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Home My WebLink AboutMiscellaneous - 43 CHRISTIAN WAY 4/30/2018 _ 43 CHRISTIAN WAY 210/104.D-0002-0000.0 - Commonwealth of Massachusetts ?� City/Town.of NORTH ANDOVER MASSACHUSETTS System Pumping Record Form 4 DEP has provided this form for use by local Boards of Health. The Syste'rn-oufyti0lnigecorc mu; be submitted to the local Board of Health or other approving auth rity. A. Facility Information Important: TOWN OF NORTH ANDOVER When filling out 1. System Location: HEAL H )EPA`ZTMENT forms on the computer, use only the tab key Address to move yourD ....- cursor-do not use the return CityfTown State ---- -- Zip Code key. 2. System Owner-, , Name Address(if different from location) City/Town — ----------- - p--/---- _.. Stat Z' C Telephone Number ----'-'- 6. Pumping Record 1. Date of PumpingDa e� dd -- 2. Quantity Pumped: Gal nW s 3. Type of system: ❑ Cesspool(s) 0-eptic Tank ❑ Tight Tank ❑ Other(describe): - __ ___._ _.__.__._._---- —....._ 4. Effluent Tee Filter present? ❑ YeIf yes, was it cleaned? [IYes ElNo C' t90 5. Condition ystem: Pumped By: Name 'C Vehicle License Number "- Vt a Company 7. Location where contents were disposed: Si ature of Ha Date ---- _.. http://www.mass.gov/dep/water/ provals/t5forms.htm#inspect t5form4.doc-06/03 System Pumping Record•Page 1 of 1 ,'�7 y'•i,.�Ii i��y�)+;yM,•'.p" ` 4..f.yi•+ '}:wt -.�•n: y ' � �.; K�•'':7�•y.'F{r�'i�' tip •• :•�,.,(tyy� ,flit nri�,.{�``��1 `+' .•++�1�ly,+yl��,� _�•,• RE EIVE-D •.o wNDEC 0 6 2005 5YSTE'\" PlJMPINU RP_Cp TOWN OFNORTH ANDOVER HEALTH DEPARTMENT AT8 OF .. ., , N rr PUM�ec •j.5al� __... .. �'tJ3POOl.t N Ytrs,. ... )vauc I•cnl n;• a00b OOt�fll'PIUN X4 F'vL. ry • K�+YY 039 „ y1�YY1.88 IN Nt✓nl.� C�.98IY8.30l,1pr3 PLOOD�d $oLlV 1V5Y9YUX;— ONER•EXPLAIN Wrn t'uMMtNTJ. �un I'tN l'y fX�1NylCXKbU ft. . Y Address �, ��7� ,�� i�r�y Title of File Page of Date File Open: ----- Date file closed: Doc Document/Action Tale Date of 6tefer to other Purpose of Doout�te t A action Document/ document/ / coon and notes---- . ote wum. Action �! De artment -------------- ------------ Board of Appeals — Board of Health Planniin,g Board ; Con servation Commission — Building Departrnen, HAUL LIC # 777 $100 1996 STEWART'S SEPTIC TANK SERVICE INST LIC # 659 $200 1996 47 RAILROAD STREET BRADFORD, MA 01835 508-372-7471 May 3, 1996 , i� 1 NO ANDOVER BOH '" ' �a TOWN HALL ANNEX 120 MAIN STREET NO ANDOVER, MA 01845 PH# 508-682-6483 508-688-9540 FAX 508-688-9556 Dear SIRS: The following is a list of properties that we purnped in your town. In accordance with TITLE V regulations, we are complying by sending you the following on a monthly basis, if need be. If we didn't pun p, you will not be notified. PUMP DATE ADDRESS GALLONS 04-01-96 197 ABBOTT STREET 1,500 105 WINTERGREEN DRIVE 11000 04-02-96 A 42 OLYMPIC LANE 11000 04-04-96 A 71 PENNI LANE 11000 04-06-96 492 SHARPNER'S POND ROAD 11000 A 39 HAYMEADOW ROAD 1,500 04-08-96 498 WINTER STREET 11000 187 SOUTH BRADFORD 11000 04-09-96 A 495 REA STREET 11000 04-10-96 A 706 FOSTER STREEET 11000 04-11-96 A 83 CAMPBELL ROAD 11000 04-11-96 A 43 CHRISTIAN la=0214 owx\ 1,500 04-12-96 7 HAYMEADOW ROAD 11000 1577 SALEM STREET 11000 04-13-96 278 BARKER STREET 1,000 HEAVY 04-16-96 A 30 BRENTWOOD CIRCLE 11000 04-17-96 A 27 COACHMAN'S LANE 11000 04-18-96 369 HIGH PLAIN ROAD 11000 28 CEDAR LANE 11000 A 121 CAMPBELL ROAD 11000 04-19-96 A 160 BRIDALPATH LANE 2,200 04-20-96 A 200 RALEIGH TAVERN LANE 1,500 A 1 GARFIELD LANE 1,800 `"�---- WAY 42� 4 �z 27l DO N63 01'-04'E O Q� 45+ 9-7 �o EXISTING FND, � �C.H F1ElD 131 6°39 `\ 68�. A• 10T- '?Gt1RJs i Il � s8 a. q47 M S'//; ` cbN -� sT �T- y3 ��► 6Y5-3 ELEVATIONS �`�c' P FND 164.70 'USE CUTLET [62. 13 INLET 1610 40 OUTLET 1610 2D BOX INLET 160.62 - BOX OUTLET IGO^72 ID FIELD 160,40 TIE SEPTIC SYSTEM WAS INSTALLED AS SHO,NN. -----.--.....--___--- INTENCED ASA WARPANTr OF THE SYSTEM,, PLAN SHOViING SUBSURFACE SEW ERAG- E � DISPOSAL SYSTEM AS BUILT LOCATION-LOT 9 CHRISTIAN WAY TOWN OF NORTH ANDOVER SYSTEM PUMPING RECORD �1 STEM OWNER & ADDRESS SYSTEM LOCATION (example: left front of house) U:\TE OF PUMPING: Z QUANTITY PUMPEDly5eZ GALLO'v) I'OOL: NO YES SEPTIC TANK: NO YES VATURE OF SERVICE: ROUTINE EMERGENCY OB.>[RV.-,\TIONS: GOOD CONDITION _� FULL TO COVEIZ HEAVY GREASE BAFFLES IN PLACE ROOTS LEACHFIELD RUNBACK EXCESSIVE SOLIDS FLOODED SOLIDS CARRYOVER O4jHER (EXPLAIN) C. U1I:NIENTS: UN'l'ENTS TIZANSFEIZRED T0: _ .:�:;,)r;tjtlfQli•;4:i��:4,�.jS;j/,IA(:(ij'f�tij•��"�'�i:?QI,�!.•.' .: ;a' .. ' . >. .•. :i:ry �,;;,,;.W:GJ�l:vultdlc0+:•.,:�ovl,rr, __ r� II\:t...,.,pts.'�rll� '•�i�/�I':� 1. , '(� ' ;tl. 1•3,�. Y 1.' j , Y r 1. C 'L G,tr j ,.y r l.• r' L S'`'STNMI. PWIPINC, 1 U01tCSS SYJTCM °CJI ri n o a In ( Jay . ,.wig;.;.:+r: (,1 1d; '�•�;'�r• i', .,• ', . .; .• • '. . _. _.._.... � �."�:;7.%•�1!(�:r'M)�ry�1•i�1y�:�;��(}}((�l)VV)i'f�i�'�1�):.\;rr�'�Sri:',• � 'i. r'�•'.. __' •. �•�iTUKf;OF;SeR'rY.iscc;`.'.�RouT1r�E. �EMeRc�.',c•! ;;'`;:` U.U.V.O.',C.�1. ',U.1119N. hUl I :TU CU !:.. ��.";CX•6ESSI,YE;�$.Q,!;fQS �::r,�.,,,,;� . F1.0.0.000• .. ... ?O.Iax iy0YYR:: ..',' :i.:('i..;1/1L(r il':i1.�I1/nl�,lri (1 Ir(�r�)1.1 ,ti(�li '.)i� :�`'•i•,1 ,1r• .—. .. !'!`r:l' ' ' .A�I,'� A` �'1''II�,JG..' 't V�{(� ,l'.�� .�.,� yet 't• . t. .: i r;l,�'1 111 i I \'::f./�,,r�f '< 11�c�1i'y•j'r:cG:•ti :. •r...;.F•L.r'�I��t.�..!':'t'I'.�• ,)r, ,sal, J. � /,•;• 'U . • 1i•r1r'.j'I'.l'M'PUMf'G�':IY': . .. . / 'l/ (��•�'!�`; ��' � '7�' � :��;i;'r'f l�k l:jr:(;lye,iwr,:q:;..�';,�,I,�l,,: l l� 1',t<c;•',.,�.• ... .. ., ' •., 'v�.'i••is��,'lij'J1'in`r�5'�C!li�i�(�0''i'u;• :' . . . .. .. 1 COMMONWEALTH OF MASSACHUSETTS `y EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS DEPARTMENVOIF ENVIRONMENTAL PROTECTION TITLE 5 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM PART A CERTIFICATION Property Address: y.3 CH 12)&T)t / Ay NoizTHr A&yPo ve.2 , An A Owner's Name: G9140 ; A,,jiv (Zos Fkv gAyyy Owner's Address: fR I s j7A,v fN Ay 'yo QT1l_ ANO Gu ra 41,4 Date of Inspection: I 1/110c:) Name of Inspector:(please print) 6FKxT44Aj-,U _ S6.001:> Company Name:&EW ANG-LRkJ EN(r1•v cc?�2iIV Mailing Address: 60 P G EE-rH D210o Abt)/ZTWA,,vvo,.,r/2 -viA '0�8yS Telephone Number: q7 — 6 8 6— /768 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: Passes Conditionally Passes Needs Further Evaluation by the Local Approving Authority Fails Inspector's Signature: Date: The system inspector shall submit a copy of this inspec ®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 ownerand 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. Title 5 Inspection Form 6/15/2000 page 1 Page 2 of 11 OFFICIAL IN FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTIONFORM PART]A ; CERTIFICATION (continued) Property Address: 'I3 Cy2Isi RN W/�Y Owner: GRiI D > A.v yr 2osC v g/9vM Date of Inspection: 12//y/ap Inspection Summary: Check A,B,C,D or E/ALWAYS complete all of Section D A. System Passes: Y 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 ig 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 I i ND explain: Title 5 Inspection Form 6/15/2000 2 Page 3 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address: 93 G N/2 1-577 AN; N41tZ JO A/VP 0662 Owner: 6rfzt3G RniNE 2vsiivGp0177 Date of Inspection: Z�/ LV-jOy C. Further Evaluation is Required by the Boird of Health: Conditions exist which require further evaluation by the Board of Health in order to dete a if the system is 'ling to protect public health,safety or the environment. 1. tem will pass unless Board of Health determines in accordance with 310 C 15.303(1)(b)that the syst is not functioning in a manner which will protect public health,safe and the environment: Cessp 1 or privy is within 50 feet of a surface water Cesspoo privy is within 50 feet of a bordering vegetated wetlan or a salt marsh 2. System will fail;unless the Boar of Health(and Public ater Supplier,if any)determines that the system is functioning in a manner tha rotects the publi ealth,safety and environment: _ The system has a septic tank and soil sorptio system(SAS)and the SAS is within 100 feet of a surface water supply or tributary to a surface at supply. The system has a septic tank and SAS a the AS is within a Zone 1 of a public water supply. The system has a septic tank and S and the SA ' within 50 feet of a private water supply well. The System has a septic tank SAS and the SAS is les than 100 feet but 50 feet or more from a private water supply well".Me d used to determine distance "This system passes if the ell water analysis,performed at a DEP died,laboratory,for coliform bacteria and volatile.org c compounds indicates that the well is free fr pollution from that facility and the presenile of ammo ' nitrogen and nitrate nitrogen is,equal to or less th 15 ppm,provided that no other failure crit'e'ria-are: gered.A copy of the analysis must be attached to this i 3. Other: I Title 5 Inspection Form 6/15/2000 3 7 In Page 4 of 11 OFFICIAL INSPECTION FORM;NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEAf INSPECTION FORM PART A CERTIFICATION(continued) Property Address: it G h f?i0t)/-JN w R y __A1'u 1ZTK 66-700J.014 . 'A Owner: t's2 rp f 14N At IF /ZO FN 010171 Date of Inspection:_L2_/_1/y'00 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 1� 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 _ f Liquid depth in cesspool is less than 6"below invert or available volume is less than 1/2 day flow ✓Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s).Number of times pumped _ ✓Any portion of the SAS,cesspool or privy is below high ground water elevation. 7 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. _L 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 �p are triggered.A copy of the analysis must be attached to this form.] /y O ('Yes/No)The system fails.I have determined that one or more of(he 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. arge Sys gtems: p d.be sidered a large system the system must serve a facility with a design flo 0,000 gpd to 15,000 You must indica ither"yes"or"no"to each of the following: (The following critena ly to large systems in addition to the crite ove) yes no _ the system is within 400 feet o surface g water supply _ the system is within 200 feet tributary surface drinking water supply the system is loc in a nitrogen sensitive area(Inte ' Wellhead Protection Area—IWPA)or a mapped Zone II of lic water supply well If you hav swered"yes"to any question in Section E the system is considere ignificant threat,or answered "yes" ' ection D above the large system has failed.The owner or operator of any Iar system considered a significant threat under Section E or failed under Section D shall upgrade the system in acc ce with 310 CMR 15.304.The system owner should contact the appropriate regional office of the Department. Title 5 Inspection Form 6/15/2000 4 Page 5 of;l l OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST PropertyAddress: : ly Cr/AQ577AiV wAy 'l/oaTH A,ynojEi2. �e A Owner: 6-(1Ay ANNE RoSc'N,$AVM Date of Inspection: JZ y I ao 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 _]C_ Were any of the system components pumped out in the previous two weeks? v/_ 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) v 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 prpper 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 xisting 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)] i I Title 5 Inspection Form 6/15/2000 5 ar Page 6 of I I OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM' PART C SYSTEM INFORMATION Property Address: CH21'5T1i1N W J% NORT-d A /AA Owner: 6,IZAD NNE /2o S rti A3 A V.n Date of Inspection: 2jWoo FLOW CONDITIONS RESIDENTIAL Number of bedrooms(design): Number of bedrooms(actual):A_ DESIGN flow based on 310 CMR 15.203(for example: 110 gpd x#of bedrooms): Number of current residents: 6- Does residence have a garbage grinder(yes or no): Is laundry on a separate sewage system(yes or no): [if yes separate inspection required] Laundry system inspected(yes or no):- Seasonal use:(yes or no): IVO Water meter readings,if available(last 2 years usage(gpd)): Sump pump(yes or no): IVO Last date of occupancy:C,y rt fZ 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: 1o� r 1 Etq 2 Pmt&o P(: 2 pc.V YJ F/L Was system pumped as part of the inspection(yes or no): 660 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: y CAI 25S Were sewage odors detected when arriving at the site(yes or no):–,dzo Title 5 Inspection Form 6/15/2000 6 Page 7 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: y3 CM R IsTjtgAJ 1,--I piy Owner: tZ4- 1> 5 ANnf—fl05Gt/31404j Date of Inspection: 12))&-))o0 BUILDING SEWER(locate on site plan) Depth below grade: _ Materials of construction:_:NZcast iron _40 PVC other(explain): Distance from private water supply well or suction line: IVA Comments(on condition of joints,venting,evidence of leakage,etc.): P, PL hoop, S G co�� C • i3r�s =.►.�r SEPTIC TANK:_(locate on site plan) Depth below grade: 6 Material of construction:_zconcrete_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: /'6-0c) 6-ALLIZ,u s Sludge depth: z 1 Distance from top of sludge to bottom of outlet tee or baffle: 2-7 Scum thickness: /11 Distance from top of scum to top of outlet tee or baffle: 7 Distance from bottom of scum to bottom of outlet tee or baffle: /7 How were dimensions determined: ✓hEf>Sv,2 724- 4A Comments(on pumping recommendations,inlet and outlet tee or baffle condition,structural integrity,liquid levels as related to outlet invert,evidence of leakage,etc.): T6}oJ A, tn1 o epa 3 1T-70A./, C'0.y( k2 L-j-F- %c'c= l ti ( ) f oN D .-r7 tD GREA5E 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.): Title 5 Inspection Form 6/15/2000 7 Page 8 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: q3 CH R I_i;-R AM w A Y A)o aTH AiJD_QU6'2, ASIA Owner: frit" 7 ANNI RoscNgAvM Date of Inspection ►2l igloo 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: (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.): P>ox 1� dun s0L.as cH-2a6 :--%t2 1�CA-I�WI�-E IN p,2 o"T_ PUMP CHAMBERAZA_(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.): Title 5 Inspection Form 6/15/2000 8 Page 9 of 11 -OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 43 C ij(z i 5 TI fg N -"'./Ay !Von-)a Ov c2 , ^4l9 Owner: 6-a4n AlvlvC ROS 0V 136v," Date of Inspection: )2 )1 y /oO 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: —z"'leaching fields,number,dimensions: Et+c K f-1 L L't: a�` X LP ` 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 veget4tion, etc.): Afzr1- fll—, /�G cD s c.�t�,. �o�E2c�a. 4264 rfoTi4CC.v 3a;t CESSPOOLS:NL(cesspool must be pumped as part of inspection)(locate on site plan) Number and configuration: Depth—top of liquid to inlet invert: Depth of solids layer: Depth of scum layer: Dimensions of cesspool: Materials of construction: Indication of groundwater inflow(yes or no): Comments(note condition of 56il,signs of hydraulic failure,level of ponding,condition of vegetation,etc.): i 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.): Title 5 Inspection Form 6/15/2000 9 Page 10 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS - SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 3 C H 21 S i✓fiN WAY AY ` �v2'n� a,v�0��,2 iv►a Owner: AN A/C !Zo 5 G�Bi)vM Date of Inspection: 12 f 19.1 v 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. r ,r F i Title 5 Inspection Form 6/15/2000 10 a Page 1 I of I 1 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: y/3 f li R 1 S i?AV L,v 14 y rvn al-W A N+7 DJC(Z ,niA Owner: C-Eg&.D 01VIVC a&,1;iWBr 0Aj Date of Inspection: I-z 11)y��,v SITE EXAM Slope Surface water ni,Al e Check cellar ,vo 5,,,.,,,+� Shallow wells V o N 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: p &A/ P"-A.y� NN D ICfiM SYS7"Z'M 0IYS+GAV CZ> �'J ` � 136 lie w&T ej2 _ P LF> ►4 w i b R ERIL of L o j L.+A_ (�t2oPs a�� aZ Z.v j�L i w�i}t tiL: c r64FIE 42 pnrsct �C--_ i Title 5 Inspection Form 6/15/2000 11 Commonwealth of Massachusetts Executive Office of Environmental Affairs Department of Environmental Protection William F.Weld Governor Trudy Coxe Secret EDEA David B. Struhs Commissioner SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A _ CERTIFICATION Property Address: `• J r Address of Owner: Date of Inspection: �. �" % r' j 7 (If different) v Name of Inspector: '��;: IJ 0�3 Company Name, Address and Telephone Number: CERTIFICATION STATEMENT I certify that I have personally inspected the sewage disposal system at this address and that the information reported below is true, accurate and complete as of the time of inspection. The inspection was performed based on my training and experience in the proper function and maintenance of on-site sewage disposal systems. The system: Passes _ Conditionally Passes _ Needs Further Evaluation By the Local Approving Authority Fails Inspector's Signature: . /.' Date: The System Inspector shall submit a copy of this inspection report to the Approving Authority within thirty (30) days of completing tl*e inspection. If the system is a shared system or has a design flow of 10,000 gpd or greater, the inspector and the system owner shall submit the report to the appropriate regional office of the Department of Environmental Protection. The original should be sent to the system owner and copies sent to the buyer, if applicable and the approving authority. INSPECTION SUMMARY: Check A, B, C, or D: A] SYSTEM PASSES: _ I have not found any information which indicates that the system violates any of the failure criteria as defined in 310 CMR 15.303. Any failure criteria not evaluated are indicated below. B] SYSTEM CONDITIONALLY PASSES: One or more system components need to be replaced or repaired. The system, upon completion of the replacement or repair, passes inspection. Indicate yes, no, or not determined (Y, N, or ND). Describe basis of determination in all instances. If"not determined", explain why not) The septic tank is metal, cracked, structurally unsound, shows substantial infiltration or exfiltration, or tank failure is imminent. The system will pass inspection if the existing septic tank is replaced with a conforming septic tank as approved by the Board of Health. (revised 8/15/95) 1 One Winter Street a Boston,Massachusetts 02108 a FAX(617)556-1049 a Telephone(617)292-5500 i4)Printed on Recycled Paper 1 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: fJ C. Is '� Owner: Date of Inspection: , ,,. •E.- B]SYSTEM CONDITIONALLY PASSES (continued) All Sewage backup or breakout or high static water level observed in the distribution box is due to broken or obstructed pipe(s) or due to a broken, settled or uneven distribution box. The system will pass inspection if(with approval of the Board of Health): broken pipe(s) are replaced obstruction is removed distribution box is levelled or replaced The system required pumping more than four times a year due to broken or obstructed pipe(s). The system will pass inspection if(with approval of the Board of Health): broken pipe(s) are replaced obstruction is removed C1 FURTHER EVALUATION IS REQUIRED BY THE BOARD OF HEALTH: Conditions exist which require further evaluation by the Board of Health in order to determine if the system is failing to protect the public health, safety and the environment. 1) SYSTEM WILL PASS UNLESS BOARD OF HEALTH DETERMINES THAT THE SYSTEM IS NOT FUNCTIONING IN A MANNER WHICH WILL PROTECT THE PUBLIC HEALTH AND SAFETY AND THE ENVIRONMENT: Cesspool or privy is within 50 feet of a surface water Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh. 2) SYSTEM WILL FAIL UNLESS THE BOARD OF HEALTH (AND PUBLIC WATER SUPPLIER, IF APPROPRIATE) DETERMINES THAT THE SYSTEM IS FUNCTIONING IN A MANNER THAT PROTECT THE PUBLIC HEALTH AND SAFETY AND THE ENVIRONMENT: _ The system has a septic tank and soil absorption system and is within 100 fee! to a surface water supply or tributary to a surface water supply. The system has a septic tank and soil absorption system and is within a Zone I of a public water supply well. The system has a septic tank and soil absorption system and is within 50 feet of a private water supply well. The system hay a septic tank and soil absorption system and is less than 100 feet but 50 feet or more from a private water supply well, unless a well water analysis for coliform bacteria and volatile organic compounds indicates that the well is free from pollution from that facility and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm. D1 SYSTEM FAILS: t` 1 have determined`that the system violates one or more of the following failure criteria as defined in 310 CMR 15.303. The basis for this determination is identified below. The Board of Health should be contacted to determine what will be necessary to correct the failure. Backup of sewage into facility or system component due to an overloaded or dogged 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. (revised 8/15/95) 2 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: ` Owner: Date of Inspection: D]SYSTEM FAILS (continued): r ;' e Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool. Liquid depth in cesspool is less than 6" below invert or available volume is less than 1/2 day flow. Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number of times pumped Any portion of the Soil Absorption System, cesspool or privy is below the high groundwater elevation. Any portion of a cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. Any portion of a cesspool or privy is within a Zone I of a public well. Any portion of a cesspool or privy is within 50 feet of a private water supply well. Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality analysis. If the well has been analyzed to be acceptable, attach copy of well water analysis for coliform bacteria, volatile organic compounds, ammonia nitrogen and nitrate nitrogen. E]LARGE SYSTEM FAILS: The following criteria apply to large systems in addition to the criteria above: The design floe, of system is 10,000 gpd or greater (Large System) and the system is a significant threat to public health and safety and the environment because one or more of the following conditions exist: the system is within 400 feet of a surface drinking water supply the system is within 200 feet of a tributary to a surface drinking water supply the system is located in a nitrogen sensitive area (Interim Wellhead Protection Area (IWPA) or a mapped Zone II of a public water supply well) The owner or operator of any such system shall bring the system and facility into full compliance with the groundwater treatment program requirements of 314 CMR 5.00 and 6.00. Please consult the local regional office of the Department for further information. (revised 8/15/95) 3 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST LST Property Address: Owner: Date of Inspection: Check if the following have been done: _Pumping information was requested of the owner, occupant, and Board of Health. None of the system components have been pumped for at least two weeks and the system has been receiving normal flow rates during that period. Large volumes of water have not been introduced into the system recently or as part of this inspection. Asf7uilt plans have been obtained and examined. Note if they are not available with N/A. The—facility or dwelling was inspected for signs of sewage back-up. _Thol3ystem does not receive non-sanitary or industrial waste flow The site was inspected for signs of breakout. All system components, excluding the Soil Absorption System, have been located on the site. G The septic tank manholes were uncovered, opened, and the interior of the septic tank was inspected for condition of baffles or tees; material of construction, dimensions, depth of liquid, depth of sludge, depth of scum. Thepsize and location of the Soil Absorption System on the site has been determined based on existing information or }pproximated by non-intrusive methods. _The facility o,.ner ;and occupants, if different from owner) were provided with information on the proper maintenance of Sub- Surface Disposal System. (revised 8/15/95) 4 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION a i Property Address: "�3 r! Owner: Date of Inspection: FLOW CONDITIONS RESIDENTIAL: , (, G►�i� Design flow::.- Rallors Number of bedrooms: , Number of current residents: , Garbage grinder(yes or no):_ Laundry connected to system (yes or no):_ Seasonal use (yes or no):_ , r- Water meter readings, if available: f (' Last date of occupancy: P � COMMERCIAL/INDUSTRIAL: Type of establishment: ��!_ Design flow: gallons/day T 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: OTHER: (Describe) Last date of occupancy: GENERAL INFORMATION PUMPING RECORDS and source of information: 0f t-{ b System pumped as part of inspection: (yes or no)_ If yes, volume pumped Rallons Reason for pumping: TYPE OF"3YSTEM L Septic tank/distribution box/soil absorption system Single cesspool Overflow cesspool Privy Shared system (yes or no) (if yes,attach previous inspection records, if any) Other(explain) APPROXIMATE AGE of all components, date installed (if known) and source of information: Sewage odors detected when arriving at the site: (yes or no)_ (revised 8/15/95) S S SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: j 1,3 Owner: Date of Inspection: SEPTIC TANK:311' (locate on site plan) Depth below grade: !� / Material of construction: 114oncrete _metal _FRP—other(explain) Dimensions: Sludge depth: .� Distance from top of sludge to bottom of outlet tee or baffler Scum thickness: I " Distance from top of scum to top of outlet tee or baffle: / Distance from bottom of scum to bottom of outlet tee or baffle: Comments: (recommendation for pumping, condition of inlet and outlet tees or baffles, depth of liquid level in relation to outlet invert, structural integrity, evidence of leakage, etc,) GREASE TRAP:_ t a (locate on site plan) Depth below grade: Material of construction: _concrete _metal _FRP—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 battle: Comments: (recommendation for pumping, condition of inlet and outlet tees or baffles, depth of liquid level in relation to outlet invert, structural integrity, evidence of leakage, etc.) (revised 8/15/95) 6 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: ! Owner: Date of Inspection: *, r' TIGHT OR HOLDING TANK:_ (locate on site plan) �' �✓ Depth below grade: Material of construction: _concrete_metal _FRP—other(explain) Dimensions: Capacity: gallons Design flow: gallons/day Alarm level: Comments: (condition of inlet tee, condition of alarm and float switches, etc.) DISTRIBUTION BOX:_j t (locate on site plan) Depth of liquid level above outlet invert: �'f/ Comments: (note if level and distributicr is equal, evidence of solids carryover, evidence of leakage into or out of box, etc.) -41 a � PUMP CHAMBER:_ `? (locate on site plan) r ' Pumps in working order:(yes or no) Comments: (note condition of pump chamber, condition of pumps and appurtenances, etc.) (revised 8/15/95) 7 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C f SYSTEM INFORMATION Scontinuer� f ' Property Address: ' Owner: Date of Inspection: f Cr t SOIL ABSORPTION SYSTEM(SAS): ' .'- (locate on site plan, if possible; excavation not required, but may be approximated by non-intrusive methods) If not determined to be present, explain: ,r f I" r_ Type: leaching pits, number:_ leaching chambers, number:_ , leaching galleries, number: r ✓� tr � leaching trenches, number,length: �s t leaching fields, number, dimensions: overflow cesspool, number: Comments: (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation,etc.) CESSPOOLS: (locate on site plan) Number and configuration: Depth-top of liquid to inlet invert: Depth of solids layer: Depth of scum layer: Dimensions of cesspool: Materials of construction: Indication of groundwater: inflow (cesspool must be pumped as part of inspection) Comments: (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, 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.) (revised 8/15/95) 8 e t SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: — Owner: Date of Inspection: SKETCH OF SEWAGE DISPOSAL SYSTEM: include ties to at least two permanent references landmarks or benchmarks locate all wells within 100' c / 1 ', �it �'- . w •�1 r r r s DEPTH TO GROUNDWATERIT Depth to groundwater: feet method of determination or approximation: (revised 8/15/95) 9 of NF .;-F r Gf�►�ST r�iJ Cw,aS C_OAc,E� (,vgTEi� Sv NPt.7 TbWt� O WEL - AI' ouC�D4TC SS Z9 to 5CPric SyS iEAA SESCA ,�OAJ ITows DI SAPPRpVED 1A jE ' R�45oNS D 311 ScPl-f c SY$T6M I.0 S TA U-A- I OA J a ,ff7 ,-X4X4V T OAJ )�.�C�'G c►-roti Nrc 0 P11 E] F41L. �wA� I tiSP�TIonJ /�PPI�UVEJ7 Di�TC -i 7 AP1�r 10\)IAvG AUTHoI-�ti 4�DIT(0�,4L� I�5►�.��jti� X11=- ,o�y) DiS��Pt'ROvED DA I��✓J`.A,vs , FV AL APPROVAL APP��Ov�G /�v i HoR► +�/ TOWN ' O F-NORT AND OV E� , SYSTEM PUMPI0j RECORI))A F� SYSTEM UWNEK & ADDRESS ySTEM LOC [O N V-5 DATE OF PLJMPINO:_ !�.T 7- PUMPED: CLSSP(X)L: NO---- YES_ S400C I'ank: NO- YES NA SURE OF SERVICE: KOUTINE....kl✓MERUENC'), 013SERVATIONS: GOOD CONDITION VFULI...rU covER DEC 0 7 2004 HEAVY OREASE BAFFLES IN PLACE ROOTS LEACKRELD RUNBACK BXCF,SSIVE SOLIDS FLOODED SOLID CARRYOVER .^_OTHER EXPLAIN SY&LOM pwnpcd by 7" Ice-) 5) M4 z - .7L 177a CoMMhNTN. ............. CUN I LN I'S f'KANSFhl(UD I'L) A A � � s•�•»� r t ;�ity�chusetts oRTH-AIUDOVER ' M A S S A C QlT '.q• ',�• ., Y}7}8. �.,.,:. HUSETTS ,••{i!bA•tW!"i .:�u.mpin. Record• . _ ��r FQ � �1d; 1 N47tiM �;y` ,a r;•:r',,:• " ;�'{t.: .i ,�'v,�'11.::',gl'�^!�J)!;)r(I�i�A^'I rtj.;4:•li', �! 'n.lii r�;4'•�,1 •: 1 r��. hh ll 7•• 1 :1 �:'.I: J .� ..v.j`^,IJEt? o, r'.,w,. � '"'1•14•u,..,C;l�.. .; ,'- .. ,. • "`�'`"'��!'�' •,has provided th>s form�for use by loca be submled to the.local'Board of Health or othe — stem Pumping Recorc m s horl A; Facility InforiN on DEC 0 7 2007 1,'?.yYhOrlfy- fillln9 out �.. System location; TOq NORTH ANDOVER .; th0 6 TMEN �u ,4i onfy Ne tab key Address to move your --- ausa(.do not usi the rotum :,Clty/Town Stat ' �� :;�•��,1.:,..,;>.• ' ; .. :;; .. Z1p Code System :Address(If different from bcAtJon) ti.' ClglTown. State Zi C Telephone Number 4 PIUMPIng Rekord r -�l`,II'�•!� .rr l,�,iFlrt„/'Y{U�.l•,J.'�'w�•,, •.// /�/ (//nom ,•� > , Dato'of Pumping Oete 2, QuantJty Pumped: �v Gallons — ype pf system;`, ❑ Cesspool S) (�'Septic Tank ❑ Tight Tank 11 Other(describe);" Effluent Tee Fliter present? ❑ Yes.�10 If yes, was It cleaned? ., ❑ Yes ❑ No r'K ':Co�ditlOn`ofS sf a•:u'!��.,'trrl`,{�s':,Yn!•,•i;r;i;:i!;:�ifrr�i:a4''r„•; .� .1•' .�,{I'r Y.i1 Y`,,}'%.IJ'.:/�rl:7.'(4•�, 11.. Pumped .. . .jrr' Vehl cane Numb or Y:•:.�Y��jr`%`fir',;h iJrf 141 t7!C i:cf� Y't` 'TU(t7 /i cc�i ' '�Yr:r' � '.(. •'�;>'t �%r .J.� .�•.�'.�.,;Y'!u,y-vrjiy>J/��}"�y''�'yy' ;`'�illriat•>�.,,�,.. J :✓::,yy'. ti'.,..,.•. ��+•.'.i,;�..:7 ;,�L•. , r J'+.Y,t�'yr i., d�(:�{'•.J I.a�(Y�•ii I�,,.;��'.r: i.r Kr,t•11�ik�1.J ( : :!�`I%l,F�.1' T. L•ocau'on where contents yrere diPposed; ..-'-•' � ^.w' iJ,• .. •,. Y:f�l:•i.'' it Ir.:.•4'p';,, (,. , :,,.:,,,`:,��• ,�' ,: Sf�nature of Hauler, Date ht pJ/4vww.mans.9ov/dephvafar/approvals/t5fonns,htm#Inspect . . t5torrM:doa.OdIQ3 ,. . System Pumping Record Page 1 r!�,) r, �'\ �f 4 •lt 1 '7�� ,I �yi � , �r Pjiri•Lt'y1 '� I( r!117/ V A 1al 7M11 1M I tills L)C .. , �'r ! ' III f11 r -e�•.�>c_ 'I ��; • ' p ► �BCOIid ' quit. 'k lfl ,,1i11.�14Jty(' l�/4!r�{►/I�''li'y� I,I,,�,V,I'ri 1, ,�'fl�V rl.t�'� „ , L�Y,•V r i j�v f „y, r ,!, TOWN OF NORTH ANDOVER QeP'hli p/OYld1nllyl0�rn ICr HEALTH DEPARTMENT 01 It,b/11111,ed.10 Vll IOC11801fc !�v' min p! CIIIOI fAafOrl,l lry A. Faclll'ty orrr'!�►lon c I'.Inof ink. . . 11�• yy , , 'i 4,1,`,f I f l;'.,�J r�l rry ', .r � •-----__.. • '�N'J' 2r'''• Own °�,:' . . >� , ��;/ ,,,111 1(1';'�t��Y •�y�r�r�i►•m er,'�,,,I'•. _: . . . � J6i I f.!yl��f,f Jr�'11�1'1u.lr'�/t•�r rl„',.�,I'y�,!, � .. ' ,. ',l,' `I 'ill.ral y': x/11�•; ii��'l'''�l' , r,/, , ,,,.,, wr I, t Irinl ,cYnbuVvnl �_ C q 197 , • I n',mol� V 'rl,.Irl. ((,l'•, ,I', �'I�' ,i,',�,r. �,,•. 61;Rg umP1ng; egord '1111'lilr''y`il`'p Il ►r'`r"'�''� ' 1' Oale. of Pv 111!1' I. mpinQ ; .��; �' � . 0111 ? ^•.'d r'. r < �—==— 'r Jr' 'rYp► 41 �yilvm,';; Co>��ool(�) ;ac �:r:., • .r�� 'l;'r..,I. ''►'1";.;I,�•;�; oDl!c Tan, � Ir!I loo'nj4 Tflf ;l1l� '(rfr,3onR [' Yo j nb 11 ',.i';'iijll"yl;r ';lr�r!1'j' Y•''11L'ui ,; �11 N!II)'4r'i'''�,1' YO). n'91 I; C:0an00� '1 T "Y'-6 LIl l'+IfrShlr';.' � •O,a Irl1)r11u1 t1=1,,''„l�1�'y�'1111 1 41 Pv �' '. '. �i!'�� irrr�ll�), 1 r�' ,�1('�• � �1,,�'IV � I rlitiy'� '� 1 YIltIG1( ' C4nl I h''•T. . S' ,;, • • ... '��'�'��. .�Irl''I ,,; 4r1rwn41f�99{�linli;�ero dlsposav: 1,! 1�'fl,rl '�nlrlldv 1�1V Id 5J'SOY/d�p'4ylll(/1 r ! �nr.ma CVE $ a mR MASSACHUSE77 �.;, '•. " Record O�P.hel provided lnli lolm for neo ' y loco! 8oar�,pl •, oe +'.�rr.11lod to the loch 8oarc: r! a 4no Sry'd� c Or Clnvr 4AAr0:,n� 00,lry A. Facility Inforrrftn _ - .r.;<:1 ., ♦ TOWN OF NORTH AND (-f4,• :�; ;,I SyS19^11OC8��On; HEALTHDEPARTMEINTER ..� t'•1 1,L L4, M (II P„° C17/i4rrn u •;v'�(•;�'�.. � .',:�:.� ;•:,:��' ,,;,:..::.,'. , , 51111 �_— �.;� •,i, ,.4 ;, �.�i m Own ar,.. .:�, , IWQrµ4'(II MOM 1.t"10(;4Upn) CQ^o n ------------- TI e9nonl r.,mpl, �� 84:P..umping Ra�ord 3, Type of +y)(eC699pooi(y) 6pl.0 Ten^ , •IS^� rax �l"2-5 o? (O.J6nf? Y09 (1' Emvartl Too F11l9(pIL'1 c,aa ao7 r7 Y — Pt,'mpad 8y; .. . in•:i�4S�•�,�1�`' �'U� ��,,'r�4�� ''1�I�� d,l c ' ,�� ,�``r•,11.1; loca on where conlan4a'yrare dlypos6o: V;1,11., 'ra 9 dreier/epproYaJa/Iblorm�.r,.'11A1.�9p6C1 Commonwealth of Massachusetts W City/Town of No.Andover System Pumping Record 4M SVB 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 Reco_rd must be submitted to the local Board of Health or other approving authority within 14 days from th pu p accordance with 310 CMR 15.351. A. Facility Information Important: TOWN OF NORTH ANDOVER When filling out 1. System Location: HEALTH[DEPARTMENT � chvi forms on the -eq computer, use only the tab key Address to move your No.Andover Ma 45 cursor-do not City/Town State Zip Code use the return key. 2. System OW I ler r� Name reran Address(if different from location) City/Town State Zip Code Telephone Number B. Pumping Record A0-0- �1 /\,-�-6 1. Date of Pumping pate / / / 2. Quantity Pumped: Gallons V 3. Type of system: ❑ Cesspool(s) 4/septic Tank ❑ Tight Tank ❑ Grease Trap ❑ Other(describe): 4. Effluent Tee Filter present? ❑ Yes ❑ No If yes, was it cleaned? ❑ Yes ❑ No 5. Condition of System: 6. �em Pumped Name Vehicle License Number Stewart's Septic Service Company 7. Location where contents were disposed: At wart's Pre- rem Plant, 20 So. Mill Bradford, Ma 01835 V "zL-,- ge er Datl(�—) iving Facility Date t5form4.doc•03/06 System Pumping Record•Page 1 of 1