HomeMy WebLinkAboutMiscellaneous - 21 EASY STREET 4/30/2018 (2)CV)
U)
Commonwealth of Massachusetts RBCW—
City/Town of JUN " «jZ
System Pumping Record
411 Form 4
TOWN OF NORTH ANDOVER
HEALTH DEPARTMENT
DEP has provided this form for use by local Boards of Health. Other forms may be used, but the
information must be substantially the same as that provided here. Before using this form, check with your
local Board of Health to determine the form they use. The System Pumping Record must be submitted to
the local Board of Health or other approving authority.
A. Facility Information
1. System Location: Left / Right front of house, Left / Right rear of house, Left / right side of house, Left /
Right side of building, Left / Right front of building, Left / Right rear of building, Under deck
t5form4.doc• 06/03 System Pumping Record • Page 1 of 1
Address
City/Town
State
Zip Code
2.
System Owner.
Name J
Address (if different from location)
City/Town
State
Zip Code
a/1
Telephone Number
B. Pumping Record
a�� l °2
1b�
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 No
If yes, was it cleaned? ❑ Yes ❑ No
5.
Condition of System:
6.
System Pumped By:
Neil Bateson
F5821
Name
Vehicle License Number
Bateson Enterprises Inc
Company
7.
Location where contents were disposed:
. S. Lowell Waste Water
Signkufe cj-Ha-ulerf I
Date
t5form4.doc• 06/03 System Pumping Record • Page 1 of 1
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 Rigigightf�r�onbof
s , Left / Right rear of house, Left / right side of house, Left /
Right side of building, Left building, Left / Right rear of building, Under deck
Address
City/rown State
2. System Owner.
OQ�+ �b S
Name
Address (if different from location)
City/Town
B. Pumping Record
1. Date of Pumping
3. Type of system: ❑
Zip Code
}
State
Telephone Number
Date 2. Qua. tity Pumped:
Gallons
Cesspool(s) ;--SeptiucaTank ❑ Tight Tank
❑ Other (describe):
4. Effluent Tee Filter present? ❑ Yes No
5. Conditio�stem:
v
6. System Pumped By:
Neil Bateson
Name
Bateson Enterprises Inc-
Company
nc
Company
If yes, was it cleaned? ❑ Yes ❑ No.
7. Location where contents were disposed:
F5821
Vehicle License Number
System Pumping Record • Page 1 of 1
� S�.�zc�n'i�s •
�.
Year IIIIII�l�
r �
COPY
PUBLIC HEALTH DEPARTMENT
Town of North Andover
Community Development Division
CERTIFICATE OF.
COMPLIANCE
As of: 9/6/13
This is to certify that the individual subsurface disposal system received a
SATISFACTORY INSPECTION of the:
Repair of D -box and Tee
By: Todd Bateson
At:
21 Easy Street
Map 038 Lot 01.66
North Andover, MA 01845
The IssupWe of this gextificate shall not be construed as a guarantee that the system will function satisfactorily.
Public Health Agent
1600 Osgood Street, North Andover, Massachusetts 01845
Phone 978.688.9540 Fax 978.688.8476 Web www.townofnorthandover.com
North Andover Health Department
(ommunity Development Division
ONSITE WASTEWATER SYSTEM CONSTRUCTION NOTES
LOCATION INFORMATION
ADDRESS: 21 Easy Street MAP: 038 LOT: 0166
INSTALLER: Todd Bateson
DESIGNER:
PLAN DATE:
BOH APPROVAL DATE ON PLAN:
INSPECTIONS
DBox and Tee: 9/5/13
TANK INSPECTION:
DATE OF BED BOTTOM INSPECTION:
DATE OF FINAL CONSTRUCTION
INSPECTION:
DATE OF FINAL GRADE INSPECTION:
SITE CONDITIONS
❑
Contractor r orts any changes to design plan
❑
Existing septi tank properly abandoned
❑Internal
plumbi g all to one building sewer
❑
Topography not ppreciably altered
Comments:
SEPTIC TANK
❑
Buildin sewer in continuous grade, on
compact d firm base
❑
Cleanouts er plan
❑
Bottom of t k hole has 6" stone base
❑
Weep holep gged
E]1500
gallon to has been installed
H-10 loading
E]
Monolithictankco s uction
❑
Water tightness of tank has been achieved by
visual testing
❑ Inlet tee installed, centered under access port
❑ Outlet tee installed, centered under access port
(gas baffle/effluent filter)
❑ inch cover to within 6" of finish grade
installed over one access port
❑ Hydraulic cement around inlet & outlet
Comments:
PUMP CHAMBER
❑ B om of tank hole has 6" stone base
❑ Wee ole plugged
❑ 1500 g lion Pump Chamber installed
❑ H-10loa 'ng
❑ Monolithic ank construction
❑ Inlet tee in ailed, centered under access port
❑ Pump(s) ins lied on stable base
❑ Alarm float w rking
❑ Pump On/Off f ats working
❑ Separate on/off oats
❑ Drain hole in pres re line
❑ cover at fina rade installed over pump
access port `
❑ Water tightness of tank has been achieved by
testing
❑ Hydraulic cement around inlet & outlet
Comments:
CONTROL PANEL
❑ Alarm ump are on separate circuits
❑ Alarm so ds when float is tripped
❑ Location of ontrol panel: basement
❑ Alarm signal Gated inside: basement
Comments:
DISTRIBUTION -BOX
Installed on stable stone base
H-20 D -Box
Inlet tee (if pumped or >0.08'/foot)
Hydraulic cement around inlet & outlets
Observed even distribution
Speed levelers provided (not required)
Comments:
13
• .�°`7
Commonwealth of Massachusetts Map -Block -Lot
038.00166
--------------------
BOARD OF HEALTH
Permit No
North Andover BHP -2013-0880
P.I.
FEE
F.I. $125.00
-----------------------
DISPOSAL WORKS CONSTRUCTION PERMIT
Permission is hereby granted Todd Ba-teson--
------------------------------------------------------------------------------------------------
to (Repair) an Individual Sewage Disposal System. TL� C4-.1 & 0
at No - 2_1 --
EASY STREET
--------------------------- -
as shown on the application for Disposal Works Construction Permit No. BHP -2013-088 ed Aug t__ ___2_013 -----
= -----�---
Issued On: Aug -29-2013 BOARD OF HEALTH
----------------------------------------------------------------------------------
Commonwealth of Massachusetts
Map -Block -Lot
038.00166
BOARD OF HEALTH
---------------------
Permit No
North Andover
BHP -2013-0880
---------------------
FEE
$125.00
DISPOSAL WORKS CONSTRUCTION PERMIT
Permission is hereby granted Todd Bateson -------------------------------------------------
to
_--_-__--_---------------------------------to (Repair) an Individual Sewage Disposal System. -L) 1JlJx C -TOL
at No 21 EASY STREET
as shown on the application for Disposal Works Construction Permit No. BHP -2013-088 Dated August 29, 2013
----------------------------------------------
Issued On: Aug -29-2013
-----------------------------------------------------------------------------
BOARD OF HEALTH
`10f `NUORTH 1y_ _ / a
09
: Town of North Andover
HEALTH DEPARTMENT
,SSACNUstt
CHECK #. DATE: _ f
LOCATION:
H/ O NAME:
CONTRACTOR NAME:
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) $ r
❑ Septic Disposal Works Installers (DWI) $
❑ Title 5 Inspector $
❑ Title 5 Report $
❑ Other. (Indicate) $.
Health Agent Initials ;
White - Applicant Yellow - Health Pink - Treasurer
W.
m Application for Septic Disposal System
-, TODAY'S DATE
Construction Permit —TOWN OF
NORTH ANDOVER, MA 01845 $ 25 00 - comRepair
Important: Application is hereby made for a permit to:
When filling out ❑ Construct a new onsite sewage disposal system*
forms on the
computer, use ❑ Re -or replace an existing onsite sewage disposal system*
only the tab key
to move your epair or replace an existing system component -What.?
cursor - do not
use the return A. Facility Information
key. 01 -S - - -
Address or Lot # I RECEiym
CitylTown V�
' 2.- *TYPE OF SEPTI YSTEW:
➢ ❑ Pump ravity (choose one)
***If pump sy ttach copy of electrical permit to application***
➢ Conventional System (pipe and stone system)
➢ ❑ Infiltrator or Biddiffuser (Gravel -Less) (Attach a copy of your certification to install_ this type of system.)
➢ ❑ Pressure Distribution S.A.S. (No D -Box)
➢ ❑ Pressure Dosed (D -Box Present) S.A.S.
➢ ❑ Does the system require an effluent filter? Yes No
If yes, does plan specify make and model of filter? YES = (no further info. needed)
NO = (installer must specify brand of filter before DWC issuance)
What is the Make? What is the Model.
2. Owner Information
Name
Address (if different from above)
City/Town State Zip Code
a-ss��
Telephone Number
3. Installer Information
BAMi1n1 ENTERPRISES,
Name Name of Company 111 ARGIU A ROAD .
I 14t- ; ( (n4 AWOVEM olm
Address
4
City/Town State ^- Zip Cod
Telephone Number (Cell Phone # if possible please)
4. Desictner Information
Name Name of Company
Address
City/Town
State Zip Code
Telephone Number (Best # to Reach)
Application for Disposal System Construction Permit • Page 1 of 2
�^ Application for Septic Disposal System
TODAY'S DATE
Construction Permit -TOWN OF
NORTH ANDOVER, MA 01845 $ 250.00 - Full Repair
$125.00 - Component
PAGE 2OF2
A. Facility Information continued....
5. Type of Building: Residential Dwelling or Commercial
B. Agreement
The undersigned agrees to ensure the construction and maintenance of the afore -described
on-site sewage disposal system in accordance with the provisions of Title 5 of the
Environmental Code, as well as the Local Subsurface Disposal Regulations for the Town of
North Andover. l understand that until a final Certificate of Compliance has been issued by
this Boar Health, the installed system is not approved.
Name Date
Application,proved By: (B -'"id of Health Representative)
f—����
Name Date
Ap cation Disapproved for the following reasons:
For Office Use Only:
1.
Fee Attached?
Yes
No
2.
Project Manager Obligation Form Attached.
Yes
No
3.
Pump S sv tem? Ifso, Attach copy ofElectrical Permit
Yes
No
4.
Reviewed approval letter, all paperwork received.
Yes
No
MISSIng:'
5. Foundation As -Built. (new construction only):
(Same scale as approved plan)
Yes_ No
6. Floor Plans? (new construction only): Yes No
Application for Disposal System Construction Permit - Page 2 of 2
SEP'T'IC S .$TF,M.�IN$T- A�EjK'PRGJE� NAGEMEN'Y' OBLIGATIONS
As the North Andovtr.liccnsetl installer foot constructionforthe septic systetu•for.the---property at:
For plans by
(Ad*6i of septic system) (Engineer)
Relative to the.application of %>-�, ' 'Q 5d``✓
(i'n'stallers name) And dated
ngina date).
.
Dated ' S ---n_(-3
o a s ate)
With revisions dated
(Last revised date)
I understand the following obligations for management of -this project:
1. As the installer, I am .obligated to obtain. an permits and Board of Health approved plans l to
er
;pO=Liag any work on a site. I.must have the ap vec�plans and the hermit. on site when any work is
..
b.n
2. As the ing4er,.I mu'st.-call -for, any and ail'inspt't'tions. If homeowner, contractor, ,project manager, or any
schedules -in inspection and the system is not ready, then
other person not associated with my company
item three. shail.b4. appjicablo.
As •tli4 rtstahtr, f atn•xequarcd to. have .tine ttecrssaty work -compieted-p#oi to the :applicable inspections as
indicated below- T.t j ft o_ fs:.n -chit ,.pr; e� p pn, ..moi g,,t �' pletion: of the -items in. accordanei
J1=511\b f.S1R4 =
4.
a, . Bo'ttoYri df.ed. generally, tliis is the fixs:.(1 `j; in'speotton tYnless, there is a retaining wall, which
should•be driie<l"trst: Thenstallniusttcqust dit iispectio�l but cloesnot have to be present .
b. Fina. CnRtfijct'opch'ori — En$aeer rd!ius't first do then r nsect<on for elevations; trek, etc.
As-hiiilt of verbal OK'(or e-mail•to: fieaitlid�nto 0 otlhandober.00mL from the engineer must
be stibniitEed•to'.the.Board-ofHealth,, aftetwliieliinstaller.cails for. -an inspection time. 'Installer must
be present for t4b.inspecti6p, Vi ith a put%p 'ad', ail elecCrical work must:be ready and• able to
cause;pump.to arork aiid:alartn'.to function..
c. :Fin : `Gt�ade Thstaller must request'inspection tvheii' 11 grading is complete...Installer'does not
have to be •on=site. '
As -the installer,' I =iersiand that only I -Vinay perform the .work (other than iixple excavation) and'I am required
to complete the-installatibn of the system identified in the atiaached application for installation.' ' ie
5.. ,As the.instiller,1 understand
6.
of the following construction.
steps:..
x Detem adorn that.the proper efewdon of the excaradon has beer reached -
A Inspection ofthe'saad and a64e -to be used.
c. Prna1 inspectroa by Boa& of�Ierilth staffor consultant.
d. Installadon..oftank D Boxy prpes, stone, vent, primp chamber, retariirrg walland other
COM
ponents.
Undersigned Uceased Scptic.Inatallex: p� _ (Today's I) ate)
� Of MORiN 1
e,z•tia
of Permit or License: (Check box)
9
Town of North Andover
`,�'•� ;'i
,SSACHUst�
HEALTH DEPARTMENT
CHECK#:
n
r p CD lea
I 1 UDATE: h
LOCATION:
H/O NAME
CONTRACT
6572
Type
of Permit or License: (Check box)
❑
Animal
$
❑
Body Art Establishment
$
❑
Body Art Practitioner
$
❑
Dumpster
$
❑
Food Service - Type:
$
❑
Funeral Directors
$
❑
Massage Establishment
$
❑
Massage Practice
$
❑
Offal (Septic) Hauler
$
❑
Recreational Camp
$
❑
Sun tanning
$
❑
Swimming Pool
$
❑
Tobacco
$
❑
Trash/Solid Waste Hauler
$
❑
Well Construction
$
SEPTIC Systems:
❑ Septic - Soil Testing $
❑ Septic -Design Approval $
❑ Septic Disposal Works Construction (DWC) $
❑ Septic Disposal Works Installers (DWI) $
❑ Title 5 Inspector $
Title 5 Report x �*'x $]K!O
❑ Other. (Indicate) $
Health A ent Initials
White - Applicant Yellow - Health Pink - Treasurer
Owner
information is
required for
every page.
Important:
When filling out
forms on the
computer, use
only the tab key
to move your
cursor - do not
use the return
key.
ISI
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Asses:
21 Easy Street
Property Address
Debbie Williams
Owner's Name
North Andover
Citylrown
MA 01845
State Zip Code
RECEIVED
Dn
AUG 26 2013
TOWN OF NORTH F i &
HEALTH DEPP.I? s f 1 ' .
8/20/2013
Date of Inspection
Inspection results must be submitted on this form. Inspection forms may not be altered in any
way. Please see completeness checklist at the end of the form.
A. General Information
1. Inspector:
Neil J. Bateson
Name of Inspector
Bateson Enterprises Inc.
Company Name
111 Argilla Road
Company Address
Andover MA 01810
City/Town
978-475-4786
Telephone Number
B. Certification
State
S115
License Number
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
❑ Need§k Further Evaluation by the Local Approving Authority
c
8/20/2013
Insa ors ignature Date
The system inspector shall submit a copy of this inspection report to the Approving Authority (Board
of Health or DEP) within 30 days of completing this inspection. If the system is a shared system or
has a design flow of 10,000 gpd or greater, the inspector and the system owner shall submit the
report to the appropriate regional office of the DEP. The original should be sent to the system owner
and copies sent to the buyer, if applicable, and the approving authority.
""This report only describes conditions at the time of inspection and under the conditions of use
at that time. This inspection does not address how the system will perform in the future under
the same or different conditions of use.
t5ins • 3/13 Title 5 official Inspection form: Subsurface Sewage Disposal System • Page 1 of 17
Owner
information is
required for
every page.
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
21 Easy Street
Property Address
Debbie Williams
Owner's Name
North Andover MA 01845 8/20/2013
Cityrrown State Zip Code Date of Inspection
B. Certification (cont.)
Inspection Summary: Check A,B,C,D or E / always complete all of Section D
A) System Passes:
❑ I have not found any information which indicates that any of the failure criteria described
in 310 CMR 15.303 or in 310 CMR 15.304 exist. Any failure criteria not evaluated are
indicated below.
Comments:
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 • 3113 Title 5 Official Inspection Form: Subsurface Sewage Disposal System • Page 2 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 Easy Street
Property Address
Debbie Williams
Owners Name
North Andover MA 01845 8/20/2013
City/rown State Zip Code Date of Inspection
B. Certification (cont.)
❑ Pump Chamber pumps/alarms not operational. System will pass with Board of Health approval if
pumps/alarms are repaired.
B) System Conditionally Passes (cont.):
❑ Observation of sewage backup or break out or high static water level in the distribution box due
to broken or obstructed pipe(s) or due to a broken, settled or uneven distribution box. System will
pass inspection if (with approval of Board of Health):
❑ broken pipe(s) are replaced
❑ obstruction is removed
❑ distribution box is leveled or replaced
❑ Y ® N ❑ ND (Explain below):
❑ Y ® N ❑ ND (Explain below):
❑ Y ® N ❑ ND (Explain below):
❑ The system required pumping more than 4 times a year due to broken or obstructed pipe(s). The
system will pass inspection if (with approval of the Board of Health):
❑ broken pipe(s) are replaced ❑ Y ® N ❑ ND (Explain below):
❑ obstruction is removed
❑ Y ® N ❑ ND (Explain below):
C) Further Evaluation is Required by the Board of Health:
❑ Conditions exist which require further evaluation by the Board of Health in order to determine if
the system is failing to protect public health, safety or the environment.
1. System will pass unless Board of Health determines in accordance with 310 CMR
15.303(1)(b) that the system is not functioning in a manner which will protect public health,
safety and the environment:
❑ Cesspool or privy is within 50 feet of a surface water
❑ Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh
t5ins • 3113 Title 5 Official Inspection Forth: 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 Easy Street
Property Address
Debbie Williams
Owner's Name
North Andover MA 01845 8/20/2013
City/Town 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 fecal
coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal
to or less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis must
be attached to this form.
3. Other:
Outlet tee in septic tank & d -box needs to be replaced.
D) System Failure Criteria Applicable to All Systems:
You must indicate "Yes" or "No" to each of the following for all inspections:
Yes
No
❑
®
Backup of sewage into facility or system component due to overloaded or
clogged SAS or cesspool
❑
®
Discharge or ponding of effluent to the surface of the ground or surface waters
due to an overloaded or clogged SAS or cesspool
❑
®
Static liquid level in the distribution box above outlet invert due to an overloaded
or clogged SAS or cesspool
❑
®
Liquid depth in cesspool is less than 6" below invert or available volume is less
than % day flow
t5ins • 3113
Title 5 Official Inspection Form: Subsurface Sewage Disposal System •Page 4 of 17
Commonwealth of Massachusetts
Title 5
Official Inspection Form
a Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
21 Easy Street
Property Address
Debbie Williams
Owner Owner's Name
information is
required for North Andover
MA 01845 8/20/2013
every page. Cityrrown
State Zip Code Date of Inspection
B. Certification (cont.)
Yes
No
❑
® Required pumping more than 4 times in the last year NOT due to clogged or
obstructed pipe(s). Number of times pumped:
❑
® Any portion of the SAS, cesspool or privy is below high ground water elevation.
❑
® Any portion of cesspool or privy is within 100 feet of a surface water supply or
tributary to a surface water supply.
❑
® Any portion of a cesspool or privy is within a Zone 1 of a public well.
❑
® Any portion of a cesspool or privy is within 50 feet of a private water supply
well.
❑
® Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet
from a private water supply well with no acceptable water quality analysis. (This
system passes if the well water analysis, performed at a DEP certified
laboratory, for fecal coliform bacteria indicates absent and the presence
of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm,
provided that no other failure criteria are triggered. A copy of the analysis
and chain of custody must be attached to this form.]
❑ ® The system is a cesspool serving a facility with a design flow of 2000gpd-
10,000gpd.
❑ ® The system fails. I have determined that one or more of the above failure
criteria exist as described in 310 CMR 15.303, therefore the system fails. The
system owner should contact the Board of Health to determine what will be
necessary to correct the failure.
E) Large Systems: To be considered a large system the system must serve a facility with a
design flow of 10,000 gpd to 15,000 gpd.
For large systems, you must indicate either "yes" or "no" to each of the following, in addition to the
questions in Section D.
Yes No
❑ ❑ the system is within 400 feet of a surface drinking water supply
❑ ❑ the system is within 200 feet of a tributary to a surface drinking water supply
❑ ❑ the system is located in a nitrogen sensitive area (Interim Wellhead Protection
Area — IWPA) or a mapped Zone II of a public water supply well
If you have answered "yes" to any question in Section E the system is considered a significant threat,
or answered "yes" in Section D above the large system has failed. The owner or operator of any large
system considered a significant threat under Section E or failed under Section D shall upgrade the
system in accordance with 310 CMR 15.304. The system owner should contact the appropriate
regional office of the Department.
t5ins • 3/13 Title 5 Official Inspection Fonn: Subsurface Sewage Disposal System - Page 5 of 17
Commonwealth of Massachusetts
I I uvTitle 5 Official Inspection Form
�. Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
21 Easy Street
Property Address
Debbie Williams
Owner Owner's Name
information is
required for North Andover MA 01845 8/20/2013
every page. Cityrrown State Zip Code Date of Inspection
C. Checklist
Check if the following have been done. You must indicate "yes" or "no" as to each of the following:
Yes No
®
❑
Pumping information was provided by the owner, occupant, or Board of Health
❑
®
Were any of the system components pumped out in the previous two weeks?
®
❑
Has the system received normal flows in the previous two week period?
❑
®
Have large volumes of water been introduced to the system recently or as part of
The size and location of the Soil Absorption System (SAS) on the site has
this inspection?
®
❑
Were as built plans of the system obtained and examined? (If they were not
® ❑
Determined in the field (if any of the failure criteria related to Part C is at issue
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): 4 Number of bedrooms (actual): 4
DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x # of bedrooms): 600
t5ins • 3/13 Title 5 Official Inspection Form: Subsurface Sewage Disposal System •Page 6 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
21 Easy Street
Property Address
Debbie Williams
Owner
information is
required for
every page.
Owner's Name
North Andover
Cityrrown
D. System Information
Description:
Number of current residents:
MA 01845 8/20/2013
State Zip Code Date of Inspection
Does residence have a garbage grinder?
Is laundry on a separate sewage system? (Include laundry system inspection
information in this report.)
Laundry system inspected?
Seasonal use?
Water meter readings, if available (last 2 years usage (gpd)):
Detail:
Sump pump?
Last date of occupancy:
Commerciallindustrial 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:
❑
Yes ®
No
❑
Yes ®
No
❑
Yes ❑
No
❑
Yes ®
No
Yes
❑ Yes ® No
Current
Date
Gallons per day (gpd)
❑ Yes ❑ No
❑ Yes ❑ No
❑ Yes ❑ No
t5ins • 3/13 Title 5 Official Inspection Form: Subsurface Sewage Disposal System •Page 7 of 17
Commonwealth of Massachusetts
lrTithe 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
� 21 Easy Street
Property Address
Debbie Williams
Owner Owner's Name
information is
required for North Andover
every page. Cityfrown
D. System Information (cont.)
Last date of occupancy/use:
Other (describe below):
Pumping Records:
Source of information:
MA 01845
State Zip Code
General Information
Was system pumped as part of the inspection?
If yes, volume pumped:
How was quantity pumped determined?
Date
8/20/2013
Date of Inspection
Pumped last May, owner
gallons
LE U 110,
Reason for pumping:
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 - 3113 Title 5 ficial Inspection Form: Subsurface Sewage Disposal System - Page 8 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 Easy Street
Property Address
Debbie Williams
Owner's Name
North Andover
Cityrrown
D. System Information (cont.)
State
01845
Zip Code
8/20/2013
Date of Inspection
Approximate age of all components, date installed (if known) and source of information:
29 years old, 10/1/1984, as built plan
Were sewage odors detected when arriving at the site? ❑ Yes ® No
Building Sewer (locate on site plan):
Depth below grade: 1.8
feet
Material of construction:
® cast iron ® 40 PVC ❑ other (explain):
Distance from private water supply well or suction line: feet
Comments (on condition of joints, venting, evidence of leakage, etc.):
4" Cast iron through wall, 3" PVC in house, no leaks visible
Septic Tank (locate on site plan):
Depth below grade:
Material of construction:
® concrete ❑ metal
.8
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:
1"
❑ Yes ❑ No
t5ins • 3113 Title 5 Official Inspection Form: Subsurface Sewage Disposal System - Page 9 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
M . ' 21 Easy Street
Owner
information is
required for
every page.
t5ins • 3113
Property Address
Debbie Williams
Owner's Name
North Andover
City/Town
D. System Information (cont.)
Septic Tank (cont.)
MA 01845
state Zip Code
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
8/20/2013
Date of Inspection
N/A
3"
N/A = Outlet tee off
N/A
How were dimensions determined? Tape Measure
Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity,
liquid levels as related to outlet invert, evidence of leakage, etc.):
Inlet tee ok. Outlet tee corroded off, needs to be replaced. Liquid level at outlet invert. No
evidence of leakage.
Grease Trap (locate on site plan):
Depth below grade:
Material of construction:
❑ concrete ❑ metal
Dimensions:
Scum thickness
❑ fiberglass
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:
feet
❑ polyethylene ❑ other (explain):
Date
Title 5 official Inspection Form: Subsurface Sewage Disposal System • Page 10 of 17
�� �.�nnn�itwGaiui �� maaaawiva��w
Title 5 Official inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
21 Easy Street
Owner
information is
required for
every page.
Property Address
Debbie Williams
Owner's Name
North Andover MA 01845 8/20/2013
Cityrrown State Zip Code Date of Inspection
D. System Information (cont.)
Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity,
liquid levels as related to outlet invert, evidence of leakage, etc.):
Tight or Holding Tank (tank must be pumped at time of inspection) (locate on site plan):
Depth below grade:
Material of construction:
❑ concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other (explain):
Dimensions:
Capacity:
Design Flow:
Alarm present:
Alarm level:
gallons
gallons per day
❑ Yes ❑ No
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 - 3/13 Title 5 official Inspection Form: Subsurface Sewage Disposal System - Page 11 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 Easy Street
Property Address
Debbie Williams
Owner's Name
North Andover
Cityfrown
D. System Information (cont.)
MA 01845 8/20/2013
State Zip Code Date of Inspection
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, any
evidence of leakage into or out of box, etc.):
D -box level and distribution not equal. Evidence of leakage, liquid below outlets. Corrosion
holes at water level. Evidence of carrvover.
Pump Chamber (locate on site plan):
Pumps in working order:
❑
Yes
❑
No*
Alarms in working order:
❑
Yes
❑
No*
Comments (note condition of pump chamber, condition of pumps and appurtenances, etc.):
* If pumps or alarms are not in working order, system is a conditional pass.
Soil Absorption System (SAS) (locate on site plan, excavation not required):
If SAS not located, explain why:
t5ins • 3/13 Title 5 official Inspection Form: Subsurface Sewage Disposal System • Page 12 of 17
Owner
information is
required for
every page.
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Forth - Not for Voluntary Assessments
21 Easy Street
Property Address
Debbie Williams
Owner's Name
North Andover MA 01845 8/20/2013
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:
®
leaching fields
number, dimensions:
❑
overflow cesspool
number:
❑
innovative/alternative system
30'x 34'
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 • 3/13 Title 5 Official Inspection Form: Subsurface Sewage Disposal System • Page 13 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 Easy Street
Property Address
Debbie Williams
Owner's Name
North Andover MA 01845 8/20/2013
Citylrown 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 - 3/13 Title 5 official Inspection Form: Subsurface Sewage Disposal System • Page 14 of 17
Owner
information is
required for
every page.
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
21 Easy Street
Property Address
Debbie Williams
Owner's Name
North Andover MA 01845 8/20/2013
City/Town 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
u�a�e�r
M+z�cs
�t
rtav,1ti. a
tp,
t5ins • 3113 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
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
21 Easy Street
Property Address
Debbie Williams
Owners Name
North Andover
Cityrrown
D. System Information (cont.)
Site Exam:
®
Check Slope
®
Surface water
®
Check cellar
®
Shallow wells
Estimated depth to high ground water:
MA 01845
State Zip Code
>4
feet
8/20/2013
Date of Inspection
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: 3/21/1981
Date
❑ Observed site (abutting property/observation hole within 150 feet of SAS)
® Checked with local Board of Health - explain:
Design plan
❑ Checked with local excavators, installers - (attach documentation)
❑ Accessed USGS database - explain:
You must describe how you established the high ground water elevation:
Test pit data on design plan shows water @ 5'6"
Before filing this Inspection Report, please see Report Completeness Checklist on next page.
t5ins • 3113 Title 5 Official Inspection Form: Subsurface Sewage Disposal System • Page 16 of 17
Commonwealth of Massachusetts
• Tu,p
itle 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
21 Easy Street
Property Address
Debbie Williams
Owner
information is
required for
every page.
Owner's Name
North Andover
Cityfrown
State
01845
Zip Code
8/20/2013
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 - 3/13 Title 5 Official Inspection Form: Subsurface Sewage Disposal System •Page 17 of 17
Summary Record Card generated on 80/2013 2:54:04 PM by Karen Hanlon Page 1
Town of North Andover
Tax Map # 210-038.0-0166-0000.0
Parcel Id 12955
21 EASY STREET
WILLIAMS, CRAIG
21 EASY STREET
N. ANDOVER, MA
01845
Class 101 Single Family Property Type 1 Residential
Zoning2 1 Residential Zoning3 1 Residential
Size Total 1.09 Acres
FY 2014
UB Mailina Index
Name/Address
WILLIAMS, CRAIG
21 EASY STREET
N. ANDOVER, MA
01845
UB Account Maint.
Account No Cycle
Bldg Id. 13998.0 - 21 EASY STREET
2100538 02 Cycle 02
UB Services Maint.
Account No. 2100538
Service Code
MISCFEE ADMIN FEE
WTR WATER
UB Meter Maintenance
Type Loan Number Active/Inact. From
Payor
Occupant Name Active/Inactive
Last Billing Date 6/10/2013
Active
Rate Charge Multiplier/Users
0.635/8 7.82 11
01 ALL METER SIZE /1
Account No. 2100538
Type Size
YTD Cons
Serial No Status
w Water 0.63 0.63
Location
44103824 a Active
Posted Date
ERT F. R.
Date
Reading
Code
5/2/2013
2
a Actual
2/6/2013
2
a Actual
10/31/2012
1
a Actual
9/12/2012
0
n New Meter
9/12/2012
5430
r Replacement
5/4/2012
5328
m Manual estimate
2/7/2012
5318
m Manual estimate
11/2/2011
5308
m Manual estimate
8/4/2011
5288
m Manual estimate
MSG
3/15/2011
-79%0
5/4/2011
5228
a Actual
2/3/2011
5222
m Manual estimate
MSG SNOW
6/9/2010
26%
11/1/2010
5217
a Actual
8/5/2010
5195
a Actual
5/5/2010
5137
a Actual
2/3/2010
5132
a Actual
11/3/2009
5128
a Actual
8/5/2009
5111
a Actual
5/6/2009
5088
a Actual
2/4/2009
5086
m Manual estimate
MSG
3/14/2008
-83%
11/4/2008
5081
aActual
8/5/2008
5072
a Actual
5/6/2008
5038
a Actual
2/4/2008
5030
a Actual
11/5/2007
5028
a Actual
8/6/2007
5016
a Actual
5/7/2007
4990
a Actual
Until
Brand
Type Size
YTD Cons
b Badger
w Water 0.63 0.63
104
Consumption
Posted Date
Variance
0
6/18/2013
-100%
1
3/13/2013
-50%
1
12/13/2012
-100%
0
9/26/2012
-100%
102
9/26/2012
577%
10
6/20/2012
0%
10
3/14/2012
-54%
20
12/15/2011
-66%
60
9/14/2011
878%
6
6/13/2011
25%
5
3/15/2011
-79%0
22
12/13/2010
-60%
58
9/13/2010
1047%
5
6/9/2010
26%
4
3/11/2010
-77%a
17
12/11/2009
-25%
23
9/11/2009
1050%
2
6/16/2009
-60%
5
3/16/2009
-45%
9
12/10/2008
-74%a
34
9/12/2008
330%
8
6/18/2008
296%
2
3/14/2008
-83%
12
1/15/2008
-54%
26
9/14/2007
1843%
1
6/22/2007
-75%
Board of Haalth = .
North An ver Haas•
OVED DATg
F
162-
i
SEPTIC STSTEH Mlam`/ 2 . 51-
INSTALLATICK CHECK LIST LOT"
AVATICH Ob FAIL
1. Distance Tot
a. Wetlands
b. Drains
c.. Well
2. Water Line Location
3. No PVC Pipe
%. Septic Tank
a. _Tees -_Length & To Clean Oat Covers
b. Cement Pipe to Tank On Both Sides of Tank
5. Distribution Box
a. Covers & Box - No Cracks
b. All Lines Flo-.ing Equal Amounts
c. No Back Flow
6.. Leach Field or Trench
a. Dimensions
b. Stone Depth
c: Capped lads
d. Clean Double- Washed -Stone'
7. Leach Pits
a. Dimensions
b. Stone Depth
c. Splash Pads
d. Teas
e. Cement Pipe to Pit - Both Sides
f. Clean Double Washed Stone
8. No Garbage Disposal
9. -Final Grading Inspection
10. Barricading Covered System
11. As Built Submitted
a. Lot Location
b. Dimensions of System
c. Location with Regard -to Pere Test
d. Elevations
e. Water Table
y'
Board of -Tran Ch
&GyV�%%/'
t�OT'h %FIS: c'T`1i�3,8$ •
SL1B ''ACE DISPOSAL DWIGN CHECK LIST
LOT
APPROTO DATE DISAPFROPED DAIS
Provided: Reasons:
t ���
t
Tide F
__._� '•F
Reg 2.5
a submitted plan must Shaw as a minimum:
the lot to be served -arca, dimensions lot #,abutters
location and log deep observation hoes -distance to ties
location and results percolation tests -distance to ties
design calculations do calculations showing required leaching area
location and dimensions of system -including eeserve area
f
existing and proposed contours
g) location any wet areas Athin 1001 of sewage disposal system or
disclaimer -check wetlands mapping
face and subsurface drains within 100' of sewage disposal
system or disclaimer
Iv i location srgy drriaaage ex.ser tints within 1001 of serge disposal
system or disclaimer -Planning Board files
(j) M sources of inter supply within 2001 of ' sewage disposal
system or disclaimer
(k) location of arq 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 PVC 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
Mer elevations _
(r) maAmam ground water elevation in area sewage disposal system
(s) plan mast be prepared by a Professional Engineer or other
professional authorized by law to prepare such plans
Reg 6 otic Tanks
(a) capacities -150s of flow, water table, tees, depth of tees,
f access, pumping
(b) cleanout
. (c) 101 from cellar val1 or inground swimming pool
(d) �5, from subsurface drains_
Reg 10.2 Distribution Boxes
I(a) slope greater than 0.08
Reg 10.4 b) sump
Subsurface boiij Check Liat Pz 3 2
Reg 15.1
15.4
15.8
3.7
Reg 14.1
14.3
14.6 14
14.7
14.10
Reg 9.1
9.6
FAIL
4g
1
1
1
Leaching Pits
Leaching pits are preferred where the installation is possible
a) calculations of leaching area-vinimm 500 eq ft
b) spacing
c •surface drainage 2.1
d corer material
e) 2' x2 t x4" splash pad
f) tea at elbow
;) no bends in pipe from d -box to pipe
Leaching Fields
a) no greater than 20 minutes/inch
area -minimum 900 sq ft
construction of field
3) surface drainage 2 %
B) 201 from cellar wall or inground and mmdng pool
Leachin Trenches 0—calculations of leaching area -min 500 sq ft
s) spacing -4 ft min 6 ft with reserve between
:) dimensions
1) construction
3) stone
P) surface drainage 2%
Dounhi.11 Slop e
L) ss o e -yTx —='M be shown)
)) y/x x 150 =• (to be shown)
EMS
L) approval
)) stand-by power
El
J
ki
OPT-if
f
a ,
'
stt3sn�'a
IAIVER,r Ed
DIV
3 out-
x
y,
ox oKt
� 8
JCn..r IJAiC
7s.to
fAuk
TO: >.;NOR.TH ANDOVER; MASS
k0ARD 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
5 i' North Andover, Mass.
SITE LOCATION
The grades and construction are'`as specified in rplans and specifications dated
C�
Commonwealth of Massachusetts RF�`��
City/Town of l
System Pumping Record SEP 2 5 2ED
0 6
w„
. •,•-
Form 4 TOWN OF NORTH ANDOVER
HEALTIA DEr ARTMENT
DEP has provided this form for use by local Boards of Health.. The System Pumping ecord must
be submitted to the local Board of -Health or other approving authority. .
A. Facility Information
Important:
When filling out 1. System Location:
fomes on the r C
computer, use
only.the tab key Address
to move your�-
cursor - do not Cit /Town
use the: return City/Town Zip Code
key.
2, System Owner:
Name
"6fA Address (if different from location)
City. /Town State Zip Code
Telephone Number
B. Pumping Record
1. Date, of Pumping Date 2. QuantityPumped:
Gallons
3. Type of system: ❑ Cesspool(s)Septic Tank ❑ Tight Tank
❑ Other (describe):
4. Effluent Tee Filter present? ❑ Yes 2 No Ifes was i
y t cleaned? E] Yes ❑ No
5. Condition ot System:
6. System Pum e y `
Name Vehicle License Number
Company --
7. Locatio hese contents :!
isd
_�
Signatur of ul Date
h.ftp://www.mass.gqvidep/water/approvals/t5forms.htm#inspect
t5form4.doc• 06103 System Pumping Record • Page 1 of t
TOWN OF JV • 2LJj„J-eC
SYSTEM PUMPING RECORD
DATE: -Wox
SYSTEM OWNER & ADDRESS
ai 6GLS1 5+
SYSTEM LOCATION
(example: left front of house)
DATE OF PUMPING: 4 QUANTITY PUMPED: t Q6 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: (='- L— - '61 P Ir
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F0101 A - SYSTEM PUMITNG KEC01W
Cottttttonllealtlt of Alassachusetts
, Massachusetts
S'ysterrt l't[rrtp >wecvrrd
ystettt Loca
BOARD OF HEALTH
NOV 2 11995
F
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Date of Pumping i/l c 1
Cesspool: No P 1 es ❑ grntir TAnt-1 Yest�j
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System Pumped by: License
Contents transferred to: '
Date
Inspector
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Commonwealth of Massachusetts
Massachusetts
Svstem Pumping Record
System Owner
System Location
Date of Pumping: `4 , l (., Qr7 Quantity Pumped: l S� gallons
Cesspool: No 1.4 - Yes 1.1 Septic Tank: No IJ
System Pumped by: tett`edart F,.&Ol a License #
Contents transferrred to : Greater Lawrence Sanitary District
Date: Inspector:
Yes
Conor onw allh ;A).=
_
system Pumping Record
System Owner
Date of Pumping: q—(
`
Cesspool: No Yes LJ
System Location
Quaidity Pumped
Septic Tank: No U
System Pumped by: Farejea Sit Ve"eQ License #
Contents transferrred to : Greater Lawrence Sanitary District
Date: _ Inspector:
1�^�allons
Yes
TOWBODFH�°HS R
ARO /
APR 2 619N
Comm nwealth of Massachusetts
Massachusetts
System Pumping Record
System Owner
O-Av
Date of Pumping:
Cesspool: No Yes
System Location
Quantity Pumped: �� gallons
Septic Tank: No Yes 17'
System Pumped by: Fcttedart go4lhiaed License #
Contents transferrred to Greater Lawrence sanitary District
llate:
Inspector:
awl
Ir
TOWN OF NORTH ANDOVER
SYSTEM PUMPING RECORD
DATE: -] 0 ",3'O(
SYS
SYSTEM LOCATION
(example: left front of house)
OCT 2 5 2001
DATE OF PUMPING: D`3 -0 QUANTITY PUMPED 1 S&� GALLONS
CESSPOOL: NO YES SEPTIC TANK: NO YES —Z
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: l9 , Z— ` s ,
TOWN OF
SYST]
DATE: - D
SYSTEM OWNER & ADDRESS
wl�l� a�5
a l�
P PING RECORD�
E
v.
SYSTEM-LOC�!6N
(example: left front of house)
r 1, k 04-0 kd�s�
DATE OF PUMPING: � - 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