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HomeMy WebLinkAboutMiscellaneous - 21 ASH STREET 4/30/2018l TOWN OF SYSTEM PUMPING RECORD DATE: SYSTEM OWNER & ADDRESS CIO ) v 61'1 VVN'� �Ct v._ r -"A SYSTEM LOCATION ,�,�,""""."'r.� (example: left front of house)�� rc�j a2 DATE OF PUMPING: --014 QUANTITY PUMPED: GALLONS CESSPOOL: NO YES SEPTIC TANK: NO YES NATURE OF SERVICE: ROUTINE EMERGENCY OBSERVATIONS: GOOD CONDITION FULL TO COVER HEAVY GREASE BAFFLES IN PLACE ROOTS LEACHFIELD RUNBACK EXCESSIVE SOLIDS FLOODED SOLIDS CARRYOVER OTHER (EXPLAIN) SYSTEM PUMPED BY: Bateson Enterprises, Inc. COMMENTS: CONTENTS TRANSFERRED To: G.L.S.D Lowell Waste I i .Important: When filling out forms on the computer, use only the tab key to move your cursor - do not use thereturn key. Commonwealth of Massachusetts F.RECEIVED .Clty/Town of I 4 2006 System Pumping Record2FOrm 4 ORTH ANDOVERDEPARTMENT DEP has provided this form for use by local Boards of Health. The System Pumping Record must be submitted to the local Board of Health or other approving authority. A. Facility Information 1. System Location: Address - ` ,r4S Gity/Town State Zip Code 2. System Owner: C 'y % Name Address (if different from location) City/Town State .-1 Zip Code � is s Telephone Number B. Pumping Record 1. Date. of Pumping Date - 2. Quantity Pumped: Gallons 3. Type of system: ❑ Cesspool(s) eptic Tank ❑ Tight Tank ❑ Other (describe): — 4. Effluent Tee Filter present? ❑ YesY "� If yes, was it cleaned? El Yes F] No 5. Condition of System: f ",__ 6. System Pumped B&(-,; ---� Name �'-� / Vehicle License Number Company----�"'�11 7. Location w�hg.e contents were dispose h.ttp://www.mass.gov/dep/­watericipprovals/t5forms.htm#inspect t5form4.doc• 06103 system Pumping Record • Page 1 of 1 A LL 4- 0 v 4-d z c d I I I }O V a E u 0 D w 0 m H O a L, p C � � O � co E1� 'L 0 .b,.r c O o € c v u i= C 0 a 14 ` � r � r E 0 O U O O c, 13 m Z is C m 0 E 0 u C: O . I� c 0 U I E O m TOWN OF NORTH ANDOVER SYSTEM PUMPING RECORD DATE: 9 L6 —,>,, ( & ADDRESS ct, (example: left front of house) (,ze DATE OF PUMPING: QUANTITY PUMPED GALLONS CESSPOOL: NO YES SEPTIC TANK: NO YES NATURE OF SERVICE: ROUTINE / EMERGENCY OBSERVATIONS: GOOD CONDITION HEAVY GREASE ROOTS EXCESSIVE SOLIDS SOLIDS CARRYOVER SYSTEM PUMPED BY: COMMENTS: FULL TO COVER BAFFLES IN PLACE LEACHFIELD RUNBACK FLOODED OTHER (EXPLAIN) CONTENTS TRANSFERRED TO: rl, commonwealth of Massachusetts i� • _, Massachusetts system Pumping Record System Owner � V�kAj � Date of Pumping: L4 — (&-99 Cesspool: No ("1 Yes 1.1 System Location AS � Quantity Pumped: (S 'gallons Septic Tank: No U Yes L� System Pumped by- vaedole gdavwda License # Contents transferrred to : Greater L awrence Sanitau District = Date: - -- Inspector: ",I'm � � ©F � R7H' AN �V�ct3f gt?ARt) OF HEALTH APR�6 rvr--ivI u - LU I RELEASE FORM INSTRUCTIONS: This form is used to verify that all necessary approvals/ er i Boards and ^apartments having jurisdiction have been obtained. This dp m from the applicant and/or landowner from compliance with any a s not relieve applicable oele or requirements, ***''t`*******""'APPLICANT FILLS OUT THIS SECTION Z�APPLICANT/'I///aF3 Com y� _' �''�-'ri /� �,�,G � —,%/ c PHONE S S - ��/� LOCATION: AssessorsMap Number PARCEL_j SUBDIVISION LOT (S) • t/ STREET / S A— ST. NUM BER ,�2-/ OFFICIAL USE ONLY i RECOMMENDATIONS OF TOWN AGENTS: CONSERVATION ADMINIST TOR DATfREJECTED D � p DAT COMMENTS , TOWN PLANNER 7' TH TH DATE APPROVED DATE REJECTED DATE APPROVED DATE REJECTED DATE APPROVED DATE REJECTED PUBLIC WORKS - SEWER/WATER CONNECTIONS_ DRIVEWAY PERMIT FIRE DEPARTMENT RECEIVED BY BUILDING INSPECTOR DATE FROM : STAINLESS**M`A'LES** PHONE NO. : 508 685 8014 Mar. 16 1998 05:06PM P1 1V'- 0" 0 uD FROM : STAINLESS**MYLES** PHONE NO. : 508 685 8014 Mar. 16 1998 01:31PM P1 O f 00 00 > U) 00 00 2: un o °b p0 a z o Q —I C co co ;;a O RC1 -G C -Ti cr 'U O C m O -P- -P y C C— y >< m � � Z O 00 -P- CJ's . 16 "So Paul Calk ool LL Governor Commonwealth of Massachusetts Executtve Office of Environmental Affairs JAN 2 Department of Environmental Protection_ . Trudy Co" Y David B. Struhs Cam *Wow • SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM j PART A _ i CERTIFICATION Addree Park' c a '4, 5T:✓ADVr7l�. Address of Owner. c S n,� rnrrSUv✓ Date of, (If different) Name of I /j,_,ager R, vIC i Company N a. Address and Telephone Number. s D�-7G - 4QjoS 8K>;s Tam CERTIFICATION STATEMENT l I cut* that I have personally inspected the sewage disposal system at this address and the information reported below is true, accurw and complete as of the time of inspection. The inspection'was performed based on nay tra' ng and experience in the proper luactia' aced maintenance of on-site sewage disposal systems. The system: ��asses _ Conditionally Passes Needs>Furthar Evaluation By the Local Approving Authority Fails Inspector's Signature: Date: The System Inspector shall submit a copy of this inspection report to the Approving Authority within thirty (30) days of complating this inspection. Ifahe'system it.a sharedIsystem or has a design flow of 10,000 gpd or greater, the inspector and the system owner_ shall submit the repos t;to.the,appropriate1regional, office of the Department of,Environmental Protection. The original should be sent to the system owner and copies sent to the buyer, if appliceb1e and the approving authority. �r q�nT,� rrlwK SL �aP«i5 ,,v Goon INSPECTION SUMMARY: D — Q O X j �✓ Go o A cu�erKi r/(y eU n 4'T• i� /V�.r/1/'�vMM<; Check A,�B, C, or D: S S )7S Al/ SYSTEMIPASSES:` v I have not found any tnixuation which indicates that the system violates any of the Mum criteria ss defined in 310 CMR 15.303. i' Any failure criteria not evaluated are indicated below. BJ SYSTEM CONDITIONALLY PASSER: One or more system components used to be replaced or repaired. The system, upon completion of the replaoearsnt or repair, pasty inspection - Indicate yes, no, or not determined (Y, N, or ND). Describe basis of determination in all instances. If 'bot determined", explain why not) The septic tans: is metal, cracked, strtcturaly unsound, shows substantial infiltration or e d tration, -or tank Aulure W imminent. The system will pass inspection if the existing septic tank is replaced with a ponforming septic tank as approved by the Board of Health. (revised 11/03/95) 1 One WhAw Street a BOSOM%, Massachusetts 02106 a FAX (617) SW1649 a Teisphons (617) 292-56M Printed on s.cyd.d P.P; t z I i i SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORT[ PART A CERTIFICATION (000tinued) Property Address: 1 /1 SH ST N, A N AD v rrR ) Owner. S �Si9 �✓ e RSo ✓ Date of InspeWon ! i Bi -SYSTEM CONDITIONALLY PASSES (continued) .t Sewaga backup or breakout or high static water level observed m the dist tmuou boa is due to broken or obstructed pipe(s)i` 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 boa is levelled or replaced The system required pumping,more than four times a year due to broken or obstructed pipe(s). The systam will pass inspection if (with approval of the Board of Health): broken pipe(s) are replaced obstruction is removed . 1 C) FURTHER EVALUATION IS REQUIRED BY THE BOARD OF HEALTH:- Conditions EALTH:Conditions exist which require thither evaluation by the Board of Health in order to determine if the systema 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 MANNERaWHICH WILL PROTECT THE PUBLIC HEALTH AND SAFETY AND THE ENVIRONMENT: Cesspool or privy is within 50 feet of a surface water Ceapool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh. Y) SYSTEM WILL;FAIL.UNLESS THE BOARD OF HEALTH (AND PUBLIC WATER SUPPLIER. IF APPROPRIATE)" i DETERMINES THAT THE SYSTEM IS FUNCTIONING IN A MANNER THAT PROTECT THE PUBLIC HEALTH AND 7; SAFETY AND -.THE ENVIRONMENT. ,F Theisystem+has aseptic tank and soil absorption system and is within 100 feet to a surface water supply or tributary'to a surface—ater. suppl y. l The:-1has a septic tank and soil absorption system and is within a Zone I of a public water supply we1L The system has a septic tank and soil absorption system and is within 50 feet of a private water supply wall. The.system has aseptic tank and soil absorption system and is less than 100 feet. but 50 feet or more from a private water' supply w4 unless a well water analysis for coliform bacteria and volatile organic oompouada indicates tbatitba'wsll)is &" from polt tion from that 6 ility and the presence of ammonia nitrogen and nitrate nitrogen is equal to or lean thin.&ppm. S) OTHER e (revised 11/03/95) 2 y SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (oontinued) {4 Property Address: 011 4Siy 57-,/v,/J.v�dVrL2 1 Owner.. SVS/9-,V e ARSm nI Date of Inspection: /-'7-97 DI SYSTEM FAILS: -`— I have determined that the system violates one or more of the following failure criteria as this determination is identified below. The Board of Health sharld be son deed in 310 CMR 15.303. The basis for failure. tatted to determine what will be necessary to correct the — Backup of eswage into facility or system component dui to an overloaded or clogged SAS or cesspool. — Discharge or ponding of effiuent to the surface of the ground or surface wcesspool.aters due to an overloaded or clogged 3A3 or — 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 lea than 1/2 day flow, i 1 — R*qWM Pumping more than 4 time in the last year NOT due to clogged or obstructed pipe(s). Number of tune pumped f — Any portion of the Soil Absorption System, cesspool or f j Poo Pavy is below the high groundwater elevation. � — Any portion of a cesspool or privy is within 100 feet of a surface water supplys or tributary to a surface avatar supply. — Amy portion of a cesspool or privy is within a Zone I of a public wall. — Any portion of a:ceespool or privy is within 50 feet of a private water supply well. ._ Any -portion of a osespool or privy is les than 100 fest but greater than 50 feet from a private water supply well with no acceptable water quality analysis. If the well has been j oohform bacteria,` volatile o � to be acceptable, attach Dopy of well water analysis for organic compounds, ammonia nitrogen and nitrate nitrogen. EI LARGE SYSTEM FAILS: The following criteria apply to large systems in addition to the criteria above: Thesystem ssrvas a r qty with a design flow, of 10,000 gpd or greater (Large SysUM) and the system is a significant threat to � health sad safety and the environment because one or more of the knowing conditions enst:, public F — the sysEem is within 400 bet of a surface drinking water supply — the system is within 200 feet of a tributary to a surface drinkdag water supply �ssTstem� located in a nitrogen "art" area (Interim Wellhead Protection Area (IWPA) or a mapped Zona H of a pubfz The owner or operator of any suck►system shall bring the system and bciliq into !till Dom hence with the requirements of 314 CMR 5.00 end 6.00. Plow consult the Beal P groundwater treatment program o®ce of the Department for Anther, iaformstion, i • 4 (revised 11/03/95) 3 1:• 'I. • i SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST Propaty Address j / A $ N S�. N' /7lVd6V lrfZ Ownar: S. S~ eo4o?SO& Data of Inspootioo: Cbsck if the &Vowing have been dons: _ Pumping informAtion was requested of the owner, occupant, and Board of Health. (_,-None of the system components have been pumped for at last two weeks and the system has been reonving normal flow rata during that -period. Large volumes of water have not been introduced into the system recently or as part of this inspection. 1411A_As built plans have been obtained and examined. Note if they are not available with N/A. ,,h& facility or dwelling was inspected for signs of sewage back-up. zThe system does not receive non4anitary or industrial waste flow _ The'site was inspected for siggas of breakout. f 1-�M ,system components, uciuding the Soil Absorption System, haw been located on the site. septic tank manhole were uncovered, opened, and the interior of the septic tank was inspected for condition of bafn or Was, material of ooastrucWn. dimensions, depth of liquid, depth of sludge, depth of scum. sire and kocation of the:Soil Absorption System on the site has been determined bored on wasting information or approzimated`by non -Intrusive methods. The ficility.owner (and oowpanta, if different from owner) were provided with information on the proper maintenance of Sub- Sur4a'Disposal System. z fr i (revised 11/03/95) 4 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION Property. Addre" a ) ASH 5T • /V • 11006 0 v r?2 70wner. J us 4A/ AAk'SOh/ Date of Inspection: /., 1-97 FLOW CONDITIONS Design fiow._j_jLysllon& Number of bedroo®s:a_` Number Of current residents: a Garbage grinder (fee or no):_D Lundry.00nnected:to4ystem-(yes or no): ?S Seasonal vee (Yee�or no): �' Water mater readings, if available: ,P'P I' jV AT,4;- W );'J - Z Last date of occupancy: e MR174 i COMMERCIAL IINDUSTRIAL- Typo of establishment DesigntDow:�llons/day :1 Grove-trap,prwnt: (ywor no)_ i Industrial Waste Holding Tank prwnt: (yea or no)_ , Noa�aaitar7 waste dischuged to the 'Title 6 system: (yes or no )_ Water meter readiW if available: Last date of occupancy: OTHER (Describe) Last date of oocupanoy: GENERAL INFORMATION PUMPING RECORDS and source of information: /V//l� 9ysum pumpedtn part of inspection (yes or ao)�/10 If ywtvalume)pumped: plloas Reason for pumping - TYPE OF SYSTEM f�Septic--tnakkirt;ibtrtioaZ baa/soil absorption system Siagie,oesspool ' Overflow cesspool Privy Al 0 Shared system (yes or no) (if Yee, attach previous inspection records, if any) Other (explain) APPROXIMATE AGE of all components, date installed (if known) and source of informatioon Sewage odors detected when arriving at the aite: (yes or no) Ll) (revised 11/03/95) SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C RgiZ l SYSTEM INFORMATION (continued) rnv�R q Property Address: 4q, I /js ff S 7 Al • /1,V0 e v 17 2 _, y Owner. $vs/-)r� PARSon/ Date of Inspection: SEPTIC TAN&_ -- (locate on site plan) Depth below grads: Material of construction: �ncete _metal _FRP _otAMeiplain) �C.(toe tr .47�� . Dimensions: l p''3 h tom'' , Cr, TC s l S Q O (A..44AJ. 7Arv(,, Sludge depth: 3 Distance from top of sludge to bottom of outlet tee or baffle: a �! scum thielmess: c� _ Distance from top of scum to top of outlet tee or baffie:_ Distance from bottom of scum to bottom of outlet tee or baffle: Comments: (recommendation- for pumping, condition of inlet and outlet tees or baffias, depth of liquid level m relation to outlet invert, structural, integrity, evidence of leakage, etc.) `)`'-A"k_ /RJ JCR?/ 63,04) C.dOhjr?t ire l — /1ri'$AS t9Vm pi nib- GREASE TRAP -W/+ (locate on site plan Depth below grade Material of construction: _Concmw _metal _FRP _othertezplain) ' Dimensions: Scum thickness: Distance from top of -scum to top of outlet tee -or baIDs: Distance from bottom of scum to bottom of outlet tee or b&M@: Comments: (recommendation for pumping, condition of inlet and outlet tees or bef"aes, depth of liquid level in relation to outlet invert, strvctnral integrity. evidence of leakage, etc.) (revised 11/03/95) 6 SVESURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: Owner. S u S tpv t' s vAl Date of Inspection: /— 9_C 7 TIGHT OR -HOLDING TAN&w �4 (locate on site place) Depth below grads: Material of const:uctioa: _concrete _metal _FRP _othrr(e:plain) Dimensions: Capacity: Dssi�a flow: na/day Alarm level: Comments: (oondition'of inlet -too, condition of alarm and float switches, rte.) i i DISTRIBUTION BOX_ (locate on sits plan) Depth of liquid level above outlet invert:_ ; Comments: �I I (note if level and distribution is equal, evidence of solids carryover, evidence of leakage into or out of ba:, etc.) No 5'nl-,O, A.,Q aA4U-2— �'duAi— D,'Srrrr/3,/rror✓• i _ s e PUMP CHAMBER ' V, (locate on'site plan) . Pumps in working order:(yes or no) Comments: (note condition of pomp chamber, condition of pumps and appurtenances, etc.) i (revised 11/03/95) 7 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM . PART C SYSTEM INFORMATION (oontinuW) Prapeety Address: J- I ASM -3-1- Al' A --'p o v'PA Owner. 50-541V enf?t >D.V Date of Inapeotiod / _ 9, 9 -7 SOIL ABSORPTION SYSTEM (SAS)%L' (locate as site plan, it powbL; acavation not required, but may be appraaimated by non -intrusive methods) If not determined to be present, espla:a: Type: i leachh% -pits,- number: leachinS chambers, number:_ leschiagalleries, number. leschiatrench", number,length:�_ leach- -fields, number, dimensions: / J. S' x - overflow cesspool, number. Comments: (note oondition of soil, signs of hydraulic failure, level of ponding, condition of vegetation stc.) }� 6jz- Pte►cCork- ¢- v�rG-cr?1.77,uPv &4pm,91 - n,o Pd+uorn . CESSPOOLS: � 4 P (locate on site lan) / Number. and configuration: y Depth -top ot;ligaid to inlet invert: Depth of solids layer: Depth of scum layer. Dimensions of cesspool: Materials of constriction: Indication of groundwater. inflow(- y x l':aust be pumpedas part of inspection) Comments: (note condition of sail, signs of hydraulic failure , level of ponding, condition of vegetation, etc.) r PRIVY: (locate oa site plan) Materials of oonstruction: Dimsnsioas• Depth of solids: Comments: (note condition of soft, signs of bydrwlic &Bm, level of pondm& condition of vegetation, etc.) (revised 11/03/95) a • SUDSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: a A S // S! N, f}n/ 4 0 V 171'� Owner. 5L,,54 -,L/ rlm S a tv Date of Inspection: / 9 -'7 7 SKETCH OV SEWAGE DISPOSAL SYSTEM: include tin to at least two permanent references landmrrlu or benchmarks locate all wells within 100' 47 DEPTH TO GROUNDWATER 3S -C Depth to voundwater:_t—feet 4 method of dstermiaation or approximation. N o u-, T-trr0, nV.. P ?tet /M - w o S U M p titi j } (revised 11/03/95) 9 f t-eephl-viva Ash St. APPLICATION FOR SEWAGE DISPOSAL INSTALIATION HEALTH DEPARTMNT - NORTH ANDOVER, MASS. I hereby make application for a permit for a sewage disposal installation at St. . I will install this system in ac- cordb,nce with all the laws of the Commonwealth of Massachusetts and regulations of the Board of Health of the Town of North Andover. Further, I will construct the house sewer of bell and spigot pipe, the minimum diameter being 4 inches, and will maintain a minimum grade of 1% until 10 feet pre- ceding the septic tank, where the grade shall not exceed 2%. I will install a con- crete septic tank of 750 gal. in size. A manhole (s) permitting easy cleaning will be provided with removable cover (s) of iron or concrete within 12 inches of the ground surface. I will provide subsurface disposal field with 4 inch perforated or open jointed pipe and laid in a series of trenches, the bottom of which will pro- vide a minimum of 180 lineal (QPXM) feet of effective absorption area. The pipes will be laid on a 6 inch layer of washed gravel or crushed stone ranging in size from 3/4 to 1-1/2 inches (dia.) and the pipes will be surrounded by similar material to a height of 2 inches above the crown of the pipe. The joints of these pipes will be protected from clogging and before filling the trench, 2 inches of gravel or stone 1/8" to 1/4" (dia.) will be placed over the course gravel or stone. The disposal field will be installed at a grade of 4 to 6 inches/100 feet. No single tile line will exceed 100 feet in length and in any case, two lines of tile will be installed. A minimum of 6 feet will be maintained between the center lines of the disposal field trenches and the average depth of trench shall not exceed 36 inches. No part of the installation will be less than 100 feet from any private water supply, 25 feet from any stream, 20 feet from any dwelling or 10 feet from any property line. I further agree not to cover any portion of this installation until approved by the inspection officer, as provided below, and to incorporate any additional requirements that may be attached to the permit. Plot Plans must be submitted with application. DA TE B : 1 • 9-0 / y' ignature of Applicant I hereby issue the above permit for the Board of Health of the Town of North Andover, Massachusetts. DA 7.E� � � T_1 d / -71 _L (7ignature of Health Agent I have inspected the uncovered system indicated above and find everything done as described. DA TE__ &,I, 7� Signature o nspecting Officer 4z� Percolation Test 5 min. Soil: Clay Garbage Grinder No November 11, 1961 Miss Mary Sheridan R. N. Health Agent Board of Health North Andover, Mass. Dear Miss Sheridan: An examination was made as requested in order to determine the suitability of the soil for the subsurface disposal of sewage on the proposed Berry Street building site of Joseph Viveiros. The land in general is high. The subsoil in the area was of clay content and a 5 -minute percolation test was conducted. It is recommended that a 750 gallon concrete septic tank be installed together with 180 lineal feet of drain pipe. WJD : hd Very truly yours, Uilam Isco I IV J HOARD OF HEALTH TOWN OF NORTH ANDOVER9 MASS. - J J 4 14-- f sz) �p r 1, NAME DATE 2. ADDRESS , � �'s� ��/� f�i'�. LOT NO. TEL 3. NO, OF BEDROOMS DEN YES N0. . 4. GARBAGE GRINDER. YES N0. 5. SHOD DIhENSIONS OF HOUSE 6. SHOW DISTANCES OF HOUSE TO ALL PROPERTY LINES 7. SHOW DITJIENSIONS OF IAT 8. SHOW LOCATION AND SIZE OF SEPTIC TANK OR CESSPOOL 9, NOTE LOCATION AND DISTANCE OF WELL FROM SEWERAGE SYSTEM 10. SHOW LOCATION OF BROOKS, STREAMS, DITCHES, LEDGE OUTCROP, ETC. 11. SHOW DISTANCE OF SEPTIC TANK OR CESSPOOL FROM HOUSE NOTE .@ LOCAL REGULATIONS SHOULD BE READ CAREFULLY. T' f .. � s . ., � � � .. � � �' � e —�. c r 4 o +. —�. W P 107 Forest St. FORM 4 - SYSTEM PUMPING RECORD Middleton, MA 01949 Q , (508) 774.2772 10 'U r Commonwealth of Massachusetts -4, Massachusetts `x�,� System Pumping Record 'stem ,%mer ystem ocatton = .. 'ef ` f , �M4W 141 1 Date of Pumping: � 7 Quantity Pumped: l gallons Cesspool: No ❑ Yes ❑ Septic Tank: No ❑ Yeses❑ System Pumped by: License 4:.. Contents transferred to: Date 5�. '% r% Inspector k7LI v 0 THE PROFESSIONAL EXPERTS IN THE SEPTIC AND DRAIN INDUSTRY 9 Commonwealth of Massachusetts RECEIVED City/Town of System Pumping Record DEC 15 2009 Form 4 TOWN OF NORTH ANDOVER HEALTH DEPARTMENT DEP has provided this form for use by local Boards of Health. Othe e information must be. substantially the same as that provided here. Before using this form, check with your local Board of Health tQ determine the form they use. The System Pumping Record must be submitted to the local Board of Health ol^ottzer approving authority. A. Facility Information 1. System Location: Le Lsie of house, Right side of house, Left front of house, Right front of house, Left rear of house, i ht rear of ho . Left rear of building. Right rear of building. Address City/Town State Zip Code 2. System Owner: co Ov- bo Sc3l,� Name Address (if different from location) City/Town B. Pumping Record 1. Date of Pumping 3. Type of system: ❑ ❑ Other (describe): State„ ® Lf�� - p�Code Telephone Number t�[i :---LA Date 2 -'Quantity Pumped Cesspool(s) Septic Tank Gallons ❑ Tight Tank 4. Effluent Tee Filter present? ❑ Yes [j -<o"' If yes, was it cleaned? ❑ Yes ❑ No 5. Condition of System: 6. System Pumped By: Neil Bateson Name Bateson Enterprises Inc Company 7. Location where contents were disposed: Lowe I Wase Water 1 r 1 Signature F5821 Vehicle License Number Date t5form4.doc• 06/03 System Pumping Recons • Page 1 of 1 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 hous, Left Righ r of hous Left/ right side of house, Left/ Right side of building, Left / Right front of bl7t ing, Left Ig t rear of building, Under deck Address City/Town 2. System Owner. Name Address (if different from location) City/Town B. Pumping Record 1. Date of Pumping 3. Type of system. ❑ State Zip Code Statey 7Zip Code , Telephone Number i A__q-t 3 Date 2. Quantity Pumped Cesspool(s) Septic Tank Gallons ❑ Tight Tank ❑ Other (describe): 4. Effluent Tee Filter present? ❑ Yes o If yes, was it cleaned? ❑ Yes ❑ No. 5. Conditio of stem: 6. System Pumped By. Neil Bateson F5821 Name Vehicle License Bateson Enterprises Inc Company 7. Location s were disposed: Lowell Waste Water 5IMMR,&R" "_ I� .. RECEI ED Nov 'I 9 [013 TOWN OF NMH ANDOVER HEALTH DEPARTMENT t5form4.doc• 06/03 System Pumping Record • Page 1 of 1 Commonwealth of Massachusetts City/Town of---- System Pumping Record P�AN �iVED Form 4 X012 DEP has provided this form for use by local Boards of Health. Other orQ�i��==with information must be substantially the same as that provided here. B oryw 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(!5� Rig rear f , Left / right side of house, Left / .Right side of building, Left / Right front of building, Left / Right rear of building, Under deck Address < k)(f 7(%� ATL��� a t Ac-> City/Town 2. System Owner: Name State Zip Code Address (if different from location) CitylTown State � l ipQde Telephone Number B. Pumping Record LID 1. Date of Pumping Date 2. Quantity Pumped: Gallons 3. Type of system: ❑ Cesspool(s) Septic Tank ❑ Tight Tank ❑ Other (describe): 4. Effluent Tee Filter present? ❑ Yes to If yes, was it cleaned? ❑ Yes ❑ No 5. Condition of System: (AJ69 �- ull-�� � � A- 6. 6. System Pumped By: Neil Bateson F5821 Name Vehicle License Number Bateson Enterprises Inc Company 7. Location where contents were disposed: geHaule Lowell Waste Water Sig Date t5form4.doc• 06/03 System Pumping Record • Page 1 of 1 Commonwealth of Massachusetts City/Town of W° System Pumping Record Form 4 DEC 1 X010 DEP has provided this form for use by local BoardsofHealt�"�; but the y information must be substantial) the same as that rovided check with our 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. Syste n: Left front of house, right front of house, left side of house, right side of house, ar of hous ght rear of house, left side of building, right rear of building, under deck. A�k SA7- City/Town State Zip Code 2. System Owner: Name Address (if different from location) City/Town B. Pumping Record 1. Date of Pumping 3. Type of system: ❑ ❑ Other (describe) Te ephone Number Date 2. Quantity Pumped: Gallons Cesspool(s) eptic Tank ❑ Tight Tank 4. Effluent Tee Filter present? ❑ Yes No If yes, was it cleaned? ❑ Yes ❑ No 5. Conditionf S stem* 6. System Pumped By: Neil J. Bateson F5821 _ Name Bateson Enterprises Inc. Company 7�G. Loc i where contents were disposed: L.S.d _A)owgll Wastehaieer Signature Vehicle License Number Date t5form4.doc• 06/03 System Pumping Record • Page 1 of 1 NORTH , (. * •ice 9 • 0 AL Town of North Andover •,4�,0_-=�','•'' rrr, A r rnrr TTT . rr�_ SS�CHUst�� CHECK #: LOCATION: H/O NAME: CONTRACT( 4626 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 $ ❑ TrashlSolid Waste Hauler $ ❑ Well Construction $ SEPTIC Systems: ❑ Septic - Soil Testing $ ❑ Septic - Design Approval $ ❑ Septic Disposal Works Construction (DWC) $ ❑ Septic Disposal Works Installers (DWI) $ ❑ Title 5 Ins ector $ ❑(�T�tTe 5 Report $ ❑ Other. (Indicate) $ 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. Commortwetilth of Massachusetts Title 5 Official Inspection Fo Subsurface Sewage Disposal System Form - Not for Voluntary) 21 Ash Street RECEIVED 2 3 2009 Property Address O N OF NORTH DEPAANDOVER Robin Colombosian Owner's Name North Andover MA 01845 12/4/2009 City/Town State Zip Code Date of Inspection 1 0,.. 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 Cityrrown 978-475-4786 Telephone Number B. Certification Ma State SI15 License Number 01810 Zip Code 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 Section 15.340 of Title 5 (310 CMR 15.000). The system: ® Passes ❑ Conditionally Passes ❑ Fails El NNIQedsifurther Evaluation by the Local Approving Authority J r 12/4/2009 Insp or4s Signature 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 • 09/08 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 21 Ash Street Property Address Robin Colombosian Owner's Name North Andover MA 01845 12/4/2009 Citylrown 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 - 09/08 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 21 Ash Street Property Address Robin Colombosian Owner Owner's Name information is required for North Andover MA 01845 every page. Cityfrown State Zip Code B. Certification (cont.) 12/4/2009 Date of Inspection 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 •09/08 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 21 Ash Street Property Address Robin Colombosian Owner's Name North Andover MA 01845 12/4/2009 Cityrrown State Zip Code Date of Inspection B. Certification (cont.) 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 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: 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 Y2 day flow t5ins • 09/08 Title 5 Official Inspection Form: Subsurface Sewage Disposal System - Page 4 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 21 Ash Street Property Address Robin Colombosian Owner's Name North Andover Cityfrown B. Certification (cont.) Yes No MA 01845 State Zip Code 12/4/2009 Date of Inspection ❑ ® 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 • 09/08 Title 5 Official Inspection Form: Subsurface Sewage Disposal System • Page 5 of 17 Commonwealth of Massachusetts v Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 21 Ash Street Property Address Robin Colombosian Owner Owner's Name information is required for North Andover MA 01845 12/4/2009 every page. Citylrown 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 of the 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): N/A Number of bedrooms (actual): 3 DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x # of bedrooms): N/A t5ins - 09108 Title 5 Official Inspection Forth: Subsurface Sewage Disposal System - Page 6 of 17 Commonwealth of Massachusetts u Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 21 Ash Street Owner information is required for every page. Property Address Robin Colombosian Owner's Name North Andover Cityrrown D. System Information Description: State 01845 12/4/2009 Zip Code Date of Inspection Sump pump? Last date of occupancy: Commercial/Industrial Flow Conditions: Type of Establishment: Design flow (based on 310 CMR 15.203): Basis of design flow (seats/persons/sq.ft., etc.): Grease trap present? Industrial waste holding tank present? Non -sanitary waste discharged to the Title 5 system? Water meter readings, if available: Gallons per day (gpd) ❑ Yes ® No Current Date ❑ Yes ❑ No ❑ Yes ❑ No ❑ Yes Number of current residents: No 3 Does residence have a garbage grinder? ❑ Yes ® No Is laundry on a separate sewage system? [if yes separate inspection required] ❑ Yes ® No Laundry system inspected? ❑ Yes ❑ No Seasonal use? ❑ Yes ® No Water meter readings, if available last 2 ears usage ( 9 ( Y .� gpd))� Yes Detail: Sump pump? Last date of occupancy: Commercial/Industrial Flow Conditions: Type of Establishment: Design flow (based on 310 CMR 15.203): Basis of design flow (seats/persons/sq.ft., etc.): Grease trap present? Industrial waste holding tank present? Non -sanitary waste discharged to the Title 5 system? Water meter readings, if available: Gallons per day (gpd) ❑ Yes ® No Current Date ❑ Yes ❑ No ❑ Yes ❑ No ❑ Yes ❑ No t5ins • 09/08 Title 5 Official Inspection Form: Subsurface Sewage Disposal System • Page 7 of 17 Commonwealth of Massachusetts w Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 21 Ash Street Property Address Robin Colombosian Owner Owner's Name information is required for North Andover MA 01845 12/4/2009 every page. 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 two years ago, owner 1500 gallons Measured tank. Inspect tank & bafffle & tee ® Yes ❑ No Type of System: ® Septic tank, distribution box, soil absorption system ❑ Single cesspool ❑ Overflow cesspool ❑ Privy ❑ Shared system (yes or no) (if yes, attach previous inspection records, if any) ❑ 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 • 09108 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 21 Ash Street Property Address Robin Colombosian Owner information is required for every page. Owner's Name North Andover MA 01845 12/4/2009 Cityfrown State Zip Code Date of Inspection D. System Information (cont.) Approximate age of all components, date installed (if known) and source of information: House built in 1982. owner Were sewage odors detected when arriving at the site? ❑ Yes ® No Building Sewer (locate on site plan): Depth below grade: 1_5 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.): Finished cellar unable to see Dioina Septic Tank (locate on site plan): Depth below grade: Material of construction: ® concrete ❑ metal 0 feet ❑ 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'x 5'x 4' Sludge depth: 2" ❑ Yes ❑ No t5ins • 09/08 Title 5 Official Inspection Form: Subsurface Sewage Disposal System • Page 9 of 17 Owner information is required for every page. t5ins • 09/08 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 21 Ash Street Property Address Robin Colombosian Owner's Name North Andover Cityrrown D. System Information (cont.) MA 01845 12/4/2009 State Zip Code Date of Inspection 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 2511 211 811 1911 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.): Pumped septic tank. Inlet baffle ok. Outlet tee ok Depth of liquid at outlet invertNo evidence of leakage. Grease Trap (locate on site plan): Depth below grade: Material of construction: ❑ concrete . ❑ metal Dimensions: Scum thickness feet ❑ fiberglass ❑ polyethylene ❑ other (explain): 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: Date Title 5 Official Inspection Forth: Subsurface Sewage Disposal System - Page 10 of 17 Commonwealth of Massachusetts w Title 5 Official Inspection Form o Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 21 Ash Street Property Address Robin Colombosian Owner Owner's Name information is required for North Andover MA 01845 12/4/2009 every page. 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 El other (explain): Dimensions: Capacity: gallons Design Flow: gallons per day Alarm present: ❑ Yes ❑ No Alarm level: Alarm in working order: Date of last pumping: Date Comments (condition of alarm and float switches, etc.): ❑ Yes ❑ No "Attach copy of current pumping contract (required). Is copy attached? ❑ Yes ❑ No t5ins • 09/08 Title 5 Official Inspection Form: Subsurface Sewage Disposal System - Page 11 of 17 Commonwealth of Massachusetts 4 Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments M 21 Ash Street Property Address Robin Colombosian Owner Owner's Name information is required for North Andover MA 01845 12/4/2009 every page. Cityfrown State Zip Code Date of Inspection D. System Information (cont.) Distribution Box (if present must be opened) (locate on site plan): Depth of liquid level above outlet invert 0 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 cover broken, replaced it. D -box level & distribution equal. No evidecne of leakage. Evidence of n� rn ins mr 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.): Soil Absorption System (SAS) (locate on site plan, excavation not required): If SAS not located, explain why: t5ins • 09/08 Title 5 Official Inspection Form: Subsurface Sewage Disposal System • Page 12 of 17 Commonwealth of Massachusetts a Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 21 Ash Street Property Address Robin Colombosian Owner Owner's Name information is required for North Andover MA 01845 12/4/2009 every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Type: ❑ leaching pits number: ❑ leaching chambers number: ❑ leaching galleries number: ® leaching trenches number, length: 4 trenches 40' 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 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 t5ins • 09/08 Title 5 Official Inspection Form: Subsurface Sewage Disposal System • Page 13 of 17 Commonwealth of Massachusetts N Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 21 Ash Street Owner information is required for every page. I-roperty Address Robin Colombosian Owner's Name North Andover MA 01845 12/4/2009 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 • 09/08 Title 5 Official Inspection Form: Subsurface Sewage Disposal System • Page 14 of 17 • Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments M 21 Ash Street Property Address Robin Colombosian Owner Owner's Name information is North Andover required for MA 01845 12/4/2009 every page. Cityfrown 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 100 feet. Locate where public water supply enters the building. Check one of the boxes below: ® hand -sketch in the area below ❑ drawing attached separately I Se A +o k = 30 `t cf a=L4 4i� t5ins • 09/08 Title 5 Official Inspection Form: Subsurface Sewage Disposal System • Page 15 of 17 Owner information is required for every page. Commonwealth of Massachusetts Title 5 Official Inspection Form e Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 21 Ash Street Property Address Robin Colombosian Owner's Name North Andover MA 01845 12/4/2009 Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Site Exam: ® Check Slope ® Surface water ® Check cellar ® Shallow wells Estimated depth to high ground water: >6feet 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: Date ❑ Observed site (abutting property/observation hole within 150 feet of SAS) ® Checked with local Board of Health - explain: No design plan on file ❑ Checked with local excavators, installers - (attach documentation) ® Accessed USGS database - explain: Essex County Soil Map You must describe how you established the high ground water elevation: Essex Conty Soil Map, Sheet # 36, Canton Soil, Water> 6' Deep Before filing this Inspection Report, please see Report Completeness Checklist on next page. t5ins • 09/08 Title 5 Official Inspection Forth: Subsurface Sewage Disposal System • Page 16 of 17 Commonwealth of Massachusetts a Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments M 21 Ash Street Owner information is required for every page. I-roperty Aooress Robin Colombosian Uwners Name North Andover Citylrown State 01845 12/4/2009 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 - 09108 Title 5 Official Inspection Form: Subsurface Sewage Disposal System • Page 17 of 17 Summary Record Card generated on 12/4/2009 8:28:55 AM by Karen Hanlon Page 1 Town of North Andover Tax Map # 210-106.D-0041-0000.0 Parcel Id 17801 21 ASH STREET COUYOUMJIAN, ROBIN 21 ASH ST NORTH ANDOVER, MA 01845 Class 101 Single Family Property Type 1 Residential Size Total 1.22 Acres FY 2010 UB Mailing Index Name/Address Type Loan Number Active/Inact. From Until COUYOUMJIAN, ROBIN Payor 21 ASH ST NORTH ANDOVER, MA 01845 UB Account Maint, Account No Cycle Occupant Name Active/Inactive Bldg Id. 17927.0 - 21 ASH STREET Last Billing Date 10/7/2009 3170595 03 Cycle 03 Active UB Services Maint. Account No. 3170595 Service Code Rate Charge Multiplier/Users MISCFEE ADMIN FEE 1 1 9.18 1/ WTR WATER 01 ALL METER SIZE 64.60 /1 UB Meter Maintenance Account No. 3170595 Serial No Status 17264380 a Active Location ERT HH Brand Type Size YTD Cons Date Reading Code METE METE Consumption w Water 1 1 Posted Date 113 9/11/2009 416 aActual 17 10/15/2009 Variance 6/9/2009 399 a Actual 22 7/20/2009 -31% 3/17/2009 377 a Actual 25 4/29/2009 4% 12/8/2008 352 a Actual 20 1/20/2009 12% 9/10/2008 332 a Actual 16 10/10/2008 35% 6/6/2008 316 a Actual 13 7/16/2008 10% 3/12/2008 303 a Actual 15 4/11/2008 9% 12/13/2007 288 a Actual 12 1/22/2008 ° 35% 9/7/2007 276 a Actual 9 1 /° 150/12/2007 6/15/2007 267 a Actual l l " `7%20/2007 -10% 3/15/2007 256 m Manual estimate 11 4/16/2007 5% 12/8/2006 245 a Actual 11 1/19/2007 1211 9/13/2006 234 a Actual 9 10/20/2006 % 6/14/2006 225 a Actual 13 7/10/2006 24% 3/6/2006 212 a Actual 10 ' "4/17/2006 _4% 12/21/2005 202 a Actual 10 '1%17/2006 12% 9/20/2005 191 a Actual 11 10/14/2005- 12% 6/9/2005 180 a Actual 12 7/15/2005 -23% 3/15/2005 168 a Actual 10 4/5/2005 34% 12/9/2004 158 a Actual 11 1/14/2005 20% 9/15/2004 147 a Actual 11 10/8/2004 14% 14% i t5form4.doc• 06/03 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 side of house, Right side of house, Left front of house, Right front of house, Left rear of house, ig t rear of Nous Left rear of building. Right rear of building. Address t City/Town 2. System Owner: Name A-5� %log--�\ Av\c\ou-Q • Address (if different from location) Cityrrown B. Pumping Record 1. Date of Pumping State (fjC 0V" -V) aN Gt,/V\� Zip Code State Zip Code Telephone Number to-q`oct Date 2. Quantity Pumped: 3. Type of system: ❑ Cesspool(s) ❑ Other (describe): lsoc.) Gallons [.t] -'Septic Tank ❑ Tight Tank 4. Effluent Tee Filter present? ❑ Yes �o If yes, was it cleaned? ❑ Yes D–Na- 5. Condition of System: 6. System Pumped By: Neil Bateson Name Bateson Enterprises Inc Company 7. Location where contents were disposed: G.L.S. , L,swell Waste Water F5821 Vehicle License Number Date v System Pumping Record • Page 1 of 1 Commonwealth of Massachusetts City/Town of RECEIVE( System Pumping Record p+ Form 4 APR 2 8 2008 DEP has provided this form for use by local Boards of Health. Other fo s rpay,^j�RT ArvpaO 8 R information must be substantially the same as that provided here. Before using Is orm, la 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. B. Pumping Record 4 r �� J l 1. Date of Pumping Date 2. Quantity Pumped: 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. ConditionSystem:— � U 6. SysterrtPur�tp�c�.By:� Name.. � Vehicle License Number Company 7. 0 Date �i W t5form4.doc- 06103 System Pumping Record • Page 1 of 1 A. Facility Information Important: When filling out forms on the 1. SyStm Location: computer, use only the tab key to move your Address -� cursor- do not use the return Gity/Town State Zip Code key. 2. System Owner: Coco Name Address (if different from location) ISI City/Town State Zip Codi Telephone Number B. Pumping Record 4 r �� J l 1. Date of Pumping Date 2. Quantity Pumped: 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. ConditionSystem:— � U 6. SysterrtPur�tp�c�.By:� Name.. � Vehicle License Number Company 7. 0 Date �i W t5form4.doc- 06103 System Pumping Record • Page 1 of 1