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Home My WebLink AboutMiscellaneous - 50 CHRISTIAN WAY 4/30/2018 50 CHRISTIAN WAY _ 210/104.D-0139-0000.0 Commonwealth of.Massachusetts City/Town of No Andover ."y 4 Z)13 System Pumping Record Form 4 wN 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, 5b (�y-�i S�a use only the tab V n key to move your Address cursor-do not No andover Ma . use the return City/Town State Zip Code key. 2. System Owner: l a n�-cr �I Name - ienm Address(if different from location) City/Town r. State Zip Code Telephone.Number B. Pumping Record 1. Date of Pumping Date 2• Quantity Pumped: Gallons 3. Type of system: ElCesspool(s) 2/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. System Pumped By: ami a Vehicle License Number Stewart's Septic Service Company 7. Location where contents were disposed: Stewart's Pre-treatment Plant, 20 So. Mill Bradford, Ma Q1835 u Date i ature of Receiving acility Date t5form4.doc•03/06 System Pumping Record•Page 1 of 1 Commonwealth of Massachusetts City/Town of NORTH ANDOVER, MASSACHUSET System Pumping Record , Form 4 DEP has provided this form for use by local Boards of Health. The System Pumping Record must be submitted to the local Board of Health or other approving authority. A. Facility Information Important: When filling out 1. System Location: forms the 1> computer, use only the tab key Address to move your cursor-do not CitylTo n ' use the return State Zip Code key. 2. System Owner: Name L Address(if di _ tion _ City/Town S Zip Code MAY 11 2006 �,F" 77�75 Baa Telephone Number TOWN OF NORTH ANDOVER E4. HEALTH DEPARTMENT umping Recordte of Pum In /`" Cp gDate Quantity Pumped: Ga ons pe of system: ❑ Cesspool(s) eptic Tank ❑ Tight Tank Other(describe):luent Tee Filter present? ❑ Yes/bLJ�'Nc If yes, was it cleaned? ❑ Yes ❑ No ndition of System: f�C Ce 56 //J S 6. System Pumped B Name — V hicle License Number 3 Company 7.�Location where contents were disposed: f Signature auler Date http://www.mass.gov/dep/wa er/approvals/t5forms.htm#inspect t5form4.doc•06/03 System Pumping Record•Page 1 of 1 1 Address Jr.D CHRIST/AA( Wf} y Title of File Page — of Date File Open: ------ Date file closed: Doc Document/Action Title Date of _ action Refer to other Purpose of DocurnE�ntJAetlon and nates Document/ docurnent/ fW um. Action De ;"+Ment :l:: �--� S Board of Appeals — Board of Heal h Planning Board _ Cons ervatiion Commission - Building Departrnen,t TOWN OF NORTH ANDOVER SYSTEM PUMPING RECORD DATE: SYSTEM OWNER &ADDRESS SYSTEM LOCATION (example: left front of house) DATE OF PUMPING: ` QUANTITY PUMPED C� 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: COMMENTS: 4 CONTENTS TRANSFERRED TO: • COMMONWEALTH OF MASSACHUSETTS Z Y EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS u a d DEPARTMENT OF ENVIRONMENTAL PROTECTION �'M 5re TITLE 5 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM PART A CERTIFICATION Property Address: 50 Christian Way_ _North Andover_ Owner's Name: Joseph Carrolo Owner's Address:_50 Christian Way_ _North Andover,Ma. 01845_ Date of Inspection:4/27/2001_ 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 s Inspector's Signature: /,.a s Date: _4/27/2001_ The system inspector shall A*a copy Qhis inspection report to the Approving Authority(Board of Health or DEP)within 30 days of completing this inspection.If the system is a shared system or has a design flow of 10,000 gpd or greater,the inspector and the system owner shall submit the report to the appropriate regional office of the DEP.The original should be sent to the system owner and copies sent to the buyer,if applicable,and the approving authority. Notes and Comments ****This report only describes conditions at the time of inspection and under the conditions of use at that time.This inspection does not address how the system will perform in the future under the same or different conditions of use. r Page 2 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address:_50 Christian Way_ _North Andover — Owner: Carrolo Date of Inspection:_4/27/2001_ 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 tunes 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:_50 Christian Way_ North Andover— Owner: Carrolo Date of Inspection: 4/27/2001 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: 50 Christian Way _North Andover— Owner: Carrolo Date of Inspection: 4/27/2001_ 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 feet but greater than 50 feet from a private water supply well with no acceptable water quality analysis. [This system passes if the well water analysis, performed at a DEP certified laboratory,for coliform bacteria and volatile organic compounds indicates that the well is free from pollution from that facility and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm,provided that no other failure criteria are triggered.A copy of the analysis must be attached to this form.] 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 II 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:_50 Christian Way_ North Andover— Owner: Carrolo Date of Inspection:_4/27/2001_ 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 baffles 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 diancste is unacceptable) [3 10 CMR 15.302(3)(b)] Page 6 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION Property Address:_50 Christian Way_ _North Andover — Owner: Carrolo Date of Inspection:_4/27/2001_ 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):_600 Number of current residents: 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:April 20 to April 01=16,100 W X 7.5=120,750 Gals./365 Days=331 Gals./Day Sump pump(yes or no):_No Last date of occupancy:_Current COMMERCIALANDUSTRIAL 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 four 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&tees 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:_14 years old. 7/10/1982 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: 50 Christian Way- —North ay_North Andover— Owner: Carrolo Date of Inspection: 4/27/2001_ BUILDING SEWER(locate on site plan)X Depth below grade:_18" Materials of construction —X—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"Cast iron thru wall to septic tank.3" PVC in house. No leaks. SEPTIC TANK: X locate on site plan) Depth below grade:—6"T 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 depth 12" Distance from top of sludge to bottom of outlet tee or baffle: 15"_ 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&outlet tees 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: 50 Christian Way_ _North Andover — Owner: Carrolo Date of Inspection: 4/27/2001_ TIGHT or HOLDING TANK: (tank must be pumped at time of inspection)(locate on site plan) Depth below grade: Material of construction: concrete metal fiberglass_polyethylene other(explain): Dimensions: Capacity: gallons Design Flow: gallons/day Alarm present(yes or no): Alarm level: Alarm in working order(yes or no): Date of last pumping: Comments(condition of alarm and float switches,etc.): DISTRIBUTION BOX: 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 to 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: 50 Christian Way _North Andover— Owner: Carrolo Date of Inspection:_4/27/2001 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: leaching trenches,number,length: _X_leaching fields,number,dimensions: 25'x 42'Leach bed._ 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.):—Soil oL Vegetation oL No sign of ponding to surface._ CESSPOOLS: (cesspool must be pumped as part of inspectionxlocate on site plan) Number and configuration: Depth—top of liquid to inlet invert: Depth of solids layer: Depth of scum layer: Dimensions of cesspool: Materials of construction: Indication of groundwater inflow(yes or no): Comments(note condition of soil,signs of hydraulic failure,level of ponding,condition of vegetation,etc.): PRIVY: (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: 50 Christian Way_ _North Andover— Owner:_Carrolo Date of Inspection:_4/27/2001_ 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. 25' 42' D- Box Driveway House B 1 2 Water Meter A A to 1 =23'10" Ato2=31'8" A to D-Box=52'3" Bto1=17'8" B to 2=25'9" B to D-Box=43'6" Page 11 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address:_50 Christian Way_ North Andover — Owner: Carrolo Date of Inspection: 4/27/2001_ 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:_7/10/1987_ 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 built plan._ � r r w + r r 190.00 r � LCT 4 ' 4s l77 O EX15TING FND f ---------------- r r f r 1 + ' 66 T r 180,00 i � 4 44: D-RISTIAN WAY I C'`+'VV �!)' '' T�7 SEPTC SYSM)V,65 1&t S A�.i�-D AS 5}iO'"id• ENlED AS AVAFIRr<J�TY OF-TpZ SYSTEM. PLAN 51-iOVVIt 4G SUBSURFACE SRV5I GF � D-Sx SAL SYSTEM AS ICU ILT EIEVATIONS LOCATION LOT 4 CHRIST IAN WAY OWNER ETAL RI=ALT Y TRUST ' '�� a f76:7 COTE 7-10-3 ' S(-,A[f 14r)' CUTLET ;72.5 _`_ 5?I,.,Y FT 172,0 PREPARED BY, �' 0rdi�FT f7(-,85LCX y DOX ii )TL' G E� 169.0 169DL�:sqn Fpq,rneei t-OG".�TLT 16.9..0 0 Fr i D if,8,9 t Po 0c,po Y No -th �l7C�oVE'Y Town of North Andover, Massachusetts Form No. 1 G NORT11 BOARD OF HEALTH 3�0�t 646 oL 19 * T�' f. ,f APPLICATION FOR SITE TESTING/INSPECTION 7 A°RATED �SSACHUS�� Applicant NAME ADDRESS TELEPHONE Site Location Engineer NAME ADDRESS TELEPHONE Test/Inspection Date and Time CHAIRMAN,BOARD OF HEALTH Fee Test No. S.S. Permit No. D.W.C. No. C.C. Date Plbg. Permit No. L (IRD of FBF ,i .X r `-^ Lo--rH Cy/5rA/V 1)Q ,'vol�Th &PnUL-)-�i MA, �PPLt CAti I ((JAS Co,4jE"� (,vq(�i� Svf'H�7 -�Tbwnl D WELL AP�ouCD114TC S3 3 WTI C Sy S I L� �F'F�i�ovr=v PAr6' 0. 2-Z�87 AP13�0vIN6 /uTho�lry COAJPiTlOAJ5= &�(ii5loti 0 TED 2 UI�PPRUVEp �/�TE 7c rp lAT Lllv( SV5TEit-1 PJS1AUAT'n-AJ G YC/� `1 fC►.'J J��C;>�GT�O�J U/J (G Q I��SS E] FINAL ►IJ5(�FGTio� � �-j- Gohn��s �� S 4PPROOEP J/J[- TL AVDITIoMAL 1�15� c1 ICjn�S C1►=A'`'y� DI;lsPt'K�v�V DAT-C R�jSo tis , FVAL APPROVAL , PATRICK J. DONOVAN ASSOCIATES, INC. "CLAIM AND LOSS ADJUSTMENTS" P.O. Box 110 Wakefield, MA 01880 (617) 245-5540 FORM OF NOTICE OF CASUALTY LOSS TO BUILDING UNDER MASS. GEN. LAWS. CHP. 139, SEC. 3B R -rVi ANS®v��t tv( gOHRD OF TO: Building Commissioner or Inspector of Buildings City or Town Hall �� 1Q17�v °/-� s- ply RE: Insured: -J-65fM Property Address: Policy Number: �fad �y7� Loss Type: Date of Loss: Our File Number: Claim has been made involving loss, damage or destruction of the above- captioned property, which may either exceed $1,000 or cause Mass. Gen. Laws, Chapter 143, Section 6, to be applicable. If any notice under Mass. Gen. Laws, Chapter 139, Section 3B is appropriate, please direct it to the attention of the writer and include a reference to the captioned Insured, location, policy number, date of loss and file number. Adjuster z Donovan As crates, Inc. Wakefield, MA ,7 On this date, I caused copies of this notice to be sent to the persons named above at the addresses indicated above by first class mail. Commonwealth of Massachusetts City/Town of NORTH ANDOVER, MASSACHUSETTS System Pumping Record _�_ Form 4 DEP has provided this form for use by local Boards of Heal . Thg-MsteA R ing cord must be submitted to the local Board of Health or other approvin authority. N of NORTH ANDOVER A. Facility Information HEALTH DEPARTMENT Important: When filling out 1. System Location: forms the ch r computer,use 1 � 1 only the tab key Address to move your cursor-do not use the return City/Town State Zip Code key. . 2. System Owner: % (2 lo On+ i o n i Name ICS 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) &/Septic Tank ❑ Tight Tank Other(describe): 4. Effluent Tee Filter present? ❑ Yes ❑ No If yes,was it cleaned? ❑ Yes ❑ No 5. Condition of System: qoWj 6. S stem Pum ed By: Q n Lo a e Vehicle License Number x`43 &PA 1c ompany 7. Location where contents were disposed: Ily MY ped clk 0, V///o SignatuqpP&Hauler Dat http://www.mass.gov/dep ater/approvalslt5forms.htm#inspect t5form4.doc-06/03 System Pumping Record•Page 1 of 1