HomeMy WebLinkAboutMiscellaneous - 232 CANDLESTICK ROAD 4/30/2018 (2) / 232 CANDLESTICK ROAD gad «1
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RECEIVED
Commonwealth of Massachusetts
W City/Town of North Andover OCT 18 2012
System Pumping Record TOWN OF NORTH ANDOVER
Form 4 HEALTH DEPARTMENT
M
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
Important:When
filling out forms 1. System Location:
on the computer,
use only the tab
dz�a-
key to move your Address
cursor-do not North Andover Ma
use the return City/Town State Zip Code
key.
2. System Owner:
Name
reran
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: ❑ Cesspool(s) Septic Tank ❑ Tight Tank ❑ Grease Trap
❑ Other(describe):
4. Effluent Tee Filter present? ❑ Yes ❑ No If yes, was it cleaned? ❑ Yes ❑ 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
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re of Hauler Date
re of Receiving Facility Date
t5form4.doc•03/06 System Pumping Record•Page 1 of 1
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TOWN OF NORTH ANDOVEP,
UA i't SYSTEM PUMPING RECc)KD
SYSTEM OWNER do ADDR$SS SYSTEM LT10N
DATE OF PVWNQ:
. ---.._QUANT1TY PUMPED:.../ll .. .
Snpc c Tank:
` _ [HEJAL
ECE A
NA rUKEi ON SLRVIce: KOU'rINE
MAY p 6 2005
'-RTH ANDOVER
GOOD CONDITION T �ARTMENT
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Commonwealth of Massachusetts
ME Executive Office of Environmental Affairs ,
Department of
Environmental Protection, . w
William F.Weld
Govemor
Trudy t^,oxe
Secretary,EDEA
David B. Struhs
Commissioner
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
JS LU a'. Zit PART
f ;✓ CERTIFICATION
Property Address: A, �2 d�C` Sr 'Gjt" rAddress of Owner:
Date of Inspection: �- 7._ 9 7 (If different)
Name of Inspector:] t fjV S�
Company Name, Address and Telephone Number:
CERTIFICATION STATEMENT 9,e 0 f Gi2!') »'
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 sewa e`disposal systems. The system:
Passes
Conditionally Passes .
Needs Further Evaluation By the Local Approving Authority
Fails
Inspector's Signature j ff Date:
The SystemI sn pector shall submit a copy of this inspection report to the Approving Authority within thirty (30) days of completing Obis
inspection If the system is a shared system or has a design flo%% 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 tho system owner and copes sent to the buyer, if applicable and the approving dutlwli1�.
INSPECTION SUMMARY:
Check'A, B, C, or D
A] SYSTEM PASSES:
C
I have not found any information which indicates that the system violates any of the failure criteria as defined in 310 CMR 15.303.
I Any failure criteria not evaluated are indicated below.
B] SYSTEM CONDITIONALLY PASSES: /4
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) 1
One Winter Street a Boston,Massachusetts 02108 a FAX(617)556-1049 a Telephone(617)292.5500
A
i,Pnmeel on Recycled Paper
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SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
44ERTIFICATION (continued)
Property Address: o231-
Owner: / 3_ S
,Date of Inspection:
B) SYSTEM CONDITIONALLY PASSES (continued) 1 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 lo 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
Cl 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.
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:
1 h system nas a septic tank and soil absorption system and is will iin 100 feet to d surfd,-C water supe y atributary to a
surface water supply.
The system ha, a septic tank and soil absorption system and is within a Zone 1 of a public water supply well.
The system has aFseptic tank and`soil absorption system and is within 50 feet of a private water supply well.
The systen, ha, 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: /
1 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 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.
(revised 8/15/95) 2
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
n CERTIFICATION (continued)
Property Addrdss: .�-3 �,,, ` a 111 c /`P 'Ty`r c
Owner: W v y "Z. < �l
I Date of Inspection:
/z-- 3- 7
D)SYSTEM FAILS(continued):
Static liquid level i�te 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
r
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.
El LARGE SYSTEM FAILS: �•
The following criteria apply to large systems in addition to the criteria above:
The design flow 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
t— the system.is_lo_cated_in a nitrogen sensitive.aLeaAn1erini Wellhead Protec4on Area (IWPA) or a mapped Zone II of a
public water supply;'e'll! ' t- �' • r
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
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART B
CHECKLIST
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Property Address:
Owner: Kwo I y
Date of Inspection:
Check if the following have been done:
' P fmping infcfrrAation Is requested of the owner occupant, and Board of Health.
`
a
None of the system components have been pumped for 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 part of this inspection.
fr4As built plans have been obtained and examined. Note if they are not available with N/A.
_t"The facility or dwelling was inspected for signs of sewage back-up.
`"The system does not receive 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.
'The septic tank manholes were uncovered, opened, and the interior of the septic tank was inspected 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 existing information or
approximated by non-intrusive methods.
—The facilit- ov,ner (and occupants, if different from owner) were provided with information on the proper maintenance of Sub-
Surface Disposal System.
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(revised 8/15/95) 4
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SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION / 4-,010 Property Address; O'`',3a �2 h J /r- ST[ct<. f'�•�, f`�• hl �l0
Owner: kGV U
Date of Inspection: h,I �C77 /
FLOW CONDITIONS
RESIDENTIAL:
Design flow: gallons
Number of bedrooms:
Number of current residents:_ L /
Garbage grinder (yes or no):4-s - 6'�/"t n+
Laundry connected to system (yes or no):-)4-
Seasonal use (yes or no):--4/
'WWaterinete` readings; if av4labie:
A.
{
Last date of occupancy: i+L
COMMERCIAUINDUSTRIAL: /
Type of establishment: �f
Design flow: gallons/day
Grease trap present: (yes or no)_
Industrial Waste Holding Tank present: (yes or no)_
Non-sanitary waste discharged to the Title S system: (yes or no)_
Water meter readings, if available:
I
Last date of occupancy:
t.
OTHER: (Describe)
} Last date of occupancy:
}
GENERAL INFORMATION
PUMPING RECORDS and source of information: l
System pumped as part of inspection: (yes or no)-Ye S
If yes,}volume pumped AD gallons4 j
-Reason for pumpingr I -1011 en - iii;is - r a 4 Fe u3-j'jZ r ri7 r.y
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)
t
t APPROXIMATE AGE of all components, date installed (if known) and source of information:
k
1 t
I Sewage odors detected when arriving at the site: (yes or no) t
(revised 8/15/95) 5
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SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM.INFORMATION (continued)
Property Address: 2 3,� - 1 It fc iL
Owner: J<w
Date of Inspection:
SEPTIC TANK:- 0 s
(locate on site plan) a
O
Depth below grader
Material of construction: _ oncrete _metal _FRP —other(explain)
Dimensions
Sludge depth: 14
_` r t'
4
Distance from top of sludge to bottom of outlet tee or baffle: a
Scum thickness: L/A--� /
Distance from top of scum to top of outlet t e or baffle4� t/
Distance from bottom of scum to bottom of outlet tee or baffler
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.)
P5/LP T 4 a'uf G.-P T
' GREASE TRAP:_
(locate on site plan)
'• Depth belov., 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 hottom M r++- t- hottnm of outlet tee or battle
Comments:
(recommendation for pbmping, conoitton,of inlettand outlet.tees baffles, depth of.liquid feved in relation to outlet invert, structural
integrity, evidence of leakage. etc.) r ?
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' (revised 8/15/95) 6
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SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION ((continued)
Property Address: j 1 J `t. ST t c i,, I . /u 4 Ala
Owner: I " W O
Date of Inspection: /
TIGHT OR HOLDING TANK:_
(locate on site plan) /
Depth below grade:
Material of construction: _concrete _metal _FRP—other(explain)
Dimensions:
Capacity: gallons 4 t
Design flow: gallons/day
Alarm level:
Comments:
(condition of inlet tee, condition of alarm and float switches, etc.)
DISTRIBUTION BOX: Yt�1
(locate on site plan)
I
Depth of liquid level above outlet invert:
Comments:
(note if le.c' and dstrib:a r.;,:,�, e•.;dente of olid, evidence of leakage into or out of box, etc)
U P a b t'!/
0-4o i *P i n as-y opt C.3 tic) rs n UJ-! h �-��.•,
PUMP CHAMBER:_
(locate on site plan)
Imps in working order.(yes or no)
Comments:
(note condition of pump chamber, condition of pumps and appurtenances, etc.)
(revised 8/15/95) 7
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SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Property Addre s: �?� C zi, -1 A,,
Owner: J`�
Date of Inspection:
1 Z-3-��
SOIL ABSORPTION SYSTEM (SAS): ,�.3
(locate on site plan, if possible; excav tion not required, but may be approximated by non-intrusive methods)
If not determined to be present, explain:
t
Tye:;
leaching pits, krftber:
leaching chambers, number:_ t
-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.)
All) /ool,!/y h s,
CESSPOOLS: _ L
(locate on site plan) p`r
i
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)
Commenth: (note condition of so l,tsigns of hydraulic failure,'ievdl of ponding, tondition of vegetation,xetc.) 1* } r?
-
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
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SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
f? / SYSTEM INFORMATION (continued))
/
Property Address: p� 3z l h `//c- 5T/ c-,t, A-- '
Owner: .
Date of Inspection: 9A.)A.) 0
SKETCH OF SEWAGE DISPOSAL SYSTEM:
include ties to at least two permanent references landmarks or benchmarks
locate all wells within 100'
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DEPTH TO GROUNDWATER
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Depth to groundwater: if J feet {
method of determination or approximation: l V! QW A4 Uy }-t b ,p- (SOX
).j u L�, 1-c✓ -r
GrG w
4-,4
(revised 8/15/95) 9