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HomeMy WebLinkAboutMiscellaneous - 21 FULLER MEADOW ROAD 4/30/2018N 'o J b 0 0 0 North Andover Board of Assessors Public Access r 4 Parcel ID: 210/104.D-0128-0000.0 Community: North Andover SKETCH Click on Sketch to Enlarge PHOTO No Picture Available Location: 21L-50 FULLER MEADOW ROAD Owner Name: JHA, SHITANSHU RITU GUPTA Owner Address: 21 FULLER MEADOW ROAD City: NORTH ANDOVER State: MA ZIP: 01845 Neighborhood: 7 - 7 Land Area: 1.62 acres Use Code: 101 - SNGL-FAM-RES Total Finished Area: 2700 sqft ASSESSMENTS CURRENT YEAR PREVIOUS YEAR Total Value: 599,500 561,200 Building Value: 381,400 359,200 Land Value: 218,100 202,000 Market Land Value: 218,100 Chapter Land Value: LATEST SALE Sale Price: 420,000 Sale Date: 06/24/1999 Arms Length Sale Code: Y -YES -VALID Grantor: PALUCH, JAMES Cert Doc: DOC 70725 Book: 00122 Page: 0361 Page 1 of 1 http://csc-ma.us/NandoverPubAcc/j sp/Home.j sp?Page=3 &LinkId=808229 6/13/2006 N N O O N N N N U c(' O 0 o U W o fli 4) d m U L) U U U) CL N w d (1) (n N c O m D. 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This does not relieve the applicant and/or landowner from compliance with any applicable local or state law, regulations or requirements. **************!* plicant fills out this section***************** APPLICANT: ' M Phone LOCATION: Assessor's Map Number Parcel Subdivision 10 / Lot(s) Street 4 (I % iozoo St. Number 1J - ************************Official Use Only************************ AGENTS: Conservation Adm'nistr/a�tolr Comments ° ( l c �faG�� N�S� Town Planner Comments Food Ins tor-Health Septic nspector-Health Comments Public Works - sewer/water connections - driveway permit Fire Department Date Approved M194 Date Rejected (Z" - w N19(e Date Approved Date Rejected Date Approved Date Rejected Date Approved 2z Date Rejected Received by Building Inspector Date -ice / - "310 CMR 10:,99 r Form 5 Jtta� r=Y Commonwealth of Massachusetts -;— F REGI iVU JOYCE BRAt� 11AW TOWN CLERK NORTH ANDOVER fEB 8 8 57 'AM '96 DEP Fite r,lo. ( 242-786 (Io Ln Lwuvx>rri by 1)EI'1 City, Town North Andover AmAcafit James -T. Paluch 21 Fuller Meadow Road, Lot Number 50 Order of Conditions Massachusetts Wetlands Protection Act G.L. c. 131, §40 and under the Town of North Andover's Bylaw Chapter 3.5 NORTH ANDOVER CONSERVATION COMMISSION James T. Paluch To (Name of Applicant) 21 Fuller Meadow Road Address North Andover MA 01845 This Order is issued and delivered as follows: James T. Paluch (Name of properly owner) 21 Fuller Meadow Road Address North Andover MA 01845 ❑ by hand delivery to applicant or representative on (date) by certified mail, return receipt requested on �d �l / �CXU (date) J ' This project is located at 21 Fuller Meadow Road The property is recorded at the Registry of Norrharn Eq -,ex Book - LC63 Page 125 Certificate (if registered) #9530 The Notice of Intent for this project was filed on December 21, 1995 (date) ' The public hearing was closed on January 24, 1996 (date) Findings The North Andover Conservation Commission has reviewed the above -r elerenced force of Intent and plans and has held a public hearing on the project. Based on the tnformalion avallaDle to the NACC at this time, the __J1ACC _ has delerrTrrned that the area on which the proposed work is to be done is significant to the following interests in accordance v.ith the Presumptions of Significa hc1�g e s ort in the regulations for each Area Subject to Proteclrori Lender the �. Recreation Act (check as appropriate): Ch. 178: Prevention of Erosion & Sedimentation Ch. 178-4 Wildlife Pubilc water supply Flood control ❑ Lnnd containing shellfish Private water supply Storm damage prevention Fisheries Ground water supply Prevention of pollution Pk Protection of wildlife habitat Total Filing Fee Submitted $105.00 State Share $40.00 _ City/Town Share ('•'_ lee in excess of S2--) Total Refund Due S City/Town Portion S State Portion S (Yz total) (Yz .total) 3 2 Li � V 9 Town of North Andover `+�'••,,,,, ..,' HEALTH DEPARTMENT ,SSAC NU`+tt CHECK #: 'DATE: 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 $ ❑ Trash/Solid Waste Hauler $ ❑ Well Construction $ SEPTIC Sys: ❑ Septic - Soil Testing $ ❑ Septic - Design Approval $ ❑ Septic Disposal Works Construction (DWC) $ ❑ Septic Disposal Works Installers (DWI) $ ❑ Titlee nspector $ aw 0 --Title 5 Report $-6-02. ❑ Other: (Indicate) $ Health Agent Initials White - Applicant Yellow - Health Pink - Treasurer ti COMMONWEALTH OF MASSACHUSETTS EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS DEPARTMENT OF ENVIRONMENTAL PROTECTION TITLE 5 OFFICIAL INSPECTION FORM — NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM PART A CERTIFICATION Property Address: 21 Fuller Meadow Road North Andover,Ma.01845 Owner's Name: Shitanshu iha Owner's Address: SAME Date of Inspection: 4 / 1 / 0 8 Name of Inspector: (please print) Brian S . Murphy Company Name:B&D Septic Inspections Mailing Address:P . O . Box 47 Hul1,,Ma_02045 Telephone Number: t.7 81 ) 2 9 0— 9 9 4 2 RECEIVE® APR 112008 TOWN OF NORTH HEALTH DEPARTMENT E CERTIFICATION STATEMENT I certify that I have personally inspected the sewage disposal system at this address and that the information reported below is true, accurate and complete as of the time of the inspection. The inspection was performed based on my training and experience in the proper function and maintenance of on site sewage disposal systems. 1 am a DEP approved system inspector pursuant to Section 15.340 of Title 5 (310 CMR 15.000). The system: X Passes _ Conditionally Passes _ Needs Further Evaluation by the Local Approving Authority Fails Inspector's Signature: L_ Date: �/Ov 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. Notes and Comments ****This report only describes conditions at the time of inspection and under the conditions of use at that time. This inspection does not address how the system will perform in the future under the same or different conditions of use. Title 5 Inspection Form 6/15/2000 page 1 COP i Page 2 of 11 OFFICIAL INSPECTION FORM — NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: 21 Fuller Meadow Rd. N.Andover,Ma. Owner: Shitanshu Jha Date of Inspection: 4/ 1 /08 Inspection Summary: Check A,B,C,D or E / ALWAYS complete all of Section D A. System Passes: X 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. Answer yes, no or not determined (Y,N,ND) in the for the following statements. If "not determined" please explain. The septic tank is metal and over 20 years old* or the septic tank (whether metal or not) is structurally unsound, exhibits substantial infiltration or exfiltration or tank failure is imminent. System will pass inspection if the existing tank is replaced with a complying septic tank as approved by the Board of Health. 'A metal septic tank will pass inspection if it is structurally sound, not leaking and if a Certificate of Compliance indicating that the tank is less than 20 years old is available. ND explain: Observation of sewage backup or break out or high static water level in the distribution box due to broken or obstructed pipe(s) or due to a broken, settled or uneven distribution box. System will pass inspection if (with approval of Board of Health): broken pipe(s) are replaced obstruction is removed distribution box is leveled or replaced ND explain: The system required pumping more than 4 times a year due to broken or obstructed pipe(s). The system will pass inspection if (with approval of the Board of Health): broken pipe(s) are replaced obstruction is removed ND explain: Page 3of11 OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: 21 Fuller Meadow Rd. N.Andover,Ma. Owner: Shitanshu Jha Date of Inspection: 4/1/08 C. Further Evaluation is Required by the Board of Health: Conditions exist which require further evaluation by the Board of Health in order to determine if the system is failing to protect public health, safety or the environment. 1. System will pass unless Board of Health determines in accordance with 310 CMR 15.303(1)(b) that the system is not functioning in a manner which will protect public health, safety 'and the environment: Cesspool or privy is within 50 feet of a surface water Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh 2. System will fail unless the Board of Health (and Public Water Supplier, if any) determines that the system is functioning in a manner that protects the public health, safety and environment: _ The system has a septic tank and soil absorption system (SAS) and the SAS is within 100 feet of a surface water supply or tributary to a surface water supply. _ The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water supply. _ The system has a septic tank and SAS and the SAS is within 50 feet of a private water supply well. _ The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or more frons a private water supply well". Method used to determine distance "This system passes if the well water analysis, performed at a DEP certified laboratory, for coliform bacteria and volatile organic compounds indicates that the well is free from pollution from that facility and the presence of ammonia nitrogen and nitrate 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: Page 4 of 11 OFFICIAL INSPECTION FORM — NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: 21 Fuller Meadow Rd. N.An over,Ma. Owner: Shitanshu Jha Date of Inspection: 4/1/08__ D. System Failure Criteria applicable to all systems: You must indicate "yes" or "no" to each of the following for all inspections: Yes No _ x Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool _ x Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool X Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool X Liquid depth in cesspool is less than 6" below invert or available volume is less than 1/2. day flow x Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number of times pumped x Any portion of the SAS, cesspool or privy is below high ground water elevation. x Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. X Any portion of a cesspool or privy is within a Zone 1 of a public well. _ x Any portion of a cesspool or privy is within 50 feet of a private water supply well. X Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality analysis. [This system passes if the well water analysis, performed at a DEP certified laboratory, for coliform bacteria and volatile organic compounds indicates that the well is free from pollution from that facility and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis must be attached to this form.] NO (Yes/No) The system fails. I have determined that one or more of the above failure criteria exist as described in 310 CMR 15.303, therefore the system fails. The system owner should contact the Board of Health to determine what will be necessary to correct the failure. E. Large Systems: To be considered a large system the system must serve a facility with a design flow of 10,000 gpd to 15,000 gpd. You must indicate either "yes" or "no" to each of the following: (The following criteria apply to large systems in addition to the criteria above) yes no — _ the system is within 400 feet of a surface drinking water supply _ the system is within 200 feet of a tributary to a surface drinking water supply the system is located in a nitrogen sensitive area (Interim Wellhead Protection Area — IWPA) or a mapped Zone 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. Page 5 of I 1 OFFICIAL INSPECTION FORM — NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST Property Address: 21 Fuller Meadow Rd. N.Andover,Ma. Owner: Shitanshu Jha Date of Inspection: 4 / 1 / 0 8 Check if the following have been done. You must indicate `yes" or "no" as to each of the following: Yes No X _ Pumping information was provided by the owner, occupant, or Board of Health X Were any of the system components pumped out in the previous two weeks? X _ Has the system received normal flows in the previous two week period ? X Have large volumes of water been introduced to the system recently or as part of this inspection ? X _ Were as built plans of the system obtained and examined? (If they were not available note as N/A) X _ Was the facility or dwelling inspected for signs of sewage back up? X _ Was the site inspected for signs of break out ? X _ Were all system components, excluding the SAS, located on site ? . X_ 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 ? X _ Was the facility owner (and occupants if different from owner) provided with information on the proper maintenance of subsurface sewage disposal systems? The size and location of the Soil Absorption System (SAS) on the site has been determined based on: Yes no X _ Existing information. For example, a plan at the Board of Health. _ , Determined in the field (if any of the failure criteria related to Part C is at issue approximation of distance is unacceptable) (3 10 CMR 15.302(3)(b)] Page 6 of 11 OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION Property Address: 21 Fuller Meadow Rd. N.Andover,Ma. Owner: Shitanshu Jha Date of Inspection: 4/1/08 FLOW CONDITIONS RESIDENTIAL 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): 4 x 1 50=600 gpd. Number of current residents: 5 Does residence have a garbage grinder (yes or no): no Is laundry on a separate sewage system (yes or no): no [if yes separate inspection required] Laundry system inspected (yes or no): _ Seasonal use: (yes or no): no Water meter readings, if available (last 2 years usage (gpd)): appx . 3 9 3 gpd . (sprinkler) Sump pump (yes or no): no Last date of occupancy: present COMMERCIAIANDUSTRIAL Type of establishment: Design flow (based on 310 CMR 15.203): gpd Basis of design flow (seats/persons/sgft,etc.): Grease trap present (yes or no): _ Industrial waste holding tank present (yes or no): _ Non -sanitary waste discharged to the Title 5 system (yes or no): _ Water meter readings, if available: Last date of occupancy/use: OTHER (describe): GENERAL INFORMATION Pumping Records Source of information: system last pumped 10/07, (homeowner) Was system pumped as part of the inspection (yes or no): no If yes, volume pumped: _gallons — How was quantity pumped determined? Reason for pumping: TYPE OF SYSTEM X 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) _ Tight tank _ Attach a copy of the DEP approval Other (describe): Approximate age of all components, date installed (if known) and source of information: 23+ yr,;- s)zstem installed 7/84.10 a BOH r ordG- Were sewage odors detected when arriving at the site (yes or no): no Page 7 of 11 OFFICIAL INSPECTION FORM — NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: 21 Fuller Meadow Rd. N.Andover.Ma. Owner: Shitanshu Jha Date of Inspection: 4 / 1 / 0 8 BUILDING SEWER (locate on site plan) Depth below grade: 12 " Materials of construction: _& _Cast iron _40 PVC _other (explain): _ Distance from private water supply well or suction line: Comments (on condition of joints, venting, evidence of leakage, etc.): SEPTIC TANK: x (locate on site plan) Depth below grade: 8" Material of construction: X concrete _metal _fiberglass _polyethylene _other(explain) If tank is metal list age: _ Is age confirmed by a Certificate of Compliance (yes or no):_ (attach a copy of certificate) Dimensions: 1 0' x 5' x 5' 1500 ga 1. Sludge depth: 2 " Distance from top of sludge to bottom of outlet tee or baffle: 28" Scum thickness: 1 " Distance from top of scum to top of outlet tee or baffle: 5" Distance from bottom of scum to bottom of outlet tee or baffle: 2 2 " How were dimensions determined: MEASURED IN FIELD Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): of leakage. GREASE TRAP: _(locate on site plan) Depth below grade: _ Material of construction: _concrete _metal _fiberglass _polyethylene _other (explain): Dimensions: Scum thickness: Distance from top of scum to top of outlet tee or baffle: Distance from bottom of scum to bottom of outlet tee or baffle: Date of last pumping: Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): Page 8 of 11 OFFICIAL INSPECTION FORM — NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: 21 Fuller Meadow Rd. N_Andover,Ma_ Owner: Shi tanshu Jha Date of Inspection: 4 / 1 / 0 8 TIGHT or HOLDING TANK: (tank must be pumped at time of inspection)(locate on site plan) Depth below grade: Material of construction: concrete metal fiberglass _polyethylene other(explain): Dimensions: Capacity: _____gallons Design Flow: gallons/day Alarm present (yes or no): Alarm level: Alarm in working order (yes or no): Date of last pumping: Comments (condition of alarm and float switches, etc.): DISTRIBUTION BOX: X (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 in fair condition,box shows some signs of deterioration, liq»>rl 1Pvpi distribution equal,no signs of carryover or leakage PUMP CHAMBER: (locate on site plan) Pumps in working order (yes or no): Alarms in working order (yes or no): Comments (note condition of pump chamber, condition of pumps and appurtenances, etc.): Page 9 of 11 OFFICIAL INSPECTION FORM — NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: 21 Fuller Meadow Rd. N . Andover. Ma . Owner: Shitanshu Jha Date of Inspection: 4/1 / 08 SOIL ABSORPTION SYSTEM (SAS): X (locate on site plan, excavation not required) If SAS not located explain why: Type leaching pits, number: _ leaching chambers, number: leaching galleries, number. leaching trenches, number, length: X leaching fields, number, dimensions: 1@ 20'x45' 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 conditions normal,no signs of hydraulic failure,vectetation ., CESSPOOLS: (cesspool must be pumped as part of inspection)(locate on site plan) Number and configuration: Depth — top of liquid to inlet invert: Depth of solids layer: Depth of scum layer: Dimensions of cesspool: Materials of construction: Indication of groundwater inflow (yes or no): 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, Ievel of ponding, condition of vegetation, etc.): Page 10 of 11 OFFICIAL INSPECTION FORM — NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: 21 Fuller Meadow Rd. N.Andover,Ma. Owner: Shitanshu Jha Date of Inspection: 4 / 1 / 0 8 SKETCH OF SEWAGE DISPOSAL SYSTEM Provide a sketch of the sewage disposal system including ties to at least two permanent reference landmarks or benchmarks. Locate all wells within 100 feet. Locate where public water supply enters the building. A-1 =26' B-1=20' A-2=20' B-2=27' A-3=25' B-3=33' D R I V E Page 11 of 11 OFFICIAL INSPECTION FORM — NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: 21 Fuller Meadow Rd. N.Andover,Ma. Owner: Shitanshu Jha Date of Inspection: 4/1/08 SITE EXAM Slope Surface water Check cellar Shallow wells Estimated depth to ground water 6 feet Please indicate (check) all methods used to determine the high ground water elevation: X Obtained from system design plans on record - If checked, date of design plan reviewed: 2 / 15 / 8 4 _ Observed site (abutting property/observation hole within 150 feet of SAS) _ Checked with local Board of Health -explain: _ Checked with local excavators, installers- (attach documentation) Accessed USGS database -explain: You must describe how you established the high ground water elevation: Groundwater determined from design plan on record at local BOH, I _ n _ i _ _ _ __ _ _ _ 7 L _ L _ _ L f l _ _ ---I- L _ — L a _ L —A C /I n /0 ] � 1 :: �• •u � -u 11 Town of North Andover Tax Map # 210-104.D-0128-0000.0 21 FULLER MEADOW ROA JHA, SHITANSHU Since Jan 2003 RITU GUPTA 21 FULLER MEADOW ROAD NORTH ANDOVER, MA 01845 Class 101 Single Family Size Total 1.62 Acres FY 2008 UB Mailina Index Name/Address Type JHA, SHITANSHU Payor 21 FULLER MEADOW ROAD NORTH ANDOVER, MA 01845 UB Account Maint. Account No Cycle Bldg Id. 18711.0 - 21 FULLER MEADOW ROA 3160406 03 Cycle 03 UB Services Maint. Property Type Loan Number Active/Inact. Occupant Name Last Billing Date 3/28/2008 From Active/inactive Active Service Code Rate Charge Multiplier/Users MISCFEE ADMIN FEE 0.635/8 7.82 1/ WTR WATER 01 ALL METER SIZE 187.93 /1 UB Meter Maintenance Serial No Status Location Brand Type 32945348 a Active 00 b Badger w Water Date Reading Code Consumption Posted Date 3/6/2008 389 a Actual 41 4/11/2008 12/6/2007 348 a Actual 43 1/22/2008 9/13/2007 305 a Actual 114 10/12/2007 6/12/2007 191 a Actual 27 7/20/2007 3/9/2007 164 a Actual 23 4/16/2007 12/5/2006 141 a Actual 38 1/19/2007 9/6/2006 103 a Actual 68 10/20/2006 6/12/2006 35 a Actual 29 7/10/2006 3117/2006 6 a Actual 6 4/17/2006 2/21/2006 0 n New Meter 0 4/17/2006 2/21/2006 3692 r Replacement 16 4/17/2006 12/15/2005 3676 a Actual 16 1/17/2006 Trouble Code:03 9/14/2005 3660 a Actual 29 10/14/2005 Trouble Code:03 6/7/2005 3631 a Actual 25 7/15/2005 3/5/2005 3606 m Manual estimate 20 4/5/2005 MSG 12/8/2004 3586 a Actual 22 1/14/2005 Trouble Code:03 9/15/2004 3564 a Actual 42 10/8/2004 Trouble Code:03 6/9/2004 3522 a Actual 30 7/30/2004 4/15/2004 3492 m Manual estimate 30 5/17/2004 12/5/2003 3462 n New Meter 0 12/5/2003 Size 0.63 0.63 1 Residential Until YTD Cons Variance -12% -58% 331% 16% -42% -47% 137% 33% -100% -100% 35% -41% 10% 16% -12% -39% -21% 140% 0% 0% 4.1 V c L c o w i L v Z Z t.1 V cc y ° � E w a .c Ol c c m a� 0 V c L � o w � L v Z Z t.1 V cc w d a> a d cc aQi a� 0 0 a) rn m a V L � o d � Z Z f Z u C) 3 9 ,o a eo -c O O cq E. S � � 40. i N _ , O y co y„ S m a y ayi a o w C E d E m y w a 0 N O O J Z Z Z U w c_ Elo ZL 3 O -;a avi E m v o d ID as 'c G ` H m 0 a) rn m a O � o Z Z f Z u C) 3 9 ,o o -c S � � a i N _ , O y co y„ S m y ayi a C E d E a 0 m p� Elo ZL 3 O -;a m v o d ID G ` to d 0 a) rn m a -�5 r Town of North Andover Health Department Date: Location: OK-/ 1 1 ez• W K/ (Indicate Address, if Residential, or Name of Business) Check #: Type of Permit or License: (Circle) ➢ Animal $ ➢ Dumpster $ ➢ Food Service - Type. $ ➢ Funeral Directors $ ➢ Massage Establishment $ ➢ Massage Practice $ ➢ Offal (Septic) Hauler $ ➢ Recreational Camp $ ➢ SEPTIC PERMITS: ❑ Septic - Soil Testing $ ❑ Septic - Design Approval $ ❑ Septic Disposal Works Construction (DWC) $ ❑ Septic Disposal Works Installers (DWI) $ ➢ Sun tanning $ ➢ Swimming Pool $ ➢ Tobacco $ ➢ TrashlSolid Waste Hauler $ ➢ Well Construction $ ➢ OTHER: (Indicate) '1536 Health Agent Initials' White - Applicant Yellow - Health Pink - Treasurer NEw ENGLAND ENGINE EAG SERVICES, INC. 1600 Osgood Street RECIE1 ED Building 20 Suite 2-64 North Andover, MA 01845 'Fel: (978) 686-1768 • Fax: (978) 327-6138 MAY - 1 2006 Benjamin C. Osgood, Jr., P.E. President Ms. Susan Sawyer North Andover Board of Health 400 Osgood Street North Andover, MA 01845 TOWN OF NORTH ANDOVER HEALTH DEPARTMENT April 28, 2006 Title 5-06-38 RE: TITLE V REPORT: 21 Fuller Meadow Road, North Andover, MA 01845 Enclosed is the Title V report for the above referenced property. The septic system PASSED our inspection. If there are any questions please call me at my office, 686-1768. Sincerely, Benjamin C. Osgood, Jr. Certified Title 5 Inspector I of 11 COMMONWEALTH OF MASSACHUSETTS EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS DEPARTMENT OF ENVIRONMENTAL PROTECTION TITLE 5 OFFICIAL INSPECTION FORM- NOT FOR VOLUNTARY ASSESSMENT SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM PART A CERTIFICATION Property Address: 21 Fuller Meadow Road, North Andover, MA 01845 Owner's Name: Shitanshu Jha Owner's Address: 21 Fuller Meadow Road, North Andover, MA 01845 Date of Inspection: April 26, 2006 RECE* -:0 MAY — 1 2006 TOWN OF NORTH ANDOVER HEALTH DEPARTMENT Name of Inspector: (please print) Benjamin C. Osgood, Jr. Certified Title 5 Inspector Company Name: New England Engineering Services Inc. Mailing Address: 1600 Osgood Street Building 20 Suite 2-64, North Andover, MA 01845 Telephone Number: 978-686-1768 CERTIFICATION STATEMENT I certify that I have personally inspected the sewage disposal system at this address and that the information reported below is true, accurate and complete as of the time of the inspection. The inspection was performed based on my training and experience in the proper function and maintenance of the on site sewage disposal systems. I am a DEP approved system inspector pursuant to Section 15340 of Title 5 (310 CMR 15.000). The system: Inspector's Signature: —A/ Passes Conditionally Passes Needs Further Evaluation by the Local Approving Authority Fails 2z- /O The system inspection 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 .hall submit the report to the appropriate regional office of the DEP. The original should be sent to the system owner and copies sent to the buyer, if applicable, and the approving: authority. Notes and Comments ""This report only describes conditions at the time of inspection and under the conditions of use at that time. This inspection does not address how the system will perform in the future under the same or different conditions of use. OFFICIAL INSPECTION FORM — NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: 21 Fuller Meadow Road, North Andover, MA 01845 Owner's Name: Shitanshu Jha Date of Inspection: April 26, 2006 Inspection Summary: Check A, B, C, D or E/ALWAYS complete all of Section D A. System Passes: F 5 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. Answer yes, no or not determined (Y,N,ND) in the for the following statements. If "not determined" please explain. The septic tank is metal and over 20 years old* or the septic tank (whether metal or not) is structurally unsound, exhibits substantial infiltration or exfiltration or tank failure is imminent. System will pass inspection if the existing tank is replaced with a complying septic tank as approved by the Board of Health. *A metal septic tank will pass inspection if it is structurally sound, not leaking and if a Certificate of Compliance indicating that the tank is less than 20 years old is available. ND explain: Observation of sewage backup or break out or high static water level in the distribution box due to broken or obstructed pipe(s) or due to a broken, settled or uneven distribution box. System will pass inspection if (with approval of Board of Health): Broken pipe(s) are replaced Obstruction is removed Distribution box is leveled or replaced ND explain: The system required pumping more than 4 times a year due to broken or obstructed pipe(s). The system will pass inspection if (with approval of the Board of Health): Broken pipe(s) are replaced Obstruction is removed ND explain: 3of11 OFFICIAL INSPECTION FORM — NOT FOR VOLUNTARY ASSESSMENT SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: 21 Fuller Meadow Road, North Andover, MA 01845 Owner's Name: Shitanshu Jha Date of Inspection: April 26, 2006 C. Further Evaluation is Required by the Board of Health: AJ 0_ Conditions exist which require further evaluation by the Board of Health in order to determine if the system is failing to protect public health, safety or the environment 1. System will pass unless Board of Health determines in accordance with 310 CMR 15.303(1)(b) that the system is not functioning in a manner which will protect public health, safety and the environment: Cesspool or privy is within 50 feet of a surface water Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh 2. System will fail unless the Board of Health ( and Public Water Supplier, if any) determines that the system is functioning in a manner that protects the public health, safety and environment: The system has a septic tank and (SAS) Soil Absorption System and the (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 the SAS is within 50 feet of a private water supply well. The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or more from a private water supply well**. Method used to determine distance ** This system passes if the well water analysis, performed at a DEP certified laboratory, for coliform bacteria and volatile organize compounds indicates that the well is free from pollution from that facility and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5ppm, provided that no other failure criteria are triggered. A copy of the analysis must be attached to this form. 3. Other: 4of11 OFFICIAL INSPECTION FORM — NOT FOR VOLUNTARY ASSESSMENT SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: 21 Fuller Meadow Road, North Andover, MA 01845 Owner's Name: Shitanshu Jha Date of Inspection: April 26, 2006 D. System 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 y— Discharge or ponding of effluent to the surface of the ground or surface waters due to an overload or clogged SAS or cesspool. Static liquid level in the distribution box above outlet invert due to an overload or clogged SAS or cesspool ✓ Liquid depth in cesspool is less than 6" below invert or available volume is less than V2 day flow ✓ Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number of times pumper Any Portion of the SAS, cesspool or privy is below high ground water elevation. V 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 coliform bacteria and volatile organic compounds indicates that the well is free from pollution from that facility and the presence of ammonia nitrogen and nitrogen is equal to or less than 5ppm, provided that no other failure criteria are triggered. A copy of the analysis must be attached to this form.) P(Yes/No) The system fails. I have determined that one or more of the above failure criteria exist as described in 310 CMR 15.303, therefore the system fails. The system owner should contact the Board of Health to determine what will be necessary to correct the failure. E. Large Systems: To be considered a large system the system must serve a facility with a design flow of 10,000 gpd to 15,000 gpd. You must indicate either `yes" or "no" to each of the following: (The follow criteria apply to large systems in addition to the criteria above) Yes No The system is . 400 feet of a surface drinking waterLsugThe system is within 200 f a tributary to ace dwater supply The system is located in a of a public water supply_y (Interim Wellhead Protection Area — IWPA) or a mapped Zone II If you answered "yes" to estion in Section E the system is considered a s ' cant threat, or answered "yes" in Section D above the large systemed. The owner or operator of any large system considered a 69acant threat under Section E or failed under Section D upgrade the system in accordance with 310 CMR 15.304. The system owner should contact the appropriate regional office of the Department. 5of11 OFFICIAL INSPECTION FORM — NOT FOR VOLUNTARY ASSESSMENT SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST Property Address: 21 Fuller Meadow Road, North Andover, MA 01845 Owner's Name: Shitanshu Jha Date of Inspection: April 26, 2006 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 an 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 sign of break out? _ Were all system components, excluding the SAS, located on site? Were all 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 difference from owner) provided with information on the proper maintenance of the subsurface sewage disposal systems? The size and location of the Soil Absorption System (SAS) on the site has been determined based on: Yes No 1✓ Existing information. For example, a plan at the Board of Health. Determined in the field (if any of the failure criteria related to Part C is at issue approximation of distance is unacceptable) [3 10 CMR 15.302(3)(b)] 6of11 OFFICIAL INSPECTION FORM — NOT FOR VOLUNTARY ASSESSMENT SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION Property Address: 21 Fuller Meadow Road, North Andover, MA 01845 Owner's Name: Shitanshu Jha Date of Inspection: April 26, 2006 FLOW CONDITIONS RESIDENTIAL Number of bedrooms (design) Number of bedrooms (actual): x DESIGN flow based in 310 CMR )x.203 ( for example: 110 gpd x # of bedrooms) Number of current residents: X Does residence have a garbage grinder (yes or no):'� Is laundry on a separate sewage system (yes or no): [if yes separate inspection required] Laundry system inspected ( yes or no): -- Seasonal use: (yes or no): VO Water meter readings, if avails le (last 2 years usage (gpd): � 36 CAPD Sump Pump (yes or no):� Last date of occupancy L. COMMERCIAL/INDUSTRIAL Type of establishment: Design flow (based on 310 CMR 15.203): gpd Basis of design flow (seats/persons/sgfl, etc Grease trap present (yes or no): Industrial waste holding tank present (yes or no): Non -sanitary waste discharged to the Title 5 system (yes or no) Water meter readings, if available: Last date of occupancy/use: OTHER (describe): GENERAL INFORMATION Pumping Records Source of information: U N y. Al C, Was system pumped as part of the inspection (yes or no): If yes, volume pumped: gallons — How was quantity pumped determined? 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) Tight tank Attached a copy of the DEP approval Other (describe): Approximate age of all components, date installed (if known) and source of information: Were sewage odors detected wen arriving at the site (yes or no): A/ 0 7of11 OFFICIAL INSPECTION FORM — NOT FOR VOLUNTARY ASSESSMENT SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: 21 Fuller Meadow Road, North Andover, MA 01845 Owner's Name: Shitanshu Jha Date of Inspection: April 26, 2006 BUILDING SEWER (locate on site plan) Depth below grade: Materials of construction:_ —cast iron 40 PVC other (explain) Distance from private water supply well or suction line: A,11#4 Comments (on condition of joints, venting, evidence of leakage, etc.): SEPTIC TANK: (locate on site plan) Depth below grade: 6?,% Material of construction:_,,,,' concrete metal fiberglass polyethylene Other (explain) If tank is metal list age: Is age confirmed by a Certificate of Compliance (yes or no): (attach a copy of certificate) Dimensions: Sludge depth: Distance from top of sludge to bottom of outlet tee or baffle: 0 Z Scum thickness: C 2 " Distance from top of scum to top of outlet tee or baffle: 3 " Distance from bottom of scum to bottom of outlet tee or baffle How were dimensions determined:_ A4 t^ i'r su ae S7�crC Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): f1N IN f�c il Lvti f (�li/l/r Cr).JC 2E l�--- I j57 e, o O i 7l o n./. GREASE TRAP:-&�(locate on site plan) Depth below grade: Materials of construction: concrete metal fiberglass polyethylene other (explain) Dimensions: Scum thickness: Distance from top of scum to top of outlet tee or bade: Distance from bottom of sludge to bottom of outlet tee or battle: Date of last pumping: Comments (on pumping recommendations, inlet and outlet tee or baffle condition structural integrity, invert, evidence of leakage, etc. liquid levels as related to outlet 8of11 OFFICIAL INSPECTION FORM — NOT FOR VOLUNTARY ASSESSMENT SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: 21 Fuller Meadow Road, North Andover, MA 01845 Owner's Name: Shitanshu Jha Date of Inspection: April 26, 2006 TIGHT OR HOLDING TANK:_t�_(tank must be pumped at time of inspection)(locate on site plan) Depth below grade: Materials of construction: concrete metal fiberglass polyethylene other (explain) Dimensions: Capacity: gallons Design Flow: gallons/day Alarm present (yes or no): Alarm level: Alarm in working order (yes or no): Date of last pumping: Comments (condition of alarm and float switches, etc.): DISTRIBUTION BOX: (if present must be opened)(locate on site plan) Depth of liquid level above outlet invert: D 'rfr Comments ( note if box is level and distribution to outlets equal, any evidnence of solids carryover, any evidence of leakage into or out of box, etc.): 13&,K Ian/ pK CoAj I>, -Do Aj, A/0 JE -,v CE 0T 1, 09%4 r9& Iry v/t of., -t D/c- i D A --i ISS C /¢ "Y -ou c,/— PUMP CHAMBEP- locate on sire plan) Pumps in working order (yes or no) Alarms in working order (yes or no) Comments (note condition of pump chamber, condition of pumps and appurtenances, etc.): 9of11 OFFICIAL INSPECTION FORM — NOT FOR VOLUNTARY ASSESSMENT SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: 21 Fuller Meadow Road, North Andover, MA 01845 Owner's Name: Shitanshu Jha Date of Inspection: April 26, 2006 SOIL ABSORPTION SYSTEM (SAS): (locate on site plan, excavation not required If SAS not located explain why r�0 leaching pits number leaching chambers, number leaching galleries number leaching trenches, number in length �K leaching fields, number, dimensions: �/Gc,p P2o e-,9.d[.ca 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) a.V D otz a s✓ a-& 6-119 Z— u, EL, E4---2 aAJ, CESSPOOLS: d✓ (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 Constriction: Indication of groundwater inflow (yes or no): Comments(note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): PRIW:__6J*_(locate on site plan) Material of construction: Dimensions: Depth of solids: Comments (note condition of soil signs of hydraulic failure, level of ponding, condition of vegetation, etc. 6 10 of 11 OFFICIAL INSPECTION FORM — NOT FOR VOLUNTARY ASSESSMENT SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: 21 Fuller Meadow Road, North Andover, MA 01845 Owner's Name: Shitanshu Jha Date of Inspection: April 26, 2006 SKETCH OF SEWAGE DISPOSAL SYSTEM Provide a sketch of the sewage disposal system including ties to at least two permanent reference landmarks or benchmarks. Locate all wells within 100 feet. Locate where public water supply enters the building. 1=T 24"o Z -T 23,0 I ng 33.1 z'P3 Zs. 11 of 11 OFFICIAL INSPECTION FORM — NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: 21 Fuller Meadow Road, North Andover, MA 01845 Owner's Name: Shitanshu Jha Date of Inspection: April 26, 2006 SITE EXAM Slope `lo Surface water -Jc v c Check cellar r", X1 I -, � ).t- P Au ? Shallow wells ,, 0 N L Estimated depth to ground water (o feet Please indicate (check) all methods used to determine the high ground water elevation: Obtained from system design plans on record — If checked, date of design plan reviewed: _ Observed site (abutting property/observation hole within 150 feet of SAS) Checked with local Board of Health — explain: Checked with local excavator, installers — (attach documentation) Accessed USGS database -explain: You must describe how you established the high ground water elevation: :: 15 1 Oo t L:-,- I N t�}ti' f�}/%l /� off%[ 1-5; 1979t,ue- v n./ thin. 4 tqd-eez SYSTEM OWNER & ADDRESS SYSTEM LOCATION (example: left front of house) 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: a s �E COMMENTS: CONTENTS TRANSFERRED TO: , �Q� SYSTEM OWNER & ADDRESS SYSTEM LOCATION C j 5 j (example: left front of house) ca 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: L COMMENTS: CONTENTS TRANSFERRED TO: 1Q lv� CO to � Q A v 0 n c o CD fl. o n D a p' 3 v Q, r.,; I ro 0 Q D 0 'D y ate, rr p' C (D I � � 7 rt +" v 3 3 0 M u tD rt z � G r > O to s f9 v 0 i C rt 7 0 o► ICL ,n CO to S-' uj FORM U - LOT RELEASE FORM INSTRUCTIONS: This form is used to verify that all necessary approvals/permits from Boards and Departments having jurisdiction have been obtained. This does not relieve the applicant and/or landowner from compliance with any applicable local or state law, regulations or requirements. ************�(*'***Applicant fills out this section***************** APPLICANT: �1 • �%1LUC. t4 Phone t(, q--2.Z-Z, LOCATION: Subdivision Street Assessor's Map Number Parcel ,�A!• (� Lots) S� 2 ( � t[EQ- 1�6S�dLJ `�.� St. Number V ************************Official Use Only************************ RECOMMENDATIONS OF TOWN AGENTS: Conservation Administrator Comments Town Planner Comments Food Inspector -Health tic Inspector- Health Comments Public Works - sewer/water connections - driveway permit Fire Department Received by Building Inspector Date Approved Date Rejected Date Approved Date Rejected Date Approved Date Rejected Date Approved Date Rejected Date _. ._.._� HERE"C[RTI►Y THAT J NAV[ EXAMINED 7H[ MEMISUAND ALL [AKM D IT$ TITLE [NTf [ MASSACHU INFURTNER[NTCf ER IF •TILOTNOS ARE LOCATED ON THE GROUND AS SHOWN. ' r�.wW�!f�nANAY TONING LAWS AND AMENDMENTS, eUjL O1N0 SHOWN 00( 1. ) CONFORM TO THE WHEN CONSTRUCTED • o• (FRONTSID[ 0 .I ►URTN[R REAR YARD SET SACK LOCATED IN THE Fe...,FU _. CERTIFY THAT THS• ............. °HETI OF 140M ArJtY�.Kr �a 73,81 1 r �I 1- i 1 t 1 LOT 50 4p'S75 6 R M E� • 1 F-ASEM;ENT %E I'-ERTIrf THAr THE SEPTIC SYSTEM WAS INSTALLED ASSHOVIN,THIS PLAN IS NOT If-TEf ED ASA WARRANTY OF THE SYSTEM, FOUNDATION CERTIFICATION AND LOCATION By K-RKAPAINSKI APED ASSOC. "PROPOSED S.UBSURr'ACE SEWERAGE DIS-POSAL S�STC�,f AS- F,"'i1.T OWNER 7vibi [• J 1DANI LOCATION LOT %.L DATE 7-27-8-4 PREPARED BYE- - aymyLss(r..,PC p0.0BOX5E): PLAC, �•1 t ELEVATIONS TOP PhD 138.75 HOWHE OUTLET 137:00 7-N ST INLET 136.84 ST OUTLET 13674 D BOX INLET 135,2 D BOX OUTLET 13x•52 1 END FIELD 136,32 I'-ERTIrf THAr THE SEPTIC SYSTEM WAS INSTALLED ASSHOVIN,THIS PLAN IS NOT If-TEf ED ASA WARRANTY OF THE SYSTEM, FOUNDATION CERTIFICATION AND LOCATION By K-RKAPAINSKI APED ASSOC. "PROPOSED S.UBSURr'ACE SEWERAGE DIS-POSAL S�STC�,f AS- F,"'i1.T OWNER 7vibi [• J 1DANI LOCATION LOT %.L DATE 7-27-8-4 PREPARED BYE- - aymyLss(r..,PC p0.0BOX5E): PLAC, �•1 t Board of Health ' Ncr}.is .,ndover,Yasis FACE DISPOSAL DESIM CEECK MST -LOT '� �y��E1� M�ff�•� APPR(NED DATE DISAPPRGM DATE Provided:CE Reasonss Title V FAII. Reg 2.5 e submitted plan must short as a nd im"msoO - lot #2abutters the lot to be serve-area,di-mensiona holes-distance to ties location and log deep observation location and results percolation tests-distance to ties c design calculations k ealcula.tions showing required leaching area location and dimensions of system -including reserve area xisting and proposed contours location any vot areas -4thin 100' of seiage disposal system or g ""F_�disclaimer-check h) wetlands mapping surface and subsurface d3ns 'At-hin 100' of swage disposal r�. i) system or disclaimer location any drainage easements 16thin 100' of sevage disposal- j) Pl ann na Board files system or diselai��er- -i-D know sources of sorter simply -within 200' of sev?ge dis_oocai a _ -- --k system or discl.ainer o sere lot-100�from leaching facil kation-of arm proposed ,-ell tv _ ---, 00 location of later Lees on property-10' Brom leaching faci lty_ of benchmark isek-,ys V2.0cation rbage disposals _ q) PVC to be used in construction profile of system-elevations of basement, plumb, pipe, septic tank, distribution box inlets and outlets, distribution field piping and Otter elevations majii m ground -.-ester elevation in area se-wagedisposal system plan mast be prepared by a Professional Engineer or other professional authorized by ldu to prcpare such plans Reg 6 �(a) Septic Tanks capacities-150' of flog, meter table, tees, depth of tees, Oe access, pining b) cleanout 10' from cellar imll or iia,-round sZ.,—ng pool d) 251 from subsurface drains . Reg 10.2 Distribution Foxes slope greaten' than 0.08 Reg 10.4 I b) sump (D r4o CV N �'� Board of Fjealth North Anonverom"Be LIVED DATE BISAPPR NO J i .2 -ILLY easanst M SEPTIC SISTEK INSTALLATICIQ CHECCB IZ3T LOT 04 . EXCAVATICH OK 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 Out Covers. b. Cement Pipe to Tank Ca Both Sides of Tank 5. Distribution Box a. Covers & Box - No Cracks b. All Lines Flowing Equal Amounts c. No Back Flow 6. Leach Field or Trench a. Dinnensions b. Stone Depth c: Capped Ends d. Clean Double -Washed Stone` 7. Leach Pits a. Dimensions b. Stone Depth c. Splash Pads d. Tees e. ement Pipe to Pit - Both Sides f. Clean Double Washed Stone 8. No Garbage Disposal 9. -Fi na1 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 • WILLIM! F WELD Gown -ow ARGEO PAUL CELLUCCI IA. Govcmor COMMON\VEALTH OF MASSACHUSETTS EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS DEPARTMENT OF ENVIRONMENTAL PROTECTION ONE WINTER STREET. BOSTON. AIA 02108 617-292-5560 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION Property Address:� � �F2 _� _der✓_ i�_`- �' A, v Address of Owner: Date of Inspection: (0/3 �� (II different) Name of Inspector: BEfU IN C. OSGOOD JR. ' I am a DEP approved system inspector pursuant to Section 15.340 of Title S (310 CMR 15.000) Company Name: NEW ENGLAND ENGINEERING SERVICES, INC. Mailing Address: 33 WALKER ROAD, NORTH ANDOVER, MA 01845 Telephone Number: 508-686-1768 TRUDY CORE Scacur% i DAVID B. STRUHS Commissioner CERTIFICATION STATEMENT r 1 certify that I have personally inspected the sewage disposal system at this address and that the information reported below is true, accurate and complete as of the time of inspection. The inspection was performed based on my training and experience in the proper function and maintenance of on-site sewage disposal systems. The system: PLLasses Condttronall. Passes Needs Further Evaluation By the Local Approving Authority _ Fails Inspector's Signature: — - - Ci C/� Date: G 3 The Svstem !nspector shall submit a copy of this4i�spection report to the Approving Authority (within thirty (30) days of completing this inspection. I( the system is a shared system or has a design (low of 10.000 gpd or greater, the inspector and the system owner shall submit the report to the appropriate regional office of the Department of Environmental Protection. The original should be sent to the system owner and copies sent to the byyer, if applicable. and the approving authority I INSPECTION SUMMARY: Check A, 8, C, or D: AI SYSTEM PASSES: I have not found any information which indicates that the system violates any of the failure cr:te:ia as dzfined in 310 CmR 15.303. Any failure criteria not evaluated are indicated below. COMMENTS: BI 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 pus. Indicate yes. no. or not determined (Y. N. or NO). Desaibe basis of determination in all instances: If -not determined', explain why not. The septic tank is metal, unless the owner or operator has provided the system inspector with a copy of a Certifinte of Compliance (attached( indicating that the tank was insulted within twenty (20) years prior to the date of the inspection; or the septic tank, whether or not metal, is cracked, structurally unsound, shows substantial infiltration or exfiitration, or tank failure is imminent. The system will pus inspection if the existing septic tank is replaced with a conforming septic tank as approved by the Board of Health. rr—i—d 04fis/97) Pau- 1 or 10 SUBSURFACE SEWAGE DISPOSAL. SYSTEM INSPECTION FORM s PART A CERTIFICATION (continued) Property Address: -el A.11160! l0eazAw � /T•�cXDUGC Owner: J r m Pa h e ti Date of Inspection: (' `3l9Q . BJ SYSTEM CONDITIONALLY PASSES (continued) Sewage backup or breakout or high static water level observed in the distribution box is due to broken or obstructed pipe(s) or due to a broken. settled or uneven distribution box. The system will pass inspection if (with approval of the Board of Health;. Describe observations: broken pipe(s) are replaced obstruction is removed distribution box is levelled or replaced The system required pumping more than four times a year due to broken or obstructed pipe(s). The system will pass inspection i((with approval of the Board of Health): broken pipe(s) are replaces obstruction is removed 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 the public health. safety and the environment. t) SYSTEM WILL PASS UNLESS BOARD OF HEALTH DETERMINES THAT THE SYSTEM IS NOT FUNCTIONING IN A MANNER WHICH WILL PROTECT THE PUBLIC HEALTH AND SAFETY AND THE ENVIRONOENT: Cesspool or pri.�• is within So feet of a surface water Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh. 2) SYSTEM WILL FAIL UNLESS THE BOARD OF HEALTH (AND PUBLIC WATER SUPPLIER, IF APPROPRIATE) DETERMINES THAT THE SYSTEM IS FUNCTIONING IN A MANNER THAT PROTECTS THE PUBLIC HEALTH AND SAFETY AND THE ENVIRONMENT- t The system has a septic tank and soil absorption system (SAS) and the SAS is within 100 feet to a surface water supply or tributary to a surface water supply. I The system has a septic tank and soil absorption system and the SAS is within a Zone I of a public water supply well. The system has a septic tank and soil absorption system and the SAS is within SO feet of a private water supply well. The system has a septic tank and soil absorption system and the SAS is less than too feet but So feet or more from a private water supply well. unless a well water analysis for coliform bacteria and volatile organic compounds indicates that the well is free from pollution from that facility and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm. Method used to determine distance (approximat;on not valid). 3) OTHER (revisal 04/75/771 r•4. 2 of 10 z , SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: Z j f ,.-jack /t4e�bw 1a A). f}v�o�ee Owner: J r rn Date of Inspection: )a /,,,4 �lalg8 D) SYSTEM FAILS: You must indicate either -Yes- or "No" as to each of the following: 1 have determined that the system violates one or more of the f611owing failure criteria as defined in 310 CMR 15.303. The basis for this determination is identified below. The Board of Health should be contacted to determine what will be necessary to correct the failure. Yes No Backup of sewage into facility or system component due to an overloaded or clogged SAS or cesspool. Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool s � Static liquid level in the distribution box above outlet tnven due to an overloaded or clogged SAS or cesspool. Liquid depth in cesspool is less than 6- below invert or available volume 0 less than 1/2 day flow. Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number of urrtes pumped Any porton of the Soil Absorption System, cesspool or privy is below the high groundwater elevation. Anv portion of a cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. Any ponron of a cesspool or privy is within a Zone I of a public well. I Any portion of a cesspool or privy is within 50 feet of a private water supply well Anv portion of a cesspool or privy is less than 100 feet but greater than 50. feet from a private water supply well with no acceptable water quality analysis. if the well has been analyzed to be acceptable. attach copy of well water analysis for cohiorm bactgria. volatile organic compounds, ammonia nitrogen and nitrate nitrogen. E) LARGE SYSTEM FAILS: I You must indicate either -Yes" or "No" as to each of the following: The following criteria apply to large systems in addition to the criteria above: The system serves a facility with a design flow of 10,000 go or greater (Large Systeml and the system is a significant threat to public health and safety and the environment because one or more of the following conditions exist: Yes No the system is within 400 feet of a surface drinking water supply the system is within 200 feet of a tributary to a surface drinking water supply the system is located in a nitrogen sensitive area (Interim Wellhead Protection Area - IWPA) or a mapped Zone 11 of a public water supply well) The owner or operator of any such system shall bring the system and facility into full compliance with the groundwater treatment program requirements of 314 CMR 5.00 and 6.00. Please consult the local regional office of the Department for further inforrnation. (revised 04/25/971 Page 3 of 10 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST Property Address: el /Wlek /V• A. - Owner: Dale of Inspection: �J hi c Check if the following have been done: You must indicate either 'Yes- or -No- as to each -of the following: Yes No Pumping information was provided by the owner, occupant, or Board of Health. None of the system components have been pumped (or at least two weeks and the system has been receiving normal flow rates during that period. Large volumes of water have not been introduced into the system recently or as pan of this inspection i As built plans have been obtaireed and examined. Note ii they ere not available with N/A. The facility or dwelling was inspected for signs.oi sewage back-up. _ The system does not recFtve non -sanitary or industrial waste flow. The site was inspected for signs of breakout. , _ All system components. excluding the Soil Absorption System, have been located on the site. s/•. _ The septic tank rnanholets were uncovered, opened. and the interior of the septic tank was injpected for condition of baffles or tees, material of construction, dimensions, depth of liquid, depth of sludge, depth of scum. — The size and location of the Soil Absorption System on the site has been determined based on: The facility owner (and occupants, if different irom owners were provided with information on the proper maintenance of / Sub -Surface Disposal System. 1 Existing information. Ex.tPlan at B.O.H. t _ Determined in the field to anv of the failure criteria related to Pan C is at issue, approximation of distance is unacceptable) (15.302(3)(b)j I (r.vi..d 04%75/27) f.q. 4 or 20 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION -FORM PART C SYSTEM (INFORMATION //JJ Property Address: Z� fe✓/f� /f/1c�•cJ�� ./ )er� N• 19—d" "t/" - Owner: Date of Inspection: FLOW CONDITIONS RESIDENTIAL: Design flow: e.p.dJbedroom (or S.A.S Number o(bedrooms:—.4-1 Number of current residents: Garbage g,,r.der (yes or no!:A/' Laundry connected to system (yes or no): Seasonal use (yes or no);4/-- Water meter readings, i(available (last two (2) year usage (gpd): G `� oZ �o . a ✓ cls c. s r Z b ��S Sump Pump (yes or no):A," L1 CC( Last date of occupancy: G ,-,-e/! "f COMMERCIAL/INDUSTRIAL: Type 67 establishment: Design flow•: callons/dav Grease trap present: (yes or not_ , Industrial Waste Holding Tank present: tees or nol_ Non -sanitary waste discharged to the Title i system (yes or no)_ Water meter readings, d available_ Last date of o• cupanc•: OTHER: (Describe! Last date of occupancy. GENERAL INFORMATION PUMPING RECORDS and source of information t System pumped as part of tnspection: ryes or nol&fo If yes, volume pumped: gallons Reason for pumping eye - 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) VA Technology etc. Copy of up to date contract? Other I APPROXIMATE AGE of all components, date installed (i( known) and source of information: y yta,�s O /cY Sewage odors detected when arriving at the site: (yes or no)& (revised 04/2S/97) rage 5 of 20 P r SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION -FORM PART C SYSTEM (INFORMATION //JJ Property Address: Z� fe✓/f� /f/1c�•cJ�� ./ )er� N• 19—d" "t/" - Owner: Date of Inspection: FLOW CONDITIONS RESIDENTIAL: Design flow: e.p.dJbedroom (or S.A.S Number o(bedrooms:—.4-1 Number of current residents: Garbage g,,r.der (yes or no!:A/' Laundry connected to system (yes or no): Seasonal use (yes or no);4/-- Water meter readings, i(available (last two (2) year usage (gpd): G `� oZ �o . a ✓ cls c. s r Z b ��S Sump Pump (yes or no):A," L1 CC( Last date of occupancy: G ,-,-e/! "f COMMERCIAL/INDUSTRIAL: Type 67 establishment: Design flow•: callons/dav Grease trap present: (yes or not_ , Industrial Waste Holding Tank present: tees or nol_ Non -sanitary waste discharged to the Title i system (yes or no)_ Water meter readings, d available_ Last date of o• cupanc•: OTHER: (Describe! Last date of occupancy. GENERAL INFORMATION PUMPING RECORDS and source of information t System pumped as part of tnspection: ryes or nol&fo If yes, volume pumped: gallons Reason for pumping eye - 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) VA Technology etc. Copy of up to date contract? Other I APPROXIMATE AGE of all components, date installed (i( known) and source of information: y yta,�s O /cY Sewage odors detected when arriving at the site: (yes or no)& (revised 04/2S/97) rage 5 of 20 P SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: 2 F.� lie4 /IAcao"J (Q0, N, 4-'c00')kL Owner: J-% Date of Inspection: BUILDING SEWER: (Locate on site plan) Y Depth below grade: Material of construction: cast iron _ 40 PVC _ other (explain) Distance from private water supply well or suction lice IVA Diameter I • Comments: (condition of joints, venting, evidence of leakage, etc.) /7 evc1,-/ I'll baserrre.r� P. Pc rcJC�s re-P�accc`/ c� bvJ� Z te0- 4--s ctac� SEPTIC TANK:_ (locate on site plant 4 Depth below grade: Material of construction: Zoncrete _metal _Fiberglas) _Polyethylene —other(explain) If tank is metal. list age _ Is age coniumed by Cendtcate of Compliance _ (Yes/No) Dimensions: /6-Q0 &r,//O,? S Sludge depth: 420 r Distance from top of sludge to bottom of outlet tee or bafflte: 2 e Scum thickness: O 1. rr Distance from top of scum to top of outlet tee or baffle: AF 6 Distance from bottom of scum to bottom of outlet tee or battle: Z/ How dimensions were determined: eneayci I -e- sncx Comments: (recommendation for pumping, condition of inlet and outlet tees or baffles, depth of liquid level in relation to outlet invert, struoural integrity, evidence of leakage, etc.) TANK 1-60A5 7z aE /-<,/ GO©jp GREASE TRAP: /Vil (locate on site,plan) Depth below grade: Material of construction: _concrete _metal _Fiberglass _Polyethylene _other(explain) Dimensions: Scum thickness: Distance from top of scum to top of outlet ter or baffle: Distance from bottom of scum to bottom of outlet tee or baffle: Date of last pumping: Comments: (recommendation for pumping, condition of inlet and outlet tees or baffles, depth of liquid level in relation to outlet invert, structural integrity, evidence of leakage, etc.) - (r.vi..d 04/)S/97) P.q. 4 or 10 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C /SYSTEM INFORMATION (continued) Property Address: Z j r_,) (e2 Mc Iso,; (ZCQ / /V. Owner: ' Nyytf "[ v c.' Date of Inspection: ('13)a TIGHT OR HOLDING TANK: Tank must be pumped prior to, or at time, of inspection) (locate on site plan) Depth below grade: Material of construction: _concrete _metal _Fiberglass _Polyethylene —other(explain) Dimensions: Capacity: gallons Design floes . gatlonJda% Alarm level Alarm in working order _ Yes. _ No Date of previous pumping: Comments: (condition of inlet tee, condition of alarm and float switches. etc.) DISTRIBUTION BOX:_ (locate on site plan) Depth of liquid level above outlet inven:�_ Comments: (note if level and distribution is equal, evidence of solids carryoler evidence of leakage into or out of box etc.) + R0 X /-5 1 n 4 c7n to C e)'-4 /'Udl _ so nr P G u 'd,, #i ee f� PUMP CHAMBER:/IM (locate on site plan) Pumps in working order: (Yes or Not Alarms in working order (Yes or No) Comments: (note condition of pump chamber, condition of pumps and appurtenances, etc.) (revised 0{/25/97) Fag. 7 of 10 ...... -_..._ _----�- SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM t PART C SYSTEM INFORMATION (continued) Property Address: 2l FAcjZ 4AccJo_,, 00 Owner: v iM Date of Inspection: SOIL ABSORPTION SYSTEM (SAS):_ (locate on site plan, if possible: excavation not required. but may be approximated by non -intrusive methods) If not determined to be present, explain: W leaching pits. number:_ leaching chambers, number:_ leaching galleries, number: leaching trenches, number,length: ` leaching fields, number, dimensions:_/ SO 9OJ Se. Fll' overflow cesspool, number: Alternative system: Name of. Technology: Comments: ` (note condition of soil, signs o hydraulic failure level of ponding. condition of veg=tion, etc.) /4'^e_' Ascf Sk401 Gb � 0© CESSPOOLS: C, (locate on site plan) Number and configuration: Depth -top of liquid to inlet invert. DRpth,of solids layer: , Depth of scum laver: Dimensions of cesspool: Materials of construction: Indication of groundwater: inflow (cesspool must be pumped as pan of inspection) Comments: (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.) PRIVY: /y (locate on site plan) Materials of construction: Depth of solids: Comments: (mote condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.) (r•vis.d 04/2s/f7) P.0. • of 10 Dimensions: a SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: 21 R, efZ /vl clicY p,,—) N , sq rcp J( z Owner: Date of Inspection: 03�qg - SKETCH OF SEWAGE DISPOSAL SYSTEM: include ties to at least two permanent references landmarks or benchmarks locate all wells within 100' (Locate where public water supply comes into house) U fz (r•viv•d 04/]5/97) paq• 9 of 10 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: If,_)I(c,e /�«cQo..✓ ilk, AJ• �K��✓ems Owner: ,� l Date of Inspection: �131�a Depth to Groundwater Feet Please indicate all the methods used to determine High Groundwater Elevation: Obtained from Design Plans on record Observation of Site (Abutting property, observation hole, basement sump etc.) Determine it irom local conditions Check .,!th !oca! Board of health Che6 FEMA neaps Check pumping recotds Check local excavators, installers Use USGS Data Describe in .-aur own words how you established the High Groundwater Elevation.: (Must be completed) 0- S(� 01— ScPhc -ds�ew• c} �.�L�J1 ct��✓e C, f,;5 S � Z0 t l9 -s, s . C, S- I MS PS 51,o.,f t I (r—i-.d 04/71/9,) Pay. 10 of 10 TOWN OF NORTH ANDOVER SYSTEM PUMPING RECORD DATE: a 1 X51 o a SYSTEM OWNER & ADDRESS SYSTEM LOCATION (example: left front of house) DATE OF PUMPING: 9 I Z,j) t)a QUANTITY PUMPED so o GALLONS CESSPOOL: NO % YES SEPTIC TANK: NO YES NATURE OF SERVICE: ROUTINE EMERGENCY OBSERVATIONS: GOOD CONDITION FULL TO COVER HEAVY GREASEBAFFLES IN PLAOE ROOTS LEACHFIELD RUNBACK EXCESSIVE SOLIDS FLOODED SOLIDS CARRYOVER OTHER (EXPLAIN) 11 SYSTEM PUMPED BY: 3 5. Znzer 3erv; c e COMMENTS: CONTENTS TRANSFERRED TO: h Commonwealth of Massachusetts ; , D = v City/Town of NORTH ANDOVER [MASSA SE System Pumping Record Nov 14 2007 Form 4 M TONT,,, i jl N( RTH ANDOVER Ht- :,I,rti ;DEPARTMENT DEP has provided this form for use by local Boards a ystem Pumping Record must be submitted to the local Board of Health or other approving authority. A. Facility Information Important: When filling out 1. System Location: a forms the A Il r,lA' 1 r computer, use f" 1 only the tab key AdVs s / to move your ( cursor - do not City/Town State Zip Code use the return key. 2. System Owner: Name Address (if different from location) City/Town Stat Zip Code '--6-('93- L9 f Telephone Number B. Pumping Record 1. Date of Pumping 3. Type of system: ❑ ❑ Other (describe): n2. Quantity Pumped: Date Gallons Cesspool(s) P' Septic Tank ❑ Tight Tank 4. Effluent Tee Filter present? ❑ Yes 9 No 5. Condition of System: 6. System Pumped By: If yes, was it cleaned? ❑ Yes ❑ No e iVehicle License Number V11-1 A CJ A- 9�4 A MY- L�8'1 Company 7. Location where contents were disposed: C\ ��-, - -- nature of Hauler yDate http://www.mass.gov/dep/water/approvals/t5forms.htm#inspect t5form4.doc• 06/03 System Pumping Record • Page 1 of 1 0 y Na 'n �. r y r y m� n o 5� O °nfu oCZ*. 0 0 ori o m m C CD m y b! CD y i Q C p cQ (0 d CD c'"D y .1 7 3 3 AA 0 o o Cl)cx oo rn 0 � ? v A y 3.� y_ y 3 0 3 0 3 QIC (A N co Q T 3 p O O cu m y o c O y 0 0 0 y • a y �• O O � � y x CD 03 y 3 � n ID P 0 0 o Ort O v 0 cn o 0 r- 0 n � w m cx C o CD v cn m y O 0 (n y a C � a y y � y ? 1 Q o �CD 0 Gv coy v v r g n CO)� o �, � a x 3 o. 0 v r r Z p ''• N zr a' o C) = 3 CD y CD t ° 0 a t V C O o C) y 0D C) y Na 'n �. r y r y m� n o 5� O °nfu oCZ*. 0 0