HomeMy WebLinkAboutMiscellaneous - 210 RALEIGH TAVERN LANE 4/30/2018 (2)I
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04/06/1997 15:02 5083736611
STEWART/ANDOVER-- PAGE 01
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RECE71VED
Commonwealth of Massachusetts
U�
City/Town of North Andover 5 6`4 U 0� 14
System Pumping Record TOWN OF NORTH ANDOVER
HEA
rLT, DEPARTMENT
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 CM R 15.35 1.
5. Condition of System:
6. System Pumped By:
Name Vehicle License Number
Stewart's Septic Service
Company
7. Location where contents were disposed:
Stewart's Pre-treatment Plant, 20 So. Mill Bradford, Ma 01835
Signature of Hauler
Signature of Receiving Facility
Date
Date
t5form4.doc- 03/06 System Pumping Record - Page 1 of 1
A. Facility Information
Important: when
filling out forms
1. System Location:
on the computer,
210 691/e(!�6'Touzffn
hne
use only the tab
key to move your
Address
cursor - do not
use the return
North Andover
Ma
01886
key.
CityfTown
State
Zip Code
2. Systallowner:
) 5 ro
Name
Address (if different from location)
City/Town
State
Zip Code
Telephone Number
B. Pumping Record
1. Date of Pumping Date 2.
Quantity Pumped:
Gallons
3. Type of system: El Cesspool(s) Iq Septic
Tank El Tight Tank
0 Grease Trap
Other (describe):
4. Effluent Tee Filter present? 0 Yes F� No
-if yes, was it cleaned?
0 Yes 0 No
5. Condition of System:
6. System Pumped By:
Name Vehicle License Number
Stewart's Septic Service
Company
7. Location where contents were disposed:
Stewart's Pre-treatment Plant, 20 So. Mill Bradford, Ma 01835
Signature of Hauler
Signature of Receiving Facility
Date
Date
t5form4.doc- 03/06 System Pumping Record - Page 1 of 1
�L\ Commonwealth of Massachusetts R E C I f.:
City/Town of No Andover 2
'-9 13
S� tu
EP 12 20-113
System Pumping Record
TOWN Or- NORTH ANDU VER
t
Form 4 LHEALTfH1, DE:P 'TM t"
AP
t' MENT
DEP has provided this f6rm 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 aetermine the form they use. The System Pumping Record must be submitted to
the local Board of HeaW or other approving authority within 14 days from the pumping date in
accordance with 310 CMR 15.351.
.4
A. Facility Information
Important: When
filling out forms 1 . System Location:
on the computer,
use only the tab 210 Raleigh Tavern Lane
key to move your Address
cursor - do not No andover
use the return
key. -- C-itylown- State Zip Code
2. System Owner:
Driscoll
Name
Address (if different from location)
City/Town State Zip Code
Telephone Number
B. Pumping Record
1. Date of Pumping 2. Quantity Pumped: 15069 LS
Date Gallons
3. Type of system: El Cesspool(s) R71 Septic Tank El Tight Tank El Grease Trap
El Other (describe):
4. Effluent Tee Filter present? 0 Yes E] No If yes, was it cleaned? F-1 Yes E] No
5. Condition of System:
-
6. System Pumped By:
7
Name
Stewart's Septic Service
Company
Vehicle License Number
Location where contents were disposed:
Stewart's Pre-treatment Plant, 20 So. Mill Bradford, Ma 01835
1 fl�ffl
SignaturkWadle/ Date
Signature of Receiving Facility
Date
t5form4.doc- 03/06 System Pumping Record - Page 1 of 1
-of Massachusetts
omm
-onwealth
Cit /T
y own of NORTH ANDOVER
MASS CHU
System P6'mp Sq �qnu
ing Record
Form 4 6 2006
TOWN OF NORTH ANDOVER
DEP has provided this form for use by local Boards of Health. JA%ke ord mu,,
be submitted to the local Board of Health or other approving authority,
A. Facility Information
Important:
When filling out 1. System Location:
forms on the
computer, use
only the tab key Address
to move your
cursor - do not
use the return City/Town
'late Zip Code
key.
2. System Owner:
Name
Address (if di Tere_�t —froi; I�cati�n)
U7
lt;7/ _�w____
T n State de
7
Tele�h—oTeNum—be—r--*---''*—*'------�----------------
Pumping Record
1. Date of, Pumping 2. Quantity Pumped:
D Gallons
3. Type of system: Cesspool(s) eptic Tank 7 Tight Tank
Other (describe):
4. Effluent Tee Filter present? YeaNg If yes, was it cleaned? Yes No
5. Condition of System:
6, SMem P�umped By:
Name '�_ehicle License
Company
7. Location where contents were disposed:
_C�_jQ_\Lz _22�',dt
IVi ature f Hsu
ture 0
Date
http://www.ma's�;gov,/dep/water/ provals/t5forms.htm#inspect
t5form4.doc- 06103
System Pumping Record - Page I of
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Sys'T'sm PuMPINQ U-Clokl-.. -SEP - 7
TOWN OF NORA/ANDOVER
HEALTH DEPAPTMENT
or
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SYSTEM OWNER & ADDRESS
cl
TOWN 0
sysAm
. FRECEIVED
....... ..........
TH ANDOVER SEp — 7 2004
'INQ RECORI-)
TOWN OF NORTH ANDOVER
0' �(�)±K.RTIIENT
' �i OC
HEALT�i_
M LVk;ATJON
'Z&4t
DATF OF PUMPING�
_�_._QUANTITY PUMPED:_.
CL8SPo(,)L: NOI---...,-...�-IYESI-".�-.-.�.- Septic Tank: YES
NATL)REOF SERVICE: KOU'I'INL,_/,.,-EMERC;EN(,,�,-.-,
013SERVA rioNs.
GOOD CONDITION FULLTO COVER
HEAVY GRF.ASE BAFFLES IN PLACE
ROOT$ LEACHFIELD RUNBACK
EXCESSIVE SOLIDS FLOODED
SOLID CARRYOVER'__- OTHF
R EXPLAIN
Syl'Lom Rwnpcd by
COMMENTS,
---------_---
CONTLNTS FKAN8FhRREDT().l_.___ 4/
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TO:
NORTH ANDOVER, MA. --,S. 19
BOARD 10! HEALTH
FROM: DESIGN ENGINEER Re: Soil Absorption
Sewage Disposal
System
This is to certify that I have inspected the construction materials of
said disposal system at
A �tion
North Andover, Mass. ' -�s
RICHARD
06", F.
The grades and -construction materia rKAPMUSKs
N
specifications dated
fied in my plans and
ilt 19 e�' 7).
Zv A
.Prof E96k0i%"L1?/Reg. Sdnitarian
TO:
NORTH ANDOVER, MASS. 19
BOARD OF HEALTH
FROM: DESIGN ENGINEER Re:
This is to certify that I have inspecte the Ic - ns u tic
said disposal system at
fl;niation
North Andover, Mass.
The grades and1construction materia
specifications dated 'Q2,�2, 6 -
Soil Absorption
Sewage Disposal
System
jaterials of
. . � . . 1. . �
R I CHARD
F.
fied in my plans and
ilt* 1� zi
.Prof. EHFIMPT/Reg. sd'hitarian
3oard of'Realth
lorth Ank- SEMC SMM
INSTM"TICK CM!X;K LISr LOT :j,A
IPPR VED DATE EXCAVATIM OK FAIL
7/7-10L
<
FAIL OK
1. Distance To:
a. Wetlands
b. Drains
Well
2. Water Line Location
No PVC Pipe
Septic Tank ----
a. -Tees �__Length & To Clean Out Covers
b. Cement Pipe to Tank - On Both Sides of Tank
5. Distribution Box
a. Covers & Box - No Cracks
b. A21 Lines Flowing Bqual Amounts
c. No Back Flow
Leach Field or Trench
a. Dimensions
b. Stone Depth
c . Capped Bads
d. Clean Double, Washed Stone
7. Leach Pits
a. Dimension
b. Stone th
ce SO Pads
d. s
L �h
i Pitr on
St �si
on th
:§h Pad
p
C. s r
d. Oa
6 C : pip
..e Cement Pipe to Pit Both Sides 01
r f
Clean Double Washed Stone
-TV 1-7
8. No Garbage Disposal
9. Final Grading.Inspection
10. Barricading Cove -red System
32. As Built Submitted
a. Lot Location.
b. Dimensions of System
c. Location with Regard -to Pere Test
V� d. Elevations
'I / a.* Water Table
Board of ffeelth
1.1a
Nor-th.-?"Odovor's, Ss
APPROVED DATE -;?-
Provided *
�
UF r
SI ISURFACE DISMAL DE61M CMIX LIST
LOT 10-0
4 K_; L3_A_ - - �
DISAPPROVEM DATE
Reasons:
Reg 2.5
The submitted plan mwt sholl as a
:a) the lot to be served-area.,dlmensioDn lot #.,ahmatters,
'b location =d log deep observation hoies-distance to ties
Nc location and results percolation tests -distance to ties
design calculations & calculations showing required leaching area
(a) lo, ation and dimensions of system -including reserve area
(f) eAsting and proposed contours
(g) location my wet areas vithin 1001 of sewage disposal system or
disclair.-r-check wetlands mapping
(h) surface and subsurface drains within 1001 of sevuge disposal
tem or disclaimer
(i) location my drainage easements idthin 3.001 of asuage dieposal
systEm or disclafter-PlamUng Board files
(J) Im-o= sources of water supply within 200t of sevage disposal
oyster, or disclaimer
location of W. 1)roposed vell to serve lot -1001 from leaching facility
(1) Tocaldon of vater 2ja On P,'�-�qpvarty-101 A-�om leacM_sig facility
location of be%Aimrk
drivei�ays
(o) sarbage diq*sals
(p) no PVC to be used In construction
q) pr,:)r1le of sysetsm-elevations of hasc-ment., plumb., pipe.. aeptic tank.,
distribut-ion box inlots =d cutlotsj, distribution field piping and
bt'uer el(E�.vations
(r) mwdyimm ground water elevation in area sounage disposal system
_(s) plan mst be prepared by a Professional Engineer or other
professional authorized by law to prepare such plans
Reg 6
Septic Tanks
(a) _ea_pa_H_tTs=s- 50% of flowp %mtar table., tees.9 depth of toes.,
access., pumping
(b) cleanout
110.2
(c) 101 from cellar -hnall or Ingratmd GmAming pool
(d) 259 from mbsurface drains
leg
Distribution Boxes
e 9 :Lo. 4
L=_�(b)
(a) s ope greater than 0.06
Subsurface
Reg 3-1.2
11.4
11.10
11.3-1
Reg 15.1
15.4
15.8
3.7
sign Chw�k
FAIL OK
List
Leachinp,, Pits
Leaching pits &re preferred where the installation is possible
a) calculations of leaching area-zinimum 500 sq ft
b) spacing
c) surface drainage 2%
[d) cover material
e) VxVAO splash pad
f) tee at elbow
% -- -bax to pipe
g) no bends in pip e from d
Laaehin Fields
a) n I o greater thihn 20 Ninutes/inch
b area -minim= 900 aq ft
c� construction of field
'd) surface drainage.2 %
1 e) 201 fftm cellar vall or inground swindng pool
—1c)
-1-1b)
Leaching T-Venches
Reg 14,1
14.3
14.4
14.6
14.7
a)--calcula ZT-leachiug area -min 500 aq ft
b) spacing -4 ft min 6 ft with reserve between.
dimwzlons
td) caustraction
e) aune
snrface drainage 2%
Domb-411, S1 e
a) s a X = to be shomn)
y/x X 150 = (to be shown)
—1c)
-1-1b)
3
Reg 9.1 a) ;jVraval
9.6 b) stand-by power
SOIL PROFILE & PERCOLATION TEST DATA
77-
12
North Andovert Mass. Street No 1,4,�
—Lot No
Loc/Subdiv. Pland Owner
Investigator
(2 Observer e�
SOIL PROFILE DATES
l.Elev 2.Elev 3.Elev 4.Elev
2- S)
0
0 0
1 1
2
4
5
n,
-0, 6
7
MU -0
9
10
Benchmark
Elevation
9 If,)
C
DATES
2
3
I
I
Location
Datum
PERCO�ATION TESTS
2
3
.9
5
6
7
8
9
10
Ties t
._,Q Test
riTIS
L-Aj%-, --
Pit Number 1 2
4
5
Start Saturation
Soak -Minutes
Start Test-WITMe
Drop of 311 -Time
Drop of 611 -Time
Mns.lst 311 drop
Mins.2nd 3" Drop
Percolation
-13
Lo -r
, r
("-N
v
It,
Lo -I- Z e
t5 C.^- L -s C
Y -A r-1 I" SKI F- L- I NJ J:�', E: 5
Ff E --5 rzc Ec- -f- �s
E� P-7
V. P P GL .0 UT
A -Z r. I a
I CAB,
Z� 0
Y. I ElE ox
9- E L-
A's/ F- 8Z A C4 E 5 -r<> -M
067 10 T -H _<2 P it c� e6 EF
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V_ . - -f
William F. Weld
Gavenno
Argeo Paul Celluccl
U. Governor
Commonweafth of MOSSaChusetts,
Executive Office of Environmental Affairs
Department of
Environm6ntal,,-Prote , di
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A '
CERTIFICATION
�?6
W
Truly Coxe'
/. I Secretary
'David B. Struhs
Commissioner
Property Address: 1 0 Lv A44
Date of Inspection: A Ovirner.
(If different)
Name of Inspector -
Company Name, Address and Telephone Numben BATESON ENTERPRISES, INC TEL: (508) 475-147/4
50 "7S- L4 r7 air, Excavating - Water & �ewer Lines - Septic Systems & Pumping Service FAX: (508) 475-5451
CERTIFICATION STATEMENT I I I Argilla Road Andover, Mass. 01,810
J "rti(Y 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
rnaintenance of on-site sewage disposal systems. The system:
I- -P. e s
Conditionally Passes
Needs Further Evaluation By the Local Approving Authority
Inspectoes Signature: Date:
The System Inspector shall submit a copy of this inspection report to the Approving Authority within thirty (30) days of completing this
inspection. It the system is a shared system of 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 ES:
=found any information which indicates that the system violates any of the failure criterlaas defined in 310 CMR 1 1 5.303.
Any failure criteria not evaluated are indicated below.
III SYSTEM CONDITIONALLY PASSES:
One or more system components need to be replaced or repaired. The system, upon completion of the replacement or repair, pas"s
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 failu*re is
imminent. The system will pass inspection if the existing septic tank is replaced with aponforming septic tank as approved
by the Board of Health.
(revised 11/03/95)
One Winter Street 0 Boston, Massachusetts 02108 9 FAX (617) S56-ioa Telephone (617) 292,5500
Pnnfed on Recyded Paper
9
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM'
PART A tr
CERTIFICATION (continued)
Property Address:
Ovvner. chc> Q VkACLAA
Date of Inspection: —9/
BI SYSTEM CONDITIONALLY PASSES (continued)
Sewage backup or breakout or high static water level observed in the distribution box is due to broken or obstructed pipe(s)
or due to a broken, settled or uneven distribution box. The system will pass inspection if (with approval of the Board of
Health):
broken, pipe(s) are replaced
obstruction is removed
distribution. box is.levelled or replaced
The system required pumping more than four times a year due to broken or obstructed pipe(a). The system will pass
inspection if (with approval of the Board of Health):
broken pipe(a) are replaced
obstruction is removed
Cl FURTHER EVALUATION IS REQUIRED BY THE BOARD OF HEALTH:
Conditions exist which require huther 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 ISNOT FUNCTIONING IN A
MANNER WHICH WILL PROTECT THE PUBLIC HEALTH AND SAFETY AND THE ENVIRONMEN11
— Cesspool or privy is within 50 feet of a surface water
— Cesspool or privy is within 60 feet of a bordering vegetated wetland or a aalt 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 soilabsorption system and is within 100 feet to a surf ce
a water supply or tributary to a
surface water supply. . 1, � '�: , " - rlj� f
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 60 feet of a private water supply wel',
The system has a septic tank and soil absorption system and is legs 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 thAiAe well is'free
from pollution from that facility and the presence of ammonia nitrogen and nitrate nitrogen is equal to or iess than 5 ppm.
3) OTHER
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION (continued)
Property Address:D10 Pok -t -e-1 L -V\
Owner.
Date of Inspection:
D) SYSTEM FAILS:
I have determined that the system violates one or more of the following failure criteria as defined in 310 C'MR 15.303. The basis for
th4 datormination JA idonjitiod below, The Board of Health should be c*ntacted to detormine whAt will be necessary to correct the
failure.
- Backup of sewage into facility or system component due to an overloaded or clogged SAS or cesspool.
— Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or.
cesspool.
— Static liquid level in the distribution box above outlet invert due to an overloaded or cloned SAS or cesspoc�l.
— 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 wen.
— 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 60 feet from a private water supply well with no
acceptable water quality analysis. If the well has been analyzed to be acceptable, attach copy of well water analysis for
coliform bacteria, volatile organic compounds, ammonia nitrogen and nitrate nitrogen.
El LARGE SYSTEM FAILS: 4
The fol.lowing criteria apply to large systems in addition to the criteria above:
The system serves a facility with a design flow of 10,000 gpd or greater (Large System) and the system is a significant threat to public
health and safety and the environment because one or more of the following conditions exist:
— the system is within 400 feet of a surface drinking water supply
— . . the system in 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 H of a public
water supply well)
The owner or operator of any such system shaU bring the system and facility into full compliance with the groundwater treatment program
requirements of 314 CMR 5.00 and 6.00. Please consult the local regional office of the Department for further information.
(revised 11/03/95) 3
I
I
SUBSURFACE SEWAGE DISP09AL SYSTEM INSPECTION FORM
PART B
CHECKLIST
Property Address:
Owner.
Date of Inspection:
Check if the foll ' have been done:
�P""O..i. information was requested of. the owner, occupant, and Board of Health.
�N,., If the system components have been pumped for at least two weeks and the system has been receiving normal flow rates
d i 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 NIA.
Thoofacility or dwelling was inspected for signs of sewage back-up.
ZTh �m does not receive non -sanitary or industrial waste flow
Th"rie was inspected for signs of breakout.
All system componenta, 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
ZZtees laterial of construction, dimensions, depth of liquid, dep�.h of sludge, depth of Acum.
he Pa. and location of the Soil Absorption System on the site has been determined based on existing information of,
C;app . ted by non-int'rusive methods.
The 7cifity owner (and occupants, if different from owner) were provided with information on the proper maintenance of Sub -
Surface Disposal System.
(revised 11/03/95) 4
7!11
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION
_T2 Property Address:
Owner.
Date of Inspection:
FLOW CONDITIONS
RESIDENTIAL,
Design flow: _g4llons 01U-0 �Q�
Number of bedrooms: Ll
Number of current residents: QL
Garbage grinder (yes or no):
Laundry connected to (yes or no): Yle-s
Seasonal use (yes or nrp!on
Water meter readings, if available:9 &cq-q�s "7, S
(4 1 00
L4 + e; 'cz -V'
V19
Last date of occupancy: C/—U<y'Z'.'k
COMMERCL4,L/INDUSTRLA.L-
Type of establishment: --
Design flow:____gaUons/day
Grease trap present: (yes or no)—
Industrial Waste Holding Tank present: (yes or no)
Non -sanitary waste discharged to the Title 5 systern: (yes or no)
Water meter readings, if available:
Last date of occupancy:
OTHER:- (Describe)
Last date of occupancy
PUMPING RECORDS and source of information:
GENERAL INFORMATION
. If
System Pumped as part of inspection: (yes or no) .\j
If yes, volume purnped� I S --&O X9.1lorp I
Reason for pumping: AaIA--t-,
7
.4
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)
Other (explain)
PROIaMATI� AGE of all components, date installed (if known) and source of information:
Sewage odors detected when arriving at the site: (yes or no) &10
(revis6d 11/03/95)
6
1 3
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued),
Property Address: LV\
Owner. Vokj VIAaAAA
Date of Inspection: FAC� Geofa�?-
SEPTIC TANK
(locate on site plan)
Depth below grade:
Material of construction: L--.-'n.rte —metal _FRP _other(explain)
Dimensions: Pr- t/ 21 5- Ovk�
Sludge depth: It
Distance from top of sludge to bottom of outlet tee or baffle:
Scum thickness: 3 11
top of scum to top of outlet tee
Distance from or baffle:
Distance from bottom of scum to bottom of outlet tee or baffle:
Comments:
(locate on site plan)
Depth below grade:_
Material of construction: —concrete —metal —FRP —other(explain)
Dimensions:
Scum thickness:
Distance from top of scum to top of outlet tee or baffle
Distance from bottom of scum to bottom of outlet tee or baffle:—
Comments:
(recommendation for pumping, condition of inlet and outlet tees or baffles, depth of liquid level in relation to outlet invert, structural integrity,
evidence of leakage, etc.)
(revised 11/03/95) 6
SUBSURFACE SEWAGE. DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Property Addrese. Q%C)
Owner.
Uo�j 1&&CkA4
Date of Inspection:
TIGHT OR HOLDING TAPM-V�CJ�
(locate on site plan)
Depth below grade:_
Material of construction: —concrete —metal —FRP _other(explain)
Dimensions:
Capacity: gallons
Design f[ow:______gallons/day
Alarm level:
Comments:
(condition of inlet toe, condition of alarm and float switches, et6.)
DISTRIBUTION BO)L-L---��
(locate on site plan)
Depth of liquid level above outlet invert:
Comments: .
(no if levVI anddistribution is equal, evidence of solids'c
(�if yover, evidence
_M, 1p t2\ t Jr., I J.1 0
CT -1 A
PUMPCHAMBER:-A1v?,,0- — cYcw
(locate on site plan)
Pumps in working order:(yes or no)
Comments:
(note condition of pump chamber, condition of pumps and appurtenances, etc.)
(revised 11/03/95) 7
box, etc.)
10K
a
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Property Address: a 10 Polp-% 4vA�-
Owner.
Date of Inspection: 69D
SOIL ABSORPTION SYSTEM (SAS):
(locate on site plan, if possible; excavation not required, but may be approximated by non-intrusive,ihethoda)
If not determined to be present, explain:
Type:
leaching pita, number:
leaching chambers, number:
leaching galleries, number:_
leaching trenches, number,length:
leaching fields, number, dimensions 3 0' 9 r-)
overflow cesspool, number:_
(note
CESSPOOLS:
(locate on site plan)
Number and configuration
of
pond.intcondip of,
ki f . 0
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.)
PRI`VY:VN0Ne—
(locate on site plan)
Materials of construction: Dimensions:
Depth of solids:
Comments: (note condition of soil, signs of hydraulic failure, level of ponding, condition ot vegetation, etc.)
(revised 11/03/95) 8
a
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Property Address- 'a to gcje% v�-Va.Aj-�At-n.
Owner. Oe- 0
Date of Inspection:
SKETCH OF SEWAGE DISPOSAL SYSTEM<— ':� 0
include ties to at least two permanent references landmarks or benchmarks
locate all wells within 100,
Ll (0 Lf
A -A0 :S
A-
A -o
aa
DEPTH TO GROUNDWATER
Depth to groundwaten. Ll feet jj J �A e_�
method of determination or approximation: - . -
(revised 11/03/95) 9
----- -----
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WANTITY PUMPC D
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SYSTEM PUMPT.NG RECORD
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OWNER & ADDRESS
AV91
SYSTEM LOCATION
(example: left front or house)
Alta-,
OF PUMPINC:-6'-9-1 —e27QUANTITY PUMPED 0 A L L O,�
(.1.' �,S POOL: No ��YES' SEPTIC TANK: NO y E S
'VATURE OF SERVICE: ROUTINE L,"-<ERGENCY
[�.SFRV.�\TIONS:
GOOD CONDITION
FU
HEAVY CREASE
13, A
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EXCESSIVESOLIDS
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SOLIDS CARRYOVER
.94
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LL TO COVEI�
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of Health or other approving author Ity.
p
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SYStem Pumping Record , Page 1 of 1
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Important: ,
Men filling out
forms on the
computer, use
only the tab key
to move your
cursor-. do not
use the return
key,
2.
VQ
I - 41
Sysiez Owner
Address (if different from location)
City/Town State Zip Code
Telephone Number
V B.. Pumping Record
1. - Date of Pumping oq. Quantity Pumped: k---)
Date�' Gallons
I.: Ty.pe.Qf system: Cesspool(s) Tank Tight Tank
Other (describe):
4. Effluent Tee Filter present? M Yes No If �e's','Was it cleaned? Yes F� No
5. Condition of System:
6. System Pumped By:
Eld
Na*, , A;\. 1, ',
VehlcJe License Number
ocalon,�Iere co t sposed:
13
V -7 V
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Signature of Hauler I
http:/twww.r�ass.gov/deptwater/approval&/t5forms.htm#inspect
t5form4.doc- 06103 System Pumping Record - Page I of 1
z
SEP f
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x Com onwe'alth of Massachusefts
V
NORTH -ANDOVER, MAS S
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MEN
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System'Pumping Record
V.
Form 4
DEP has provided this form for use by lopal Boards of Health.
The System Pu I mping Record must
be submitted to the local Board of Health or other approving authority
..A.. Facility Inforrii ation
Important: ,
Men filling out
forms on the
computer, use
only the tab key
to move your
cursor-. do not
use the return
key,
2.
VQ
I - 41
Sysiez Owner
Address (if different from location)
City/Town State Zip Code
Telephone Number
V B.. Pumping Record
1. - Date of Pumping oq. Quantity Pumped: k---)
Date�' Gallons
I.: Ty.pe.Qf system: Cesspool(s) Tank Tight Tank
Other (describe):
4. Effluent Tee Filter present? M Yes No If �e's','Was it cleaned? Yes F� No
5. Condition of System:
6. System Pumped By:
Eld
Na*, , A;\. 1, ',
VehlcJe License Number
ocalon,�Iere co t sposed:
13
V -7 V
A k -V
Signature of Hauler I
http:/twww.r�ass.gov/deptwater/approval&/t5forms.htm#inspect
t5form4.doc- 06103 System Pumping Record - Page I of 1
Important:
When filling out
forms on the
computer, use
only the tab key
to move your
cursor - do not
use the return
key.
few
Commonwealth of Massachusetts REC91VI-o'
City/Town of North Andover
SEP 12zoll
System Pumping Record
[TIOWN OF NORTH ANDOVE
Form 4 He R
HEALTH DEPARTMENT
DEP has provided this form for use by local Boards of Health. Other forms may be used, but the
information must be substantially the same as that provided here. Before using this form, check with your
local Board of Health to determine the form they use. The System Pumping Record must be submitted to
the local Board of Health or other approving authority within 14 days from the pumping date in
accordance with 310 CMR 15.351.
A. Facility Information
1.
City/Town
2. System
Name
N.Andover Ma 01845
Address (if different from location)
City/Town
State
State
Zip Code
Zip Code
Telephone Number
B. Pumping Record 5� 24HI ) I
1. Date of Pumping Dafe- 2. Quantity Pumped: Gallons
3. Type of system: El Cesspool(s) EE_5eVtrc—_Tank E] Tight Tank El Grease Trap
[:1 Other (describe):
4. Effluent Tee Filter present? 0 Yes 0 No
5. Condition of System:
6. jjystern Pumped
Name
Stewart's Seotic Service
Company
7. Location where contents were disposed:
If yes, was it cleaned? El Yes El No
Vehicle License Number
Pre-treo-Wrlent Plant, 20 So. Mill Bradford, Ma 01835
rd-ofAlauler
Facility
Date .2 q,l
Date
t5form4.doc- 03/06 V System Pumping Record - Page 1 of 1
Important: When
filling out forms
on the computer,
use only the tab
key to move your
cursor - do not
use the return
key.
&W___h
4�=A
R E
Commonwealth of Massachusetts CEi '�6)
S
City/Town of North Andover -
SEP 25,
U
System Pumping Record TOWN OF NORTH ANID)OVER
LTH De
L TM
Form 4 HEALTH fo)epAR e
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 CIVIR 15.351.
A. Facility Information
1. System
Address
north andover Ma'
City/Town State
2. System Owner:
Name
Address (if different from location)
north andover
City[Town
State
Telephone Number
Zip Code
Zip Code
B. Pumping Record
1. Date of Pumping ffate 2. Quantity Pumped: -da- I V �s-
3. Type of system: El Cesspool(s) ,Idseptic Tank El Tight Tank R Grease Trap
El Other (describe):
4. Effluent Tee Filter present? 0 Yes K No
5. Condition 0
If yes, was it cleaned? El Yes Ej No
6. System P Z.
Name Vehicle License Number
Stewart's Septic Service
Company
7. Location where contents were disposed:
Stewart's Pre-treatment Plant, 20 So. Mill Bradford, Ma 01835
Signat e of auler
ftn9rur—e of teceiving Facility 4::��
Date
Date
t5form4.doc- 03/06 System Pumping Record - Page 1 of 1