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Commonwealth of Massachusetts
City/Town of NORTH ANDOVER, MAS
System Pumping Record
Form 4
DEP has provided this form for use by local Boards of Healtt
be submitted to the local Board of Health or other approving
A. Facility Information
I . System Location: �?
i . r , T -x) n
Address
I - �
Cfty/Town
2. System Owner
RChrn)(
JI Tiv I
OCT - 5 2010
TOWN OF NORTH ANDOVER
TWMJMPWhUTRe1ord must
ithority.
� n \,e I
- I F tk-A
state
�f
Zip Code
Name
Address (if dIfferent from location)
City/Town State Zip Code
Telephone Number
B. Pumping Record
1. Date of Pumping Q / 6 //C)
Date 2. Quantity Pumped: Gallons
3. Type of system: Cesspool(s) Vseptic Tank Tight Tank
Other (describe):
4. Effluent Tee Filter present? C3 Yes El No
5. Condition of S ys tem: K K
If yes, was it cleaned? E] Yes F-1 No
6. Ws�pm P m d B
U(ju
nVehicle License Number
mpany
7.
http:/twww.mass.gov/deptwater/approvalstt5forms.htm#inspect
t5form4.doc- 06/03 System Pumping Record - Page 1 of 1
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TOWN OF NORTH ANDOVER
SYSTEM PUMPING RECOR-D
1). A I F:
0 STEM OWNER & ADDRESS
&s- bUA
0
SYSTEM LOCATION
(example: left front of house)
,gI4�f /-(
DAT C 0 F P U M P I N c: ci k QUANTITY PUMPED 0 A L L 0
S.S POOL: NO S SEPTIC TANK: NO YES
YE
NATURE OF SERVICE: ROUTINE t----�EMERGENCY
() [�.S F R V.I\ T 10 N S
GOOD CONDITION FULL TO COVER
HFAVY CREASE 13,AFFLES IN I'L.ACE
ROOTS LEACHFIELD RUNBACK
EXCESSIVE SOLIDS FLOODED
SOLI D.S CARRYOVER �J�HF.rz (EXPLAIN)
PUMPED BY:
C U Nklyl EN T S: /,4-� �-
( U NTENTS TRA N S F E IZ R E D TO:
0C)e ,�- /OV/:5
I
.r
rd of H --_, th
1).7 17 'ILI CB_ K UST
A P F", I WE D Mrs
Rro-Ac%,dt
S/ �/ '�,
L OT
Title V
nui
Cc
Rog 2.5
The subrxitted plan rust &how ne a rzlrim.m:
:a) the lot to be lot #jab-attsrB
b location end log ez�ap obucrvation OLx-dizt--lace to ties
location and results pervolation. tests -distance to ties
dasiga calculations & calculations shmdng required lueaebing arca
(e) location and dimensions of aystem-including reserve area
M wdsting and proposed contours
(g) location eny v3t areas vl-thin 1001 of sowage disposal systcm or
disclaim3r-check w,:,)t3xnds rap?ing
(h) atwface and subsurface drains witLdn 100 1 of sewage diupposal
ayL,jA"_3- cr C_1Lsclt_4_msr
(i) location rmy go aan�,- _; ...ats -I- I1.1 LA -n of .�.Za ff Lpo sal
ajrstcm or roard Mas
(J) vourtea of v-A,,Lx La;�,pV. 200t of aspoval
or discl-An3r
W location of siW, pi-aposed i -M to &:�,rra lot-1CO' from leeching facility
(1) location of -trit(,x linus on pAx.c�pcxty-3.01 Avi,,i Linching fr,�:ility
1(m) location of benchmark
1(n) driveways
��(o) garbase disposals
(p) no PVC to ba uijed in constraction
(q) profile of of basvix_nt.. p2:u--ibj pipe., septic tz�t*s
Ustribution. box inlets and outlets, distribution field piping ead
Otliar elevations
(r) rg,-ound vater elevation in area eicposal system
(s) Plan wist, be pr3pai�,;d by a Froft;ztAc�-wl or othar
profosb1onal authorized by law to px-,.pzxe such plans
Reg 6
Septic Tanks
(a) Tw._�,c_it =-s-150% of flow, water Utble., tacs., d--pth of toes,,
accees., purping
(b) c1c-suout
(c) 101 from cellar irall or lmzrouad m�U: pool
(d) 251 from subaurfrze drains
Reg 10.2
Rc;g 10.4
Wxtribution Eoxus
P-) 0-ope grettor thrm 0.08
oll
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1A]i
T
LIST
I. Di.3tance Tot.
a. We t1an ds
b. Drains
c. Well
i r
L
2* Water Line Location
No PVC Pipe
4. Septic Tank ----
a. Tees - Length & To Clean Out Covers
b. Cement Pipe to Tank - On Both Sides of Tank
5. Distribution Box
a. Covers &_ Box - No Cracks
b. All Lines Flowing EquRl Amunts
c. No Back Flow
6. Leach Field or Trench
a. Dimensions
b. Stone Depth
c. Capped Ends
d. Clean Double Washed Stone
7. Leach Pits
a.
Dimensions
b.
Stone De
"Ons
C.
Spl Pads
d.
8
.
C emmen t Pip�e to Pit - Both Sides
f
Clean Double Washed Stone
8. No Garbage Disposal
9. Final Grading Inspection
10. Barricading Covexed System
11. As Built Submitted
a. lot Location
b. Dimensions of System
c. Location with Regard -to Perc Test
d. Elevations
e. Water Table
rrr
J�
TO:
BOARD OF 1, EA:�'�'H
DESIGN ENGINEER Re: Soil Absorption
FROM: Sewage Disposal
System
This is to certify that I have inspected the construction materials of
said disposal,system at
Site -Location
North Andover, Mass.
The grades and construction materials are as specified in my plans and
specifications dated 19�_11_ and 19
Reg. Prof. EngineerAeg. Sanitarian
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I
77ELL DATABASE
ADDRESS: -
AGE OF WELL: WELL DR] LLER:
WELL PERMIT' : WELL LocAu6n /*
WELL PERMIT DATE: DEPfH OF WELL.
TYPE OF WELL: a- DRILLED ��D,�G, c. UNKNOWN
TYPE OF WATER BEARING ROCK:
ESE: Y N
WATER ANALYSIS DATE. 1 -UGH MANGAN
MGH IRON: Y N OTHER CONTAlANANTS: Y N
WELL DATABASE
ADDRESS:
AGE OF WELL: t -5 WELL DRILLER:
WELL PERMIT WELL LOCA,.,,gN-
WELL PERMIT DATE: DEPTH OF V�E
TYPE OF WELL: a.. DR.ILLED b. DUG C.
�OWN
TYPE OF WATER BEARING ROCK:
WATER ANALYSIS DATE: HIGH NLkNGANESE: Y N
HIGH IRON: Y IN OTHER CONTAN�(INANTS: Y
A4
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NOV 10 2009
w, j%jQRTH ANDOVER,
IMIT01 [W:LPAR�TMENT
-umping.
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