HomeMy WebLinkAboutMiscellaneous - 36 WOODBERRY LANE 4/30/2018Commonwealth of Massachusetts
Z F
City/Town of North Andover RECEIVED
a System Pumping tilAY E1 2012
Form 4
' TOWN OF NORTH ANDOVER
Important: When
filling out forms
on the computer,
use only the tab
key to move your
cursor - do not
use the return
key.
DEP has provided this form for use by local Boards of Health. Other form . 7 - I A_01"r1T
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 within 14 days from the pumping date in
accordance with 310 CMR 15.351.
A. Facility Information
1. System Location:
35 Wood Berry Lane
Address
No Andover _
City/Town
2. System Owner:
schrader
Ma
State
Zip Code
Name
Address (if different from location)
City/Town State Zip Code
Telephone Number
B. Pumping Record
1. Date of Pumping //P/ Date 2. Quantity Pumped: G
Gallons
3. Type of system: ❑ Cesspool(s) U/Septic Tank ❑ Tight Tank ❑ Grease Trap
❑ Other (describe):
4. Effluent Tee Filter present? ❑ Yes tKNo If yes, was it cleaned? ❑ Yes ❑ No
5. Condition of System:
&- Or 6d. d �j
6. S em P ed By:
Na
Stewart's Septic Service
Company
7. Location where contents were disposed:
Stewart's Pre treatment Plant, 20 So. Mill B
fri \ 1 17"�
Signat re f Ha
Signature o Re e' ing Facility
Vehicle License Number
Ma 01835
Date
Date
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State Zip Code
state• .J� ' ' ZIP/Cods
Toiophone Number
Quantlty Pumped:
aeons
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El Tight Tank
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System Pumping Record - Page i of i
TOWN OF NORTH AN-DOVEp,
UA I 't <51ZI�3
SYSTF-M PUMPINQ RECC)pdj
�YS1 Cm VWNUR & ADDRESS SYSTEM LOCAT70N
DATE. OF PMNO: ........................ ................ --
QUANTITY
PUMPED:
Nu
"A rUKU OF SERVICE: bMlrRUtNC r�*CEIVED
UkISFAVA,nom: 0 JUN 0 3 2005
O'DODCONDITIONN-.,�pU L.L ry L ov�X TOWN OF NORTH ANDOVER
KBAVY OUA.3B j HEALTH DEPARTMENT
13AME3 IN PLACL,
LEACHneLD KUNBACK
OXCE361VE SOLIDS FLOODED
-30LrD CAKAYoyu—"
QTKER BX?LA IN
C:�70
177a.
,-:vNt*eN,r:s rKAN�iuuL) Ib
TOWN OF NORTH 'ANDOVF -
R
SYSTEM PUMPING RECORD
�1 �1'EM OWNER & ADDRESS SYSTEM LOCATION:x-:�` ~~� ��—
(eUmPle: left front of house)
" �►4e oe
U. OF..RUMPINC; QUANTITY PUMPCDA�.AL.Lo)V)
NO YES
SEPTIC TANK; NO YES
Ic
\aTURE OF SERVICE; ROUTINE EMERCENCY
(ffl>FRVATIONS;
GOOD CONDITION. FULL TO CUVCk
HrAVY CREASE BAFFLES IN PLACE
ROOTS LEACHFIELD RUNBACK .
EXCESSIVE SOLIDS FLOODED
SOLIDS CARRYOVER AHER (EXPLAIN)
SV . 'TLM PUMPED RY:
�'UNI �1 r:NT5;
UN I b..NT' TRANSFERRED TO:
TOWN OF NORTH ANDOVER
SYSTEM PUMPING RECORD
DATE: C�vZ
SYSTEM OWNER & ADDRESS
DATE OF PUMPING:
SYSTEM LOCATION
(example: left front of house)
�'dQeiv
QUANTITY PUMPED GALLONS
CESSPOOL: NO YES SEPTIC TANK: NO YES
NATURE OF SERVICE: ROUTINE v EMERGENCY
OBSERVATIONS:
GOOD CONDITION
HEAVY GREASE
ROOTS
EXCESSIVE SOLIDS
SOLIDS CARRYOVER
SYSTEM PUMPED BY:
COMMENTS:
v
FULL TO COVER
BAFFLES IN PLACE
LEACHFIELD RUNBACK
FLOODED
OTHER (EXPLAIN)
CONTENTS TRANSFERRED TO:
r-'
Town of North Andover,
0,
Watershed Septic SVstemf
Servicingl G%�.ReROKI-
12
Date:
Homeowner: �IOECKEL Pumper ANDOVER SEPTIC'
Street 36 WOODBERRY LN, NA. Address: P.O.B.OX 4,173. Andove
Phone (508) 688-8532 Phone (508)475-25,93
Nattkire of Service: I Routine
4& Emergency
Observations: Good Condition
Full to Cover
Baffles in Place
Leachfield Runback
Excessive Solids
Heavy Grease
Roots
other (Explain)
Description o lk,:
0
Irvit
III I
JII�oi, Ui I
(r,49 L el
ay
Comments:
/V,
5
A 1
TOWN OF NORTH ANDOVER rT0vj�3OF
SYSTEM PUMPING RECORD , BflAFT OF. 6E� T�--
tm
n , r
DATE:
SYSTEM OWNER & ADDRESS SYSTEM LOCATION
(example: left front of house)
b rr
DATE OF PUMPING: `� QUANTITY PUMPED GALLONS
CESSPOOL: NO YES SEPTIC TANK: NO YES
NATURE OF SERVICE: ROUTINE EMERGENCY
OBSERVATIONS:
GOOD CONDITION
HEAVY GREASE
ROOTS
EXCESSIVE SOLIDS
SOLIDS CARRYOVER
SYSTEM PUMPED BY:
COMMENTS:
FULL TO COVER
BAFFLES IN PLACE
LEACHFIELD RUNBACK
FLOODED
OTHER (EXPLAIN)
CONTENTS TRANSFERRED TO:
�, < .'.. •. y �4`TOWN. OF NORTH ANDOVER
SYSTEM PUMPING RECORD
>< —'
���
1a��1, -� 1(.,��rd
'
S• ii F^ f.11,rdi'hiL�i w�'ss ; 1 `
n hi 1 ti' 1 N.
SSTEM Ol"ER & ADDRESS SYSTEM LOCATION.
i,
(example: left front of house)
rn
�.o -41l _
l• �
7 J
be(�� bane r.t h. S' e
t i •
i 1
t y , t yrs rrl x`4f,-
'`x � +4r'9 MATE: OF PUMPING: Lf � QUANTITY PUMPED `
/ GALLONS
�i;rCESSP,00L:' NO .:YES SEPTIC TANK: NO
YES
OF SERVICE: ROUTINE •A
t EMERGENCY
�1
a
�i,�;'"�t 1,AV{��ri�.t, ' �M�ti .,t fP ISS, �'itI `I` 4 •:•i f 1 -•" � t•^
4rty; Ri k�{ t�ii t ���� I
SVATIONS
' `rwt'GOOD CONDITION . ''
HEAVY GREASE FULL TO COVER
,� 1\ BAFFLES IN PLACE
ROOTS �CHFIELD RUNBACK _
EXCESSIVE SO
LIDS FLOODED
�1
SOLIDS CARRYOVER ems. OTHER (EXPLAIN)
4�{3,X^SM PUIV�PED,X• �bv
all
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A 4..2001
SEPTIC SYSTEM INSPECTION FORM
ADDRESS ��- .� (,c�66A 6-err�
DATE INSPECTED (Z '8(&
PROPERLY FUNCTIONING? Y) N
.WEATHER CONDITIONS
COMMENTS:
DYE TEST PERFORMED? Y N
DATE?
SKETCH:
WATERSHED RESIDENTS QUESTIONNAIRE
1. Name �eo �C9-e �/,4M���� Z_
2. Street Address J re Woo /) bewp Z
3. How many members are in your household? 6
4. What type of sewage disposal system do you have?
❑ cesspool
C�r septic tank and leaching area
❑ connection to municipal sewer
❑ other (describe)
❑ do not know
5. Ar the plans (drawings) for your sewage disposal system on file with the Board of Health?
7 Lrl yes ❑ no ❑ do not know--
6.
now• 6. How old is your sewage disposal system? ❑ 0-5 years 2 6-10 years ❑ 11-20 years--=>-
❑ over 20 years ❑ do not know
7. Has your se wa a disposal system been rebuilt or repaired?
❑ yes no ❑ do not know
If yes, approximately how long ago? years. What was done?
8. How frequently is your sewage disposal system pumped out? LSI annually
❑ every 2-4 years ❑ every 5-10. years ❑ over 10 years ❑ never
9. Have you had any problems with your sewage disposal system? ❑ yes Cimino
If yes, what problems? - -�
❑ repeated pump -outs needed
❑ system clogs, backs up, or drains slowly
❑ odors
❑ sewage surfaces through ground
10. How many of each appliance are connected to your sewage disposal system?
_ washing machine '� dishwasher '� garbage disposal —
`' k. -dehumidifier drain sump pump toilet
roof/pavement drains showerlbathtub
11. Please state the bran y� and type (liquid or powder) of detergent you use for:
dishwasher f
clotheswasher
12. Does your property have a lawn? (' yes ❑ no
If yes, approximately what size?
❑ less than 1/4 acre 4 Er 1/4 acre ❑ 1/2 acre ❑ 3/4 acre ❑ 1 acre
❑. more than 1 acre (Specify) acres
13. How often do you fertilize your lawn?
No. of applications per year
Season(s) of the year
14. Please state the brand and type (liquid or ranu of lawn fertilizer you use:
Check here if your lawn is maintained by a professional landscape contractor.
SOIL PROFILE & PERCOLATION TEST DATA
Town/City No.&Streets Zn. Lot No._
Loc./Subdiv.,/%�� ,�jlC.-4—X fe �/Plan Owner is llv
_�'"
Investigator C1Q �`�C7 Observer
SOIL PROFILES -DATE
Elev. ?° Elev. 3° Elev. a°Elev.
0 0 0 0
Benchmark
Elevation
2
3
4
5
7
D
9
10
2
Ke
4
5
0
7
a
9
10
Location
Datum
Percolation Tests -Date
7
3
4
5
G
7
9
10
Pit Number
.-
1 2 3 4 5
Start Saturation
Soa':-Mins.SM*
Start Test -Time
'0
Drop of 3" -Time
12.11
Drop of 6" -Time
2:22
Mins .1st 3"Drop
-
-71
Mins ° 2nd 3"Drop
Notes & Sketches on Back Frank C. Gelinas & Associates, North And.
r
- - ___.
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V SOIL PROFILE & PERCOLATION TEST DATA
o/0ue,.--L e, -r % Lot No.
Town/City No.&Street �J Nom.
Loc./Subdiv,/,?G���b�e�--iC� e c✓ Plan Owner
y
Investigatory !J�/l� Observer
0 SOIL PROFILES -DATE
3 4.
Elev. �' Elev. -= Elev. Elev.
�) 01 0 0. -- 0, -----�
I�
Benchmark
Elevation
1
PA
3
0
5
C.1
7
1.1
9
10
1
2
3
4
5
M
7
ME
M
10
Location
Datum
Percolation Tests -Date
---tet . -1
11
21
31
41
5I
M
7
FM
7
10
-441 111 .-
Pit Number 1 2
3
4
5
Start Saturation
Soa'c-Mins.
Start Test -Time 2, b
Drop of 3" -Time
Drop of 611-Time:22
Mins.lst 3"Dro
Mins . 2nd 3"Drop /L '
Notes & Sketches on Back Frank C. Gelinas & Associates, North And.
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