HomeMy WebLinkAboutMiscellaneous - 4 CHRISTIAN WAY 4/30/2018 (2)North Andover Board of Assessors Public Access
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North Andover Board of Assessors
roperty Record Card
Location: 4 CHRISTIAN WAY
Owner Name: MERSKI, DALE R
LISA S MERSKI
Owner Address: 4 CHRISTIAN WAY
City: NORTH ANDOVER State: MA
Zip: 01845
Neighborhood: 7 - 7 Land Area:
1.19 acres
Use Code: 101-SNGL-FAM-RES Total Finished Area:
2464 sqft
ASSESSMENTS CURRENT YEAR PREVIOUS YEAR
Total Value: 539,200 569,300
Building Value: 312,100 343,100
Land Value: 227,100 226,200
Market Land Value: 227,100
Chapter Land Value:
http://csc-ma.us/PROPAPP/display.do?linkld=1518318&town=NandoverPubAcc 3/5/2010
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Commonwealth of Massachusetts
RECEIVED —
W City/Town of NORTH ANDOVER JUN s 2013
System Pumping Record TOWN OF NORTH ANDOVER
Form 4 j HEL4TH DEPARTMENT
i41M 4Y -
Important:
When filling out
forms on the
computer, use
only the tab key
to move your
cursor - do not
use the return
key.
t\f%`
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 within 14 days from the pumping date in
accordance with 310 CMR 15.351.
A. Facility Information
1. System Location:
4 CHRISTIAN WAY
Address
NORTH ANDOVER MA
City/Town State
2. System Owner:
ANDREW BIERSHIED
Name
Address (if different from location)
City/Town
B. Pumping Record
1. Date of Pumping
3. Type of system:
❑ Other (describe)
6/4/13
Date
❑ Cesspool(s)
State
Telephone Number
2. Quantity Pumped:
® Septic Tank ❑ Tight Tank
4. Effluent Tee Filter present? ❑ Yes ❑ No
5. Condition of System:
GOOD CONDITION
6. System Pumped By:
JAMES H. CURRIER
Name
J's SEPTIC & DRAIN
Company
7. Location where contents were disposed:
GLSD
Signature of Hauler
Signature of Receiving Facility
01845_
Zip Code
Zip Code
1500
❑ Grease Trap
If yes, was it cleaned? ❑ Yes ❑ No
H79 406
Vehicle License Number
6/4/13
Date
Date
t5form4.doc• 03/06 System Pumping Record • Page 1 of 1
Commonwealth of Massachusetts Map -Block -Lot
104.DO142
--------------------
Board of Health
-- e- , � -. Dtp�fmit No
E nl�
North Andover VP -2010-0514
--------------------
FEE
PA
ILI $125.00
F.I. -----------------------
DISPOSAL WORKS CONSTRUCTION PERMIT
Permission is hereby granted John S�uqy ---------------------------------------------------------------------------------------------
to (Repair -OUTLET BAFFLE) an Individual Sewage Disposal System.
atNo-4-CHRISTIAN-WAY ----------------------------------------------------------------------------------------------------------------------
as shown on the application for Disposal Works Construction Permit No. -BHP-201-0--051 --- Dated --March-0-3,-2-0-1-0 ------
-----------------------------------------------------------
Issued-On:_ M-ar-03-- 201 - 0 ------------------------------------------------- Board of Health
'40priq Commonwealth of Massachusetts Map -Block -Lot
,,go ""+ 104.DO142
'jinadim6mL 0 Board of Health -----------------
North Andover
CERTIFICATE OF COMPLIANCE
THIS IS TO CERTIFYThat the Individual Sewage Disposal System (Repair -OUTLET BAFFLE)
by.... John Sowy -----------------------------------------------------------------------------------------------------------------------------------
Installer
atNo-4-CHRISTIAN-WAY -------------------------------------------------------------------------------------------------------------
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 -20 1-0- - 051 __ Dated --- March_03,_2010 .....
--------------------------------------------------------
Printed On: M ar-05 -201 0 Board of Health
t
0
Town of North Andover
. .... HEALTH DEPARTMEN
6 �, 11
U
'IS CHU to / 12
CHECK #: Z��o 771 -DATE: �s I.; "It,
LOCATION: -�/c
/if /111 1 - 11 . "or 1
H/0 NAME:
CONTRACTOR N
TYRe
of Permit or LicensF (Check box)
0
Animal
$
•
Body Art Establishment
$
•
Body Art Practitioner
$
0
Dumpster
$_
0
Food Service - Type:
$
0
Funeral Directors
$
0
Massage Establishment
$
0
Massage Practice
$
0
Offal (Septic) Hauler
$
0
Recreational Camp
$
0
Sun tanning
$
•
Swimming Pool
$
•
Tobacco
$
•
TrashlSolid Waste Hauler
$_
•
Well Construction
$
SEP77C Systems
0
Septic - Soil Testing
$
0
Septic> -Design Approval
$
0._0Stic Disposal Works Construction
$
(DWC)
0
Septic Disposal Works Installers (DWI)
$_
0
Title 5 Inspector
$
11
Title 5 Report
$
0 Other (Indicate) $
Health Agent Initials
White - Applicant Yellow - Health Pink - Treasurer
Application for Septic Disposal System
*Construction Permit - TOWN OF D! DATI
ORTH ANDOVER MA 01845 $ 250.00 —Full Repair
+�,�•.,...�" $125.00 - Component
Important: Application is herebv made for a permit to:
When filling out
❑ Construct a new on-site sewage disposal system*
forms on the
computer, use
❑ Repair or replace an existing on-site sewage disposal system*
only the tab key
to move your
Repair or replace an existing system component — What? CV44 `
cursor - do not
use the return
A. Facility Information
key.
/
���
A/f
I ue
I I
Address or Lot #
/y,. &I VV14—
City/Town \ &1
2.- *TYPE OF SEPTIC SYSTEM*:
❑ Pump ❑ Gravity (choose one)
***If pump system, attach copy of electrical permit to application***
❑ Conventional 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 0&jh. V r ► � •
Name
Address (if different from above)
City/Town
3. Installer Information
kA
Name
Address
City/Town
4. Desictner Information,� / "I
Name / t
Address
City/Town
State Zip Code
Telephone Number
SCqLtc
Name of Company
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
TO: THANK
YOU
FROM: MONTH DAY YEAR
❑ MUCH APPRECIATED El
SO HELPFUL ❑SHOULDN'T HAVE
❑ FOREVER INDEBTED
❑ MADE MY DAY ❑ MY HER
REGARDINr_. 1
O
--- �"e L, INC.
J l f
Application for Septic Disposal System L
3: •"•'' `' •' °c TODAY' DAT
F -Construction Permit - TOWN OF
.. ORTH ANDOVER MA 01845 $ 250.00 -Full Repair
�''^•.*,. �"� $125.00 - Component
PAGE 2OF2
A. Facility Information continued....
5. Type of Building:Residential 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
Environ tal Code, as well as the Local Subsurface Disposal Regulations for the Town of
North.hcjbver, and not to place the system in operation until a e 'ficate of Compliance has
buss ed by this Board of Health. 2 22
—
Avg / 7 / 7
Name / ) Date
Application Approved By: (Board of Health Representative)
Name
Application Disapproved for the following reasons:
For Office Use Only:
L Fee Attached?
Z. Project Manager Obligation Form Attached?
3. Pump Svstem? If so, Attach cop,v ofElectrical Permit
4. Foundation As -Built? (new construction ronly):
(Same scale as approved plan)
5. Floor Plans? (new construction only):
Date
Yes i/ No
Yes
No Z
Yes
No '✓
Yes
No L/
V
Yes
No
Application for Disposal System Construction Permit • Page 2 of 2
Town of North Andover
HEALTH DjePARTMENT
3 CHU IJ41 1?7�11
CHECK#: / - - DATE:
LOCATION: `7
H/O NAME:
CONTRACTOR NAME:
Type
of Permit or License: (Check box)
0
Animal
$
0
Body Art Establishment
$
13
Body Art Practitioner
$
0
Dumpster
$-
0
Food Service - Type.
$
•
Funeral Directors
$-
•
Massage Establishment
$
0
Massage Practice
$
0
Offal (Septic) Hauler
$
0
Recreational Camp
$-
0
Sun tanning
$
•
Swimming Pool
$
•
Tobacco
$
•
TrashlSolid Waste Hauler
$
•
Well Construction
$
SEP77C Systems
•
Septic - Soil Testing
$
•
Septic - Design Approval
$
0
Septic Disposal Works Construction (DW0
0
Septic Disposal Works Installers (DW[)
0 Title 5 Inspector
e ---Title Report
$
$
5
0 Other (Indicate) $
Health Agent Initials
White - Applicant Yellow - Health Pink - Treasurer
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.
VIQ
F few
�--4-m
Commonwealth of Massachusetts
Title 5 Official Inspection Fo
Subsurface Sewage Disposal System Form - Not for Voluntary
4 Christian M
Property Address
Dale Merski
Owner's Name
North Andover
City/Town
MA 01845
State Zip Code
nents
YQWN or NORTH AND
HEALTH _ CUPAR"M
2/1/2010
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 J. 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
SI15
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. 1 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 urther Evaluation by the Local Approving Authority
'
2/1/2010
Inspecto s ignature 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.
t5ins • 09/08 Title 5 Official Inspection Form: Subsurface Sewage Disposal System • Page 1 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
4 Christian W.
Property Address
Dale Merski
Owner's Name
North Andover MA 01845 2/1/2010
City/Town State Zip Code Date of Inspection
B. Certification (cont.)
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.
❑ Y ® N ❑ ND (Explain below):
t5ins • 09/08 Title 5 Official Inspection Form: Subsurface Sewage Disposal System - Page 2 of 17
11
Owner
information is
required for
every page.
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
4 Christian W;
Property Address
Dale Merski
Owner's Name
North Andover MA 01845 2/1/2010
City/Town State Zip Code Date of Inspection
B. Certification (cont.)
B) System Conditionally Passes (cont.):
❑ 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
❑ Y
® N
❑
ND (Explain below):
❑
obstruction is removed
❑ Y
® N
❑
ND (Explain below):
❑
distribution box is leveled or replaced
❑ 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 - 09/08 Title 5 Official Inspection Form: Subsurface Sewage Disposal System • Page 3 of 17
Vii -
M1
Owner
information is
required for
every page.
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
4 Christian W,
Property Address
Dale Merski
Owner's Name
North Andover MA 01845 2/1/2010
Cityrrown 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 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:
Outlet tee in septic tank corroded off, & needs to be replaced.
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 '/2 day flow
t5ins • 09108
Title 5 Official Inspection Form: Subsurface Sewage Disposal System • Page 4 of 17
❑ ® 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
❑ ❑ 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.
t5ins • 09/08 Title 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
4 Christian Way
Property Address
Dale Merski
Owner
information is
Owner's Name
required for
North Andover
MA 01845 2/1/2010
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
❑ ❑ 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.
t5ins • 09/08 Title 5 Official Inspection Form: Subsurface Sewage Disposal System - Page 5 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
4 Christian W�
Property Address
Dale Merski
Owner's Name
North Andover MA 01845 2/1/2010
City/Town State Zip Code Date of Inspection
C. Checklist
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):
Number of bedrooms (actual):
DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x # of bedrooms):
M
t5ins - 09108 Title 5 Official Inspection Form: Subsurface Sewage Disposal System - Page 6 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
M 4 Christian Way
Property Address
Dale Merski
Owner Owner's Name
information is
required for North Andover MA 01845 2/1/2010
every page. Cityrrown State Zip Code Date of Inspection
D. System Information
Description:
Number of current residents:
2
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 ears usage d
9 ( Y 9 (gP ))�
Yes
Detail:
Sump pump?
❑
Yes
®
No
Last date of occupancy:
Current
Date
Commercial/Industrial Flow Conditions:
Type of Establishment:
Design flow (based on 310 CMR 15.203):
Gallons per day (gpd)
Basis of design flow (seats/persons/sq.ft., etc.):
Grease trap present?
❑
Yes
❑
No
Industrial waste holding tank present?
❑
Yes
❑
No
Non -sanitary waste discharged to the Title 5 system?
❑
Yes
❑
No
Water meter readings, if available:
t5ins - 09/08 Title 5 Official Inspection Form: Subsurface Sewage Disposal System - Page 7 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
4 Christian Way
Property Address
Dale Merski
Owner Owner's Name
information is
required for North Andover MA
every page. Cityfrown State
D. System Information (cont.)
Last date of occupancy/use:
Other (describe below):
01845 2/1/2010
Zip Code Date of Inspection
Date
General Information
Pumping Records:
Source of information: Pumped three years ago, owner
Was system pumped as part of the inspection?
If yes, volume pumped: 1500
gallons
How was quantity pumped determined? Measured tank
Reason for um in m Inspect tank & baffles
p p g
Type of System:
® 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 • 09/08 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
4 Christian Way
Property Address
Dale Merski
Owner Owner's Name
information is
required for North Andover MA 01845 2/1/2010
every page.
CityrFown
D. System Information (cont.)
State Zip Code
Date of Inspection
Approximate age of all components, date installed (if known) and source of information:
23 years ago, 11/24/1987, as built plan
Were sewage odors detected when arriving at the site?
Building Sewer (locate on site plan):
Depth below grade: 1.5
feet
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.):
4" PVC thru wall to tank, 3" PVC in house, no leaks visible
❑ Yes ® No
Septic Tank (locate on site plan):
Depth below grade: .5
feet
Material of construction:
® concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other (explain)
If tank is metal, list age:
years
Is age confirmed by a Certificate of Compliance? (attach a copy of certificate)
Dimensions: 10' x 5' x 4'
Sludge depth:
2"
❑ Yes ❑ No
t5ins • 09108 Title 5 Official Inspection Form: Subsurface Sewage Disposal System - Page 9 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
< 4 Christian Way
Property Address
Dale Merski
Owner Owner's Name
information is
required for North Andover MA 01845 2/1/2010
every page. Cityrrown State Zip Code Date of Inspection
D. System Information (cont.)
Septic Tank (cont.)
Distance from top of sludge to bottom of outlet tee or baffle
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
24"
3-
81,
19"
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. Inlet baffle ok. Inlet pipe not into tee, goes into baffle. Outlet tee partially
corroded off, needs to be replaced. Depth of liquid at outlet invert. No evidence of legakage.
Grease Trap (locate on site plan):
Depth below grade:
Material of construction:
❑ concrete ❑ metal
Dimensions:
Scum thickness
feet
❑ fiberglass ❑ polyethylene ❑ other (explain):
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:
t5ins • 09/08
Date
Title 5 Official Inspection Forth: 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
4 Christian Way
Property Address
Dale Merski
Owner Owner's Name
information is
required for North Andover
every page. Cityrrown
State
01845
Zip Code
2/1/2010
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:
Design Flow:
gallons
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
t5ins - 09/08 Title 5 Official Inspection Form: Subsurface Sewage Disposal System - Page 11 of 17
oil
Owner
information is
required for
every page.
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
4 Christian W,
Property Address
Dale Merski
Owner's Name
North Andover MA 01845 2/1/2010
Cityrrown State Zip Code Date of Inspection
D. System Information (cont.)
Distribution Box (if present must be opened) (locate on site plan):
Depth of liquid level above outlet invert
U
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 & distibution equal, has flow levelers. No evidence of leakage. Evidence of carryover,
pumped d -box to clean. D -box cover broken, replaced it.
Pump Chamber (locate on site plan):
Pumps in working order: ❑ Yes ❑ No
Alarms in working order: ❑ 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 • 09/08 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
M ' 4 Christian Way
Property Address
Dale Merski
Owner Owner's Name
information is
required for North Andover
every page. Cityfrown
D. System Information (cont.)
Type:
❑
leaching pits
❑
leaching chambers
❑
leaching galleries
❑
leaching trenches
®
leaching fields
❑
overflow cesspool
❑ innovative/alternative system
MA 01845 2/1/2010
State Zip Code Date of Inspection
number:
number:
number:
number, length:
number, dimensions:
1 field 25'x 55'
number:
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 snow covered. 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 • 09108 Title 5 Official Inspection Forth: Subsurface Sewage Disposal System - Page 13 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
4 Christian W;
Property Address
Dale Merski
Owner's Name
North Andover MA 01845 2/1/2010
Citylrown 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 - 09108 Title 5 Official Inspection Form: Subsurface Sewage Disposal System • Page 14 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
4 Christian Wa
Property Address
Dale Merski
Owner's Name
North Andover
cityrrown
D. System Information (cont.)
MA n1 RA -r%
JIGIC uN a,wc
2!1!2010
Date of Inspection
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
0
5 0AA
I L�
a
ffi7isc
Or.
t5ins - 09/08 Title 5 Official Inspection Form: Subsurface Sewage Disposal System - Page 15 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
4 Christian Way
Property Address
Dale Merski
Owner's Name
North Andover MA 01845 2/1/2010
Cityrrown State Zip Code Date of Inspection
D. System Information (cont.)
Site Exam:
®
Check Slope
®
Surface water
®
Check cellar
®
Shallow wells
Estimated depth to high ground water: 11.6
feet
Please indicate all methods used to determine the high ground water elevation:
® Obtained from system design plans on record
If checked An of Ansi n Ian re i d'
4/27/1984
U p v ewe . 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:
No water 4' below field as per test pit data on design plan
Before filing this Inspection Report, please see Report Completeness Checklist on next page.
t5ins - 09/08 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
4 Christian Way
Property Address
Dale Merski
Owner Owner's Name
information is
required for North Andover MA 01845 2/1/2010
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 - 09108 Title 5 Official Inspection Form: Subsurface Sewage Disposal System • Page 17 of 17
Summary Record Card generated on 211/201012:30:31 PM by Karen Hanlon
Town of North Andover
Tax Map # 210-104.D-0142-0000.0
Page 1
Parcel Id 16828
4 CHRISTIAN WAY
MERSKI, DALE
4 CHRISTIAN WAY
NO. ANDOVER, MA
01845
Class 101 Single Family Property Type 1 Residential
Size Total 1.19 Acres
FY 2010
UB Mailina Index
Name/Address
MERSKI, DALE
4 CHRISTIAN WAY
NO. ANDOVER, MA
01845
UB Account Maint.
Account No Cycle
Bldg Id. 17773.0 - 4 CHRISTIAN WAY
3170437 03 Cycle 03
UB Services Maint.
Account No. 3170437
Service Code
MISCFEE ADMIN FEE
WTR WATER
UB Meter Maintenance
Account No. 3170437
Brand
Serial No Status
YTD Cons
34429333 a Active
b Badger
Date
Reading
12/11/2009
258
9/8/2009
241
619/2009
221
3/16/2009
203
12/8/2008
183
9/11/2008
161
6/6/2008
100
3/10/2008
64
12/12/2007
42
9/21/2007
0
9/21/2007
3199
6/19/2007
3137
MSG
61
3/15/2007
3102
12/12/2006
3077
9/13/2006
3032
6/19/2006
2980
3/8/2006
2951
12/22/2005
2929
9/20/2005
2890
6/2812005
2831
3/30/2005
2805
12/14/2004
2776
9/27/2004
2756
6/23/2004
2718
4/16/2004
2699
Type Loan Number Active/lnact From
Payor
Occupant Name Activellnactive
Last Billing Date 1/4/2010
Active
Rate Charge Multiplier/Users
0.635/8 7.82 1/
01 ALL METER SIZE 64.60 /1
Until
Location
Brand
Type Size
YTD Cons
ERT HH
b Badger
w Water 0.63 0.63
194
Code
Consumption
Posted Date
Variance
a Actual
17
1/12/2010
-18%
a Actual
20
10/15/2009
4%
a Actual
18
7/20/2009
4%
a Actual
20
4/29/2009
-18%
a Actual
22
1/20/2009
-60%
a Actual
61
10/10/2008
54%
a Actual
36
7/16/2008
65%
a Actual
22
4/11/2008
-52%
a Actual
42
1/22/2008
-100%
n New Meter
0
10/12/2007
-100%
r Replacement
62
10/12/2007
81%
m Manual estimate
35
7/20/2007
36%
m Manual estimate
25
4/16/2007
-46%
a Actual
45
1/19/2007
-17%
a Actual
52
10/20/2006
115%
a Actual
29
7/1012006
-3%
a Actual
22
4/17/2006
-31%
a Actual
39
1/17/2006
-40%
a Actual
59
10/14/2005
143%
a Actual
26
7/15/2005
6%
a Actual
29
4/5/2005
7%
a Actual
20
1/14/2005
-35%
a Actual
38
10/8/2004
42%
a Actual
19
7/30/2004
-8%
a Actual
37
5/17/2004
0%
t*
Commonwealth of Massachusetts
_ City/Town of
� System Pumping Record
w Form 4
DEP has provided this form for use by local Boards of Health. Other forms may be used, but the
information must be substantially the same as that provided here. Before using this form, check with your
local Board of Health to determine the form they use. The System Pumping Record must be submitted to
the local Board of Health or other approving authority.
A. Facility Information
1. System Location: Left side of hous Right side of house, Left front of house, Right front of house,
Left rear of house, ouse. Left rear of building. Right rear of building.
Address
L4 CUN r�aA,_ ko�
City/Town State Zip Code
2. System Owner. H
Name
t5form4.doc- 06/03
Address (if different from location)
City/Town
B. Pumping Record
1. Date of Pumping
3. Type of system: ❑
❑ Other (describe):
D —` —to
Date
Stat(S— � 8-3 'p
Tele -phone Number
2. Quantity Pumped: ` `C
Gallons
Cesspool(s) �epfic Tank ❑ Tight Tank
4. Effluent Tee Filter present? ❑ Yes [ o If yes, was it cleaned? ❑ Yes ❑ No
5. Condition of System:
ouk -e-�.
6. System Pumped By:
Neil Bateson=
Name
Bateson Enterprises Inc
Company
7. Location where contents were disposed:
Of
Lowell Waste Water
Vehicle License Number
Date
System Pumping Record • Page 1 of 1
Town of North Andover, Massachusetts Form No.1
BOARD OF HEALTH
S. ,
19
MAPPLICATION FOR SITE TESTING/INSPECTION
Applicant NAME ADDRESS TELEPHONE
Site Location
Engineer NAME ADDRESS TELEPHONE
Test/l nspection Date and Time
Fee
CHAI RMAN, BOARD OF HEALTH
Test No.
S.S. Permit No.-D.W.C. No.-C.C. Date-Plbg. Permit No.
LO_ 7
,....., -,
L 17
.L I Wer
5T 0L Y_FT
E;
L9�f
Pt 1r7 741f
r
t ,
i
lk
,....., -,
L 17
.L I Wer
5T 0L Y_FT
E;
L9�f
Pt 1r7 741f
r
TOWN OF NORTH ANDOVER
SYSTEM PUMPING RECORD
DATE: d� ,
r
SYSTEM OWNER & ADDRESS SYSTEM LOCATION
(example: left front of house)
fi)CtOVQ % ar o c
DATE OF PUMPING:,aa_,D- QUANTITYPUMPED GALLONS
CESSPOOL: NO.' YES SEPTIC TANK: NO YES
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)
4--
0
T
3U13D of Hca --m
s5 ,, 73
�PPl�avl=5p
.
COA)PlTIoNS :
DI54PPR4v5p:
RQ-soNS
(,&),4T
0/1 Te
LOT 7 C hR )`>TI,"
,Q'PPL( CAti I_ & r 4 L_
5()PPL7 _FbWnl ❑ WELL. APS
SEPT -IC S -r STE., PE-'si�J
S-1-� 7 4PRfiov1N6 Aunyoi?iTy
D Mti� StPT'(C SYSTEM I J STA A1
�1..QTl0
i�
ex4v4Tlol� 1NSP �Tio&J
J
94rc ��' _ IT -1--4-)5 S Cl FAIL_
T � 13v��
(0 AL, IA)5tTz� foNS
DtSAPPi?ovF,D DArE
FKvAL APPI�QvAL D,p�� )2-3p 4 7
5 -flu, Iva5FP5 owG !
I-
-4
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTI
L
Owner
Address of property"
Owner's name C
V 1
Y^ V
Date of Inspection Y t"
PART A
CHECKLIST k._
Check if the following have been done:
Pumping information was requested of the owner, occupant, and Board of•'•y"
/ Health.
None of the system components have been pumped for at least two weeks -`
and the system has been receiving normal flow rates during that
period. Large volumes of water have not been introduced into the
/ system recently or as part of this inspection.
V As built plans have been obtained
and examined. Note if they are not
available with N/A.
JThe facility or dwelling
/ was inspected for signs of sewage back-up.
y The site was inspected for signs of breakout.
All system components, excluding the SAS, have been located on the
/ site.
J The septic tank manholes were uncovered, opened, and the interior of
the septic tank was inspected for condition of baffles or tees,
material of construction, dimensions, depth of liquid, depth of
sludge, depth of scum.
The size and location of the SAS on the site'has been determined based
on existing information or approximated by non -intrusive methods.
The facility owner (and occupants, if different from owner) w
provided with information on the proper maintenance of SSDS, were
.4
a
r
Su#SUiFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
i PART B
SYSTEM INFORMATION
FLOW CONDITIONS
If..residential
number of bedrooms
number of current residents
N� garbage grinder, yes or no
Y� laundry connected to system, yes or no
NO seasonal use, yes or no
If nonresidential, calculated flow:
Water meterreadings, readings, if available: rw EAP-Mxu S� /,! �6,' 6
Cv2aath Last date of occupancy
GENERAL INFORMATION
Pumping records and source of information:
System pumped as part of inspec on, ye or no
if yes, volume pumped
Reason for pumping:
Typ of system
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)
Other (explain)
Approximate age of all components. Date installed, if known. Source of
information:
TSewage odors detected when arriving at the site, yes or no
a
8
l
9
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART B
SYSTEM INFORMATION continued
SEPTIC TANK:–,/–
(locate
ANK:(locate on site plan)
depth below grade:
material of construction: V concrete metal FRP o (explain)*
s
dimensions:— �� to���
sludge depth
distance from top of sludge to bottom of outlet tee or baffle
scum thickness
_ distance from top of scum to top of outlet tee or baffle
/5"' distance from bottom of scum to bottom of outlet tee or baffle
Comments:
(recommendation for pumping, condition of inlet and outlet tees or baffles,
depth of liquid level in relation to outlet invert, structural integrity,
evidence of leakage, recommendations for repairs, etc.)
DISTRIBUTION BOX:_
-V/
(locate on site plan)
O�
depth of liquid level above outlet invert
Comments:
(note if level and distribution is equal, evidence of solids carryover,
evidence of leakage into or out of box, recommendation for repairs, etc.)
PUMP CHAMBER:
(locate on site lan)
pumps in.working order, yes or no
A
Comments:
(note condition of pump chamber, condition of pumps and appurtenances,
recommendations for maintenance or repairs,etc.)
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART B
SYSTEM INFORMATION continued
SOIL ABSORPTION SYSTEM (SAS):
(locate on site plan, if possible; excavation not required, but may be
approximated by non -intrusive methods)
If not determined to be present, explain:
Type
leaching pits and number
leaching chambers and number
leaching galleries and number
leaching trenches, number, length
leaching fields, number, dimensions
overflow cesspool, number
t
Comments:
(note condition of soil, signs of hydraulic failure, level of ponding,
condition of vegetation, recommendations for maintenance or repairs,etc.)
CESSPOOLS (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 (cesspool must be pumped as
part of inspection)
Comments:
(note condition of soil, signs of hydraulic failure, level of ponding,
condition of vegetation, recommendations for maintenance or repairs,etc.)
PRIVY:
(locate on siteplan)
materials of construction
dimensions
depth of solids
Comments:
(note condition of soil, signs of hydraulic failure, level of ponding,
condition of vegetation, recommendations for maintenance or repairs,etc.)
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART B
SYSTEM INFORMATION continued
SKETCH OF SEWAGE DISPOSAL SYSTEM:
include ties to at least two permanent references landmarks or benchmarks -,M.
locate all wells within 100'
i4
SI
DEPTH TO GROUNDWATER
/ Idepth o groundwater
method of determiiation or approiimation:
Q
0
I
12 f
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C.
FAILURE CRITERIA
Indicate yes, no, or not determined (Y, N, or ND). Describe basis of
determination in all instances. If "not determined", explain why not)
tv Backup of.sewage into facility?
.JAJ Discharge or ponding of effluent to the surface of the ground or
surface waters?
Static liquid level in the distribution box above outlet invert?
N Liquid depth in cesspool <6" belowinvert or available volume< 1/2 day
flow?
Required pumping 4 times or more in the last year?
number of times pumped
-AZ Septic tank is metal? cracked? structurally unsound? substantial
infiltration? substantial exfiltration? tank failure imminent?
,) Is any portion of the SAS, cesspool or privy:
N below the high groundwater elevation?
within 50 feet of a surface water?
within 100 feet of a surface water supply or tributary to a surface
water supply?
dwithin a Zone I of a public well?
within 50 feet of a bordering vegetated wetland or salt marsh
(cesspools and privies only, not the SAS)?
within 50 feet of a rivate water supplywell?
P
less than 100 feet but greater than 50 feet from a private water
supply,.well with no acceptable water quality analysis? If the well
has been analyzed to be acceptable, attach copy of well water analys`
for coliform bacteria, volatile organic compounds, ammonia nitrogen
and nitrate nitrogen.
J
13
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART D
CERTIFICATION
Name'of Inspector
v c �ro.
Company Name `
Company Address g3 C7 Lw l -�vlj
Certification Statement
I certify that I have personally inspected the sewage disposal system at
this address and that the information reported is true, accurate and
complete as of the time of inspection. The inspection was performed and
any recommendations regarding upgrade, maintenance and repair are
consistent with my training and experience in the proper function and
manitenance of on-site sewage disposal systems.
Chec one:
I have not found any information which indicates that the system fails
to adequately protect public health or the environment as defined in
310 CMR 15.303. Any failure criteria not evaluated are as stated in
the FAILURE CRITERIA section of this form.
I have determined that the system fails to protect public health and
the environment as defined in 310 CMR 15.303. The basis for this
determination is provi d in the AI URE CRITERIA section of this
form.
Inspector's Signa ur s `X_
Date
Original to system owner
Copies to: ,J 0 Ce RCP I evvs 7:r,-4S,VG40 ¢2
Buyer (if applicable)
Approving authority
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Commonwealth of Massachusetts REC
City/Town of
System Pumping Record • �, r,�,
Form 4
TQWN OF NORTH AND u�
DEP has provided this form for use by local Boards of Health. Oth T _ hsh' _ he
information must be substantially the same as that provided here. Before using this ck with your
local Board of Health to determine the form they use. The System Pumping Record must be submitted to
the local Board of Health or other approving authority.
A. Facility Information
1. System Location: Left side of hous , Right side of house, Left front of house, Right front of house,
Left rear of house, ouse. Left rear of building. Right rear of building.
Address Lf cba'� ��o ct"�
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
Stat 8S 8 -,Zip ode I
Tele -phone Number 3
2. Quantity Pumped: R�
Gallons
Cesspool(s) eptic Tank ❑ Tight Tank
4. Effluent Tee Filter present? ❑ Yes Oho
5. Condition of System:
c�
6. System
Neil Bateson
If yes, was it cleaned? ❑ Yes ❑ No
4,
21
8
Name Vehicle License Number
Bateson Enterprises Inc
Company
7. Location where contents were disposed:
Lowell Waste Water
of
Date
a - i r®
t5form4.doc• 06/03 System Pumping Record • Page 1 of 1