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HomeMy WebLinkAboutMiscellaneous - 21 SOUTH CROSS ROAD 4/30/2018 (2)r 1 ,.t .P IiG raG �.t ,.P I�t Int 1 r'� x771-zZ,) so �2o g OWN - 0., 3C)������ M -57 2 MAP # �s - PARCEL # 1,? -)C) I w LOT STREET ZD HAS PLAN REVIEW FEE BEEN PAID? YES z NO PLAN APPROVAL: DATE APP. BY.-,,, e w, DESIGNER: PLAN DR -TE. CONDITIONS— Z:>—,e3cw '7-0 06 'oplkeeo Rr_3 WATER SUPPLY: TOWN WELL WELL PERMIT WELL TESTS: CHEMICAL DATE APPROVED. -..-- BACTERIA I BACTERIA Il COMMENTS: DATE APPROVED DATE APPROVED FORM U APPROVAL: APPROVAL TO ISSU NO DATE ISSUED BY CONDITIONS: - ----- ---------- FINAL APPROVAL: YES ALL PERMITS PAID (4k;—, NO WELL CONSTRUCTION APPROVAL NO SEPTIC SYSTEM CONSTRUCTION APPROVAL YES NO OTHER YES NO ANY VARIANCE NEEDED YES 01 FINAL BOARD OF HEALTH APPROVAL: DATE: - BY BY* too SEPTIC IS THE INSTALLER LICENSED? TYPE OF CONSTRUCTION: NEW CONSTRUCTIRWA.-- CERTIFIED PLOT PLAN REVIEW CONDITIONS OF APPROVAL (FROM FORM U) YES NO -REPAIR NO YES NO ISSUANCE OF DWC PERMIT YES NO D WC PERMIT 0 WC PNO. INSTALLER: lj BEGIN INSPECTION EXCAVATION INSPECTION; lo� 40 (ONO: NEEDED: CONSTRUCTION INSPECTION: NEEDED: . . ..... ..... ..................... . ........... . .. AS BUILT PLAN SATISFACTORY: I - YES: APPROVAL TO BACKFILL: DATE :_�40/ BY FINAL GRADING APPROVAL: DATE ----BY- FINAL CONSTRUCTION APPROVAL: DATE: BY Commonwealth of Massachusetts City/Town of No Andover ° 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 within 14 days from the pumping date in accordance with 310 CMR 15!351. A. Facility k4formation - . - Important: When filling out forms 1. System Location: on the computer, use only the tab key to move your Address cursor - do not No Andover use the return key. City/Town 2. System Owner: tenon Name Address (if different from location) Cityrrown ,n cI Ma State State Telephone Number -B. Pumping Record 1. Date of Pumping 3. Type of system: ❑ Other (describe) Zip Code Zip Code Irvo Date 2. Quantity Pumped: %allons ❑ Cesspool(s) [�' Septic Tank ❑ Tight Tank ❑ Grease Trap 4. Effluent Tee Filter present? ❑ Yes 0 No 5. Condition of System: / 6. System d By: Name Stewart's Septic Service Company 7. If yes, was it cleaned? ❑ Yes ❑ No Vehicle License Number contents were disposed: aatment Plant, 20 So. Mill Bradford, Ma 01835 Date Date t5form4.doc• 03/06 System Pumping Record • Page 1 of 1 REL ED E c v JAN 0 6 2005 UA I't JYS77-?�-j POMPINQ R?- �TR'WN OF NORTH ANDOVER LT P TM T T M 7 EALT LH DEPARTU!ENIT UA Ct VMN DATI OF TITY :'.`.41POOL; rvKu . cwv-6'. YY PvLL I'v cov KZAQuAis KOM.: 0 excusNo Yl. �iil r{1!1 l.�a!•�IN {; I,�A Yt7i1 Ur�`!`.wr 'j. 41-t ��j� Y k't��(1 7 r 1 y Ya 1 { ' K'SI 11 � 1J 'i t J � 1' 1 • t< � , i ... . f i' ripri'`:ftr t.f1N+,a1\r,Mr 1 r•!i { . ... OCT • 1 .� f�'2T+N,{,� ♦� A.1 .1 r t i O it ! • !r r 2 001 r(y t, J_r f•� f 1r1 } IS 'l,�r•�rr;J,F 1a!�1. =f •.. �1 R: �1.r 7 •oF� No�T�• SYSTEM `AVER PUMPING RECORD - !� ' ` .•«�L.',�� �;f•.�•f.•y,��,7rw' :�� !t� aij •'�•f �t. , ;.,i•' �: , Q }: r�� �' i�: r�'iq' �i :�}j \•• ol 1, ?A!,: • • J���� r� a�'�ry� � �"Ix���i,�I�{'iM.�•,# •r i��l•�� �'"'K�%� ,`�iy �"�` a•Yk,::L'�F� .i+r1. �. 1r 1 ,�' ,. v 1S r• �•'r'� ) f �. � � �Y OWNER,iE ' SYSTEM LOCATIO`2 ka-frost Of houn)N rr r.:. \ vq •f"+ � ' �. 9y,: } ..d i �f.. rt_y.� J 4r, 1 r`\��y� �f sJ r 1' r 1 ��( .. tQVANTITY PUMP o F.a� GALLONS _--•.,f1't (�� * f('.:•. ,•�_ 4M4, Y '�1'�; r;[..�(+:��Rk�:}<oJl ' dr`alh NO ����� tiiil<r S i 1r, ' YES 'PneL��'`�"� a •k` �rM"•M � �'�Y � f 1- rg c 'i�w� 1. (��,. u{Ir l°.y ^h 1., f•� \•>tOUTMM' �N./"a'' ./1 __ /.//•�/• ` dERGENCY �J �.`r p h;Y �, +....� r "�i•3ii� i.Mkl'il� � 7 �hi,� n}�f.^.�rr y�IT�ON.S• it Ti+.`.".. ayCt,. 1 • " � h�'t �+ " ..... �, • .. . , �..... ',I�,��OD'C411�j��ON�..i1f�.:�� ,r;�.r7j'•w ',. , . _ _:� I • . $GOTS CAS$ , B'Ff TO ovER IN p LACE SOLIDS FIELD RUNBACK LOom CARRYOVU 071M (WLA" '�prr ��,• Ilk. 90 'i. Nfy'A'�N i� rrril r r.Y,� `hit' r cti�11 r 1,'1 f i•t ' , ell 0001, . f. 1'+'�{ . \ rJ,i �'{jaiti7 I�.�;r. + , r,�• i�Qy ff r . ; . .. ,. '�''�}Ji,"11,,�, t'�irs. 1 �` ;t�''ti1• f a �'r>,+i.l.l t - I.T��,G{�)y,.'in�4 1+.. .:1'�yr.f11�!;. 1 l•'11"V !h'jy1J`• •• j, , lr Ilr .•r �, v ?i'+�.t�f 4}1.r 4: R`��tl^" _ 7L///�`� /�. /�/ r•. 1 f;Y � A rl' • f / t s*('•�1`f : 4° �"i1�� 167'� Town of North Andover, Massachusetts Form No. 1 NORTH BOARD OF HEALTH 16 -19 10i APPLICATION FOR SITE TESTING/INSPECTION Applicants�- NAME ADDRESS TELEPHONE Site Location•° ., r Engineer -- -;I ,, �i� � �- cr:iG�,� � - NAME ADDRESS- �r{,�.�v� _ r JELEPHONE Test/Inspection Date and Time J, CHAIRMAN, BOARD�OF HEALTH Fee Test No.`s( S.S. Permit No. D.W.C. No—) � C.C. Date Plbg. Permit No. SCOTT L. GILES, R.P.L.S. 50 Deer Meadow Road North Andover, MA 01845 683-2645 ,3//0 /f i f� C-�7�?O�✓S O eLj Cp ? ' a -.1 o v ill /V�� ell Aj 13 /t,3 �q t V PLAISTOW PRECAST CORP. /V- c• - ROUTE 108, PLAISTOW, N.H. 03865 -TELEPHONE 1-603-382-4040424C1--rl 4" A C o v F- r4 3 R E & A R p 12 " 0 C L-'. 0 T H 5 ,-- --- --1--- 11 - - � I - - --- 17 I la UJul Jul 'M 8 L 11, Ell 9 all ri) to' Lui'l L IL CAPACi-,y n: AtAFTER . 500 A 414 48 3-7 10 ' --oo 56 , 0 m 83 70 PEC I F: CAT 10 N 5 rRC NGTofy p 5 I. AT 26 DAYS •NFOAC6MI. . 6"X/0 GACAGE srEF-L pFPRO►�ED R.A.M. ENGINEERING ROBERT A. MASYS, P.E. ONE MASYS WAY HAVERHILL, MA 01 830 PHONE: (61 7) 372-0449 January 28, 1991 Board of Health Town of North Andover Town Hall Main Street North Andover, MA. RE: Lots # 1 & # 2, South Cross Road, North Andover Dear Mr. Rossetti, Attached, please find two copies of the above revised plans. We have added the information you requested in your comments of January 24, 1991. If I can furnish any additional information, please call me. Very truly yours, Robert A. Masys, P.E. L.oG AT E� l U i.1 nrz-r H A u D D �!t•=ice y �-/� ASS 2�22(go ufloNeQ—= 4. Z Gtr VZT 1 F� '"['HAT' THE. dF'FS�cT'S Suow1,-A 1-1 '1-- X055 e a c� FFS�T� �+ia..v ►J A1Z� �ol�. `C'NE, ,. USE. O F• `T'1-� �. a U t t� i7 t t..i C� � u S PECtt7 . ;i C e�:) ►.1 Com`/ A --► fl S Crc3 �t W'Y o► -.i Go ►..1 Fo2,N1- � * \Y� \A.1 H G k -A Go lk. SYIP, tJGTC=' ,= IW2 r FOIui U TOWN OF NORTH ANDOVER LOT RELEASE FOR11 SUBDIVISION ASSESSORS MAP SUBDIVISION LOT(S) PERMANENT ADDRESS ASSIGNED BY D.13 W. STREET APPLICANT ��\���� v{ �`L 1'HONL' DATE OF APPLICATION TOWN USE BELOW 1111S LINE CONSERVATION COHRISSION CONSERVATION ADMIN. i BOARD OF HEALTH DEPARTMENT OF PUBLIC WORKS DRIVEWAY PEiu1IT 6,04 SEWER/WATER CONNECTIONS r FIRE DEPT. &Y C�- TlU RECEIVED BY BUILDING INSPECTION DATE DATE APPROVED DATE REJECTED DA'Z'E APPROVED DATE REJECTED DATE APPROVEID �_;? DATE REJECTED This form shall be signed by the agents of the Planning and llealtll Bonrds, the Conservation Commission prior to the issuance of any bullding per.inf.ts for the subject lot. This form sliall not releive the applicant from the compliance of any applicable Town requirement or Bylaw. NORTH Ot z"�O ,° 9ti0 t 9 �9SSncfHUSEI BOARD OF HEALTH 120 MAIN STREET TEL: 682-6483 NORTH ANDOVER, MASS. 01845 Ext. 32 or 33 December 13, 1990 Mr. Robert Masys Ram Engineering One Masys Way Haverhill, MA 01830 Dear Bob: This office is in receipt of proposed septic designs for Lots 1 and 2 So Cross Rd. According Board of Health records, no fees to this Department were ever paid for any of these lots. Please inform your client that all fees must be paid before a review of the plans will be conducted. The following fees must be paid: - Soil Testing ($150/lot) 4 lots $600.00 - Plan Review Fee ($60/lot) 2 lots 120.00 Total $720.00 Once these fees have been received, a review of the plans submitted will commence. Sincerely, Michael J. Rosati Health Agent MJR/rel DATE OF PUMP11ya.- -QuANTITY Ptjmpr,-i>. / 'eae LN -SPOOL, No- y NA YURL KQU UNh. (M-NERVA DONS. Gt)OD CONDI 1'1(.)N FULL ro,�oVt* HEAVY GREASF BAFFLES IN IyPILA(:i. RO()T$ LEAC-HWjf.,LD p - EXCESSWL., S,()LIL)s FLOODED � NBACK -SOLID CARRYoVF_R ------ (.)'MER EXPLAIN tAJMMLN I N k.'UN I LN la I K.ANS#-tKRED I ofHFA. i�-1 Lar Z S . G'gp5S �27 . (A )A -r S� Nf'Ly �] F6)wtJ - 0 Ujc u— �P�oyCD 1Y,ITG sS :5 PT'Ic sYs T� �� /J!'r��v�NG /u7r-1oKrry �I�QPPR4VED Co,��(���5 R�4SoNS = .mac .cam ��w G - � N DwC-- c7YCAV4TMJ C SV 5TEM \ ,k.) 51%o 1 SPt�-.G TIOtiJ 4 PP1�C�V ED GQ/JTC Dt�,l.1Pt�KUvEIJ rC DA Re&so NS FVAL APPI�DVAL 016—r in" Ll %� 'S [� F -A ►L- F T/J L1 Pry S5 `— t=4)L �i'1�l�Vrn.�G �lUr�fUI�ITy I N<0T4 t; AP��ov �6 /S v i�-►OJ�I i�j Town of North Andover, Massachusetts Form No. 1 NORTH BOARD OF HEALTH qq� Q��T,Eo ib q�rOOL / 191/__ m� APPLICATION FOR SITE TESTING/INSPECTION R ' L qo ccE oP` .F Applican Site Location "I- 14 — Engineer Test/Inspection Date and Time Fee Z�j U" S.S. Permit N (� L � 0-/- �) M C) CHAIRMAN, BOA RlY4>F tWALTH— Test N o. W.C. No. C.C. Date Plbg. Permit No. DATE 1 124. 1 1 E Sheet of '2._ BOARD OF HEALTH TOWN OF NORTH ANDOVER SUBSURFACE DISPOSAL DESIGN REVIEW FEE /160 PERMIT # _ APPLICANT QLZW C...20SGi/-) ADDRESS PCS f-yC 95-2- L%�Zc�2G�c ENGINEER XMA/ ADDRESS % MNI S PLAN DATE DATE RECEIVED SSOR'S P RCEL # %sTiTEET # L-, r-2. C41c) -5 12LD REVISIO DATE t I --bo CONDITIONS OF APPROVAL: \ ` APPROVED DISAPPROVED JS Aa s S�-'�35crtl T -V to sau � 'F'(a►� � ��1,-�J IQ ��t, t � �-tc �( � s�-�c � ��- � �� � dor � ` � GG ;_X 1 ekc_renn►- S �� �-s N� c`t✓ CZ �t�?� � � t N �tZ=�u -c� 'ck; VA r REVIEW CONTINUED SHEET OF Z` q� L N J E►'�-t d �8:� Ll.r� c� �. 'TU �E�� �-i� j � ST"C.=� P(PL. LC-xv� T71 d e cS r -r ("J/ 2.10 s �or F i G:?T-1 �-► ECS 'f cru i..d rx�:-c-� r7 sa.� '��....-� :.� lrocca-r�r> > u ►��r�,-c-�__A ►.a r��.r��,�r>_..�t .ass, 22 3 rsj4t IL flbv�e.Macs_ 1. Hsi• I"tG.3R � GE.2T11=� THAT o F'FSE^TJ �}-Idk� ►..i AE.E� �02. Tl -{E, ^�r.^tf �� -. THEr oFFSrcTS uSE, oF- -T-44 4E— nl►..1CZ, c:TL� >I O �LC.�y A �...1 O S UGH U S rC.. 1 S �� 2� t iqr • ,%e IS \,cl lT �t THE. ZALj' ��T E�2 til t %.1 AT l 01._i d F' Z.o !`i t ti G �/ 1. •Ati (S t7 C•o ►•1 F- 02 !-tel lT ?/ oTL L-1 a ►-.l C.o ►.J T=CAr- M- k -I co L-.► ST le, 10GTc-.D. bc(14 Ult.,T Z 22(Qo ills 9C William F. Weld Gowmor Trudy Coxe a Seenty EDEA David B. Struhs Commissioner Commonwealth of Massachusetts Executive Office of Environmental Affairs Department of Environmental Protection n SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION PART A v CERTIFICATION n Q/j lo Property Address: d� Sa • C'�o �s GA res of Owne�" Date of Inspection: �_rJ` (If different) Name of Inspector: c Company Name, Address and Telephone Number: 5 4 m.t TOWN OF NORTH ANDOVEI BOARD OF HEALTH JUS 14 1996 '-N,IDvty Spf"Irc CERTIFICATION STATEMENT #7 441 L/LvAn t'/ -e., A/V - I certify that I have personally inspected the sewage disposal system at this address and that the information reported below is true, accurate and complete as of the time of inspection. The inspection was performed based on my training and experience in the proper function and maintenance of on-site sewage disposal systems. The system: Passes Conditionally Passes Needs Further Evaluation By the Local Approving Authority _ Fails Inspector's Signature: 66"p-.0 Date: The System Inspector shall submit a copy of this inspection report to the Approving Authority within thirty (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 Department of Environmental Protection. The original should be sent to the system owner and copies sent to the buyer, if applicable and the approving authority. INSPECTION SUMMARY: Check A, B, C, or D: A) SYSTEM PASSES: i I have not found any information which indicates that the system violates any of the failure criteria as defined in 310 CMR 15.303. Any failure criteria not evaluated are indicated below. B] SYSTEM CONDITIONALLY PASSES: 14. iA One or more system components need to be replaced or repaired. The system, upon completion of the replacement or repair, passes inspection. Indicate yes, no, or not determined (Y, N, or ND). Describe basis of determination in all instances. If "not determined", explain why not) The septic tank is metal, cracked, structurally unsound, shows substantial infiltration or exfiltration, or tank failure is imminent. The system will pass inspection if the existing septic tank is replaced with a conforming septic tank as approved by the Board of Health. (revised 8/15/95) One Winter Street a Boston, Massachusetts 02108 a FAX (617) 556-1049 a Telephone (617) 292-55W 0 Printed on Recycled Paper SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: ,2/' SQ. Cross XJ Owner: %� / \ Date of Inspection: V 4 gra- B] SYSTEM CONDITIONALLY PASSES (continued) N Sewage backup or breakout or high static water level observed in the distribution box is due to broken or obstructed pipe(s) or due to a broken, settled or uneven distribution box. The system will pass inspection if (with approval of the Board of Health): broken pipe(s) are replaced obstruction is removed distribution box is levelled or replaced The system required pumping more than four times a year due to broken or obstructed pipe(s). The system will pass inspection if (with approval of the Board of Health): broken pipe(s) are replaced obstruction is removed C] FURTHER EVALUATION IS REQUIRED BY THE BOARD OF HEALTH: p. A. Conditions -exist which require further evaluation by the Board of Health in order to determine if the system is failing to protect the public health, safety and the environment. 1) SYSTEM WILL PASS UNLESS BOARD OF HEALTH DETERMINES THAT THE SYSTEM IS NOT FUNCTIONING IN A MANNER WHICH WILL PROTECT THE PUBLIC HEALTH AND SAFETY AND THE ENVIRONMENT: -- Cesspool or privy is within 50 feet of a surface water Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh. 2) SYSTEM WILL FAIL UNLESS THE BOARD OF HEALTH (AND PUBLIC WATER SUPPLIER, IF APPROPRIATE) DETERMINES THAT THE SYSTEM IS FUNCTIONING IN A MANNER THAT PROTECT THE PUBLIC HEALTH AND SAFETY AND THE ` ENVIRONMENT: The system has a septic tank and soil absorption system and is within 100 feet to a surface water supply or tributary to a surface watei supply. The system has a septic tank and soil absorption system and is within a Zone I of a public water supply well. The system has a septic tank and soil absorption system and is within 50 feet of a private water supply well. The system has a septic tank and soil absorption system and is less than 100 feet but 50 feet or more from a private water supply well, unless a well water analysis for coliform bacteria and volatile organic compounds indicates that the well is free from pollution from that facility and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm. D] SYSTEM FAILS: P. A. I have determined that the system violates one or more of the following failure criteria as defined in 310 CMR 15.303. The basis for this determination is identified below. The Board of Health should be contacted to determine what will be necessary to correct the failure. Backup of sewage into facility or system component due to an overloaded or dogged 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 i cesspool. (revised 8/15/95) •* -2 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: 1 SQ f!"��s s � 14Q V ~ Owner: /� � � � P✓ Date of Inspection: D] SYSTEM FAILS (continued): A t A 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 1/2 day flow. Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number of times pumped Any portion of the Soil Absorption System, cesspool or privy is below the high groundwater elevation. Any portion of a 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 I 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. If the well has been analyzed to be acceptable, attach copy of well water analysis for coliform bacteria, volatile organic compounds, ammonia nitrogen and nitrate nitrogen. E] LARGE SYSTEM FAILS: 1-1, A The following criteria apply to large systems in addition to the criteria above: The design floe of system is 10,000 gpd or greater (Large System) and the system is a significant threat to public health and safety and the environment because one or more of the following conditions exist: the system is within 400 feet of a surface drinking water supply the system is within 200 feet of a tributary to a surface drinking water supply the system is located in a nitrogen sensitive area (Interim Wellhead Protection Area (IWPA) or a mapped Zone II of a public water supply well) The owner or operator of any such system shall bring the system and facility into full compliance with the groundwater treatment program requirements of 314 CMR 5.00 and 6.00. Please consult the local regional office of the Department for further information. (revised 8/15/95) 3 4 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST Property Address: Owner: /� 4R Q e /L Date of Inspection: (,� Check if the following have been done V P-Lmping information was requested of the owner, occupant, and Board of Health. V_ None of the system components have been pumped for at least two weeks and the system has been receiving normal flow rates Suring that period. Large volumes of water have not been introduced into the system recently or as part of this inspection. _ As built plans have been obtained and examined. Note if they are not available with N/A. /Tte facility or dwelling was inspected for signs of sewage back-up. e system does not receive non -sanitary or industrial waste flow The site was inspected for signs of breakout. 7_ All system components, excluding the Soil Absorption System, have been located on the site. The septic tank manholes were uncovered, opened, and the interior of the septic tank was inspected for condition of baffles or 1tees, material of construction, dimensions, depth of liquid, depth of sludge, depth of scum. he size and location of the Soil Absorption System on the site has been determined based on existing information or / approximated by non -intrusive methods. The facility o-,%ner (and occupants, if different from owner) were provided with information on the proper maintenance of Sub - Surface Disposal System. (revised 8/15/95) 4 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION Property Address: p�,/ ✓ t, f'GSS „�� �,�! as 6��� Owner: Date of Inspection: G�(� e e:f2—/�"� FLOW CONDITIONS RESIDENTIAL: Design flow: stallogs Number of bedrooms: t -J Number of current residents: Garbage grinder (yes or no): yf Laundry connected to system t(yes or no)y Seasonal use (yes or no): Water meter readings, if available: ALA. Do MG"r' V Ta flR ff coot 1t4 0'►'✓ Last date of occupancy: is tr Pt ''- 4 COMMERCIAL/INDUSTRIAL: t( n Type of establishment: Design flow:_allons/day 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: OTHER: (Describe) Last date of occupancy: GENERAL INFORMATION PUMPING RECORDS and source of information: G#j f ve.3 ✓ System pumped as part of inspection: (yes or If yes, volume pumped _.Z_ lh gallons Reason for pumping: TYPE Off -SYSTEM t/ Septic tank/distribution box/soil absorption system Single cesspool Overflow cesspool Privy Shared system (yes or no) (if yes, attach previous inspection records, if any) Other (explain) t°S APPROXIMATE AGE of all components, date installed (if known) and source of information: PA. Sewage odors detected when arriving at the site: (yes or no) _ (revised 8/15/95) 5 Property Address: Owner: Date of Inspection: SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) / S� Goss �'-� 1�1. 1�J-r ©oV'Pv ri- 9d TIGHT OR HOLDING TANK:_ (locate on site plan) 7 Depth below grade: Material of construction: _concrete _metal _FRP —other(explain) Dimensions: Capacity: gallons Design flow: gallons/day Alarm level: Comments: (condition of inlet tee, condition of alarm and float switches, etc.) DISTRIBUTION BOX: Yes (locate on site plan) Depth of liquid level above outlet invert: tJ•2 Comments: (note if level and distributicr i� equa!, evidence of sohd< carryover, evidence of leakage into or out of box, etc.) NU v1gfHce Of Cc'2R.i5.e - PUMP CHAMBER:_' (locate on site plan) Pumps in working order:(yes or no) Comments: (note condition of pump chamber, condition of pumps and appurtenances, etc.) (revised 8/15/95) 7 r SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C /� Q SYSTEM INFORMATION (continued) Property Address: (� �7 d 2 e� / S' 4 e"o S S )Gi�` �' ' A" = v Owner.: Date of Inspection: 6 �r SEPTIC TAN410-5, (locate on site plan) Depth below grade: Material of construction: _concrete _metal _FRP —other(explain) Dimensions: 4- Sludge Sludge depth: � Distance from top o sludge to bottom of outlet tee or baffle: Scum thickness: V ` t „ Distance from top of scum to top of outlet tee or baffle: Distance from bottom of scum to bottom of outlet tee or baffle: 1 �4 r► 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.) / 1-1 Le r + OQ T (,c?- 4rt4(_r,_G G c O STRyc iu IZAL�l G p o h GREASE TRAP:_ (locate on site plan) Depth below grade: Material of construction: _concrete _metal _FRP —other(explain) Dimensions: Scum thickness. Distance from top of scum to top of outlet tee or baffle: Distance from bottom of scum to bottom of outlet tee or battle: Comments: (recommendation for pumping, condition of inlet and outlet tees or baffles, depth of liquid level in relation to outlet invert, structural integrity, evidence of leakage, etc.) (revised 8/15/95) Qs 6 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C n SYSTEM IINNFFORMATION (continued) Property Address: �� SO"Y�SS �` v -t Owner: Date of Inspection: (24a a U z 6 — • fl SOIL ABSORPTION SYSTEM (SAS): Yl- N (locate on site plan, if possible; excavation not required, but may be approximated by non -intrusive methods) If not determined to be present, explain: Type: leaching pits, number: P(7-5 leaching chambers, number:_ leaching galleries, number: leaching trenches, number,length: leaching fields, number, dimensions: overflow cesspool, number: Comments: (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation,etc.) CESSPOOLS: (locate on site plan) Number and configuration: Depth -top of liquid to inlet invert: Depth of solids layer: Depth of scum layer: Dimensions of cesspool: Materials of construction: Indication of groundwater: inflow (cesspool must be pumped as part of inspection) Comments: (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.) PRIVY: _ (locate on site plan) Materials of construction: Dimensions: Depth of solids: Comments: (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.) (revised 8/15/95) 8 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: �% % �a US'S' v '� V Owner: Date of Inspection: r, SKETCH OF SEWAGE DISPOSAL SYSTEM: _ include ties to at least two permanent references landmarks or benchmarks /ok),q locate all wells within 100' *. OI 11) L"r, ) ),Jq 5 DEPTH TO GROUNDWATER �. Depth to groundwater:�feet method of determination or approximation: Due, Vw i,/ W l I " at c 14 Lf /a 7112 lu4rt•✓ VV i3SP✓Ue (revised 8/15/95) 9 DEP hal p(OvIdod if fcrnfor bo +�'�n,lllod to the local Boars c1 Ar r fl�)at I o �n Faculty �I �n Tno Sy3;0,m p (n 0 r I ry. HEALTHlDEPARTMENT y�, � I I t-11RTMENT1 4UL)VLR PA 3X5("Im LoczUon: ST �XVOM(Dwnr, I 7N7n �f Q n,mpor ,:Pumping .Record L D'a,e of Pu*m' pinp OS�;: 2. an -.r —Z5 TYPQ 91 oy3l6mCDO QPUc TanK EtflUOM To oMo( p(p_wr? L Y050 If Yes, was 1, .,Car, n � yes n n y e y Ic, wn v� n Where. cQ nls'Wera c,'5posad WI m P P (,Q rM5, nl,- Im 5 nm ty �L\ Commonwealth of Massachusetts-_ *--- \. City/Town of NORTH ANDOVER MASSA USET S System Pumping Record FE6 � 4 U10 l;t@�� Form 4 TOWN OF NORTH ANDOVER DEP has provided this form for use by local Boards of Health. Th must be submitted to the local Board of Health or other approving authority. City/Town V State Zip Code State Telephone Number Zip Code B. Pumping Record rr\� 1. Date of Pumping a l V 2. Quantity Pumped: Date Gallons 3. Type of system: ❑ Cesspool(s) °Septic Tank ❑ Tight Tank Other (describe): 4. Effluent Tee Filter present? ❑ Yes ❑ No 5. Condition of Svstem: 6. System Pumped By: rk"r-f Se►�-IC Company 7. Location where contents were disposed: Signature of Hauler http://www.mass.gov/dep/water/approvals/t5forms.htm#inspect If yes'was it cleaned? ❑ Yes ❑ No Vehicle License Number Date k t5for4.doc- 06/03 System Pumping Record • Page 1 of 1 A. Facility Information Important: When filling out fors on the 1. System Lo n: /� e computer, use lJ� only the tab key A dress to move your ctn,ka. cursor - do not ity/ Town use the return key. VQ 2. System Owner: Do r hjnc�— Name Address (if different from location) City/Town V State Zip Code State Telephone Number Zip Code B. Pumping Record rr\� 1. Date of Pumping a l V 2. Quantity Pumped: Date Gallons 3. Type of system: ❑ Cesspool(s) °Septic Tank ❑ Tight Tank Other (describe): 4. Effluent Tee Filter present? ❑ Yes ❑ No 5. Condition of Svstem: 6. System Pumped By: rk"r-f Se►�-IC Company 7. Location where contents were disposed: Signature of Hauler http://www.mass.gov/dep/water/approvals/t5forms.htm#inspect If yes'was it cleaned? ❑ Yes ❑ No Vehicle License Number Date k t5for4.doc- 06/03 System Pumping Record • Page 1 of 1