both Sidt 3 of Tank 5. Distribution Box a. Covers & Box - No Cracks b. All Lines Flo wing Equal Amount. c. No Back Flow 6. Leach Field or Trench a. Dimensions b. Stone Depth c. Capped lids d. Clean Double Washed Stone 7. Leach Pits a. Dimensions b. Stone Depth c. Splash Pads d. Tees e. Capt Pipe- to Pit - Both Sides f. Clean Double Washed Stone " 8. 110 Garbage Disposal 9. Final Grading Inspection 10. Barricading Covered System 11. As Built Submitted ae Lot Location b. Dimensions of System c. Location with Regard -to Perc Test d. Elevations e: Water Table i 4-2-0 ' Health udover,Mass APPROM DATE Provided: SUBSORFACE DISPOSAL DESIGN CHECK LIS" LOT # 3q CARD f�G�1/ DISAPPROVED DATE Reasons: I_ DrcivI eciSCvvv!�AnT + UO C105-0 T6 -,S 7 areei . _Pkc Title O Reg 2.5 FAIL 09 —� -- �— The submitted plan must show as a minimum: a) the lot to be served-area,dimensions lo- #,abuttera blocation and log deep observation Mes.distance to ties c location and results percolation testa-#letance to ties d design calculations do calculations showing required leaching area (e) location and dimensions of system -inclining reserve area f) existing and proposed contours (g) location any wet areas wLthin 1001 of at wage 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 within 1001 of sewage disposal system or disclaimer -Planning Hoard files (j) known sources of water supply within 2001 of sewage disposal o system or disclaimer (k) location of axW. proposed well to serve lot -1001 from leaching facility (1) location of water lines on property -101 from leaching facility (m) location of benchmark (n) driveways (o) garbage disposals (p) no PDC 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 otter elevations (r) maximum ground water elevation in area rewage disposal system (s) plan mast be prepared by a Professional &tgineer or other professional authorized by law to prepare such plans Reg 6 Reg 10.2 Reg 10.4 Septic Tanks a) capacities -15D% of flow, water table, teas, depth of tees, access, pumping b) cleanout c) 101 from cellar wall or inground s74.mdn,, pool d) 251 from subsurface drains Distribution Boxes a) slope greater than 0.08 b) sump .. TOWN OFNO'4TH ANDOVER SYSTEM PUMPING RECORD DATE-NoV. A, C-2003 SYSTEM OWNER & ADDRESS (_)Ae riv / C -,Q r17LnAl . olv ove_el SYSTEM LOCATION DATE OF PUMPING c)) --QUANTITY PUMPED Avo CESSPOOL NQYfsSEPTIC TANK NO YES NATURE OF SERVICE;_ROUTINE ENCY OBSERVATIONS: GOOD CONDITION FULL TO COVER HEAVY GREASE BAFFLES IN LACE ROOTS LEACBFIELD RUNBACK EXCESSIVE SOLIDS 'FLOODED SOLID CARRYOVER OTHER EXPLAIN SYSTEM PUMPED BY 0 I'M ZINN 0 00 UFNOR N LX,) v; UAi� SYMN,i PUMPINQ RRCC)KI, JYM, ADDUSS . ......... 14-0 QUA 71 T pUNf PFC, L ",44sPQQL: NQ NA.rVK4 O?Uxyji' L)b4UA V D; bNfl!'1'{UN FULL IN PLAL4 a�tc�4SIY6 " {jos � r%f 1 V K U -N A FLOODED SOL rD CA K"A y EXPLAIN Y 14M 0.1 0 Commonwealth of Massachusetts City/Town of NO. ANDOVER System Pumping Record Form 4 M yVy`e Important: When filling out forms on the computer, use only the tab key to move your cursor - do not use the return key. tab f return RECEIVED NOV 10, 2009 TOWN OF NORMHiA4tMEDMIM DEP has provided this form for use by local Boards of Health. Oth ` ' ' e 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: 201 CARLTON LANE Address NO. ANDOVER MA 01845 Cityrrown State Zip Code 2. System Owner: ROBERT DOHERTY Name Address (if different from location) City/Town B. Pumping Record 1. Date of Pumping 3. Type of system: ❑ ❑ Other (describe): 10/23/09 Date Cesspool(s) 4. Effluent Tee Filter present? ❑ Yes 5. Condition of System: 6. System Pumped By: Benjamin Shute Name J's Septic & Drain Company 7. Location where contents were disposed: GLSD ZI State Telephone Number ySeptiG uantity Pumped Tank Zip Code 1500 Gallons ❑ Tight Tank No If yes, was it cleaned? ❑ Yes ❑ No H79 406 Vehicle License Number 10/23/09 Date t5form4.doc• 06/03 System Pumping Record . Page 1 of 1 Commonwealth of Massachusetts City/Town of North Andover ... System Pumping Record Form 4 OCT I $ Q11 GSH Important: When filling out forms on the computer, use only the tab key to move your cursor - do not use the return key. VQ return DEP has provided this form for use by local Boards ofI .CID"` tI�Ommjlllis used, but the. information must be substantially the same as that prr��idV'��hi�i P �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 within 14 days from the pumping date in accordance with 310 CMR 15.351. A. Facility Information 1. Svstem Location: No.Andover Z'n Ma City/Town State 2. System Owner: Do re Name Address (if different from location) City/Town State Telephone Number 01845 Zip Code Zip Code B. Pumping Record 1. Date of Pumping Date 9/9/// 2. Quantity Pumped: Gallons �(./ 3. Type of system: ❑ Cesspool(s) ['"Septic Tank ❑ Tight Tank ❑ Grease Trap ❑ Other (describe): 4. Effluent Tee Filter present? ❑ Yes ❑ No 5. Condition of System: 6. stem Pumped By: St hr, C/ %// 1 Name Stewart's Septic Service Company 7. Location where contents were disposed: If yes, was it cleaned? ❑ Yes ❑ No Vehicle License Number St rt's Pre -treat ent P/; nt, 20 So- Mill Bradford, Ma 01835 S i gT atur of h YL,Ier Dater a C Signature of R ceiving Facility Date t5form4.doc• 03/06 System Pumping Record • Page 1 of 1