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Miscellaneous - 50 LOST POND LANE 4/30/2018 (2)
50 LOST POND LANE i I 210/104.&0012-0000.0 i i I r r .,�„ c a �x ` �`''��' � a"} w' ;-s,z r'a q,xt+,rk fira* sg , €a•, } „�.�.p,r .ir.� ., ,rr r ,, • r,. r• z�_ t �F.1�� x �(yn j` �'r���>1 L sast�`ltti�-�`tt d f�yy llbr't�r� t4 yY. i V �. .Y ` n .h . .w t �f ". e'�'1�, ' '�41� 5+ •` ��i� ; �, ��+y��'7"� M����y . MAP # PARCEL # " STREET �ONSTRUCTIQN A.PPRO _. HAS PLAN REVIEW FEE .BEEN PAID? YES NO PLAN APPROVAL: DATE APP. BY_ /� �/���_!�. _ DESIGNER: AU&ye PLAN DATE. - CONDITIONS 7-FC'TA/1y1y6 WATER SUPPLY: TOWN WELL WELLBERM IT~---• DRILLER._.: WELL TESTS: _CHEM.ICAL DATE APPROVED BACTERIAI DA f E E1(�PRUVEU BACTERIA II DAT -tPRUVEll COMMENTS: FORM U APPROVAL: APPROVAL TO ISSUE YE5 NO DATE ISSUEDBY CONDITIONS: FINAL APPROVAL: . ALL PERMITS PAID YES NO WELL CONSTRUCTION APPROVAL YES NU SEPTIC SYSTEM CONSTRUCTION APPROVAL YES NO JJ OTHER YES NU 1z'Id ab" ANY VARIANCE NEEDED YES NU FINAL BOARD OF HEALTH APPROVAL: DATE:. .._BY: ./�'� i t _ �E_pT I G SY�IEM_�.NSS�4t,.8L� kit y�r .,,-+1. + ..�, r .. s..a> , •. .a.' e_ u�-: a ..,s_ r�+ .�a \ 1 - i ♦C 1 +�; '� sA IS THE INSTALLER LICENSED? N YES NO f :TYPE. OF CONSTRUCTIO . ? NE • REPAI EW CONSTRUCTION: CERTIFIED PLOT PLAN REVIEW YES NO ' c - ' 4 - CONDITIONS OF:.APPROVAL. YDS NO (FROM FORM U) . 1 ISSUANCE OF DWC PERMIT r - ` NO . . '. DWC PERMIT N0. � � t INSTALLER:tw BEGIN INSPECTION YES NO: EXCAVATION .,INSPECTION: : NEEDED: -APASSED )BY .-.:CONSTRUCTION INSPECTION: NEEDEDa AS BUILT PLAN SATISFACTORY: YES: - APPROVAL TO BACKFILL: DATE: BY � � C— " fINAL • GRADING APPROVAL: DATE 71 — ,• BY � FINAL CONSTRUCTION APPROVAL: DATE: BY COMMONWEALTH OF MASSACHUSETTS Z f EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS d DEPARTMENT OF ENVIRONMENTAL PROTECTION F Wt SV TITLE 5 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM PART A CERTIFICATION RECEIVED Property Address:_50 Lost Pond Lane_ _North Andover AUG 0 5 2005 Owner's Name:_David Russell_ Owner's Address:_50 Lost Pond Lane_ TOWN OF NORTH ANDOVER North Andover,MA 01845_ HEALTH DEPARTMENT Date of Inspection 7/30/2005_ 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 certifythat I have ersonall inspected the sewage disposal system at this address and that the information reported P Y P 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 Fa' s r 7/ Inspector's Signature: Date: 0/2005_ 3 _ 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. I Page 2 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address:_50 Lost Pond Lane_ _North Andover_ Owner: Russell_ Date of Inspection:_7/30/2005_ 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: i I 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 i 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 Lost Pond Lane_ _North Andover— Owner:_Russell_ Date of Inspection:_7/30/2005_ 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 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 Lost Pond Lane_ _North Andover_ Owner:_Russell_ Date of Inspection:_7/30/2005_ D. System Failure Criteria applicable to all systems: You must indicate"yes"or`no"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''/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 Lost Pond Lane_ _North Andover— Owner:_Russell_ Date of Inspection:_7/30/2005_ 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 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? 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. _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 Lost Pond Lane_ _North Andover- Owner:_Russell_ Date of Inspection:_7/30/2005_ FLOW CONDITIONS RESIDENTIAL Number of bedrooms(design):_4_ Number of bedrooms(actual):_4_ DESIGN flow based on 310 CMR 15.203_440_ Number of current residents:_2 Does residence have a garbage grinder(yes or no): No_ 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: Yes_ Sump pump(yes or no):-Nom- Last 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&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:_10 years old,12/30/1995, Design 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:1-50 Lost Pond Lane_ _North Andover_ Owner:_Russell_ Date of Inspection:_7/30/2005_ BUILDING SEWER_X_ (locate on site plan) Depth below grade:_20"_ Materials of construction: _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"PVC thru wall to tank.3"PVC in house,no leaks visible._ SEPTIC TANKS: X 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'—x4' Sludge depth —4"_ Distance from top of sludge to bottom of outlet tee or baffle:_24"_ Scum thickness:_4"_ 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: 18"_ 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 tee ok.Outlet tee ok.Depth of liquid at outlet invert.No evidence of tank leaking._ 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 Lost Pond Lane_ _North Andover_ Owner:_Russell_ Date of Inspection: 7/30/2005_ 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-Box level&distribution equal. No evidence of leakage.Evidence of carryover.Pumped d-box to clean_ 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 Lost Pond Lane_ _North Andover_ Owner: Russell_ Date of Inspection:_7/30/2005_ SOIL ABSORPTION SYSTEM(SAS): (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 53'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 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 Lost Pond Lane_ _North Andover Owner:_Russell_ Date of Inspection:_7/30/2005_ 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. D-Box Porch rl 2 Septic Tank House Driveway 1 A Water Meter A to 1=32'5" Ato2=39' A to D-Box=54'5" Bto1=17'6 B to 2=18'5" B to D-Box=3417" I 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 Lost Pond Lane_ _North Andover— Owner:_Russell_ Date of Inspection:_7/30/2005 SITE EXAM Slope Surface water Check cellar Shallow wells Estimated depth to ground water _4'no water_ 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:_12/30/1995_ 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_ Summary Record Card generated on 7/29/2005 2:45:08 PM by Elaine Barclay Page 1 Town of North Andover Tax Map # 210-104.B-0012-0000.0 50 LOST POND LANE DAVID RUSSELL HONG LI 50 LOST POND LANE NORTH ANDOVER, MA 01845 Class 101 Single Family Property Type 1 Residential Size Total 0.62 Acres FY 2006 UB Mailing Index Name/Address Type Loan Number Activellnact. From Until DAVID RUSSELL Owner HONG LI 50 LOST POND LANE NORTH ANDOVER, MA 01845 KUNIEGA, LINDA Previous Customer Inactive 6/30/2004 50 LOST POND LANE NORTH ANDOVER, MA 01845 UB Account Maint. Account No Cycle Occupant Name Active/Inactive Bldg Id. 2957.0- 50 LOST POND LN Last Billing Date 7/8/2005 3180021 03 Cycle 03 Active UB Services Maint. Service Code Rate Charge Multiplier/Users MISCFEE ADMIN FEE 0.635/8 7.82 1/ WTR WATER 01 ALL METER SIZE c 100.30 /1 UB Meter Maintenance Serial No Status Location Brand Type Size YTD Cons 13242335 a Active ERT HH METE METE w Water 0.63 0.63 0 Date Reading Code Consumption Posted Date Variance 6/14/2005 122 a Actual 30 7/15/2005 406% 3/23/2005 92 a Actual 7 4/5/2005 -29% 12/15/2004 85 a Actual 9 1/14/2005 -76% 9/17/2004 76 a Actual 33 10/8/2004 89% 6/30/2004 43 a Actual 15 6/29/2004 -4% 4/23/2004 28 a Actual 28 5/17/2004 0% 12/23/2003 0 n New Meter 0 12/23/2003 0% _ a e q Telnet 10°1.71.55 W/S ACCOUNT HISTORY 3180021-HUNIEGA, LINDA MEIER 41: 3180021 . 4a BK:50 LOST POND LN 4 CYCLE SERUICE PRIOR CURRENT USE IIATER SERER FEES TOTAL ` 1 2000-13 10/01/1999 307 425 118 322.14 0.00 0.00 322.14 3w* 2 2000-23 01/11/2000 425 460 35 95.55 0.00 0.00 95.55 �yti -`� 3 2000-33 03/28/2000 460 480 20 54.60 0.00 0.00 54.60 ° ` 4 2000-43 06/14/2000 480 S06 26 70.98 0.00 0.00 70.98 5 2001-13 09/26/2000 506 S56 50 i36.50 0.00 11.00 147,50 6 2001-23 12/12/2000 5S6 576 20 54.60 0.00 11.00 65.60 ` Q 7 2001-33 04/02/2001 S?6 605 29 79.1.7 0.00 11.00 90.17 8 2001-43 06/19/2001 605 641 36 98.28 0.00 11.00 109.28 9 2002-13 09/04/2001 641 694 53 167.87 0.00 5.5S 173.42 10 2002-23 02/07/2002 694 ?S0 S6 156.24 0.00 5.55 161.79 11 2002-33 04/10/2002 750 767 17 41.99 0.00 5.55 47.54 12 2002-43 06/17/2002 ?67 785 18 44.46 0.00 5.55 50.01 13 2003-13 09/17/2002 785 840 55 179.18 0.00 5.97 185.15 14 2003-23 12/16/2002 840 865 25 66.60 0.00 5:97 72.5? s 15 2003-3303/17/2003 865 888 23 59.00 0.00 5.97 64.97 16 2003-43 06/12/2003 888 911 23 59.00 0.00 5.97 64.9? D 17 2004-13 09/17/2003 911 954 43 125.84 0.00 ?.42 133.26 18 2004-23 12/18/2003 0 0 23 55.22 0.00 ?.42 62.64 REUIEU CHOICE 4 or <ENTER> -MORE HISTORY: EJ�' Pon r, iimoc,ft vVo;d b , RER1 T S_00,5 as •. /1 1 1 • 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: 50 Lost Pond Lane, North Andover Owner: Russell Date of Inspection: 7/30/2005 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. C i Neil J. Bateson Bateson Enterprises, Inc. TOWN OF _ Af - A,&da- SYSTEM PUMPING RECORD RECEIVE® DATE: Q-0 5 AUG 0 5 2005 TOWN OF NORTH ANDOVER HEALTH DEPARTMENT SYSTEM OWNER& ADDRESS SYSTEM LOCATION (example:left front of house) Lo DATE OF PUMPING: '~2,0 - 6 C2 QUANTITY PUMPED : C7 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.D Lowell Waste Commonwealth of Massachusetts City/Town of RECEIVED System Pumping Record Form 4 DEC 1 12007 I DEP has provided this form for use by local Boards of Health.Other 11*9T �f� information must be substantially the same as that provided here. B th 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 ocatlo forms on the computer,use only the tab key Address Q� touse the return move your Lw: b v �u cursor-do not Cityfrown State Zip Code key. 2 System Owne Name Address(if different from location) City/Town State Trp Code Telephone Number B. Pumping Record 1. Date of Pumping Date 2. Quantity Pumped: Gallos � 3. Type of system: ElCesspool(s) Septic Tank C3Tight Tank ❑ Other(describe): 4. Effluent Tee Filter present? ❑ Yes ES No If yes,was it cleaned? ❑ Yes M/No 5. Condition of System: 6. System Pum By: Name Vehicle Licede Wumber Company 7. Location where contents were disposed: G_1- '�,� Signature of Hauler Date t5fonn4.doc•06/03 System Pumping Record^Page 1 of 1 I Commonwealth of Massachusetts rRECEIVED City/Town of I� Z 4 2013 System Pumping Record `rowN 01=NORTH ANDOVER Form 4 HEALTH DEPARTIb]EtdT" DEP has provided this form for use by local Boards of Health. Other forms may be used, but the information must be substantially the same as that provided here. Before using.this form, check with your local Board of Health to determine the form they use.The System Pumping Record must be submitted to the local Board of Health or other approving authority. A. Facility Information 1. System Location: Left/Right front of house, Left/Right rear of house, Left/ side of hous Left eco / Right side of building, Left/Right front of building, Left/Right rear of building, Under Address City/Town' State �f Zip Code 2. System Owner. Y `^ Name Address(if different from location) City/Town State i Co e Telephone Number B. Pumping Record 1. Date of Pumping Date 2. Quantity Pumped: Gallons 3. Type of system: ❑ Cesspool(s) 9-Septic Tank ❑ Tight Tank ❑ Other(describe): 4. Effluent Tee Filter present? ❑ Yes to— If yes, was it cleaned? ❑ Yes ❑ No 5. Condition of System: 6. System Pumped By: j Neil Bateson F5821 Name Vehicle License Number Bateson Enterprises Inc Company 7. WHaule were disposed: owell Waste Water In rl) Crate t5form4.doc•06/03 System Pumping Record•Page 1 of 1 COMMONWEALTH OF MASSACHUSETTS EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS DEPARTMENT OF ENVIRONMENTA_L_PROTECTION y` B 6RJ)OF HEALT',A r EC-2 ,3-20 TITLE 5 _ OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM PART A CERTIFICATION Property Address: ,-5e 105f. 3-74 Owner's Name://�/7/��/L Owner's Address: Date of Inspection: /ol Name of Inspector: (please print) /n6.'.rY� Company Name: /!! Mailing Address:c)�.70,,50.,/)')/ Telephone Number:97Y-97Z-7 71 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: Passes Conditionally Passes Needs Fufther Evaluation by the Local Approving Authority Fai Inspector's Signature: 'C 6hte: 4 / -2 b L 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. Title 5 Inspection Form 6/15/2000 page 1 .�Page�"bf 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A lhC L CERTIFICATION (continued) Property Address: /[� �'�/)/1l-1 1l /)P, Owner: Date of Inspection: Inspection Summary: Check A,B,C,D or E/ALWAYS complete all of Section D A. System Passes: 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 pipes)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: 2 Page 3 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address: JVD /1)371 1411W1 14/)0., - 47/a//1-)11�?'j Owner:�Z21-6-447 Date of Inspection: / 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 Y 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 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. r 3. Other: 3 "Page 4 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address:,-:5/-D /QST Alal holo, Owner: Date of Inspection: ` f D. System Failure Criteria applicable to all systems: You must indicate"yes"or"no"to each of the following for all inspections: Yes No/ _V Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool 7ZDischarge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool Static liquid level in the distribution.box above outletinvert due to an overloaded or clogged SAS or !spool 1 '' � ,iquid depth in cesspool is less than 6"below invert or available volume is less than'/2 day flow _,/Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s).Number /of times pumped . _ &, Any portion of the SAS,cesspool or privy is below high ground water elevation. Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. ,Any portion of a cesspool or privy is within a Zone 1 of a public well. Any portion of a cesspool or privy is within 50 feet of a private water supply well. _ _ 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.] �f (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 4: 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. 4 • P g 5ofll OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B L CHECKLIST Property Address:0&7 Owner: Date of Inspection: /. Check if the following have been done.You must indicate"yes"or"no"as to each of the following: Yes No Pumping information was provided by the owner,occupant,or Board of Health _/Were any of the system components pumped out in the previous two weeks? Y . 4 Has the system received normal flows in the previous two week period? //Have large volumes of water been introduced to the system recently or as part of this inspection? ZWere as built plans of the system obtained and examined?(If they were not available note as N/A) tl _ Was the facility or dwelling inspected for signs of sewage back up ? Was the site inspected for signs of break out? Were all system components,excluding the SAS,located on site? Were the septic tank manholes uncovered,opened,and the interior of the tank inspected for the condition of the baffles or tees,material of construction,dimensions,depth of liquid,depth of sludge and depth of scum? _✓_ Was the facility owner(and occupants if different from owner)provided with information on the proper maintenance of subsurface sewage disposal systems? The size and location of the Soil Absorption System(SAS)on the site has been determined based on: Yes Existing information.For example,a plan at the Board of Health. 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)] r 5 • Page 6 of I 1 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION Property Address: Owner:�/!� L�� � 'f Date of Inspection: FLOW CONDITIONS RESIDENTIAL Number of bedrooms(design): Number of bedrooms(actual): / �/L O DESIGN flow based on 310 015.203 (for example: 110 gpd x#of bedrooms): / Number of current residents: '`j` Does residence have a garbage grinder(yes or no): � Is laundry on a separate sewage system(yes or no):�[if yes separate inspection required] Laundry system inspected(yes or no):— Seasonal use:(yes or no),"U Water meter readings,if available(last 2 years usage(gpd)):' t , Sump pump(yes or no):A"� Last date of occupancy: 6)C&—I J e C4 COMMERCIAL/INDUSTRIAL Type of establishment: Design flow(based on 310 CMR 15.203): Ud 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: U Was system pumped as part of the inspection(yes or no): PS If yes,volume pumped; allons--How was Iva pumped determined? t Reason for pumping: /lv S n e c T- TCL -s f� TYPE F SYSTEM eptic tank,distribution box,soil absorption system y _Single cesspool Overflow cesspool —ivy _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: 6 �/�cc lis Were sewage odors detected when arriving at the site(yes or no): /V D 6 + Page 7-of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: �QS�I�D ��/� Owner: Date of Inspection:/ BUILDING SEWER(locate on site plan) Depth below grade: t, �,/ Materials of construction:_cast iron k 4U PVC_other(explain): Distance from private water supply well or suction line: Comments(on condition of joints,venting,evidence of leakage,etc.): SEPTIC TANK:jz(locate on site plan) i Depth below grade: Material of construction:_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:,6 `5-Y 5 ` Zi K /a-b Sludge depth: �? " r. Distance.from top of sludge to bottom of outlet tee or baffle: Scum thickness: C) Distance from top of scum to top of outlet tee or baffle: Distance from bottom of scum to bottom of outlet tee or biffle: How were dimensions determined: 0-0 7.C1 5-y r-P Comments(on pumping recommendations,inlet and outlet tee or baffle condition,structural integrity,liquid levels as related utlet invert,evidence o leakage,etc.): /a- �2 t GREASE TRAP:_(locate on site plan) Depth below grade:_ e t m r Material of construction: concrete* metal_fiberglass'_ 'Polyethylen'e_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.): 7 -*Page�8 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SY��STEM/l INFORMATION(continued) Property Address:.A- Owner• Date of Inspection: / 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: (if present must be opened)(locate on site plan) Depth of liquid level above outlet invert: b Comments(note if box is level and distribution to outlets equal,any evidence of solids carryover,any evidence of le ge into or out of bex,etc.): .D 0 Jvo polki od e G V PUMP CHAMBER: (locate on site plan) , Pumps in working order(yes or no): i Alarms in working order(yes or no): Comments(note condition of pump chamber,condition of pumps and appurtenances,ell « ,, _ 8 Page'9 o°T 11 o OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C S,YYSTEM/INFORMATION(continued) Property Address Owner: Date of Inspection: SOIL ABSORPTION SYSTEM(SAS): (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: 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.): U O C/ 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: t 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.): 9 ,Page-10•of 11 j OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DLSPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address:, �O Z2,S-,/- Owner: Date of Inspection: 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. "1 011r ly 7-5 ' t 3� 3 10 1 .: Page 11 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: Owner: Date of Inspection. 3 SITE EXAM Slope Surface water Check cellar Shallow wells Estimated depth to ground water/6L feet 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: 3'0/9 S 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: �-- rj toiVS 'q S i }t s I «� r 11 TOWN OF NORTH ANDOVER,.,, ,f-�,,-.. .� i SYSTEM PUMPING R -ECjiI dc°t-N1 I 6 , JAN _ 62O, � � l TEM OWNER & ADDRESS SYSTEM LOCATION _ (example; left front of house) U \"I E OF PUMPING: QUANTITY PUMPED /,17cD C � LLO I:»PO0L: NO YES SEPTIC TANK: NO YES -\TUBE OF SERVICE: ROUTINE EMERCENCY u uI R v.:\TIONS: GOOD CONDITION. FULL TO COVER HEAVY CREASE BAFFLES IN PLACE ROOTS LEACHFIELD RUNBACK EXCESSIVE SOLIDS FLOODED SOLIDS CARRYOVER Qj�HFR (EXPLAIN) >� \)"1 LNC PUMPCD BY: i U 1 m PY NTS: tl ANSFEIZRED TO: TOWN OF SYSTEM PUMPING RECORD DATE:"3'8 SYSTEM OWNER& ADDRESS SYSTEM LOCATION (example:left front of house) lA►'ll'� 0. I_ 0 5T o v�dl DATE OF PUMPING: _ ' 0 0� QUANTITY PUMPED : `' GALLONS / CESSPOOL: NO �/ YESSEPTIC TANK: NO YEST 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(EXPLAIlS) SYSTEM PUMPED BY: Bateson Enterprises, Inc. COMMENTS: CONTENTS TRANSFERRED TO: �' ` H-- ' FORM U - LOT RELEASE FORM Id '�a-` ` 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 or requirements. *****************************APPLICANT FILLS OUT THIS SECTION*********************** APPLICANT P ONE LOCATION: Assessor's Map Number D r PARCEL SUBDIVISION LOT(S) vSTREET , `� � L---"ST. NUMBER ************************************OFFICIAL 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 Q ,A) S SEPTIC INSPECTOR-HEALTH DATE APPROVED DATE REJECTED COMMENTS �4� P Q 1 � RC1 5 . Q1, be- PUBLIC WORKS-SEWER/WATER CONNECTIONS DRIVEWAY PERMIT FIRE DEPARTMENT RECEIVED BY BUILDING INSPECTOR DATE Revised 9\97 jm Plan of L and /n North Andover, Mass. Sho wing "As—Built " Foundation Location Lot l - Lost Pond Lane 823� Prepared For '730.40a,jeR ' °h Flin tlo ck, Inc. 9 123.71 Scale: 1" = 40' Date: April 22, 1996 Zoning District: R- 1 (Residence 1) Y"� Qt, •' o t 1 (Planned Residential Development) A , 7 7 27, 116 S.F. Note: 0.62 Acres Property line data taken from a Planned Residential X4 � � � / Aland= 18,9 S.F. Development plan by Thomas E. Neve Assoc., Inc., 6S dated Sept. 23, 1994, revised to May 5, 1995 Top Of �bundation O E/evationh= 135.28' 4 5.5 - l \ 'i +ndation is not in a Flood on the U.S.D.H.U.D. Flood Thomas M. and o Ka tbryn Jodka (� 5 D 5 Nc o '50098 0007 C) CIA o �' \ I ha5-�" . ury that the foundation on this property is �ocated as shown on plans and complies with the zoning requirements of the Town of North Andover, � G Massachusetts. Profess l31 eyor 724 �pryAL lAhO i Thomas E. Neve Associates, Inc. Lot 2 Engineers — Surveyors — Land Use Planners 447 Old Boston Road — U.S. Route 1 Tops field, Mossachuse t is 01983 887-8586 1276- 1—CFP 4 P/ars o f L cnd /n North Andover, Mass. Sho wing "As-Built " Foundation Location Lot 1 — Lost Pond Lane 82.31 Prepared For a R �30•4�' I05 Flintlock, Inc. a23•�� Scale: 1" = 40' Date: April 22, 1996 Zoning District. R- 1 (Residence 1) Q , 7 Q t (Planned Residential Development) e �• ?��1 1.0 *7>_--- .60 *7 27 1 16 S.F. d�,�ti � 9 2 Note: �g 0.62 Acres Property line data taken from a Planned Residential p I&pland= 18,9 S.F. Development plan by Thomas E. Neve Assoc., Inc., �O / 3' Top Of `Fbundation dated Sept. 23, 1994, revised to May 5, 1995 �2 6 Elevation^= 135.28' 4, v 5.5� rn 0 .In my opinion, this foundation is not in a Flood off' hazard Zone as shown on the U.S.D.H.U.D. Flood Thomas M. and Hazard Boundary Maps. Ka thrpn Jodk� (Community Panel No. 250098 0007 C) c0��°'•° cr '0 4, 2r s t�,'�Voc o�c o `,, \ N / hereby certify that the foundation on this property ? N is located as shown on plans and complies with the zoning requirements of the Town of North Andover, o° N N Massachusetts. 46 'S/ \ ` � 1 Professl No.31724 w eyor AL Thomas E. Neve Associates, Inc. Lot 2 Engineers — Surveyors — Land Use Planners 447 Old Boston Road — U.S Route 1 Tops fie/d, Massachusetts 01983 887-8586 1276- 1—CFP -- ----- --==----------"----= ------ ------------- - =----- _ ______ _ 061'19/1996 11: 17 50 8-6580 69 t_OLLCIPY EHGi IHEERIHG PAGE 03 COLS PY ENGINEERING CONSULTANTS 65 AYER IVREET METHUEN, MA 01844 FRANCIS H.COLLOP; Rbn REO.PROFESSIONAL ENOMER a. . r.��,. •7968 TOWN OF NORTH ANDO �Eo)7 68S-8080 _- v HEALTH � � .. BOARD OF er + V1 1 0�tt 1A 0`�` �,� c I0 L1 9 1996 Town of North Anova North Ar.dover , MA 0184 To Whort. '17, t''ay "on ~ern : I am writing in regarc,s to the boat Pond developre;<t in NnttYt 5isdover, MA . in particuiar, TJ an, t4riting r'elgatave to the, Reinforced Concrete Barrier Wall on Lot ? � The location of this w&%1 iB drown on Drawing No . S- 1276-1 , titled "s arl tarry t7Ilgpoeal System, drawn by Thomas E. Neve Assoc:iater. 0f Tope-fie)-d , MA, wrtic:ii had prev oc sl J been submitted to the. Town boards by Mr . Dave Kindred of FjifltlLoc,', X Inc , the ctevelo;^er . Eai°iter Chir ;rear , i Provided Mr . Kindred wit}, a 5truct:iart;l erig�neez ir; de,8i-3i Of this Wall based or, the proposf�d locations and eonto,irs shoW;a on the Neve plan . The Structural erigineN r ing dt:&;ign ckieet w}-sic:=-, 7 forwarded to Mr . Kindred ahvvred the rpgU,ired 6i�,e of the wall and the neceeeary steel reinforcing rads . On two different occasions , namely June 1.3 , and Jane i8 ; 1896, I visited the cite arid isxspected t�se iooation 0f the wal ? };?:e sire of the Wali , an the rein,1'Lrcing bars placed in '-the footjgg and in the .F gg ll 1 I`hic tetter is to indicate to your Board that the barrier wail has been built according to my design play;, doted 4/4/96 , wrh-j(--j1 I h&ve tncl.oaed herein for the >°Ec:ords . If you have any questions concerning this matter, Pl.eaee do rsot heeitate to call this oz"jce . 5incerei s v FRANCIS F � COLLOPY ENGINEERING CONSULTANTS CMLosr - 2017 do Francia H . C0110pY, F. E. structural Engineer '�^�/0NAL '� CULLCiPY ENGI JEERIPAG PAGE 02 G C4i�i..LO�Pq�1LNINEERIN8 rJ 65 Ayer Street cALcui t,rEQSULTANTS _ PiIFTHUEN. !ASSACHU.SE ES 01844 (508) 685-8068 --- -- —_� • - __.__ _. ..._ ----._ -_. sem- _._ .�.._-. __.. .�.,,._.. 14 I L 1r 1 � , y i i 1 1 f rte...{{; {'1:I,.: •� ` f� pit v�\ Yom/.-� \„i.�' !L' .�-�.i., - A � ! ! °7, ( �"•.`JAY „{•l'n w S I / LL��'?'_� �'$!s•',��°s''�? :��"' �'��.�'//►��i✓r "fix+° t�.� �'�{f3�.�.�% Pwovxr W isqr siwai?05-,irrueu�LAKEDWet o:G+vror.ft me.to O,a,?xoNE'O.t=9Ef t.M&,[S(W90 THOMAS E. NEVE ASSOCIATES, INC. �C44�Q OCA 4G3LaCvJ�G�04`�Lad Engineers • Land Surveyors 9 Land Use Planners 447 Boston Street US #1 TOPSHELD, MASSACHUSETTS 01983 Q 887-8586 DATE (508) ATTENTION FAX (508) 887-3480 t,A. �2'rA r TO Atli �,rt A��2. �j. RE: 1,D _rCjt�C D L_AE- �A-t?� JUVVI ANDOVER/ 8&kD OF HbALI n C 14UV WE ARE SENDING YOU Attached ❑ Under separate cover via th foll in9 items: ❑ Shop drawings Prints ❑ Plans ❑ Samples ❑ S cifications ❑ Copy of letter ❑ r k- ❑ r COPIES DATE / DESCRIPTION �t► �,�/ / �j�b FosL Ac SAt.�►'TY�1G-t' I7►SpdSA{. S�Q�T�11it NC_VS1 �SSoc�A"[ES tuG. Cff THESE ARE TRANSMITTED V'" ❑ For approval Resubmit `� copies for approval ❑ For your use / l�Cv /// 7 Submit copies for distribution > ❑ As requested \t � Return corrected prints ` ❑ For review and c, D FOR BIDS DUE 19 ❑ PRINTS RETURNED AFTER LOAN TO US REMARKS- � ..IclR"Jp '. ( ,�,��}ztw4 CDnlr_S c)<-q416- �4ts'w csl- . A L.�, 5� 11o`t� THfl�C_ t rJ oe-IDW 1'rb} prLL_ C3_ "roL 2. t!U-i�� t=wi V�rj 1St�r.�Ep C.ltii�a A. L"-Sic�t." vJ l lL7 -/�1�`tP�yt PrasY> D� ��-r' -► w LJ. VE cXK)cf-tl_s Vt.4A'5�cya rsrsl' �jtt-1c4az�L.:f COPY TO i RECYCLED PAPER: G t� gP Contents:40/Pre-Consumer-1o/Post-Consumer SIGNED: -A If enclosures are not as noted,kindly notify us at once. ,•y-�.,:%ydi.-,j �.i s-•t'`y�; si'� .��•� � t" i .!._•� .C '.� _"3f•_`.y 'E''..' 1 i`.,��»�f-'�>�'i�+y' 1 RRR J I LLLLLjj '.�b•..'�1w'a �.f,'�.. t ....tip �•K {;l (•.'3,. ;,�i �,r•:'t,;,' � <�y�••� a� Y .:.; y� �} •yr�' '-•4 C:} + ' �•�, 9t* �4t-. .f p ".... i._,, i^_ 14,- t e,i ..1i y' . », ^� a .'R 1�. y '..,� ' -�. �+,1... :d•1,� +,a,.y'l C...r,;` '�'& i.. _ •-'�� � ..J' '."�J-.3� ,.R` + J ;.d'. '.i <.f `.\t•71" S �J '•.:,:�',`` .,D•S+'_ ..f "'�-�'}'7..,'`]y}^' -i .1, 'e`�f `'moi;. "��`�_'` �<...e �: » 'wi ...f, j ...1 I.J, 'f'frl _y T�,!' 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LO'f �l ' Lll✓� {�vl�-Q� L�tri"�, WO-1-14 Arty Gbyt&'1_7 M A- AtdDOVE // gpgRD OF H Lj WE ARE SENDING YOU Attached ❑ Under separate cover via th foil ing items: > ❑ Shop drawings Prints ❑ Plans ❑ Samples ❑ S cifications ❑ Copy of letter ❑ Change order ❑ t^ k l.i COPIES DATE NO. DESCRIPTION V ��`/( PL_p,►—i FofG Ac SAtv►— V4W-'-P 1715 PU^5F}t 5�F5?'r." �� Zo o�y 121 co-1 1..0c_4zVr-> ora L uT-*-I Arr L l.A*_aE, . i�1�t�A�E� 8"•� 'ti}�jVv1t�S E,. N�Vt=., �r55oca.A'ZE.S t�G, THESE ARE TRANSMITTED as checked below: ❑ For approval ❑ Approved as submitted Resubmit 4 copies for approval ❑ For your use ❑ Approved as noted ❑ Submit copies for distribution ❑ As requested ❑ Returned for corrections ❑ Return corrected prints ❑ For review and comment ❑ {-Ell�F--OORwR BIDS DUE 19 El PRINTS RETURNED AFTER LOAN TO US REMARKS '/C�''� � b` f• BJ� �11—�� '= CAZ PW 4 C.D�I�iS �IMC 4C*V15W M51 E!"ep Ut'- 19v5je' 'It1g- 116W -n-TL6:Sz t\t0-tom. lvfp ' t>ti oevE2 1Tt} 1�-LA_ C�r- I C�c.I Com, A� Cyt' tt� -dot�t2 �-c't oc - 10lot l�5 ll- -I� �tCwi (N lilE SIG�I.�Ep LlSl►-iia A. Sic'k" f jj � 1G4-f' A*-V A 1WIPA-V-�T -Vy4t-L- W L L-L- $E IK35 AL-L� t tc `yCb� t- tL Nv_ _f 01115- ctyrl)crce4NS Vt4fl-15�c VD Kb-r Com}-LL_. �(�i-p�.ttL �o�-► � � -Tinny tti1 �E,wtNq COPY TO i RECYCLED PAPER: Contents:40%Pre-Consumer•10 Post-Consumer SIGNED• I If enclosures are not as noted,kindly notify us at once. , r A " f 1 �s'r,l'�� ��1w• fro',!'Y~,�i��'4—t�.w a •- "' ,• ?.v`$ ._j +�. '.1`i s# '.t J�..} ; �" �j"^;j:.._.4 .��..•`_,, K',�t._'= tai t a ` J3 l Xl- '-sl-_�^a ,.•"`••. )r .... ♦ '1`•.,: .:G. F:•L-t - :sal �',c-'.'="=: •�.i,� .,� < s ?. ;..".t;� !! `.,j, P '�1 r; ,.11f.,-i� �yf••`-A�._..t... ,. ....�4 ~..f,�'';-,{-ff -'� ;<r...r.i','^ A i..,i «"�rR.i�:... ;� 'f'i .t `�.ti�:�� j !r'_�r�i yt���•'' �']�;"� _ �'j'-�,�i� .i:.r �i .A'•.�,f�,.'x .�i.sF,`j e�i� \.2'_.gr's �i47"9,j...F`'! '�.,:,�y,'—"��l'� !i8`r `�.t •.,; •r ..:�i 1~ ,�'i f^� !�� .�i �:e:^��`i._:''; ,� ;;'1•,^i �'v"','�r.J(..�'x�s of..�� `4� � �:...'�`f�I r�r�_ ^.:i.��d :,.l�j{ •''-:�: _R`.r—�"Yx.�„ .+Y J, 4 i! .f ��>..�-..� T ..f�, � .,+ .i i j .. �.3 f .t .,...r c:^� •��..# (;.i�.,'..-1 '`".. - _ r .. ..a ., L�..e;.�•"l^� � s 7 i•!`J`�, -�' , r•. y ✓1 �,. t.t -4.t '1 {,�; ,^a{� S r "-.^.fs C ,� ;..�'d < -�,_, .i. ^� 1<�- •�;-.. �.•�j `-! ;s��.j•-��^*�'�. q''?e. 4 r�'�-,�*�� '�A'� --�'��1 �T?^ -�`. r��") '•`+. �_r6 F'�� SC' ����-,'f :� �_•�• ,. :•�...: `-.1 a- R•�Z.1:,-� �;�., y..Vr�s ��� ^��: ` °.? c'�:�r.�..�f... �� ! j ,✓t1 �_ "•' _3_a,. � t- :,✓!�>_%.} _'i. J _ �3 �".4; _l,P{e 1 _�`,3:+_.lel�� ..�._) e S'..A.,J,; J!J,_.s!•�•j t ,�`C�a� -j � � -..i! It J'`„ ,�j..£ r j PLAN REVIEW CHECKLIST ADDRESS /\.lT / 106, o,U� ENGINEER GENERAL 3 COPIES �� STAMPLOCUS NORTH ARROW SCALE CONTOURS PROFILE SECTION �-- BENCHMARK 6---- SOIL & PERCS ELEVATIONS WETS. DISCLAIMER WELLS & WETS _ WATERSHED? t,10 DRIVEWAY (Elev) WATER LINE S FDN DRAIN✓� SCH40 f TESTS CURRENT? SOIL EVAL U254/S� S779eC SEPTIC TANK MIN 1500G C,"' . 17 INVERT DROP GARB. GRINDER(+200% EDF) 25 ' TO CELLAR MANHOLE ELEV GW ## COMPS. D-BOX SIZE # LINES�Z FIRST 2 ' LEVEL STATEMENT INLET �'aZ9 �b - OUTLET (2" OR .17 FT) TEE REQ'D?/!/0 LEACHING a I(J (LD /,:� MIN 660 GPD?,�' RESERVE AREA 1, � 4 ' FROM PRIMARY? 2% SLOPE 100 ' TO WETLANDS 100 ' TO WELLS 4 ' TO S.H.GW_z (5 ' >2M/IN) 35 ' TO FND & INTRCPTR DRAINS 325 ' TO SURFACE H2O SUPP 4 ' PERM. SOIL BELOW FACILITY 6--' MIN 12" COVER ✓ FILL? :/ (25 ' if above natural elev; 10 ' if below) BREAKOUT MET? TRENCHES MIN 660 gpde SLOPE (min .0'05 or 6"/100 ' ) v SIDEWALL DIST. 3X EFF. W OR D (MIN 6 ' ) C/ RESERVE BETWEEN TRENCHES? IN FILL? MUST BE 10 ' MIN. t/, � 4" PEA STONE?VENT? t,--"'(>3 ' COVER; LINES >50 ' ) BOT ua2 � + SIDE 21 �5' LDNG TOT 387 (L x W x #) (DxLx2x##) (G/f t2) Copyright © 1995 by S.L. Starr NORTH ANDOVER BOARD OF HEALTH DESIGN REVIEW REPORT FEE: &6-� PERMIT DATE RECEIVED APPLICANT �iqV/& K/,Upe j MAP PARCEL ADDRESS LOT # j ENG. ST. ADD. PLAN DATE REV. DATE CONDITIONS OF APPROVAL APPROVED DISAPPROVED _ - REASONS FOR DISAPPROVAL: K � OF 5y6T�NJTeR /UD T 4 (7) N� D,e►v�cv�y OL) C c--/�"ll'" THS IV oA 51 TCS G� �, • CC/9 vim-, .�iVSC1.�.�'rcrG%ti7 LE�C/� �9�C/9 �/i9I<5" �ot�C (1sIX16 /97,9 j UT jv6T6 T�/�r ,gGr�,e c�o�sr, � �'P�� ➢,E• sy�� sv,B�-r ir- L' E/27`• � F C'�NT 55 D 3 j FORM U - VERIFICATION 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***************** l APPLICANT: - Flt- o c Phone LOCATION: Assessor' s Map Number 4"M Parcel *_T` /"-7 L o s j f d,�� / Subdivision / Lot(s) Street L a S/ / ° ^� '�'�' St. Number ************************Official Use Only************************ RECOMMENDATIONS OF TOWN AGENTS: rCtS 't Q9�__ Date Approved _ Conservation Administrator Date Rejected Comments Date Approved Town Planner Date Rejected Comments Date Approved Food Inspector-Health Date Rejected Date APP 13// rovedl Septic Inspector-Health Date Rejected Comments I Public Works .- sewer/water connections driveay .permit Fire Department Received by Building Inspector Date C O`rr4OW CALL_ FORDATE TIME ;M M PkbNEQ OF RETURNED PHONE [� d Y9RCALL AREA C DE NUMBER EXTENSION MESSAGE f �,,-��� LEASE CALL e WILL CALL �.C_., ✓Si@ O- tG AGAIN / GAME T0' SEE YOU WANTS TO SEE YOU SIGNED TOPS I FORM 4003 U] W 0 Town of North Andover HOR7h 1 OFFICE OF 3?01�"'t- �O L COMMUNITY DEVELOPMENT AND SERVICES A 146 Main Street �, 40',T, ,.•�y North Andover, Massachusetts 01845 1SSACHuS�S (508) 688-9533 December 29, 1995 Mr. David Kindred 40 Marbleridge Road North Andover, MA 01845 Re: Lot #1 Lost Pond Road Dear Dave: This letter is to confirm, that on December 28, 1995, the North Andover Board of Health granted a waiver to the North Andover Regulations for the Minimum Requirements for the Subsurface Disposal of Sanitary Sewage #2. 14 to allow the design flow to be based on 110 gpd and the minimum leaching area capacity to be 440 gallons. If you have any questions, please do not hesitate to call the Board of Health Office. Sincerely, Sandra Starr, R.S. Health Administrator SS/cjp cc: Neve Associates BOARD OF APPEALS 688-9541 BUILDING 688-9545 CONSERVATION 688-9530 HEALTH 688-9540 PLANNING 688-9535 Julie Parrino D.Robert Nicetta Michael Howard Sandra Starr Kathleen Bradley Colwell Form No.3 Town of North Andover, Massachusetts BOARD OF HEALTH MORTH p< <... ;e 1" - aZ l 19 3? e�*, "a O0L p " F 9 DISPOSAL WORKS CONSTRUCTION PERMIT ,SSACMUS�� J Applicant ADDRESS TELEPHONE NAME Site Location Permission is hereby granted to Construct ( ) or Repair ( ) an Individual Soil Absorption Sewage Disposal System as shown on the Design Approval S.S. No. 5 �CHAIRMAN7B—���� OARD OF HEALTH D.W.C. No. " _.. -_ - - Town of North Andover, Massachusetts Form No.z f MON7q BOARD OF HEALTH y^r O�t1"D I•,hO � f t f w 9 DESIGN APPROVAL FOR ass"C""5SOIL ABSORPTION SEWAGE DISPOSAL SYSTEM Applicant- _ _ Test No. Site Location (j)rReference Plans Plans and Specs.— �l�'1/� ht �J��-- /e '9 5 ENGINEER DESIGN DATE Permission is granted for an individual soil absorption sewage disposal system to be installed in accordance with regulations of Board of Health. CHAIRMAN,BOARD OF HEALTH dv Fee D Site System Permit No.��� Town of North Andover, Massachusetts Form No.4 BOARD OF HEALTH CERTIFICATE OF COMPLIANCE 19 This is to certify that the Individual Soil Absorption Sewage Disposal System constructed by Peter Breen � ) or repaired ( ) INSTALLER at 'Lot #1 Lost Pond Road North Andover MA has been installed in accordance with Board f Health tth Regulations as described in the Design Approval Site System Permit No. 761 g dated The issuance of this certificate shall not be construed as a guarantee- that 79 function satisfactorily. the system will �AR H NORTH ' Town of over O 0 4 �.. .- d6ver, Mass., 19 �6 COC MIC ME WICK A0RATE1) p'? Cl 00 BOARD OF HEALTH PERMIT T D Food/Kitchen Septic System 2tj� B. LDING INSPECTOR THIS CERTIFIES THAT �.7.-..........G -, .. -......................................... has permission to erect........ .4....p........ buildings on .........�'.0......../1..A.S..7. .-:.....P. .1 . ............... ough _ to be occupied as...................................................,. ,�, ..6' C .............. .. ..e�-. el............................... im e provided that the person accepting this permit shall in every respect conform to the terms of the application on file in this office, and to the provisions of the Codes and By-Laws relating to the Inspection, Alteration and Construction of Buildings in the Town of North Andover. PLUMBWG INSPECTOR b VIOLATION of the Zoning or Building Regulations Voids this Permit. U Z • V U"�"DA StAff FE-,PERMIT EXPIRES IN 6 MONFES-- ---�-'� ytv Si UNLESS CONSTRUCTION STS FERMtT � ELECTR INSP T PERMIT FOR FOUNDATION ONLY - REGULATED BY pARn. 114.8-S. B.C. ............................ ... .................. ... C ervice vl�G/�r BUILDING INSPECTOR DATE �16��� 1 �� it Required to Occupy Building GAS INSPE& OR Display in a Conspicuous Place on the Premises — Do Not Remove Rough s, Final No Lathing or Dry Wall To Be Done FIRE DEPARTMENT Until Inspected and Approved by the Building Inspector. Burn �— i PERM REGULATED FOUND ` 1 Z ATION ONLY 1 REGULATED BY PARA. 114.8-S. B.C. t �'� '" i `LI Qf moke �;✓��"�l� Town of North Andoverof „ORTH -1 OFFICE OF 3a ,�` �� COMMUNITY DEVELOPMENT AND SERVICES 41A 146 Main Street 9 KENNETH R.MAHONY North Andover, Massachusetts 01845 9SSAcHUS�t Director (508) 688-9533 October 10, 1995 Mr. Thomas Neve Neve Associates 447 Boston Road Topsfield, MA 01983 Re: Lot #1 Lost Pond This is to inform you that the proposed plans for the site referenced above have been disapproved for the following reasons: 1) Bottom of system not 4 feet from groundwater - 125.8 feet. 2) 15. 240 (7) - No driveway on leaching area. 3) Tank less than 25 feet to foundation. 4) Leach area less than 35 feet to foundation. 5) Insufficient leach area with 1995 code. If using 1978 code, please address slope/breakout using 125.8 feet as groundwater table. If you have any questions, please do not hesitate to call the Board of Health Office at the number below. Sincerely, I / Sandra Starr, R.S. Health Administrator SS/cj p I BOARD OF APPEALS 688-9541 BUILDING 688-9545 CONSERVATION 688-9530 HEALTH 688-9540 PLANNING 688-9535 Julie Parrino D.Robert Nicetta Michael Howard Sandra Starr Kathleen Bradley Colwell I oi�u n�mvenlll�uC Mgss�cl�usells Mass�lcliuselts o - 8ysle�tt 12"Ill"1119 neuord System Owiser!'------ -----�— Systeitt !_ucdiiuit i)ete taf i'utnpinH: �� 1`�� �'�j tluaiilily i'ui�Ipt'd: (C5 U�-'g�ildlt! ('esspool: No I If Yes I. .) septic -1,1111k: No (_.) Yes System Pumped by: IFdreaed l5Kt'e vizi License 0 (.:�,nlenls tinnsleirted i(f : t3�bAfdr I�wtenta b11111wItY Uitlblta _ l��specl�t: s Commonwealth of Massachusetts 71, City/Town of ��� � � �; System Pumping Record Form 4 TOWN OF NORTH ANDOVER HEALTH PARTMENT 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 tQ determine the form they use. The System Pumping Record must be submitted to the local Board of Health ofother approving authority. A. Facility Information 1. System Location: Left side of hou Right side o , Left front of house, Right front of house, Left rear of house, Right rear of house. a rear of building. Right rear of building. Address City/Town State Zip Code 2. System Owner: Name Address(if different from location) Citylrown State Code -77 -- 7 Telephone Number B. Pumping Record 1. Date of PumpingDate `r 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: 6. System Pumped By: Neil Bateson F5821 Name Vehicle License Number Bateson Enterprises Inc Company 7. Location re contents were disposed: .L. Lqwell W ste Water Signat re H ler Date t5form4.doc-06/03 System Pumping Record•Page 1 of 1 I I