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HomeMy WebLinkAboutMiscellaneous - 337 HILLSIDE ROAD 4/30/2018 (2)i COMMONWEALTH OF MASSACHUSETTS /2I,. lx --13 -mss EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS DEPARTMENT OF ENVIRONMENTAL PROTECTION SEP - 7 2005 TITLE 5 TOWN OF NORTH ANDOVER HEALTH DEPARTMENT OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM PART A CERTIFICATION Property Address: 337 Hillside Road_ —North Andover_ Owner's Name: _Carol Potvin_ Owner's Address: _337 Hillside Road_ _ North Andover MA 01845_ Date of Inspection: _6/14/2005_ 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: X_ Passes Conditionally Passes I[A N Further Evaluation by the Local Approving Authority ds Inspector's Signature: Date: _6/14/2005_ The system inspector shall submit a copy of this inspection report to the Approving Authority (Board of Health or DEP) within 30 days of completing this inspection. If the system is a shared system or has a design flow of 10,000 gpd or greater, the inspector and the system owner shall submit the report to the appropriate regional office of the DEP. The original should be sent to the system owner and copies sent to the buyer, if applicable, and the approving authority. Notes and Comments: ****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: _337 Hillside Road_ _ North Andover— Owner: _Potvin_ Date of Inspection: _6/14/2005_ Inspection Summary: Check A,B,C,D or E / ALWAYS complete all of Section D A. System Passes: X 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: One or more system components as described in the "Conditional Pass" section need to be replaced or repaired. The system, upon completion of the replacement or repair, as approved by the Board of Health, will pass. Answer yes, no or not determined (Y,N,ND) in the for the following statements. If "not determined" please explain. 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: 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: 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: _337 Hillside Road_ _ North Andover — Owner: _Potvin_ Date of Inspection: 6/14/2005 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 su_rface 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: _337 Hillside Road _ _ North Andover— Owner: _Potvin_ Date of Inspection: _6/14/2005_ D. System Failure Criteria applicable to all systems: You must indicate "yes" or "no" to each of the following for all inspections: _ _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 _ NoLiquid depth in cesspool is less than 6" below invert or available volume is'h 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 1 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 YYoou 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 11 OFFICIAL INSPECTION FORM — NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST Property Address: 337 Hillside Road _ _ North Andover— Owner: _Potvin_ Date of Inspection: _6/14/2005_ Check if the following have been done. You must indicate `yes" or "no" as to each of the following: Yes No Yes_ _ Pumping information was provided by the owner, occupant, or Board of Health No Were any of the system components pumped out in the previous two weeks ? Yes_ — Has the system received normal flows in the previous two week period ? No Have large volumes of water been introduced to the system recently or as part of this inspection ? Yes_ _ Were as built plans of the system obtained and examined? Yes Was the facility or dwelling inspected for signs of sewage back up ? Yes _ Was the site inspected for signs of break out ? Yes _ Were all system components, excluding the SAS, located on site ? _Yes_ _ Were the septic tank manholes uncovered, opened, and the interior of the tank inspected for the condition of the baffles or tees, material of construction, dimensions, depth of liquid, depth of sludge and depth of scum ? _Yes_ _ Was the facility owner (and occupants if different from owner) provided with information on the proper maintenance of subsurface sewage disposal systems ? The size and location of the Soil Absorption System (SAS) on the site has been determined based on: Yes no _Yes_ — Existing information. _Yes_ _ Determined in the field (if any of the failure criteria related to .Part C is at issue approximation of distance is unacceptable) [3 10 CMR 15.302(3)(b)] Page 6 of 1 I OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION Property Address: _337 Hillside Road _ _ North Andover— Owner: _Potvin _ Date of Inspection: 6/14/2005_ FLOW CONDITIONS RESIDENTIAL Number of bedrooms (design): _3_ Number of bedrooms (actual): _4_ DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x # of bedrooms): _600_ Number of current residents: _2 Does residence have a garbage grinder (yes or no): Yes Is laundry on a separate sewage system (yes or no): --Bi-00 1 ®-�2-�-5 Laundry system inspected (yes or no): _ Seasonal use: (yes or no): _No_ Water meter reading: _On well water _ Sump pump (yes or no): _No_ Last date of occupancy: _Current COMIVIERCIALMMUSTRIAL 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 last year, 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 & tees_ 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: 24 years old, 9/10/1981, As built plan _ 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: 337 Hillside Road_ _ North Andover _ Owner: _Potvin_ Date of Inspection: 6/14/2005_ BUILDING SEWER _ X _ (locate on site plan) Depth below grade: _20"_ Materials of construction: _X_ 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.) 3" PVC in garage. Unable to see piping leaving foundation. No leaks visible_ SEPTIC TANKS: X Depth below grade: _8"_ 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: 2"_ Distance from top of sludge to bottom of outlet tee or baffle: _25" _ Scum thickness: _3" _ Distance from top of scum to top of outlet tee or baffle: _8" _ Distance from bottom of scum to bottom of outlet tee or baffle: _18" _ How were dimensions determined: _Tape measure_ 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 ok. Depth of liquid at outlet invert. No evidence of leakage. _ GREASE TRAP: (locate on site plan) Depth below grade: _ Material of construction: _concrete _metal _fiberglass _polyethylene _other (explain): Dimensions: Scum thickness: Distance from top of scum to top of outlet tee or baffle: Distance from bottom of scum to bottom of outlet tee or baffle: Date of last pumping: Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): Page 8 of 11 OFFICIAL INSPECTION FORM — NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: _337 Hillside Road_ _ North Andover— Owner: _Potvin_ Date of Inspection: 6/14/2005_ TIGHT or HOLDING TANK: (tank must be pumped at time of inspection)(locate on site plan) Depth below grade: Material of construction: concrete metal fiberglass _polyethylene other(explain): Dimensions: Capacity: gallons Design Flow: gallons/day Alarm present (yes or no): Alarm level: Alarm in working order (yes or no): Date of last pumping: Comments (condition of alarm and float switches, etc.): DISTRIBUTION BOXES: _X 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 -Boa level & distribution equal. No evidence of leakage. No evidence of carryover._ PUMP CHAMBER: X (locate on site plan) Pump in working order (yes or no): Yes_ Alarm in working order (yes or no): Yes, light only bell inoperative._ Comments (note condition of pump chamber, condition of pumps and appurtenances, etc.): Pump cycled on then off. Alarm has visual but no audible. Bell inoperative. Page 9 of 11 OFFICIAL INSPECTION FORM — NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: 337 Hillside Road_ _ North Andover _ Owner: _Potvin_ Date of Inspection: 6/14/2005 SOIL ABSORPTION SYSTEM (SAS): —X - If SAS not located explain why: (locate on site plan, excavation not required) Type _ leaching pits, number: _ leaching chambers, number: — leaching galleries, number: _ leaching trenches, number, length: _X leaching fields, number, dimensions: _1 field 20' x 451 _ overflow cesspool, number: innovative/alternative system Typelname 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 sludge 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 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: 337 Hillside Road_ _ North Andover— Owner: _Potvin _ Date of Inspection: 6/14/2005_ SKETCH OF SEWAGE DISPOSAL SYSTEM Provide a sketch of the sewage disposal system including ties to at least two permanent reference landmarks or benchmarks. Locate all wells within 100 feet. Locate where public water supply enters the building. Page 11 of 11 OFFICIAL INSPECTION FORM — NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: _337 Hillside Road_ _North Andover — Owner: _Potvin_ Date of Inspection: _6/14/2005_ SITE EXAM Slope Surface water Check cellar Shallow wells Estimated depth to ground water _6'_ Please indicate (check) all methods used to determine the high ground water elevation: _X_ Obtained from system design plans on record - If checked, date of design plan reviewed: _3/16/1979_ Observed site (abutting property/observation hole within 150 feet of SAS) Checked with local Board of Health -explain: _ Checked with local excavators, installers- (attach documentation) _ Accessed USGS database -explain: _ You must describe how you established the high ground water elevation: As per design plan _ Tel: (978) 475-4786 Fax: (978) 475-5451 BATESON ENTERPRISES, INC. Excavating -Water.& Sewer Lines -Septic Systems & Pumping Service 111 Argilla Road Andover, Mass. 01810 Title 5 Inspection Report Property Address: 337 Hillside Road, North Andover Owner: Potvin Date of Inspection: 6/14/2005 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. RAI Neil J. Bateson Bateson Enterprises, Inc. TOWN OFIV SYSTE DATE: SYSTEM OWNER & ADDRESS po�u PUMPING RECORD- RECEIVED JUN 2 0 2005 TOHEAOF NORTH LLTER H DEPARTMENT OT SYSTEM LOCATION (example: left front of house) C 4- c4 DATE OF PUMPING.. QUANTITY PUMPED: � GALLONS CESSPOOL: NO ES SEPTIC TANK: NO YES NATURE OF SERVICE: ROUTINE EMERGENCY OBSERVATIONS: GOOD CONDITION HEAVY GREASE ROOTS EXCESSIVE SOLIDS SOLIDS CARRYOVER FULL TO COVER BAFFLES IN PLACE LEACIHHLD RUNBACK FLOODED OTHER (EXPLAI ) SYSTEM PUMPED BY: Bateson Enterprises, Inc. COMMENTS: CONTENTS TRANSFERRED TO: G.L.S.D Lowell Waste SOIL PROFILE & PERCOLATION TEST DATA ' North Andover,2..Iss. No.&Street Lot. No. Loc./Subdiv. Plan OwnerY�, Invest;_gator Observer 1 1. Elev. 0 1 2 3 4 5 6 7 8 9 0 Benchmark Elevation 2. Elev.- 0 1 2 3 4 5 6 7 8 9 10 3. Elev. w 0 1 2 3 4 5 6 7 8 9 10 Location Datum Percolation Tests -Date T..i� 4'Elev. Ties to Test fits Pit Number 1 2 3 4 S Start Saturation Soak -Mins. Start Test -Time Drop of 3" -Time - "-Time-Dro Drop of 6" -Time Mins.lst.3"Dro . Mins.2nd 3"Dro Percolation Rate Notes & Sketches on Hack TOWN OF /V•. A6Ore- SYSTEM PUMPING RECORD DATE: - a 0 SYSTEM OWNER & ADDRESS t ` (V\, SYSTEM LOCATION (example: left front of house) DATE OF PUMPING: _ a- 602 QUANTITY PUMPED: LO O C7 GALLONS CESSPOOL: NO YES S PTIC TANK: NO YES i2NATURE OF SERVICE: ROUTINE EMERGENCY OBSERVATIONS: GOOD CONDITION HEAVY GREASE ROOTS EXCESSIVE SOLIDS SOLIDS CARRYOVER FULL TO COVER BAFFLES IN PLACE LEACIOULD RUNBACK FLOODED OTHER (EXPLAIN) SYSTEM PUMPED BY: Bateson Enterprises, Inc. COMMENTS: CONTENTS TRANSFERRED TO: ( 'r • 1— "C -) - t ) Coma om=101 `Nassachusetts t " � ,Massachusetts System Puinpind Record System Owner V\, System Location 3Sr7 Date of !lumping: `'� Quantity Pumped: �`� allons Cesspool: No ice' Yes Septic Tank' No Yes System Pumped by: License # Contents transfertred to : Greater Lawrence Sanitary District _ Date: -- _ Inspector: TOWN OF SYSTEM PUMPING RECORD'�0gv" Aem"1--- DATE:uL-( SYSTEM OWNER & ADDRESS pe t � V'�' ?_ -'lfs4e IV -1 SYSTEM LOCATION (example: left front of house) (�4ecy(-- ke-� DATE OF PUMPING: r-3-'30-0 QUANTITY PUMPED: GALL NS CESSPOOL: NO SEPTIC TANK: NO YES NATURE OF SERVICE: ROUTINE OBSERVATIONS: GOOD CONDITION HEAVY GREASE ROOTS EXCESSIVE SOLIDS SOLIDS CARRYOVER EMERGENCY FULL TO COVER BAFFLES IN PLACE LEACHFIELD RUNBACK FLOODED OTHER (EXPLAIN) SYSTEM PUMPED BY: Bateson Enterprises, Inc. COMMENTS - -� U'X c� CONTENTS TRANSFERRED TO: G.L.S.D Lowell Waste Board of Health North An&vertMass AW SUBSURFACE DISPOSAL DESIGN CHECK LIST / LOT` APPROVED DATE_ DISAPPROVED DATE Provied, Reasons, k 4 Title V FAIL Ci -g) Reg 2.5 submitted plan must show as a minimums the lot to be served -area dimensions lot #,abutters location and log deep observation hoes -distance to ties location and results percolation tests -distance to ties design calculations & calculations showing required leaching area location and dimensions of system -including reserve area existing and proposed contours location any wet areas within 1001 of sewage disposal system or disclaimer -check wetlands mapping C. --(h) surface and subsurface drains within 1001 of sewage disposal system or disclaimer 4-1"(1) location any drainage easements within 1001 of sewage disposal systema or disclaimer -Planning Board files (j) knom sources of water supply within 2001 of sewage disposal system or disclaimer location of ate* proposed well to serve lot -1001 from leaching facility ( location of water lines on property -10t from leaching facility Xlocation of benchmark driveways garbage disposals no PVC to be used in construction q)L,,.,,,profile of system -elevations of basement, plumb, pipe, septic tank, distribution box inlets and outlets, distribution field piping and Other elevations ( maximum ground water elevation in area sewage disposal system► s) plan must be prepared by a Professional Engineer or other professional authorized by law to prepare such plans Reg 6 otic Tanks 4,JC capacities -15D% of flow, water table, tees, depth of tees, access, pumping b) cleanout 101 from cellar wall or inground swimming pool d) 251 from subsurface drains Reg 10.2 Distribution Boxes } slope gre—a—ter-ItHE 0.08 Reg 3.0.4 b) sump Reg 11.2 11.4 11.10 11.11 Reg 15.1 15.4 15.8 3.7 Reg 14.1 14.3 14.4 14.6 14.7 14.10 Reg 9.1 9.6 FAIL, OK Leaching Pits Leachingpits um a preferred where the installation is possible a) calculation of leaching area-minim500 sq ft b) spacing c surface a 2% dj cover terial e) P_'x2' " splash pad f) tee at elbow g) no bends in pipe from d-box to pipe Leachin Fields ) no greater than 20 minutes/inch area-id ni =in 900 eq ft construction of field surface drainage 2 % e) 20' from cellar gan or inground mdmmring pool Leachin Vvenches a) cam ons o leaching area-min 500 aq ft b) spacin ft min 6 ft with reserve between c) dimsn ons d) cons ction e) sto f) ace drainage 2% Downhill Slope a) slope ;r-7x—_-jto be shown) b) y/x x 150 = (to be shown) s a) app vel b) s d-by power / ✓ t . Board'of Health BLPTIC SISTEK North An ver Maes. INSTALLATICK CHECK LIST LOT 4�®�8�� APPROM DATE AVATICK OK FAIL �spns! FAIL OK ' 1. Distance To: ` a. Wetlands b. Drains c. Well 2. Water Line Location '' 3• No PPC Pipe 1t. Septic Tank - - a. _Tess -_Length & To Clean flat Covers. b. Cement Pipe to Tank .- On Both Sides of Tank - 5. Distribution, Box a. Covers & Box - No Cracks b. All Lines Flowing Lqual Amo -ants -�* c . No Back Flow 6. Leach Field or Trench a. Dimensions b. Stone Depth c. Capped ids -Washed Stone' i d. Clean Double 3 ?. Leach Pits a. Dimensi ns b. Stone/Depth c. Sp sh Pads d. T s e. emnt Pipe to Pit - Both Sides iz f. Clean Double Washed Stone 8. No Garbage Disposal Final Grading Inspection t 10. Barricading Covered System 11. As Built Submitted. - a. Lot Location - -- _-- b. Dimensions of System c. Location -4th Aegar&to Pere Test R d. Elevations , e: Water Table y f r i FOR 14 - SYSTEM Pt.NLPL�G RECORD Commonwealth of Massachusetts , Massachusetts System Pumping Record N -stem Owner rj (s. C 0-�o 1 QA' n Date of Pumping: ^-C) 9 -,5 - Cesspool: No Yes ❑ System Pumped by: Contents transferred to �7 A (/S�) �e pk-�A 4aa), C -44-7A rQG� Quantity Pumped: gallons Septic Tank: No ❑ Yes License #: Date Inspector Frank C. Gelinas and Associates Engineers & Architects North Andover Office Park NORTH ANDOVER, MASS. 01845 Phone 687-1483 TO LIEUTER ori Taa.RSOUML ATTENTION RE: GENTLEMEN: WE ARE SENDING YOU ❑ Attached ❑ Under separate cover via Ej Shop drawings ❑ Prints ❑ Plans ❑ Copy of letter ❑ Change order ❑ JOB NO. the following items: ❑ Samples ❑ Specifications COPIES DATE NO. DESCRIPTION THESE ARE TRANSMITTED as checked below: ❑ For approval ❑ Approved as submitted ❑ For your use ❑ Approved as noted ❑ As requested ❑ Returned for corrections ❑ For review and comment ❑ ❑ FOR BIDS DUE 19 REMARKS ❑ Resubmit copies for approval ❑ Submit copies for distribution ❑ Return corrected prints ❑ PRINTS RETURNED AFTER LOAN TO US COPY TO SIGNED: 42,AQ— It enclosures are not as noted, kindly notify u # It once. Ile* \1 IV 4 L,C>T C: VtILL:cj Cv� ,A6! Q %el J-14 Y .4r, INV }PIPE OUT OF H51:--- ink e E5 u i L -r i WV- PPE INTO -7;5,V V-- 6i\j PA M- OUTOE I-Abiv- r a _' _ __ _ Vim► U 9- r,4x yd5-f- em r-- e7uT �v ENI© or -- CZ. L E - I 4 N 1 L�.S1C> E-- 2oAp 1dLY___P1PE 01�T Qom' ��E" .4 6- E5 U I `„!„T L IKIV 1�fPE �htTo ew Z4o 4Z t&JsZ ut •� 1TOF' Tottst Pu e -+t �' �-� rGE !':� i�G�'JAt.-. INV PI FM INITQ�D ._ ?4l 4-726cJV INV_ PI Dom_ OUT haX_ 74 Z- �-7 '�Y'�►"i' Etat �t+.1 =my OF' PI PE Z4, 5I NJ Cf 1' Pen Ave - 11,4 Ia 11,4Ia AQGM IT�G T' S Commonwealth of Massachusetts City/Town of System Pumping Record RLEE C-V�D Form 4 AUG 2 4 2006 DEP has provided this form for use by local Boards of Health. T1 e S stem Pumping Record must be submitted to the local Board of Health or other approvin , aui�lQ RYDEPARr' i_rAr A. Facility Information Important: When filling out 1. Syste Locatiqwm forms on the computer, use e only the tab key Address to move yourik cursor - do not use the return Cityfrown StateZ Zip Code key. 2. System Owner: Vol \ `� Name Address (i(different from location) City/Town State , Zip ^ode ! Telephone Number --------------- 1:5. rumping Record L4 14—CC, �,.y� �---, 1. .Date. of Pumping Pate -- �2. Quantity Pumped: Ga . 3. Type of system: ❑ Cesspool(s) ptic Tank El Tight Tank [] Other (describe): 4. Effluent Tee Filter present? ET Yes aNo If yes, was it cleaned? El Yes Ej No 5. Conditio of Sys m: 6. Syste Pumper; BB Name Vehicle 1� Compan -- http://www.mass. ;icense Number t5form4.doc• 06/03 System Pumping Record • Page 1 of 1 -C\- Commonwealth of Massachusetts City/Town of System Pumping Record Form 4 M Important: When filling out forms on the computer, use only the tab key to move your cursor - do not use the return key. Baan DEP has provided this form for use by local Boards of Health. Oth information must be substantially the same as that provided here. local Board of Health to determine the form they use. The System the local Board of Health or other approving authority. A. Facility Information 1. Syst r Locati Sia Address��i1e. City/Town d State 2. System Owner: Name Address (if different Citylrown RECEIVED AUG 1 3 2007 s may be usedc; Zip Code Stat Zip Code Telephone Number B. Pumping Record 1. Date of Pumping Date 2. Quantity Pumped: Gallons 3. Type of system: ❑ Cesspool(s) eptic Tank ❑ Tight Tank ❑ Other (describe): ,, k with your submitted to 4. Effluent Tee Filter present? ❑ Yes 2-1 o� If yes, was it cleaned? ❑ Yes ❑ No 5. Conditjsr► oSystem: 7AX:2&A t4*c -- 6. Systerg Pumped By., 7. Location re contents AN l— , Signat)frelfq6uler t5form4.doc• 06/03 Imo Date License Number System Pumping Record • Page 1 of 1 It—\ Commonwealth of Massachusetts City/Town of RECEIV System Pumping Record Form 4 JUN 0 2 2008 F H ANDOVER DEP has provided this form for use by local Boards of Health. Other forms may &g i lWiA,,ggTMENT information must be substantially the same as that provided here. Before using Ott th 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 Important: When filling out 1. Syst m Location: forms on the computer, use only the tab key Address 73-<317 to move our cursor - do not Cityfrown State Zip Code use the return key. 2 System Owner: 'Q Name 11 Address (if different from location) City/Town Stgq` Code (Z: Telephone Number B. Pumping Record 1. Date of Pumping Date 2. Quantity Pumped: Gallons 3. Type of system: ❑ Cesspool(s) eptic Tank ❑ Tight Tank ther (describe): 141 42 LA 4. Effluent Tee Filter present? ❑ Yes No If yes, was it cleaned? ❑ Yes ❑ No 5. Cond tion of Sy em:'���{ u.�C�_� �► CJ� �, �'� 6. System um �By: Name - Vehicle License Number Company 7. t5form4.doc• 06/03 System Pumping Record • Page 1 of 1 �LN Commonwealth of Massachusetts City/Town of RECEIVRU System Pumping Record Form 4 OCT I g Nil l GM TOWN OF NORTH ANDOV ER DEP has provided this form for use by local Boards of Health. Other forms maj belgAefdi loifft)MMENT information must be substantially the same as that provided here. Before using is torm, 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 house, right front of house, of Nous fight side of house, Left rear of house, right rear of house, left side of building, right rear of building, under deck. City/Town 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: ❑ ❑ Other (describe): Date Cesspool(s) Stay L( rde Telephone Number — 2. Quantity Pumped: eptic Tank 10� Gallons ❑ Tight Tank 4. Effluent Tee Filter present? ❑ Yes Leo If yes, was it cleaned? ❑ Yes ❑ No 5. Conditign of System: 6. System Pumped By: Neil J. Bateson Name Bateson Enterprises Inc. Company 7. Locajbpawhhere contents were disposed: L.S.D. owdll Waste Water. Signature F5821 Vehicle License Number Date (C-")--1 `f -1 r t5form4.doc• 06/03 System Pumping Record • Page 1 of 1 Commonwealth of Massachusetts City/Town of RECEIVED System Pumping Record 2009 Form 4 JUN ' 8 r OF NNORTH ANDOVER DEP has provided this form for use by local Boards of Health. Other ol�ti 0i3��i information must be substantially the same as that provided here. Be g is 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 Important: When filling out forms on the computer, use only the tab key to move your. cursor - do not use the return key. 1. System Location: Left front, left re left side of hous Right front, right rear, right side of house. Address ��� ' q �S� City/TownfU- 2. System Owner: Name Address (if different from location) City/Town B. Pumping Record 1. Date of Pumping 3. Type of system: 8 Other (describe): M -M State Zip Code StatR Zip Code —c tf Telephone Number G —3 --<fDF� Date 2. Quantity Pumped: Gallons Cesspool(s) - eptic Tank Tight Tank 4. Effluent Tee Filter present? 0 Yes 4 If yes, was it cleaned? p Yes L] No 5. Condition of System: 6. System Pumped By: Neil Bateson Name Bateson Enterprises Inc Company 7. Lo a contents were disposed: g.L.S.D Lowell Waste Water F 5821 Vehicle License Number of H;Jutbr Date t5form4.doc• 06/03 System Pumping Record • Page 1 of 1