HomeMy WebLinkAboutMiscellaneous - 437 SALEM STREET 4/30/2018 437 SALEM STREET
210/038.0-0082-0000.0
: Commonwealth of Massachusetts
City/Town of MOVED
System Pumping-Record 7 N S�
Form 4 0//
]t Wq4 OF N0PT1 F,AC�DCVE' /C
r7 RIME. T .
DEP has provided this form for use=by local Boards of Health. OK41% i may�e 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 house Z t re rof Nous Left/right side of house, Left/
Right side of building, Left/Right front of buildirig, Left/Right rear of building, Under deck
. Address
City/Town State �V Zp Code
2: System Owner.
Name*
Address(if different from location)
City/Town State z — e
Telephone Number
B. Pumping 'Record
. �f
1. Date of Pumping gate
�. Qu�anPumped:
Gallons
3. Type-of system. ❑ Cesspool(s) c Tank ❑ Tight Tank'
❑ Other(describe):
4. Effluent Tee Filter present? ❑ Yes o If yes, was it cleaned? ❑ Yes ❑ Na
5. Condition of System:
6: System Pumped By:
Neil.Bateson F5821
Name Vehicle License Number
Bateson Enterprises Inc
Company
7. Location where contents-were disposed:
.L S Lowell Waste Water
Sign a Haul Date
t5form4.doc•06/03 System Pumping Record•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 hou , Left Rightj§ of hous. Left/right side of house, Left/
Right side of building, Left/Right front of bul m9� Left/Right rear
of building, Under deck
Address L�3 /
Ctty/Town State Zip Code ,
2. System Owner.
Name
TOv.
Address Cd different from location)
Citylrown ' S Zip Code
Telephone Number
a
B. Pumping Record
1. Date of Pumping Date 2. Quantity Pumped: Gallons }.
3. Type of system: ❑ Cesspool(s) eptic Tank ❑ Tight Tank
❑ Other(describe):
4. Effluent Tee Filter present? 0 Yap 0-60 If yes, was it cleaned? ❑ Yes ❑ Na
" 5. Condition stem:
6. System Pumped By:
Neil.Bateson F5821
Name Vehicle License Number
Bateson Enterprises Inc'
Company
7. Lo here contents were disposed:
O S. Lowell Waste Water
Sign gtHaulwuDate F
t5form4.doc-06/03 System Pumping Record•Page 1 of 1
Commonwealth of Massachusetts [FIE
ECEIVED --
' _ � City/Town of
System Pumping-Record i� 2 1014
Form 4 OF NORTH ANDOVER
H DEPARTMENT
DEP has provided this form for use by local Boards of Health. Other forms may be 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
1. System Location: Left/Right front of hou" Jg rear of house Left/right side of house, Left/
Right side of building, Left/Right front of building, Left/Rig rear of building, Under deck
Address
Cityt-rown State Zip Code
2. System Owner.
Name
Address(f different from location)
city/Town Smote
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 Leo If yes, was it cleaned? ❑ Yes ❑ No.
5. Condition of stem:
6. System Pumped By:
Neil.Bateson F5821
Name Vehicle License Number
Bateson Enterprises Inc-
Company
ncCompany
7. Loca' re contents were disposed:
Cx�S. Lowell Waste Water
Sign HaulwU Date 7
t5fom4.doc-06/03 System Pumping Record•Page 1 of 1
Commonwealth of Massachusetts ;��
_ City/Town of
System Pumping Record r MA4Q14
Form 4
1Y
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 house, Right ar df hou , Left/right side of house, Left/
Right side of building, Left/Right front of building, Left/.Right rear of building, Under deck
Address
_Y1 S ct 1'�V-1
City/Town State Zip Code
2. System Owner. I _
Name
Address(f different from location)
City/Town State Zip Code
Telephone Number
- r
B. Pumping Record .
1. Date of Pumping _ ��1 1 . Quantity Pumped: cob
Date peGallons
3. Type of system: ElCesspool(s) Septic Tank El Tight Tank
❑ Other(describe):
4. Effluent Tee Filter present? ❑ Yep No If.yes, was ft cleaned? ❑ Yes ❑ No.
5. Condition of System:
6. System Pumped By.
Neil.Bateson F5821
Name Vehicle License Number
Bateson Enterprises Inc-
Company
7. Locatignwhere contents were disposed:
C Lowell Waste Water
SignAtu a 9t Haul Date
t5form4.doc•06/03 System Pumping Recons•Page 1 of 1
i
Commonwealth of Massachusetts RECEIVED
City/Town of f.,PR 29 2013
System Pumping Record TOWN OF NUKTH ANDOVER
Form 4 HEALTH DEPARTMENT
DEP has provided this form for use,by local Boards of Health. Other forms may be used, but the
information must be substantially the same as that provided here. Before using.this form, check with your
local Board of Health to determine the form they use.The System Pumping Record must be submitted to
the local Board of Health or other approving authority.
A. Facility Information
1. System Location: Left/Right front of house/Right j:e of_hous , Left/right side of house, Left/
Right side of building, Left/Right front of building, Left/Right rear of building, Under deck
Address 3 r7
Cityrrown State Zip Code
2. System Owner.
Name
Address(if different from location)
City/TownState t,Zi Code
�a-�-oma ��
Telephone Number
B. Pumping Record
1. Date of Pumping Date 2. Quantity Pumped- Gallons
3. Type of system- ❑ Cesspool(s) eptic Tank ❑ Tight Tank
❑ Other(describe):
4. Effluent Tee Filter resent? Yes o If es*, was it cleaned?❑ � eaned. Y
P Y ❑ es ❑ No
5. Condition of System: `�-•
6. System Pumped By:
Neil Bateson F5821
Name Vehicle License Number
Bateson Enterprises Inc
Company
7Isign
where contents were disposed:
Lowell Waste Water
�Haule Date
t5form4.doc•06/03 System Pumping Record•Page 1 of 1
Commonwealth of MassachusettsrE-C—E ®
ul
City/Town ofSystem Pumping Record I J'i 20.13
Form 4 TOWN OF NORTH ANDOVER
HEALTH DEPARTMENT '
DEP has provided this form for use-by local Boards of Health. Other forms may be" sed, 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 house,/Ri re r o hous Left/right side of house, Left/
Right side of building, Left/Right front of building, L Right rear of building, Under deck
Address
Cityrrown State Zip Code
2. System Owner:
ver cu—�
Name
Address(if different from location)
r
Citylrown stat,,—
tat Zip Code
xf
Telephone Number
B. Pumping Record
1. Date of Pumping pate 2. Quantity Pumped:
Gallons
3. Type of system: ❑ Cesspool(s) eptic Tank ❑ Tight Tank
I
❑ Other(describe):
4. Effluent Tee Filter present? ❑ Yes a No If yes, was it cleaned? ❑ Yes ❑ No,
" 5. Condition of Systerng
6. System Pumped By:
Neil Bateson F5821
Name Vehicle License Number
Bateson Enterprises Inc-
Company
ncCompany
7. L here contents were disposed:
i
Cx S. Lowell Waste Water
Signitufe 9t Haule Date
t5fomu4.doc•06/03 System Pumping Record•Page 1 of 1
Commonwealth of Massachusetts --- --City/Town of PRECEIV70System Pumping Record pR �.,4
Form 4
' TOWN OF NORTH ANDOVER
DEP has provided this form'for use by local Boards of Health. Othe ALT%DEPARTMENT 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/Right front of house, eft Rig rear of ho eft/right side of house, Left/
Right side of building, Left/Right front of building, Left/Right rear of building, Under deck
Address ),. j�
Cityrrown State Zip Code
2. System Owner.
cn,��O<-cv'-
Name
Address(if different from location)
CitylTown Stat i ',,5`�- ��?. p Code
Telephone Number
B. Pumping Record
1. Date of Pumping Date Gallons
2. Quantity Pumped:
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 System,
6. System Pumped By:
Neil Bateson F5821
Name Vehicle License Number
Bateson Enterprises Inc
Company
7. Lo on a contents were disposed:
G.L.S.R Lowell Waste Water
Sig t e Haule Date
t5form4.doc•06/03 System Pumping Record•Page 1 of 1
Commonwealth of Massachusetts RECEllI
F _ City/Town of
W° System Pumping Record APR 2.0 X041
Form 4 TOWN OF NORTH ANDOVER
°�M s••"•� HEALTH DEPARTMENT
DEP has provided this form for use by local Boards of Health. Other forms may be used, but the
information must be substantially the same as that provided here. Before using this form, check with your
local Board of Health to determine the form they use. The System Pumping Record must be submitted to
the local Board of Health or other approving authority.
A. Facility Information
1. System Location: Left front of house, right front of house, left side of house, right side of house, Left
rear of house, right rear of house, left side of building, right rear of building, under deck.
City/Town State Zip Code
2. System Owner:
Name
Address(if different from location)
City/Town State Code
Telephone Number
B. Pumping Record
1. Date of Pumping Date 2. Quantity Pumped: Gallons
3. Type of system: ❑ Cesspool(s) eptic Tank ❑ Tight Tank
❑ Other(describe):
4. Effluent Tee Filter present? ❑ Yes EI-1—No If yes, was it cleaned? ❑ Yes ❑ No
5. Condition of System-
'� c�
' FL 9 �
6. System Pumped By:
Neil J. Bateson F5821
Name Vehicle License Number
Bateson Enterprises Inc.
Company
7. Location wh re contents were disposed:
G.L.S.D o ell Waste Water
71- ---
Signatgfe/o H ler Date
t5form4.doc•06/03 System Pumping Record•Page 1 of 1
Commonwealth of Massachusetts
= City/Town of 1 + 1
a a° System Pumping Record
Form 4 MAY 2 5 201
M yea e
DEP has provided this form for use by local Boards of Health. Ot eT the
information must be substantially the same as that provided here. Ueck 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 side of house, Right side of house, Left front of house, Right front of house,
ar of ho Right rear of house. Left rear of building. Right rear of building.
Address
City/Towh l r State Zip Code
2. System Owner:
Name
Address(if different from location)
City/Town State Zip Code
�-OU"?
Telephone Number
B. Pumping Record
3//
D
1. Date of Pumping 2. Quantity Pumped:
Date Gallons
3. Type of system: ❑ Cesspool(s) Septic Tank ❑ Tight Tank
❑ Other(describe):
4. Effluent Tee Filter present? ❑ Yes No If yes, was it cleaned? ❑ Yes ❑ No
5. Condi *on of Sys em: r
6. System Pumped By:
Neil Bateson F5821
Name Vehicle License Number
Bateson Enterprises Inc
Company
7. Location where contents were disposed:
L Lowell Waste Water
�-J- h
!,ygj6tue of Haul(r/ Date
t5form4.doce 06/03 System Pumping Record•Page 1 of 1
Commonwealth of Massachusetts RECEIVED
City/Town of JUN - 8 2009
System Pumping Record
TOWN OF NORTH ANDOVER
Form 4 HEALTH DEPARTMENT
DEP has provided this form for use by local Boards of Health. Other forms may be used, but the
information must be substantially the same as that provided here. Before using this form, check with your
local Board of Health to determine the form they use.The System Pumping Record must be submitted to
the local Board of Health or other approving authority.
A. Facility Information
Important:
When filling out 1. System Location: Left fron left ear left sid of house Right front, right rear, right side of house.
forms on the
computer,use
only the tab key Address
to move your. ,
cursor-do not
use the return Citylrown State Zip Code
key. 2 System Owner:
Name
Address(if different from location)
City/Town . state Zip Code
Telephone Number
B. Pumping Record
1. Date of Pumping Date 2. Quantity Pumped: Gallons
3. Type of system: Q Cesspool(s) eptic Tank Tight Tank
Other(describe):
4: Effluent Tee Filter present? Yes G]-�No If yes, was it cleaned? [ Yes No
5. Con ition�•�of�S�y�,em: � � � ��Q
6. System Pumped By:
Neil Bateson F 5821
Name Vehicle License Number
Bateson Enterprises Inc
Company
7. Loca ere contents were disposed:
L.S.D ' Lowell Waste Water
igna ure of H"r Date
t5form4.doc•06/03 System Pumping Record•Page 1 of 1
N Commonwealth of Massachusetts
City/Town of
.: ' �iVED
System Pumping Record
Form 4
JUN 2 5 2008
DEP has provided this form for use by local Boards of Health.Other,forrp�{may I*ta` . �, but the
information must be substantially the same as that provided e�'e� e ire To check with your
local Board of Health to determine the form they use. Theem� Pu p g Record must be submitted to
the local Board of Health or other approving authority.
A. Facility Information
Important:
When filling out 1. SySt@ITl Location: ���� I ' ��
forms on the (J (/' l
computer, use
only the tab key Address 4-3"7
Q`
to move your AL
cursor-do not Cityrrown State Zip Code
use the return
key' 2. System Owner:
r
Name
i ISI Address(if different from location)
City/Town State
Telephone Number
B. Pumping Record
co
1. Date of Pumping 2. QuantityPumped:
p g DateGallons
3. Type of system: ❑ Cesspool(s) eptic Tank ❑ Tight Tank
❑ Other(describe):
4. Effluent Tee Filter present? ❑ Yes No If yes,was it cleaned? ❑ Yes ❑ No
5. Conditi
6. System.
Name Vehicle License Number
Company
7. Location re contents werenosed:
Signaturwu WultDate
t5fonn4.doc<06/03 System Pumping Record^Page 1 of 1
�L\ Commonwealth of Massachusetts RECEIVED
City/Town of
System Pumping Record OCT 2 4 2006
r Forme 4
TOWN OF NORTH
D PART
ANDOVER
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. System L ation:
forms on the ^/L
computer,use
only the tab key Address
to move your
cursor-do not
use the;return Cityfrown State 14
Zip Code
key.
2. System Owner: C
1
Name
Address(if different from location)
CdyrrownSta .:
^�L �� Zip Code`
Telephone Number
B. Purrrping Record J
1. Date.of Pumping 2. Quantity`Pumped:
Date allons %%"
3. Type of system: ❑ Cesspool(s) eptic Tank- ❑ -right Tank
❑ Other(describe):
4. Effluent Tee Filter present? ❑ Yes ❑•-fro . If yes, was it cleaned? ❑ Yes ❑ No
5. Condition of Syste
ry
6. System P edeBy, )
Name Vehicle License Number
Company --
.7. Locatio where contents wer disposed:
Signa'tur of auI r Date
http://www.mass.gov/dep/waterlapprovalt/t5fonns.htm#inspect
t5form4.doc•06/03 System Pumping Record•Page 1 of 1
TOWN OF
SYSTEM PUMPING RECORD,,.
DATE: ,
SYSTEM OWNER& ADDRESS SYSTEM LOCATION
j (example:left front of house)
�'-R �"& j
DATE OF PUMPING: O QUANTITY PUMPED : GALLONS
CESSPOOL: NO YES PTIC TANK: NO YES
NATURE OF SERVICE: ROUTINE EMERGENCY
OBSERVATIONS:
GOOD CONDITION FULL TO COVER
HEAVY GREASE BAFFLES IN PLACE
ROOTS LEACIOULD RUNBACK
EXCESSIVE SOLIDS FLOODED
SOLIDS CARRYOVER OTHER(EXPLAIN)
SYSTEM PUMPED BY: Bateson Enterprises, Inc.
COMMENTS:
CONTENTS TRANSFERRED TO: C—
TOWN OF NORTH ANDOVER
SYSTEM PUMPING RECORD
DATE:
SYSTEM OWNER &ADDRESS SYSTEM LOCATION
(example: left front of house)
�Q✓�v►ti�G��
�.� bD-c t— 8' v ol15-c
DATE OF PUMPING: _ QUANTITY PUMPED l O(SZ-'3 GALLONS
CESSPOOL: NO YES SEPTIC TANK: NO YES
NATURE OF SERVICE: ROUTINE ZEMERGENCY
OBSERVATIONS:
GOOD CONDITION FULL TO COVER
HEAVY GREASE BAFFLES IN PLACE
ROOTS LEACHFIELD RUNBACK
EXCESSIVE SOLIDS FLOODED
SOLIDS CARRYOVER OTHER(EXPLAIN)
SYSTEM PUMPED BY:
COMMENTS:
CONTENTS TRANSFERRED TO:
`l
Commonwealth of Massachusetts
Massachusetts
System Pumping Record
System Owner System Location
Late of Pumping: Quantity Pumped: gallons
Cesspool: No W" Yes L:J Septic Tank: No Yes
System Pumped by: gctredert Sif&"7ftaa License#
Contents transferrred to : Greater Lawrence Sanitary District
Date: _ Inspector-
'1 OF NORTH APJb�J�'EF3/
BOARD OF HEALTH
JUIN
4
Town of North Ando,-,,7e-r, Mtn ®._
TOWN OF NORTH AK
Watershed Septic System BOARD OF HEALTH
Servicing Rep rt SEP 71995
Date:��-�y�-
r
Homeowner: (s1 nJSk 1 Pumper :� Mom. a
Street Address:
Phone ( jp�, -�e��n Phone te"kt
Nature of Service: Routine
Emergency
Observations: Good Condition 0(
Full to Cover
Baffles in Place
Leachfield Runback Q
Excessive Solids Vj
Heavy Grease
Roots r
Other (Explain)
Description of Work:
Comments:
i
Commonweatth of Massachusetts
Executive Office of,Environmental Affairs
Department of
Environmental Protection
William F.Weld
Governor
Trudy Coxe
Seoratary,EDEA
David B. Struhs
Commissioner
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION
Property Address: 43 . Address of Owner:
Date of Inspection: /A - ct.SR` (if different)
Name of Inspector: ,� �
Company Name, Addressnd eAone Number: ¢�
t
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:
k"�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 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 subunit
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:
Ve'3 1 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: ,f
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 • FAX(617)556-1049 a Telephone(617)292-5500
I&D Printed on Recycled Paper
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART,A
CERTIFICATION (continued)
Property Address:
Owner: (r,f
Date of Inspection: 1 _ —el
B]SYSTEM CONDITIONALLY PASSES (continued)
_ Sewage backup or breakout or high static water level observed in the distribution box is due to broken or obstructed
pipe(s) or due to a broken, settled or uneven distribution box. The system will pass inspection if(with approval of the
Board of Health):
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
C] FURTHER EVALUATION IS REQUIRED BY THE BOARD OF HEALTH: p 4-
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 feel 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 has 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
PPmr
D) SYSTEM FAILS: t.
I have determined that the system violates one or more of the following failure criteria as defined in 310 CMR 15.303. The basis
for this determination is identified below. The Board of Health should be contacted to determine what will be necessary to correct
the failure.
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
u
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION (continued)
Property Address:
Owner:
Date of Inspection: f _ � 9.3
D)SYSTEM FAILS(continued):
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.
r,
_ 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.
El LARGE SYSTEM FAILS:
The following criteria apply to large systems in addition to the criteria above:
The design flow 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:
r.
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
t
ti
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART B
CHECKLIST
Property Address: 4(3`
/144
Owner:
Date of Inspection:
Check if the
following have been done:
110, 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.
10-
As built plans have been obtained and examined. Note if they are not available with N/A.
f�`The facility or dwelling was inspected for signs of sewage back-up.
l !�The system does not receive non-sanitary or industrial waste flow
kZThe site was inspected for signs of breakout.
All system components, excluding the Soil Absorption System, have been located on the site.
The septic tank manholes were uncovered, opened, and the interior of the septic tank was inspected for condition of baffles or
tees, material of construction, dimensions, depth of liquid, depth of sludge, depth of scum.
Zhe size and location of the Soil Absorption System on the site has been determined based on existing information or
approximated by non-intrusive methods.
ZThe facility o,ti 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
Property Address:
Owner:
Date of Inspection:
- fir. C'.
FLOW CONDITIONS
RESID�ENTIALL;
Design flow: fJ allons
Number of bedrooms: .
Number of current residents: `
Garbage grinder (yes or no):—H
Laundry connected to system (yes or no):
Seasonal use (yes or no):
iL
Water meter readings, if available:
Last date of occupancy: 0 CC VoI "
COMMERCIAL/INDUSTRIAL: x
Type of establishment: f'F
Design.flow: gallons/day
Grease trap present: (yes or no)_
Industrial Waste Holding Tank present: (yes or no)_
. Non-sanitary waste discharged to the Title 5 system: (yes or no)_
Water meter readings, if available:
Last date of occupancy:
OTHER: (Describe)
Last date of occupancy: r
GENERAL INFORMATION
PUMPING RECORDS and source of information: v SJ"�`u* y-r.�
System pumped as part of inspection: (yes or no)_
If yes, volume pumped 000 gallons /
Reason for pumping: "/1 t't;r i?'Q"0j r— Y /r �M
f
r
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)
Other (explain)
APPROXIMATE AGE of all components, date installed (if known) and source of information: a S t
{
Sewage odors detected when arriving at the site: (yes or no) )qta
(revised 8/15/95) 5
i
k
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Property Address: /
Owner:
Date of Inspection:
SEPTIC TANK:
(locate on site plan)
Depth below grade: n
Material of construction: +'concrete _metal _FRP—other(explain)
Dimensions: OL v
Sludge depth:
Distance from top ofsludgeto bottom of outlet tee or baffle:q"f
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:
w•
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.)
+�J L C 7" t,,l Uri,"'r 'ter 5 ` d G r? E 0A0p—/c,
i`L.v c: r 1►a t~��
9'6 0,,t
GREASE TRAP:_ `
(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 «um tn 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.)
P
(revised 8/15/95) 6
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Property Address:
Owner:
Date of Inspection:
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.)
t
DISTRIBUTION BOX:_
(locate on site plan) /
Depth of liquid level above outlet invert:
Comments:
(note if level and distribut;cn i, equal, evidence of solids carryover, evidence of leakage into or out of box, etc.)
It#0 i n�11 c c t? f _2.svw/ (J a t'✓ u lr r
' srSJ-tL�rrior+
PUMP CHAMBER:_ +{�
(locate on site plan)
Pumps in working order:(yes or no)
Comments:
(note condition of pump chamber, condition of pumps and appurtenances, etc.)
(revised 8/15/95) 7
U
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Property Address:
Owner:
Date of Inspection:
SOIL ABSORPTION SYSTEM (SAS): t�
(locate on site plan, if possible; excav tion not required, but may be approximated by non-intrusive methods)
If not determined to be present, explain:
Type:
leaching pits, number:_
leaching chambers, number:_
leaching galleries, number:
leaching trenches, number,length:
leaching fields, number, dimensions:
overflow cesspool, number:
Comments: (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation,etc.)
CESSPOOLS: _ 1
(locate on site plan) f
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
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Property Address: � f�-
Owner:
Date of Inspection: ,r
SKETCH OF SEWAGE DISPOSAL SYSTEM:
include ties to at least two permanent references landmarks or benchmarks
locate all wells within 100'
00�
14-
14
F.
Ce
f
7
o 0
Tae "
DEPTH TO GROUNDWATER l�J� , S
69� '"✓
Depth to groundwater: feet ,�
method of determination or approximation: c '�' � -)06o J A/0.4 1
"Gz - /54'4 1Y N -Yr=;,.j G• SrHvr
(revised 8/15/95) 9