Loading...
HomeMy WebLinkAboutMiscellaneous - 44 LACONIA CIRCLE 4/30/2018 44 LACONIA CIRCLE E - 2101105.D-0153-0000.0 Commonwealth of Massachusetts _ City/Town of North Andover J� C W4 _ ;ate m Pumping Record Form 4 check with your w` 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 theyat use. Thed here.SystemPutore mping using Reco d must be submitted o local Board of Health to determine the form y date in the local Board of Health or other approving authority within 14 days from the pumping, accordance with 310 CMR 15.351. q. facility information importance when filling out forms 1. System Location: on the computer, C(r, use only the tab key to move your Address Ma 01886 cursor-do not North Andover Zip Code use the return State Cfijlr own key. 2. System Owner: Name roman v , Address(if different from location) State Zip Code Cityrown Telephone Number B. Pumping Recolyd 1540 UCro�� 1. Date of Pumping Date 2. Quantity Pumped: Gallons Tight Tank ❑ Grease Trap 3. Type of system: El Cesspool(s) Septic Tank ElTi 9 ❑ Other(describe): 4. Effluent Tee Filter present. ❑ Yes ❑ No .If.yes, was it cleaned? ❑ Yes ❑ No 5. Condition of System: 6. System Pumped By: Vehicle License Number Name Stewart's Septic Service Company 7. Location where contents were disposed: Stewart's Pre-treatment Plant, 20 So. Mill Bradford, Ma 01835 Signature of Hauler Date Signature of Receiving Facility Date System Pumping Record-Pag t5form4.doc-03/06 O,NORTM9 6665 • Town of North Andover `�'•,,,,p.. ,' HEALTH DEPARTMENT ,SSACMU CHECK#: as DATE: V l 3 LOCATION: da H/O NAME: CONTRACTOR NAME: (' 5 00 x Type of Permit or License:(Check box) ❑ Animal $ ❑ Body Art Establishment $ ❑ Body Art Practitioner $ ❑ Dumpster $ ❑ Food Service-Type: $ ❑ Funeral Directors $ ❑ Massage Establishment $ ❑ Massage Practice $ ❑ Offal(Septic)Hauler $ ❑ Recreational Camp $ ❑ Sun tanning $ ❑ Swimming Pool $ ❑ Tobacco $ ❑ TrashlSolid Waste Hauler $ ❑ Well Construction $ SEPTIC Systems: ❑ Septic-Soil Testing $ ❑ Septic-Design Approval $ ❑ Septic Disposal Works Construction(DWC) $ ❑ Septic Disposal Works Installers(DWI) $ ❑ Title 5 Inspector $ Title 5 Report $ S ❑ Other:(Indicate) $ I Health Agent Initials White-Applicant Yellow-Health Pink-Treasurer N5.ORM 6665 .• 9 Town of North Andover HEALTH DEPARTMENT ,SSACM�St� CHECK#: , � DATE: LOCATION: _.v H/O NAME: l CONTRACTOR NAME: ' 4 `1 Type of Permit or License: (Check box) ❑ Animal $ ❑ Body Art Establishment $ ❑ Body Art Practitioner $ ❑ Dumpster $ ❑ Food Service-Type: $ ❑ Funeral Directors $ ❑ Massage Establishment $ ❑ Massage Practice $ ❑ Offal(Septic)Hauler $ ❑ Recreational Camp $ ❑ Sun tanning $ ❑ Swimming Pool $ ❑ Tobacco $ ❑ Trash/Solid Waste Hauler $ ❑ Well Construction $ SEPTIC Systems: ❑ Septic-Soil Testing $ ❑ Septic-Design Approval $ ❑ Septic Disposal Works Construction(DWC) $ ❑ Septic Disposal Works Installers(DWI) $ ❑ Title 5 Inspector $ D Title 5 Report $ ❑ Other. (Indicate) $ Health Agent Initials White-Applicant Yellow-Health Pink-Treasurer Commonwealth of Massachusetts ID Title 5 Official Inspection Form Subsurface s Sewage Dis osaLS em Form-Not for Voluntary Assessments 44 9 P Yt ry M �ac nme air rope Address Ownerer am _ q�v� �1 information is required for ��1 N L 1�Aol b-/lf-,(' every page. Cityr town State Zip Code Date of Inspection Inspection results must be submitted on this form. Inspection forms may not be altered in any way.Please see completeness checklist at the end of the form. Important: A General Information When filling out forms on the computer,use 1. Inspector. only the tab key to move your Nkiri) e5 J ' &U X cursor-do not Name of Inspector use the return Ukey. J� U X I Company Name a 3 �} Yl Company Address�^ U-j Ur fl D 1 ISI City/Town -79- �40 - q4 � 4 - State Zip Code Teleph ne Number License Number B. Certification 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. l am a DEP approved system inspector pursufint to,Sction 118340 of Title 5(310 CMR 15.000).The system: �._..w.�. `d E✓ Passes ❑ Conditionally Passes ❑ FailiC 10 ZQ13 ❑ Needs Further Evaluation by the Local Approving Authority In ctor's Signature Date The system inspector shall submit a copy of this inspection report to the Approving Authority(Board of Health or DEP)within 30 days of completing this inspection. If the system is a shared system or has a design flow of 10,000 gpd or greater,the inspector and the system owner shall submit the report to the appropriate regional office of the DEP. The original should be sent to the system owner and copies sent to the buyer, if applicable, and the approving authority. ""`This report only describes conditions at the time of inspection and under the conditions of use at that time.This inspection does not address how the system will perform in the future under the same or different conditions of use. Title 5 offidal Inspection Form:subsurface sewage Disposal system•page 1 of 17 t5ins-03!13 r Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments ,cj/[_ CQilaCir Property Address Owner Owner's Name Information is required for every page. City/Town State Zip Code Date of Inspection B. Certification (cont.) 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: AWAVA I J m ca 4(� P 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. Check the box for"yes", "no"or"not determined"(Y, N, )for the following statyements. If"not determined, "please explain. The septic tank is metal and over 20 years old'or a septic tank(whether metal or not)is structurally unsound, exhibits substantial infiltrati or exfiltration or tank failure is imminent. System will pass inspection if the existing tank is repla d with a complying septic tank as approved by the Board of Health. *A metal septic tank will pass inspecti if it is structurally sound, not leaking and if a Certificate of Compliance indicating that the tank' less than 20 years old is available. ❑ Y ❑ N ND (Explain below): t5ins•03/13 Title 5 Official Inspection Form Subsurface Sewage Disposal System-Page 2 of 17 l Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form- Not for Voluntary Assessments Y-14 Q Property Address Owner Owner's Name Information is required for every page. City/Town State Zip Code Date of Inspection B. Certification (cont.) B) System Conditionally Passes(cont.); ❑ Observation of sewage backup or break out or high static water level in the distribution box due to broken or obstructed pipe(s)or due to a broken, settled or uneven distribution box. System will pass inspection if(with approval of Board of Health): ❑ broken pipe(s)are replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below): ❑ distribution box is leveled or replaced ❑ Y ❑ N ❑ N xplain below): ❑ The System required pumping more/4tli year due to brokenor obstructed pipe(s). The system will pass inspection if(with aBoard of Health): ❑ broken pipe(s)are replaced Y ❑ N ❑ ND (Explain below): ❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below): C) Further Evaluation is Required by the Board of Health: ❑ Conditions exist which require further evaluation by the Board of Health in order to determine if the system is failing to /dHea c health, safe y or the environment. 1. System will pass uof Heal determines in accordance with 310 CMR 15.303(1)(b)that the st fun oning in a manner which will protect public health, safety and the environ❑ Cesspool or pri0 feet of a surface water ❑ Cesspool or pri50 feet of a bordering vegetated wetland or a salt march t5ins•03/13 Title 5 Official Inspection Form Subsurface Sewage Disposal System•Page 3 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form t Subsurface Sewage Disposal System Form- Not for Voluntary Assessments coy C,r- Property Address Owner Information is Owner's Name required for every page. City/Town State Zip Code Date of Inspection B. Certification (cont.) 2. System will fail unless the Board of Health (and Public Water Supplier, if any) deterimes that the system is functioning in a manner that protects the public health, safety and environment: ❑ The system has a septic tank and soil absorption system (SAS)and the SAS is within 100 feet of a surface water supply or tributary to a surface water sup Y. ❑ The system has a septic tank and SAS and the SAS is within a ne 1 of a public water supply. ❑ The system has a septic tank and SAS and the SAS is wi n 50 feet of a private water supply well. ❑ The system has a septic tank and SAS and the SA s less than 100 feet but 50 feet or more from a private water supply well** Method used to determine distance: **This system passes if the well water anal y ' , performed at a DEP certified laboratory, for coliform bacteria indicates absent and the presenc of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other ilure criteria are triggered. A copy of the analysis must be attached to this form. 3. Other: D) System Failure Criteria Applicable to All Systems: You must indicate"Yes"or"No"to each of the following for all inspections: Yes No ❑ Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool ❑ Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool ❑ t1ct Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool 99 P �j ❑ Liquid depth in cesspool is less than 6" below invertor available volume is less I VVff�� than % day flow t5ins-03113 Title 5 Official Inspection Form Subsurface Sewage Disposal System-Page 4 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments o / 601I fir' Property Address Owner Information is Owner's Name required for every page. City/Town State Zip Code Date of Inspection B. Certification (cont.) Yes No ❑ Q� Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number of times pumped: ❑ 0' Any portion of the SAS, Cesspool or privy is below high ground water elevation. ❑ D 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. ❑ 0' Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality analysis. [This system passes if the well water analysis, performed at a DEP certified laboratory,for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other',failure criteria are triggered. A copy of the analysis and chain of custody must be attached to this form.] ❑ R� This system is a cesspool serving a facility with a design flow of 2000gpd- 10,000gpd. ❑ The system fails. I have determined that one or more of the above failure criteria exist as described in 310 CMR 15.303, therefore the system fails. The system owner should contact the Board of Health to determine what will be necessary to correct the failure. E) Large Systems: To be considered a large system the system must serve a facility with a design flow of 10,000 gpd to 15,000 gpd. For large systems, you must indicate either"yes"or"no"to each of the following, in addition to the questions in Section D. Yes No ❑ ❑ the system is within 400 feet o surface drinkiing water supply ❑ ❑ the system is within 200 et of a tributary to a surface drinking water supply ❑ ❑ the system is locat in a nitrogen sensitive area (Interim Wellhead Protection Area- IWPA or apped Zone II of a public water supply well If you have answered "yes"to a question in Section E the system is condidered a significant threat, or answered"yes" in Sectio above the large system has failed. The owner or operator of any large system considered a si (cant threat under Section E or failed under Section D shall upgrade the system in accordance ith 310 CMR 15.304. The system owner should contact the appropriate regional office of the Department. t5ins-03/13 Title 5 Official Inspection Form Subsurface Sewage Disposal system•Page 5 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form- Not for Voluntary Assessments Property Address Owner Information is Owner's Name required for every page. City/Town State Zip Code Date of Inspection C Checklist ;heck if the following have been done. You must indicate"yes"or"no"as to each of the following: Yes No ❑ ❑ Pumping information was provided by the owner, occupant, or Board of Health ❑ ❑ Were any of the system components pumped out in the previous two weeks? ❑ ❑ Has the system received normal flows in the previous two week period? ❑ ❑ Have large volumes of water been introduced to the system recently or as part of this inspection? ❑ Were as built plans of the system obtained and examined? (If they were not available note as N/A) 0 ❑ Was the facility or dwelling inspected for signs of sewage back up? U ❑ Was the site inspected for signs of break out? ❑ Were all system components, excluding the SAS, located on site? ❑ Were the septic tank manholes uncovered, opened, and the interior of the tank inspected for the condition of the baffles or tees, material of construction, dimensions, depth of liquid, depth of sludge and depth of scum? ❑ Was the facility owner(and occupants if different from owner) provided with information on the proper maintenance of subsurface sewage disposal systems? This size and location of the Soil Absorption System (SAS)on the site has been determined based on: R" ❑ Existing information. For example, a plan at the Board of Health. Lam! ❑ Determined in the field (if any of the failure criteria related to Part C is at issue approximation of distance is unacceptable) [310 CMR 15.302(5)] D. System Information Residential Flow Conditions: Ll L Number of bedrooms (design): T Number of bedrooms (actual): DESIGN flow based on 310 0CMR 15.203 (for example: 110 gpd x#of bedrooms): t5ins-03N3 Title 5 Official Inspection Form Subsurface Sewage Disposal System-Page 6 of 17 L Commonwealth of Massachusetts Title 5- Official Inspection Form ;Subbsurff ce Sewage Disposal System Form-Not for Voluntary Assessments s aco r Property Address Owner Information is Owner's Name required for every page. City/Town State Zip Code Date of Inspection D. System Information Description: P61 Number of current residents: Does residence have a garbage grinder? ❑ Yes El No Is laundry on a separate sewage system? [if yes separate inspection required] ❑ Yes d No Laundry system inspected? 1:1 Yes ❑ No J Seasonaluse? ❑ Yes No Water meter readings, if available(last 2 years usage (gpd)): OA) R -p-et- Detail: ---�-- Sump pump? ❑ Yes ❑ No Last date of occupancy: ` c� Commercial/Industrial Flow Conditions:. Date Type of Establishment: Design flow(based on 310 CMR 15.203)• Basis of design flow(seats/persons/s Gallons per day(gpd) ,etc.): Grease trap present? ❑ Yes ❑ No Industrial waste holding tank pr ent? ❑ Yes ❑ No Non-sanitary waste dischar d to the Title 5 system? ❑ Yes ❑ No Water meter readings, if available: 15ins-03/13 Title 5 Official Inspection Form Subsurface sewage Disposal System-Page 7 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form a o Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 4q LfAcm6w �01r Property Address Owner Owner's Name Information is required for every page. Cityfrown State Zip Code Date of Inspection D. System Information (cont.). Last date of occupancy/use: Date Other(describe below): General Information Pumping Records: Source of information: Qt- ► JeK Was system pumped as part of the inspection? ❑ Yes No If yes, volume pumped: gallons How was quantity pumped determined? Reason for pumping: Type of System: L 1 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 contractto be obtained from system ystem owner)and a copy of latest inspection of the I/A system by system operator under contract Y ❑ Tight tank. Attach a copy of the DEP approval. ❑ Other(describe): t5ins-03/13 Title 5 Official Inspection Form Subsurface Sewage Disposal System•Page 8 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form n.Mom Subsurface Sewage Disposal System Form Not for Voluntary Assessments 44 �MMIO, CIT P operty Address Owner Owner's Name Information is required for every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Approximate age of all components, date installed (if known)and source of information: Were sewage odors detected when arriving at the site? ❑ Yes No Building Sewer(locate on site plan): Depth below grade: aZ ' C feet Material of construction: ❑ cast iron 40 PVC ❑ other(explain) -A Distance from private water supply well or suction line: 1:16feet � Comments (on condition of joints, venting, evidence of leakage, etc.): 4 Septic Tank(locate on site plan): Depth below grade: feet Material of construction: 9 concrete ❑ metal ❑ fiberglass ❑ pol thylene ❑ other(explain) - ---7 X -- If tank is metal, list age: AAA years -�—' Is age confirmed by a Certificate of Compliance?(attach a copy of certificate) ❑ Yes ❑ No Dimensions: .S 00 Sludge depth , t5ins•03113 Title 5 Official Inspection Form Subsurface Sewage Disposal System•Page 9 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Di7y, sal System Form -Not for Voluntary Assessments G Property Address Owner Owner's Name Information is required for every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Septic Tank (cont.) Distance from top of sludge to bottom of outlet tee or baffle J4 Scum thickness Distance from top of scum to top of outlet tee or baffle T" Distance from bottom of scum to bottom of outlet tee or baffle 1, 0 How were dimensions determined? S��drn Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): i L C ,P -e r U T/Pd p 5 r1�?$ -�I� l reeI AC Q — Grease Trap(locate on site plan): Depth below grade: feet Material of construction: ❑ concrete ❑ metal ❑ erglass El polyethylene ❑ other(explain) Dimensions: Scum thickness Distance from top of scum to t of outlet tee or baffle Distance from bottom of sc to bottom of outlet tee or baffle Date of last pumping: Date t5ins-03/13 Title 5 Official Inspection Form Subsurface Sewage Disposal System•Page 10 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments cbyn IQ el r Property Address Owner Information is Owner's Name required for every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): 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 ❑ olyethylene ❑ other(explain) Dimensions: Capacity: /switches, Design Flow: ay Alarm present: ❑ No Alarm level: rking order: ❑ Yes ❑ No Date of last pumping: Comments (condition of alarm a *Attach copy of current pumping contract(required). Is copy attached? ❑ Yes ❑ No t5ins•03/13 Title 5 Official Inspection Form Subsurface sewage Disposal System Page 11 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form ' Subsurface Sewage Disposal System Form-Not for Voluntary Assessments Ali Ck�Cc4V11Ar Property Address Owner Information is Owner's Name required for every page. Cityfrown State Zip Code Date of Inspection D. System Information (cont.) Distribution Box(if present must be opened)(locate on site plan): Depth of liquid level above outlet invert 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.): { ..v {.._._.N a i r ti Pump Chamber(locate on site plan): Pumps in working order: Yes ❑ No Alarms in working order: ❑ Yes ❑ No Comments (note condition of pump chamber, condition of mps and appurtenances, etc.): Soil Absorption System (SAS)(locate on site plan, excav 'on not required): If SAS not located, explain why: M1 t5ins-03/13 Title 5 Official Inspection Forth Subsurface Sewage Disposal System•Page 12 of 17 I Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 46c6y\IR roperty Address Owner Owner's Name Information is required for every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Type: ❑ leaching pits number: ❑ leaching chambers number: ❑,( leaching galleries number: LJ leaching trenches number, length: p 0 ❑ leaching fields number, dimensions: ❑ overflow cesspool number: ❑ innovative/alternative system Typeiname of technology: Comments (note condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of vegetation, etc.): :SJ)L�b) "R(A' YN (2\(-rAV9, X n 11 yl 6 iq/r) lIJ I t L6 — Cesspools (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 ❑ No tsins•03113 Title 5 Official Inspection Form Subsurface Sewage Disposal System-Page 13 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 0 Co roperty Address Owner Information is Owner's Name required for every page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): Privy (locate on site plan): Materials of construction: Dimensions Depth of solids Comments (note condition of soil, signs of by aulic failure, level of ponding, condition of vegetation, etc.): t5ins•03/13 Title 5 Official Inspection Form Subsurface Sewage Disposal S)stem•Page 14 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disppsal System Form- Not for Voluntary Assessments 4, �oYua Ir roperty Address Owner Owner's Name Information is required for every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Sketch Of Sewage Disposal System: Provide a view of the sewage disposal system including ties to at least two permanent reference landmarks or benchmarks. Locate all wells within 100 feet. Locate where public water supply enters the building. Check one of the boxes below: El hand-sketch in the area below ❑ drawing attached separately 1 3�yr 4i 4' t5ins•03!13 Title 5 Official Inspection Form Subsurface Sewage Disposal System•Page 15 of 17 F Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments Property Address Owner Information is Owner's Name required for every page. Ci /Town tY State Zip Code Date of Inspection D. System Information (cont.) j Site Exam: ❑ Check Slope ❑ Surface water / ❑ Check cellar v ❑ Shallow wells Estimated depth to high ground water: H, b feet Please indicate all methods used to determine the high ground water elevation: Obtained from system design plans on record If checked, date of design plan reviewed: S Date ❑ Observed site(abutting property/observation hole within 150 feet of SAS) ❑ Checked with local Board of Health -explain: i ❑ Checked with local excavators, installers-(attach documentation) ❑ Accessed USG$database-explain: You must describe how you established the high ground water elevation: (4n A-A � LkA Before filling this Inspection Report, please see Report Completeness p s Che ckhst on next page. t5ins•03/13 Title 5 Official Inspection Form Subsurface Sewage Disposal System•Page 16 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form.-Not for Voluntary Assessments � kaC6)4 Property Address Owner Owner's Name Information is required for every page. City/Town State Zip Code Date of Inspection E. Report Completeness Checklist Inspection Summary:A, B, C, D, or E checked Q� Inspection Summary,D (System Failure Criteria Applicable to All Systems)completed System Information - Estimated depth to high groundwater Sketch of Sewage Disposal System either drawn on page 15 or attached in separate file t5ins-03/13 Title 5 official Inspection Form Subsurface Sewage Disposal System•Page 17 of 17 I Commonwealth of Massachusetts ' A�-4-0 W City/Town of North Andover System Pumping Record ` 5 2013 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 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, Laconto C c�P.use only the tab key to move your Address cursor-do not North Andover Ma 01845 use the return City/Town State Zip Code key. 2. System Owner: rffi Name rerun Address(if different from location) City/Town State Zip Code Telephone Number B. Pumping Record I /Soo 1. Date of Pumping 2. Quantity Pumped: Date 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: 6. Stem Pumped By: ,yke er�� Name Vehicle License Number Stewart's Septic Service Company 7. Location where contents were disposed: St art's Pre-treatment Plant, 20 So. Mill Bradford, Ma 01835 re of Haule Date S Signature of Reoe6ing Facility Date t5form4.doc•03/06 System Pumping Record•Page 1 of 1 �I OCI li- D //i/ SCi/�f C•/II `�_ Lf,�/fir•-�.--, S.L.CIL ES R.!.S. LA!,VRF-AICL- I I k ` � I I I ` ' / . 1 / CE19 I F Y THAT TH OFFSETS SHO!MA/ AP, E FOR T/✓E USF OF- f 1=FSF TS SHOT✓N THE SU/LDING INSPECTOR 0AIL Y, 0- SUCI-" Na,1 -Y,; T�) THE USE /S FOR DETERJai//+/,!1 T/Oiy S )" /_A;-s' OF CONFORif/T Y OR NGiV C0fVFOPJ�6/i 4 Y.,1HEI✓ C19A1ST-,UC i CD Commonwealth of Massachusetts W City/Town of NORTH ANDVOER a W° System Pumping Record w Form 4 M 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, 44 LACONIA CIR use only the tab key to move your Address cursor-do not NORTH ANDOVER_ _ MA use the return Cit /Town —'� —� key. y State Zip Code 2. System Owner: OTTO Name reran Address(if different from location) �^ City/Town State Zip Code Telephone Number B. Pumping Record 1. Date of Pumping � 2. Quantity Pumped:ed:Date -- � ��2 --- Gallons 3. Type of system: ❑ Cesspool(s) /9 Septic Tank ❑ Tight Tank ❑ Grease Trap VN ❑ Other(describe): 4. Effluent Tee Filter present? ❑ Yes0 If yes, was it cleaned? ❑ Yes ❑ No S. Condition of Svstem: C -(i.�C� Vn2rL5 6. System Pumped By: Name Vehicle License.Numbp_r Stewart's Septic Service Company A 7. Location where contents were disposed: 1, Stewarts Pre-treatment Plant, 20 So. Mill Bradford, Ma 01835 10`+y 7ignatu I Date �� Ea= Date t5forrn4.doc•03/06 System Pumping Record•Page 1 of 1 t i SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM ' PART C SYSTEM INFORMATION (continued) Property Address Owner SKETCH OF SEWAGE DISPOSAL SYSTEM: include ties to at least two permanent references landmarks or benchmarks locate all wells within 100' -3 ab`4 " Qk ^ 3 a.�n },) D=boy. _ Ll p� x I i --� I i DEPTH TO GROUNDWATER Depth to groundwater: l feet � method of determination or approximation: 1 I (revised 11/03/95) 9 Commonwealth of Massachusetts ' Executive Office of Environmental Affairs , 2 5 199 Department of Environmental. Protection---- William F.Weld 1§ noverr,or --� Trudy Cox* Argeo Paul Cellucci Secretary U.GovernorDavid B. Struhs Commissioner SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION Property Address: Y�/ Lacov>;ck. C f-C-.IQ– 6j6f�� wr One . (late of Inapeotionl / (It different) Name of Inspector. Kle , % q. Company Name,Address and Telephone Number. BATESON ENTERPRISES, INC. TEL(508)475-1474 6ccavating-Water&Sewer Lines-Septic Systems&Pumping Service FAX:(508)475-5451 CERTIFICATION STATEMENT 111 Argilla Road Andover,Mass.01810 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: '� P"asses Conditionally Passes Needs Further Evaluation By the Local Approving Authority Fails Inspector's Signature: Date: 3--p1 1—9 7 The System Inspector shall su mit a co 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 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) 3YSPASSES: �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 ponforming septic tank as approved by the Board of Health. (revised 11/03/95) ; 1 One Winter Street a Boston,Massachusetts 02108 • FAX(617)556-1049 • Telephone(617)292-5500 iA=Printed on Recycled Paper ' SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address y y L.ctCp�,c� �11C L1 Nc< ► v \ Owner: I H,C', Date of Inspection: .3 -;- 1 1—19 _19 r7 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(a)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 para inspection if(with approval of the Board of Health): broken pipe(s)are replaced obstruction is removed CI 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 4bsorption system and is within 100 feet 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 ppm. 3) OTHER (revised 11/03/95) 2 F SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address: LlqL., 1 v�� Owners Date of Inspection: r `WC`s (U V\A l•Q A�0 D) SYSTEM FAILS: 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 clogged SAS or cesspool. Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or Cesspool. Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool. Liquid depth in cesspool is less than 6"below invert or available volume is less than 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. El LARGE SYSTEM FAILS: The following criteria apply to large systems in addition to the criteria above: The system serves a facility with a design flow of 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 11/03/95) 3 ' SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST Property Address: L4 yfoy-Nin, c1 SGl-e_ KkDc�� AJO� Owner. C• p��1 C � d/\,t 1M 1 Q.1\+d Date of Inspection: Check if the folio have been done: r5"' information was requested of the owner, occupant,and Board of Health. Nof the system components have been pumped for at least two weeks and the system has been receiving normal flow rates d period. Large volumes of water have not been introduced into the system recently or as part of this inspection. _ As bj3 plans have been obtained and examined. Note if they are not available with N/A. _The/ • ty or dwelling was inspected for signs of sewage back-up. _h Jgstem does not receive non-sanitary or industrial waste flow _Th was inspected for signs of breakout. m components,excludin the Soil Absorption System, have been located on the site. B rP septic tank manholes were uncovered, opened, and the interior of the septic tank was inspected for condition of babes or material of construction, dimensions, depth of liquid,depth of sludge,depth of scum. �/' The siz ' d location of the Soil Absorption System on the site has been determined based on existing information or ap ted by non-intrusive methods. _The facility owner(and occupants, if different from owner)were provided with information on the proper maintenance of Sub- Surface Disposal System. P (revised 11/03/95) 4 s SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION Property Address: Lq � vo<`�lv\ N'I, e4- Owner- 4- O� M .Dof Inspection: ( I-q7 FLOW CONDITIONS RESIDENTIAL- Design flow:�Q_,gallons Number of bedrooms: 2 Number of current residents: 3 Garbage grinder(yes or no):_—y(S Laundry connected to system(yes or no):�S Seasonal use(yes or no). D ) Water meter readings, if available: �S ��� X �'S 66 7 365' S !83 /� ,a l r-j Last date of occupancy: Cu C12wA' v COMMERCIAL/INDUSTRIAL: Type of establishment: 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, 0 available: Last date of occupancy: OTHER: (Describe) Last date of occupancy: GENERAL INFORMATION PUMPING RECORDS and source of information: System pumped as part of inspection: (yes or no) vA.e, If yes,volume pumped: OQ o Reason for pumping: �.- TYPE_ O"MTEM 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) APPRQXIMATE AGE of all components, date installed(if known)and source of information: Sewage odors detected when arriving at the site: (yes or no) No (revised 11/03/95) 5 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: Y L � (� OVI}I C� ��\( G,�\\ 1 vaCAb, "vaq— Owner. t*"Ar. (�. L �Y \ t V"11 Q kA 1'U Date of Inspection: 3 tj SEPTIC TANK_✓ (locate on site plan) Depth below grade: Materiel of construction:Vconcrete metal_FRP,other(explain) Dimensions: Sludge depth: !� Distance f}omP of to to bottom of tantlpt tett or baffle Scum thicktness:�sludge_ It Distance from top of scum to top of outlet tee or baffle: f A Distance from bottom of scum to bottom of outlet tee or baffle: 0 Comments: (recommendation for pum ' condition of inlet and outlet tees pr baffle ,depth of liqle el in relation to outlet inve in ty, evr ence of t 6KV 16 vc, v Q G QPM NJ GREASIA TRAP: (locate on site plan) Depth below grade: Material of construction: _concrete_metal_FRP^other(explain) Dimensions: Scum thickness: Distance f-om 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.) (revised 11/03/95) G f SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM * PART C I , SYSTEM INFORMATION(continued) Property Address: 4�9 La60V ,6'- (n C' N 0('4- \ 1, A- Owner. 1�1 pct..C� 1, c-� ��\IOAA (Q\A t Date of Inspection- 1 � —� �—qt7 TIGHT OR HOLDING TANK: /\D`n0- (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- (locate OX(locate on site plan) Depth of liquid level above outlet invert: Comments: o out of x etc. if level and distri ion is�ce of solids carryover,evidence of leafage into r o ) SOvv�c�� . �v agu o P r' u1 s PUMP CHAMBER.Y � G� (L'LN � �!w.{�� (locate on site plan) U v Pumps in working order:(yes or no) Comments: (note condition of pump Chamber, condition of pumps and appurtenances,etc.) (revised 11/03/95) 7 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM r PART C SYSTEM INFORMATION (continued) Property Address: Li 4 v��,C� G rc\e Aj4('4-�k A AAX_� Owner. ` Date of Inspection: SOIL ABSORPTION SYSTEM (SAS): v (locate on site plan,if possible;excavation 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:Op�G��S leaching fields, number,dimensions: overflow cesspool, number: Comments: (notecondi ' of soil, signs of hydraulic ,ev 1 of nding, clition of ve tation,etc.) 1 b `on C VZ 1 • WD0 v •e CESSPOOLS: Y�OV�e (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: POV118 (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 11/03/95) 8 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM ' PART C /SYSTEM INFORMATION (oontinued) PropertyAddreex Ovvner. ly�y C/�W,V ,q- cveoe Qoa \ &��' SKETCH OF SEWAGE DISPOSAL SYSTEM: include ties to at least two permanent references landmarks or benchmarks locate all wells within 100' 1 A3y � 1 A-+0 3 X37 Lf Lua �=ck CL:�w�wc DOW S 3 pp:�, ird :3 2a17 0-Sox Ll o��x �-- 601 ----� DEPTH TO GROUNDWATER Depth to groundwater: l feet method of determination or approximation: 0S ` ti (revised 11/03/95) 9 t y h ,�. .ts'r�t Commonwealth of Massachusetts CityTown of NORTH ANDOVER MASS System Pumping Record ,.,Form 4 SEP - 6 2006 DEP has provided this form for use by local Boards of Health. tm!6y#'t6rnpuh � lord mu; be submitted to the local Board of Health or other approving a } �-�H DEPAR Nt A. Facility Information Important: When filling out 1. System Location: forms on the computer, use only the tab key Address to move your cursor•do not Cit /Town •--- - -- -- - use the return y State Zip Code 2. System Owner: Address(if different from location) cityfrown State Zi C2ode - - Telephone Number - - B, Pumping Record - - -- _ �,� x. 1. Date of Pumping Date — -- 2. Quantity Pumped: 1-- ----- Gallons Type of system: ❑ Cesspool(s) tic Tank ❑ Tight Tank ❑ Other(describe): -_ _-- ---.___..__..._____—._-----.... _—•---.._._----...... _-. 4. Effluent Tee Filter present? ❑ Yes�lo If yes, was it cleaned? ❑ Yeslo r 5. Condition of System: 6. Sy em Pumped By: AVehicle License Number Company 7. Location where contents were disposed: .010 _._...__FK/ Si ature of liau f/ —_-- �__..._.-._..� w----- ---- --- Date - - http://www.mas§;gov/dep/water/ provals/t5forms,htm#inspect t5form4.doc-06/03 System Pumping Record•Page 1 of '.1; 7:f y. •r`/'tri,?ic :..Fi.i�i'r�.M1r•1tii�;l+`4w.' •.;�y'h01t)i'JJ'farl�i'•1'tt t•4 �`y1:z.:ty ..�.jfr..'r:•u�r4�t;7�1,ti•.4 fv�.x'^'✓p•f.••. `,.: ... . '„��'•'N!yMr��'' • ��}',�•'I.i,jiil:i4�1:!•1'I,�.Y'•I'�1.:.�'..�.'.. • DECEIVED TOWN u� r��x i ii r�n' [HWEALTH DEC 0 6 2005 5Y9'T'�t,•1 PIJMPiNU RPC,. N OF NORTH ANDOVERWN�� DEPARTMENT TITY PUMP�f` ,•_,�..._ ..__. .. POOL; N � Y��,• rm ON jeRvice. kv , v riNr. enitKu�.ti� u���Rv��f1UNJ. .' ► good cor.+flrriuH •.�rv�,,. ►v �����rx RZAYY RC10T3• LF", W QLD KUh FLOODED �ocroc��Ya�� omeR'r;xP�r,�N �uN i'�N�'� tJ�INyr�xKbU 1't y tii. 1 TOWN OF NORTH ANDOVER SYSTEM PUMPING RECORD LIAR - 4 �3 � 1 STEM OWNER & ADDRESS SYSTEM LOCATION �S (example; left from of house) U �'I E OF PUMPING: D QUANTITY PUMPED 0 � LLc»� C. I.)SPUUL: NO YES SEPTIC TANK: NO YES V � ATURE OF SERVICE: ROUTINE EMERGENCY ffl1->FRVATIONS COOD CONDITION. FULL TO COVEII HEAVY CREASE BAFFLLS IN PLACE ROOTS LEACHFIELD 1ZUNBACK EXCESSIVE SOLIDS FLOODED SOLIDS CARRYOVER O�HFR (EXPLAIN) >1 1'LM PUMPED BY: L U 1I M rNTS: 0N NT[,".NT `l'IZANSFEIZIZED TO: P-URD of HEAL-11-1 �aT /a b�UTA Crr - - wgT6R -SOPPL-f Q wtu, -t�-Tat)AJ APPRovCD ❑'iE5 (3mo 5tPri c 51r STE,, VGs16A3 DAr6' IZ -1 /JPMOUPJ6 /urryoi ,rry 0-� ) PIG' ;tiWL 70 R�Coc oT� Ham, ' SW���f��� �GiJGHq(�E,� . Y(�E,vGt�S ��✓ �b� gyp` X45 �I�Q PPRpVEp S TGt ti 'L/J rV ^'K)a t'JV Vl R�4SoNS = SrPT'�c SySTEr� t�SfA(.(�QT'roilJ i!FX4V/JTroI�J )tiSP�GTrOtiJ T�- Q RMS - � C F IL- D � �rNAL i�SP�TIai� •- , ,bP(�I�dvE1? Q3TE �6PPra7�rivG ��r�tor P any) s TC FVAL Ap Prat, A i * Aii r r- - = ` F 77 a - « v 23 - 1 S • J 7-7---77 -— f rl)''I,Q'�,U)�i�•�+��' ��r 1��i�`)i'?41� llt4j)r�l��lj I�I��t' iia'• Itr,` ��( (/�(� .h , ii rbc or SYS PUMr'( 1 hUOKCSS SYJTCm '© "(.J wIAgeron c1 Cir 00! r\0 ''�c Ph UKC,OF.SERYl CC;"R0UTINC ErE,RCc�C ' i_CACFi — ' - r M'PVMf'CO 0Y - ,,' f rrr: 6I (I Vl lt,:.P 1.. Il1+���,lrli - .� - 1 STEWT S SEPTIC TANK SE ICE )fid �IA�n Sf 47 RAILRQAD STREET AlA it h A BRADFORDt MA 01835 "a I Lie. I Sl-pp 978-372-7471 LnS�G 11 Lam # /a57'7� mom of Ocfd bpr- c�?�O 1" T1'IiI,Y REPW FOR 7%MN of /Uo A h OdVell- DATE ADDRESS GALIDNS ca*lENTS /O-A 65d. Ssr l a.3 rd --- C)/-Ym/,o Jc let, e l U-L ql� Oq k s ,ar WOO 76 Tucke,rRrm . ® jq 66 L166 win -k r 3f I� 1 a sb 79,0 le 5hqrptier,5 Pond tel'. 10-1 (, yL/ tc� DOAn 5co Wo oxtebu C t r L6 TOWN OF NORTH ANDOVER SYSTEM PUMPING RECORD DATE: SYSTEM OWNER & ADDRESS SYSTEM LOCATION (example: left front of house) DATE OF PUMPING: I('2Z-6/ QUANTITY PUMPED J` lXy GALLONS CESSPOOL: NO YES SEPTIC TANK: NO YES NATURE OF SERVICE: ROUTINE� EMERGENCY OBSERVATIONS: GOOD CONDITION FULL TO COVER HEAVY GREASE BAFFLES IN PLACE ROOTS LEACHFIELD RUNBACK EXCESSIVE SOLIDS FLOODED SOLIDS CARRYOVER OTHER(EXPLAIN) SYSTEM PUMPED BY: 0 �� ��✓ COMMENTS: CONTENTS TRANSFERRED TO: )Y ' r yrs. Commonwealth of Massachusetts Topsfield; M sachusetts &Jtem Pum in Record Systcm Owner Sygm Location DEC 0 7 2004 Type: Emergency 0 RoT�tine/ I _ Cesspool: No 0 Yes 0 Septic Tank: No 0 Ye Date of Pumping / J, (' Quantity PumpedjJ20_gallons System Pumped by(Company) J 1 -64J*ITJr , fOz2 c. Permit # Contents transferred to: o Contents disposed at:. Date Pumper Signature Condition of system/other comments: m 'Recon' DEC 0 HUSETTc 5 2008 Kr.' �+IYiJ• ;�r.YI,I,'Ir�l.p�:,: ,"�)':r'::, ., . _. 'D 1.1.1 i'r,i ,�I,l;.'..6.1:` }+ •1 . �' .y,..�; TOWN OF NORTH ANDOVER OEP.hei provIdod jhli loan r)r neo ,;' ' H T EPART �qT 00 -�n'I(lOd (Q.-'01 loci' cl 8oerc: ,oal,n pr clnvr , cInprlry A• Faclllty Inforrrl�clon loc�Uon: ,,Y'�I.;','y r" .��.'J:.!:1�:.<,,.,:L� �i' •' + SIM �------ r;� Owner,. �, '�,,�:y''t;• '.�,I,Y',ill,,. .I. ',� 7; Umf ";);Iµ4 (114VIIIIAI fjQM"UQf)) fq^o•,n Toe2M01 n,mpr, r •-,.;r is 1. mpng Rarord 1. Oale o! Pvmpinp ca.l �� ? n:ar:�J tet✓ 3' Type P( +y)lam;. C999�001(y) Sapl!c Tens Emvenl Tao Fllle(,P(0.3onr7 No 11 +1 .11..1; Y89. �8) I. C'9ane0� yes — "rr' b,l ridlpori'Q(:9yj, m,,.�,, •'1�1',, I +C7W � PvmP od 6 ' a I'',•J'.Ir,lSrf�'��TI1 I �..' i�•, �'� '•',I�,�',�r('d,l(1'. /0111 . In�:,1'^��'r+l/fldd� ,M1' i' '�`' 1' 1• C J Ge Jcan�l snU'were dlyposav: 222,,\'11.. •�J, 1' SII��,� ',� maSJ. 0Y/d9 pp �I r 9 dreier/e rpYa a/Iblorm�.r:�naln9�acl ..t. chu�.etts ;ti �AIVDOVERr MAS SE ' ,s.i: yr ( ORT SACfHU 58, !r' r7 .!Y!.p.ln. 'rRecord' 5� 'Y,u ,���rlf:J!r.:,.: ,:r•. .;1{ y' •'n.J1 .,r �:c DEP..has provided �hh form for use by local Boa be:ubmi ed to the.local'Board of Health or oth r ap Pumping Record m s F ac• I, n fo " ,:. �Y. tion , DECice;: :.�� .r�1 7 0 rtanG�: 7 J,;,When(>l11np out .1;. System l.ocatlon: '•;.tOri;T1i. . :i;.:. NOF ANDOV '��'••COff1DUt8li'uSe, � , • ., � ALTH DEPARTMEN only the tab key Address to move your:, �. . :=;.aus4r:-do dot; q[TownState s,1`:•�'rl• FP CTd 'tYar, i system Owner:;vr•;:r:'• •!,� •;,':'1,/•':r'�"•.i�,5 :'i",fir','•,;,Name":0•a`r' !".•.ri••f l,:, l.!r�.,':.�.v.•! dtfterent from bcatlon) . �,, ;:°�'.CkylTown,•>� .• :,;.:,�:;: .r;: State' :"� ,,''. :' :•:," i Zip Code PUm.ping .R.e.Gord; r' ,.���;:. ,,•;i' I�f�'VJt'4.C1''r�r;�.�r��ll�.;.:a9�=/�{fl!.�•LJ''•y�'.' '.'' ' Date of Pumping"'..:'' ; Date 2. Quantity Pumped; !� s r `��r Type Qf system,Y �. ❑ Cesspools) Potept)c Tank ❑ Tight Tank Y.•• ;!❑.JOther ;i'; 4rV Effl.uen•t Tee Fliter r�ssnt?..❑ YesNo If yes, was It cleaned? $fD1 No R... .'` 1�CondlOn.of,.Sy;t .. _.. _ .1:':,':`.;'�. •J1,"11.,y17u1r.'J'fivVT},1�i''Lr..ii.Yfl� !/ ... � a,^•1•••�•�•f;`C�.'�':�•L1�',/4.r 'J ff•':'.':•'+ ;+,,r�y��.7}'r',i..�`, _ �1 •'' :1�7Ir:`'';r;i,;'t`�..�u.%>i�`y:ir�f'�'il•'��;+l;�d;• ,'�:;,, , ._. •'•'•'•• �'',i.' Iii,,,, i(tl'i.1'..".i v�C�:��b�':�i t1l:Sl'ti�Ii Jt'�l,\n}•�,�'; ::': : ' •: : n.,.-..Sy P,umped By;'.•.:.; • -�.. >'`'W.I. :. .'S'r'i r ..•S; ls`r+ra �1GrP �r f,J:•>f�'�,.:,; ' ,.� ^Vehicle Ucenfe Number �p'?Y�'.,w'`T,„k`��vS',,i1((JJ11.�•��r r`3.1L:ri• .r11X �i,i�� i{' �'. {Vlu . •a•,a .'1, f Y',1 r,v� ''+1. < + I f1s`�t'>i' •7�',?: ::�::.a�, .r:�' ” iu. YAW i5 i1v.aJ}� � 3. °4P;1.�•►111i 1. ' "r Y`�!rri•. ,:;i i t ilii 1::t', i.. y� '!•• �'J+'�N'1i�.1'�.1.�)1•t•.y :� I` �Ir�1�S''. y ' �j'';1 .f.':r:JM.Y �;I 1 +:r. Jp 5'1(/.1,�� .r:L{•;;;;',�; �' f:;'•F; r.;'•,,7;.(•L'oca�on.where contents*Were '' is t:;'v:Y. :':`:.i•. ., Ia' 'il''I,. C i .11` :1., i.lid. ••. .,l•. i(ti;r�}'C�''1'� .lj;::, httpJ/www,macs,9oV/daawalermpp.rQviji)t6forms,htm#Inspect ' tSforrM.doa�08IQ3 ' ,s .. .� • � � .. 'r" " System Pumping Record Pale I _. . ' CU R�"�{ d o v ► ' r 1't,r Cd HU E T-T r�•I ' 1111 I I, IN , �/r I,'��I! I111�V, �� � 1' /.!I'; 0 , NOV. 1 0 2009 P Ir p/orldod lhl� loan ror ��o �;' lo.;or oa/c1 or „ui::� TQ ,,J oe 1vbn71(IOd to lhi l0 1 qF r , C1 BCIIC c''1 noJlln 0/ uYV, H� H0- � M'rth' n A, Faclllty lnrorm�(Ion �• UJ'�;"lY�'f`�'' 1'"�' �''1 rl��JiCrrvl ''' 'I''•'� ''.',,' $I I I I •—��_ ,,', r�,�•l, �.I�.�,S slam Own�ol;'��'-'���'• -;;� ' . . v'';,�I\, /I; ;11,,1•v�:ry�,l . I ,l(�r(I;'►vl,'11,''', tr,rrf;'I/„ .Yr"�Tr. .,,. r,/, it :��Il�i,:l,�'I •!'�1'� 1•fl�•1'',1P ,'LI,, .I•., V r.,. 1' 'i,'►(,I'llr'V'll r r r r'1 ' ' ,111/'. ' /I�,',`C �� 'NOr►+1 ( 4 1 Irinl ran bWON 1!,lynpn! n,mo!! l101p� •. '. ;el:Pumplllg,�a��ord olio t�;;'•�; rII;I, lye (o oI Pvmplnp mf .'' r 9, • rrY�l•41,� ' '', ' •' 'ec r ,• !; ),1r,.,:r,' commt $90oc Ten. ! OJC�rib9�. m4onj,rlr0`FIIII(�(r0,r jn? n Yo, rlr, 1 p 'V n' II Y97. Y,8) it C'Oan0o7 '� T� "I" I VY , J'r I�7'r,�11�14lV�YP6' Y1lk11 'JG4n SS c l ,Yr'1 YJ �i , li mss,. It r,OFd 4�r Wn 0 V�1 !��lin� rroio Ol�posoo: 1 r I .1 1.0Ar /J p a�a. orlde 1' A' 'eleApp(9YaJ�/Iblormf,r:'naln��oc1 Orrl • J Commonwealth of Massachusetts City/Town of No.Andover System Pumping Record TOWN 6R N@Rtm ANY&ER Form 4 MBALTM BUPA TMENT �M Sye 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 1. System Location forms on the L/"� computer,use / only the tab key Address to move your No.Andover Ma 01845 cursor-do not City/Town State Zip Code use the return key. 2. System Owner: VQ Lam) Name Address(if different from location) City/Town State Zip Code Telephone Number B. Pumping Record 1. Date of PumpingDate ^� 2. Quantity Pumped: Gallons �� 3. Type of system: ❑ Cesspool(s) Septic Tank ❑ Tight Tank ❑ Grease Trap ❑ Other(describe): 4. Effluent Tee Filter present? ❑ Yes ]CN�o 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 r1A Signature of z I Date Signature of R iving Facility Date Ea t5form4.doc•03/06 System Pumping Record•Page 1 of 1