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HomeMy WebLinkAboutMiscellaneous - 42 JERAD PLACE 4/30/2018 i 42JERAD PLACE 210/106.A-0010-000.0.0 f A ram75 tet) z� Commonwealth of Massachusetts _ 1. City/Town of System Pumping- Record 1u14 Form 4 [�HEA,17�4 N of jq TIi'gl'ipCNER '' D'tPARTME T DEP has provided this form for use-by local Boards of Health. Other forms may be use , u 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 Locatio . Rig fr�ofh Left/Right rear of house, Left/right side of house, Left/ Right side of buitttir g. Left/Right front of building, Left/Right rear of building, Under deck Address L �L ��^ �� Cityfrown �lQ� State Zip Code 2. System Owner. — Name Address(if different from location) City/Town - State I de Telephone Number B. Pumping Record 1. Date of Pumping Date 2. Quantity Pumped: Gallons F 3. Type of system'-.yp y ❑ Cesspool(s) eptic Tank El Tight Tank ❑ Other(describe): 4. Effluent Tee Filter present? ❑ Yes o If yes, was it cleaned? ❑ Yes ❑ No: 5. Condition of Sys m: v\., 6. System Pumped By: Neil Bateson F5821 Name Vehicle License Number Bateson Enterprises Inc Company 7. Lo contents were disposed: Ca.L S.t...--fraLowell Waste Water A. -3 Sign HauiwU Date t5fonn4.doc-06103 System Pumping Record•Page 1 of 1 Of NO oTN'1M 6650 . O Town of North Andover HEALTH DEPARTMENT ,S'SACNUSt� CHECK#: DATE: 1191113 LOCATION: H/O NAME: b( A Y1 W CONTRACTOR NAME Type of Permit or License:(Check box) ❑ Animal $ ❑ 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 $ ❑ Septic-Design Approval $ ❑ Septic Disposal Works Construction(DWC) $ ❑ Septic Disposal Works Installers(DWI) $ ❑ Title 5 Inspector $ Title 5 Report $� ❑ Other. (Indicate) $ Health Agent Initials White-Applicant Yellow-Health Pink-Treasurer 11 ` FILE# N A nd 111913 TITLE V INSPECTION f Dean G. Luscomb II & Sons P.O. Box 135pV "i X013 Middleton, MA 01949 TOT i ANDOVER 978-774-4065 Licensed Plumber # 20285 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PROPERTY OWNERS NAMED i 2Q h(� PROPERTY ADDRESS qy� J e rad P I a c P R2d N AndoU r M DATE OF INSPECTION )V oy e hn b e- r ) ,? a 0 In NAME OF INSPECTOR [DP (2 C, G. L I L�om QUALITY IS NUMBER ONE TO US Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments w„ s42 Jerad Place Road ( I Property Address Distefano Owner Owner's Name information is required for North Andover MA 01845 November 18, 2013 every page. 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. Important: Whenfilling out A. General Information When forms on the computer,use 1. Inspector: only the tab key to move your Dean G. Luscomb II cursor-do not Name of Inspector use the return key. Dean G. Luscomb II &Sons Company Name P.O. Box 135 Company Address Middleton MA 01949 Citylrown State Zip,Code 978-774-4065 S1848 RECEIVEED Telephone Number License Number NOV 212013 B. Certification TOWN OF NORTH ANDOVER HEALTH D-PARTMENT 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 F rther Evaluation by the Local Approving Authority November 18, 2013 Inspe s Signature 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.3113 Title 5 Official Inspection Form:Subsurface sewage Disposal system-Page 1 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments .�' 42 Jerad Place Road Property Address Distefano Owner owner's Name information is required for North Andover MA 01845 November 18, 2013 every page. City/Town State Zip Code Date of Inspection B. Certification (cont.) Inspection Summary: Check AJB,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: 13) 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 lU determined," please explain. NThe 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•3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 2 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 42 Jerad Place Road Property Address Distefano Owner Owner's Name information is required for North Andover MA 01845 November 18 2013 every page. Cityrrown State Zip Code Date of Inspection B. Certification (cont.) ❑ Pump Chamber pumps/alarms not operational. System will pass with Board of Health approval if pumps/alarms are repaired. h B) System Conditionally Passes(cont.): V ❑ 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): U ❑ 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•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 3 of 17 Commonwealth of Massachusetts u Title 5 Official Inspection Form a Subsurface Sewage Disposal System Form -Not for Voluntary Assessments s 42 Jerad Place Road Property Address Distefano Owner Owner's Name information is required for North Andover MA 01845 November 18, 2013 every page. 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: l� ❑ 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. U 3. Other: D) System Failure Criteria Applicable to All Systems: You must indicate"Yes" or"No"to each of the following for all inspections: Yes No v Backup of sewage into facility or system component due to overloaded or El ® 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•3/13 Title 5 Official Inspection Forth: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 '- 42 Jerad Place Road Property Address Distefano Owner Owner's Name information is required for North Andover MA 01845 November 18, 2013 every page. Cityrrown 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) L e Systems: To be considered a large system the system must serve a facility with a dest flow of 10,000 gpd to 15,000 gpd. For large syste you must indicate either"yes"or"no"to each the following, in addition to the questions in Sectio o Yes No / ❑ ❑ the system is ' hin feet of a surface drinking water supply ❑ ❑ the syste ' within 2 eet of a tributary to a surface drinking water supply ❑ ❑ th ystem is located in a nit en sensitive area(Interim Wellhead Protection rea—IWPA)or a mapped Zone of a public water supply well If you have an ered "yes"to any question in Section E the s tem is considered a significant threat, or answere yes" in Section D above the large system has faile . he owner or operator of any large system considered a significant threat under Section E or failed unde ection D shall upgrade the system in accordance with 310 CMR 15.304. The system owner should c act the appropriate regional office of the Department. t5ins•3113 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 42 Jerad Place Road Property Address Distefano Owner Owner's Name information is North Andover MA 01845 November 18, 2013 required for every page. Citylrown 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): 4 Number of bedrooms(actual): 4 DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): 440 gpd t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 6 of 17 I Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 42 Jerad Place Road Property Address Distefano Owner Owner's Name information is required for North Andover MA 01845 November 18, 2013 every page. Citylrown State Zip Code Date of Inspection D. System Information Description: owner Number of current residents: 3 Does residence have a garbage grinder? ® Yes ❑ No Is laundry on a separate sewage system?(Include laundry system inspection ❑ Yes ® No information in this report.) Laundry system inspected? ❑ Yes ® No Seasonaluse? ❑ Yes ® No Water meter readings, if available(last 2 years usage(gpd)): QG�h Detail: Sump pump? ❑ Yes a No Last date of occupancy: Current Date Co mercial/Industrial Flow Conditions: Type of Esta . ment: V Design flow(based on 310 15.203): Gallons per day(gpd) Basis of design flow(seats/ ersons/s .ft. Grease trap present? ❑ Yes ❑ No Industrial waste holding tank prese ❑ Yes ❑ No Non-sanitary waste d' arged to the Title 5 system? s ❑ No Water mem eadings, if available: t5ins•3/13 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 42 Jerad Place Road Property Address Distefano Owner Owner's Name information is required for North Andover MA 01845 November 18, 2013 every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) L ccu ancy/use: Date Other(describe below): General Information Pumping Records: Source of information: Pumped on average every yr-owner Was system pumped as part of the inspection? ❑ Yes ® No If yes, volume pumped: gallons How was quantity pumped determined? Reason for pumping: No need at this time 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 UA system by system operator under contract ❑ Tight tank. Attach a copy of the DEP approval. ❑ Other(describe): t5ins•3113 Title 5 Official Inspection Forth:Subsurface Sewage Disposal System•Page 8 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form s Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 42 Jerad Place Road Property Address Distefano Owner Owners Name information is required for North Andover MA 01845 November 18, 2013 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: System is from 1991 -22 yrs old - town records Were sewage odors detected when arriving at the site? ❑ Yes ® No Building Sewer(locate on site plan): Depth below grade: 24"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.): Main line and joints are in very good condition. Septic Tank(locate on site plan): S Depth below grade: 12"feet / Material of construction: ® concrete ❑ metal ❑fiberglass ❑ polyethylene ❑ other(explain) Precast rectangular- 1500 gallons If tank is metal lista e: Is e y a Certificate of Compliance?(attach a c�c�ica��� No Dimensions: 5'x 5'x 10'- 1500 gallons Sludge depth: 1" t5ins•3/13 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 w„ 42 Jerad Place Road Property Address Distefano Owner Owners Name information is required for North Andover MA 01845 November 18, 2013 every page. City/Town 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 34" 2" Scum thickness Distance from top of scum to top of outlet tee or baffle 6" Distance from bottom of scum to bottom of outlet tee or baffle 15" How were dimensions determined? sticks and 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.): The septic tank and baffles are in very good condition. The liquid in the tank is running at it's correct working heigth. The solids in the tank are very light and do not require pumping at this time. G se Trap(locate on site plan): Depth below de: feet UMaterial of construction: ❑ concrete ❑ metal El fiberglass El polyethylene of er(explain): Dimensions: Scum thickness Distance from to cum to top of outlet tee or baffle Distanc rom bottom of scum to bottom of outlet tee or baffle Date of last pumping: Date t5ins•3/13 Title 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 M �~ 42 Jerad Place Road Property Address Distefano Owner Owner's Name information is required for North Andover MA 01845 November 18, 2013 every page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Com s(on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels elated to outlet invert, evidence of leakage, etc.): Ti ht or Holding Tank(tank must be pumped at time of inspection) (locate on site plan): Depth elow grade: Material of c struction: ❑ concrete ❑ metal ❑ fiberglass ❑ polyethylene other(explain): Dimensions: ZZ Capacity: gallon Design Flow: allons per day Alarm present: ❑ Yes ❑ No Alarm level: arm in working order: ❑ Yes ❑ No Date of last pumping: Date Comments(condition of al and float switches, etc.): Attach copy of current pumping contract(required). Is copy attached? ❑ Yes ❑ No t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 11 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments w 42 Jerad Place Road Property Address Distefano Owner Owner's Name information is required for North Andover MA 01845 November 18, 2013 every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Distribution Box(if present must be opened) (locate on site plan): SDepth of liquid level above outlet invert Zero / 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.): The d-box is 16"below grade and is 16"x 16"square. The d-box is located under the hot top driveway, it was dug up and visually inspected. The d-box is level and in good general condition. The liquid in the d-box is running at it's correct working heigth. The soil in this area is clean and dry with no signs of any problems. Pu Chamber(locate on site plan): Pumps in wor i order: ❑ Yes ❑ No" Alarms in working order: es ❑ No* Comments(note condition of pump cham on of pumps and appurtenances, etc.): *If pumps or alarms are not in working order, system is a conditional pass. Soil Absorption System (SAS) (locate on site plan, excavation not required): If SAS not located, explain why: / The SAS was located by asbuilt drawings. t5ins-3113 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 42 Jerad Place Road Property Address Distefano Owner Owner's Name information is required for North Andover MA 01845 November 18, 2013 every page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Type: ❑ leaching pits number: ❑ leaching chambers number: / ❑ leaching galleries number: ® leaching trenches number, length: 2-60' ❑ 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.): The SAS is in good general condition with no signs of any problems.The soil in this area is clean and dry with no signs of ponding or breakout. C--- ools(cesspool must be pumped as part of inspection) (locate on site plan): Number and con ation V Depth—top of liquid to inlet in Depth of solids layer Depth of scum layer Dimensions of cesspool Materials of con tion Indica' of groundwater inflow ❑ Yes ❑ No t5ins•3/13 Title 5 Official Inspection Form: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 M , 42 Jerad Place Road Property Address Distefano Owner Owner's Name information is required for North Andover MA 01845 November 18, 2013 every page. 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, - ........... _. P • (locate on site plan): �1 Materials nstruction: V Dimensions Depth of solids Comments(note condition of soil, signs o aulic failure, of ponding, condition of vegetation, etc.): t5ins-3113 Title 5 Official Inspection Forth: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 42 Jerad Place Road Property Address Distefano Owner Owners Name information is required for North Andover MA 01845 November 18, 2013 every page. CitylTown 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 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 tl to-r ` a a C = S1 3 jig �- >i�K O ' D_�3oDC t5ins•3/13 Title 5 Official Inspection Forth:Subsurface Sewage Disposal System•Page 151 5 17 r Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 42 Jerad Place Road Property Address Distefano Owner Owner's Name information is required for North Andover MA 01845 November 18 2013 every page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Site Exam: ® Check Slope &V,61 ® Surface water /06f 1—P ® Check cellar '�D<'t ® Shallow wells NO/w2 Estimated depth to high ground water: 11 +/ 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: 1991 Date ® Observed site(abutting property/observation hole within 150 feet of SAS) ® Checked with local Board of Health-explain: Permit, proposed and asbuilt on file. ❑ Checked with local excavators, installers-(attach documentation) ❑ Accessed USGS database-explain: You must describe how you established the high ground water elevation: Deep hole test done in 1991 showed no water at 132" below grade. The basement is 8' below grade with no sump pump. Before filing this Inspection Report, please see Report Completeness Checklist on next page. t5ins.3/13 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 42 Jerad Place Road Property Address Distefano Owner Owner's Name information is required for North Andover MA 01845 November 18, 2013 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-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 17 of 17 Commonwealth of Massachusetts City/Town of System Pumping Record Form 4 DEP has provided this form for us&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:4i?Rig ont of ho , Left/Right rear of house, Left/right side of house, Left/ Right side of building, Left/Right front of building, Left/Right rear of building, Under deck Address L4 a (� , City/Town State Zip Code 2. System Owner. Name Addre ifdifferent from location) CitylT T . NOV 1 2013 Stat (2�ip c Telephone Number TOWN OF NORTH ANDOVER HEALTH DEPARTMENT z 1 B. Pumping Record 1. Date of Pumping Date 2. Quantity Pumped: Gallons 3. Type of system: ❑ Cesspool(s) Septic Tank ❑ Tight Tank ❑ Other(describe): 4. Effluent Tee Filter present? ❑ Yes No Ifes was it cleaned? y E] Yes ❑ No. 5. Condition qf stem: Le�-4t,-L� k, 6. System Pumped By: Neil Bateson F5821 Name Vehicle License Number Bateson Enterprises Ince Company 7. Lo!aiO767Mpew contents were disposed: G LAM Lowell Waste Water Sign a Haule Date t5form4.doc•06/03 System Pumping Record•Page 1 of 1 I Commonwealth of Massachusetts City/Town of a W° System Pumping Record Form 4 ytM Sve Y`'y '� DEP has provided this form for use by local Boards of Health. ther forms may_ g used, but the information must be substantially the same as that provided h re. B r'6 U'SW�l1 form check with your local Board of Health to determine the form they use. The Sys m Pum ingg Recp�rdmiLS be submitted to the local Board of Health or other approving authority. TO1NN gNt�RTH ANIV�r� HEALTH DEPARTMENT A. Facility Information 1. System Location: eft front'of hour right front of house, left side of house, right side of house, Left rear of house, right rear o ouse, left side of building, right rear of building, under deck. L( a- �)l� 9- C Cityrrown State Zip Code 2. System Owner: Name Address(if different from location) City/Town State,—'\ i f Zip Code 1 Telephone Number B. Pumping Record 1. Date of Pumping Date 2. Quantity Pumped: Gallons 3. Type of system: ❑ Cesspool(s) �epticTank ❑ Tight Tank ❑ Other(describe): 4. Effluent Tee Filter present? ❑ Yes LSO If yes, was it cleaned? ❑ Yes ❑ No 5. Condition of S stem: 6. System Pumped By: Neil J. Bateson F5821 Name Vehicle License Number Bateson Enterprises Inc. Company 7. Lo ere contents were disposed: G.L.S.D. I-ow,411 Wast Water Signatur f ul r Date t5form4.doc•06/03 System Pumping Record•Page 1 of 1 I ` COMMONWEALTH OF MASSACHUSETTS Z EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS DEPARTMENT OF ENVIRONMENTAL PROTECTION A C TITLE 5 OFFICIAL INSPECTION FORM —NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM PART A CERTIFICATION Property Address: 42 Jerad Place_ _North Andover_ Owner's Name:_Al DelloIacono Owner's Address: 42 Jerad Place_ _North Andover,Ma.01845_ Date of Inspection:_10/19/2001_ OCT 2 62001 Name of Inspector: Neil J.Bateson_ l� .,_,.,,,,..,.,, Company Name: Bateson Enterprises Inc._ Mailing Address:_I11 Argilla Road_ �--—� _Andover,Ma.01810_ Telephone Number:_(978)475-4786_ CERTIFICATION STATEMENT I certify that I have personally inspected the sewage disposal system at this address and that the information reported below is true,accurate and complete as of the time of the inspection.The inspection was performed based on my training and experience in the proper function and maintenance of on site sewage disposal systems.I am a DEP approved system inspector pursuant to Section 15.340 of Title 5(310 CMR 15.000). The system: _X Passes Conditionally Passes Needs Further Evaluation by the Local Approving Authority Fail AInspector's Signature: Date: _10/19/2001_ 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:_42 Jerad Place_ _North Andover — Owner:_DelloIacono_ Date of Inspection:_10/19/2001_ Inspection Summary: Check A,B,C,D or E/ALWAYS complete all of Section D A. System Passes: _X I have not found any information which indicates that any of the failure criteria described in 310 CMR 15.303 or in 310 CMR 15.304 exist.Any failure criteria not evaluated are indicated below. Comments: B. System Conditionally Passes: One or more system components as described in the"Conditional Pass"section need to be replaced or repaired.The system,upon completion of the replacement or repair,as approved by the Board of Health,will pass. Answer yes,no or not determined(Y,N,ND)in the for the following statements.If"not determined"please explain. The septic tank is metal and over 20 years old*or the septic tank(whether metal or not)is structurally unsound,exhibits substantial infiltration or exfiltration or tank failure is imminent.System will pass inspection if the existing tank is replaced with a complying septic tank as approved by the Board of Health. *A metal septic tank will pass inspection if it is structurally sound,not leaking and if a Certificate of Compliance indicating that the tank is less than 20 years old is available. ND explain: Observation of sewage backup or break out or high static water level in the distribution box due to broken or obstructed pipe(s)or due to a broken,settled or uneven distribution box. System will pass inspection if(with approval of Board of Health): broken pipe(s)are replaced obstruction is removed distribution box is leveled or replaced ND explain: The system required pumping more than 4 times a year due to broken or obstructed pipe(s).The system will pass inspection if(with approval of the Board of Health): broken pipe(s)are replaced obstruction is removed ND explain: Page 3 of 11 OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address: 42 Jerad Place_ _North Andover_ Owner•_DelloIacono_ Date of Inspection:_10/19/2001_ C. Further Evaluation is Required by the Board of Health: Conditions exist which require further evaluation by the Board of Health in order to determine if the system is failing to protect public health,safety or the environment. 1. System will pass unless Board of Health determines in accordance with 310 CMR 15.303(1)(b)that the system is not functioning in a manner which will protect public health,safety and the environment: _ Cesspool or privy is within 50 feet of a surface water Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh 2. System will fail unless the Board of Health(and Public Water Supplier,if any)determines that the system is functioning in a manner that protects the public health,safety and environment: _ The system has a septic tank and soil absorption system(SAS)and the SAS is within 100 feet of a 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: 42 Jerad Place_ _North Andover_ Owner:_DelloIacono Date of Inspection:_4-1-9/2001_ 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 liquid 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 1/2 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 II of a public water supply well If you have answered"yes"to any question in Section E the system is considered a significant threat,or answered "yes"in Section D above the large system has failed.The owner or operator of any large system considered a significant threat under Section E or failed under Section D shall upgrade the system in accordance with 310 CMR 15.304.The system owner should contact the appropriate regional office of the Department. Page 5 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST Property Address: 42 Jerad Place_ _North Andover— Owner:_DelloIacono_ Date of Inspection:_10/19/2001_ 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 N/A) 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) [3 10 CMR 15.302(3)(b)] Page 6 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION Property Address: 42 Jerad Place_ _North Andover_ Owner:_DelloIacono_ Date of Inspection:_10/19/2001_ 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:_4 Does residence have a garbage grinder(yes or no):_No Is laundry on a separate sewage system(yes or no):—Nov- [if yes separate inspection required] Laundry system inspected(yes or no):_ Seasonal use: (yes or no): No_ Water meter readings:_N/A_ Sump pump(yes or no):—NO-- Last o_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 June 2001,owner Was system pumped as part of the inspection(yes or no):_No_ If yes,volume pumped:_gallons--How was quantity pumped determined? Reason for pumping: TYPE OF SYSTEM J 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:_10 years old. 11/14/1991. 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:_42 Jerad Place_ _North Andover_ Owner:_Dellolacono_ Date of Inspection:_10/19/2001_ BUILDING SEWER(locate on site plan)X Depth below grade:_24" Materials of construction:_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"PVC thru wall to septic tank.3"PVC j in house.No leaks. SEPTIC TANK: X locate on site plan) Depth below grade:_12" 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:_109x 5'x 4' Sludge depth: 0 Distance from top of sludge to bottom of outlet tee or baffle: 27" Scum thickness: 1" 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:_26" 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.):_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:_42 Jerad Place_ North Andover— Owner:_DelloIacono_ Date of Inspection: 10/192001_ 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.):_Unable to excavate d-box,located under driveway.Camera inside of d-box thru outlet pipe in septic tank.Water at outlet invert.No carryover.No leakage. 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:_42 Jerad Place_ _North Andover- Owner:_DelloIacono_ Date of Inspection:_10119/2001_ 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 60'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.Excavate trench,no water in same.Camera other trench thru vent pipe,no water in same._ 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) ( P ) Materials of construction: Dimensions: Depth of solids: Comments(note condition of soil,signs of hydraulic failure,level of ponding,condition of vegetation,etc.): Page 10 of 11 OFFICIAL INSPECTION FORM —NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) i Property Address: 42 Jerad Place_ _ _ North Andover Owner:_DelloIacono_ Date of Inspection:_10/19/2001_ 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. Ato1=31' Ato2=44'8" A to Test Hole=63'9" A to D-Boz=48' House Driveway B to 1=32'9" Bto2=36'7" B to Test Hole=42'4" B teT Meter B to D-Boz=27' A Walk 60' 1 Septic D- Tank Boz 2 Test Hole Page 11 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 42 Jerad Place_ _ _ North Andover Owner:_DelloIacono_ Date of Inspection:_10/19/2001_ 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 plan reviewed:_4/1989_ 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: Design plan test pit info shows water @ 132"_ Tel: (978) 475-4786 Fax: (978) 475-5451 BATESON ENTERPRISES, INC. Excavating-Water.& Sewer Lines-Septic Systems&Pumping Service 1 I I Argilla Road Andover, Mass. 01810 Title 5 Inspection Report Property Address: 42 Jerad Place, North Andover Owner: DelloIacono Date of Inspection: 10/19/2001 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. Ba eson Bateson Enterprises, Inc. Commonwealth of Massachusetts RECEIVED City/Town of DEC 0 3 2007 � System Pumping Record Form 4 TOWN OF NORTH ANDOVER HEALTH DEPARTMENT 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 Important: When filling out 1. System Location forms on the l 5�— computer,use t only the tab key Address to move your cursor-do not City/Town Stat Zip Code use the return key. 2. System Owner: ®Ir__ A ` Name �Shc Address(if different from location) City/Town State75=a `/ Zip Code Telephone Number ! / B. Pumping Record 1. Date of Pumping Date C 2. Quantity Pumped: Gallons 3. Type of system: ❑ Cesspool(s) tic Tank ❑ Tight Tank ❑ Other(describe): 4. Effluent Tee Filter present? ❑ Yes No If yes,was it cleaned? ❑ Yes ❑ No 5. Condition of System 6. System P�ppped Name Vehicle License Number Company 7. Location whe co tents were di ed: Signature of H I Date t5form4.doc•06/03 System Pumping Record•Page 1 of 1 Commonwealth of Massachusetts City/Town of OCT 2 3 208 System Pumping Record Form 4 DEP has provided this form for use b local Boards of Health. Other forms may be used but the P Y Y , information must be substantially P here. Before the same as that provided h r . B f r e usingthis form check with our Y local Board of Health to determine the form they use. The System Pumping Record must be submitted to the local Board of Health or other approving authority. A. Facility Information Important: When filling out 1. System Location eft front, left rear, left sid of house Right front, right rear, right side of house. forms on the computer, use only the tab key Address to move your cursor-do not use the return Cityrrown State Zip Code key. 2 System Owner: Name y Address(if different from location) CitylTown Stay ,� � ( f Zip Code Telephone Number B. Pumping Record 1. Date of Pumping Date 2• Quantity Pumped: Gallons 3. Type of system: 0 Cesspool(s) Septic Tank Tight Tank Other(describe): 4. Effluent Tee Filter present? QYes — No If yes, was it cleaned? Yes No 5. Condition o te� v\- 6. System Pumped By: Neil Bateson F 5821 Name Vehicle License Number Bateson Enterprises Inc Company 7. Location where contents were dis osed: Q.L.S.D Lowell Waste Water MaJA - igna ure of H"r Date t5form4.doc•06/03 System Pumping Record•Page 1 of 1 �LN Commonwealth of Massachusetts CEIVE-1) Rr- City/Town of System Pumping Record SEP 2 5 2006 Form 4 TOWN OF NORTH ANDOVER HEALTH DEPARTMENT DEP has provided this form for use by local Boards of Health. The SystemTPufpling Record must be submitted to the local Board of Health or other approving authority. . A. Facility Information Important: When filling out 1. System L ation- forms the computer,use only the tab key Address to-move your �\J cursor-do not C.L use the;retum Cityrrown S to Zip Code key. 2. System Owner:' Name 1�1 Address(if different from location) City/Town Sta 11 Zip Code" Telephone Number B. Pumping Record 1. Date.of Pumping 2. Quantity Pumped: [ Date Gallons 3. Type of system: ❑ Cesspool(s) eptic Tank' ❑ Tight Tank ❑ Other(describe): 4. Effluent Tee Filter present? ❑ Yes L`FNo If yes, was it cleaned? Ye ❑ s ❑ No 5. ConditionS. to d 6. System Pumped By Name Vehicle License Number Company -- 7. Location where contents were 4 j}�"a\posed: Signat a of Siler Date h,ftp://www.mass.gov/dep/water/approvals/t5forms.htm#inspect i t5form4.doc-06/03 System Pumping Record-Page 1 of 1 I TOWN OF SYSTEM PUMPING RECORD � OCT 1 2 2005 i - �5 DATE: TOW ,r .,f r ,wE� HEAL....��""L AR i` =tiT SYSTEM OWNER& ADDRESS SYSTEM LOCATION n� (example: left front of house) V✓ - DATE OF PUMPING: 5QUANTITY PUMPED : 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(EXPLAIl14) SYSTEM PUMPED BY: Bateson Enterprises, Inc. COMMENTS: i ,. CONTENTS TRANSFERRED To: G.L.S.D Lowell Waste .. �7::./. IK�': ,{ 'ri.j\�r1`i. �IY' Vl '•r91'4,.r'�o`'��Ir:r,is ,t`I'• n`'fi+,. ;rr;.. t, `.�'' , ,ra'�"4,r � �.ySi,.c ,t�:,id.,. ,�•,'t�`�.I /�7 �'; r,,J,;.`, •i�.:a�li':,,'•r-;r.,.,'.'>�:.:'r''. :•}.f=ri.•^•'i tr�� (.{:1.�.�7f•ly:�':\r'.., ,l'��r:��,I SJ�.•�?',l�l .11/{I r �.4,.t'�.t...ol ,5,� ,(�„ .t,, A. �j�,•, v`. •t' .'1'S.rx."�t.!'gn:./I:l,j� '.:L,il'•(,!.II'..4`• II.1�.. �ltj;l, .t(^,1;r<:i:';r: , MIT.. 1'.{ t r `(D-? N O R�' ST I'EM..0::WNR:& 'hl?DR:CSS SYSTCM L (ez�mpIV: Ie0 from Qr Hour. -- .. `-�°�:;� ,��'r �cc�e X11 � • �r�o'r��haus MAY � � IS �F' PVMJ'1N�; , �� QUANTITY f'UMPQ , y S'EPTIC' TANK. NO Y E � aTUKE.O.FSERYICEI. ROUTINE,''' EM ERC EN C Y — lJ illi l .I•. \:. V,,:.;... ;'. ... ' ,,'�C;U.V•,Q cU;NU11'I�ON �:. .h,U��:TU CUYciz. ' : ' :a: 'flr•r�',�,Y`,C:K.�;rI�SC:1;,�,Y, . . : .(3a'FFI.LS' N I'•lra � ____ LEACHFICLD ltUNUACK, FL�GO.DCD': --- S'OI;IUI�YrCaRRYOY>✓R �._ „0 HF(t (�'X!'IA.IN) y 1 r, �lrS1y•pyylleir•;S�rJr Ir IY l V7 },J( ,Iv „ r( '! •, . . r 5x t„�Y ,) 1y l�f•;,lStrk l{✓`�\�` S �f;,:` ,f �1 ,{ i� is /... , , liM PUM PC6''QY '.1. :II .; Irl., '.J'• •• ;.f�1�:�1t't.':��'ts 1:;1�; i.'�''I:1�2irlr�;,'.:.1.;,��,'••.I:;.,)':''::;: - �'�; t•j:Y,, :�i:u}.�,�(. '•i4:`�..J;` Y',V,if.'a!r:�:?;j 1�%{.°5;.:�!i:'i,Lj:• �'!:' :!1: �,�' ,(!..;}i�:S. ,�:i'�: ;•,i1f:,;y.�;1t,i.,�.lfyt�f;..af;:,, �:,c,.;�'. .... i�l`,tai,i.. ..':./:pY�y':`'1�,�',y;�J•b'b'1:^�:r,',;,{ti.n.p i,.." . � { .,•'f'r.'rl, 7 •r 4 I.J� -;~1 iL�:. :r r . .. ��' t1r i '11 (M' Fri { �rr44r � SJ1 S14v'S'I�L r;.��,�:•..r}•. .. r F I hh Iru ,r�, Commonwealth f Massachusetts f ECEEiVED �0�� , Massachusetts NOV - 2 2004 TOWN OF NORTH ANDOVER HEALTH DEPARTMENT Sys e urn in Record System Owner Ste System Location -e o S f n OVLs � -raj V Date of Pumping: l0 —d_o '—U Quantity Pumped: [506 gallons Cesspool: No Yes [I Septic Tank: No [] Yes [ System Pumped by: 64&4" License# Contents transferred to: Greater Lawrence Sanitary District Date: 1,o —go Q `-�' Inspector: TOWN OF NORTH ANDOVER SYSTEM PUMPING RECORD DATE: SYSTEM OWNER &ADDRESS SYSTEM LOCATION WCL (example: left front of house) �!2 Jt rack l, DATE OF PUMPING: QUANTITY PUMPED ( 50� GALLONS J CESSPOOL: NO YES SEPTIC TANK: N O 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: COMMENTS: CONTENTS TRANSFERRED TO: Ali I$ Ur AIA/s11C�lllfell/ ► �U98ElCIlU88��8 i Bj11alt1"tattit0 —"5j'iteui Lncainn V a� Pe- 61c©VIo • , Imo• �A 1 C�IIg111I1}' 1+U111i+fli! / DD Dime for Nu►npll+� '�f/2 5�//� I' i / Ce/si+cull t:u Pets (� firhtl� 'i al l 1 t.+.► Yet st•sle►►1 Pumped 1). a�eS Lice►�se al Cunlc►IIs i►nnslel►ed la: t)nle Iusp�Ciut . r Commonwealth of Massachusetts I RECEIVEDi City/Town of NOV 2 4 2009 System Pumping Record Form 4 BOARD OFLIE _ T 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 Che unth local Board of Health tQ determine the form they use. The System Pumping Rcor I ed t the local Board of Health of=othher approving authority. A. Facility Information 1. System Location: Left side of house, Right side of hou , L=frontfER Left rear of house, Right rear of house. Left rear of building. Right rear of Address � L� ---- � � City(rown State Zip Code 2. System Owner: U� Name Address(if different from location) Cityrrown Stat Zip Code 17 _a1, � Telephone Number B. Pumping Record 1. Date of Pumping Date 2. Quantity Pumped: Gallons 3. Type of system: ❑ Cesspool(s) eptic Tank ❑ Tight Tank ❑ Other(describe): 4. Effluent Tee Filter present? ❑ Yes to If yes, was it cleaned? ❑ Yes ❑ No 5. Con iti n of System- 6. tef m: 6. System Pumped By: Neil Bateson F5821 Name Vehicle License Number Bateson Enterprises Inc Company 7. Location where contents were disposed: L. .D Lowell Waste Water /� — `C Signature of Hauler Date i t5form4.doc•06/03 System Pumping Record•Page 1 of 1 Commonwealth of Massachusetts — City/Town of a System Pumping Record NOU 16 2Q1Q wM s Form 4 TOWN OF NORTH ANDOVER DEP has provided this form for use by local Boards of Health. OtL EALTH DEP RIME 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 front of house, right front of house, left side of house, right side of house, Left rear of house, right rear of house, left side of building, right rear of building, under deck. Cityrrown State Zip Code 2. System Owner: Name Address(if different from location) City/Town Stt?d?�-� � P Zip Code Telephone Number B. Pumping Record p g 1. Date of Pumping Date �eptic Pumped: Gallons 3. Type of system: ❑ Cesspool(s) k ❑ TightTank ❑ Other(describe): 4. Effluent Tee Filter present? ❑ Yes ❑ If yes, was it cleaned? ❑ Yes ❑ No 5. Condition of ystem: A- 6. System Pumped By: Neil J. Bateson F5821 Name Vehicle License Number Bateson Enterprises Inc. Company 7. rLoc.SlQnynr a contents were disposed: .D. owell VY4teWater Signat f uler Date t5form4.doc•06/03 System Pumping Record•Page 1 of 1 ' 'ED Commonwealth of Massachusetts Affj� City/Town of OCT 16 20i2 System Pumping Record TOWN OF NORTHANDOI ER Y p 9 Form 4 HEALTH DEPARMENT 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 ig eft/Right rear of house, Left/right side of house, Left/ Right side of building, Left/Right front of building, Left/Right rear of building, Under deck Address 14 a Cityfrown v State Zip Code 2. System Owner. Name Address(if different from location) Cityrrown State Zip Code Telephone Number B. Pumping Record �ag-ca C � 1. Date of Pumping 2. Quantity Pumped: Date Gallons 3. Type of system: ❑ Cesspool(s) Septic Tank ❑ Tight Tank ❑ Other(describe): 4. Effluent Tee Filter present? ❑ Yes If yes,was it cleaned? ❑ Yes ❑ No 5. Condition of System: ��� � � ��""-"_'`✓ U 6. System Pumped B P Y Neil Bateson F5821 Name Vehicle License Number Bateson Enterprises Inc Company 7. Location where contents were disposed: G.L S. Lowell Waste Water Pignitufe cfHaule Date t5fomt4.doc•06!03 System Pumping Record.Page 1 of 1