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RECEIV
DEC 0 6 2005
��)wN Uf' NUK I'1y Lh,.) TOWN OF NORTH ANDOVER
J Y S 'B m P k) M P► N u FZp C O lI L. HEALTH DEP
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�L\ Commonwealth of Massachusetts roSEP 25
City/Town of North Andover "�ACTHp°RrHAn,
System Pumping Record gRTM�Nr��
Form 4
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:�F777Q �, j-_ I
� ��
on the computer,
vfcn
use only the tab
key to move your Address
cursor - do not North Andover Ma
use the return City/Town State Zip Code
key.
2. System Owner:
0(
Name
ietren
Address (if different from location)
City/Town
State
Telephone Number
Zip Code
B. Pumping Record
1 . Date of Pumping ate 2. Quantity Pumped: Gallons
3. Type of system: ❑ Cesspool(s) —Z( 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:
7
Name Vehicle License Number
Stewart's Septic Service
Company
Location where contents were disposed:
Stewart's Pre-treatment Plant, 20 So. Mill Bradford, Ma 01835
SignQ,turejbf Hauler Date
SkjolftureNof Receiving Facility Date
t5form4.doc• 03/06 System Pumping Record • Page 1 of 1
'a
F Commonwealth of Massachusetts _
City/Town,of NORTH ANDOVER, MASAG-HUSETS
System pumping Record
Form 4 DEC 6 2006 I
DEP: has provided thIs form for use by local Boards of He ItfaW �?e F' A ovEa ; Record mu,.
pp 5; „r�rptng
be submitted to the local Board of Health or other a rovi, ft
A. Facility Information
Important:
When ruing 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 ti State'--'-- -`
key. Zip Code
2. System Owner-
-Wim
Address (if different from location) -- "—.......
' — -- —
City/Town ---------- State
.(.--7--/----- Zi Code -
Telephone Number
B. Pumping.Record
1. Date. of Pumpin' in .
Date 2• Quantity Pumped:
B -----.--_-__
Gallons
Type of system: ❑ Cesspool(s) eptic Tank ❑ Tight Tank
❑ other (describe):_.—. ----__._--
4. Effluent Tee Filter present? ❑ Yes o If yes, was it cleaned? ❑ Yes ❑ No
V. -
5. Condition of System:
6. Sy em Pumped By:
!Name-
/� Vehicle License Number AjoCompany
7.% Location where contents were disposed:
/I _ __ --- ---�� �' _ - ---- - -
Si ature fH u --
o a Date
http://www.mass gov/dep/water/ provals/t5forms.htm#inspect
t5form4.doc, 06/03
1�
System Pumping Record • Page 1 of 1
TOWN OF NORTH ANDOVER
SYSTEM PUMPING RECORD
er , , �' 1 ani ; iER/'
�,.._ HEAALT
NO'v - 4 20
1
�l Elul OWNER & ADDRESS SYSTEM LOCATION
(example: Ief( frons of house)
611,1 61 7
U i E OF PUMPINC:Id `l % w e2. QUANTITY PUMPED
)SIlOOL: NO L.,- YES SCPTICTANK: NO YES
> ATURE OF SERVICE; ROUTINEEM ERGENCY
FRV.\TIONS:
CUOD CONDITION FULL TU CUVL:�
HFAVY CREASE 13AFFLL;S IN PLAC1:
ROOTS LEACHFIELD RLNBACK
EXCESSIVE SOLIDS FLOODED
SOLIDS CARRYOVER O�jHER (EXPLAIN)
i
>1 > 1 LM PUMPED BY� �A' r :71
FNTS:
U-0 (:'N I'S TIZANSFEIZIZED TO
TOWN OF NORTH ANDOVER
SYSTEM PUMPING RECORD
DATE:
SYSTEM OWNER & ADDRESS
CSC t�,
cXAl I
I�
SYSTEM LOCATION
(example: left front of house)
DATE OF PUMPING: l�' 3fl"'d / QUANTITY PUMPED J500
CESSPOOL: NO YES SEPTIC TANK: NO YES
v
NATURE OF SERVICE: ROUTINE
OBSERVATIONS:
GOOD CONDITION
HEAVY GREASE
ROOTS
EXCESSIVE SOLIDS
SOLIDS CARRYOVER
SYSTEM PUMPED BY:
COMMENTS:
CONTENTS TRANSFERRED TO:
EMERGENCY
FULL TO COVER
BAFFLES IN PLACE
LEACHFIELD RUNBACK
FLOODED
OTHER (EXPLAIN)
00000
t SOIL PROFILE & PERCOLATION TEST DATA.
. North Andover,
ss. No•&Street �1�,,-e�'�t Lot No. 4f
Loc./Subdiv. Plan Owner
Lp
Investigator - Observer._ `
SOIL PROFILES. -DATE
1_ Elev. Eley, 3. Elev. 4'Elev.
0 0 0 0
Ties to Test Pits
2 2 2 2
3 3 3 3 - —
4 4 4 4
S 5 5 .5
6 6 6 6
7 7 7 7
8 :. s 8 - g g
g 9 - 9 _ -.9 -
10 10 10 - 10
Benchmark -Location
Elevation Datum
.Percolation Tess -Date ,
Lazo-----
Pit Number 1
F
3
4
S
Start Saturation
Soak -Mins
Start - Test-Time-----
Dro " of 3" -Time -
Drop of G" -Time
Mins. lst. 3"Dro
Mins_2nd 3"Dro p-
Pe=-colaticn Rate - _
-
Board cHealth •-
h'ar�,.h A6:1 SEPTIC STSTEM
INSTALLATION CHECK LIST
APPA—CIVr D DATE M W11ROVED UAttS
s eaamnss
3 FAIL
r
LOT
X AVA`I`I ON OK FAI L
1. Distance TO!-
a. Wetlands 0
b. Drains
c. Well
2. Water Line Location
3 •
No PPC Pipe
h. 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 Crackq
b. All Lines Flowing Equal Amounts
c. No Back Flow
6. Leach Field or Trench
a. Dimensions
b. Stone Depth
c. Capped Ends
d. Clean Double Washed Stone
7. Leach Pits _.
a. Dimensions
b. Stone Depth.
c. SplasK Pads
d. T
e. C t Pipe to Pit - Both Sides
f. lean Double Washed Stone
8. No Garbage Disposal
9. Final Grading Inspection
10. Barricading Covered System
11. As Built Submitted
a. Lot Location
b. Dimensions of System
c. Location vi.th Regard -to Pere Test
d. Elevations
e: Water Table -
Iloatd of Health
north Andover,M ss h
WDSURFACE DEPOSAL DFM(Rt CH K ;LI
LOT #
APPROVED DATB
Provideds `
DISAPPROVID DATE
Reasons:
Title V
FAIL
Reg 2.5
submitted plan -wt Ohoi7 as a �.Dimom:
e lot to be served-arca,dimensions lot #,abutters
cation and log &iep obscrrvation lloias-distance to ties
jIb
cation and results pei�.olation tests -di dtannce to ties
sign calcUat�ions & erl,etlations shDvdI tg raged. leaching area
cation and edmenniens of t r„-i� ,cl45ding veserve area
isting and propos ed eonWurs
cation any wt areas iii -.un IGO, of 8Qwage M-sposal system or
disclaimer -check wetlands mapping
(h) surface and subsurface drains within 1001 of seen dissal
`
system or divelai.mer
.. (J) Location arq drainage easements v.thin 1001 of ass ge CA*Posal
system or disclaimer -Planning Board files
(J) laiom Lources of -ester supply within 2001 of sevage disporAl
system or disclaimer
location of mW proposed vrel.l to serve lot -1001 from leaching facility
1 ovation of nater lines on property 101 from leaching facility
ocatioan of benchmark
drive' .. ys
o gart�age disposals
Bio PVC to be u -ed in consk.mcUon
Q) profile of of ba;serixnt, plumb, pipe, septic talc,
dts bu-Uon box inlot.a fn.A Gatl.ets, distribution field piping and
Outer F 1 °r ti.e-dgs
MAP"1 &XVtInd -':- tr,.Y' ?.i tri 4i in ::' a a ;,s. ;e di.-Posal system
plan ir.,tst be prapau-d by a r7vofcsti:IoiWC. Pas oor or other
professionn.l G"utYiS?riz :d by lair to prcpar e such plans
Reg 6
e stic 'Tanks
a) ca pacilt 50% of flow, hater table, toes, dapth of tees,
access, puping
cle.nout
101 from coo lar til or inground mom ging pool
rd) 251 from subs'urf'ace drains
_
Reg 10.2
Reg l0.4
21",
tion Doxes
0.08
i
mmurrace Lesign unem
3 ` FAIL I OK
Reg 15.1
15.4
15.8
3.7
Reg 14,1
14.3
14.4
14.6
14 .7
14.10
Reg 9.1
9.6
List
.2
LeachLg Pits
Leaching pits,t�e preferred where the installation is possible
a) /ee2aof leaching area-r4ninm 500 sq ft
b) c) nage 2%
d) iale)ash pad
f)g) pipe from d -bore to pipe
/""Leachin Fields
o gr€►aer than 20 Mates/inch
a -Minim= 900 aq ft
onstructi®n of field
surfac® drainage 2
e) 20, from cellar tel. or inground siAmndng pool
a)-� one —Teaching ares: -min 5 DO aq ft
b) spacing -4 f 6 ft with reserve betwen
c) dasi.on
d) etr�a on
e) stone
f) surfa a drainage 2%
s ope y� to be shown)
b) y/x % 150 (to be shown)
PUMS/
a) Tsd-by
val
b} power
TOS `Oo. ALiCoyc-g-'
'FROM: V--eAQV-
A,,) r -Assoc_ . Tm c_ .
NORTH ANDOVER, MASS. Aj V UST b .198 1
BOARD OF HEALTH
DESIGN ENGINEER Re: Soil Absorption
Sewage Disposal
System
This is to certify that I have inspected the construction materials of
said disposal system at L - L -4r-- LA Taves e -N
Site Location
North Andover, MA.
The grades and construction materials are as specified in my plans and
specifications dated Z -AN - 19 e-1 and Aucau.S"T 18 19031
v
Reg. Prof. Engineer/Reg. Sanitarian
a,
4-4
cypli
LblV. PIPS DU7 F-jd5E LOOT
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IV
i
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
t► ,r f* 5
J,4 M
Address of property r -fir �►r` t - t�+e
Owner's -name
Date of Inspection,,(_
PART A
CHECKLIST
Chec .if the following have been done:
Pumping information was requested of the owner, occupant, and Board of
/''Health.
"` 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.
As built plans have been obtained and examined. Note if they are not
available with N/A.
/The facility or dwelling was inspected for signs of sewage back-up.
The site was inspected for signs of breakout.
All system components, excluding the SAS, 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 SAS on the site has been determined based
on existing information or approximated by non -intrusive methods.
The facility owner (and occupants, if different from owner) were
provided with information on the proper maintenance of SSDS.
t� .....�....-_ _,..,,��,„.t.r`-. ."�, r+-.,r-,--y.,+'a. M ,. .., ,. .. - nw ...,y..�is.r--- - 4x11"�Y,..,-.���,-'Y�-.�"'�l�h V�.. -•i n'.--y.-Y. �
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C -
FAILURE CRITERIA
Indicate yes, no, or not determined (Y, N, or ND). Describe basis of
determination in all instances. If "not determined", explain why not)
00 Backup of sewage into facility?
�1Q Discharge or ponding of effluent to the surface of the ground or
surface waters?
A/6 Static liquid level in the distribution box above outlet invert?
Liquid depth in cesspool <6" below invert or available volume< 1/2 day
flow?
Required pumping 4 times or more in the last year.
number of times pumped
P6 Septic tank is metal? cracked? structurally unsound? substantial
infiltration? substantial exfiltration? tank failure imminent?
Is any portion of the SAS, cesspool or privy:
below the high groundwater elevation?
10 within 50 feet of a surface water?
//Q within 100 feet of a surface water supply or tributary to a surface
water supply?
V -d within a Zone I of a public well?
within 50 feet of a bordering vegetated wetland or salt marsh
(cesspools and privies only, not the SAS)?
°U within 50 feet of a private water supply well?
0V less than 100 feet butreater than 50 feet from a
g private water
supply well with no acceptable water quality analysis? If the well
has been analyzed to be acceptable, attach copy of well water analys
for coliform bacteria, volatile organic compounds, ammonia nitrogen
and nitrate nitrogen.
r.. wy.�t•-r.,. "" .y `" .,.r,rt.r.,-. y.�.? ' :�.y-Yr....,r.rii. �__RT`✓, Tom.
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART B
SYSTEM INFORMATION continued
SEPTIC TANK:
(locate on site plan)
er
depth below grade -,
material of constructiontconcrete metal FRP other(explain)
dimensions •
_ sludge depth
3., distance from top of sludge to bottom of outlet tee or baffle
scum thickness
distance from top of scum to top of outlet tee or baffle
,4' 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, recommendations for repairs, etc.)
DISTRIBUTION BOX:
(locate on site plan)
/vH f depth of liquid level above outlet invert
Comments:
(note if level and distribution is equal, evidence of solids carryover,
evidence of leakage into or out of box, recommendation for repairs, etc.)
PUMP CHAMBER:
(locate on site plan)
pumps in working order, yes or no
Comments:
(note condition of pump chamber, condition of pumps and appurtenances,
recommendations for maintenance or repairs,etc.)
• •...- x r M , -.y xr r Y..I..r�'Y r r...nr...�..*,.-Ty... ._i.t^N+rR,.x+r-wZ+.^`^^r T- -t ... �,...M1,, eN1.w✓ .,. x. t
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART B
SYSTEM INFORMATION
FLOW CONDITIONS
If residential
number of bedrooms
number of current residents
_v garbage grinder, yes or no
S laundry connected to system, yes or no
. seasonal use, yes or no
If nonresidential, calculated flow:
Water meter readings, if available:
41vt<<L IN
Last date of occupancy
GENERAL INFORMATION
Pumping records and source of information:
Alo0 f d qsr 7 ye # -T
S System pumped as part of inspection, yes or no
if yes, volume pumped
Reason for pumping:
iI% r ro 1i i'f=l� 5 )"`4 /I le,
I -/f Al /-
Type f 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)
Approximate age of all components. Date installed, if known -'Source of
information:
Sewage odors detected when arriving at the site, yes or no
.......k_.' I._....111 .,
i
i.
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART B
SYSTEM INFORMATION continued
SOIL ABSORPTION SYSTEM (SAS):
(locate on site plan, if possible; excavation not required, but may be
approximated by non -intrusive methods)
If not determined to be present, explain:
Type
leaching pits and number
leaching chambers and number
leaching galleries and number
leaching trenches, number, length Lu 1.d A -
leaching fields, number, dimensions
overflow cesspool, number
Comments:
(note condition of soil, signs of hydraulic failure, level of ponding,
condition of vegetation, recommendations for maintenance or repairs,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, recommendations for maintenance or repairs,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, recommendations for maintenance or repairs,etc.)
'wr.:ry'Yr'+`ea"^�.`Y-r ... -o ti.+R'b" ..s ♦ ��.. Y^ "+1^"'+Kc .r^<ir'1"'^'�
s SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART B
SYSTEM INFORMATION continued
SKETCH OF SEWAGE DISPOSAL SYSTEM:
include ties to at least two permanent references landmarks or benchmarks
locate all wells within 100'
DEPTH TO GROUNDWATER
1 depth to groundwater
method of determination or approximation:
)'A
yr
4'e SUBSURFACE SEWAGE DISPOSAL SYSTEN INSPECTION FORM
PART D
CERTIFICATION
Name of Inspector ,j dpl 13 a S o'
Company Name let ti
A,Company Address
Certification Statement
I certify that I have personally inspected the sewage disposal system at
this address and that the information reported is true, accukaate and
complete as of the time of inspection. The inspection was performed and
any recommendations regarding upgrade, maintenance and repair are
consistent with my training and experience in the proper function and
manitenance of on-site sewage disposal systems.
Chec one:
toO I have not found any information which indicates that the system fails
to adequately protect public health or the environment as defined in
310 CMR 15.303. Any failure criteria not evaluated are as stated in/
the FAILURE CRITERIA section of this form.
I have determined that the system fails to protect public health and
the environment as defined in 310 CMR 15.303. The basis for this
determination is provided in the FAILURE CRITERIA section of this
form.
Inspector's Signature
Date t,1-/ y ►
Original to system owner
Copies to:
Buyer (if applicable)
Approving authority
I
G
,rowN OFNORTHDIOVER
DA 1,h SYSTEM PUMPIN PRLF- C 0 R. L)
SYSTEM OWNFR-j �ADDRESS
A ���
LATE OF PUMPINO:
T a I r -M LWAT-10N
_QUANTITY PUMPED:
CLSSPOOL: NO>- .. YES.- S00c Tank: NO
NA SURE OF SERVICE: Rou-rINE,,.4.--- �EMEROENC,y
L)bSF-RVA'rioNs:.
GOOD CONDITION POLI LL'TYJ COVER
HEAVY ()"-ASE BAFFLES IN PLACL
ROOTS
Y Es
DEC 0 7 2004
TO' )rZTH ANDOVER
'AR rtviLNT
OXCUSIVE SOLIDS —__ FLOODED
LoAl-K UDRUNBIACK...—
..—
SOLID CARRYOVER,_..'_. . OTHER EXPLAIN
SYstom Pumpod by
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