HomeMy WebLinkAboutMiscellaneous - 274 OLD CART WAY 4/30/2018F -I
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FORM U APPROVALs APPROVAL TO ISSUE __ES NO
DATE ISSUED ?IZO By
-CONDITIONS:
FINAL APPROVAL:
NO
.ALL PERMITS PAID :i6:?
WELL CONSTRUCTION APPROVAL NO
SEPTIC SYSTEM CONSTRUCTION APPROVAL NO
..OTHER YEP NO
ANY VARIANCE NEEDED
FINAL BOARD OF HEALTH APPROVAL:
YES NO
DATE
MAP
�LOT
STREET
HAS PLAN REVIEW-FEE.BEEN
PAID? f NO
PLAN APPROVAL:
DATE— APP. BY
el
DESIGNER: ":�� ,,'oy'ool�.'
PLAN DATE 42 // �r
CONDITIONS
WATER SUPPLY:,.
WELL
(T� rl� -
WELL PERMIT
DRILLER—
WELL TESTS:
CHEMICAL DATE APPROVED
BACTERIA I DATE APPROVED.------
BACTERIA II DATE APPROVED.
COMMENTS:
FORM U APPROVALs APPROVAL TO ISSUE __ES NO
DATE ISSUED ?IZO By
-CONDITIONS:
FINAL APPROVAL:
NO
.ALL PERMITS PAID :i6:?
WELL CONSTRUCTION APPROVAL NO
SEPTIC SYSTEM CONSTRUCTION APPROVAL NO
..OTHER YEP NO
ANY VARIANCE NEEDED
FINAL BOARD OF HEALTH APPROVAL:
YES NO
DATE
THE INSTALLER LICENSED?
YES NO
TYPE.OF CONSTRUCTION:
N �E REPAIR
�.NEW CONSTRUCTION: CERTIFIED
PLOT PLAN REV I Ew �YE NO
CONDITIONS
OF..APPROVAL YES NO
(FROM FOR M
U
-',ISSUANCE.OF DWC PERMIT
YES NO
DWC PERMIT NO.
INSTALLER:
BEG I N INSPECTION
EXCAVATIOWINSPECTION:
NEEDED:
�'-PASSED
)BY
...CONSTRUCTION INSPECTION:
NEEDEDz
AS BUILT PLAN SATISFACTORY:
YE
APPROVAL TO BACKFILL: DATE: BY
..FINAL,GRADING APPROVAL: DATE
By
DATEv By./
FINAL CONSTRUCTION APPROVAL:
Commonwealth of Massachusetts
City/Town of
System Pumping Record NORTH ANDOVER
Form 4
DEP has provided this form for use by local Boards of Health. Other forms may be used, but the
information must be substantially the same as that provided here. Before using this form, check with your
local Board of Health to determine the form they use. The System Pumping Record must be submitted to
the local Board of Health or other approving authority within 14 days from the pumping date in
accordance with 310 CIVIR 15.351.
A. Facility Information
Important:
When filling out 1 . System Location:
forms on the
computer, use
--- Q 4 a
only the tab key Addres
to move your
cursor - do not
use the return CityfTown r Zip Code
key. 2. System Owner:
Name TO,
Address (if different from location) L
CityrTown State Zip Code
Telephone IQumber
B. Pumping Record
1. Date of Pumping � 1)? 2. Quantity Pumped:
Date I Gallons
3. Type of system: El Cesspool(s) Septic Tank 0 Tight Tank El Grease Trap
7 Other (describe): --- — ---
4. Effluent Tee Filter present? E] Ye2:�.]7NO If yes, was it cleaned? 0 Yes 0 No
5. Condition of System:
6. System Pumped By
Name Vehicle License NVnbee
Company
7. Location where contents were disposed:
G.L.S.D.
A -",I %N,, -r A 4 A
Aigature iofHaule�r Date
Signature of Receiving Facility Date
t5form4.doc- 03/06
System Pumping Record - Page 1 of 1
Important:
When filling out
forms on the
computer, use
only the tab key
to move your
cursor - do not
use the return
key.
Commonwealth of Massachusetts
City/Town of H AWOVER
-'H ANOOVER
E:R TM T
stem Pumping Record NORTH A1\ I L) RALTH DEF ARTMENT
Sy i ur
Form 4
DEP has provided this form for use by local Boards of Health. Other forms may be used, but the
information must be substantially the same as that provided here. Before using this form, check with your
local Board of Health to determine the form they use. The System Pumping Record must be submitted to
the local Board of Health or other approving authority within 14 days from the pumping date in
accordance with 310 CMR 15.351.
A. Facility Information
I . System Location:
-a-7L
Old
Address
6 1 —yr(own
2. System Owner:
--joc -.Vq1Uyy)bo-- - -----
Name
-MA
State Zip Code
Wddre�is-(ii(44:16�nt f�O� lc�c�tlon)
§tate Zip Code
dit-yWfoWn Smt
Telephone Number
B. Pumping Record 4-12 - 1500
1. Date of Pumping _ jo - --- 2. Quantity Pumpedi
Date
3 Type of system: Cesspool(s) [/Septic Tank E] Tight Tank E] Grease Trap
Other (describe)�
4. Effluent Tee Filter present? 0 Yes E/No
5. Condition of System:
------ - ---------- _. 1�- -- - - -- — --
6. System Pumped By.
-Jiyy)
N'm'Wind -Rivc,� F-nv-lr-o - n ' m c. * Y)�ai
company
7. Location where contents were disposed:
--- - -- WOMAndom MA.;
-§-9n�1-Ure, of Hauler
-§:igr�-aTus� - o-fR—eceiv-i-ngF a c-iiit—y
t5form4.doc- 03106
If yes, was it cleaned? Yes [�T'No
Vehicle License Number
Date
Date
System Pumping Record - Page 1 of 1
CommonweaK of Massachusetss
: Massachusetts
gystem PuMWna Record
Location
Type: Emergency
Cesspool; w
Date of Pumping:
System Pumped By:
Contents transferred to:
Contents Disposed at:
Routine
Yes
ww River Env*90nmental, LLC
Date: Pumper Signature:
lCondition of System/Other Comments
Dep Appmved From - 12107195
Form 4 -- System Pumping Record
Septic tank: f4. =Yes
Quan" Pumped: I C
Gallons
Permit
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Form 4 -- System Pumping Record
Commonwealth of Massachusetss
: Massachusetts
System Pumping Record
System Owner System Location
C
Type: Emergency Routine
Cesspool: hlo Yes Septic tank: W =Yes
Date of Pumping: Q-7- 31 Qua" Pumped: Gallons
System Pumped By: Wind Nw Env#wynental, LLC Permit #:
Contents transferred to:
Contents Disposed at.
Date: Pumper Signature:
lCondition of System/Other Comments
Dep Appmved From - 12107195
V%O*Tol
4r..
CHUS
Town of North Andover, Massachusetts
BOARD OF HEALTH
Form No.2
0 OkQ 6CA- 9 1 9_23=_
DESIGN APPROVAL FOR
SOIL ABSORPTION SEWAGE DISPOSAL SYSTEM
Applicant Test No
Site Location LoT :F1
Reference Plans and Specs.
Permission is granted for an individual soil absorption sewage disposal system to be installed
in accordance with regulations of Board of Health.
'It
Fee (jo
CHAIRMAN, BOARD OF HEALTH
Site System Permit No. 57 F9 I —
Town of North Andover, Massachusetts Form No. 3
,AORTh BOARD OF HEALTH
19
'4647
DISPOSAL WORKS CONSTRUCTION PERMIT
SSA
4/
Applicant_(,- -C
NAME ADDRESS 1ELLMUNt
Site Location
Permission is hereby granted to Construct (,,,Kor Repair an Individual Soil Absorption
Sewage Disposal System as shown on the Design Approval S.S. No.
CHAI RM -9-N, BOARD OF HEALT
Fee
D.W.C. No.
Z
�A
Z(, -f 1-7
FORM U - LOT RELEASE FORM
INSTRUCTIONS: This form is used to verify that all necessary
approvals/permits from Boards and Departments having jurisdiction
have been obtained. This does not relieve the applicant and/or
Jandowner from compliance with any applicable local or state law,
regulations or requirements.
****************Applicant fills out this section*****************
APPLICANT: c�c oc,,� P C -,
Phone
LOCATION: Assessor's Map Number Zt-�-7 R Parcel
Subdivision Lot(s)
Street C-4 OaNN St. Number
************************Official Use Only************************
RECOMMENDATIONS OF TOWN AGENTS:
Conservation Administrator
Comments
Town Planner
Comments
Food Inspector -Health
Septic -Inspector -Health
Comments
Public Works - sewer/water connections
- driveway permit
Fire Department
Date Approved
Date Rejected
Date Approved
Date Rejected
Date Approved
Date Rejected
Date Approved
Date Rejected
Received by Building Inspector Date
DATE lvz
Sheet of
BOARD OF HEALTH
TOWN OF NORTH ANDOVER
ADDRESS PARCEL # IX 7
LOT # /-7
ENGINEER STREET - 064 69127- IV41K
ADDRESS
PLAN DATE REVISION DATE
CONDITIONS OF APPROVAL:— --E&Z6ea) 7-49 R�6-
- 5,,r--7- 7-0 dQA1571-;,Wl1cr,-1,l4J
APPROVED
DISAPPROVED
SUBSURFACE DISPOSAL DESIGN
IEW
FEE.. 761�)
PERMIT #
DATE
RECEIVED
APPLICANT
ASSESSOR'S
MAP
1676
ADDRESS PARCEL # IX 7
LOT # /-7
ENGINEER STREET - 064 69127- IV41K
ADDRESS
PLAN DATE REVISION DATE
CONDITIONS OF APPROVAL:— --E&Z6ea) 7-49 R�6-
- 5,,r--7- 7-0 dQA1571-;,Wl1cr,-1,l4J
APPROVED
DISAPPROVED
'o /2
PLAN REVIEW CHECKLIST
ADDRESS Z 0 7- / 7 611-1) —ENGINEER lViTRI?l 10 1�6
GENERAL
3 COPIES L--' STAMP LOCUS NORTH ARROW Z----" SCALE
",-0 e tf
CONTOURS PROFILE L_-` SECTION BENCHMARK/ SOIL &
PERC INFO ELEVATIONS --- WETS. DISCLAIMERZ_� WELLS &
WETLANDS WATERSHED?/4/49 DRIVEWAY_L:::�' WATER LINE
(Elev)
FDN DRAIN,�-_ SCH40 TESTS CURRENT? 19861
SEPTIC TANK
MIN 1500G. .17 INVERT DROP GARB. GRINDER,&L(+200% EDF)
251 TO CELLAR__L:�,- MANHOLE TO GRADE,!!�r ELEV GW
D -BOX
SIZE LINES FIRST 21 LEVEL STATEMENT
INLET,�/744_ - OUTLET, -2/72,7 17 (211 OR .17 FT) TEE REQ I D? /VO
LEACHING
RESERVE AREA 41 FROM PRIMARY? L--' 100' TO WETLANDS 1,-� 2% SLOPE
100' TO WELLS,--,' 35' TO FND & INTRCPTR DRAINS �,� 4' TO S.H.GW
325' TO SURFACE H20 SUPP 41 PERM. SOIL BELOW FACILITY,,,�,-
MIN 12" COVER L----FILL?_��(251 if above natural elev;('� IN
_10 I if below)
BREAKOUT MET?
TRENCHES
MIN 660 gpd SLOPE (min .005 or 611/1001) - VENT
_� >31 COVER?
SIDEWALL DIST. 2X EFF. W OR D (MIN 61) IS RESERVE BETWEEN
TRENCHES? L/""' IN FILL? L---- MUST BE 101 MIN. 411 PEA STONE?
BOT 366 X LDNG 1.0 + SIDE �4 X LDNG TOT
(L x W x #) (G/ft ) (DxLx2x#)
N� ,
Rzr -dk
/- v 4-5
i - �P 4�7191e7- W4�1
�Z 11,5XCdY' 71le 7-17e-- 1A1S6,,'eOvC,4vO
7V 77147 IS ea--47L-,O OA1
r'lle --Orfs egA1,-,aew
:W7,
AW,f.4"Mla J*d74MCrX,�OZOW - -f1-eed7'-V
--r C7,,-7;Ve-e 7WI-T
Z0447e'.0
052V
REY U3 Z
...... . . . . . .
V���kA/XP- /-. 5-.
17z- or
,4z eXA*1W 1=ale
.47-1011 774,e�541 5eaW 67-VIS7--l(la 11?414W
8oard of Health Lot
North Andover, Mass
Applicant
Water Supply Town Well Approved Date
S.S. Septic System Design
Approved Date 6 Approving Authority
CONDITIONS+
Disapproved
Reasons=
DWC
Date
Septic System Installation
Excavation Inspection Date
Final Inspection
Approved Date
Additional Inspections (if any)
Disapproved Date
Reasons
Pass Fail
Approving Authority
Final Approval Da+e Approving Authority
13
CHECKLISI FOR
PLAN REQUIREMENIS
FOR
SUBSURFACE SEWAGE DISPOSnL SYSIEMS
TOWN OF NO. ANDOVER BOARD OF HEnL'I'li
MARCH, 1990
1. Lo.c.u.s M..ap_._. (Suggested Scale: I" = 2000, )
A. Locus identified.
B. Streets and narnes within 1/2 mile.
.___�C. North arrow and scale
2. Slte--Pl a.n. (Suggested Scale: I" = 201)
Lot to be served, its dimerimions and aren.
Ef . Fronting street.
AC - North arrow and scale.
Assessor"s designation.
E . Abutters names and lot numbers.
Easements.
. ..... G Property lines.
Footprint of proposed housr- to be served showing
garage (attached or detached).
J. Where applicable setbacks to house.
-.J. Number of proposed bedrooms.
__K. Location and type of material (if known) of
driveway.
Water service line from main in street o+--wr--44.
_M. Location of existing or proposed well.
Location of deep observation holes arid percolation
tests.
Existing and proposed contours.
Bench marks (2) and ties to proposed systrw
leaching facility from bench nuirks or other
permanent physical fratures (storievoallt:*.,
---Z--Q. Location and dimensions of nyitrw (sr?ptir' tank,
pipes and leaching facility) including the reserve
area.
Profile and section rwrows.
..... S. Location of any streawn, watrr bodies, !3LIrfaCP Arid
subsurface drains, known sources of watei- supply
within 200 -feet, nnd wntlaridn within 100 -feet
(locate wetlands, specify type of resourcr and show
100 -foot buffer zone line if applicable).
...... / - -T. Erosion control devices aS I'E-qLtired by Con. Coraw. ,
Board of Health or Planning Doard with dc --?tail and
description of device proposed.
I
A.
a
3. Desion Calculations and Notes
.......... . ...... . ..... . .......... .. . ........... ..... ... . ...... ... .. ... .........
- A. Percolation rate used for design.
-B. Soil log results - designate various strata depths
and description, depth to ledge arid/or groundwater
if encountered.
C. Date of percolation and deep hole tests.
I D. Number of bedrooms.
11! E. Calculations for leaching area requirements.
4. P r of i IR -of --Sys.t.e.m. (Suggested Scale: I" = 47
5.
A. Finished floor of house.
B. Invert elevations at house, septic tni-ij( (irijf?t &
outlet), and distribution box. If applicable for
pump systems, inlet and outirt of pUmp chrimbri- arid
pump bloat switch settings with supporting
calculations.
C. Length, type and grade of pipe and length or
leaching facility.
D. Elevation of ledge arid/or, groundwater.
E. Elevation of bottom of leaching facility.
F. Existing and proposed grades.
G. Slope (breakout) requirement and calculatiorim.
H. Scale.
rdss-S.ec-tA-on.o-fSY-s-tem. (Suggested Scale: 1" 10)
A. Elevations of various components.
Existing and proposed grades.
C. Type, dimensions and stone and system components
specifications.
-D. Elevation of ledge and/or groundwater.
E. Elevation of bottom leaching facility.
Dimensions.
--------- G. Slope (breakout) requirements and uzklculatiori!7�.
.--..Z—H. Scale.
6. Additional Notes and Other Details
...... . ... ....... . . ................. .......
Owner"s name., addrens and phone number.
B. Applicant's namr-37 address and phone number.
e' C. Engineer's name, address arid phone riumber.
D. The designer should indicate any notes or spocial
conditions peculiar to the site of' interest to the
Board, Installer or Owner.
E. Plans should be dated. Any rrvised plan-, arter thp
initial submission should show a revision date and
abbreviated explanation of the revision.
J .---F. If a pump system, type, Make, modrl, hf-ad
and pump rates sliould be provided. rill required
alarm, power and float switch dota -,hould bc--
----------provided-for review and approval.
'
___ System components (septic tank, U -box, etc.)
details should be provided if other than standard
as required from local suppliers. Component spec
should be indicated somewhere on the plans for
standard items.
Reviewed and recommended by:
Date
0
In
I
REVIEW FORM
FOR
SUBSURFACE SEW( -)GE i)isrusnL SYSYEM PL(INS
TOWN OF NORTH ANDOVER BOARD OF IfEnL'ill
RE-C.OMME-NAR-T-1 QRS
RECOMMENDED
REASONS
I
REASONS (CONT.)
RECOMMENDED
CONDI T I ONS /COMMENTS-._-__-_. � ............. .............. . .... .. ... .......... .... ................... .. . ............. ... . ..
'107 Forest St. FORM 4 - SYSMI PUNITNIG RECORD
Middleton, MA 01949 tID V�oX4
(508) 774-2772
Conunonwealth of Massachusetts
A/v Massachusetts
JUL 8
-�'Reco
'�vslem U\\mer�
-2 -�c A
Al -A tucu vtl
66 1— /Zz3
bU P&( JC4 &cc/
Date of Pumping: f ��o
Quantity Pumped: --clallons
Cesspool: No El Yes El Septic Tank: 'No El Yes
System Pumped by- C C/,L tc r e- --u
Lic e*nse #:
transferred to:
Date
Inspector
Commonwealth of Massachusetss
Massachusetts
System Pumviniz Record
Owner
Type: Emergency Poutine
Cesspool: W Yes
Daft of Pumping:
System Pumped By: Wind River EinowwYnental, LLC
Contents transferred to:
System Location
East Fitch b u I
Contents Disposed at:
Waste Water Pla,nL,
KIA.
baft: P/o/v Pumper
lCondition of Systwn/Other Comments
Dep Approved Form - 12/07/95
Form 4 System Pumping Reem-d
Septic tank: I ,
w F -- =
4#9ff"I'4niped: IS00 6allons
Commonwealth of Massachusetss
Massachusetts
System AumoinQ Record
0%mer i J.'system, Location
I " '' . . .
Type: Emer9ency Routine
Cesspool: No Yes
Date of Pumping: A-7 q-?— —,o C/
System Pum;wd By: Wind fttw- Env~~tal, UC
Contents transferred to:
Contents Disposed at:
Date: PumW Signature.
lCondition of Sytem/Othr Comments
Dep Approved Form - 12/07/95
Form 4 -- System Pumping Record
Septic tank: W - F L--; I
,,WYe
Quantity Pumped: I , Gallons
Permit #:
V�E--CEIVED
'AUG 0 4 2004
TOWN OF NORTH ANDOVER
HEALTH DEPARTMENT
NEW ENGLAND ENGINEERING
INC
October 10, 1998
North Andover Board of Health
Town Hall Annex
27 Charles Street
North Andover, MA 0 1845
RE: TITLE V REPORT/ 274 Old Cart��y
SERVICES
14
Enclosed is a copy of the Title V report for 274 Old Cart Way, North Andover, MA. The system
passes ourinspection.
If there are any questions please call me at my office, 686-1768.
Yours truly,
Benj?CS4
C. 0 go J
=
President
33 WALKER ROAD - SUITE 23 - NORTH ANDOVER, MA 01845 - (978) 686-1768 - (888) 359-7645 - FAX (978) 685-1099
CO\41,4ON\\TEALTH OF MASSACHUSETTS
EXECUTIVE OFFICE OF ENvIRONMENTAL AFFAIRS
DEPARTMENT OF* ENVIRONMENTAL PROTECTIO-S
ONE WINTER STREET. BOSTO.S. MA 021011 617-292-5$60
WILLIAM F WELD
Govcrno:
ARGEOPAULCELLUCCI
LA. Govcrnor SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION
;�? IS � Addrcss of Owner:
Property Ad( A
Ircss: r277_71_� (if dificrcriO
D'atc o(lnspcclion: is
Name of Inspector: VEQUAMIN C. OSGOOD JR.
I arn a DEP approved system inspector pursuant to S-ection 15.340 of Title 5 (310 CMR 15-000)
Company Name: NEW ENGLAND ENGINEERING SERVICES. INC.
Mailing Address: 33 WALKIEt!R!, _ROAD�NORTH ANDOVER., MA 0 184 5
Telephone Number: 508-686-1768.
1 4
TRUDY COXE
sccrctw�
DAVID B. STRUHS
Commissioner
CERTIFICATION STATEIAENT is true. accurate
I cenifythat I have personally inspected the sewage disposal System at thts address and that the in(or-2tion reported belo w'
and complete as of the time of inspection. The inspection was performed bj:ied on my training and experience in the Proper function and
maintenance of on-site sewage disposal systems. The system:
_��P,asses I
&ndtttonall% Passes
Needs Further Evaluation By the Local Approving Authority
Fails
Inspector's Signature: Date:
within thirty (30) days o(completing this
The Svstcm !nspeCtor shall submit a copy of this—inspection report to the Approving Authority,
inspection. (I'the system is a shared system of has a design flow of 10-000 Wd of greater. the inspector and the system owner shall submit
the report to the appropriate regional office of the Department of Envi(onmental P(otwion. The original should be sent to the system owner
and copies sent to the byycr. if applicable. and the approving authority I
INSPECTION SUMMARY- Check A, B, C, or D:
SSES:
in 310 CMR 15.303 -
not found any information which indicates that the sy�tern violztes any o(tt* (ailurc cf*tc-* zS
Any failure crittria not evaluated are indicated b -clow.
COMMENTS:
81 SYSTEM CONDITIONALLY PASSES:
One or more system Components as described in the -Conditional Pass- section need to bee replaced Of (CP'red. The system. Upon
completion of the replacement or (cp2ir, as apptovcd by the Board of Health, will pass.
Indicate yes. no. or not cittermined (Y. N. or ND). Describe basis o(determination in A( insunccs� If -not determined-, explain why not.
12 cnificuc of
The �Wic tank is n-.eul. unless the owner or operator has provided the system inspe-adf with a COPY 0 C
Compliance (.2ruched) indicating that the Unk was insulted within twenty (201 years Prior to the date of the ing')Cct'on; of
the septic tank. whether of no( metal, is cracked. structurally unsound, shows substantial infiltration or cxfiltr2tiOn- or unk
failure is imminent. The system will pass inspeaion i(thc existing septic tank is replaced with a con(orrning ScP(ic Unk
as approved by the Board of Health.
I
IRFACE SEWAGE DISPOSAC SYSTEM INSPECTION FORM
PART A
CERTIFICATION (continued)
Property Address: -271 01,0 CcAf Al- 14,�6oe&-
Owner: /–&,-A
Date of Inspection: ,
f/I1,
A, 49
81 SYSTEM CONDITIONALLY PASSES (continu�dj
Sewage backup or breakout of high static water level observed in the distribution box is due to broken or obstructed
pipe(s) or due to a broken. scaled or uneven distribution box. The system will . pass inspection if -(with approval of the
Board of Heal(h;. Describe observations:
broken pipe(s) are replaced
obstruction is removed
distribution box is levelled or replaced
The system required pumping more than fou( times a year due to broken or obstructed pipe(s). The system will pass
inspe�tion d(with approval o(the Board o(Healthl-
broken pipe(s) are (eplacec
Air-iction is removed I
C) FURTHER EVALUATION IS REQUIRED BY THE BOARD OF HEALTH:
Conditions exist which require iunher evaluation by the Board of Health in order to determine if the system.is failing to protect the
publit health. safety and the environment:
SYSTEM WILL PASS UNLESS BPARD OF HEALTH DETERMINES THAT THE SYSTEM IS NOT FUNgIONING IN A MANNER
WHICH WILL rROTECT THE PUBLIC HEALTH AND SAFEIrY AND THE ENVIRONOENT: I
— Cesspool or pfi%v is within 50 feet Of a SUrf3CC water
— Cesspool or pct%-%. is within So feet of a borde(tng vegetated wetland or a salt marsh.
2) SYSTEM WILL FAIL UNLESS TME BOARD OF HEALTH (AND PUBLIC WATER SUPPLIER, IF APPRQPRIATE) DETERMINES THAT
THE SYSTEM IS FUNCTIONING IN A MANNER THAT PROTECTS THE PUBLIC HEALTH AND SAFETY AND THE
ENVIRONMENT:
— The System has 2 septic tank and soil absorption system (&AS) and the SAS is within 100 feet to a surface water supply or
tribut4ry to a surface water supply.
— The system has a septic tank and soil absof ption system and the SAS is within a Zone I of A public water supnlv well.
— The system has 2 septic tank and soil absorption s�stem and the SAS is within 50 feet of a private water Supply well.
— The system has a septic tank and soil absorption system and the SAS is less than loo feel but So feet or more from a
private water supply well. unless a well water analysis for coli(orm bacteria and volatile organic compounds indicates that
the well is free from pollution from that facility and the presence o(ammonia nitrogen and nitrate nitrogen is equal to Of
less than 5 ppm. method used to determine distance (approximation not valid).
3) OTHER
(r—i--d 04/25/171
P&V. 3 f 10
IRFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
#_tK &IM -Al 1UN ,cont nuc
Property Address: V 7 CZZ—i Wey, A]. 't"'O.3va-
Owner: C -e- ff
Date of Inspection: -7
"/ I's
Di SYSTEM FAfLS:
You must inclicam either -Yes- or -No' as to each o(the following:
I have determined that the system violates one or more of the (61lowing failure criteria as defined in 310 CMR 15.303. The basis
(or this determination is identified below. The Board of Health should be contacted to determine what will be necessary to conva
the failure.
Yes No
Backup of sewage into facility or system component due to an overloaded or clogged SAS or cesspool.
Discharge or ponding of effluett to the surface of the ground or surface w2ters due to an overloaded or clogged SAS or
cesspool
Static liquid level in the distribUtion box above outlet invert I due to an overloaded or clogged SAS ot cesspool.
Liquid depth in cesspool is less than 6- below invert or available volume is less than 112 day flow.
Required pumping more than 4 times in the last year NOT 8ue to clogged or obstructed pipe(s).
Number of tiAnes pumped
Any portion of the Soil Absorption Svstem. cesspool or privy -is below the high groundwater elevation
An%* portion o; a cesspool or pri%j- is within 100 feet ol'a surface water supply or tributary to a surface water supply.
I I I i I
Any portion o(a cesspool or privy is within a Zone I of a public well.
An% portion of a cesspool or privy is within 50 feet of a private water supply well
Anv portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water supply well with no
acceptable water quality analysis. if the well has been analyzed to be acceptable. attach copy oi w6li water analysis for
colitofm bactfria. volatile organic compounds, ammonia nitrogen and nitrate nitroFen.
El LARGE SYSTEM FAILS:
You must indicate either -Yes- or -No- as to each, of the following:
,The following criteria apply to large systems in addition. to the criteria above:
The system serves a fa6lity with a design flow of 10,000 gpd or greater (Large Systeml and the system is a significant threat to
public health and safety and the environment because one or more of the following conditions exist:
Yes No
the system is within 466 feet of a surface drinking water supply
the system is within 200 feet o(a tributary to a surface drinking water supply
the system is located in a nitrogen sensitive area (Interim Wellhead protcajon Area - IWPAJ or a mapped Zone If of a
public water supply well)
The owner or operator o(any such system shall bring the system and facility into full compliance with the groundwater treatment progfiam
requirements of 314 CMR 5.00 and 6.00. Please consult the local regional office of the Department for further information.
(rovivad 04/25/911 rage 3 Of 10
T
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECtION FORM
PART B
CHECKLIST
Property Address: Z74/ 01.0 <:14/2,� Wo
Owner: Je-,A Ceff
Date of Inspection: -I/' 1 05 1
Check if the following have been done: You must indicate either -Yes- or 'No" as to each,of the following:
Pumping information was provided by the owner. occupant. or Board of Health.
None of the' system components have been pumped (or at least two we�cks and the System has been receiving normal'
flow rates during that period. Large volumes of water have not been introduced into the system recently or
as pan of this inspection
As built plans have been obtairted and examined. I Note if ther d(e not 2vailab:e with NIA. I
The i[acilitv or dwelling was inspected for signs oi sewage back-up.
The system does not receive non -sanitary or industrial waste flow.
The site was inspected iot signs of breakout
All system components. excluding the Soil Absorption System. have been located on the site.
The septic tank manhole� were uncovered, open4 and the iaterior of the septic tank as . pected (or condition of
baffies or tees. material oi construction. dimensions. depth of liquid, depth of sludgot, dept�o SCUM.
The size and location o(the Soil Absorption System on the site has been determined based on:
The iacility owner (and occupants. if different irom owner I were provided with information on the proper maintenance of
Sub -Surface Disposal System.
Existing information. Ex.4PI2n at B.O.H.
Determined in the field (if any o(the failure criteria (elated to Pan C is at issue. approximation of distance is
unacceptable) (15.302(31(b)]
t
H
(r.via.d o4/25/971 4 of 10
I
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION -FORM
PART C
SYSTEM INFORMATION
Property Address: 27 L/ 01,0 6aAf Waj,
Owner:
Date of Inspection:
FLOW CONDITIONS
RESIDENTIAL:
Design flow: !�'L6C p.dA)edroom for S.A.S
Number of bedrooms:- '�t
Number of current residents -3
Qrbage Storder (yes or no):AL9
Laundry conne�ted to system (yes or no);,��
Seasonal use (yes or no):Z—V-O
Water meter readings. i(available (last two (2) year usage (gpd):
.Surnp f ump (yes or. no):_"
Last 61te of occupancj-:6V,6ee^1
i
COMMERCIAIJINDUSTRIAL:
Type qf establishment:
Design flow:______!pllons/day
Grease trap present: (yes or no)
Industrial Waste Holding Tank present: (ves or nol_
Non-sanitary...waste discharged to the Title 5 system: (yes or no)
"later meter readings. d available-
Last.date of . 0�cupanp% I
OTHER. (DescriW
Last date oi occupancy.
1 0 GENERAL INFORMATION
PUMPING RECORDS an sour e oi ini . ormation I
- 0 rm — "�7 -(1 6 '-V -.1 e,
System pumped as part of i e
.0�7—yes no)"
n s p A n: (M�,
If yes, volume pumped:
Reason forpumping-
TYPE OF SYSTEM
Septic tank/distribution box/soil absorption system
Single cesspool
Overflow cesspool
Privy
Shared system (yes or no) (if Yes.'Ittach previous inspection records, if any)
VA Technology etc. Copy of up to date contract?
Other
APPROXIMATE AGE of all components, date installed (if known) and source of information:
Scwate odors detected when arriving at the site: (yes or no) &,0
V -V- S *f 10
a
I
a
F,�
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Property Address: 27 4 01& C&41- viaj, AJ-,-J-t, ftiZoiet
Owner.
Date of Inspection:
CA11ki 9.a
BUILDING SEWER:
(Locate on site plan)
De-pth below grade:
material of construction: cast Iron /40 PVC — other (explain)
Distance from private water supply well or suction tort
Diameter J/"
Comments: (co d* ton o(joints. venting. evidence o(leakage. etc.)
7" bor., ekn e,- 7"
SEPTIC TANK:
(locate on site plani
Depth Wow grade: /Z ' t I
material oi construction: V'-c'oncrete —metal Foberglas� _Polyethylene —other(explain)
If tank is metal. list age — is age confirmed by Cendicate of Compliance (YeS/Nol
Dimensions: 1,5-00 A& ijc
Sludge depth:
Distance from top oisludge to boAom of outlet tee or baiflce: -72-
Scum thicknew J P. . //
Distance from top of scum to top of outlet tee or baffle:, 13
Distance from bonom of scum to bonom o(outlet tee or baffle:
How dimensions were determined: _, �77ci<
Comments:
(recommendation for pumping. condition of inlet and outlgt tees or baffles, depth of liquid level in relation to outlet invert, st �tural
integrity. evid nce o(leaka ic.) --F-e ok ke 17 e- If e4D r1r`,t ifft
.:7 C.7^ -T-14 L�.A -
I
GREASE TRAP:"
(locate on site plan)
Depth below grade:
t�uteirial of construction: —concrete —metal _Fiberglass _Polyethylene —other(txplain)
Dimensions:
S,curn thickness:
Distance from top of scum to top of outlet tee or baffle:
Disunce from bonom of scum to bottom of outlet tee or baffle:
Date of Iasi pumping:
cornments:
(recommendation (or pumping. condition of inlet and outlet tees or baffles. depth of liquid level in relation to outlet invert. Structural
integrity. evidence oi leakage. etc.)
ireviv.d 04/25/91) rag. 4 of 10
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Properly Address:
A),
Owner:
Date of Inspection:
TIGHT OR HOLDING TANK: Nd-t`Tank must be pumped prior to. or at time. of inspection)
(locate on site plan)
Depth below grade:
material o(construction: —concrete --metal —Fiberglass _Polyethylene —other(expl2in)
Dimensions:
Capacity: gallons
Design i!ow g4llonrJda%
Alarm level Alarm in working drder Yes. No
Date of previous pumping:
Comments:
(condition of inlet tee. condition of alarm anV float switches. etc.)
DISTRIBUTION BOX:—
(locate on site plan!
Depth of liquid level above outlet inven:
Comments:
I
I
PUMP CHAMBER-,a��
(locate on site plan)
Pumps in working order: (Yes or Nol
Alarms in working order (Yes or No)
Comments:
(note condition of pump chamber. condition o(pumps and appurtenances, etc-)
(r -via -d 04/25/971 P -gr- 7 of 10
'_"j" Alwn
.4in..........
SUBSURFAtE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Property Address: �Z7&1 069- Cc�aj— LAj Aj 11 Q 0,eA_
Owner:
Date of Inspection: ++j
1%((qS
SOIL ABSORPTION SYSTEM (SAS):_
(locate on site plan. if possible; excavation not required. but may be approxim2ted by non -intrusive methods)
If not determined to be present. explain:
Type:
leaching pits. number:
leaching chambers. number:
leaching galleries. number:
leaching trenches. number.length: Z
leaching iields' ' 'lumber. dimensions:
overflow cesspool. number:
Alternative system: -
Name of. Technology:
Co'mments:
(note condition of soil. signs of raulic (ailure. level of ponding. condition of vegetatio tc.)
l.. I I
CESSPOOLS: AL4
(locate on site plan)
Number and configuration.
Depth -top of liquid to inlet invert:
Dr-pth.of solids layer:
Depth o(scum laver:
Dimensions oi cesspoo!:
Nlaterials of construction:
Indication of groundwater:
inflow (cesspool must be pumped as pari oi inspecii6n)
Comments:
(note condition o(soil. signs of hydraulic failure, level of ponding, condition of vegetation. etc.)
PRIVY: A0- .
(locate on site plan)
Materials o(construaion:
Depth of solids:
Comments:
(riote condition of soil. signs of hydraulic failure. level of ponding, conidition of vegetation, etc.)
(r -via -d
Dimensions:
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTE 1 N (continued)
M NFORMATIO
Property Address: 0
Owner:
Date of Inspection:
SKETCH OF SEWAGE DISPOSAL SYSTEM:
include ties to at least two perrnanent references landmarks or benchmarks
locate all wells within 100* (Locate where public water supply comes into house)
I
..........
P
(r-viv.d 04/25/971 P.q. 9 of 10
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Properiv Addr'cls: -7'7 4 c)t& cetA- ljQc:�, �j _ jq-Z
Owner:
Date of Inspeclion:
qk(
Depth to G(oundwater>-L Fee(
Pleas,e indicate 211 the methods used to determine High Groundwater Cleva(ion:
Obtained from Design Plans on record
—�k Observation of Site (Abuning p(opert)-. observaticiri hole. basement sump e(c.)
Deiefminie it i(om local conditions
Check v!th !o --z! Board of health
Che6 FEMA Niaps
Check pumping records
Check local excavators. installers
-?Q Use USGS Data.
Describe n voSi own words how you established the High Groundwater flevatton.1
(Must be completed)
C,
-0- -D+:5
P&q, 10 of 10
t
f,
FORM 4 - SYSTEM PUMPING RECORD
CURIVIRIER
SEPTIC & DRAIN SERVICE
107 FOREST STREET; MIDDLETON, MA 01949
(978) 774-2772
COMMONWEALTH OF MASSACHUSETTS --
A/ - A CA J 0,_/ CA-- , MASSACHUSETTS
S YS TEM P UMPING RE CORD
SYSTEM OWNER:
LA
o(dcAv4
Q�_
'�
DATE OF PUMPING:
CESSPOOL: NO 21�YES F7
SYSTEM LOCATION:
�p (_ �L
t� Aj 0-0
QUANTITY PUMPED: (.-SZ) Z-3 -GALLONS
SEPTIC TANK: NO = YES [:�]-
SYSTEM PUMPED BY: CURRIER SEPTIC & DRAIN SERVICE
CONTENTS TRANSFERRED TO: c' L s l-'6
DATE: p /,go
.IN SPECTOR:- k -e 6f 0
4�7
�_Z\ Commonwealth of Massachusetts
City/Town of
System Pumping Record NORTH ANDOVER
Form 4
DEP has provided this form for use by local Boards of Health. Other forms may be used, but the
information must be substantially the same as that provided here. Before using this form, check with your
local Board of Health to determine the form they use. The System Pumping Record must be submitted to
the local Board of Health or other approving authority within 14 days from the pumping date in
accordance with 310 CMR 15.351.
I RECEIVED
A. Facility Information I JUL - 7 2010
Important:
When filling out
forms on the
computer, use
only the tab key
to move your
cursor - do not
use the return
key.
1.
2.
System Location: TOWN OF NORTH ANDOVER
HEALTH DEPARTMENT
4��Tq_ —_ I
Address /01
-z-L-1 4
-dityrTown State Zip Code
System Owner:
Name
Address (if different from location)
cia—yrrown State Zip Code
cN9 - &V Z -2-o 3__
Telephone Number
B. Pumping Record
6-3-
1.
Date of Pumping Date
2. Quantity Pumped: Gallons
3.
Type of system: F-1 Cesspool(s) ff-Septic Tank El Tight Tank Grease Trap
El Other (describe):
4.
Effluent Tee Filter present? F� Yes R No
If yes, was it cleaned? 0 Yes E] No
5.
Condition of S tem'.
. .
--5- 00�0 ____
--- ____
6.
System Pumped By:
--14 go -
Name
Vehicle License Number
7.
Location where contents were disposed:
Signature of Hauler
Date
Signature of Receiving Facility
Date
t5form4.doc- 03106
System Pumping Record - Page 1 of 1
RECEIVILD
RE CV�
Commonwealth jof assap )I CL
busetts
City/Town of
J 3 1 2008
System Pumping Reco4r
0 1
TOWNOFNORP ANDOVER
Form 4 HEALTH DEPA TMENT
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 y r
local Board of Health to determine the form they use. The System Pumping Record must be submitted to
the local Board of Health or other approving authority within 14 days from the pumping date in
accordance with 310 CMR 15.351.
A. Facility Information
Important:
When filling out 1 . System Location:
forms on the A ---,
computer, use -4. -rq o a zi U")o- �A
only the tab key Address
to move your A). ry) n. C) 113 q 5
cursor -do not City[Town State Zip Code
use the return
key. 2. System Owner:
d ---h —.11
Name
Address (if different from location)
City/Town State Zip Code
q -4-% - Gk a GL C> --s
Telephone Number
B. Pumping Record
1. Date of Pumping (12 lo- 0-,6 2. Quantity Pumped: )-1300
Date Gallons
3. Type of system: El Cesspool(s) M Septic Tank El Tight Tank n Grease Trap
Other (describe):
4. Effluent Tee Filter present? El Yes 54 No If yes, was it cleaned? E] Yes 0 No
5. Condition of System:
!�' 00
�.j
6. System Pumped By:
j_q
0);'Ve' 5U!�
Name Vehicle License Number
Company Ipswich Water
7. Location where contents were disposed: Treatment Plant
1 10- R_ I -A.1 ich, MA 01938
Signature of Hauler
Signature of Receiving Facility
t5form4.doc- 03/06'
1
Date
Date
System Pumping Record - Page I of 1