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Miscellaneous - 36 WINDSOR LANE 4/30/2018 (2)
Gaf)Ct+ mdtr U-a bu/yl-- Commonwealth of Massachusetts--- City/Town ofMEN 4 System Pumping Record OCT 2 3 2008 Form 4 Important: When filling out forms on the computer, use only the tab key to move your cursor - do not use the return key. ISI 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 fro , left ear, eft side qiHuip Right front, right rear, right side of house. ` Address -�3 (S Ui ) City/Town State Zip Code 2. System Owner: Name Address (if different from location) Cityrrown B. Pumping Record 1. Date of Pumping 3. Type of system: M [j Other (describe): Stat( C `c. —'W' Zip Telephone Number LO- 16, r-119 Date 2. Quantity Pumped: Gallons Cesspool(s) _= Septic Tank Ll Tight Tank 4. Effluent Tee Filter present? [] Yes a -go If yes, was it cleaned? p Yes [ No 5. Condition of System: 6. System Pumped By: Neil Bateson Name Bateson Enterprises Inc Company 7. Location where contents were disposed: S. Lowell Waste Water F 5821 Vehicle License Number of Hdutbr Date t5form4.doc• 06/03 System Pumping Record • Page 1 of 1 Important: When filling out forms on the computer, use only the tab key ` to move your cursor - do not use theretum key. Commonwealth of Massachusetts RECEIVED City/Town of System Pumping Record APR - 2 2007 Form 4 TOWN OF NOK i H ANDOVER DEP has provided this form for use by local Boards of Health. The st" i -P�uix plrag-heNUwd be submitted to the local Board of Health or other approving authority. . A. Facility Information 1. SysteT Location: Address Qityfrown 2. System Owner: State Zip Code Name Address (if different from location) Cityfrown State � c ''Z a e' -4 Telephone Number B. Pumping Record , .Date. of Pumping 2. Quantity Pumped :PateGallons 3. Type of system: ❑ Cesspool(s) eptic Tank ❑ Tight.Tank ❑ Other (describe): 4: Effluent Tee Filter present? ❑ Yes No If yes, was it cleaned? El Yes ❑ No 5. Condi ' n of System: ?.v,rV4, t5form4.doc• 06/03 als/t5i System Purnping Record • Page 1 of 1 TOWN OF NORTH ANDOVER SYSTEM PUMPING RECORD j .. r DATE: �"'o— c- (-IkP yea 1 420 (example: left front of house) DATE OF PUMPING: c� QUANTITY PUMPED (S -Z GALLONS CESSPOOL: NO YES SEPTIC TANK: NO YES ' f NATURE OF SERVICE: ROUTINE EMERGENCY OBSERVATIONS: GOOD CONDITION FULL TO COVER HEAVY GREASE BAFFLES IN PLACE ROOTS LEACHFIELD RUNBACK EXCESSIVE SOLIDS FLOODED SOLIDS CARRYOVER OTHER (EXPLAIN) (�� SYSTEM PUMPED BY: COMMENTS: CONTENTS TRANSFERRED TO: G,. L " 3,n R Owner information is required for every page. Important: When filling out forms on the computer, use only the tab key to move your cursor - do not use the return key. t5ins • 11/10 Commonwealth of Massachusetts Title 5 Official Inspection Form �� zol / Subsurface Sewage Disposal System Form - Not for Voluntary Assessments TC.V`0: MCR -r; i Fi;• _-;7 j� 36 Windsor Lane Property Address James Brennan Owner's Name North Andover Cityrrown MA 01845 State Zip Code 11/23/20U Date of Inspection Inspection results must be submitted on this form. Inspection forms may not be altered in any way. Please see completeness checklist at the end of the form. A. General Information 1. Inspector: Neil James Bateson Name of -Inspector Bateson Enterprises Inc. Company Name 111 Argilla Road Company Address Andover Cityrrown 978-475-4786 Telephone Number B. Certification MA State SI 15 License Number 01810 Zip Code 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 ❑ Fails ❑ 4Nee,,,..F her E uati n by the Local Approving Authority 11/23/2012 Inspecorsgnature Date 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. ""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. Title 5 Official Inspection Form: Subsurface Sewage Disposal System • Page 1 of 17 r— = Owner information is required for every page. Important: When filling out forms on the computer, use only the tab key to move your cursor - do not use the return key. t5ins • 11/10 r Commonwealth of Massachusetts / Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not -for Voluntary Assessments 36 Windsor Lane Property Address James Brennan Owner's Name North Andover MA 01845 11/10/2012 Cityrrown State Zip Code Date of Inspection Inspection results must be submitted on this form. Inspection forms may not be altered in any way. Please see completeness checklist at the end of the form. A. General Information 1. Inspector: Neil James Bateson Name of Inspector Bateson Enterprises Inc. Company Name 111 Arailla Road Inv C.Q ZOIZ TOWN OF NORTH ANDOVER 'Company Address Andover MA 01810 Cityfrown State Zip Code 978-475-4786 S115 Telephone Number License Number B. Certification 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 ❑ Fails ❑ Needs Further Evaluation by the Local Approving Authority 11/10/2012 Inspe o s gnature Date 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. ****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. Title 5 Official Inspection Form: Subsurface Sewage Disposal System • Page 1 of 17 Owner information is required for every page. t5ins • 11/10 Commonwealth of Massachusetts Title.5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 36 Windsor Lane Property Address James Brennan Owner's Name North Andover City[rown B. Certification (cont.) MA .01845 State Zip Code 11/10/2012 Date of Inspection 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: ® 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. Check the box for "yes", "no" or "not determined" (Y, N, ND) 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. ARMENF®RK ❑ ND (Explain below): Title 5 Official Inspection Form: Subsurface Sewage Disposal System • Page 2 of 17 Owner information is required for every page. Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 36 Windsor Lane Property Address James Brennan Owner's Name North Andover Cityrrown B. Certification (cont.) B) System Conditionally Passes (cont.): MA 01845 State Zip Code 11/10/2012 Date of Inspection ❑ 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 ❑ Y ® N ❑ ND (Explain below): ❑ Y ® N ❑ ND (Explain below): ❑ Y ® N ❑ ND (Explain below): ❑ 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 ❑ Y ® N ❑ ND (Explain below): ❑ obstruction is removed ❑ Y ® N ❑ ND (Explain below): 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 t5ins - 11110 Me 5 Official Inspection Form: Subsurface Sewage Disposal System • Page 3 of 17 Owner information is required for every page. Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 36 Windsor Lane Property Address James Brennan Owner's Name North Andover NIA 01845 11/10/2012 Citylrown State Zip Code Date of Inspection B. Certification (cont.) 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 fecal coliform bacteria indicates absent 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: D -box needs to be replaced & risers install on top of d -box. D) System Failure Criteria Applicable to All Systems: You must indicate "Yes" or "No" to each of the following for all inspections: Yes No ❑ ® Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool ® Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool ❑ ® Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool ❑ ® Liquid depth in cesspool is less than 6" below invert or available volume is less than Y2 day flow t5ins • 11/10 Title 5 Official Inspection Form: Subsurface Sewage Disposal System • Page 4 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments M 36 Windsor Lane Property Address James Brennan Owner Owner's Name information is required for North Andover MA 01845 11/10/2012 every page. City/Town State Zip Code Date of Inspection B. Certification (cont.) Yes No ❑ ® Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number of times pumped: ❑ ® Any portion of the SAS; cesspool or privy is below high ground water elevation. ❑ ® Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ ® Any portion of a cesspool or privy is within a Zone 1 of a public well. ❑ ® Any portion of a cesspool or privy is within 50 feet of a private water supply well. ❑ ® 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 fecal coliform bacteria indicates absent 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 and chain of custody must be attached to this form.] ❑ ® The system is a cesspool serving a facility with a design flow of 2000gpd- 10,000gpd. ❑ ® 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. For large systems, you must indicate either "yes" or "no" to each of the following, in addition to the questions in Section D. Yes No ❑ 3 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 ID ❑ 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 y6o 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. . r t5ins • 11/10 Tide 5 Official Inspection Form: Subsurface Sewage Disposal System • Page 5 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 36 Windsor Lane Property Address James Brennan Owner Owner's Name requir atifor North Andover required for every page. Cityrrown C. Checklist t5ins • 11/10 MA 01845 State Zip Code 11/10/2012 Date of Inspection Check if the following have been done. You must indicate "yes" or "no" as to each of the following: Yes No Pumping information was provided by the owner, occupant, or Board of Health Were any of the system components pumped out in the previous two weeks? Has the system received normal flows in the previous two week period? Have large volumes of water been introduced to the system recently or as part of this inspection? Were as built plans of the system obtained and examined? (If they were not available note as N/A) Was the facility or dwelling inspected for signs of sewage back up? Was the site inspected for signs of break out? Were all system components, excluding the. SAS, located on site? . 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? 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: Existing information. For example, a plan at the Board of Health. Determined in the field (if any of the failure criteria related to Part C is at issue approximation of distance is unacceptable) [310 CMR 15.302(5)] D. System Information Residential Flow Conditions: Number of bedrooms (design): 4 Number of bedrooms (actual): 4 DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x# of bedrooms): 600 Title 5 Official Inspection Form: Subsurface Sewage Disposal System • Page 6 of 17 Type of Establishment: Design flow (based on 310 CMR 15.203): Basis of design flow (seats/persons/sq.ft., etc.): Grease trap present? Industrial waste holding tank present? Non -sanitary waste discharged to the Title 5 system? Water meter readings, if available: Gallons per day (gpd) ❑ Commonwealth of Massachusetts ❑ No ❑ Title 5 Official Inspection Form ❑ No ❑ Subsurface Sewage Disposal System Form - Not for. Voluntary Assessments ❑ No 36 Windsor Lane Property Address James Brennan Owner Owner's Name information is required for North Andover MA 01845 11/10/2012 every page. CitylTown State Zip Code Date of Inspection D. System Information Description: Number of current residents: 3 Does residence. have a garbage grinder? ® Yes ❑ No Is laundry on a separate sewage system? [if yes separate inspection required] ❑ Yes ® No Laundry system inspected? ❑ Yes ❑ No Seasonaluse? ❑ Yes ® No Water meter readings, if available (last 2 years usage (gpd)): Yes Detail: Sump pump? ❑ Yes E. No Last date of occupancy: Current Date Commercial/Industrial Flow Conditions: Type of Establishment: Design flow (based on 310 CMR 15.203): Basis of design flow (seats/persons/sq.ft., etc.): Grease trap present? Industrial waste holding tank present? Non -sanitary waste discharged to the Title 5 system? Water meter readings, if available: Gallons per day (gpd) ❑ Yes ❑ No ❑ Yes ❑ No ❑ Yes ❑ No t5ins - 11110 Title 5 Official Inspection Form: Subsurface Sewage Disposal System - Page 7 of 17 Commonwealth of Massachusetts w Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 36 Windsor Lane Property Address James Brennan Owner Owner's Name information is required for North Andover MA 01845 11/10/2012 every page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Last date of occupancy/use: Date Other (describe below): General Information Pumping Records: Source of information: Was system pumped as part of the inspection? If yes, volume pumped: How was quantity pumped determined? Reason for pumping: Type of System: Pumped 2010,owner 1500 gallons Measured tank Inspect tank y - ■ ® 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) and a copy of latest inspection of the I/A system by system operator under contract ❑ Tight tank. Attach a copy of the DEP approval. ❑ Other,(describe): t5ins • 11/10 Title 5 Official Inspection Form: Subsurface Sewage Disposal System • Page 8 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments lug 36 Windsor Lane Property Address James Brennan Owner Owner's Name information is required for North Andover MA 01845 11/10/2012 every page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Approximate age of all components, date installed (if known) and source of information: 26 years old, 8/211986, as built plan Were sewage odors detected when arriving at the site? ❑ Yes ® No Building Sewer (locate on site plan): Depth below grade: 1.8feet Material of construction: ❑ cast iron ❑ 40 PVC ❑ other (explain): Distance from private water supply well or suction line: feet Comments (on condition of joints, venting, evidence of leakage, etc.): Finished cellar unable to see piping Septic Tank (locate on site plan): Depth below grade: , Material of construction: ® concrete ❑ metal U feet ❑ fiberglass ❑ polyethylene ❑ other (explain) If tank is metal, list age;, years Is age confirmed by a. Certificate of Compliance? (attach a copy of certificate) ❑ Yes ❑ No Dimensions: 10'x 5'x 4' Sludge, depth: 5" t5ins • 11110 Title 5 Official Inspection Form: Subsurface Sewage Disposal System - Page 9 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 36 Windsor Lane Property Address James Brennan Owner information is required for every page. t5ins • 11/10 Owner's Name North Andover Cityrrown D. System Information (cont.) Septic Tank (cont.) MA 01845 11/10/2012 State Zip Code Date of Inspection Distance from top of sludge to bottom of outlet tee or baffle 22 4„ _. Scum thickness 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 15„ 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 Grease Trap (locate on site plan): Depth below grade: feet 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: Date TrUe 5 Official Inspection Form: Subsurface Sewage Disposal System • Page 10 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 36 Windsor Lane Property Address James Brennan Owner owner's Name information is ired for re North Andover MA 01845 11/10/2012 w 4 every page.Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): 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 per day Alarm present: ❑ Yes ❑ No Alarm level: Alarm in working"order: ❑ Yes ❑ No Date of last pumping: Date Comments (condition of alarm and float switches, etc.): * Attach copy of current pumping contract (required). Is copy attached? ❑ Yes ❑ No l5ins • 11/10 Title 5 official Inspection Form: Subsurface Sewage Disposal System • Page 11 of 17 Owner information is required for every page. Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 36 Windsor Lane Property Address James Brennan Owner's Name North Andover City/Town D. System Information (cont.) MA 01845 State Zip Code 11/10/2012 Date of Inspection Distribution Box (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. Evidence of carryover, pumped d -box to clean. D -box has corrosion holes, needs to be replaced. Pump Chamber (locate on site plan): Pumps in working order: Alarms in working order: ❑ Yes ❑ No ❑Yes ❑No Comments (note condition of pump chamber, condition of pumps and appurtenances, etc.): Soil Absorption System (SAS) (locate on site plan, excavation not required): If SAS not located, explain why: t5ins - 11!10 Title 5 Official Inspection Form: Subsurface Sewage Disposal System • Page 12 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 36 Windsor Lane Property Address .James Brennan Owner Owner's Name information is required for North Andover MA 01845 11/10/2012 every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Type: ❑ leaching pits number: ❑ leaching chambers number: ❑ leaching galleries. number: ® leaching trenches number, length: 2 trenches 45' 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 ❑ No t5ins • 11/10 Title 5 Official Inspection Forth: Subsurface Sewage Disposal System . Page 13 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 36 Windsor Lane Property Address James Brennan Owner Owner's Name information is required for North Andover MA 01845 11/10/2012 every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 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.): t5ins • 11/10 1Title 5 Official Inspection Form: Subsurface Sewage Disposal System • Page 14 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 36 Windsor Lane Site Exam: Property Address James Brennan Owner Owner's Name information is required for North Andover MA 01845 every page. Cityrrown State Zip Code Shallow wells D. System Information (cont.) Site Exam: ® Check Slope ® Surface water ® Check cellar ® Shallow wells 11/10/2012 Date of Inspection Estimated depth to high ground water. 4 feet Please indicate all methods used. to determine the high ground water elevation: ® Obtained from system design plans on record If checked, date of design plan reviewed: Date 86 Date ❑ 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 test pit data on design plan Before filing this Inspection Report, please see Report Completeness Checklist on next page. t5ins • 11/10 Title 5 Official Inspection Form: Subsurface Sewage Disposal System - Page 16 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 36 Windsor Lane Property Address James Brennan Owner Owner's Name information is required for North Andover. MA 01845 11/10/2012 every page. Citylrown State Zip Code Date of Inspection D. System Information (cont.) Sketch Of Sewage Disposal System: Provide a view 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. Check one of the boxes below: ® hand -sketch in the area below ❑ drawing attached separately t5ins • 11110 0 aS2 w -ate— 'Z' t Title S.Official Inspection Form: Subsurface Sewage Disposal System • Page 15 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 36 Windsor Lane ,p Property Address James Brennan Owner Owner's Name information is North Andover MA 01845 11/10/2012 required for every page. Cityrrown State Zip Code Date of Inspection E. Report Completeness Checklist ® Inspection Summary: A, B, C, D, or E checked ® Inspection Summary D (System Failure Criteria Applicable to All Systems) completed ® System Information.— Estimated depth to high groundwater ® Sketch of Sewage Disposal System either drawn on page 15 or attached in separate file t5ins - 11/10 Title 5 official Inspection Form: Subsurface Sewage Disposal System - Page 17 of 17 t5fomt4.doc• 06/03 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: Left / Right front of house Right<6@o ous Left / right side of house, Left j Right side of building, Left / Right front of building, Left / Right rear of building, Under deck Address '36 LV-\ IVo� 4 Cityrrown State Zip Code 2. System Owner. Name Address (if different from location) Citylrown B. Pumping Record 1. Date of Pumping 3. Type of system: ❑ State Zip Code X26 --ay Telephone Number I(-10-- to Date 2. Quantity Pumped Cesspool(s),."' eptic Tank ❑ Other (describe): 4. Effluent Tee Filter present? ❑ Yes 5. Condition of System: 3 ri System Pumped By.- Nell y: Neil Bateson Name Bateson Entemrises Inc Company Location where contents were disposed: Gallons ❑ Tight Tank If yes, was it cleaned? ❑ Yes ❑ No F5821 Vehicle License Number System Pumping Record • Page 1 of 1 ' Summary Record Card generated on 10/16/2012 2:03:32 PM by Maureen McAuley T• Town of North Andover Tax Map # 210-106.D-0073-0000.0 • Parcel Id 17830 36 WINDSOR LANE BRENNAN, JAMES & ANNE 36 WINDSOR LANE NORTH ANDOVER, MA 01845 Page 1 Class 101 Single Family Property Typa 1 Residential Zoning2 1 Residential Zoning3 1 Residential Size Total 1 Acres FY 2013 UB Mailina Index Name/Address BRENNAN, JAMES & ANNE 36 WINDSOR LANE NORTH ANDOVER, MA 01845 UB Account Maint. Account No Cycle Bldg Id. 13420.0 - 36 WINDSOR LANE 2100065 02 Cycle 02 UB Services Maint. Account No. 2100065 Service Code MISCFEE ADMIN FEE WTR WATER UB Meter Maintenance Account No. 2100065 Serial No Status 19647589 a Active Date 8/1/2012 5/2/2012 2/1/2012 11/1/2011 8/4/2011 5/3/2011 2/7/2011 11/2/2010 8/2/2010 5/5/2010 2/2/2010 11/3/2009 8/6/2009 5/1/2009 2/2/2009 11/5/2008 8/5/2008 5/1/2008 2/1/2008 11/6/2007 8/1/2007 5/3/2007 2/21/2007 11/2/2006 8/21/2006 5/25/2006 2/8/2006 11/3/2005 8/10/2005 5/5/2005 Reading 1923 1825 1803 1778 1722 1638 1620 1595 1510 1416 1391 1366 1288 1185 1161 1136 1017 895 870 847 734 632 613 583 554 478 436 ''411 332 226 Type Loan Number Payor Active/Inact. From Occupant Name Active/Inactive Last Billing Date 9/17/2012 Active Rate Charge Multiplier/Users 0.635/8 7.82 1/ 01 ALL METER SIZE 508.90 /1 Location ERT HH Code a Actual a Actual a Actual a Actual a Actual a Actual a Actual a Actual a Actual a Actual a Actual a Actual a Actual a Actual a Actual a Actual a Actual a Actual a Actual a Actual a Actual a Actual a Actual a Actual a Actual a Actual a Actual a Actual a Actual a Actual Brand METE METE Consumption 98 22 25 56 84 18 25 85 94 25 25 78 103 24 25 119 122 25 23 113 102 19 30 29 76 42 25 79 106 21 Type w Water Posted Date 9/26/2012 6/20/2012 3/14/2012 12/15/2011 9/14/2011 6/13/2011 3/15/2011 12/13/2010 9/13/2010 6/9/2010 3/11/2010 12/11/2009 9/11/2009 6/16/2009 3/16/2009 12/10/2008 9/12/2U08 6/18/2008 3/14/2008 1/15/2008 9/14/2007 6/26/2007 3/23/2007 12/22/2006 9/13/2006 6/20/2006 3/13/2006 12/14/2005 9/12/2005 6/8/2005 Size 0.63 0.63 4- I- 0 0 w a W a Ql N In Cc O m P-- u.i w � w w a w Ul Z t t= a U N u w L m 0 iv \ x" PUBLIC HEALTH DEPARTMENT Town of North Andover Community Development Division CERTIFICATE OF COMPLIANCE As of: 11/21/12 This is to certify that the individual subsurface disposal system received a SATISFACTORY INSPECTION of the: D -Box replacement By: Todd Bateson At: 36 Windsor Lane Map 106D Lot 73 North Andover, MA 01845 The Issuance of this certificate shall not be construed as a guarantee that the system will function satisfactorily. Michele Grant Public Health Agent t~ J,—cioy 1600 Osgood Street, North Andover, Massachusetts 01845 Phone 918.688.9540 Fax 918.688.8416 Web www.townofnorthandover.com North Andover Health Department Community Development Division ONSITE WASTEWATER SYSTEM CONSTRUCTION NOTES LOCATION INFORMATION ADDRESS: 36 Windsor Lane INSTALLER: Todd Bateson DESIGNER: PLAN DATE: 11-21-12 BOH APPROVAL DATE ON PLAN MAP: 106D LOT: 73 D -Box Replacement INSPECTIONS TANK INSPECTION: DATE OF BED BOTTOM INSPECTION: DATE OF FINAL CONSTRUCTION INSPECTION: DATE OF FINAL GRADE INSPECTION: SITE CONDITIONS Comments: SEPTIC TANK ❑ Contractor reports any changes to design plan ❑ Existing septic tank properly abandoned ❑ Internal plumbing all to one building sewer ❑ Topography not appreciably altered ❑ Building sewer in continuous grade, on compacted firm base ❑ Cleanouts per plan ❑ Bottom of tank hole has 6" stone base ❑ Weep hole plugged ❑ 1500 gallon tank has been installed H-10 loading ❑ Monolithic tank construction ❑ Watertightness of tank has been achieved by visual testing ❑ Inlet tee installed, centered under access port Comments: PUMP CHAMBER Comments: CONTROL PANEL Comments: DISTRIBUTION -BOX ❑ Outlet tee installed, centered under access port (gas baffle/effluent filter) ❑ inch cover to within 6" of finish grade installed over one access port ❑ Hydraulic cement around inlet & outlet ❑ Bottom of tank hole has 6" stone base ❑ Weep hole plugged ❑ 1500 gallon Pump Chamber installed ❑ H-10 loading ❑ Monolithic tank construction ❑ Inlet tee installed, centered under access port ❑ Pump(s) installed on stable base ❑ Alarm float working ❑ Pump On/Off floats working ❑ Separate on/off floats ❑ Drain hole in pressure line ❑ cover at final grade installed over pump access port ❑ Water tightness of tank has been achieved by testing ❑ Hydraulic cement around inlet & outlet ❑ Alarm & Pump are on separate circuits ❑ Alarm sounds when float is tripped ❑ Location of control panel: basement ❑ Alarm signal located inside: basement ❑ Installed on stable stone base X H-20 D -Box ❑ Inlet tee (if pumped or >0.08'/foot) X Hydraulic cement around inlet & outlets X Observed even distribution X Speed levelers provided (not required) Comments: There are 2 risers on it now SOIL ABSORPTION SYSTEM (General) ❑ Bottom of SAS excavated down to C soil layer, as provided on plan ❑ Size of SAS excavated as per plan ❑ Title 5 sand installed, if specified on plan ❑ 40 Mil HDPE barrier installed ❑ Laterals installed and ends connected to header (and vented if impervious material above) ❑ Elevations of laterals and chambers installed as on approved plan ❑ Retaining wall (boulder / concrete / timber/ block) ❑ Final cover as per plan Comments: SOIL ABSORPTION SYSTEM (Gravel -less Chambers) ❑ Brand and Model of Chamber: Standard Quick 4 Infiltrator Chambers ❑ Number of chambers per row: ❑ Number of rows (trenches): Comments: Total Chambers = FINAL GRADE ❑ Loamed? ❑ Seeded? ❑ Cover per plan? Comments: DOCUMENTS NEEDED ❑ Certification of Installation Form submitted By engineer and signed and dated by Engineer and installer ❑ As -Built Plan BM = HR= HI = SYSTEM ELEVATIONS ROD AS -BLT INVERT DESIGN INVERT ELEVATION ELEV ELEV Benchmark Building Sewer OUT Septic Tank IN Septic Tank OUT Pump Chamber IN Pump Chamber OUT Distribution Box IN Distribution Box OUT Lateral 1 TOP Lateral 1 INVERT Lateral 2 TOP Lateral 2 INVERT Lateral 3 TOP Lateral 3 INVERT Lateral 4 TOP Lateral 4 INVERT Lateral 5 TOP Lateral 5 INVERT Lateral 6 TOP Lateral 6 INVERT Top of Chamber Bottom of Bed/Chamber SKETCH PLAN CRITICAL SETBACK DISTANCES Mark those distances checked in the field against the design plan and regulatory setback 1 Suction line 222(2) 2 100 feet is a minimum acceptable distance and no variance is allowed for a lesser distance (NA 5.02). 3 As defined in 310 CMR 10.55, 10.32, 10.54, and 10.30, respectively, pursuant to 15.211(3), also by NA wetland bylaws Tank SAS Sewer ® Property line 10 10 -- ® Cellar wall 10 20 -- ® Inground pool 10 20 -- ® Slab foundation 10 10 -- ® Deck, on footings, etc 5 10 -- ® Waterline 10 10 10' ® Private drinking well 75 1002 50 ® Irrigation well 75 100 ® Surface Water 25 50 ® Bordering Vegetated Wetland , Salt Marsh, Inland / Coastal Banka 75 100 ® Wetlands bordering surface water supply or trib. (in Watershed) 150 150 ® Trib. to surface water supply 325 325 ® Public well 400 400 ® Interim Wellhead Prot. Area ® Reservoirs 400 400 ® Drains (wat. supply/trib.) 50 100 ® Drains (intercept g.w.) 25 50 ® Drains (Other) Foundation 10 (5) 20 (10) ® Drywells 20 25 1 Suction line 222(2) 2 100 feet is a minimum acceptable distance and no variance is allowed for a lesser distance (NA 5.02). 3 As defined in 310 CMR 10.55, 10.32, 10.54, and 10.30, respectively, pursuant to 15.211(3), also by NA wetland bylaws J i WC/C OK f� + 19 N K /may oX IAI oX Uct.f- / h ae' L/n/,c- -2 _/SU G G SEP f /C 71-,19 1Y Commonwealth of Massachusetts Map -Block -Lot • 106.D0073 BOARD OF HEALTH - Permit No • North Andover BHP -2012-0770 ---------------------- P.I. _ _ FEE F.I. $125.00 ----------------------- DISPOSAL WORKS CONSTRUCTION PERMIT Permission is hereby granted Todd-B-ateson --------------------------------------------------------------------------------------------------- to (Repair) an Individual Sewage Disposal System. at No 36 WINDSOR LANE ---------------------------------------------------------------------------------------------------------------------------------------------------------- as shown on the application for Disposal Works Construction Permit No. BHP -2012-077 Dated November 19, 2012 --------------------------------------------------- ----------------------------------------------------------------- Issued On: Nov -19-2012 BOARD OF HEALTH Commonwealth of Massachusetts BOARD OF HEALTH North Andover CERTIFICATE OF COMPLIANCE THIS IS TO CERTIFY, That the Individual Sewage Disposal System (Repair) byTodd Bateson ------------------------------------------------------------------------------------------------------------------------------ Installer Map -Block -Lot 106.D0073 ----------------------- at No -36-WINDS-OR-LANE has been installed in accordance with the provisions of TITLE 5 of the State Environmental Code as described in the application for Disposal Works Construction Permit No. BHP -2012-077 Dated _ _ _ November 19,_ 2012 ----------------------- ----------------------------------------------------- Printed On: Nov -19-2012 ------------------------------------------------------------------------------- BOARD OF HEALTH of,NORT :,� 6308 O 10 9 Town of North Andover ';'•�.,,,o .: HEALTH DEPARTMENT ,SSACHU`+EA CHECK #: DA, ATE: LOCATION:IVI I cif- 1 Y H/O NAME: CONTRACTOR NAME: TXRe of Permit or License: (Check box) ❑ A imal If $ ❑ Body Art Establishment $ ❑ Body Art Practitioner $ ❑ Dumpster $ ❑ Food Service - Type: $ ❑ Funeral Directors $ ❑ Massage Establishment $ ❑ Massage Practice $ ❑ Offal (Septic) Hauler $ ❑ Recreational Camp $ ❑ Sun tanning $ ❑ Swimming Pool $ ❑ Tobacco $ ❑ Trash/Solid Waste Hauler $ ❑ Well Construction $ SEPTIC Systems: ❑ Septic - Soil Testing $ ❑ xSeptic Septic - Design Approval Disposal Works Construction $,� $_� ❑ Septic Disposal Works Installers (DWI) $ ❑ Title 5 Inspector $ ❑ Title 5 Report $ ❑ Other: (Indicate) $ (,(3 Health Agent Initials White - Applicant Yellow - Health Pink - Treasurer Important: When filling out forms on the computer, use only the tab key to move your cursor - do not use the return key. nb �I Application for Septic Disposal System Construction Permit —TOWN OF TODAY'S DATE TlIWVT_T A XTTl(IIM-D A4 A a -I QA G $ 250.00 - Full Repair Application is hereby made for a permit to:I U-, Construct a new on-site sewage disposal system* �L g �G 1 F1 ❑ Repair or replace an existing on-site sewage disposal system* I TOWN OF NORTH ANDOVER HEAL DEPARTMENT epair or replace an existing system component — A. Facility Information Vv i Ncf'S d) 2 L,M Address or Lot # Cityrrown d ;AUS 5 2.- *TYPE OF MPTIC SYSTEM*: ❑ Pump ravity (choose one) ***If pump system, attach copy of electrical permit to application*** ff-C-o'nventional System (pipe and stone system) ❑ Infiltrator or Biodiffuser (Gravel -Less) (Attach a copy of your certification to install this type of system. ❑ Pressure Distribution S.A.S. (No D -Box) (Attach Draft Maintenance Agreement) ❑ Pressure Dosed (D -Box Present) S.A.S. 2. Owner Information Name Address (if different from above) A City/Town State Zip Code IK- 7`7l-- Telephone Number 3. Installer Information 1 Name Name of t4- r4 Address City/Town 4. Uesigr Name Address CityFrown 111 ARGILLA ROAD State Zip Code Telephone Number (Cell Phone # if possible please) Name of Company State Zip Code Telephone Number (Best # to Reach) Application for Disposal System Construction Permit • Page 1 of 2 M 3-�� TODAY'S DATE $.250.00 - Full Repair $725.00,- Component PAGE2OF2 A, Facility. Information continued.... 5. Type -of Building: esidential Dwelling or []Commercial B. Agreement The undersigned agrees to.ensure the construction and maintenance of the afore -described on-site sewage disposal system in accordance with the provisions of Title 5 of the Environmental Code, as well as the Local Subsurface Disposal Regulations for the Town of North Andover, and not to place the system fn operation until a Certificate of Compliance has been issue this Board of Health. Name Mte Applicatio pproved By: oard of Health Representative) Naipe Date Application Disapproved. for the following reasons: For Office Use Only: 1 Fee Attached?' Yes 2, ProjectMlbager Obligation Form Attached? Yes 3, Pum,RSystem? Ifso, Attach co,Qv ofElectrrcal Permjt` Yes 4. Foundation As Bu&P(new construction ronly). Yes_ (Sam-- scale as approved plan) 5. F1oorPlans? (hew construction only): • Yes No No • . . No No No Appi tWdn'for•Disposal Syster Odn*ud loo Permft Page 2 of 2 Mme. . SEP'T'IC SY.STEM..INSTALLF-R PROJECT MANAGEMENT OBLIGATIONS As the North Andover.licensetl "uistaller fdr the.constmedon for the septic system -property °property at (Address of septic system) Relative to 66 -application of (iustallees name) Dated�— o s ate • For plans by . (Engineer) Atid dated ngina a e . With revisions dated (Last revised date) I understand the following obligations for management of this project: ; 1. As the installer, I am .obligated to obtain. all permits and Board of Health approved plans prior to performing any:work on a site. I must have thea.. 'r and the taermit on site when any work is bein dQ one.. - 2. As the installer,.I must call for any and atinspections. If homeowner, contractor, project manager, or any other person not associated with my company schedules •an inspection and the system is not ready, then item three shall. be. applicable. .` As tji,� installer, I atn• required fo. have .tiie zrecessary work mmpleted p-tior;to the .applicable inspections as indicated belpw I Utrdeitancl that reiesttng an iiispection without. comtiletion of the items in accordance .. - ..__'fes _ ezrn•n/bani•; Int a, . Botfom Qf Beta Generally, this is thc, fitst.(1"); inspectton unless:there is i'ieta.ining wall, which shoulc •be done fYrst: Tlie :uistall must-t�quest the iiispectiori but sloes not have to be ptese'nt. b. Final- •onsti*f ori.Inspeetion —Engineer m%ust firsi::do t -h inspection for elevations; ties, etc. As-l�iiilt of verbal OK (or e-mailxo: healdideli��ownofnorthandover.com): from the engineer must be submitted -to .the.Board-of Health, after .which installdr -calls -f6r:an inspection time. Installer must be present for this inspection, with a pump .System,' all electrical wotk;•must be ready and. able to cause pump.tri work arid•alarm, .to funetion. . c. .Final�Gr _ do installer must request inspection when' 11 •grading is complete:.Installer does not have to be on=site. 4. As -the installer,' I unclexsfand that only I=perform the �wofk (other than -sim, ple excavation) and lard required to complete the •insta"llation of the system identified in tie: atfiached .application for iristallation::I further . reasons for denial -,of the.s tem and/i�revocation•or su§ 5ension of.mp hs ens -.to operate in. the Town.ot North Andover significant fines to all liersons-itivolverl:ate also possible. '„ 5.. ,As the.•installer,.I understand that'l mush' onsite during tho.pe=fc.rmance of the following construction. steps:. a. Detenminatiost that.theproper• elevation of the excatwtlon has been reached. b. Inspeetion ofthe`sand and stogie to be used. c. Final inspecdou by Board ofHealth staffor consultant. d. Installation, of tank, D Box, pipes, stone, vent,primp chamber, zeta vhw wall and other components . , Undersigned licensed Septic.Ins..taller: :: (To q's Date) .. COMMONWEALTH OF MASSACHUSETTS EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS DEPARTMENT OF ENVIRONMENTAL PROTECTION TITLE 5 OFFICIAL INSPECTION FORM — NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM PART A CERTIFICATION 7.1 Property Address: 36 Windsor Lane _North Andover Owner's Name: _Kevin Comerford_ Owner's Address: 36 Windsor Lane_ North Andover, MA 01845_ Date of Inspection: _3/6/2003_ Name of Inspector: _Neil J. Bateson_ Company Name: Bateson Enterprises Inc._ Mailing Address: _111 Argilla Road_ _Andover, Ma. 01810_ Telephone Number: _( 978 ) 475-4786 MAR 1 4 2003 __A 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 fimction 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 Needs Further Evaluation by the Local Approving Authority Fail c Inspector's Signature: Date: 3/6/2003_ 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: 36 Windsor Lane_ _North Andover— Owner: _Comerford Date of Inspection: 3/6/2003_ 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. Systcm 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 1 l OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: 36 Windsor Lane_ _North Andover — Owner: Comerford Date of Inspection: _3/6/2003 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)(6) 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: 36 Windsor Lane _North Andover_ Owner: Comerford Date of Inspection: 3/6/2003_ 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 Iiquid 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 '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 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 It 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: 36 Windsor Lane_ _North Andover — Owner: Comerford T Date of Inspection: 3/6/2003 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 ? Yes _ Were as built plans of the system obtained and examined? (If they were not available note as NIA) _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. For example, a plan at the Board of Health. No Determined in the field (if any of the failure criteria related to Part C is at issue approximation of distance is unacceptable) [310 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: 36 Windsor Lane_ _North Andover_ Owner: Comerford Date of Inspection: 3/6/2003_ FLOW CONDITIONS RESIDENTIAL Number of bedrooms (design): _4_ 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: Does residence have a garbage grinder (yes or no): _No Is laundry on a separate sewage system (yes or no): _No_ f if yes separate inspection required] 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 COMMERCIAL/INDUSTRIAL 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 & 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/Altemative 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: _17 years old. 8/2/1986 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: 36 Windsor Lane_ North Andover_ Owner: Comerford Date of Inspection: 3/6/2003_ BUILDING SEWER (locate on site plan) X Depth below grade: _22" Materials of construction: —X—cast iron _X 40 PVC _other (explain): Distance from private water supply well or suction line: Comments (on condition of joints, venting, evidence of leakage, etc.): _4" Cast iron thru wan. 3" PVC in house. No leaks visible. SEPTIC TANK: X locate on site plan) Depth below grade: _IO"_ 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: Distance from top of sludge to bottom of outlet tee or baffle: 27"_ Scum thickness: _6" 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: _15" How were dimensions determined: Subtract 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 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: 36 Windsor Lane- - North ane__North Andover — Owner: Comerford Date of Inspection: 3/6/2003_ 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._ PUMP CHAMBER: (locate on site plan) Pumps 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: 36 Windsor Lane_ North Andover Owner: Comerford Date of Inspection: 3/6/2003_ 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: _2 trenches 45' 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.): —No sign of ponding to surface_ CESSPOOLS: (cesspool must be pumped as part of inspectionxlocate 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 I 1 OFFICIAL INSPECTION FORM — NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: 36 Windsor Lane_ North Andover — Owner: Comerford Date of inspection: 3/6/2003_ 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. 45' House Porch A I Septio nk B Water Meter A Driveway I D -Box " A to D -Box = 77' B to D -Box = 60' B to Tank =17'5" C to Tank =18'5" Page 11 of 11 OFFICIAL INSPECTION FORM — NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: 36 Windsor Lane_ _North Andover— Owner: Comerford Date of Inspection: 3/6/2003 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 pian reviewed: _4/4/1986 _ 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_ 03/10/03 MON 16:32 FAX 978 688 9573 NORTH ANDOVER DPW ...... yy..yL,(( ,���{.�O.�p�y*[ Jy � lnl�l�.s. f�r1.v.���'%1• ' x1' ......";,n• s".• '' Y-'y .,.4P min:..•%'", ra•,...w.,;in:,.L. 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'�� _':• Fid7P2�" �'im�:"' — ;�tij fr�ia8'- .� LVA{}�; f•,C.l;}; R:,!;t�' S. �, :�'.""'�'x�, EG. �... ��:t-��� 'ii""'�'}'i i'`;�'i: '•:' i, t, -'�;(5i;. ;; rt ' �Q;is ��.�i[�}i1 �:i:!� � 41. {�: ,-„n'i L'rJ;j ��yy�}3:. � ' i � i ,d{�',l'-” �' •,•klY,�l Iifi ISc1H:„..!.-.:'. '' .' ' „14iI�iSYtA�k"Ji;, ��i�:i�i���ii '•�i:i� ;�t�3i.G,'�!jl::... .:........:Li:�c [a 0O1 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: 36 Windsor Lane, North Andover Owner: Comerford Date of Inspection: 3/6/2003 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. A w NORT1y Oq o Date. . ..... TOWN OF NORTH ANDOVER PERMIT FOR PLUMBING SACMUS� This certifies that ..... :. ....................... ........ has permission to perform plumbing in the buildings of...... ........ . t.,. at �.� . ! ! �. �. !...,��. ��. �,-... , North Andover, Mass. Fee._. ....... Lic. No.....! . .............................. PLUMBING INSPECTOR Check ff 7 / �, 5;5' J r 9 1 MASSACHUSETTS UNIFORM APPLICATION (Print or Type) , Mass. Date Building Location New ❑ sub—BSMT. BASEMENT IST FLOOR 2ND FLOOR 9 R D• ----- FLOOR 4TH FLOOR STH FLOOR 6TH FLOOR 7TH FLOOR, STH FLOOR Renovation ❑ RLpl&URES aAment #PERMIT TO DO PLUM/BIING' Permit # G ✓� �� Owner's Name 4) rC4�. 10/n Type of Occupancy Residential Plans Submitted: Yes ❑ No ❑ z ZN Q Z Y F- n n N o Z r- n J V a vi > 0 at W Y J n a ►- z U z N a In Z 0a Cr VU. C: ca to W r a ~ Q a. a r W0 7 W a n 2 Q W n IL J Z O O U. W= Q= 3 3 z 3 X a z z o z p a W W x 4 F a Q = N N Q a O a J J Q a: ¢ M Q O Q 3 Y J a) N O 0 J 3 = M N LL (7 D D Q 3 LL a) Installing Company Name Heritage Htg . &Pig . Co. Inc. Address 35 Pleasant Street Stoneham, Ma 02180 Business Telephone 781 -438-772.6 Name of Licensed Plumber Gordon Switzer Check one: IX Corporation L] Partnership 171 Firm/Co. Certificate 714 INSURANCE COVERAGE: I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL Ch. 142. Yes ® No ❑ If you have checked yes, please Indicate the type coverage by checking the appropriate box. A liability Insurance policy IN Other type of Indemnity ❑ Bond ❑ OWNER'S INSURANCE WAIVER: I am aware that the licensee does not have the Insurance coverage required by Chapter 142 of the Mass. General Laws, and that my signature on this permit application waives this requirement. Check one: Owner ❑ Agent ❑ I hereby certify that all of the details and information I have submitted (or entered) in above application are true and accurate to the best of my knowledge and that all plumbing work and installations performed under the permit issued for this application will be in compliance with all pertinent provisions of the Massachusetts Slate Plumbing Code and Chapter 142 of the General laws. By-92Acet 1� g ure o nsea umbel — Title Type of License: Master [X Journeyman ❑ City/Town 13 3 2 2 APPROVE L License Number I z m � J J z a 0 0 W p N � O r v � LL` � 4 a o c z a O w LL O LL 3 O z J O W m • a V J W a LL I N W 1 V W Y p N N I O V w IL I N Z i J a i z LL t z a w -m 7 M , .,ate DATE: TOWN OF SYSTEM PUMPING RECORD APR 1-3 2005 TOv , , . i i :i ANDOVER Wr. _ T NER & ADDRESS SYSTEM WC ON (example: left front of house) LAV\0.' - � A �Ioj . DATE OF PUMPING: / _ Z) �� y/QUANTITY PUMPED: /z GALLONS CESSPOOL: NO YES 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 LEACHFIELD RUNBACK FLOODED OTHER (EXPLAIN) SYSTEM PUMPED BY: Bateson Enterprises, Inc. COMMENTS: coNTENTs nuNsnwaD To: G.L.S.D Lowell Waste FORM U. TOWN OF NORTii ANDOVER LOT RELEASE FORM SUBDIVISIONd.J ASSESSORS. MAP IT) SUBDIVISION LOT(S) �S�S ��PERMAN N� A1DDR-R�(ASSILNED BY D.P.W.j /STREET �' W APPLICANT F PHONE V DATE OF APPLICATION DEPARTMENT OF PUBLIC WORKS DRIVEWAY PERMIT IV/� SEWER/WATER CONNECTIONS FIRE DEPT. RECEIVED BY BUILDING INSPECTION DATE 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. Uu64C — C� TOWN USE BELOW THIS LINE PLANNING BOARD DATE APPROVED TOWN PLANNER DATE REJECTED CONSATION.COMMISSION ,R / V DATE APPROVED •' �' CONSERVATION ADMIN. l.) DATE REJECTED JBOARD OF HEALTH ` DATE APPROVED (p 0� HEALTH 9ANItAICIAN DATE REJECTED DEPARTMENT OF PUBLIC WORKS DRIVEWAY PERMIT IV/� SEWER/WATER CONNECTIONS FIRE DEPT. RECEIVED BY BUILDING INSPECTION DATE 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. Uu64C — C� FOA -C,4 t�US6 / ao P v6c az DoT dA/ 50"a- lbse 1-Vwr r ►-L ) 3"1- �Ft i a o lc.. 'aw sem„ 2 E�rsr O BC4130 op HCAL -m NoI�TM /Jvpnvei'�, MA, LOT 2 RD wQTE>Z Sv�P(.7 fB- Tc-)wt� D WEU- S5 Ec. - ,aP ouch arc s S S5�' Stt�T"I c SY 5 1—�-:;c.� ET COAJPiTlO"5 _ D 15A PPPU VEp R�4SoNS = D4�C- StPT'l c SYSTEM t ,� Siip l.laQT i o�tJ i57KA. V4TloJ&1 VArc FINAL l Q5P6—�-Tloo Q 1-;45S E] Fi41L 4PRROOEP QU6' 1-25-�6 Apf2MoJtA)6AuT-Hoj�1iy AVDITIOMAL l�5 zj (Otis 11- o►-iy DISAPl'evvFlD D,arC Rj�6'50 NS FVAL APPROVAL D,d�� �'2 �� APP)�Ov vJ6 TOWN OF NORTH ANDOVER SYSTEM PUMPING RECORD DATE: Lila 102- 1 SYSTEM OWNER & ADDRESS Comer SYSTEM LOCATION (example: left front of house) Act DATE OF PUMPING: i� �o QUANTITY PUMPED /,�✓y GALLONS CESSPOOL: NO YES SEPTIC TA : NO YES NATURE OF SERVICE: ROUTINE OBSERVATIONS: GOOD CONDITION HEAVY GREASE ROOTS EXCESSIVE SOLIDS SOLIDS CARRYOVER SYSTEM PUMPED BY: COMMENTS: CONTENTS TRANSFERRED TO: EMERGENCY FULL TO COVER BAFFLES IN PLACE LEACHFIELD RUNBACK FLOODED OTHER (EXPLAIN) Commonwealth of Massachusetts City/Town of System Pumping Record Form 4 DEC 'i 4 2M DEP has provided this form for use by local Boards of Health. Ot r forms ma be used, bu the information must be substantially the same as that provided here. 9f ck with your local Board of Health to determine the form they use. The Syste ubmitted to the local Board of Health or other approving authority. A. Facility Information 1. System Location: Left front of house, right front of house, left side of house, right side of house Left mouse, ht rear of house. left side of buildina. riaht rear of buildina under deck City/ I own ~ State 2. System Owner: 1&evx-eyy-�, Name Address (if different from location) City/Town Zip Code State ` /Zip ^Code Telephone Number B. Pumping Record 1. Date of Pumping Date 0 2. Quantity Pumped: 3. Type of system: ❑ Cesspool(s) /Septic Tank ❑ Other (describe): 4. Effluent Tee Filter present? ❑ Yes 5. Condition of System: C 6. System Pumped By: Neil J. Bateson Name Bateson Enterprises Inc. Company 7. Loca ' ere contents were disposed: G L.S Lowell Waste Water Signature of Hauler I so 0 Gallons ❑ Tight Tank If yes, was it cleaned? ❑ Yes ❑ No F5821 Vehicle License Number Date t5form4.doc• 06/03 System Pumping Record • Page 1 of 1