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HomeMy WebLinkAboutMiscellaneous - 250 JOHNSON STREET 4/30/2018 (3)IP4-7� a kt AV,%r w �1ZPte�r"�(l �Q����rr22}kt t 1� '��i4",^j.�M�"y'�r `�r��4►p,nwal�f� .af Massachusetts /Town of DOVER MASS CH 0 ty . ;'gystj Pumping Record. TOWN OFNORTH ANDOVER Fon» 4' HEALTH DEPARTMENT ` DEP has provided this form for use by local Boards of Health. The system Pum*, g Record must be submitted to the local Board of Health or other approving authority, A: Facility Information out 1, System Location, q F form: on the p y ft jab key Add to mow your cursor • do not Chyfrown use the return key'..., 1 2, System Owner, F Name Address (If different Imm location) CItyffown E� State Telephone Number Zip Code Zip Code B. Pumping Record a�Ll' _Ia. Quantity Pumped: Gauons 1. Date of Pumping Dat 3. Type of system. cesspool(s)tic Tank ❑ Tight Tank ,` ❑ Other (describe): 4. Effluent Teo Filter present? ❑ Yes ❑ No If yes, was it cleaned? E]Yes C3 No S, Conditlon of System 96inA- 6. Sys m Pumped 6 : Z b Vehicle Uoense Number raw Y.: 7. Location whtre contents were disposed: Sip 4Wm of Ha*'... Date http:l/www.masa.govldeptwaterlapprovalslt5fomts.htm#4nspect t6 WM.d000 06103 M System Pumping Record • Page t of t Of NORTH , O F A i • sSACHUSe Applicant Site Local Town of North Andover, Massachusetts BOARD OF HEALTH �/ >7 19 9� DISPOSAL WORKS CONSTRUCTION PERMIT Form No. 3 Permission is hereby granted to Construct ( ) or Repair (g) an Individual 5oil Absorption Sewage Disposal System as shown on the Design Approval S.S. No.— A1114 /11 Fee el 5 CHAIRMAN, BOARD OF HEALTH D.W.C. No. /0// ' ' •.�, a rr � �' nf° � �: �5 �9'F9 " i F - �:� q � d � r t IJ U4 V��� - SYBTEm pUMPtNU R.FC'OKl. - sYSiEM © �R � �tRAR.�SS-. oaf; o� �vt�NQ; �,✓�° � �-��- � .��. N,, rvK a xv;,c��1 kUvriNx 000 D NOI 10)4 t't�i.: t v ��ivrx x�'fikr, �tl:l.p RL7Yfi�<'�, IN PLAIL�� A � OXC�SIY6�`spllp8,.:PL40Mp SULFt7CA Y0y R . «; OBER EXPLAIN `^r , n. «1Nt�N1 Frl.11Y�t�K&to�1 � ) 0 0 n 0 W CL �11 w h cn M ca)o OA v O A 3 Q 0 a D a � m co0 a 0 t, = avv A w rOr O C (D 3 3 A rt 1 3 rt i Q D � J D � S J } � o 3 m 9 O� � v i D n rt a l 0 n 0 W CL �11 w h cn M WILLIAM F. WELD Govemo: ARGEO PAUL CELLUCCI Lt. Governor P,,D, _ COMMONIX'EALTH OF MASSACIHUSETTS EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS DEPARTMENT OF ENVIRONMENTAL PROTECTION ONE WINTER STREET. BOSTON. NIA 02108 611-293-5500 14AY 2 7 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A ' f��` ,C(s'="ERTIFICATION Property Address: Cts I' fes-- ibCkkk 'CAddresw of Owners Date of Inspection:�t �--Q� 1 � pf different) Name of Inspector.- q itiQc I am a D per ved system ins ect r pursu�nttoection 340 of Title S (310 CMR.15.000) Company Name:1Mailing Address: L 0. vel Q, O f8 ( Q Telephone Number: TRUDY COXE Secretary DAVID B. STRUHS Commissioner 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 inspection. The inspection was performed based on my training and experience in the proper function and maintenance of on-site sew/age disposal systems. The system: _ PLasses Conditionally Passes Ne s urther valuation By the Local Approving Authority _ F a i A inspector's Signature: Date: v �� The System Inspector shal su mit a copy of this inspection report to the Approving Authority within thirty (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 ownbt shall submit the report to the appropriate regional office of the Department of Environmental Protection. The original should be sent to the system owner and copies sent to the buyer, if applicable, and the approving authority. INSPECTION SUMMARY: Check A, B, C, or D': A] 7�:tund anv information which indicates that the system violates any of the failure criteria as defined in 310 CMR 15.303. Any 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. 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, unless the owner or operator has provided the system inspector with a copy bf a Urtif c9te of Compliance (attached) indicating that the tank was installed within twenty (20) years prior to the date of the inspection; or the septic tank, whether or not metal, is 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. : (zovised 04/25/97) ftgi I O! 10 DEP on the world Wide web: http:/h~.magnet.state.ma.uWdep 0 Printed on Recycled Paper e`oard of Health North AndovergMass. J SEPTIC SYSTEM INSTALLATICK CHECK LISP LOT EXCAVATION WFAIL �easonst . 1. Distance To: a. Wetlands b. Drains c. Well 2. Water Line Location 3• No PVC Pipe 4. Septic Tank a. Tees - Length & To Clean Out Covers b. Cement Pipe to Tank - On Both Sides of Tank 5. Distribution Box a. Covers & Box - No Cracks b. All Lines Flowing Equal Amounts c. No Back Flow 6. Leach Field or Trench a. Dimensions b. Stone Depth c. Capped gids d. Clean Double Washed Stone 7. Leach Pits a. Dim�sas ns b. Stone epth C. Spl Pads d. T s e. t Pipe to Pit - Both Sides f. Clean 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 with Regard -to Perc Test d. Elevations e: Water Table SUBSURFACE DISPOSAL' SYSTEM CHECK LIST AP�'ROVED DATE PROVIDED Title 5 Reg. 2.5 Reg. 6 Fail NORTH ANDOVER BOARD OF HEALTH DISAPPROVED DATE TIME REASON JOKI The submitted plan must show as a minumum: al— the lot to be served (area,dimensions,lot #,abutters) (Planning Board files) 'U) location and log of deep observation holes -distance to ties C-)— location and results of percolation tests -distance to ties d -)—design calculations & calculations showing required leaching area e -location and dimensions of system (including reserve area) existing and proposed contours location of any wet areas within 100' of the sewage disposal system ok" disclaimer (check wetlands mapping) h-} surface and subsurface drains within 100' of sewage disposal system or'disclaimer i-) location of any drainage easements within 100' of sewage disposal system or disclaimer (planning board files) , �3-- known sources of water supply within 200' of sewage disposal system or disclaimer k-)- location of any proposed well to serve the lot (-100' from leaching facility) i) location of water lines on property (10' from leaching facilities) mi— location of benchmark n-)- driveways .o-) garbage disposers -no PVC is to be used in construction ,)--Q profile of the system (elevations of basement, plumber pipe septic tank, distribution box inlets and outle:-s, distribution field piping and any other elevations) r)" maximum ground water elevation in area of sewage disposa system plan must be prepared by a Professional Engineer or other professional authorized by law to prepare such plans Septic Tanks (a) C acities - 150% of flow, water table, tees, depth of tees, access, pumping, (,Or" Cleanout C) 10' from cellar wall or inground swimming pool d) 25' from subsurface drains __ tiu„�u�lace disposal syste.m check list - Page 2 it Reg. 10.2 Reg.10.4 Reg. 11 .2 Reg. 11 .4 Reg.11.1i Reg. 11 .1' Reg. 15.1 Reg. 15.1 Reg. 15.4 Reg. 15.8 Reg. 3.7 Reg.14.1 Reg.14.3 Reg.14.4 14.5 Reg.14.6 Reg. 14.7 Reg.14.1C Reg. 9.1 Reg. 9.6 Distribution Boxes i ISlope greater than 0.08 (b Sump Leaching Pits Leaching pits are preferred where the installation is possible (a) Calculations of leaching area (minimum 500 S.F.) (b Spacing (c Surface drainage 2% d Cover Smaterial Leachi00-sk P,4 ng Fields 3) `� �'�"� (a) RoGreater than 20 minutes/inch (b) A -x"6 a (minimum 900 S.F.) (c)z Construction of field ( I Surface drainage 2% -(e) 20' from cellar wall or inground swimming pool Leaching Trenches (a) Calculations of leaching area (min. 500 S.F.) MSpacing (4 ft. min. 6 ft. with reserve between) Dimensions (d) Construction (e) Stone (f) Surface drainage 2% Downhill Slope (a) Slope y/x = (to be shown) (b) y/x X 150 = (to be shown) Puma (a) Approval (b) Stand-by power ?eet 0 L E' P, I �Ct JLATrOI TFST .. _. _ _ J T . � l DATA Boacd of Health--r\Tort i Andover, f rfgSS. ' Street 1— Lot No. Subdivision „�- Investigator Owner ----�- — Observer L Da t e_S Elev. Inches 0 2. Date Elev.- SOIL PROFILES 3. Date Elev. Date---,— m Top & subsoil depth; depth of refusal. "Timber ^t Saturation --'iiriS. Test-ii^e of 3t�_T�rle _ of 6"_ -Tung .on - -- <'7!d depths of other soil types; PERCOLATION PESTS Date Date Date 4. Date Elev. Ties to Test Pits 1. 2. ;�-' 4 " 1-1)117111n depth of water table; Date Date T 4— 5 T v 0 �J) te �U ZT « L—E. VA -r e ©r te. L� P_ LPA 0 Q T 0 NSE_ _ I&LPJPF- IMT� il l V- P1P l qTI O- p-5OJS _ - — LWL PIP -F- OUT p SQA --- ,NV aNID 0-p- pi py- n Pp 5A L— �JYS"i �M I IN F'2A'► V- CC7EL�r.1AS 4 A53UGtl�'TES E:iN61NEE-.QS� ARL4-(17-tGT`Z) ,0. WILLI.ANI F. WELD Govemo: ARGEO PAUL CELLUCCI Lt. Governor Property Address: Q Date of Inspection: a' Name of Inspector:Q << I am a D19 ed Company Name: Mailing Address: Il Telephone Number: COMMONWEALTH OF MASSACHUSETTS EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS DEPARTMENT OF ENVIRONMENTAL PROTECTION / ONE )KINTER STREET. BOSTON. NIA 02108 617-292-5500 fi TRUDY COXE ' 4 " 7 7 Secm4ary DAVID B. STRUHS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM Commissions PART A � ppCE��RTIFICATION ; /- -P1—& XZ/C^ Address of Owner: of different) to Section 15.340 of Title 5 (310 CMR 15.000) 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 inspection. The inspection was performed based on my training and experience in the proper function and t'naintenance of on-site sewage disposal systems. The system: Pate�s _e --- _��onditionally Passes Needs Further Evaluation By the Local Approving Authority _ F it Ins ector8 's Si nature: �"� Date: `� P The System Inspector shall submit a copy of this inspection report to the Approving Authority within thirty (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 Department of Environmental Protection. The original should be sent to the'system owner and copies sent to the buyer, if applicable, and the approving authority. INSPECTION SUMMARY: Check A, B, C, or D� A) SYSTEM PASSES: I have not found any information which indicates that the system violates any of the failure criteria as defined In 310 CMR 15.303. Any failure criteria not evaluated are indicated below. COMMENTS: B) SYSTEM C DITIONALLY PASSES: One or more system components as described in the 'Coriditional Pass" section need to be replaced or repaired. The system, upon completion of the replacemen or re h, as approved by t Board o ealth, c c U �� � �c inba�d r Vf.%M� Indicate yno, or not determined(Y, N, or D). bescribe basis of eterminationll"not determined", Oxplairt why not. 1[_/ The septic tank is metal, unless the owner or operator has provided the system inspector with a copy bf a Certificate of Compliance (attached) indicating that the tank was installed within twenty (20) years prior to the date of tht inspection; or the septic tank, whether or not metal, is cracked, structurally unsound, shows substantial infiltration of exfiltmlion, or tank failure is imminent. The system will pass inspection if the existing septic tank is replaced with A conformifil septic tank as approved by the Board of Health. , (revisod 04/25/97) Vag* 1 of 16 DEP on the World Wide Web: h":Nwww.magr*LkWtt.ma.uWdep 0 Printed on Recycled Paper SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A ' CERTIFICATION (continued) Property Address: Owner: Pate of Inspection: Bj SYSTFM CONDITIONALLY PASSES (continued) 1 Sewage backup or breakout or high static water level observed in the diitfibution-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). D cribe observations: !/broken pipe(s) are replaced obstruction is removed distribution box is levelled or replaced NThe system required pumping more than four 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 CJ 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) 6YSTEM WILL FAIL UNLESS THE BOARD -OF HEALTH (AND PUBLIC WATER SUPPLIER, IF APPROPRIATE) DETERMINES THAT THE SYSTEM IS FUNCTIONING IN A MANNER THAT PROTECTS THE PUBLIC HEALTH AND SAFETY AND THE ENVIRONMENT: The system has a septic tank and soil absorption system (SAS) and the SAS is within 100 feet to a surface water supply or tributary to a surface water supply. _ The system has a septic tank and soil absorption system and the SAS is within a Zone I of a public water supply well. _ The system has a septic tank and soil absorption system and the SAS is within 50 feet of a private water supply well. The system has a septic tank and soil absorption system and the SAS 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. Method used to determine distance (approximation not valid). 3) OTHER (sevisod 0{/35/97) Pago 2 of 10 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: 0e —01 Owner: � .�0� Date of Inspection: Dj SYSTEM FAILS: You must indicate either "Yes" or "No" as to each of the following: I 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. Yes No Backup of sewage into facility or system component due to an overloaded or clogged SAS or cesspool. Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool. Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool. Liquid depth in cesspool is less than 6" below invert or avjilable volume is less than 1/2 day flow. Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number of times pumped _. Any portion of the Soil Absorption System, cesspool or privy is below the high groundwater elevation. Any portion of a cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. r 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 anatysir for coliform bacteria, volatile organic compounds, ammonia nitrogen and nitrate nitrogen. El LARGE SYSTEM FAILS: You must indicate either "Yes" or "No" as to each of the following: The following criteria apply to large systems in addition to the criteria above: The system serves a facility with a design flow of 10,000 gpd or greater (Large System) and the system is a significant threat to public health and safety and the environment because one or more of the following conditions exist: 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) 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. (srvifM 01/2s/97) fapj 3 of 10 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART 6 CHECKLIST Property Address: Qac (�t;'-� S , Opyner. Date of Inspection: Check if the following have been done: You must indicate either "Yes" or "No" as to each of the following: Yest>! l.. Pumping information was provided by the owner, occupant, or 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 pan 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 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: The facility owner (and occupants, if different from owner) were provided with information on the proper maintenance of Sub -Surface Disposal System. Existing information.Ex. Plan at B.O.H. Determined in the field (if any of the failure criteria related to Part C is at issue, approximation of distance is unacceptable) 115.302(3)(b)] (roviVId 04/25/97) Pago 4 of 20 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C ' SYSTEM INFORMATION Property Address:�S+ ZSIAAj, 4,L4 --c Owner: Date of Inspection: FLOW CONDITIONS RESIDENTIAL: Design flow: i_g. /bedroom for S.A.S. Number of bedrooms: Number of current residents: Garbage grinder (yes or no): A0 Laundry connected to systgrlt (yes or no):,�45 Seasonal use (yes or no): o Water meter readings, if v 'lable (last two (2) year usage (gpd): Sump Pump (yes or no): 300 Last date of occupancy: C'VCCQ&&A- COMMERC I AUI N D USTR I Al: Type of establishment: Design flow:_____$allons/day Grease trap present: (yes or no)_ Industrial Waste Holding Tank present: (yes or no)_ Non -sanitary waste discharged to the Title S system: (yes or no)_ Water meter readings, if available: Last date of occupancy: OTHER: (Describe) Last date of occupancy: PUMPING RECORDS and source of information: til.( Uj ex- GENERAL INFORMATION System pumped as part of inspection: (yes or no) If yes, volume pum • ( gallo5 Reason for pumping: �1 - -VI tRSA TYPE 9�,YSTEM Septic tank/distribution box/soil absorption system Single cesspool Overflow cesspool Privy Shared system (yes or no) (if yes, attach previous inspection records, if any) I/A Technology etc. Copy of up to date contractt Other APPRO,V�MA�TE f�GE of all components, date installed (if known) and source of information: C'N s, V-) Q l'A-' D (Olay Sewage odors detected when arriving at the site: lyes or no) U0 (twi0ld 0{/25/87) Page 5 of 10 Iffm SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address:� ( �(�$� �• N� �QQ Owner: Date of Inspection: t ^ Qo BUILDING SFK1 R:t, ,-` U (locate on site plan) Depth below grade: a y Material of cortstru ion: t iron _ 0 PVC other (explain) to tQs+(� u'�'ra- � t; �Init� t � 3 `_ gP Distance from 7rivate water supply I well or suction line /05) ' Diameter Commeras: (copdit�ojoints, venting, evidence of leakage, etc.) SEPTIC TANK, -L—` (locate on site plan) it Depth below grade: 1 C% Material of construction: _, oncrete _metal _Fiberglass ,Polyethylene _other(explain) If tank is metal, list age _ Is age confirmed by Certificate of Compliance ^ (Yes/No) Dimensions: f 1C S X 4 / ?��, �� = /`� . Sludge depth: a Disiance from top of sludge to bottom of outlet tee or baffle:_ Scum thickness:_ r Distancefrom top of scum to top of outlet tee or baffle: U ! u Distance from bottom of scum to bottom of Quitlet tee or baffle: _ I (, S 4c -1-Q 1Q�t How dimensions were determined_%trb`t'`aG SC;L'vM� Comments: (recommendation for pumping, conditipt�of inlet and optlet es or ba es, dept of liqui level in re atio to inteitrity. evidence of lejAkage, etc.). �l�f ' ``"� a k ..�� p - GREASE TRAP: L> (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 baffle: Distance from bottom of scum to bottom of outlet tee or baffle: Date of last pumping: 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.) (rov*sad 04/25/97) Pago 6 of 10 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address:C�� Owner: I" Date of Inspection: 5= t TIGHT OIC 14OLOING TANK:22±—CTank must be pumped prior to, or 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 level:_ Alarm in working order _ Yes; — No Date of previous pumping: Comments: (condition of inlet tee, condition of alarm and float switches, etc.) DISTRIBUTION BOX: ✓ (locate on site plan) Depth of liquid level above outlet invert: PUMP CHAMBER WV Q- (locate on site plan) v 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.) (sovio*d 04/35/97) Pogo 7 of 10 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: FMQS - STS 01 4111�4�uo-"(- Owner: Date of Inspection: T� l �= is 3a, SOIL ABSORPTION SYSTEM (SAS):_ (locate on site plan, if possible; excavation tot required, but may be approximated by non -intrusive methods) If not determined to be present, explain: Type: leaching pits, number:_ leaching chambers, number:_ leaching galleries, number: leaching trenches, number,length: / leaching fields, number, dimensions: IA 2, z43 K overflow cesspool, number: Alternative system: r Name of Technology: ao,, �'a - as u` 4- p Comments: (noteXondilion_of,soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.) CESSPOOLS: �e (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, etc.) PRIVY: OAA (locate on site plan) Materials of construction: Depth of solids: Comments: (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.) (slvipod 0{/25/97) r6ge • of 10 Dimensions: , SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: (lei N,' Owner: Date of Inspection: UC, lII \\ SKETCH OF SEWAGE DISPOSAL SYSTEM: include ties to at least two permanent references landmarks or benchmarks locate all wells within 100' (Locate where public water supply comes into house) vql (zevissd 04/25/97) Page 9 of 16 V -2)-o-?, JD 3 aL4 r11I� I ua�It r a p a� 49'q p- = 68 3.r (zevissd 04/25/97) Page 9 of 16 V -2)-o-?, SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: Owner: Date of Inspection: Depth to Groundwater 1._ Feet Plea=�b�lained a methods used to determine High Groundwater Elevation: Design Plans on record . O(/ bserva ' of Site (Abutting property, ro , observation hole, basement sump etc.) Determi t from local conditions Check with local Board of health Check FEMA Maps Check pumping records Check looaJ_excavators, installers U'' se USGS Data Describe in your own words how you established the High Groundwater Elevation. (Must be completed) 0 - C QS) ( r ptaj-,, USGS , �� G I c6T b (revised 04/25/97) Page 10 of 10 TEL: (508) 475-1474 FAX: (508) 475-5451 BATESON ENTERPRISES, INC. Excavating - Water & Sewer Lines - Septic Systems & Pumping Service 1 1 I Argilla Road M Andover, Mass. 0 18 10 Title 5 Inspection Report Property Address: ---------- ----- O.l - o V-, Owner: ----------------------------- Date Of Inspection:- S—,3-99 --- 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. Neil J. Bateson Bateson Enterprises Inc. Page 11 of 11 • �Cq�'r� ,J1Tt tr a riK a�' 't} �1 "� �} P �. iGI{ ytt, k�*irt�h� if *�t•I+j, 4�" 1'" tf ' �1 ' t r ,Y' �+r��,•, 1 ' ` � � ;-e�l ♦1 rl ik t � r, .a'S�� t r� tri r �• . 1 rr t+. { 1 It 1 t y,��; 7l;�_lhft•tt .kyNk G h,'� �I"' f J r1'.R�, t.lr•� ;r�N, ' i a `�-' .. 41 of NORTH ADO .:,i�:•� SYS P VER UWWG RECORD .., r 'j� r r�h�`u�, �,�,•. ;,S•, t ( I-,•�,Iy�y`t � }. yam, . :� i�r�j� ,�{' F'yy�.'•■w-w••'f�r�.�'ti. 1 � S iii tlf�,:M�'!•�i.�J;4,i;a*tIT>;'�t' ;•' �,:'� t WNER &ADDRES SSYSTEM LOCATI ON (ple= ift•front of hou") Kr T w 4' �* a 7 • + f!Ct• • t: , it n •yltli ro '� ' ' T ` ,,,y� ' `c '�., a '' • " .' t�:i :i .:�+r t'r 5l a". � �a3 .qtr � F, iT • �� PEED r/� HMP GALLO NS f t t „'t F•r, �f; SEP'T'IC TANI{•• Np YES v' f w�,`.?`Tjfi'1,��..ru.�'�.:. ^Itl•.-f; }: y ��. r �� w- 4 . t, >riti lyt ri„ _;�� r. • ROUTIN$ t • . , XMERGENCy ry 1���'`�f r 1 �1�uxl,El�OAr�' 1y��..� t r�f..r„p / • ... �_ _ • YA1"J VI{jf r 1,T KP i ! M, f�Ir.� H . . ; •: �,::.• RRA/ VY G TO COVFIZ , �RhASE'. yy' ra ROOTS AFF....17II1i ..__ �• f PLACE M " },. j' l p' (� "� •'r.9 t,; .: ", Ary�(�/i` NMliA7C �r ■ _ SOLVDS . RUNBACK ScOT•iDS ED q..'}l�i+'t.:•�:,`i:."s'.:�ti "^.��Ia�YO�EA_*�1� FLOOD •�...1. �:�;,. #?. •f f1, 1 _',�:1w OTHER lair - 777 �;'t'�,,tf1}f}'�'11t{LIfLtr71�ry1,� ii J'7�j.{�,..tii !• ,•�' 1 S, i - W,,.. ' . r,�,� 1'NI"'S .,''�]Ii �^'il �lf6Y•'.\i '��i r �n , .t r. t.�: r�� ± 1J:. , ,. Y,dSi!,oj 4),. 3f�S. }{,l.j'r , t P 3:A `�,�,�' , r• :' / • � �`;1��s�ir.fr�,Yf�4' iNt e , t� 'F't E(',fi k �S t�!"1 , S n .. f , alai• r �'j . �P Y r � 1 !/ 20 �,'t'•`, 1 rel. g' ": fir{ ►�l 1 fi 1 , , J li,�id�•:••�`Q w r �, � �, e' ' tf < tt;' 3 yk a 1 r .. ~tPlli�!it.13i?I ��LY. �'i7i l•:1�i r{; ?n. r + .. , e'� r'k 4i1 1•(N;,r , Y•�M+ �r� aS-it'llt (. j.. LA2. 14 V` /V' ! t, ✓ 1„ i + y 1 +r �� 1 t 1 . p • •A+l../'P yi !1 c .i J r; r • S ,, l�l.` . �- • 9 I ,�i-.. •. 'iii ., - -'. • �'b�YN OF NORTH'A(ipOVER SYS'T'EM PUMPING RA,CORD r i n vrrnt!;tt N AUUKCSS Q W r " �✓'0 0 #Ott 5 2 u I'L, OF PVm?INCi QUANTITY f'UMf'CD �� r , ,L-- - �. PQ0L;'N0 YES SEPTIC TANK; NO ->TURE OFSERY E / 1C r ROUTINE 1�! EMERCENCY 00D,.CQ.N0.11'I0N, NLL TO COY�k fI(A'YY.'.OKI;ASC''' l3AFFLLS' IN N,ACI' --- - RUO.TS' LEACNFICLD RUNjA' ---- CXCESSIYE'SO.LIDS FLOODED` - SOl;lur� C},ARRY4Yi~R ;,lJ�NFR (�'Xf'LA.1N� —�--- �•u.��l -�a� } � r•s lit , �, ,:1'IZAN CIZLD TO ul TOWN OF/'0,,R.-l-li ANDOVE, L)A I SYSTEM/kMPINQ RECORI..) SYSTEM OWNER & ADDRES gni � ��� � s� --"W" DATE OF I a y,'5 I r LOCATION PUMPED: .. _ j c0spOiOL: No YES '. SOPtic Wank: NO_ y El s NA FURE ()F SERVICE: KOUTINE. LIVIERGEN(*), RECEIVED OCT 0 5 2004 TOWN OF NORTH ANDOVER HEALTH DEPARTMENT 013 iF-RVA 171ONS GOOD CONDI*rio.NFULL 7'U COVER HEAVY GREASEBAFFLES IN PLACE ROOTS LEACHFIELD RLfNBACK EXCESSIVE SOLIDS FLOODED SOLID CARRYOVER. -----......, OTHER EXPLAIN . sYatvm Pwnpcd by SO/ CPO. lgr67al-79rr� L'UMMENT,-, CUN I EN 1',li MANSYI:�RKED 1-0 �� � `i'�/// � J .Si �"3r3J,'i; '• 1 ih' w G'r/'i�.;;�.a,u.,::�- .. . ,. '.r. •:i •�l • ii�11rr `�il.l r r�JF s� t•� K.'K`4�,��at y\Li 7 .. \V// r ,1 •ic,J .i t. Ci!1,•.ft, rl,.�9��1V ' ' : t.t. DEP.has prov(o the this form for use by local Boards of Health. Th System Pump(ng Recor must be submitted to the local'Board of Health or other approving auth r1ty, .: .....:.. E007 A. Facility Inforrmtion r. 41mwrwt:, TOWN OF NOR H ANDOVER r j,7.jNherl Filling out 1 • System LOCatlon HEAL?H De ,,K ;ENT 9sl computer, use D L only the tab key Address to move your sor Cur• d0 not ' — use the rotum ; : Clty/Tovm , : State Zip Code �;•J'' keYSys'';..:i.�;�';;:..:; .tem ow' . Name' ;�r,'•r.(, r Ag' Address pr different from location) Clty/Town Statep e Telephone Number Y .A Pumping Record J7'Vt,1,(,,t r� r r•�Date of Pumping 2, Quantity Pumped: Typo of system;, ❑ Cesspool(s) a tic Tank • • •' - � P Tight Tank ❑'.Other (describe); Effluent Tee Filter present? ..❑ Yesof es was it cleaned? w, yes, El Yes []'No � �• Vr is r:t,. r..'� �,� ^� .240 C .._� '••�' � ''(:+ ;;!>;Y.';.i+4:j'{'r;�, i•„i,l't,.'bt 'I�fiJ'>„i' � � ' TY }•' S; : %: .rj ;Ii'' arne•:1'+'•J'i:'i'i „ f'4 t `!h tr.4•t��l�r �+'.tt� `61 irdll(' #+I +'�ti t;.: ' � , t r •.� it yn. ><r r�•� ro�1 f r,�! Ivw� .,i:k lk3 . c: • F IR;�pJ;1'; v vo . ' ':: .•_., �,J t:. ;%fri�ri: �+.. y.''I� H'g1A'h. i�atjW;t?1:�::r':�!' t/7.y ( r Locatlon.where contents were disposed: t N —. yi-':, , r.. • :� •+t r �. t ...1 ^ < 6 , j� l . .1• n' t ' :. Y. � �„•: t J,�,... '•;�,;'•J':a:r.�,�:; :•.;..;.SIQn � 0 u�8f:c►�'•.•t'.u;k,•,;..,..,,....: http://wwvr.mass.goV/depJwafer/approvals/t5forms, htm#Inspect vonlun ucen*e numoer l� Date System Pumping Record , Page 1 of i