HomeMy WebLinkAboutMiscellaneous - 261 REA STREET 4/30/2018 (2)6
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North Andover Board of Assessors Public Access
rA
Parcel ID: 210/038.0-0032-0000.0 Community: North Andover
SKETCH
Click on Sketch to Enlarge
PHOTO
No Picturfe,
Available
Location: 261 REA STREET
Owner Name: SIPSEY, MICHAEL L
M SHARON SIPSEY
Owner Address: 261 REA STREET
City: NORTH ANDOVER State: MA ZIP: 01845
'4eighborhood: 6 - 6 Land Area: 1.04 acres
Jse Code: 101 - SNGL-FAM-RES Total Finished Area: 2752 sqft
ASSESSMENTS CURRENT YEAR PREVIOUS YEAR
Total Value: 531,700 508,900
Building Value: 337,200 323,600
Land Value: 194,500 185,300
qaarket L d Value: 194,500
Mapter Land Value:
LATESTSALE
3ale Price: I Sale Date: 10/26/1997
krms Length Sale Code: F-NO-CONVNIENT Grantor: MICHAEL SIPSEY
Cert Doc: Book:04875 Page:0132
Page I of I
http://csc-ma.usNandoverPubAcc/jsp/Home.jsp?Page=3&Linkld=462118 12/8/2005
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Commonwealth of Massachusetts
IM City/Town of
S 'tem Pumping- Record
YS
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 tame as that provided here. Before using.this form, check with your
local Board of Health to determine the form they use. TheSystern Pumping Record must be submitted to
the local Board of Health or other approving authority.
A. Facility. Information
hou t rear of house, Left/ right side of house, Left
1. System Locatiq : Le Righ %fr �nt;�
,u 0-e nt of hous6 Left / Righ'
Mn
Rif T f building, Left / Right rear of building, Under deck
Right side of bu i ag. Left 0
Address
Cityfrown
2. System Owner
Name'
Address (if different fron
C C
fuo� 7
location)
B. Pumping Record
1. Date of Pumping
3. Type of system
4.
S+-,
state
Zip Code
stle�
`7 -zip,,C!%-,,
Telephone Number
Date Q u �zal n t umped: Gallons
eptic Ta
Cesspool(s) eptic Tank Tight Tank
Other (describe):
Effluent Tee Filter present? (I Yep a<o
'5. Condition of.System:
— J'\Jo �\Ajk"�iA Ir
6. System Pumped By.
7.
If yes, was it cleaned? El Yes El No.
Nell Batesion F5821
Name Vehicle Ucanse Number
Bateson Enterprises Inc-
-dompany
contents- were disposed:
Aa -11a -(L( .. e
Data
t5fbrm4.doe- 06/03 System Pumping Record - Page I of I
TRANSMISSION VERIFICATION REPORT
TIME
11/08/2007 11:52
NAME
HEALTH
FA*x"
9786888476
TEL
9786888476
SEP.#
OOOB4J120960
DATEJIME 11 , /OR 11:52
FAX NO.,-'HAME 819786851463
DURATInH 00:00:10i
PA('JE � 01
RESULT OK
MODE STANDARD
ECM
111449
f,
0) $1
-0 01 v
IV
Commonwealth of Massachusetts
D2 City/Town of
System Pumping Record
Form 4
DEP has provided this form for us&, by local Boards of Health. Other forms may beused, 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 fbrrh 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 house, Left/ Right rear of house, Left/ right side of house, Left I
Right side of building, Left / Right front of building, Left / Right rear of building, Under deck
Address C
Cityfrown
2. System Owner
Name'
24-
State
Zip Code
Address (if diffarent from location)
Cityfrown State Zi C
Telephone Number
B. Pumping Record
1. Date of Pumping Date 2. Quantity Pumped: Gallons 7,
Cesspool
3. Type of system' (S) 3--geptic Tank -right Tank
4.
F-1 Other (describe):
Effluent Tee Filter present? F1 Yes 0 -N --o If. yes, was ft cleaned?
5. Condition of.System-
6. System Pumped By. -
Nell. Meson
Name
Bateson Enterprises Inc-
-dompany
7. Lo(�:qao�e contents were disposed:
Lowell Waste Wi
F5821
0 Yes [--] No
Vehicle Ucense Number��
10 9
Date
t5fbrm4.doo- 06/03 Sy stem Pumping Record - Page I of I
//7. Page 10 of 1,1
OFFICIAL INSPECTION FORM — NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Property Address: 261 Rea Street
Owner: —Sipsey_ — North Andover—
Date of Inspection: _10/7/2005_
SKETCH OF SEWAGE DISPOSAL SYSTEM
Provide a sketch of the sewage disposal system including ties to at least two permanent reference landmarks or
benchmarl— T -+ 11 11 1-:- 1 - I
e a we s
A to Tj
A to DL
B to TE
B to D-
Commonwealth of Massachusetts
City[Town of
System Pumping Record
Form 4
I r ?VN
DEP has provided this form for use7 by local Boards of Health. Other- V*(J�e'd, 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.
J!�:
k
A. Facility Information
1. System Location e Rig front of house eft / Right rear of house, Left / right side of house, Left
.. 9-- D. lid
Right side of bui ding, Left /<Rigaoh iiino ibuilding, Left / Right rear of building, Under deck
Address ��L
Cityrrown
2. System Owner
Name
Address (if different from locabon)
Cityrrown
B. Pumping Record
1. Date of Pumping
3. Type of system:
El Other (describe):
S"14-
la -6 -( C),
Date
Cesspool(s)
4. Effluent Tee Filter present? E] Yes [3 No
5. Condition of System:
6. System Pumped By:
Neil Bateson
Name
Bateson Enterprises Inc
Company
7. Location where contentsc were disposed:
GLL
. Lowell Waste Water
f V 10; M
Zip Code
State Z* C de
a '3
Telephone Number
2. Quantity Pumped
n septic Tank
Gallons
El Tight Tank
If yes, was ft cleaned? [I Yes F1 No
F5821
Vehicle License Number
Date
6 - k,= -)L -
t5form4.doc- 06/03 System Pumping Record - Page 1 of I
Important:
When filling out
forms on the
computer, use
only the tab key
to move your
cursor - do not
use the return
key.
011� �-- -
qv!t�—A
Commonwealth of Massachusetts RECEIVED
City/Town of
System Pumping Record
JUN 5 2009
Form 4
TOWN OF NORTH ANnn
DEP has provided this form for use by local Boards of Health. Other foriis,4!4����
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: ft rear, left sip �of hou�seight front, right rear, right side of house.
e�l ------------ —
Address
C —G �
City/Town
2. System Owner:
Name
Address (if different from location)
Cityrrown
B. Pumping Record
1. Date of Pumping
3. Type of system: 0
jj Other (describe):
SA-
State
� S�C-�
Telephone Number
I
61 - 2. Quantity Pumped
Date
Cesspool(s) 0-9e--ptic Tank
Zip Code
Gallons
Tight Tank
4. Effluent Tee Filter present? Q Yes [3"K -o If yes, was it cleaned? El Yes L] No
5. Condition of System -
6. System Pumped By:
Neil Bateson
Name
Bateson Enterprises Inc
Company
7. Location where contents were disposed:
4@�� Lowell Waste Water
F 5821
Vehicle License Number
j A . 6 -( CD
of H�ut6r Date
t5form4.doc-.06/03 System Pumping Record - Page 1 of I
Important:
When filling out
forms on the
computer, use
only the tab key
to move your
cursor - do not
use the return
key.
VQ
REICEIVED'�
Commonwealth of Massachusetts JUN 0 9 2008
Cityfrown of
WN F NORTH ANDOVER
T P
System Pumping Record [7HEAOL H DE ARTMENT
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.
A. Facility Information
1. Sy -+-m Locajion:
TJ2'�
Address 'D 0,
Cityrrown State
2. System Owner:
Name
Address (if different from location)
Cityrrawn
B. Pumping Record
1. Date of Pumping
3. Type of system: El
n Other (describe):
Date
Zip Code
State a Y e
Telephone Number
jo���
2. Quantity Pumped: Gallons
Cesspool(s) -Septic Tank Tight Tank
4. Effluent Tee Filter present? El Yes Er'No If yes, was it cleaned? El Yes 0 No
5. Condition of System:
- V\L-)CKL"-� V\-
6. Systeln Pump@d By:
Name
Company
7. Locatio ere contents posed:
n -is
Vehicle License Number
t5form4.doc- 06/03 System Pumping Record - Page I of 1
Town of North Andover ORT11
Of to
Office of the Health Department
Community Development and Services Division
400 OSGOOD STREET
North Andover, Massachusetts 01845
Susan Y. Sawver, REHS/RS 978.688.9540 - Phone
Public HealthDirector 978.688.8476 - Fax
fWWq7j"qtFO(F COWtvr TINCE
%.' A-# A. A6ftf 'j— JLJA.1 AL
As of:
December 7, 2005
This is to certify that
the individua(su6surface disposa(system was a
Septic Component — Distfibution (Bo, -,c
by
9 e Reiffy
Vik
261 Rea Street
Xorth,Udover, 911,4 01845
.7fas 6een installed in accordance with the provisions of Titre V of the State Sanitary Code and
with the Yorth.A ndover 0oardofY/ealth regulations.
7he issuance of this certificate shall not 6e construed as a guarantee that the system witr
Junction satisfactorily.
�/x ua
9dichere E- Grant '
Tu6lic Yfealth Inspector
130AIZI)OI�AI'1)1-'AI.S698-94;41 RUIHAN6688-9545 CONSFRVATION689-9530 HEALTI-1688-95-40 PLANNIN6688-95-335
Town of North Andover
Office of the Health Department
Community Development and Services Division
400 OSGOOD STREET
North Andover, Massachusetts 01845
Susan Y. Sawyer, REHS/ RS
Public Health Director
978.688.9540 - Phone
978.688.8476 - Fax
OT C05VfQj-Djr-VAT-409A1LjrVCE
As of-.
December 7 2005
,This is to certify that
the individualsu6surface disposaf system was a
Septic Component — Distribution (Bo-�
by
9 e Reiffy
Vik
At:
261Rea Street
Yorth,Udover, 911,9 01845
Ifas been instaffed in accordance with the provist . ons of Titfe V of the State Sanitary Code and
u4th the YorthAndover 0oardof Ifealth regulations.
'The Issuance of this certifi*cate shaff not be construed as a guarantee that the system wiff
function satisfactorify.
z' P-
Wichele E- Grant "
Mlic Yfealth inspector
130AI�1)01-'AI'Pl-'i\I.S6."-9541 BUILDIW688-9545 CONSFRVATION688-9530 HFALT11688-954o PLANNING688-9535
TOVVN OF IAZ "`U�
SYSTEM PUMPING REd6p-j5-,rE1VED
DATE:
SYSTEM OWNER & ADDRESS
DATE OF PUMPING:
OCT 1 2 2
TOWN OF i"40FNI ri "'NrJU07
HEALTH DEPAR�,',AENT
SYSTEM LOCATION
(example: left front of
1,��-'7-0-�'QUANTITY PUMPED:
GALLONS
CESSPOOL: NO SEPTICTANK: NO YES ___j
NATURE OF SERVICE: ROUTINE EMERGENCY
OBSERVATIONS:
GOODCONDITION
HEAVY GREASE
ROOTS
EXCESSIVE SOLIDS
SOLIDS CARRYOVER
FULL TO COVER
BAFFLES IN PLACE
LEACHFIELDRUNBACK
FLOODED
OTHER (EXPLAIN)
SYSTEM PUMI?ED BY: Bateson Enterprises, Inc.
COMMENTS:
CONTEWS nUNSFERRED To: G.L.S.D Lowell Waste
UA i k
5 !T M
DA -11 OF PV�J)�No:
212
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ROM "IN AUG 12 2005
R
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TOWIHEALTH DEPARTMENT
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COMMONWEALTH OF MASSACHUSETI'S
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: 261 Rea Street —
— North Andover_
Owner's Name: _�Me Sipsey_
Owner's Address: 261 Rea Street —
— North Andover, Ma 01845
Date of Inspection: 10/24/2005_
Name of Inspector: — Neu J. Bateson—
Company Name: —Bateson Enterprises Inc._
Mailing Address: —111 Argilla Road —
— Andover, Ma. 01810
Telephone Number: _( 978 ) 475-4786_
RECEIVED
DEC 0 7 2005
TOWN OF NORTH ANDOVER
HEALTH DEPARTMENT
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 15.340 of Title 5 (310 CMR 15.000). The system:
Passes
Conditionally Passes
Needs Further Evaluation by the Local Approving Authority
IF
Inspector's Signature: f V V Date: _ 10/24/2005
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 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: After permit from B.O.11, installation of new d -box by FP Reilly & Sons, inspection
from B.O.IL, septic system now passes Title 5 Inspection.
****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 me.
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: 261 Rea Street —
— North Andovu_
Owner's Name: — Nfichael Sipsey_
Owner's Address: 261 Rea Street
— North Andovir, MA 01845
Date of Inspection: 10/7/2005
Name of Inspector: —Neil J. Bateson—
Company Name: —Bateson Enterprises Inc,
Mailing Address: 111 Argilla Road —
— Andover, Ma. 01810
Telephone Number: _(978) 4754786_
R E - - ,
CEIVED
OCT 1 4 �005
"OWN OF NORI
HEALTH DEP �' ANDOVER
�-��ENT
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 ftinction and maintenance of on site sewage disposal systems. I am a DEP
approved system inspector pursuant to Section 15.340 of Title 5 (310 CMR 15.000). The system:
Passes
_X_ Conditionally Passes
Needs Further Evaluation by the Local Approving Authority
"s
Inspector's Signature: Date: 10/7/2005
Y V
The system inspector shall submit a copy o4s 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 owner shall submit the report to the appropriate regional office of the
DER 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 does not address how the system will perform in the future under the same or different
conditions of use.
, 0
Page 2 of 11,
OFFICIAL INSPECTION FORM — NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION (continued)
Property Address: 261 Rea Street –
– North Andover–
Owner: Sipsey_
Date of fnspection: _10/7/2005 –
Inspection Summary: Check AACM or E / ALWAYS complete all of Section D
A. System Passes:
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:
X 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,NND) in the for the following statements. If "not
determined" please explain. Replace d -box
— N 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:
N Observation of sewage backup or break out or high static water level in the
distribution ;�x—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:
N 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):
ND explain:
broken pipe(s) are replaced
obstruction is removed
Page 3 of 11.
OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION (continued)
Property Address: — 261 Rea Street —
— North Andover—
Owner: —Sipsey_
Date of Inspection: 10/7/2005
C. Further Evaluation is Required by the Board of Health:
Conditions exist which require ftirther 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 CNM 15.303(l)(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 will fail unless the Board of Health (and Public Water 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
iurface water supply or tributary to a surface water supply.
The system has a septic tank and SAS and the SAS is within a Zone I 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
jW7tvate 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 I
OFFICIAL INSPECTION FORM — NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION (continued)
Property Address: 261 Res Street -
- North Andover_
Owner: -Sipsey-
Date of Inspection: _10/7/2005
D. System Failure Criteria applicable to all systems:
You must indicate "yee' or "no" to each of the following for all inspections:
-No- Backup of sewage into fitcility or 0�gem compD due to overloaded or-cl2gged SAS or cesspool
-No- Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or
clogged SAS or cesspool
-No- Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or
cesspool
- No Liquid depth in cesspool is less than 6" below invert or available volume is 1/2 day flow.
-No- Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s).
Number of times pumped
-No- Any portion of the SAS, cesspool or privy is below high ground water elevation.
-No- Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface
water supply-
-No Any portion of a cesspool or privy is within a Zone I of a public well.
-No�- Any portion of a cesspool or privy is within 50 feet of a private water supply well.
-No- 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 pasm 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.]
(Yes/No) The system fails '. I have determined that one or more of the above failure criteria exist as described
in 3 10 CMR 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 Dow of 10,000 gpd to 15,000
gpd.
You must indicate either "yes" or "no,' 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
"yee' 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 3 10 CMR
15.304. The system owner should contact the appropriate regional office of the Department.
Page5 ofil.
OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART B
CHECKLIST
Property Address: 261 Rea Street -
North Andover
Owner: -Sipsey_
Date of Inspection: 10/7/2005
Check if the following have been done. You must indicate "yes" or "no?' as to each of the following:
Yes No
-yes- — Pumping information was provided by the owner, occupant, or Board of Health
-No- Were any of the system components pumped out in the previous two weeks ?
-Yes- — Has the system received normal flows in the previous two week period ?
-No- Have large volumes of water been introduced to the system recently or as part of this inspection ?
-yes- — Were as built plans of the system obtained and examined?
-Yes- — Was the facility or dwelling inspected for signs of sewage back up ?
-Yes- — Was the site inspected for signs of break out ?
-Yes- — Were all system components, excluding the SAS, located on site ?
-Yes- — 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 ?
-Yes - — 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
- Yes Existing information.
Yes-'— Determined in the field (if any of the failure criteria related to Part Cis at issue approximation of
distaj�celi_sunacceptable) [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: 261 Rea Street -
- North Andover -
Owner: -Sipsey
Date of Inspection: _10/7/2005_
FLOW CONDITIONS
RESIDENTIAL
Number of bedrooms (design): 4 Number of bedrooms (actual): -4-
DESIGN flow based on 3 10 6H -Cl 5.203 600
Number of current residents:
Does residence have a garbage grinder (yes or no): - Yes -
Is laundry on a separate sewage system (yes or no) -
Laundry system inspected (yes or no):
Seasonal use: (yes or no): -No-
Water meter reading: -Yes-
Sump pump (yes or no): -No-
Last date of occupancy: -Current-
COMMERCIAL/INDUSTRIAL
Type of establishment:
Design flow (based on 3 10 CMR 15.203): ___gpd
Basis of design flow (seats/persons/sqft,etc.):
Grease trap present (yes or no): _
Industrial waste holding tank present (yes or no):
Non -sanitary waste discharged to the Tide 5 system (yes or no):
Water meter readings, if available:
Last date of occupancy/use:
OTHER (describe):
GENERAL INFORMATION
Pumping Records
Source of information: -Pumped last year, owner
Was system pumped as part of the inspection (yes or no): -Yes-
If yes, volume pumped: _1000 gallons - How was quantity pumped determined? -Measured tank -
Reason for pumping: -Inspect tank & baffles -
TYPE OF SYSTEM
_X_ 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: 29 years old,
3/27/1976,as built plan_
Were sewage odors detected when arriving at the site (yes or no): -No-
Page7ofll,
OFFICIAL INSPECTION FORM — NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Property Address: 261 Rea Street –
North Andover
Owner: –Sipsey_
Date of Inspection: _10/6/2005_
BUILDING SEWER – X – (locate on site plan)
Depth below grade: –24"
Materials of construction: – X – cast iron –X 40 PVC —other
Distance from private water supply well or suction line:
Comments (on condition ofjoints, venting, evidence of leakage, etc.) –4" Cast iron thur wall. 3" PVC in house,
no leaks visible
�Ivw I re-gro N3w–
Depth below grade: _12" _
Material of construction: –X– concrete — metal —fiberglass ___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)
Dimensions: — 71 x5lx4l–
Sludge depth. – I" –
Distance from top of sludge to bottom of outlet tee or baffle: –31"—
Scum thickness: –1"–
Distance from top of scum to top of outlet tee or baffle: – 8"
Distance from bottom of scum to bottom of outlet tee or baffle: –15"—
How were dimensions determined: – Tape Measure _
Comments (on purnping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels
as related to outlet invert, evidence of leakage, etc. –Pumped septic tank. 1ulet baffle ok. Outlet bafde ok. Depth
of liquid at outlet invert. No evidence of leakage.,
GREASE TRAP: _(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 (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: 261 Rea Street –
– North Andover_
Owner: –Sipsey_
Date of Inspection: _10/7/2005_
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 BOXES:
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.):–D-box badly corroded. Needs replaced. Evidence of leakage. Evidence of
carryover, pumped d -box to clean_
PUMW CHAMBER: (locate on site plan)
Pump in working order (yes or no):
Alarm in working order (yes or no):
Comments (note condition of pump chamber, condition of pwnps and appurtenances, etc.):
Page9oflL
OFFICIAL INSPECTION FORM — NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Property Address: 261 Rea Street -
North Andover
Owner: - Sipsey_
Date of Inspection: _10/7/2005_
SOIL ABSORPTION SYSTEM (SAS): _X_ (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:
_X_ leaching field, number, dimensions: -1 field 201 x 451
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.): -Soil ok. Vegetation ok. No sign of ponding to surface -
CESSPOOLS:
Number and configuration: _ _
Depth - top of liquid to inlet invert:
Depth of sludge layer:
Depth of scum layer: _
Dimensions of cesspool:
Materials of construction:
Indication of groundwater Ofl-ow (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: 261 Rea Street –
– North Andover–
Owner: _Sipsey_
Date of Inspection: _10/7/2005_
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.
F -- I
I —porch
Deck
House
A
./ Water Meter
Septic Tank
(�D ���D-
Box
• to Tank = 20'8"
• to D -Box = 36'1"
B to Tank = 2615"
B to D -Box = 23'6"
Driveway
Page 11 of It
OFFICIAL INSPECTION FORM — NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Property Address: 261 Rea Street –
– North AndoveFm_
Owner: –Sipsey_
Date of Inspection: 10/7/2005
SrM EXAM
Slope
Surface water
Check cellar
Shallow wells
Estimated depth to ground water – 41
Please indicate (check) all methods used to determine the high ground water elevation:
_X_ Obtained from system design plans on record - If checked, date of design plan reviewed: 3/27/1976
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: –As per design plan_
MIDJ,
;LlTelnet 10.1.71.55
II/S ACCOUNT
HISTORY
2100516-SIPSEY,
MICHAEL
L. METER 01:
2100516
-------------------
BR:261 REA
ST
4 CYCLE
SERUICE
PRIOR
CURRENT
USE
VATER
SBIER
FEES
1 1999-100
0?/15/1999
106.47
0.00
0.00
2 1999-130
OS/IS/1999
0.00
0.00
0.00
3 1999-160
02/06/1999
2.11
0.00
0.00
4 1999-190
12/29/1998
0.00
0.00
0.00
5 2000-12
08/05/1999
3766
3833
6?
182.91
0.00
0.00
6 2000-22
12/10/1999
3833
3892
S9
161.0?
0.00
0.00
7 2000-32
03/13/2000
3892
3924
32
87.36
0.00
0.00
8 2000-42
OS/23/2000
3924
3948
24
6S.S2
0.00
0.00
9 2001-12
08/09/2000
3948
3982
34
92.82
0.00
11.00
10 2001-22
11/15/2000
3982
4005
23
62.79
0.00
11.00
11 2001-32
02/lS/2001
4005
4028
23
62.79
0.00
11.00
12 2001-42
05/23/2001
4028
4053
25
68.2S
0.00
11.00
13 2002-22
12/12/2001
4086
4119
33
84.8?
0.00
S.ss
14 2002-32
03/18/2002
4119
4148
29
79.47
0.00
5.55
1S 2002-42
05/1?/2002
4148
4164
16
39.52
0.00
S.ss
16 2002-12A
08/07/2001
40S3
4086
33
96.0?
0.00
s.ss
17 2003-12
08/0?/2002
4164
4210
46
146.40
0.00
S.97
18 2003-22
11/13/2002
4210
4252
42
12532
0.00
5.97
REUIEU CHOICE 0 ot- (ENTEV MORE HISTORY:
TOTAL
106.4
0.0
2.1
0.0
182.9
161.0
8?.3
6S.5
103.8
73. ?
?3. ?
79.2
90.4
85.0
4S.0
101.6
152.3
131.4
I-I'A
I
SA 4 "1
C I I A E L
0,q 06�
44.1'
IC,
All
I-I'A
I
SA 4 "1
C I I A E L
0,q 06�
44.1'
IC,
Summary Record Card generated on 10/712005 10:58:46 AM by Lisa Warren Page 1
Town of North Andover
Tax Map # 210-038.0-0032-0000.0
261 REA STREET
SIPSEY, MICHAEL L.
261 REA STREET
N. ANDOVER, MA
01845
Class 10 1 Si : ngl e Family Property Type 1 Residential
Size Total 1.04 Acres
FY 2006
LIB Mailing Index
Name/Address Type Loan Number Active/Inact. From Until
SIPSEY, MICHAEL L. Payor
261 REA STREET
N. ANDOVER, MA
01845
1.113 Account Maint.
Account No Cycle Occupant Name Active/inactive
Bldg Id. 14019.0 - 261 REA STREET Last Billing Date 8/31/2005
2100516
02 Cycle 02
UB Services Maint.
?
w Water 0.630.63
Service Code
Consumption
Rate
MISCFEE ADMIN FEE
45
0.63 5/8
WTR WATER
30
01 ALL METER SIZE
LIB Meter Maintenance
31
3/15/2005
Serial No Status
19
Location
0022746055 a Active
ENC L
Date
Reading
Code
8/10/2005
4561
a Actual
5/11/2005
4516
a Actual
2/22/2005
4486
a Actual
11/17/2004
4455
a Actual
8/12/2004
4436
a Actual
5/18/2004
4409
a Actual
2/17/2004
4384
a Actual
11/6/2003
4357
n New Meter
Active
Charge Multiplier/ Users
7.82 1/
200.30 /1
Brand
Type Size
YTD Cons
?
w Water 0.630.63
0
Consumption
Posted Date
Variance
45
9/12/2005
29%
30
6/8/2005
20%
31
3/15/2005
63%
19
12/17/2004
-38%
27
9/20/2004
14%
25
6/14/2004
5%
27
4/16/2004
0%
0
11/6/2003
0%
. A
BATESON ENTE"RISES, INC.
Excavating -Water.& Sewer Lines -Septic Systems & Pumping Service
111 Argilla Road Andover, Mass. 01810
Title 5 Inspection Report
Property Address: 261 Rea Street, North Andover
Owner: Sipsey
Date of Inspection: 10/7/2005
Tel: (978) 475-4786
Fax: (978) 475-5451
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 ffirther
operation of your current septic system.
MI'mi,
Neil J. BatEson
Bateson Enterprises, Inc.
4.
TOWN OF NORTH ANDOVER TH
Office of COMMUNITY DEVELOPMENT AND SERVICES
0
HEALTH DEPARTMENT 41
400 OSGOOD STREET
4 -
NORTH ANDOVER, MASSACHUSETTS 0 1845 CINU
Susan Y. Sawyer. REHS/RS 978.688.9540 - Phone
Public Health Director 978.688.9542 - FAX
SEPTIP-SYSTEM CONSTRUCTION NOTES
ADDRESSr--,'-,/O/ MAP: LOT:
INSTALLER: //9�p
DESIGNER: ' " I -
PLAN DATE:-- AIIR—
BOH APPROVAL DATt ON PLAN:
DATE OF BED BOTTOM INSPECTION:
DATE OF FINAL CONSTRUCTION INSPECTION:
DATE OF FINAL GRADE INSPECTION:
SELECT SYSTEM TYPE
GRAVITY DISTRIBUTION
PRESSURE DISTRIBUTION
PRESSURE DOSING
HOLDING TANK
ADVANCED TREATMENT
OTHER
COMPONENT SUMMARY FROM PLAN
GALLON TANK =
LOADING OF SEPTIC TANK
GALLON PUMP CHAMBER =
LOADING OF PUMP CHAMBER
TYPE OF SAS =
DIMENSIONS AND DETAILS OF SAS:
SITE CONDITIONS
El Existing septic tank properly abandoned
11 Internal plumbing all to one building sewer
Comments: 0 Topography not appreciably altered
A� 0 �7 /
Page I of 4
Page 2 of 4
TOWN OF NORTH ANDOVER Th
Office of COMMUNITY DEVELOPMENT AND SERVICES
HEALTH DEPARTMENT
v '
10 W "
4
400 OSGOOD STREET
NORTH ANDOVER,
MASSACHUSETTS 01845
Susan Y. Sawyer, REHSi"RS
Public Health Director
978.688.9540 - Phone
978.688.9542 - FAX
SEPTIC TANK
El
Bottom of tank hole has 6" stone base
Weep hole plugged
gallon tank has been installed
(H-1 0 or H-20) (monolithic or 2 piece)
El
Water tightness of tank has been achieved
(Visual or Vacuum Test or Water held for 24hrs)
El
Inlet tee installed, under access port
Outlet tee (gas baffle or effluent filter) installed, under
access port
El
inch cover to within 6" of final grade installed over
one access port, must be over outlet of tank if effluent
filter is present
Hydraulic cement around inlet & outlet
Comments:
PUMP CHAMBER
Bottom of tank hole has 6" stone base
El
Weep hole plugged
El
gallon Pump Chamber installed
(H-1 0 or H-20) (monolithic or 2 piece)
El
Inlet tee installed, under access port
El
Pump(s) installed on stable base
Alarm float working
Pump On/Off float working
Drain hole in pressure line
inch cover to within 6" of final grade installed over
one access port
Water tightness of tank has been achieved
Visual or Vacuum Test or Water held for 24 hrs
Hydraulic cement around inlet & outlet
Comments:
Page 2 of 4
TOWN OF NORTH ANDOVER Tol
Office of COMMUNITY DEVELOPMENT AND SERVICES
0
HEALTH DEPARTMENT
400 OSGOOD STREET
NORTH ANDOVER, MASSACHUSETTS 01845
C us
Susan Y. Sawyer. REHS/RS 978.688.9540 - Phone
Public Health Director 978.688.9542 - FAX
D -BOX
Installed on stable stone base
Inlet tee (if pumped or >0.08'/foot)
Hydraulic cement around inlet & outlets
��Sbserved even distribution
peed levelers provided (not required)
Comments:
SOIL ABSORPTION SYSTEM
11
11
El
El
El
El
Comments:
PRESSURE DISTRIBUTION
Bottom of SAS excavated down to soil layer, as
provided on plan
Size of SAS excavated as per plan
Title 5 sand installed, if specified on plan
3/4-1 Y2" double washed stone installed
1/8-1/2" (peastone) double washed stone installed
laterals installed and ends connected to header (and
vented if impervious material above)
Orifices @ 5 & 7 o'clock positions
Gravelless disposal systems: type, number and
location as per plan
Elevations of laterals installed as on approved plan
40 Mil HDPE barrier installed
Retaining wall (boulder / concrete / timber/ block)
Final cover as per plan
inch manifold
laterals installed with end sweeps
size:
material:
Squirt test ft in height
Equal distribution to all laterals
Comments: El orifice size inch as per plan
Page 3 of 4
TOWN OF NORTH ANDOVER
Office of COMMUNITY DEVELOPMENT AND SERVICES
HEALTH DEPARTMENT
0
400 OSGOOD STREET
NORTH ANDOVER, MASSACHUSETTS 0 1845
ED
Susan Y. Sawyer. REHS/RS 978.688.9540 - Phone
Public Health Director 978.688.9542 - FAX
CONTROLPANEL
El Alarm & Pump are on separate circuits
El Alarm sounds when float is tripped
11 Location of control panel:
El Rated for exterior if placed outside
Comments:
SYSTEM ELEVATIONS
Benchmark:
Rod at Benchmark:
Height of Instrument:
INVERT ON DESIGN ELEVaTOPOF-071—PE INVERTELEVATION
Building Sewer OUT
Septic Tank IN
Septic Tank OUT
Pump Chamber IN
Pump Chamber OUT
Distribution Box IN
D -Box OUT Manifold
Lateral 1 HIGH
Lateral 1 LOW
Lateral 2 HIGH
Lateral 2 LOW
Lateral 3 HIGH
Lateral 3 LOW
Lateral 4 HIGH
Lateral 4 LOW
Lateral 5 HIGH
Lateral 5 LOW
Page 4 of 4
, R1. Commonwealth of Massachusetts Map -Block -Lot
cc
038.0- 0032 -
C Board of Health
Pennit No
North Andover BHP -2005-0576
P.I. FEE
F. 1. $125.00
Disposal Works Construction Permit
Permission is hereby granted Mike Reilly
to (Repair -D -BOX ONLY) an Individual Sewage Disposal System.
at No 261 REA STREET
as shown on the application for Disposal Works Construction Permit No. BHP -2005-057 Dated October 19, 2005
Issued On: Oct -19-2005
Board of Health
Map -Block -Lot
Commonwealth of Massachusetts
038.0- 0032 -
Board of Health
North Andover
Certificate of Compliance
, 'A
0
THIS 1,5 TO CERTIFYThat the Individual Sewage Disposal System (Repair -D -BOX ONLY)
by Mike Reilly
Installer
at No 261 REA STREET
has been installed in accordance with the prcyvfsions of TITLE 5 of the State Environmental Code as described in the
application for Disposal WorksConstruction Permit No. BHP -2005-057 Dated October 19, 2005
Printed On: Oct- 19-2005 Board of Health
_L�XO 14671e�_5'
r
Tow-ra of rth 2Andov
Health Department Date:
Location:
(Indicate Address, if Residenti&kQLyame of Business)
Check #: L9 _4(en
Tvpe of Permit or License: (Circle)
>
Animal
>
Dumpster
$
>
Food Service - Type:
$
>
Funera I Directors
>
Massage Establishment
>
Massage Practice
$
>
Offal (Septic) Hauler
$
>
Recreational Camp
$
>
SEP77C PERMITS:
L3
Septic - Soil Testing
$
L3
Septic - Design Approval
$
Lj,�-S
�tic Disposal Works Construction (DWO
L3
Septic Disposal Works Installers (DWF)
>
Sun tanning
$
>
Swimmingpool
$
>
Tobacco
$
>
TrasWSolid Waste Hauler
$
>
Well Construction
$
> OTHER:- (Indicate)
9A. 6 Health Agent Initials
White -Applicant Yellow -Health Pink -Treasurer
Important:
When filling out
forms on the
computer, use
only the tab key
to move your
cursor - do not
use the return
key.
411_�
4 16 �1
Application for Septic Disposal System
Construction Permit— TOWN OF
NORTH AND
OVER, MA 01845
Application is hereby made for a permit to:
El Construct a new on-site sewage disposal system*
'Xlo 111ille9s—
TODAY'S bATE'
F-1 Repair or replace an existing on-site sewage disposal system*
ER"R"'epair or replace an existing system component
A. Facility Information
-1 to / RQ'f
Address or Lot #
wo.-il Ageav'-"c
0ity/Town '
2.- *TYPE OF SEPTIC SYSTEW:
F-1 Pump [:1 Gravity (choose one)
***If pump system, attach copy of electrical permit to application***
F1 Conventional System (pipe and stone system)
F-1 Infiltrator or Biodiff user (Gravel -Less) (Attach a copy of your certification to install this type of system.
F-1 Pressure Distribution S.A.S. (No D -Box) (Attach Draft Maintenance Agreement)
0 Pressure Dosed (D -Box Present) S.A.S.
2. Owner Information,
/W I(I-A /' 4 / r -
Name
Address (if different from above)
City/Town
3. Installer Information
State
Telephone Number
Zip Code
M r4A,<,t A F - A A e,, Ali, f- rwr
Name Name of Company
-?,v& A,,lo
Address
A 42�a�
Ciiy/Town
4. Designer Information, /V/*
Name
Address
City/Town
A'71 -;'-
State Zip Code
Telephone Number (Cell Phone # if possible please)
Name of Company
State
Zip Code
Telephone Number (Best # to Reach)
Application for Disposal System Construction Permit - Page 1 of 2
PAGE 2 OF 2
X.Facility Information continued....
M
5. Type of Buildina: /Residential Dwelling or FICommercial
B. Agreement
10—f ?_ 05 -
TODAY'S DATE
$ 250.00 - Full Repair
$125.00 - Component
The undersigned agrees to ensure the construction and maintenance of the afore -described
on-site sewage disposal system in accordance with the provisions of Title 5 of the
Environmental Code, as well as the Local Subsurface Disposal Regulations for the Town of
North Andover, and not to place the system in operation until a Certificate of Compliance has
been issued bv this Boar# of Health.
0 /'0
Name Date
Applicat�ioAXpproved By. (507d of Health Representative)
Date
"'Zlication Disapproved for th`e"::��following reasons:
For Office Use Only:
L Fee Attached? Yes No
2. Project Manager Obligation Form Attached? Ye s (�N�o,6
3. PumpSystem? If so, Attach cop.y ofEkarical Permit Yesh, No
4. Foundation As -Built? (new construction ronly): Yes No
(Same scale as approwdplan)
5. Floor Plans? (new construction only): Ye s No
W�
.00 Application for Disposal System Construction Permit - Page 2 of 2
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978-372-7471
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ZS OF SYS
OF PROFESSIC
UW OF LOT OWNER
10 CR SANITARIAN CONDUCTING TESTS
ADIRESS
SHOW APPROXIMTE LOCATION OF PITS ON SKETCH ON REAR OF THIS SHEET
Soil Loz,. ToDsoil . Subsoil DeDths & TvDes
Total
WatAr Tt-vp-1 Pi +. I)m+.b
Time to Time to
Perc Tests Depth Saturation Time Drcm 1211 - 9t' brnn gif - (,It
A&
Other Considerat ions: � C-4-- �-e -/
Recommendations:
t/
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op
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MINNOW-
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/..,e pos
MINNOW-
TO: NORTH ANDOVER, MASS 19 7 �C
BOARD OF HEALTH
FROM: DESIGN ENGINEER Re: Soil Absorption Sewage
System Inspection
This is to certify that I have inspected the construction of the said disposal system at
Rel? Sr - North Andover, Mass.
SITE LOCATION
The grades and construction are as specified in my plans d ications ate
A�\ OF
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O.F NORTH
SYSTEM PUM'PI.NC WOR -D
M 0 WN FR A D D RE SS YSTEM L
IM from or hou�t)
uATcoFp.vmpINc,.,
QUANTITY PUMPCD
_Ze
.15�6 L L 0.'�
,'.'I S I'Q Q L N 0 YE� -,SEPTIC TANK: NO y E s
NATURE OF SERYIM, ROUTINE EMIERCEN'
c y
CO.01) C.ONVII1110N, PU L.L TO CO Y E
'L,ACI'
.13AFFLES IN 1)
R 0. OTIS LEACHFICLD RUNUACK...
c. XCESSI.-YE SOLIDS FLOODED'
��OLII).�'CAR-'RYOYER-. xW'HFR (EXPLA.IN)
�l Im PVMPCO 0 Y:,
ILI
u m
Y.] eN T s:
lo:
A P C B D TO
TOWN OF NORTH ANDOVER
DATE 57-�g7— 01 SYSTEM PUMPING RECORD
SYSTEM OWNER & ADDRESS
sips *�
DATE OF PUMPING: ��
CESSPOOL; NO— /YES
LOCATION
QUANTITY PUMPED:
Septic Tank: NO YES—lZ/
NATURE OF SERVICE: ROUTINE V--XEMERGENCY
OBSERVATIONS:
GOOD CONDITION FULL TO COVER
14EAVY GREASE BAFFLES IN PLACE
ROOTS LEACHFIELD RUNBACK
EXCESSIVE SOLIDS FLOODED
SOLID CARRYOVER. OTHER EXPLAIN
SysternPumpedby
COMMENTS:
CONTENTS TRANSFERRED TO— -<'9t)
.�, I /If 4
vv "I Ur A ux I H AA DO VER
SYSTEM PUMPING RECORD
DATE:
tV,
SYSTEM OWNER & ADDR SS SYSTEM LOCAT
ION
(example:jleft froitt of hou
se)
M r
7 4-
361
IV-0)qnOL,
14
�D
1 ATE OF PUMPING: 572511 vi
QUANTITY PUMPED 16'6' GALLONS
"T
C
ESSPOOL: NO
YES
SEPTIC ANK: NO —YES 4_��
NATURE OF SERVICE: ROUTINE
�CM
EMERGENCY.
0
GOOD CONDITI 14
FULL TO COVER
HEAVY GREASE
BAFFLES IN PLACE
ROOTS
LEACHFULD RUNBACK
EXCESSIVE SOLIDS
FLOODED
SOLIDS C.AJUJYOVER OTHER (EXPLAIN)
SYSTEM P
UMPED, BY: c
1
L
ENTS;
x0MM
WWI
TRANSFERRED TO:.
I - <�4 -
z22/
0 C/ nc
TOWN OF NORTH ANDOVER
SYSTEM PUMPING RECORD
c-4--1,112 A,7,
-�Y.STENI OWNER & ADDRESS
0 F 11 U M PI N G:
/7
('l:'.SSJ)OOL: NO N YES
SYSTEM LOCATION
(example: left front of house)
7P' HV%rS C-
QUANTITY PUMPED 1000 G/ki-LONS
SEPTIC TANK: NO YES
N:kTUREOFSERVICE: ROUTINE X EMERGENCY
13.S ER V. -VIA 0 N S:
GOOD CONDITION
HEAVY GREASf-
ROOTS
EACESSIVE SOLIDS
SOLIDS CARRYOVER
.�YSTEM PUMPED BY:
C, ().N l-,-'NT.S:
('ONTENTS TRANSFERREDTO:
FLJI-,L,ro covEiz
B A FFL E S I N I'L A CE
LEACHFIELD RUNBACK
FLOODED
OTHE-R (EXPLAIN)
Ar
Commonwealth of Massachusetts
CityfTown of
System Pufftping Record
Form 4
Nov -
TOWN OP OATH ANDOVER
DEP has provided this form for use by local Boards of Healthl but the
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 opottier approving authority.
A. Facility Information
1. System Location: Left side of house, Right side of house Left front of house ight front of house,
Left rear of house, Right rear of house. Left rear of buildinggaiigat riar;oibuilding.
Address
Cityrrown State
2. System Owner: S,:;')V\'
Name
Address (if different from location)
City/Town
B. Pumping Record
1. Date of Pumping
3. Type of system: El
0 Other (describe):.
Zip Code
St t I
In'
-7 )A
Telephone Number
to- t5- to /
Date 2. Quantity Pumped: Gallons
Cesspool(s) E�-<�ptic Tank El Tight Tank
4. Effluent Tee Filter present? Ej Yes 91KI01" If yes, was it cleaned? [:] Yes [:] No
5. Conditiop of,System:
P� f �W � V�
6. System Pumped By:
Neil Bateson
Name
Bateson Enterprises Inc
Company
7. Locayboqyhere contents were disposed:
/G.L.s.'D
2 Lowell Waste Water
F5821
Vehicle License Number
Date
t5form4.doc- 06/03 System Pumping Record - Page 1 of I
4"\ Commonwealth of Massachusetts
q.-- - OF City/Town of
ASCOVEC
System Pumping Record
Form 4 DEC -8 W1
DEP has provided this form for use by local Boards of Health. Other fo
IMANT1 V, ,ry
information must be substantially the same as that provided here. Be =I Mith 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 Locatioq L - Rigo!]R���, Left / Right rear of house, Left / right side of house, Left-/
Right side of buil Ping.,)Left / Right front of building, Left / Right rear of building, Under deck
Address a G
Cityrrown
2. System Owner:
Name
Aaaress (it ciaterent trom location)
City/Town
B. Pumping Record
1. Date of Pumping
3. Type of system: El
El Other (describe):
Date
Cesspool(s)
State
'C-', e --N^,
Zip Code
State ip Code
Lf —
Telephone Number
— 2. Quanti Pumped
EJ-Sepfic Tank
4. Effluent Tee Filter present? Ej Yes I]-ICo-
5. Condioon of System:
I \j z'x– o -A aj'�'
6. System Pumped By:
Neil Bateson
Name
Bateson Enterprises Inc
Company
7. Location where contents were disposed:
— _0
Z_L_,S-Q - Lowell Waste Water
1__ff6TA_
Gallons
El Tight Tank
If yes, was it cleaned? E] Yes E] No
� CA_
F5821
Vehicle License Number
6c�-- ( —( �
Date
t5form4.doc- 06/03 System Pumping Record - Page I of 1