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HomeMy WebLinkAboutMiscellaneous - 326 CANDLESTICK ROAD 4/30/2018MAP # LUT #___ PARCEL # STREET CONSTRUCTION APPROVAL HAS PLAN REVIEW FEE BEEN PAID? NO PLAN APPROVAL: APP. DESIGNER: PLAN DATE CONDITION WATER SUPPLY: WELL PERMIT WELL TESTS: TOWN WELL � A I DATE (-)[)PROVED BAt���IA II DAlE APPRUVED______ _ FORM U APPROVAL: APPROVAL 10 ISv' E 'OVAL10 1 NO .DATE ISSUED _..... '...... .... / � -...... FINAL APPROVAL: / � ALL PERMITS PAID -YIE-q___ NO WELL CONSTRUCTION APPROVAL YES NO SEPTIC SYSTEM CONSTRUCTION APPROVAL YES NO OTHER YES NO ANY VARIANCE NEEDED YES NO ` - FINAL BOARD OF HEALTH APPROVAL: DATE:__ __ BY: r a I IS THE INSTALLER LICENSED? LES NO , ._-TYPE OF CONSTRUCTION:- NEW - REPAIR NEW CONSTRUCTION: CERTIFIED PLOT PLAN REVIEW YES NO CONDITIONS OF APPROVAL YES NO (FROM FORM U) ISSUANCE OF DWC PERMIT YES NO DWC PERMIT NO. _ INSTALLER:——- NSTALLER:_._____.I, If BEGIN INSPECTION YES NO: 1 EXCAVATION INSPECTION: NEEDED: PASSED - BY--------- ---- -- _ -_ ----- CONSTRUCTION INSPECTION: NEEDED: _..__.._._._.__.:_._._............. _____.__......_._ ............. ____- ------------ _�__,._.._ AS BUILT PLAN SATISFACTORY: YES:. APPROVAL TO BACKFILL: DATE: -- FINAL GRADING APPROVAL: DATE FINAL CONSTRUCTION APPROVAL: DATE:___ i Commonwealth of Massachusetts City/Town of System Pumping- Record 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. System Location: Lef ktj ig Ft front of hous , Left / Right rear of house, Left / right side of house, Left / Right side of building, Left ig ron o uildirig, Left / Right rear of building, Under deck Address `7: >`�; Cityfrown state Zip Code 2. System Owner. Name' Address Cd different from location) RECEIVED Citylrown S Zip Code SPR Telephone Number TOWN OF NORTH ANDOVER HLALiH DEPARTMENT B. Pumping Record 1. Date of Pumping Date 2. Quantity Pumped: C� Gallons ;. 3. Type of system. ❑ Cesspool(s) Septic Tank ❑ Tight Tank ❑ Other (describe): 4. Effluent Tee Filter present? ❑Yes 940 If yes, was it cleaned? ❑ Yes ❑ No: 5. Condition 6. System Pumped By: tj t5form4.doc• 06/03 Neil. Bateson Name Bateson Enterprises Inc Company contents were disposed: F5821 Vehicle Lioense Number System Pumping Record • Page 1 of 1 Commonwealth of Massachusetts RECEIVED 11-11 City/Town of System Pumping Record MAR 2 F 2013 Form 4 TOWN OF NORTH ANDOVER HEAT D DEP has provided this form for use_by local Boards of used, but the information must be substantially the same as that provided here. Before using.this form, check with your local Board of Health to determine the form they use. The System Pumping Record must be submitted to the local Board of Health or other approving authority. A. Facility. Information 1. System Location: Left / fight front of h s'l Left /Right rear of house, Left /right side of house, Left / Right side of building, Left / ight front of building, Left / Right rear of building, Under deck Address Cityrrown State Zip Code 2. System Owner: Name Address (if different from location) City/Town B. Pumping Record 1. Date of Pumping 3. Type of system: ❑ stat (2j 0�^ �ip�e Telephone Number �� Date 2. Quantity Pumped Cesspool(s) eptic Tank ❑ Other (describe): 4. Effluent Tee Filter present? ❑ Yes No 5. Conditign of System: (�`-'l o--�w�-C..,C 6. System Pumped By: Neil Bateson Name b Bateson Enterprises Inc Company ksc-4---� Gallons ❑ Tight Tank If yes, was it cleaned? ❑ Yes ❑ No 7. Location where contents were disposed: Lowell Waste Water F5821 Vehicle License Number - Date t5form4.doc• 06103 System Pumping Record • Page 1 of 1 Commonwealth of Massachusetts City/Town of 1 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 authority. A. Facility Information Important: When fining out 1. System Location: forms on the�,,�� fa computer, use .. only the tab key Address to move your cursor - do not i Qtyown state use theretum irrZip Code key. 2. Syste caner: Name Address (if different from location) Cityfrown st Zip Code Telephone Number B. Bumping Record 1.: Date. ofRum.ping Date 2. Quantity` Pumped 3. Type of system: ❑ Cesspool(s) eptic Tank- ❑ Other (describe): 4: Effluent Tee Filter present? ❑ Yes 9_1V0 5. Condition of System: Gallons ❑ Tight.Tank If yes, was it cleaned? ❑ Yes ❑ No 6. System Pumped By" tkj Name Vehicle License Number Company 7. LoAptiog where contents were disposed: Date hftp://www.mass.90v/dep/Water/approvals/t5forms.htm#inspect t5form4.doc• 06103 System Pumping Record . Page 1 of 1 No 3 t aGr Jsets o� $0P� �C, coil ��O05 /�// s bso`vti\or ZM ANp DOSP I �S .` P I• • ** °O�noont•o yy ��� t o. • MASSI.GO �e5 N -(N M Or oJ a p.QQ� �o of PQQ �,oeat`or tea to or tre OeS P\�MPN �° G �o ' Sit e`eby �tR` as your 1 O �l S Lk/ LICA ' \SS`or `S o a\Syste Of/�.J SI Q elo O�sQ � GNA ?'i.,' c P"'oe cllkck Ov AIR` t,.� '•• � �� /�� �jp• l� CoNS�r, TR 1PNEW �4 UcTIc' '/ STRUCTIoN• HFOUNDATI $1 7S 00 Fee ONAS+BELT. Attached Fou n Ad�iinlstr�t'v ndatiO �r AS'buYes llt? \ e se Only lO°r plus on �Yes NO le� 1pprOv al Yes ` NO NO Date. �l 1 M �. eo N z O O O W O O In � 14. w N CN b Q b (B b � � x M �. eo N z O O O W O O In � 14. w N CN b Q b (B V Town of North Andover, Massachusetts Form No. 3 NORTH Ot<�`'D ye.1ti0 3? a or -'•. .. a OL O A i off^ - - .-- >'' • SSACHus BOARD OF HEALTH DISPOSAL WORKS CONSTRUCTION PERMIT Applicant fz'e''7&Vz1 'j o2 /�'Y NAME ADDRESS TELEPHONE Site Location Permission is hereby granted to Construct ( ) or Repair�— �an Individual Soil Absorption Sewage Disposal System as shown on the Design Approval S.S. No. CHAIRMAN, B.OARDG/OF LTH Fee D.W.C. No. Z50 %/ ws/'� a -- APPLICATION FOR DISPOSAL WORKS CONSTRUCTION PERMIT DATE: i- a 3 LOCATION: a j & 6 CURRENT INSSTA�JLLER'S LICENSE#, LICENSED INSTAIyER: �'O� �Z SIGNATURE: CHECK ONE: TELEPHONE# REPAIR: NEW CONSTRUCTION: &CJ/.e %ems CA -11y IF NEW CONSTRUCTION, PLEASE ATTACH FOUNDATION AS -BUILT. Administrative Use Only $175.00 Fee Attached? Yes No Foundation As -built? Yes No Floor plans on file? Yes No_ Approval Date: 1,422 INSTALLER PROJECT MANAGEMENT OBLIGATIONS As the North Andover licensed installer for the/construction of the septic system for the property at S �o G�9—�►�(� ST���C relative to the application of dated for plans by and dated with revisions dated I understand the following obligations for management of this project: 1. As the installer I am obligated to call for any and all inspections. If homeowner, contractor, project manger, or any other person not associated with my company schedules an inspection and the system is not ready then item two shall be applicable. 2. As the installer I am required to have the necessary work completed prior to the applicable inspections as indicated below. I understand that requesting an inspection,. without completion of the items in accordance with Tile 5 and the Board of Health Regulations may result in a $50.00 fine being levied against my company. a) Bottom of Bed - generally first inspection unless there is a retaining wall which should be done first. Installer must request the inspection but does not have to be present. b) Final inspection — Engineer must first do their inspection for elevations, ties, etc. As -built or verbal OK from engineer must be submitted to Board of Health, after which installer calls for inspection time. Installer must be present for this inspection. With pump system all electrical work must be ready and able to cause pump to work and alarm to function. c) Final Grade — Installer must request inspection when all grading is complete. Does not have to be on site. 3. As the installer I understand that persons or companies not associated with my company may not perform the work required by my company to complete the installation of the system identified in the attached application for installation. I further understand that work by others unlicensed to install septic systems in North Andover can constitute reasons for denial of the - system, and/or revocation or suspension of my license in the Town of North Andover plus significant fines to all persons involved. 4. As the Installer I understand that I must be on site during the performance of the following construction steps: a) Determination that the proper elevation of the excavation has been reached. b) Inspection of the sand and stone to be used. c) Final inspection by Board of Health staff. d) Installation of tank, D -box, pipes, stone, vent,pump chamber, retaining wall and other components. 5. As the installer I understand that I am solely responsible for the installation of the system as per the approved plans. No instructions by the homeowner, general contractor, or any other persons shall absolve me of this obligation. Licensed Septic Installer Date: '7— r' a.3 Disposal Works Construction Permit # CD o ft N x mr rA U) m � G O M x �7 N z 00 o• W 0 0 n 00s 0 5* r. M c� N CN b cn ^� IliO b (B 11 COMMONWEALTH OF MASSACHUSETTS EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS DEPARTMENT OF ENVIRONMENTAL PROTECTION TITLE 5 TOihlill OF �URT_u _ H ANOCVER/ FBOARD OF HEA! i H OFFICIAL INSPECTION FORM — NOT FOR VOLUNTARY ASS—ESS SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM PART A CERTIFICATION Property Address: 326 Candlestick Road _ —North Andover_ Owner's Name: _Marlene Bowman_ Owner's Address: _326 Candlestick Road_ —North Andover, MA 01845_ Date of Inspection: 7/9/2003_ Name of Inspector: Neil J. Bateson_ Company Name: Bateson Enterprises Inc._ Mailing Address: _111 Argilla Road_ _Andover, Ma. 01810 Telephone Number: _( 978 ) 475-4786 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 Fail Inspector's Signature: ate: _7/9/2003_ 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 installing new outlet tee with gas baffle in septic tank, 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 use. TOWN OF_NORTH ANDOVER BOARD OF HEALTH / a Location Permit #` Food Service $ Retail Food $ i Limited Retail $ Seasonal $ Disposal Works Installers $ Disposal Works Construction,' $. Soil Testing $ Design Approval Permit $ Dumpster Permit $ Burial Permit $ Swimming Pool Permit $ Animal Permit $ Recreational Camp Permit $ Well Construction Permit $ Funeral Directors Permit $ Massage Establishment License $ Massage Practice License $ Suntanning Establishment $ offal/Trash Hauler $ Other % 6991-' .74 Health Agent White - Applicant Yellow - Dept. Pink - Treasurer COMMONWEALTH OF MASSACHUSETTS EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS DEPARTMENT OF ENVIRONMENTAL PROTECTION TITLE 5 OFFICIAL INSPECTION FORM — NOT FOR �:�� �F i �ORTVI P,�1DO"`'Zi/ 3 2003 VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM PART A CERTIFICATION Property Address: 326 Candlestick Road _ North Andover_ Owner's Name: _Marlene Bowman_ Owner's Address: _326 Candlestick Road_ _North Andover, MA 01810_ Date of Inspection: 6/18/2003_ Name of Inspector: Neil J. Bateson_ Company Name: Bateson Enterprises Inc._ Mailing Address: _111 Argilla Road_ _Andover, Ma. 01810_ Telephone Number: _( 978 ) 475-4786_ 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 _X_ Conditionally Passes Needs Further Evaluation by the Local Approving Authority aailsInspector's Signature: _67�_LDate: _6/18/2003_ 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: ****This report only describes conditions at the time of inspection and under the conditions of use at that time. This inspection does not address how the system will perform in the future under the same or different conditions of use. Page 2 of 11 OFFICIAL INSPECTION FORM — NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: 326 Candlestick Road_ _North Andover— Owner: _Bowman Date of Inspection_: _6/18/2003_ Inspection Summary: Check A,B,C,D 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 310 CMR 15.303 or in 310 CMR 15.304 exist. Any failure criteria not evaluated are indicated below. Comments: B. System Conditionally Passes: _N 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. Outlet tee in septic tank needs replaced. Answer yes, no or not determined (Y,N,ND) in the for the following statements. If "not determined" please explain. _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 box 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): broken pipe(s) are replaced obstruction is removed ND explain: Page 3 of 11 OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: 326 Candlestick Road_ North Andover— Owner: _Bowman_ Date of Inspection: _6/18/2003_ C. Further Evaluation is Required by the Board of Health: Conditions exist which require further evaluation by the Board of Health in order to determine if the system is failing to protect public health, safety or the environment. 1. 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 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 surface water supply or tributary to a surface water supply. _ The system has a septic tank and SAS and the SAS is within a Zone 1 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 private 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 11 OFFICIAL INSPECTION FORM — NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: _326 Candlestick Road- - North oad__North Andover— Owner: _Bowman_ Date of Inspection: _6/18/2003_ D. System Failure Criteria applicable to all systems: You must indicate `yes" or `no" to each of the following for all inspections: Yes No _No_ Backup of sewage into facility or system component due to overloaded or clogged 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 less than 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 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.] _No_ (Yes/No) The system fails. I have determined that one or more of the above failure criteria exist as described in 310 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 flow 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 II 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 "yes" 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 310 CMR 15.304. The system owner should contact the appropriate regional office of the Department. Page 5 of l l OFFICIAL INSPECTION FORM — NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST Property Address: 326 Candlestick Road_ North Andover— Owner: _Bowman_ Date of Inspection: _6/18/2003_ 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 ? N/A _ Were as built plans of the system obtained and examined? (If they were not available note as N/A) _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.. Design plan, no as built plan. No Determined in the field (if any of the failure criteria related to Part C is at issue approximation of distance is unacceptable) [3 10 CMR 15.302(3)(b)] Page 6 of 11 OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION Property Address: 326 Candlestick Road- - North oad__North Andover— Owner: _Bowman Date of Inspection:_6/18/2003_ FLOW CONDITIONS RESIDENTIAL Number of bedrooms (design): _4_ Number of bedrooms (actual): _4 MR_ DESIGN flow based on 310 C 15.203 (for example: 110 gpd x # of bedrooms): _600_ Number of current residents: _3 Does residence have a garbage grinder (yes or no): Yes Is laundry on a separate sewage system (yes or no): _ No Laundry system inspected (yes or no): Seasonal use: (yes or no): _No_ Water meter readings: Yes_ Sump pump (yes or no): _No_ Last date of occupancy: _Current COMMERCIALANDUSTRML Type of establishment: Design flow (based on 310 CMR 15.203): gpd Basis of design flow (seats/persons/sgft,etc.): Grease trap present (yes or no): _ Industrial waste holding tank present (yes or no): Non -sanitary waste discharged to the Title 5 system (yes or no): Water meter readings, if available: Last date of occupancy/use: OTHER (describe): GENERAL INFORMATION Pumping Records Source of information: _ Pumped two years ago, owner Was system pumped as part of the inspection (yes or no): Yes_ If yes, volume pumped: _1500_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: _14 Years old, Info at B.O.H. Were sewage odors detected when arriving at the site (yes or no): No Page 7 of 11 OFFICIAL INSPECTION FORM — NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: 326 candlestick Road- - North oad__North Andover— Owner: _Bowman_ Date of Inspection: 6/18/2003_ BUILDING SEWER (locate on site plan) X Depth below grade: _36"_ Materials of construction: _cast iron _X_40 PVC _other Distance from private water supply well or suction line: Comments (on condition of joints, venting, evidence of leakage, etc.): _4" PVC thru wall. 3" PVC in house, no leaks visible. SEPTIC TANK: X locate on site plan) Depth below grade: _24"_ 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: 10' x 5' x 4' Sludge depth 6"_ Distance from top of sludge to bottom of outlet tee or baffle: N/A Scum thickness: Distance from top of scum to top of outlet tee or baffle: _N/A N/A = Outlet tee corroded off Distance from bottom of scum to bottom of outlet tee or baffle: _N/A_ How were dimensions determined: _Measured scum & sludge depth to tee length _ Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): Pumped septic tank. Inlet tee ok. Outlet tee corroded off and needs replaced. 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 l 1 OFFICIAL INSPECTION FORM — NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: _326 Candlestick Road_ _North Andover - Owner: _Bowman_ Date of Inspection: _6/18/2003_ 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 BOX: X (if present must be opened)(locate on site plan) Depth of liquid level above outlet invert: _0 Comments (note if box is level and distribution to outlets equal, any evidence of solids carryover, any evidence of leakage into or out of box, etc.): _D -box level & distribution equal. No evidence of leakage. Evidence of carryover, Pumped d -box to clean. _ PUMP CHAMBER: (locate on site plan) Pump in working order (yes or no): _ Alarms in working order (yes or no): _ Comments (note condition of pump chamber, condition of pumps and appurtenances, etc.): _ Page 9 of 11 OFFICIAL INSPECTION FORM — NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: _326 Candlestick Road- - North oad__North Andover — Owner: _Bowman_ Date of Inspection: _6/18/2003_ 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: X_ leaching trenches, number, length: —3 trenches 43' long_ leaching fields, number, dimensions: — 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: (cesspool must be pumped as part of inspection)(locate on site plan) Number and configuration: Depth — top of liquid to inlet invert: Depth of solids layer: Depth of scum layer: Dimensions of cesspool: Materials of construction: Indication of groundwater inflow (yes or no): Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): PRIVY: (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: 326 Candlestick Road_ North Andover— Owner: _Bowman_ Date of Inspection: _6/18/2003_ SKETCH OF SEWAGE DISPOSAL SYSTEM Provide a sketch of the sewage disposal system including ties to at least two permanent reference landmarks or benchmarks. Locate all wells within 100 feet. Locate where public water supply enters the building. Page 11 of 11 OFFICIAL INSPECTION FORM — NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: 326 Candlestick Road_ North Andover_ Owner: _Bowman_ Date of Inspection: _6/18/2003_ SITE EXAM Slope Surface water Check cellar Shallow wells Estimated depth to ground water _ 4 feet 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: _4/18/1989_ 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: Design Plan_ Jun 23 03 11:23a ss 1 ^:IO a I ;^, .c rrlrl .. Sro' 0 �N c NNNNNNNNNNNNNNN o::,...� m m I W f QOOOQQQpQ OOO Q p OO ._,.,.�; o :: • CL Q d p 0 0 D 0 0 0 Q p ©Q p O O W W WNNNNN�..Ls..LOpOCD n I I I I I I I I I I I I I I I I n r w N r W r w N -+ o www w w w w w w w W w w w w :. o C) I o clr- I .� Ix xr �•-c' I rn:: W N�OOO.rN�00.r��O W Jp , 3.: ppNN�ONNW..Lp O W V V l n -A b 01. Zr O N W •ns D:: N N N N N N N N N N N N N N N J CD ii n poo000000Q01=QQp�O m D p DOD Q p p p Q O Q Q D Q `O o —1 ;.m49tnulvicrw W WNNN.+p � bQV'1 V NQ.tnNU1bo Vrcc64 wco +� �7 m p00 V NwpNN�OrOV s_aNN 3:. cl.::.......... O. o. v1 V1 V9 V9 V9 r w w w o •oyi -j aatm1 .n%o.Itr co 1-� 77 NQOONV WpNN.Or0�11..►.-iN .... N W 07 ..►JN V V1NNV'INNtfllrl � ........ NNjprw07©wcnaosoa©.op VI %4 1 w W 0`N a a.4o.,ltn0.p u•lwp-Pr rN.000 WCO0 Apr -+.o N N 00 r V1 -► j .o O. N �' O .O O. O V1 -. OQCOOo00..LO�p�OV'Ir�lODO V p © p p p O Q 0040 Q 0 p Q Q D p . . . © Q Q p O Q Q O Q Q p Q 0 0 D Q O© p p O O Q D Q© Q p p p O Q _. VI V1 V9 p V'1 VI V'1 kn J —L —L .i p © p p M N VmVn V1 Vn0 ,6000p6 Vpoui n n©©DO©DOQ o � � 5 ss 1 ^:IO a I ;^, .c rrlrl .. m I W Ir m I m I o ai I .� Ix xr �•-c' I { z w O V O p W un C7 1 C W CO 77 N O zap M xna tea= v 3 cra V) m ao m C4 -+m " _ C"� m z m z c � 0 0 m z 3 m -.1 cn m m z mm xs O � W J V T7 p m CO m A V7 N1 o ti I �s 77 � p.1 Tel: (978) 475-4786 Fax: (978) 475-5451 B ATE S ON ENTERPRISES, INC. Excavating -Water.& Sewer Lines -Septic Systems & Pumping Service 111 Argilla Road Andover, Mass. 01810 Title 5 Inspection Report Property Address: 326 Candlestick Road, Andover Owner: Bowman Date of Inspection: 6/18/2003 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 further operation of your current septic system. Neil J. Bateson Bateson Enterprises, Inc. FORM U - LOT RELEASE FORM INSTRUCTIONS: This form is used to verify that all necessary approvals/ permits from Boards and "^,artments having jurisdiction have been obtained. This does not relieve the applicant and/or landowner from compliance with any applicable or requirements,;. ***"'APPLICANT FILLS OUT THIS SECTION APPLICANT , t,y P o LS -f-N n� PHONE ��9' 83b x 7 LOCATION: 'Assessors Map Number PARCEL r. SUBDIVISION LOT (S) 4 A STREET 326 ST. NUMBER `**OFFICIAL USE ONLY RECOMMENDATIONS OF TOWN AGENTS: .! 4y . CONSERVATION ADMINISTRATOR DATE APPROVED' DATE REJECTED COMMENTS TOWN PLANNER DATE APPROVEDy` DATE REJECTED . COMMENTS: F. FOOD INSPECT R -HEALTH DATE APPROVED ... .r DATE REJECTED '51&T"SPk&OR-H—EXLTH DATE APPROVED 7 1!` DATE REJECTED COMMENTS _PUBLIC WORKS - SEWER/WATER CONNECTIONS DRIVEWAY PERMIT FIRE DEPARTMENT . RECEIVED BY BUILDING INSPECTOR DATE 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 or requirements. *****************************APPLICA-NT FILLS OUT THIS SECTION***************� ��** APPLICANT /Ir,2 PHONE 3�V LOCATION: Assessoes Map Number 106 PARCEL 3 SUBDIVISION LOT (S) STREET ls�o� (_/�►I�CI�-%u�- Iii1N2� ST. NUMBERr,&a(O *******************************OFFICIAL USE RECOMMENDATIONS OF TOWN AGENTS: v CONSERVATION ADMINI: COMMENTS TOWN PLANNER COMMENTS FOOD INSPECT-OR-HEALI t, 6 C-,-) -,-s 5 s--,ej-- 5-1-- -L)mrC-ArVKUVF-E)- DATE REJECTED SEPTfCANSOECOR-HEALTH DATE APPROVED DATE REJECTED r COMMENTS PUBLIC WORKS - SEWERIWATER CONNECTIONS DRIVEWAY PERMIT - FIRE DEPARTMENT RECEIVED BY BUJLDMG INSPECTOR DATE Revised 9197 Jim 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 or requirements. *****************************APPLICA-NT ffLi-S OUT THIS SECTION'"'***********''""`""'�"""** APPLICANT�C�%���� /'-'�i° PHONE LOCATION: Assessor's Map Number /OG PARCEL3 SUBDIVISION //�/� LOT (S) STREET l�o� (-:Jy k"-'Ck bilV 2, ST. NU.MBERr.&o2( USE RECOMMENDATIONS OF TOWN AGENTS: CONSERVATION ADMINISTRATOR DATE APPROVED DATE REJECTED COMMENTS TOWN PLANNER COMMENTS DATE APPROVED DATE REJECTED_ FOOD INSPECTOR -HEALTH DATE APPROVED DATE REJECTED R -HEALTH DATE APPROVED DATE REJECTED_ c / COMMENTS A-� PUBLIC WORKS - SEWER/WATER CONNECTIONS DRIVEWAY PERMIT - FIRE DEPARTMENT RECEIVED BY BUJL04NG MISPE-CTOR DATE �a Revised 9197 jm 2 FORM U - LOT RELEASE FORM INSTRUCTIONS: This form is used to verify that all necessary approvals/pern*3 from Boards and ^n, artments having jurisdiction have been obtained. This does not relieve the applicant and/or landowner from compliance with any applicable or requirements. "*APPLICANT FILLS OUT THIS SECTION APPLICANT S01 T + A4&-rL L , DW A-, t" PHONE LOCATION: Assessors Map Number PARCEL a - SUBDIVISION f I n I LOT (S) STREET 32,6 l /� -t J, � S1�Z� I� ST. NUMBER 3 2 � ""OFFICIAL USE ONLY RECOMMENDATIONS OF TOWN AGENTS: CONSERVATION ADMINISTRATOR DATE APPROVED GATE R�JECTED COMMENTS i TOWN PLANNER DATB APPROVED DATE REJECTED COMMENTS FOOD INSPECTOR -HEALTH DATE APPROVED DATE REJECTED SEPTIC INSPECTOR -HEALTH DATE APPROVED DATE REJECTED 1:5QU l'40A' (51u/ /—c •i; ' PUBLIC WORKS - SEWER/WATER CONNECTIONS r, DRIVEWAY PERMIT S}j r FIRE DEPARTMENT '1 t: `' RECEIVED BY BUILDING INSPECTOR DATE r Lf prop -- a 98F 14 � 1 98 ' 98.74 -Porch y BIUVId _PIS• i Edge 8ft. Conc. I � I `� Fs#finc� Building I Driveway WI st r G26 Porch .k ON - 1— �+t 4M1 l Y S � f ry s �R 01" V LOT 4 d WeLbands. .<- . ' Existin Reta ning Was of wetlan as -YY 9 W mnno W.F.- A6 W.F.-A7 Ed a � k 1 t ' W.F.- A ,--------------- s _ ---- ---------- 93.15 ----- Lim;# Exist. Retain. Walls R' sk fzr - �� / /• Trees �� �- ' Prop. Haybaies � —Eros. Contr.99. �It ' Fj(IStiil9 POOi _ en 1 AP prox. LOctaior PTOP096 � -- 113 � ' a L — o cn Disturbed fea =1,000 s.f. b 94.24 ---- 1 iy M t i 0 De -wafering 5 40 " Basin *�3r 0 sed pool t r Lf prop -- a 98F 14 � 1 98 ' 98.74 -Porch y BIUVId _PIS• i Edge 8ft. Conc. I � I `� Fs#finc� Building I Driveway WI st r G26 Porch .k ON - 1— �+t 4M1 l Y S � f ry s �R 01" V LOT 4 Comm nw alth of Massachusetts P, ^ , Massacliusetts System Pumping Record System Urvner Vow Vtk-(�^- System Location Date of Pumping:+��y' Quantity Pumped: /6 -gallons Cesspool: No 14--" Yes Septic Tank: No Yes CJ System Pumped by: 97arwOet License # Contents transferrred to : Greater Lawrence 3ailitartt District Date: Inspector: TOWN OF NORTH ANDOVFi i BOARD OF HEALTH APR 2 61999 DATE 3 24 2 Sheet of BOARD OF HEALTH c� TOWN OF NORTH ANDOVER `�' 1ceo tAe SUBSURFACE DISPOSAL DESIGN REVIEW FEE PERMIT # DATE RECEIVED APPLICANT 7'0>4-40 ASSESSOR'S MAP ADDRESS PARCEL # LOT # 43, '� ��.; _ 1���i Y 10 ENGINEER Ww , g e STREET ADDRESS 441 q,p PLAN DATE r REVISION DATE 31(a Z CONDITIONS OF APPROVAL: APPROVED DISAPPROVED x ro -Ek 40 �� �i1 �a►����� cw sib x.11 S �' -0 6F F�t�S\� Gc�I-a0 A -l50 C, �. t�, i� . St�r�Jko �e 5�-� �F�C� its •Z4" Mini Lon -44 (150-200 9e.0tsle F(Obr cteq . � tit -Z �tn=L pmt• �E K 4"T .11 W-1 Cg ►�oI� trt�.r�i+� t�tso s t o� z��, �,� ►,3 s( R,O luoic-AT 5-f , \T lSts1 t'ip 'iU, A. d1rtlGz Ca+rt.�� of WKS S't�ovi�o -66 5�gKlt'a r' Y FORM U TOWN OF NORTH ANDOVER LOT RELEASE FORti SUBDIVISION ASSESSORS MAP SUBDIVISION LOT(S) PERMANENT ADDRESS (ASSIGNED BY D.P.W. STREET /j�wV Lt-S%7&1C APPLICANT /% /y. �; /���/�T/Ec3 PHONE DATE OF APPLICATION Z — Z TOWN USE BELOW THIS LINE PLANNING BOARD DATE APPROVED TOWN PLANNER DATE REJECTED CONSERVATION COMMISSION DATE APPROVED CONSERVATION ADMIN. ATE REJECTED BOARD OF HEALTH H SAN1'TARIAN G' 4 6e�ee-,del DEPARTMENT OF PUBLIC WORKS DRIVEWAY PERt1IT SEWER/WATER CONNECTIONS FIRE DEPT. RECEIVED BY BUILDING INSPECTION DATE DATE APPROVED 3 �� DATE REJECTED This form shall be signed by the agents of the Planning and Health Boards, the Conservation Commission prior to the issuance of any building permits for the subject lot. This form shall not releive the applicant from the compliance of any applicable Town requirement or Bylaw. Town of North Andover, Massachusetts Form Na 2 Of pOR71y BOARD OF HEALTH a • t DESIGN APPROVAL FOR SSACHUSE< SOIL ABSORPTION SEWAGE DISPOSAL SYSTEM � � Q Applicant i"�D�,t4Z, Test No. Site Location Reference Plans and Specs.- ENGINEER DESIGN ------7 Pp DATE Permission is granted for an individual soil absorption sewage disposal syste be ' stalled in accordance with regulations of Board of Health. lid`` ��T �� rL/ `L�4�6� P12 0&- CHAIRMA H Fee oma- Site System Permit No. f 1►ORTIy O <�No �a14.0 O? F 9 �SSACMUSEt Applicant &n. Site Location Town of North Andover, Massachusetts Form No. 3 BOARD OF HEALTH (:),, a` 19� DISPOSAL WORKS CONSTRUCTION PERMIT 4* Permission is hereby granted to Constructxor Repair ( ) an Individual Soil Absorption Sewage Disposal System as shown on the Design Approval S.S. No. CHAIRMAN, BOARD OF HEALTH Fee D.W.C. No. S% (�J :O.L a aASl� VKL SlN2LLK I 51 vi r •aui Isasiad.ialua uosalug :Ag (tadwad waLsAs (»taxa) lialuo QaQOOrm xavaulu ariaL IDvarl 33VId NI S31:1-AV8 HaAOJ 01 rIlM SdA ON :?IlWI3LLadS a MdWad A.LLLNVfla (asnoq 3o ;aoj; gai .ajdmexa) NOL VDOrl WHISAS HaAOAMWJ SOT'IOS SQI'IOS amsmxa SlOOM 3sv3us A"3H NOLLICIKOJ 0000 :SNOLLVAUHSHO 2M LfIOH :93IAHaS 30 a2If UVN SQA ON VIOOdSS213 :9NldWad 30 HIVQ SSHIQQV v H:gNAAO WHISAS ,c :HJLVG Q2I0392i 9mIdWlld INH.LS1iS I /V .30 NMOL Town of North Andover, Massachusetts Form No. -3 f NOR71� BOARD OF HEALTH . p L 19 �-- CHU DISPOSAL WORKS CONSTRUCTION PERMIT : Applicant NAME ADDRESS Site Location s tt Z TELEPHONE Permission is hereby granted to Constructor Re air n the Desi n A p ( an Individual Soil Absorption Sewage Disposal System as shown o Design Approval S.S. No. CHAIRMAN, BOARD OF HEALTH Fee D.W.C. No. n►-- N ;Qcll- l ti� ►STN' /�tiC,wt=l�, MA, nor 5 -0 PPRO uCD NLC- 56P f C sy s I EAA vES► 6J APRzvul,06 AUTmoi�iTy 4� PCAAJ D65i 61J6 DI SAPPR� VEp CO�p(T�o�JS PwL E74U4T(clJ 5cPT(6 SY STEM w siA Lt "dTl o" l v5PF:�:Tloo APPI3o\jEP OF -415S Q F141L- F( ISE FT2VA-\ HOOS ry V ry r L1 I?A S5 `Q F/OIL ADD(T(DMAI_ 115 Zj (ONS (11=- A►ji) DISAP17i UO\J D RSO 50 NS DArC APFt)vw6 AuTHoi�rTy NsT&L&f& FVAL /JPPIZVAL por APPRoavJ6 4u i Hogg t\/t 1` o Q e � S. O Qao � _ 41 Co V �v �aV) CA IVOL V Q �� -77 , Q \ 2112' 1 \a ZOCUS /VIA P aSCA4 E: / s/-' h t 173c' `J ssoo �; .. _I �00 p 'q o nkj ") �v y Q-N/Q s � �sR stir VN lL� � Z W l� O /Iu.�.la5�9ya�� a3/I�l `� �2 , N86�=�- Ll/ �POBEh� T �USZ ,-I PPRO VA L L INDER THE SUBDIVISION CONTROL LAW NOT RE U�RED. NORTH ANDOVER PL AIVAI/NG 6OARo DA TE: 0 "3 - 2 Y - `I c� Amy ,JA AIL/ / CERT/FY THAT TH/S PLAN WAS /A/ CO/VFORA-IA/VCE INiTH THE RULES REGULATIONS OF Th'E REG/S7-ER OF OR/i F7-5MA N 3/f/9Z DA TE R L. 5 M K ROAO VAT� ;i S/3024- 26 /50.00' � V) V) o \ wog tV W X Q l`Y x Q *s v �s I' III ` 47 13' O'a\S) IIS' "OZ 223.0 cK (PR R OAO �'AI�lOLE S?v�rE R=5/6.22" S/3° 2 /D"/50.00" ... L = 39 97 � 1 1 o. I. �3 �o� �z 0 4 yW 0 NOON b* �� 0 CL 4K tn Iii, W LAJ o. � I Q\ Q �' m C) LJ10 , v DATE: TOWN OF NORTH ANDOVER SYSTEM PUMPING RECORD (example: left front of house) UAlt. Vii rUlVlrliNk3: 11UA1N 111 Y rU1V1rLl) I---) CESSPOOL: NO —,YES SEPTIC TANK: NO NATURE OF SERVICE: ROUTINE - EMERGENCY OBSERVATIONS: GOOD CONDITION HEAVY GREASE ROOTS EXCESSIVE SOLIDS SOLIDS CARRYOVER SYSTEM PUMPED BY: COMMENTS: UALLON 5 YES 80ARC � NOV 30 2001 FULL TO COVER BAFFLES IN PLACE LEACHFIELD RUNBACK FLOODED OTHER (EXPLAIN) CONTENTS TRANSFERREDw �, ` (i TO: & J i 4- O I MA 'a QJ O U N •4; ru b A '3 a.+ c o � c m o 0 ooa U F- O � 14 Q � Z a U O C Commonwealth of Massachusetts EC IVED lugCity/Town of System Pumping Record MAR 'I " Z012 Form 4 [HEALTH N OF NORTH ANDOVER DEPARThnF:niT DEP has provided this form for use by local Boards of Health. Other forms may be used, but the information must be substantially the same as that provided here. Before using this form, check with your local Board of Health to determine the form they use. The System Pumping Record must be submitted to the local Board of Health or other approving authority. A. Facility Information 1. System Location: Le Right front of ho , Left / Right rear of house, Left / right side of house, Left / Right side of building, Le Ight front of building, Left / Right rear of building, Under deck Address Citylrown State 2. System Owner. Name G�VG�7 �o Address (if different from location) City/Town B. Pumping Record 1. Date of Pumping 3. Type of system: ❑ ❑ Other (describe): Date Cesspool(s) a- - 2. Quantity Pumped: eptic Tank 4. Effluent Tee Filter present? ❑ Yes No 5. Con 'tion of System - 6. System Pumped By: Zip Code State 691 n ^1 - 6 Zip Code Telephone Number Gallons ❑ Tight Tank If yes, was it cleaned? ❑ Yes ❑ No Neil Bateson F5821 Name Vehicle License Number Bateson Enterprises Inc Company 7. Lo -cation where contents were disposed: G. L S. Lowell Waste Water Sig t Haule Date t5form4.doc• 06/03 System Pumping Record • Page 1 of 1 Commonwealth of Massachusetts = City/Town of a.o System Pumping Record M 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. System Location: Left side of house, Right side of house, Left front of hoib,Left rear of house, Right rear of house. Left rear of building. Right rearof Right nt of house, Address -�)D (o City/Town State Zip Code 2. System Owner: Name Address (if different from location) City/Town B. Pumping Record 3 _d�) -40 1. Date of Pumping Date 2. Quantity Pumped: eptic Tank Stateip Code Telephone Number 3. Type of system: ❑ Cesspool(s) Gallons ❑ Tight Tank ❑ Other (describe): 4. Effluent Tee Filter present? ❑ Yes [-I o If yes, was it cleaned? ❑ Yes ❑ No 5. Con ition of Sy Qya— ✓� 6. System Pumped By: Neil Bateson Name Bateson Enterprises Inc Company 7. Location where contents were disposed: 0.L/13.D /7 � Lowell Waste Water Of F5821 Vehicle License Number Date t5form4.doc• 06/03 System Pumping Record • Page 1 of 1 Commonwealth of Massachusetts Ze. City/Town of a W° System Pumping Record O Form 4 TOWN O HEALT DEP has provided this form for use by local Boards of Health. Other forms may be use information must be substantially the same as that provided here. Before using this form, check with your local Board of Health to determine the form they use. The System Pumping Record must be submitted to the local Board of Health or other approving authority. A. Facility Information 1. System Location: Left front of hou right front of ��, left side of house, right side of house, Left rear of house, right rear of house, le oouilding, right rear of building, under deck. (:'-Vto P4 City/Town State 2. System Owner: �f xuG�c-) 1 l Name Address (if different from location) City/Town B. Pumping Record 1. Date of Pumping 3. Type of system: ❑ Date Cesspool(s) Zip Code Telephone Number — 2. Quantity Pumped Septic Tank Gallons ❑ Tight Tank ❑ Other (describe): 4. Effluent Tee Filter present? ❑ Yes � If yes, was it cleaned? ❑ Yes ❑ No 5. Condition of 6. System Pumped By: Neil J. Bateson Name Bateson Enterprises Inc. Company k!(��VLP—t � A, 7. Location where contents were disposed: L.S.D. F5821 Vehicle License Number Date t5form4.doc° 06/03 System Pumping Record ° Page 1 of 1