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HomeMy WebLinkAboutMiscellaneous - 50 JAY ROAD 4/30/2018 (2) 50 JAY ROAD / 21DIM&A-0059-0000.0 COMMONWEALTH OF MASSACHUSETTS EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS DEPARTMENT OF ENVIRONMENTAL PROTECTION Y F �t I � TITLE 5 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM PART A CERTIFICATION RECEIVED7SEP Property Address: 50 Jay Road _ 6_North Andover_ 2005 Owner's Name:_Allan Marcus_ TOWN OF NORTH ANDOVER Owner's Address:_50 Jay Road_ t tEA�-1 DE -�,RTMENT North Andover,MA 01845_ -- A Date of Inspection 9/12/2005_ 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 t Inspector's Signature: Date: _9/12/2005_ The system inspector shall submit a copy of this inspection report to the Approving Authority(Board of Health or DEP)within 30 days of completing this inspection.If the system is a shared system or has a design flow of 10,000 gpd or greater,the inspector and the system owner shall submit the report to the appropriate regional office of the DEP.The original should be sent to the system owner and copies sent to the buyer,if applicable,and the approving authority. Notes and Comments: ****This report only describes conditions at the time of inspection and under the conditions of use at that time.This inspection does not address how the system will perform in the future under the same or different conditions of use. Page 2 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: 50 Jay Road_ _North Andover — Owner:_Marcus_ Date of Inspection: 9/12/2005_ Inspection Summary: Check AAC 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`Sot 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: 50 Jay Road_ _North Andover_ Owner:_Marcus_ Date of Inspection: 9/12/2005 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 Ili 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 ce water 1 or tri to a surface water supply. surfs supply tributary The system has a septic tank and SAS and the SAS is within a Zone I 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 1 I OFFICIAL INSPECTION FORM —NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address: 50 Jay Road_ _North Andover— Owner: Marcus_ Date of Inspection: 9/12/2005_ D. System Failure Criteria applicable to all systems: You must indicate"yes"or`Sno"to each of the following for all inspections: 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'h day flow. _ No_ �I pumping R uiredmore 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 31.0 CMR 15.303 therefore thesY stem 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: 50 Jay Road_ _North Andover_ Owner:_Marcus_ Date of Inspection:_9/12/2005 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 iri the previous two week period? No Have large volumes of water been introduced to the system recently or as part of this inspection? _N/A_ _ Were as built plans of the system obtained and examined? Yes Was the facility g P �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 _ No Existing information. _Yes_ _ Determined in the field(if any of the failure criteria related to Part C is at issue approximation of distance is unacceptable)[3 10 CMR 15.302(3)(b)] Page 6 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION Property Address:_50 Jay Road_ _North Andover — Owner:_Marcus_ Date of Inspection: 9/12/2005 FLOW CONDMONS RESIDENTIAL Number of bedrooms(design):—N/A_ Number of bedrooms(actual): 3_ DESIGN flow based on 310 CMR 15.203_N/A_ Number of current residents:_5 Does residence have a garbage grinder(yes or no): Yes Is laundry on a separate sewage system(yes or no):_No Laundry system inspected(yes or no): _ Seasonal use:(yes or no):—No— Water meter reading:—No Sump pump(yes or no): No_ Last date of occupancy:—Current_ COMMERCIAIA NDUSTRIAL Type of establishment: Design flow(based on 310 CMR 15.203):__pd Basis of design flow(seatstpersons/sg8,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 three years ago,owner_ Was system pumped as part of the inspection(yes or no): Yes_ If yes,volume pumped:_1000_gallons—How was quantity pumped determined?—Measured tank Reason for pumping: Inspect tank&tees_ TYPE OF SYSTEM X Septic tank,distribution boat,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: House built 1971,owner Were sewage odors detected when arriving at the site(yes or no): No Page 7 of I 1 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 50 Jay Road_ _North Andover_ Owner:_Marcus_ Date of Inspection:_9/12/2005_ BUILDING SEWER_X_ (locate on site plan) Depth below grade:_22"_ Materials of construction: _X_cast iron _X_40 PVC_other Distance from private water supply well or suction line: Comments(on condition of joints,venting,evidence of leakage,etc.) 4"cast iron thru wall._ SEPTIC TANKS: X Depth below grade:_10"_ 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: 7'x 5'x 4'— Sludge '_Sludge depth 3"_ Distance from top of sludge to bottom of outlet tee or baffle: 20"_ Scum thickness:_12" 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: How were dimensions determined:_Tape Measure_ 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 baffle ok.Outlet baffle corroded on top.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 scan 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 I I OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 50 Jay Road_ _North Andover_ Owner: Marcus_ Date of I_nspection:_9/12/2005 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 BOXES: X 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-Boz level&distribution equal.Evidence of carryover,pumped d-bog to clean.No evidence of leakage _ PUMP CHAMBER:_(locate on site plan) Pump in working order(yes or no):_ Alarm 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 Jay Road_ _North Andover_ Owner:_Marcus_ Date of Inspection:_9/12/2005 SOIL ABSORPTION SYSTEM(SAS):_X (bate 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: 4 trenches 40'long leaching field,number,dimensions: overflow cesspool,number: innovativelalternative system Typetname 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 sludge 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 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address•. 50 Jay Road_ _North Andover— Owner: Maras Date of Inspection:_9/12/2005 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. e Gara House g A Water Meter Driveway 1 Septic Tank 2 D- Boz Ato1=39'5' A to 2=42'9" A to D-Boz=36' BtoI=12' Bto2=17'6" B to D-Boz=22'3" Page I 1 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address:_50 Jay Road_ _North Andover – Owner:_Marcus_ Date of Inspection:_9/12/2005 SITE EXAM Slope Surface water Check cellar Shallow wells Estimated depth to ground water _1.5 to 3.1_ Please indicate(check)all methods used to determine the high ground water elevation: Obtained from system design plans on record-If checked,date of design plan reviewed:— Observed site(abutting property/observation hole within 150 feet of SAS) Checked with local Board of Health-explain: Checked with local excavators,installers-(attach documentation) X Accessed USGS database-explain:_Essex County Soil Map_ You must describe how you established the high ground water elevation: Essex County Soil Map,Sheet#36, Sudbury Soil,Water 1.5 to 3.0 deep. Front yard elevated above road >5'_ Tel: (978)475-4786 i 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: 50 Jay Road, North Andover Owner: Marcus Date of Inspection: 9/12/2005 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. Ne4J. ason Bateson Enterprises,Inc. Commonwealth of Massachusetts REC109t City/Town of JUL 10 2012 System Pumping Record TOWN OF NORTH ANDOVER Form 4 HEALTH DEPARTMENT DEP has provided this form'for use by local Boards of Health. Other forms may be used, but the information must be substantially the same as that provided here. Before using this form, check with your local Board of Health to determine the form they use.The System Pumping Record must be submitted to the local Board of Health or other approving authority. A. Facility Information 1. System Location: Le Riaht front of ho �� -, Left/Right rear of house, Left/right side of house, Left/ Right side of buildin eft44ight frame ilding, Left/Right rear of building, Under deck Add typo State Zip Code 2. System Owner. Name Address(if different from location) City/Town Stat e/1� 1 C Zip Code Telephone Number B. Pumping Record 1. Date of Pumping Date 2. Quantity Pumped: Gallons 3. Type of system: ❑ Cesspool(s) Septic Tank EI'Tight Tank ❑ Other(describe): 4'. Effluent Tee Filter present? ❑ Yes D o If yes,was it cleaned? ❑ Yes ❑ No 5. Condition of System: 6. System Pumped By: Neil Bateson F5821 Name Vehicle License Number Bateson Enterprises Inc Company 7. Locati re contents were disposed: G.L S. Lowell Waste Water Sign$tufe fHaulev Date t5form4.doc•06/03 System Pumping Record•Page 1 of 1 Commonwealth of Massachusetts RECEIVED City/Town of System Pumping Record APR 2 3 2008 Form 4 TOWN OF NORTH�ANDOVIEJRHEALTH D PADEP has provided this form for use by local Boards of Health.Oth information must be substantially the same as that provided here. Before using this form,check with your local Board of Health to determine the form they use.The System Pumping Record must be submitted to the local Board of Health or other approving authority. A. Facility Information Important: When filling out 1. System Location: forms on the \f\ LJ computer,use only the tab key Address Q to move your /`lJ C.IL9 cursor-do not City/Town State Zip Code use the return key. 2. System Owner: Name Address(if different from location) City/Town State 4 Trp 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`e—Igo— If yes,was it cleaned? ❑ Yes ❑ No 5. Condition of System: YLC,)f [42,,U-9A C, (A. 6. System Pumped By: Name Vehicle License Numb 0 Comp 7. Locatio ere 7otntsweredi sed: � , • Signatu ler Date l/V t5form4.doc-06/03 System Pumping Record.Page 1 of 1 Commonwealth.of Massachusetts City/Town of I FHEA 5 2006 System Pumping Record : Hr.YAR TMtiV 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 ruing out 1. System Location: forms on the computer.use only the tab key Address —� to move your cursor-do not use the return Cityfrown State Zip Code .key. 2, System Owner Name Address(if different from.location), cdyfrown. state Zip code. Telephone Number .B. Pumping Record 1: _Date.of Pumping Date 2. Quantity Pumped Gallons Type of system: ❑ Cesspool(s) eptic Tank- ❑ Tight Tank ❑ Other(describe),-: 4: Effluent Tee Filter present? ❑ Yes Leo If es, was it cleaned? Y ❑ Yes`❑ No 5. Condition of.System:. 6. Syste P mpQq By Name Vehicle license Number Company -- 7. Location w e contents a dis d:: Signa d of aul r Date http://www.mass.g.. /wa r(approval�t5forms.htm#inspect t5fonn4.doc-06%03 System Pumping Record•Page 1 of t 1 TOWN OF SYSTEM PUMPING RECORD _ RECEIVED DATE: �V SEP 16 2005 TOWN OF NORTH ANDOVER HEALTH DEPARTMENT SYSTEM OWNER & ADDRESS SYSTEM LOCATION (example:left front of house) ries V �t r)-(�l -Av DATE OF PUMPING: 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: G.L.S.Dy Lowell Waste APPLICATION FOR DISPOSAL WORKS CONSTRUCTION PERI IIT DATE: -- �S" U CTj­RRENT DNSTALLER'S LICENSEm LOCATION: LICENSED L`1STALL %J SIGNATURE: TELEPHONEm 6� '�d3 CHECK ONE: REPAM: NEN CONSTRUCTION: IF NEW CONTUCTION, PLEASE ATTACH FOUNDATION AS-BUILT. Administrative Use Only 575.00 Fee Attached? Yes ✓ No Foundation As-Built? Yes No Floor Plans? Yes No A royal Date: PP G ( INSTALLER PROJECT MANAGEMENT OBLIGATIONS As the North Andover licensed installer for the construction of the septic system for the property at 'SSD relative to the application of d �-e fid�✓ dated for plans by and dated with revisions dated I understand and agree to the following obligations for management of this project: 1. As the installer I am obligated to call for any and all inspections. If homeowner, contractor, project manger, or any other person not associated with my company schedules an inspection and the system is not ready then item two shall be applicable . 2. As the installer I am required to have the necessary work completed prior to the applicable inspections as indicated below. I understand that requesting an inspection, without completion of the items in accordance with Title 5 and the Board of Health Regulations may result in a $50.00 fine being levied against my company. a) Bottom of Bed—generally first inspection unless there is a retaining wall which should be done first. Installer must request the inspection but does not have to be present. b) Final Inspection—Engineer must first do their inspection for elevations,ties,etc. As-built or verbal OK from engineer must be submitted to BOH,after which installer calls for inspection time. Installer must be present for this inspection. With pump system all electrical work must be ready and able to cause pump to work and alarm to function. c) Final Grade—Installer must request inspection when all grading is complete. Does not have to be on site. 3. As the installer I understand that persons or companies not associated with my company may not perform the work required by my company to complete the installation of the system identified in the attached application for installation. I further understand that work by others. unlicensed to install septic systems in North Andover can constitute reasons for denial of the system, and/or revocation-or suspension of my license in the Town of North Andover plus significant fines to all persons involved. 4. As the Installer I understand that I must be on site during the performance of the following construction steps: a) Determination that the proper elevation of the excavation has been reached- b) eachedb) Inspection of the sand and stone to be used. c) Final inspection by Board of Health staff. d) Installation of tank,D-box,pipes,stone,vent,pump chamber,retaining wall and other components. 5. As the installer I understand that I am solely responsible for the installation of the system as per the approved plans. No instructions by the homeowner, general contractor, or any other persons shall absolve me of this obligation. Undersig icensed Septic Installer Date: Form No.3 Town of North Andover, Massachusetts BOARD OF HEALTH NORTH '""'.•�� Of st��O 6, 0 3t a e O L O 9 H DISPOSAL WORKS CONSTRUCTION PERMIT ,SSACHUSES Applicant / TELEPHONE pp NAME RESS f Site Location J� I, Permission is hereby granted to Construct ( ) or Repair ( n Individual Soil Absorption Sewage Disposal System as shown on a Design A proval S.S. No. g p Y Pf1� r�uA /o FuNJATian- AN, B CAR t OF HEALTH 'Fee D.W.C. No. D • Address Sb y y Title of File Page of Date File Open: Date File closed: Doc Document/Action Title Date of Refer to other Purpose of Document/Action and notes T action Document/ document/ Num. Action Department Board of Appeals — Board of Health — Planning Board — Conservation Commission — Building Departmer t i TOWN OF NORTH ANDOVER SYSTEM PUMPING RECORD DATE: co — SYSTEM OWNER &ADDRESS SYSTEM LOCATION (example: left front of house) vt '�' DATE OF PUMPING:6,(,- QUANTITY PUMPED C GALLONS CESSPOOL: NO S SEPTIC TANK: NO YES NATURE OF SERVICE: ROUTINE v. 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: CONTENTS TRANSFERRED TO: 1 � SyJ Commonwealth'of Massachusetts City/Town of LQtherform—n System Pumping Record Form 4 9 �M DEP has provided this form for use by local Boards of Healtbutthe information must be substantially the same as that providedcheck with your local Board of Health to determine the form they use. The System Pumping Record must be submitted to the local Board of Health or other approving authority. A. Facility Information 1. System Location: Left side of house, Right side of house, Left front of hou , Right front of house Left rear of house, Right rear of house. Address PrA Citylrown State Zip Code 2. System Owner: Name Address(if different from location). City/Town Stat Zip Code Telephone Number B. Pumping Record 1. Date of PumpingDate . 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: v\, 6. System Pumped By: Neil Bateson Name Vehicle License Number F5821 Bateson Enterprises Inc Company 7. Locati re contents were disposed: G.U5.D Lowell Waste Water 5 n ur of Haul r Date t5form4.doc•06/03 System Pumping Record•Page 1 of 1 Commonwealth of Massachusetts City/Town of W° System Pumping Record Form 4 DEC G'IM DEP has provided this form for use by local Boards of Health. Other OT IN60 information must be substantially the same as that provided here. B c with your local Board of Health to determine the form they use. The System Pumping Record must be su mitted to the local Board of Health or other approving authority. A. Facility Information 1. System Location: Left front of hous g t front of hou , left side of house, right side of house, Left rear of house, right rear of house, left side of building, right rear of building, under deck. City/Town State Zip Code 2. System Owner: CArG� Name Address(if different from location) City/Town State Zip Code G8S= Sys" 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 Filterresent? p ❑ Yes'' No If yes, was it cleaned? ❑ Yes ❑ No 5. Condition ofSystevm^ 6. System Pumped By: Neil J. Bateson F5821 Name Vehicle License Number Bateson Enterprises Inc. Company 7. Location where contents were disposed: L.S.D. L we aste Water 1117-, Signature of HaWer U Date t5form4.doc•06/03 System Pumping Record•Page 1 of 1 I