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HomeMy WebLinkAboutMiscellaneous - 427 SUMMER STREET 4/30/2018 (2) 427 SUMMER STREET C J7 ' 210/107.A-0082-0000.0 �- t - APPLICANT: 1 . 1 427 SUMMER STREET .75-2005-0283 Project Detail Report Printed On:Thu Oct 07,2004 Project Name: GIS#: 7390 Project No: JS-2005-0283 Owner of Record,LOUGHRAN,KEVIN&CAROLE r ao"'s , Map: 107.A Date Submitted: Sep-30-2004 427 SUMMER STREET o iwtitfl,•.�o. : +` Block: 0082 Status: . Open NORTH ANDOVER,MA 01845 Lot: Work Category: Work Location: 427 SUMMER STREET Zoning: Proposed Use: District: land Use: 101 Proposed Use Detail Subdivision c« Description ADDITION Comments: of Work: Department Status GeoTMS Module: Status Fite No. Comments: LCDate: Board of Health GREEN FLAG BHJ-2004-01.43 10/7/04-Mr.Bill Penny,Builder,stopped by re:427 Summer Street..Currently has a Form U going around. There were changes on the plan,they plan an addition,and there were some changes to the distances from the columns to the leaching area. Please call him at: 781.844.9748. He also spoke with Mike,and he has to re-do some paperwork due to changes, but he would like you to look at the plan he dropped off. Plan is in file in your inbox.--p.d. Building,Electrical&Mechanical Permits GREEN FLAG BEM-2005-0229 Permit History Type: Permit No: Issue Date Status Work Category Contractor Project No:. Description of Work: Building BP-2005-0223 Sep-30-2004 OPEN Residential Alteration&Repairs JS-2005-0283 ADDITION FormUSignoff-construct BHP-2004-0679 Sep-20-2004 DENIED JS-2005-0283 Addition GeoTMS®2004 Des Lauriers Municipal Solutions,Inc. Page 1 of 1 Commonwealth of Massachusetts City/Town of System Pumping Record Form 4 DEP has provided this form for use,by local Boards of Health. Other forms may be used, but the information must be substantially the same as that provided here. Before using .this form, check with your local Board of Health to determine the form they use.The System Pumping Record must be submitted to the local Board of Health or other approving authority. A. Facility Information 1. System Location: Left/Right front of houses RightdgVrear ouse eft/right side of house, Left/ Right side of building, Left/Right front of building, Left of building, Under deck Address City/TownS e Trp Code 2. System Owner. Name Address(if different from location) Cityrrown State Zip Code otq— Sly Telephone Number (' B. Pumping Record 1. Date of Pumping date _`�� `�� Quantity Pumped: � I Gallons 3. Type of system. ❑ Cesspool(s) Septic Tank ❑ Tight Tank ❑ Other(describe): 4. Effluent Tee Filter present? ❑ Yeas E2/No If yes, was it cleaned? Yes No. 5. Condition of System: 6. System Pumped By: ��® REC EI Neil.Bateson F5821 Name Vehicle License Number _ 0,C 0 9 2013 Bateson Enterprises Inc- Company TOWN OF NORTH ANDOVER 7. Locatio re contents were disposed: HEALTH DEPARTMENT Lowell Waste Water Signitufe cf Haule Date t5fomu4.doc•06/03 System Pumping Record•Page 1 of 1 Commonwealth of Massachusetts City/Town of System Pumping-Record Form 4 SV ` 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 the use.Th System The y Pumping Record must be submitted to the local Board of Health or other approving authority. A. Facility. Information 1. System Location: Left/Right front of house, Right ar f ho , Left/right side of house;Left/ Right side of building, Left/Right front of building, Left/Right rear of building, Under deck Address City/rown State Zip Code 2. System Owner. Name Address Cd different froih location) 4 CitylTown State Code ����V�y Hyl l'•v�~-� �, 4 Telephone Number 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? ❑ Yep No If yes, was it cleaned? ❑ Yes ❑ No. 5. Condition of System n V11- 6. 6. System Pumped By: Neil.Bateson F5821 Name Vehicle License Number Bateson Enterprises Inc Company 7. Locatio-jiwhere contents were disposed: aL v Lowell Waste Water (4 V00 SignAtufe it Haul Date t5fbrm4.doc•06/03 System Pumping Record•Page 1 of 1 NEW ENGLAND ENGINEERING SERVICES INC QCT 16 2Mis 1 October 15, 2002 North Andover Board of Health Town Hall Annex 27 Charles Street North Andover, MA 01845 RE: TITLE V REPORT: 427 Summer Street,North Andover, MA Dear Sirs:. Enclosed is a copy of the Title V report for the above referenced property. The system PASSED our inspection. If there are any questions please call me at my office, 686-1768. Sincerely 6 o' Benjamin C. Osgoo , Jr. 60 BEECHWOOD DRIVE-NORTH ANDOVER,MA 01845-(978)686-1768-(888)359-7645-FAX(978)685-1099 t .a COMMONWEALTH OF MASSACHUSETTS EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS DEPARTMENT OF ENVIRONMENTAL PROTECTION 5� TITLE 5 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM PART A CERTIFICATION Property Address:_y Z 7 5 u nit M E Q. f2 Jyo RTW ANvo--S9, Owner's Name: K Ev tN l.o u e.�H QAW Owner's Address: y 2-7 S 0 M M r/t s-I- tic, %I!W .No %I!W An).DQJG2 Date of Inspection: I Name of Inspector:(please print) G. 0X&-66V3,9- Company X -6av3'2Company Name: "w Fm&rL4q s p E N(rt N 6-Ft2lN Cr- Mailing Address:_&o Ditw Q 0 (M Aa S>b Q q1e, Meq Telephone Number:--?78- &86 -17,.8 CERTIFICATION STATEMENT I certify that I have personally inspected the sewage disposal system at this address and that the information reported below is true,accurate and complete as of the time of the inspection.The inspection was performed based on my training and experience in the proper fimction and maintenance of on site sewage disposal systems.I am a DEP approved system inspector pursuant to Section 15.340 of Title 5(310 CMR 15.000 The system: asses Conditionally Passes Needs Further Evaluation by the Local Approving Authority Fails Inspector's Signature: Date: (o-do 2- The The system inspector shall submit a copy of this inspegi7on 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. • N Page 2 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: NZI SdM AA l R S% NO Fm4 !%►N U D Ji:2 An�4 Owner: 14Fv IAJ 1- crw ruw Date of Inspection: Inspection Summary: Check A,B,C,D or E/ALWAYS complete all of Section D A. System Passes: 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 ger 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 det ' ed(Y,N,ND)in the for the following statements.If"n etermined"please explain. The septic tank is metal and ov 0 years old*or the septic tank(wheth etal or not)is structurally unsound,exhibits substantial infiltration exfiltration or tank failure is imm' t.System will pass inspection if the existing tank is replaced with a complying se is tank as approved by the and of Health. *A metal septic tank will pass inspection if it is cturally sound,not ing and if a Certificate of Compliance indicating that the tank is less than 20 years old is ailable. ND explain: Observation of sewage backup or break out or gh sta' water level in the distribution box due to broken or obstructed pipe(s)or due to a broken,settled or un en distributi box. System will pass inspection if(with approval of Board of Health): broke ipe(s)are replaced ob ction is removed istribution box is leveled or replaced ND explain: The system r ired pumping more than 4 times a year due to broken or ob ed pipe(s).The system will pass inspection i th 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: Z7 Sam m ER- sCTZ& T- Owner: Y.F-V t RA" Date of Inspection: 10121--L C. Further Evaluation is Required by the Board of Health: Conditions exist which require fiuther evaluation by the Board of Health in order to determine if the tem is failing to protect public health,safety or the environment. 1. Systeih ' t pass unless Board of Health determines in accordance with 310 CMR 15 3(1)(b)that the system is t functioning in a manner which will protect public health,safety and a environment: Cesspool o rivy is within 50 feet of a surface water _ Cesspool or p ' is within 50 feet of a bordering vegetated wetland or It marsh 2. System will fail unless the Board Health(and Public ater Supplier,if any)determines that the system is functioning in a manner that p tects the publ' ealth,safety and environment: _ The system has a septic tank and soil a orpt' system(SAS)and the SAS is within 100 feet of a surface water supply or tributary to a surface er supply. _ The system has a septic tank and S and the AS is within a Zone 1 of a public water supply. _ The system has a septic tank SAS and the SA ' within 50 feet of a private water supply well. _ The system has a septic and SAS and the SAS is le than 100 feet but 50 feet or more from a private water supply well* .Method used to determine distance **This system passe f the well water analysis,performed at a DEP ified laboratory,for coliform bacteria and volat organic compounds indicates that the well is free m,pollution from that facility and the presenceo onia nitrogen and nitrate nitrogen is equal to or less ' 5 ppm,provided that no other failure triter' are triggered.A copy of the analysis must be attached to this rm. 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: 421 S V M M C R s7rt e; Owner: 1 t.E J I N t..o J&W244N Date of Inspection: i o)2! a 2 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 —� 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 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.] (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`bio"to each of the following: (The following 'teria apply to large systems in addition to the criteria above) yes no _ the system is within feet of a surface drinking wat pply _ the system is within 200 feet o bu a surface drinking water supply, — _ the system is located in a n' en sensiti ea(Interim Wellhead Protection Area—IWPA)or a mapped Zone Il of a public supply well If you have answer yes"to any question in Section E the syste is considered a significant threat,or answered "yes"in Section above the large system has failed.The owner or op or of any large system considered a significant threat under Section E or failed under Section D shall upgrade tem in accordance with 310 CMR 15.304.The system owner should contact the appropriate regional office of the Ient. Page 5 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST Property Address: 2? 5.,,,n .. E 2 STnee 7- Woo -Wo .fin! D w E 2. . ,v%A Owner: ►1.LV►Av e..04(rK&W✓ Date of Inspection: ► e 17- 0 2 Check if the following have been done.You must indicate"yes"or"no"as to each of the following: Yes No �G 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? A& 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? fWas 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 bales 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: Yes no -"'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(3)(b)] N Page 6 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION Property Address: ri 2.1 5✓M.r.9-rt � u0Pm4 AwjDoJGQ' Owner: 4AAN Date of Inspection: 1012 o L FLOW CONDITIONS RESIDENTIAL Number of bedrooms(design): -- Number of bedrooms(actual): j DESIGN flow based on 310 CMR 15.203(for example: 110 gpd x#of bedrooms): Number of current residents: 4 Does residence have a garbage gender(yes or no): Is laundry on a separate sewage system(yes or no):y [if yes separate inspection required] Laundry system inspected(yes or no):= Seasonal use:(yes or no):_AA2 Water meter readings,if available(last 2 years usage(gpd)): Sump pump(yes or no):AD Last date of occupancy: C✓ 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: CC IV Q 64. o�,•�N Was system pumped as part of the inspection(yes or no):AO If yes,volume pumped: gallons--How was quantity pumped determined? Reason for pumping: 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) Tight tank _Attach a copy of the DEP approval —Other(describe): Approximate age of all components,date installed(if known)and source of information: 1q%5 PCC QLalAl6�L Were sewage odors detected when arriving at the site(yes or 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: 12-7 So M M c R D. IA09oaa/L Owner: A( v1^, Date of Inspection: 101 2(a Z BUILDING SEWER(locate on site plan) Depth,below grade: ;(o I Materials of construction:_✓cast iron _40 PVC_other(explain): Distance from private water supply well or suction line: Comments(on condition of joints,venting,evidence of leakage,etc.): PI►&' w e1K 4o NQ Ino, N bA-5C AAeAi# SEPTIC TANK:_(locate on site plan) Depth below grade: Z ti Material of construction:_✓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: i z?-3,Zo (�-Ai r.•o ,.,5 Sludge depth: '00 `' Distance from top of sludge to bottom of outlet tee or baffle: a Scum thickness: 41 9# Distance from top of scum to top of outlet tee or baffle: " Distance from bottom of scum to bottom of outlet tee or baffle: 42 How were dimensions determined: s i1,1 E�j s f2E ?Ie 14. Comments(on pumping recommendations,inlet and outlet tee or baffle condition,structural integrity,liquid levels as related to outlet invert,evidence of leakage,etc.): T14-rs1-k IW 01( ao%*o •'1on. 2CcD&teNa L.jsTRc."A 7)Q^ a ' seisEN —to w,iNIN , OIG 6-4400# R6c,oAJC-4110.-1 o FOC I I,ET Aiva oq-&Gr7— 71Fr.0, 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: 427 SJM M E 2 S?rt e7 N d!L't1N Ass D o,)EA %A Owner: "at N I.0.0 Cv-ga*Al Date of Inspection: I o Z(p t TIGHT or HOLDING TANK;i1/A' (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.): I� DISTRIBUTION BOX: (if present must be opened)(locate on site plan) Depth of liquid level above outlet invert: D 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.): �c LN OV0 O (—&^0 o%10/Lr PUMP CHAMBERN (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.): w Page 9 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 92-1 5 y M M Eet s?eze.T. t.�oAV A&DnOJSti Owner: 14c,,,.,., L�.� G�(Q�►J Date of Inspection: t o 2.)0-2- SOIL SOIL ABSORPTION SYSTEM(SAS): (locate on site plan,excavation not required) If SAS not located explain why: Type ✓leaching pits,number: leaching chambers,number: leaching galleries,number: leaching trenches,number,length: leaching fields,number,dimensions: overflow cesspool,number: innovativelaltemative system Type/name of technology: Comments(note condition of soil,signs of hydraulic failure,level of ponding,damp soil,condition of vegetation, etc.): AMA Co F s yAT-C,,4 L-4>6 14s JeAA.4L- CESSPOOLS:NA<cesspool must be pumped as part of inspectionxlocate on site plan) Number and configuration: ° Depth-top of liquid to inlet invert: Depth of solids layer: Depth of scum layer: Dimensions of cesspool: Materials of construction: Indication of groundwater inflow(yes or no): Comments(note condition of soil,signs of hydraulic failure,level of ponding,condition of vegetation,etc.): PRIVY: (locate on site plan) Materials of construction: Dimensions: Depth of solids: Comments(note condition of soil,signs of hydraulic failure,level of ponding,condition of vegetation,etc.): i r Page 10 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: +f 27 Sam m j5A sT,-ee ; u o 2-TW AAj c ou rpt, ,44 rr Owner: A E0 t.o,#C-H PA-V Date of Inspection: =02, 2 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. DEC y- \17 Li f Page 11 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: N Z 7 su M G 2 7me7 N?s itW Ati Pw ct, A44 Owner: u►EVtw 1•0#jG-W4AA1 Date of Inspection: 1 o 1 t l b 2 SITE EXAM Slope /% Surface water V o�vif Check cellar Shallow wells o o C Estimated depth to ground water V feet Please indicate(check)all methods used to determine the high ground water elevation: Obtained from system design plans on record-If checked,date of design plan reviewed: 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: i You must describe how you established the high ground water elevation: tt- uS &.5 c AiD r C Airs �7Si2 (o O :_R#59M E nr' O a -C-OAA P I Commonwealth of Massachusetts FOCT City/Town of System Pumping Record - 9 2008 Form 4 U 4 TOGA/N OF".JRTH ANDOVER FWrl ii b42-'C _ed E b t the DEP has provided this form for use by local Boards of Health. Other�forms maybe used;=__ _ 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. Syst m Loca ' n: forms on the �J computer,use only the tab key Address to move your V cursor-do not Cityfrown State Zip Code use the return key. 2 System Owner: SII Name ISI Address(if different from location) Citylroum Statef�(? / `rZip CqAk �� Telephone Number '— J B. Pumping Record 1. Date of Pumping Date 2. Quantity Pumped: Gailons 3. Type of system: ❑ Cesspool(s) [-Septic Tank ❑ Tight Tank ❑ Other(describe): 4. Effluent Tee Filter present? ❑ Yes Q-1q6­ If yes,was it cleaned? ❑ Yes ❑ No 5. Condition of�l �l_�t/l V\� 6. System Name Vehicle License Number Company 7. Location ere conte we nesposed: Signature/of I Date t5form4.doc-06/03 System Pumping Record<Page 1 of 1 Commonwealth..of Massachusetts City/Town of System Pumping Record Form 4 �y DEP has provided this form for use by local Boards of Health.. 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 Syst m Location: fomes to the l computer,.use ` `1 only the tab key Address �` o to move your � 1 cursor-do not City/Town Zip Code use the return State key. 2. System Owner: r CC - RECEIVED Name Address(if different from location) City/Town S ate WN GFT NIDI P 1 CTE .. Code Telephone Number B. Rumpii Record 1, Date of Pumping pate 2. Quantity Pumped: Gallons 3. Type of system: ❑ Cesspool(s) eptic Tank ❑ Tight.Tank ❑ Other(describe) . .4: Effluent Tee Filter present? ❑ Yes [- If yes, was it cleaned? ❑ Yes ❑ No 5. Condition of Syste��m� 6. System Pumped By t�- <S7 a Name Vehicle License Number Company 7. Locatio here contents were dis osed:. Si attire f H ter Date hftp://www.mass:.gov/dep/`Water/approvalt/tSforTs.htm#inspeCt t5form4.doc•06103 System Pumping Record•Page 1 of 1 FORM U .- LOT RELEASE FORM TRUCTIONS: This form is used to verify that all necessary approvals/permits from Lards and Departments having jurisdiction have been obtained. This does not relieve a applicant and/or landowner from compliance with any applicable or requirements. i ***************************APPLICANT FILLS OUT THIS SECTION*********************** r PPLICANT �tl�oe�/y� G. Pdv�✓►Y PHONE `i L q44-9-74 ? .LOCATION: Assessor's Map Number PARCEL SUBDIVISION LOT(S) STREET SU✓ywtno&✓ st'� ST. NUMBER��1 *****************************************OFFICIAL USE ONLY**** ****************************** RECO ENDATIONS OF TOWN AGENTS: l CONSERVATION ADMINIS ATOR DATE APPROVED DATE REJECTED COMMENTS i . TOWN PLANNER DATE APPROVED DATE REJECTED COMMENTS f I F D INSP TOR-HEALTH DATE APPROVED DATE REJECTED PT I TOR-H TH DATE APPROVED DATE REJECTED COMMENTS PUBLIC WORKS- SEWERAVATER CONNECTIONS DRIVEWAY PERMIT FIRE DEPARTMENT RECEIVED BY BUILDING INSPECTOR DATE Revised 9\97 jm 7-1 r ��r•t n�r a""�,L� 'i ' WN OF NORTH'ANDOVER . SYSTEM PUMPING RECORD .., - 2003 .. 1'sTFM O1'YNJ?,lt &A—VID RUS wo SYSTEM LOCATION ]LI . (exxumPIe^,: left front of house) 00 1 7/ 1 ,�/ UA'1'E OF PUMPJNC: QUAi�t ITY PUMi�CO- CALLc� %, C',I SPUUL: NO ,_.�, YE9 SEPTIC TANK: NO YES a NATURE OF SERVICE; ROUTINE ,„_, EMERGENCY uwir. RVAT(ONS: s' GOOD CONDJT10M FULL TO COYC(t til?AYY GREASE BAFFLES' IN PLACE ROOTS LEACHFJELD J?UtiBACK— EXCESSIVE SOLJDS FLOODED SOLIDS CARRYOYERHER (EXPi,AJN) ii-S-1-cm PUM Pleb BY: UN"!'IsN'1'S' �'12AN5'1�L�1212JrD TO: L i LC _ � C � ✓r1 /' 3Vt i 60 4 �= 1 ,.►% -1 fl►� V��z T FL FVA-rTI o,q_S FcuYpAT1oN WALL v O O r PROP. ADDITION PROP. BAY WINDOW 47.0' ia.ao s 3`0 39.7' #427 39.8' cn ' 0 156.35' PLOT PLAN 427 SUMMER STREET NORTH ANDOVER, MASS. �k CF SCALE. 1 ' = 40' AUGUST 18, 2004 :. RREL J. CAARRELL H PREPARED BY / 4 No 34613 v y�A aP EDWARD J. FARRELL �q�,, Fss��• oQ SUR�Ey PROFESSIONAL LAND SURVEYOR 1 10 WINN STREET — SUITE 203 — WOBURN, MA. (780933 - 9012 Town of North Andover • health Department 27 Charles Street • North Andover,MA 01845 facsirnfle-ftatismiffal To: Bill Penny Fax: 781932-1174 Fes: Susan Sawyer,Health Dir Date: 9/20/2004 Re: [C- ' Pages: 4 0 Urgent x For Review 0 Please Comment 0 Please Reply ❑Please Recycle I reviewed your fax and have additional comments.Your proposed submission shows a storage room over the garage.The plan you faxed shows a four bedroom,the fourth being over the _� garage.: 1s still difficult to determine pre and post number of rooms.Please submit a clear before and after rendering showing no increase in total#of rooms as you indicated last week.Also,I have" attached 3 versions of the location of the septic components.The original As-built,your submittal and the 2002 title V version.I need you to show the actual location of the septic on the same plan as the proposed home.It appears that the new portion is right next to the line to the pit. We need to be sure not to compromise this system,as it is already 20 years old. To move this off my desk for now,I am writing denied on your form"U"until the Health Dept.receives all the information. Thank you . . . . . . . . . . . . . . . . . . . . . . a age 10 of i l OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS 5, SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM S l,w m PART C SYSTEM INFORMATION(continued) Property Address: +f 27 .Suwn m i5A 0.,^et ; aN D' C,J Owner: t.o,) Gff RA Date of Inspection: joltloz 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. t, 3 l � r t r' ' y i COMMONWEALTH OF MASSACHUSETTS EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS DEPARTMENT OF ENVIRONMENTAL PROTECTION Sr TITLE S OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM PART A CERTIFICATION Property Address: X127 5v AA M E S "o RTL4 6Nvo%jE9- Owner's Name: W N Lou GH S-Aw Owner's Address: y 2'7 S o M m c IL t,. POO (z:T" ANaye 2 Date of Inspection: I o`-.j o 2 Name of Inspector:(please print) Q a nJ?AA4#n, C. Q S(r6 e v 3'2. Company Name: VX w £N(,4A,y D E M 6.1 N L�121N C, Mailing Address:&0 6 EEc M wa d p R.l wo om-f Aa Dbvee1Q. M19 Telephone Number:--?7g- &S 6 -/7G A CERTIFICATION STATEMENT I certify that I have personally inspected the sewage disposal system at this address and that the information reported below is true,accurate and complete as of the time of the inspection.The inspection was performed based on my training and experience in the proper 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: asses Conditionally Passes Needs Further Evaluation by the Local Approving Authority Fails Inspector's Signature: Date: e> Z bo 2 The system inspector shall submit a copy of this insp ion 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: L121 N o R,Tt.t A r.� a o i"s 2 AA� Owner: AF.V w ruw Date of Inspection: Inspection Summary: Check A,B,C,D or E/ALWAYS complete all of Section D A. System Passes: 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 nr 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 det ed(Y,N,ND)in the for the following statements.If"n etermined"please explain. The septic tank is metal and ov 0 years old*or the septic tank(wheth etal or not)is structurally unsound,exhibits substantial infiltration exfiltration or tank failure is imm' t.System will pass inspection if the existing tank is replaced with a complying se is tank as approved by the d of Health. *A metal septic tank will pass inspection if it is cturally sound,not g and if a Certificate of Compliance indicating that the tank is less than 20 years old is ailable. ND explain: Observation of sewage backup or break out or gh water level in the distribution box due to broken or obstructed pipe(s)or due to a broken,settled or un en distributi box. System will pass inspection if(with approval of Board of Health): brok ipe(s)are replaced o ction is removed istribution box is leveled or replaced ND explain: The system r ired pumping more than 4 times a year due to broken or o ed pipe(s).The system will pass inspection i th approval of the Board of Health): broken pipe(s)are replaced obstruction is removed ND explain: r Page 3 of 11 OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address:_ x-127 5jm,u rot gm& l- Al%j ID es 01F 4 Owner: 14-EVIN L-0%34HQAA1 Date of Inspection: I o)2 t a L 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 emY: ' is failing to protect public health,safety or the environment. :< 1. SystekXyrill pass unless Board of Health determines in accordance with 310 CMR 1 3(1xb)that thr ` system is t functioning in a manner which will protect public health,safety and a environment: _ Cesspool o rivy is within 50 feet of a surface water ._ _ Cesspool or p ' is within 50 feet of a bordering vegetated wetland or t marsh 2. System will fail unless the Board Health(and Public ater Supplier,if any)determines that the system is functioning in a manner that p tects the publ' ealth,safety and environment. _ The system has a septic tank and soil a rpt' system(SAS)and the SAS is within 100 feet of a surface water supply or tributary to a surface er supply. _ The system has a septic tank and S and the AS is within a Zone 1 of a public water supply. The system has a septic tank SAS and the SA ' within 50 feet of a private water supply well. The system has a septic and SAS and the SAS is I than 100 feet but 50 feet or more from a private water supply well* .Method used to determine distan **This system pass the well water analysis,performed at a DEP ified laboratory,for coliform , bacteria and volat' organic compounds indicates that the well is free pollution from that facility and the presence o monia nitrogen and nitrate nitrogen is equal to or less 5 ppm,provided that no other failure crit are triggered.A copy of the analysis must be attached to this rm. 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: 421 5 .MER s'Trt e7- NbQTM 6NVe)06!Q, Owner:-- 1k F J t N I-o✓ K/1r4N Date of Inspection: t o)Z` a 2 D. System Failure Criteria applicable to all systems: You must indicate`yes"or`Sno"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%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 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 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 l,`Pd• You must indicate either"yes"or`ono"to each of the following: (The following 'teria apply to large systems in addition to the criteria above) yes no — _ the system is within feet of a surface drinking wat pply the system is within 200 feet o bu a surface drinking water supply the system is located in a n' en sensiti ea(Interim Wellhead Protection Area-IWPA)or a mapped Zone II of a public supply well If you have answer yes"to any question in Section E the syst s considered a significant threat,or answered "yes"in Section above the large system has failed.The owner or op or of any large system considered a significant threat under Section E or failed under Section D shall upgrade tem in accordance with 310 CMR 15.304.The system owner should contact the appropriate regional office of the D ent. Page 5 of I 1 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST Property Address:4 2? 5.,,,,,,k E�(3, 5T.'tC7 0-o M ern! D A)E 2 .,w%A Owner: I1%CUJiAj l.o.,crHAWV Date of Inspection: i t>17- a 2 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? A& Were as built plans of the system obtained and examined?(If they wert 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: Yes no ✓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) [3 10 CMR 15.302(3)(b)] Page 6 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY.AS.MZ + - SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FOW[ PART C SYSTEM INFORMATION Property Address: 112.1 Ei QoR'[N )E Owner: l�.£✓nom t...�a L-HdA�v Date of Inspection: 1012 10?, FLOW CONDITIONS RESIDENTIAL Number of bedrooms(design): — - Number of bedrooms(actual): DESIGN flow based on 310 CMR 15203(for example: 110 gpd x 4 of bedrooms): Number of current residents: _ Does residence have a garbage gender(yes or no):_,kb Is laundry on a separate sewage system(yes or no):y if yes separate inspection rte— Laundry system inspected(yes or no):= Seasonal use:(yes or no):_A,&2 Water meter readings,if available(last 2 years usage(gpd)): Sump pump(yes or no):,0 Last date of occupancy: ✓ t„� COMMERCIAL/INDUSTRIAL Type of establishment: Design flow(based on 310 CMR 15.203): od 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: TO 19C}V f; o c'Ai E Rr Was system pumped as part of the inspection(yes or no):AO If yes,volume pumped: gallons--How was quantity pumped determined`' Reason for pumping: 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 mxknm r,K-afm to 6M 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 infotmador I q B 3 pE2. o,-,�; 9=n Were sewage odors detected when arriving at the site(yes or no): VV Page 7 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: y Z-7 su M M taR f' 1J• IAIJ-POdG ti Owner: lett:y-^/ W-.1()-V JZ14,v Date of Inspection: Z10 z BUILDING SEWER(locate on site plan) Deptk below grade:�Io Materials of construction: ✓cast iron 40 PVC_other(explain): Distance from private water supply well or suction line: — Comments(on condition of joints,venting,evidence of leakage,etc.): _PIPE Iw/ vK co NO ino, .ni bA-5-r eA1 SEPTIC TANK:_(locate on site plan) Depth below grade: 2 k Material of construction: - 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: !� CTAir.o ,vs Sludge depth: '01 Distance from top of sludge to bottom of outlet tee or baffle: a y" Scum thickness: 41 Distance from top of scum to top of outlet tee or baffle: ] Distance from bottom of scum to bottom of outlet tee or baffle: Z2 How were dimensions determined: a,,J&�s 0 2 E c tt c jL. Comments(on pumping recommendations,inlet and outlet tee or baffle condition,structural integrity,liquid levels as related to outlet invert,evidence of leakage,etc.): g � ) T14riA 1W D1C GadwaO •1y A- IZCe-DOLCN9 1NSTRL-t,(4?)� ar $euAFtJ 'Zj aahtN(N 6' OF �T'2�}'0 (yl9G.OA.aOwe D POC l -+LET Amj> 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: 42'1 SoM.KE2 S. Nd(LTV ASD boeA MA Owner: ",it iv laj G-git*Al Date of Inspection: TIGHT or HOLDING TANK;Ne (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: (if present must be opened)(locate on site plan) Depth of liquid level above outlet invert: O 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.): �itix IN c7y Ga�O �j1oti, PUMP CHAMBERA/A— (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: �2Z Sy nA M SO- 610+e ci R�eQ.'lk /�w�flOJo ti Owner: IL.cy�wi Cr}{R�4v Date of Inspection: 1 o 2�o 2 T' SOIL ABSORPTION SYSTEM(SAS): (locate on site plan,excavation not required) If SAS not located explain why: Type ---leaching pits,number: 2. leaching chambers,number: leaching galleries,number: leaching trenches,number,length: leaching fields,number,dimensions: overflow cesspool,number: innovativelalternative system Type/name of technology: Comments(note condition of soil,signs of hydraulic failure,level of ponding,damp soil,condition of vegetation, etc.): .ILEA a F s ysTB t-. t-C�o 14-S 'e A4 .4 CESSPOOLS: I14-(cesspool must be pumped as part of inspectionxlocate on site plan) Number and configuration: Depth-top of liquid to inlet invert: Depth of solids layer: Depth of scum layer: Dimensions of cesspool: Materials of construction: Indication of groundwater inflow(yes or no): Comments(note condition of soil,signs of hydraulic failure,level of ponding,condition of vegetation,etc.): PRIVY: (locate on site plan) Materials of construction: Dimensions: Depth of solids: Comments(note condition of soil,signs of hydraulic failure,level of ponding,condition of vegetation,etc.): a Page 10 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: 127 lam m Est sT,^et ; 0 0 P-1V Ant D 0§J CA 14 d!' Owner: K 601 t,oJ CrH RAA1 Date of Inspection: o t o 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. r. 3 r f)C:c 1- < < r • f f Page 11 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: y 2 Z Su M Alt s?/e c NafL'f1{ AtiP M .v%tf Owner: Evim P000r W 4 A&i Date of Inspection: j o(t a 2 SITE EXAM Slope Surface water ,lJ,vS Check cellar Shallow wells h 0,%C Estimated depth to ground water feet Please indicate(check)all methods used to determine the high ground water elevation: Obtained from system design plans on record-If checked,date of design plan reviewed: 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: ,r v s crs c n.!a,c A-Tes AIM- ? (wo` ' 13 A✓CM E 7` B L�•.. 4-AP 6 w t 00 a r_0 L L o— ,� .S! Jf IAS 4 6' f, -err• �,�� �►a I V�� Fi EVP,Tt9,65--- ��PE T FcuAIMT DN WALL ANK WL E7 l E'i" TANK Ou7LE� > bis- 1-30Y m LZ i IST 3OX OUTLET /00.3a C o� P/PC AT b'nl�� 0 T P! T� /oo, 7- Pir'� A �ri J> vF Pyr /oa. 00 TOWN OF SYSTEM PUMPING RECORD DATE: SYSTEM OWNER& ADDRESS SYSTEM LOCATION (example:left front of house) a,A_ DATE OF PUMPING: QUANTITY PUMPED : 6b GALL NS 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(EXPLAW) SYSTEM PUMPED BY: Bateson Enterprises, Inc. COMMENTS: CONTENTS TRANSFERRED TO: G.L.S.D Lowell Waste TOWN OF NORTH ANDOVER SYSTEM PUMPING RECORD DATE: "� t SYSTEM OWNER &ADDRESS SYSTEM LOCATION Lai (example: left front of house) DATE OF PUMPING: ((,-3 ANTITY 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 (EXPLAIN) SYSTEM PUMPED BY: � 3' '` COMMENTS: CONTENTS TRANSFERRED TO: I � e2- 1Z Loreo xor log T///S OLAN tp' ND T f/ELO Pea-.E52Ty i L/NE OEV4T/ON, l� 4vl-Y"roc Z"IA,(4 �U.PPDSES, ew 6A:l pvv y TLsINs a.vz> L��.4T/av ct� s�u�cLucKj-c E DoT r.. Z� ffE�Ee f' CES/Fy 7,4-lAr T /y.4 VE' A O ALG N AA96NJ'S, ANO By/L1 /,v,�S lrx�7- o v Tf,/E si`�OWN. I i�JR7'ryE� CE•e.Tiiy � . 7 47" TNS Av/4.0,wys s.,4orvi✓ ,'C •L�J1�s A� tet/ AA/G��E.0 WHEN R4 A r { QIP �R 0�1VSTcu4rED. -z- f-61&7aE,e `\ C )eTFr THAT TNAt PJeoPE.eTy IS � . LpCAAW ./iN Ti�� ESj�.►t3L/.5,•6/Fh fI ?��;�� .. H4-'QP AIAZ.4, Z) meq, 4.e H4-'QP em ock an ine¢rin rvi a , in . 66 park stroo - andov¢r, nnasscichusatts o1e10 a4te.— t dephon¢ : (617) 475-3555 oti _ ('onimonweal tIt of Massachusetts e V e/L , Massachusetts System Pumping Record System Owner System Location L s� Date of Pumping: 3- 1000 Quantity Pumped: S p a gallons Cesspool: No Yes IJ Septic Tank: No Yes L System Pumped by: aredea Sie&npldP,a License# Contents transferrred to : Greater Lawrence Sanitary District Date: _ Inspector. �� ? �D Board of Health BEPTIC STSTEK North An ver Haas. /� ' INSTAI.I.Ai'ICK CHECK LIST LOT 2 u�/9EL APPROVED D g) DISAPPROVED EXCAVATION , OKI FAIL - � ' 83 - $eamms /.�/.S�/%f ��lG �' s �4lvrr: ,cam v�f � S :evlGT TD �/ lclvi sr� r�&/> OK 1. Distance To: a. Wetlands b. Drains c. Well 2. Water Line Location 30 NO PDC Pipe ,tic7 /�/ � //Go 4. Septic Tank a. _Tess --Length & To Clean Ont Covers b. Cement Pipe to Tank On Both Sides of Tank 5. Distribution Box a. Covers & Box - No Cracks b. A11 Lines Flowing Lqual mounts c. No Back now 6e . Leach FielLis Trench a. Dimers' b. Sto Depth c. C ed ids d. Clean Double Washed Stone.' 7. Leach Pits a. Dimensions b. Stone Depth c. Splash y AoA1c d. -Tees e. Cement Pipe to Pit - Both Sides. f. Clean Double Washed Stone 8. No Garbage Disposal 9. Final Grading Inspection —7b Be Pav6 10. Barricading Covered System As Built Submitted a. Lot Location ' b. Dimensions of System c. Location with Begard_to Perc Test d. Elevations e. Water Table `Board of Heal Ncle,y, I�ndovers ass SUBSURFACE DISPOSAL DESIGN CHECK LIST LOT APPROQID D DISAPPROVED DAA Reasons: Provided-* d 7/8 8 Title V FAIL CK Reg 2.5 a submitted plan must Show as a m3nitrmm= the lot to be served-areas dimensions lot #,abutters ,if ocation and log deep observation holes-distance to ties lties ocation and results percolation tests-distance rim ied leaching area design calculations & calculations showing required ovation and dimensions of system-including reserve area xi sting and proposed contours - g) location any xet areas Athin 100' of sewage disposal system or disclaimer-check wetlands mapping (h) surface and subsurface drains within 2A0t of sewage disposal system or disclaimer (i) location any drainage easements vithin 100' of stege disposal system or disclairer_Plann1mg Board files (3) kno= sources of -.ster supply witbin 2001 of stege disposal a system or disclaimer cation eY -anypropased_ 11 to serve lot-100'from leaching facili 1 location of water lines on property-10' from leaching facili cation of benchmark ( driveways garbage disposals . no PVC to be used in construction ri e, septic tsar q) profile of system-elevations of basement, plumb, p p eP s distribution box inlets and outlets, distribution field piping and OtLer elevations (r ,,,ayim,m ground water elevation in area sewage disposal system S) plan must be prepared by a Professional �ineer or other P professional authorized by lax to prepare such plans Reg 6 S�tic�Tanks (a) capacities-150% of flow, water table, tees, depth of tees, access, pining b) cleanout pool C 10' from cellar wall or inground s-Am.-ng P 25t from subsurface drains Reg 10.2 Distribution Foxes ( ) slope greater taan 0.08 Reg 10.4 b) suV Subsurface Design Check List Page 2 FAIL 0g Leaching Pits Leaching pits are preferred where the installation is possible leg 11.2 a) calculations of leaching area-n n mm 500 eq ft 32.4 ) spacing . 11.10 ) face drainage 2% 11.11 cover material e k'x2 I A splash pad tee at elbow g) no bends in pipe from d-box to pipe Leaching Fiel teg 15.1 a) no greater ttmffi 20 minutes/inch b) area- 900 sq ft 15.4 Ic) constra on of field 15.8 d) surf a drainage 2 % 3.7 e) 202 from cellar wall or inground swimbdng pool eaching ches - .eg 1.4.1 a) calculati s of leaching area-nfn 500 sq ft 14.3 b) spacin�A ft min 6 ft with reserve between 14.4 c) ons 14.6 d) co action 14.7 e) s ne U.10 f) rface drainage 2% Dia ?1 Slope 810 e y x = to be shown) 7/x % 150 = (to be shown) - s eg 9.1 a) roval 9.6 b) d-by power Commonwealth of Massachusetts , Massachusetts r h_0` APR 3 0 199 System Pumping Record System owner System Location Lou �-7 Date of Pumping: `— ( � Quantity Pumped: gallons Cesspool: No [_4'- Yes U Septic Tante: No FJ Yes Com' System Pumped by: Felade t '51mr jw'w License# Contents transferrred to : Greater Lawrence Sanitary District Date: Inspector: 4 i � rr Col imonwealth of Massachusetts Massachusetts VI"r System f'urning Record System Owner System Location Late of Pumping: l � ��� ( Quantity Pumped:. C�w gallons Cesspool: No Yes U Septic Tank: No U Yes � Gc System Pumped by: $ctteQort it&"tATmed License# Contents transferrred to : Greater Lawrence Sanitary District Date: Inspector: Com none ealth of Massachusetts • , Massachusetts 5ystem Pumping Record System Owner System Location L ., � a� , . _ � q Date of Pumping: L Quairiity Pumped: l J gallons No 1� Yes L) Se tic Tank: No U Yes L� Cesspool: P System Pumped by: vctt`edort gorez'GWed License# Contents transferrred to : Greater Lawrence Sanitary District Date: Inspector: OF 86't'1VO TOWN OF NORTH ANDOVER A( 9 SYSTEM PUMPING RECORD DATE: =d ' SYSTEM OWNER &ADDRESS SYSTEM LOCATION (example: left front of house) Lu cr �a DATE OF PUMPING: 1 h -31-o( QUANTITY 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 (EXPLAIN) SYSTEM PUMPED BY: L�t=ntA A COMMENTS: CONTENTS TRANSFERRED TO: L TOWN OF ,1 SYSTEM PUMPING RECORD DATE: lslox SYSTEM OWNER& ADDRESS SYSTEM LOCATION (example:left front of hoose) bcA Wv6f— DATE OF PUMPING: ^U oZ QUANTITY PUMPED : S CQGALLONS 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) SYSTEM PUMPED BY: Bateson Enterprises, Inc.- COMMENTS: nc.COMMENTS: CONTENTS TRANSFERRED TO: !� _ Commonwealth of Massachusetts RECEWrD City/Town of OCT 15 2007 System Pumping Record ~' Form 4 TO HN F NORTH ANDEALTH DEPARTMENT 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,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 computer,use only the tab key Address to move your 4 j � � ~] O gl,J cursor-do not City/Town tate Zip Code use the return key. 2. System Owner: Name Address(if different from location) Cityrr wn State Zp_Code Telephone Number B. Pumping Record P 9 1. Date of Pumping Date 2. Quantity Pumped: Gallons 3. Type of system: ❑ Cesspool(s) eptic Tank ❑ Tight Tank ❑ Other(describe): B-14-o-N 4. Effluent Tee Filter present? El Yes B o if yes, was it cleaned? ❑ Yes ❑ No 5. Condition of System: I 6. System Pumped`:�� F�a't Name Vehicle License Number Company 7. Locatio errcontetw(.:,-nrsposed: Sign r a er Date t5form4.doc•06/03 System Pumping Record•Page 1 of 1 &\ Commonwealth of Massachusetts RECEIVED City/Town of W° System Pumping Record DEC 15 2009 Form 4 M 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 tQ determine the form they use. The System Pumping Record must be submitted to the local Board of Health ouother approving authority. A. Facility Information 1. System cation: Left side of house, Right side of house, Left front of house, Right front of house, eft rear of hII Right rear of house. Left rear of building. Right rear of building. Address Cityrrown State Zip Code 2. System Owner: L Name Address(if different from location) City/Town State � ��`���d� Telephone Number B. Pumping Record �C-17 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 If yes, was it cleaned? ❑ Yes ❑ No 5. Condition of System: V1Cx G�vr�, � 6. System Pumped By: Neil Bateson F5821 Name Vehicle License Number Bateson Enterprises Inc Company 7. Locati here contents were disposed: G.ILr5.V Lowell Waste Water Signature of Hauler Date t5form4.doc•06/03 System Pumping Record•Page 1 of 1 Commonwealth of Massachusetts I NO City/Town of E CIEW u° System Pumping Record Form 4 F NOV R 3 Z., 10 hi VER TOWN OF NORTH A DEP has provided this form for use b local Boards of Health. M ' T p y Oth e 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 hous -Le r ar of hous , right rear of house, left side of building, right rear of building, under deck. Citylrown State Zip Code 2. System Owner: Name Address(if different from location) City/Town Stat i C ���(' _ 3 Telephone Number B. Pumping Record 1. Date of Pumping Date 2. Quantit Pumped: Gallons 3. Type of system: F1Cesspool(s) Septic Tank ❑ Tight Tank ❑ Other(describe): , 4. Effluent Tee Filter resent? ❑ Yes No If es was it cleaned? Y p y ❑ es ❑ No 5. Condition of System- 6. yste6. System Pumped By: Neil J. Bateson F5821 Name Vehicle License Number Bateson Enterprises Inc. Company 7. Loc tioj ere contents were disposed: G.L;S.D. ell Wao W e Signatu o a ler Date t5form4.doc•06/03 System Pumping Record•Page 1 of 1 1 Commonwealth of Massachusetts � � = City/Town of W° System Pumping Record '/ i ZQII Form 4 TOWN OF NORTH ANDOVER EALTH DEP has provided this form for use by local Boards of Health. Other foWDEPART�E Iti;bit information must be substantially the same as that provided here. Before using this form, check with your local Board of Health to determine the form they use.The System Pumping Record must be submitted to the local Board of Health or other approving authority. A. Facility Information 1. System Location: Left/Right front of hous , Lei Rr _ae, Left/right side of house, Left/ Right side of building, Left/Right front of I ding, Left/Right rear of building, Under deck Address l�/, 3 City/Town State Zip Code 2. System Owner: Name Address(if different from location) CitylTown State�^r �. ,3�QZi de Telephone Number B. Pumping Record 1. Date of Pumping Date 2. Quantity Pumped: Canons 3. Type of system: ❑ Cesspool(s) Septic 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 Pumped By: Neil Bateson F5821 Name Vehicle License Number Bateson Enterprises Inc Company 7. Loca ' here contents were disposed: G.L SW'e Lowell Waste Water ---1 Sign Date t5form4.doc•06/03 System Pumping Record•Page 1 of 1 RECEIVED Commonwealth of Massachusetts ug City/Town of NOV 2" 1U12 System Pumping Record TOWN OF NORTH ANDOVER NEALTFt®EPARTMENT 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: Left/Right front of hous��Righ ear of hou Left/right side of house, Left/ Right side of building, Left/Right front of building, Left/—R--igTit rear of building, Under deck Address C t22 (-4-V t V-A 4 ke—JA d City/Town State Zip Code 2. System Owner. Name Address(if different from location) ` City/Town State Zip Code `7 1q, - d Telephone Number B. Pumping Record 1. Date of Pumping i 2. uantity Pumped: Date Gallons 3. Type of system: ❑ Cesspool(s) Septic 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 Pumped By: Neil Bateson F5821 Name Vehicle License Number Bateson Enterprises Inc Company 7. Lo here contents were disposed: G_. S. Lowell Waste Water Sign t e 9t HaulerU Datet o2 f t5form4.doc•06/03 System Pumping Record•Page 1 of 1 .