HomeMy WebLinkAboutMiscellaneous - 48 SUNSET ROCK ROAD 4/30/2018 r 48 SUNSET ROCK ROAD 3d 210(106.A-0244-0000.0 Y 1 • � MAP # Lt]T PARCEL # STREET CONSTRUCTLON_APPROVA.I, �`-- HAS PLAN REVIEW FEE BEEN PAID 1 l ` ES NO 1!� PLAN APPROVAL: DATE APP. BY DESIGNER: /t/ UG PLAN CONDITIONS 1,1)firf2 ON& Mdse 5N/FTe-fD WATER SUPPLY: WELL WELL PERMIT DRILLER___—_---- _._.__....._.. ---._:___._ .........._. - WELL TESTS: CHEMICAL DAIS APPRUVED.......___.__..__._.___. BACTERIA I DATE (IPPRUVED BACTERIA II DATE APPROVED-.-^____-._- COMMENTS: FORM U APPROVAL: APPROVAL TO ISSUE YE U DATE ISSUED _BY CONDITIONS: FINAL APPROVAL: - ALL PERMITS PAID YES NO WELL CONSTRUCTION APPROVAL YES NO SEPTIC SYSTEM CONSTRUCTION APPROVAL YES NO OTHER YES NO ANY VARIANCE NEEDED YES NO BY: FINAL BOARD OF HEALTH APPROVAL: �( 4 y•.`.1�, �` �. tw '�7 1 C :�lk N Yy 4� y t 4 ,t� h rI+J. t i�t`a _ .' ,.. '.�: .1 • a`. • .� — «..} 1 .r' a � �^/ M�TU�+., ",'•• ' - - '' r .r• �T-.r��iL �LrL'RttllaL:r71��6r �Vl 11, •y;, ' +� f'.+: Y # r1�.•�'`�' t i. .rrr •.i 1 \. ,:I:' _r,.y;::>}:•'.'� �' 5 ..'i.•:..:.:.:.;;�'S'. ...':iR_yew � }.<y'w, s +j- t� S S= r. .��T r + t' IS"THE' INSTALLER LICENSED? ',y.< •* 1 , �+► S NO TYPE. OF- CONSTRUCTION: ?� " REPAIR' NEW CONSTRUCTION: , CERTIFIED PLOT. PLAN REVIEW YES NO CONDITIONS OF..APPROVAL YE NO (FROM .FORM U) ' l ••1 t '... .cid`. '; .-:,. ,. . .. a;. >� _: I • SSUANCE •OF DWC PERM ` DWC PERMIT NO. �c INSTALLER: BEGIN INSPECTION YE 0: � ' - ' EXCAVATION . INSPECTION: : NEEDED: .ED • BY ,SS '-.:'CONSTRUCTION INSPECTION: NEEDED: = AS BUILT PLAN SATISFACTORY: YE . . fi� BY APPROVAL. TO BACKFILL. ' DATE. FINAL• GRADING APPROVAL: DATE e AIZ'i A BY .FINAL CONSTRUCTION APPROVAL: DATE: �/� BY '1•�4 . 1•f`,•••••`'t` - .. 1. i �•• _ _ / ; 1 i Commonwealth of Massachusetts City/Town- of Meused, butthe System Pumping Record Foran 4 TOOVER NT DEP has provided this form for use-,by local Boards of Health. Other fo m , 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(oRigh t of house Left/Right rear of house, Left/right side of house, Left/ Right side of building, Left/Right n o uildirig, Left/Right rear of building, Under deck Address L4 F5 U V CWrown State Trp Code 2. System Owner. PL Name Address(d different from location) City/Town - Stag Zia Cod Telephone Number B. Pumping Record 1�fL�'* 1. Date of Pumping Date 2. Quantity Pumped: Gallons 3. Type of system: ❑ Cesspool(s) Septic Tank E3 Tight Tank ❑ Other(describe): 4. Effluent Tee Filter present? ❑ Yes 9-go if yes, was it cleaned? ❑ Yes ❑ No: 5. Cond' 'on of System: 6. System Pumped By: Neil Bateson F5821 Name Vehicle License Number Bateson Enterprises Inc Company 7.lsjgg kH tents were disposed: Lowell Waste Water Date t5fomA.doc•06/03 System Pumping Recent•Page 1 of 1 CERTIFIED PLOT PLAN LOCATED IN NORTH ANDOVER, MASS. SCALE:1"=40' DATE:6/5/96 'CORRECTED 6/17/96 44.78' Scott L. Giles R.P.L.S. 50.Deer Meadow Road North Andover, Mass. N� ,ted` 0 Q LOT#1 LOT#2 0-k40,664 S.F. / / rn / c to z �. LL 2 Z ! j. / M. i ! X � n ' o 0 � N v r i 39-2Z 119.22` LOT#12 Of I CERTIFY THAT OFFSETS SHOWN ARE FOR THE USE THE OFFSETS OF THE BUILDING INSPECTOR ONLY SHOWN COMPLY AND SUCH USE IS FOR,THE Af S H WITH THE ZONING DETERMINATION OF ZONING 139 BY LAWS OF CONFORMITY OR NON-CONFORMITY �" 6rsrE NORTH ANDOVER WHEN CONSTRUCTED. WHEN BUILT J COMMONWEALTH OF MASSACHUSETTS EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS A , DEPARTMENT OF ENVIRONMENTAL PROTECTION �g V� TITLE 5 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM PART A CERTIFICATIONORTPI "t�Q"J�!fJr iiC�R?'1-!/aNI3O\`73/ B(',"=nr)Or HEAL.4 Property Address: ,_48-Sunset-RockRoad_ @ _North Andover_ MAY 2 3 Owner's Name: Jesus Cabrera_ Owner's Address:_48 Sunset Rock Road- -North Andover,Ma 01845_ Date of Inspection:_5/10/2003_ _— Name of Inspector:_Neil J Bateson_ Company Name: Bateson Enterprises Inc._ Mailing Address:_111 Argilla Road_ _Andover,Ma.01810_ Telephone Number: (978)475-4786_ 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: _X Passes Conditionally Passes Needs Further Evaluation by the Local Approving Authority is Inspector's Signature: Date: _5/10/2003_ 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 on describes conditions at the time of inspection and under the conditions of use at that P only P time.This inspection does not address how the system will perform in the future under the same or different conditions of use. i Page 2 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address:_48 Sunset Rock Road_ North Andover— Owner: Cabrera Date of Inspection:_5/10/2003_ Inspection Summary: Check A,B,C,D or E/ALWAYS complete all of Section D A. System Passes: _X_ I have not found any information which indicates that any of the failure criteria described in 310 CMR 15.303 or in 310 CMR 15.304 exist.Any failure criteria not evaluated are indicated below. Comments: B. System Conditionally Passes: One or more system components as described in the"Conditional Pass"section need to be replaced or repaired.The system,upon completion of the replacement or repair,as approved by the Board of Health,will pass. Answer yes,no or not determined(Y,N,ND)in the for the following statements.If"not determined"please explain. The septic tank is metal and over 20 years old*or the septic tank(whether metal or not)is structurally unsound,exhibits substantial infiltration or exfiltration or tank failure is imminent.System will pass inspection if the existing tank is replaced with a complying septic tank as approved by the Board of Health. *A metal septic tank will pass inspection if it is structurally sound,not leaking and if a Certificate of Compliance indicating that the tank is less than 20 years old is available. ND explain: Observation of sewage backup or break out or high static water level in the distribution box due to broken or obstructed pipe(s)or due to a broken,settled or uneven distribution box. System will pass inspection if(with approval of Board of Health): broken pipe(s)are replaced obstruction is removed distribution box is leveled or replaced ND explain: The system required pumping more than 4 times a year due to broken or obstructed pipe(s).The system will pass inspection if(with approval of the Board of Health): broken pipe(s)are replaced obstruction is removed 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: 48 Sunset Rock Road_ North Andover— Owner: Ca—brera Date of Inspection:_5110/2003_ 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. System will pass unless Board of Health determines in accordance with 310 CMR 15.303(1)(b)that the system is not functioning in a manner which will protect public health,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 any)determines 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 supply. _ The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water supply. The system has a septic tank and SAS and the SAS is within 50 feet of a private water supply well. The system has a septic tank and SAS and the SAS is 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 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. 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: 48 Sunset Rock Road_ _North Andover— Owner: Cabrera Date of Inspection: 5/10/2003_ D. System Failure Criteria applicable to all systems: You must indicate`yes"or"no"to each of the following for all inspections: Yes No _No_ Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool _No_ Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool _No_ Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool No Liquid depth in cesspool is less than 6"below invert or available volume is less than''/z day flow _No_ Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number of times pumped _No_ Any portion of the SAS,cesspool or privy is below high ground water elevation. _No_ Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. _No_ Any portion of a cesspool or privy is within a Zone 1 of a public well. _No_ Any portion of a cesspool or privy is within 50 feet of a private water supply well. _No_ Any portion of a cesspool or privy is less than 100 fat but greater than 50 feet from a private water supply well with no acceptable water quality analysis. [This system passes if the well water analysis, performed at a DEP certified laboratory,for coliform bacteria and volatile organic compounds indicates that the well is free from pollution from that facility and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm,provided that no other failure criteria are triggered.A copy of the analysis must be attached to this form.] No (Yes/No)The system fails.I have determined that one or more of the above failure criteria exist as described in 310 CMR 15.303,therefore the system fails.The system owner should contact the Board of Health to determine what will be necessary to correct the failure. E. Large Systems: To be considered a large system the system must serve a facility with a design flow of 10,000 gpd to 15,000 gpd• You must indicate either"yes"or`no"to each of the following: (The following criteria apply to large systems in addition to the criteria above) yes no 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 lI of a public water supply well If you have answered"yes"to any question in Section E the system is considered a significant threat,or answered "yes"in Section D above the large system has failed.The owner or operator of any large system considered a significant threat under Section E or failed under Section D shall upgrade the system in accordance with 310 CMR 15.304.The system owner should contact the appropriate regional office of the Department. Page 5 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST Property Address: 48 Sunset Rock Road_ _North Andover_ Owner: Cabrera Date of Inspection:_5/10/2003_ Check if the following have been done You must indicate"yes"or"no"as to each of the following: Yes No Yes _ Pumping information was provided by the owner,occupant,or Board of Health No_ Were any of the system components pumped out in the previous two weeks? Yes Has the system received normal flows in the previous two week period? No_ Have large volumes of water been introduced to the system recently or as part of this inspection? Yes Were as built plans of the system obtained and examined?(If they were not available note as N/A) Yes Was the facility or dwelling inspected for signs of sewage back up? Yes Was the site inspected for signs of break out? Yes Were all system components,excluding the SAS,located on site? _Yes_ _ Were the septic tank manholes uncovered,opened,and the interior of the tank inspected for the condition of the bales or tees,material of construction,dimensions,depth of liquid,depth of sludge and depth of scum? _Yes_ _ 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 Yes Existing information.For example,a plan at the Board of Health. _No_ 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 I 1 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION Property Address:_48 Sunset Rock Road_ _North Andover– Owner: Cabrera Date of Inspection:_5/10/2003_ FLOW CONDITIONS RESIDENTIAL Number of bedrooms(design):_4_ Number of bedrooms(actual):—4— DESIGN flow based on 310 CMR 15.203(for example: 110 gpd x#of bedrooms):_660 Number of current residents:—5— Does residence have a garbage grinder(yes or no):_No_ Is laundry on a separate sewage system(yes or no):_No_ [if yes separate inspection required] Laundry system inspected(yes or no): Seasonal use: (yes or no):_No Water meter readings: Yes_ Sump pump(yes or no):_No Last date of occupancy:_Current COMMERCIAL/INDUSTRIAL Type of establishment: Design flow(based on 310 CMR 15.203): gpd Basis of design flow(seats/persons/sgft,etc.): Grease trap present(yes or no):_ Industrial waste holding tank present(yes or no):— Non-sanitary waste discharged to the Title 5 system(yes or no): Water meter readings,if available: Last date of occupancy/use: OTHER(describe): GENERAL INFORMATION Pumping Records Source of information:_Pumped two years ago,owner_ Was system pumped as part of the inspection(yes or no):_Yes_ If yes,volume pumped:_1500_gallons--How was quantity pumped determined? Measured tank_ Reason for pumping:_Inspect tank_ TYPE OF SYSTEM X Septic tank,distribution box,soil absorption system _Single cesspool _Overflow cesspool Privy _Shared system(yes or no)(if yes,attach previous inspection records,if any) _Innovative/Alternative technology.Attach a copy of the current operation and maintenance contract(to be obtained from system owner) Tight tank _Attach a copy of the DEP approval Other(describe): Approximate age of all components,date installed(if known)and source of information:_7 years old.6/24/1996. As built plan Were sewage odors detected when arriving at the site(yes or no):_No_ Page 7 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 48 Sunset Rock Road- -North oad__North Andover— Owner: Cabrera Date of Inspection:_5/10/2003 WELDING SEWER(locate on site plan)X Depth below grade: 9' Materials of construction:_cast iron _X_40 PVC_other(explain): Distance from private water supply well or suction line: Comments(on condition of joints,venting,evidence of leakage,etc.):_4"PVC thru floor.3"PVC in house,no leaks visible SEPTIC TANK: X locate on site plan) Depth below grade:_8'_ Material of construction:—X—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: 10'x 5'x 4'_ Sludge depth6"_ Distance from top of sludge to bottom of outlet tee or baffle: 21"_ Scum thickness:_8"_ Distance from top of scum to top of outlet tee or baffle:_8"_ Distance from bottom of scum to bottom of outlet tee or baffle:_13"_ How were dimensions determined: Subtract scum&sludge depth to tee length._ Comments(on pumping recommendations,inlet and outlet tee or baffle condition,structural integrity,liquid levels as related to outlet invert,evidence of leakage,etc.):_Pumped septic tank Inlet tee ok Outlet tee ok.Depth of liquid at outlet invert.No evidence of leakage._ GREASE TRAP: (locate on site plan) Depth below grade:_ Material of construction:_concrete_metal_fiberglass_polyethylene_other (explain): Dimensions: Scum thickness: Distance from top of scum to top of outlet tee or baffle: Distance from bottom of scum to bottom of outlet tee or baffle: Date of last pumping: Comments(on pumping recommendations,inlet and outlet tee or baffle condition,structural integrity,liquid levels as related to outlet invert,evidence of leakage,etc.): Page 8 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 48 Sunset Rock Road_ _North Andover_ Owner: Cabrera Date of Inspection:_5/10/2003_ TIGHT or HOLDING TANK: (tank must be pumped at time of inspection)(locate on site plan) Depth below grade: Material of construction: concrete metal fiberglass_polyethylene other(explain): Dimensions: Capacity: gallons Design plow: 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: X (if present must be opened)(locate on site plan) Depth of liquid level above outlet invert:_0 Comments(note if box is level and distribution to outlets equal,any evidence of solids carryover,any evidence of leakage into or out of box,etc.):_D-box level.Distribution equal.No evidence of leakage.Evidence of carryover,pumped d-box clean._ PUMP CHAMBER: (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: 48 Sunset Rock Road_ _North Andover_ Owner: Cabrera-- Date abrera_Date of Inspection: 5/10/2003_ SOIL ABSORPTION SYSTEM(SAS): X (locate on site plan,excavation not required) If SAS not located explain why: Type leaching pits,number:_ leaching chambers,number: leaching galleries,number: X leaching trenches,number,length: 2 trenches 56'long— 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.):_Soil ok.Vegetation ok.No sign of ponding to surface. 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 or no): Comments(note condition of soil,signs of hydraulic failure,level of ponding,condition of vegetation,etc.): PRIVY: (locate on site plan) Materials of construction: Dimensions: Depth of solids: ►. Comments(note condition of soil,signs of hydraulic failure,level of ponding,condition of vegetation,etc.): Page 10 of 11 OFFICIAL INSPECTION FORM NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 48 Sunset Rock Road_ _North Andover_ Owner: Cabrera Date of Inspection:_5/10/2003_ 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. House Driveway A Septic Tank 56' D- Box A to Tank=19' A to D-Box=31'6" B to Tank=43' B to D-Box=41' Page 11 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 48 Sunset Rock Road- -North oad__North Andover— Owner: Cabrera Date of Inspection:_5/10/2003_ SITE EXAM Slope Surface water Check cellar Shallow wells Estimated depth to ground water 4 feet Please indicate(check)all methods used to determine the high ground water elevation: X Obtained from system design plans on record-If checked,date of design plan reviewed:_12/6/1994_ 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:_As per design plan_ .;'' •.;•. .;.: •_ ,^ , _ . t•: !:;- �Y' .yi'r�..;:.:X�sa;,;�-'�3yt`'�i';L' . '•. -.- s:��,�,-� ;1;rrj. _ WATER BILLING HIST•�ORY `3170}3'4- 5-CABRE`-R- A�, JESUS ESUS �rA. .,::�� ��'"_�.•__ _����r -;�_-s:i�� �;:,-�.f>i•.:�•s� _,�� fa _,. METER 111: 3170345 ------------- 48 SUNSET ROCK RD --..-�.- .. .. {/��A yy■r.�n._ St' Fit,)-i` .$.i 11 CYCLE SERVICE PRIOR CURRENT USE WATER SEWER FEES TOTAL • 1 2000-13 10/01/1999 437 669 232 633.36 0_00 0.00 633.3 2 2060-23 01/14f2000 669 712 43 117.39 9-.00 0.00 .- 13 2000-33 03/31/2000 712 . 732 20 154^6,0 0.00 0.00• 54.6d. `4 2000-43 06/21/2000 732 766 54 147.42 0_00 0.00 147.42 5 2001-13 09/20/2000 786 874 88 240.24 0.00 11.00 251.24 6 2001-23 01/03/2001 874 898 24 65.52 0.00 11.00 76.52 6 7 2001-33 04/04/2001 898 925 27 73.71 0.00 11_00 84.71 a 8 2001-43 06/21/2001 925 982 57 155.61 0.09 11.00 166-61 r 9 2002-13 09/24/2001 982 1095 113 404.39 0.005.55 409. �`� - %)''' 10 2002-23 02/06/2002 1695 1144 49 135.59 0.00 5-55 141AUMlim .1 r ' d o�tt Y 1 2002-33 04/09/2802 1144 1169 25 67.35 0.00'. 5.55 72.90 12 2002-43 06/11/2002 1169 1199 30 85:30 0_00 S.55 90.85 X13 2002-CRD 09/25/2001 1095 1095 0 -8.80 0.00 10.00 -8.00 x 14 2003-13 09/17/2002 1199 1265 66 215_30 0.00 5.97 221.2T= :� a X15 2003-23 12/16/2002 126S 1294 29 81.80 0-00 5.97 87,77: " :'k cg 16 2003-33 03/13/2003 1294 1317 23 59.00 0.00 5.97 64_9 T0 /f�T- f r 1 REUIEW CHOICE 11 or <EETER> MORE HISTORY: z m• }Cd W?��:;, ]�:easrEf�IjiDel� z :��. . t `r-,-�,,,- •tt�:'�,b�. ;C ---- - tl,.i, - ,; ii�:<�' ,,a-:'tom-*, -, •:�: i= s:_ -:r- _ -.r�!� 'Qt� �lt.._...,�� � �C�ttBt:sl Y •.�=' ;ss' -_ y�.'nr •;r.:a.•;'•.c•-:.:L SS,�'...: }}:� - I _}_ :y"•- :._;�,_ - _ _ :iS=t�.: .;, _- -:,`.,i,4--=''ate"+ "�r'' i:.l. ,y-^; - - •YY•' .fi'IxT�. :... iti,'t !x-::-.':.a(ay - -t, .tisT•. - •s--�„� _i:'• , -.i .tri:. _ - - .:-e• - - - r-1 '•r: u3`•''--'..i',fi; g�r :s`si•if' _ .s.- rL:�z;: .ti-: �- ;.{� :•.; ���,.. :S. , �•� }� ;:t `r..'y�^`,,..,�.�t r- ; P '.}.a � <::':y-: r=;�,tY'�•::f.�:,'e° _{.:t-;!' "'::��% .:.'s.-."3: _ '•.3 _ ,,tri":. y.,,.,( �.t�, �.-,r»;t a - 'S2� ... :ray 1,. S:Y._�..4.:�::•�'` (s 3:'S•�i'�+�.,'-i•.; Tj:l... -.i L:�:__ - _ ' -s�. ';(.�'��:i' btd;r'. •-Y.,�,i;.-�•.: �,1'�`_i<is f !. _ .3 '_�K!!-i•r i f_ �-••- i%.t` -y=• '1i;�'�3','=,'?Y`.•'"y E�I-i .£•".,t�"'!. (, - -iA. � 1t:i<�: _ t;'' ,• t zs�:�:-"•:e-n-y3a ea'-:r`; ;�,.�y :xna ..tr,( �"^"!=':'• tk':. ,?L.T3rsKnr_..J:��Ii4 a�.:is '�L.-•"�'[3-'�a: err=:tom.�;.2:::. '^..!��'� E•i� O , m I(7 - O Tel: (978)475-4786 Fax: (978) 475-5451 BATESON ENTERPRISES, INC. Excavating-Water.& Sewer Lines-Septic Systems&Pumping Service 111 Argilla Road Andover, Mass. 01810 Title 5 Inspection Report Property Address: 48 Sunset Rock Road, North Andover Owner: Cabrera Date of Inspection: 5/10/2003 My report contained herein does not constitute a guarantee of future usage and the functionality of the existing septic system Such report issued herewith is merely based upon my observations, and I hereby disclaim any further operation of your current septic system. Neil J. Bateson Bateson Enterprises, Inc. AS-BUILT SEPTIC SYSTEM LOCATED IN NORTH ANDOVER, MASS. SCALE:1"= 40' DATE:6/24/96 Scott L. Giles R.P.L.S. 44.78' 50 Deer Meadow Road North Andover, Mass. TOWN OF NORTH ANDOVER/ BOARD OF HEALTH &W 2 51996 _j LOT#2 40,664 S.F. LOT#9 TABLE OF ELEVATIONS INV. OUT HSE.=155.00 INV. 1N TANK =154.38 11 OUT TANK=154.14 / IN D.BOX=154.07 / 113p� OUT D. BOX=153.89 @ 2 PIPES / " END TRENCH=153.42 @#1 / p =153.42@#2 / .00. a SEPTIC TANK 0 13-13 3 / / v r w\ O.W.=162.9 /JQ r^ / EXISTING / Cb Z FOUNDATION 0 p VENTED 01 1 /` I I 0 39.22' 119.22' � l \ LOT#12 tw Or 3 H I CERTIFY THAT OFFSETS SHOWN ARE FOR THE USE THE OFFSETS OF THE BUILDING INSPECTOR ONLY SHOWN COMPLY AND SUCH USE IS FOR THE WITH THE ZONING DETERMINATION OF ZONING BY LAWS OF CERTIFIED PLOT PLAN LOCATED IN NORTH ANDOVER, MASS. SCALE:1"=40' DAT E.6/5/96 CORRECTED 6/17/96 44.78' Scott L. Giles R.P.L.S. 50 Deer Meadow Road North Andover, Mass. N� ^d` O LOT#1 / LOT#2 / 40,664 S.F. / k / / OO / (0z II C _ uj = h�/ Z 41 / ml w 0 / I p lfsX/ 0 / N_ v ( r 39.22' 119.22' LOT#12 t1 or a ol I CERTIFY THAT OFFSETS SHOWN ARE FOR THE USE THE OFFSETS OF THE BUILDING INSPECTOR ONLY SHOWN COMPLY AND SUCH USE IS FOR-THE H WITH THE ZONING DETERMINATION OF ZONING 13972BY LAWS OF {� NORTH ANDOVER CONFORMITY OR NON-CONFORMITY rS1EnE9 WHEN CONSTRUCTED. WHEN BUILT Commonwealth of Massachusetts iE��I1/E City/Town of JUL 16 2009 System Pumping Record FormTOWN OF NORTH ANDOVER _5 By`O 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 Locatio eft ro , left rear, left si of o s . 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: ISI Name Address(if different from location) City/Town StaCode t o--?(-? 5�3"_7 Telephone Number B. Pumping Record 1. Date of Pumping Date 2. Quantity Pumped: Gallons 3. Type of system: rl Cesspool(s) Septic Tank El Tight Tank 0 Other(describe): I 4. Effluent Tee Filterresent? p El Yes _ o If yes,was it cleaned? Q Yes No 5. Condition of System- y 6. System Pumped By: Neil Bateson F 5821 Name Vehicle License Number Bateson Enterprises Inc Company 7. Location where contents were disposed: L.S.D Lowell Waste Water tignalluke of H u r Date t5form4.doc•06/03 System Pumping Record•Page 1 of 1_ Commonwealth of Massachusetts RECEIVE City/Town of System Pumping Record JUL 15 2008 Form 41NN OF NORTH ANDOVER t-iEALTH 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 LocatiQn �; forms on the 1� computer,use 1 only the tab key Address q � SLA�to move your cursor-do not Cityfrown State Zip Code use the return key 2 System Owner: vI� � Name Address(if different from location) Cityrrown State Zip Code 3 /C7 Telephone Number B. Pumping Record 1. Date of Pumping Date 2. Quantity Pumped: Gallons 3. Type of system: ❑ Cesspool(s) peptic Tank ❑ Tight Tank ❑ Other(describe): 4. Effluent Tee Filter present? ❑ Yes ET-14o— If yes,was it cleaned? ❑ Yes ❑ No 5. Condit'on of System: 6. Syst m Pumped By: Name Vehicle License Number Company 7. Location erecontents sposed: Sign r auler Date t5form4.doc•06103 System Pumping Record•Page 1 of 1 Commonwealth of MassachusettsFforms City/Town of System Pumping Record Form 4 TOW�DEP has provided this form for use by local Boards of Hsed, 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. SysteFn LOcatiO forms on the computer,use only the tab key Address �e to move your L� cursor-do not Cityfrown State Zip Code use the return key. 2. System Owner: VQ Name DX 0 Address(if different from location) City/Town State ^Zip Code Telep one Number B. Pumping Record r3 --01? 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 0'60If yes,was it cleaned? ❑ Yes ❑ No 5. Condition of System: 6. SysteP p�By: ` " ( NameVehicle License Number Company 7. Location contents n.d,ied: Signature Date t5form4.doc•06/03 System Pumping Record•Page 1 of 1 Commonwealth.of Massachusetts RECE E City/Town of I 200.6 System Pumping Record JUN 2 8 y *•,• Form 4 TOWN OF NORTH ANDOVER HEALTH DEPARTMENT 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 fining out I. System Location: forms on the Uv'v computer,use only the tab key Address to move your /1l cursor-do not use the;retum City/Town State Zip Code .key. 2._ System Owner: Name 1ml Address(d different from-location) City/Town State Zi Code' Telephone Number B. Pai�mping Record c:)G C 1. Date.of Pumping Date 2. Quantity Pumped: Gallons 3. Type of system: ❑ Cesspool(s) S-81ptic Tank- ❑ Tight Tank ❑ Other(describe): 4. Effluent Tee Filter present? ❑ Yes Vo If yes, was it cleaned? ❑ Yes ❑ No 5. Condition of System: n Q A 6. Syste Pu. p y;- Name Vehicle License Number Company . 7. Loca"o where contents a disp S" natu of auler Date http://www.mass.go. dep ater/approvals/t5forms.htmAnspect t5form4.doc•06103 Systern Pumping Record•Page 1 of 1 TOWN OF M - SYSTEM PUM#PING RECO RDY�of�oGrA,"LTA_ _ 180 . - DATE: SYSTEM OWNER& ADDRESS SYSTEM LOCATION (example: left front of house) qj SU4�cj— 4ct DATE OF PUMPING: ` 0 QUANTITY PUMPED : -50-6 GALLONS CESSPOOL: NO YES EPTIC TANK: NO YES NATURE OF SERVICE: ROUTINE EMERGENCY OBSERVATIONS: GOOD CONDITION FULL TO COVER HEAVY GREASE BAFFLES IN PLACE ROOTS LEACHFIELD RUNBACK EXCESSIVE SOLIDS FLOODED SOLIDS CARRYOVER OTHER(EXPLAIN) SYSTEM PUMPED BY: Bateson Enterprises, Inc. COMMENTS: coNTENrs TRANsFERRED To: G.L.S.D Lowell Waste TOWN OF SYSTEM PUMPING RECORD 7o ° :`10 -,J' DATE: SYSTEM OWNER& ADDRESS SYSTEM LOCATION Cc (example:left front of house) DATE OF PUMPING: yl 3 QUANTITY PUMPED: � GALLONS CESSPOOL: NO YES SEPTIC TANK: NO YES NATURE OF SERVICE: ROUTINE EMERGENCY OBSERVATIONS: GOOD CONDITION FULL TO COVER HEAVY GREASE BAFFLES IN PLACE ROOTS LEACHFIELD RUNBACK EXCESSIVE SOLIDS FLOODED SOLIDS CARRYOVER OTHER(EXPLAIN) SYSTEM PUMPED BY: Bateson Enterprises, Inc. COMMENTS: CONTENTS TRANSFERRED TO: ` TOWN OF NORTH ANDOVER SYSTEM PUMPING RECORD DATE: (0 SYSTEM OWNER &ADDRESS SYSTEM LOCATION 1 Q (example: left front of house) (4 a L�[itI � ��-.-� c G� DATE OF PUMPING!U r�"� QUANTITY PUMPED I-5"' —""'GALLONS CESSPOOL: NO I- 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: COMMENTS: �F 't' ' w �l CONTENTS TRANSFERRED TO: �' 1211 111111!_ �Y1rn1111I1�It1ARgpcllUt►ellll Delo 1111111111110: of Nit Y'en ( � 8ep110 .1 0a,k: Nu ( .� ea YIIOIp 111111111foil by -- �'It111�11is I1n11a1�111F11 lu : � ---- s DATE /' z 9 Sheet of BOARD OF HEALTH TOWN OF NORTH ANDOVER SUBSURFACE DISPOSAL DESIGN REVIEW FEE PERMIT / a- / Q DATE RECEIVED/jj Z 1� �� �O C�_..—_---. APPLICANT • A/UUS ASSESSOR' S MAP ADDRESS PARCEL rr LOT _ STREET ENGINEER ADDRESS -� f PLAN DATE �C� /9 REVISION DATE CONDITIONS OF APPROVAL: APPROVED DISAPPROVED 7W6- V 7-;"1/aT 711.6� R G/-/r 5 b E a/J ��;�,�� s / D o Tff� r ,4ORTN O `.�.° �,�° BOARD OF HEALTH � � OL � p a _ s 120 MAIN STREET TEL. 682-6483 SAC U5 NORTH ANDOVER, MASS. 01845 Ext23 January 30, 1995 Mr. Thomas Neve 447 Boston Road Topsfield, MA 01983 Re: Lots #1, #2 & #12 Sunset Rock Road Dear Tom: I have reviewed and approved lots #1 and # 12 Sunset Rock Road. Lot #2 can also be approved if the water line is shifted to the south side of the lot. If you have any questions, please do not hesitate to call me. Thank you. Sincerely, Sandra Starr, R.S. Health Administrator SS/cjp TOWN OF NORTH ANDOVER/ BOARD OF HEALTH CERTIFIED PLOT PLAN IM "7 M3 LOCATED IN NORTH ANDOVER, MASS. SCALE:1"=40' DATE:6/5/96 44.78, Scott L. Giles R.P.L.S. 50 Deer Meadow Road North Andover, Mass. N� mob. �s 0 LOT#1 LOT#2 40,664 S.F. / t °to if. uj / to I x / m1 I W o r 39.22' 119.22' LOT#12 orI CERTIFY THAT THE OFFSETS OFFSETS SHOWN ARE FOR THE USE �o OF THE BUILDING INSPECTOR ONLY SHOWN COMPLY AND SUCH USE IS FOR THE WITH THE ZONING DETERMINATION � N • `� BY LAWS OF ZONING CONFORMITY OR NON-CONFORMITY G�STER� NORTH ANDOVER WHEN BUILT WHEN CONSTRUCTED. L LpNaS r NORTH F Town of over No. 03 'F rt . dover, 1lilass. S 19 O K ) f CocHICHEWICK A()RATED )'9'9�,��� F- S BOARD OF HEALTH Food/Kitchen PERMIT T D Septic System BUILDING INSPECTOR THIS CERTIFIES THAT ........................C.0'0.. .. .. ................b.e..U..�...........CO..R. ,................................. Foundation has permission to erect.......---7-.................... buildings on ........e.3..........S 44. Rough -... to be occupied as........................................... l.l.U.�'4.'.e.............�./. .....1... .zs��'i ......1-apileinchimney provided that the person accepting this permit shall in every respect conform to the ternthe'application on file in Final this office, and to the provisions of the Codes and By-Laws relating to the Inspection, Apgftg i n of Buildings in the Town of North Andover. ��0 6 `ION ONLY PLUMBING INSPECT )R ON BY PARA. 114.8.S. B.C. VIOLATION of the Zoning or Building Regulations Voids this Permit. <- ��� ,2 PERMIT EXPIRES IN 6 MONT7 S Final �"96 SEE PAID - UNLESS CONSTRUCTION ST TS ELECTRICAL INSPECTOR Rough OC 7-16 y... ..... .... ...... Service DING INSPECTOR Final Occupancy Permit Required to Occupy Building GAS INSPECTOR Rough Display in a Conspicuous Place on the Premises -- Do Not Remove Final No Lathing or Dry Wall To Be Done FIRE DEPARTMENT Until Inspected and Approved by the Building Inspector. Burner Street No. Smoke Det. i Town of North Andov Form No,q er, Massachusetts g BOARD OF HEALTH -Aucrust 14 19 CERTIFICATE OF COMPLIANCE the Individual Soil Absor ti This is to certify that p on Sewage Disposal System constructed by Dave Maynard ) or repaired ( ) INSTALLER r at Lot #2 Sunset Rock�Ro �d(L#48)has been installed in accordance oHeSITE loN Health Regulations asd Approval Site System Permit No. 698 described in the Design dated December 13 19 94 The issuance this of -_. certificate shall not function satisfactorily. be construed as a guarantee that at the system well uL�C� BOARD OF HEALTH ;t .. . .... :. Town of North Andover, Massachusetts Form No.3 BOARD OF HEALTH 14ORTM O A �. -•,,,o,•� DISPOSAL WORKS CONSTRUCTION PERMIT + 'Ss^cNuse� :� Applicant NAME ADDRESS TELEPHONE Site Location r Permission is hereby granted to Construct (�r -F�pair ( ) an individual Soil Absorption Sewage Disposal System as shown on the Design Approval S.S. No. _ —• r CHAIRMAN, BOARD OF HEALTH /"0 Fee D.W.C. No. 3 I FORM U - IAT RELEASE FORM 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: Phonen��. , LOCATION: Assessor's Map Number G Parcel Subdivision /G,�/- eLce-Cc Lots) Street St. Number C Use Only************************ RECOMMENDATIONS OF TOWN AGENTS: Conservation Administrator Date Approved Date Rejected Comments Town Planner Date Approved Date Rejected Comments Food Inspector-Health Date Approved Date Rejected Septic Inspector-Health Date Approved Date Rejected Comments Public Works - sewer/water connections - drivewayP ermit Fire Department Received by Building Inspector Date THOVASST ENC. February 6, 1995 Sandra Starr, R.S. Board of Health 120 Main Street North Andover, MA 01845 Re: Lots 2,11,13,15,16 & 18 Sunset Rock Road Dear Sandy: Please find enclosed 3 prints each of the revised septic designs for the above mentioned Lots, except Lot 13. No revisions were required for the septic design on Lot 13 per our conversation on Friday, February 3. Also,please find enclosed a detail of the leaching catch basins at the end of the cul-de-sac on Sunset Rock Road. Please note that these are leaching basins, septics only need to be 25' away from these structures. Following is a summary of the revisions made to each design: Lot 2: The water line has been relocated to the south side of the lot. Lot 11: A note has been added to the system profile that all pipe to be 4" PVC (sch. 40). Also a note has been added to the plan stating that a bench- mark is to be set within 50' of the system prior to construction. Lot 15: The finish grading has been revised along the lot line between Lots 15 & 16 to accommodate the redesign of Lot 16. Lot 16: The system has been redesigned such that the bottom of the system is at elevation 15 5.0, 4' above the change in soil that occurs at elevation 151.0. • ENGINEERS• • LAND SURVEYORS • • LAND USE PLANNERS • 447 Old Boston Road U.S. Route #1 Topsfield, MA 01983 (508) 887-8586 FAX (508) 887-3480 t Page Two Sandra Starr Lot 18: Per our discussion on Friday February 3,perc A has been removed from the plan. We also discussed the problems of considering the fill require- ment as part of the system,no changes have been made to the location of the system or the fill requirement. Thank you for your time and effort spent reviewing these issues with me. If you should have any further questions or concerns please do not hesitate to call me. Sincerely, Thomas E.Neve Associates, Inc. 9' vt � 't John Morin, E.I.T. Civil Engineering Consultant JM/cp Enc. R�N► � 149.4 ± . Cironi fe !iurb -5 ton dord C.B. Fr _E_Cover o� verses Qs _z Povin�5 6 ��Lo4m I... Qa 1= c*=3 n a jw M c-3 a n a e /'f- Golvc�ni3ccl Slee/ , Frccvst COnrrete Sccurt yScrcenrn ;o• a a n rl a fQs teased S CC -e y ;� n a t� a n u q Ground L.eoch Pi t �� b cx Q a att �� ' 31.4-°- Crushed -D Tr . �eoching Ca � tch X30 sln �� at� �a�� Lo«►-*Efl Cot-. Oe- SAC. on S unsET Rot,,1t ROAa PLAN REVIEW CHECKLIST ADDRESS ,�� a0l)569--7CZ�R ENGINEER GENERAL 3 COPIESt� STAMP &---""LOCUS NORTH ARROW SCALE / -( IS / CONTOURS 1� PROFILE tSECTION �� BENCHMARK, tj It,. & PERC INFO ELEVATIONS WETS. DISCLAIMER WELLS & WETLANDS ✓ WATERSHED?,d DRIVEWAYElev) WATER LINE FDN DRAIN ✓ SCH40 C---- TESTS CURRENT? SEPTIC TANK `/ MIN 1500G Z� . 17 INVERT DROP L---' GARB. GRINDER(+200% EDF) 25 ' TO CELLAR t✓ MANHOLE TO GRADE ✓ ELEV f GW D-BOX SIZE # LINES FIRST 2 ' LEVEL STATEMENT INLET / - OUTLET/53.8, (2" OR . 17 FT) TEE REQ'D? /I/ LEACHING MIN 660 GPD? RESERVE AREA L-"�"4 ' FROM PRIMARY? 2% SLOPE '�� 100 ' TO WETLANDS L--'1001 TO WELLS 1--"" 4 ' TO S.H.GW 35 ' TO FND & INTRCPTR DRAINS 11----- 3251 TO SURFACE H2O SUPP 4 ' PERM. SOIL BELOW FACILITY �l MIN 12" COVER C11", FILL?--' (25 ' if above natural elev• 10 ' if elow) BREAKOUT MET? TRENCHES MIN 660 gpd c/ SLOPE (min . 005 or 6"/1001 ) --"� >31COVER?-VENT SIDEWALL DIST. 2X EFF. W OR D (MIN 61 ) t✓ IS RESERVE BETWEEN TRENCHES? IN FILL? ' MUST BE 10 ' MIN. L,"" ' 4" PEA STONE? BOT X LDNG �d� + SIDE X LDNG `� TOT (L x W x #) (G/ft2) (DxLx2x#) (G/ft2) Copyright© 1993 by S.L.Starr Commonwealth of Massachusetts �E� City/Town of System Pumping Record tvC`V 6 2010 Form 4 TOWN A Apo MEALT DEP nTM VER DEP has provided this form for use by local Boards of Health. Other forms ma 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 Locati : Left ront of ight front of house, left side of house, right side of house, Left rear of house, righ rear of house, left side of building, right rear of building, under deck. (�a NO Cityrrown State Zip Code 2. System Owner: Name Address(if different from location) City/Town Stat 2 E Zip Code Telephone Number B. Pumping Record 1. Date of Pumping Date 2. Quantity Pumped: Gallons 3. Type of system: ❑ Cesspool(s) Septic Tank ❑ Tight Tank ❑ Other(describe): 4. Effluent Tee Filter present? ❑ Yes No If yes, was it cleaned? ❑ Yes ❑ No 5. Condition �f Sys '/� 6. System Pumped By: Neil J. Bateson F5821 Name Vehicle License Number Bateson Enterprises Inc. Company 7. Lo ere contents were disposed: G.L.S. owell VyasteANater - -�v Signatu e 0 rler Date t5form4.doc•06/03 System Pumping Record•Page 1 of 1 �L\ Commonwealth of Massachusetts MUCity/Town of E�VED System Pumping Record 'r'�11 Form 4 �t ,- WN OF NORTH ANDOVER DEP has provided this form for use by local Boards of Health. t *A0gt , but the information must be substantially the same as that provided h e ore 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 Locatiorr�Righ ont of house Left/Right rear of house, Left/right side of house, Left/ Right side of building, Left/Right front of building, Left/Right rear of building, Under deck Address t�"� 'yn —L City/Town State Zip Code 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: ❑ Cesspool(s) eptic Tank ❑ Tight Tank ❑ Other(describe): 4. Effluent Tee Filter present? ❑ Yes D-19 If yes,was it cleaned? ❑ Yes ❑ No 5. Condit! n pf System: \ �OUfLA, 6. System Pumped By: Neil Bateson F5821 Name Vehicle License Number Bateson Enterprises Inc Company 7. Location wh a contents were disposed: G.L,S. Lowell Waste Water Sign toe I Hauler(,/ Date t5form4.doc•06/03 System Pumping Record•Page 1 of 1 �L\ Commonwealth of Massachusetts ' RECEIVED City/Town of �12 20 System Pumping Record NOV Form 4 TOWN OF NORTH ANDOVER HEALTH DEPARTMENT DEP has provided this form for use by local Boards of Health. Other forms,may be used, but the information must be substantially the same as that provided here. Before using this form, check with your local Board of Health 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 Le /Right nt of house Left/Right rear of house, Left/right side of house, Left/ Right side of buil g, Left/Right front of building, Left/Right rear of building, Under deck Address II 495V'A� City/rown State Zip Code 2. System Owner. Name Address(if different from location) City/Town State � ? r (ip Code Telephone Number 1 B. Plumping Record 1. Date of Pumping Date �QuPumped: 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 n System: 6. System Pumped By: Neil Bateson F5821 Name .Vehicle License Number Bateson Enterprises Inc Company 7. Locati a contents were disposed: -LAPLowell Waste Water t'( Sig Haule Date t5form4.doc•06/03 System Pumping Record•Page 1 of 1