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HomeMy WebLinkAboutMiscellaneous - 43 OXBOW CIRCLE 4/30/2018 (2) 43 OXBOW CIRCLE / 210/107.B-0142-0000.0 i r 7 C i I # y3 C `-L t Lot & Street ("')X bb—V—) �� Map/Parcel CONSTRUCTION APPROVAL Has plan review fee been paid: S NO Permit# Plan Approval: Date: 9/oZ7 `�7 Approved by: Designer: M g;2 If/M 196 Plan Date: 9 X? Conditions: Water Supply: �wn Well Well Permit: Driller: Well Tests: Chemical Date Approved Bacteria I Date Approved Bacteria II Dat Ape proved Plumbing Sign-Off: Wiring Sign-Off: Comments: Form"U" Approval: Approval to Issue: j_ NO ' Date Issued By: Conditions: Final Approval: All Permits Paid? YES NO Well Construction Approval? YES NO Septic System Construction Approval? YES NO Certification? YES NO Other YES NO Any Variance Needed? YES NO FINAL BOARD OF HEALTH APPROVAL: DATE: APPROVED BY: SEPTIC SYSTEM INSTALLATION Is the installer licensed? YE NO Type of Construction: REPAIR New Construction: Certified Plot Plan Review NO Floor Plan Review YES . NO Conditions of Approval from Form UNO Issuance of DWC permit: CTs_� NO DWC Permit Paid? / NO DWC Permit # `75/ Installer: 2,41r_ Begin Inspection: YES NO Excavation Inspection: Needed: Passed: 97, By: Construction Inspection: Needed: As Built Plan Satisfactory: YES: Approval of Backfill: Date:__S �- BY- Final Grading Approval: Date: By: Final Construction Approval: Date: By: Certificate of Compliance: Approval: Date: Commonwealth of Massachusetts Cit /Town of No Andover L < . 0 System Pumping Record Form 4 OCT C ' 2023 TOVVI OF NCRTH ANDOVER HEALTH nFp,,.' ,-.._ DEP has provided this form for use by local Boards of Health. Other-forms may.be;usejq but the information must be substantially the same as that provided here. Before using this form, check with your local Board of Health to determine the form they use. The System Pumping Record must be submitted to the local Board of Health or other approving authority within 14 days from the pumping date in accordance with 310 CMR 15.351. A. Facility Information Important:When filling out forms 1. System Location: l ' on the computer, use only the tab `{ key to move your Address cursor-do not No Andover Ma use the return key. City/Town State Zip Code 2. System Owner Name xenon Address(if different from location) Citylrown State Zip Code • Telephone Number B. Pumping Record l 1. DafP Lk/ Date • Pumping Date 2. Quantity Pumped: Gallons 3. Type of system: ❑ Cesspool(s) „-2"geptic 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. System Pumped By: Name Vehicle License Number Stewart's Septic Service Company 7. Location where contents were disposed: Stewart's Pre-treatment Plant, 20 So. Mill Bradford, Ma 01835 Signature of Ha��IP�- Date i �ivingFacility t5form4.doc•03/06 System Pumping Record•Page 1 of 1 NEW ENGLAND ENGINEERING SERVICES INC OF DEC - 2 R r s December 5, 2003 North Andover Board of Health Town Hall Annex 27 Charles Street North Andover, MA 01845 RE: TITLE V REPORT: 43 Oxbow Circle,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 '3' � 0- Benjamin C. Osgood, J . 60 BEECHWOOD DRIVE—NORTH ANDOVER,MA 01845—(978)686-1768—(888)359-7645-FAX(978)685-1099 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:_ 1-13 O X 8 r w C R(L t= Owner's Name: �,(t 1 s i L.•� �} �= g pc �f Owner's Address: _ y 3 � 8�,..� Date of Inspection.• _ 1 z-l H Name of Inspector.(please print) Benjamin C. Osgood, Jr. 1° Company Name:New England Engineering Services Inc. MailingAddress:60 Beechwood Drive. - North Andover, MA 01845 Telephone Number: 978-686-1768 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: 2- q/-1 3 The system inspector shall submit a copy of this inspection report to the Approving Authority(Board of Health or DEP)within 30 days of completing this inspection.if the system is a shared system or has a design flow of 10,000 gpd or greater,the inspector and the system owner shall submit the report to the appropriate regional office of the DEP.The original should be sent to the system owner and copies sent to the buyer,if applicable,and the approving authority. Notes and Comments ****This report only describes conditions at the time of inspection and under the conditions of use at that time.This inspection does not address how the system will perform in the future under the same or different conditions of use. Page 2 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: 43 ©A t3 r,,%j L,czc L-& 1�! A jPoo YZ Mrd Owner: V'V2 Xs TFi�-; +A�LS F1L Date of Inspection: Inspection Summary: Check A,B,C,D or E/ALWAYS complete all of Section D A. .System Passes: I have not found any information which indicates that any of the failure criteria described in 310 CMR 15.303 or in 310 CMR 15.304 exist.Any failure criteria not evaluated are indicated below. Comments: B. System Conditionally Passes: One or more system components as described in the"Conditional Pass"section need to be replaced or repaired The system,upon completion of the replacement or repair,as approved by the Board of Health,will pass. Answer yes, or not determined(Y,N,ND)in the for the following. "not determined"please explain. The septic tank etal and over 20 years old' or the septic tank ether metal or not)is structurally unsound,exhibits substantia ' filtration or exfiltration or tank failure. imminent.System will pass inspection if the existing tank is replaced with a plying septic tank as approved the Board of Health. *A metal septic tank will pass in 'on if it is structurally not leaking and if a Certificate of Compliance indicating that the tank is less than 20 s old is available. ND explain: Observation of sewage backup or br or static water level in the distribution box due to broken or obstructed pipe(s)or due to a broken,settl or uneven bution box.System will pass inspection if(with approval of Board of Health): oken pipe(s)are replaced obstruction is removed distribution box is leveled or repla ND explain: The syst required pumping more than 4 times a year due to broken or o *acted pipe(s).The system will pass inspect if(with approval of the Board of Health): broken pipe(s)are replaced obstruction is removed ND explain: Page 3 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address: 3 4x Bow Owner: 1k12y5ry-�j Date.of Inspection: )i,1,t)' 03 C. Further Evaluation is Required by the Board of Health: Conditions exist which require further evaluation by the Board of Health in order to determine if the system is failing to protect public health,safety or the environment. 1. S will pass unless Board of Health determines in accordance with 310 CMR 3(lxb)that the system' not functioning in a manner which will protect public health,safety it the environment: __ Cesspoo privy is within 50 feet of a surface water — Cesspool or 'vy is within 50 feet of a bordering vegetated wetland or salt marsh 2. System win fail unless the Board o ealth(and Public W r Supplier,if any)determines that the system is functioning in a manner that p ects the public th,safety and environment: _ The system has a septic tank and soil a ti em(SAS)and the SAS is within 100 feet of a surface water supply or tributary to a surface wat ply. _ The system has a septic tank and SAS d the S within a Zone 1 of a public water supply. _ The system has a septic tank an AS and the SAS is wi 50 feet of a private water supply well. The system has a septic and SAS and the SAS is less than feet but 50 feet or more from a private water supply well** ethod used to determine distance **'This system passes' the well water analysis,performed at a DEP certifi boratory,for coliform bacteria and vol ' organic compounds indicates that the well is free from poll 'on from that facility and the presence o onia nitrogen and nitrate nitrogen is equal to or less than 5 p rovided that no other failure cxi a are triggered.A copy of the analysis must be attached to this form. 3. Other: Page 4 of 11 OFFICIAL INSPECTION FORM--NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address: 6f 3 O X a o Q, A,,),9o.7E2 n�r4 Owner: ill?1STKIN Date of Inspection: 1 zj`i (0 D. System Failure Criteria applicable to all systems: You must indicate"yes"or-no"to each of the following for all inspections: Yes No E✓ Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool �C 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 V'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.] A/D (YesJNo)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 entad 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 mast serve a facility with a design Sow of 10,000 gpd to 15,000 1'd You must indicate either`yes"or`bio"to each of the following: (The followincriteria apply to large systems in addition to the criteria above) yes no -� the system is within 400 of a surface drinking w-a-ter syp.ply — _ the system is within 200 feet of a tary torface drmkin water supply = rr y — the system is located in a nitrogedsensitive ar Interim Wellhead Protection Area-IWPA)or a mapped Zone II of a public w er supply well If you have answered"yes"to any question in Section E the system is sidered a significant threat,or answered `yes"in Section D above the large system has failed.The owner or operator any large system considered a significant threat under Section E or failed under Section D shall upgrade the sys in accordance with 310 CMR 15.304.The system owner should contact the appropriate regional office of the Dep ent. Page 5 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST Property Address: cf 3 OX 6 b w C i 2 f--L,U IJ©R-'1 --f Pr J s> oo m 1&4A Owner: Pr j i- &A-,,q Date of inspection: ►z 1 3 Check if the following have been done.You must indicate`des"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 ? V/ Have large volumes of water been introduced to the system recently or as part of this inspection? _�— Were as built plans of the system obtained and examined?(If they were not available note as N/A) Was the facility or dwelling inspected for signs of sewage back up? Was the site inspected for signs of break out? — Were all system components,excluding the SAS,located on site? — Were the septic tank manholes uncovered,opened,and the interior of the tank inspected for the condition of the baffles or tees,material of construction,dimensions,depth of liquid,depth of sludge and depth of scum? 4f — 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 ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION Property Address:_ 43 A-'-) Owner: Date of Inspection: FLOW CONDITIONS RESIDENTIAL Number of bedrooms(design): Number of bedrooms(actual): DESIGN flow based on 310 CMR 15203(for example: 110 gpd x#of bedrooms): A,)q O Number of current residents: 5 Does residence have a garbage grinder(yes or no):�jG 5 Is laundry on a separate sewage system(yes or no):MQ [if yes separate inspection required] Laundry system inspected(yes or no):_ Seasonal use:(yes or no), MO Water meter readings,if available(last 2 years usage(gpd)): Sump pump(yes or no): Last date of occqpancy:_ q-L, at2t;N v'--____.---- COMMERCIAL/INDUSTRIAL Type of establishment: Design flow(based on 310 CMR 15.203): gpd Basis of design flow(seats/persans/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): Pumping Records GENERAL INFORMATION Source of information: t��,.M�t� 1011P,1 v 3 Was system pumped as part of the inspection(yes or no): N J 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(Altenative 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: f 4 IM9 Ig5 g 0+GT Were sewage odors detected when arriving at the site(yes or no):iL u Page 7 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 0 ,; O X 6 y .,(zc LC t ova-p-t A-,j p o,.,0#Z ,.A Owner. Kak5i-F1v 0,0�gFltie� Date of Inspection: ca, BUILDING SEWER(locate on site plan) Depth below grade: I Z" Materials of construction: cast iron v-40 PVC other(explain): Distance from private water supply well or suction line: 4/4 Comments(on condition of joints,venting,evidence of leakage,etc.): f 1 VIC )N' N a--i l!i�.J �,�'7(�i V v�S L�►�,E tiT SEPTIC TANK:_(locate on site plan) Depth below grade: 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 L e� &p 4 �j 1. Sludge depth: 2 Distance from top of sludge to bottom of outlet tee or baffle: i Scum thickness; <1" Distance from top of scum to top of outlet tee or baffle: to Distance from bottom of scum to bottom of outlet tee or baffle: /V How were dimensions determined: iv1 G_AS a 0 Comments(on Pumping recommendations,inlet and outlet tee or baffle condition,structural integrity,liquid levels as related to outlet invert,evidence of leakage,etc.): 144J A, !N 4+a;C <,Z? U "T'7 O 1`l, ly i'L;4- AJ GREASE TRAP:tol(locate on site plan) Depth below grade:— Material of construction: concrete_metal fiberglass (explain). _polyethylene other 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 umpingComments(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: Ox b o w t c OV EYL Owner:_ R7 5-1-uIy Date of Inspection: 1 Z���3 3_ TIGHT or HOLDING TANK-./VA (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: 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.): -`'�l (nl G�c � Gc.�t7 �•7)c:i�.'. .PtSr Ri vil�i� �©.,� ►4V ic/� 'moi CNCL OF Sr)�l p f rdP-y ovc2 C7/2 G-e-#+ r46-C PUMP CHAMBER:AVS(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: Q3 c k2 c(_p _1J a Q_ j 19 Owner: i�2tS N vt. �}GN Date of Inspection: 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 � !.C-n-e[f i;S leaching fields,number,dimensions: overflow cesspool,number: innovative/alternative system Type/name of technology: Comments(note condition of soil,signs of hydraulic failure,level of ponding,damp soil,condition of vegetation, etc.): 4-1�1 4� CESSPOOLS: (cesspool must be pumped as part of inspectionxlocate on site plan) Number and configuration: Depth–top of liquid to inlet invert: Depth of solids layer: Depth of scum layer: Dimensions of cesspool: Materials of construction: Indication of groundwater inflow(yes or no): Comments(note condition of soil,signs of hydraulic failure,level of ponding,condition of vegetation,etc.): PRIVY:At(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.): Page 10 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: o x9 v c- (zLL L ly D 271 AAJ0c) ,i:;t* ,vt1} Owner: AL)1-gfiCq Date of Inspection:_L gj a 3 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. oov�� � 0 C�XgDw C 12C LL • J • Page 11 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: a=3 DXBvo— L j jzc C- k)- Arj7D.?t .2 Owner: j c!3 Date of Inspection: Av i-s3 flc" SITE EXAM Slope Surface water N c UE Check cellar ,v,;, Shallow wells nre!4� Estimated depth to ground water (m feet Please indicate(check)all methods used to determine the high ground water elevation: _4 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: FORM 11 - SOIL EVALUATOR FORM Page I No. ................ .............. Commonwealth of Massachusetts Date Wov-TVI AwwtFZ, Massachusetts Soil SuitabWo Assessment for On-site Sewage Disposal Performed By: ....W-a-Li-A-M......D.u. &J.e. ......................... .-2.y..-.97 Witnessed By: . ..................... .... .... ..... ................................................................................................................................................................................................................................................................... Location Address or A.C. BuitDEP-5; lwc_. Lar Address.vW -33 WALVef& ROAD )�-o-r ZZ ,K 0BOLA.) CAL4:44S Telephone# T.t-1 PAP-. lkt WOIZn4 Al�,SWVEIZZ, MA. Di gNS New Construction Repair ❑ Office Review Published Soil Survey Available: No ❑ Yes Year Published ... Publication ScaleU-1.5V90 Soil Ma ..q... ,Snit 0,;*f'c9.0 Drainage Class ..5........ Soil Limitations ..... . ........................................................ Surficial Geologic Report Available: No El Yes El Year Published ...._.r..... Publication Scale GeologicMaterial (Map Unit) ..................................................I.............I.................................................................................... Landform .............................................................................................................................................................................................................. Flood Insurance Rate Map: +' zs-60,16 00 to B d,-Is 01 Above 500 year flood boundary No 1:1 Yes Within 500 year flood boundary No Yes ❑ Within 100 year flood boundary No LVJ Yes El Wetland Area: National Wetland Inventory Map (map unit) .............. P.-........q k T1�........ ...... Wetlands Conservancy Program Map (map unit).........................................................................11.................. Current Water Resource Conditions (USGS): Month Range Above Normal El Normal � Below Normal El AsSo"15D Other References Reviewed: ^ FORM It - SOI[ EVALUATOR FORM Page 2 On-site Review Deep Hole Number .LZ-' Date: ��`� Tlnnm:- Weather����, ao1har C4woy- S-- ��� Locadon <idendfyonobaplan) --~.~.°~~—.�4A..w.......................................................................................................................................... Land Use SIJJ.&^Y&A^AS-f!........ Slope '.L.O�--. Surface Stones -.�� ......................................................... Vegetation --_------'---'_---------_--____-_-_--------------_----_—. �d& Lano/ornm --�s��«�,^....-.............................................................................................................................................................................................................. Position onlandscape (sketch onthe back) ........Y. .-------------------_______. Distances from: Open Water Body faa1 Orainagemay-2.51t feet Possible Wet Area '100.T. feet Property Line -.10 17' feet � Drinking Water Well feet Cbhor ----....------' DEEP OBSERVATION HOLE LOG Depth from Surface Soil Horizon Soil Texture Soil Color Soil Mottling Other (inches) (USDA) (Munsell) (Structure,Stones,Boul'ders, Consistency, %Gravel) ! ' � ' W.Parent K8atmha| (0ao|ogic) -.��������&��--.�_f��^�~-----------------� Depth to Bedrock: -z��� ---' Depth to Groundwater: Standing VVo1or in the Hole: ....—~-- Weeping from Pb Face: Estimated Seasonal High Ground Water: ` FORM 11 - SOEL EVALUATOR FORM Page 3 Determination for Seasonal High Water Table Method Used: ❑ Depth observed standing in observation hole-.....7' inches ❑ Depth weeping from side of observation hole ....... inches 2 Depth to soil mottles .SWR6 inches ❑ Ground water adjustment feet Index Well Number ....'.... Reading Date ................... Index well level ................... Adjustment factor .........'`... Adjusted ground water level ...................................................... Depth of Naturally Occurring Pervious Material Does at least four feet of naturally occurring pervious material exist in all areas observed throughout the area proposed for the soil absorption system? If not, what is the depth- of naturally occurring pervious material? Certification I certify that on (date) I have passed the examination approved by the Department of Environmental Protection and that the above analysis was performed by me consistent with the required training, expertise and experience described in 310 CMR 15.017. SignatureC[ Date FORNI 12 - PERCOLATION TEST COMMONWEALTH OF MASSACHUSETTS WOM A►.Wvt=2 , Massachusetts Percolation Test east T� 1+-i-- SoAKS Date: �- j..-q.`7. .3-2-`Iy Time: ......t�.-..1'°1............. Observation Hole # - P- 18 P-2A Depth of Perc Start Pre-soak End Pre-soak 10: 0-7 6) , 0_7 Time at 12" Io : o`7 10 . 07 Time at 9" Time at 6" Time (9,._6„) -9 MN Mt Rate Min./Inch Zo H10Jw zo Mcu I Site Passed LJ Site Failed ❑ Performed By: i✓I<S CzOD��( Witnessed By: !�L) SA jj r`d VD Comments: ....P:..1.......��..... :.2......... .D.i .cou..iiu E .. . Q1?►.oR,r...Tn.........a 2.u�GHT. .SoA.tK........ SEPTIC PLAN SUBMITTALS / LOCATION. �j oZ D NEW PLANS: YES (/ $60.00/PlanZ REVISED gPLANS: YE�S7 $25.00/Plan DATE: / / �/ / DESIGN ENGINEER: �T g P l e f !ti O Ya U D S When the submission is all in place, route to the Health Secretary 1 PLAN REVIEW CHECKLIST ADDRESS 2 07a 0,460UJ ENGINEER /-AXSee//r'1/¢C1<__ GENERAL 3 COPIES L/ STAMPL--- LOCUS L—"" NORTH ARROW �� SCALE CONTOURS c/ PROFILE� (Sc) SECTION t/ BENCHMARK SOIL & PERCS ELEVATIONS WETS . DISCLAIMER C--- WELLS & WETS WATERSHED?-&a DRIVEWAY ei WATER LINE FDN DRAIN 1--- M&P SCH40y TESTS CURRENT?—L----- SOIL EVAL DL�Fi�LSys SEPTIC TANK MIN 150OG . 17 INVERT DROP L--' GARB. GRINDERM(2 comps +200) 10 ' TO FDN L"" MANHOLE ELEV -- GW ## COMPS . GB D-BOX SIZE ## LINES FIRST 2 ' LEVEL STATEMENT C� INLET - OUTLET 165'.75 = (2" OR . 17 FT) TEE REQ'D? 416 LEACHING MIN 440 GPD? RESERVE AREA C/ 4 ' FROM PRIMARY? L-"�_ 20 SLOPE 100 ' TO WETLANDS 100 ' TO WELLS G---- 4 ' TO S.H.GW �-1 (5 ' >2M/IN) 20 ' TO FND & INTRCPTR DRAINS/ 400 ' TO SURFACE H2O SUPP 4 ' PERM. SOIL BELOW FACILITY MIN 12" COVERS FILL? BREAKOUT MET? _ TRENCHES MIN 440 gpd SLOPE (min . 005 or 6"/100 ' ) SIDEWALL DIST. 3X EFF. W OR D (MIN 61 ) RESERVE BETWEEN TRENCHES? IN FILL? e- � MUST BE 101 MILAN. 4" PEA STONE? �� VENT? (>3 ' COVER; LINES >50 ' ) BOT 416 + SIDE !!��/ X LDNG - `123 = TOT 446 4.46 (L x W x #) (DxLx2x#) (G/ft2) Copyright @ 1996 by S.L. Starr Town of North Andover NORTH t1 OFFICE OF 3a o�",t ,•�0 COMMUNITY DEVELOPMENT AND SERVICES ° 30 School Street :�o North Andover,Massachusetts 01845 4,9 Eo t i WILLIAM J. SCOTT SSAcHUSt Director September 27, 1997 Aurele Cormier AC Buiilders 33 Walker Road North Andover, MA 01845 RE: Woodland Estates Dear Aurele: This letter is to inform you that the proposed septic plans for Lot 15 Puritan Drive and Lot 22 Oxbow Circle have been approved. If you have any questions, please do not hesitate to call the Board of Health office at the number below. Sincerely, Sandra Starr, S. Health Administrator cc: Wm. Scott, Dir. CD&S Merrimack Engineering File CONSERVA77ON 688-9530 HF,ALTH 688-9540 PLANNING 68?-9535 , i� } 1t1�i- fl� ,; f • r I 5 I •f i r I �. F. i Town of North.Andover, Massachusetts FO""NO I NORrh ,. i. • BOARD�O� HEALTH .p Oft«•• r•,'1•° �i'r. `} t i _ •Q -41 . M i i +` il' c i 4' 1, l u •i41 ;.DESIGWAPPROVAL*OR r 1 G l sACHUS t� L i ._ .. i .4.. y. .' SOIL ABSORPTION SEWAGE;DISPOSAL SYSTEM Applicant C �.;' i _ y Test No. • , Site Location C r a-a-j ':0 k O'l%J'�` i wy y7s ) 1 dly�d Specg Z- Reference Plans an ENGINEER r +DESIGN D TE , Permission is granted for an;iA 'Niddal soil absorption+sewage disposal,system to'be•Installed j in accordance with regulations of Board 'of Health. J �•:•i. _ i L�tI ,, I'!?•� �N3`)$y F . ..r t�. +#�, r I{i'• +.y r'I� iii },i ` +(, t i� �•. i I, il a '�� r i . `1 1 i I .� I'fl �..".�i li.k 1 1 i �p rjlttt �i♦� � 1 .� I j .rt f J I� �: I. ' .. . a � �� t � I ! ,II j :1• fir+ , � �' i � ���tl ��1 ��1r�� a'I 1'�I ��, �� i� z I .r: i. j xjy a tp.4f CHAIRMAN,BOARD OF HEALTH -F -! %'� ;• j1 ,'4F ry`t.{+ }M i `� itp`"! •'� 1` <,,3 ,.�, i1��F yi; 1�' Ir z j r ` t !�• �� � t. .. i .t 'i 1 , z . . �'J•; �. +�ri, i i #.' 'dl 1 #�1 } ! '+, '1' :e tJ/ r s x111- ti�;M1 ' .�i ' Site System Permit'No. �$ j j!r.�{.rt'fir""'" .sir U• + i::t�. •• _ .....,�, r + I �i '� t I,'. ;y r + it' r•'+i r �! 2 {rr•• I F • {�f "1 I. t y ��� � f' ' try �" (t t i•��rl t s � ` J, + � I k:���n i .,}i-., �} <�1��'.�_.iE-1`riri��i .,�' .r.l E+1�.;�:'�,j.l�.i •�r trr�, _,.ir«1.�}r I ._i..,.. ..�3 li{,I� •1 t, Town of North Andover, Massachusetts Form No.3 MORTF� BOARD OF HEALTH • t 19C L • O • p +� '•,,.00 DISPOSAL WORKS CONSTRUCTION PERMIT ,S'SA CHUS Applicant NAME ADDRESS TELEPHONE Site Location �-v -22 d Y 6c� w C-'•-�/c : Permission is hereby granted to Construct) or Repair ( ) an Individual Soil Absorption Sewage Disposal System as shown on the Design Approval S.S. No. 9 7 `i.. - -• ... CHAIRMAN,BOARD OF HEALTH • Fee 75 D.W.C. No. FOVJ( U - LOT RELEASE FORK INSTRUCTIONS: This form is used to verify that all necessary approvals/permits from Boards and Departments having jurisdiction have been obtained. This does not relieve the applicant and/or landowner from compliance with any applicable local or state law, regulations or requirements. ****************Applicant fills out this section***************** APPLICANT: A • C, 6 I 1 JJAt(5 :1 OO AG Phone �05 -8350 LOCATION: Assessor's Map Number Parcel Subdivision WDOJ' iOAJ EST ATtS Lots) a- Street LOX-8oW (-';r61& St. Number ************************Official Use Only************************ RECOMMENDATIONS OF TOWN AGENTS: Date Approved Conservation Administrator Date Rejected Comments Date Approved Town Planner Date Rejected Comments Date Approved Food Inspector-Health Date Rejected Date Approved Septic Inspector-Health Date Rejected Comments Public Works - sewer/water connections - driveway permit Fire Department Received by Building Inspector Date �67 j N� a wwo t-rY141 '7J,41 ' 1 ,,.r �Q'j•�-N12rlK.'71LI/� - e•�1.1•LtDEk I I I �Y Z11 EATI.!*,JG AREA III � iQ tt as I' 4 _--= Kl TGHEN Ar /� =:9 -7. .>: _ i`N�•y.i - •fitQ:• `�.� LIVING ROOM DWNG ROOM t I - i FOYER IIni 4 X65 I t I -cILI 3-� s- 3.3• Vii— ���•. i _ . TS T FLQOIL-:EUAL t MAST 1.ikOAG ! T AT M CL BED � OAR,% M1i�7 l v1 L -6 _ 7 z43 i i Z APPLICATION FOR DISPOSAL WORKS CONSTRUCTION PERMIT DATE: q t� l�� CURRENT INSTALLER'S LICENSE# LOCATION: �c�� G�� ox-bo-,j LICENSED INSTALLER:. SIGNATURE: c TELEPHONE# `�° CHECK ONE: REPAIR: NEW CONSTRUCTION: ✓,_. IF NEW CONSTUCTION, PLEASE ATTACH FOUNDATION AS-BUILT. Administrative Use Only $75.00 Fee Attached? Yes No Foundation As-Built? Yes '� No Floor Plans? Yes No Approval Date: �S ?� MAr`=,4-y8 THU 10:36 - L P. 01 a� HAYES ENGINEERING,INC. 603 SALEM STREET WAKEFIELD,MA 01880 NANTUCKET,MA 02554 (781)246-2800 (508)228-7909 REFER To FILE# FAX(781)246-7596 May 14, 1998 Susan Ford No. Andover Board of Health 120 Main Street No. Andover, MA 01845 Susan, On 5113198 Hayes Engineering did field locations of the septic system on Lot 22A Oxbow Circle in No.Andover. The elevations of the system are in accordance with the proposed system as shown on the plan by Merrimack Engineering Services dated September 9, 1997. Sincerely, Peter Ogren, P.E., P.L.S- President PJO/sw TOWN OF NORTH ANDOVER SEWAGE DISPOSAL SYSTEM INSTALLATION CERTIFICATION The undersigned hereby certify/that the Sewage Disposal System constructed; ( )repaired; by le-5 � located at Z, was installed in conformance with the.North Andover Board of Health approved plan, System Design Permit,4 �s dated with an approved design flow of gallons per . The materials— ed were in�conformance with those specified n g P �Y p o the approved plan;the system was installed in-accordance with the provisions of 310 CMR 15.000, Title 5 and local regulations, and the final gradi:iig'agrees substantially with the approved plan. All work is -accurately represented on the As-built which has been submitted to the Board of Health. Installer: Lic. #: Date: 1 �8 Design Engineer: O Date: Form No.4 Town of North Andover, Massachusetts BOARD OF HEALTH May 15 , 1998 CERTIFICATE OF COMPLIANCE This is to certify that the Individual Soil Absorption Sewage Disposal System constructed (X ) or repaired ( ) by Charles Zaher INSTALLER at T ni- #22 � } ^ �o rl�ar Nnrth AndnvarMA nl R45 has been installed in accordance with Board of Health Regulations as described in the Design Approval Site System Permit No. 951 dated Sept. 9 , 19 97 The issuance of this certificate shall not be construed as a guarantee that the system will function satisfactorily. OARD OF HEALTH x4O R T 0VM Of 9 over L No. * Z � � � � 199 * 0 z . dover, Mass., LAKE 9 COC HICHEWICK T E b S E BOARD OF HEALTH PERMIT T D Food/Kitchen Septic System..lr .j .�.�..�., ..� ....� 13UrLDING INSPECTOR : THIS CERTIFIES THAT................... ..........................A.-C.......... ............. Foundation has permission to erect....................I................... buildings on .............T...3..... ......... ou t0 be OCCUpled as.................................................��./ .�?.A.fi��....... � .�.l.,✓....................................................... himney % provided that the person accepting this permit shall in every respect conform to t terms of the application on file in i this office, and to the provisions of the Codes and By-Laws relating to the Inspection, Alteration and Construction of Buildings in the Town of North Andover. PL BdfN ACTOR �./ VIOLATION of the Zoning or Building Regulations Voids this Permit. PERMIT EXPIRES IN 6 MONTHS a� - -.�;-z UNLESS CONSTRUCTION ST S ELEC IC INSPE Roug f �� ... .............. .. ...... .. ..................................... Service UI ING INSPECTOR final / Z � � Occupancy Permit Required to Occupy Building bAS NSPE&OR Display in a Conspicuous Place on the Premises — Do Not Remove Rough Final [/v No Lathing or Dry Wall To Be Done FIRE DEPARTMENT Until Inspected and Approved by the Building Inspector. Burner Street No. ` Smoke Det. C � VG/V..!/1-)7r VV. V JVV.7/x0011 .71CwHr.I/"Iluuvr-`-, rRur- GSM3 1JD in Sf TfS SEPTIC TAM SOMCE 47 RAIIRoAD glpELT J1/e orlin A MR 01835 W-a v t 978-372-7471 OP u NoiclMy REPORT FOR MW CF ADERESS '7s sf tS� /oQU ✓� " 165q' 0,56,ewj /Uoo : ✓ /907 r �Hjn Cin r f -I 103 zd4Cc�rgvm 16� 1550 5z/e,,ij :S J 626 word 6prrZlqpc, 1660 6x.5 �s ✓6 -(0 Oyu �bts n j t Wo idvly UR. AN- r ER/ rB >O 4ACI TOWN OF NORTH ANDOVER! NO. ` 4202 � YSTEM PUMPING R.ECOf_D -- TEM OWNER & ADDRESS SYSTEM LOCATION (ele: lefc iron( of hou5t) f4l YArd (1yoger xi-rd 844 U I E OF PUMPINC: 1�'I " (QUANTITY PUMPED/5� SPOOL. NO YES SEPTIC' TANK : NO YLS ATURE OF SERVICE: ROUTINE EMERCENCY "M1 F(ZV \TIONS: (.FOOD CONDITION G.,-" FULL TO COVF1Z _ HFAVY CREASC BAFFLL:S IN PLACE: _ ROOTS LEACHFIELD R NUACK. CXCESSIVE SOLIDS FLOODED ^ SOLIDS CARRYOVER Oj�HER (EXPLAIN) • 1 > I Lm PUM1'CD BY u�I "drNTS: I'S TIZANSFCIZIZLD TO: .':••�''�)'�� .:j:i i•ayp tl, .•ISN, TOWN 0� V^ I, / t SO5 SY8'1"81�•1 PUMPI1vU �Y5r8M i� -~-�T__---._ _..._.._.._....._........... ._.. �Td DATI OF PVMMNQ: QUANTITY . P'00 L; NO.. ,.. . Y�J„ rV0 UN 3eRYle xoV' tS J. 000D CONfl ' I`V LL rte PAI-, KO�OTS. ✓rElrtiCK1�'1.(? KVNSnt'r. ex 0MY6 sol,�pa ��.. PL�oDeD got,Co CA XA YO YAR' 01'KU.E X P L A I N ulv I tN I'y fll.�N3tGXKbU 11 •,•.t l' �iF+ n v ,a,',:(,nl.• '1}•}• ,Jjyls'• 1�,l..Uri , VES" MAS ,• �• Tv�t.,.; ,�fy�. .; ,�;��, , i rt,.:,:.(,. .,'c;,./��;`{�:;)�:7.7 t,•I:, .,. MAY .A '9. 200$ FP,.has provided �hli form for usij by local Boards o(Healt " ::ba subm► a'd to the.local'Soard o!Health or other approving a a vx aX trF,'W Jldrg ec0rc rn__ �' �•: ;;r. ::.:y :' ;,.;;'ai;,;.t;c(,::, tiSH DEPARTM NT :.:A; Faclif ty lnfotr tlon ��,�DO(�nt:. ::..`:.r•I x..1,.1!. .`J.. '•'��,�:��i�,�)j �',ti; ' .•JsrW�n Nunp.out' .1'. . System l.ocatlon;' ' , `.0.*Lha Lab kay Address to move your .;'.;town ;, :•:;,::.; a 7J Code . . s,,• p ow 2s ,,System n'ar.,•, :, _ • ► . ,•..,; 'r ,'ari. •cilli:.•,. �!,. •',t, • `t:' °i•;,';rl,' ;° �`,'')afc:'�^i";��',,Nt!Tle ''a;;!`• r••„�r•.�i"j,, ..,�.., Addim(if dVferen! rem IocaUon) ' ;. State - ZJp code -- —_ Telephone Number 13 Pum.ping ,. f,•' •.,'. v'E �,t r•,,, Lll4;::r)ir-l�'�f1�i, l�iv•� U Date of Pumpinq pat 2,�Quantlty Pump �� r. G �Jon� Cesspools) S ptic Tank ❑ Tight Tank :, ,; .'��.,: Q%Other(descrlba�;•• ''�' ” ' �• 'rJ y.' "•� i>.A,i•,'ij{Yiii(r':�;'ytl�iy�;ij.1r•.�'"•,. .,.,, •� .:: .. :; ?; ;;4,;I,,,Effiuei l Tae Flite{, f,Qsen,t?.(] Yes o If , 17,, "' p. yes, was It oleaned? ❑. yes ❑ N • _ .. :is . "��t:.,r ''y"114•,r'�',,J•.il�•�n..il'�,i�aSf�: II l r.,' .�,,. ,r•,: . .I., Y i ' 'J";Condlklon.Q.(.8 f71;;'''' ' ------------- .' '��:,"':���.ii .,.;�f�;L�,,`'•�!�'y;�'j'�;il: J:Y;7'�Y;,��j;',�i:yi, j,,5tr,i;�:;��,: .. ,' : ' '� .'��i ��.�..J1(`f��./%�t�::�Iii•�j:':��IJ '�•��:�:�),,. ',,, .. - •—• :';,t• ••,;i•',J �';, t,. uJ:S•o, "tir;'iy'i;i;ll1,�+,'�'�� •'• , .:'i.:..1jt'..!,1'.,J• •�,:�,/'.'44: ;•'�a�:j�; �rj'ia 1.\W,i�'j:j",., ;i}�''i���� �N ''' 1� +• „' . ,. �.. iYl r1 ,t I,�„r'. VehlcJe U '�� .�r'�• 'j'���'„y, , {�;� 7r ,; r. 'j�vT Ntunber r•1 , , T';tyn�)v�:l''1 Ja" C.it .�;� �' v7" S1 N�:�•,LI':,:�:�,� ���{/-'��i�l.��yl�•1. � ' � •. �vl Gf ♦� ► (Y{ • •r �. :Sir �' yi,::`.,",J•J'/''' `'' • • Y-"�G u�' %I;�'' � {'I� 1 >y.V.).i J ' :.as;. .r. ', iv;..•Y%vtU•i it I� i'r ,y�l; �f%�•�,r rit, •)•''.i'; ' �r•`.�`�,'r i•if.•4:,t•,. Ila�1 1\'�.�Y �• �!'M��/,t'�j1t5'', v fr oh.where oonlents' ere:dl ' :'.;; ;,,::::, 7•'.,,,:: I,.,Wi W., ;posed; .,1.•.`t: �'11,.i�j,rc:'.•:'�)j.dj i Pj '::r'}�' ',,rr ,!•a•' :,'f 1 / /y :,,;: '�'J:;.;':.,�°�;;:,�1;�;�..... r,Slpnalwe IHau tib „;•y..,',....r., • /`:�jl' Date tittp/tiiunv.mass,BoV/dapiwa(e�/89prQV&J&lt0orms,htm#Inspect ' ' Syelam Pumpinp Record P;qe 1 .. . �j �Qy 1•t f,., •�%,I •r. lel. ER S ACH'U '1 �•J''��r:, ,, 'j'r ' ��; ir•�.�.dl" t����,f►°I' �I,C�;r�9C0�rd � E NOV 10 2009 ?,h11 proyldrd -0e Ivornl11e0 Ioh of lhl ol+c+IclB � In F NORTH ANDOVER A� R DEPARTMENT,pr , �. rnpriry A' Faclllty In(orm��lon UOn: .'.Y ,'.I ll; lar ;,.•, � ., � ,OOf1pj,, 49- fit �� Q17— lem ,Y r�,, . ,r�i y!I4P�1•'1„I:.'ly�d'��r•,rr�;•I�, //�,�^/ '•'" ''' ''' '%'I,lu.,,11;x•', VpI ll;'`y;'1,I'•,lY'yr''•lis .,•,, _ `'"' l '.• �:''Ndrµr { 4.'Irinl rcYn buVonl 7170e—X — �ron, •`,l , 'III''il�'„4,lli,,u ilr/�Irr�l' r ' 13 LOP 1Ype vl 1y� on”'"' 0 . r• ' r;` 1•,• ,:+,, �� I�)� SaDI!c Tan,. , (�rOthO/(deJClfb9 It rw;r;�),lym`�0nl,rri F�IIr (.P.,;0111 Yo) CD NO[' , ;���;;;;;�,�•�r�,,.,,,,1''�'�1,,�,r��l'li,��1��„(I,v`;I�{+•,,• Ilre�. „el rlc�vaneo� '� , .. . +<'•,; ,r'�,r�;C'Q�dlyon Q $Y JLR1� 1"C�" � s ,, • ' ,I,., I�1„V1'I,�' Pvmped �'� 1�—•.�_ Ylnlul Ucen lc� On, A wner� lenu� l ,00 :kofo 11;pos0Q. �: , rr,li•Sj ial, / Y/1 Pip ppt4YeJ�Jlblorm�,n:�nNln)�OCI �►�� „ Commonwealth of Massachusetts ----� RECEIVED W City/Town of North Andover a System Pumping Record OCT 18 2011 Form 4 TOWN OF NORTH ANDOVEP M HEALTH DEPARTMENT DEP has provided this form for use by local Boards of Health. Other fo information must be substantially the same as that provided here. Before using this form, check with your local Board of Health to determine the form they use. The System Pumping Record must be submitted to the local Board of Health or other approving authority within 14 days from the pumping date in accordance with 310 CMR 15.351. A. Facility Information Important: When filling out 1. System Location: - forms on the Oxtza )computer, use US C1 only the tab key Address to move your No.Andover Ma 01845 cursor-do not use the return City/Town State Zip Code key. 2. System Or: ci �O Name 9 Address(if different from location) City/Town State Zip Code Telephone Number B. Pumping Record 1. Date of Pumpingpat 2. Quantity Pumped. gallons 3. Type of system: ❑ Cesspool(s) ❑ 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: CUA (pod no 6. USstem Pu d By: i 6e- �f)6L, 1-�) — Name Vehicle License Number Stewart's Septic Service Company 7. Location where contents were disposed: art's Pre-tr tment Plant, 20 So. Mill Bradford, Ma 01835 /Wt6 re of Ha-u leY Date Signature of R6Eeiving Facility Date t5form4.doc•03/06 System Pumping Record•Page 1 of 1 Commonwealth of Massachusetts City/Town of North Andover System Pumping Record Form 4 GM 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 they use. The System Pumping Record must be submitted to the local Board of Health or other approving authority within 14 days from the pumping date in accordance with 310 CMR 15.351. A. Facility Information Important:When filling out forms 1. System Location: on the computer, ` use only the tab 3 5 Sd� r,- r- key to move your Address cursor-do not North Andover use the return Cityrrown State Zip Code key. 2. System Owner: Name zasn Address(if different from location) City/Town State Zip Code Telephone Number B. Pumping Record /�- c9-3'` /�oy 1. Date of Pumping Date * Quantity Pumped: Gallons 3. Component: ElCesspool(s) Septic Tank ❑ Tight Tank ❑ Grease Trap ❑ Other(describe): 4. Effluent Tee Filter present? ❑ Yes D1<01 If yes, was it cleaned? ❑ Yes ❑ No 5. Observed c diti n of component pumped: 9 / to 6. Sy t m Pumped �l Name Vehicle License Number Stewarts Septic 58 So Kimball St Bradford Ma Company 7. Location where contents were disposed: 20 so st bradford ma 1.:2 ` ��-✓� Signature of Aauler Date Signature of Receiving Facility(or attach facility receipt) Date t5form4.doc•11/12 System Pumping Record•Page 1 of 1