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HomeMy WebLinkAboutMiscellaneous - 42 CROSSBOW LANE 4/30/2018 (2) 42 CROSSBOW LANE J 210/106.B-0197-0000.0 Commonwealth of Massachusetts H W City/Town of No andover , a System Pumping Record Form 4 I M 5y0y`' 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 Important:When filling out forms 1. System Loc ti n' on the computer, r use only the tab C-OLS S key to move your Address cursor-do not No Andover Ma use the return — key: Citylrown .rt State - Zip Code v7Q,1 2. System Owner: RLCEI!/ED IL Name JUN 212012 Address(if different from location) TOWN OF NORTH ANDOVER City/Town State EPA RT Telephone Number B. Pumping Record -.1. Date of Pumping Date 2• Quantity Pumped: Gallons 3. Type of system: ❑ Cesspool(s) U�—S­eptic Tank ❑ Tight Tank ❑ Grease Trap ❑ Other(describe): 4. Effluent Tee Filter present? ❑ Yes VNo If yes, was it cleaned? ❑ Yes ❑ No 5. Condition of System: l 6. Sys umped By: Nam Vehicle License Number Stewart's Septic Service Company 7. Location where contents were disposed: Stewao'k Pre,4heaLnent Plant, 20 So. Mill Bradford, Ma 01835 0 V I Sign u of ' ul Date, �� I Signa re f Reriving Facility Date t5form4.doC•03/06 System Pumping Record•Page 1 of 1 e"1� �s �rti',.,,f<�R: �ell ��!. 1, ' Iqr 1,.it - - i r -< 4� • r TOWN-OF NORTH ANDOVER SYSTEM PUMPING RECORD '` r -^.i• f l n,l! :i �;'' i, u. y I�� M" 1�r�,�r �,�i l�,<��d`�-t rr P'r t k lit �� ��elry6w t i ��j!. M'. l N •r .�it S�tSTEM OWNER& ADDRESS SYSTEM LOCATION. 4. t. (example: left front of house) J'. �i1�F��''�(i�R�F��i'�� �1't;�``��},i�f'�'it,�'�,�Rx1y11;'�'i .t •:. ,�!'rY.r��'•'�e r'q j""'r�" '•. •ri. .. ..._.. � .. _.. �I I�RAS,AFT PING:' QUANTITY PUMPED l� ---�.�GALLONS qj '� q 'P � 4".43, �i�tl,, y ray �,"Itf,!krIj r'' ,,I�{7EES$ OOL: NO .S YES EPTIC TANK: NO_ YES off,JA IAJ 111 r 1• + 1 �p �. J ' 4 OF SERVICE: ROUTINE EMERGENCY S +...i�%�ev' '6-^�t���}��I ���•!�� Ir 4.•e 31 '`I to �� .•, � x.« ! .. `. .. . .... ,. ..... .. .�, ..� � ,. � �.. CC-�}� a t 4 ,yk J, ` 4;` I•:w3� '1� �a_?i VAP �' ilI�t� r�t9 IfkE�:GOOD CONDITION ,,•" " FULL TO HEAVY GREASE COVER AM17 ;!4 t� ii 1 ( ` BAFFLES IN PLACE ROOTS LEACHFIELD RUNBACK IVE SOLIDS It`t� 1`r� �7rr 7 i-. �'f, r' •.EXCESS —�• �w•..r. SOLIDS CARRYOVER�— FLOODED L, I OTHER(EXPLAIN) ���', WQo',RPP Fd.7,BY. �,r(�rL/ -- I t+n�l•�I���1'�f�1�3=�tfl t" ''�1��34 3.1 r ti'r I I -X' .. _ y tAM `i�jll+kl I,i Fi i44 q + � fr,�.,Z tRl;*r!., t .*t4 f ;',� ,• - _ —.r.r+�"""'. TRy1SFE TT . wwQQ — f Il� (,. ,� +•'�� I.qid Prf h, t' rt ,r , G D:,Tp• G/`��(.Y' j���„,�1 p 44"1 }a� '�i .ISt��}Ytt'Vi . ) ��"y/rt jjrt��f f+ xl l•i}n.u� �orz .'i + -, . ., a t �L �- _k lt.j! , I��.� ��`rl•S�i�j!}•is r��,;ii r' 1.}I :3' ���1/ �''�, � .. . " 1 �F ��' Smm*� tri i i-1.,! 1•t-. �4 1'" ��l!'ti�. ,4 ra ,. � '�,' �Ay'ytj��;^tarr �. i. �1, �, ..�r� .k�1'. `�•, .. ''"•t t:� -. �' ' Address Title of Fi:ie Page — of Date File Open: ------- Date fjle closed:_ Doc Document/Action Title =Actiomn' Purpose of Docume t action Nun-i. /Aeon and nute5 Board of Appeals — Board of Health = Planning Board Cori seruatiion Commission — Building Departmen-t FORM U - LOT RELEASE FORM INSTRUCTIONS: This form is used to verify that all necessary approvals/permits from Boards and Departments having jurisdiction have been obtained. This does not relieve the applicant and/or landowner from compliance with any applicable or requirements. • ************-k***'*AFPLICANT FILLS OUT THIS S�CT10N• *** * APPLICANT c. C��- �, PHONE Glh 6.2.15 �c!AS l LOCATION: Assessors Nlap Number PARCEL 9 SUBDIVISION LOT (S) ZO STREET Cx- - ST. NUMBER OFr1C1AL USE ONLY• RECOMMENDATIONS OF TOWN AGENTS: CONSERVATION ADMINISTRATOR DATE APPROVED DATE REJECTED o - COMMENTS It-- � TOWN PLANNER DATE APPROVED DATE REJECTED COMMENTS ii I FOOD INSPECTOR-HEALTH DATE APPROVED DATE REJECTED SEPTIC INSPECTOR-HEALTH DATE APPROVED S DATE REJECTED COMMENTS PUBLIC WORKS -SEWER/WATER CONNECTIONS DRIVEWAY PERMIT i FIRE DEPARTMENT j RiCEIVED EY BUILDING ;INSPECTOR M DATE - i Revised 9y91 im II 7�1 � S oS ! . 1 c� A/A '&4 bin I / op t,r ti j l �ZN OF MqS �� O= JOSEPH ti J' '-l.t SARBACALLO ti O � l. TE464 ALS ,t'7% I V4 r i (l �� Y I ` � I Board, of Health SEPTIC SZ5T1<�i . 'North p42P-3-�Kaae. j INSTALLATIoK CHBCB LIST LOT" ` 6 ' - EXCAVATION ' 0 FAIL, ;_PPOVED DATE IIT SAPPiiOV� { • easvnst , FAIL O 1. Instance Tot a. Wetlands b. Drains c.. Well 2. Water Line Location 3. No PVC Pipe Septic Tank - a. _Tees -_Length & To Clean Ont Covers. b. Cement Pipe to Tank -- On Both Sides of Tank 5. Distribution Boa a. Covers & Box - No Cracks b. All Lines Flo0mg Equal Amounts c. No Back Flow 6. • Leach Field or Trench a. Dimensions b. Stone- c , tone c. Capped ids -- - — -- _ _ d. Clean Double Washed Stone - - Leach Pits Dinbnsions- r b. Stone Depth . a. Splash Pads_ d.-- Tees e. Cement Pipe to Pit - Both Sides f. Clean Double Washed Stone - - 8. No Garbage Disposal -Final Gradin Inspection 10. Barricading Covered System 11. As- Built Submitted__ _ - --a. Lot Lo.e.atioh - - b. Dime-r,.siddns of System c. Location Stith Regard-to Perc Test d. 'Elevation-s - e. Water Tab'Le - - 4 Board of Health !Jarth',ndover,Yass r SUBSURFACE DISPOSAL DESIGN CEKK LIST LOT APPROVE DATE . DISAPPR DATE Provided: Reason Title V FAIL Reg 2.5e submitted plan must show as a mini nn1m: the lot to be served-area,dimensions lot f,abutters location and log deep observation h2es-distance to ties PTh location and results percolation tests-distance to ties design calculations & calculations showing required leaching area location and dimensions of system-including reserve area f) existing and proposed contours (g) location any vet areas Athi.n 100' of sewage disposal system or disclaimer-check wetlands napping (h) surface and subsurface drains Within 1001 of sewage disposal system or disclaimer (i) location any drainage easements vithi.n 1001 of serge disposal system or disclaim--r-Planning Board files (3) knoun sources of pater supply within 2001 of serge disposal e system or disclaimer _ - — — - — -location of aur -proposed well Ao sere 1--ot_1001 from leaching facili- location of water lines on property-101 from leaching facility M) location of benchmark Pdriveways garbage disposals no PVC to be used in construction q) profile of system-elevations of basement, plumb, pipe, septic tank., distribution box inlets and outlets, distribution field piping and 0-Ier elevations IV(r) maxJx= ground -water elevation in area sewage disposal system 7_7(s) plan roast be prepared by a Professional Ragineer or other professional authorized by law to prepare such plans Reg 6S�tic Tanks a) capacities-15o� of flog, water table, tees, depth of tees, access, pining (b) cleanout c) 101 from cellar wall or inground sZ—zing pool d) 251 from subsurface drains Reg 10.2 Distribution Boxes a) =SOpe eater than 0.08 Reg 10.2 b) p t�cw Lim �i1.�st� 4�oE cA�•-�nv� S N v Sib S M r IS Nc (�w Subsurface Design Check List Page 2 Mt I Cg Leaching Pits Leaching pits are preferred where the installation is possible leg 11.2 a) calculations of l g area-minizmm 500 eq ft 11.4 b) spacing 11.10 c) surface a 2 11.11 d) cover mate e) lash pad f) tee at bow g) no ds in pipe from d-box to pipe LeachinFields teg 15.1 no greater an 20 minutes/inch area-minimum 900 sq ft 15.4 } construction of field 15.8 surface drainage 2 % 3.7 e) 201 from cellar call or inground s in dng pool Leachin Tr-caches - "eg 14.1 a) calculations o eaching area-min 500 sq ft 14.3 b) spacing-4 ft 6 ft with reserve between 14.4 c) dimension 14.6 1d) contra on 14.7 e) ston 14.10 f) ace drainage 2% Doyphi l 1 Slope- a) lo e-a) slop e y x _ to be shovm) —L_ "S 0 b) y/x x 150 - (to be sho,„,n) _ �d PU, s .eg 9.1 a) 4 !2d-by 9.6 b) power SOIL PROFILE b pf R , ; _.__ OLI, ION rrST DATA. North Andover,l :ss. No. &Street -- Lot ?Jo ✓ �ur� . Loc . /Subdiv. an . Ownerl/ �-r , Invest .gator = - Observer �I SOIL PR FI -DAT - . 1 • .. . Eley. Elev. /'R4'Elev. 0 _ U - 0 0 T'IF � -- � -Ti 2 Z - 2 �� S 2 �� s Ties to Test Pi 1, . - ; 3 4 f r7 4 t►R ' N 4 0 4 Q. 5 5 5 5 6 b A3 6 G 7 _ 7 7 ' 8 8A�C $ 1.10 :.fib 1?�Gt, 10 10 - 10 oN 20 f o Benchmark Location - V Elevation Datum Percolation Tests-Date Mato--: s 9.3 lU �� Pit Number- Start umber Start Saturation 3.1�0 x'•03 �:�o Soak -Mins. .___. Start Drop of 3"—Time _-- Drop of 611 '.4J L; - I;ins _ 1st - 3"Dro tb �a Mins . 2nd 3"Dro , - Percolation Rate �� 5 w ..d_.. .. �Al e o7-6 = f Z , M& �lpl BE Re-;re- BOARD OF HEALTH DESIGN APPROVAL Lot # STREET Septic Tank Permit # Proposed Construction Approx Building Size 3c7X(pQ Garage Under Attached None Min elevation of top of slab Min elevation of top of foundation / • � Height of foundation wall �rS Footing in fill yes no Further Comments 47-,r— ,r ��Z� ���/,1 ��. •Cam>rrC �f��E�� .�/� TOWN OF NORTH ANDOVER/ BOARD OF HEALTH COMMONWEALTH OF MASSACHUSETTS l EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS FEB 33 a DEPARTMENT OF ENVIRONMENTAL PROTECTI .. t ONE H'I'TTER STREET. BOSTON. MA 02108 617-292-5500 e V / TRUDY COXE I r WILLIAM F. EL� Gov�rno: Secretary ARGEO PAUL CELLUCCI DAVID B.STRUHS Lt.Governor SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM Commissioner PART A CERTIFICATION Property Address: Address of Owner: Date of Inspection: --1-0 1 J`� ,/ (If different) Name of Inspector: - oAA) / IGrt / �) J�✓2� I am a DEP approvid system inspector pursuant to Section 15.340 of Title 5 (310 CMR 15.000) Company Name: Q !!` IF A9 7-1 C_ Mailing Address: 4Q/ Telephone Number: 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 inspection. The inspection was performed based on my training and experience in the proper function and maintenance of on-site sewage disposal systems. The system: Passes Conditionally Passes Needs Further Evaluation By the Local Approving Authority Fails _ ` j Inspector's Signature: Date;- The System Inspector all submit a copy of this inspection report to the Approving Authority within thirty (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 Department of Environmental Protection. The original should be sent to the system owner and copies sent to the buyer, if applicable, and the approving authority. INSPECTION SUMMARY: Check A, B, C, or D: A] SYSTEM P SES: I have not found any information which indicates that the system violates any of the failure criteria as defined in 310 CMR 15.303. 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. t Indicate yes, no, or not determined (Y, N, or ND). Describe basis of determination in all instances. If"not determined", explain why not. _ The septic tank is metal, unless the owner or operator has provided the system inspector with a copy of a Certificate of Compliance (attached) indicating that the tank was installed within twenty (20) years prior to the date of the inspection; or the septic tank, whether or not metal, is cracked, structurally unsound, shows substantial infiltration or exfiltration, or tank failure is imminent. The system will pass inspection if the existing septic tank is replaced with a conforming septic tank as approved by the Board of Health. (revised 04/25/97) Page 1 of 10 DEP on the World Wide Web http:/twww.magnet.state.ma.us/dep > Printed on RecyGed Paper 1 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) e } Property Address: ��s�r ktt/ �•N o oV� Bl�t.Pr ! Owner:10,6 t-.e- Date of Inspection: q BI SYSTEM CO DITIONALLY PASSES (continued) _ Sewage backup or breakout or high static water level observed in the distribution box is due to broken or obstructed pipe(s) or due to a broken, settled or uneven distribution box. The system will pass inspection if(with approval of the Board of Health). Describe observations: broken pipe(s) are replaced obstruction is removed distribution box is levelled or replaced The system required pumping more than four 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 CI 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 the public health, safety and the environment. 1) SYSTEM WILL PASS UNLESS BOARD OF HEALTH DETERMINES THAT THE SYSTEM IS NOT FUNCTIONING IN A MANNER 4 WHICH WILL PROTECT THE PUBLIC HEALTH AND 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 GOND PUBLIC WATER SUPPLIER, IF APPROPRIATE) DETERMINES THAT THE SYSTEM IS FUNCTIONING IN A MANNER THAT PROTECTS THE PUBLIC HEALTH AND SAFETY AND THE ENVIRONMENT: The system has a septic tank and soil absorption system (SAS)and the SAS is within 100 feet to a surface water supply or tributary to a surface water supply. The system has a septic tank and soil absorption system and the SAS is within a Zone I of a public water supply well.. The system has a septic tank and soil absorption system and the SAS is within 50 feet of a private water supply well. The system has a septic tank and soil absorption system and the SAS is less than 100 feet but 50 feet or more from a private water supply well, unless a well water analysis for coliform bacteria and volatile organic compounds indicates that the well is free from pollution-from-that facdityand-the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm. Method used to determine distance (approximation not valid). 3) OTHER (revised 04/25/97) Paye 2 of 10 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property dress: Owner: 4/dre }-4""'w"". �- �__- - .>,,«<•,M. ..� q ri Date of Inspection: DJ SYSTEM FAILS: You must indicate either "Yes" or "No" as to each of the following: I have determined that the system violates one or more of the following failure criteria as defined in 310 CMR 15.303. The basis for this determination is identified below. The Board of Health should be contacted to determine what will be necessary to correct the failure. Yes No Backup of sewage into facility or system component due to an 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 1/2 day flow. 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 Soil Absorption System, cesspool or privy is below the high groundwater elevation. Any portion of a 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 I 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. If the well has been analyzed to be acceptable, attach copy of well water analysis for coliform bacteria, volatile organic compounds, ammonia nitrogen and nitrate nitrogen. Ej LARGE SYSTEM FAILS: You must indicate either "Yes" or "No" as to each of the following: The following criteria apply to large systems in addition to the criteria above: The system serves a facility with a design flow of 10,000 gpd or greater (Large System) and the system is a significant threat to public health and safety and the environmentbecause one or more of the,following conditions exist: 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) The owner or operator of any such system shall bring the system and facility into full compliance with the groundwater treatment program requirements of 314 CMR 5.00 and 6.00. Please consult the local regional office of the Department for further information. (revised 04/25/97) Page 3 of 20 a SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST Property Address: ' i C R-os$:A.Q.t t./.. 4A`1 Owner:Dor--e.7_jL� Date of Inspection: 9 z r ) Check if the following have been done: You must indicate either "Yes or"No" as to each of the following: Yes No Pumping information was provided'by the owner, occupant, or Board of Health. _ None of the system components have been pumped for at least two weeks and the system has been receiving normal flow rates during that period. Large volumes of water have not been introduced into the system recently or as part of this inspection. _ As built plans have been obtained and examined. Note if they are not available with N/A. The facility or dwelling was inspected for signs of sewage back-up. _ The system does not receive non-sanitary or industrial waste flow. _ The site was inspected for signs of breakout. _ All system components, excluding the Soil Absorption System, have been located on the site. _ The septic tank manholes were uncovered, opened, and the.interior of the septic tank was inspected for condition of baffles or tees, material of construction, dimensions, depth of liquid, depth of sludge, depth of scum. The size and location of the Soil Absorption System on the site has been determined based on: _ The facility owner (and occupants, if different from owner) were provided with information on the proper maintenance of Sub-Surface Disposal System. _ Existing information. Ex. Plan at B.O.H. / eo _ Determined in the field (if any of the failure criteria related to Part C is at issue, approximation of distance is unacceptable) (15.302(3)(b)) (revised 04/2S/97) page 4 of 10 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION Property Address: A/9 Cron$ 6atA/ Ad. AN&-laccer Owner:490 r\e to Date of Inspection: V 'Q FLOW CONDITIONS RESIDENTIAL: Design flow:_ ¢.P.I./bedroom for S.A.S. Number of bedrooms: ... Number of current residents: e G-o f7'1 N „J D n G r^a� d Garbage gnr:der (yes or no): � Gn !�- pL Laundry connected to system (yes or no)j� / 7-r Seasonal use (yes or no):� Water meter readings, if available (last two (2) year usage (gpd): Sump Pump (yes or no), Last date of occupancy:OGCl,JpI +e COMMERCI.AUI N DUSTRIAL: Type of establishment: Design flow:_gallons/day 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 o,.cupancy: OTHER: (Describe) Last date of occupancy: GENERAL INFORMATION PUMPING RECORDS and source of information: System pumped as part of inspeqion: (yes or no)_ If yes, volume pumped: /520allons Reason for pumping -� /I/T�4.r: JlZM C TYPE __j:!! F STEM _ "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) I/A Technology etc. Copy of up to date contracts' Other APP XIMATE AGE of all components, date installed (if known) and•'source of information: Sewage odors detected when arriving at the site: (yes or no)/101 (revised 04/25/97) Page 5 of 10 s + �N SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property_Address: t C SSS �o f Thr � � � � Owner:fj©r^ r Datei of Inspection: BUILDING SEWER: (Locate on site plan) H Depth below grader Material of construction: _ iron _40 PVC_other (explain) Distance fromrate water supply well or suction llrf, Diameter Comments: (condition of joints, venting, evidence of leakage, etc.) SEPTIC TANK: (locate on site plan) Depth below grade:t� Material of construction: oncrete _metal _Fiberglass _Polyethylene —other(explain) z If tank is metal, list age _ Is age confirmed by Certificate of Compliance _(Yes/No) Dimensions: Sludge depth 1 Distance from top of sedge to bottom of outlet tee or baffle:, Scum thickness:_ Distance from top of scum to top of outlet tee or baffler Distance from bottom of scum to bolt ,of outlet tee or baffle:' How dimensions were determined: Comments: (recommendation for pumping, condition of inlet and outlet tees or baffles, depth of Iilevel in relation to ou et inve structural integrity, evidence of leakage, etc.) . LG s7L' d L e +e7— -'C +QL A17 N GREASE TRAq (locate on sit V/ J 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: (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, etc.) (revised 01/25/97) Paye 6 of 10 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: Owner: A90 Date of Inspection: TIGHT OR HOLDING TANK: (Tank must be pumped prior to, or 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/daN Alarm level: Alarm in working order_Yes; _ No Date of previous pumping: Comments: (condition of inlet tee, condition of alarm and float switches, etc.) DISTRIBUTION BOX: (locate on site plan) .}- Depth of liquid level above outlet invert /V/-Pt4L �Lt15 ! Comments: (note if level and di tribution is equal, evidence of solids carryover, evidence of leakage into or out of box, etc.) Ll 40, PUMP CHAMBER: (locate on site pla ) Pumps in working order: (Yes or No) r Alarms in working order (Yes or No) Comments: (note condition of pump chamber, condition of pumps and appurtenances, etc.) (revised 04/75/97) Page 7 of 10 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: Owner: a r•G r Date of Inspection: 1�t 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, number:_ leaching chambers, number: leaching galleries, number: leaching trenches, number,length:_ leaching fields, number, dimensions: �7 overflow cesspool, number: Alternative system: Name of Technology: Comments: (n to conditi n of sclil, signs of hydrauli lure, level of ponding, condition of ve tation, etc.) ci a AICA14. IV6 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) e � 6 i Comments: e (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.) (reviaad 04/25/97) Page a of 10 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: G`!'aSS, St��.J Owner: � Date ofAnhspedioT SKETCH OF SEWAGE DISPOSAL SYSTEM: include ties to at least two permanent references landmarks or benchmarks locate all wells within 100' (Locate where public water supply comes into house) A a to i (revised 04/25/97) Page 9 of 10 s � SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) PropertyAddress: J^Q55 bOuU N Owner: P O('c Date of Inspection: Depth to Groundwater Feet Pleaseicate all the methods used to determine High Groundwater Elevation: Obtained from Design Plans on record Observation of Site (Abutting property, observation hole, basement sump etc.) _Vtoetermine it from local conditions Check with local Board of health Check FEMA Maps _ZoCheck pumping records eck local excavators, installers Use USGS Data Describe in your own words how you established the High Groundwater Elevation. Must be completed) 6 'V'1 I- to r I I 10V I L 4'-V (revived 0{/25/97) Page 10 of 10 TOWN OF 2\vler SYSTEM PUM G RECORD RECEIVED DATE: _ MAY 2 5 2005 TOW1y yr-,v a�TH ANDOVER HEALTH d SYSTEM OWNER& ADDRESS SYSTEM LOCATION (example:left front of house) �k '�4t 6� w U S-C- DATE OF PUMPING: !S C L' D QUANTITY PUNTED : 4 n c> GALLO S CESSPOOL: NO YES EPTIC 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) SYSTEM PUMPED BY: Bateson Enterprises, Inc. COMMENTS: coNTENTs TRANsFERRED To: G.L.S.D Lowell Waste 100 E ISE7 '.Ree. , �1 C�. TOM OF NORTH ANDOVER i �r,., �.� y/`;. ,')/.Q1•�7 'f'�;u'+;`` 1 t• ''';5�; t'::, HEALTH DEPARTMENT 0EP.hoi provided ihI4 roan ror �'ev �, !Dear 6oarc4 or ba + bmliiod to the IQcal pcarp cr r,oa cn Qr ccnvr +p?/ovrn Y Q +�lnorlry. 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IIS No Andover J&S Development dba 1600 Osgood St Stewart's Septic Building 20 Suite 2-36 Andover Septic No. Andover, Ma 01845 58 South Kimball Street Bradford, MA 01835 MIMED Date ;Name & Address Gallons Comments 1-Ma f, Patter reafity 81 Sawmill Rd 1600 Good TOWN OF NORTH ANDOVCR 2-May Mulcahy.'350 Sharpners Pond Rd 1500 Good int=ACTH DEPAR��/I, ;F,Gree-e`62 Willow Ridge Rd 1000 Good 3-Mayvaaross'259 Grandville 2500 Good 4-May R jncon�115 Sherwood Dr 1500 Xsolids HG 9-May,Callahn-040 Foster St 1500 Good 10-May" Melerim;1444 Salem St 1500 Xsolids 15-MayzDiraffdl'3 Brenkin ridge Rd 1500 Good tbepari,175 Stone Cleave Rd 1500 Good 16-May Martin 701 Forest St 1500 Good • ..M by 16 Carleton Lane 1500 Good 18: � May dergraaf 267 Old Cart Way 1500 Good Solano"21.98 Tnok St 1000 Rh 21-MayAomichoI115 Laconia r 1500 Good 4Reti 42 Cross Bow 1500 Good 24-May arbonell 1560 Salem St 1000 Good 29-May Thurber 210 Farnum St 1500 Good X31=May Cleary X05 Wintergreen Dr 1000 Good i �