HomeMy WebLinkAboutMiscellaneous - 50 SAW MILL ROAD 4/30/2018 (2) 50 SAW MILL ROAD
210/104.A-0086-0000.0
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Commonwealth of Massachusetts
City/Town of
W System Pumping Record "I '12014
Form 4 TOWN OF NORTH ANDOVER
LHEEALTH DEPART,;ENT
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,��/right ,
Right side of building, Left/Right front of building, Left/Right rear of building, Under deck
Address'
� n� aver
City/Town State Trp Code
2. System Owner.
C a ro
Name
Address(if different from location)
City/rown Sta
• �_ /� I ' f�n Zin Code ,
Telephone Number
f
B. Pumping Record
. 1 � ons
1. Date of Pumping gate ;;e-pticTankEl
Qua Pumped: Ga�l5o a
3. Type of system: ❑ Cesspool(s) 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 where contents were disposed:
jSignH*au
S. Lowell Waste Water
_ y
Date
t5fomut.doc-06/03 System Pumping Record•Page 1 of 1
Commonwealth of Massachusetts RLCEIIE
D
City/Town of
System Pumping Record
� 012013
TOWN 0 NORTH ANDOVER
y 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: Left/Right front of house, Left/Right rear of house righ Ide of house Left/
Right side of building, Left/Right front of building, Left/Right rear of building, Under deck
Address PA- �JCA
City/Town State Zip Code
2. System Owner. -.
Name
Address(if different from location)
City/Town Stat Zip Code
t-7 5—/C`�
Telephone Number
B. Pumping Record
1. Date of PumpingDam 2. Quantity Pumped:
Gallons
3. Type of system: ❑ Cesspool(s) 0-Se'ptic Tank ❑ Tight Tank
❑ Other(describe):
4. Effluent Tee Filter present? ❑ Yes If yes, was it cleaned? ❑ Yes ❑ No
5. Con ' ' n of System: (^ 1
6. System Pumped By:
Neil Bateson F5821
Name Vehicle License Number
Bateson Enterprises Inc
Company
7. Location where contents were disposed:
G.L S. Lowell Waste Water
Sign t e Haule Date
t5form4.doc•06/03 System Pumping Record•Page 1 of 1
� SETTLED�64�
PUBLIC HEALTH DEPARTMENT
Town of North Andover
Community Development Division
CERTIFICATE OF
COMPLIANCE
As of: 3/28/2013
This is to certify that the individual subsurface disposal system has been installed in accordance
with the provisions of Title 5 of the State Environmental Code:
Component Repair — Pipe and D-Box
By: Todd Bateson
At: _..
, 50 Saw Mill Rd.
Map 104A Lot 0086
North Andover, MA 01845
The'Ilsstiance of this ce9if cafe shall n&be construed as a guarantee that the system will function satisfactorily.
Michele Grant y
Public Health Agent
'e"410 ri
Y
1600 Osgood Street,North Andover,Massachusetts 01845
Phone 978.688.9540 fax 978.688.8476 Web www.townofnorthandover.com
a
• 'ILED l6yc .
North Andover Health Department
(ommunity Development Division
ONSITE WASTEWATER SYSTEM CONSTRUCTION NOTES
LOCATION INFORMATION
ADDRESS: 50 Saw Mill Rd. MAP: 104A LOT: 0086
INSTALLER: Todd Bateson
DESIGNER:
PLAN DATE:
BOH APPROVAL DATE ON PLAN:
INSPECTIONS
TANK INSPECTION: 3/28/13 Pipe and D-Box
DATE OF BED BOTTOM INSPECTION:
DATE OF FINAL CONSTRUCTION INSPECTION:
DATE OF FINAL GRADE INSPECTION:
SITE CONDITIONS
❑ Contractor reports any changes to design plan
❑ Existing septic tank properly abandoned
❑ Internal plumbing all to one building sewer
❑ Topography not appreciably altered
Comments:
SEPTIC TANK
❑ Building sewer in continuous grade, on
compacted firm base
❑ Cleanouts per plan
❑ Bottom of tank hole has 6" stone base
❑ Weep hole plugged
❑ 1500 gallon tank has been installed
H-10 loading
❑ Monolithic tank construction
❑ Water tightness of tank has been achieved by
visual testing
❑ Inlet tee installed, centered under access port
-1
t
X Outlet tee installed, centered under access port
(gas baffle)
❑ inch cover to within 6" of finish grade
installed over one access port
❑ Hydraulic cement around inlet & outlet
Comments: j
PUMP CHAMBER
❑ Bottom of tank hole has 6" stone base
❑ Weep hole plugged
❑ 1500 gallon Pump Chamber installed
❑ H-10 loading
❑ Monolithic tank construction
❑ Inlet tee installed, centered under access port
❑ Pump(s) installed on stable base
❑ Alarm float working
❑ Pump On/Off floats working
❑ Separate on/off floats
❑ Drain hole in pressure line
❑ cover at final grade installed over pump
access port
❑ Water tightness of tank has been achieved by
testing
❑ Hydraulic cement around inlet & outlet
Comments:
CONTROL PANEL
❑ Alarm & Pump are on separate circuits
❑ Alarm sounds when float is tripped
❑ Location of control panel: basement
❑ Alarm signal located inside: basement
Comments:
DISTRIBUTION-BOX
X Installed on stable stone base
X H-20 D-Box
X Inlet tee (if pumped or >0.08'/foot)
❑ Hydraulic cement around inlet & outlets
X Observed even distribution
X Speed levelers provided (not required)
Comments:
r r...... ....................................................................................................................................................................z
50 SAW MILL ROAD Reference No: BHJ-2013-000022
Department: Permit No: BHP-2013-0609
North Andover BOARD OF HEALTH
......................................................................................... Account No: 1001001.1.5.0510.00
Fee Type: ....................................
DWC-Component Repair PERMIT Receipt No: REC-2013-001258
......................................................................................... ....................................
Paid By: Paid in Full On: Tue Mar 26,2013
ToddBateson ....................................
........................................................................................ Check No: 7312
Received By: ....................................
Lisa Blackburn
............................................•............................................ ;
DEPARTMENT'S COPY Amount: $125.00
...................................................................................................................................... ::::::::::::......:::...............�
r•
• 5� pot Commonwealth of Massachusetts Map-Block-Lot
• 104.A0086
BOARD OF HEALTH
----------------------
North Andover
C ICATE OF CO PLIA CE
THIS 1 O CERTIFY,Th the Individual Sewag isposal System ( air)
by ...Todd Bateson
--------------------------------------------------- ------------------- -------------------------------------------------------------------------
Installe
at No 50 SAW MILL ROAD
----------------------------------------------------------------------------------------------------------------------------------
has been installed in accordance with the provisions of TITLE 5 of the State Environmental Code as described in the
application for Disposal Works Construction Permit No. BHP-2013-060 Dated-_March 26,2013_
-----------------------------------------------------------------
Printed On:Mar-26-2013 BOARD OF HEALTH
• 5��"TED��e Commonwealth of Massachusetts Map-Block-Lot
• 104.A0086
~T BOARD OF HEALTH -----------------------
Permit No
North Andover -BHP-2013--06-09------------ -- --
FEE
$125.00
-----------------------
DISPOSAL WORKS CONSTRUCTION PERMIT
Permission is hereby granted Todd B-ateson
- - - - ----------------- --------------------------------------------------------------------
to(Repair)an Individual Sewage Disposal System.
at No 50 SAW MILL ROAD '' --
as shown on the application for Disposal Works Construction Permit No. BHP-2013-060 Dated March 26,2013
Issued On: Mar-26-2013
--- ---- --------- --- ------------- --- ------------- -- ---------- BOARD OF HEALTH
r O
f
rpf 00*T"quo Application for Septic Disposal System
3:•':' �� TODAY'S DATE
} =Construction Permit — TOWN OF
'° •r ORTH ANDOVERMA 01845 $250.00–Full Repair
�'°•,,.°.�•'`� r, $125.00-Component
,SgAC►N1SE4
Important: Application is hereby made for a permit to:
When filling out
forms on the El Construct a new on-site sewage disposal system*
computer,use ❑ Re i or replace an existing on-site sewage disposal system*
only the tab key ��—yy,/RR p
to move your epair or replace an existing system component–What? D jl;�� ><
cursor-do not
use the return A. Facility Information
key.
Baa Address or Lot#
11 City/Town
2.- *TYPE OF SEPTIC SYSTEM*:
❑ Pump ravity(choose one)
***If pump system,attach copy of electrical permit to application***
504
Conventional System (pipe and stone system)
❑ Infiltrator or Biodiffuser(Gravel-Less) (Attach a copy of your certification to install this type of system.
❑ Pressure Distribution S.A.S. (No D-Box)(Attach Draft Maintenance Agre me"RECEIVED
0 Pressure Dosed (D-Box Present)S.A.S.
2. Owner Information MAR 2E 2013
/r4y 'TOWN OF NORTH ANDOVER
Name
-f> .S,1 u!/"1'%/ P4 WALTH DEPARTMENT
Address(if different from above)
City/Town State Zip Code
Telephone Number
3. Installer Information
Name Name of Compianv r1rNIbL80 INC.
111 ARGILIA ROAD
Address
fh-t�►�-e-�- �"1�- e f�r��
Cityirown State Zip Code
Telephone Number(Cell Phone#if possible please)
a. Designer Information
Name Name of Company
Address
Cityrrown State Zip Code
Telephone Number(Best#to Reach)
Application for Disposal System Construction Permit•Page 1 of 2
oRTit Applicati•on..for Septic Disposal :System_ 3- oVa- t3
3i.`�, '.�,• o� . TODAY'S DATE
Construction -Permit - T'O'WN -OF
* *•' rf' -ORTH ANDOVER, MA 01.845 �25 00-1-comp Component
CHUS
PAGE 2 OF 2
A, FacilitOnformatlo.n continued....
5. Two-of Building: esidential Dwelling or[]Commercial
B. Agreement
The undersigned agrees to.ensure the construction and maintenance of the afore-described
on-site sewage disposal system in accordance with the provisions of Title 5 of the
Environmental Code,as well as the Local Subsurface Disposal Regulations for the Town of
`= North An or,and not to place the system in operation until a Certificate of Compliance has
been I ue by this Board of Health.
'73 <�
Na Date
Applicatio pproyed By: ( and of Health Representative)
� _ZIr--, _(�2
Name Date
pli tion Disappved,for a following reasons:
For Office Use Only:
1 FeeAmched?: Yes No
2.. ProjectMariager Obligation Form Attached. Yes_ M
A: Puma S sv tem? Ifso,Attach copy ofElectSrical Permit`. Yes No
4. FoundatronAs Budt.?(hew construction ronly); Yes_ No
(Samc scale as approved plan)
e
5. FloorPlans?(hew construction only): Yes_ No
APplfcation'�or Dfspp3al$j+stem oust ction Permit**Page 2 of 2
SEPTIC SYSTEM.INS'I AL EI pRGJECT MANAGEMENT OBLIGATIONS
As tilie North Andover•licensedinstall�r for the construcdoti for�•the septic system.for.the property.at:
0 ��w For plans by
(Address of septic system) 4I-A
r)
Relative to the.application of And dated
(in'staller's name) a e .
Dated �a�� -1 3 With revisions ate
(Ioday's ate (bast revised date)
I understand the following obligations for management of 11iis project:
1. As the installer,I am.obligated to obtain.aH permits and Board of Health approved plans-grior to
<perfomzing any work on a site: I must have the approved tilans and the permit•on site when any work is
bein dQ one•. .
2. As the installer,.I must-call-for any and all-inspections. If homeowner,contractor,.project manager, or any
schedules-an inspection and the system is not ready,then
other person not associated with my company
item three-shall br.applicable.
.`' As the installer,I ani requYred to.havethe necessary work'completed prio ;to the.applicable inspections as
indicated below: I_tiindef land that re gisting a,nirisgection without comvletion•of the items in accordance
with Title 5 and the Boafcl of Health I e2ulations-may.resuYtin a$50 00 brie beim levied aQatnst me.and/or
a,: Bo`ttorri of B.ed-Generally,this is the 3�xst.(1"j:inspection finless.there is a reWil ng mall,which
should•be dorie< rst: The installPr must quest die iitspectiori but does not have to be present. .
b. Final ronstivct ori Itis»ectiori—Eng neermust firsi.do their insj ection for elevations;ties,etc.
As->ziiilti of verbal OK dor a-mail xo: �e lthde townofiiorthandover.com):from the engineer must
be submitEed-to..the.Board of Health,aftex:whieliinstaller,ca3ls or-an inspectipn time. Installer must
be present for this.inspection, lith a pump Systom-all electrical�woi k;must be ready and able to
•' cause:pump.tri work arid,alaxni.to function.. � '
c. .Final � tad• installer must xequest inspection vvheii' Il•grading'is.complete: .Installer does not
have to be on-site.
4. As-the installer,•I understand that only I-ml perform the world(other than shVie excavation)and I atn required
to complete the-installation of the systesii identified in the.attached.application for.installation.: .1 fiiither
unden nd•that work done by-others uiilicensed.to'iristalf seliticsystems-in North Andover can corisriiute
reasons for denial-of the.mtem andlor"revocatiotz.or susfierision of.mv lkense.•to operate in.the Town.af
North Andover'si�ficant fines to all pdrsons-involvetl:are also possible.
5. As the.installer,I uaderstaud that:I mist#�e on-site during the.lierf&mance of the following construction,
steps:.
a: Dete=inadm;that.theproperelevadon of the excatradon has been reached,
A Inspection ofthe`sand and stove to be used.
c. Final rnspecdorr by Board of.Realth staff or consultant.
d. Installation..oftank,DBox pipes,stone, vent,primp cbamker,retaining wall and other
components. °
6. &s thg installer I understand that I:am solely responsible for the installation.of the.system as per the
approved Iilans. No instructions by ihe:homeowner,general.contra�tor_.or�any.otlier persons shall-absolve
me Qf�tliis obligation. .
Undersigned l_:iceased Se tic.Inst.alley oda. s Date a -1,3
ame:- ..rtnt yw
�.: . > ,.
6455
Town of North Andover
HEALTH DEPARTMENT
�SS�cHust4
CHECK#: DATE: �Q J�
LOCATION: H )l I
H/O NAME: mcy)l( -
CONTRACTOR NAME: '6q4 9
Tyye of Permit or License:(Check box)
0 Animal $
❑ Body Art Establishment $
❑ Body Art Practitioner $
❑ Dumpster $
❑ Food Service-Type. $
❑ Funeral Directors $
❑ Massage Establishment $
❑ Massage Practice $
❑ Offal(Septic)Hauler $
❑ Recreational Camp $
❑ Sun tanning $
❑ Swimming Pool $
❑ Tobacco $
❑ Trash/Solid Waste Hauler $
❑ Well Construction $
SEPTIC Systems:
❑ Septic-Soil Testing $
❑ Septic-Design Approval $
❑ Septic Disposal Works Construction(DWC) $
❑ Septic Disposal Works Installers(DWI) $
❑ Title 5 Inspector $
Title 5 Report $
❑ Other:(Indicate) $
Health Agent Initials
White-Applicant Yellow-Health Pink-Treasurer
Commonwealth o4 Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
M
50 Saw Mill Road `j 4
Property Address
Katherine Brooks
Owner Owner's Name
information is
required for North Andover MA 01845 3/18/2013
every page. Cityfrown State Zip Code Date of Inspection
Inspection results must be submitted on this form. Inspection forms may not be altered in any
way. Please see completeness checklist at the end of the form.
Important:
When filling out A. General Information REC MW
forms on the
onlycomthe tab key uter, use 1. Inspector: MAR 2013
to move your Neil James Bateson ANDOVER
cursor-do not Name of InspectorOF NORTH
use the return HEALTH DEPARTMENT
key. Bateson Enterprises Inc.
Company Name
111 Argilla Road
Company Address
Andover MA 01810
City/Town State Zip Code
978-475-4786 S115
Telephone Number License Number
B. Certification
I certify that I have personally inspected the sewage disposal system at this address and that the
information reported below is true, accurate and complete as of the time of the inspection. The inspection
was performed based on my training and experience in the proper function and maintenance of on site
sewage disposal systems. I am a DEP approved system inspector pursuant to Section 15.340 of
Title 5(310 CMR 15.000).The system:
❑ Passes ® Conditionally Passes ❑ Fails
❑ Needs Further Evaluation by the Local Approving Authority
3/18/2013
Inspector's Signature Date
The system inspector shall submit a copy of this inspection report to the Approving Authority(Board
of Health or DEP)within 30 days of completing this inspection. If the system is a shared system or
has a design flow of 10,000 gpd or greater, the inspector and the system owner shall submit the
report to the appropriate regional office of the DEP. The original should be sent to the system owner
and copies sent to the buyer, if applicable, and the approving authority.
****This report only describes conditions at the time of inspection and under the conditions of use
at that time.This inspection does not address how the system will perform in the future under
the same or different conditions of use.
t5ins•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 1 of 17
` Commonwealth of Massachusetts
T"`
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
50 Saw Mill Road
Property Address
Katherine Brooks
Owner Owner's Name
information is
required for North Andover MA 01845 3/18/2013
every page. CitylTown State Zip Code Date of Inspection
B. Certification (cont.)
Inspection Summary: Check A,B,C,D or E/always complete all of Section D
A) System Passes:
❑ I have not found any information which indicates that any of the failure criteria described
in 310 CMR 15.303 or in 310 CMR 15.304 exist. Any failure criteria not evaluated are
indicated below.
Comments:
B) System Conditionally Passes:
® One or more system components as described in the"Conditional Pass"section need to be
replaced or repaired. The system, upon completion of the replacement or repair, as approved by
the Board of Health,will pass.
Check the box for"yes", "no"or"not determined" (Y, N, ND)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.
❑ Y ® N ❑ ND (Explain below):
t5ins-11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 2 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
M " 50 Saw Mill Road
Property Address
Katherine Brooks
Owner Owner's Name
information is
required for North Andover MA 01845 3/18/2013
every page. City/Town State Zip Code Date of Inspection
B. Certification (cont.)
B) System Conditionally Passes(cont.):
❑ Observation of sewage backup or break out or high static water level in the distribution box due
to broken or obstructed pipe(s) or due to a broken, settled or uneven distribution box. System will
pass inspection if(with approval of Board of Health):
❑ broken pipe(s) are replaced ❑ Y ® N ❑ ND (Explain below):
❑ obstruction is removed ❑ Y ® N ❑ ND (Explain below):
❑ distribution box is leveled or,replaced ❑ Y ® N ❑ ND (Explain below):
❑ 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 ❑ Y ® N ❑ ND (Explain below):
❑ obstruction is removed ❑ Y ® N ❑ ND (Explain below):
C) Further Evaluation is Required by the Board of Health:
❑ Conditions exist which require further evaluation by the Board of Health in order to determine if
the system is failing to 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
t5ins•11/10
Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 3 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
"< 50 Saw Mill Road
Property Address
Katherine Brooks
Owner Owner's Name
information is
required for North Andover MA 01845 3/18/2013
every page. Cityrrown State Zip Code Date of Inspection
B. Certification (cont.)
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 fecal
coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal
to or less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis must
be attached to this form.
3. Other:
Outlet pipe to d-box&d-box needs to be replaced.
D) System Failure Criteria Applicable to All Systems:
You must indicate"Yes" or"No"to each of the following for all inspections:
Yes No
❑ ® Backup of sewage into facility or system component due to overloaded or
clogged SAS or cesspool
❑ ® Discharge or ponding of effluent to the surface of the ground or surface waters
due to an overloaded or clogged SAS or cesspool
❑ ® Static liquid level in the distribution box above outlet invert due to an overloaded
or clogged SAS or cesspool
❑ ® Liquid depth in cesspool is less than 6" below invert or available volume is less
than %day flow
t5ins•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal posal System•Page 4 of 17
LN i Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
M " 50 Saw Mill Road
Property Address
Katherine Brooks
Owner Owner's Name
information is
required for North Andover MA 01845 3/18/2013
every page. City/Town State Zip Code Date of Inspection
B. Certification (cont.)
Yes No
El ® 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.
1-1 ® 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.
z 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 fecal coliform bacteria indicates absent and the presence
of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm,
provided that no other failure criteria are triggered.A copy of the analysis
and chain of custody must be attached to this form.]
❑ ® The system is a cesspool serving a facility with a design flow of 2000gpd-
10,000gpd.
❑ ® The system fails. I have determined that one or more of the above failure
criteria exist as described in 310 CMR 15.303, therefore the system fails. The
system owner should contact the Board of Health to determine what will be
necessary to correct the failure.
E) Large Systems: To be considered a large system the system must serve a facility with a
design flow of 10,000 gpd to 15,000 gpd.
For large systems, you must indicate either"yes"or"no"to each of the following, in addition to the
questions in Section D.
Yes No
❑ ❑ the system is within 400 feet of a surface drinking water supply
❑ ❑ the system is within 200 feet of a tributary to a surface drinking water supply
❑ M 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.
t5ins-11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 5 of 17
\ %,ommonweann oT massacnuseuz
Title 5 Official Inspection Form
Subsurface Sewage Disposal System f=orm - Not for Voluntary Assessments
50 Saw Mill Road
Property Address
Katherine Brooks
Owner Owner's Name
information is
required for North Andover MA 01845 3/18/2013
every page. Cityrrown State Zip Code Date of Inspection
C. Checklist
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?
® ❑ Has the system received normal flows in the previous two week period?
❑ ® Have large volumes of water been introduced to the system recently or as part of
this inspection?
® ❑ Were as built plans of the system obtained and examined? (If they were not
available note as N/A)
® ❑ 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:
® ❑ 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) [310 CMR 15.302(5)]
D. System Information
Residential Flow Conditions:
Number of be (design): 4 Number of bedrooms(actual): 4
DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): 600
t5ins•11/10 Title 5 Official Inspection Forth:Subsurface Sewage Disposal System-Page 6 or 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
50 Saw Mill Road
Property Address
Katherine Brooks
Owner Owner's Name
information is
required for North Andover MA 01845 3/18/2013
every page. Citylrown State Zip Code Date of Inspection
D. System Information
Description:
Number of current residents:
Does residence have a garbage grinder? ® Yes ❑ No
Is laundry on a separate sewage system?[if yes separate inspection required] ❑ Yes ® No
Laundry system inspected? ❑ Yes ❑ No
Seasonaluse? ❑ Yes ® No
Water meter readings, if available last 2 ears usage Yes
9 ( y 9 (gpd))�
Detail:
Sump pump? ❑ Yes ® No
Last date of occupancy: Current
Date
Commercial/Industrial Flow Conditions:
Type of Establishment:
Design flow(based on 310 CMR 15.203): Gallons per day(gpd)
Basis of design flow(seats/persons/sq.ft., etc.):
Grease trap present?
❑ Yes ❑ No
Industrial waste holding tank present?
❑ Yes ❑ No
Non-sanitary waste discharged to the Title 5 system? ❑ Yes ❑ No
Water meter readings, if available:
t5ins•11/10 Title 5 Official Inspection Forth:Subsurface Sewage Disposal System-Page 7 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form .
J
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
50 Saw Mill Road
Property Address
Katherine Brooks
Owner Owner's Name
information is
required for North Andover MA 01845 3/18/2013
every page. Cityfrown State Zip Code Date of Inspection
D. System Information (cont.)
Last date of occupancy/use: Date
Other(describe below):
General Information
Pumping Records:
Source of information: Pumped Nov. 2008, owner
Was system pumped as part of the inspection? Yes ❑ No
If yes, volume pumped: 1500
gallons
How was quantity pumped determined? Measured tank
Reason for pumping: Inspect tank&tees
Type of System:
® 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)and a copy of latest
inspection of the I/A system by system operator under contract
❑ Tight tank. Attach a copy of the DEP approval.
❑ Other(describe):
t5ins•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 8 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
Zi
°r 50 Saw Mill Road
Property Address
Katherine Brooks
Owner Owner's Name
information is
required for North Andover MA 01845 3/18/2013
every page. Cityrrown State Zip Code Date of Inspection
D. System Information (cont.)
Approximate age of all components, date installed (if known) and source of information:
32 years old, 5/13/1981, as built plan
Were sewage odors detected when arriving at the site? ❑ Yes ® No
Building Sewer(locate on site plan):
Depth below grade: 1.3
feet
Material of construction:
® cast iron ® 40 PVC ❑ other(explain):
Distance from private water supply well or suction line: feet
Comments (on condition of joints, venting, evidence of leakage, etc.):
4"Cast iron through wall 3" PVC in house, no leaks visible.
Septic Tank(locate on site plan):
Depth below grade: .3
feet
Material of construction:
® concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain)
If tank is metal, list age:
years
Is age confirmed by a Certificate of Compliance? (attach a copy of certificate) ❑ Yes ❑ No
Dimensions: 10'x 5'x 4'
Sludge depth: 4.1
t5ins•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 9 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
50 Saw Mill Road
Property Address
Katherine Brooks
Owner Owner's Name
information is North Andover MA 01845 3/18/2013
required for
every page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
Septic Tank(cont.)
Distance from top of sludge to bottom of outlet tee or baffle
17"
4.,
Scum thickness
Distance from top of scum to top of outlet tee or baffle
8"
Distance from bottom of scum to bottom of outlet tee or baffle
13"
How were dimensions determined? 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. Tank level high, found collapsed outlet pipe to d-box, needs to be
replaced.Inlet tee ok, not in use. Outlet tee ok, not in use. Pipe enters side of tank&leaves on side of
tank. Outlet baffle ok.
Grease Trap(locate on site plan):
Depth below grade: feet
Material of construction:
❑ concrete ❑ metal ❑ fiberglass ❑ polyethylene
El 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:
Date
t5ins•11110 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 10 or 17
• Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
M 50 Saw Mill Road
Property Address
Katherine Brooks
Owner ' Owner's Name
information is
required for North Andover MA 01845 3/18/2013
every page. Cityrrown State Zip Code Date of Inspection
D. System Information (cont.).
Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity,
liquid levels as related to outlet invert, evidence of leakage, etc.):
Tight or Holding Tank(tank must be pumped at time of inspection) (locate on site plan):
Depth below grade:
Material of construction:
❑ concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain):
Dimensions:
Capacity:
gallons
Design Flow: gallons per day
Alarm present: ❑ Yes ❑ No
Alarm level: Alarm in working order: ❑ Yes ❑ No
Date of last pumping: Date
Comments(condition of alarm and float switches, etc.):
Attach copy of current pumping contract(required). Is copy attached? ❑ Yes ❑ No
t5ins•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 11 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
50 Saw Mill Road
Property Address
Katherine Brooks
owner Owner's Name
information is
required for North Andover MA 01845 3/18/2013
every page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
Distribution Box(if present must be opened) (locate on site plan):
Depth of liquid level above outlet invert 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 cover broken, replaced. D-box has corrosion holes, needs to be replaced.
Evidence of carryover.
Pump Chamber(locate on site plan):
Pumps in working order: ❑ Yes ❑ No
Alarms in working order: ❑ Yes ❑ No
Comments(note condition of pump chamber, condition of pumps and appurtenances, etc.):
Soil Absorption System (SAS) (locate on site plan, excavation not required):
If SAS not located, explain why:
t5ins-11110 Title 5 Official Inspection form:Subsurface Sewage Disposal System•Page 12 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
50 Saw Mill Road
Property Address
Katherine Brooks
Owner Owner's Name
information is
required for North Andover MA 01845 3/18/2013
every page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
Type:
❑ leaching pits number:
❑ leaching chambers number:
❑ leaching galleries number:
❑ leaching trenches number, length:
® leaching fields number, dimensions: 1 field 25'x 40'
❑ overflow cesspool number:
❑ innovative/alternative system
Type/name of technology:
Comments (note condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of
vegetation, etc.):
Soil ok. Vegetation ok. No sign of ponding to surface
Cesspools(cesspool must be pumped as part of inspection)(locate on site plan):
Number and configuration
Depth-top of liquid to inlet invert
Depth of solids layer
Depth of scum layer
Dimensions of cesspool
Materials of construction
Indication of groundwater inflow El Yes ❑ No
t5ins•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 13 of 17
. Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
50 Saw Mill Road
Property Address
Katherine Brooks
Owner Owner's Name
information is
required for North Andover MA 01845 3/18/2013
every page. Cityfrown State Zip Code Date of Inspection
D. System Information (cont.)
Comments(note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation,
etc.):
Privy(locate on site plan):
Materials of construction:
Dimensions
Depth of solids
Comments(note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation,
etc.):
t5ins-11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 14 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
r` 50 Saw Mill Road
Property Address
Katherine Brooks
Owner Owners Name
information is
required for North Andover MA 01845 3/18/2013
every page. Cityrrown State Zip Code Date of Inspection
D. System Information (cont.)
Sketch Of Sewage Disposal System: Provide a view of the sewage disposal system, including ties to
at least two permanent reference landmarks or benchmarks. Locate all wells within 100 feet. Locate
where public water supply enters the building. Check one of the boxes below:
® hand-sketch in the area below
❑ drawing attached separately
•
C)
vhe Dr/ ve
U
1-o `-34cr
r Sr 3� `orf
tr
t5ins 11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 15 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
50 Saw Mill Road
Property Address
Katherine Brooks
Owner Owner's Name
information is
.required for North Andover MA 01845 3/18/2013
every page. Cityfrown State Zip Code Date of Inspection
D. System Information (cont.)
Site Exam:
® Check Slope
® Surface water
® Check cellar
® Shallow wells
Estimated depth to high ground water: 4
feet
Please indicate all methods used to determine the high ground water elevation:
® Obtained from system design plans on record
If checked, date of design plan reviewed: 7/19/1980
Date
❑ Observed site(abutting property/observation hole within 150 feet of SAS)
® Checked with local Board of Health -explain:
Design plan
❑ Checked with local excavators, installers-(attach documentation)
❑ Accessed USGS database-explain:
You must describe how you established the high ground water elevation:
As per test pit data on design plan
Before filing this Inspection Report, please see Report Completeness Checklist on next page.
t5ins•11110 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 16 of 17
Commonwealth of Massachusetts
Title .5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
"< 50 Saw Mill Road
Property Address
Katherine Brooks
Owner Owner's Name
information is
required for North Andover MA 01845 3/18/2013
every page. City/town State Zip Code Date of Inspection
E. Report Completeness Checklist
® Inspection Summary: A, B, C, D, or E checked
® Inspection Summary D (System Failure Criteria Applicable to All Systems)completed
® System Information—Estimated depth to high groundwater
® Sketch of Sewage Disposal System either drawn on page 15 or attached in separate file
t5ins-11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 17 of 17
Summary Record Card generated on 3/13/2013 9:10:24 AM by Karen Hanlon Page 1
Town of North Andover
Tax Map # 210-104.A-0086-0000.0
Parcel Id 16313
50 SAW MILL ROAD
BROOKS, KATHERINE M.
50 SAW MILL ROAD
N. ANDOVER, MA
01845
Class 101 Single Family Property Type 1 Residential
Zoning2 1 Residential Zoning3 1 Residential
Size Total 1 Acres
FY 2013
UB Mailing Index
Name/Address Type Loan Number Active/Inact. From Until
BROOKS, KATHERINE M. Payor
50 SAW MILL ROAD
N.ANDOVER,MA
01845
UB Account Maint.
Account No Cycle Occupant Name Active/Inactive
Bldg Id.18142.0-50 SAW MILL ROAD Last Billing Date 1/3/2013
3180170 03 Cycle 03 Active
UB Services Maint.
Account No.3180170
Service Code Rate Charge Multiplier/Users
MISCFEE ADMIN FEE 0.635/8 7.82 1/
WTR WATER 01 ALL METER SIZE 11.40 /1
UB Meter Maintenance
Account No. 3180170
Serial No Status Location Brand Type Size YTD Cons
13242478 a Active 00 METE METE w Water 0.63 0.63 147
Date Reading Code Consumption Posted Date Variance
12/13/2012 397 aActual 3 1/9/2013 9%
9/19/2012 394 a Actual 3 10/15/2012 -3%
6/18/2012 391 a Actual 3 7/16/2012 2%.
3/20/2012 388 a Actual 3 4/14/2012 2%
12/19/2011 385 a Actual 3 1/17/2012 -39%
9/16/2011 382 a Actual 5 10/13/2011 58%
6/13/2011 377 a Actual 3 7/20/2011 -25%
3/15/2011 374 a Actual 4 4/13/2011 -20%
12/15/2010 370 a Actual 5 1/12/2011 -13%
9/16/2010 365 a Actual 6 10/15/2010 -49%
6/14/2010 359 a Actual 11 7/15/2010 31
3/18/2010 348 a Actual 9 4/14/2010 -23%
12/14/2009 339 a Actual 11 1/12/2010 -7%
9/16/2009" 328 a Actual 13 10/15/2009 24%
6/10/2009 315 a Actual 9 7/20/2009 -29%
3/18/2009 306 a Actual 14 4/29/2009 -2%
12/15/2008 292 a Actual 14 1/20/2009 -7%
9/15/2008 278 a Actual 16 10/10/2008 21%
6/10/2008 262 a Actual 12 7/16/2008 33%
3/14/2008 250 a Actual 9 4/11/2008 -56%
12/17/2007 241 a Actual 22 1/22/2008 81%
9/14/2007 219 a Actual 11 10/12/2007 -16%
6/21/2007 208 a Actual 15 7/20/2007 3%
3/16/2007 193 a Actual 14 4/16/2007 -20%
12/13/2006 179 a Actual 16 1/19/2007 14%
9/19/2006 163 a Actual 15 10/20/2006 -11%
6/20/2006 148 a Actual 17 7/10/2006 92%
3/20/2006 131 a Actual 8 4/17/2006 -51%
12/27/2005 123 a Actual 19 1/17/2006 8%
Commonwealth of Massachusetts
• City/Town of
System Pumping Record
Form 4
DEP has provided this form for use,by local Boards of Health. Other forms may be used, but the
information must be substantially the same as that provided here. Before using.this form, check with your
local Board of Health to determine the form they use.The System Pumping Record must be submitted to
the local Board of Health or other approving authority.
A. Facility Information
1. System Location: Left/Right front of house, Left/Right rear of house rights Left L
Right side of building, Left/Right front of building, Left/Right rear of building, Under deck
Address.
.5D 0 Al ti Pa'n-6 IV cxA-kr.
Cityrrown State Zlp.code
2. System Owner.
Name
Address(if different from location)
CitylTown State Zip Code
Telephone Number
B. Pumping Record
3-
1. Date of Pumping Date 2• Quantity Pumped:
Gallons
3. Type of system: ❑ Cesspool(s) eptic Tank
El Tight Tank
El Other(describe):
4. Effluent Tee Filter present? ❑ Yes o If yes, was it cleaned? ❑ Yes ❑ No.
5. Condition of System:
6. System Pumped By.-
Neil
y:Neil.Bateson F5821
Name Vehicle License Number
Bateson Enterprises Inc-
Company
ncCompany
7. Location where contents were disposed:
G S• Lowell Waste Water
Sig a Hauls Date
t5fomu4.doc•06/03 System Pumping Record•Page 1 of 1
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Commonwealth of Massachusetts
City/Town of I RECEIVE®
System Pumping Record JUN 1 2 2006
Form 4
OF NORTH A
DEP has provided this form for use by local Boards of Health.. Th SO4f" pier Id r�RkVor must
be submitted to the local Board of Health or other approving authority. .
A. Facility Information
Important:
When filling out 1. System Location:
forms the I ����_CJ�i1
computer,use
only the tab key Address
to move your
cursor-do not
use the:retum Cityrrown State Zip Code
key.
2, System Owner:
Name
Address(if different from location
City/Town Stat
Zip de
Telephone Number
.B. Pumping Record
1 Date of Pumping Date 2. QuantityPumped:
Gallons
3. Type of system: ❑ Cesspool(s) Septic Tank ❑ Tight.Tank
❑ Other(describe):
4. Effluent Tee Filter present? ❑ Yes D-tdo If yes, was it cleaned? ❑ Yes ❑ No
5. Condition of System:
L.
6. System Pumped By
� 7 _
Name Vehicle License Number
Company
7. Locatio where contents were osed:
Sig tur of auler Date
http://www.mass:gov/dep/water/a pprovaWt5forrns.htm#inspect
t5form4.doc•06103
System Pumping Record•Page 1 of 1
TOWN OF NORTH ANDOVER
SYSTEM PUMPING RECORD
DATE: "( —O
SYSTEM OWNER &ADDRESS SYSTEM LOCATION
(example: left front of house)
cJ i<< � ' L ff-- s O IF tfi��5 e-
5 �t
DATE OF PUMPING: ::j-[ -0 r�. QUANTITY PUMPED 'ek"�' 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: D
COMMENTS:
CONTENTS TRANSFERRED TO: Z '
Commonwealth of Massachusetts
4Massachusetts
System Pumping Record
System Owner System Location
Slaw u
Date of Pumping: t� — [ ��-- Quantity Pumped: I' k—gallons
Cesspool: No [�]� Yes [I Septic Tank: No [] Yes [1'
System Pumped by: 64&4" 46a&04&e4 License#
Contents transferred to: Greater Lawrence Sanitary District
Date: Inspector:
JAN 2 0
TOWN OF NORTH ANDOVER
SYSTEM PUMPING RECORD
DATE: `K \
SYSTEM OWNER &ADDRESS SYSTEM LOCATION
(example: left front of house)
qn-
DATE OF PUMPING: '�CP '�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:
COMMENTS:
AQ
CONTENTS TRANSFERRED TO: �- '
/ ('otroi nw allh orMassachusetts
,��-�.t/
�Massacitusells
.gvstem Pumpla Record
System Owner System Location
Date of Pumping: C r?r C Quahtity Pumped: /J�4'-"�gallons
Cesspool: No Yes L.l Sewie Tank: No U Yes � r
System Pumped by: vctiwelf 9w&n,6 mem License~#
Contents transferrred to : Greater L6renca Sanitary District
Date: _ Itespector:
11vz-LjL n"uaverjrasB
� svB
SURFACE DISPQSAL DFMfw- CHECK LIST
LOT
LPPROgID DATE DISAPPROPg,� DATE .
.'rovideds
Reasonss
`i tl e Y FAIL Ob
.eg 2.5 The submitted plan must show as a minim=:
a) the lot to be served-area,dimensions lot
location and log deep observation ho�es-distance
to
cation and results percolation tests-distance ties
design calculations & calculations showing required leaching area
location and dimensions of system-includin
f existing and proposed contours g reserve area
g location any, Xet areas within 100, of
disclaimer-check wetlands mappingsewage disposal system or
(h) surface and subsurface drains within 1.00+ of sewage disposal
stem or disclaimer
i) location any drainage easements within loot of $
system or disclaimer-p; g Board Piles ege disposal
W knoll sources of ---ater supply within 2001 of sgcage disposal
system or disclaimer
location of anY proposed sire1.1, to serve lot-100j
( ocation of water lines on property-10t �m leaching
from leaching facility
location of benchmarkfacility
'Ari
g�agedisposals
o PVC to be used in construction
(4) 11Profile of system-elevations of basement
distribution box inlets and outlets dies Plumb
s Pipe, septic tanks
'Other elevations trioutioa field piping and
mum ground water elevation in area sek-age die
(s) Plan rmst be prepared by e0
a Professional poral system
Professional authorized r' or other
by law to prepare such plans
g 6 '-'Septic Tanks
(a) cap ac t es- 50� of flow
accesss pumping water tables teess depth of tees,
(b) cl eanout
(!c) 10' from cellar wall or inground swimmin '
(d) 251 from subsurface drains swimming 'Pool -
10.2. Distribution Boxes
10.E v b)
( Pe greater 0.08 I
sum
i
F Uh�k List
Pa a 2'
j � Leachin Pita .
Leaching pita a Preferred where the installation is Possible
Reg 11.2 Pa calculation
11.4 b� spacing of leaching area-udnimum 500 sq ft
11.10 c surface �
11.11 d3 cover teMal e .
e 21a2 t a splash Pad
f tee t elbow
g no ends in pipe from d-box to pipe
Reg 15.1
Leachin Fields
no greater an 20 rinutes/inch
area-r�iMxrm 900
15'4 onstruction of fie
X5.8 v surface
3.7 e) 20� from cellarMU
2 �
ua11 or inground sjdumdng pool
Reg 14.1 Leachinrenc s
one
3-4.3b spacin f eaching area-mfn 500 aq ft
6
c dimemnsio
3-4 min 6 with reserve betieaa
�7 d) construc on
1.10 a stone
f surfa a drainage 2%
Ib S e
a sopa x = tob
be shote
b Y/x 50 )
(to be shown) .
ag 9.1
a)
9.6 vel
b) .s d-by Poorer
40
{
Board of Health
North An ver Maas. BEPTIC STSTEH
INSTALLATICK CHECK LIST LOT
APN5—M DATE DISAPPROVED 95NVATICK OK FAIL
eamms!
FA OE
I. Distance Tot
4 a. Wetlands
b. Drains
c. Well
2. Water Line Location
f
3. No PPC Pipe
�i. Septic Tank -
a. _Tess -_Length & To Clean Out Corers.
b. Cement Pipe to Tank On Both Sides of Tank
5. Distribution Box
a. Covers & Box - No Cracks
b. All Lines Flowing Equal Amounts
` o
C. No Back Flow
6. • Leach Field or Trench
a. Dimensions
b. Stone Depth
c. Capped Ends
i d. Clean Double-Washed Stone'
a -
?. Leachs
' a. _ions
b. Sto a Depth
T c. 8p ash Pads
T s
e. C t Pipe to Pit - Both Sides.
f. tan Double Washed Stone
8. No Garbage Disposal
9. Final Grading Inspection
10. Barricading Covered System
11. As Built Submitted
_- a. Lot Location
b.
-
b. Dimensions of System
c. Location with Regard-to Pere Test
f
A. Elevations
F / e; Water Table
f
t
x
..LOT
GAL
EktST'" 4 �
r
�cl 1
.? t+r
�f
tx
IMV
Lc�ty APP.-IN►T2ETAx.
.INV_ptPF E LTJ t? Pte""
up.
i N V bt Get`?C�..-►� ___.�._"{�1• ��
1- - 3---
r
t
IM �` Ari'?-CtH{
\�
Q �S
�,�
r
FOILNI 4 - SISTEMI PUMITNG RECO L)i
1
Comtnonmcealth of Massachusetts
Massachusetts
System 1'urrrf �ecvr �oF�o�
sicn a M, er yatcnt a tioll v-
j
Quantity Pumped:
Date of Pumping
Cesspool: No ,r�I yes LJ Sentir Tnnt- N.. Yes
S%-stem Pumped by: License #:
Contents transferred to: _ r
Date Inspector
i
TOWN OF t
SYSTE PUMPING RECORD
DATE:
SYSTEM OWNER& ADDRESS SYSTEM LOCATION
(example:left from of house)
So ��� ► 11
DATE OF PUMPING: ` (a'- ` QUANTITY PUMPED : ` CS C2 GALLONS
CESSPOOL: NO YES EPTIC TANK: NO YES
NATURE OF SERVICE: ROUTINE EMERGENCY
OBSERVATIONS:
GOOD CONDITION FULL TO COVER
HEAVY GREASE BAFFLES IN PLACE
ROOTS LEACHFIELD RUNBACK
EXCESSIVE SOLIDS FLOODED
SOLIDS CARRYOVER OTHER(EXPLAIN)
SYSTEM PUMPED BY: Bateson Enterprises, Inc.
COMMENTS:
coNTEVTsTRANsFERREbTo: G.L.S.D , Lowell Waste
Commonwealth of Massachusetts
City/Town of RECIE IVit
System Pumping Record MAY 2 12008
� Form 4
TOWN OF NORTH ANDOVER
HEALTH DEPARTMENT
DEP has provided this form for use by local Boards of Health.Oth s may=be used,b e
information must be substantially the same as that provided here. Before using this form,check with your
local Board of Health to detemnine 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. Syste Location:
forms on the
computer,use
only the tab key Address I /
to move your V�
cursor- not
use the return Cityfroun / State Zip Code
key. 2. System Owner:
Name
1 1 Address(if different from location)
City/Town Stateq,,--,, Trp Code
Telephone Number
B. Pumping Record
1. Date of Pumping � 2. Quantity Pumped:
Date Gallons
3. Type system:y tem: ❑ Cesspool(s) eptic Tank El Tight Tank
❑ Other(describe):
4. Effluent Tee Filter present? ❑ Yes LSO If yes,was it cleaned? ❑ Yes ❑ No
5. Condition of System:
6. System u ped :7
Name Vehicle License Number
Company
7. Location ere cont disposed:
Signatur of F#ult
Date
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