HomeMy WebLinkAboutMiscellaneous - 280 REA STREET 4/30/2018C)
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System Owner
Barber ken
280 Rea Street
torth Andover, MA, 11845
(978)-333-1701 x
Type; Emergen
Cesspool: No
Date of Pumping
System Pumped By:
Contents Transferred to:
Contents Disposed at:
Commonwealth of Massachusetts
Massachusetts
System Pumping Record
Routine
r -4 '11_*� Yes
-Wind River Environmental, LLC
Date: -_ Pumper Signature:
Condition of System/Other Comments A&
07/25/2013
Form 4 -- System Pumping Record
C
AUG 0 2'31")
Towli OF NORTH. kNDOVER
- - -U n=tP-.%�'. �11 f
System Location
Primary Rome
200 Rea Street
North Andover, VIA, 01845
(978)-333-1701 x
Barber
Printed on recycled paper Dep Approved Form - 12/07/95
Septic Tank: No = Yes 1�
Quantity Pumped: Gallons
Permit #:
I.W.W.T
.P
Commonwealth of Massachusetts
City/Town of
System Pumping Record NORTH ANDOVER
Z 0 13
Form 4
DEP has provided this form for use by local Boards of Health. Other forrns,may.be_qsp07 but the_-....-,
information must be substantially the same as that provided here. Before u'sing'this-for�,` 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 �" cc,\, ('Z"�
computer, use 0!W0 —
only the tab key Address
to move your Aida f ryl &14 -
cursor - do not City[Town '�tate Zip Code
use the return
key. 2. System Owner:
Name
Address (if different from location)
Cityrrown State Zip Code
2 1
Telephone Number
B. Pumping Record
1 . Date of Pumping /-W/ 2. Quantity Pumped:
Tate j i Gallons
3.. Type of system: Cesspool(s) Septic Tank F-1 Tight Tank 7 Grease Trap
F Other (describe):
4. Effluent Tee Filter present? F� Yes �I_No If yes, was it cleaned? E] Yes 0 No
5. Condition of System:
6. System Pumped By:
_T1 M&Joh
Naine d Vehicle License Number
Company
7. Location where . contents were disposed: North Andover, MA.
-111% —
of Hauler
of Receiving Facility
Date
Date
t5form4.doc- 03/06 System Pumping Record - Page 1 of 1
Commonwealth of Massachusetts
City/Town of NORTH ANDOVER, MASSACHUSETTS
System Pumping Record
Form 4
DEP has provided this form for use by local Boards of Health. The System Pumping Record must
be submitted to the local Board of Health or other approving z ri .
RECEIVED
A. Facility Information
Important: SEP 112007
When filling out 1 . Systen�Location. n
forms on the TOWN OF NORTH ANDOVER.
computer, use HEALTH BE.
only the tab key Address
to move your
cursor - do not
AN
use the return City/Town State Zip Code
key. 2. System Owner -
V
Name
Address (if different from location)
City/Town State6) <-).p, =Code
�:7
Telephone Nurhber
B. Pumping Record
1. Date of Pumping 0
Date 2. Quantity Pumped:
/ I Gallons
3. Type of system: El Cesspooi(s) Septic Tank El Tight Tank
El Other (describe):
4. Effluent Tee Filter present? 0 Yes 0 If yes, was it cleaned? M Yes El No
5. Condition of System:
C)
6. Syst :)ed By:
&hy
Name '5 Vehicle License Number
Company
7. Location wherpcontents d
L
Signature of H er
http://www.mass.gov/dep/wate pprovals/t5forms.htm#inspect
t5form4.doc- 06/03
0
Date
System Pumping Record - Page 1 of 1
System Owner
Type: Emergency
KID
Cesspool: jx7xs, to
bate of Pumping: le
Commonwealth of Massachusetss
Massachusetts
System Pumping Record
Routine
Yes
oystem Pumped By: Wind Pjw L-nww~taj
U, -
Contents transferred to:
i Location
Pumping Record
QFT 2 6 2005
Septic tank: W F-'-JYe.
Quantity Pumped: Ape -'�) r
9,< anons
Permit #:
bate: Pumper
lCondition Of SYstem/Other Comments
Dep Approved Form - 12/07/95
1 07 FOREST STREET
MIDDLETON, MA 01949
(978) 774-2772
6qi7 -",
Am �loq'q�
-[604 Of
FILE # 32999A
Jo
DID
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PROPERTY OWNER'S NAME: GILLEN
PROPERTY ADDRESS: 280 REA ST, N.ANDOVER.MA
ADDRESS OF OWNER: SAME
(IF DIFFERENT)
DATE OF INSPECTION: 29 MARCH 1999
NAME OF INSPECTOR: THOMAS J. CHIGAS
THE PROFESSIONAL EXPERTS IN THE SEPTIC AND DRAIN INDUSTRY
Form 4 -- System Pumping Record
Commonwealth of Massachusetss
: Massachusetts
System Pumving Record
Owner
I I - ?
Type: Emergency Routine
Cesspool: No I Ll--,' Yes
Date of Pumping: U 1) (.1 C3
System Pumped By: Wind River Ehw�,onmental, UC
Contents transferred to;
Contents Disposed at:
I
Date: IC -1 ) b I Pumper Signature:
lCondition of SystenVOther Comments
Location
Septic tank: W =Yes �
Quantity Pumped: I S'* m "Ions
Permit #:
Dep Appmved Fmm - 12107195
k
1 4 2001*
I I - ?
Type: Emergency Routine
Cesspool: No I Ll--,' Yes
Date of Pumping: U 1) (.1 C3
System Pumped By: Wind River Ehw�,onmental, UC
Contents transferred to;
Contents Disposed at:
I
Date: IC -1 ) b I Pumper Signature:
lCondition of SystenVOther Comments
Location
Septic tank: W =Yes �
Quantity Pumped: I S'* m "Ions
Permit #:
Dep Appmved Fmm - 12107195
k
1 4 2001*
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION
PROPERTY ADDRESS:280 REA STREET NAME OF OWNER: GILLEN
NORTH ANDOVER ADDRESS OF OWNER: SAME
DATE OF INSPECTION: 29 MARCH 1999
NAME OF INSPECTOR: (PLEASE PRINT) THOMAS J. CHIGAS
I AM A DEP APPROVED INSPECTOR PURSUANT TO SECTION 15.340 OF TITLE 5 (3 10 CMR 15.000)
COMPANY NAME: CURRIER SEPTIC & D
MAILING ADDRESS: 107 FOREST STREET. MIDDLETON, MA 01949
TELEPHONE NUMBER: (978) 774-2772
CERTIFICATION STATEMENT
I CERTIFY THAT I HAVE INSPECTED THE SEWAGE DISPOSAL SYSTEM AT THIS ADDRESS AND THAT THE INFORMATION REPORTED BELOW IS
TRUE, ACCURATE AND COMPLETE AS OF THE TIME OF INSPECTION. THE INSPECTION WAS PREFORMED BASED ON MY TRAINING AND
EXPERIENCE IN THE PROPER FUNCTION AND MAINTENANCE OF ON-SITE SEWAGE DISPOSAL SYSTEM. THE SYSTEM:
YES PASSES
CONDITIONALLY PASSES
NEEDS FURTHER EVALUATION BY THE LOCAL APPROVING AUTHORITY
FAILS
INSPECTOR'S SIGNATURE: or �&V/'Kz DATE: 29 MARCH 1999
THE SYSTEM INSPECTOR SHALL SUBMIT A COPY OF Tllf:S� INSPECTION REPORT TO THE APPROVING AUTHORITY (BOARD OF HEALTH OR DEP)
WITHIN THIRTY (30) DAYS OF COMPLETING THIS INSPECTION. IF THE SYSTEM IS A SHARED SYSTEM OR HAS A DESIGN FLOW OF 10,000
GALLON GPD OR GREATER, THE INSPECTOR AND THE SYSTEM OWNER SHALL SUBMIT THE REPORT TO THE APPROPRIATE REGIONAL OFFICE
OF THE DEPARTMENT OF ENVIRONMENTAL PROTECTION. THE ORIGINAL SHOULD BE SENT TO THE SYSTEM OWNER AND COPIES SENT TO
THE BUYER, IF APPLICABLE, AND THE APPROVING.
NOTES AND COMMENTS:
REVISED 9/2/98 PAGE I OF 11
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION (CONTINUED)
PROPERTY ADDRESS: 280 REA S
OWNER: GILLE
DATE OF INSPECTION: 29 MARCH 99
INSPECTION SUMMARY: CHECK A, B, C, OR D:
A. SYSTEM PASSES:
YES I HAVE NOT FOUND ANY INFORMATION, WHICH INDICATES THAT ANY OF THE FAILURE CONDITIONS
DESCRIBED IN 3 10 CMR 15.303 EXIST. ANY FAILURE CRITERIA NOT EVALUATED ARE INDICATED BELOW.
COMMENTS:
B. SYSTEM CONIDTIONALLY PASSES:
NONE OR MORE SYSTEM COMPONENTS AS DESCRIBED IN THE "CONDITIONAL PASS" SECTION NEED TO BE
REPLACED OR REPAIRED. THE SYSTEM, UPON COMPLETION OF THE REPLACEMENT OR REPAIR, AS APPROVED
BY THE BOARD OF HEALTH, WILL PASS.
INDICATE YES, NO, OR NOT DETERMINED (Y, N, OR ND). DESCRIBE BASIS OF DETERMINATION IN ALL
INSTANCES. IF "NOT DETERMINED", EXPLAIN WHY NOT.
N/A THE SEPTIC TANK IS METAL, UNLESS THE OWNER OR OPERATOR HAS PROVIDED THE
SYSTEM INSPECTOR WITH A COPY OF A CERTIFICATE OF COMPLIANCE (ATTACHED) INDICATING
THAT THE TANK WAS INSTALLED WITHIN TWENTY (20) YEARS PRIOR TO THE DATE OF THE
INSPECTION; OR THE SEPTIC TANK, WHETHER OR NOT METAL, IS CRACKED, STRUCTURALLY
UNSOUND, SHOWS SUBSTANTIAL INFILTRATION OR EXFILTRATION, OR TANK FAILURE IS
IMMINENT. THE SYSTEM WILL PASS INSPECTION IF THE EXISTING SEPTIC TANK IS REPLACED
WITH A COMPLYING SEPTIC TANK AS APPROVED BY THE BOARD OF HEALTH.
N SEWAGE BACKUP OR BREAKOUT OR HIGH STATIC WATER LEVEL OBSERVED IN THE
DISTRIBUTION BOX IS DUE TO BROKEN OR OBSTRUCTED PIPE(S) OR DUE TO A BROKEN, SETTLED
OR UNEVEN DISTRIBUTION BOX. THE SYSTEM WILL PASS INSPECTION IF (WITH APPROVAL OF
THE BOARD OF HEALTH).
BROKEN PIPE(S) ARE REPLACED
OBSTRUCTION IS REMOVED
DISTRIBUTION BOX IS LEVELLED OR REPLACED
N THE SYSTEM REQUIRED PUMPING MORE THAN FOUR TIMES A YEAR DUE TO BROKEN OR
OBSTRUCTED PIPE(S). THE SYSTEM WILL PASS INSPECTION IF (WITH APPROVAL OF THE BOARD
OF HEALTH):
N BROKEN PIPE(S) ARE REPLACED
N OBSI)TRUCTION IS REMOVED
REVISED 9/2/98 PAGE 2 OF I I
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION (CONTINUED)
PROPERTY ADDRESS: 280 REA S
OWNER: GILLEN
DATE OF INSPECTION: 29 MARCH 1999
C. FURTHER EVALUATION IS REQUIRED BY THE BOARD OF HEALTH:
N CONDITIONS EXIST WHICH REQUIRE FURTHER EVALUATION BY THE BOARD OF HEALTH IN ORDER TO
DETERMINE IF THE SYSTEM IS FAILING TO PROTECT THE PUBLIC HEALTH, SAFETY AND THE ENVIRONMENT.
1) SYSTEM WILL PASS UNLESS BOARD OF HEALTH DETERMINES IN ACCORDANCE
WITH 310 CMR 15.303 (1)(B) THAT THE SYSTEM IS NOT FUNCTIONING IN A MANNER
WHICH WILL PROTECT THE PUBLIC HEALTH AND SAFETY AND THE
ENVIRNONMENT:
N/A CESSPOOL OR PRIVY IS WITHIN 50 FEET OF SURFACE WATER
N/A 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 AND SAFETY AND THE ENVIRONMENT:
N THE SYTEM HAS A SEPTIC TANK AND SOIL ABSORPTION SYSTEM (SAS) AND THE
SAS IS WITHIN 100 FEET OF A SURFACE WATER SUPPLY OR TRIBUTARY TO A SURFACE
WATER SUPPLY.
N THE SYTEM HAS A SEPTIC TANK AND SOIL ABSORPTION SYSTEM AND THE SAS IS
WITHIN A ZONE I OF PUBLIC WATER SUPPLY WELL.
N THE SYSTEM HAS A SEPTIC TANK AND SOIL ABSORPTION SYSYTEM AND THE SAS
IS WITHIN 50 FEET OF A PRIVATE WATER SUPPLY WELL.
N THE SYSTEM HAS A SEPTIC TANK AND SOIL ABSORPTION SYSYTEM AND THE SAS
IS LESS THAN 100 FEET BUT 50 FEET MORE FROM A PRIVATE WATER SUPPLY WELL,
UNLESS A WELL WATER ANALYSIS FOR COLIFORM BACTERIA AND VOLATILE ORGANIC
COMPOUNDS NDICATES THAT THE WELL IS FREE FROM POLLUTION FROM THAT
FACILITY AND THE PRESENCE OF AMMONIA NITROGEN AND NITRATE NITROGEN IS
EQUAL TO OR LESS THAN 5 PPM. METHOD USED TO DETERMINED DISTANCE
(APPROXIMATION NOT VALID).
3) OTHER:
N
REVISED 9/2/98 PAGE 3 OF I I
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION (CONTINUED)
PROPERTY ADDRESS: 280 REA S
OWNER: GILLEN
DATE OF INSEPCTION: 29 MARCH 99
D. SYSTEM FAILS:
YOU MUST INDICATE EITHER "YES" OR "NO" TO EACH OF THE FOLLOWING:
N I HAVE DETERMINED THAT ONE OR MORE OF THE FOLLOWING FAILURE CONDITIONS EXIST AS
DESCRIBED IN 3 10 CMR 15.303. THE BASIS FOR THIS DETERMINATION IS IDENTIFIED BELOW. THE BOARD OF
HEALTH SHOULD BE CONTRACTED TO DERTERMINE WHAT WILL BE NECESSARY TO CORRECT THE FAILURE.
YES NO
N BACKUP OF SEWAGE INTO FACILITY OR SYSTEM COMPONENT DUE TO AN OVERLOADED
OR CLOGGED SAS OR CESSPOOL.
N DISCHARGE OR PONDING OF EFFLUENT TO THE SURFACE OF THE GROUND OR SURFACE WATERS
DUE TO AN OVERLOADED OR CLOGGED SAS OR CESSPOOL.
N STATIC LIQUID LEVEL IN THE DISTRIBUTION BOX ABOVE OUTLET INVERT DUE TO AN
OVERLOADED OR CLOGGED SAS OR CESSPOOL.
N/A LIQUID DEPTH IN CESSPOOL IS LESS THAN 6'BELOW INVERT OR AVAILABLE VOLUME IS LESS
THAN'/2 DAY FLOW.
N REQUIRED PUMPING MORE THAN 4 TIMES IN THE LAST YEAR NOT DUE TO CLOGGED OR
OBSTRUCTED PIPE(S). NUMBER OF TIMES PUMPED
N ANY PORTION OF THE SOIL ABSORPTION SYSTEM, CESSPOOL OR PRIVY IS BELOW THE HIGH
GROUNDWATER ELEVATION.
N/A ANY PORTION OF A CESSPOOL OR PRIVY IS WITHIN 100 FEET OF A SURFACE WATER SUPPLY OR
TRIBUTARY TO A SURFACE WATER SUPPLY.
N/A ANY PORTION OF A CESSPOOL OR PRIVY IS WITHIN A ZONE I OF A PUBLIC WELL.
N/A ANY PORTION OF A CESSPOOL OR PRIVY IS WITHIN 50 FEET OF A PRIVATE WATER SUPPLY WELL.
N/A ANY PORTION OF A CESSPOOL OR PRIVY IS LESS THAN 100 FEET BUT GREATER THAN 50 FEET
FROM A PRIVATE WATER SUPPLLY WELL WITH NO ACCEPTABLE WATER QUALITY ANALYSIS. IF THE
WELL HAS BEEN ANALYZED TO BE ACCEPTABLE, ATTACH COPY OF WELL WATER ANALYSIS FOR
COLIFORM BACTERIA, VOLATILE ORGANIC COMPOUNDS, AMMONIA NITROGEN AND NITRATE
NITROGEN.
LARGE SYSTEM FAILS:
YOU MUST-NDICATES EITHER "YES" OR "NO" TO EACH OF THE FOLLOWING:
THE FO ING CRITRTIA APPLY TO LARGE SYSTEMS IN ADDITION TO THE CRT ABOVE:
IN
S CILI
10, 000 P RE S)
EM ER E OF G G ATER (LAR E
V Ty WIT! T 0
S
L
N THE SYSTEM SERVES CILITY WITH A DESIGN FLOW OF 10PO GP GREATER (LARGE SYSTEM)
AND THE SYSTEM IS A SIGNIFICAN AT TO PUBLIC HEALTH AND ETY AND THE ENVIRONMENT
RE
BECAUSE ONE OR MORE OF THE FOLLO CONDITIONS EXIS
YES NO
THE SYSTEM IS WITHIN 400 �F�Of A SURFA� KING WATER SUPPLY
THE SYSTEM is WIT 00 FEET OF A TRIBUTARY T RFACE DRIN KING WATER SUPPLY
0' 0
THE SYSEM 1�,L "t SI I MWI
Z PATED IN A NITROGEN SENSITIVE AREA M WELLHEAD PROTECTION
AREA-IWPA) 0_RA-54-APPED ZONE Il OF A PUBLIC WATER SUPPLY WELL
THE OWNLk-GR OPERATOR OF ANY SUCH SYSTEM SHALL UPGRADE THE SYSTEM IN ACCORD3XNCFWITH 3 10
Cyj��.304(2). PLEASE CONSULT THE LOCAL REGIONAL OFFICE OF THE DEPARTMENT FOR FURTHER-'-�
INFORMATION.
REVISED 9/2/98 PAGE 4 OF I I
SUBSURFACE SEWAGE DISPOSAL SYSTEM INPSECTION FORM
PART B
CHECKLIST
PROPERTY ADDRESS: 280 REA S
OWNER: GILL
DATE OF fNSPECTION: 29 MARCH 99
CHECK IF THE FOLLOWING HAVE BEEN DONE: YOU MUST INDICATE EITHER "YES" OR "NO" AS TO
EACH OF THE FOLLOWING:
YES NO
Y - PUMPING INFORMATION WAS PROVIDED BY THE OWNER, OCCUPANT, OR BOARD OF
HEALTH.
Y - NONE ON THE SYSTEM COMPONENTS HAVE BEEN PUMPED FOR AT LEAST TWO WEEKS
AND THE SYSTEM HAS BEEN RECEIVING NORMAL FLOW RATES DURING THAT PERIOD. LARGE
VOLUMES OF WATER HAVE NOT BEEN INTRODUCED INTO THE SYTEM RECENTLY OR AS PART
OF THIS INSPECTION.
Y - AS BUILT PLANS HAVE BEEN OBTAINED AND EXAMINED. NOTE IF THEY ARE NOT
AVAILABLE WITH N/A.
Y - THE FACILITY OR DWELLING WAS INSPECTED FOR SIGNS OF SEWAGE BACK-UP.
Y THE SYSTEM DOES NOT RECEIVE NON -SANITARY OR INDUSTRIAL WASTE FLOW.
Y THE SITE WAS INSPECTED FOR SIGNS OF BREAKOUT.
Y - ALL SYSTEM COMPONENTS, EXCLUDING THE SOIL ABSORPTION SYSTEM HAVE BEEN
LOCATED ON THE SITE.
Y - THE SEPTIC TANK MANHOLES WERE UNCOVERED, OPENED, AND THE INTERIOR OF THE
SEPTIC TANK WAS INSPECTED FOR CONDITION OF BAFFLES OR TEES, MATERIAL OF
CONSTRUCTION, DIMENSIONS, DEPTH OF LIQUID, DEPTH OF SLUDGE, DEPTH OF SCUM.
THE SIZE AND LOCATION OF THE SOIL ABSORPTION SYSTEM ON THE SITE HAS BEEN
DETERMINED BASED ON:
Y - EXISTING INFORMATION. FOR EXAMPLE, PLAN AT B.O.H.
Y - DETERMINED IN THE FIELD (IF ANY OF THE FAILURE CRITERIA RELATED TO PART C IS
AT ISSUE, APPROXIMATION OF DISTANCE IS UNACCEPTABLE) [15.302(3)(b)]
Y - THE FACILITY OWNER (AND OCCUPANTS, IF DIFFERENT FROM OWNER) WERE PROVIDED
WITH INFORMATION ON THE PROPER MAINTENANCE OF SUBSURFACE DISPOSAL SYSTEMS.
REVISED 9/2/98 PAGE 5 OF I I
SUBURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION
PROPERTY ADDRESS: 280 REA S
OWNER: GILLEN
DATE OF INSPECTION: 29 MARCH 99
FLOW CONDITIONS
RESIDENTIAL:
DESIGN FLOW: 440G.P.D./BEDROOM.
NUMBER OF BEDROOMS (DESIGN): 4 NUMBER OF BEDROOMS (ACTUAL): 4
TOTAL DESIGN FLOW: 440
NUMBER OF CURRENT RESIDENTS: 5.
GARBAGE GRINDER (YES OR NO): NO
LAUNDRY (SEPARATE SYSTEM) (YES OR NO): NO; IF YES, SEPARATE INSPECTION REQUIRED
LAUNDRY SYSTEM INPECTED (YES OR NO): NO
SEASONAL USE (YES OR NO): NO
WATER METER READINGS, IF AVAILABLE (LAST TWO YEAR'S USAGE (GPD): 29,300c
SUMP PUMP (YES OR NO): NO
LAST DATE OF OCCUPANCY: CURRENT
TYPI�?�TABLISHMENT:..
S ...
DES GN FLOW-- GPD (BAESED ON 15.203)
BASIS OF DESIG
No)* ----
GREASE TRAP PRESENT (Y �NO): .....
INDUSTRAIL WASTE HOLDING TA SEN
NON -SANITARY WASTE DISCHARGED
WATER METER RED7AINGS, IF A ABLE: .....
LAST DATE OF OCCUPA
OTHER (D
��E): .....
LA��E OF OCCUPANCY: .....
ORNO): .....
5 SYSTEM (YES OR NO): .....
GENERAL INFORMATION
PUMPING RECORDS AND SOURCE OF INFORMATION:
SYSTEM PUMPED AS PART OF INSPECTION (YES OR NO): YES
IF YES, VOLUME PUMPED: 1000 GALLONS
REASON FOR PUMPING: OWERS REQEST
TYPE OF SYSTEM
YES SEPTIC TANK/DISTRIBUTION BOX/SOIL ABSORPTION SYSTEM
n SINGLE CESSPOOL
OVERFLOW CESSPOOL
PRIVY
n SHARED SYSTEM (YES OR NO) (IF YES, ATTACH PREVIOUS INSPECTION RECORDS, IF ANY)
n I/A TECHNOLOGY ETC. ATTACH COPY OF UP TO DATE OPERATION AND MAINTENANVE CONTRACT
TIGHT TANK
OTHER: n
COPY OF DEP APPROVAL
APPROXIMATE AGE OF ALL COMPONENTS, DATE INSTALLED (IF KNOWN) AND SOURCE OF INFORMATION:
INSTALLED 10/7175 243as
SEWAGE ODORS DETECTED WHEN ARRIVING AT THE SITE (YES OR NO): NO
REVISED 9/2/98 PAGE 6 OF I I
SUBSURFACE SEWAGE DISPOSAL INSPECTION FORM
PART C
SYSTEM INFORMATION (CONTINUED)
PROPERTY ADDRESS: 280 REA S
OWNER: GILLE
DATE OF INSPECTION: 29 MARCH 99
BUILDING SEWER:
(LOCATE ON THE SITE PLAN)
DEPTH BELOW GRADE: 14"
MATERIAL OF CONSTRUCTION: YES CAST IRON - 40 PVC OTHER (EXPLAIN) .....
DISTANCE FROM PRIVATE WATER SUPPLY WELL OR SUCTION LINE: N/A
DIAMETER: 4"
COMMENTS: (CONDITION OF JOINTS, VENTING, EVIDENCE OF LEAKAGE, ETC.)
INLET PIPE SHOWS NO SIGNS OF LEAKAGE IN OR OU
SEPTIC TANK: YES
(LOCATE ON SITE PLAN)
DEPTH BELOW GARDE: 7"
MATERIAL OF CONSTRUCTIOMYESCONCRETE METEL FIBERGLASS POLYETHYLENE -OTHER
(EXPLAIN): .....
IF TANK IS METAL, LIST AGE N/A IS AGE CONFIRMED BY CERTIFICATE OF COMPLIANCE (YES/NO) -----
DIMENSIONS: 8'X 5'X 5'OUTLET INVERT@4'2" 1000 gal
SLUDGE DEPH: 12"
DISTANCE FROM TOP OF SLUDGE TO BOTTOM OF OUTLET TEE OR BAFFLE: 141,
SCUM THICKNESS: 2"
DISTANCE FROM TOP OF SCUM TO TOP OF OUTLET TEE OR BAFFLE: 5"
DISTANCE FROM BOTTOM OF SCUM TO BOTTON OF OUTLET TEE OR BAFFLE: 22"
HOW DIMENSIONS WERE DETERMINED: SLUGE JUDGE,RODE.RULER
COMMENTS:
(RECOMMENDATION FOR PUMPING, CONDITION OF INLET AND OUTLET TEES OR BAFFLES, DEPTH OF LIQUID
LEVEL IN REALTION TO OUTLET INVERT, STRUCTURAL INTEGRITY, EVIDENCE OF LEAKAGE, ETC.) THE OUTLE
TEE BAFFLE IS IN GOOD SHAPE.THERE'S NO SIGNS OF LEAKAGE IN OR OUT.LIQUID LEVEL IS @ NORMAL HIGHT.
ASE TRAP:
(LOCA SITE PLAN)
DEPTH BELOW G
MATERIAL OF CONSTRUC CONCRETE -METAL F RGL POLYETHLENE OTHER
(EXPLAIN) .....
DIMENSIONS:
SCUM THICKNESS:
DISTANCE FROM TOP OF SCUM TO TOP OF OU TE AFFLE:
DISTANCE FROM BOTTOM OF SCUM T ON 0 UTLET R BAFFLE:
DATE OF LAST PUMPING:
COMMENTS:
FLE TH OF I
T
(RECOMM
�!MTION FOR PUMPING, Cp?6ITION OF INLET AND OUTLET TEES OR BAFFLE TH OF LIQUID
�E L
REALTION TO OUTLET ;&4RT, STRUCTURAL INTEGRITY, EVIDENCE OF LEAKAGE, ET
REVISED 9/2/98 z PAGE 7 OF I I
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (CONTINUED)
PROPERTY ADDRESS: 280 REA S
OWNER: GILLEN
DATE OF INSPECTION: 29 MARCH 99
TIGHT OR HOLDING TANK: N(TANK MUST BE PUMPED PRIOR TO, OR AT TIME OF, INSPECT
ZQATE ON SITE LPLAN)
DEPTH BEL GRADE:
MAT
ERIAL OF CO UCTION:-CONCRETE METAL FIB ASS POLYETHYLENE OTHER
(EXPLAIN) .....
DIMENSIONS:
CAPACITY: GALLONS
DESIGN FLOW: GALLONS/D
ALARM PRESENT:
ALARM LEVEL: A
DATE OF PREV16LTS�U
IN WORKING ORDER:
NO
OF INLET TEE, CONDITION OF ALRM AND FLOAT SWITCHES,
DISTRIBUTION BOX: YES
(LOCATE ON SITE PLAN)
DEPTH OF LIQUID LEVEL ABOVE OUTLET INVERT: 0" DEPTH BELOW GRADE: 24"
COMMENTS:
(NOTE IF LEVEL AND DISTRIBUTION IS EQUAL, EVIDENCE OF SOLIDS CARRYOVER, EVIDENCE OF LEAKAGE INTO OR OUT OF BOX, ETC.)
NO SIGNS OF LEAKAGE IN OR OUT, THERE'S ONE INLET AN FOUR OUTLETS ORENGEBERG
CONSTRUCTION IN GOOD SHAPE. THE D -BOX IS LEVEL AN EQUALLY DIST. D -BOX IS @ 24" BELOW
GRAD
N
(LOCATE ON
PUMPS IN WORKING ORDER (
ALARMS IN WORKING ORDER
COMMENTS:
(NOTE CONDITION
.S.A�UMP
No):
CHAMBER, CONDITION
REVISED 9/2/98 PAGE 8 OF I I
AND APPURTENANCES, ETC.)
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (CONTINUED)
PROPERTY ADDRESS: 280 REA S
OWNER: GILLEN
DATE OF INSPECTION: 29 MARCH 99
SOIL ABSORPTION SYSYEM (SAS): YES
(LOCATE ON SITE PLAN, IF POSSIBLE; EXCAVATION NOT REQUIRED, LOCATION MAY BE APPROXIMATED BY NON -INTRUSIVE METHODS)
IF NOT LOCATED, EXPLAIN: .....
TYPE:
LEACHING PITS, NUMBER: .....
LEACHING CHAMBERS, NUMBER: .....
LEACHING GALLERIES, NUMBER: -----
LEACHING TRENCHES, NUMBER, LENGTH: .....
LEACHING FIELDS, NUMBER, DIMENSIONS: LEACH BED 20'W X 451
OVERFLOW CESSPOOL, NUMBER: .....
ALTERNATIVE SYSTEM:
NAME OF TECHNOLOGY:
COMMENTS:
(NOTE CONDITION OF SOIL, SIGNS OF HYDRAULIC FAILURE, LEVEL OF PONDING, DAMP SOIL, CONDITION OF VEGETATION, ETC.)
THERE'S NO SIGNS OF HYDRAULIC FAILUR,NO SIGNS OF PONDING IN OR NEAR SYSTEM. THE YARD IS WELL
MAINTAINED NOSIGNS OF WETLAND VEGETAION.
OL: N
(LOCATE-ON,SITE PLAN)
NUMBER AND CONFIGCRAZION:
DEPTH -TOP OF LIQUID TO INL ERT: -----
A Co
P OF LIQU
ID
G
To 10
L
N*
DEPTH OF SOILD LAYER:
ND NF
IN ERT,
DEPTH OF SCUM LAYER:
DIMENSIONS OF CESSPOOL:
MATERIALS OF CONST ION:
INDICATION OF WATER:
(C SSPOOL MUST B.PUM
INF (CESSPOOL MUST BE PUMPED AS PART OF INSPEC�TION
COMMENTS:
(NOTE CONDITION OF SOIL, SIGNS OF HYDRAULIC FAILURE, LEVEL OF PONDING, CONDITION OF VEGETATION, ETC.)
PRIVY: N --
(LOCATE ON
MATERIALS OF CONSTRUCTION: SIONS:
I
DEPTH SOLIDS:
COMMENTS:
SOIL, SIGNS OF HYDRAULIC FAILURE, LEI
(NOTE CONDITI
REVISED 9/2/98 PAGE 9 OF I I
PONDING, CONDITION OF VEGETATION, ETC.)
J
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (CONTINUED)
PROPERTY ADDRESS: 280 REA S
OWNER: GILLEN
DATE OF INSPECTION: 2214ARCIJ92
SKETCH OF SEWAGE DISPOSAL SYSTEM:
INCLUDE TIES TO AT LEAST TWO PERMANENT REFERENCE LANDMARKS OR BENCHMARKS
LOCATE ALL WELLS WITHIN 100'(LOCATE WHERE PUBLIC WATER SUPPLY COMES INTO HOUSE)
a
I
REVISED 9/2/98 PAGEIOOFII
r, G/
Z tZ19cf-
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (CONTINUED)
PROPERTY ADDRESS: 280 REA S
OWNER: GILLEN
DATE OF INSPECTION: 29 MARCH 99
NRCS REPORT NAMEN/A
SOIL TYPE N/A
TYPICAL DEPTH TO GROUNDWATER NZA
USGS DATE WEBSITE VISITED
OBSERVATION WELLS CHECKED
GROUNDWATER DEPTH: SHALLOW N/A MODERATE DEEP
SITE EXAM SLOPE
SURFACE WATER
CHECK CELLAR
SHALLOW WELLS
ESTIMATED DEPTH TO GROUNDWATER 10'+ APPROX FEET
PLEASE INDICATE ALL THE METHODS USED TO DETERMINE HIGH GROUNDWATER ELEVATION:
N/A OBTAINED FROM DESIGN PLANS ON RECORD
Y OBSERVED SITE (ABUTTING PROPERTY, OBSERVATION HOLE, BASEMENT SUMP, ETC.)
Y DETERMINED FROM LOCAL CONDITIONS
N CHECKED WITH LOCAL BOARD OF HEALTH
N CHECKED FEMA MAPS
Y CHECKED PUMPING RECORDS
N CHECKED LOCAL EXCAVATORS, INSTALLERS
Y USED USGS DATA
DESCIBE HOW YOU ESTABLISHED THE HIGH GROUNDWATER ELEVATION. (MUST BE COMPLETED)
THERE'S NO SUMP PUMP IN BASEMENT AN BASEMENT IS DRY. WHILE DIGGING IN YARD THE SOILS
WERE CLEAN AN DRY,NO SIGNS OF WATERTABLEDUG IN AREA OF THE S.A.S. (@ 4' NO
ABUTTING PROPERTY'S WELLS WITHIN 100'FROM SYSTEM. NO WETLANDS WITHIN 100'
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do not hesitate to contact this office.
Very truly yours,
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Sandra Starr,
Administrator
IATION 688-9530 HEALTH 688-9540 PLANNING 688-953'
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TO: NORTH ANDOVER, MASS 3 If 19 72—
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
Z- o -7 Pc C-- -7—
r - — North Andover, Mass
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The grades and construction are as specified in my plans and specifications dated
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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
landowner from compliance with any applicable local or state law,
regulations or requirements. z'
App n fills out this section*****************
APPLICANT: -17, Jt4 I L&d_41 Phone
LOCATION: Assessor's Map Number
Parcel
Subdivision Lot(s)
Street St. Number 9,E(_n
************************Official use only************************
RECOMMENDATIONS OF TOWN AGENTS:
Z7 Date Approved
conservation Administrator Date Rejected
Comments
Date Approved L1:J_J!V(Qk
Town Planner Date Rejected
Comments
Food Inspector -Health
Septic Inspector -Health
Date Approved
Date Rejected
Date Approved
Date Rejected
Comments _D67i_,& 7-6 141 f,,,91),2C
Public Works - sewer/water connections
- driveway permit
Fire Department
Received by Building Inspector. Date
4
TO: NORTH ANDOVER, MASS (DIFC S' 19 72—
BOARD OF HEALTH
F ROM: DESIGN ENGINEER Re: Soil Absorption Sewage
System Inspection
This is to certify that I have inspected the construction of the said disposal system at
/—o -7 R F;4 S7—, North Andover, Mass.
SITE LOCATION
The grades and construction are as specified in my plans and specifications dated
19—
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CURRIER
SEPTIC & DRAIN SERVICE
107 FOREST STREET; MIDDLETON, MA 0 1949
(978) 774-2772
m
FORM 4 - SYSTEM PUMTING RECORD
I TOWN OF NORTH ANDOVER/
BOARD OF HEALTH
FAPR' 1 5 1999
COMMONWEALTH OF MASSACHUSETTS
20 — ek_�� , MASSACHUSETTS
S YS TEM P UMPING RE CORD
SYSTEM 0 SYSTEM LOCATION:
e1v
de m 6 0,4
DATE OF PUMPING: 9,9 QUANTITY PUMPED: 16 (Z70 'GALLONS
CESSPOOL: NO YES SEPTIC TANK NO F__] YES,,n
SYSTEM PUMPED BY: CURRIER SEPTIC & DRAIN SERVICE
CONTENTS TRANSFERRED TO:- _��o
DATE: -INSPECTOR:
K
Form 4 -- System Pumping Pecord
Commonwealth of Aossachusetss
: Aossachusetts
System PumvinQ Record
owner Isystem Location
Type: Emergency Routine
cesspool: NIO Yes Septic tank: KJO =Yes
Date of Pumping: pt-� 4 Quantity Pumped: Gallons
!z� -0 2::::
System Pumped By: Wind River Envymninental, UC Permit #*.
contents transferred to.
j
Contents Disposed at:
Date: Pumper Signature:
lCondition of Syst.WOtlw Comments
Dep AA"ved Fmm - 12107195
CommonweaK of Massachusetss
Massachusetts
O�
tm Location
I
Type: Emergency Routine
Cesspool: NIO Yes
Date of Pumping: —Or
System Pumped By: Wind River Enwmninental, UC
Contents transferred to.
Contents Disposed at:
Date:
of Systern/Other Comments
Pumper
V --t Iz � B (i
Dep Approved Form - 12/07/95
Form 4 -- System
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f—P
Septic tank: I'la F--jY.. r—L-.;t
Quantity Pumped: Gallons
Permit #:
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 NORTH ANDOVER, MASSACHUSETTS
System Pumping Record
Form 4
DEP has provided this form for use by local Boards of Health. The System Pumping Record must
be submitted to the local Board of Health or other approving a EIVED
A. Facility Information
1. System Location
0
Addr A
" DOWEL -A
CityfTow?F State
2. System Owner.-
KCny) 2) G�f
Name
Address (if different from location)
NOV 10. 2009
TOWN OF NORTH ANDOVER
HEALTH DEPARTMENT
I
Zip Code
City/Town State Zip Code
q-78- U89- 0520
Telephone Number
B. Pumping Record
1 . Date of Pumping 9-"�3-09 2. Quantity Pumped: /COO
Date Gallons
3. Type of system: El Cesspool(s) 5eSeptic Tank E] Tight Tank
F-1 Other (describe):
4. Effluent Tee Filter present? El Yes [��No If yes, was it cleaned? E] Yes 5��No
5. Condition of System:
Good
,6. System Pumped By:
JIfy) GcJIQY)� 7667�
Nam'kAA Vehicle License Number
Company
7. Location where contents were disposed: Ipswich Water
Treatment Plant
Ipswich, MA 01938
Signature of Hauler Date
http://www.mass.gov/dep/water/approvals/t5forms.htm#inspe,ct
15form4.doc- 06/03
System Pumping Record - Page 1 of 1