HomeMy WebLinkAboutMiscellaneous - 260 BRADFORD STREET 4/30/2018Z5
p m
0 mi
Commonwealth of Massachusetts RECEIVED
City/Town of
SI -1 25 NU
System Pumping Record TOWN OF NORTH ANDOVER
19 Form 4 HEALTH DEPARTMENT
lu. -
DEP has provided this formlor use by local Boards of Health. Other forms may be used, but the
information must be substantially the same as that provided here. Before using this form, check with your
local Board of Health to determine the form they use. The System Pumping Record must be submitted to
the local Board of Health or other approving authority.
A. Facility Information
I . System Location: Left / Right front of house, Left Left / right side of house, Left
Right side of building, Left / Right front of building, Left / Right rear of building, Under deck
Address
City/Town
2. System Owner
Name
Address (if different from location)
City/Town
State
W�V\V\
State
,o,r."::::: . ........
Telephone Number
B. Pumping Record
1. Date of Pumping Date 2. Quantity Pumped
3. Type of system: El Cesspool(s) U -Se �icTank
F-1 Other (describe):
4. Effluent Tee Filter present? E] Yes [5 No If yes, was it cleaned? n Yes [:] No
Zip Code
Gallons
Tight Tank
5. Condition of Syste A -JnAA�—C
6. System Pumped By:
Neil Bateson F5821
Name Vehicle License Number
Bateson Enterprises Inc
Company
7. Location contents were disposed:
Lowell Waste Water
Date
t5form4.doc- 06/03 System Pumping Record - Page 1 of 1
N9,\ Commonwealth of Massachusetts RECEIVED
City/Town of
S * tem Pumping Record JUN 0 2 Z014
YS
Form 4 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 Health or other approving authority.
A. Facility Information
1. System Location: Left / Right front of hous RigI`1r;ejjajj;r;bf �hou Left/ right side of house, Left
a rear of ,
Right side of building, Left / Right front of baing, Left / Ig rear of building, Under deck
Address
City/Town State Zip Code
2. System Owner
Name
Ujv\N.-
Address (if different from location)
CRyfrown staw/- de
—6"r'*1eZ
Telephone Number
B. Pumping Record
i. Date of Pumping 2. Quantity Pumped:
Date Gallons
3. Type of system- E] Cesspool(s) . 3-S—eptic Tank Tight Tank
F-1 Other (describe):
4. Effluent Tee Filter present? El Yes 2-90—� If yes, was ft cleaned? El Yes E] No
5. Condition of System:
Q-A�_(:2�A . o"
6. System Pumped By -
Nell. Bates�on F5821
Name Vehicle License Number
Bateson Ente rises Inc-
mpany
7. Lo92&'xrVvftre contents. were disposed:
GaLLSJ�) Lowell Waste Wi
t L(
ularl j Date
t5fbrm4.doo- 06/03 System Pumping Record - Page I of I
NEW ENGLAND ENGINEERING SERVICES
INC
North Andover Board of Health
Town Hall Annex
27 Charles Street
North Andover, MA 0 1845
RE: TITLE V REPORT: 260 Bradford Street, North Andover, MA
Dear Sirs:
MAY 2003
May 24, 2003
Enclosed is a copy of the Title V report for the above referenced property. The system PASSED
our inspection.
If there are any questions please call me at my office, 686-1768.
Sincerely
c
Benjamm C. Osgoo�a-
60 BEECHWOOD DRIVE - NORTH ANDOVER, MA 01845 - (978) 686-1768 - (888) 359-7645 - FAX (978) 685-1099
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
PropertyAddress- ?—&(-)
Owner's Name: pF2,j'ZA c -A L-k-
Owner'sAddress:
G- ov
IV IL J( A -i P e),A---�
Date of Inspection: i
Name of Inspector: (please print) Ben -i amin C. Osgood, Jr.
CompanyName:New England Engineering Services Inc.
MailingAddress:60 Beechwood Drive,
ljorth Andover, MA 01845
Telephone Number: 978-686-1768
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 to Section 15.M of Title 5 (310 CMR 15.000� The system:
,----'Passes
Conditionally Passes
Needs Further Evaluation by the Local Approving Authority
Fails
Inspector's Signature: 13 Date: , at 1-1
C. I
9-1
The system inspector shall submit a copy of this inspectioF6 report to the Approving Authority (Board of Health or
DEP) within 30 days of completing this inspection. If the system is a shared system or has a design flow of 10,000
gpd or greater, the inspector and the system owner shall submit the report to the appropriate regional office of the
DEP. ne original should be sent to the system owner and copies sent to the buyer, if applicable, and the approving
authority.
Notes and Comments
****This report only describes conditions at the time of inspection and under the conditions of use at that
time. This inspection does not address how the system will perform in the future under the same or different
conditions of use.
Page 2 of I I
OFFICIAL INSPECTION FORM — NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION (continued)
Property Address: 260 S -T
/VOfZTH AA-1D0QC--yZ-
Owner: DE90-A- CA)-Llq6-,/
Date of Inspection: -511 �j L)
Inspection Summary; Check ABCD or E / ALWAYS complete all of Section D
A. � System Passes:
,//,'have not found any information which indicates that any of the failure criteria described in 3 10 CMR
15.303 or in 3 10 CMR 15.304 exisL 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
repqk!d. 1he system, upon completion of the replacement or repair, as approved by the Board of Health, will. pass.
Answer yes, no cT'not determined (YNND) in the for the followingstatcments. If "not�det ined"please
explain.
The septic tank is �ietal. and over 20 years old* or the septic tank (whether metalJ� 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,ozf Health.
*A metal septic tank will pass inspe��Iif it is structurally sound, not lc!�irig- and if a Certificate of Compliance
indicating that the tank is less than 20 yea , ils,i�ld is available.
ND explain:
Observation of sewage backup or break out or *J�,;tatic water level in the distribution box due to broken or
obstructed pipe(s) or due to a broken, settled or u�eme'n disihbution box. System will pass inspection if (with
approval of Board of Health):
br�opijpe(s) are replaced
i"'
ction is removed
ND explain: =.distribution box is leveled or repla
The sVem required pumping more than 4 times a year due to broken or obstru�ted pipe(s). 1he system will
pass inspept-kon if (with approval of the Board of Health):
broken pipe(s) are replaced
obstruction is removed
ND explain:
Page3 ofll
OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION (continued)
Property Address: E60 SZNqbr-,.-,fzD
tJ 0 RTH AAJ D O -/E7.? --
Owner: De-gjZft CAL-L-R&y
Date of Inspection: �4/0
C. Further Evaluation is Required by the Board of Health:
Conditions adst 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. Syiqtem. will pass unless Board of Health determines in accordance with 310 CMR 15.303(l)(b)
syste'bk:is not functioning in a manner which will protect public health, safety and the envirom
Ces, 'b I or privy is within 50 fed of a surface water
nni
poot7privy is within 50 feet of a bordering vegetated wetland or a salt marsh
Sal marsh
2. System win fan unless the Board of Health (and Public Water Sup r, if any) determines that the
viro m
system is functioning in a mannerAat protects the public health, aZd environment:
The system has a septic tank an&soil. absorp - ,
n tern S
t'07SYS�, AS) and the SAS is within IGO feet of a
surface water supply or tributary to a s"c I e water supply
S Sj t
The system has a septic tank and SAS and'11je is within a Zone I of a public water supply.
— The system has a septic tank and SAS an,"e SAS�is within 50 feet of a private water supply well.
— The system has a septic tank and SASand the SAS is 1�than 100 feet but 50 feet or more from a
private water supply well". Method
,pb'ed to determine distance'�L,,_
"This system passes if the we4`4-ater analysis, performed at a DEI) ified laboratory, for coliform
bacteria and latile organic npounds indicates that the well is flr-�'ni Hution from that fitcility and
vo
ppm, provided that no other
failure criterh ;7ered. A copy of the analysis must be attached to this 5-
I
the presence ()=�oni �--Zen and nitrate nitrogen is equal to or less I'
t e FS forntp,
3.
Page 4 of I I
OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION (continued)
Property Address; 'Z(cc) &ZAor--og-b 5-)-.
-MOR17-4 A"Aj-z>0QG-V�-
Owner:
Date of Inspection:
D. System Failure Criteria applicable to all systems:
You must indicate "Yee' or "no?'to each of the following for Ainspections:
Yes No
-Z Backup of sewage into fiteility or system component due to overloaded or clogged SAS or cesspool
Discharge or ponding of effluent to the surface of the ground or surfitce waters due to an overloaded or
clogged SAS or cesspool
Static liquid level in the distribuition box above outlet invert due to an overloaded or clogged SAS or
cesspool
_jgf Liquid depth in cesspool is less than 6" below invert or available volume is less than V2 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.
_L --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 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. [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 fornL]
L ') N (YesNo) The system LajL& I have determined that one or more of the above failure criteria exist as
described in 3 10 CMR 15.303, therefore the system fiLils. The system owner should contact the Board of
Health to determine what will be necessary to correct the failure.
F. Large Systems:
To be considered a large system the system most serve a facility with a design flow of 10,000 gpd to 15,000
gpd.
You must indicate either "yee' or "no?' to each of the following:
(The "log criteria apply to large systems in addition to the criteria above)
yes no,
the system is i in 400 feet of a surfa:ce drinkin supply
f r�
the system is within 200 a t:ri to a sur ace drinking water supply
the system is located �*�trogen sensi _ea n
t' '" (Interim Wellhead Protection Area - IWPA) or a mapped
Zone 11 of a pu lie -'Water supply well
em
If you wered "yes" to any question in Sed:tion E the system is ider:etd a significant threat, or answered
1 0
"yes" id Section D above the large system has failed. The owner oroperat r y large system considered a
significant threat under Section E or failed under Section D shall upgrade the system in accordance with 3 10 CMR
15.304. The system owner should contact the appropriate regional office of the Department.
Page 5 of I I
OFFICIAL INSPECTION FORM — NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART B
CHECKLIST
Property Address: 2- 60 IZOIN Fb
hi , 0 0 Q C vp--
Owner: DFsfzft C-AL-1-A&Y
Date of Inspection: — -- '9-) )!� �02.
Check if the following have been done. You must indicate "yes" or "no" as to each of the following:
Yes No
4Z — Pumping information was provided by the owner, occupant or Board of Health
-%ZWere any Of the system components pumped out in the previous two weeks ?
Has the system received normal flows in the previous two week period ?
-),ZHave large volumes of water been introduced to the system recently or as part of this inspection
WWere as built Plans of the sy-slem obtained and examined? (If they were not available note as N/A)
z— Was the facility or dwelling inspected for signs of sewage back up ?
Z- Was the site inspected for signs of break out ?
AZ- Were all system components, excluding the SAS, located on site ?
V- Were the septic tank manholes uncovered, opened, and the interior of the tank inspected for the condition
;f—thi�ffles 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
i�alnienance of subsurface sewage disposal systems 7
The size and location of the Soil Absorption System (SAS) on the site has been determined based on:
Yes no
— — Existing information. For example, a plan at the Board of Health.
Ve'�etermined 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 I I
OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION
Property Address: a 1-0 G1Z4DV:709-1t-- .5117,
tZ-q4 . A /i p o L)z r, -
Owner:
Date of Inspection: Lj
FLOWCONDMONS
RESH)ENTLAL
Number of bedrooms (design): Number of bedrooms (actual):
DESIGN flow based on 3 10 CMR 15.203 (for example: 110 gpd. x #of bedrooms):
Number of current resid;��
Does residence have a j;C—inder (yes or no):
Is laundry on a separate sewage system (yes or no): Al o [if yes separate inspection required]
Laundry system inspected (yes or no): —
Seasonal use: (yes or no), lVo
Water meter readings, if available (last 2 years usage (gpd)):
Sump pump (yes or no): Ala
Last date of occupancy-
COMMERCULIMUSTRUL
Type of establishment:
Design flow (based on 3 10 CMR 15.203): RDd
Basis of design flow (seats/persons/sqftetc.):
Grease trap present Cyes 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: ":-�A L -L- z1v 0 0
Was system pumped as part of the inspection (yes or no): -LV0
If yes, volume pumped: How was quantity pumped determined?
Reason for pumping:
TYPE OF SYSTEM
-j/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)
Tighttank Attach a copy of the DEP approval
Other (describe):
Approximate age of all components, date installed (if known) and source of information:
-5 L,' 5- jfl�- Al 1z 6– P Irl a- c o ) 9 le .�;
Were sewage odors detected when arriving at the site (yes or no): "
Page 7 of I I
OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Property Address: '060 2> R Pt r> yz:�6 R S7-1
Owner: P F-13, Vz 0+ :f- A -L- I- A 6- Y
Date of Inspection: 5-1 t�j Jos
BUELDING SEWER (locate on site plan)
Deptk below grade: 1 4>'
Materials of construction: _Zcast iron 40 PVC other (explain):
Distance from private water supply well or suction line: 4/4
Comments (on condition ofjoints, venting, evidence of leakage, etc.):
jp I F07 (.7 Aj p 16 X 6. LIP z iA) ""j E ez 416L -
SEPTIC TANK: _ (locate on site plan)
Depth below grade: 6 .,
Material of construction: L -,,concrete metal —fiberidass __polyethylene
If tank is metal fist age: _ Is age confirmed by a Certificate of Complianc—e(yes or no): (attach a copy of
certificate)
Dimensions: l000 &-jq L- L- 0 A. -I
Sludge depth: 4 2-"
Distance from top of sludge to bottom of outlet tee or baffle: 2
Scum thickness; 4)'
Distance from top of scum to top of outlet tee or baffle:
Distance from bottom of scum to bottom of outlet tee or baffle: .2 o
How were dimensions determined: 14 b�O-e, o)z F -,-- 7 e t1,
Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels
as related to outlet invert, evidence of leakage, etc.):
1/---) 3 117 0 0 AJ C 12 C 11544F
6-00 C3 -/
GREASE TRAP:216!!�Gocate 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 (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 I I
OFFICIAL INSPECTION FORM — NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Property Address: 260 0?-4pFbj2A:)
zVaP-1W AAjD6L)&vZ-
Owner: 0 EB P- 0 ?qjjA(�,y
Date of Inspection: -
TIGHT or HOLDING TANK: A/&(tank must be pumped at time of inspection)(locate on site plan)
Depth below grade:
Material of construction: concrete metal fiberalass
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 BOM _ (if present must be opened)(tocate on site plan)
Depth of liquid level above outlet invert: 0 "
Comments (note if box is level and distribution to outlets equal, any evidence of solids carryover, any evidence of
leakage into or out of box, etc.):
—9 -)e /,;? " 8,��va
jZC—'-X, Al-., A,' 0 4-Fte'l 0 E fJ CC-- ja 6-F- 6,�Z- -SL,�A-10S Cd-0-�oLi-QC
PUMIP CHAMEBER#d!�/Y(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.):
Page 9 of I I
OFFICIAL INSPECTION FORM — NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Property Address: Z&O J?>jZA-DMr--j> <--7-
lyoA7Y
Owner: Del -
Date of Inspection: _ L33
SOIL ABSORPTION SYSTEM (SAS): — (locate on site plan, excavation not required)
If SAS not located explain why:
Type
leaching pits, number:
leaching chambers, number:
leaching galleries, number:
leaching trenches, number, leng1h:
leaching fields, number, dimensions: A-PPa,-)x
overflow cesspool, number:
innovativelalternative system Typetname of technology:
Comments (note condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of vegetation,
etc.):
0,0.
CESSPOOILS-W
&-(Cesspool must be pumped as part of inpectionXlocate 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 fidlure, level of ponding, condition of vegetation, etc.):
PRIVY/1/-�L (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 I I
OFFICIAL INSPECTION FORM — NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Property Address: Z&O eP-,tDPb1W
I—VOILIPf - pw�D 6UJ� "s-liq
Owner: - pEa
Date of Inspection:
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.
Page 11 of 11
OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
rroperty Address: 2-(-0 &ZODilb (Zo !g—)
po("J, P%"
Owner: ClqLL-tg&y
Date of Inspectiow.
SUE EXAM
Slope
Surface water
Check cellar
Shallow wells
Estimated depth to ground water feet
Please indicate (check) all methods used to determine the high ground water elevation:
Obtained from system design plans on record - If checked, date of design plan reviewed:
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)
,�t Accessed USGS database -explain:
You must describe how you established the high ground water elevation:
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's -.� t) Te"..— aA-is E r) 2- iv 3 vic- -1,5- —1 AZIDUC,- 0 L-0 "e')"A'D
TOWN OF vk
&1-0—d
SYSTEM PUMPING RECORD
DATE:
SYSTEM OWNER & ADDRESS
W1, vlv^�
ozub �raj--�(a --0,+
SYSTEM LOCATION
(example: left front of house)
��A- 6, - 6u-�
DATE OF PUNIPING: (E QUANTITY PUMPED: GALLONS
CESSPOOL: NO YES SEPTIC TANK: NO YES
NATURE OF SERVICE: ROUTINE 7— EMERGENCY
OBSERVATIONS:
GOOD CONDITION
HEAVY GREASE
ROOTS
EXCESSIVE SOLIDS
SOLIDS CARRYOVER
FULL TO COVER
BAFFLES IN PLACE
LEACHFTELD RUNBACK
FLOODED
OTIHER (EXPLAIN)
SYSTEM PUI%WED BY: Bateson Enterprises, Inc.
CONIMENTS:
CONTENTS TRANSFERRED TO:
Lowell Waste
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| } owner name last,first,mi | address
F | 121 CALLAGY. SHAUN | 260 BRADFORD ST
| telephone
| | method of alarm
MASSACHUSETTS
MASSACHUSETTS
_0_____|
FIRE INCiDENT
REPORT ~`STATE
FIRE MARSHA/
| hazardous material | substance
! special equip used |
| _____|
|incident no.
| exp | date |
day Warm tm|arry tm|time
in servi
A }
stolen ? | estimated total dollar |
|_/
| situation found
| |
action taken |
| mutual aiu |
B |
...... .......
AZA�I>_--_'l-_4--|_''_-N/A-_'_-__-|
|
I fixed property
| |
ignition factor
| |
C |
origin | equip inv in ignition |
N{}_R
|
| correct address
L |
| zip code
| census |
D |
M|
|
|
) | occup.name last,first,mi
|
| telephone
!room or apt/
E | I1| CALLAGY. SHAUN
Ni
1(978)688-9863
| |
| } owner name last,first,mi | address
F | 121 CALLAGY. SHAUN | 260 BRADFORD ST
| telephone
| | method of alarm
| | district | shift | no.alarms |
G |
_0_____|
| |#fire service }#tankers
|#engines |#aerial app | # other vehicles|
H |_|
| hazardous material | substance
! special equip used |
| _____|
| numbers of injuries
| number of fatalities | rescues |
I |
!
| mobile property | | vehicle
stolen ? | estimated total dollar |
J |
|
| insurance company
|total insurance | claim paid |
|
|
I |year | make \ model
Icolor| lic no }vin# |
�
|
| |if equip involvediyear|make
|model 1 serial no |
|
|
| complex | > area of
origin | equip inv in ignition |
K ||
| form of heat ignition} material
ignited |form i type | |
L |
|
| method of extinguishment
} I level of fire origin | |
M|
|
| numbers of stories
| I construction type | |
|
|
| extent of flame damage
| | extent of smoke damage | |
Ni
|
| detector performance
i | sprinkler performance | i
P|
|
| if smoke spread | material generating|form
| Itype | |
| beyond room | most smoke:
| 1001 | 001
Q�
|
R | weather conditions | |
| -------------------- I entries
contained in this report are intended for !
| CLEAR & COLD 25 | The sole
use of the state fire marshal. Estimat— |
) | ions & evaluations
made herin represent "MOST |
| | LIKELY"
& "MOST PROBABLE" cause & effect. Any |
| } representation
as to the conditions outside the |
/ / 9tatp Fjrp
ma'yh+]s Offirp i, npithpr intpnUd r'~`
| J__��L_..... ......___|
CHECKLIST FOR CARBON MONOXIDE
Location of Incident:-,:�&) 2&Bi(o'Qt� (`�r - —Dateofincident )Z-js-q7
QUICK CHECKLIST OF OCCUPANTS
Headache yes_ no Fatigue yes no
Nausea yes_ no Dizziness yes no
Confusion yes_ no
Are any members of the household feeling ill? yes_ no'V"
Do the residents feel better away from the house? yes_ noT--
Since the detector's alarm went off, what have you done?
Shut- off carbon monoxide sources yes— no
If yes which sources
Let in fresh air? yes v,' no
If yes how did you let the air in Aj.00JS
How long did you let the air in to minkar's
PPM reading ambient outside the dwellin
Highest PPM reading in the dwelling 0 VL�
Carbon monoxide detector present? yes -V—/ no
If yes list the number of detetors locations and make, and serial number of each below.
I OCT
Tzj� La- RQ0 01
2.
3.
4.
Which detector(s) by number above activated? I
SOURCE CHECKLIST LOCATION PPM READING
Chimney clogged flue, blocked opening coo
Fireplace(s) Natural gas, LPG, Wood(indicate type for each fireplace)
Gas Appliance (if Gas Company on Scene they can perform this check)
(IF MORE THAN I OF THE FOLLOWING APPLIANCES LIST EACH ADDITIONAL
ON THE COMMENTS PAGE WITH ITS LOCATION, AND PPM READING)
reffigerator
stove
vent over stove
clothes dryer
water heater
furnace
Oil burner
car garage
Entranceway from garage to house
Name of individual operating the CO olnitorp
Person completing the Checklist
Date: C�
14 A a,,o i d tt
Homeowner:
Street
Phone
Town of North Andover, MA
Watershed Septic Syste
servicing Report
Pumper : Stevart's Septic Tank Svc.
Address: 47 Railroad St., Bradford
Phone : 508-372-7471
Nature of Service: Routine
Emergency
Observations: Good Condition
Full to Cover
Baffles in Place Ve
Leachfield Runback 7/71t -21o.
Excessive Solids AA)
Heavy Grease /VO
Roots A0
Other (Explain)
Description of Work:
PMV'septic tank — #,
Comments:
P
This is not a septic certification. Should not be used to provide at closinCFs
That is an additional fee.
;.Cap::
4
STEWART'S SEPTIC TANK SERVICE
47 RAILROAD STREET - BRADFORD, MA 01835
TEL.: (508) 372-7471
Please forward us as much of thle followilla information that is possible*
I. Tvr)e of system
2. Age
3. Loca t i on;
4- Maintenance records and dRte Of last pumpinp- out
I
'Docum,,ntrition of repairs and reconstruction
6. Site conditions
7. Builder of system
Engineer who approved,
Site
— System
9. Installation Procedure
10. Problems
- 21 -
9
/ /qgb k, rd Ekrfe I C ff
24 o L3t4q 19 D A P, 0 65.
Ka . A
SEPTIC SYSTEM INSPECTION FORM
ADDRESS epo fai -(-6 r A
DATE INSPECTED I - / 160
PROPERLY FUNCTIONING? (j) N
WEATHER CONDITIONS
COMMENTS:
NATER QUALITY TESrEb'Z.
DYE TEST PERFORMED? Y N
DATE?
SKETCH:
WATERSHED RESIDENTS QUESTIONNAIRE
1. Name J/L)
2. Street Address
3. How many members are in your household?
4. What type of sewage disposal system do you have?
El cesspool
91 septic tank and leaching area
El connection to municipal sewer
El other (describe)
0 do not know
5. Are the plans, (drawings) for your sewage disposal system on file with the Bo ard of Health?
__E1 yes El no Nr do not know
6. How old is your sewage disposal system? El 0-5 years El 6-10 years �t�11-20 years
El over 20 years El do not'know
7. Has your sewa disposal system been rebuilt or repaired?
El yes 7/n'o EI do not know
If yes, approximately how long ago?
years. What was done?
.8.
How frequently is your sewage disposal system pumped out? [I annually
every04 years every 5-10 years EJ over 10 years El never
9.
Have you had any problems with your sewage disposal- system? yes no
If yes, what problems?
El repeated pump -outs needed
El system clogs, backs up, or drains slowly
El odors
El sewage surfaces through ground
10.
How many of each appliance are connected to your sewage disposal system?
washing machine dishwasher garbage disposal
dehumidifier drain sump pump toilet IZ
roof/pavement drains showerlbathtub
11.
Please state the brand and type (liquid or of detergent you use for:
-Powder)
dishwasher W b EP_ — C A S c,'%Aa
clotheswasher W I S 12-, —Q Cu t.n — ALJO W C-ko-^k"C --ft) r'96 L-0 0
wc-- boril-t ozcg C --X1
L-16
12.
Does your property have a LL%. '(SM
1 lawn [K yes El no
t
.If yes, approximately what
El less than 11/4 acre '/;4 c7r El acre F-1 % acre El 1 acre
El more than 1 acre (Sped acres
13.1
f d wn?
How. o ten o.You fertilize your la
No.6f polications.per year
a'
Season(s) of the year . . . . . . . . . . . . . .
��,Qiquid or granular) of lawn fertiliz&: you use*
14. Ylease
4
V!
_Vt
t, A
4
G N
i 461 laridsciiie 7T
q- I q- tk" f
APPLICATION FOR SEWAGE DISPOSAL INSTALLATION
HEALTH DEPARTMENT - NORTH ANDOVER, MASS.
he eby make application for a permit for a
cordarice with all the(la-ws of -the Commonwealth of
the Board of Health of the Town of North Andover.
�Urry Corp*
Bradford Street
sewage disposal lation at
will install this system in ac -
Massachusetts and regulations of
Further, I will construct the house sewer of bell and spigot pipe, the minimum
diameter being 4 inches, and will maintain a minimum grade of 1% until 10 feet pre-
ceding the septic tank, where the grade shall not exceed 2%. 1 will install a con-
crete septic tank of in size. A manhole (s) permitting easy cleaning
will be provided with removabl; —cover (s) of iron or concrete within 12 inches of
the ground surface. I will provide subsurface disposal field with 4 inch perforated
or open jointed pipe and laid in a series of trenches, the bottom of which will pro-
vide a minimum of lineal (square) feet of effective absorption area.
The pipes will be laid on a 6 in�b layer of washed gravel or crushed stone ranging
in size from 3/4 to 1-1/2 inches (dia.) and the pipes will be surrounded by similar
material to a height of 2 inches above the crown of the pipe. The joints of these
pipes will be protected from clogging and before filling the trench, 2 inches of
gravel or stone 1/811 to 11LO' (dia.) will be placed over the course gravel or ston . e.
The disposal field will be installed at a grade of 4 to 6 inches/100 feet. No single
tile line will exceed 100 feet in length and in any case, two lines of tile will be
installed. A minimum of 6 feet will be ;naintained between the center lines of the
disposal field trenches and the average depth of trench shall not exceed 36 inches.
No part of the installation will be less than 100 feet from any private water supply,
25 feet from any stream, 20 feet from any dwelling or 10 feet from any property line.
I further agree not to cover any portion of this installation until approved by the
inspection officer, as provided below, and to incorporate any additional requirements
that may be attached to the permit. Plot Plans must_ be submitted with application.
DATE
I hereby issue the above permit for the Board of Health of the T6wn of North
Andover, Massachusetts.
DA TE 4, s� iat- 2
8'ignour—e ofHe7alth Agent
I have inspected the uncovered system indicated above and find everything done
as described.
DATE
4 �Zew
Signatur-/7of-Inspecting Officer
Percolation Test
Garbage Grinder
'7L-
41
1w
-4
BOARD OF HEALTH OF NORTH ANDOVER, MASSACHUSETTS
SEWAGE DISPOSAL
DATE july 29, lo,67,
NAME OF APPLICANT c,
. surre�Z ReaT 'Rstatp,
LOCATION T,aL 4*3, R;Caafg;.,d at.
Address of lot no.
BUILDING: Dwelling x Other
SYSTEM: New___Z _ Repair
GENERAL DESCRIPTION OF LAND High
SUBSOIL: Clay X Gravel Sand
PERCOLATION TEST 26' minutes per inch.
MINIMUM INSTALLATION RECOMMENDATIONS
CONCRETE SEPTIC TANK__l.L.000
. _ gallon capacity.
LEACH FIELD 180 lineal feet of drain pipe.
T T-'- - "T
I N1 S, T -D �-,- A,,'0WrDA1,TCF* J-TH
-AE-,A TO 3E. FILLED I'1%, A',�D SYSTE". -�LLH
L
FLA17, BY J. 3ARBAGAILL0 R.S., DZCED 4//221/67.
.4
William J, Dri"oll, Enginerr\\
Board of Health
FI o A LTo % P 9- r- -r I oAJ
1A Y a (A r S -t 4)
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DIRECtION5
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42
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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
P rope rty Address: ;,� 4,0 6P -%4r-> F'D(Z I-->
/V0 an -t /+,j C> #4
Owner's Name: L2Ee! C-01-j—)4&V
Owner'sAddress: 2joc2
A)- dtZ00,)0R-
Date of Inspection: 101
Name of Inspector: (please print) &eK�AAAtAj
CompanyName: K)e----,
MailingAddress: 9b0-ec-k-tx,)co,-
A)C> (LQ4 R1JL->01JC--1L IL4A- OLBL(]&�
Telephone Number:
CERTIFICATION STATEMENT
I certify that I have personally inspected the sewage disposal system at this address and that the information reported
below is true, accurate and complete as of the time of the inspection. The inspection was performed based on my
training and experience in the proper fimction and maintenance of on site sewage disposal systems. I am a DEP
approved system inspector pursuant to Section 15.340 of Tide 5 (310 CMR 15.000� The system:
Passes
Conditionally Passes
Needs Further Evaluation by the Local Approving Authority
Fails
Inspector's Signature: Date: -TJ) /01
The system inspector shall submit a copy of this inKpection report to the Approving Authority (Board of Health or
DEP) within 30 days of completing this inspection. If the system is a shared system or has a design flow of 10,000
gpd or greater, the inspector and the system owner shall submit the report to the appropriate regional office of the
DEP. The original should be sent to the system owner and copies sent to the buyer, if applicable, and the approving
authority.
Notes and Comments
Bop p.D C)F HEAJJ "A
MAI 10 2001
****This report only describes conditions at the time of inspection andjunder-the-couditidatf use at that
time. This inspection does not address how the system will perform in the future under thesame ordifferent
conditions of use.
Page 2 of I I
OFFICIAL INSPECTION FORM — NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION (continued)
PROPERTY ADDRESS: 260 Bradford St
North Andover, NIA
OWNER Debra Callagy
DATE OF INSPECTION: 5/1/01
Inspection Summary: Check AB,C,D or E /ALWAYS complete all of Section D
A. System Passes:
V/ I have not found any information which indicates that any of the failure criteria described in 3 10 CMR
15.303 or in 3 10 CMR 15.304 exist. Any failure criteria not evaluated are indicated below.
Comments:
B. System Conditionally Passes:
N�e or mor = components as described in the "Conditional Pase' section need to be replaced or
syst; completion of the replacement or repair, as approved by the Board of Health, will pass.
N"�Answer yes, no o�rt determined (YN,ND) in the for the folloN7
explain. " �tements. If "not determined" please
The septic tank is in nd over 20 years old* or the se c tank (whether metal or not) is structurally
M t,
!O,� ,o
unsound, exhibits substantia n or exfiltration or failure is imminent. System will pass inspection if the
existing tank is replaced with com *g septic tank as proved by the Board of Health.
11yin
*A metal septic tank will pass m7sp)ecti if it is stru Ily sound, not leaking and if a Certificate of Compliance
indicating that the tank is less than 20 y Id is flable.
ND explain:
Observation of sewage backu r break out or static water level in the distribution boxAue to broken or
obstructed pipe(s) or due to a bro settled or uneven di box. System will pass inspection if (with
approval of Board of Health):
c
broken pipe(s) are replaced
- r
obstruction is removed
lov I or rM
distribution box is leveled or r la
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: 260 Bradford St
North Andover, MA
OWNER Debra Callagy
DATE OF INSPECTION: 511101
C. Further Evaluation is Required by the Board of Health:
Conditions exist which require fin-ther 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 ill pass unless Board of Health determines in accordance w4'310 CMR 15.303(l)(b) that the
system is t functioning in a manner which will protect publi th, safety and the environment:
t
fuln
Cesspool or i is within 50 feet of a surface water
Cesspool or pri is within 50 feet of a bordering vegetated wetland or a salt marsh
2. System will fail unless the Board of Health#nd Public Water Supplier, if any) determines that the
system is functioning in a manner that prot"jhe public health, safety and environment:
The system has a septic tank and�s61l absorption system (SAS) and the SAS is within 100 feet of a
surface water supply or tributary to -"-surface water supply.
.7.7
— The system has a septic and SAS and the SAS iswithin a Zone I of a public water supply.
— The system has a ic tank and SAS and the SAS is within 50 feet of a private water supply well.
— Thesysternh aseptic tank and SAS andthe SAS is less than 100 feet but 50 feet ormore from a
e s
y
Th y
5
s
tern
h
a sept
w s w
pnvatewateirsu ly well". Method used to determine distance
"This s s m passes if the well water analysis, performed at a DEP certified laboratory, for coliform
I y
bacteria d volatile organic compounds indicates that the well is free from pollution from that fitcility and
t pr
he ence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other
fai e criteria are triggered. A copy of the analysis must be attached to this form.
3. Other:
Page 4 of I I
OFFICIAL INSPECTION FORM — NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION (continued)
PROPERTY ADDRESS: 260 Bradford St
North Andover, MA
OWNER Debra Callagy
DATE OF INSPECTION: 511101
D. System Failure Criteria applicable to all systems:
You must indicate "yes" or "no" to each of the following for all inspections:
Yes No
acility or system component due to overloaded or clogged SAS or cesspool
Backup of sewage into f
ischarge 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 V2 day flow
vRequired 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.
— V-I'Any portion of a cesspool or privy is within a Zone I of a public well.
— -i,-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 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.]
AtO (YesNo) The system fails. I have determined that one or more of the above failure criteria exist as
described in 3 10 CNM 15.303, therefore the system fails. The system owner should contact the Board of
Health to determine what will be necessary to correct the failure.
E. Large Systems:
To be considered a large system the system must serve a facility with a design flow of 10,000 gpd to 15,000
gpd.
You must indicate e 'yes" or "no" to each of the follov
(The following criteria appry,to large systems in addition w7th.-ge� �teriaabove)
yes no,
the system is within 400 eet o a surfic6drinking water supply
the system is within 200 feet of a tribu to a surface drinking water supply
the system is local nitrogen sensitive ar (Interim Wellhead Protection Area - lVvTA) or a mapped
Zone 11 of a pu ic water supply well
he s
If you have ans "yes" to any question in Section E t :�� is considered a significant threat, or answered
'1�
"yes" in S 'on D above the large system has failed. The owner or erator of any large system considered a
signifi t threat under Section E or failed under Section D shall upgrade the system in accordance with 3 10 CMR
15.304. The system owner should contact the appropriate regional office of the Department.
Page 5 of I I
OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART B
CHECKLIST
PROPERTY ADDRESS: 260 Bradford St
North Andover, MA
OWNER Debra Callagy
DATE OF INSPECTION: 511101
Check if the following have been done. You must indicate "yes" or "no" as to each of the following:
Yes No
_IZ- Pumping information was provided by the owner, occupant, or Board of Health
_IZWere any of the system components pumped out in the previous two weeks ?
v"" Has the system received normal flows in the previous two week period ?
— _,Z'*have large volumes of water been introduced to the system recently or as part of this inspection ?
— ALOWere as built plans of the system obtained and examined? (If they were not available note as N/A)
V/- Was the facility or dwelling inspected for signs of sewage back up ?
Was the site inspected for signs of break out ?
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
�f—thebaffles or tees, material of construction, dimensions, depth of liquid, depth of sludge and depth of scum ?
_Z_ 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
— 7Existing information. For example, a plan at the Board of Health.
_ Z"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 I I
OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PROPERTY ADDRESS: 260 Bradford St.
North Andover, NIA
OWNER Debra Callagy
DATE OF INSPECTION: 5/1/01
PART C
SYSTEM INFORMATION
r LOW CONDMONS
RESEDENTUL
Number of bedrooms (design): _ Number of bedrooms (actual):
DESIGN flow based on 3 10 CMR 15.203 (for example: I 10 gpd x # of bedrooms):
Number of current residents:
Does residence have a garbage grinder (yes or no): A e -.C,
Is laundry on a separate sewage system (yes or no):�kVj [if yes separate inspection required]
Laundry system inspected (yes or no): —
Seasonal use: (yes or no): NO
Water meter readings, if available Oast 2 years usage (gpd)):
Sump pump (yes or no):
Last date of occupancy:
COMIKERCMUMUSTRL&L
Type of establishment:
Design flow (based on 3 10 CMR 15.203): Rod
Basis of design flow (seats/persons/sqftetc.):
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: 0 c T -o f, E IZ_ 2-z> e>
Was system pumped as part of the inspection (yes or no): _
If yes, volume pumped: _____gallons -- How was quantity pumped determined?
Reason for pumping:
TYPE OF SYSTEM
_�A_ 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
�b—tained 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:
j4b-y-e- za2u-1 J!aV4 4-rewys C
Were sewage odors detected when arriving at the site (yes or no): AO
Page 7 of I I
OFFICIAL INSPECTION FORM — NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
PROPERTY ADDRESS: 260 Bradford St.
North Andover, MA
OWNER Debra Callagy
DATE OF INSPECTION: 5/1/01
BUELDING SEWER (locate on site plan)
Depth below grade:
Materials of construction: —cast iron 40 PVC — other (explain):
Distance from private'water supply well or suction line:
Comments (on condition ofjoints, venting, evidence of leakage, etc.):
Q� C\ c,--, -R-x> 9- 11'� P, g+--�C-At&Aj
SEPTIC TANK: _ (locate on site plan)
Depth below grade: &I C-1
Material of construction: crete —metal —fiberglass __polyethylene
If tank is metal list age: _ Is age confirmed by a Certificate of Compliance (yes or no): (attach a copy of
certificate)
Dimensions:
Sludge depth:
Distance from top of sludge to bottom of outlet tee or baffle:
Scum thickness: IV
Distance from top of scum to top of outlet tee or baffle: '7
Distance from bottom of scum to bottom of outlet tee or baffle:
How were dimensions determined: AAen.Swr,,_ fq.T,,r-�
Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels
as related to outlet invert, evidence of leakage, etc.):
TA101k k j a, v, e--,, 0-,> , -r4,-j g, is ,)e--. C C>rl
&-00 C7 C C."& C7> 0 Ad,
GREASE TRAP: VA(locate on site plan)
Depth below grade:
Material of construction: —concrete __.jnetal fiberglass other
__polyethylene
(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 (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels
as related to outlet invert, evidence of leakage, etc.):
Page8 ofll
OFFICIAL INSPECTION FORM — NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
PROPERTY ADDRESS: 260 Bradford St
North Andover, MA
OWNER Debra Callagy
DATE OF INSPECTION: 5/1/01
TIGHT or HOLDING TANK:,A�A (tank must be pumped at time of inspection)(locate on site plan)
Depth below grade:
Material of construction: —concrete —metal fiberglass ____polyethylend —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: _ (if present must be opened)(locate on site plan)
Depth of liquid level above outlet invert:
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.):
i� Z>Y' I tr, C'in"p V7 C>. Ac>
PUW CHAMBER: AA (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.):
Page 9 of I I
OFFICIAL INSPECTION FORM — NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
PROPERTY ADDRESS: 260 Bradford St. 1QV-QTEM INFORMATION (continued)
North Andover, MA
OWNER Debra Callagy
DATE OF INSPECTION: 511101
SOIL ABSORPTION SYSTEM (SAS): _ (locate on site plan, excavation not required)
If SAS not located explain why:
Type
leaching pits, number:
leaching chambers, number:
leaching galleries, number:
leaching trenches, number, length:
leaching fields, number, dimensions: d '90' X q<:�
overflow cesspool, number:
innovativetalternative system Typetname of technology:
Comments (note condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of vegetation,
etc.):
A(Le-A- oF 'F:)
CESSPOOLS: N)+ (cesspool must be pumped as part of inspectionXIocate 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: Alft (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 I I
OFFICIAL INSPECTION FORM — NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
PROPERTY ADDRESS: 260 Bradford St
North Andover, MA
OWNER Debra Callagy
DATE OF INSPECTION: 511101
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.
Page I I of I I
OFFICIAL INSPECTION FORM — NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
PROPERTY ADDRESS: 260 l3radford St.
North Andover, MA
OWNER Debra Callagy
DATE OF INSPECTION: 511101
SITE EXAM
Slope
Surface water
Check cellar /up
Shallow wells Ao- L
Estimated depth to ground water feet
Please indicate (check) all methods used to determine the high ground water elevation:
Obtained from system design plans on record - If checked, date of design plan reviewed:
Observed site (abutting property/observation hole within 150 feet of SAS)
Checked with local Board of Health -explain:
Checked with local excavators, installers- (attach documentation)
X Accessed USGS database -explain:
You must describe how you established the high ground water elevation:
Q�745' 15V1L- A4j&r"> I Ail,> (C PKIT A -Ta V_' 2- -M 3. F_6_��_ 'E't 0
!�, y 5 -IC- 44 iZ ft e, 60 Z �- -m> -Z I Aa-,�e oy_Lc_Amo4-L
-�LN Commonwealth of Massachusetts
City/ -Town of
System Pumping Record SEP 29 20io
Form 4 TOWN OF NORTH MOOVER
DEP has provided this form for use by local Boards of Heal HEALTH DEM&O"rRAL-hrr butthe
information must be, substantially the same as that provided here. Before using this form, check with your
local Board of Health tq determine the form they use. The System Pumping Record must be submitted to
the local Board of Health of -other approving authority.
A. Facility Information
1. System Location:
Left rear of hoLKe, Right rear of
2
side of house, Left front of house, Right front of house,
t rear of building. Right rear of building.
Address
City/Town State Zip Code
System Owner. V—A V\
Name
Address (if different from location)
Cityrrown
B. Pumping Record
1. Date of Pumping
3. Type of system: 1:1
El Other (describe):
State A
Zip Code
Telephone Number
Pumped
Date 12. Quanti
S Ptic T
Cesspool(s) eptic Tank
.t�
Gallons
El Tight Tank
4. Effluent Tee Filter present? E] Yes [J,,ko If yes, was it cleaned? El Yes No
5. Condi'
.qon qf System: I
V\JeA U'� V\_
6. System Pumped By:
Neil Bateson
Name
Bateson Enterprises Inc
Company
7. Locoi6n- wt*e contents were disposed:
G.L.
Signature
F5821
Vehicle License Number
— q-(4,(6
Date
t5form4.doc- 06/03 System Pumping Record - Page I of 1
commonwealth. of Massachusetts
City/Town of I
ZD
V
R
-D
System Pumping Record
Form 4 APR - 2 2007
kA Lel
_ u N
DEP has provided this form for use by local Boards: of Health.. The cord U
,�N, M
dkMu It
Sys eTnoll'AN-4, &N1,R,,d._fk;d'qVr ]
be submitted to the local Board of Health or other approving authority. MENT
A. Facility Information
Important:
When filling out 1. System Location -
forms on the
computer. use C -60k -AC ko"i—se
only the tab key Address
to move your
cursor - do not F�j /L/, A�
use the,retum Cityrrown State
Zip Code
key.
2. System Owner:
V\ V\
Name
Address (if different frorn. locationy
Cityfrown _�tate 7P —C—od
j, e
P7
Tele horie Number
13. PuMpinig. Re'dord
Ire-
'�3
1. Date, of Purnping Date Quantit . y Pumped:
Gallons
3. Type of system: Cesspool(s) ��epticTank El TightTaW
El Otber (describe),.
Effluent Tee Filter present? Yes B No Jf yes, was it cleane
d? 0 Yes El No
Condition o
f,,System:
System Pumip�A By-.�
N Nam4A
ame, Vehide.License Number
Company
Locatiop',where W ptltj!:�re disp
I
osed:
`3