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HomeMy WebLinkAboutMiscellaneous - 250 ABBOTT STREET 4/30/2018C y `r Commonwealth of Massachusetts City/Town of North Andover System Pumping Record M SVe J. Form 4 DEP has provided this form for use by local Boards of Health. Other forms may be used, but the information must be substantially the same as that provided here. Before using this form, check with your local Board of Health to determine the form they use. The System Pumping Record must be submitted to the local Board of Health or other approving authority within 14 days from the pumping date in accordance with 310 CMR 15.351. A. Facility Information Important: When filling out forms 1 on the computer, use only the tab key to move your cursor - do not use the return key. �n 2 System Location: Address North Andover City/Town State System Owner: n Zip Code Name RECEIVED Address (if different from location) City/Town JUN 15 2015 State TOWN OF NORTH AN6i \ e AITI DEPARTMENT Telephone Num er B. Pumping Record 1. Date of Pumping eitll/ 1 2. Quantity Pumped Date 3. Type of system: ❑ Cesspool(s) Septic Tank ❑ Tight Tank ❑ Other (describe): 4. Effluent Tee Filter present? ❑ Yes ❑ No 5. Condition of System: Soo Gallons ❑ Grease Trap If yes, was it cleaned? ❑ Yes ❑ No 90cri. __.. _ 6. System Pumped By: !me S e tic Service Company 7. Location where contents were disposed: Stewart's Pre-treatment Plant, 20 So. Mill Bradfol Signature of Hauler Signature of Receiving Facility Vehicle License Number Ma 01835 Date Date t5form4.doc• 03106 System Pumping Record • Page 1 of 1 <C,\Cornrnonwealfh of Massachusets �E� CifylTown of North Andover System Pumping Record Form 4- s form for use by local Boards of Health. Other forms may be used, but the DEP has provided thisame as that vided-here. Before using this form, check with your information must be substantially the local Board of Health to determine 'the form they us . The System Pumping Record muni be submitted to the local Board of Health or other approving authori within 14 Q ds the pumpna date in bI accordance with 310 CMR 15.351. �`� important When filling out forms on the computer, use only the tab key to move your cursor - do not use the return key. d rmcn A. Facility Information )r Nur J HEX 1. System Location: a(5o �r- Address 01886 North Andover Ma State Zip Code CityfTown 2. System Owner: a)1v Name _ Address (ii different from location) State Zip Code City/Town Telephone Number B. Pumping Record ®Gtr 2 Quantity Pumped: Gallons 1. Date of Pumping Date ❑ 3. Type of system: ❑ Cesspool(s) F9`1Tiht Tank Grease Trap] Septic Tank ❑ 9 ❑ Other (describe): 4. Effluent Tee Filter present. ❑ Yes ❑ No If .yes, was it cleaned? ❑ Yes ❑ No 5. Condition of System: 6. System Pumped By* Vehicle License Number Name 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 Date Signature of Receiving Facility t5form4.doc• 03/06 Date System Pumping Record . Pag R. .�719ZO14] � Commonwealth Of (Massachusetts" tjAy City/Town of No AndoverSystem Pum in RecordYowNuc Np 9 �.r Form 4 DEP has provided this form for use by local Boards of Health. Other forms may be used, but the information must be substantially the same as that provided here. Before using this form, check with your local Board of Health to determine the form they use. The System Pumping Record must be submitted to the local Board of Health or other approving authority within 14 days from the pumping date in accordance with 310 CMR 15.351. ❑ Other (describe): 4. Effluent Tee Filter present? ❑ Yes P No 5. C itipn of System_ If yes, was it cleaned? ❑ Yes ❑ No Name Vehicle License Number Stewart's Septic Service Company 7. Location where contents were disposed: Start's Pre-treatment Plant 20 So. Mill Bradford, Ma 01835 Date re of Receiving Facility 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, use only the tab 6,�/-" J' 250 key to move your Address emsor - do not use the return No Andover Ma key. City/Town State Zip Code 2. System Owner: &lamc4 mann Name Address (if different from location) City/Town State ! Zip Code i elephone Number B. Pumping Record Y_� 1. Date of Pumping 2Date. Quantity Pumped: G Ilo'a ns 3. Type of system: ❑ Cesspool(s) Septic Tank ❑ Tight Tank ❑ Grease Trap ❑ Other (describe): 4. Effluent Tee Filter present? ❑ Yes P No 5. C itipn of System_ If yes, was it cleaned? ❑ Yes ❑ No Name Vehicle License Number Stewart's Septic Service Company 7. Location where contents were disposed: Start's Pre-treatment Plant 20 So. Mill Bradford, Ma 01835 Date re of Receiving Facility Date t5form4.doc 03/06 System Pumping Record • Page 1 of 1 7RE-C�EIVED JUL '10 2013 TOWN OF NORTH ANDOVER 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 Hearth 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 tab1-5 key to move your Address cursor -do notuse Na andover Ma key, the return City/rown state Zip Code 2. System Owner. Name Address (Idifferent from location) CitylTown State Zip Code Telephone Number B. Pumping Record 1. Date of Pumping nate 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: 14 6., System Pumped By: Name / vehicle Lioense Number Stewart's Septic Service Company 7. Location where contents were disposed: Stewart's Pre-treatment Plant, 20 So. M 1 Bradford, Ma 01835 signature ofDate Signature wing Facility Date t5form4.doc• 03/06 System Pumping Record •Page 1 of 1 Commonwealth of Massachusetts N W City/Town of No.Andover Q 01VOID System Pumping Record A 10 1'kil Form 4 t>r`� ^" TOWN OP NORTH ANDOVIR DEP has provided this form for use by local Boards of Health. Othe F R7MN7 e 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. B. Pumping Record 1. Date of Pumping �—D ate 2. Quantity Pumped: Gall2. 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: �r`�`�/ ' ` Lr lie )'t- �4 c /22 1 Name T� 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 Si ture o auler Date Sig r e of Receiving Facility Date t5form4.doc- 03/06 System Pumping Record • Page 1 of 1 A. Facility Information Important: When filling out forms the 1. System Locatio . computer, use only the tab key Address to move your No..Andover Ma 01810 cursor - do not use the return CitylTown State Zip Code key. 2. System Owner: C� J� rab v l ryl 0� 00 Name Address (if different from location) City/Town State Zip Code Telephone Number B. Pumping Record 1. Date of Pumping �—D ate 2. Quantity Pumped: Gall2. 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: �r`�`�/ ' ` Lr lie )'t- �4 c /22 1 Name T� 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 Si ture o auler Date Sig r e of Receiving Facility Date t5form4.doc- 03/06 System Pumping Record • Page 1 of 1 Commonwealth of Massachusetts a City/Town of No andover System Pumping Record y` Form 4 DEP has provided this form for use by local Boards of Health. Other forms may be used, but the information must be substantially the same as that provided here. Before using -this form, check with your local Board of Health to determine the form they use. The System Pumping Record must be submitted to the local Board of Health or other approving authority within 14 days from the pumping date in accordance with 310 CMR 15.351. A. Facility Information Important: When filling out forms 1, System Location: on the computer, use only the tab key to move your Address cursor - do not No Andover use the return City/Town ksy. 2. System Owner: mum Name Ma State f Zip Code Address (if different from location) City/Town G State Zip Code Telephone Number B. Pumping Record 1. Date of Pumping nate Z` —2. Quantity Pumped: Gallons 3. Type of system: ❑ Cesspool(s) eptic 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-treatmAnt Plant, 20 So. Mill Bradford, Ma 01835, Signature of Hauler Signature of Receivinj Facility Da I ` r Date t5form4.doc• 03106 System Pumping Record • Page 1 of 1 ,RV 5T V ' A 4 �`�2-0 •,.i -.r+ 4 y _.l£ ,yw+.e¢' at;.'vsse �,�3i.^wi4a•it '•I ,i� ►T'' . �1� ('� [) ry �,,s y f { L SYSTEm PUMPiNu R?COK Aesop ?vPuc !'u�a ntc,, � • ..�. WEXPLAIN �f w g g� i� 47#i�� ��-3f} v cuNt�Nl� jitflN�j'� !t G.,7 i� y 44�.Mt ads �s-,�y�`u7k ff��' �`" � tr r✓ o+ i..7 r s fm:s k+Lxr J.6FF'«✓1i+N�r�3t`'('�v'iilb"#�'�'u"T�4� y &. . s t _ �,�•" �� r stet n,�+,VL COMMONWEALTH OF MASSACHUSETTS EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS DEPARTMENT OF ENVIRONMENTAL PROTECTION TITLE 5 . OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM PART A CERTIFICATION Property Address: 'LS 0 AW6 ('T 5-', R, a6t��', Owner's Name: Pti ,Lul =r 1 f- y: �-A W p Lr - Owner's Address: '2 So nB-��-r S-1, Z(-Rkgove,& MA &EAS Date of Inspection: _ �1/`��( l Name of Inspector: (please print) OR M f}mx Company Name: — Mailing Address: Telephone Number: `tiaL , .44 et • 6 a Q f 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 function and maintenance of on site sewage disposal systems. I am a DEP approved system inspector pursuant t� tion 15340 of Title 5 (310 CMR 15.000). The system: Passes Conditionally Passes Needs Further Evaluation by the Local Approving Authority Fails Inspector's Signature: a Date: 5, ( > C 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 o,, -,mer 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 docs 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: 293 qK&- -[ Cv;� tk MAr )1841; Owner: Nimzp +TeksrA bio Date of Inspection: 5 . t - O 1 Inspection Summary: Check A,B,CM or E / ALWAYS complete all of Section D A. Systgm 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: One or more system components as described in the "Conditional Pass" section need to be replaced or repaired. The system, upon completion of the replacement or repair, as approved by the Board of Health, will pass. Answer yes, no or not determined (Y N,ND) ir, u e for the following statements. If "not determined" please explain. The septic tank is metal and over 20 years old* or the septic tank (whether metal or not) is structurally unsound, exhibits substantial infiltration or exfiltration or tank failure is imminent. System will pass inspection if the existing tank is replaced with a complying septic tank as approved by the Board of Health. *A metal septic tank will pass inspection if it is structurally sound, not leaking and if a Certificate of Compliance indicating that the tank is less than 20 years old is available. ND explain: Observation of sewage backup or break out or high static water level in the distribution box due to broken or obstructed pipe(s) or due to a broken, settled or uneven distribution box. System will pass inspection if (with approval of Board of Health): broken pipe(s) are replaced obstruction is removed distribution box is leveled or replaced ND explain: The system required pumping more than 4 times a year due to broken or obstructed pipe(s). The system will pass inspection if (with approval of the Board of Health): broken pipe(s) are replaced obstruction is removed ND explain: Page 3 of I I OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: ZGO AZZ , y jW,, Ar,t-�vc��A k M14 a��345f •. Owner: PA tL>,.Q a- TEittal �U o t F Date of Inspection: S r l O l 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 2. System w;ll fail unless the Board of Healtu (and Public 3=dater 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. _ 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. 3. Other: Page 4 of I 1 OFFICIAL INSPECTION FORM — NOT FOR.VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: • —60 A3'80-°7 S -r. Owner: A(L-we 4r:E� woLq Date of Inspection: G = k • o D. System Failure Criteria applicable to all systems: You must indicate "yes" or `bio" to each of the following for all inspections: Yes No Backup of sewage into facility or system component due to 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 clogged SAS or cesspool Liquid depth in cesspool is less than 6" below invert or available volume is less than '/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 SAS, cesspool or privy is below high ground water elevation. ✓ Any portion of 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 1 of a public well. _f 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. [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-poliation 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 (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 systmm 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 `ho" 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 of 11 OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST Property Address: ZraQ 5t H. AiaflcV&C4 M at5+5 Owner: P&I-Lft -F 'C c4 WO L.F Date of Inspection: 5-t, O l Check if the following have been done. You must indicate "yes" or "no" as to each of the following-._ Yes No ✓� — Pumping information was provided by the owner, occupant, or Board of Health Were any of the system components pumped out in the previous two weeks ? v"4 _ Has the system received normal flows in the previous two week period ? Have large volumes of water been introduced to the system recently or as part of this inspection Fere as built plans of the system obtained and examined? (If they were not available note as N/A) _ Was the facility or dwelling inspected for signs of sewage back up ? _ Was the site inspected for signs of break out ? i✓ — Were all system components, excluding the SAS, located on site ? ✓ 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 ? ✓/ ____ 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 4A_ Existing information. For example, a plan at the Board of Health. Determined in the field (if any of the failure criteria related to Part C is 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: 22S13N fteo-!�r S .. Ae}dw tk, A-tA oU�Nl 24 -©t8'4-5 Owner: N _vt i A W n t_'F Date of Inspection: S t t- a t FLOW CONDITIONS RESIDENTIAL Number of bedrooms (design): Number of bedrooms (actual): DESIGN flow based on 310 CM-l't 15.203 (for example: l 10 gpd x # of bedrooms): 4-40 Number of current residents: -3 Does residence have a garbage grinder (yes or no): YF_S Is laundry on a separate sewage system (yes or no): V4a [if yes separate inspection required] Laundry system inspected (yes or no): — Seasonal use: (yes or no):tk0 Water meter readings, if available (last 2 years usage (gpd)):$ Sump pump (yes or no): 1!Lo Last date of occupancy: O CGv Pi t_D COIVEVIERCIAL/INDUSTRIAL Type of establishment: Design flow (based on 310 CMR 15.203): gpd Basis of design flow (seats/persons/sgft,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: Ocurtt; K — LATS -7 eot•nq &!ev t tp V �NIF, Zoo o Was system pumped as part of the inspection (yes or no): j.io If yes, volume pumped: _gallons -- How was quantity pumped determined? Reason for pumping: T)TE 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) _ 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: 23 �ISA2s 'nLj> - Owt(CA_ Were sewage odors detected when arriving at the site (yes or no): NAO Page 7 of 11 OFFICIAL INSPECTION FORM — NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PARTC SYSTEM INFORMATION (continued) Property Address: 250 Azlaa -( 16F—( 1A PtNOoUt Ml4 d t°�s�t5 Owner: P&kLU A -t% Date of Inspection; 5 BUILDING SEWER (locate on site plan) Depth below grade: ( a " Materials of construction: t.,'cast iron 40 PVC _other (explain): Distance from private water supply well or suction line: Comments (on condition of joints, venting, evidence of leakage, etc.): G000 0 Itt 011-tto14 SEPTIC TANK: locate on site plan) Depth below grade: Zt� Material of construction: -concrete metal _ibergiass_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) c j f Dimensions: tti- 4`k L �C - 2 X r,> Sludge depth: I `t 1 Distance from top of sludge to bottom of outlet tee or baffle: 7_4' Scum thickness: t it Distance from top of scum to top of outlet tee or baffle: A� 11_ Distance from bottom of scum to bortom of outlet tee or baffle: S 3t' How were dimensions determined: M"csi•__ Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invent, evidence of leakage, etc.}: F GREASE TRAP: _(locate on site plan) Depth below grade: _ Material of construction: _concrete . metal _fiberglass ___polyethylene _other (explain): Dimensions: Scum thickness: i t Distance from top of scum to top of outlet tee or baffle: Distance from bottom of scum to bottom of outlet tee or baffle: 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: _2 `"C7 s Owner: _Qui -t ��P-�`1F1RR A W01.C- Date of Inspection: 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: f(if present must be opened)(locate on site plan) Depth of liquid level above outlet invert: - d 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.): L PUTNIP CHAMBER: (locate on site plan) Pumps in working order (yes or no): Alarms in working order (yes or no): Comments (note condition of pump chamber, condition of pumps and appurtenances, etc.): X Page 9 of 11 OFFICIAL INSPECTION FORM — NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: 2'S O V,QrOZZ 2k- N , At-06vv : A ©�a4 Otivner: P41 t_uf + -T-2026A kJti1.F Date of Inspection: S • l , 0 1 SOIL ABSORPTION SYSTEM (SAS): (locate onsite plan, excavation not required) If SAS not located explain why: Type leaching pits, number: _ leaching chambers, number: leaching galleries, number: 4 leaching trenches, number, length: 54 t S leaching fields, number, dimensions: overflow cesspool, number: innovative/alternative system Type/name of technology: Comments (note condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of vegetation, etc.): 66re c-tcaA n f- P2r� c3is CESSPOOLS: (cesspool must be pumped as part of inspectionxlocate 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 (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: Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): Page 10 of 11 OFFICIAL INSPECTION FORM —NOT FOR, VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: 2roo AMo-rc 57 K . htW,0VNL, MA Owner: Q 4}tLL�� -rWit ¢ Date of Inspection: S , k • n l 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. w� M R � n I � f c.�wtaooe�w-u c� of suM a �DtS'zp�.c�5 5�'Ci e.. TPr�eK ti�l�cr-( Q Cd aF MAiK NQ-,ro__ c- S QL -CA"V, OQJ L_�-t 'D G +0 3oX AT Tuot �k L k%4 E 7-4-o G, t -o A+cIF tS- ctoF ��-� Page I 1 of I 1 OFFICIAL INSPECTION FORM — NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: SSO 0— '�;(_ vuk, MA o t"5 Owner: Q�kIU_1 A� 4 WoL-e Date of Inspection: 5 � t - 01 SITE EXAM Slope Surface water Check cellar Shallow wells Estimated depth to ground water 8 iy feet Please indicate (check) all methods used to determine the high ground water elevation: ✓aObtained from system design plans on record - If checked, date of design plan reviewed: '7, i (o 2300 Q ST 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) Accessed USGS database -explain: You must describe how you established the high ground water elevation: n'a-© L. V -S Cok) (:5 i"rud 'g cit sew W A -wk La:` t3 3 mac, w 5� s C 23ib tz'E'A sem. `i�l(� �9 �tm% -BY %M lro 2 1 ot�.�PZ�G S`{s Cc1 — KttCt z o G �2ou0 w cam `�Z' '6�� r� k9 North Andover Board of Health 120 Main St. North Andover Ma.01845 Haul Lic. #151 -OOH Install Llc. # 128-0 Date Address 11/1/2000 303 Chester St 11/1/2000 50 Willow Rd 11/1/2000 160 Carelton Ln 11/1/2000 165 Bridal Path 11/4/2000 174 Ingals St 11/4/2000 1062 Salem St 11/6/2000 373 Raligh Tavern Ln 11/6/2000 252 Boxford St 11/6/2000 150 Liberty St 11/6/2000 149 Osgood St 11/7/2000 255 Haymeadow 11/7/2000 850 Winter St 11/8/2000 25 Windsor Ln 11/9/2000 249 Carlton Ln 11/9/2000 767 Johnson St 11/10/2000 56 Academy Rd 11/14/2000 Sugar Cane Ln 1 1/1 4/2000 250 Abbott St 11/15/2000 195 Winter St 11/15/2000 187 Winter St 11/16/2000 85 Laconia Cir 11/16/2000 86 Willow Ridge 11/17/2000 2135 Turnpike St 11/20/2000 203 Grandville Ln 11/2012000 391 Pleasant St 11/20/2000 124 Tucker Farm Rd 1112212000 394 Boston Rd 11/22/2000 728 Forest St 11/22/2000 18 Johnney Cake St 11/24/2000 106 Rockey Brook Rd 11/24/2000 258 Rea St 11/2812000 1815 Great Pond Rd 11/28/2000 1420 Great Pond Rd 11/29/2000 266 Lacy St 11129/2000 155 Laconia Cir Andover Septic 47 Railroad St. Bradford Ma. 01835 Gallons Comments 1000 1000 1500 1500 1000 1250 1000 1000 Leachfield Run Back/ Ex. Solids 1500 1000 1500 1250 1500 1500 1500 1500 1500 1000 Extra Solids 1500 1500 1500 1000 1500 1000 Flooded 1500 1500 1500 1500 1500 1500 1000 1000 1500 1000 1500 'ro" OF/NORTH ANDOVEE 1) SysTtm UMPIN 9?P(' ul SYSTEM OWNER &-A6D-RESs 66&ra4�-2 0? 3 0 DATE OF PLIMPING:­�. SYSTEMLOCATION RECEIVED OCT 0 5 2004 TOWN OF NORTH ANDOVER PUMPED: CLSSPWL: NO _(-,-"YES . ...... .... puc 1'aak: NO YES NA PURE OF SERVICE: Kou-rINh,_.­j 08SERVATIONS: GOOD CONDITIONKI FULLTU COVER HEAVY GREASE O ROOTS BAFFLES IN PLACE LEACKFIELD RUNBACK BXCUSIVE SOLIDS ----'FLOODED SOLID CARRYOVER ------ ---- - OTHER EXPLAIN SysLorn Pumped by IZ/ 177a Ls- / Z)/6f) (5L COMMENTS. ............ ........ .... . ...... CON I EN I'S I"KANSFERKED 1-0 • YY11fl� form". cam} . orLy to .n; WB: usa L .- ht�ar,� t5forrr '"x/t1Y`X(vt'i�iffl��'*kraf`W�'�'''YtYlt Ev 1'tkJi,PY�if� V, t •r t �+ CoMM"eal ,, of Massachusetts SyStem' Pum in Record R r; . p g HEA TN DEPARTMENT Form' 4' DEP has proylded this form for use by loyal Boards of Health, The System Pumping Record mug be submitted to the local Board of Health or other approving authority. 1 -%.y t • 1. SYstert-Location, JL Add v Gty/Town State Zip Code 2, System Owner, Name Address (if different from location) CQ—Town State Zip Code Telephone Number B. Pumping Record 1, Date of Pumping1 2. Quantity Pumped:data Gallons 3, , Type of system:. ❑ Cesspool(s) V Septic Tank ❑Tight Tank Other (describe): 4. Effluent Tee ,Filter present? ❑ Yes ❑ No If yes,`was It cleaned? ❑ Yes ❑ No 5. Condition of System: FTA kSy PumpedBy: Vehicle t.icense Number rU1C� 7. Locatio where contents were disposed: 1 Sin t aider . oats ss.gov/de .',.titer/ipprovalsA$forms;htrn#Inspect 3 System Pumping Record Page 1 or 1 No Andover J&S Development dba 1600 Osgood St Stewart's Septic Building 20 Suite 2-36 Andover Septic No. Andover, Ma 01845 58 South Kimball Street Bradford, MA 01835 Date Name & Address Gallons Comments 2 -Jul Bake N Joy Willow St ✓ 4800 Grease 3 -Jul Coltin 316 Rolwey Tavern Lane 1000 Xsolids HG 9 -Jul Bake N joy Willow Ave 5000 Grease & ** 2 inside grease traps 12 -Jul Mukherjee 30 Sherwood Dr�/' .� 1000 Good 18 -Jut Hanny 45 Innis street\/ 1000 good 19 -Jul Butcher Rte 125% 16-1 -7 SSG 200 grease 19 -Jul Chipolte 93 turnpike✓ 3000 grease 26 -Jul Driscoll 110 Forest street✓ 1500 good 26 -Jul Hudson 1850 Salem street✓� / 1500 good 27 -Jul Ferragamo 1112 Tnpk streetl� 1500 good 27 -Jul Perry 303 Berry street � 1500 good 30 -Jul Barry 62 Stone cleave road 1000 good 7- 2S ��O &mmu )G U Uo d5 0 � ;`� fi Sia✓ /000 Cad