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HomeMy WebLinkAboutMiscellaneous - 224 FOSTER STREET 4/30/2018 (2) I 224 FOSTER STREET S+ J/ 210/104.1)-0067-MOO-0 k i I I a F t { i � I I � I { Septic System Information 224 FOSTER STREET Printed On:Friday,January 26, 2007 1 System ID: BHS-2002-0794 i General System Information Latest Permit Information Calcaluted Design Flow: Test Pits Septic Tank Disposal Trench Design Flow: One Two Capacity: Number: , Design Flow Provided. Minutes per inch: Width: Width: Total Flow. Depth: Length: Length: Seasonal: No No Depth to Water. Diameter. Leaching: Grinder: No No Soil Type: Depth: Laundry. No No Inspections: Inspected. Expires: Inspector: Status: 01/23/2007 Neil J. Bateson Conditionally Passes (,,`�.'(�(� Comments: Title 5 v ; Page 1 of 1 GeoTMS®2007 Des Lauriers Municipal Solutions, Inc. COMMONWEALTH OF MASSACHUSETTS 2 kv` e55 EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS a d DEPARTMENT OF ENVIRONMENTAL PROTECTION W F W� O,9 by0 TITLE 5 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM PART A CERTIFICATION Property Address:_224 Foster Street North Andover_ Owner's Name:_Miriam Zwanziger Owner's Address:_224 Foster Street ,%+ _North Andover,MA 01845 Date of Inspection:_1/23/2007 JAN 2 6 2007 Name of Inspector: Neil J.Bateson_ Company Name: Bateson Enterprises Inc. TOWN u -4-1- - • Q Mailing Address:_111 Argilla Road HEALTH OEPARTMC,41 _Andover,MA 01810 Telephone Number:_(978)4754786_ 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 fimction and maintenance of on site sewage disposal systems.I am a DEP approved system inspector pursuant to Section 15.340 of Title 5(310 CMR 15.000). The system: Passes X Conditionally Passes Needs Further Evaluation by the Local Approving Authority a' i� Inspector's Signature: 1 Date: _1/23/2007_ 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. Page 2 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: 224 Foster Street_ North Andover_ Owner:_Zwanziger_ Date of Inspection:_1/23/2007_ C�or E/ALWAYS complete all of Section D Inspection Summary: Check A,B, A. System Passes: I have not found any information which indicates that any of the failure criteria described in 310 CMR 15.303 or in 310 CMR 15.304 exist.Any failure criteria not evaluated are indicated below. Comments: B. System Conditionally Passes: R One or more system components�of�e replacementeTn�e laced or repaired The system,upon compfor "Conditional pass"section need to be rep yes,no or not determined(Y,N,ND)m the approved by the Board of Health,will pass.Answer y that are repair,as aper � �° lease explain._D-Boz 1&2 needs replaced.Leach Pipes the following statements.If `not determined7l P broken needs replaced._ The septic tank is metal and over 20 years N * e tic tank(whether metal or not)is struchually unso exhibits eeplacedtlwiinfiltration cPlying septic tank old or th sep inspection if the existing ar tank failure is imminent.System will pass msp and if a Certificate of Compliance as approved by the Board of Health. *A metal septic tank will pass inspections ift is structurally isav able sound,not leaking indicating that the tank is less than 20 years ND explain: backup or break Observation of sewage N or pipe(s)or due to a broken,settled or out or high static water level in the distribution box due to brokenoval 0 Board of Health): uneven distribution box. System will pass inspection if(with approval broken pipe(s)are replaced obstruction is removed distribution box is leveled or replaced ND explain: more than 4 The system required pumping P g oval of the Board of The system will pass inspection if(with appy times a year due to broken Or obstructeN d pipe(s)- Health): broken pipe(s)are replaced obstruction is removed ND explain: Page 3 of 11 OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address: 224 Foster Street_ North Andover— Owner:_Zwanziger Date of Inspection:_1/23/2007_ 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 i 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. i The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water supply. The system has a septic tank and SAS and the SAS is within 50 feet of a private water supply well. The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or more from a private water supply well".Method used to determine distance. "This system passes if the well water analysis,performed at a DEP certified laboratory,for coliform bacteria 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. i 3. Other: i Page 4 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address: 224 Foster Street_ North Andover— Owner:_Zwanziger Date of Inspection:_1/23/2007_ D. System Failure Criteria applicable to all systems: You must indicate"yes"or`no"to each of the following for all inspections: _ _No Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool _No_ Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool _No_ Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool — _No Liquid depth in cesspool is less than 6"below invert or available volume is%Z day flow. — _No_ Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number of times pumped — _No_Any portion of the SAS,cesspool or privy is below high ground water elevation. _No Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. _No_ Any portion of a cesspool or privy is within a Zone 1 of a public well. _NoL Any portion of a cesspool or privy is within 50 feet of a private water supply well. _No_ 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 11 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 o1'11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST Property Address:_224 Foster Street_ North Andover_ Owner: Zwanziger Date of Inspection:_1/23/2007_ Check if the following have been done.You must indicate"yes"or"no"as to each of the following: Yes No Yes _ Pumping information was provided by the owner,occupant,or Board of Health No Were any of the system components pumped out in the previous two weeks? _Yes_ ` Has the system received normal flows in the previous two week period? No Have large volumes of water been introduced to the system recently or as part of this inspection? N/A _ Were as built plans of the system obtained and examined? Yes _ Was the facility or dwelling inspected for signs of sewage back up? Yes _ Was the site inspected for signs of break out? Yes Were all system components,excluding the SAS,located on site? _Yes _ 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? _Yes_ _ 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 _No_ _ Existing information. Yes _ Determined in the field(if any of the failure criteria related to Part Cis 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:_224 Foster Street_ _North Andover– Owner: Zwanziger_ Date of Inspection:_1/23/2007_ FLOW CONDITIONS RESIDENTIAL Number of bedrooms(design): N/A Number of bedrooms(actual):_6 DESIGN flow based on 310 CMR 15.203 N/A Number of current residents:_7 Does residence have a garbage grinder(yes or no):_No Is laundry on a separate sewage system(yes or no):_No Laundry system inspected(yes or no): _ Seasonal use: (yes or no): No_ Water meter reading: Yes Sump pump(yes or no): No Last date of occupancy:_Current_ CONMIERCIAL/INDUSTRIAL Type of establishment: Design flow(based on 310 CMR 15.203):_Rd Basis of design flow(seats/persons/sg8,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: Pumped 2002,owner_ Was system pumped as part of the inspection(yes or no): Yes_ If yes,volume pumped:_1500 gallons--How was quantity pumped determined?_Measured tank Reason for pumping: Inspect tank&tees_ 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:_Original system._ 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:_224 Foster Street_ North Andover_ Owner: Zwanziger Date of Inspection:_1/23/2007_ BUILDING SEWERS_X_ (locate on site plan) Depth below grade:—30"_ Materials of construction: _cast iron _X_40 PVC`other Distance from private water supply well or suction line: Comments(on condition of joints,venting,evidence of leakage,etc.) _4"PVC thru wall.3"PVC in house.No leaks visible SEPTIC TANKS: X Depth below grade:_18"_ 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: 10'x 5'x 49 _ Sludge depth 6"_ Distance from top of sludge to bottom of outlet tee or baffle: 21"_ Scum thickness:_6" Distance from top of scum to top of outlet tee or baffle: 8" Distance from bottom of scum to bottom of outlet tee or baffle:_15"_ How were dimensions determined:_Tape Measure_ Comments(on pumping recommendations,inlet and outlet tee or baffle condition,structural integrity,liquid levels as related to outlet invert,evidence of leakage,etc _Pumped septic tank Inlet tee ok.Outlet tee corroded on top.Depth of liquid at outlet invert.No evidence of septic tank leaking._ 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 bale: 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: 224 Foster Street North Andover- Owner: Zwanziger Date of Inspection:_1/23/2007_ 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# 1 X_ (locate on site plan) Depth below grade _4'_ 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#1 is a drop bog.Only one pipe out to d-box#2.Evidence of leakage. D-box has heavy corrosion holes.Needs to be replaced.Evidence of carryover.D-box cover broken,replaced it. PUMP CHAMBER:_(locate on site plan) Pump in working order(yes or no):_ Alarm in working order(yes or no): Comments(note condition of pump chamber,condition of pumps and appurtenances,etc.):_ Page 8 of I 1 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address:_224 Foster Street_ North Andover— Owner: Zwanziger Date of Inspection:_1/23/2007_ 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 Jpolyethylene 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# 2 X_ (locate on site plan) Depth below grade 311 _ 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 level&distribution equal..D-bog has heavy corrosion holes.Needs to be replaced.No evidence of carryover.Evidence of leakage._ PUMP CHAMBER:_(locate on site plan) Pump in working order(yes or no):_ Alarm 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 ASSION FORM TS SUBSURFACE SEWAGE DISPOSALRTYSTE SYSTEM INFORMATION(continued) Property Address: 24 Foster Street_ _North Andover_ Owner: Zwanziger_ Date of Inspection:_1/23/2007_ 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: X leaching trench,number,length: 3 trenches 30'long— leaching ongleaching field,number,dimensions: overflow cesspool,number: innovative/alternative system Type/name of technology: dam soil condition of vegetation, Comments(note condition of soil,signs of hydraulic failure,level of ponding, p > etc.): Soil ok.Vegetation ok.No sign of ponding to surface.Roots from fruit trees entered into leach pipes& broken them.Pipes should be replaced._ CESSPOOLS:— Number and configuration:_ Depth—top of liquid to inlet invert: Depth of sludge 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: condition of vegetation,etc.): Comments(note condition of soil,signs of hydraulic failure,level of ponding, . I Page 10 of I 1 OFFICIAL INSPECTION FORM —NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION Property Address:_224 Foster Street_ North Andover_ Owner: Zwanziger Date of Inspection:—1/23/2007_ 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 Garage House A Water Meter ® Septic Tank D-Bog D-Boz #1 #2 Driveways A to Tank=19' A to D-Boz#1=94'6" AtoD-Boz#2=145' B to Tank=47' B to D-Boz#1=91'6" B to D-Bog#2=138' Page 11 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address:_224 Foster Street_ North Andover— Owner: Zwanziger Date of Inspection:_1/23/2007_ SITE EXAM Slope Surface water Check cellar Shallow wells Estimated depth to ground water_>6'_ 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: X 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) X Accessed USGS database-explain: Essex County Soil Map_ You must describe how you established the high ground water elevation:_Essex County Soil Map,Sheet#30, Canton Soil,Water>6'deep.House located high on hill.Brook ran beside property.No liquid 4'below trenches._ Summary Record Card generated on 1/24/2007 10:44:46 AM by Elaine Barclay Page 1 'town of North Andover Tax Map # 210-104.D-0067-0000.0 224 FOSTER STREET ZWANZIGER, MIRIAM 224 FOSTER STREET NORTH ANDOVER, MA 01845 Class 101 Single Family Property Type 1 Residential Size Total 6.99 Acres FY 2007 UB Mailing Index Name/Address Type Loan Number Active/Inact. From Until ZWANZIGER, MIRIAM Payor 224 FOSTER STREET NORTH ANDOVER, MA 01845 UB Account Maint. Account No Cycle Occupant Name Active/Inactive Bldg Id. 17740.0-224 FOSTER STREET Last Billing Date 1/11/2007 3170406 03 Cycle 03 Active UB Services Maint. Service Code Rate Charge Multiplier/Users MISCFEE ADMIN FEE 1.5 1 1/2 10.55 1/ WTR WATER 01 ALL METER SIZE 149.72 /1 UB Meter Maintenance Serial No Status Location Brand Type Size YTD Cons 32006334 a Active ERT HH b Badger w Water 1.5 1.5 Date Reading Code Consumption Posted Date Variance 12/12/2006 38 a Actual 38 1/19/2007 0% 10/3/2006 0 n New Meter 0 10/20/2006 0% 10/3/2006 14110 r Replacement -50 10/20/2006 -144% 6/13/2006 14160 m Manual estimate 100 7/10/2006 31% MSG ENC GONE 3/7/2006 14060 m Manual estimate 60 4/17/2006 53% MSG 12/20/2005 14000 m Manual estimate 50 1/17/2006 -21% MSG 9/13/2005 13950 m Manual estimate 50 10/14/2005 17% MSG 6/28/2005 13900 m Manual estimate 50 7/15/2005 19% 3/30/2005 13850 m Manual estimate 50 4/5/2005 -17% 12/13/2004 13800 m Manual estimate 50 1/14/2005 -21% 9/15/2004 13750 m Manual estimate 60 10/8/2004 3% 6/23/2004 13690 m Manual estimate 50 7/30/2004 62% r ` Commonwealth.of Massachusetts City/Town of System Pumping Record Form 4 DEP has provided this form for use by local Boardsof Health..The System 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: fomes the computer.use only the tab key Address to move your ✓ 'tl �..� � �1 cursor-do not - use theretum C�rrown State Zip Code key. 2 System Owner. Name Address(if different fron7,iocation) City/Town: Stat Zip Code Telephone NUmber 13Purn �g :Recaord 1. Bate.of Pu6ning Hate 2. Quantity Pumped: Gallons 3. Type of system: ❑ Cesspool(s) Septic Tank- ❑ Tight Tank ❑ Other(describey 4. Effluent-Tee Filter present? ❑ Yes If yes,was it cleaned? E] Yes ❑ No 5. condition of System:. ` 0_7. 6. Syst m Pumped B Nam V� VehiGe t'icense Number Company . .: 7. Locatio eie co =`nts a disposed: . Sign atur f aule tate http://www.mass':govLdep/waterlappravaitft5forms.-h"nspect t5f0rM4.doc-06/03 System Pumping Record•Page.1 of 1 Tel: (978) 475-4786 Fax: (978) 475-5451 BATESON ENTERPRISES, INC. Excavating-Water.& Sewer Lines-Septic Systems&Pumping Service 111 Argilla Road Andover,Mass. 01810 Title 5 Inspection Report Property Address: 224 Foster Street, North Andover Owner: Zwanziger Date of Inspection: 1/23/2007 My report contained herein does not constitute a guarantee of future usage and the functionality of the existing septic system. Such report issued herewith is merely based upon my observations, and I hereby disclaim any further operation of your current septic system. eNeilJ. Bat on Bateson Enterprises, Inc. Of Town of North Andover HEALTH DEPARTMENT S�CHUSf CHECK#: 91d DATE: //pfd B LOCATION: ���` s �' S H/O NAME: 9 Z zX CONTRACTOR AME: 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 $ ❑ Tras4lSolid Waste Hauler $ ❑ Well Construction $ SEPTIC Systems: ❑ Septic-Soil Testing $ ❑ Septic-Design Approval $ ❑ Septic Disposal Works Construction(DWC) $ ❑ Septic Disposal Works Installers(DWI) $ ❑ Title 5 Inspector $ ��4itle 5 Report $ �•©v ❑ Other. Indicate •i'lY� 23 02 Health Agent Initials White-Applicant Yellow-Health Pink-Treasurer TOWN OF "JeAr SYSTEM PUMPING RECORD DATE:- SYSTEM OWNER & ADDRESS SYSTEM LOCATION (example:left front of house) cd . l 4 West DATE OF PUMPING: ` -Q 3`Q 0A- QUANTITY PUMPED : 12 job GALLONS CESSPOOL: NO v YES SEPTIC TANK: NO YES NATURE OF SERVICE: ROUTINE EMERGENCY OBSERVATIONS: GOOD CONDITION FULL TO COVER HEAVY GREASE BAFFLES IN PLACE ROOTS LEACHFIELD RUNBACK EXCESSIVE SOLIDS FLOODED SOLIDS CARRYOVER OTHER(EXPLAIN) SYSTEM PUMPED BY: Bateson Enterprises, Inc. COMMENTS: CONTENTS TRANSFERRED TO: C.uuut1un"ealtlt of MassrirhuseUs Massachusetts �5'vsterrt 1'untIg Recor j'tllt�°Uiiiti* --ss em oca foil , , Date of I'umonp Quentlt; f'uutp�dt t Cesspool: Ves TPA KtA � Yes s�-stent Pumped by: a�C 2S License C Contents transferred to: Date Inspeclor u p,P:�O���/ TQw%OFR�OGF�ar;x+TH g�H QpR 1 194 To �l Commonwealth of Massachusetts Massachusetts MAR i I �cr� System Pumping Record system Owner System Location N Date of Pumping: Quantity Pumped: gallons Cesspool: No Yes U Septic Tank: No 0 Yes System Pumped by: Sctire44rt 46K�QeQ License# Contents transferrred to : Greater Lawrence Sanitary District Date: Inspector: 4 ('ommonV eallh of Massachusetts 4rAAMassachusetts System Pumping Record System Owner System Location Date of Pumping: '—��j�� Quantity Pumped: �jrvG�gallons Cesspool: No Yes U Septic Tank: No Yes System Pumped by: FelreQ4f6 gimm taa License# Contents transferrred to : Greater Lawrence Sanitary District llate: _ Inspector- "]l � Commonwealth.of Massachusetts City/Town of I JAN 2 6 20- System Pumping Record TOIAN OF NORTH At w� Form 4 r EALTH DEPARTv: .. DEP has provided this form for use by local Boards of Health. The System Pumping Record must be submitted to the local Board ofHealth or other approving authority. . A. Facility Information Important: When filling out 1. System Location forms the computer,use only the tab key Address C \ , to move your J--c .� ✓S- cursor-do not �``'�� use the return Cityfrown State Zip Code key. 2. System Owner: 2 UA-' � - Name — Address(if different from,location). Crty.frown State Zip Code' Telephone Number B. P um ping Rekord --0-2 / S 1. Date.of PumpingDate 2• Quantity Pumped: Gallons Type of system: ❑ Cesspool(s) Septic Tank ❑ Tight Tank ❑ Other(d'escribe) 4: Effluent Tee Filter present? ❑ Yes 13-1 o If yes, was it cleaned? ❑ Yes`❑ No 5. Condition of System: 6. Syst m Pumped B e. Nam. r--� Vehicle,:License Number Company ... _. 7. Locatio h re co, °nts a disposed:: SJgnatur f aide Date http://www.mass.gov/deplwater/approval.t/tSforms;htm inspect t5form4.doc•06103 System Pumping Record•Page 1 of 1 Commonwealth of Massachusetts City/Town of a System Pumping Record RECEIVED ' 5 By0 Form 4 FEB 10 2009 DEP has provided this form for use by local Boards of i1�lvt N used, but the information must be substantially the same as that proLd'ec&p�LqPrH I form, check with your local Board of Health to determine the form they use. ping-Record must be submitted to the local Board of Health or other approving authority. A. Facility Information Important: When filling out 1. System Locati : Left front ft rear, left sid of house. fight front, right rear, right side of house. forms on the computer,use At A_ only the tab key Address "Q to move your cursor-do not City/Town use the return State Zip Code key.. -� 2 System Owner: Name Address(d different from location) City/Town State�� �7�Code Telephone Number \7� B. Pumping Record As 1. Date of PumpingQuantity Pumped: Gallons 3. Type of system: Ej Cesspool(s) _ eptic Tank El Tight Tank El Other(describe): 4. Effluent Tee Filter present? Yes 2-9.0 If yes, was it cleaned? Q Yes No 5. Condition of System: 6. System Pumped By: Neil Bateson F 5821 Name Vehicle License Number Bateson Enterprises Inc Company 7. Location contents were disposed: L.S.D Lowell Waste Water igna ure of T"ur Date t5form4.doc•06/03 System Pumping Record•Page 1 of 1 �L\ Commonwealth of Massachusetts REI` ® \\\\j City/Town of10 a W° System Pumping Record Form 4 TOWN OF NORTH ANpOVER HEALTH DEPARTMENT DEP has provided this form for use by local Boards of Health. Other forms may be used, but the information must be substantially the same as that provided here. Before using this form, check with your local Board of Health to determine the form they use. The System Pumping Record must be submitted to the local Board of Health or other approving authority. A. Facility Information 1. System Location: Left side of house, Right side of ho , Left front ofof ho��— Ught front of house, Left rear of house, Right rear of house. Left rear of building. Right rear of building. Address Citylrown `-� C (J� State Zip Code 2. System Owner: Name Address(if different from location) City/Town ' State ./ �%� � JipCo, Telephone Number (J Cj-- B. Pumping Record 1. Date of Pumping Date 2. Quantity Pumped: Gallons 3. Type of system: ❑ Cesspool(s) eptic Tank ❑ Tight Tank ❑ Other(describe): 4. Effluent Tee Filter present? ❑ Yes JPO If yes, was it cleaned? ❑ Yes ❑ No 5. Condition of Stem: 6. System Pumped By: Neil Bateson F5821 Name i Vehicle License Number Bateson Enterprises Inc Company 7. Location where contents were disposed: MofHaul Lowell Waste Water g Date t5form4.doc•06/03 System Pumping Record•Page 1 of 1 Commonwealth of Massachusetts City/Town of iRECEIVED System Pumping Record Form 4 DEP has provided this form for use by local Boards of Health. Other fo 9,A he information must be substantially the same as that provided here. Befo UIS, , �j h your local Board of Health to determine the form they use. The System Pumping ec itted to the local Board of Health or other approving authority. A. Facility Information 1. System Locati : Left front ofRhouseright front of house, left side of house, right side of house, Left rear of house, rig o , side of building, right rear of building, under deck. Cityfrown State Zip Code 2. System Owner. 0 Name Address(if different from location) City/Town State _ Zip C�od,e a _ l Telephone Number B. Pumping Record �46 ✓ 1. Date of Pumping " p ng 2, Quantity Pumped: Date Gallons 3. Type of system: ❑ Cesspool(s) �icTank ❑ Tight Tank ❑ Other(describe): 4. Effluent Tee Filter present? ❑ Yes If yes, was it cleaned? ❑ Yes ❑ No 5. Condition of System: 6. System Pumped By: Neil J. Bateson F5821 Name Vehicle License Number Bateson Enterprises Inc. Company 7. Loc here contents were disposed: G.L.S.D L ell Was)OW 3- 6 Signatur of au r Date t5form4.doc•06/03 System Pumping Record•Page 1 of 1 Commonwealth of Massachusetts RECEIVED City/Town of System Pumping Record JUL 31 2012 Form 4 TOWN OF NORTH ANDOVER M r HEALTH DEPARTMENT DEP has provided this form'for use by local Boards of Health. O er Gans may be us ut the information must be substantially the same as that provided here. Before using this form, check with your local Board of Health to determine the form they use.The System Pumping Record must be submitted to the local Board of Health or other approving authority. A. Facility Information "1. System Locafion� a Rig , Left/Right rear of house, Left/right side of house, Left/ Right side of buil g, Left/Right front of building, Left/Right rear of building, Under deck Address �� ����`� Citylrown State Zip Code 2. System Owner. Off,\ V\ Name (� y Address(if different from location) City�rown State F r�3__OC Code Telephone Number o� B. Pumping Record 1. Date of Pumping Date 2. Quantity Pumped: Gallons 3. Type of system: ❑ Cesspool(s) a<eptic Tank ❑ Tight Tank ❑ Other(describe): 4. Effluent Tee Filter present? ❑ Yes No If yes,was it cleaned? ❑ Yes ❑ No 5. Conditiop of System: 6. System Pumped By: Neil Bateson F5821 Name Vehicle License Number Bateson Enterprises Inc Company 7. Location ere contents were disposed: LL/S.1-N Lowell Waste Water '4 Ka 0))- signitufe I Haule Date t5form4.doc•06/03 System Pumping Record•Page 1 of 1